Talk:Home birth/Archive 1

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)

If you go back to the original 12th Report of the Perinatal and Infant Mortality Committee of WA (2002-2004), the Forward says: "These data [the perinatal homebirth data] ..do not allow for definitive conclusions to be reached as the numbers are relatively small ....'" The latest (2006) statistics for WA show a 0% fetal death rate amongst homebirths.(Quainton (talk) 00:29, 19 May 2009 (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)

Gillyweed's summary of the government's study was correct. "concluded that five out of the six deaths had no link to place of birth". Doesn't mean its true, it's just an accurate reflection of what is stated by the source. Chemical Ace (talk) 07:14, 20 April 2009 (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)

Those "exorbitant" fees in Australia are half what they are in the UK and similar to those charged by independent midwives. If you think the fees charged are exorbitant for 24 hour emergent availability for months, clinics, procedures and delivery normally or surgical by someone with a minimum of 14 years training, then why do women have to book as soon as they're pregnant such is the demand? They must think they're getting a good deal, or don't you respect women enough to assume they'd be able to make the right choice? Why do independent midwives charge a similar amount to obstetricians when they have a fifth of the training, can sort out very few problems and carry no insurance?

Why don't IMs halve their fees which would still give them the earnings of a senior teacher if they're so committed to everyone getting a non-interventional birth? Because they're in it for the money of course.

500 women/yr would be completely unmanageable believe me. 200/yr will have the obstetrician in on many nights and is the most I've seen. —Preceding unsigned comment added by 165.118.1.51 (talk) 05:57, 1 September 2008 (UTC)

Can you please provide some references for your assertions about IPM rates please? Gillyweed has given some above and they are quite in line with what I understand is charged. You appear to have a vendetta against a profession than many obstetricians are more than happy to work with. I humbly suggest that your contributions to this debate are so tainted with bias that nothing you write here has any gravitas. I am quite aware of obstetricians in my city that book 500 women a year through their practice. They freely admit that they may not make it to the birth, but the women still come. You suggest that IPMs should halve their rates. If they charge $1500 per birth and do 40 per year, then they are paid $60,000 gross. If you are travelling 300km a week to provide home birth services (one IPM I know in WA travels 80,000 km per year) then there isn't a lot of change after they have paid their travelling costs. In addition IPMs practically guarantee attending a birth (well over 85% of women are attended by their IPM) so the things you demand from midwives cannot and should not be provided by obstetricians. I find your hostility unprofessional. Obman (talk) 06:40, 3 September 2008 (UTC)

Who cares what you think? I don't need to give references for their rates as they're Gillyweed's figures (can't you read), but I will. http://www.bubhub.com.au/community/forums/archive/index.php/t-25017.html and http://www.alternativebaby.net/?q=node/14674. You'll see that the cost is $2500-$4500, so STOP LYING about their income. Little left after their fuel? Ha ha ha. Most IPMs operate in a small patch AS YOU WELL KNOW. If independent midwives are so into helping every woman get a wonderful birth experience, they should halve their rates and double their numbers, thus doubling the joy. They'll then still earn double a senior schoolteacher's salary. Everyone wins. So why don't they. Answer: money, not principles. —Preceding unsigned comment added by 202.89.167.125 (talk) 12:15, 8 September 2008 (UTC)

Off topic. Not all homebirths are attended by midwives. Let's not be led into a smoke-stack of bitter argument if it doesn't further the article. (though I've yet to meet a midwife who drives a Mercedes!) Lcwilsie (talk) 13:41, 9 September 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)

Hi. Can you add information about the lack of support for pre-natal testing among midwives? (or support if you can prove it) In my experience, I have found homebirth midwives to be ignorant of prenatal testing, supplying false and misleading information about prenatal testing and afraid to say they are pro-choice (if they are) (as a lot of their clients are pro-life). My point is that if you are pro-choice and want a homebirth, you should know where to get prenatal testing and know what kind of test you want before you start seeing a homebirth midwife. There seems to be a meme in homebirth that people who do prenatal testing are motivated by "profit" and that it is dangerous to the baby (there is some risk of course!) yet they seem to be ignorant that many conditions can be treated in the womb and that it may be helpful to have some knowledge of abnormalities from the get go. —Preceding unsigned comment added by 12.159.234.138 (talk) 18:43, 30 July 2009 (UTC)

I don't have any references that discuss prenatal testing as it specifically relates to HB. Gaskin's Guide to Childbirth discusses the tests in detail, but in a very informative way, encouraging women to be informed and make their own choices. One complication may be that not all midwives have prescribing capabilities and would have to refer a woman to a physician or midwife who can write prescriptions/referrals for such testing. Lcwilsie (talk) 01:54, 14 August 2009 (UTC)

WHO Reference

The conclusion of the WHO reference is as follows:

"So where then should a woman give birth? It is safe to say that a woman should give birth in a place she feels is safe, and at the most peripheral level at which appropriate care is feasible and safe (FIGO 1992). For a low-risk pregnant woman this can be at home, at a small maternity clinic or birth centre in town or perhaps at the maternity unit of a larger hospital. However, it must be a place where all the attention and care are focused on her needs and safety, as close to home and her own culture as possible. If birth does take place at home or in a small peripheral birth centre, contingency plans for access to a properly-staffed referral centre should form part of the antenatal preparations."

I couldn't find anything in the reference with the WHO exclusively advocating "the use of more naturalistic, small-scale methods of childbirth, rather than the large-scale units now prevalent in developed countries" (from the wiki article)

There is something "The call for a return to the natural process in many parts of the developed world..." but that is not a statement by the WHO in support of "naturalistic methods".

A summary of the WHO's views, written by me: "The WHO has released a statement supporting the right of women to choose where they give birth. In the case of low-risk pregnancies, with appropriate support and contingency plans women can give birth at home." —Preceding unsigned comment added by Chemical Ace (talk • contribs) 13:11, 15 April 2009 (UTC)

Edit War

We seem to be engaged in an eternal edit war, not blaming anyone - I've put this article on the neutrality board for advice. —Preceding unsigned comment added by Chemical Ace (talk • contribs) 01:21, 18 April 2009 (UTC)

The article as it presently stands does not even remotely meet Wikipedia's NPOV standard. Statistics and studies are selectively cited to give the impression that there is a consensus that home birth is a safer alternative, when that is not the case. E.g., “Planning birth at home: increases the likelihood of normal vaginal birth and satisfaction in women who are committed to giving birth in this setting, compared with planning birth in a hospital” or “All medical interventions were substantially decreased in the home birth sample” - hmmm, in a home without immediate access to immediate medical assistance, those are foregone conclusions - and the only reason I can deduce for their inclusion is to foster POV.

At that point, a non-vaginal delivery is far less likely to be an option, even if the mother decides on it or the situation requires it, and dead mothers or infants have no need for an “intervention.” That may sound harsh, and I'm not an opponent of midwifery or natural childbirth at all. However, the purpose of this article should be to give a balanced view of the subject. Instead, what we have seems to be more what you would expect from a brochure promoting a midwife's home birthing service. And that is a dangerous thing in many instances - completely inappropriate for an encyclopedia entry. IMO, this article or at least the Safety section should be labeled as disputed POV until both sides can present something more balanced. Astynax (talk) 18:10, 18 April 2009 (UTC)

This is not true. If Astynax reads the actual studies it will be apparent that the cohorts are matched for risk. Viz, a low risk woman is more likely to have a vaginal birth at home than a woman with itentical risk factors in a hospital. It is the hospital interventions that lead to the non-vaginal birth. Not other factors. 125.168.40.224 (talk) 02:34, 20 April 2009 (UTC)

The cohorts are NOT matched in any of these studies. That IS the point. The BMJ one - unmatched. The BJOG - very poorly compared and unmatched etc etc. The only way you will get a complete match is a large randomised trial in low-risk women - and that isn't going to happen (UTC)

"Putting quotes from every interest group isn't going to help this article. " Gillyweed's comment when the position of the Royal_Australian_and_New_Zealand_College_of_Obstetricians_and_Gynaecologists was deleted. - If we're going to have quote from anybody we ought to have there's. They are an interest group, but a pretty important one at that with academic kudos.

Chemical Ace (talk) 11:34, 19 April 2009 (UTC)

The problem with this approach is that there are many pro-birth advocates who can come up with just as many pro-hb statements as RANZCOG can come up with anti-hb statements. The other problem is that RANZCOG has a pecuniary interest in a medical-baed approach to birth, while the pro-HB groups tend not to have any monetary interest. I think it is far better not to have any interest group statements as it muddies the water. Or shall I find a bunch of pro-hb statements from those with academic kudos too? 125.168.40.224 (talk) 02:17, 20 April 2009 (UTC)

"pro-HB groups tend not to have any monetary interest" . Seriously, are you really THAT uninformed? Read the discussion up the page. Whether these women book at home or in hospital makes no difference in monetary terms to ANY obstetrician, but homebirth midwives make nearly $100/hr with minimal costs ($3.5K/40 hours work).

Gillyweed is a homebirth midwife (or partner of same), who thinks that he can tell everyone what's what because he's some minor wikipedia editor. He lacks the intellectual faculty to understand the literature surrounding this subject, as evidenced by his putting the recent BJOG study (yet another fairly useless observational unmatched "cohort" study in a failing maternity system with some of the worst outcomes in Europe) at the top of the safety section in a previous edit. If the neutrality board had seen this article before I started bringing some semblance of balance and order, they'd have been even more shocked. This article was truly laughable then, rather than the fairly rubbish one we have now. —Preceding unsigned comment added by 202.89.167.125 (talk) 12:52, 19 April 2009 (UTC)

This anon editor from Western Australia who seems to enjoy slandering anyone with a view other than his has been trying to censor anything out of this article that suggests that HB is safe. Just look at his edit history. At least Gillyweed attempts to stick within WP rules and doesn't just simply blank material left right and centre. She seems to explain her position in edit statements too. I was of the understanding that BJOG is one of the most respected journals in obstetrics and therefore slamming the study (especially when it was publihed only last week) seems a little bit pathetic and grasping at straws. 125.168.40.224 (talk) 02:29, 20 April 2009 (UTC)

How can you slander someone who is anonymous, silly? BTW, you know more about me than Gillyweed - she is the anon one, isn't she? (Or maybe you are her and you're a sockpuppet - maybe I should have you investigated?) Her edits are POV, and against wikipedia guidelines, as evidenced by the opinion of the neutrality board. My opinion is that homebirth is less safe than hospital, but my edits simply say that there is insufficient evidence either way. She (you?) should adopt the same principle, but she (you?) won't because of bias and pecuniary interest. The BJOG is a journal I've published in twice as lead author. It publishes plenty of stuff that is not that great - I should know - my papers weren't. It's mainly CV embroidery, and the recent HB paper is definitely that type of thing as it doesn't advance the evidence at all. Not pathetic and grasping at straws - analysis - something you know absolutely squat about.

