September 28, 2002

Letter to the Editor of Obstetrics & Gynecology
(American College of Obstetricians and Gynecologist's professional journal -- the 'Green Journal'):

Re: Pang JW, et al. Outcomes of planned home births in Washington State

    The study by Pang et al. regrettably adds much heat but little light. Its literature review misrepresented the consensus of research on home-based birth services for healthy women. When care is provided by an experienced professional, in conjunction with appropriate access to medical services for complications, the consensus of the literature is that it is equally safe and also protective for mothers and babies by reducing the operative delivery rate and associated complications.

    The authors also did not understand the idea of “planned” home birth from the perspective of the practitioner. Midwives do not arrive at that determination until we have personally evaluated the mother after active labor has begun. This is the same protocol used by small community hospitals. They do not “plan” to provide intrapartum care to women with obstetrical complications and so routinely evaluate the mother at the onset of labor and transfer those found to be at high risk. So also for midwives.   The Pang study did not/could not make this distinction because the Washington State birth registry does not identify the intended place of birth or the circumstances of hospital transfer.

    But regardless of the exact numbers used, the bottom line is that the neonatal mortality rate for home-based care is generally excellent -- determined by most studies to be around 2 per 1,000, excluding congenital anomalies (1). Using that criteria, even this flawed study only recorded a rate of 2.48 per 1,000, with a total Cesarean / operative rate of less than 4%. The difference between the two cohorts was slightly more than one per 1,000. However this 1/10 of one percent “advantage” in the hospital cohort came with the consider cost (economic and otherwise) of an approximately 30% operative rate. Were immediate and down-stream complications associated with the normally high operative rate in planned hospital births, especially those in post-cesarean women, factored into the authors’ definition of “relative safety”, then home-based birth services would have to be considered a protective form of care for the babies of healthy women.

  1. "Meta-Analysis of the Safety of Home Birth." BIRTH 24:4-13. Rooks, Judith Pence. 1997.

Faith Gibson, LM, CPM
3889 Middlefield Road, Palo Alto, CA 94303
650 / 328-8491
Executive Director, American College of Domiciliary Midwives
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