APPLES TO APPLES

I know…there are “lies, damned lies, and statistics” (according to Mark Twain) and I have previously written a blog post about what is considered “low risk” vs “high risk” and statistics related to that..
But this blog post I want to get people thinking about what they read in a different and more critical way.

“Compare apples to apples…not apples to oranges.”

Sometimes I think people THINK they are looking at apples, when they aren’t.  We need a critical eye (and mind) whenever someone starts talking statistics.

Recently I have seen touted in headlines over and over again: Homebirth rates have increased 20% in the last 4 years! WOW! That’s amazing! Until you look closer at the numbers and while 20% sounds like a lot, and some headlines even read “Dramatic 20% increase”…

0.67%

That’s what the most current homebirth rate is. 0.67%. Nationally, the homebirth rate rose from 1 in 179 in 2004 to 1 in 143 in 2008. That is 0.56% – 0.67%. Not quite as “dramatic” when you look at it that way.

But that’s what people do – they look at things and think, “how can I make this sound the way I want it to without being dishonest”.

I want to know the truth, not your version of it, not your interpretation of it, not your swing on it.

We run into the same problem when trying to compare hospital births to homebirth. Hospital supporters cry out, “It’s not a fair comparison! We are dealing with pre-existing high risk pregnancies and births! You can’t weed out the high risk mothers, send them to us, and include them to prove homebirth is safer!” They are absolutely right, that doesn’t tell you anything! Are you trying to prove that homebirth is safe? Or are you actually interested in the TRUTH – looking at our outcomes, seeing what they are, how they compare, and how we can improve…?

Homebirth supporters are equally indignant and exclaim, “You are including unattended accidental homebirths and known demises and that’s not a fair comparison!” They, too, are absolutely right. Those aren’t homebirths – they are hospital births that didn’t make it. Or someone without any prenatal care.

There are times when I wish I had the education, money, and ability to run a study, crunch numbers, and come up with an unbiased true valid comparison. Here is what I want to do…
* Hospital births attended by either CNM or OB that were low-risk at the onset of labor.

~ COMPARED TO ~

* Homebirths attended by a CPM, CNM, or LM (or equivalent) who were low-risk at the onset of labor and are in a state in which the midwife is well integrated into the medical system. She is practicing legally and able to provide full prenatal care (including screening tests, labs, ultrasound, etc) as well as transfer freely to the hospital without fear of retribution.

I think that is what is needed in order to see how the LOCATION (and care provider) affects the outcome. It’s unfair to include high risk mothers in the hospital statistics, and it’s also unfair to tie a homebirth midwife’s hands so that she can’t make it as safe as possible and claim that she is making it unsafe.

How can you look at homebirths without full prenatal care and think that’s a fair comparison? How can you include someone who calls themselves a “midwife” without knowing what she MEANS by calling herself that? I knew a mother once who chose an unassisted homebirth – she had no professional prenatal care and no professional present at her birth.  She told me, “My husband was my midwife.” I have to disagree – your husband was your husband, he just took care of you the best he could with his limited knowledge and experience.  He was not a midwife.  Being the most knowledgeable person in the room doesn’t make you a midwife anymore than it makes you an OB.

A midwife should have training and experience.  She should also be able to carry the tools that she knows how to use and that allows her to actually do her job effectively! How can you tell a midwife that she can’t carry oxygen, can’t carry a Doppler, can’t carry emergency equipment, can’t order labs, can’t order an ultrasound…and then compare her outcomes she is able to achieve with her hands tied that much to hospital births?  That’s like me telling a man he must build me a home but he can’t use blueprints or a hammer or screwdriver.  Am I trying to see his skills as a builder or am I trying to prove that he’s incompetent?