"Or shall I find a bunch of pro-hb statements from those with academic kudos too? " (125.168.40.224) You hit the nail on the head! The position of the interest group is not what should keep it in this article but its academic kudos or in wiki lingo "reliability" - see: http://en.wikipedia.org/wiki/Wikipedia:Sources#Sources . We need sources to be able to write anything on the subject, the more reliable the better. In regards to you finding pro-hb sources - Ideally you should be motivated by the search for truth, not backing up your viewpoint so what we want is information from as many reliable sources as possible. Look, no-one's trying to take away anyone's right to have a homebirth (well I'm not) we just want the information in the wiki article to be backed up by reliable sources as per wikipedia's policies. Furthermore, I think it's fair to say that none of us are experts and that even the experts disagree on this topic, it's not our job to fix this. All we need to do is note the controversy, state some of the different findings on the subject from reliable sources and continue on with the rest of the article.

Chemical Ace (talk) 06:59, 20 April 2009 (UTC)

The problem with including comments from anyone is we have to know the motivation for their statement. If you include a comment from the WHO, they are a generally unbiased group, with a stated interest in promoting best practices for health around the world. Having a statement from an association of obstetricians and gynecologists has the appearance of bias because obstetricians and gynecologists provide (almost universally) hospital-only birth. Similarly, having a statement from an organization of homebirth midwives would have the appearance of pro-homebirth bias. If this were an article on automobile safety, would we provide a quote from GM stating that American cars are safer than foreign models? Or would we include statements from independent testing organizations? Lcwilsie (talk) 12:56, 30 April 2009 (UTC)

Actually, most obstetricians and gynecologists, and even hospitals (many of which run birthing centers), will and do work with midwives and women who choose midwife-assisted and home births. At least that is the case in my part of the U.S., and is also the case in many other nations. I don't think that prejudices them, and they do not (as is sometimes implied) make choices for their patients by forcing them into C-sections, hospitalization, etc. There are some mighty big myths being promoted out there (patients choose, not doctors, except in the most dire situations where the patient is unable to make a choice). However, I also agree that their associations (or any home birthing group) are not particularly equipped to conduct studies. Wikipedia doesn't require covering every side of an issue, just basing the statements upon reliable sources and keeping the article NPOV. IMO, you need to directly cite studies from universities and health organizations. In many cases, that info may not be directly available on the web, and unless someone does the leg-work to track down such publications and look into the studies they cite to see if the information has been misapplied or superceded. If there in fact are no studies which definitively establish safety, then I would think a warning that that this has not been established would suffice.

A statement somewhere that this decision should be undertaken only in consultation with the woman's obgyn is lacking - and should be prominently inserted - neither this article or other web-based source will ever replace the need for professional medical evaluation and monitoring. That is completely irresponsible. As I noted previously, the article contains statements which are nothing more than POV rhetoric, and that is a disservice to Wikipedia readers. And the Safety section of the article still cites a study based upon "low risk" births, which leaves an invalid, POV impression. Astynax (talk) 21:34, 30 April 2009 (UTC)

What evidence do you have Astynax that an Obgyn is the gatekeeper of homebirth safety? As you may be aware, the major Obgyn groups in the USA and Australia are vehmently against HB and thus most of their members will follow the dictate of the Obgyn groups. There are no shortage of people, both academics and HB proponents who argue that most Obgyns take the anti-HB position on the basis of fear of litigation, fear of birth or worry that their business will be undermined by a competitor. This is not a popular view from obstetricians (look at the comments from some of them on this page) but it is A view held by some people. I think stating that obgyns are the best people to make a decision about a woman's body will bring no end of revision wars. 124.176.8.197 (talk) 07:01, 1 May 2009 (UTC)

I am certainly not aware of those things, and comes across more like typical demagoguery than fact. Again, no physician makes “a decision about a woman's body.” The fear-mongering that patients are somehow “forced” into treatments they do not want is simply impossible, and untrue. Physicians are very aware that they may be sued for going against a patient's refusal of any procedure or treatment, and it is unfair to impute that they are anti-HB on the basis of partisan speculation, or to speculate on the extent or validity of their positions based upon the same type sources. One does not have to be pro or anti HB to detect that the entry, as it now stands, contains much POV. The article can be descriptive without such biased statements and inferences. Astynax (talk) 17:34, 1 May 2009 (UTC)

BJOG

This all seems a bit silly. Why has the BJOG reference been removed by 125.168.40.224? It is the biggest study of HB yet done and is the most recent and yet because it apparently doesn't meet his/her requirements (while it does meet the peer review requirements of the journal) it is removed? I can only conclude that because it states that HB is as safe as hospital birth it goes against his/her biases and thus needs to go. Is this true? Let's deal with this one issue and then when we have agreement move onto the next point? 125.168.41.123 (talk) 00:08, 21 April 2009 (UTC)

Why haven't you put the big studies in that show homebirth to be riskier than hospital as well then? BIAS. I haven't put them in because they're poor quality too and my edits are not biased, unlike yours. The BJOG study is no better than these other studies in methodology (in fact it's worse as it concerns itself with a unique maternity system with exceedingly poor results in every birth arena - the worst in Europe, despite a healthy population). So you'll be reverted each time you try to include this BJOG study without an analysis of it's many shortcomings, and inclusion of the other big studies with analysis. The NICE report is right - not enough evidence either way - and that should stay. They've looked at all the data and all the studies. They know what they're talking about. You know less than nothing. Very arrogant to think you know more than the panels of experts at NICE, aren't you? I'm very patient, you'll be reverted every day, until what you write isn't biased and NPOV according to wikipedia's guidelines. —Preceding unsigned comment added by 202.89.167.125 (talk) 11:47, 21 April 2009 (UTC)

I'm sorry. Why are you attacking me? I have placed the BJOG study back as it is the largest of its kind. Its conclusions are no different from a range of other studies that say that home birth is as safe as hospital birth - it's hardly radical - other than being a very large study. Yes, the Netherlands maternity services do have a worse outcome than the rest of Europe and this is why the study was undertaken to check if homebirth was leading to the poorer outcomes. This large study found that it was not homebirth causing the poor outcomes but something else (as yet not identified) and that's an important finding. If there is a published analysis of the BJOG article then of course it should be included, but as far as I know there is no such analysis. Thank you for listening. 125.168.41.123 (talk) 00:00, 22 April 2009 (UTC)

Because you're ill-informed, arrogant, and think you know better than expert reviewers (eg NICE) despite being a layperson with no relevant knowledge. There are several large (flawed) studies showing homebirth to be more deadly than hospitals. You haven't got a clue about them of course. So reverted again, and will continue to do so. You will give up before me. The analysis of ALL previous published & relevant work is in the NICE publication referenced in the article. The BJOG study will be included within their analysis in due course, but won't change the conclusions. NOT ENOUGH EVIDENCE EITHER WAY - because all the studies are case reviews, usually by biased people for or against homebirth, not large RANDOMISED CONTROLLED TRIALS. —Preceding unsigned comment added by 202.89.167.125 (talk) 12:53, 22 April 2009 (UTC)

Please provide a summary of the studies you have identified (pro and con homebirth), with their conclusions and study design. You can see section 20 of this discussion for the format a previous editor used. That was quite useful and we would all appreciate the updated list of references you seem to know about. Lcwilsie (talk) 12:47, 30 April 2009 (UTC)

In science (and medicine falls under the scope of science) conclusions are often drawn from suggestive evidence. Ideal studies cannot always be performed, as in this case where individual variables impact choice in birth location which precludes the possibility of randomized trials. Suboptimal data cannot be summarily deleted, it must be evaluated with caveats in mind. The BJOG study needs to be included, with a description of the study design. It is true that we cannot say HB is X% safer/less safe than hospital birth. But we can continue to capture the growing body of data, as published by both sides. (the preceding comment written by a scientist with advanced degrees and statistical training) Lcwilsie (talk) 12:47, 30 April 2009 (UTC)

Only include the flawed BJOG study if you include the other equally flawed studies saying homebirth's more risky. Reverted once again. Comment by someone who actually understands study design and stats. —Preceding unsigned comment added by 202.89.167.125 (talk) 16:43, 4 May 2009 (UTC)

Please provide references for the "equally flawed" studies you mention. We should include them in the discussion of safety with a very clear caveat of their quality. For the moment, instead of reverting and removing the BJOG study, could you please provide a brief criticism of the study? This might provide a productive means to move forward toward common ground. Lcwilsie (talk) 02:40, 5 May 2009 (UTC)

Unmatched cohorts therefore different populations, no attempt to get proper matching data for subgroup matched cohort analysis eg they analyse socioeconomic status by postcode only, improper outcome measures, etc etc. Even if the study were gold standard, the results would be irrelevant because the Netherlands has a unique maternity setup with some of the poorest results in overall one of the healthiest populations in Europe ie. hospital AND home birth safety is appalling, different standards of neonatal care and collation of figures to the rest of the developed world, and finally a mode of maternity care which is rapidly being abandoned for modern standards of care. (UTC) —Preceding unsigned comment added by 202.89.167.125 (talk)

Disputes about this study don't seem so much about the accuracy of the statistics gathered, than about how and which stats are drawn upon to make statements and conclusions (both in the study and the way people cite the study). For example, hospital stats included both high and low risk, while the CPM's in the study referred any high risk cases to hospitals. In addition, cases with congenital anomalies and breech deliveries (both of which increase the incidence of mortality), were excluded from the home birth stats, but included in the hospital stats. Critics also note that the study did not address incidents during delivery which can raise neonatal mortality. A simple web search brings up people who have run the same statistics comparing home and hospital births where complicating factors during delivery were not excluded only from one side, and thus show choosing a HB setting as having 2-3 times the incidence of mortality.

