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I have removed the following paragraph:
"Conversely, there are some studies that demonstrate a higher perinatal mortality rate with assisted home births (e.g. Perinatal death associated with planned home birth in Australia: population based study. BMJ. 317(7155):384-8, 1998 Aug 8.) Despite these, It is generally accepted that properly assisted home birth carries no greater risks than hospital birth for low-risk pregnancies.
The reason I have done so is that the Bastian study is highly contentious in Australia, not only for the conclusions drawn but also the methodology. In short, the study showed that for normal healthy women, the outcomes at home were as good, if not better than in hospital. But for women with complications, home birth was less safe. The reason for this lower safety aspect was that in transferring from home to hospital, the transfer was 'stuffed up' and the woman did not receive adequate hospital treatment.
Prof Sally Tracy has done quite a bit of work on the Bastian et al study and one of her letters regarding the study can be found on the BMJ site here: BMJ 1999;318:605 ( 27 February) http://bmj.bmjjournals.com/cgi/content/full/318/7183/605/b?hits=10&FIRSTINDEX=0&AUTHOR1=bastian&SEARCHID=1117021210508_6194&gca=bmj%3B318%2F7183%2F605%2Fb&
I've got umpteen references at work that shows that HB is as safe, if not safer than hospital births. I'll put up references to them tomorrow.
But, I don't think we want to have reference arguments in the article text. Here is a good place for reference arguments. -- Maustrauser 11:57, 25 May 2005 (UTC)
I've removed the several references to homebirth being as safe or safer than hospital birth as this is opinion (and was anyway contradicted further down in the article). This belief is not based upon any available evidence. All the references quoted below refer to published work that is deeply flawed and subject to much bias. Unfortunately, It is technically almost impossible to randomise women to proper trials of birth location in order to minimise bias. Quite rightly, women want to choose for themselves where to give birth, not take part in a trial.
The best evidence thus far for birth safety when doctors aren't supervising is quoted in the article. Cochrane reviews are non-biased, quite rigorously performed and have great influence. This Cochrane review gathers several trials comparing birth centres with a homely environment run exclusively by midwives, with hospital care. They are properly conducted randomised trials. Several effects were noted, not least of which was an increase in perinatal mortality of about 80% in the birth centres. This is an important fact, probably the most important in this debate, and should be discussed in the article.
Women are served by having access to evidence from both sides of the debate. Perinatal mortality is low overall in low-risk women, wherever the birth takes place. Obscuring the relative risks however, is not acceptable, and I hope these changes help understanding. —The preceding unsigned comment was added by 87.113.31.143 ( talk) 18:31, 28 April 2007 (UTC).
I've removed the stuff on babies being immune to infections at home. Evidence please. Most infections seen in paediatric practice are community acquired. Do babies get infections at home? Obviously. They are not immune! MRSA (for instance) is widely carried in the community. To say that MRSA is common in new mothers and their babies is also untrue. I've seen 1 case in 10 years. Evidence please? MS
Not sure if this is the right place to discuss this, but better than starting another section on Safety. I removed the following paragraph, in reference to the Johnson & Daviss 2005 BMJ article:
Neonatal mortality in itself is not even discussed in the BMJ article. The authors list a combined intrapartum and neonatal death rate of 1.7/1000. Also, the figure of 0.9/1000 is incorrect as discussed below in the Citations section. FlyingLattice 21:31, 3 August 2007 (UTC)
There is no scientific evidence that shows that homebirth is as safe as hospital birth. All the existing scientific evidence shows that homebirth has an increased rate of preventable neonatal death in the range of 1-2/1000 ABOVE the rate in the hospital. There are studies that CLAIM to show that homebirth is as safe as hospital birth, but none of them compare homebirth to hospital birth among low risk women in the same year.
Consider the most widely quoted paper, the Johnson and Daviss paper (BMJ, 2005). In 2000, the neonatal death rate for low risk women at term in the hospital was 0.7/1000, substantially less than the homebirth neonatal death rate. Look at the paper. Where is the neonatal death rate for low risk women in the hospital in 2000? The authors left it out and compared homebirth in 2000 to hospital birth in out of date papers extending back to 1969. Johnson and Daviss ACTUALLY showed that homebirth has a neonatal death rate more than 3 times higher than hospital birth.
The National Center for Health and Clinical Excellence, a healthcare watchdog organization, has recently performed a comprehensive review of the entire homebirth literature:
"... The quality of evidence available is not as good as it ought to be for such an important health care issue, and most studies have inherent bias. The evidence for standalone midwife led units and home births is of a particularly poor quality.
The only other feature of the studies comparing planned births outside [physician] units is a small difference in perinatal mortality that is very difficult to accurately quantify, but is potentially a clinically important trend. Our best broad estimate of the risk is an excess of between 1 death in a 1000 and 1 death in 5000 births. We would not have expected to see this, given that in some of the studies the planned hospital groups were a higher risk population."
I only quoted a brief excerpt from the report. The report itself analyzes each paper in depth. I urge people to read the report itself; there is not enough room here to quote each specific analysis, but among the papers discussed:
The Janssen study showed substantially higher neonatal mortality in the homebirth group. (They don't mention it, but Janssen subsequently publicly renounced her original contention that she had shown homebirth to be as safe as hospital birth).
The Bastian study showed substantially higher neonatal mortality in the homebirth group.
The National Birthday Trust compared a low risk homebirth group to a high risk hospital group.
The Farm study is merely a case series. The author should not have chosen a high risk hospital group for comparison and therefore, the study cannot even be regarded as a comparison study.
The Johnson and Davis study shows a high level of neonatal deaths. (They don't mention it, but Johnson and Daviss also have undisclosed conflicts of interest.)
Amy Tuteur, MD August 7, 2007.
I have removed the following paragraph with regard to the NICE study:
This quote was taken from the 22 June 2006 report, which was subsequently updated 22 March 2007. The updated report has removed all quantifiers of perinatal mortality when comparing home birth to hospital birth. I have replaced the old quote with the newest information. FlyingLattice 23:15, 11 September 2007 (UTC)
The following paragraph has been removed:
This is an uncited statement of speculation and has no evidence basis whatsoever. FlyingLattice 23:15, 11 September 2007 (UTC)
These references conclude that home birth is as safe if not safer than hospital birth.
Sorry for not getting them up earlier as promised. -- Maustrauser 13:23, 31 May 2005 (UTC)
All of these are incredibly poorly conducted studies that have marked biases and are statistically almost useless. Why haven't you quoted the many studies showing excess mortality? (Although these are similarly methodologically poor)
Nandesuka has removed the reference to women at home being less susceptible to hospital based infection, such as Golden Staph. Whilst I agree that the sentence was not written particularly well, it is a truism that if you aren't in a hospital then you are not likely to get hospital based illnesses. Why not point this out?
Frankly, I know how clean my house is. I control who my guests are. I don't have an airconditioning system potentially spreading airborne diseases all over the place. Of course, a normally kept, hygienic home is cleaner than a hospital full of sick people. -- Maustrauser 12:02, 25 May 2005 (UTC)
I just found the Dr. Lewis Mehl study in the PubMed database. Searching for "mehl l" finds the study and a followup. The author has published a number of other interesting articles as well; the Tasered mother one is kind of famous I think.
Hopefully this link to the abstract isn't going to expire. Notice that the midwives came out slightly ahead even after the worst 50% of the doctors were eliminated from the comparison. (more fetal distress and placental problems with the doctors)
That's pretty damning I think.
A 1983-1989 study by the Texas Department of Health shows births attended by doctors having 3x the death rate of births attended by non-nurse midwives. The name of this study is:
Maybe somebody knows where to find the text?
AlbertCahalan 03:44, 27 May 2005 (UTC)
Pretty damning? I don't think so. A retrospective, (obviously non-randomised) very low-powered study, with no information on points of comparison between the two groups, published in an obscure journal 28 years ago. Surprisingly analysed by intention to treat, which is actually a small thing in it's favour.
No-one argues that midwives intervene less - of course they do. The point is that lack of intervention costs lives. This study is nowhere near powerful enough to demonstrate anything that fact or it's absence, not withstanding it's methodological flaws. Try again. —Preceding unsigned comment added by 202.89.167.125 ( talk) 10:24, 20 August 2008 (UTC)
I removed the sentence which said that "Certified Nurse-Midwives may attend homebirths in all 50 States, if their back-up physician will allow it." I can't speak to other states, but I know that in Nebraska it's illegal for a CNM to attend a homebirth regardless of physician approval. I suspect this may be the case elsewhere as well, but as I said I can't say for certain. spoko 5:47, 11 June 2006
I removed the sentence which said that first-time mothers are especially likely to want assistance at a home birth. In the U.S., practically everyone wants assistance. The number of unassisted home births is vanishingly small, first-time mother or not.
I also changed the passage that said that midwife-assisted home-birth is illegal in the listed states. It is not. Our son was born at home in Illinois with two midwives assisting -- nothing illegal about it. Midwives who assist at births must be nurse-practitioners, which makes finding one hard, but not impossible. I suspect the other states listed have wiggle-room as well -- and that the states listed as "legal" have some restrictions. I would strongly suggest taking down that map. It's deceptive, and providing deceptive information about such a subject is kind of indefensible . Providing a link to a site that gives an in-depth discussion of conditions in all 50 states would be a much better option. NoahB 14:34, 2 August 2005 (UTC)
I'm fairly sure homebirth is actually legal in NY, since I've had three (2000, 2002, 2004), attended by a midwife and paid for by Medicaid, so I imagine if it were illegal someone would have said something! It would probably be a good idea to check the accuracy of the rest of the map, too.
This is the only site on the web that analyzes the homebirth studies from a scientific point of view. It is not pro-homebirth, because the reality is that there is not a single study that demonstrates that homebirth is as safe as hospital birth. There are studies that claim to demonstrate homebirth safety, but a statistical analysis shows that they do not.
I find it interesting that it was removed because it "attacks" homebirth. Don't people deserve the opportunity to read both points of view, and make a decision for themselves? One of the most notable things about homebirth advocacy is the absolute unwillingness to respond to scientific and medical criticism of homebirth. Professional homebirth advocates do not present their claims to meetings of scientific or medical peers, and never put themselves in a position to take or answer questions posed by scientific or medical peers.
Women (and men) do not need to be protected from opposing points of view. Homebirth advocacy should be able withstand scientific and medical critique, and not have to hide from it by deleting any references that are not favorable.
Amy Tuteur, MD January 23,2007 —The preceding unsigned comment was added by 66.31.153.193 ( talk) 14:34, 23 January 2007 (UTC).
1. The first sentence as it stands is nonsense. Taken logically from this, a birth in an ambulance, in a car, on a plane, in a workplace, a school, a shopping centre or anywhere else other than a hospital or 'birthing centre' is a home birth.
2. The statement In countries where midwives are the main carers for pregnant women, home birth is more prevalent is contentious. In the UK, midwives are the main carers but home birth is NOT more prevalent. Perhaps the writer was looking from a US position, where I believe physicians are the main carers.
3. Legal situation in the United States section: either the first or the last sentence should go - they say the same. Emeraude 18:30, 1 February 2007 (UTC)
I am checking citations. I loath to remove something that is on here, but if it is unsupported then I will. Need help on this one: "Matthews et al., Infant Mortality Statistics from the 2000 Period Linked Birth/Infant Death Data SetNational Vital Statistics Report, Volume 50, Number 12, August 2002. Shows that the hospital neonatal death rate for 2000 was 0.9/1000..." I have read the report and cannot find the "hospital neonatal death rate for 2000 was 0.9/1000" anywhere in the report. In fact, the report states, "Other variables that are available in the linked file data set (1), but are not discussed in this report include: …place of delivery…" Whomever added this reference, please provide the page on which it appears. Thanks. Kreisman 00:48, 18 February 2007 (UTC)
You need to perform the calculations yourself. Infant Mortality Statistics from the 2000 Period Linked Birth/Infant Death Data SetNational Vital Statistics Report does not separate the statistics by risk level. The appropriate comparison group for the Johnson and Daviss study would be white women at term with singleton pregnancies. Looking at the raw data we find:
2,824,196 births to white women at term (37+ weeks), see Table 2 and 2,602 deaths of white babies weighing more that 2500 gm see Table 6 for a death rate of 0.9/1000. Amy Tuteur, MD 01:31, 19 February 2007 (UTC)
According to ATuteur's references above, her numerator and denominator are not from the same population, which is necessary to compute a valid mortality rate. As she states above, her neonatal deaths were white babies who weighed more than 2500g, but the population she chose for live births were white babies at 37 weeks or greater. This is not a valid calculation. To determine a valid neonatal death rate, you must use deaths of babies born at 37 weeks or greater, over live births of babies born at 37 weeks or greater (or deaths of babies weighing more than 2500g over live births of babies weighing more than 2500g). Babies weighing more than 2500g may still be preterm, and babies born after 37 weeks could weigh less than 2500g. The tables in the referenced dataset don't give the data that is required to calculate a real rate. ATuteur's annotation for this reference should be removed, and quite possibly also the National Vital Statistics citation itself, as it carries no references to home birth.
