research into place of birth statistics

Although I am not pregnant, and not even trying to get pregnant, I have been looking in to where I want my next birth to occur. My first was born in a hospital with a certified nurse-midwife, and lately I've been really interested in having the next one at home.

Somehow, whilst browsing the internet for information, I keep ending up coming across the "Dr. Amy's Homebirth Debate" blog. I know from my research that statistics can be manipulated, and I think both sides of the natural vs. medical birth war may be guilty of doing it.

Dr. Amy claims that the Johnson and Daviss CPM 2000 study--the largest study on American Homebirth to date--used the wrong hospital comparison group, and that the correct comparison group shows a significantly higher death rate (2.7/1000 vs 0.9/1000...and if you control it for congenial anomalies, it becomes 0.9/1000 vs 0.34/1000) among the homebirth group compared to a hospital group of low risk women—the same group that the authors of the study used for their comparison of interventions, but not for the death rate. I think there may be a flaw in the use of this group because there are probably quite a few "high risk" women included in the homebirth group, and I think matching pairs would be a better comparison. There has been one matched pairs homebirth study that I know of, I read about it in the book The Five Standards For Safe Childbearing, and it showed no difference in death rate with much higher intervention rates for the OB-attended hospital group, but the sample size is was somewhat low, making it not "robust".

Let’s assume, for the sake of discussion, that Dr. Amy’s statistics are good. I’m only interested in statistics that are corrected for congenial anomalies, because those deaths are not preventable, so using 0.9/1000 for CPM births and 0.34/1000 for hospital births, we get a disparity factor of 2.6, so preventable deaths in homebirths would be 2.6 times more likely to occur. Twice as likely as a 0.00034 percent chance is still not very likely, but we can’t totally dismiss numbers based on smallness. Based on these numbers, it is likely that about 0.34/1000 or 0.00034 percent of babies will die, even if they are born in the hospital where all of the technology is immediately available. The homebirth number of 0.9/1000 is 0.56/1000 or 0.00056 percent higher than this number, meaning 0.00056 percent of deaths in homebirths potentially could have been saved in the hospital.

Dr. Amy claims that the licensing requirements for CNMs are not good enough and that better training in handling emergencies is necessary. She seems to believe that the best choice for someone hoping for a natural birth is a CNM attended hospital birth. I'd be inclined to see her point if I didn't believe that being in the hospital itself can lead to complications, including specifically stalled labor, because of the effects of the birthing environment on a woman's feelings, and hence, her hormones...I believe that women should choose to birth where they feel safe and comfortable...I'm just trying to figure out what that is for myself, who has a history of slow and stalling labor. I mean, what if there was a complication, and I was part of that 0.00056 percent that could have had my baby saved by being in the hospital, I could never forgive's a very small percent, but it exists. When a baby is lost in a homebirth, there’s no way of knowing, unless there is a congenial anomaly, if the baby would have survived if it were born closer to emergency care.

Then again, hospitals may be saving 0.56/1000 babies (lets put that in a real number…about 6 out of every 10,000), but at what cost? Subjecting many, many more women and babies to unnecessary procedures—overuse of pitocin, of which we don't know all of the long-term effects; unnecessary c-sections, which put a stamp on the rest of the woman's reproductive life and make all her future pregnancies and births more complicated; as well as hospital-borne morbidities—including infections, even if they are rare. Hospitals may be good at treating the damage they cause, but I really believe they still cause damage. After all, is “safety” just about morality, or is it about morbidity too? I know that if I had my baby in a hospital and the baby suffered a permanent ill effect of iatrogenic origin and either lived with it or died from it, I would never be able to forgive myself then, either.

IF I can find a CNM I feel comfortable with, who is willing to use expectant management of PROM—not inducing just for ruptured membranes (as that is what kept me from having a natural birth last time), and who attends births at a hospital that encourages self hydration during labor (eating would be good, too, but I won’t make that a pre-requisite) and does not require IVs, that uses intermittent fetal monitoring, and supports freedom of movement during labor and upright pushing positions, THEN I see no reason not to have a hospital birth as long as I can convince myself that I won’t feel uncomfortable going to the hospital during labor.