Don’t believe the home-birth horror headlines
|
If you’ve been half awake in recent days, you might have heard of a new study showing that “babies are seven times more likely to die during home births”. It’s worth having a close look at what the study actually found (the full article is available here in the Medical Journal of Australia), and also considering some of the broader context that has been sadly lacking from most of the coverage I’ve seen and heard. Please bear with me — I’m about to hit you with a stack of figures — but it is worth taking the time to examine them in some depth. You may end up with a different impression from what the headlines have been saying. The researchers compared the outcomes for 287,192 planned hospital births that took place in SA between 1991 and 2006 with those of 1141 planned home births. Note that this latter group was defined as any birth intended to occur at home at the time of antenatal booking, but about 30% actually ended up occurring in hospital (the researchers were unable to say how many women went to hospital before or during labour). During those 16 years, there were nine perinatal deaths in the planned home birth group (seven of which actually occurred in babies born in hospital), and 2440 deaths in the group with a planned hospital birth. Two deaths occurred among the 792 infants born at home, one of whom had congenital abnormalities. Once the babies with birth defects were excluded from the calculations, the perinatal mortality rate for planned home births was 4.5 per 1000 births versus 6.7 per 1000 for hospitals — the difference was not statistically significant. As you might expect, the rates of caesarean sections and other interventions were significantly lower in the home-birth group. Nine per cent of women who’d planned a home birth ended up having a caesarean, versus 27% of the hospital birth group. The home-birth babies were more likely to die during labour and delivery (intrapartum death) but the numbers were so small, there is a wide range of uncertainty surrounding the estimates of how their risk compared with the hospital group’s. (And remember that the overall perinatal death rate for the two groups was the same). Where the media generally reported home-birth babies being seven times more likely to die during delivery, the estimate ranges from them being anywhere between 1.5 and 36 times more likely to have this happen. Such a wide-ranging estimate means, as the authors themselves state, “small numbers with large confidence intervals limit interpretation of these data”. To go back to the actual numbers, over the period of the study, there were 247 intrapartum deaths among the planned hospital births and two among the planned home births (one of which occurred in a baby who ended up being born in hospital). A similar caution surrounds the widely reported finding that home-birth babies were 27 times more likely to die from lack of oxygen during delivery. Again, this finding had wide confidence intervals, with the estimate ranging from eight to 89 times greater — clearly, another one to take with caution. Looking at the raw data, 87 babies in the hospital group died due to lack of oxygen during the delivery, compared with three in the planned home-birth group (two of whom ended up being born in hospital). The researchers note that during the 16 years of the study in relation to the home births, “there were only three perinatal deaths for which one can reasonably assume that a different choice of care provider, location of birth or timing of transfer to hospital might have made a difference to the outcome.” It is also worth noting that one of these three deaths occurred in a twin. The reason the parents persisted in a home birth despite being advised against it was that they “had had unsatisfactory hospital experiences during previous pregnancies”. The researchers also said “it is reassuring that the rate of postpartum haemorrhage, which had been of concern in earlier Australian studies, was not higher for planned home births than planned hospital births”. In other words, there is quite a lot of good news for home-birth advocates in this study. Given the health system’s historic lack of support for those who choose home birth and their carers, you could argue that one of the main inferences from the study is that it is quite amazing that more adverse outcomes were not reported. Another inference I take is that rather than damming home birth, the health system and health professionals should be doing more to improve support and integration of care. So why did we end up with headlines emphasising the shock horror out of all context? One factor has to be the MJA’s decision to have Dr Andrew Pesce, an obstetrician and gynaecologist who is the president of the AMA, which is opposed to home birth in Australia, write the editorial accompanying the study. Given the intense politicking that has surrounded home-birth policy in the context of maternity services reform, it might have been more useful to have an editorialist from outside the political fray, or even the country. The editorial gave the AMA another platform for directing the media coverage, and its press release accompanying the journal also was geared towards producing the headlines we got. I’m not surprised that the Australian College of Midwives has sent its take on the whole sorry saga to Media Watch, where it deserves some serious attention. One home-birth advocate told me that of the several journalists who interviewed her, none had actually read the study and all just swallowed the AMA line. Meanwhile, it seems more pertinent than ever to borrow the final words of the study’s authors:
What we’ve learnt in recent days is that we can’t rely on the media — or medical organisations — to contribute much light to this debate. |
|
|
|
Crikey's Guide to Julia Gillard
24 Comments
Thank you Melissa for being the first journalist who hasn’t swallowed the AMA’s press release and editorial whole! We need more journos who are prepared to take the time to look beyond the AMA’s spin doctoring and actually do their own research. What hope do we have for genuine health reform in this country when the AMA has so much influence over our government AND our media?