FlyingLattice 20:50, 3 August 2007 (UTC)
Under 'Safety' the following para appears:
This was NOT a study of home birth vs hospital. it was a study of birth centres. Further, I am unable to figure out how the 80% figure was calculated, unless it is using the Scandanavian BC study which was flawed. Either way, this is not a study of HB and should be deleted. Any views? Gillyweed 12:49, 15 May 2007 (UTC)
I've removed it as it was not a HB study. Meerkate 06:50, 21 May 2007 (UTC)
It was not a homebirth study, but it is a gold standard combination of RCT studies demonstrating an 80% increase in risk of death in babies born under the care of midwives in birth centres next door to labour wards. Therefore, even when access to rapid medical help is available, midwives still presided over a large increase in the death rate. Gillyweed once again shows that she can't understand simple statistics. The 80% (actually 83%) refers to the relative risk increase in death in the birth centre babies ie RR=1.83. If Gillyweed had even the most basic grasp of stats she would have realised this. She should stop editing on areas involving research or statistics as she has not the cognitive ability to interpret anything more than the simplest of comparisons. —Preceding unsigned comment added by 202.89.167.125 ( talk) 08:17, 9 August 2008 (UTC)
I would just like to note that there is a Cochrane review on, specifically, "Home vs. hospital birth" by Olsen O and Jewell MD. It was published in 1998, Issue 3, which I don't have remote access to at the moment, so I don't have it in front of me. I should drop by the library within the next week or so, so I'll update the article with that information. --[[User:Astraflame|Astraflame] ( talk) 04:34, 22 August 2008 (UTC)
I removed several sentences refuting the conclusions of the Johnson & Daviss article. As mentioned in the "Systematic review of safety" section, this article doesn't discuss neonatal mortality alone, but combines it with intrapartum mortality. So the subsequent remarks were irrelevant (comparing apples to oranges), and proper citations were not given. Furthermore, the reference to an out-dated 1969 was not salient as this study reported a hospital neonatal mortality rate of 0.5--1.1/1000 which was among the lowest in the study, and comparable to the 0.72/1000 rate mentioned.
The further paragraphs on the National Center for Health and Clinical Excellence should probably also be double-checked. Minded17 05:33, 29 August 2007 (UTC)
I've re-read the Johnson & Daviss article and the NICE recommendations and appropriately (at least according to my reading) edited the section. I removed the Enkin article as it did not seem as well-supported and repeated NICE's final recommendation anyway, but if someone sees the need for it to be there, feel free to add it back in. Astraflame ( talk) 15:24, 12 August 2008 (UTC)
I've added the BMJ study's own comparisons between the hospital & home groups showing that they were hugely different. Equivalent groups are required for valid comparisons between cohorts, so this is a vital part of the criticism of this flawed case series.
I've also adjusted the perinatal mortality rates which were incorrectly quoted on here and in the study. Stillbirths are part of the perinatal mortality rate, and reflect the standard of care given. They are always included in maternity statistics. Planned breeches & twins are high-risk and outside the study, so the rate of 2.7 is reduced back down to 2.4/1000.
The image on this page may be too erotic for a health and safety article. Please consider the visually implied POV. Collin239 19:22, 9 October 2007 (UTC)
WP is censored. Items contrary to WP policies are routinely removed. I assume you are a woman, and you don't know how the image looks to a man.
Besides which, is this image real? Why does she still have that big a bulge if the baby is that far out of her? Collin239 09:58, 10 October 2007 (UTC)
If it were my own lover giving birth to my own child, I would have the right to see her. What I'm worried about is the average man, getting off on the picture, submitting this page to AdSense, etc. Collin239 10:49, 10 October 2007 (UTC)
The photo also caught my attention, but mostly with a question: Why is it that I've seen about a dozen similar photos over the last few years, and never yet found a single birth photo online in which the woman is wearing anything at all? I know several women who have given birth at home, and none of them has stripped completely naked (although two wear nothing except a soft bra after the early stages of labor). Is it just that the only women who are actually willing to post a birth photo also have minor exhibitionist streaks? Are they perhaps trying to make a political point about top-free equality? Perhaps it's a regional thing, or that no one takes a picture of home births that happen during the winter? I wouldn't want to discourage any birthing woman from doing anything that makes her more comfortable, but I wonder if the exclusion of clothes-wearing women promotes a subtle POV bias.
(This message written by a woman whose toes are still cold despite central heat, a mild climate, two blankets and a pair of heavy socks.) WhatamIdoing ( talk) 03:00, 17 December 2007 (UTC)
I removed this text from the article:
Most hospitals have a policy of trying to deliver the baby within 30 minutes of determining a caesarean is required, however, owing to the theatre preparation time, this goal is only achieved 66% of the time. Despite this, an increase in morbidity or mortality has not yet been shown in the literature when it takes longer than 30 minutes. This generally fits with the view that very few obstetric emergencies require immediate action. [2]
There is indeed an article by Tuffnell, Wilkinson, and Beresford that says this. It's an article that addresses hospital standards in performing C-sections, and talks about the standards in question. This has no particular link between the sentence that precedes it (stating that some women prefer to be closer to a hospital in case of emergencies.) First, proximity to a hospital is valued by some women not only because of the speed of a c-section, but because of proximity to a NICU, in cases where delays that threaten the life or health of the neonate can be measured in minutes, if not seconds (e.g., premature delivery before 32 weeks). Second, "hospitals don't meet their own standards for delivering a baby within 30 minutes" does not mean "hospital emergency c-section is not faster than home birth followed by c-section. Lastly, "no increase in morbidity when a hospital takes more than 30 minutes to perform a c-section" is different than "no increase in morbidity in home vs. hospital births," which is addressed in the previous section. In short, this text looks like something someone went on a fishing expedition to find so they could perform synthesis to "respond" to a point of view that they found distasteful. Nandesuka ( talk) 11:02, 19 July 2008 (UTC)
Jolly good. I'll go on record to say that the user Gillyweed is biased and is an inappropriate editor of this page. She constantly reverts evidence that shows homebirth is detrimental to the health of the baby. I will continue to revert to my edit everytime an inappropriate statement is written that is not balanced and evidence based. The reason most hospital births don't adhere to the 30 minute standard is that monitoring allows a judgement to be taken as to speed. in those emergencies where rapid delivery by Caesarean section is vital, it takes place within 10-15 minutes in hospitals. Homebirthers would still be being loaded onto the ambulance. Hence the 2% perinatal mortality rate - see the UK independent midwives database of stats for confimation of this figure. —Preceding unsigned comment added by 202.89.167.125 ( talk) 13:49, 25 July 2008 (UTC)
As with many controversial topics on wikipedia, this article rides the razor edge of swinging to a pro/anti sentiment. Wikipedia does not give advice, and it is our job as editors, coming from all different backgrounds on this issue, to keep the content accurate and neutral. What I don't understand is - *why* is homebirth controversial? No one is being forced to give birth at home if they'd rather birth in the hospital. If it is only an issue of "threat to the life of the baby" then why aren't the anti-home birthers clamoring for better pre-natal care and testing, too? Successful birth is more than just the hours of labor. The well-being of the mother is not to be ignored, and it seems that most statements against home birth simply parade neonate mortality (and even the statistics on this being more of a risk are questionable). There is no question that maternal well-being (defined as intact perineum, vaginal birth, etc) is better when a birth is at home. Please enlighten me (without a loooong rant) as to what issues we could address to make anti-home birth advocates more comfortable with the article. Lcwilsie ( talk) 16:43, 31 July 2008 (UTC)
No Gillyweed you are not busy. Hence your ability to spend half your life on here. (UTC)
I think that this area of health is contentious because a birth at home threatens the livelihood of those who see childbirth as a disease needing medical attention. If the majority of births could be handled without vast quantities of medical intervention (and only the small proportion who really need medical care went to hospital) then many would feel a pinch in their hip pocket nerve. It's all about power and not evidence. Gillyweed ( talk) 10:46, 9 August 2008 (UTC)
Wrong again Gillyweed. I can see that there is jealousy driving your inaccurate opinions on this topic. The hospital I work at has lower intervention rates for low risk women than the local homebirth service. So, how would homebirthing affect livelihoods? The homebirth service is much more expensive per delivery and requires more midwives to be employed as it's less efficient. It gives considerable disruption to the lives of the midwives who are on call 24 hours, 7 days a week. The homebirth risk of perinatal death averages 1.5% over the 8 years since inception, and this is low-risk women only in a high-income area. To compare, our hospital's perinatal death rate is 0.2% despite sorting out all the high-risk women as well. The local homebirth maternal death rate has been supressed but there have been deaths which is totally unacceptable given the low-risk women. Do you really think that allowing an excess of death of mothers and babies and neonatal brain damage is a cheaper way of delivering healthcare? What a silly opinion - it makes lots of work for neonatal units. Another example: look at New Zealand where a left-wing government has enabled the practice of large numbers of independent community midwives. The CS rate there continues to climb and is one of the highest in the world... Evidence is something Gillyweed knows little about unfortunately. —Preceding unsigned comment added by 202.89.167.125 ( talk) 07:58, 10 August 2008 (UTC)
Do you actually bother searching properly, Gillyweed?
First page of search results.
These are all highly motivated women, as well.
YOUR NHS reference of 14% refers to a) ALL women not just primips and b) Does not include transfers after the 2nd stage of labour eg. PPH, retained placenta, neonatal problems, 3rd degree or extensive tears. These transfers count.
Even the independent midwife quoted has a 25% rate!
You think my figures are an "order of magnitude" out? Sorry.
Your credibility is in your boots I'm afraid. —Preceding unsigned comment added by 165.118.1.51 ( talk) 08:40, 26 August 2008 (UTC)
If we are going to discuss transfer rates, we must discuss reasons for transfer. As written it would seem that all transfers are due to obstetric emergency, but this is not true. Many women transfer due to fatigue, failure to progress, or because they want analgesia (if we want to use just one midwife as an example, Anonymous' ref#2 cites 27/39 transfers for these reasons). Others transfer because symptoms during labor indicate there may be a need for intervention and the attending professional feels it is prudent to be near higher tech equipment (these symptoms may or may not bear out as an eventual emergency). And yes, still others transfer due to an imminent emergency. Lcwilsie ( talk) 03:13, 27 August 2008 (UTC)
Gillyweed, I've left in your recent restoration of the first paragraph in the "safety" section, but I have re-reverted your removal of the discussion of the Government of Western Australia's release here: http://www.health.wa.gov.au/press/view_press.cfm?id=756. This seems like a perfectly appropriate source, and is perfectly on topic. If you want to remove it, could you please discuss that here first? Thanks. Nandesuka ( talk) 11:23, 10 August 2008 (UTC)
Nandesuka has removed Gillyweed's text for no apparent reason. My reading of the WA press release supports exactly Gillyweed's changes. I'm putting it back. Obman ( talk) 06:04, 13 August 2008 (UTC)
(un-indenting) Good catch about "excess". I've rewritten it as "A review indicating a relatively higher neonatal mortality rate of babies born at term to mothers who had chosen a home birth...", which is in line with the precise wording in the statement. Nandesuka ( talk) 23:48, 13 August 2008 (UTC)
The piece about obstetricians' emergency indemnity arrangements is irrelevant to an article on homebirth so is removed. —Preceding unsigned comment added by 202.89.167.125 ( talk) 11:34, 20 August 2008 (UTC)
Gillyweed's summary of the government's study was correct. "concluded that five out of the six deaths had no link to place of birth". Doesn't mean its true, it's just an accurate reflection of what is stated by the source. Chemical Ace ( talk) 07:14, 20 April 2009 (UTC)
I don't know if this is appropriate to include, but it came up in some discussions recently. One reason there are so few home births in the US is that liability insurance is prohibitively expensive for midwives and their covering physicians. Many home birth midwives practice without insurance, others practice in a birth center to avoid the fees they would incur if they tried to be insured. I would, of course, have to dig up references to support this prior to posting anything. It seems a bit inaccurate to say that women choose between a home birth and a hospital birth purely because of their personal preferences or their perception of the safety issues, when in many parts of the US the only option is a hospital birth, or at best a birth center. Home birth is more common in countries where it is more accessible. Just curious if anyone would support including some information to this effect. Lcwilsie ( talk) 19:48, 11 August 2008 (UTC)
This paragraph has been inserted and removed several times. Let's discuss here and stop wasting bandwidth with reverts.