I just had to transfer a client 4 days ago to the hospital – and as I called my CNM friends on their cell phones and gave report and arranged for medical care to be waiting for them at the hospital and sent them off to the hospital knowing they would be well taken care of, being told by my CNM friends, “Good job!” – never having to think for one minute whether there would be legal retribution for me having done my job…I realized how lucky MY CLIENTS are that we live in the state that we do. That I am ALLOWED (by virtue of being a licensed midwife) to be the best midwife I can be, as non-interventive and as supportive as possible but also to be able to provide medical responses if they need them, to have tools to be able to identify problems earlier (labs) and treat them sooner (O2, Pitocin, etc) – that is not for me, that is for the client. That makes things safer for the client.

So why can we not compare THOSE numbers? Look at what homebirths CAN be compared to what hospital births CAN be! (and I would include those who transfer to the hospital in labor or postpartum into the HOMEBIRTH stats! After all, that is MY client and the fact that she turned high risk is still on me…and my responses are on me…)

All the numbers tossed from person to person, juggled then handed off like a hot potato – do you want to prove a point or do you want to learn? I want to learn, and I am not so proud and arrogant as to think that don’t have room for improvement! I do keep track of my statistics, the raw statistics, and think we need to get away from “us vs. them” and get into “birthing families” and so they can make informed decisions with real information.

What do you think?

24 Comments

  1. Erika wrote:

    I have to agree with your point about my hands being tied. Living in an alegal state, there are a lot of restrictions. Sometimes a transfer happens because we don’t have the tools to deal with what ‘might’ happen. Sometimes a transfer happens because even though I know what needs to be done, I’m worried about what will be thought of me for having done it. I transfer when appropriate because it’s best for mom and baby, but I am always a little scared at the reception we will receive.
    It makes me nervous that I will be judged as having practiced medicine without a license simply for the lack of a clear definition of what practicing midwifery means. And yet, my transfer rate is still only 6%.

    In order to reduce fear – and therefore increase safety – the first step is to recognize that there’s a problem. Lack of continuity among providers threatens the well being of mom and baby. THEN argue over what non-nurse midwives can/cannot should/should not do. Lastly, to remember that a woman must always retain the right to birth where and with whom she chooses. If those three things can be addressed, significant headway will have been made.

    Like you, I also bristle at the fact that intentional unassisted births AND accidental homebirths are usually included in any homebirth study. How in the heck can that be relevant to the safety of midwifery? Clearly, if you had a precipitous birth with no intention of delivering at home, you had very limited(if any) interaction with a midwife. As for unassisted births, even if the woman’s best friend/husband/mother/sister functioned as her caregiver, that does not make them a midwife. And doesn’t saying they were her midwife kinda discredit the fact that the woman wanted to birth unassisted (as in NOT assisted)??
    Why would the subset of unassisted women even figure into homebirth midwifery research?

    As usual, a stimulating and well written post 🙂

    Sunday, September 11, 2011 at 11:26 am | Permalink
  2. Naomi Thomas wrote:

    I nearly wanted to stand up and CHEER when I read this post! I always love what you write, Stephanie, but this one really hit home. And I have a story to go with it: (its a good one I promise 😉

    Last year when the Wax “study” was released we were expecting our 2nd, and our first home birth. Granted, I was a birth professional and had been for years by that point, and felt very secure with our decision to have our son at home. So when I first saw this study, I admit my thought was “What a load of CRAP! Of COURSE home birth is safe!” To which my dear, amazing husband replied “well now wait a minute – if there is something to this I want to know about it. We should understand the background about this before just assuming.”

    I’m not going to lie, my pregnancy hormones made it so much easier for me to be irked by his insistence on giving this another thought, but true to his nature, he hunted down the study, which he quickly found was simply a meta-analysis and then went on the hunt for each of the individual studies that compiled it. He refused to form an opinion before having all the information.

    *Side note on this – when my husband was 23 he owned a business and had a few employees who had wanted to have out of hospital births and approached him about having the company pay for the births since it wasn’t covered. This was in the Philippines and would have cost him about $80 of US money, but before approving it he wanted to check out the facilities of the birth center. So here he is, a single 23 year old man, touring a midwifery center and was struck at how pure and safe birth really was. He had figured from that point on that he would have his children outside of a hospital because to him it just made sense.

