Continued from yesterday’s post
This is the last in the series about a research paper published in the Am Journal of Obstetrics and Gynecology’s that claimed to have proven that PHB is associated with a 10- to 19-fold increase in zero 5-minute Apgar.
The effect of systematic prejudice and discrimination by those professionals with a hidden agenda against OOH birth services and “other” midwives:
In the meantime, we have to face yet another round of tactics that if related to skin color would be called racial prejudice, or if they concerned religious affiliation, a form of anti-Semitism, bias against Muslims, etc.
And just like prejudice in these other areas of life, the blatant prejudice will result in the needless criminalizing of families and midwives that planned a home birth, or labored at home before needing hospital-based care.
How can I say with certainty that activities by this small but dedicated group of obstetrical professionals are prejudicial?
For the last hundred-plus years, the obstetrical profession has generally maintained a public relations position that constantly reiterests some version of “midwives kill babies”, while obstetricians simultaneously portray themselves as saving the lives.
(Link to 5-part series “The Official Plan to Eliminate the Midwife – 1899 to 1999”)
Just since 2000, this PR plan has shown up as salacious headlines that read:
- “Twice as many babies die in home births” (PANG, 2002 )
- “3 to 4 times higher rate of neonatal mortality in PHB” (Wax Meta-analysi, 2011)
- “10-fold increase in 5-minute Apgars of zero for home birth midwives” (Chervenaket et al, 2013).
What we see in the most recent case is exactly the same “political advantage” elements that organized medicine has used before when PHB and ‘other” midwives were either receiving favorable notice in the media (the “Business of Being Born” by Rick Lake), or there was pending legislation that benefitted community-based midwifery, or legally expanded the ability of ‘other’ midwives to provide care.
In April of 2002 ACOG called a press conference and distributed press-releases claiming the as yet unpublished Pang study (Outcomes of Planned Home Births in Washington State — click here for earlier critique) had established that “twice as many babies die in planned home births“.
It wasn’t until the study was finally published 5 months later in August that the rest of us got to read the study and discovered that PANG methods were fatally flawed and broke the most basic rules of scientific research. By the time we knew the truth about the PANG study, the media was no longer interested in reporting such ‘old news’ or publishing a retraction.
PANG study’s poor methodology & inaccuracy or missing data
From the authoritative tone of this study, one would assume that it fulfilled the basis scientific methodology of contrasting ‘like with like’, so that the data produced could be fairly compared and thus provide a meaningful conclusion.
Pre-publication newspaper accounts didn’t mention that a large number of similar studies that had already been published; this made it seem that PANG was either the first of its kind, or had some other special attribute, such as being a bigger, better or a more well-designed study.
But unfortunately, it was not the first, or the biggest or the best designed.
Based on its many very serious flaws it could not, from the standpoint of a definitive scientific statement, support its conclusion best characterized as ‘hospital equal safe/home equals danger’ for healthy women with normal pregnancies have a spontaneous childbirth under the care of a professional birth attendant.
In fact the authors admitted that 4 out of the studies 5 outcome criteria were “soft” data, at high risk for error or misclassification.
“Several of the outcomes in this study may have been misclassified, namely *respiratory distress, requiring assisted ventilation for more than 30 minutes, prolonged labor and postpartum hemorrhage.” (page 8, *emphasis added)
PANG’s methodology was so bad that had it been submitted by college student in a course in the scientific research methods, the paper would have been returned with an “F” and a note to come to the professor’s office pronto!
The dirty little secret is that the Pang study on neonatal outcomes of ‘planned‘ OOH birth was based state birth certificate data in a state (Washington) that does not collect data on the plan place of birth as a part of its birth registration process.
Why on earth would anyone fund a large study on intended place of birth — in particular planned home birth — by specifically and ONLY using data from birth certificates in a state that does NOT include such facts? Does an “educated guess” replace the collection of accurate data?
