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.
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