I think we need more than just this study in the safety section to improve the data. We need statistical significance, not just percentages (many studies have few patients, so 40% vs 31% might not be significant). All studies are going to have their flaws, but by looking at many we increase the odds of being able to draw realistic conclusions. Lcwilsie ( talk) 12:31, 22 August 2008 (UTC)
(unindent) Anonymous poster: Proper WP etiquette would be to continue the discussion here rather than resuming the edit wars. See some of the discussions above for examples.
Astraflame: thank you for your edit, it is an improvement.
Several studies show that the perinatal mortality rate remains quite low in homebirth (0.8-2%). Studies show that medical intervention (augmentation, anesthesia, surgery) is quite low in homebirth. Does this mean homebirth is more or less risky than a hospital birth? This is the difficult part to document. If the data comparing homebirth to hospital birth is not adequate, then perhaps we can't make statements that homebirth is more/less risky. However, we can mention the studies that attempt to reliably make these reports. We can report the data from several studies that provide statistics on homebirth outcomes. We can report data on the outcomes of hospital births.
Lcwilsie (
talk) 20:06, 22 August 2008 (UTC)
Astraflame. Thanks for your edit and I'm happy now not to revert as long as Gillyweed and Lcwilsie leave alone something they are unable to understand - the shortcomings of published research. The problem with wikipedia is that the uneducated are allowed a say on complex topics with many shades of grey. I will be looking very regularly to make sure they haven't changed things to reflect their anti-medical/hospital agenda. The UK is conducting a large-scale review of homebirth over the next few years. Again it will not be a RCT, but hopefully, the study design will be tight and allow us to be more confident about the obvious risks & benefits of homebirth.
Again, I emphasise that our hospital manages to get similar emergency CS rates, episiotomy rates etc (with a fraction of the perinatal mortality) to the local public homebirth service, despite us having a mixed low & high risk clientele. Hospital birth does not have to mean interventional birth, and excellent midwives can flourish in hospital. High-risk women need to benefit from good midwifery & hence reduced intervention too. We would hope to publish our figures in the next year or two - maybe I can persuade the local homebirth management into a direct comparison (with properly matched but unselected cohorts of course) - unlikely as they know the score! (UTC)
Study | Years | Location | Sample | Matching Criteria |
---|---|---|---|---|
Gulbransen G, et al. N Z Med J 110:475 | 1973-1993 | New Zealand | 9776 - home birth
? - hospital birth |
unknown, unable to obtain a copy |
Woodcock HC, et al. Midwifery 10:125 and Med J Aust 154: 367 | 1981-1987 | Western Australia | 976 - home birth
2928 - hospital birth |
Year of birth, parity, previous stillbirth, previous death of liveborn child, maternal age, maternal height, and marital status |
Janssen PA, et al. Birth 21:141 | 1981-1990 | Washington State | unknown | unknown, unable to obtain a copy |
Ackerman-Liebrich U, et al. BMJ 313:1313 | 1989-1992 | Zurich, Switzerland | 489 - home birth
385 - hospital birth (207 matched pairs) |
age, parity, gynaecological and obstetric history, medical history, partner situation, social class, nationality |
Wiegers TA, et al. BMJ 313:1309 | 1900-1993 | Gelderland, Netherlands | 1140 - home birth
696 - hospital birth |
post-hoc control of background differences (of race, attendance at antenatal classes, uncertain dates, non-optimal body mass, and obstetric history) by splitting groups into relatively favorable and infavorable backgrounds |
Lindgren HE, et al. Acta Obstet Gynecol Scand 87:751 | 1992-2004 | Sweden | 897 - home birth
11341 - hospital birth |
unknown, unable to obtain a copy |
Chamberlain G, et al. Pract Midwife 2:35 | 1994 | UK | 5971 - home birth
4634 - hospital birth |
age, number of previous children, location, past obstetric history |
Janssen PA, et al. CMAJ 166:315 | 1998-1999 | British Columbia, Canada | 862 - home birth
743 - physician-attended hospital birth |
obstetric risk status; multivariate analysis was used to control for other variables (maternal age, lone parent status, income quintile, parity and use of illicit substances) |
Above is the list of studies that I found that were looking at home birth from 1980 onwards. Unfortunately for the world, but fortunately for me trying to do a review of the literature, there aren't that many home birth studies of relatively reasonable quality out there, period. Many studies are simply descriptive or of the mothers' impressions of their experiences, so I disregarded many more studies than I have included here. As they are all cohort studies (no randomized controlled trial studies exist for home birth), the main methodological issue, as far as I can see, was looking at how they controlled for variations in the study.
The two cohort studies that I excluded (Johnsson and Daviss BMJ 330:1416 and Bastian, et al. BMJ 317:387) seemed to just take the national averages in the nations they were studying, so frankly, their data seemed not even worth looking at. Most of the cohort studies for which simply listed the matching criteria matched the backgrounds of the populations before data was even collected, i.e. Ackerman-Liebrich, et al. made 'matched pairs' of their patients and Woodcock, et al. selected the hospital records so that they would match the population of the home birth patients (it was a retrospective study). Janssen, et al. tend to use multivariate analysis during the study to correct for the effect of confounding factors.
Wiegers, et al. used a much cruder method of post-hoc controlling of confounding factors -- by making an index of background factors and then splitting the women into four groups: primiparous with 'favorable' background, primiparous with 'unfavorable background, multiparous with 'favorable' background and multiparous with 'unfavorable' background. I'm not sure if that's a particularly statistically sound method, and furthermore, as they report their perinatal data with a similar index, it seems to me that comparing their results to other studies' results would probably not be worth the effort.
As I was unable to obtain the copies of three of the papers listed above, I wasn't able to determine how well their study was actually conducted. Concerns have already been raised on this talk page regarding the Chamberlain, et al. (also known as the National Birthday Trust) study, and I'm suspicious about the Lindgren, et al. study as it mentions "randomly selecting" the hospital records for the control sample without any mention of matching criteria. However, the Janssen, et al. study speaks of using multivariate analysis again to control for confounding variables, and so the results should be relatively trustworthy, though one would have to look up the paper to be sure.
Regarding editing the actual 'Safety' section, I agree with Lcwilsie that a summary of the actual studies (or at least, the ones that are reliable) would be more accurate than trying to make any statement concerning the 'riskiness' of home birth. The NICE recommendation can probably serve as a rough summary of the lack of research and the tentativeness of the conclusions that one can draw from the research, but I don't think that it's sufficient for actually describing what's going on here. Frankly, it's a much more muddled picture than even pro-home birth and pro-hospital birth advocates are willing to believe. -- Astraflame ( talk) 13:30, 23 August 2008 (UTC)
I propose we add or expand sections discussing: history of homebirth, international practices (beyond US, Europe, Australia), childbirth preparation, potential benefits of homebirth (won't this be contentious!). Other suggestions? Lcwilsie ( talk) 14:24, 25 August 2008 (UTC)
I agree with this. Perhaps Gillyweed can use her large amount of free time to be more constructive and provide this information, instead of (unsuccessfully) obfuscating detailing of the existing research knowledge on homebirth and making sarcastic comments. —Preceding unsigned comment added by 165.118.1.50 ( talk) 08:02, 26 August 2008 (UTC)
Hi. Can you add information about the lack of support for pre-natal testing among midwives? (or support if you can prove it) In my experience, I have found homebirth midwives to be ignorant of prenatal testing, supplying false and misleading information about prenatal testing and afraid to say they are pro-choice (if they are) (as a lot of their clients are pro-life). My point is that if you are pro-choice and want a homebirth, you should know where to get prenatal testing and know what kind of test you want before you start seeing a homebirth midwife. There seems to be a meme in homebirth that people who do prenatal testing are motivated by "profit" and that it is dangerous to the baby (there is some risk of course!) yet they seem to be ignorant that many conditions can be treated in the womb and that it may be helpful to have some knowledge of abnormalities from the get go. —Preceding unsigned comment added by 12.159.234.138 ( talk) 18:43, 30 July 2009 (UTC)
The conclusion of the WHO reference is as follows:
"So where then should a woman give birth? It is safe to say that a woman should give birth in a place she feels is safe, and at the most peripheral level at which appropriate care is feasible and safe (FIGO 1992). For a low-risk pregnant woman this can be at home, at a small maternity clinic or birth centre in town or perhaps at the maternity unit of a larger hospital. However, it must be a place where all the attention and care are focused on her needs and safety, as close to home and her own culture as possible. If birth does take place at home or in a small peripheral birth centre, contingency plans for access to a properly-staffed referral centre should form part of the antenatal preparations."
I couldn't find anything in the reference with the WHO exclusively advocating "the use of more naturalistic, small-scale methods of childbirth, rather than the large-scale units now prevalent in developed countries" (from the wiki article)
There is something "The call for a return to the natural process in many parts of the developed world..." but that is not a statement by the WHO in support of "naturalistic methods".
A summary of the WHO's views, written by me: "The WHO has released a statement supporting the right of women to choose where they give birth. In the case of low-risk pregnancies, with appropriate support and contingency plans women can give birth at home." —Preceding unsigned comment added by Chemical Ace ( talk • contribs) 13:11, 15 April 2009 (UTC)
We seem to be engaged in an eternal edit war, not blaming anyone - I've put this article on the neutrality board for advice. —Preceding unsigned comment added by Chemical Ace ( talk • contribs) 01:21, 18 April 2009 (UTC)
"Putting quotes from every interest group isn't going to help this article. " Gillyweed's comment when the position of the Royal_Australian_and_New_Zealand_College_of_Obstetricians_and_Gynaecologists was deleted. - If we're going to have quote from anybody we ought to have there's. They are an interest group, but a pretty important one at that with academic kudos.