And there are other factors: in those home births requiring transfer to hospital, infant mortality was 8x the hospital rate. And those deaths, are added to the hospital rate, but excluded from the HB statistics. The application of various study results also have been criticized as having been improperly extended to apply to situations where the same factors are not in place (e.g., level of midwife training required, distances to a primary care facility, prior evaluation, legal requirement to refer suspicions of complications to a obgyn, etc.). The lack of randomization is also brought up, which is a serious obstacle to forming any valid conclusions from studies to date (hence the qualifiers inserted all over the place).

As the BJOG Editor put it: “Essentially women who opt for a home birth face either a very successful, satisfying outcome, or a potentially disastrous one - there isn't the greyer area that you see with hospital births.” I think that is blunt, but not at all inaccurate based on the studies which have been referenced here so far - the BJOG study included. You really cannot have a “Safety” section where conclusions can be inferred by readers from inconclusive studies. So, again, why devote so much space to studies which don't offer any way to conclude anything about safety? • Astynax ^talk 21:03, 11 May 2009 (UTC)

Proposal: New section for safety

The safety arguments are ruining the rest of the article. I think that the re-write about study methodology was well done by Astraflame (see section 20 of discussion and "Research on Safety" as it stands at this moment in the article) and I think it adequately addresses many of the issues brought up as the concerns over what studies to include is hashed out over and over in the discussion. Based on the literature and study methodologies, I do not think it is possible to conclude whether homebirth is as safe, safer, or less safe than other birth locations and thus no statement should be made in the article. I propose that the body of the article discuss the details of homebirth (what it is, where it occurs worldwide, etc), and there could be a link to a separate page for a detailed discussion of safety. Also, the factual accuracy claim at the top of the homebirth page seems to apply only to the accuracy of home vs hospital birth, rather than to the accuracy of other details in the article. If I am wrong, please provide a detailed list of questionable facts so they may be properly addressed. Lcwilsie (talk) 17:28, 29 April 2009 (UTC)

I agree that it may be best to drop any reference to safety, other than to suggest that any decision upon home birth be decided in consultation with one's obstetrician. Some pregnancies are not "low risk" and there are good reasons why a woman may wish to choose a hospital or birthing center over a home birth. A physician's evaluation and monitoring is needed. There are still POV statements scattered throughout the article, however, which seem to be tilted towards home birthing. For example, “In choosing home birth, the mother generally has more control over her surroundings, and can eat and move around, sleep and do anything she pleases - activities which may be discouraged in a hospital setting. Midwives generally view birth as a natural process, and therefore keep their intervention and any other sort of medical intervention to a minimum.” - this is simply rhetoric (women can do such things in hospitals and birthing centers, and midwives keep medical interventions to a minimum not only out of choice, but certainly also because those options are not readily available in a home setting). This requires rewriting, IMO. Perhaps it would be helpful to flag the article POV-check, since some here are wont to undo without discussion. Astynax (talk) 22:04, 30 April 2009 (UTC)

I agree with Lcwilsie's view that we could move the Safety of Homebirth to a separate article. I don't agree with the above comments from Astynax where it is suggested that HB must be overseen by a physician. In the UK, Australia and New Zealand, midwives are more than adequately trained to monitor birth and know when to refer women to obstetric care. It is certainly not necessary for women to be under the care of physicians UNLESS there is something wrong. The UK normal birth campaign shows that midwifery and obstetric care are complimentary and necessary and not mutually exclusive. The preferred default system is that women are cared for by midwives until indicated otherwise and then are cared jointly by obstetricians (or doctors) and midwives. 124.176.8.197 (talk) 06:54, 1 May 2009 (UTC)

I come from a very US-centric experience, but in the hospitals here the policy is to insert an IV upon admission, all liquids are to be withheld, and no access to showers are allowed - unless the OB directs otherwise. Fetal monitoring is to be performed for 20-30min upon admission to obtain a "baseline," and subsequent monitoring is intermittent (15-30 min out of every hour) or continuous depending upon the OB's preference. Food is prohibited in all cases. All of these hospital policies severely restrict a woman's ability to move during birth. If this is not consistent with hospital policy in other areas of the US, or other countries, then the statement quoted above by Astynax is only partly true. As written, it does state "activities which may be discouraged in a hospital setting" not "activities which are always discouraged in a hospital setting." Lcwilsie (talk) 00:18, 3 May 2009 (UTC)

Actually, what I described is the case throughout the U.S. What you describe may have been policy years ago, but does not reflect the current position of either physicians or hospitals. No patient may be forced to accept a medical treatment - period. And neither physicians or hospitals are angling for a lawsuit by insisting on items which the patient refuses. Again, if this article is to move forward, then such obvious POV needs to be removed. Astynax (talk) 05:15, 3 May 2009 (UTC)

Well, my statements above were made based upon observation and specific question/answer with hospital staff and obstetricians in the past three months - not years ago. There may very well be a discrepancy between what is recommended by the AAPS and what is actually done in practice. While I agree that no procedure can be forced upon women (except for this and this example of being forced to submit to C-section - another example of discrpancy between AMA recommendation and practice), laboring women are at a severe disadvantage to advocate for their own rights. Lcwilsie (talk) 01:43, 4 May 2009 (UTC)

Again, that is not the position of either physician or hospital groups, nor of physicians or hospitals. The Angela Carder case occurred well before the policies now in place regarding patient rights. As I've said, no hospital or physician is out there angling for a lawsuit, no matter that you seem to prefer to think that this is the rule. And while I agree that laboring women can be impaired when advocating for their rights, that is as much the case in a home birthing situation as in a hospital or birthing center situation where they can be guided or misguided into not seeking or delaying medical intervention. If you want to argue that here, then fine. But such POV-ism cannot be allowed to carry over into the article. Astynax (talk) 19:54, 4 May 2009 (UTC)

You state: “It is certainly not necessary for women to be under the care of physicians UNLESS there is something wrong.” - and exactly WHO determines THAT? Again, this is Wikipedia, and the article is not to be a brochure for Home Birthing, which is how it now reads. Health safety decisions should only be taken in consultation with a physician, and that needs to be mentioned. But the blatant POV statements need to go.

As to moving the safety to a separate article, Wikipedia does not allow creating article forks to deal with POV issues. They create clutter, and are just an avoidance of making an article NPoV. This article can be descriptive without all the POV. But with the previous reverting of edits, there needs to be more acceptance by the editors of what Wikipedia wants (a neutral article), rather than what either side would like to promote. Astynax (talk) 18:29, 1 May 2009 (UTC)

Let's not forget that a) midwives are not just trained in attending births, but in assessing risk. Midwives regularly decline patients who they deem high risk (by specific criteria) and refer women to an OB when they become high risk during the course of pregnancy, or during the course of labor. And b) not all homebirths are attended by midwives; there are "freebirths" where there is NO medical person in attendance. Whether you agree with this or not, it is something that happens, and something that women choose. WP is not to be a source for what people should or shouldn't choose. To say that HB must be done "under the care of a physician" is prescriptive. Whether it SHOULD be done under the care of an OB or midwife is not necessarily reflective of what happens every time, nor is it the place of WP to state such. Lcwilsie (talk) 23:49, 2 May 2009 (UTC)

You are no doubt perfectly aware that not all midwives are trained to assess risks, and that even midwives trained to assess some risks are neither trained nor qualified to assess all risks. So inserting that sort of broad statement is inappropriate. Nor did I state “HB must be done 'under the care of a physician'” - a lot of sophistry which is not useful, and wearing very thin. Astynax (talk) 05:49, 3 May 2009 (UTC)

I am not advocating inserting a statement about the role of midwives and risk assessment, I am simply reminding the editors of what is covered elsewhere. The training and regulation of midwives is something to leave to the midwifery article. In our attempts to reach NPOV, let's not make this a "how to" article. Lcwilsie (talk) 01:43, 4 May 2009 (UTC)

None of the material being cited from these studies seems very useful. Few average readers will detect qualifiers backing the statements, and even so, much of the information is not going to be presented in proper context here. This can leads to PoV inferences. Suspicion of selective citing seems also be behind some of the previous reversions. The studies present conflicting statements even within themselves - taking back what seems to be said with a qualifier. So they aren't conclusive. Even were there such a study, as mentioned before, each unique pregnancy demands separate evaluation and consideration before HB choice is made. I can see why safety is relevant to the HB topic if it can be dealt with neutrally. And I can see why safety studies deserve a mention. However, I'm wondering why more than a very cursory mention of the studies is warranted here? Astynax (talk) 21:59, 6 May 2009 (UTC)

Hmmm. Anyone have a reason that partial quotes and extrapolations from inconclusive studies need to be such a prominent part of this? • Astynax ^talk 20:24, 11 May 2009 (UTC)

Finding a way forward

Hi Astynax, I wonder how we can find our way through these two extremes. I think what we are dealing with are two philosophies. (1). (The HB view) is that birth is not an illness nor a sickness and thus physicians should not be required unless otherwise indicated. Midwives are the appropriately trained people to determine whether there are medical problems that need oversight by a physician. The other philosophy (2) (The medical view) is that birth (because it is physiological and things can go wrong) should be managed by medical specialists. I doubt whether you will ever persuade one person who is firmly in one camp to move from one to another. Nor do we need to. What we need to present is information from a neutral position. Stating that a homebirth requires the agreement of an obstetrician is just as extreme as saying home birth is safe under all circumstances. Neither is true. The waters for this article are further muddied by people from different countries writing material. Eg. In UK, the Government is encouraging more homebirth. In US, the Government doesn't seem the slightest bit interested. In NZ, home birth is on the increase and the majority of women are cared for by midwives without obstetric involvement. In Australia there is a god almighty battle occuring between RANZCOG and the maternity consumer groups for 'control' of the maternity system. These national battles also get played out on these pages too and some of the editors (I am accused of being one, but hope I'm not) get rather extreme in their edits. Now none of this is unique to homebirth and WP has many policies designed to over come them. I'd forgotten about the POV forking policy. You're right. We just need get this one right. Perhaps we can try and get a consensus on the statement that you want included that "A physician's evaluation and monitoring is needed." What evidence can we find to make this statement? No doubt we can find an ACOG statement about this, but we can also find a RCM statement saying it isn't necessary. Perhaps we meed a paragraph explicitly explaining why there is so much debate over this issue and the reasons for the passion arise from the different philosophies about birth (I noted above). Do we want quotes from both sides about this? What do you reckon? Gillyweed (talk) 05:23, 2 May 2009 (UTC)

I agree that saying that “homebirth requires the agreement of an obstetrician” goes too far. Short of a prison or legal incompetence, no physician is able to dictate to patients. A home birth always has been a woman's choice, based on many factors.

