Eliminate Aluminum Millinery

Betcha can't say that five times fast.  This is a post about faith and facts and tinfoil hats, sparked by the assertion that homebirth advocates are driven by the first and disregard the second.  Amy Tuteur, in particular, thinks that we are determined to ignore the evidence in favor of hospital birth.

I disagree.

The first time I heard about a friend who had a homebirth I was appalled.  She did what? I exclaimed.  What?  It was the evidence that changed my mind.  Friends' homebirth stories were intriguing -- they're the reason I looked at the evidence -- but the stories alone wouldn't have persuaded me that homebirth was a good idea.  I didn't read the full texts of the research at that point, but I read lots of abstracts and editorials -- all I could find, pro and con.

There's not much con out there.  I've been looking -- is homebirth controversial among epidemiologists?  Is the public health community arguing about its position on homebirth?  In developed countries where homebirth is a larger part of the landscape, are women being encouraged to move to hospitals because too many babies have died at home?

Best I can tell, the answers are no, no, and no.

During the Neonatal Doc discussion I emailed Mark Durand, author of the 1992 study comparing birth outcomes at The Farm with birth outcomes for a control group.  When he wrote me back two weeks later the thing that most stood out to me about his reply was its subtlety.  It made the whole conversation at Neonatal Doc look like something out of a Warner Bros. cartoon, with Elmer Fudd yelling, "Incweased pewinatal death wates!" and Bugs Bunny replying, "Naaaaah -- homeboith, Doc!"  [insert several minutes spent wondering if it is rude to make the other side be Elmer Fudd since he always comes off worst -- I can be Elmer Fudd if anyone prefers, talking about the muthah's bawth expewience.]  With Dr. Durand's permission, I am pasting the text of his email down below in the comments.

I have never claimed to be a statistical sophisticate.  (Another tongue-twister!  I'm on a roll.)  But neither, as far as I can tell, is Dr. Amy.  Now the point of this post is not to trash Amy Tuteur, a smart woman with whom I agree about some important issues, but I have to say that there have been some statistical clunkers in her assertions about homebirth safety.  And as I consider her re-analysis of studies that found homebirth safe for low-risk women, I have many unanswered questions.

For instance:  could you cite a definition that distinguishes intrapartum death and intrauterine fetal demise, since the distinction is central to your revision of the Murphy-Fullerton study?

[crickets chirp]

What does the epidemiological literature say about including or excluding deaths from congenital anomalies?  Can you show some support for your contention that excluding congenital anomalies is a "hide the bodies" strategy?

[crickets continue chirping]

Where are the data to support your assertion that the intrapartum death rate in hospitals is "vanishingly small"?

[I wonder idly if the monkeys/typewriters/Hamlet idea has a crickets/stridulation/Paganini analog]

Homebirth spawned a 250+-comment thread at the NHSblogdoc.  An obstetrician calling himself M said, "Look, the Cochrane reviewers say homebirth is dangerous and that BMJ study is worthless anyway since it's retrospective."  I have not been participating in that discussion, but I had to post a response to M.  I said, "In the report you cite the Cochrane reviewers were talking about 'home-like birth centers...in or near conventional labour wards'; they reached different conclusions about homebirth.  Furthermore, the Johnson & Daviss study, whatever its weaknesses may be, was prospective." He said, Yeah, well, we can't call homebirth safe without RCTs.

The problem is, we can't do randomized controlled trials for birth site.  It's not ethical to assign women randomly to deliver at home or in the hospital.  If you say the only thing that would change your mind is research that's never going to happen, to my ear it sounds a lot like, "Don't confuse me with the facts."  It makes me wish briefly for a tinfoil hat, the better to contain the fragments of my exploded head. 

Make no mistake, there are crazy homebirthers out there.  Like the Zion Birth people, who say the only acceptable response to a postpartum hemorrhage is calling on the name of Jesus.  (I hope you don't have to read much of this blog to see reverence for the name of Jesus; if I hemorrhage, I'll also be calling on the midwife to administer oxytocics pronto.)  Or the unassisted childbirth folks who say that if a baby's cord prolapsed they might just try to birth through it.  (Shudder.  I read that on one of the UC boards a few weeks ago and it haunts me.) 

