American College of Domiciliary Midwives
“Outcomes of Planned Home Birth In Washington State”
University of Washington School of Public Health
and Community Medicine, Seattle Washington;
Jenny W. Y. Pang, MD, MPH James D. Heffelfinger, MD;
Greg J. Huang, DMD, MSD; Thomas Benedetti, MD, MHA
& Noel S. Weiss, MD, Dr. PH
Link to Comprehensive Review & Critique on the
Pang-Benedetti Study on Home-based Birth
ACDM's Letter to the Editor -- Obstetrics and Gynecology -- ACOG's "Green Journal"
Synopsis & Commentary: How Asking the wrong questions gives you the wrong answers!
~ The Pang-Benedetti study appears to have been designed to mislead and to artificially create a media "event" to generate flattering publicity for obstetricians and hospital birth by making home-based birth care appear dangerous. Perhaps this is a misguided effort to neutralize the extensive media coverage of deaths in hospital patients as a result of medical mistakes, antibiotic-resistant infections and adverse drug reactions. Why we put healthy women and babies into such a bio-hazardous environment is a source of wonderment. However, two wrongs do not make a right.
The authors of this study distorted and misrepresented research on the safety of midwifery and home birth. The research paper contained the following serious methodological flaws:
- Substituted "educated guesses" for factual data
- Used "soft" data to arrive at "hard" conclusions
- Skimmed off the operative complications from the hospital group before calculating the complication rate for the hospital cohort
- Came to global conclusions based on extremely narrow criteria that included (by their own admission) missing and misclassified data
- Ignored an astronomical rate of upstream medical interventions (such as Pitocin-accelerated labors, narcotic use, epidurals, episiotomies and admission of babies to neonatal intensive care) associated with "planned hospital birth"
- Ignored all the subsequent down-stream complications associated with the high operative rate in planned hospital births, especially those in post-cesarean women
- Efficacy was obviously not part of their equation
I must assume that all this slight of hand was a desperate attempt to distract us from asking the really important questions -- is interventionist hospital care safe for healthy women with normal pregnancies? Is it scientific and evidence-based? Is it cost-effective? Does it meet the practical needs (emotional and developmental as well as long term safety) of mothers and babies? If we have a national emergency, such as a bio-terrorism attack or a “dirty bomb”, will it be appropriate to take up 20% of our entire medical and surgical resources to provide maternity care to healthy mothers and normal babies while our loved one suffer unattended in the hospital parking lot? Do we want to hospitalize healthy women and normal babies under such circumstances, exposing them to small pox, anthrax or sarin nerve gas? Is it wise to a have a national maternity care system in which doctors only know how to numb mothers up with drugs and anesthesia and then suck, pluck or cut the baby out with instruments or surgery?
To keep the public continually distracted and derailed from these topics, there has been a virtual media blitz in the last couple of years reporting on "research" that claims to have scientifically established the dangers of all vaginal breech deliveries, natural labor in post-cesarean pregnancies (VBAC), the so-called "silent epidemic" of normal vaginal birth and now the supposed "double neonatal mortality rate" of community-based midwifery. Simultaneously with this campaign to eliminate normal birth, organized medicine has been actively promoting and idealizing the elective or "maternal choice" Cesarean (and daylight obstetrics!) as better and safer lobbying for a return to "Once a Cesarean, always a Cesarean". If you want to eliminate normal birth you have to eliminate its advocates and guardians -- the midwives -- and then belittle and question the respectability of midwifery consumer groups like Citizens for Midwifery and the International Cesarean Awareness Network (ICAN). Organized medicine's favorite modus operendi has always been biased research (or a prejudiced rendition of it in the lay press) and a plan to denigrate everything associated with midwives, physiological management and the families who choose home-based maternity care.
This is what happens when all oversight and public accountability is removed from an "expert" system -- a phenomenon recently brought to light in the Enron / Author Anderson / World.com accounting scandal. The vast majority of Americans don't understand the stock market or high finance accounting and are not personally affected enough to want to do the necessary "home work". We all trusted (wrongly it turns out) that unbiased 'experts' within these systems would be honest and that some how, somewhere, someone "in the know" was watching and would report any wrong-doings. The same lack of public knowledge applies to normal childbirth, the 'expert' system of obstetrics and relative medical research. It is especially true for the technical language and statistical principles used in studies published on the relative safety or risks of various obstetrical interventions and philosophies of normal childbirth care. Our assumptions that somebody somewhere is watching and holding people accountable for the truth certainly was not true for those that benefited from the manipulations of corporate earnings. Unfortunately it also is not true for interventionist obstetrics and those that benefit from the manipulation of its research. It is an expert system dominated by its own self interests, without adequate public accountability and no critical oversight by the media.The authors of this study used three major (and many minor) methods to manipulated the data, which included a hidden agenda in the research design and poor scientific methods, such as missing and misclassified data. First they took note of observations from a 1996 Washington State study on licensed midwives and planned home birth that identified an unusual number of neonatal deaths from congenital malformations. This was the result of choices by pregnant women not to utilize genetic testing and/or not to abort babies with birth defects. Then the study authors designed a research project to make it appear as if the cause of these neonatal deaths was the danger of "planning" a home birth and that if these same women had instead "planned" a hospital birth, twice as many of their babies would have lived.
