by Judy Cohain
(GreenMedInfo) With the Am Journal of ObGYN’s recent anti-homebirth campaign sacrificing the lives of an estimated 100 US women per year, Judy Cohain strikes to the heart of the mythology that hospital birth is safer, revealing quite the opposite to be true.
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Oft quoted research studies state 3X to 10X more babies die in the first week after low risk homebirth than hospital birth. In order for low risk homebirth to have higher perinatal mortality rates there would have to be a theory to explain this. There would have to be one or more complications of low risk homebirths that result in death in the first week that can be prevented by being in hospital, and death from these complications would have to occur more often than low risk deaths at planned hospital births.
The problem is… there is no explanation for why low risk newborns would have a higher rate of death in the first week after Planned Attended Homebirth than after Planned Hospital birth. All the studies that make this conclusion pretend to count low risk perinatal deaths but actually count other things. The rate of preventable perinatal deaths is no more than 1 per 10,000 low risk births for both home and hospital low risk births. Cord Prolapse and attendants not expert in resuscitation are the only complications that cause preventable low risk homebirth deaths in the first week. Some of these deaths might have been prevented by the woman planning a hospital birth or hiring a better trained midwife. These deaths are balanced by deaths in hospital, for examples: caused by the doctor not being present to do resuscitation, nurse busy doing paperwork and didn’t notice baby stopped breathing, and hospital-caused: infections, cord prolapses, placenta abruptions, uterine ruptures, and Amniotic Fluid Embolisms (AFE) at low risk births. These hospital-caused deaths of the newborn in the first week likely could have been prevented by the woman having a homebirth with a well-trained attendant. Although it appears that the preventable newborn deaths at home and hospital birth balance out, homebirth is clearly safer when you take into consideration the risk of maternal death that 20% of low risk U.S. women face as a result of avoidable cesareans which became necessary because they went to hospital. When this 20% risk of death is compared to the 0.02% rate of cord prolapse during labor at homebirth that might have a better outcome if it happened in hospital, this means that a low risk woman has a 1000 times higher chance of having a life threatening complication either to her life or her fetus/newborns life at planned hospital birth, than if she plans to have an attended homebirth with a well-trained practitioner. High risk births such as premature, breech and twins ARE at high risk of perinatal death and overall have superior outcomes when delivered in hospital. About 10% of breech delivered at homebirths suffer damage or death.
An In Depth Explanation
Most low risk babies that are stillborn or die at birth, die as a result of congenital defects incompatible with life or unexplained stillbirths and would die no matter where the birth takes place. The rate of unexplained stillbirth at term for low risk pregnancy is 1/1000 (Smith Lancet 2003). No more than 1 in 10,000 low risk babies, whose mothers are healthy, non-smokers, normal blood pressure, with adequate protein and micronutrients in their diet, die in the first week from plausibly preventable causes at home or hospital. While this has never been directly published, it can be extrapolated from Pasupathy JAMA 2009, which reported 432 deaths due to intrapartum anoxia in the first FOUR weeks among 1,012,266 (or 4 deaths/9372 births ) term, singleton, head down births including all types of high risk pregnancy known to have high perinatal mortality rates such as Type 1&2 diabetics, gestational diabetics, cholestasis, toxemia, preeclampsia, IUGR, drug addicts, alcoholics, heavy smokers, etc. Logically at least 3 out of 4 of those deaths occurred in women who were unsuitable for homebirth or occurred after the first week, which would amount to a maximum of 1 in 10,000 preventable low risk deaths in the first week after birth. A 3/10,000 intrapartum death rate for same criteria- head down, term, singleton including all high risk was found in Ireland. (Walsh. 2008. AJOG)
The three recent papers published in American Journal of ObGyn: Wax metaanalysis (2010), Chervenak (2013), Grunebaum****(see note at bottom) (Apgar 0, 2013) and the U.K. Birth Place study (2013) report perinatal death rates from homebirth as 3 times or 10 times higher than perinatal death rates in the first week than hospital birth. All of these studies profess to count how many babies supposedly die at planned attended low risk homebirth, but none of them do. Wax et al includes unattended, unplanned, preterm, breech, hypertensive, gestational diabetics and other high risk homebirths. Chervenak quotes the UK Daily Mail newspaper as his source of data. Grunebaum et al count the fetuses who died before labor started (antepartum stillbirths). The U.K. BirthPlace study admits that perinatal death is too rare to count so counts transient events of no relevance to long term outcomes. None of these studies suggest a theory to explain their findings. It is possible the bias of these authors originate from never having attended a homebirth and extrapolating from the horrendous emergencies that happen at hospital births, thinking that they also happen at homebirths, when they don’t.
Preventable causes of death at low risk birth attended by a trained practitioner:
Shoulder Dystocia : Big shoulders getting stuck after the head is out occurs in 1/200 births and is the most life threatening event of low risk birth. In the event of asphyxia, the newborn almost never dies in the first week of life so does not contribute to death rates in the first week. No death rate from shoulder dystocia has ever been published, possibly partly because it is often months after the birth.
Cord prolapse occurs at about 1/400 low risk hospital births and about 1/5,000 (0.02%) homebirths and only where rupturing membranes is not restricted. Cord prolapse definitely has better outcomes when it happens in hospital but when it occurs during labor it is usually caused by the routine of breaking the water. Artificially rupturing membranes is routine at hospital birth. Hospital caused cord prolapse has nephariously rarely been documented in the literature, but a recent paper documents 23 hospital-caused cord prolapses among 33,000 intended vaginal deliveries (Gabbay-Benziv et al J Matern Fetal Neonatal Med. 2013). About 1 life threatening cord prolapse occurs as a result of every 300 artificial rupture of membranes in low risk women. (Cohain J Matern Fetal Neonatal Med.2013) This can be eliminated wherever birth takes place by severely restricting breaking the sac as well as vaginal exams.
Amniotic fluid embolism (AFE) appears in 70% of cases to be caused by/associated with a combination of artificial rupture of membranes and zealous induction. The increasing rate of inductions and cesareans may account for all or most AFE in the USA. What else would explain the increase in AFE from 1/120,000 during the years 1950 to 1990 (Clark SL Am J Obstet Gynecol 1995) to 1/13,000 for the years 2000-2008 (Abenhaim HA. Am J Obstet Gynecol 2008)? It is unknown whether it has ever happened at low risk homebirth with a well-trained attendant present.