So yeah, there are some tinfoil-hat people on my side of the conversation.  I am troubled, though, by resolute and irrational opposition to homebirth despite good science in support of the choice.  In her comment on my last birth post, Amy said, "I understand the attractiveness of making the homebirth debate about your opinion vs. my opinion."  This is not about my opinion.  Please, whoever you are out there, do not plan a homebirth because Jamie Gladly said it was a nice idea.  I urge you, if you are interested in homebirth, to do your own homework.

I think it is a mistake for anybody, on any health-related issue, to presume that he (or she) knows the truth forever and ever amen.  I think it's critically important to look at new evidence with an open mind -- not to assume results that challenge our assumptions must be flawed somehow.  I have written thousands of words about breastfeeding in this space, but one word never appears:  asthma.  Right now there's some ambiguity about the effects of breastfeeding on the subsequent development of asthma.  I could complain about the studies that don't confirm my point of view; I could mutter darkly about formula company funding.  But I think the wiser choice is to wait and see what happens with future research.  I will never tell you that the verdict is in when the jury is still out. 

But the jury isn't out on planned attended homebirth.  With one exception (the badly done 2002 study by Jenny Pang), every recent paper on the topic concludes that it's a safe option for low-risk women and their full-term vertex babies.  If you redefine terms, recalculate results, and rewrite conclusions, you can try to make the papers say something other than they actually say.  On which tactic, I must refer you to Benjamin Disraeli.

Amy objects to conspiracy-theorizing among homebirth advocates, and I have tried to avoid it in our conversations.  It's true that making midwifery care the norm for low-risk pregnancies would displace a lot of obstetricians, but I'm happy to talk about the data and not possible financial motivators.  In talking about the data, though, Amy seems to be driven by a conspiracy theory of her own, in which a lone non-practicing obstetrician with one semester's coursework in statistics and epidemiology can see The Truth that has eluded the authors, peer reviewers, and editors of every paper on the topic (save the magical mind-reading Jenny Pang) and the public health researchers who have published statements supporting homebirth.  Somehow they've all been duped by the Vast and Alarming Cabal Understating Out-of-hospital partUrition's Scariness.

Marsden Wagner, who spent 15 years as director of Women's and Children's Health for the WHO?  VACUOUS pawn.

Peter Schlenzka, whose Stanford sociology dissertation concluded that "...apparent disadvantages of the obstetric approach have such large order of magnitude, that in any clinical trial it would be considered unethical to continue with the obstetric treatment"?  VACUOUS tool.

Faith Gibson? Sheila Kitzinger? CIMS (perhaps they're secretly the Coalition to Increase Mortality Statistics)?  VACUOUS, baby.

Or maybe not.

I am going to stay in the conversation at Homebirth Debate for a while, making my Bugs Bunny-level contributions, even though sometimes I'm pretty sure I took a wrong toin at Albuquoique.  And if in the future there's solid new research showing a statistically significant difference in mortality for home-born babies, you can bet I'll re-examine my position.  I would be disappointed if homebirth were shown to be less safe than hospital birth, but I recognize that something might change to make it so.  I don't think it's likely, but it's possible.

One other important question remains unanswered at Homebirth Debate:  I asked Amy what evidence it would take for her to think homebirth was as safe as hospital birth.  ...And the crickets play a steady ostinato, but no answer is forthcoming.  Somewhere in that silence I start to suspect I'm sensing the singular susurration of a sizable silvery sombrero.  And I could be mistaken -- please tell me if you think I'm mistaken -- but I'm pretty sure it's not on my head.

Comments

[A. Mark Durand, MD, MPH (posted by Jamie)]

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

[Arwen]

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.

[Sarah]

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.

[blestwithsons]

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!

[k]

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

[frectis]

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.

[alicia]

way to go

[SD]

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.

[Jamie]

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,

[Lauren]

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.

[Jane Lebak]

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...

[Lauren]

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

[Hannah]

More like ENERGIZER bunny, not BUGS Bunny contributions.

You are so darned smart.

Hh

[HomebirthMama]

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!