Talk:Home birth

god pleese take down the nude lady gave birth pic. its too sick to look at, like we needa see that. —Preceding unsigned comment added by 71.102.65.171 (talk) 15:37, 22 February 2008 (UTC)

Bastian Study

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)

Systematic review of safety

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).

Please sign your posts. I have removed your changes as they were uncited and appear to be as 'biased' as you claim the other statements are. What does 'deeply flawed' refer to? If the references quoted are not acceptable, indicate what research you have to show they are 'deeply flawed', rather than simply removing material. Plase cite your claim that there is an 80% increase in perinatal mortality in birth centres. Gillyweed 06:34, 29 April 2007 (UTC)

If you'd bothered to read my additions, you'd see my statements were referenced - a Cochrane review. Doesn't the best evidence on safety interest you? I explained what "deeply flawed" meant - the studies quoted by you or your doppelganger are subject to biases because they are not randomised controlled trials. If you don't know what one of these is, you shouldn't be commenting on scientific subjects? The "claim" (actually a major finding with scientific validity, not a "claim") of an 80% increase in perinatal mortality WAS cited ie. the Cochrane article. The reference was at the bottom. Have you bothered to access it? I find it interesting that most of this article was written by just a few people, and people who want to quote the best available evidence on this topic are "removed" by someone who can't even be bothered to look at the data. How sad and how fraudulent. MS

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:

However, same data also show 2.7/1000 neonatal deaths at homebirth compared to 0.9/1000 neonatal deaths in the hospital for white women with single babies at term [2000 data]. This excess rate of neonatal death appears to be comparable to other studies, as outlined in a summary of the homebirth research found in the Intrapartum Care Guidelines released by the National Institute for Health and Clinical Excellence in the United Kingdom.

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:

The National Center for Health and Clinical Excellence, a healthcare watchdog organization, has recently performed a comprehensive review of the entire homebirth literature and concluded that homebirth has an excess risk of neonatal death as compared to hospital birth:

"... 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."

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:

"Of note, MANA (the Midwives' Alliance of North America), the group that collected the statistics for the BMJ study, continued collecting statistics for all registered midwives from 2001-2006 and up through the present. This database contains somewhere in the range of 30,000 deliveries, perhaps more. MANA is refusing to share that data with the public. MANA is offering to release the data, but only to pre-approved individuals who sign confidentiality agreements preventing them from sharing the data with anyone else."

This is an uncited statement of speculation and has no evidence basis whatsoever. FlyingLattice 23:15, 11 September 2007 (UTC)

References on homebirth safety

These references conclude that home birth is as safe if not safer than hospital birth.

• Patricia Janssen, Shoo Lee, Elizabeth Ryan, Duncan Etches et al, Outcomes of planned homebirths versus planned hospital births after regulation of midwifery in British Colombia Canadian Medical Association Journal, FEB. 5, 2002; 166 (3)315-324.

• Chamberlain G, Wraight A, Crowley P. Birth at home: a report of the national survey of home births in the UK by the National Birthday Trust. Pract Midwife1999;2:35-39.

• Janssen P, Holt V, Myers S. Licensed midwife-attended, out-of-hospital births in Washington State: Are they safe? Birth 1994;21:141-8.

• Wiegers T, Keirse M, van der Zee J, Berghs G. Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands. BMJ1996;313:1309-13.

• Ackermann-Liebrich U, Voegeli T, Günter-Witt K, Kunz I, Züllig M, Schindler C, et al. Home vs. hospital deliveries: follow up study of matched pairs for procedures and outcome. BMJ1996;131:1313-8.

• Gulbransen G, Hilton J, McKay L, Cox A. Home birth in New Zealand 1973–93: incidence and mortality. N Z Med J1997:110;87-9.

• Patricia A. Janssen, Shoo K. Lee, Elizabeth R. Ryan, R and Lee Saxell, An Evaluation of Process and Protocols for Planned Home Birth Attended by Regulated Midwives in British Columbia, J Midwifery Womens Health 2003;48: 138–146

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)

Hello anonymous. If these studies are so poorly conducted and have such marked biases, could you detail them here for us fellow Wiki-editors? I'm personally conducting a review of these studies, and I'd love to have some help separating the crap from the useful material. Thank you for your assistance. Astraflame (talk) 14:44, 12 August 2008 (UTC)

Golden staph and other hospital infections

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)

There are any number of facts we can choose to include in an article like this. For example, one might observe that a home birth is safer than a hospital birth because if you give birth at home, you run no risk of being run over by a truck on the way to the hospital. Likewise, a hospital birth is safer because if lightning strikes the building you are delivering in, the larger hospital will provide less chance of the lightning coming in the window and striking you in the face, killing you. Implicit in including such facts is the trust on the part of the reader that we included them because they were relevant. Particularly with regards to medical issues, common sense is often a less useful guide than research. If women are dropping like flies from Golden Staph (or even if there's a statistically significant elevated risk of such), then surely there should be a study supporting that claim (and let's be clear: there is absolutely no shortage of studies on the safety of home birth.)

I'm willing to let this percolate in Talk for a few days, but I call bullshit on the Golden Staph claim unless you can show not just that it's "common sense" that women are at greater risk of catching it at the hospital, but that they actually do. Nandesuka 12:37, 25 May 2005 (UTC)

Some nice points about the lightning and the truck! I wonder how many women are injured in the 'race to the hospital for the birth?' "Sorry Officer, I was speeding because my wife is having contractions... Shame about the carnage Ihave left!" Hmm. With regard to Golden Staph etc, the Association for Improvements in Maternity Services Journal has an interesting article regarding hospital based infections. See: http://www.aims.org.uk/Journal/Vol12No3/infection.htm --Maustrauser 12:54, 25 May 2005 (UTC)

I don't know about Golden Staph in particular, but I think it's safe to say that women truly are more at risk of developing an infection in the hospital than they are at home. I think it's ridiculous to compare it to something like getting run over on the way to the hospital or getting struck by lighting. Those things could happen, but they're not really related to birth or the birth environment, except by going out on a limb. Exposing yourself and your newborn baby to a whole host of pathogens in a hospital birth setting is directly related to birth. The article that Maustrauser pointed out notes that there are studies that are showing that there is a risk of infection in the hospital. That risk is much less at home. Hospitals are where sick people go and thus where sickness is breeding. You cannot brush off that particular benefit of home birth by saying that it's "going out on a limb" like one would say about quoting the risk of being hit by lighting. Skrimpy 04:56, 28 December 2005 (UTC)

I've removed the statements on infections being more prevalent in women in hospital. There is no evidence for this statement. Your house may be clean. As a practising professional who has given care in people's houses, I'd have to say that you are lucky. There may be increased transmission of bugs between patients, however, but you need evidence to show this. Let us know the reference for good evidence comparing homebirth vs. hospital birth and infection? [Unsigned comment by 87.113.31.143]

Lewis Mehl study and Texas Department of Health study

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.