Melissa, your article on home birthing is a beacon. I am a retired midwife, and had to work in a hospital setting. I then assisted a home birth midwife in Sydney
in the 1980’s a few times. The mothers giving birth at home were better prepared, in that they understood what was happening, the midwife had plenty of time to support and monitor. The whole process was natural, if the circumstances were suitable for nature to take over. Pregnant mothers, on the whole, are not sick!
I read your ‘take’ on the figures and agree with the way you presented the outcomes.
Please Melissa, try not to walk away from this issue. It is too important, and you have such a good handle on it. The Mothers, Midwives, and Famillies in this country need your Voice added to the struggling Home Birth Midwives all across the country. If you want some reading as to what male Obstetricians and Gynaecologists are capable of, have a look at A Savage Enquiry, about Wendy Savage in London, an obstetrician and gynaecologist 25 years ago. They eventually got her struck off. Good luck.
Melissa, your article is a breath of fresh air amidst all the polluted, sensationalist rubbish that is thrown around by the media. Please continue your clear, succinct analysis of such issues. The public need to be made aware that the AMA cannot be trusted to speak the truth if it means that their level of power and control could be threatened.
“…the AMA’s spin doctoring.” Now there’s a concept.
Robyn Thompson
Around 200 women, men and children rallied outside the AMA Union Headquarters in Melbourne today, observed continuously by two Security Guards placed at the driveway entrance. Two police women observed from their vehicle for a while then drove off. Speakers raised various issues about the intention of the AMA and the research paper by Keirse et al. Points were raised about the contraversial risks of Media and others who read only the spin doctor Editorial by Andrew Pesce or the Abstract of this questionable research paper by Keirse et al. Thank you Melissa and I believe Hannah Dahlen for responsibly interpreting and informing the public about the facts behind the statistcial content of this research paper and for questioning the misleading propaganda that continues to flow from the Australian Medical Association via Andrew Pesce. Identifying the flaws, as you have done so well is important to Australian women, their families and the midwives who provide private homebirth services.
Thank you Melissa!
I am a PhD student working in the area of birth politics in Australia and I’m a home birth mum. I am constantly frustrated by the way the AMA manipulates figures and tries to brainwash women into not trusting their own bodies.
Pregnant women are not sick and birth is not pathological. The WHO tell us that in any given culture and country, at least 80% of women are physically capable of giving birth without any medical intervention.
Why doesn’t the Australian and the AMA tell people about the Canadian study- published in the Canadian Medical Association Journal only 4 months ago - which has found that home birth is just as safe if not SAFER than hospital birth. This study has much better confidence intervals than the one referred to in The Australian earlier this week. It reports better outcomes for women and babies in the homebirth group compared to two different hospital birth groups.
Home birth isn’t for everyone, and I’d be the last person to push a woman into something she didn’t want to do. I have respect for women that consider all the options and then decide that the hospital is what suits them best. But with the AMA pushing their own agenda, and the media helping them do it, women do not have a chance at actually getting access to any real information.
For all the women who believe that ‘Doctor knows best’ when it comes to childbirth think again. YOU ARE BEING LIED TO.
Congratulations to you Melissa and to Crikey for bucking the media trend!
Bri
Comming from a Midwife I think you have done a great service to women of Australia Melissa, it is good to read facts and unbiased reporting thank you for fair play. As you have pointed out this article is questionable and the data misleading. We want choice for women, informed choice not scare tactics as used by the AMA. Homebirth is a choice not a crime.