It is true that babies with congenital heart disease (which accounted for 5 deaths from birth defects) are easier to manage when they are born in a large hospital with a cardiac specialist immediately present. However, this argument could then be used to force all pregnant women to have extensive genetic testing (which is not always accurate) and to require that all deliveries occur only in big medical centers with 24-7 coverage by pediatric cardiologists. The take-home message is that aborting "defective" fetuses is an excellent strategy for shaving a few tenths of a percent off the perinatal mortality statistics for obstetrician-attended hospital births, since only live births are counted while terminated pregnancies are not. By using these dubious numbers the subsequent bragging rights is likewise an excellent strategy for gaining media attention by claiming to have proved the superiority of interventionist obstetrics for healthy women. Left to its own "merits" interventionist obstetrics always fails to provide superior results.
The second major manipulation in the “Outcomes of Planned Home Birth In Washington State” study was the core premise of the research combined with its core method -- a study of safety based on intended place of birth conducted in a state that does not keep track of that information. This study should never have been entitled "Planned Home Birth" because this characteristic could not be accurately quantified. The birth registry in Washington State does not record "Intended Place of Birth". It is not an "intended" home birth when the midwife assesses the mother at the onset of active labor and, detecting a potential or actual problem (bleeding, meconium, heart rate irregularities, etc), recommends immediate hospitalization. It is not an intended home birth when a premature baby delivers precipitously as the midwife walks in the front door. However, the Pang-Benedetti method -- based on assumptions instead of verifiable facts -- counts both of these circumstances as "planned" home births, even though one of the two deliveries did not even occur at home. One wonders why anyone would plan to use birth certificate data from a state that does not collect information on “intended” place of birth as the foundation for a study on birth outcomes relative to "intended" place of birth? (If you are confused it is because they want it to be confusing.) Since when does an "educated guess" based on a series of unsupported assumptions replace accurate data, especially when talking about such a small data set -- 12 neonatal deaths out of 6,133 birth? That is a ratio of 6,133 to 0.02 or 2/10th of one percent.
And last but not least, they sealed this sweet deal by excluding operative deliveries from the hospital cohort. By not counting the inevitable complications (infection, maternal hemorrhage, depressed baby, intracranial bleeding, etc) associated with planned hospital birth -- a 30% forceps / vacuum extraction / Cesarean section rate, compared to 5% for planned home births -- they came very close to being able to claim perfection -- less than one neonatal death per 1000 (actually 0.75: 1000). The CEOs of several infamous corporations (Enron, Author Anderson, World.com, etc) would instantly recognize the 'creative' accounting strategy -- ignore negative numbers, count the positives four or five times and sweep everything embarrassing under the rug. Irrespective of these machinations, a half dozen "fatal" methodological flaws renders their conclusions invalid for any purpose other than documenting the differences in choices made by families who choose community based birth services with a licensed midwife. With this data they could design public services announcements on informed choice and potential benefits of genetic testing aimed at this small subgroup of parents-to-be.
As usual, the issue of “home birth” is a really red herring -- that is, a topic that distracts us from the more important and more obvious issue which is the quality of care received by the 99% of women who choose to labor and give birth in hospitals or, due to medical circumstances, must labor and give birth in hospitals. The US spends more money on maternity services than any other country in the world, yet we have next to the lowest vaginal birth rate and are 22nd (third from the bottom) in perinatal mortality out of 25 developed countries. Shame on us. This is a very subtle or "soft" form of institutionalized violence against women and babies. In addition to the outrageous cost and other inefficiencies, there are multiple problems with the current interventionist system that beg for correction. We pray that the American College of Obstetricians and Gynecologists will rise enthusiastically to this worthy challenge.
The issue before the public is not actually the relative safety of home birth but the relative risks of "standard" interventionist hospital obstetrics for healthy women. It is hospital birth that is not "safe" and it is hospital birth that must be rehabilitated. The real story, from an investigative journalist's point of view, is why organized medicine has embarked on a smear campaign focused on all forms of normal labor or natural birth. What are the hidden economic advantages and egocentric or professional agendas for doing this? How exactly are they 'cooking the books' so that a plethora of "junk science" can be spoon fed to an uncritical media?
The problem with contemporary obstetrical care in the US is the uncritical acceptance of an unscientific method -- interventionist care for healthy women. It is a 90 year old failed experiment that never honestly assessed its hypothesis. Speaking for mothers, midwives and other consumer advocates, our goal is to require physicians of all classes (GPs, FPs and OBs) to learn, teach and utilize the physiological management of labor and birth for all healthy women, regardless of the setting (home, hospital or independent birth center) for labor and delivery.
Clearly the answer to these problems is not home birth midwifery. The challenge, as always, is to improve our hospital-based maternity care system. This requires that medical educators learn and subsequently teach the principles of physiological management to all categories of professional caregivers. It compels us to utilize physiological management and evidenced-based practice parameters for all normal labors and births, regardless of whether the birth attendant is a doctor or a midwife. This includes "patience with nature", non-drug pain management and "right use of gravity". To achieve this we must "normalize" normal labor and birth services by staffing our L&D units with certified nurse-midwives who are empowered and supported in providing the midwifery model of care as the "standard of care" for healthy women.
We must integrate community-based midwifery into the health care system a valid and respectable choice for healthy women and provide (without prejudice) essential and preventative medical services to home birth families, especially mothers who transfer into the hospital during labor. All of these corrections and improvements need to be done in conjunction with substantive changes in our national maternity care policies that underlie the provision of these services and the reimbursement of its careproviders by third-party payors and government programs.
Please go on the Comprehensive Review and Critique for
specific data and point by point rebuttal
Link to comments by Peter Humber of the Geo. C Marshall Institute
on lack of scientific rigor in obstetrical medicine
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