Perhaps the solution is a bit simpler than trying to present several, conflicting viewpoints. Despite the efforts on the safety section from all sides, I'm afraid that even a definitive study(s) - on whichever side it tends to support - is going to be a very general observation.

The question arises: are conclusions in the studies compelling and definitive enough to be relevant to this article? Or is it more important to get across the point that safety is something which will vary from woman to woman, and from pregnancy to pregnancy? Safety for any individual pregnancy isn't going to be determined by a study/studies, and safety decisions shouldn't be based upon impressions gleaned from this or any other article. There are a wide variety of medical conditions which can render lack of access to immediate medical intervention dangerous, even fatal. Thus, acknowledging the above in a NPOV way, with some statement encouraging medical evaluation and monitoring of each pregnancy before making the decision on where and how the birth takes place may be more relevant than citing various studies.

Even cases where access to medical intervention is prudent or necessary, in many areas (including mine) a woman may still elect to choose a midwife, rather than a physician, to handle her delivery in a hospital setting, or in a birthing center adjacent or attached to a hospital. There are many options, and a woman's decision should ideally be made on a fully informed, dispassionate, case-by-case basis. There are certainly instances where some can legitimately argue that excessive medical intervention does occur - though often at the prompting of patients rather than some conspiracy by medical professionals. Just as surely there are people who put themselves at risk, and limit their choices, by putting themselves in a situation where immediate medical intervention is unavailable. There are no blanket rules or advice to be given, other than to arm oneself with knowledge of one's options and to include medical evaluation and advice as part of that individual decision.

I also agree that the sort of passionate disagreement which we find here can be worked through with a good article as the outcome. Neither side need compromise their stances in order for this to happen. But those personal views should be kept out of the article. Aside from the Safety section, there is much good information in this article. Even so, there are still some POV issues, some likely unintentional, sprinkled throughout which could be eliminated by some minor rewording here and there to render it neutral. Astynax (talk) 08:25, 2 May 2009 (UTC)

I agree with nearly everything you say. It all sounds quite reasonable. I also agree that we need to make the case that informed decision-making is the essential criteria for every woman. I need to think further about how we can then go about a cooperative re-writing of this article. I guess I didn't mean to imply that there is a conspiracy by the medical profession to provide excessive interventions, but rather the system of litigation in Western Countries and the approach that many people take that birth can be made risk-free leads to decisions being made that are sub-optimal. But as you say it all comes down to personal decisions about what risks people wish to take, and that then comes down to informed choice. We can't weigh them up in this article for them. Does one prefer an episiotomy or a tear? Or are they not mutually exclusive if other care takes place before hand? So much about birth is an art, rather than a science and yet we try to make it all cut and dried. I'm sorry, I don't have any proposals yet. I'll need to think a bit further about a good structure. Any thoughts? Gillyweed (talk) 11:07, 2 May 2009 (UTC)

I think there is quite a bit we could add to the article - it seems to have been stripped of so much content that it is nearly down to being a recitation of studies. One thing that I find severely lacking is information about what a homebirth is. Unfortunately this only comes from first hand accounts, as published by Ina May Gaskin and others, and these are not going to be at all balanced (very pro-HB). However, they would be illuminating and informative for anyone coming to WP seeking to learn about a homebirth. It's difficult to discuss what a homebirth is without comparing it to a hospital birth. It's also important to avoid setting people up to expect what they may not get, as midwives differ significantly in their practice both within country and between countries (i.e. not all use warm compresses and counter pressure to avoid tears, TENS and gas/air are common in UK but not US, some use herbs and homeopathy some don't - and on and on). And finally, it's important to avoid making the article too midwife/OB centric as, again, homebirth includes those who birth without medical assistance. Lcwilsie (talk) 00:10, 3 May 2009 (UTC)

I have commenced rewriting the article but have started with only the first two paragraphs. I won't do any more until I see whether it gets reverted! I've simply tried to define a home birth and also describe the two types. I can find references if necessary but believe that these are fairly self-evident. I think the next section should be entitled "Prevalence" and this should describe some of the statistics about the prevalence of HB in different countries. After this I believe there should be a section labelled Controversy and this should explicitly recognize that there is a conflict between different groups over the safety of home birth. A subsection could then look at the safety studies (both pro and anti). Then we could have a section about the experiences of HB (as indicated above - from Gaskin/Vernon/Kitzinger et al. Finally, keep the section about its status in Western Countries. Watcha reckon? Gillyweed (talk) 06:24, 3 May 2009 (UTC)

On the face of it, wise words - in contrast to all your previous edits of course. You still revert to a version that only includes positive messages about homebirth and ignores the negative. Would you include an account from someone who's child died in a wholly preventable way in your "experience of homebirth", by the way? (UTC) —Preceding unsigned comment added by 202.89.167.125 (talk)

I've rewritten the Prevalence" section but then renamed the section "The Rapid Decline and Gradual Rise of Home Birth in the West because it is a descriptor and also indicates that we are talking about the developed world. Is it a bit twee? If so, we can go back to prevalence. I also thought it might be useful to put some explanatory material in that shows one of the reasons why at the beginning of the twentieth century 95% of births were at home, and now at the beginning of the twenty-first 99% are in hospitals. Of course the sanitation is not the only reason, but the quotes were quite illustrative. Gillyweed (talk) 09:47, 5 May 2009 (UTC)

202.89.167.125 - hopefully some balance is fortcoming. You should feel free to contribute some cautionary material. But both sides need to be stated from an objective, neutral point of view. Obviously, many home births are problem-free. But I agree that choosing to deliver at home entails having fewer options immediately at hand when the time comes. There are indeed situations (both foreseeable and unforeseen) where that can result in negative outcomes, and that does need to be noted - but in a neutral way. Astynax (talk) 19:28, 4 May 2009 (UTC)

202.89.167.125 - please view the discussion I initiated at your talk page. I look forward to your response. Lcwilsie (talk) 19:42, 6 May 2009 (UTC)

202.89.167.125 - please view the updated discussion on your talk page. I have elevated this concern to WP:WQA, which you can view here. Lcwilsie (talk) 13:46, 14 May 2009 (UTC)

Please consider adding a note(s) to the reading list mentioning that these works are from the HB advocacy community. Otherwise, someone might be reasonably justified in challenging and removing items, or the entire section, as has occurred in other articles. Noting the orientation(s) will help neutralize that possibility. If possible, some works with opposing views could well be added (similarly noted). Astynax (talk) 22:05, 6 May 2009 (UTC)

Done. Look okay? I don't know of any specifically anti-HB books. We shall wait for any to be added. Gillyweed (talk) 23:44, 6 May 2009 (UTC)

NPOV dispute

I came here because of a request on the NPOV board, and have been reading the history and monitoring as time permited. There is a problem, which I have already noted. As this area has not yet been addressed, I have tagged the article to note the dispute. Please work towards eliminating POV statements and inferences. If you cannot edit without inserting your own viewpoints, then please don't bother. This edit war is close to attracting more serious intervention than just the NPOV board having a look. Astynax (talk) 05:52, 3 May 2009 (UTC)

Please note the edits in the past 48hrs. Gillyweed and myself have attempted to rewrite the first two paragraphs of the article to eliminate POV statements, and these edits have been summarily reverted with absolutely no discussion of the edits. Suggestions? Lcwilsie (talk) 17:13, 4 May 2009 (UTC)

You can go back and restore the edits on which you were working. Reverting is not a cooperative way to move forward with an article. This article was and is far from any the point where it cannot be improved. Whatever was there does not “belong” to anyone. It is more constructive to edit whatever new has been added, working together to refine and better the article. If something was removed, then consider adding only such material back into the article in a NPoV way. At some point, repeated reversions without explanation or an attempt to discuss become vandalism, and intervention will be required. Astynax (talk) 19:12, 4 May 2009 (UTC)

I've done as you have advised. Regretfully we are still having trouble with continued undiscussed wholesale blanking, which does not lead us to an improved article. This rewrite will take sometime but we'll get there. Gillyweed (talk) 00:54, 6 May 2009 (UTC)

Asynax, as you have offered to provide some balance to this issue, could you please look at the behaviour of User 202.89.167.125 who once again reverted all the work I did today, which was mostly adding better referencing, and fitting in with MOS (eg capitalisation of headings). This editor reverts my stuff without even considering what I have written. May I invite you to review the tone and content of this editor's comments on this page. I have reverted this person's changes again. Gillyweed (talk) 12:21, 6 May 2009 (UTC)

I think that in some of the dispute, there is compromise language which will keep the description going, but without specific language which trips warning bells. Some of the deletions probably would make for a clearer, NPoV article. Not that there is anything wrong with presenting different sides, but that when there is very much of that, it becomes confusing to the average reader. I'll edit the latest deletions and you can look and see how it reads to you. I'll do so section by section, so it will be easier to undo or edit them individually. Astynax (talk) 18:39, 6 May 2009 (UTC)

Reversions do not make a better article, nor do they make it NPOV. Two specifically I question: [9] – It is unclear why these sources were removed. They are appropriate further reading for women considering a home birth.