    So back to the research of the Wax “Study” (sorry I can’t help myself from putting it in quotes…) The more he read the more frustrated and irritated he became at the lies and dishonesty of how everything was compiled. Even though he came to the same conclusion that I jumped to, that who experience really touched me on how much he values real, true information – even if it proves you were WRONG. In this case it didn’t but I could see he was truly be unbiased about his approach.

    As he always says “I’m not married to anything except my wife” and he means it when he says he’s always open to new ideas and ways of thinking.

    Just had to share, in detail, why I loved this post so much and a little bit from my world 😉

    Sunday, September 11, 2011 at 11:34 am | Permalink
  3. Such a study has already been done in Canada:
    http://www.cmaj.ca/content/181/6-7/377.full.pdf
    This study had the SAME midwives providing care in both the home birth and hospital midwifery births, and the physician births are in the same hospital as the midwifery. It’s a large study, too.
    But of course there will be those who dismiss it because it isn’t in the US….and of course, US women are vastly different biologically than our neighbors to the north. (rolls my eyes…)

    Sunday, September 11, 2011 at 11:45 am | Permalink
  4. elfanie wrote:

    Andrea:
    That is awesome…..standing ovation…..good call! I didn’t know about this study and it’s EXACTLY the type of thing I wanted to know….well done!

    Sunday, September 11, 2011 at 12:25 pm | Permalink
  5. That data has been collected by MANA, the Midwives Alliance of North America. They have death rates for 23,000 planned homebirths. They collected it for the publicly stated purpose of showing that homebirth is as safe as hospital birth.

    Now that it has been collected and analyzed, though, they refuse to release the death rates. If the data showed that homebirth is safe, MANA would be shouting it from the rooftops. The fact that they are hiding it means their OWN data shows that American homebirth has an unacceptably high neonatal death rate.

    Sunday, September 11, 2011 at 8:31 pm | Permalink
  6. elfanie wrote:

    And the statistics that MANA collects, IMO, would be irrelevant since they collect data from every state in the country….legal status or not, integrated into the medical system or ostracized…
    I thought I was clear in my blog post that I didn’t think that is a relevant figure. Having the outcomes of women practicing illegally with their hands tied with regards to their tools and responses does NOT indicate the safety of HOMEBIRTH…it indicates the safety of operating under that obstetrical model.

    Andrea’s study is much more accurate and relevent.

    Sunday, September 11, 2011 at 9:12 pm | Permalink
  7. Andrea’s study is, as she almost certainly knows, completely irrelevant because American homebirth midwives don’t meet the standards of Canadian midwives.

    The Netherlands is often touted as a place where homebirth is safe and a 2009 study showed that homebirth with a midwife had the same death rate as hospital birth with a midwife. However, a 2010 study showed that low risks birth (at home or in the hospital) with Dutch midwives have a HIGHER mortality rate than high risk birth with Dutch obstetricians.

    It only stands to reason that hospital birth is safer. When there is a life threatening emergency at home where the baby requires immediate C-section or is born needing an expert resuscitation with intubation, the baby simply dies at home.

    MANA knows homebirth has an appalling neonatal death rate. They just don’t want American women to find out.

    Sunday, September 11, 2011 at 9:24 pm | Permalink
  8. elfanie wrote:

    What MANA stats do or do not show, I will not comment on as I’m not privy to that information. (seems rather tacky to quote myself, but…”I want to know the truth, not your version of it, not your interpretation of it, not your swing on it.”) Guessing at something based on the LACK of access to the information is WORSE than spinning it to suit your needs – as there isn’t even information to spin, just wild baseless guesses.
    I didn’t mention the Netherlands because it’s not relevant to how obstetrics is practiced in this country. In what way are canadian midwives standards different than those of US midwives?