How sweet is the voice of reason! Thank you for your article Melissa. The AMA and Dr ‘3am’ Pesche are sadly out of line with their ‘spin doctoring’ shroud waving approach to the issue of women’s choice to birth at home. Seeking to frighten women and the community about birth is very unethical. Even the uneducated in ancient cultures knew that pregnant women and their babies did best when they felt supported and bad news was kept away from pregnant and birthing women. Emotions are powerful chemicals and influence our physiology in ways that clearly the AMA and Pesche are unaware of!
Your article clearly articulates the need for hospital management to consider their processes and work out ways to ensure women feel valued and respected within in the ‘system’.
This ridiculous and polarising behaviour by the AMA and Pesche has to stop! Our job as health care providers is to work with a woman so that she has the place, care provider and opportunity to birth in the best way for her and her baby. Fighting and engaging in turf war behaviour to protect one’s own ‘turf’ is absolutely inappropriate in this day and age. Time for those who seek to maintain the ‘boy’s club’ to grow up and become real men. Real men truly care for women and want the best for them.
Ann Jorgensen, while this is a great article that rips apart the AMA’s misleading statements, it’s not the first.
I had a report on Brisbane’s 4ZZZ-FM’s Brisbane Line show interviewing both Dr Pesce and Justine Caines of Home Birth Australia yesterday, following up from a report we did on the Monday morning news on 4ZZZ.
These stories were both inspired by this article at the Hoyden About Town blog.
I would like to add my vote of appreciation to Melissa Sweet and Crikey for this analysis of the paper Planned home and hospital births in South Australia …
It’s not rocket science. The misrepresentation of the data is blatant and obviously part of a campaign to rid our community of those indominatable home birthers and their midwives.
The conclusion of the paper that “Perinatal safety of homebirths may be improved substantially by better adherence to risk assessment, timely transfer to hospital when needed, and closer fetal surveillance” cannot be concluded from the data reviewed. When there was no investigation of risk assessment, time of transfer, and details of fetal surveillance, how can the ‘researchers’ conclude that outcomes may be “substantially improved” if it was done better? Better than what?
In my opinion this paper may well discredit the authors and the organisation that published it.
All right. I read the stupid article in the paper and thought, just by the title, what a biased piece BUT I don’t feel suddenly that “For all the women who believe that ‘Doctor knows best’ when it comes to childbirth think again. YOU ARE BEING LIED TO.” I mean really as a person doing the studying you are doing that is extremely inappropriate.
Pregnant women are not sick. Not if there is a lovely healthy pregnancy BUT, and yes there is a but, those are the cases where it is a lovely healthy pregnancy. No matter how much a woman may want to do her own thing the reality is when her and/or her child’s life is threatened or is in a position to be threatened then all advice should be taken in consideration particularly medical advice from the Doctor who, sadly gets to see terribly things on a daily basis, does know best. Is the woman forced to take that advice, no but she should be prepared and any decent midwife will make sure she is prepared even if she does start of with a home birth.
I would never do a home birth but I believe 100% that if someone else would like to do it then way to go. Just don’t damn all doctors, ones who deliver babies are usually very nice, because of a stupid headline.
Excellent article and pertinent comments from readers too. But when you Eastern States centric folk are talking about this topic why oh why don’t you recognise the brilliant Community Midwifery Program here in WA. Fabulous midwives, totally mum and baby focussed service, and cheap as chips (unlike ES services). O - oh now I’ve done it, the medico/business lobby will discover this great program and kill it stone dead if they get a chance!
Ok, so I appreciate and accept gracefully the criticism of my earlier statement (thank you delerious). However I do not think that I was over stating the case when I say that women are being lied to - is this situation brought to light by Melissa not a classic example of lies and deception? I have seen this repeatedly, and there is a very very long history of medicine using lies to discredit individuals and organisations which seek to promote alternatives to the biomedical paradigm.
Its simple - birth conducted outside the sphere of medical influence is not acceptable to the AMA and the majority of obstetricians because they see all birth as pathological. According to medical thinking, birth can only be seen as safe in retrospect. Yet, so many births worldwide proceed without the necessity for medical intervention and as I stated before, 80% of women are capable of giving birth without medical assistance.