[10] These reverts (removal of BJOG study) are the subject of ongoing discussion [11]. Continuing to remove them when there are multiple editors who would like to include them is against WP policy WP:DE. The NICE study that is cited in the article was written in 2007, which only covers published data through 2007. Are we to avoid including any other data until another such review is published? The BJOG study is current and needs to at least be discussed. If it is too contentious to include it in the safety section, it should be included in a "Legal situation in the Netherlands" section, as the Australia-specific safety paragraph is included in the "Legal situation in Australia" section.

The reversion by 202.89.167.125 ("Undid biased pro-homebirth editing by Gillyweed, and replaced with NPOV") [12] actually resulted in reverting past eleven intermediate changes, from four different editors and a bot. The minor spelling corrections and capitalization corrections will have to be redone. This is a waste of everyone's time. Lcwilsie (talk) 20:13, 6 May 2009 (UTC)

As I stated, I am going over the article section by section comparing Gillyweed's last undo with 202.89.167.125's last edit. I was about to address the Safety and Reading sections. Nothing is lost on WP, so don't overreact. Your last edits have not only interfered with my review - waste of time or not - but have reintroduced unnecessary PoV statements. I challenged the author for a citation for one statement, and it isn't fair to remove it unless it cannot be backed. Astynax (talk) 20:50, 6 May 2009 (UTC)

After going through the article for PoV, I want to observe that undoing an entire article for material contained in one section can be more disruptive than constructive. Please confine yourselves to changing sections whenever possible. However, the tactic of editing an entire article instead of editing section by section also can cause people to revert an entire article. Don't edit that way, and you'll see less of your work reverted. Some of the last undo's were justified, IMO and others were not. The article cannot end up as advocacy for HB. That doesn't mean that it should be anti-HB, but that it must be neutral with properly cited RS's. I will post my comments on Safety and Reading list, which need further discussion, separately. Astynax (talk) 21:38, 6 May 2009 (UTC)

Let's be clear. My opinion is that homebirth is more dangerous, but that isn't in my edits. The main reason for that danger is the practice of homebirth midwives, most of whom are scarily ignorant and pseudoscientific. The lack of knowledge of what makes a good study is writ large here - some of the editors here can't even add up, despite claims of advanced degrees. I cannot however back my opinion with good research, because only poor quality research exists. The BJOG study is quite a poor piece. The home-birth apologists on here think because there is a large number of subjects in this study and has their wanted result it is a good study. They don't seem to recognise that it is purely a descriptive study, attempts to compare apples with oranges, and then says they're just the same because they're both fruit. It's also based in a country with weird practices, and incredibly poor outcomes - it's not applicable to another country on the planet. So, when I edit I make it neutral - I don't write homebirth is unsafe, I write there's no evidence for or against, although I believe differently (and of course the vast majority of people share my view). The NICE guideline sums the state of play well, and people who want to delve into the rubbish research on this issue can access it through that link. I actually don't disapprove of homebirth for the right women, with the right midwives (ie not unethical non-indemnified independent midwives) and who've been PROPERLY informed of the small but definite risks. The other editors on here want to hide information from women. I wonder why - it's either political feminist reasons or, more likely, the huge fees earned which are much higher than equivalent professions, or their rather more competent midwifery colleagues who practise in hospital.

So, I'll keep on reverting any biased edits. Meanwhile I'm very happy if you get others involved who are committed to neutral articles. It would be instructive to examine this article before I started editing. It's laughable, and you can see in the edits who constructed it! —Preceding unsigned comment added by 202.89.167.125 (talk) 12:07, 7 May 2009 (UTC)

202.89.167.125: If, rather than reverting the entire article, you can focus on editing specific sections with which you disagree, that keeps down the frustration level. Others may have made good or neutral edits in the meantime which get swept up in your reversion. Even better than reverting, edit what's there so that it reads as more NPoV in your eyes. I've questioned whether we should be citing these inconclusive studies at all in the New section for safety comments above. I think we can work together to come up with some general statements which are more relevant and useful to readers? • Astynax ^talk 16:31, 7 May 2009 (UTC)

202.89.167.125, you say "The BJOG study is quite a poor piece." This might be true, or it might not. I don't know. It certainly seems to be a widely cited piece, and has been cited by major news source as supporting the proposition that home births are "as safe as hospital" (see, e.g., http://news.bbc.co.uk/2/hi/health/7998417.stm.) Would you happen to have any sources that support the contention that it's problematic in the way you describe? Nandesuka (talk) 00:32, 8 May 2009 (UTC)

I don't know that I would agree that it is a “poor piece.” I would, however, call it “inconclusive.” I think the basic problem people have with it lies more in how its statistics are improperly used as evidence for this or that conclusion. In the case of 202.89.167.125, s/he seems to have a problem with the conculsion so widely touted (either by implication or explicitly) that BJOG shows that HB is "safer than" or "as safe as" hospital birth. That is clearly going too far, and it doesn't help that pro-HB sites are the main voices in turning this into a tool promoting a specific PoV. Part of the problem with all the studies, including BJOG, has been that the populations included in the HB statistics were self-selecting and not truly random. Among several other problems affecting the statistics generated, are differences in the qualifications and training required of midwives and their association with medical professionals (and, yes, hospitals), from nation to nation. The situation in place for a study in the Netherlands or in Britain, is far different than what exists in, say, most of the U.S. Too many variables either not addressed, or inadequately addressed, in any study thus far. And drawing conclusions from inconclusive studies seems necessarily PoV - dropping qualifiers, and reading into what is actually there. • Astynax ^talk 19:06, 14 May 2009 (UTC)

1 week protection

I have protected the article from editing for a week. Please use this time to arrive at a consensus on the talk page as to what material should or should not be included. 202.89.167.125 please consider this a formal admonishment to restrict your comments to the article rather than the editors. That same advice goes for everyone participating here. Nandesuka (talk) 12:37, 7 May 2009 (UTC)

Is it possible for everyone to summarize their stand on what seems to be the major points of contention? The discussion is getting quite splintered.

I vote that the WHO statement stand alone, rather than having ACOG or RANZCOG or other interest groups statements. The WHO reviews data worldwide rather than just within one country, and it does not represent any professional group.

Agree Gillyweed (talk) 06:03, 8 May 2009 (UTC)

Fine 202.89.167.125 (talk) 23:59, 7 May 2009 (UTC)

Disagree (I have no problem with the WHO statement per se, but limiting to a statement from an organization which tends to issue pronouncements mixing medical and political considerations, and in light of the acknowledged lack of definitive studies, seems overly restrictive) • Astynax ^talk 16:22, 8 May 2009 (UTC)

"Factors in choosing a homebirth" or similar needs to be part of the article. To ignore the fact that there is a difference between labor/delivery in a hospital/birth center vs at home is to ignore a very large aspect of homebirth. I acknowledge that it will be difficult to reach consensus when writing this section.

Agree Gillyweed (talk) 06:03, 8 May 2009 (UTC)

According to you, women in hospital can't eat, drink, move around etc, but they can at a homebirth. This is not going back in as it's wrong. 202.89.167.125 (talk) 23:59, 7 May 2009 (UTC)

Comment Sorry. Why do you say it is according to me? I don't recall writing that. Incidentally, there are many hospitals in Australia which have protocols saying that women cannot eat or drink (other than water or ice) during labour in case they require a caesarean. Do you want them listed here? Oh, why do you refuse to sign your posts? You have been asked many times to do so. It would be polite. Gillyweed (talk) 14:11, 8 May 2009 (UTC)

Some of us have worked in many hospitals in different nations. I can't recall one that restricts women in movement. Most will limit the intake in women who are at high risk of CS. The safety of high-risk women in hospital has nothing to do with homebirth. Low risk women are allowed to eat in every hospital I've ever worked in. So I don't agree with narrow, POV assertions that are incorrect. I find it interesting how a "male" who is "not" a midwife "knows" so much about protocols in all these hospitals. Care to explain your sources? 202.89.167.125 (talk) 22:56, 8 May 2009 (UTC)

Some links to limitations that are placed on all women who labor in US hospitals:

• Hospitals limit who/how many people can be present for the labor [Barnabas] limits to spouse + 1, |Brigham and Women's hospital encourages only 1 but allows 2 – all must be older than 16 years old
• Hospitals require 20-30 min "baseline" external fetal monitoring which limits a woman's ability to move more than 2 feet from the hospital bed [Barnabas policy] (page 2)
• An article in [Mothering] discusses the fact that US hospitals restrict women to sips of fluid or ice chips during childbirth, but Mothering is not the quality of source I'd like to reference in a WP article.

I'm having difficulty finding policies at many hospitals, as most don't post this information online, so if anyone can help I'd appreciate it. Lcwilsie (talk) 21:22, 13 May 2009 (UTC)

Well at my hospital, we have none of these restrictions, so what do your references prove? The world consists of many more countries than the USA, perhaps you should recognise that. Even our high risk women can mobilise how they like, even outside, as we have wireless CTGs. In fact they often mobilise more than those low-risk women who receive intermittent monitoring. What do you say about that? As for numbers of visitors, some have restrictions, some don't. We don't. Visitors aren't a defining characteristic of homebirth, are they? Just your biases coming to the fore....again. Eating I've referred to above. Again, you're coming from a US-centric view. In the UK & Australia, low risk women eat in labour if they want. —Preceding unsigned comment added by 202.89.167.125 (talk) 04:03, 14 May 2009 (UTC)

In the U.S., as in many other countries, no hospital can force a legally competent patient to do or not do anything. On the other hand, if it looks like a certain course of action is very likely (such as administration of general anesthesia), they may prescribe avoidance of solid food. That doesn't mean they're forcing anything upon the patient, or that patients cannot ignore. If you search on patient's rights you should find plenty of links from both hospitals and physicians regarding this. I had already posted 2 links under the New section for safety header above. Limitations on number of people probably varies from hospital to hospital (depending on the size of their rooms). Certainly more have been allowed in the hospital deliveries in my family, while less were allowed in the home birth setting (both at the choice of the mother). Making statements such as “hospitals require” comes across as an extremely over-broad generality (though you may not have meant it that way). Not all hospitals “require” anything - and a patient's rights trump any “policy.” • Astynax ^talk 19:35, 14 May 2009 (UTC)

Agree • Astynax ^talk 16:22, 8 May 2009 (UTC)

I propose that safety be reserved for the “Research on Safety” section. This is not to disguise the safety/lack thereof of HB, but to keep the article from contradicting itself.