“Because Washington State birth certificates do not identify which home births are planned, we defined planned home birth as those singleton newborns of at least 34 weeks gestation who were delivered at home and who had a midwife, nurse or physician listed as either attendant or certifier on the birth certificate.” p.2 [emphasis added]
At the very same time the state of California, which has many more total births, had been collecting birth registration data on planned place of birth since 1989. In 1999, a PhD candidate at Stanford University (Peter Schlenzka) published a 218-page thesis using the data from over a million California birth certificates, as well as hospital discharge records for mothers and their newborns from the very large RAND databases. This allowed the birth record information to be cross-referenced for accuracy with the hospital records.
With three mutually validating data streams, Dr. Schlenzka officially concluded that the physiological management of normal (spontaneous) childbirth in OOH setting as provided by midwives of all educational backgrounds (including “other” or non-nurse midwives”) was a safe alternative to hospital-based care.
As determined by California birth records and the RAND data, midwife-attended PHB had a significantly lower rate of medical and surgical interventions, a similarly low rate of NNM and thus provided superior outcomes for all categories of risk except for women or unborn babies perviously diagnosed with serious medical complications.
Since Dr Schlenzka’s thesis was published, a significant number of other credible and respected studies have reiterated his finding that:
- neonatal mortality is relatively the same regardless of place-of-birth for essentially healthy women
- when healthy childbearing families choose low medical intervention birth setting (birth centers and family’s home) the rate of medical interventions and surgical procedures is reduced from 2 to 10 times without in adverse effect to either mother or baby
Nonetheless, a number of talented, well-respected and influential obstetrical professionals spent well over a year on this project. Since they didn’t have any direct facts to determine the parents’ or the midwife’s planning status relative to OOH birth, these authors made up their very own proxy criteria.
They decided that any birth certificate for an OOH birth in Washington State that occurred after 34 weeks of pregnancy (3 wks premature and 6 wks before the due date) that was signed by a doctor, a nurse or a midwife was both a planned AND professionally-attended home birth.
They also decided that all birth certificates for hospital-born babies in which a midwife’s name was listed as having provided prenatal care during the pregnancy was again obviously (in their personal judgment) an intrapartum (during labor) transfer from an ‘attempted’ PHB (274 of the 6,133 birth records, and accounting for 19 of the 20 neonatal deaths).
It does not take a rocket scientist to realize that these co-incidental facts may just as easily be totally irrelevant to the parents’ planned place-of-birth. Other researchers have calculated by that at least 25% of all births that occurred at home were not planned, but represented unattended emergencies.
But despite these established facts, the PANG’s authors used this type of proxy criteria, which obviously was not actually able to establish that the 6,133 birth tagged by the PANG authors as PHB had, in actual fact, been established to be PHB.
But the biggest problem that also could not be solved with their proxy data system was whether the particular 20 neonatal deaths that occurred in this subset of 6,133 births ACTUALLY were (or weren’t) planned to occur at home.
As mentioned above, the study states that only one of the neonatal deaths occurred at home, all the rest were at the hospital in the group of 274 births that had a midwife’s name as having provided prenatal care.
In addition to not being able to tell the difference between intentional and unintentional home births, this proxy criteria also could not determine or did not distinguish:
- whether or not the baby was term or premature (the gestational age for 74 babies was pre-term)
- whether the birth was attended or unattended,
- Whether it occurred before the midwife arrived
- whether the babies that died were normal and healthy, or had an undiagnosed and fatal birth defect (8 out of 20 had serious or lethal anomalies)
None of these facts were part of the headlines about the PANG study that screamed: “twice as many babies die in planned home births”.
To summarize, PANG et al contained the following serious methodological flaws:
- Substituted “educated guesses” for factual data
- Used “soft” data to arrive at “hard“ conclusions
- Skimmed off the operative complications from the hospital group before calculating the complication rate for the hospital cohort
- Came to global conclusions based on extremely narrow criteria that by their own admission included missing and misclassified data
- Ignored the extremely high rate of upstream medical interventions and their complications when assessing the safety of “planned hospital birth” (Pitocin-accelerated labors, narcotic use, epidurals, episiotomies and admission of babies to neonatal intensive care)
- Ignored all the subsequent down-stream complications associated with the high operative rate in planned hospital births, especially those in post-cesarean women (intra-operative complication such as hemorrhage, blood transfusions, emergency hysterectomy [13 x increase], and post-op complications such as infection, pulmonary embolism, and admission to the ICU
Then in 2011, the authors of the Wax meta-analysis of 529,000 home and hospital births decided to take the study’s neonatal mortality rate NOT from the meta-analysis’s own data pool, which was a total of 342,056 PHBs, but instead to whittle down the data set for calculating the NNM to a mere 16,500 PHB.