• where: Women Health. 1980 Summer;5(2):17-29
• title: Evaluation of outcomes of non-nurse midwives: matched comparisons with physicians.
• authors: Mehl LE, Ramiel JR, Leininger B, Hoff B, Kronenthal K, Peterson GH
• PMID: 7210691 [PubMed - indexed for MEDLINE]

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:

• Berstein & Bryant
• Texas Lay Midwifery Program, Six Year Report, 1983-1989
• Appendix VIIIf
• Austin, TX
• Texas Department of Health.

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)

laws on homebirth in U. S.

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)

Nurse-practitioners are often not considered to be true midwives. They generally only operate in a hospital setting while under the supervision of a physician. In other words, they are nurses. If you had a situation where the nurse practitioner was answering only to the parents, you had something rather unusual. AlbertCahalan 04:07, 14 August 2005 (UTC)

In any case, a link to in-depth discussion of all 50 states is provided at the bottom of the page. Your state is listed as "Prohibited by Statute, Judicial Interpretation, or Stricture of Practice". AlbertCahalan 04:07, 14 August 2005 (UTC)

There are nurse practitioners who are also midwives who do homebirths and are not associated with a hospital. It's not that common, but it happens. There are a handful in Chicago. There are also doctors who assist in homebirths (not midwives, at all.) The point is that it is possible to have a legal assisted home birth in Illinois (or at least in Chicago.) You just have to know what you're doing. I suspect that's the case in most cases where it's "illegal" -- and I also suspect that in many states where it's "legal", you still need certain qualifications if you're going to present yourself as a midwife. The situation is complicated, which is why the map does more harm than good, from my POV. NoahB 00:20, 17 August 2005 (UTC)

New York State

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.

It's actually kind of complicated as far as I know. Direct-entry midwives are prohibited, but nurse-midwives (CNMs) are technically nurses, so that's okay. The midwives I know in New York City that practice homebirth are all CNMs, but I'm not sure what the proportions are in the state as a whole, nor do I claim by any means to know all of the midwives in New York City ;) Hope that helps, and when I get a chance (and find the research to back my claim), I'll go back and try to fix those sections of the midwifery & homebirth articles. Astraflame (talk) 18:53, 15 August 2008 (UTC)

Homebirth Debate

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).

Firstly, post at the bottom of the page, not at the top. Secondly, please sign your posts. Thirdly, posting links to your own websites is considered 'poor form' and demonstrates your lack of desire to be neutral in your contributions to the encyclopaedia. It breaches Wikipedia Guidelines WP:COI and [[WP{:Links]]. Fourthly, your website exists to disparage homebirth and not as you claim to scientifically analyze the safety of homebirth. I removed the link to it because it did not have the balance that you profess in your link description. It reads more like a blog than an attempt to provide envidenced-based science. Where studies support homebith you claim the studies were badly designed. Where studies do not support homebirth you claim that they are well designed. Your bias is obvious. Your site attacks professions, such as midwifery, as a whole. Please feel free to add references to scientific research to this article that are peer-reviewed and verifiable. Maustrauser 21:53, 23 January 2007 (UTC)

Couple of suggestions

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)

Citation Discussion

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)

I've now read the paper too and I cannot find the rates as claimed. I think the document was added by User:Amy Tuteur, MD who runs an anti-homebirth website [1]. I had some discussions with this user on my talk page. See: [2] Maustrauser 02:05, 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)

Hodnett Study

Under 'Safety' the following para appears:

A study comparing home-like settings with hospital settings , has shown that birth in home-like settings is 80% more likely to lead to perinatal death than hospital birth (Home-like versus conventional institutional settings for birth.

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)

As this is an article about homebirth rather than midwife-attended birth, I agree the data should not be included. Birth at a birth center is not a homebirth, likewise it excludes any data about unattended homebirths. Lcwilsie (talk) 15:33, 21 August 2008 (UTC)

That study is viewed by reliable sources as being indicative of the risks of home birth (we know this because the WHO cites it as such). Excluding it on grounds like this is original research and, it seems to me, cherrypicking. Nandesuka (talk) 15:41, 21 August 2008 (UTC)

This data might be very appropriate if we were discussing the safety of midwife-attended births, or birth in facilities with a "philosophical orientation towards normal birth" (as defined in the article), but we aren't. It might also be appropriate if there were no data specifically studying births in the home, as this article defines home birth. Please provide the WHO links and I'd be happy to review them; if the WHO deems this relevant, we should link through their reports and specify what "home-like" means, but the emphasis should be on studies of true home birth. The Cochrane review states that there was a trend toward higher perinatal mortality - by definition a trend means that more infants died in the home-like setting than in the hospital setting, but the difference was not statisically significant. When you tally the differences, there was an overall 0.4% perinatal mortality in the hospital and 0.8% in the home-like setting. If I were cherry-picking to endorse homebirth, I'd emphasize inclusion of this data rather than decry it, as the conclusion of this study is that it is not statistically more dangerous (as defined by perinatal mortality) to give birth in a home-like setting. Also, the authors mention that the perinatal mortality may have been influenced by poor communication and inter-unit rivalry meaning that when a problem was identified the proper care was not immediately given by the hospital. This is not a flaw of the home-like setting, but the conflict between practitioners of the two philosophies. Although technically accurate to report the RR of 1.83 as an 80% increase (if the "not statistically relevant" bit is included, or the rates of 0.4% and 0.8%), it is inflammatory to report it as such because most people don't understand relative risk, and it ignores the very broad confidence intervals. Lcwilsie (talk) 18:07, 21 August 2008 (UTC)

Unfortunately you do not understand staistical significance. This data is a whisker away from showing statistical significance. The next RCT included will take it over the dge into statistical significance. Interesting how you criticise this A grade evidence and extol the BMJ study which is not even C grade evidence. (UTC) —Preceding unsigned comment added by 202.89.167.125 (talk)

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)

And to follow-up on my own comment, it turns out that I do have access to the Cochrane review online, but the home vs. hospital birth study happily is completely inconclusive as there are no randomized, controlled studies of home vs. hospital birth. Not entirely shocking as I doubt that anyone has been able to get enough people to participate in such a thing, but simply unfortunate. Guess we're back to arguing about cohort studies ... --Astraflame (talk) 17:53, 22 August 2008 (UTC)

Johnson & Daviss BMJ article

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)

Nice work! Nandesuka (talk) 16:31, 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.