Chemical Ace ( talk) 11:34, 19 April 2009 (UTC)
Gillyweed is a homebirth midwife (or partner of same), who thinks that he can tell everyone what's what because he's some minor wikipedia editor. He lacks the intellectual faculty to understand the literature surrounding this subject, as evidenced by his putting the recent BJOG study (yet another fairly useless observational unmatched "cohort" study in a failing maternity system with some of the worst outcomes in Europe) at the top of the safety section in a previous edit. If the neutrality board had seen this article before I started bringing some semblance of balance and order, they'd have been even more shocked. This article was truly laughable then, rather than the fairly rubbish one we have now. —Preceding unsigned comment added by 202.89.167.125 ( talk) 12:52, 19 April 2009 (UTC)
Chemical Ace ( talk) 06:59, 20 April 2009 (UTC)
The problem with including comments from anyone is we have to know the motivation for their statement. If you include a comment from the WHO, they are a generally unbiased group, with a stated interest in promoting best practices for health around the world. Having a statement from an association of obstetricians and gynecologists has the appearance of bias because obstetricians and gynecologists provide (almost universally) hospital-only birth. Similarly, having a statement from an organization of homebirth midwives would have the appearance of pro-homebirth bias. If this were an article on automobile safety, would we provide a quote from GM stating that American cars are safer than foreign models? Or would we include statements from independent testing organizations? Lcwilsie ( talk) 12:56, 30 April 2009 (UTC)
This all seems a bit silly. Why has the BJOG reference been removed by 125.168.40.224? It is the biggest study of HB yet done and is the most recent and yet because it apparently doesn't meet his/her requirements (while it does meet the peer review requirements of the journal) it is removed? I can only conclude that because it states that HB is as safe as hospital birth it goes against his/her biases and thus needs to go. Is this true? Let's deal with this one issue and then when we have agreement move onto the next point? 125.168.41.123 ( talk) 00:08, 21 April 2009 (UTC)
Why haven't you put the big studies in that show homebirth to be riskier than hospital as well then? BIAS. I haven't put them in because they're poor quality too and my edits are not biased, unlike yours. The BJOG study is no better than these other studies in methodology (in fact it's worse as it concerns itself with a unique maternity system with exceedingly poor results in every birth arena - the worst in Europe, despite a healthy population). So you'll be reverted each time you try to include this BJOG study without an analysis of it's many shortcomings, and inclusion of the other big studies with analysis. The NICE report is right - not enough evidence either way - and that should stay. They've looked at all the data and all the studies. They know what they're talking about. You know less than nothing. Very arrogant to think you know more than the panels of experts at NICE, aren't you? I'm very patient, you'll be reverted every day, until what you write isn't biased and NPOV according to wikipedia's guidelines. —Preceding unsigned comment added by 202.89.167.125 ( talk) 11:47, 21 April 2009 (UTC)
The safety arguments are ruining the rest of the article. I think that the re-write about study methodology was well done by Astraflame (see section 20 of discussion and "Research on Safety" as it stands at this moment in the article) and I think it adequately addresses many of the issues brought up as the concerns over what studies to include is hashed out over and over in the discussion. Based on the literature and study methodologies, I do not think it is possible to conclude whether homebirth is as safe, safer, or less safe than other birth locations and thus no statement should be made in the article. I propose that the body of the article discuss the details of homebirth (what it is, where it occurs worldwide, etc), and there could be a link to a separate page for a detailed discussion of safety. Also, the factual accuracy claim at the top of the homebirth page seems to apply only to the accuracy of home vs hospital birth, rather than to the accuracy of other details in the article. If I am wrong, please provide a detailed list of questionable facts so they may be properly addressed. Lcwilsie ( talk) 17:28, 29 April 2009 (UTC)
Hi Astynax, I wonder how we can find our way through these two extremes. I think what we are dealing with are two philosophies. (1). (The HB view) is that birth is not an illness nor a sickness and thus physicians should not be required unless otherwise indicated. Midwives are the appropriately trained people to determine whether there are medical problems that need oversight by a physician. The other philosophy (2) (The medical view) is that birth (because it is physiological and things can go wrong) should be managed by medical specialists. I doubt whether you will ever persuade one person who is firmly in one camp to move from one to another. Nor do we need to. What we need to present is information from a neutral position. Stating that a homebirth requires the agreement of an obstetrician is just as extreme as saying home birth is safe under all circumstances. Neither is true. The waters for this article are further muddied by people from different countries writing material. Eg. In UK, the Government is encouraging more homebirth. In US, the Government doesn't seem the slightest bit interested. In NZ, home birth is on the increase and the majority of women are cared for by midwives without obstetric involvement. In Australia there is a god almighty battle occuring between RANZCOG and the maternity consumer groups for 'control' of the maternity system. These national battles also get played out on these pages too and some of the editors (I am accused of being one, but hope I'm not) get rather extreme in their edits. Now none of this is unique to homebirth and WP has many policies designed to over come them. I'd forgotten about the POV forking policy. You're right. We just need get this one right. Perhaps we can try and get a consensus on the statement that you want included that "A physician's evaluation and monitoring is needed." What evidence can we find to make this statement? No doubt we can find an ACOG statement about this, but we can also find a RCM statement saying it isn't necessary. Perhaps we meed a paragraph explicitly explaining why there is so much debate over this issue and the reasons for the passion arise from the different philosophies about birth (I noted above). Do we want quotes from both sides about this? What do you reckon? Gillyweed ( talk) 05:23, 2 May 2009 (UTC)
202.89.167.125 - please view the discussion I initiated at your talk page. I look forward to your response. Lcwilsie ( talk) 19:42, 6 May 2009 (UTC)
202.89.167.125 - please view the updated discussion on your talk page. I have elevated this concern to WP:WQA, which you can view here. Lcwilsie ( talk) 13:46, 14 May 2009 (UTC)
I came here because of a request on the NPOV board, and have been reading the history and monitoring as time permited. There is a problem, which I have already noted. As this area has not yet been addressed, I have tagged the article to note the dispute. Please work towards eliminating POV statements and inferences. If you cannot edit without inserting your own viewpoints, then please don't bother. This edit war is close to attracting more serious intervention than just the NPOV board having a look. Astynax ( talk) 05:52, 3 May 2009 (UTC)
You can go back and restore the edits on which you were working. Reverting is not a cooperative way to move forward with an article. This article was and is far from any the point where it cannot be improved. Whatever was there does not “belong” to anyone. It is more constructive to edit whatever new has been added, working together to refine and better the article. If something was removed, then consider adding only such material back into the article in a NPoV way. At some point, repeated reversions without explanation or an attempt to discuss become vandalism, and intervention will be required. Astynax ( talk) 19:12, 4 May 2009 (UTC)
Reversions do not make a better article, nor do they make it NPOV. Two specifically I question: [9] – It is unclear why these sources were removed. They are appropriate further reading for women considering a home birth.
[10] These reverts (removal of BJOG study) are the subject of ongoing discussion [11]. Continuing to remove them when there are multiple editors who would like to include them is against WP policy WP:DE. The NICE study that is cited in the article was written in 2007, which only covers published data through 2007. Are we to avoid including any other data until another such review is published? The BJOG study is current and needs to at least be discussed. If it is too contentious to include it in the safety section, it should be included in a "Legal situation in the Netherlands" section, as the Australia-specific safety paragraph is included in the "Legal situation in Australia" section.
The reversion by 202.89.167.125 ("Undid biased pro-homebirth editing by Gillyweed, and replaced with NPOV") [12] actually resulted in reverting past eleven intermediate changes, from four different editors and a bot. The minor spelling corrections and capitalization corrections will have to be redone. This is a waste of everyone's time. Lcwilsie ( talk) 20:13, 6 May 2009 (UTC)
I have protected the article from editing for a week. Please use this time to arrive at a consensus on the talk page as to what material should or should not be included. 202.89.167.125 please consider this a formal admonishment to restrict your comments to the article rather than the editors. That same advice goes for everyone participating here. Nandesuka ( talk) 12:37, 7 May 2009 (UTC)
Resolved:
Somewhat Resolved: The legality sections will focus on legality, with safety discussion limited to that which is driving legislation. Any safety discussion here needs to be held to the same standards as applied to the Research on Safety section. For example, it is appropriate to state that "The Department is...in the process of commissioning an independent professional review of home births," but selectively quoting portions of the article, or quoting and making conclusions from a newspaper article rather than the original source is original research and below the standards permitted elsewhere in this article.
Continued discussion/resolution needed:
Lcwilsie ( talk) 13:46, 13 May 2009 (UTC)
Attention both Gillyweed and anonymous editor 202.89.167.125: You are prolonging the edit war that several of us have been trying to mitigate. Please stop. Both of you.
202.89.167.125 - the version you keep reverting to is not an ideal version, so your reversions undo other improvements. Also, you have not yet responded to my comment on your talk page, or the post to WP:WQA. Your etiquette has not improved, despite several requests from several editors, and until you at least address the comments I left for you, few of us will take you or your edits seriously. As several people have mentioned, it is more helpful to improve upon text rather than revert. Calling Gillyweed a vandal does not validate your reversions, as he is attempting to incorporate some of the discussions we've had above (see specifically the changes to the "further reading" section). Your continued reverting, despite calls to stop, meets the definition of vandalism.
Gillyweed - the large number of changes you are making in each edit is making it difficult to counteract the anonymous editor's knee-jerk reversion. Some of the changes you have made have been quite good, but they are getting lost and undone. Please make smaller, incremental changes, one section at a time. I appreciate your contributions to the article, but we must all work together to make the article less POV, and that is hard to do when there are massive changes in each edit. Lcwilsie ( talk) 20:34, 19 May 2009 (UTC)
You will see progress on this article when you take my opinions seriously, and reflect on your own biases, and meet me in a neutral place. The BJOG has published a critical appraisal (Abstract: http://www3.interscience.wiley.com/journal/122379095/abstract) this month of the BJOG home birth study which (although written by a homebirth-supportive consultant - Sue Bewley) rips it to shreds for EXACTLY the reasons I've stated above. Quite a surprise it's been done so quickly, in fact. The 'weed's edits are no more discourteous than mine, I am simply mirroring her tactics. Your tactics seem to try and involve admins who then opine that my edits are OK & more neutral than yours, and amusingly you then call these vandalism. I'm keeping debate on the talk page until agreement is reached unlike the 'weed, and this is vandalism also. You completely ignore any relevant points. I've made on this discussion page, and expect me to respond to "lectures" on petty issues like not having a user name! It's all quite amusing. I'm even claiming CPD points for it! My midwifery & medical colleagues all think it's amusing also, and are anxious to get involved should it be necessary (it's not yet).
Let me be clear. Women make decisions on the basis of websites such as this. They trust what they read. It's OUR duty to make sure the info within is not propaganda either way whatever we believe. Informed choice is the goal, but can't be achieved if the information is wrong. If your edit says homebirth is great and all the research says it is so, and it's taken to heart by women who then have a poor outcome, you are responsible for misleading them. Perhaps already babies have died as a result of your edits? We'll never know. —Preceding unsigned comment added by 202.89.167.125 ( talk) 10:22, 22 May 2009 (UTC)
I disagree with inclusion of this statement: "For other women, immediate access to medical help in a birthing center or hospital setting is very important." Although we can cite references for the reasons women choose to birth at home, the reasons women birth at a birthing center or hospital are more complex. Summarizing it as simply a desire to be close to medical help is inaccurate. Some women don't know HB is an option, for some women their insurance will only cover hospital birth, others live in an apartment and would feel uncomfortable laboring at home, still others live in areas where HB midwives are unavailable - in short, there are many, many reasons a woman might birth in a hospital. To simply say it is based on a choice of safety or medical access polarizes the article unnecessarily. Also - is it at all useful to include? It seems the more valid point for the article is why women would choose to birth at home, when 70-99.5% of the women in their country (depending on location) would make a different choice. Lcwilsie ( talk) 20:54, 19 May 2009 (UTC)
I'd appreciate contributions as anyone finds them: In Birth by Tina Cassidy she cites finances as a reason many women do/don't choose homebirth (before medical insurance many women gave birth at home because it was cheaper with a midwife, when free hospital care was available many poor women went there -- now many women go the hospital because not all countries/insurance companies offer homebirth, and in the Netherlands there are incentives for homebirth which may contribute to their higher rate). Ina May Gaskin cites personal and spiritual reasons in Spiritual Midwifery and Guide to Childbirth. I know it is complex and I hope to capture as much as we can. It isn't only the dichotomy between intervention/no intervention. Lcwilsie ( talk) 19:58, 26 May 2009 (UTC)
Please discuss and agree on content disputes. 202.89.167.125, the article is semi-protected for awhile, so you won't be able to directly edit it. Please persuade the established editors here to make changes. — EncMstr ( talk) 20:05, 22 May 2009 (UTC)
The WA report "Review of Homebirths in Western Australia" has finally been released. A copy can be found here: [14]. Page 17 refers to deaths from 2000-2006 (there were no perinatal 'home birth' deaths in 2007/08) and states:
Of the 18 perinatal deaths and one post-neonatal death from 2000 to 2006, nine (9) had lethal congenital or chromosomal abnormalities; two (2) were premature (27 and 32 weeks gestation); two (2) had group B streptococcus which was reported as the attributing factor and three (3) were rated as having ‘low’ or ‘no’ preventability. Of the three (3) remaining deaths, there are questions as to preventability. These are the two (2) cases of hypoxic peripartum death (Cases 10 and 11); and the baby with shoulder dystocia (Case 17).
The report goes on with an analysis of the problems besetting homebirth services in the State and recommends a range of improvements to further reduce mortality (including increased training for midwives and medical practitioners in hospitals when transferes occur). It does find that for low-risk women there is no increase in mortality but also finds that the current HB model used accepts women of varying risk levels (including high risk) and thus this could explain some of the higher rates of mortality from 2000-06. The hospital at a higher total perinatal death rate than HB but hospitals take women with all risk profiles, not simply low risk.
In summary, the WA report provides little evidence either one way or another regarding the safety of home birth for low-risk women. It does not recommend the closure of the current home birth programs. It actually proposes the expansion of home birth to SW WA.
