Monday, January 18, 2010

Planned home and hospital births in South Australia, 1991–2006: differences in outcomes

The Medical Journal of Australia has released a paper and is claiming wildly increased rates of deaths among home births in South Australia. Read the synopsis - complete with 27 times higher! 7 times higher! bad APGARs!! - and then read the study and LOOK at the contradictions. It is appalling that this stuff ever gets published. And what's with the random throwaway inclusion of SIDS in there? I don't even begin to understand that inclusion...

Edited to add: and interviewed for on NewsRadio!!
Mon 10:45 - Babies are seven times more likely to die during a homebirth labour than a hospital labour -- according to a new study ... (audio)
Mon 10:50 - Homebirth advocates have accused the AMA of conducting a scare campaign ... (audio)

So let's take it apart as Joy has done, just for kicks - cause we all know that the "dead baby" card is a winner, regardless of the facts. Lisa has written a great summary of this as well.
  • Although presented as research, it is not - it is a report on the statistics that were available. In research terms, this is the lowest of the low and has no control for biases and no statistical power which is interesting as I am (a) hopeless with statistics and (b) unschooled in them. The conclusions drawn are not backed up by solid numbers so are no better than opinion which is interesting because if you listen to the above interview (first one) the guy is not actually saying what is being reported. He clearly says that homebirth is safe.
  • The planned homebirths that are reported are confounded three ways - no one can tell whether they were under the care of a registered and experienced midwife, or were unattended births, or under the supervision of a hospital-based program; the "planned homebirth" number is ~1000 and the actual number is ~300 so we're not talking about actual homebirths - just those that at the first antenatal appointment said they'd like one; and lastly - the way statistics are gathered changed during the time period reported.
  • The title tells us something - it was about planned hospital and planned homebirths, at time of booking. This is a LONG way from the actual outcome, some 8-9 months later and the study author clearly states that they are unable to separate planned homebirths to actual homebirths out. Lots of planned homebirths don't eventuate for lots of reasons, and not all of them have anything to do with the pregnancy or maternal health. Having filled in the form that is being used here, I can tell you - the midwife looks at the Handheld Record and writes something down. No discussion is entered in to about the whys and wherefores of what changed those plans.
  • There are probably only 2 situations in all those years where someone's baby died and it was at home and they planned to be there. 2. In 16 years. 1 had known high-risk indicators as it was a twin pregnancy. So we're down to 1 surprise death. In 16 years. That's pretty good odds.
  • There is no way to look at such a rare outcome of intrapartum death with a small sample. Someone else has pointed out that with those odds you'd need 10,000 births at home to demonstrate this. I'm not a statistician so can't comment on those.
  • I've listened to an interview with the author and he does say quite clearly that homebirth is a safe option as long as the woman is prepared, is assessed for risks, and is close to a hospital.
  • I agree with Hannah Delaney (as Joy quoted her): I find it amazing that in a broken system, with uninsured midwives with no rights in hospitals, the death rate is actually no different.
  • The intervention rates are STARKLY different - c-section 9.2% in planned homebirth vs 27.1% in hospital births, episiotomy rates of 3.6% in planned homebirth vs 21.7% in planned hospital births (one sixth the rate!!!!! And CLEARLY shown to be a bad idea anyway. 3.6% is also for the "planned homebirth" women, 70% of whom birthed in a hospital so is not "of women who birthed at home" but includes a large number of women who were perhaps treated the same (ie were likely to have a 21.7% chance of an episiotomy anyway) so the actual % would be lower still).
  • Lisa's comments about PPHs got me thinking: that the comparison of post-partum haemmorhage is ridiculous enough to call the whole thing in to question. The numbers are similar once the authors took out the know reasons for PPH in hospitals (episiotomies, induction and augmentation, surgery etc) and so the author concludes that oxytocic drugs are used with the same gay abandon at home as they are in hospitals. Um - no. You the author firstly don't ask if drugs are used, so you can't make that conclusion from the stats. And further you clearly have NO idea how homebirth works and that the calm nature of birth, along with skin-to-skin immediately, breastfeeding, bonding, known care provider and so on decreases the risk of PPH. Even something as simple as keeping the room warm is said by people such as Odent to help. And perhaps because you took out all the confounding factors that are iatrogenic to the birth process in hospital, and found the same number, there is always going to be a background level of PPH and that nothing can be done to avoid a small number of them. It comes down then to how they are managed.
Women will always choose this and my concern is that this is going to go even more underground than it already is. I've heard women saying now that these changes make them LESS likely to hire a midwife to birth at home. Not less likely to have a homebirth but less likely to be attended by a registered, trained and competent professional. They are saying they are more likely to freebirth or just hire a doula for comfort. This is going to make the outcomes worse, not better, and probably not change the numbers.

The authors state that ‘women's autonomy in choosing reproductive behaviour is a fundamental human right enshrined in Australian law'. It is about autonomy. Others have said "The excess mortality continues to be found in high-risk women and women need to be informed of this risk." but are missing the point - that even when informed of the risk, some women would rather birth at home and not go to a hospital. And there are some practitioners who will take on those at high risk.

This does give me pause for thought about my own practice. What risk appetite do I have? As a beginner practitioner, I am prepared to go with some known knowns - breech, grand multip, reasonable distance from a hospital - but not twins, or pre-term, or probably a few others. The unknown unknowns I am trained to deal with and know that I have a whole heap of midwives at my phone-tips to call and discuss with, and I can't assess those beforehand so just need to keep up my training and skills and calm to deal with them.

Lastly - this is about the babies. Think of the children!! But there is no measure made of the maternal mortality, and only a very crude analysis made of maternal morbiditiy. No measure of maternal satisfaction.

Hoyden About Town said:
"If this study had shown a substantial increase in fetal deaths with home birth, this would still not be a reason to place legal restrictions on reproductive choice. It would not be a reason to imprison women in hospital by State force, and it would not be a reason to stop women from making informed decisions about our own bodies. They are our bodies, and until a fetus is born, we get the final say in what happens to us."

And therein is the crux of this - it is about the women and their bodies. The fetus does NOT exist legally until it takes its first breath. So what we are talking about it restricting the rights of roughly half the population. Sure, they are rights that a lot won't exercise, and choices that many of them will never make but - just like I have the choice to smoke - I have the choice about where I have this baby.


lauredhel said...

Thanks for this post - it's important to get the word out. Would you mind please attributing my article to me at Hoyden About Town, not to "the blogotariat"?

Emma Someone said...

Apologies for that - my mistake!