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PAPERS: Kenneth C Johnson and Betty-Anne Daviss Outcomes of planned home births with certified professional midwives: large prospective study in North America BMJ 2005; 330: 1416 [Abstract] [Full text]

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Rapid Responses published:

Home birth is safe, but can we improve access?

Sara Wickham   (17 June 2005)

Home Birth: good outcomes and few interventions

Susan S Hodges   (17 June 2005)

Not only being afraid of death

Wen Bin Liang   (17 June 2005)

Political Barriers to Accessing Care of Certified Professional Midwives in Illinois

Michelle S. Breen   (17 June 2005)

Rethinking midwifery training to protect normal birth

Mary Stewart   (17 June 2005)

Thank you for your article

Anna F. Swisher   (18 June 2005)

Putting into practice

Jane F EVANS   (20 June 2005)

Turning the Tide of Fear

Lorna D Davies   (20 June 2005)

Great idea, but unfortunate methodology.

Yogi Sehgal   (21 June 2005)

In appreciation

Kerry A. Dixon   (21 June 2005)

Physician Supports Home Birth

Laurel L. Walter, MD   (21 June 2005)

The Fly in the Ointment

Dav id A. Rivera   (22 June 2005)

Well done

Pam D Stewart   (23 June 2005)

The General Practitioner / Family Doctor and home birth

Assi Albert Cicurel   (25 June 2005)

Re: Not only being afraid of death

Sarah J Buckley   (25 June 2005)

Midwifery and uphill battles

Christine F. Edie   (1 July 2005)

Silence of the lions

Marsden G. Wagner M.D.   (9 July 2005)

Billions Saved: An Opportunity to Use Health Care Dollars More Wisely

Rondi E Anderson   (15 July 2005)

Are trials of place of birth feasible?

Soo M Downe, Denis Walsh, Fiona Dykes, James G Thornton, Andrew Symon, Gillian Gyte, Elizabeth Key and Michelle Mossa   (22 August 2005)