I'd appreciate other editors views but I recommend that we delete the section related to home birth in WA as it provides little increased clarity about homebirth in Australia. Gillyweed ( talk) 04:13, 26 May 2009 (UTC)
This page is an archive of past discussions. Do not edit the contents of this page. If you wish to start a new discussion or revive an old one, please do so on the current talk page. |
I have removed the following paragraph:
"Conversely, there are some studies that demonstrate a higher perinatal mortality rate with assisted home births (e.g. Perinatal death associated with planned home birth in Australia: population based study. BMJ. 317(7155):384-8, 1998 Aug 8.) Despite these, It is generally accepted that properly assisted home birth carries no greater risks than hospital birth for low-risk pregnancies.
The reason I have done so is that the Bastian study is highly contentious in Australia, not only for the conclusions drawn but also the methodology. In short, the study showed that for normal healthy women, the outcomes at home were as good, if not better than in hospital. But for women with complications, home birth was less safe. The reason for this lower safety aspect was that in transferring from home to hospital, the transfer was 'stuffed up' and the woman did not receive adequate hospital treatment.
Prof Sally Tracy has done quite a bit of work on the Bastian et al study and one of her letters regarding the study can be found on the BMJ site here: BMJ 1999;318:605 ( 27 February) http://bmj.bmjjournals.com/cgi/content/full/318/7183/605/b?hits=10&FIRSTINDEX=0&AUTHOR1=bastian&SEARCHID=1117021210508_6194&gca=bmj%3B318%2F7183%2F605%2Fb&
I've got umpteen references at work that shows that HB is as safe, if not safer than hospital births. I'll put up references to them tomorrow.
But, I don't think we want to have reference arguments in the article text. Here is a good place for reference arguments. -- Maustrauser 11:57, 25 May 2005 (UTC)
I've removed the several references to homebirth being as safe or safer than hospital birth as this is opinion (and was anyway contradicted further down in the article). This belief is not based upon any available evidence. All the references quoted below refer to published work that is deeply flawed and subject to much bias. Unfortunately, It is technically almost impossible to randomise women to proper trials of birth location in order to minimise bias. Quite rightly, women want to choose for themselves where to give birth, not take part in a trial.
The best evidence thus far for birth safety when doctors aren't supervising is quoted in the article. Cochrane reviews are non-biased, quite rigorously performed and have great influence. This Cochrane review gathers several trials comparing birth centres with a homely environment run exclusively by midwives, with hospital care. They are properly conducted randomised trials. Several effects were noted, not least of which was an increase in perinatal mortality of about 80% in the birth centres. This is an important fact, probably the most important in this debate, and should be discussed in the article.
Women are served by having access to evidence from both sides of the debate. Perinatal mortality is low overall in low-risk women, wherever the birth takes place. Obscuring the relative risks however, is not acceptable, and I hope these changes help understanding. —The preceding unsigned comment was added by 87.113.31.143 ( talk) 18:31, 28 April 2007 (UTC).
I've removed the stuff on babies being immune to infections at home. Evidence please. Most infections seen in paediatric practice are community acquired. Do babies get infections at home? Obviously. They are not immune! MRSA (for instance) is widely carried in the community. To say that MRSA is common in new mothers and their babies is also untrue. I've seen 1 case in 10 years. Evidence please? MS
Not sure if this is the right place to discuss this, but better than starting another section on Safety. I removed the following paragraph, in reference to the Johnson & Daviss 2005 BMJ article:
Neonatal mortality in itself is not even discussed in the BMJ article. The authors list a combined intrapartum and neonatal death rate of 1.7/1000. Also, the figure of 0.9/1000 is incorrect as discussed below in the Citations section. FlyingLattice 21:31, 3 August 2007 (UTC)
There is no scientific evidence that shows that homebirth is as safe as hospital birth. All the existing scientific evidence shows that homebirth has an increased rate of preventable neonatal death in the range of 1-2/1000 ABOVE the rate in the hospital. There are studies that CLAIM to show that homebirth is as safe as hospital birth, but none of them compare homebirth to hospital birth among low risk women in the same year.
Consider the most widely quoted paper, the Johnson and Daviss paper (BMJ, 2005). In 2000, the neonatal death rate for low risk women at term in the hospital was 0.7/1000, substantially less than the homebirth neonatal death rate. Look at the paper. Where is the neonatal death rate for low risk women in the hospital in 2000? The authors left it out and compared homebirth in 2000 to hospital birth in out of date papers extending back to 1969. Johnson and Daviss ACTUALLY showed that homebirth has a neonatal death rate more than 3 times higher than hospital birth.
The National Center for Health and Clinical Excellence, a healthcare watchdog organization, has recently performed a comprehensive review of the entire homebirth literature:
"... The quality of evidence available is not as good as it ought to be for such an important health care issue, and most studies have inherent bias. The evidence for standalone midwife led units and home births is of a particularly poor quality.
The only other feature of the studies comparing planned births outside [physician] units is a small difference in perinatal mortality that is very difficult to accurately quantify, but is potentially a clinically important trend. Our best broad estimate of the risk is an excess of between 1 death in a 1000 and 1 death in 5000 births. We would not have expected to see this, given that in some of the studies the planned hospital groups were a higher risk population."
I only quoted a brief excerpt from the report. The report itself analyzes each paper in depth. I urge people to read the report itself; there is not enough room here to quote each specific analysis, but among the papers discussed:
The Janssen study showed substantially higher neonatal mortality in the homebirth group. (They don't mention it, but Janssen subsequently publicly renounced her original contention that she had shown homebirth to be as safe as hospital birth).
The Bastian study showed substantially higher neonatal mortality in the homebirth group.
The National Birthday Trust compared a low risk homebirth group to a high risk hospital group.
The Farm study is merely a case series. The author should not have chosen a high risk hospital group for comparison and therefore, the study cannot even be regarded as a comparison study.
The Johnson and Davis study shows a high level of neonatal deaths. (They don't mention it, but Johnson and Daviss also have undisclosed conflicts of interest.)
Amy Tuteur, MD August 7, 2007.
I have removed the following paragraph with regard to the NICE study:
This quote was taken from the 22 June 2006 report, which was subsequently updated 22 March 2007. The updated report has removed all quantifiers of perinatal mortality when comparing home birth to hospital birth. I have replaced the old quote with the newest information. FlyingLattice 23:15, 11 September 2007 (UTC)
The following paragraph has been removed:
This is an uncited statement of speculation and has no evidence basis whatsoever. FlyingLattice 23:15, 11 September 2007 (UTC)
These references conclude that home birth is as safe if not safer than hospital birth.
Sorry for not getting them up earlier as promised. -- Maustrauser 13:23, 31 May 2005 (UTC)
All of these are incredibly poorly conducted studies that have marked biases and are statistically almost useless. Why haven't you quoted the many studies showing excess mortality? (Although these are similarly methodologically poor)
Nandesuka has removed the reference to women at home being less susceptible to hospital based infection, such as Golden Staph. Whilst I agree that the sentence was not written particularly well, it is a truism that if you aren't in a hospital then you are not likely to get hospital based illnesses. Why not point this out?
Frankly, I know how clean my house is. I control who my guests are. I don't have an airconditioning system potentially spreading airborne diseases all over the place. Of course, a normally kept, hygienic home is cleaner than a hospital full of sick people. -- Maustrauser 12:02, 25 May 2005 (UTC)
I just found the Dr. Lewis Mehl study in the PubMed database. Searching for "mehl l" finds the study and a followup. The author has published a number of other interesting articles as well; the Tasered mother one is kind of famous I think.
Hopefully this link to the abstract isn't going to expire. Notice that the midwives came out slightly ahead even after the worst 50% of the doctors were eliminated from the comparison. (more fetal distress and placental problems with the doctors)
That's pretty damning I think.
A 1983-1989 study by the Texas Department of Health shows births attended by doctors having 3x the death rate of births attended by non-nurse midwives. The name of this study is:
Maybe somebody knows where to find the text?
AlbertCahalan 03:44, 27 May 2005 (UTC)
Pretty damning? I don't think so. A retrospective, (obviously non-randomised) very low-powered study, with no information on points of comparison between the two groups, published in an obscure journal 28 years ago. Surprisingly analysed by intention to treat, which is actually a small thing in it's favour.
No-one argues that midwives intervene less - of course they do. The point is that lack of intervention costs lives. This study is nowhere near powerful enough to demonstrate anything that fact or it's absence, not withstanding it's methodological flaws. Try again. —Preceding unsigned comment added by 202.89.167.125 ( talk) 10:24, 20 August 2008 (UTC)
I removed the sentence which said that "Certified Nurse-Midwives may attend homebirths in all 50 States, if their back-up physician will allow it." I can't speak to other states, but I know that in Nebraska it's illegal for a CNM to attend a homebirth regardless of physician approval. I suspect this may be the case elsewhere as well, but as I said I can't say for certain. spoko 5:47, 11 June 2006
I removed the sentence which said that first-time mothers are especially likely to want assistance at a home birth. In the U.S., practically everyone wants assistance. The number of unassisted home births is vanishingly small, first-time mother or not.
I also changed the passage that said that midwife-assisted home-birth is illegal in the listed states. It is not. Our son was born at home in Illinois with two midwives assisting -- nothing illegal about it. Midwives who assist at births must be nurse-practitioners, which makes finding one hard, but not impossible. I suspect the other states listed have wiggle-room as well -- and that the states listed as "legal" have some restrictions. I would strongly suggest taking down that map. It's deceptive, and providing deceptive information about such a subject is kind of indefensible . Providing a link to a site that gives an in-depth discussion of conditions in all 50 states would be a much better option. NoahB 14:34, 2 August 2005 (UTC)
I'm fairly sure homebirth is actually legal in NY, since I've had three (2000, 2002, 2004), attended by a midwife and paid for by Medicaid, so I imagine if it were illegal someone would have said something! It would probably be a good idea to check the accuracy of the rest of the map, too.
This is the only site on the web that analyzes the homebirth studies from a scientific point of view. It is not pro-homebirth, because the reality is that there is not a single study that demonstrates that homebirth is as safe as hospital birth. There are studies that claim to demonstrate homebirth safety, but a statistical analysis shows that they do not.
I find it interesting that it was removed because it "attacks" homebirth. Don't people deserve the opportunity to read both points of view, and make a decision for themselves? One of the most notable things about homebirth advocacy is the absolute unwillingness to respond to scientific and medical criticism of homebirth. Professional homebirth advocates do not present their claims to meetings of scientific or medical peers, and never put themselves in a position to take or answer questions posed by scientific or medical peers.
Women (and men) do not need to be protected from opposing points of view. Homebirth advocacy should be able withstand scientific and medical critique, and not have to hide from it by deleting any references that are not favorable.
Amy Tuteur, MD January 23,2007 —The preceding unsigned comment was added by 66.31.153.193 ( talk) 14:34, 23 January 2007 (UTC).
1. The first sentence as it stands is nonsense. Taken logically from this, a birth in an ambulance, in a car, on a plane, in a workplace, a school, a shopping centre or anywhere else other than a hospital or 'birthing centre' is a home birth.
2. The statement In countries where midwives are the main carers for pregnant women, home birth is more prevalent is contentious. In the UK, midwives are the main carers but home birth is NOT more prevalent. Perhaps the writer was looking from a US position, where I believe physicians are the main carers.
3. Legal situation in the United States section: either the first or the last sentence should go - they say the same. Emeraude 18:30, 1 February 2007 (UTC)
I am checking citations. I loath to remove something that is on here, but if it is unsupported then I will. Need help on this one: "Matthews et al., Infant Mortality Statistics from the 2000 Period Linked Birth/Infant Death Data SetNational Vital Statistics Report, Volume 50, Number 12, August 2002. Shows that the hospital neonatal death rate for 2000 was 0.9/1000..." I have read the report and cannot find the "hospital neonatal death rate for 2000 was 0.9/1000" anywhere in the report. In fact, the report states, "Other variables that are available in the linked file data set (1), but are not discussed in this report include: …place of delivery…" Whomever added this reference, please provide the page on which it appears. Thanks. Kreisman 00:48, 18 February 2007 (UTC)
You need to perform the calculations yourself. Infant Mortality Statistics from the 2000 Period Linked Birth/Infant Death Data SetNational Vital Statistics Report does not separate the statistics by risk level. The appropriate comparison group for the Johnson and Daviss study would be white women at term with singleton pregnancies. Looking at the raw data we find:
2,824,196 births to white women at term (37+ weeks), see Table 2 and 2,602 deaths of white babies weighing more that 2500 gm see Table 6 for a death rate of 0.9/1000. Amy Tuteur, MD 01:31, 19 February 2007 (UTC)
According to ATuteur's references above, her numerator and denominator are not from the same population, which is necessary to compute a valid mortality rate. As she states above, her neonatal deaths were white babies who weighed more than 2500g, but the population she chose for live births were white babies at 37 weeks or greater. This is not a valid calculation. To determine a valid neonatal death rate, you must use deaths of babies born at 37 weeks or greater, over live births of babies born at 37 weeks or greater (or deaths of babies weighing more than 2500g over live births of babies weighing more than 2500g). Babies weighing more than 2500g may still be preterm, and babies born after 37 weeks could weigh less than 2500g. The tables in the referenced dataset don't give the data that is required to calculate a real rate. ATuteur's annotation for this reference should be removed, and quite possibly also the National Vital Statistics citation itself, as it carries no references to home birth.