Still refusing to sign your posts I see. Perhaps you are too busy. The study was about home birth and thus exclusion of the stillbirths is reasonable. Who knows where the stillbirths occurred? Could have been in hospital for all we know from the study. All we know is that they occurred to the 'planned homebirth cohort' Further, I'd have hardly said that the comparisons between the hospital and the home groups were too different. In fact, your being selective by stating that the homebirth cohort was lower risk. In fact, the homebirth cohort was older than the non-homebirth cohort and we are being told that being older is riskier (often used as an explanation for the increasing caesarean rate), so you can't have your cake and eat it too. I am reverting your material because it is your personal interpretation of the data and is thus verges on WP:OR. Perhaps you wish to provide some third party references instead. Gillyweed (talk) 12:07, 20 August 2008 (UTC)

Wrong. Home birth includes homebirth antenatal care. If the midwife ignores antenatal risk factors resulting in stillbirth, it's pertinent and included in every serious study in maternity. It is not reasonable to exclude. There were more teens in the hospital cohort. More primips. Stop being biased. I have replaced the criticism as it is completely relevant to discussion of this very poor study. Either remove the study completely or include it's many shortcomings. My posts are signed with my IP. Numbers or the name Gillyweed - anonymous as each other. —Preceding unsigned comment added by 202.89.167.125 (talk) 10:42, 22 August 2008 (UTC)

And another thing... all the BMJ study authors had to do was go to a maternity registry and find exact matches for their study participants in terms of parity, age, smoking etc. ie. construct an equivalent cohort. Would have been an easy task. Why didn't they do it? Laziness? Or perhaps they did do it, and didn't like what they found? We'll never know.

I agree with Gillyweed that these changes are original research. These sorts of criticisms are appropriate to cite if made by a third party, but it is not appropriate to craft novel arguments ourselves. Nandesuka (talk) 12:22, 20 August 2008 (UTC)

Applicability of Image

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)

Disagree. What is erotic about this photo? It is a picture of a birth. A natural birth. This is what birth looks like. WP is not censored. Gillyweed 23:07, 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)

Please see WP:CENSOR. If you had gone to my user page you would have found that I was male. The bulge is her placenta. After the placenta is birthed, it still can take up to seven days for the uterus to contract to its pre-pregnant size. If this stuff worries you, I'd not attend the labour and birth of your child. Gillyweed 10:31, 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)

If an 'average' man gets off on this image, then good luck to him. I'd spare your worrying for child porn. That is far more damaging. Gillyweed 12:51, 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've seen many a HB photo in Australia and they are nearly all naked. I certainly know my friend who gave birth at home indicated that she was simply stinking hot after all that labouring and couldn't wait to shed her clothes. But also many women in Australia give birth naked too. It's damn hot work. Gillyweed (talk) 07:22, 17 December 2007 (UTC)

Removed text

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.

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)

To be clear: Nandesuka was not implying that Gillyweed is "is biased and is an inappropriate editor." HE has made several useful contributions to keep the page from veering wildly into pro/anti stance. Nandesuka's edit seemed reasonable to me as the text doesn't add a lot of value, in my opinion. What *evidence* has Gillyweed reverted that says that homebirth is detrimental to the health of the baby? I have only seen reverts of unsubstantiated statements. Lcwilsie (talk) 16:33, 31 July 2008 (UTC)

Wrong. I have made several evidence based edits that have been removed by Gillyweed who visits regularly to revert without commenting on balancing edits that are referenced. An example would be stating that a midwife cannot manage several emergency situations at home as she can't perform a C Section - removed multiple times. This person seems to have some sort of role with Wikipedia which is undeserved as she has an anti-medical agenda that comes through in her edits. Inappropriate and I will revert ALL her edits on this page that confirm her bias in the future.

Please sign your posts. Please become a registered user so you can have a talk page and people can discuss things with you off-line, instead of being resigned to doing it on the article talk page. Feel free to provide a link to your perceived undeserved revert, and I will review it for a second opinion - without your name I cannot find the edit you refer to. Be advised, without being a registered Wiki user, you may be summarily deleted by Gillweed, myself, or any other user as your edits could be considered vandalism of the page. (edited to add my signature!)Lcwilsie (talk) 17:55, 7 August 2008 (UTC)

Hi, the wicked Gillyweed here. I delete edits that are unreferenced and appear to be made to push a particular POV. When I have time I look through the entire article and attempt to reference or correct material that has been missed in the past. I am not infallible and am always willing to discuss my edits, particularly with editors such as Nandesuka who is thorough and doesn't hide behind anonymous edits. Nandesuka and I don't always see eye to eye on things, but we usually work it out. Gillyweed (talk) 12:50, 7 August 2008 (UTC)

Why is this topic so inflammatory?