Agree Gillyweed (talk) 06:03, 8 May 2009 (UTC)

Disagree. This is simply a mechanism to reduce the impact / amount of discussion on safety in the article. Get the safety discussion exactly right and I'll change my mind. 202.89.167.125 (talk) 23:59, 7 May 2009 (UTC)

Comment I don't believe that we are aiming to make you happy but rather to have a balanced and accurate article. Why do you refuse to sign your posts? Gillyweed (talk) 14:11, 8 May 2009 (UTC)

Disagree (the limited research studies to date are problematical, inconclusive, and do not add much of anything except opportunities for POV warring, from both sides, to the article) • Astynax ^talk 16:22, 8 May 2009 (UTC)

Comment, so you are suggesting that safety be scattered throughout the article, as it has been before? Gillyweed (talk) 03:39, 9 May 2009 (UTC)

Looks like it! 202.89.167.125 (talk) 22:56, 8 May 2009 (UTC)

Comment, I'm not objecting to placing statements regarding safety in a separate section, just suggesting that such statements will be completely lost in “Research on Safety,” which deals almost entirely with inconclusive studies. • Astynax ^talk 07:32, 9 May 2009 (UTC)

If the discussion of the BJOG study is excluded, a reference of the study should be added where appropriate to the “Study design” section of “Research on Safety.” I am against excluding new studies simply because they don't live up to one editor's standards, but I am willing to negotiate.

Disagree. I think it is arrogant for editors to assert that BJOG is poorly done and that the peer reviewers have stuffed it. I am happy for critiques of BJOG to be quoted but for it not to appear on the basis of one editor's view is not acceptable. Gillyweed (talk) 06:03, 8 May 2009 (UTC)

Disagree with both opinions. The BJOG study is only one of several studies and is poor. Either quote and discuss ALL studies in context or leave it out. The NICE publication is a systematic review that more than suffices for the current state of the literature. 202.89.167.125 (talk) 23:59, 7 May 2009 (UTC)

Comment The BJOG study is the largest of its kind. It is the most recent of its kind. To leave it out would be bizarre. Your assertion that it is poor is simply an assertion. I am willing that comments critiquing the study are included if they are referenced properly. I have no objections to the NICE study. I find it odd that you are so against the BJOG study. Its conclusions were the same as NICE - viz, home birth is as safe as hospital birth. Gillyweed (talk) 14:11, 8 May 2009 (UTC)

Disagree (simply because the BJOG study, which I've now looked at, has been seriously and validly criticized on several points. It may be the largest and most recent, but that doesn't mean that it offers any more insight than other studies. The problem isn't with how well the data was done or reviewed, it is the validity conclusions drawn from the data and that qualifiers render some of the conclusions inconclusive. I think this is a problem with all the studies to date - they are inconclusive, so why such a lot of room devoted to them?) • Astynax ^talk 16:22, 8 May 2009 (UTC)

Comment Why give it room, because these studies are the best we have - flawed or not. Surely it is better to work off some data than nothing at all. Can you please cite the references critiquing the BJOG study? They should be included if they are valid criticisms. Gillyweed (talk) 03:39, 9 May 2009 (UTC)

The references don't exist yet of course. Adequate systematic analysis of complex papers, and then placing them in context with the rest of the literature requires time. Time to prepare a systematic review, write, peer review, rewrite, and then the lag time to publication. Therefore, with new studies, you won't get proper contextual analysis of them until the next systematic review is published. NICE was the last systematic review. The next big study will be the UK national retrospective study which is being conducted at the minute. I've no doubt that NICE will revise it's systematic review to include that study and the BJOG one then. This will likely take 2-3 years. A further systematic review including the BJOG study may or may not appear in the meantime. Given that it's obvious that the BJOG study won't affect NICE's conclusions (which btw are NOT the same as the BJOG study - read the paper & conclusions again won't you), I can't see independent researcher teams wasting time on this just now. Lack of understanding of how new research is put into context by the academic community and the inevitable time that this takes, is characteristic of lay people and the media, who cling on to the latest publication with dear life especially if it bolsters their (misunderstanding) of current knowledge. 202.89.167.125 (talk) 22:56, 8 May 2009 (UTC)

I suggest that the “legality” sections either focus specifically on legality of HB or expand to become “legality and culture” or something like that. The safety comments need to be removed or incorporated into the safety section (i.e. last 5 sentences in Australia safety).

Agree I had removed the last five sentence of the Australia study before Nandesuka protected the reverted version. Gillyweed (talk) 06:03, 8 May 2009 (UTC)

Disagree Safety is entirely mixed in with HB politics in each country. How can excess Western Australian HB deaths or the recent front page homebirth deaths in NSW, Australia not impact on political decision-making & future legislation? Again this is just minimising discussions on safety. 202.89.167.125 (talk) 23:59, 7 May 2009 (UTC)

Comment. There were no excess WA deaths. The report states that five of the six deaths were unavoidable regardless of birth location. Why do you keep leaving that bit out? The recent 'Front Page' home birth deaths in New South Wales muddy the waters. One was a 'freebirth' with no professional midwives in attendance. The others were also unattended by registered midwives (two were doula attended and one was by a deregistered midwife - given the result, deregistration was probably a fine idea). Focussing on death in this section gets rather messy. There were some 2091 perinatal deaths in Australia in 2006. All of these were in hospital. There were no perinatal deaths at home. There were also 69 maternal deaths in hospital and none at home What do we do with that data? Gillyweed (talk) 14:11, 8 May 2009 (UTC)

So if there were no excess deaths, why is the government reviewing the homebirth service, and more interestingly, holding back the results? If those 5 women had booked in a normal public hospital, then it's likely that 3 or 4 of them would have their babies now. It's likely that antenatal signs or symptoms have been missed or glossed over. This is typical of homebirth midwives who assume normality instead of looking for problems.

Comment: Just to make the point that the review is an independent review but commissioned by the government. The Dept of Health has assured us that the report of the review is to made public in the not too distant future. I am not quite sure how you can say that 3 or 4 of ladies would have there babies by now as the PIMC report that raised the question says that 4 of the deaths had low levels of medical preventability and 2 births had no preventability. (Quainton (talk) 09:03, 19 May 2009 (UTC))

Moreover Why do you persist in comparing homebirth stats with high risk hospital births? Why don't you compare top low-risk hospital births I wonder? The answer is because homebirth results would look shocking in comparison.

"There were no perinatal deaths at home". That's because when babies are in deep trouble or already dead, their mothers go to hospital to deliver. How can this fact not be understood?

"There were no maternal deaths at home". Same applies. Do you think a homebirth midwife would confirm the death at home and just sort it out themselves? 202.89.167.125 (talk) 22:56, 8 May 2009 (UTC)

Disagree (although I agree that the bulk of such material could be moved to safety, where a certain nation is involved in a dispute on safety, some brief mention should be allowed. Re. “Comment” - one death attributed to location of birth among 6 deaths would be considered a significant percentage, and a remarkable elevation of risk. That said, it seems likely that the sampling would not be broad enough to draw much in the way of a conclusion.) • Astynax ^talk 16:22, 8 May 2009 (UTC)

Comment This is the full quote from the WA 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.” If the statement is true that setting did not affect the outcome of 5 of the 6 deaths, then we are left with 1 death which is about 1.2 per 1000 births which is less than 2.1 deaths for the hospital cohort. This is why this section is meaningless and misleading regarding safety. It actually shows that hospitals are more dangerous, which from the studies we have show HB and hospitals are about the same! It would be nice if the Department of Health in WA released the report into these deaths. It has taken them a blooming long time. Gillyweed (talk) 03:39, 9 May 2009 (UTC)

The statement is a quotation from a government dept to a newspaper. Therefore almost by definition it's not true! You analyse in healthcare by intention to treat, as I have said before. This is expected in every serious research study comparing patients. Please look this up before further commenting. If I looked at hospital deaths, I've no doubt that most of those had no obvious link to the hospital as a place of care. Case review is helpful in improving systems & performance and assigning & deflecting criticism, but in research we use STATISTICS to tell us about differences between otherwise similar POPULATIONS undergoing different care. 202.89.167.125 (talk) 22:56, 8 May 2009 (UTC)

The interpretation that these statistics show that hospital births “are more dangerous” looks very seriously flawed. Taking out the 5 deaths to figure the HB percentage, and then comparing with the hospital percentage where such deaths were not removed, is not credible. In addition, a higher percentage of high risk births are handled by or transfered to hospitals than delivered in home settings. Skewed numbers. • Astynax ^talk 08:28, 9 May 2009 (UTC)

“Additional reading” should be expanded, not narrowed. We can certainly add more references, including those critical of homebirth, but many of those deleted are quite relevant for the purposes of childbirth education (not necessarily pro-HB, but pro-non-interventive birth). Is it the policy to exclude texts from the reading list because they are thought to be promoting HB?