Now whether women want to give birth with or without medical assistance is their business, but what I strongly object to is medical authorities telling women that they can’t do it on their own when we know that the vast majority can. What is also not considered is the long list of iatrogenic affects of medical intervention in birth which affect women and their babies.
Yes - there are many fantastic, helpful, thoughtful obstetricians out there who do a wonderful job. We need obstetricians for those situations where birth doesn’t proceed smoothly. But the AMA wants ALL WOMEN to be under medical control and I strongly object to that.
Ask yourself why they want that control? If it was for our safety then they wouldn’t need to miss-represent figures and they wouldn’t promote research that suggests home birth is unsafe whilst ignoring the numerous research papers which say it is just as safe as hospital birth (let alone the ones that suggest it is safer). This isn’t about unbiased information for public consumption, it is about manipulation of information.
Bri
David I hadn’t come across your program as I am in Melbourne. Great to see that you’ve covered the issue too!
Bundi - the Community Midwifery Program (and other publicly funded homebirth programs) are great but they have quite restrictive eligibility criteria. Many of the women who have safe and successful homebirths under the care of private midwives are unable to access these programs. The programs are an excellent addition to the range of maternity services in Australia and it would be wonderful if there were more of them. However they can never replace the option of women being able to hire their own private midwives who are directly accountable to them not to program protocols.
Bravo to Melissa, and to David Jackmanson, because he was the only journalist that I found had read the study and understood confidence intervals (as does Melissa) and reported accurately. Delerious as someone who has immersed herself in the maternity reform movement for just over 10 years (hospital and home birth) I can safely comment on how medical practitioners view women making informed consent, their use of evidence, and their ‘expert status’.
The majority of obstetricians (specialist and procedural GP’s) view birth as risky and are trained to interfere with birth, largely without a strong evidence base. The majority of them work with pregnant women in a limited capacity (ie short antenatal appointments, and small intervals of time during labour). The vast majority have not seen a labour unfold in it’s entirety and therefore have a very skewed understanding of normal physiology. Midwives on the other hand watch and wait and generally have a very good understanding of normal labour and birth. Women hoever play the most important role. Who else is better equipped to reveal her bodily function than a woman themself?? There is way too much inference that women who choose homebirth and try to avoid intervention that they are selfish, placing their own experience ahead of their child’s welfare. This is misogynistic and vastly inaccurate.
A woman who chooses a caesarean without medical indication is provided that ‘right’ and engages in nothing more than a request (in most cases) and has this choice funded and insured by the taxpayer.
The woman choosing homebirth has neither and is scuitinised beyond belief. Why? Because homebirth is outside of medical control and surgery and intervention sits firmly within the sphere of control and economic prosperity.
A woman who is treated as an overly emotional creature ill equipped to make a decision in pregnancy and birth enters parenting equipped to make thousands of decisions over many years. The industry that makes medical practioners considerable sums of money only exists while women are fearful and poorly informed.
Health Minister Nicola Roxon thought maternity reform was a good one to get done first, before moving onto chronic health! She totally underestimated the entrenched power within maternity services and the harm that has been created as a result. At this stage it seems neither her or PM Rudd have the ticker to make maternity reform about women. They have fueled the turf war from the outset and left women hanging. A very poor sign for overall health reform.
Home birthing.
In the same street but opposite, lived a man and a woman. She an artist, he an artist by exterior only. You know the type, totally esoteric in giving answers to even the simplest question. Unable to straight talk and everything imbued with a deep meaning but totally away from comprehension. He was on his third marriage and happily ignored his kids from previous encounters but always ready to criticise the terrible ‘middle classes’. His latest wife was pregnant and ready to ‘unpack’ the baby. Both were ardent believers in the alternative world of Bach remedies and early morning Chakras aligning themselves to magic columns and circles. The birth was going to be a ‘home under water birth’ in the garden and after baby just born but still attached to umbilical cord, would be kept under water for the first five minutes of his or her life. This was all part of the essential but incomprehensible deeper involvement of mysticism and very Sufism related multiple and opposite meanings.
The whole street would be kept informed and noise be kept to a minimum. The husband had rigged up an old cast iron bath with an empty 40 gallon drum elevated on bricks with a wood fire underneath next to the bath, and our old above ground pool pump would be circulating warm water from drum to the bath. The time had arrived and being mid winter the fire under the drum was kept up with a never ending supply of old timber remnants from renovations that seemed to be going on all year around everywhere.