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)

You know what? Who cares. The problem with wikipedia is that for important medical topics that are dependent on highly expert interpretation of a sub-optimal evidence base it is almost useless. I see it being replaced fairly soon by the new medipedia, knol or similar in the future. The bottom line is uneducated folk like Gillyweed have no insight into the subject and obviously have the time to inappropriately revert edits by busy professional people, who will move on with disgust. If you want the article to be balanced you will include detailed analyses of all pertinent papers all of which show a higher mortality in homebirth, mention the UK independent midwife database (see their website) which has a mortality of 2% for the baby (Brain damage unknown, probably an additional similar amount), and acknowledge that reduced monitoring, reduced skill in the attendant, less access to technology, less additional help and no operating theatre all conspire to make homebirth less interventional by far, but at a significant cost to a human being - the neonate. —Preceding unsigned comment added by 202.89.167.125 (talk) 08:39, 1 August 2008 (UTC)

I find it interesting that you say "who cares" and then proceed to care a great deal. Again, you address only neonatal mortality. Again you make personal attacks against an individual who is a registered Wiki editor, while you yourself are unsigned, unregistered. I reiterate - wikipedia is not about interpreting data! Looking at the website [3] you recommend, they note a 1.1% mortality, but that is combined home and hospital birth, not homebirth exclusively, and it is a small sample size (only 347 births). Please provide references for the data you cite - if it exists, I agree it should be included. How do you define "reduced skill"? Midwives are highly skilled, though limited in scope. Lcwilsie (talk) 19:07, 6 August 2008 (UTC)

Personal attacks don't worry me. But I do find it amusing that my anonymous critic claims that s/he is a busy professional... and I am not? Ah the arrogance! Gillyweed (talk) 12:52, 7 August 2008 (UTC)

No Gillyweed you are not busy. Hence your ability to spend half your life on here. (UTC)

Lcwilsie demonstrates that she is unable to intepret the simplest statistics provided which proves my previous points. The figures are 4 neonatal deaths & 4 stillbirths out of 347. You think that's 1.1%?! 2.3% actually. An average hospital (with much higher risk cases) will be 10 times better than this. It's pathetic & a scandal. And this is the midwives who submit their figures!! This inability to understand the simplest stats is why your kind shouldn't be editing on this topic. And of course many of those botches are born in hospital. That's where women go after the "skilled" midwives hand over their disasters. You know, so they can be sorted out. Do you understand the concept of "intention to treat"? If not, stop editing and find out what it is, because it applies in the analysis of outcomes in places of birth, although complicated. If you thirst after the "truth" then stop being biased. Reflect upon your behaviours and motivations.

Data needed to verify "10 times better" statement. The CDC data for the same time period is 0.67% deaths for in-hospital, 1.0 for out of hospital - hardly 10 times different - but "out of hospital" includes not only planned homebirths but also unplanned homebirth, birth centers, teenagers giving birth in a bathroom stall, birth in the back of an ambulance, etc. etc. This shows how tricky data is, doesn't it? I used the statistics of 4 "deaths" for calculating percentage, and Mr/Ms Unsigned used deaths AND stillbirths. And again, the 4 deaths/4 stillbirths are in combined homebirth, birth center, and "NHS consultant unit" whatever that means - for all we know based on the reporting all 8 could have been in the "NHS consultant unit" meaning that there were 0% deaths in the homebirths. These statistics are not adequate for proving/disproving safety in homebirth. Why am I arguing with someone who is afraid to sign his/her posts??? Sorry to waste everyone's time and WP bandwidth.Lcwilsie (talk) 19:40, 11 August 2008 (UTC)

You're ridiculous. 1) A stillbirth is not a neonatal death. Do you not understand that? 2) LOW RISK women's babies are 10 times safer in hospital. CAN'T YOU UNDERSTAND THE DIFFERENCE between all-women's risk and low-risk women?! Do you think 0.67% of women having low-risk births in hospital get dead babies? That 0.67% rate includes all the women with severe problems like gross prematurity, bleeding, pre-eclampsia, cardiac disease, twins etc etc. The low-risk rate in hospital is about 1:500-1000. For the record, you're not arguing - you have a very limited cognitive ability. You are espousing your point of view but it's not an argument. Censor my IP if you wish, I'll simply use a proxy if you do so. I'm not arguing on the article itself and it shows you up for what you are. Someone with a very obvious point of view - the wrong one - and happy to spread your propaganda and censor others who have the correct view and a lot of experience with homebirth midwives and their often risky and often illegal behaviour.

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)

Thank you, that seems reasonable, though something we can hardly satisfy in this article. Lcwilsie (talk) 19:40, 11 August 2008 (UTC)

PS Just so you know, birthrates are rising, complexity of births are rising with older women getting pregnant. There aren't any livelihoods being threatened by the curious activities of homebirths. Certainly, neonatatology units do very well out of homebirths. Special:Contributions/202.89.167.125|202.89.167.125]] (talk)

Nope -neonatology units do very well out of interventions in hospitals and the evidence shows it. See: [4] (quote from the research: "Babies born after any operative method of birth were at increased odds of being admitted to neonatal intensive care compared with those born after unassisted vaginal birth at 40 weeks' gestation"). Gillyweed (talk) 12:01, 15 August 2008 (UTC)

Doh wrong AGAIN. You are an independent midwife aren't you? You're saying homebirth = unassisted vaginal birth and a hospital birth = operative. It would be laughable if it weren't so dangerous to women searching for information. As is clear, homebirth with an independent midwife is associated with a mortality of 2% or greater from their own figures, compared with one-tenth that for low-risk women in hospitals. Any neonatalogist will tell you about the brain damaged infants born to homebirthers, as obstetricians will tell you about the already dead babies they see, numbers vastly out of proportion to the equivalent low-risk hospital women. —Preceding unsigned comment added by 202.89.167.125 (talk) 12:42, 16 August 2008 (UTC)

Nope. I am not an IPM. Nope, I do not say homebirth = unassisted vaginal birth. Please cease the assertions and provide the evidence. Oh incidentally I know neonatologists and obstetricians and NONE of them say what you claim. Gillyweed (talk) 12:44, 16 August 2008 (UTC)

Try reading your preceding statement again Gillyweed, and see how it looks. Funny how the many hundreds of neonatologists, obstetricians, and hospital midwives I've come into contact with think the opposite to your kind. http://news.bbc.co.uk/2/hi/health/342461.stm The most prominent independent midwife in the UK.... —Preceding unsigned comment added by 202.89.167.125 (talk) 10:37, 20 August 2008 (UTC)

