The Curious Silence about Babies Who Die at Homebirth

27 Jan

The CDC published an update on homebirth yesterday. Entitled Home Births in the United States, 1990–2009 and written by MacDorman, Mathews, M.S. Declercq, the data brief noted:

• After a decline from 1990 to 2004, the percentage of U.S. births that occurred at home increased by 29%, from 0.56% of births in 2004 to 0.72% in 2009.

• For non-Hispanic white women, home births increased by 36%, from 0.80% in 2004 to 1.09% in 2009. About 1 in every 90 births for non- Hispanic white women is now a home birth. Home births are less common among women of other racial or ethnic groups.

• Home births are more common among women aged 35 and over, and among women with several previous children.

• Home births have a lower risk profile than hospital births, with fewer births to teenagers or unmarried women, and with fewer preterm, low birthweight, and multiple births.

• The percentage of home births in 2009 varied from a low of 0.2% of births in Louisiana and the District of Columbia, to a high of 2.0% in Oregon and 2.6% in Montana.

But there’s one thing that the data brief didn’t mention at all: exactly how many of those babies died.

The authors managed to analyze homebirths by race. They managed to analyze homebirth in each and every state. They managed to analyzed the risk profile of homebirths. But somehow they couldn’t manage to check the neonatal death rate for homebirth located on one of the CDC’s own websites. They are curiously silent on the most important thing we need to know about homebirth: Is it safe?

Had MacDorman et al. bothered to look, they would have seen that the most recent CDC data shows that homebirth with a non-nurse midwife has a neonatal mortality rate 7.7 times higher than comparable risk hospital birth!

This extraordinarily high death rate is all the more remarkable because it actually under-counts the homebirth death rate. That’s because homebirth transfers ended up in the hospital MD group and were not counted in the homebirth group. The real number of homebirth deaths is almost certainly significantly higher.

While MacDorman et al. were busily analyzing the state level data, they could have learned that in the state of Colorado, which has licensed homebirth midwives since 2006, the homebirth death rate has exceeded the perinatal death rate for the state as a whole (including premature babies and pregnancy complications) in every single year since, and it has risen in every single year since 2006. The death rates are so appalling that the homebirth midwives of Colorado refused to release the death rates for 2010. Or MacDorman et al. could have learned that the state of Oregon has had at least 19 reported neonatal deaths in the past 10 years for a rate that is more than 4 times higher than the death rate for comparable risk hospital birth.

Every major news outlet has reported on this CDC data brief, and curiously, not one bothered to ask how many of the homebirth babies died. A few news outlets made vague pronouncements that homebirth might double or triple the neonatal death rate, but not a single one bothered to find out what actually happened in the group that MacDorman and colleagues studied.

I’ll admit that I’m pretty frustrated by the fact that MacDorman et al. never bothered to look at the neonatal death rate, or they looked at it and didn’t bother to report it. Who really cares that the homebirth rate rose an additional 9% since 2008? Yet somehow MacDorman et al. thought it was critical to report on that. Everyone needs to know how many of those babies died, yet MacDorman couldn’t be bothered to report on that.

And I’m also pretty frustrated by the mainstream media. There are no questions, no probing, and no investigation into the number of babies who died. It’s as if they don’t exist. Journalists just collected opposing viewpoints and wrote “balanced” articles that inexplicably left out the most important issue. And while journalists interviewed midwives and obstetricians, not a single one thought to interview a pediatrician or a neonatologist to determine whether the people who actually care for babies think about the dangers of homebirth to babies.

I’m afraid that the only thing that will shake journalists out of their complacency is the death of a celebrity’s baby at homebirth. Sooner or later that is going to happen, and journalists will “discover” that babies have been dying preventable deaths at homebirth all along. Until then, they won’t ask the difficult questions; they’ll simply accept what they read in press releases and reprint them wholesale.

Cross posted on The Skeptical OB.

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5 Responses to “The Curious Silence about Babies Who Die at Homebirth”

  1. Nick Lester Bell (@lebkin) January 27, 2012 at 4:40 pm #

    I have to, this looks to be a very anti-vax level tweaking the data with that chart. Rather than looking at the entire data set, you narrowed it down to a specific subset. If you look at the 2007 data (http://wonder.cdc.gov/lbd.html) as whole, it tells a far different story:

    Certified Nurse Midwife(CNM) 871/316,811=2.75
    Doctor of Medicine(MD) 26,372/3,729,199=7.07
    Doctor of Osteopathy(DO) 1,324/214,995=6.16
    Other 444/28,864=15.38
    Other Midwife 84/23,943=3.51
    Unknown or not stated 58/2,421=23.9
    Total 29,153/4,316,233=6.75

    Going with an MD gives you a your birth/death ratio is actually higher than average across the board births. And it’s double that of Non-CNM midwives. This gives the obvious impression that you selected a very narrow subset of the data to prove your point, rather than letting the facts tell the actual story.

    • Amy Tuteur, MD January 29, 2012 at 11:25 am #

      Nick,

      As I explained to you on my own blog, you are looking at infant mortality (a measure of pediatric care) among all mothers at all gestational ages with all pregnancy complications and pre-existing medical conditions included.

      My chart is restricted to perinatal mortality (death from birth to 27 days), white women (905 of homebirths are to white women), singelton, at term, and of normal weight.

    • Svante January 30, 2012 at 6:31 am #

      You can’t look at the total and draw any conclusions on mortality on statistics that look at all childbirths. A high-risk birth (too early or other complications) is far more likely to be done at a hospital with a MD or DO present. You have to filter the numbers to get the same risk cathegory with the different attendats to be able to make any conclusions regarding deathrates and the attending midwife.

  2. mamamara January 27, 2012 at 6:52 pm #

    Oy. Every time I see links to stories about how wonderful and natural homebirth is, I can’t help but think “arsenic is natural too, y’know.”

    I had two traumatic and horrible hospital births, so I’m not exactly a poster child for the wonders of hospital birth, but on the bright side…both my two children and I are alive and well. So on balance, I’d recommend the hospital!

  3. Simplexion February 3, 2012 at 10:45 pm #

    There can not be any certainties until a proper study is done. It is impossible to find any decent statistics on home birth. What is needed is a study that only looks at low-risk births. It needs to separate unassisted/untrained assisted home births, unplanned home births, midwife assisted home births and hospital births.
    I’d like to know what the rate of perinatal mortality is in all these circumstances. I would like to also see information included for when a home birth is transferred to a hospital birth and not have these included in the hospital birth mortality rate but included in the type of home birth they were transferred from.
    Is it difficult to get hold of this kind of information? I would really like to know whether you can have a home birth in a safe manner and what are the risks. The problem is there is so much bias either way.
    I am sceptical of home birth but I am neither for or against trained midwife assisted home birth as there is no good evidence. I am definitely against unassisted home birth and home birth assisted by a untrained person.

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