Majestically and totally very hirsute, the huge form of the wife appeared. We had front stall looks from the upper storey of our house direct into their garden across the road. She plunged into the bath, ready for the delivery of this sub-marine baby. The moaning started and the husband was flat out stoking the fire and holding the wife submerged. The pump was revving at fever pitch circulating the water that was getting so hot at one stage that the wife had to get out letting things cool down a bit. In the meantime, the husband in an act of supreme solidarity, (his astral travel the night before had taken him to powerful and hitherto unknown regions) stripped off and stepped in the bath behind his wife. Both squatted down and he held her from behind, shouting ‘push, push’, you bitch, push!
She now had much less space and was holding her legs up in the air above the bath but also sometimes against the rim to help the pushing and straining. The screaming increased in intensity and volume, the timbre of her voice not unlike a badly tuned hurdy gurdy being played in a tiled underground rail tunnel in Moscow. Our kids and their friends were hanging out of the windows and still no sign of the underwater miracle. The dogs were howling and barking in tune with the screaming wife. This went on for a few hours with both getting in and out of the bath, adjusting the temperature and fire. Some of the neighbours were shrugging their shoulders and others voicing disapproval. Not a baby in sight and the crowds started dissipating. Out of the blue, a siren was getting closer and closer. An ambulance appeared, a stretcher was produced and the poor woman dripping and with skin like a plucked chicken was without further ado strapped in and carried to the ambulance. The husband still starkers standing on the road near the ambulance, with hanging testicles like walnuts in a sock, was muttering incantations, but the baby was delivered at the hospital, a little girl.
Up until this day no one ever found out who called the ambulance. I am still wondering myself!
What a strange story Gerard, this couple must have chosen to “Freebirth”. This is not the type of birth experience that Australian Private Midwives who provide homebirth services would genuinely be involved in.
Sadly though it is this type of story that creates a graphical mental picture for the public, including the doctors, who imagine this is how birthing at home with a midwife is actually planned and carried out.
This is not the gentle, womanly work that midwives see and participate in at home. We certainly don’t have partners denegrating the woman in labour. We don’t have the amassed neighbourhood onlookers viewing from their balconies like you describe! We experienced (midwives) provide our services for and with women from early pregnancy, through labour and birth and for another 6 weeks afterwards.
How sad for this woman, what a terrible experience for her and you have just told her story to the world. My quesion to you is: did you seek consent from your neighbour to publish her story on Crikey and with access to millions on the internet?
I must agree with ‘midwife’.
We had private midwives at home, and we are ‘fairly conservative professionals’ as opposed to “ardent believers in the alternative world of Bach remedies and early morning Chakras aligning themselves to magic columns and circles.”
Our midwives were highly trained and well equip medical practitioners. The laws being pushed by the AMA would prevent professional medical staff from attending births outside the Medical environment (Hospitals and Birth centres). It is a commonly accepted belief that such laws would actually increase the numbers of people choosing to ‘freebirth’, and we would never choose that as an option.
On a personal note, my initial reaction to your comment was the shock that you were so totally condescending to these people who seem to have trusted you enough to have shared their views and ideas with you. Perhaps if they read your comment they would be less likely to be so open with their neighbors.
Let me ask you, would you be willing to share your comment with the people you are talking about? Or is this completely behind their backs.
I’ll quote Kaz Cooke…
“Keep yourself nice”
Jaq.
Sorry folks,
This true story is 30 years old when we were living in the Inner West. I come from The Netherlands were home birthing was the norm and for many still is. All my 4 brothers and sister were born at home and so was I.
The story of the couple with the bath was supposed to be humorous and for us it certainly was bizarre. Fancy having it all so public in the garden for all to experience.
They did not ask if the whole street would mind being part of the spectacle. They could not very well expect everyone to stand by and do nothing when things were getting badly out of hand.
By the way, even in Holland more and more people are giving births in Hospital. The stats tell us it is safer!