For every midwife that you can find who may have done something wrong, I can find an obstetrician. Shall we discuss the King Edward Memorial Hospital Inquiry? Shall we talk about how this hospital had nearly double the infant and maternal mortality than other comparable hospitals and that the inquiry found that midwives expertise was overruled by obstetricians and this is what led to the terrible outcomes for mothers and babies? What about the Butcher of Bega? This is a pointless exercise. We are not here to discuss the relative merits of the two professions. We are here to discuss the evidence relating to home birth. That doesn't seem to be your aim. Rather you systematically remove anything that might suggest that homebirth is a valid choice for women. I attempt to keep an NPOV but it's tricky when dealing with someone with such extreme views and yours. Gillyweed (talk) 11:53, 20 August 2008 (UTC)

Homebirth is a completely valid choice, provided the woman knows the facts. You & your crowd on here are seeking to cover up the facts. Why are you removing discussion of the shortcomings of the BMJ study, a "cohort" study that doesn't even have equivalent cohorts and is therefore a case series and is unacceptable. It might interest you to know that one of my best friends is an independent midwife. She's great, but there is an unacceptable proportion of these practitioners who are dangerous, and don't discuss the pros & cons of homebirth in an even manner, because they're after their large private fee. You discuss the vested interests of obstetricians. Most outside the USA are salaried. They get paid the same whatever - there's no financial conflict of interest, just a hatred of the avoidable disasters. You mention King Edward hospital appropriately. The problem was a lack of senior obstetric input. It was a systems failure which has now been addressed. Independent midwives have minimal supervision unless there's a disaster and a serious complaint, and that's the problem. —Preceding unsigned comment added by 202.89.167.125 (talk) 11:33, 22 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)

Assertion without evidence is not much good. Please provide references. Gillyweed (talk) 09:38, 10 August 2008 (UTC)

If the personal attacks continue, I think I will move that we request posts from IP address 202.89.167.125 be blocked by WP. Constructive improvement of the articles is appropriate, even if it is done in a way that others disagree with. The abuse by this individual is unnecessary and does not further the article, but causes antagonism and useless discussion. The matter of safety could have been handled in a much more productive way than it has been here.Lcwilsie (talk) 19:40, 11 August 2008 (UTC)

Transfer rates

PPS That small handful who need medical care. 30%-50% of low-risk homebirthers in the ir first labour transfer. A small proportion - I don't think so. Can Gillyweed tell us her occupation please? Special:Contributions/202.89.167.125|202.89.167.125]] (talk)

Please provide references for your transfer rates. They are of a magnitude greater than I understand occur in Australia. I think you have accidentally slipped a decimal point. Gillyweed (talk) 12:01, 15 August 2008 (UTC)

I looked further for any research giving the transfer rates you claim and it appears not to exist. The NHS in the UK cites a study giving a rate of about 14% [5] This article claims in the US State of Washington it is between 8 & 16% [6] The big US by Johnson and Daviss found a transfer rate of 12.1%. [7] Please provide a reference for your 30-50% transfer rates please. Gillyweed (talk) 03:12, 16 August 2008 (UTC)

Do you actually bother searching properly, Gillyweed?

First page of search results.

Reference: http://72.14.235.104/search?q=cache:rkduqHoZUZoJ:old.rcm.org.uk/info/docs/Teenage_pregnancy_where_is_NSF_taking_us_Jill_Demilew_18.10.06.ppt+transfer+rates+homebirth+primip&hl=en&ct=clnk&cd=4&gl=au&lr=lang_en

Look at the bottom of the presentation. 1:3 transferred primips in homebirth. That's 33% overall in the UK.

http://www.birthathome.co.il/statistical.htm

25% transfer of primips for this independent midwife.

http://www.southeastcoastfff.nhs.uk/getdoc/2a92edff-6a75-43c2-9f14-91ac1da3d88e/midwife-led-units.aspx

20% transfer rate of ALL planned homebirthing women, not including postpartum transfer.

50% is the local homebirthing primip rate.

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)

The first reference you give appears to be someones powerpoint presentation with no decent referencing. Who knows what the claimed rate relates to. The second reference gives a transfer rate of 10% and not 25% that you claim and the third reference gives a range of rates from 10-30%. And what is a high transfer rate proving? Is it good or bad? It is hardly an indicator of competence or risk management. A high rate might mean a highly conservative approach to labour management. A low rate might mean risks are being taken that should not be taken. What is an acceptable transfer rate? This is a non-issue as an indicator of home birth safety. Oh, I don't wear boots. Gillyweed (talk) 12:46, 26 August 2008 (UTC)

Oh dear, you really are getting desperate.

The first is a powerpoint presentation from one of the UK government's NHS maternity executive. You know, one of the people who run maternity in the UK and are keen on homebirth for feminist reasons. Please keep up. It relates to the transfer rate for all primip NHS homebirthers in the UK.

The second reference, if you'd put your brain into gear, requires that you add the before-birth transfer rate to the postbirth transfer rate. Then you get 25%. Do you see?

The third shows several examples of a homebirth transfer rate for all women (primips & multips) of up to 30%. Primips' transfer rate will be a lot higher than multips, although it doesn't say exactly what the differences are for any of the units.

You asked for references. You have them. For a "non-issue" why have you asked me several times for references and denigrated my statement (now proven) on transfer rates? I think you owe me and the board an apology, and a promise of neutrality and intellectual vigour (sadly missing so far) in the future. And you don't think transfer rates are "an indicator of safety", but you've given the reason why they are two sentences before? PLEASE. What would you know about risk management anyway? YOU DON'T EVEN THINK THERE IS A DIFFERENCE BETWEEN MULTIPS' & PRIMIPS' LABOURS & RISKS. You can't even add up two figures in an independent midwife's simple table.

These transfer rates ask the question: what is the point of resourcing homebirth for primips, when up to half have to transfer anyway - increasing risks, disagreements, stress, disappointment and depression.

I think there should be a section with this data in the main article, as women searching for info need to know the chance of hospital transfer, especially when paying midwives $6K for a service which may not even be delivered by them... Opinions? —Preceding unsigned comment added by 202.89.167.125 (talk) 16:00, 26 August 2008 (UTC)

Actually, the powerpoint presentation is not cited because it's discussing a goal for what it wants primiparous transfer rates to be. Hence, no matter who is writing the powerpoint, I wouldn't be surprised if 1:3 (with an expected improvement to 1:7) transfer rate is an estimate -- which by the way, was made in 2006, which is hardly recent. The third reference is for midwifery-led units, which as previously discussed, belongs more in the birthing center article than the home birth article.