FlyingLattice 20:50, 3 August 2007 (UTC)
Under 'Safety' the following para appears:
This was NOT a study of home birth vs hospital. it was a study of birth centres. Further, I am unable to figure out how the 80% figure was calculated, unless it is using the Scandanavian BC study which was flawed. Either way, this is not a study of HB and should be deleted. Any views? Gillyweed 12:49, 15 May 2007 (UTC)
I've removed it as it was not a HB study. Meerkate 06:50, 21 May 2007 (UTC)
It was not a homebirth study, but it is a gold standard combination of RCT studies demonstrating an 80% increase in risk of death in babies born under the care of midwives in birth centres next door to labour wards. Therefore, even when access to rapid medical help is available, midwives still presided over a large increase in the death rate. Gillyweed once again shows that she can't understand simple statistics. The 80% (actually 83%) refers to the relative risk increase in death in the birth centre babies ie RR=1.83. If Gillyweed had even the most basic grasp of stats she would have realised this. She should stop editing on areas involving research or statistics as she has not the cognitive ability to interpret anything more than the simplest of comparisons. —Preceding unsigned comment added by 202.89.167.125 ( talk) 08:17, 9 August 2008 (UTC)
I would just like to note that there is a Cochrane review on, specifically, "Home vs. hospital birth" by Olsen O and Jewell MD. It was published in 1998, Issue 3, which I don't have remote access to at the moment, so I don't have it in front of me. I should drop by the library within the next week or so, so I'll update the article with that information. --[[User:Astraflame|Astraflame] ( talk) 04:34, 22 August 2008 (UTC)
I removed several sentences refuting the conclusions of the Johnson & Daviss article. As mentioned in the "Systematic review of safety" section, this article doesn't discuss neonatal mortality alone, but combines it with intrapartum mortality. So the subsequent remarks were irrelevant (comparing apples to oranges), and proper citations were not given. Furthermore, the reference to an out-dated 1969 was not salient as this study reported a hospital neonatal mortality rate of 0.5--1.1/1000 which was among the lowest in the study, and comparable to the 0.72/1000 rate mentioned.
The further paragraphs on the National Center for Health and Clinical Excellence should probably also be double-checked. Minded17 05:33, 29 August 2007 (UTC)
I've re-read the Johnson & Daviss article and the NICE recommendations and appropriately (at least according to my reading) edited the section. I removed the Enkin article as it did not seem as well-supported and repeated NICE's final recommendation anyway, but if someone sees the need for it to be there, feel free to add it back in. Astraflame ( talk) 15:24, 12 August 2008 (UTC)
I've added the BMJ study's own comparisons between the hospital & home groups showing that they were hugely different. Equivalent groups are required for valid comparisons between cohorts, so this is a vital part of the criticism of this flawed case series.
I've also adjusted the perinatal mortality rates which were incorrectly quoted on here and in the study. Stillbirths are part of the perinatal mortality rate, and reflect the standard of care given. They are always included in maternity statistics. Planned breeches & twins are high-risk and outside the study, so the rate of 2.7 is reduced back down to 2.4/1000.
The image on this page may be too erotic for a health and safety article. Please consider the visually implied POV. Collin239 19:22, 9 October 2007 (UTC)
WP is censored. Items contrary to WP policies are routinely removed. I assume you are a woman, and you don't know how the image looks to a man.
Besides which, is this image real? Why does she still have that big a bulge if the baby is that far out of her? Collin239 09:58, 10 October 2007 (UTC)
If it were my own lover giving birth to my own child, I would have the right to see her. What I'm worried about is the average man, getting off on the picture, submitting this page to AdSense, etc. Collin239 10:49, 10 October 2007 (UTC)
The photo also caught my attention, but mostly with a question: Why is it that I've seen about a dozen similar photos over the last few years, and never yet found a single birth photo online in which the woman is wearing anything at all? I know several women who have given birth at home, and none of them has stripped completely naked (although two wear nothing except a soft bra after the early stages of labor). Is it just that the only women who are actually willing to post a birth photo also have minor exhibitionist streaks? Are they perhaps trying to make a political point about top-free equality? Perhaps it's a regional thing, or that no one takes a picture of home births that happen during the winter? I wouldn't want to discourage any birthing woman from doing anything that makes her more comfortable, but I wonder if the exclusion of clothes-wearing women promotes a subtle POV bias.
(This message written by a woman whose toes are still cold despite central heat, a mild climate, two blankets and a pair of heavy socks.) WhatamIdoing ( talk) 03:00, 17 December 2007 (UTC)
I removed this text from the article:
Most hospitals have a policy of trying to deliver the baby within 30 minutes of determining a caesarean is required, however, owing to the theatre preparation time, this goal is only achieved 66% of the time. Despite this, an increase in morbidity or mortality has not yet been shown in the literature when it takes longer than 30 minutes. This generally fits with the view that very few obstetric emergencies require immediate action. [2]
There is indeed an article by Tuffnell, Wilkinson, and Beresford that says this. It's an article that addresses hospital standards in performing C-sections, and talks about the standards in question. This has no particular link between the sentence that precedes it (stating that some women prefer to be closer to a hospital in case of emergencies.) First, proximity to a hospital is valued by some women not only because of the speed of a c-section, but because of proximity to a NICU, in cases where delays that threaten the life or health of the neonate can be measured in minutes, if not seconds (e.g., premature delivery before 32 weeks). Second, "hospitals don't meet their own standards for delivering a baby within 30 minutes" does not mean "hospital emergency c-section is not faster than home birth followed by c-section. Lastly, "no increase in morbidity when a hospital takes more than 30 minutes to perform a c-section" is different than "no increase in morbidity in home vs. hospital births," which is addressed in the previous section. In short, this text looks like something someone went on a fishing expedition to find so they could perform synthesis to "respond" to a point of view that they found distasteful. Nandesuka ( talk) 11:02, 19 July 2008 (UTC)
Jolly good. I'll go on record to say that the user Gillyweed is biased and is an inappropriate editor of this page. She constantly reverts evidence that shows homebirth is detrimental to the health of the baby. I will continue to revert to my edit everytime an inappropriate statement is written that is not balanced and evidence based. The reason most hospital births don't adhere to the 30 minute standard is that monitoring allows a judgement to be taken as to speed. in those emergencies where rapid delivery by Caesarean section is vital, it takes place within 10-15 minutes in hospitals. Homebirthers would still be being loaded onto the ambulance. Hence the 2% perinatal mortality rate - see the UK independent midwives database of stats for confimation of this figure. —Preceding unsigned comment added by 202.89.167.125 ( talk) 13:49, 25 July 2008 (UTC)
As with many controversial topics on wikipedia, this article rides the razor edge of swinging to a pro/anti sentiment. Wikipedia does not give advice, and it is our job as editors, coming from all different backgrounds on this issue, to keep the content accurate and neutral. What I don't understand is - *why* is homebirth controversial? No one is being forced to give birth at home if they'd rather birth in the hospital. If it is only an issue of "threat to the life of the baby" then why aren't the anti-home birthers clamoring for better pre-natal care and testing, too? Successful birth is more than just the hours of labor. The well-being of the mother is not to be ignored, and it seems that most statements against home birth simply parade neonate mortality (and even the statistics on this being more of a risk are questionable). There is no question that maternal well-being (defined as intact perineum, vaginal birth, etc) is better when a birth is at home. Please enlighten me (without a loooong rant) as to what issues we could address to make anti-home birth advocates more comfortable with the article. Lcwilsie ( talk) 16:43, 31 July 2008 (UTC)
No Gillyweed you are not busy. Hence your ability to spend half your life on here. (UTC)
I think that this area of health is contentious because a birth at home threatens the livelihood of those who see childbirth as a disease needing medical attention. If the majority of births could be handled without vast quantities of medical intervention (and only the small proportion who really need medical care went to hospital) then many would feel a pinch in their hip pocket nerve. It's all about power and not evidence. Gillyweed ( talk) 10:46, 9 August 2008 (UTC)
Wrong again Gillyweed. I can see that there is jealousy driving your inaccurate opinions on this topic. The hospital I work at has lower intervention rates for low risk women than the local homebirth service. So, how would homebirthing affect livelihoods? The homebirth service is much more expensive per delivery and requires more midwives to be employed as it's less efficient. It gives considerable disruption to the lives of the midwives who are on call 24 hours, 7 days a week. The homebirth risk of perinatal death averages 1.5% over the 8 years since inception, and this is low-risk women only in a high-income area. To compare, our hospital's perinatal death rate is 0.2% despite sorting out all the high-risk women as well. The local homebirth maternal death rate has been supressed but there have been deaths which is totally unacceptable given the low-risk women. Do you really think that allowing an excess of death of mothers and babies and neonatal brain damage is a cheaper way of delivering healthcare? What a silly opinion - it makes lots of work for neonatal units. Another example: look at New Zealand where a left-wing government has enabled the practice of large numbers of independent community midwives. The CS rate there continues to climb and is one of the highest in the world... Evidence is something Gillyweed knows little about unfortunately. —Preceding unsigned comment added by 202.89.167.125 ( talk) 07:58, 10 August 2008 (UTC)
Do you actually bother searching properly, Gillyweed?
First page of search results.
These are all highly motivated women, as well.
YOUR NHS reference of 14% refers to a) ALL women not just primips and b) Does not include transfers after the 2nd stage of labour eg. PPH, retained placenta, neonatal problems, 3rd degree or extensive tears. These transfers count.
Even the independent midwife quoted has a 25% rate!
You think my figures are an "order of magnitude" out? Sorry.
Your credibility is in your boots I'm afraid. —Preceding unsigned comment added by 165.118.1.51 ( talk) 08:40, 26 August 2008 (UTC)
If we are going to discuss transfer rates, we must discuss reasons for transfer. As written it would seem that all transfers are due to obstetric emergency, but this is not true. Many women transfer due to fatigue, failure to progress, or because they want analgesia (if we want to use just one midwife as an example, Anonymous' ref#2 cites 27/39 transfers for these reasons). Others transfer because symptoms during labor indicate there may be a need for intervention and the attending professional feels it is prudent to be near higher tech equipment (these symptoms may or may not bear out as an eventual emergency). And yes, still others transfer due to an imminent emergency. Lcwilsie ( talk) 03:13, 27 August 2008 (UTC)
Gillyweed, I've left in your recent restoration of the first paragraph in the "safety" section, but I have re-reverted your removal of the discussion of the Government of Western Australia's release here: http://www.health.wa.gov.au/press/view_press.cfm?id=756. This seems like a perfectly appropriate source, and is perfectly on topic. If you want to remove it, could you please discuss that here first? Thanks. Nandesuka ( talk) 11:23, 10 August 2008 (UTC)
Nandesuka has removed Gillyweed's text for no apparent reason. My reading of the WA press release supports exactly Gillyweed's changes. I'm putting it back. Obman ( talk) 06:04, 13 August 2008 (UTC)
(un-indenting) Good catch about "excess". I've rewritten it as "A review indicating a relatively higher neonatal mortality rate of babies born at term to mothers who had chosen a home birth...", which is in line with the precise wording in the statement. Nandesuka ( talk) 23:48, 13 August 2008 (UTC)
The piece about obstetricians' emergency indemnity arrangements is irrelevant to an article on homebirth so is removed. —Preceding unsigned comment added by 202.89.167.125 ( talk) 11:34, 20 August 2008 (UTC)
Gillyweed's summary of the government's study was correct. "concluded that five out of the six deaths had no link to place of birth". Doesn't mean its true, it's just an accurate reflection of what is stated by the source. Chemical Ace ( talk) 07:14, 20 April 2009 (UTC)
I don't know if this is appropriate to include, but it came up in some discussions recently. One reason there are so few home births in the US is that liability insurance is prohibitively expensive for midwives and their covering physicians. Many home birth midwives practice without insurance, others practice in a birth center to avoid the fees they would incur if they tried to be insured. I would, of course, have to dig up references to support this prior to posting anything. It seems a bit inaccurate to say that women choose between a home birth and a hospital birth purely because of their personal preferences or their perception of the safety issues, when in many parts of the US the only option is a hospital birth, or at best a birth center. Home birth is more common in countries where it is more accessible. Just curious if anyone would support including some information to this effect. Lcwilsie ( talk) 19:48, 11 August 2008 (UTC)
This paragraph has been inserted and removed several times. Let's discuss here and stop wasting bandwidth with reverts.