Agree I had already done this efore Nandesuka protected the reverted version. Gillyweed (talk) 06:03, 8 May 2009 (UTC)

Agree but pro HB texts must be balanced with anti. You need prominent links to some anti-HB websites, if you want anti-medical books in this list. Also you should make it clear which biases each text or website is coming from. 202.89.167.125 (talk) 23:59, 7 May 2009 (UTC)

Comment - great. Find some anti HB books. I don't know of any. Gillyweed (talk) 14:11, 8 May 2009 (UTC)

What about referencing Dr Amy Tuteur's homebirth website? Will you place that in the article please Gillyweed, to improve balance? 202.89.167.125 (talk) 22:56, 8 May 2009 (UTC)

I know I'm late to the discussion, but I have to object to the idea of adding Amy Tuteur's website as a reference. It is not a reliable source. It is simply the blog of one self-proclaimed expert, and falls squarely in the category of self-published sources.Jane Snow (talk) 04:19, 13 May 2009 (UTC)

Perhaps, but no more so than the authors of the books on homebirth. The only difference between her and the other authors is the medium. Tuteur's qualifications are a great deal higher than any of the homebirth "experts". Please suggest other alternative sources if you object to this, otherwise I'm going to put it in.(UTC) —Preceding unsigned comment added by 202.89.167.125 (talk)

I'm not objecting to the source because it is biased, I am objecting because it is self-published, and not from a respected authority in the field, which makes it an unreliable source per WP standards. If any of the pro-homebirth sources are self-published they should be removed as well. I will look for editorials in peer-reviewed journals that state an opposition to home birth, but in the meantime, you have the statement from the ACOG. On a related note, the sentence reading "...most studies cite a transfer rate of about 16%" really ought to be removed along with reference #1. The "Homebirth Reference Site" is subject to the same criticisms as Dr. Tuteur's site.Jane Snow (talk) 22:35, 18 May 2009 (UTC)

Agree • Astynax ^talk 16:22, 8 May 2009 (UTC)

Remove "famous homebirthers" as that is just an embarrassing section. Who cares if some vacuous celebrities have chosen HB? 202.89.167.125 (talk) 23:59, 7 May 2009 (UTC)

Agree (I don't see that it adds much) • Astynax ^talk 16:22, 8 May 2009 (UTC)

If there are other contentious issues I left out, please list them. Lcwilsie (talk) 02:39, 8 May 2009 (UTC)

Resolved and not resolved

Resolved:

• The WHO statement will stand alone for now - those wishing to add other statements from other organizations will discuss and reach consensus on the talk page first.

WP does not require editors to discuss or consensus prior to editing (it is nice when they do), so I must disagree with that portion. However, I do agree that the WHO statement should stay in. • Astynax ^talk 20:10, 14 May 2009 (UTC)

• "Factors in choosing a homebirth" will be added to the article. Statements in this section will be referenced. If you dispute a statement in this section please note with "Reference needed" rather than deleting the statement to give the author an opportunity to find the appropriate reference.

Diasgree for reasons above. A reference does not equal truth. I will revert biased changes. 202.89.167.125 (talk) 21:15, 13 May 2009 (UTC)

This article needs more content than just a convoluted and go-nowhere discussion of safety. And yet it seems that any proposal for writing about anything related to homebirth (the topic of the article) is deemed biased. The decision to have a homebirth is an emotional and personal choice for most women, and by choosing HB, I suppose, that means they must themselves be "pro-homebirth." A conundrum indeed. I never claimed that reference = truth, nor that "truth" is attainable on this or any topic. A reference simply means that someone wrote down the particular piece of information, and if that source is available to others for review it is worthy of consideration. If the reference is not a reliable source, the information should be removed or a better reference used in its place. Lcwilsie (talk) 21:17, 14 May 2009 (UTC)

Agree. I would just ask that if 202.89.167.125 disagrees with the section, simply to edit that part of the article to how it should read, reflecting a NPoV outlook. That way, it is going to be easier going forward to take your considerations seriously. Reverting just sets us back to a version that already has/had other problems. • Astynax ^talk 20:10, 14 May 2009 (UTC)

• The "Additional reading" section will be reverted to the full list. We can break it into three sections: Childbirth preparation, Homebirth resources, and Homebirth criticism. Amy Tauter's website appears to be a blog which is a very dubious thing to use as a reference. Does she have another site that would be more appropriate? Aren't there ANY better criticism resources? Her blog can't be the only one.

Disagree. The full list will not be reinstated as it is biased. There are already several references on there, which although biased, will suffice. Now we need some balance. 202.89.167.125 (talk) 21:15, 13 May 2009 (UTC)

?!? But above you said you agreed with the suggestion! If you look at the differences highlighted in this edit: [13] you will note that the sources that were removed are completely arbitrary. "Pro" homebirth sources are designated as such in the old edit. Further reading on safety and childbirth is noted, for those who want to know more about safety studies - again, if this list is biased, please add your own references to the list. And finally, there is a "birth culture" section which could definitely be expanded. There is no reason we can't have a criticism section, but it isn't appropriate to think that there can only be one "pro" reference for every "con" reference, unless there are adequate numbers of "con" resources. We are depending on you, 202.89.167.125, to provide the balance you claim to seek. I have been unable to find resources that fall into this category, but I have no doubt they exist. Lcwilsie (talk) 21:03, 14 May 2009 (UTC)

Agree. However, that the items in the list are almost entirely PoV needs to be noted. • Astynax ^talk 20:10, 14 May 2009 (UTC)

• Per suggestion by 202.89.167.125, we can remove "famous homebirthers"

Somewhat Resolved: The legality sections will focus on legality, with safety discussion limited to that which is driving legislation. Any safety discussion here needs to be held to the same standards as applied to the Research on Safety section. For example, it is appropriate to state that "The Department is...in the process of commissioning an independent professional review of home births," but selectively quoting portions of the article, or quoting and making conclusions from a newspaper article rather than the original source is original research and below the standards permitted elsewhere in this article.

Disagree - biased. Who are you to make all these decisions? 202.89.167.125 (talk) 21:15, 13 May 2009 (UTC)

I was summarizing the discussion above. Again I request that you read the conversation I tried to initiate on your talk page. I am afraid you are missing the idea behind Wikipedia. This is not an article that we are to write for your stamp of approval - it is an iterative and interactive process. Lcwilsie (talk) 21:03, 14 May 2009 (UTC)

Agree. 202.89.167.125 - I do understand that you feel the article is biased (it certainly reads that way to me). However, if you can edit to make it more NPoV, that will better address that concern. • Astynax ^talk 20:10, 14 May 2009 (UTC)

Continued discussion/resolution needed:

• Where to include safety discussions. It is now scattered throughout making the article incredibly contradictory and contentious. I agree that the Research on Safety section is challenging to understand because of the depth, but it does an excellent job explaining why there is no conclusion despite mountains of data accumulated over many years. Because the overall conclusion is that there is no consensus on whether HB is more/less safe, I urge editors to refrain from inserting references to safety elsewhere in the article unless it truly enhances that section.

• Inclusion/exclusion of the BJOG study, and any other studies since the 2007 NICE report. We have two choices: include a statement about BJOG with criticism of the study design, or reference the BJOG in the Study design section. To exclude it entirely would be incongruous with handling of previous published studies, unless the Study design section is deleted in its entirety.

Lcwilsie (talk) 13:46, 13 May 2009 (UTC)

Disagree. It's not going in, for the reasons above, unless you reference and comment upon every single homebirth publication referenced in the NICE review also. When it's included in a systematic review it'll be considered within that. "You" may have "2" choices, but others have more choices, and we'll exercise them. 202.89.167.125 (talk) 21:15, 13 May 2009 (UTC)

I was proposing that we leave pre-NICE papers out (we will assume they've been adequately reviewed/dismissed/included in that review) and only include those published since the NICE review. Then when a new NICE review (or similar) comes along we can update the entire section. Lcwilsie (talk) 21:17, 14 May 2009 (UTC)

I think the studies can be mentioned, noting that none to date have been conclusive (including the reasons why). However, I think the studies should not be the bulk of any Safety section. Rather, the need for individual assessment and monitoring of each pregnancy in conjunction with medical professionals needs to be stressed. Safety can never be determined by a study - one cannot even remotely make an informed choice of place of birth without individual assessment and monitoring. The other thing sorely missing from the studies is a clear focus on the mother's health and mortality. From many of the books and websites, you'd think it was completely or mostly all about infant mortality and health. Again, there are many, many unique factors to be considered for each woman and each pregnancy, and these can even change during the course, so any discussion about safety needs to prominently highlight the need for evaluation and consultation. • Astynax ^talk 20:10, 14 May 2009 (UTC)

This is so right. There are many studies: some probably more significant than others. The Bastian study is one (because it is Australian), the recent BJOG one another. Most studies have flaws: perhaps because they are retrospective (as in Bastian and the Pan studies) or small data size or for many other reasons. The BJOG study is an important study - if only for the size of the study and the fact that it is recent: as has been indicated, not referring to it is incongruous. A caveat, saying that all studies should be read with caution and the limitations of any research considered when making decisions based on the study, or such, surely is worthwhile. Women who are considering choosing to birth at home are - in my experience - quite able to sort out the wheat from the chaff so to speak and will read and consider a lot of information before they make their choices. A list/discussion of the important studies with a disclaimer/caveat would - I would have thought - be appropriate. Women's choices are not going to be dictated simply by a number of studies: as Astynax has indicated: other issues also impact. I am sure it is no surprise to people that women do not deliberately choose a place of birth to put their or their child's life at risk, but the choice is impacted by their own perceptions of risk, previous birth experiences, cultural beliefs and so on. Some studies highlight the high levels of maternal satisfaction and positive outcomes in terms of postnatal illness, breastfeeding retention rates and so on of homebirths: but it is arguable that this is a product of the model of care (continuity) rather than the place of birth. Women who choose a homebirth want to know that their midwife is highly trained in their scope of practice,up to date in their knowledge and skills, has access to good support structures, and has the processes in place for good transfer to obstetric care should that be deemed appropriate. These are the sorts of questions that women need to ask about any prospective homebirth midwife (or indeed any maternity service carer: obstetricians and GPs included).(Quainton (talk) 08:38, 19 May 2009 (UTC))

Thank you for joining us in our discussion. I look forward to your continuing involvement. Lcwilsie, I think your 'downgrading' of the BJOG article was a good compromise. Gillyweed (talk) 22:42, 19 May 2009 (UTC)

Further to the issue about BJOG, I found an interesting article on the NHS website which explores the methodology of the BJOG study and looks at its flaws and its strengths. I will include it as a reference in the article. I'd appreciate it if it wasn't reverted simply because I put it there. It does seem to be quite pertinent! Gillyweed (talk) 23:10, 19 May 2009 (UTC)

Reversion warning

Attention both Gillyweed and anonymous editor 202.89.167.125: You are prolonging the edit war that several of us have been trying to mitigate. Please stop. Both of you.