The second reference looks fine, but it is the data from only one midwife. At the moment, I have cited the transfer rates based on a review of about 7 articles on home birth that discuss transfer rates in the lead section. However, I agree that we do not have sufficient information to say anything beyond citing the average transfer rates based on these data. The transfer rates are not only going to vary by practice, but vary widely by location (i.e. I'm pretty sure the transfer rates in the UK are different from the Netherlands, which are also different from the US, Australia, Canada, and so on). Transfer rates are also going to be higher between primiparous and multiparous women, but again, this is going to vary widely based on where the study is conducted.

Unfortunately, I do not have the time to conduct quite so involved of a review of the literature at the moment, but I would recommend a search of PubMed instead of Google the next time you look for transfer rates, or at the very least, to start with sites that are reviewing the actual literature rather than just reporting the transfer rates for one hospital or one midwifery practice. --Astraflame (talk) 16:49, 26 August 2008 (UTC)

Yup, fair enough you got me on that third one, homebirth transfers will be similar as guidelines are similar, but I agree it should be excluded as it is birth centres. This was just on the first page of a quick google for "primip homebirth transfers". I'm sure a more detailed search will be useful.

The 1:3 is not an estimate. One thing the NHS does well is birth stats, and I will try and find an original source for this figure. In terms of stats & research, you're wrong - 2006 is recent. Certainly studies going through peer review and then published and referenced on PubMed are usually a couple of years old, often more. Studies conducted 5 years previously are not uncommon. —Preceding unsigned comment added by 202.89.167.125 (talk) 17:16, 26 August 2008 (UTC)

The 1:3 data you cite was in the notes section of slide #8. Are we that desperate for data that we can't use official stats or publications? It was what the presenter was planning to say - it appears that the speaker was saying that less experienced midwives transfer more patients to hospital, and that this changes to 1:7 with more experience. We can only assume, as there is no data given that we can independently evaluate. Does she mean all midwives have a 1:3 transfer rate, or those fresh out of school? We cannot include data that is not clear and verifiable. It may be worthwhile to mention that transfer rates vary by practitioner (as do all interventions) - but then we lean toward becoming a "how to choose where to birth" page. Our anonymous poster could make these discussions less confusing by signing his/her posts as the autobot isn't catching every single one. There are several paragraphs that are unattributed making reading less streamlined. Lcwilsie (talk) 18:31, 26 August 2008 (UTC)

No, the 1:3 refers to the current overall primip transfer rate. This is for ALL NHS homebirthers with ALL NHS homebirthing midwives. Those midwives fresh out of school rarely do homebirths as they are not experienced enough in dealing with neonatal resus, shoulder dystocia etc. As I said I will try and locate the original data, please read my post. The UK hopes to encourage homebirth a lot more for all low-risk women and is hoping that this will reduce transfer rates. This is unlikely to happen - if more women are persuaded to go for it, that will include the less committed who will bail out more easily. —Preceding unsigned comment added by 165.118.1.50 (talk) 01:43, 27 August 2008 (UTC)

When you have the data we can continue the discussion. Until then it is conjecture. Sorry, but I'm not sure which posts are yours as many are unidentified. Lcwilsie (talk) 03:13, 27 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)

Safety + Australia sections

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)

I removed if because this reference does not support the contention that the roll out of home birth services in WA has been postponed. This reference does not say that rollout has been postponed at all (unless I'm blind). This reference says that there were excess HB deaths but they did not appear to be related to place of birth and since the government oversight of protocols in 2007 there have been no perinatal deaths. Gillyweed (talk) 11:54, 10 August 2008 (UTC)

Fair enough. I restored the reference, but removed the bit about "postponement". Nandesuka (talk) 12:09, 10 August 2008 (UTC)

I've added to the text so that the text now properly matches the reference. Gillyweed (talk) 22:52, 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)

I removed the text because it seemed wildly inaccurate. The text added to the article claimed that the government "concluded that five out of the six deaths had no link to place of birth". There is absolutely no reasonable reading of that press release that supports that statement. To say that the government concluded such a thing is a complete fabrication, and it's yet another example of subtly (or, in this case, not-so-subtly) cherrypicking and twisting the words of a source to present a particular point of view in a favorable light. Nandesuka (talk) 12:16, 13 August 2008 (UTC)

This is the quote from the press release: "“The report found six unexpected deaths in planned home births during 2000-2004 which is a term perinatal death rate of 6.7 per 1,000 home births compared with 2.1 term per 1,000 in planned hospital births in the same period,” he said. “The Department is keen to examine these incidents and is in the process of commissioning an independent professional review of home births. “A preliminary review of medical records by the Department indicates that it is likely that the setting of the birth did not affect the outcome in at least five of the six deaths.” Perhaps I should not have used the word 'concluded' but as the statement currently reads it is suggesting that homebirth is unsafe. We need to remember that we are dealing with very small sample sizes here and thus the error rates when turning very small numbers into percentages is very large. If you are going to remove this statement, then you should also remove the previous statement about 'excess' neonatal deaths. With such small sample sizes you can't make the statement about 'excess'. Gillyweed (talk) 23:34, 13 August 2008 (UTC)

Caught again Gillyweed. Are you sure you should be an editor? You're totally biased on this subject. I thought you had have a neutral point of view? You're clearly biased. With regards error: the sample sizes here aren't small at all, and the incidence of the outcome being studied - death - is surprisingly not low in this low-risk group of homebirthers. Hence, error won't be bad. —Preceding unsigned comment added by 165.118.1.50 (talk) 08:14, 26 August 2008 (UTC)

Caught? Biased? Sample size is small. The report found that only one of the deaths related to the place of birth. Surely, all deaths in hospital are related to the place of the birth? What are you trying to prove? Or are they never considered? I see that in NSW today it has been reported that there were 60 unnecessary deaths in hospital in the SE Region Health Service. Some of these were maternal deaths. Fancy mentioning these? Gillyweed (talk) 12:50, 26 August 2008 (UTC)

Of course, mistakes occur and unnecessary harm results. This is true in every complex decision-making environment: hospitals, flying, war, motoring etc etc. Do you suppose that this problem doesn't exist in homebirth midwifery, where practitioners have much less experience, little help, no access to immediate diagnostics, few treatments to offer, often have attitude problems and are not up to date, have no supervision, and have their large fee to justify? Or do you think they're incapable of making mistakes? What nonsense.