I think we need more than just this study in the safety section to improve the data. We need statistical significance, not just percentages (many studies have few patients, so 40% vs 31% might not be significant). All studies are going to have their flaws, but by looking at many we increase the odds of being able to draw realistic conclusions. Lcwilsie ( talk) 12:31, 22 August 2008 (UTC)
(unindent) Anonymous poster: Proper WP etiquette would be to continue the discussion here rather than resuming the edit wars. See some of the discussions above for examples.
Astraflame: thank you for your edit, it is an improvement.
Several studies show that the perinatal mortality rate remains quite low in homebirth (0.8-2%). Studies show that medical intervention (augmentation, anesthesia, surgery) is quite low in homebirth. Does this mean homebirth is more or less risky than a hospital birth? This is the difficult part to document. If the data comparing homebirth to hospital birth is not adequate, then perhaps we can't make statements that homebirth is more/less risky. However, we can mention the studies that attempt to reliably make these reports. We can report the data from several studies that provide statistics on homebirth outcomes. We can report data on the outcomes of hospital births.
Lcwilsie (
talk) 20:06, 22 August 2008 (UTC)
Astraflame. Thanks for your edit and I'm happy now not to revert as long as Gillyweed and Lcwilsie leave alone something they are unable to understand - the shortcomings of published research. The problem with wikipedia is that the uneducated are allowed a say on complex topics with many shades of grey. I will be looking very regularly to make sure they haven't changed things to reflect their anti-medical/hospital agenda. The UK is conducting a large-scale review of homebirth over the next few years. Again it will not be a RCT, but hopefully, the study design will be tight and allow us to be more confident about the obvious risks & benefits of homebirth.
Again, I emphasise that our hospital manages to get similar emergency CS rates, episiotomy rates etc (with a fraction of the perinatal mortality) to the local public homebirth service, despite us having a mixed low & high risk clientele. Hospital birth does not have to mean interventional birth, and excellent midwives can flourish in hospital. High-risk women need to benefit from good midwifery & hence reduced intervention too. We would hope to publish our figures in the next year or two - maybe I can persuade the local homebirth management into a direct comparison (with properly matched but unselected cohorts of course) - unlikely as they know the score! (UTC)
Study | Years | Location | Sample | Matching Criteria |
---|---|---|---|---|
Gulbransen G, et al. N Z Med J 110:475 | 1973-1993 | New Zealand | 9776 - home birth
? - hospital birth |
unknown, unable to obtain a copy |
Woodcock HC, et al. Midwifery 10:125 and Med J Aust 154: 367 | 1981-1987 | Western Australia | 976 - home birth
2928 - hospital birth |
Year of birth, parity, previous stillbirth, previous death of liveborn child, maternal age, maternal height, and marital status |
Janssen PA, et al. Birth 21:141 | 1981-1990 | Washington State | unknown | unknown, unable to obtain a copy |
Ackerman-Liebrich U, et al. BMJ 313:1313 | 1989-1992 | Zurich, Switzerland | 489 - home birth
385 - hospital birth (207 matched pairs) |
age, parity, gynaecological and obstetric history, medical history, partner situation, social class, nationality |
Wiegers TA, et al. BMJ 313:1309 | 1900-1993 | Gelderland, Netherlands | 1140 - home birth
696 - hospital birth |
post-hoc control of background differences (of race, attendance at antenatal classes, uncertain dates, non-optimal body mass, and obstetric history) by splitting groups into relatively favorable and infavorable backgrounds |
Lindgren HE, et al. Acta Obstet Gynecol Scand 87:751 | 1992-2004 | Sweden | 897 - home birth
11341 - hospital birth |
unknown, unable to obtain a copy |
Chamberlain G, et al. Pract Midwife 2:35 | 1994 | UK | 5971 - home birth
4634 - hospital birth |
age, number of previous children, location, past obstetric history |
Janssen PA, et al. CMAJ 166:315 | 1998-1999 | British Columbia, Canada | 862 - home birth
743 - physician-attended hospital birth |
obstetric risk status; multivariate analysis was used to control for other variables (maternal age, lone parent status, income quintile, parity and use of illicit substances) |
Above is the list of studies that I found that were looking at home birth from 1980 onwards. Unfortunately for the world, but fortunately for me trying to do a review of the literature, there aren't that many home birth studies of relatively reasonable quality out there, period. Many studies are simply descriptive or of the mothers' impressions of their experiences, so I disregarded many more studies than I have included here. As they are all cohort studies (no randomized controlled trial studies exist for home birth), the main methodological issue, as far as I can see, was looking at how they controlled for variations in the study.
The two cohort studies that I excluded (Johnsson and Daviss BMJ 330:1416 and Bastian, et al. BMJ 317:387) seemed to just take the national averages in the nations they were studying, so frankly, their data seemed not even worth looking at. Most of the cohort studies for which simply listed the matching criteria matched the backgrounds of the populations before data was even collected, i.e. Ackerman-Liebrich, et al. made 'matched pairs' of their patients and Woodcock, et al. selected the hospital records so that they would match the population of the home birth patients (it was a retrospective study). Janssen, et al. tend to use multivariate analysis during the study to correct for the effect of confounding factors.
Wiegers, et al. used a much cruder method of post-hoc controlling of confounding factors -- by making an index of background factors and then splitting the women into four groups: primiparous with 'favorable' background, primiparous with 'unfavorable background, multiparous with 'favorable' background and multiparous with 'unfavorable' background. I'm not sure if that's a particularly statistically sound method, and furthermore, as they report their perinatal data with a similar index, it seems to me that comparing their results to other studies' results would probably not be worth the effort.
As I was unable to obtain the copies of three of the papers listed above, I wasn't able to determine how well their study was actually conducted. Concerns have already been raised on this talk page regarding the Chamberlain, et al. (also known as the National Birthday Trust) study, and I'm suspicious about the Lindgren, et al. study as it mentions "randomly selecting" the hospital records for the control sample without any mention of matching criteria. However, the Janssen, et al. study speaks of using multivariate analysis again to control for confounding variables, and so the results should be relatively trustworthy, though one would have to look up the paper to be sure.
Regarding editing the actual 'Safety' section, I agree with Lcwilsie that a summary of the actual studies (or at least, the ones that are reliable) would be more accurate than trying to make any statement concerning the 'riskiness' of home birth. The NICE recommendation can probably serve as a rough summary of the lack of research and the tentativeness of the conclusions that one can draw from the research, but I don't think that it's sufficient for actually describing what's going on here. Frankly, it's a much more muddled picture than even pro-home birth and pro-hospital birth advocates are willing to believe. -- Astraflame ( talk) 13:30, 23 August 2008 (UTC)
I propose we add or expand sections discussing: history of homebirth, international practices (beyond US, Europe, Australia), childbirth preparation, potential benefits of homebirth (won't this be contentious!). Other suggestions? Lcwilsie ( talk) 14:24, 25 August 2008 (UTC)
I agree with this. Perhaps Gillyweed can use her large amount of free time to be more constructive and provide this information, instead of (unsuccessfully) obfuscating detailing of the existing research knowledge on homebirth and making sarcastic comments. —Preceding unsigned comment added by 165.118.1.50 ( talk) 08:02, 26 August 2008 (UTC)
Hi. Can you add information about the lack of support for pre-natal testing among midwives? (or support if you can prove it) In my experience, I have found homebirth midwives to be ignorant of prenatal testing, supplying false and misleading information about prenatal testing and afraid to say they are pro-choice (if they are) (as a lot of their clients are pro-life). My point is that if you are pro-choice and want a homebirth, you should know where to get prenatal testing and know what kind of test you want before you start seeing a homebirth midwife. There seems to be a meme in homebirth that people who do prenatal testing are motivated by "profit" and that it is dangerous to the baby (there is some risk of course!) yet they seem to be ignorant that many conditions can be treated in the womb and that it may be helpful to have some knowledge of abnormalities from the get go. —Preceding unsigned comment added by 12.159.234.138 ( talk) 18:43, 30 July 2009 (UTC)
The conclusion of the WHO reference is as follows:
"So where then should a woman give birth? It is safe to say that a woman should give birth in a place she feels is safe, and at the most peripheral level at which appropriate care is feasible and safe (FIGO 1992). For a low-risk pregnant woman this can be at home, at a small maternity clinic or birth centre in town or perhaps at the maternity unit of a larger hospital. However, it must be a place where all the attention and care are focused on her needs and safety, as close to home and her own culture as possible. If birth does take place at home or in a small peripheral birth centre, contingency plans for access to a properly-staffed referral centre should form part of the antenatal preparations."
I couldn't find anything in the reference with the WHO exclusively advocating "the use of more naturalistic, small-scale methods of childbirth, rather than the large-scale units now prevalent in developed countries" (from the wiki article)
There is something "The call for a return to the natural process in many parts of the developed world..." but that is not a statement by the WHO in support of "naturalistic methods".
A summary of the WHO's views, written by me: "The WHO has released a statement supporting the right of women to choose where they give birth. In the case of low-risk pregnancies, with appropriate support and contingency plans women can give birth at home." —Preceding unsigned comment added by Chemical Ace ( talk • contribs) 13:11, 15 April 2009 (UTC)
We seem to be engaged in an eternal edit war, not blaming anyone - I've put this article on the neutrality board for advice. —Preceding unsigned comment added by Chemical Ace ( talk • contribs) 01:21, 18 April 2009 (UTC)
"Putting quotes from every interest group isn't going to help this article. " Gillyweed's comment when the position of the Royal_Australian_and_New_Zealand_College_of_Obstetricians_and_Gynaecologists was deleted. - If we're going to have quote from anybody we ought to have there's. They are an interest group, but a pretty important one at that with academic kudos.
