Informed Consent for Educating Options in Birth Setting
The July 1st, 2010 online edition of the American Journal of Obstetrics & Gynecology includes a new meta-analysis comparing home birth and hospital birth outcomes
1. “Maternal and newborn outcomes in planned home birth vs planned hospital births: a meta-analysis,” by Joseph R., Wax, MD, and colleagues, concludes that “less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate” (Am J Obstet Gynecol 2010; 203).
This meta-analysis on home-birth has blown through the United States like wildfire. And why? Because it supposedly proves that home-birth is extremely risky; in fact, they state that home birth is three times as risky as hospital birth. But, does it really?
A Meta-analysis is a type of statistical analysis that brings together the findings from a number of independent studies in order to make conclusions about the combined results
3.
It is useful when the studies included are credible and a clear and consistent methodology is presented.
Dr. Nicholas Fogelson dubs this particular meta-analysis as, “a flawed study published in a ‘second-tier journal’”. There are many reasons why he makes this bold statement. A few of the reasons include:
- It includes information on any out of hospital birth: birth on the side of the road, spontaneous and too-quick birth, unassisted birth, birth from women who abandon their babies, premature births (before 34 weeks), and women in high-risk situations to begin with. Unfortunately medical records in many of these studies only notes two types of birth: in hospital or out of hospital (which includes all of the above).
- It includes information from the Pang Study2 – a study that is also inherently flawed with the above information.
- It includes small case studies (one of which had a total of 10 women in the study – which can greatly skew the data).
- It includes old studies that include old practices that did not have the technology that we have today (such as limited or no use of fetal monitoring or ultrasound and thus, many higher-risk women were being accepted as home birth clients without knowing that they were high-risk for lack of appropriate equipment)
- It doesn’t discuss any exclusions, such as perinatal or intrapartum deaths, planned vs. unplanned home birth, demographics (health, age, income, parity, etc..), cause of death, multiples pregnancy, breech, or post-term babies.
In fact, it was so flawed that there were obstetricians and certified nurse midwives, as well as health and safety advocacy organizations that all defended planned home-birth with a skilled attendant, and shamed the meta-analysis published by the AJOG.
The American College of Nurse-Midwives
3 state,
“The safety of home birth has been the focus of significant research in recent decades. It is important to note that the authors’ conclusion differs significantly from findings of many recent high-quality studies on home birth outcomes which found no significant differences in perinatal outcomes between planned home and planned hospital births”…. “In this publication, we are puzzled by the authors’ inclusion of older studies and studies that have been discredited because they did not sufficiently distinguish between planned and unplanned home births—a critical factor in predicting outcomes. Also troubling is that several recent credible studies of home birth were excluded for no apparent reason.”
More distaste for this publication includes a press release from The Big Push for
Midwives
4,
“Many of the studies from which the author’s conclusions are drawn are poor quality, out-of-date, and based on discredited methodology. Garbage in, garbage out.” said Michael C. Klein, MD, a University of British Columbia emeritus professor and senior scientist at The Child and Family Research Institute. “The conclusion that this study somehow confirms an increased risk for home birth is pure fiction. In fact, the study is so deeply flawed that the only real conclusion to draw is that the motive behind its publication has more to do with politics than with science.”
He goes
6 on to say,
“We’re dealing with a politically motivated study”
In fact, a grass-roots organization
5 which seeks to make maternity services as safe as possible released a statement immediately afterward that included,
"In our analysis of multiple studies from countries worldwide," stated CIMS Chair Michelle Kendell, MBA, AAHCC, "CIMS found that the authors of the study included confounding data, such as outdated and low-quality studies, low-risk and high-risk mothers, babies born preterm, babies unintentionally born at home, births attended by unqualified providers, and data from birth certificates that researchers have found to be notoriously inaccurate."
Out of the largest studies included in this meta-analysis, only three of them clearly distinguish between planned and unplanned home birth. These three recent studies are in direct opposition to the meta-analysis published by the AJOG.
These three studies all found that planned home birth with a skilled attendant is as safe, if not safer, than a planned hospital birth for a healthy and low-risk woman. In fact, one of these studies meets the gold standard for quality in home birth research and found that babies born at home were just as safe as those born in a hospital setting.
In conclusion, other countries have recently done rigorous studies
7 with specific including and excluding factors for planned home birth versus planned hospital birth
8 with a skilled and qualified attendant and found that there was no increase in newborn death or illness among healthy, low-risk women
10. There is good reason to be wary of the AJOG meta-analysis.
Cole Deelah
Houston Area
and midwife apprentice
07/18/2010
Additional Reading:
- http://womantowomancbe.wordpress.com/2010/07/14/a-flawed-study-published-in-a-second-tier-journal/
- http://www.birthactivist.com/2010/07/sorry-guys-homebirth-is-still-saf/
- http://www.themidwifenextdoor.com/?p=930
- http://www.scienceandsensibility.org/?p=1349
- http://jenniferblock.com/wordpress/?p=122
Resources:
- http://www.ajog.org/article/S0002-9378%2810%2900671-X/abstract
- http://www.collegeofmidwives.org/news01/ACOG%20%20Hm%20Brth%20Study%20Aug%2002.htm
- http://www.midwife.org/documents/ACNMstatementonAJOG2010.pdf
- http://www.thebigpushformidwives.org/_ccLib/downloads/7-7-2010_PushNews_RELEASE_OB-GYN_Journal_Fast_Tracks_Publicity_on_Deeply_Flawed_Study.pdf
- http://archive.constantcontact.com/fs078/1102083584231/archive/1103553258617.html
- http://www.theglobeandmail.com/life/health/us-analysis-on-home-birth-risks-seen-as-deeply-flawed/article1624918/
- http://www.ncbi.nlm.nih.gov/pubmed/19624439
- http://www.cmaj.ca/cgi/content/full/166/3/315
- http://www.bjog.org/details/news/182410/New_figures_from_the_Netherlands_on_the_safety_of_home_births_.html
- http://www.bmj.com/content/330/7505/1416.full
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