That subset of 16,500 is only 4% of the study’s total of 342,056 PHBs or a of 96% reduction.
Given this extraordinarily unusual use of the data, we shouldn’t be surprised to learn that one third (1/3) of that drastically reduced total of PHBs were taken from (drum-roll please!) the 6,133 proxy-data determined PHBs in the PANG study. Then the authors of Wax used this same discredited proxy data to represent two-thirds of the 32 deaths the Wax meta-analysis PHB group.
Let me say that again: One discredited study — PANG, with it proxy instead of actual data — accounted for 20 out of the total 32 deaths reported by the authors of the must touted Wax Meta-analysis.
Unfortunately, this turns it into junk science on steroids.
WAX left out the NNM outcomes of 325,556 births in its own meta-analysis, (a 96% reduction) and cloned the fatally-flawed data from PANG study into the centerpiece for its own meta-analysis.
The dirty little secret is that Wax’s author only used 1.7% of its own PHB data set when calculating neonatal deaths, and yet they publicly claim their finding to represent the largest such study ever to compare PHB with planned hospital birth (207,551 hospital vs. 342,056 PHB).
From this dubious and shaky perch, they insist that their work had definitively proved that midwife-attended PHB are associated with triple or higher rate of neonatal deaths.
Many comments from by non-obstrical medical professionals reiterate that unsupportable assumption. It seems obvious to professional and lay public alike that such a study (one with such large numbers) represent irrefutable fact and should be used to make all subsequent decisions. Based on a 3 Xs higher death rate for babies, all childbirth, no matter how healthy the mother or normal it is expected to be, should logically take place in the hospital. Period, end of discussion, no need for any further research into this issue.
It’s interesting that Wax’s positive finding were never included in their aggressive media campaign. The “Results” portion of the meta-analysis acknowledged similar perinatal mortality rates (intrapartum fetal demise + stillbirth + neonatal deaths up to 28 days of age) for both low medical-intervention settings (OOH model) & high medical-surgical intervention rates (hospital model).
Wax et al actually reported improved neonatal outcomes that included:
- reduced rates of prematurity
- low birth-weight
- reduced rates of assisted newborn ventilation
And Wax’s “Conclusion” portion reported a statistically significant reduction in medical and surgical interventions for mothers:
- Cesarean delivery
- Retained placenta
- Epidural analgesia
- Operative vaginal births
- 3rd-degree perineal lacerations
- Electronic fetal heart rate monitoring
- Over all rate of perineal and vaginal lacerations
But none of these positive facts made it into the AJOG’s press-releases. A short time later, ACOG also ignored the positive finding and adopted the negative language of the “Results portion” (3 to 4Xs increase in NN deaths) as the core of its own anti-PHB policy statement.
This official ACOG publication now counsels its member-obstetricians to use this information and do all in their power to dissuade women from planning a midwife-attended home birth. It also cautions them against professionally supporting OOH births (and the midwives that attend them) unless the OOH setting is a birth center accredited by a specific nurse-mfry organization (the AABC).
And again, and without any surprise, this was followed by another round of media attacks on “other midwives” and OOH birth services.
And now we have the latest AJOG’s paper generating headlines screaming its most recent, most alarming claim, only now it 5-minute old babies who have no heart rate and aren’t’ breathing because their mothers planned a midwife-attended home birth.
It can’t tell you how frustrating it is that such headlines never question the obstetrical profession’s 33% CS rate, the rising maternal mortality rate, the incessant increase in other interventions including continuos EFM (its only apparent contribution for healthy women is to increase the CS rate), inductions, “Pit to distress” and whatever technology becomes their latest new toy.
