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May 24, 2006

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My reflections:

There are a host of factors that affect the outcome of child birth and we don't know what many, perhaps most, of them are. However, in our quest to improve outcomes we identify factors that seem to have a bearing and attempt to isolate them for study. In the case of birth outcomes, because our understanding of outcome determinants is so limited, we are forced to select variables that are really crude bundles of other, often unknown underlying factors.

Dr Tuteur is mistaken in her reading of the Farm paper- even after controlling for the differences in race between the Farm and comparison (National Natality Survey) populations, the infant mortality rate was actually less in the Farm group, though not significantly so by statistical testing (and since the statistical tests fail to show a significant difference we cannot say with confidence that either group had better results for this outcome measure). In fact, the Farm group was unlike the "average" American woman giving birth in many ways that are far more striking than for having a larger proportion of white women. Most of them were either residents or friends of a very tight knit commune or their friends, or Amish women from farms in the surrounding middle Tennessee area. Most of the households in the Farm group had incomes far below the federal poverty level. Most likely were much more physically active. Of those who lived in the commune, most consumed a vegan diet. To say that the Farm mothers should have much better outcomes than the average American mother just because more are "white" is to over-simplify.

The location of birth is an example of a very crude variable. Surely it is not the hospital or home building per se. that affects the outcome of birth. Bundled into location are factors such as the type and number of medical attendants, the presence effectiveness of non-medical ("doula") attendants, the availability of supplies and equipment, differences in protocols of care, the psychological state of the mother, and a host of other unknown factors. It is especially difficult to tease out the effects of these underlying factors because they may interact- i.e. a "package" of factors may produce an effect that is different from that of each factor in isolation. Creating a "birthing room" environment in the hospital may not have the same effect on the psychological state of the mother as being at home would (either for better or for worse!) and the psychological state of the mother may have an important bearing on outcome. To further complicate matters, this effect may differ according to the personality and cultural predispositions of the mother.

On the basis of the Farm study, it is reasonable to conclude only that the women and babies cared for by the midwives at the Farm fared as well as women who delivered in the hospital, all (measurable) things considered. Would they have fared even better had they all gone to hospital to deliver? We really cannot say on the basis of the available evidence. Would it be as safe for all "low risk" women who now deliver in hospitals to deliver at home? I certainly would not advocate that, either, on the basis of available evidence.

As a practicing doctor, I do believe in the power of modern medicine to save and protect lives. However, the ability at a moment's notice to invoke medical treatments (such as C-Sections) does not necessarily confer added protection when they are used widely (because of inability to target them exclusively to those who will be saved) when the treatments confer an element of risk to the large number of patients for whom they are used.

Anecdotal experience and "common sense" are notoriously bad ways to make health policy judgments. As health workers and researchers we should be humble enough to accept alternative approaches to handling transitions in life, including birth, until systematic study has yielded a convincing body of evidence to prove that it is really best for these transitions to occur on our turf.

Jamie, I hope this helps. You may use this as you see fit.

Best Regards,

Mark
Dr A Mark Durand
Dept. of Health Services & The Yap Area Health Education Center
Yap State
Federated States of Micronesia 96943

Jamie, thank you for taking the time to write all this stuff. I was never prejudiced against homebirth because my mother had four successful ones, but reading your posts has made me even more likely to consider it in the future. You've done a great service by introducing us to the research; I'm really thankful because if/when I do decide to pursue homebirth, having the evidence at hand will make it that much easier to defend my choice.

And by the way, I love your tone... I think it's the perfect blend of creative, hilarious, and charitable. Way to go.

Thank you for the thoughfulness and care in your homebirth posts. They have been interesting, informative and thought-provoking. I only wish I had resources like this before I had my first child and went the path of the OB-Gyn referred by a friend of a friend. And if my daughter hadn't been breech (and that led to a c-section because this was not discovered until I was in labor in the hospital), maybe it would be a future option for me. Keep up the good, fair fight.

Being a four c-section mommy, this topic doesn't interest me all that much. BUT - your writing makes me read anything

You rockin' FoilHead, you!

Brilliant! Which seems to be your usual mode.
I am a "moderate" risk for homebirth. I had a primary c/s for single footling breech. I never once had the eloquence in defending the homebirth choice when asked like you do. I just up and said.
"If I go back into a hospital, I'll get slashed open again for fun. I don't want major abdominal surgery because some doctor is scared of my scar."
It is true, ever time I relay my labours to a medical professional, they whole heartedly admit to wanting to section me hours before my children arrived.
I'm not the "low risk" mother, but I'm certainly glad I still had midwives who cared for me, much better than any doctor who would have "allowed a trial of labour".
My evidence, however warped was "If I don't go to the hospital in the first place, I won't get cut open for some silly reason". My mothers arrival was midwife assisted in rural Germany, my father was unassisted, as they could not afford to go to the hospital in Quebec. Midwifery and birth were something I grew up with. I tried to get a midwife for my first birth, but lived in the backwater Province and despite having the money in hand I was turned away in my first trimester.
Despite having my last child born "blue" with an apgar (yes singular, as in one), I do not regret her homebirth, and neither does the neonatal neurologist who saw her. People like Dr. Amy and her sheeple refuse to see the other side. It is so sad.
Must invest in tin foil this morning... I think a trip to the Costco is in order =)
k

Well written, Jamie.

I really can't figure out what inspired this crusade from Amy and as much as she protests that it isn't personal, even ACOG doesn't waste their time on this "issue" beyond writing policy statements. I also wonder where all of her respected colleagues are on the subject-- I suppose she is hoping they will join the party if she makes it to the next Grand Rounds.

Then again, I imagine if I asked her we'd hear another cricket join the chorus.

way to go

Jamie,

You are obviously not considering the crucial fact that tin and aluminum are different metals and cannot be considered equivalent for the purposes of protective headgear construction. Therefore all your conclusions must be flawed. Everyone knows that lumping tin and aluminum together in your research is just a ploy to cover up your VACUOUS agenda.

SD! Did you know that the movement from tin to aluminum by foil manufacturers is part of an Evil Plot to keep us all ignorant and pliant? Tin was much better at intercepting the orbital mind control lasers; that's why they took it off the market.

Yours conspiratorially,

Can I just say as a non-homebirther after reading some of Dr. Amy's opinions and post. . . you are the veritable well of charity and cool-headedness. The whole sex abuse and homebirthing assertion . . . well, it might just speak to the unfortunate fact the sex abuse in this day and age is common to many women.

Holy cow! Someone else who knows about the orbital mind control lasers! I love the orbital mind control lasers! :-)

We must get together to play Illuminati sometime...

Jamie Gladly-doo where are u
we've got some work to do now
Jamie Gladly-doo we need some help from u now . . .

More like ENERGIZER bunny, not BUGS Bunny contributions.

You are so darned smart.

Hh

Love this post! I'll try to find time to explore more.

Question: I've noticed those deletions on Dr. Amy's blog. Can you summarize contents of the ones that you've read and then later noticed were gone? You refer to the posts that were deleted as "innocent". I understand you might not have seen every single deletion, but there are too many for it to seem koser, if you know what I mean. Thanks in advance!

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