"One of the deaths related to the place of birth" No. Six deaths were related to the homebirth, giving a mortality for homebirth babies 3* that of all the hospital births (many of whom were high risk). You analyse this kind of thing by intention to treat (ie. planned delivery at home), not analyse by someone saying "oh that one had nothing to do with being at home", "nor did that one", actually! You should also be aware that there is at least one, maybe more maternal deaths not reported, and further dead babies recently. —Preceding unsigned comment added by 202.89.167.125 (talk) 16:27, 26 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)

And I have put it back in as it relates to the systematic bias against independent midwifery in Australia and this has a direct impact on homebirth and the legality of homebirth in Australia. Here's an interesting article showing the systematic bias: Australia's insurance crisis and the inequitable treatment of self-employed midwives published a couple of months ago. Gillyweed (talk) 12:15, 20 August 2008 (UTC)

That is original research, in my opinion. Nandesuka (talk) 15:38, 21 August 2008 (UTC)

No, obstetricians are vital to a maternity system unless someone else can do forceps or C sections? Homebirth midwives are not vital. This is why the obstetricians' insurance was addressed urgently. It is not evidence of bias at all, and is your personal opinion. —Preceding unsigned comment added by 202.89.167.125 (talk) 11:02, 22 August 2008 (UTC)

I agree. Obstetricians are essential and they know it. You might recall that they said they would withdraw their services if the government didn't pay their insurance. Blackmail I'd call that. Gillyweed (talk) 12:52, 26 August 2008 (UTC)

Wrong Gillyweed. AGAIN. It is serious professional misconduct for doctors to practice without insurance in every developed country, especially Australia. If doctors provide obstetric services without insurance they are liable to be struck off. The word "blackmail" shows your ignorance and your bias. I also note that independent midwives practice worldwide without insurance thus depriving their clients of reparations in case of negligence. Rightly, this unethical practice is being outlawed soon in the UK. —Preceding unsigned comment added by 202.89.167.125 (talk) 16:07, 26 August 2008 (UTC)

Including mention of liability coverage issues?

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)

It seems to me to be putting the cart before the horse to look for references to support a theory. The references should come before you decide to add a section to an article, not after...unless I'm misunderstanding your suggestion. Nandesuka (talk) 16:33, 12 August 2008 (UTC)

Definitely not a theory, but a fact of life for midwives in the US. I see there is a similar discussion about liability coverage in the Australian legality section, so I will follow that model. Lcwilsie (talk) 18:58, 12 August 2008 (UTC)

Edit war

This paragraph has been inserted and removed several times. Let's discuss here and stop wasting bandwidth with reverts.

Unfortunately, as the study clearly acknowledges, there was a large difference between the homebirthing women and the hospital-birthing cohort used by the study. Age, smoking history, socioeconomic status, ethnicity, educational level, birth weights and prenatal care were all different, thus the groups were not comparable as should be the case in a valid cohort study.[11] Importantly, there was a large difference between the number of previous births. 45% in the homebirthing group had 2 or more previous successful births that maintained them in the low-risk category. 27% in the hospital group had this number of previous births. 40% of the hospital births were first pregnancies and 31% in the homebirthing group. Undergoing a previous pregnancy and delivery without incident is the strongest predictor for safe normal delivery [12]and the study completely failed to control for this important variable. [13]

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)

The problem is the people removing this paragraph and who you're talking to don't know anything about study design, analysis, or stats. This is clear from their (and your) comments. There can be no statistical significance without the groups being similar. So forget the figures in this paper - they're useless. A randomised controlled trial is the gold standard, but this doesn't (and won't) exist for home birth vs. hospital birth.

A proper prospective cohort study is not bad, but the BMJ one is not one despite what it alleges - the cohorts (groups) have to be similar - these groups are completely dissimilar. If you're going to have this study on a reference article for homebirth, you need to point out that it is considered to be very poorly implemented and is not accepted by any poicymakers worldwide. The UK NICE group have considered it as well as all the other studies. They're all useless - they acknowledge this. Even if you had a study with equivalent cohorts, matched for all the variables like parity, age etc, you would still have the fundamental difference that homebirthers have a different psychological mindset to hospital birthers that may impact negatively or positively. The only way to control for that is to randomise - but women will rightly never accept this.

So you're left with the problem of you wanting a summary of this mostly useless paper extolling the virtues of homebirth without caveats. This is unacceptable and a distortion. So, either get rid and leave the NICE analysis which is fair - no good evidence either way (yet). Or leave it in with the caution that it's a bogus study. I'd prefer it were just removed - it's no better than the studies that are pro hospital birth. Gillyweed also needs to stop editing as she's a propogandist biased towards homebirth, not a seeker of the truth. What about you?

I agree that we need more studies. The NICE review may be a good place to start as they cite many studies and compare their usefulness. As the studies' results are of conflicting nature, I believe that to be the source of their reluctance to make any sort of definitive statement, rather than an overall lack of statistical significance in all of the studies, but I'll check this. Interestingly, they do not include the BMJ article in their considerations, as far as I can tell.

The paragraph above makes a good point, but it has been edited out many times because a) it is posted by an anonymous user and b) it is written in a tone that does not appear to be a neutral PoV. I have gone back and edited the paragraph to make it a bit more neutral sounding (for it is a neutral and true statement to say that a cohort study should involve cohorts that are comparable. I would appreciate if someone with more statistical knowledge looked over it to make sure that my terminology is correct in explaining this, but I know that I have the idea right). I have also removed the highlighting of the parity aspect to the difference, not because it's not important, but because there is nothing in the reporting of this information (in the BMJ article) that says whether or not the previous births were successful, or even vaginal (i.e. not a c-section). -- Astraflame (talk) 17:41, 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)

I'll happily continue to revert your edits where you fail to back them up with evidence - such as the paragraph above where you make ridiculous assertions about the safety of YOUR hospital versus the local homebirth service without providing any evidence. Knowing where you are from, I assume you mean the Community Midwifery Program of WA, which as you know has excellent results. I am still waiting for your evidence regarding the massive transfer rates for HB that you claimed earlier... Gillyweed (talk) 03:43, 25 August 2008 (UTC)

The "unbiased" propogandist Gillyweed, outargued and her "pet article" being knocked into proper shape at last. Perhaps she or her friends will have to reduce their large fees for independent homebirths when people find out the real deal about these mavericks.