    I would be intensely interested in learning the difference in outcomes in my state where midwives are a welcome addition to the obstetrical field as opposed to someplace that they are illegal and their care restricted….so if anyone has THAT information (the real information, not guesses or anecdotes), I’d love to see it!

    also…why would Andrea’s study be irrelevant if what we are trying to find out is the safety of HOMEBIRTHS? If that’s the case then having the same care provider is absolutely PERFECT, even if it is an OB or perinatologist. If you are saying it’s irrelevant because of the midwifery standards of Canada…then you’re not talking about the safety of HOMEBIRTHS, you are talking about the safety of the midwives of this country – which is an entirely different question to research and answer.

    Sunday, September 11, 2011 at 9:34 pm | Permalink
  9. Julie Westover wrote:

    I’m so grateful I’ve experienced a hospital birth, a homebirth with a lay midwife, and a homebirth with a CPM. I loved my homebirth experience with a trained professional (CPM) because my prenatal care was the most thorough and my birthing experience was supported and was absolutely my choice.

    As a newborn infant, I contracted a staph infection in the hospital nursery. It was nearly fatal and I’m so grateful that my mom took me HOME and found a wonderful nurse in her neighborhood to administer the shots of antibiotics. My mom was not going to leave me in the hospital. I guess, if I had died, I’d get to be a statistic.

    People are more important than statistics.

    Monday, September 12, 2011 at 12:07 am | Permalink
  10. Jessica wrote:

    “Applause!”

    Monday, September 12, 2011 at 6:24 am | Permalink
  11. My impression after reading this post is that you believe that there is no definitive data on homebirth safety. If so, why do you assume that it is safe?

    Doesn’t it make sense to prove that something is safe before telling women that it is safe?

    Monday, September 12, 2011 at 7:42 am | Permalink
  12. elfanie wrote:

    Amy:
    That would be an ideal world, wouldn’t it? to be able to “prove something is safe”. Unfortunately the way that the worlds works is that it’s impossible to prove something safe….that isn’t possible. We can only say that no risk has thus far been found.
    Especially in obstetrics. Have hospital births been proven safe? anesthesia? medications? Of course not.

    in life there isn’t ‘safe’…..there are only judgment calls. Driving a car safe? It may be worth the risk to you in order to gain the benefits of transportation. Hospital births safe? it may be worth the risk to you in order to gain the benefit of surgery.

    I have never asked for proof….of anything. I’m asking for information – unbiased information. If you go into this with a predetermined idea of the outcome (such as to prove one thing to be “safe” and one thing to be “dangerous”), then that is a recipe for skewing the data and providing LESS SAFE care because you aren’t looking at the actual outcomes. If I were out to PROVE HOMEBIRTHS SAFE, then I wouldn’t really be interested in helping mothers…only in furthering my own agenda. I’m not interested in proving homebirths safe, I’m interested in learning how safe they are (and how safe hospitals are!) and what we can do in both environments to improve outcomes for mothers and babies.

    Monday, September 12, 2011 at 8:56 am | Permalink
  13. “Have hospital births been proven safe?”

    Of course they have. We know the neonatal and maternal mortality rates in nature and we know, because we have extensive records, that as birth shifted from the hospital to home in the past 100 years, neonatal mortality dropped 90% and maternal mortality dropped 99%.

    Now you’re asking people to believe that giving birth at home, in the absence of the lifesaving technology of the hospital, is as safe as the hospital. That’s an extraordinary claim, so you need to provide evidence for it.

    There is no evidence that homebirth is safe, but that doesn’t stop homebirth advocates. They simply insist that it is safe, and worse yet, tell other women that there is data that shows that homebirth is safe. That’s untrue and therefore unethical.

    Monday, September 12, 2011 at 9:10 am | Permalink
  14. elfanie wrote:

    “that as birth shifted from the hospital to home in the past 100 years, neonatal mortality dropped 90% and maternal mortality dropped 99%.”
    Homebirth neonatal mortality dropped from then to now, too. How much? If you don’t know the answer to that then you can’t claim that hospitals are the reasons they dropped. See what happens when you have a foregone conclusion you are trying to prove and how dangerous that can become for families?

