Tricky Research

The AJOG printed a 'study' that, in their minds, validates the ACOG's continued stance against home birth as a safe option for healthy, low-risk women. Their conclusions were that less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate.

Before we swallow this hook, line, and sinker, though, lets break it down, shall we?

Tralee Pearce of The Globe wrote a response article to this 'study' on Thursday entitled U.S. Analysis on Home Birth Risks Seen As Deeply Flawed.

Patricia Janssen, an associate professor at the University of British Columbia’s school of population and public health, says that conclusion is “sensationalist” and based on data that are in some cases decades old, on very small samples and in some cases incomplete.

In many cases, she says, women included in the studies may not have planned to give birth at home. They may not have been attended by a properly trained midwife. And much of the data used were retrospectively, gathered using birth records, which may not include enough information...

... Michael Klein, emeritus professor of family practice and pediatrics at the University of British Columbia, says the analysis and its conclusion has to do with the climate in the United States around midwifery. It is less accepted by the medical profession there than it is in Canada, he said.

“We’re dealing with a politically motivated study,” said Dr. Klein, who was a co-author with Dr. Janssen on the B.C. study.

NHS writes their own follow-up on this study in Safety of Home Births Questioned:

Applying sensitivity analyses that excluded poorer quality studies had little effect on the findings. However, when the researchers excluded studies of home births attended by people other than certified midwives, there was no significant difference between the newborn mortality rates associated with the two locations of birth...

... There are other key points to consider when interpreting this research:

• Although home birth was associated with greater neonatal death (within 28 days), neonatal death is still very rare, and the absolute size of the risk is low (0.2% among planned home births and 0.09% among planned hospital births). The researchers calculated that only 0.3% of neonatal deaths could be attributable to birth occurring in the home rather than the hospital.
• It is also important to note that there was no increased risk of neonatal death with home birth compared to hospital birth once the analyses excluded those studies of home births attended by people other than certified midwives, i.e. when the home birth was assisted by a certified midwife there was no increase in mortality compared to a hospital birth.

Carolyn Ryan of the CBC reports that

The authors found that when babies were born at home there were fewer medical interventions like epidurals and episiotomies, and women in home deliveries tended to have fewer tears or lacerations, fewer cases of postpartum hemorrhage and fewer infections.

The team also came to the conclusion that there was a tripling of neonatal deaths for home births once babies with congenital abnormalities were left out. The tripling of fatalities represents a very small number — from four in 10,000 to 15 in 10,000, acknowledged Dr. Jay Iams, the journal's associate editor.

But Iams said the findings provide an appropriate caution to women that giving birth in a hospital can be safer.

"The study results are consistent with what common sense would tell you," Iams said.

But Dr. Michael Klein, an emeritus professor of family practice and pediatrics at the University of British Columbia, said the U.S. conclusions are "crap" that don't consider the facts.

"It's a politically motivated study that was motivated by the American College of Obstetrics and Gynecology who is unalterably opposed to home birth, and they probably were quite happy to publish this article because it fits with their political position," Klein said.

UBC epidemiologist Patricia Janssen, who collaborated with Klein, said the American study mixes their work with research dating back to the 1970s, and surveys with as few as five recorded births.

"The data and the methods taints the quality of the study," Janssen said, noting the review includes studies where the qualifications of the caregiver were not known.

In conclusion, their methodology of information gleaning doesn't support a well documented, well researched study that warrants any type of support. It doesn't lend any validity to the hospital birth debate, either.

It's not clear who attended all of the women, under what situations they were birthing at home, if it was planned or not, what types (health, age, 'riskiness', etc..) of women were birthing these babies, what training their attendees had, and what life saving equipment their attendees (if any) were carrying.

Other, more appropriate studies of planned home births with trained attendees in other countries have so far shown that there are improved outcomes for mothers and no significant increase in risk for baby.

Chalk it up to just one more case of the ACOG up to their dirty little tricks again.

** updated to add CIMS response and Science and Sensibility's response.