Gerard, you write well. You are able to tell a good yarn. The problem is that with your penchant for creative writing, you have lumped a variety of ideas together in a way that makes all of them appear ridiculous.
Your list includes: Sufism, mysticism, Bach flower remedies, neglectful fathers, artists, waterbirth, homebirth, multiple and opposite meanings, home renovations, big women, hairy women, labour, curious neighbours, barking dogs, communist states (Moscow), carnivals (the hurdy gurdy) - goodness me, you’ve wound everything in to this ‘humorous’ story.
And then. to top it all off, you end your response with ‘the stats tell us it (birth in hospital) is safer’. In fact, nothing is further from the truth.
I enjoy a good story - usually stories, the best stories, have some point or moral for the listener, some salient lesson that enables people to choose to live better lives. The underlying theme of your story is erroneous. Therefore the purpose is not to improve life, but to destroy people’s faith in the power of spirit and the human body’s natural intelligence.
Hi Carolyn,
The story of the home birth was to point out the ridiculous way that couple went about giving birth. It was without a mid wife or the basics of hygiene. It could easily have ended in disaster. As I tried to point out, previous children of that couple were ingnored and their esoteric beliefs were superficial and not at all genuine.
I tried also to highlight the rather comical side of that day with the whole neighbourhood watching on. How could they not, when it all happened in their front garden.
Anyway, that’s how it was then, a long time ago. I am sorry that you felt the story to be so somber and without merit. I’ll try harder next time.
As for home births having higher risks than in hospital, I would be surprised if you could back up the opposite with any solid evidence.
I was a firm defender of home births till even Holland changed its mind and now recommends mothers to give births in hospital as well. Of course, home births are in a much friendlier environment and mainly safe, but it is just not as risk free as being in a place were in an emergency more and better help is available immediately.
Oh Gerard, hospital emergency care immediately available! Please ever worked in one? Understand the many competing interests in our hospital system (even the rural ones where midwives also work as Nurses and could be in A&E while a woman labours). Complications are slower to be detected in hospital and a raft of staff need to be gathered to set up an operating theatre. Emergency management that can be immediate (limited) in hospital is similar in the home. Most others need specialised staff and equipment and are certainly not ‘immediate’.
Your assertions re homebirth safety in Holland were not found in a recent study of over 500,000 births (deJong et al).
The safety of 1-2-1 midwifery and the vast reduction of harm creating medical interventions cannot be overlooked. The need for ‘immediate emergency care’ is far more likely after an induced/augmented labours or after epidurals, none of which happen at home under the care of a homebirth midwife. Maintaining the health and well being of birthing women is very important and stuffing them full of synthetic hormones and narcotics does little to achieve this. Women who give birth at home are unmedicated and can use their body powerfully. This does not guarantee that nothing will ever go wrong, but this, coupled with 1-2-1 care and an established realtionship throughout pregnancy maximises clinical safety.
I’ve been thinking about this couple you spoke about Gerard. Many of us go about things we care deeply about in ways that we regret later with more insight or understanding. For a woman to birth well and feel good about herself, she requires kind, loving support, intelligent, compassionate guiding when (and if) she gets ‘lost’ in the experience, a sense of safety and for most women, a private secure place where she can be herself and focus on her ‘task’. This woman you spoke about had none of these things.
BBC news carries a story today of a programme of early labour support by midwives who listen to the mother’s concerns, offer information, care and support and help boost their confidence in their ability to give birth without intervention has halved the caesarean section rate.
http://news.bbc.co.uk/2/hi/uk_news/wales/8483149.stm
There are plenty of studies showing how birth is safe when women are lovingly supported in a safe, familiar place. The reality is that place for most women is their own home.
Hello Caroline,
The story of that couple and their attempt at a home birth was lifted from a book that I wrote some time ago.
This might be why it looked somewhat odd and out of place.
I am sorry about that.
The story is true but part of many experiences that all of us go through when travelling along life’s path. I am sure that for the most part, the home birth is the ideal way. My mother gave birth to all of us six kids but far from ideal in my own case, being four months after the beginning of WW2 and in bombed out Rotterdam.
Anyway, for what it is worth, here is the complete story and more in context.
Frank’s story at
http://oosterman.wordpress.com/