    You are stating a conclusion without good data. “as birth shifted from the hospital to home in the past 100 years, neonatal mortality dropped 90% and maternal mortality dropped 99%.” This is misleading. I danced in my front yard naked and it began to rain….therefore your conclusion apparently would be that you must dance in your front yard naked in order for it to rain. (rather than investigating the cause/effect)

    I am not asking people to believe that giving birth at home, in the absence of the lifesaving technology of the hospital, is as safe as the hospital. I am not asking people to believe anything…..I am calling for research, adequate research without motive. asking people to believe that giving birth at home, in the absence of the lifesaving technology of the hospital, is as safe as the hospital. ….is just as wrong as asking people to believe that giving birth in a hospital, with all of the added variables of interference, is as safe as homebirth.

    The conclusion of what is “safe” vs “unsafe” along with the conclusion of what level of risk a person is willing to take….I’ll leave that up to families to decide. I would simply love more ACCURATE information to give them more basis by which to come to their own conclusions.

    On a personal level…I’m not out to convert anyone, prove anything…my only goal is to be the best care provider I can be for my clients, in every sense of the word (medically, emotionally, etc). It’s not up to me what other people do or believe, nor my job (or desire) to ‘convert’ them to my way of thinking.

    Monday, September 12, 2011 at 9:31 am | Permalink
  15. Rean wrote:

    Andrea beat me to it. The exact study you’re looking for. The comments on the study over the last year or so are instructive as well. And it’s still homebirth FTW. I do think that fully integrated midwifery makes a difference. Canadian midwives have hospital admitting privileges and they are NOT nurses. They are midwives as primary care providers with four years of training before going into practice.

    Monday, September 12, 2011 at 11:03 am | Permalink
  16. “How much?”

    Don’t make the mistake of thinking that because you don’t know something, no one knows it.

    Over the past 100 years homebirth mortality has dropped substantially primarily because anyone who has any chance of complications is trasnferred to the hospital., not because of improvements in technology or treatment. Even so, according to CDC statistics, state statistics and the Johnson and Davis study, homebirth has approximately TRIPLE the neonatal mortality of comparable risk hospital birth.

    Monday, September 12, 2011 at 11:06 am | Permalink
  17. elfanie wrote:

    I really and sincerely hope you’re not referring to the “Wax report”…..
    If not, rather than reporting conclusions and interpretations, linking to the study would be more helpful because then others can see the methodology and interpret for themselves the relevance of the conclusion. (just like pretty much everyone did with the Wax report and how ridiculous that was)

    I’d love to see statistics of how homebirths within legal states with midwifery care well integrated compares to hospital births in that same area…so if you have those studies, please share them! (it would be even more poignant of a study if it comapared hospital births with homebirths with the same care provider – like Andrea’s study….but in the US that’s not possible so I think that would be the next best thing.)

    By the way Amy…I’m not making the mistake of thinking that because I don’t know something nobody knows it. I am stating that I get tired of people putting their own interpretations and spins on things and I would like a relevant unbiased study that isn’t out to prove one side or the other. If one is out there, then great – never said it wasn’t. If you beleive you are privy to such a study then please share!

    Monday, September 12, 2011 at 11:17 am | Permalink
  18. “I really and sincerely hope you’re not referring to the “Wax report”…..”

    Right, because that’s one of the very few you know about and you have heard it is not a good study. If I were referring to it, I would have mentioned it and I did not.

    “I’d love to see statistics of how homebirths within legal states with midwifery care well integrated compares to hospital births in that same area…so if you have those studies, please share them!”

    The state of Colorado mandates that licensed midwives report their statistics. Their death rates are appalling AND rising. They are well aware of this and mention it in their own communications with each other and yet have done nothing to investigate it.

    The the 2009 statistics, the most recent available, are the worst yet. In 2009 Colorado licensed midwives provided care for 799 women. Nine (9) babies died for a homebirth death rate of 11.3/1000! That is nearly DOUBLE the perinatal death rate of 6.3/1000 for the entire state (including all pregnancy complications and premature births).

