California College of Midwives,
3889 Middlefield Road
Palo Alto, Ca 94303
650 / 328-8491
September11,
2003
Dr. Joyce Brothers
King Features, 888 Seventh Ave.
New York City, New York 10019.
RE: August 9,
2003 ~ your reply
“Home birth deserves careful consideration” (copy
of her letter below)
Dear Doctor Brothers,
I have been a fan of yours for many decades and have
never seriously disagreed with your advice before now. However, I am
distressed to report that you have inadvertently become a part of the
“problem” – that is, spreading misinformation in the name of (but not
the fact of) science.
I
am sure you did not realize that your August 9th response
regarding home-based midwifery care was predicated on a single biased
study, entitled “Outcomes of
Planned Home Births in Washington State" by Pang et al. This study was designed and conducted by obstetricians and
published in the American College of Obstetricians and Gynecologists’
journal in August 2002. Unfortunately, the authors chose a distorted model
for data collection and misrepresented the previous research that clearly
documented the safety of midwifery and home birth for a healthy population.
As a result, this study gives the erroneous impression that home birth is
irresponsible and dangerous. However, that is wrong on both counts.
When
care is provided by an experienced professional, in conjunction with
appropriate access to medical services for complications, the consensus of
the scientific literature is that community-based midwifery for healthy
women with normal pregnancies has an equally low perinatal mortality rate
when compared with institutional settings. In addition, the midwifery model
of care, which is predicated on physiological management, is actually protective
for mothers and babies as it reduces the operative delivery rate from
approximately 37% to under 5%. This vastly reduces the immediate and
long-term complications that are associated with surgical delivery. The hard
question here is not whether home birth is “safe” but whether
interventionist obstetrics for a healthy childbearing population (with its
37% operative rate, 70% when episiotomy is included) is safe and cost
effective. Statistically-speaking, the answer to that has to be “no.”
Upon
careful review, this quantitative study suffers from two fatal flaws --
selection bias and measurement bias -- as well as a disingenuous design that
excluded midwives and other home-birth practitioners from its development.
Furthermore, its authors arrived at global conclusions based on extremely
narrow and non-representative
criteria that included (by their own admission) missing and misclassified
data. In promoting their research, the authors also violated established
“scientific process” which decrees that a study first be published and
critiqued by other knowledgeable professionals before its conclusions are
released to the lay press as a scientifically validated and incontrovertible
“fact.”
Instead,
this study was promoted through the press for several months before the
12-page paper was published in the ACOG journal. In May a short 2-paragraph
abstract of the Pang study was circulated to the media via press releases to
Reuters New Service (May 8th), the Associated Press (syndicated
articles across the country throughout the summer) and the NY Times (August
7th). In sensationalized newspaper style, the headlines screamed
everyone’s worst fears --“Home
Births Linked to More Infant Deaths.” The first sentence delivered the
coup de grace: “Twice as many
infant deaths occurred during home births than with hospital deliveries.”
It must emphasized again that these news stories were circulated before the
research paper was even published.
Predictably,
this triggered a firestorm of hysterical reactions by frightened
grandparents and conscientious physicians all over the country, all of whom
now were convinced that to plan a home birth was to wantonly sacrifice
innocent babies just so that parents could selfishly pursue hedonist
pleasures. Since no one could read an unpublished
study, a knowledgeable critique of the study’s methods and conclusions was
impossible and no one was able to respond factually to the many salacious
newspaper stories. I suspect that you read one of those articles yourself.
However,
I also suspect that you, as well as other members of the public, did not
realize that this methodologically-flawed study was not able to speak
definitively on the topic of safety. False conclusions were generated by a
faulty study design that skimmed off the operative complications from the
hospital birth group before they calculated the complication rate for the
hospital cohort. For example, their assessment of relative risks totally
ignored an astronomical rate of upstream medical interventions associated
with "planned hospital
birth" such as 63% Pitocin-accelerated labors, 63% epidural rate, 35%
episiotomies, 11% forceps and vacuum extraction rate and 26% cesarean
surgery. The 37% operative deliveries were not included in the study’s
statistics even though the risk of operative delivery was 6 to 10 times
greater for healthy women choosing hospital-based care than the same healthy
cohort who chose home-based birth care.
