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Dr. Amos Grunebaum, ObGyn at Cornell Medical Center New York publishes an article in American Journal of Obstetrics and Gynecology which will indirectly kill 100 U.S. birthing mothers per year.
Re: Grunebaum A, McCullough LB, Sapra KJ, et al. Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting. Am J Obstet Gynecol 2013;209:
This recent article concludes that planned attended homebirth 2007-2010 had 10 times the rate of intrapartum deaths (1/600) during labor than hospital births (1/6000) during the same period. The paper uses the term: "5 minute Apgar score of 0" as newborns that were born with a heart beat but the midwife or doctor attending the planned homebirth were unable to resuscitate the baby, so at 5 minutes the Apgar was 0 and the baby was dead. Grunebaum states that these babies would have been alive if they had been born in hospital, and concludes therefore that all women should deliver in hospital.
The small print reveals that not only were those babies not alive at birth, they were not alive when labor started: "It is not possible to know from the CDC data whether a 5-minute Apgar score of 0 was effectively a stillbirth that occurred antepartum or intrapartum."
Every year at least 100 US mothers die from cesareans (1/10,000 among the million cesareans per year) and would be alive if they had had planned attended homebirths. This article is responsible for women thinking that they are getting safer care in hospital when in fact they risk dying from this decision, with no benefit to the health of their newborn and possible detriment from unnecessary interventions.
The results section of the paper report impossible outcomes:
1. The paper reports an impossibly low Perinatal Mortality Rate of about 0.16/1000 (1.6/10,000 births) for full term birth in hospital 2007-2010: The article claims that at hospital births there was only 1.6 stillbirths per 10,000 full term births after 37 weeks. If this were true then the total perinatal mortality rate of the US 2007-2010 would be 0.2/1000 instead of the about 7/1000 which it was. Full term births make up nearly 90% of all births and antepartum stillbirth makes up 80%-90% of perinatal mortality.(1) In 2005 of the 6.6/1000 perinatal deaths: 6.2/1000 were stillbirths (mostly term) and 0.4/1000 were infants that died in the first week. (2)
2. Implausible prematurity rate: The paper reports that 2007-2010, 17% of US births were either premature and/or multiple births. This number should be around 12%.
3. Missing 16% of attended homebirth data: This article reports on 60,296 full term births 2007-2010 that were planned attended homebirths with a doctor or midwife present. The CDC reports that there were about 29,000 homebirths per year for the years 2007-2010 (3) but only 62% were attended by a trained attendant. 29,000 homebirths X 4 years = 116,000 homebirths x 62% attended by midwives = 72,000. The article reports on 60,000 homebirths, so the data/article might be missing 12,000 or more than one sixth of planned attended homebirths.
4. Last but not least: the article states that 1.6/1000 planned attended homebirths end in intrapartum stillbirth. The authors fails to give any theoretical explanation for what complication of planned attended homebirth, that is not present at planned hospital birth could account for 1 in every 625 homebirths dying during labor at the hands of licensed doctors and midwives. Janssen (5) reports 0.35 deaths / 1000 planned homebirths- including stillbirths and transfers or 1 in 3000 which is a commonly reported and expected perinatal mortality rate for full term, low risk, attended births in the US or Canada.
There are only 5 complications that have been shown to be responsible for intrapartum stillbirth:
- Amniotic Fluid Embolism: Has yet to be documented at an attended planned homebirth and very rare in hospitals so could not account for many stillbirths. (1/20,000 US hospital births and only 30% fetal loss when it happens)
- Uterine rupture - The unscarred uterus will not contract hard enough to implode in the presence of a trained attendant without intervention(Williams textbook) and scarred uterus and prostaglandin/Pitocin augmentation are generally risked out of planned attended homebirth. If uterus ruptures, it typically stops contracting, the fetal heart drops, or there is bleeding and mother is transfered to hospital so would not account for homebirth stillbirths in this study.
- Complete Placenta Abruption- does not occur at planned attended homebirth because it occurs in high risk women, or inductions neither of whom deliver at planned attended homebirth.
- Cord Prolapse- occurs at a rate of 1/3,000 full term, singleton, vertex hospital births, mostly due to routine amniotomy. Happens less frequently at homebirth due to restriction of use of vaginal exams and amniotomy- perhaps 1/10,000 births and the attendant is usually able to hold the head up to prevent pressure on the cord preventing damage or death.
- Shoulder Dystocia- may account for 1/5,000 stillbirths at home but could not account for 1.6 deaths per 1000 (1/625 births) at planned attended homebirth. Shoulder dystocia occurs more frequently at hospital births (1/200) and than homebirths (1/500) because much of shoulder dystocia is associated with diabetics and epidurals. 10% of cases of true shoulder dystocia result in fractured clavicles, fractured humeri, contusions, lacerations, or birth asphyxia. Stillbirth is a rare outcome. (4) Death occurs so infrequently that a rate has not been calculated.(4)
Early Onset Group B Streptococcus (GBS) infection of the full term newborn would not account for Apgar 0 at birth. The onset is typically during the first 24 hours after birth and accounts for less than 1 in 50,000 perinatal deaths in the first week of life.
There is no theoretical explanation for planned attended homebirth having 1.6/1000 intrapartum deaths. The basis of the conclusion, that homebirth is dangerous is based on manipulation of birth certificate data about antepartum stillbirths which has no relevance to place of birth.
Whether or not this article is retracted, it's is not science and thereby speaks reams about the goals and intents of the authors of the paper from Cornell Medical Center in New York and the Editors of the journal that publishes it.
Judy Slome Cohain, CNM
1.Mathiesen ER, Ringholm L, Damm P. Pregnancy management of women with pregestational diabetes. Endocrinol Metab Clin North Am. 2011;40(4):727-38.
2. MacDorman MF, Kirmeyer S. Fetal and perinatal mortality, United States, 2005. Natl Vital Stat Rep. 2009;57(8):1-19.
4. Doumouchtsis SK, Arulkumaran S. Is it possible to reduce obstetrical brachial plexus palsy by optimal management of shoulder dystocia? Ann N Y Acad Sci.2010;1205:135-43.
5. Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee SK. Outcomes of planned home birth with registered midwife vs. planned hospital birth with midwife or physician. CMAJ. 2009 15;181(6-7):377-83.