    The data is conveniently broken down by type of death and place of death. For example, there were three intrapartum deaths for an intrapartum death rate of 3.8/1000, more than TEN TIMES HIGHER than the intrapartum death rate commonly experienced in hospitals. There were 4 neonatal deaths for a neonatal death rate of 5/1000. That’s TEN TIMES HIGHER than the national neonatal mortality rate for low risk hospital birth with a CNM. One hundred women were transferred in labor or after delivery for a transfer rate of 12.5%. The neonatal death rate in the transfer group was 50/1000, an appalling neonatal death rate ONE HUNDRED TIMES HIGHER than that expected in a group of low risk women.

    “comapared hospital births with homebirths with the same care provider”

    That information is also available. A 2010 paper in the Journal of Perinatology, Infant outcomes of certified nurse midwife attended home births: United States 2000 to 2004, by Michael Malloy shows that homebirth with a CNM has DOUBLE the mortality rate of comparable risk hospital birth with a CNM.

    There is really no doubt about it. Homebirth increases the risk of neonatal death. You may feel that the increased risk is worth it, but in order to make an informed decision, you must understand that there is an increased risk.

    Monday, September 12, 2011 at 2:46 pm | Permalink
  19. elfanie wrote:

    Can you post links to the information you just referred to as I’d love to read the studies rather than your interpretation of the studies..?

    Thank you!

    Monday, September 12, 2011 at 4:20 pm | Permalink
  20. The Malloy study is here:

    http://www.nature.com/jp/journal/v30/n9/abs/jp201012a.html

    You can read all the details on the Colorado statistics here:

    http://skepticalob.blogspot.com/2010/10/inexcusable-homebirth-death-toll-in.html

    Monday, September 12, 2011 at 7:28 pm | Permalink
  21. elfanie wrote:

    The first study was interesting…and it showed the neonatal mortality rate to be TWICE the rate at hospitals!!
    But forgive me if I’m not impressed for the same reason I’m not impressed when they report a “dramatic 20% increase in homebirth rates!”
    going from a 0.5% to a 1% isn’t quite as dramatic and scary as ‘twice the rate!”

    The second one I have to admit that I didn’t review that closely as it appears to be a VERY biased blog with an agenda and just one persons spin on the information (which is exactly what I was complaining about in this blog). I don’t want to take one person’s spin on the information (ie. “dramatic 20% increase” or “That’s a whopping 3X higher!”)….especially without seeing the study for myself to read with a critical eye. (we are back to the “damned lies” part )

    And neither one of those links solved the issue at hand….do we pay attention to “study A” which shows a “Dramatic 2X higher neonatal mortality rate!!” (that went from 0.5% to 1.0%)
    Or do we pay attention to the study that showed NO difference in safety between homebirths and hospital births? Seems to me that the vast majority of people are paying attention to only the studies that suit their agenda and glibly shrugging off any study that doesn’t prove their point. Sad, really….that people’s agendas get in the way of true knowledge and that pride in proving one right prevents people from focusing on making things safer. (for example…if hospital births are really that bad, how can we improve them? And if homebirths are really that dangerous…how do we make them safer?) People are just too busy trying to prove they are right by spinning numbers that they don’t stop to ask questions that will actually make a difference: What are we doing and how do we make it better?

    Monday, September 12, 2011 at 9:21 pm | Permalink
  22. Sarah wrote:

    What do I think?! I think, YES!!! If I had the money I would help you do that study!!! I agree, why are we all trying to prove a different point instead of learning the true facts?!

    Monday, September 12, 2011 at 11:30 pm | Permalink
  23. MishaLee Strunk wrote:

    I understand why MW & OB’s would want this study information, for a look at the big picture. Wouldn’t it be more important for me, as the mother/patient to know my care providers specific stat’s?

    Tuesday, September 13, 2011 at 9:02 am | Permalink
  24. elfanie wrote:

    Misha:
    Mostly….yes. And I say mostly because looking at one person as a consumer should help you make decisions…but looking at the big picture allows us to identify weaknesses and flaws and come up with improvements across the board. Besides that, not everyone keeps track of their statistics….

    Tuesday, September 13, 2011 at 9:13 am | Permalink

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