Large fees? NSW IPMs charge $3000 per birth. Victorian $3500 VIctorian country $2000 ACT $3000 QLD country $2000. QLD city $2800. Tas $2000 This gives the woman 10-20 hours antenatal care. 12-24 hours care during the birth. 10-15 hours post natal care. IPMs handle 30-40 births per year. The average private obstetrician charges $3000-$5000 per birth (and some do up to 500 births per year). Oh, and the media reported that after 12 months of the Medicare Safety Net that obstetricians take home pay had increased by 269%. Gillyweed (talk) 13:06, 26 August 2008 (UTC)

So, 1 birth/ week = $140K/ year. No insurance to pay. No office costs. No wonder you're so vociferous about homebirth. Someone with a limited education, no boss, watching babies pop out and not caring about the stuff that goes wrong earning $140K/year ?!?!? You don't think that's a large income? Same as a public medical consultant after 16 years of training, more than double a teacher. You really are in cloud cuckoo land.

You think a doctor delivers 500 women/yr!!! And you think their income has trebled in a year.... Shrill insanity. —Preceding unsigned comment added by 202.89.167.125 (talk) 17:02, 26 August 2008 (UTC)

This is an interesting debate. Have you guys seen this report [8] that says: EXORBITANT obstetricians' fees blew out the Medicare safety net cost during the last election, forcing the Government to break an "iron-clad" promise and deny a million Australians help with their health bills. I'm not sure about my medical friends delivering 500 babies a year but they certainly book in 500 (at least) and they still charge whether or not they turn up at the birth. Why are you guys so het up about independent midwives? Midwives in Australia are well trained (not in surgery, granted, but have to do a three year degree, and given their work is in a limited arena, this seems quite sufficient). Can I ask what happened to WP:Civil in this discussion? I don't think the phrase "cloud cuckoo land" is particularly civil. Certainly not where I live. My two cents worth.Obman (talk) 06:33, 27 August 2008 (UTC)

Full references for primips' transfer rates in the relevant section. Gillyweed wrong again...

Nope. Call a powerpoint presentation a 'full reference'? Gillyweed (talk) 13:06, 26 August 2008 (UTC)

A Powerpoint from the managing executive of the UK NHS maternity service. Plus several other references including an independent midwife and several public homebirthing services. People can simply scroll up and see for themselves you're writing absolute biased piffle.

If the Community Midwifery Programme has excellent results no doubt when the state government has completed it's investigation into excess mortality (planned HB mortality 3 times greater than hospital birth, as referenced in the article) they'll be vindicated. I hope so for the mothers' sake. We'll see what the review brings, shall we, rather than rely on YOUR unreferenced statements about "excellent results". —Preceding unsigned comment added by 165.118.1.50 (talk) 07:57, 26 August 2008 (UTC)

Haven't you read the previous two independent reviews undertaken of the CMP over the past ten years? And as for the review, have you not read that only 1 of the five deaths can be attributed to place of birth? The others appears to be related to other factors. But am happy to wait for the review findings. Where are your references to your assertion that YOUR hospital has lower intervention rates than the CMP? Gillyweed (talk) 13:06, 26 August 2008 (UTC)

Now more deaths I understand. See elsewhere for "how to compare groups" ie. cohort analysis etc. It's not by believing a preliminary comment in a newspaper that is relying on a quick look at individual case notes - "case analysis" - a qualitative tool that tells you little about the population being studied. Case analysis lets you see the tree in detail, but tells you nothing about the wood. Any such findings will mainly be about adherence to guidelines or not. It will not answer the question "is homebirth safe" unless there are cohorts developed and compared. In which case that study would add to the findings of the other studies discussed elsewhere here.

The previous independent reviews you mention led to major changes to guidelines & leadership.

There are no references to my hospital's intervention rates (yet). I know what they are because our midwifery manager monitors & submits such stats as required by the state government, and the CMP's stats are public knowledge. OK?

Review of the Literature

Cohort Studies of Home Birth (1980-present)

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 found a pretty extensive summary of the Chamberlain study that does say that they used matched pairs, though they did not match for income or education. Perhaps this is why a previous commentator claimed that the hospital birth sample was more "high risk" than the home birth sample as that has been found in other studies. However, as overall the sample is so low risk and the results hardly conflict with the other three studies that do control for income, I'm going to leave it in and make some edits to the main page reflecting this new information --Astraflame (talk) 15:45, 24 August 2008 (UTC)

Thank you for all of the research, Astraflame. I think this is an excellent place to start from. One word of caution: we must be careful not to make "should" statements lest this become a recommendation to have a homebirth. I also note that the article is being unduly taken over by the discussion of safety (as is this discussion page). While it needs to be adequately addressed, we are neglecting issues of interest such as history, expanded international relevence (thank you for the edits here, too), relevence of childbirth preparation, and even the potential benefits of homebirth. Lcwilsie (talk) 14:21, 25 August 2008 (UTC)

What else are we missing?

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 that we are desperately in need of a section on the general practice of home birth (i.e. what actually happens at a 'typical' home birth, which would also have to consider international practices), a history of home birth, and the section on home birth rates needs to be greatly expanded. The UK stats are a bit old, and there are many other countries involved besides The Netherlands, the UK, and the US.

One reason that I'd point to for why this hasn't been done yet besides being simply distracted by the debate on safety is that much of this information is, unlike research papers, not to be found on the internet (particularly the information about history and a detailed study of general practices). There are books on the subject, but I don't have any on hand and not being a midwife, I don't actually know them off the top of my head either. I see some in the "Further Reading" section, so if anyone has such knowledge / references to contribute, that would be fantastic. --Astraflame (talk) 15:10, 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)

I have no shortage of material about this and will provide it over the coming months. I am sure that our anonymous poster will agree with everything I write. Gillyweed (talk) 13:07, 26 August 2008 (UTC)

I hope so, then I won't have to edit it. Please remember. Have a NPOV. —Preceding unsigned comment added by 202.89.167.125 (talk) 17:19, 26 August 2008 (UTC)