Chemical Ace ( talk) 11:34, 19 April 2009 (UTC)
Gillyweed is a homebirth midwife (or partner of same), who thinks that he can tell everyone what's what because he's some minor wikipedia editor. He lacks the intellectual faculty to understand the literature surrounding this subject, as evidenced by his putting the recent BJOG study (yet another fairly useless observational unmatched "cohort" study in a failing maternity system with some of the worst outcomes in Europe) at the top of the safety section in a previous edit. If the neutrality board had seen this article before I started bringing some semblance of balance and order, they'd have been even more shocked. This article was truly laughable then, rather than the fairly rubbish one we have now. —Preceding unsigned comment added by 202.89.167.125 ( talk) 12:52, 19 April 2009 (UTC)
Chemical Ace ( talk) 06:59, 20 April 2009 (UTC)
The problem with including comments from anyone is we have to know the motivation for their statement. If you include a comment from the WHO, they are a generally unbiased group, with a stated interest in promoting best practices for health around the world. Having a statement from an association of obstetricians and gynecologists has the appearance of bias because obstetricians and gynecologists provide (almost universally) hospital-only birth. Similarly, having a statement from an organization of homebirth midwives would have the appearance of pro-homebirth bias. If this were an article on automobile safety, would we provide a quote from GM stating that American cars are safer than foreign models? Or would we include statements from independent testing organizations? Lcwilsie ( talk) 12:56, 30 April 2009 (UTC)
This all seems a bit silly. Why has the BJOG reference been removed by 125.168.40.224? It is the biggest study of HB yet done and is the most recent and yet because it apparently doesn't meet his/her requirements (while it does meet the peer review requirements of the journal) it is removed? I can only conclude that because it states that HB is as safe as hospital birth it goes against his/her biases and thus needs to go. Is this true? Let's deal with this one issue and then when we have agreement move onto the next point? 125.168.41.123 ( talk) 00:08, 21 April 2009 (UTC)
Why haven't you put the big studies in that show homebirth to be riskier than hospital as well then? BIAS. I haven't put them in because they're poor quality too and my edits are not biased, unlike yours. The BJOG study is no better than these other studies in methodology (in fact it's worse as it concerns itself with a unique maternity system with exceedingly poor results in every birth arena - the worst in Europe, despite a healthy population). So you'll be reverted each time you try to include this BJOG study without an analysis of it's many shortcomings, and inclusion of the other big studies with analysis. The NICE report is right - not enough evidence either way - and that should stay. They've looked at all the data and all the studies. They know what they're talking about. You know less than nothing. Very arrogant to think you know more than the panels of experts at NICE, aren't you? I'm very patient, you'll be reverted every day, until what you write isn't biased and NPOV according to wikipedia's guidelines. —Preceding unsigned comment added by 202.89.167.125 ( talk) 11:47, 21 April 2009 (UTC)
The safety arguments are ruining the rest of the article. I think that the re-write about study methodology was well done by Astraflame (see section 20 of discussion and "Research on Safety" as it stands at this moment in the article) and I think it adequately addresses many of the issues brought up as the concerns over what studies to include is hashed out over and over in the discussion. Based on the literature and study methodologies, I do not think it is possible to conclude whether homebirth is as safe, safer, or less safe than other birth locations and thus no statement should be made in the article. I propose that the body of the article discuss the details of homebirth (what it is, where it occurs worldwide, etc), and there could be a link to a separate page for a detailed discussion of safety. Also, the factual accuracy claim at the top of the homebirth page seems to apply only to the accuracy of home vs hospital birth, rather than to the accuracy of other details in the article. If I am wrong, please provide a detailed list of questionable facts so they may be properly addressed. Lcwilsie ( talk) 17:28, 29 April 2009 (UTC)
Hi Astynax, I wonder how we can find our way through these two extremes. I think what we are dealing with are two philosophies. (1). (The HB view) is that birth is not an illness nor a sickness and thus physicians should not be required unless otherwise indicated. Midwives are the appropriately trained people to determine whether there are medical problems that need oversight by a physician. The other philosophy (2) (The medical view) is that birth (because it is physiological and things can go wrong) should be managed by medical specialists. I doubt whether you will ever persuade one person who is firmly in one camp to move from one to another. Nor do we need to. What we need to present is information from a neutral position. Stating that a homebirth requires the agreement of an obstetrician is just as extreme as saying home birth is safe under all circumstances. Neither is true. The waters for this article are further muddied by people from different countries writing material. Eg. In UK, the Government is encouraging more homebirth. In US, the Government doesn't seem the slightest bit interested. In NZ, home birth is on the increase and the majority of women are cared for by midwives without obstetric involvement. In Australia there is a god almighty battle occuring between RANZCOG and the maternity consumer groups for 'control' of the maternity system. These national battles also get played out on these pages too and some of the editors (I am accused of being one, but hope I'm not) get rather extreme in their edits. Now none of this is unique to homebirth and WP has many policies designed to over come them. I'd forgotten about the POV forking policy. You're right. We just need get this one right. Perhaps we can try and get a consensus on the statement that you want included that "A physician's evaluation and monitoring is needed." What evidence can we find to make this statement? No doubt we can find an ACOG statement about this, but we can also find a RCM statement saying it isn't necessary. Perhaps we meed a paragraph explicitly explaining why there is so much debate over this issue and the reasons for the passion arise from the different philosophies about birth (I noted above). Do we want quotes from both sides about this? What do you reckon? Gillyweed ( talk) 05:23, 2 May 2009 (UTC)
202.89.167.125 - please view the discussion I initiated at your talk page. I look forward to your response. Lcwilsie ( talk) 19:42, 6 May 2009 (UTC)
202.89.167.125 - please view the updated discussion on your talk page. I have elevated this concern to WP:WQA, which you can view here. Lcwilsie ( talk) 13:46, 14 May 2009 (UTC)
I came here because of a request on the NPOV board, and have been reading the history and monitoring as time permited. There is a problem, which I have already noted. As this area has not yet been addressed, I have tagged the article to note the dispute. Please work towards eliminating POV statements and inferences. If you cannot edit without inserting your own viewpoints, then please don't bother. This edit war is close to attracting more serious intervention than just the NPOV board having a look. Astynax ( talk) 05:52, 3 May 2009 (UTC)
You can go back and restore the edits on which you were working. Reverting is not a cooperative way to move forward with an article. This article was and is far from any the point where it cannot be improved. Whatever was there does not “belong” to anyone. It is more constructive to edit whatever new has been added, working together to refine and better the article. If something was removed, then consider adding only such material back into the article in a NPoV way. At some point, repeated reversions without explanation or an attempt to discuss become vandalism, and intervention will be required. Astynax ( talk) 19:12, 4 May 2009 (UTC)
Reversions do not make a better article, nor do they make it NPOV. Two specifically I question: [9] – It is unclear why these sources were removed. They are appropriate further reading for women considering a home birth.
[10] These reverts (removal of BJOG study) are the subject of ongoing discussion [11]. Continuing to remove them when there are multiple editors who would like to include them is against WP policy WP:DE. The NICE study that is cited in the article was written in 2007, which only covers published data through 2007. Are we to avoid including any other data until another such review is published? The BJOG study is current and needs to at least be discussed. If it is too contentious to include it in the safety section, it should be included in a "Legal situation in the Netherlands" section, as the Australia-specific safety paragraph is included in the "Legal situation in Australia" section.
The reversion by 202.89.167.125 ("Undid biased pro-homebirth editing by Gillyweed, and replaced with NPOV") [12] actually resulted in reverting past eleven intermediate changes, from four different editors and a bot. The minor spelling corrections and capitalization corrections will have to be redone. This is a waste of everyone's time. Lcwilsie ( talk) 20:13, 6 May 2009 (UTC)
I have protected the article from editing for a week. Please use this time to arrive at a consensus on the talk page as to what material should or should not be included. 202.89.167.125 please consider this a formal admonishment to restrict your comments to the article rather than the editors. That same advice goes for everyone participating here. Nandesuka ( talk) 12:37, 7 May 2009 (UTC)
Resolved:
Somewhat Resolved: The legality sections will focus on legality, with safety discussion limited to that which is driving legislation. Any safety discussion here needs to be held to the same standards as applied to the Research on Safety section. For example, it is appropriate to state that "The Department is...in the process of commissioning an independent professional review of home births," but selectively quoting portions of the article, or quoting and making conclusions from a newspaper article rather than the original source is original research and below the standards permitted elsewhere in this article.
Continued discussion/resolution needed:
Lcwilsie ( talk) 13:46, 13 May 2009 (UTC)
Attention both Gillyweed and anonymous editor 202.89.167.125: You are prolonging the edit war that several of us have been trying to mitigate. Please stop. Both of you.
202.89.167.125 - the version you keep reverting to is not an ideal version, so your reversions undo other improvements. Also, you have not yet responded to my comment on your talk page, or the post to WP:WQA. Your etiquette has not improved, despite several requests from several editors, and until you at least address the comments I left for you, few of us will take you or your edits seriously. As several people have mentioned, it is more helpful to improve upon text rather than revert. Calling Gillyweed a vandal does not validate your reversions, as he is attempting to incorporate some of the discussions we've had above (see specifically the changes to the "further reading" section). Your continued reverting, despite calls to stop, meets the definition of vandalism.
Gillyweed - the large number of changes you are making in each edit is making it difficult to counteract the anonymous editor's knee-jerk reversion. Some of the changes you have made have been quite good, but they are getting lost and undone. Please make smaller, incremental changes, one section at a time. I appreciate your contributions to the article, but we must all work together to make the article less POV, and that is hard to do when there are massive changes in each edit. Lcwilsie ( talk) 20:34, 19 May 2009 (UTC)
You will see progress on this article when you take my opinions seriously, and reflect on your own biases, and meet me in a neutral place. The BJOG has published a critical appraisal (Abstract: http://www3.interscience.wiley.com/journal/122379095/abstract) this month of the BJOG home birth study which (although written by a homebirth-supportive consultant - Sue Bewley) rips it to shreds for EXACTLY the reasons I've stated above. Quite a surprise it's been done so quickly, in fact. The 'weed's edits are no more discourteous than mine, I am simply mirroring her tactics. Your tactics seem to try and involve admins who then opine that my edits are OK & more neutral than yours, and amusingly you then call these vandalism. I'm keeping debate on the talk page until agreement is reached unlike the 'weed, and this is vandalism also. You completely ignore any relevant points. I've made on this discussion page, and expect me to respond to "lectures" on petty issues like not having a user name! It's all quite amusing. I'm even claiming CPD points for it! My midwifery & medical colleagues all think it's amusing also, and are anxious to get involved should it be necessary (it's not yet).
Let me be clear. Women make decisions on the basis of websites such as this. They trust what they read. It's OUR duty to make sure the info within is not propaganda either way whatever we believe. Informed choice is the goal, but can't be achieved if the information is wrong. If your edit says homebirth is great and all the research says it is so, and it's taken to heart by women who then have a poor outcome, you are responsible for misleading them. Perhaps already babies have died as a result of your edits? We'll never know. —Preceding unsigned comment added by 202.89.167.125 ( talk) 10:22, 22 May 2009 (UTC)
I disagree with inclusion of this statement: "For other women, immediate access to medical help in a birthing center or hospital setting is very important." Although we can cite references for the reasons women choose to birth at home, the reasons women birth at a birthing center or hospital are more complex. Summarizing it as simply a desire to be close to medical help is inaccurate. Some women don't know HB is an option, for some women their insurance will only cover hospital birth, others live in an apartment and would feel uncomfortable laboring at home, still others live in areas where HB midwives are unavailable - in short, there are many, many reasons a woman might birth in a hospital. To simply say it is based on a choice of safety or medical access polarizes the article unnecessarily. Also - is it at all useful to include? It seems the more valid point for the article is why women would choose to birth at home, when 70-99.5% of the women in their country (depending on location) would make a different choice. Lcwilsie ( talk) 20:54, 19 May 2009 (UTC)
I'd appreciate contributions as anyone finds them: In Birth by Tina Cassidy she cites finances as a reason many women do/don't choose homebirth (before medical insurance many women gave birth at home because it was cheaper with a midwife, when free hospital care was available many poor women went there -- now many women go the hospital because not all countries/insurance companies offer homebirth, and in the Netherlands there are incentives for homebirth which may contribute to their higher rate). Ina May Gaskin cites personal and spiritual reasons in Spiritual Midwifery and Guide to Childbirth. I know it is complex and I hope to capture as much as we can. It isn't only the dichotomy between intervention/no intervention. Lcwilsie ( talk) 19:58, 26 May 2009 (UTC)
Please discuss and agree on content disputes. 202.89.167.125, the article is semi-protected for awhile, so you won't be able to directly edit it. Please persuade the established editors here to make changes. — EncMstr ( talk) 20:05, 22 May 2009 (UTC)
The WA report "Review of Homebirths in Western Australia" has finally been released. A copy can be found here: [14]. Page 17 refers to deaths from 2000-2006 (there were no perinatal 'home birth' deaths in 2007/08) and states:
Of the 18 perinatal deaths and one post-neonatal death from 2000 to 2006, nine (9) had lethal congenital or chromosomal abnormalities; two (2) were premature (27 and 32 weeks gestation); two (2) had group B streptococcus which was reported as the attributing factor and three (3) were rated as having ‘low’ or ‘no’ preventability. Of the three (3) remaining deaths, there are questions as to preventability. These are the two (2) cases of hypoxic peripartum death (Cases 10 and 11); and the baby with shoulder dystocia (Case 17).
The report goes on with an analysis of the problems besetting homebirth services in the State and recommends a range of improvements to further reduce mortality (including increased training for midwives and medical practitioners in hospitals when transferes occur). It does find that for low-risk women there is no increase in mortality but also finds that the current HB model used accepts women of varying risk levels (including high risk) and thus this could explain some of the higher rates of mortality from 2000-06. The hospital at a higher total perinatal death rate than HB but hospitals take women with all risk profiles, not simply low risk.
In summary, the WA report provides little evidence either one way or another regarding the safety of home birth for low-risk women. It does not recommend the closure of the current home birth programs. It actually proposes the expansion of home birth to SW WA.
I'd appreciate other editors views but I recommend that we delete the section related to home birth in WA as it provides little increased clarity about homebirth in Australia. Gillyweed ( talk) 04:13, 26 May 2009 (UTC)