This
meant the study did not account for the inevitable complications of surgery
such as fourth degree lacerations, infection, maternal hemorrhage, depressed
babies, intracranial bleeding, NICU admissions, etc., that were vastly
increased for women who had a planned hospital birth -- a 37% forceps /
vacuum extraction / Cesarean section rate, compared to 4% operative delivery
rate for planned home births. In a
well-designed and unbiased study, this crucial data would necessarily be
part of the overall statistical analysis. Adding insult to injury they
likewise disregarded all the delayed or down-stream complications
associated with this high operative rate, such as pelvic floor dysfunction
and incontinence. Also missed were the delayed complications associated with
Cesarean surgery, including a 13-fold increase in emergency hysterectomy and complications of
post-cesarean reproduction, including increased rates of infertility, tubal
pregnancy, stillbirths, abnormal placentation (previa, accreta and percreta)
and uterine rupture in a future pregnancy resulting in neonatal death or
permanent disability of the next baby.
As
one can see from these particulars, the Pang study was not what it
represented itself to be. Instead of being an unbiased and informative
public service as advertised, it was a study in disinformation, clearly
revealing that if you ask the wrong questions, you will get the wrong
answers. The best solution to the ‘home birth’ controversy is to
make maternity care in homes and hospitals equally
safe and satisfactory so that families are not forced to choose home
birth for want of physiologically appropriate, compassionate and cost
effective care in hospitals.
The
problem with contemporary obstetrical care in the US is the uncritical
acceptance of an unscientific
method -- interventionist care for
healthy women. The important questions here are why the obstetrical
profession consistently fails to teach, learn or utilize physiological
management for healthy women, why it is promoting the risky procedure of
“maternal choice” Cesarean as safer and “better” than normal birth
and why, when provided with corrective information, it fails to take
corrective action. Does the American public realize that the basic creed of
medicine -- “In the first place, do no harm” -- is no longer being
practiced by many in the obstetrical profession?
I
hope that a future column may inform your readers of these disturbing facts
so they can join the many mothers, midwives and other concerned citizens who
are trying to rehabilitate obstetrical medicine for healthy women by
insisting that evidence-based practices become the foremost standard for 21st
century maternity care.
Accompanying
this letter is a more extensive recounting of the political and scientific
basis of these assertions as well as copies of supportive documents from
respected obstetrical publications. A comprehensive critique of the Pang
study is on our web site at www.collegeofmidwives.org.
Faith
Gibson, LM, CPM
Executive Director, ACCM/CCM
Go
on to Critique
of Broader Issues Link to Citations
for "Critique"
======================================================================
Saturday, August 9, 2003
By DR. JOYCE BROTHERS
SYNDICATED COLUMNIST
DEAR DR. BROTHERS: I love my daughter and her
2-year-old daughter, my first grandchild. She's a beautiful, healthy
youngster. She was born at home at my daughter's insistence. She's going to
have another baby in a very short time, and she again wants to have this
child at home, despite the fact that they now live in a much smaller place
that's a relatively long distance from any hospital. I've offered to pay any
costs if she'll only go to a hospital, but I don't want to fight about it.
Neither she nor the father of this child is tidy. Their home is really
filthy, but I certainly don't want to talk about dirt. Am I foolish? Should
I let this go, or should I argue? -- D.N.
DEAR D.N.: Your daughter was lucky the first time, and
you were lucky to have a healthy grandchild. I don't think you should argue,
but I do believe you should let her know that a medical journal recently
reported that the risk of neonatal death was almost twice as high when the
delivery was begun in the home. To prove how lucky your daughter was before,
this research shows that the risk of death is even higher for first-time
mothers.
The risks of heart problems, respiratory disorders and
many other unexpected problems occur more frequently in home births. If she
doesn't believe you, ask her to discuss this with a doctor at your hospital.
Although I understand that you don't want a quarrel with her over this or
her house cleaning, sanitary conditions when giving birth are certainly a
factor.
Write to Dr. Joyce Brothers via King Features, 888
Seventh Ave., New York, NY 10019.