ACNMs review of ACOGs Homebirth paper

ACNM
8403 Colesville Road, Suite 1550, Silver Spring, MD 20910-6374 240.485.1800 fax: 240.485.1818
http://www.midwife.org

July 7, 2010

ACNM Expresses Concerns Regarding
Recent AJOG Publication on Home Birth

The July 1 online edition of the American Journal of Obstetrics & Gynecology includes
a new metaanalysis comparing home birth and hospital birth outcomes. “Maternal
and newborn outcomes in planned home birth vs planned hospital births: a
metaanalysis,” by Joseph R., Wax, MD, and colleagues, concludes that “less medical
intervention during planned home birth is associated with a tripling of the neonatal
mortality rate” (Am J Obstet Gynecol 2010; 203).

The safety of home birth has been the focus of significant research in recent
decades. It is important to note that the authors’ conclusion differs significantly
from findings of many recent high-quality studies on home birth outcomes which
found no significant differences in perinatal outcomes between planned home and
planned hospital births. We therefore caution against over-interpretation of these
findings until there has been an in-depth review of this analysis which we will be
conducting. In the meantime, we express several initial methodological concerns.

A metaanalysis is a type of statistical analysis that brings together the findings from
a number of independent studies in order to make conclusions about the combined
results. A metaanalysis is a useful exercise when the studies included are credible
and a clear and consistent methodology is presented. In this publication, we are
puzzled by the authors’ inclusion of older studies and studies that have been
discredited because they did not sufficiently distinguish between planned and
unplanned home births—a critical factor in predicting outcomes. Also troubling is that
several recent credible studies of home birth were excluded for no apparent reason.

A planned home birth is generally defined as “the care of selected pregnant women
by qualified providers within a system that provides for hospitalization when
necessary.” The use of this definition prevents the inclusion of women who
experience an unplanned home birth or those who are not appropriate candidates for
home birth because of risk status.

Of the largest studies included in this metaanalysis, only three (Hutton, et al 2009;
Janssen et al 2009; & deJonge et al 2009) clearly distinguish between planned and
unplanned home births. These three studies—which comprise 93% of the women
included in the metaanalysis—found no significant differences in perinatal outcomes.
Only one study (deJonge, et al 2009) meets the gold standard for quality in home
birth research (Vedam, 2003) and had sufficient numbers on which to base
conclusions about mortality. This study found that babies born at home were
not more likely to die or to suffer severe illness in the first month.

Many credible studies have demonstrated that the best home birth outcomes are
achieved when women are appropriately screened, are attended by a qualified
provider, and can be transferred to a receptive environment when necessary. The
8403 Colesville Road, Suite 1550, Silver Spring, MD 20910-6374 240.485.1800 fax: 240.485.1818
http://www.midwife.org
authors conjecture that greater accessibility of technology in hospital settings has
produced better perinatal outcomes. This conclusion cannot be drawn from the
data presented in this metaanalysis. In fact, a number of credible studies
have shown that the increased use of technology and interventions in
childbirth for low risk women, such as elective induction of labor and
continuous electronic fetal monitoring, do not improve birth outcomes.

Based on these limitations, ACNM cautions against over-interpretation of these
findings until there has been further review. We recommend that future research on
place of birth in the United States be well-designed and conducted by
multidisciplinary teams who are knowledgeable about the complexities inherent in
researching the impact of birth setting on perinatal outcomes. This approach would
help us add to the body of knowledge about place of birth for clinicians as well as
childbearing families, and provide a venue for us to work together to achieve better
outcomes for mothers and infants in all settings.

# # #

For more information, see:

ACNM Position Statement on Home Birth, 2005).
http://www.midwife.org/siteFiles/position/homeBirth.pdf

Home Birth – Resources & Bibliography
http://www.midwife.org/siteFiles/education/Home_Birth_10_08.pdf

Home Birth: Resources for Payers and Policymakers
http://www.midwife.org/Home_Birth_Resource.cfm

Vedam, S. Home Birth versus Hospital Birth: Questioning the Quality of the Evidence
on Safety. BIRTH 2003:30;1.

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