1/ A recent analysis and commentary directly critiques our study (Nethery et al, 2021) on planned home and birth center birth in Washington State in @greenjrnl. Some thoughts after reading ajog.org/article/S0002-… in @AJOG_thegray (long thread)
2/ ‘An immutable truth’ could have also been titled “The vast majority of US home births were ‘low risk'; Low-risk home births had better outcomes than high risk home births”. And, let's improve hospital-based care + access to hospital-midwives for high risk people.
3/ They studied 'high risk' v. 'low risk' home births using US birth certificate data.
4/ Irrespective of issues (birth certificate data for birth setting research is widely critiqued, not intent-to-treat (ITT), no data on care provider), analysis and conclusions in "immutable truth" are mostly unrelated to our study.
5/ First, their main findings are not new. Others have reported on this: e.g. a w/ a US ITT cohort designed for place of birth research (Bovbjerg, 2017. Birth) and the UK Birthplace Study (Li, 2015. BJOG). None of that prior research was cited.
6/ Second, they present their work as a ‘response’ to our study (data from a single US state-Washington) but comparing ‘high risk’ v ‘low risk’ was not the aim (Nethery et al, n=10,649) of our study.
7/ Of note, in our WA study (2016-2020), less than 6.7% (n=833) of the births available were 'outside guidelines' and we do report on all births (main results and Appendices). This proportion of 'outside guidelines' (high risk) births in this study was same as reported in the UK.
8/ They state "By focusing on low-risk deliveries, Nethery et al misrepresented their conclusion that planned home births in the United States have good outcomes." We make no such conclusion.
9/ In fact, we say: "results reported in this study may not be generalizable to states with different legislation, training, and integration of community midwives".
10/ We clearly delineate our study population (Figure 1 and Methods), with specified exclusions. In our study, the target population is low-risk pregnancies at the onset of labor.
11/ So, with that target population in mind, our analysis appropriately restricted to this group (as is described in our paper).
12/ They argue by restricting to 'low risk' we are presenting biased information. But, how does data about adverse outcomes for 'higher risk pregnancies' inform the majority who are 'low risk' (and who we *know* are the best candidates for community birth)?
13/ 'People with higher risk pregnancies' are at 'higher risk' of adverse outcomes (v. 'uncomplicated or low risk') in hospital too!
14/ They state “Many midwives did not follow guidelines meant to exclude high risk patients at planned home births” – in fact, the vast majority (>91%) of births in their analysis *were* ‘within guidelines’ and ‘low risk’.
15/ Further, saying “midwives did not follow guidelines” denies that a birthing person had any agency in choosing a home birth. Implies that midwives should absolutely refuse care for anyone who is outside guidelines (or this should be regulated).
16/ (And, we also don’t even know if births in their study were actually midwife-attended, as opposed to planned home ‘unattended’, because that is not reported – but let’s assume most were)
17/ If OBs respect choice in reproductive health (#abortionishealthcare), then, respect informed choice of birth setting as well (#birthautonomy). This includes informed choice for birth setting even ‘outside guidelines’.
18/ “Some suggest that attending a woman who chooses to accept risk enables her choice. They hope that refusing to attend will force her to choose otherwise. This is a coercive and dangerous form of “chicken” that is ethically inappropriate in modern health care. ... "
19/ "Regardless of her choice, a woman and her fetus will face less risk with professional care than without it.” - Dr. Andrew Kotaska, 2018. Birth. onlinelibrary.wiley.com/doi/full/10.11…
20/ People choose home birth ‘outside of guidelines’, for many reasons. We need well-designed research evidence (as from our study) to guide informed choice discussions with birthing people about planned place of birth.
21/ And, many hospitals could improve in providing respectful, individualized care. Not everyone feels 'safe' in the hospital. Lack of access to hospital-based VBAC is a known issue and can be a driver of planned home VBAC ncbi.nlm.nih.gov/pmc/articles/P…
22/ As ACOG acknowledges, birthing people and women have the “right to make a medically informed decision about delivery” – this includes planned place of birth. #birthautonomy
23/ We can strongly and clearly recommend hospital birth with specific medical conditions, but ‘telling women/birthing people what to do with their bodies’ is patriarchal and has no place in modern health care.
24/ Absolutist and blanket statements about all US home birth (“an immutable truth”) does not improve outcomes for birthing people. This serves to further divide and create mistrust between community birth midwives, physicians and the hospital system.
25/ It also disvalues the nuanced and thoughtful choices of birthing people who may, with informed choice, choose home or birth center birth.
26/ Please do check out our original paper focused (as do other studies of planned community birth) on low-risk 'within guidelines' births and compared home to birth centers. journals.lww.com/greenjournal/f…
If you are still reading - check out this nicely reported news article.. mdedge.com/obgyn/article/…
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