This Hans Christian Andersen fairy tale reminds me of the ongoing online discussions about the safety of home birth.
Critics of home birth claim:
Babies born to parents who plan home births have triple the neonatal mortality of babies born to parents who plan hospital births.
There is no scientific data to support this.
Birth Certificate Error
Home birth critics cite various sources of mortality (death) rates for babies that are not even about planned home or planned hospital births. Having a baby at home with an experienced attendant and appropriate equipment is not the same as having a baby in the car on the way to the hospital. Information taken from birth certificates suffers from this problem since birth certificates only report where each birth actually happened, not where it was planned.
Sources with the birth certificate error include the Pang study and the CDC Wonder 2003 – 2004 dataset.
Error in Definitions
How a death is classified depends on when it happened. Looking at how many deaths happen during labor is not the same as how many happen during the first seven days of life.
| When the death occurs | It is called |
| during labor | intrapartum mortality |
| during the first 28 days of life | neonatal mortality |
| during the first 7 days of life | early neonatal mortality |
| after day 7 up to day 28 of life | late neonatal mortality |
| during the first year of life | infant mortality |
This simple error occurs when comparing the combined intrapartum and neonatal mortality rate in the Johnson-Daviss study to rates of neonatal mortality alone.
Invisible Data
Home birth critics link readers to web pages implying that those who can't find the damning numbers are either uneducated or dishonest. To avoid appearing foolish, some readers pretend to see data that isn’t there. Then they go on to debate the qualities of the imaginary data. By the end of the discussion, everyone can quote the same imaginary death rates used by the critics.
Just as the emperor had no clothes, these references to the fabled triply dangerous home birth do not exist. There are no differences in interpretation when it comes to nonexistent data. And just as in the children's story, it is the most humble, unafraid of looking foolish, who can see the truth most clearly.
There was once an emperor who loved clothes. For his birthday each year, he commissioned a tailor to make a special set of clothes for him to wear in his birthday parade.
One year a tailor came to town claiming that his work was better than everyone else’s. The tailor claimed he could weave fabric that was invisible to fools. At first the emperor was skeptical. The tailor shrugged, and started to leave saying he would weave his magical cloth for a wiser emperor. This changed the emperor’s mind and the tailor was hired.
For weeks the tailor appeared to weave, cut and sew fabric. Advisors to the emperor came and went to check on the progress. Although all of them only pretended to see the fabric, they argued among themselves as to the color and texture of the fabric in order to appear wise. The tailor also often corrected them so that when the day of the emperor’s birthday finally arrived, they all had the same description of the spectacular new clothes.
Although the emperor could not see the clothes, he held his arms out as the tailor dressed him in his new clothes. Proudly, the emperor walked in his birthday parade as all the citizens praised the tailor’s ability. Suddenly a small child pointed at the emperor and exclaimed, “But he isn’t wearing any clothes!” A ripple went through the crowd as one person after another whispered, “He isn’t wearing any clothes. He’s naked!” Louder and louder the voices grew until finally only the emperor and his advisors were left, still insisting that they were wiser than everyone else.
Original Story by Hans Christian Andersen
How interesting that you would try to address my comments to you without giving me an opportunity to respond. I found them anyway, and I have responded.
"Critics of home birth claim:
Babies born to parents who plan home births have triple the neonatal mortality of babies born to parents who plan hospital births.
There is no scientific data to support this."
That's funny. I provided you with copious scientific data to support this claim, including a long explanation of the fact that the Johnson and Daviss study ACTUALLY shows homebirth to have a neonatal death rate almost TRIPLE that of hospital birth in the same year, and a link to the CDC 2003-2004 data that shows that homebirth with a DEM has triple the neonatal mortality rate of low risk birth.
"Home birth critics cite various sources of mortality (death) rates for babies that are not even about planned home or planned hospital births. Having a baby at home with an experienced attendant and appropriate equipment is not the same as having a baby in the car on the way to the hospital. Information taken from birth certificates suffers from this problem since birth certificates only report where each birth actually happened, not where it was planned. Sources with the birth certificate error include the Pang study and the CDC Wonder 2003 – 2004 dataset."
That's right, Dr. Ho. That means that while NO homebirths with a DEM present were planned hospital births, many hospital births were originally planned homebirths. Therefore, the CDC statistics for 2003-2004 which show homebirth with a DEM to have triple the neonatal mortality rate of low risk hospital birth actually UNDERCOUNT homebirth complications. The real risk of neonatal death at homebirth is even HIGHER than what the CDC data shows.
"How a death is classified depends on when it happened. Looking at how many deaths happen during labor is not the same as how many happen during the first seven days of life... This simple error occurs when comparing the combined intrapartum and neonatal mortality rate in the Johnson-Daviss study to rates of neonatal mortality alone."
There are two problems with that claim, Dr. Ho. The first is that Johnson and Daviss made up their own definition of "intrapartum death". We know that because they included at least one liveborn baby (with an Apgar score) in their group of "intrapartum" deaths. Second, even if it were true that the "intrapartum" deaths in the J&D study really occurred during labor, you can't just forget about them. You must compare them to the intrapartum death rate in the hospital. If there were 5 intrapartum deaths in the J&D study, that's an intrapartum death rate of 1/1000. That's 3-4 times higher than intrapartum death rates of ALL risk categories in the hospital. You can't simply discard the babies who died intrapartum and pretend that they never existed. ANY way that you slice and dice the data, it still shows that homebirth with a CPM in 2000 has a much higher rate of neonatal mortality than hospital birth.
Feel free to address these issues on your website, or on mine, where I have linked to this entry and written this response.
Posted by: Amy Tuteur, MD | July 23, 2008 at 06:31 AM