This PHB-focused publicity, which has become a cottage industry enthusiastically generated by obstetrical groups, is:
(a) NEVER about their own profession’s excesses (i.e. the dubious idea that more intervention is automatically better) and its own obstinate refusal to even acknowledge physiological management as a scientifically-based standard for healthy women with normal pregnancies
(b) ALWAYS about ‘other’ midwives and OOH settings and headlines that scream some version of “Midwives Kill Babies!”
This makes it so easy for the already vitriolically anti-PHB obstetricians, and county prosecutors who are running for office and looking for a sure-fire way to get their name in the newspapers, to decide to criminally prosecute families that choose an OOH birth and/or criminally prosecute their midwife.
In just a decade, claims of bad outcomes have escalated from a 2-fold increase in 2002, to the claim in AJOG in 2013 that first-time mothers who give birth OOH with a midwife have a whooping 19-times increase in NNM.
This is what worry and depresses me.
Instead of figuring out what is (and isn’t) true about the ever-escalating claims that PHB are associated with preventable neonatal deaths, these unfounded and/or misrepresented claims are being swallowed hook, line and sinker by those who don’t want to see problems fixed, but instead will be not be satisfied with anything less than a lynching.
Planned Home Birth = a 2-part “PLAN” (part a and part b) and ONLY applies to healthy pregnant women after spontaneous onset of labor at term, and after being evaluated by their primary care provider and found to be essentially healthy with an essentially normal fetus.
I’d like everyone to note that the professional “PLAN” by midwives to attend an OOH birth actually is the ‘plan/intentition’ to attend an OOH labor. This is ALWAYS a two-part equation and ONLY comes into play after a healthy woman with a normal pregnancy has completed 37 weeks of pregnancy.
Prior to that any significant medical, obstetrical or perinatal issue by mother or baby — a complication, or the need to evaluate the mother or unborn baby for a complication — will be reason for the midwife herself to consult with a physician, or refer the mother-to-be to a physician. Midwives don’t ever PLAN to attend pre-term labors or ones in which the mother-to-be (or fetus) has already been identified as having a serious medical complication.
Assuming that both mother and baby get to the magic 37 completed-weeks of pregnancy in perfect health (85% of pregnancies in the US), only then does the PLAN for an OOH labor comes into play. That mother will ONLY give birth at home if labor progresses normally and mom and babe remain OK.
This issue would be far more accurately discussed and researched as the midwife’s plan to attend-a-labor-at-home (quite different that the issue of a family ‘choice of a “home” birth’, which is preference, not actually a ‘plan’, since it must be preceded by a normal and progressive labor, which is outside of the ability of anyone to ‘intend’.
But in the public discourse about intended place-of-birth, we instead conflate the parent’s preference for OOH care with that of the midwife’s intention to give care according to professional guidelines. While ACOG would like you to believe that the “plan” of midwives that their clients give birth at home, come heaven, hell and/or high water.
Wrong, wrong, wrong!
From the midwife’s perspective the actual “PLAN” relative to home birth is a Part A and Part B PLAN that goes like this:
PHB-Part A is providing care to healthy woman at the term of her pregnancy who has a spontaneous onset of labor that progresses ‘normally’ (fast or slow, but always moving forward) and always factors in whether or not the mother and/or baby are able to tolerate this normal but still painful and stressful biological process.
PHB-Part B is equally clear — at any time that:
- the mother’s labor is no longer progressing normally
- unborn baby gives evidence of not tolerating labor
- either mother or baby develop a medical issue or complication
- the mother simply asks to be transferred to hospital care
PLAN B goes into effect — off to the hospital!
Any type of research on the comparative safety of OOH birth that doesn’t take this PLAN’s part A/part B into account is not responsibly configured and therefore cannot definitively determine the issue of comparative safety for low medical-intervention settings (birth centers and family home).
In the near future, I will begin posting on a new topic — developing scientific criteria for studies on a the relative safety of ‘planned’ OOH birth studies (either home or birth center). This would avoid the travesty of PANG and WAX et al by focusing this process of scientific assessment on the outcomes the care actually received, instead of using the parent’s “hope” to have a physiologically-managed labor be used as a proxy for “unmedicalized care”, even though the mother:
(a) never received physiologically-based care from a professional birth attendant
(b) did receive the full spectrum of medicalization — obstetrical interventions and/or surgical delivery.