202.89.167.125 - the version you keep reverting to is not an ideal version, so your reversions undo other improvements. Also, you have not yet responded to my comment on your talk page, or the post to WP:WQA. Your etiquette has not improved, despite several requests from several editors, and until you at least address the comments I left for you, few of us will take you or your edits seriously. As several people have mentioned, it is more helpful to improve upon text rather than revert. Calling Gillyweed a vandal does not validate your reversions, as he is attempting to incorporate some of the discussions we've had above (see specifically the changes to the "further reading" section). Your continued reverting, despite calls to stop, meets the definition of vandalism.

Gillyweed - the large number of changes you are making in each edit is making it difficult to counteract the anonymous editor's knee-jerk reversion. Some of the changes you have made have been quite good, but they are getting lost and undone. Please make smaller, incremental changes, one section at a time. I appreciate your contributions to the article, but we must all work together to make the article less POV, and that is hard to do when there are massive changes in each edit. Lcwilsie (talk) 20:34, 19 May 2009 (UTC)

Fair enough. I was trying to do so, but my small changes keep getting lost by the big reverts by our anon editor. It appears that my name is on an edit and so the anon decides to immediately revert my change. Anyway, I shall do as you say and make one change per section. Gillyweed (talk) 22:36, 19 May 2009 (UTC)

My edits also keep getting swept up in the reverts, even when I'm just changing typos or punctuation. I think it's ok to make more than one change, but try to keep the changes focused in one discrete area. This way hopefully any reversions would only affect that section instead of multiple edits. Lcwilsie (talk) 01:42, 20 May 2009 (UTC)

You will see progress on this article when you take my opinions seriously, and reflect on your own biases, and meet me in a neutral place. The BJOG has published a critical appraisal (Abstract: http://www3.interscience.wiley.com/journal/122379095/abstract) this month of the BJOG home birth study which (although written by a homebirth-supportive consultant - Sue Bewley) rips it to shreds for EXACTLY the reasons I've stated above. Quite a surprise it's been done so quickly, in fact. The 'weed's edits are no more discourteous than mine, I am simply mirroring her tactics. Your tactics seem to try and involve admins who then opine that my edits are OK & more neutral than yours, and amusingly you then call these vandalism. I'm keeping debate on the talk page until agreement is reached unlike the 'weed, and this is vandalism also. You completely ignore any relevant points. I've made on this discussion page, and expect me to respond to "lectures" on petty issues like not having a user name! It's all quite amusing. I'm even claiming CPD points for it! My midwifery & medical colleagues all think it's amusing also, and are anxious to get involved should it be necessary (it's not yet).

Let me be clear. Women make decisions on the basis of websites such as this. They trust what they read. It's OUR duty to make sure the info within is not propaganda either way whatever we believe. Informed choice is the goal, but can't be achieved if the information is wrong. If your edit says homebirth is great and all the research says it is so, and it's taken to heart by women who then have a poor outcome, you are responsible for misleading them. Perhaps already babies have died as a result of your edits? We'll never know. —Preceding unsigned comment added by 202.89.167.125 (talk) 10:22, 22 May 2009 (UTC)

I think that if you read the abstract that you provided the criticism is levelled not at the most recent BJOG study about the Netherlands but about a study done using British data from 1994-2003. So we are talking about different studies. I think it is a worry that you believe debating anonymous people on a website is continuing professional development. This says a lot about RANZCOGs education requirements for obstetricians. Let me be clear. Women make decisions from many sources, including this website. I hope that they do not trust what they read but consider the many different factors and issues that make up the decision to birth at home. It is OUR duty to make sure tha the infor within is not propaganda either way whatever we believe. Informed choice is the goal, but can't be achieved if the information is wrong. If women take your view on homebirth as gospel and believe that they are likely to die because of it, simply because you are fearful and afraid of birth and the evidence that shows that for the vast majority of women, birth at home is just as safe as in a hospital and has far fewer interventions, then you are responsible for misleading them. Perhaps already babies have died and women have been needlessly mutlilated by interventions that are not required as a result of your edits. We will never know. I will make several further comments, so that people understand where I am coming from. Birth is for the vast majority of women a safe, empowering and wonderful life event. Birth is not an illness and does not require medical attention. HOWEVER the research evidence shows that for about 10-15% of women it is SAFER to birth in hospital with medical back up readily available if things go wrong. Obstetricians are essential to the maternity system. They are experts in handling emergencies and can provide surgical responses where necessary. Midwives are experts in normal birth and are trained to properly refer women to obstetric care where necessary. The best care is where midwives and obstetricians collaborate. The worst care is where the two professions attack each other and belittle each others skills, caring little for the birthing woman's needs. Gillyweed (talk) 13:24, 22 May 2009 (UTC)

Factors in choosing a hospital birth

I disagree with inclusion of this statement: "For other women, immediate access to medical help in a birthing center or hospital setting is very important." Although we can cite references for the reasons women choose to birth at home, the reasons women birth at a birthing center or hospital are more complex. Summarizing it as simply a desire to be close to medical help is inaccurate. Some women don't know HB is an option, for some women their insurance will only cover hospital birth, others live in an apartment and would feel uncomfortable laboring at home, still others live in areas where HB midwives are unavailable - in short, there are many, many reasons a woman might birth in a hospital. To simply say it is based on a choice of safety or medical access polarizes the article unnecessarily. Also - is it at all useful to include? It seems the more valid point for the article is why women would choose to birth at home, when 70-99.5% of the women in their country (depending on location) would make a different choice. Lcwilsie (talk) 20:54, 19 May 2009 (UTC)

Your point is taken. Including this sentence begs the question why we don't also include "For other women, a social caesarean is very important." or "For other women, the access to epidural pain relief is very important." or "For some women, access to neo-natal intensive care is important." This article is about birth at home and not about birth in other locations. I will remove it. Gillyweed (talk) 22:39, 19 May 2009 (UTC)

I'd appreciate contributions as anyone finds them: In Birth by Tina Cassidy she cites finances as a reason many women do/don't choose homebirth (before medical insurance many women gave birth at home because it was cheaper with a midwife, when free hospital care was available many poor women went there -- now many women go the hospital because not all countries/insurance companies offer homebirth, and in the Netherlands there are incentives for homebirth which may contribute to their higher rate). Ina May Gaskin cites personal and spiritual reasons in Spiritual Midwifery and Guide to Childbirth. I know it is complex and I hope to capture as much as we can. It isn't only the dichotomy between intervention/no intervention. Lcwilsie (talk) 19:58, 26 May 2009 (UTC)

edit warring

Please discuss and agree on content disputes. 202.89.167.125, the article is semi-protected for awhile, so you won't be able to directly edit it. Please persuade the established editors here to make changes. —EncMstr (talk) 20:05, 22 May 2009 (UTC)

Western Australian Report

The WA report "Review of Homebirths in Western Australia" has finally been released. A copy can be found here: [14]. Page 17 refers to deaths from 2000-2006 (there were no perinatal 'home birth' deaths in 2007/08) and states:

Of the 18 perinatal deaths and one post-neonatal death from 2000 to 2006, nine (9) had lethal congenital or chromosomal abnormalities; two (2) were premature (27 and 32 weeks gestation); two (2) had group B streptococcus which was reported as the attributing factor and three (3) were rated as having ‘low’ or ‘no’ preventability. Of the three (3) remaining deaths, there are questions as to preventability. These are the two (2) cases of hypoxic peripartum death (Cases 10 and 11); and the baby with shoulder dystocia (Case 17).

The report goes on with an analysis of the problems besetting homebirth services in the State and recommends a range of improvements to further reduce mortality (including increased training for midwives and medical practitioners in hospitals when transferes occur). It does find that for low-risk women there is no increase in mortality but also finds that the current HB model used accepts women of varying risk levels (including high risk) and thus this could explain some of the higher rates of mortality from 2000-06. The hospital at a higher total perinatal death rate than HB but hospitals take women with all risk profiles, not simply low risk.

In summary, the WA report provides little evidence either one way or another regarding the safety of home birth for low-risk women. It does not recommend the closure of the current home birth programs. It actually proposes the expansion of home birth to SW WA.

I'd appreciate other editors views but I recommend that we delete the section related to home birth in WA as it provides little increased clarity about homebirth in Australia. Gillyweed (talk) 04:13, 26 May 2009 (UTC)

The report does give some insight into why women may choose homebirth. Perhaps putting something along the lines of: "A recent review of homebirths in Western Australia identified that some women may choose a homebirth as a surrogate means to access midwifery continuity of carer or a waterbirth, when these are not provided as an option within mainstream maternity services." in the Factors in Choosing a Homebirth section may be appropriate. On a more general note, I think the review highlights that a system that makes it difficult for skilled professionals (in this instance midwives) to operate easily and within their full scope of practice does women a disservice. I see some of the criticisms of the WA experience as higlighted in the report as being based on systemic issues of maternity systems in general (access to pathology and daignostic services, ambulance transfer, the fact that some hospitals won't accept homebirth transfers etc.) rather than the safety of home birth per se. The view taken by the authors that "There are benefits, in terms clinical governance and safety and quality, if homebirth is seen as one part of the maternity mainstream service. Homebirth is more likely to be unsafe if it is marginalised and kept out of mainstream service." ring very true.Quainton (talk) 08:56, 26 May 2009 (UTC)

Agreed - although the report doesn't lend clarity on homebirth safety (it remains "no worse, no better, inconclusive"), I see some issues related to safety that should be included: 1) proper evaluation of risk for mothers, as the designation of "low risk" clears the way for a homebirth 2) handling of transfers when advanced care is needed 3) offering an acceptable method of care in birth centers and hospitals so that higher risk women who need it are more amenable to birth at an institution rather than taking a risk of giving birth at home. Currently the safety section focuses on back-and-forth over studies/methodologies and these are some clear safety factors that could improve that section. Lcwilsie (talk) 13:56, 26 May 2009 (UTC)