Home birth is safe, but can we improve access? 17 June 2005
Sara Wickham, Senior Lecturer, Midwifery APU, Victoria Road South, Chelmsford, CM1 1LL Send response to journal: Re: Home birth is safe, but can we improve access?	Congratulations to Ken Johnson and Betty-Ann Daviss on a well- designed and useful study. Given that any argument calling for a ‘higher’ level of evidence in this area falls down when we realise just how difficult it would be to design an effective RCT comparing home and hospital birth and, perhaps more pertinently, how very few women would be willing to have their place of birth chosen at random, their findings add further weight to the international evidence on the safety of midwife- attended home birth. Studies from the UK (1, 2, 3), Holland (4), Switzerland (5), New Zealand (6), the US (7) and Australia (8) and meta- analyses by Olsen (9) and the Cochrane Collaboration (10) have not only demonstrated that home birth is a safe option for both women and babies, and an option that reduces intervention almost across the board by comparison to hospital birth, but that it is also an option which can be made to work within many different maternity care systems and cultures. Last year, Davies (2004) published a fascinating article listing some of the reasons women in the UK had been given for not being “allowed” a home birth. Some of the more spurious reasons given included that the woman was partially sighted, that the baby’s father had a history of depression and, in an amazing display of transference of hospital rules to the home environment, that it would not be possible to arrange for the hospital electrician to come to the woman’s house to check all of her wiring. One of my favourite responses from this study was the woman who was denied a home birth because she lived on a (very safely moored) houseboat, and the Trust were concerned that the midwife might fall off the towpath and into the canal... Those of us in the UK can no longer say that the issue of women choosing to give birth at home unattended is one which we do not face. There are a small but growing number of British women who, having been told that they are not “allowed” to have a home birth for reasons that they know to be unaligned with the evidence, are choosing to have their babies at home without the support of a midwife or other trained attendant. While we have a number of obstacles to overcome (not least of which are staffing and, presumably, continuing education for midwives in negotiating towpaths) in order to make home birth a reality for more women, perhaps Johnson and Daviss’ study will act not only to further to our understanding that midwife-attended home birth is a safe option which carries fewer interventions, but as a further trigger to encourage us to find ways of increasing women’s access to home birth. 1. Chamberlain G, Wraight A and Crowley P (1997) Home Births - The report of the 1994 Confidential Enquiry by the National Birthday Trust Fund. Parthenon Publishing 2. The Northern Region's Perinatal Mortality Survey Coordinating Group. Perinatal loss in planned and unplanned home birth. BMJ 1996;313:1306-9 3. Davies J, Hey E, Reid W, Young G. Prospective regional study of planned home birth. BMJ 1996;313:1302-5. 4. Wiegers TA, Keirse MJNC, van der Zee J, Berghs GAH. Outcome of planned home and planned hospital births in low risk pregnancies in the Netherlands. BMJ 1996;313:1309-13. 5. Ackermann-Liebrich U, Voegli T, Guenther-Witt K, Kunz I, Zullig M, Schindler C, et al. Home versus hospital deliveries: a prospective study on matched pairs. BMJ 1996;313:1313-8. 6. Gulbransen G; Hilton J; McKay L; Cox A (1997) Home birth in New Zealand 1973-93: incidence and mortality. N Z Med J, 110(1040): 87-9 7. Durand AM (1992) The safety of home birth: the farm study American Journal of Public Health, Vol 82, Issue 3, 450-453. 8. Woodcock HC, Read AW, Bower C et al (1004) A matched cohort study of planned home and hospital births in Western Australia 1981-1987. Midwifery 10(3): 125-35 9. Olsen O (1997). Meta-analysis of the safety of home birth. Birth. 24(1): 4-13. 10. Olsen O, Jewell MD Home versus hospital birth (Cochrane Review) The Cochrane Library, Issue 2, 2005. Chichester, UK: John Wiley & Sons, Ltd. 11. Davies L (2004) "Allowed" shouldn't be allowed! MIDIRS Midwifery Digest , 14(2) 151-156 Competing interests: None declared
Home Birth: good outcomes and few interventions 17 June 2005
Susan S Hodges, President, Citizens for Midwifery Athens, GA 30608 Send response to journal: Re: Home Birth: good outcomes and few interventions	Johnson & Daviss’ landmark study “Outcomes of planned home births with certified professional midwives: large prospective study in North America” joins a multitude of other studies demonstrating that planned home birth attended by a trained midwife is a safe and responsible form of maternity care. This kind of care should be widely available to healthy pregnant women in the United States (U.S.) and elsewhere. Not only were outcomes comparable to births in hospitals, but many fewer interventions were preformed on the laboring mothers, suggesting that many interventions are being performed unnecessarily on women giving birth in U.S. hospitals. For many years, the American College of Obstetricians and Gynecologists and other U.S. medical organizations have asserted that “home birth is dangerous” so every birth should take place in a hospital, even though this belief is not supported by the weight of scientific evidence. Regardless, medical organizations have used their authority and political power at the state government level to oppose efforts aimed at increasing access to trained midwives for planned, midwife-attended home births. If medicine is to be “scientific,” then U.S. obstetricians must acknowledge the findings in this study and others like it, and support legislative and regulatory changes that will promote access to maternity care provided by professional (independent) midwives outside of hospitals. Otherwise, we can only conclude that in this regard maternity care in the U.S. is NOT “scientific.” The U.S. is way behind many European countries and our neighbor to the north regarding access to midwives and home birth. Canada has recognized the importance of offering a range of birthing options to women, and now more than half of Canadian women have the option of choosing a home birth with a midwife. When we have ample and conclusive evidence that planned, midwife- attended home birth is a safe and responsible choice for the majority of pregnant women, is it ethical for the medical community to act to prevent access to credentialed home birth midwives, while performing unnecessary interventions on hospitalized pregnant women? Citizens for Midwifery (www.cfmidwifery.org) hopes that this study will be a wake up call to refocus U.S. maternity care on evidence-based practice including access to midwives and out-of-hospital birth. Competing interests: None declared
Not only being afraid of death 17 June 2005
Wen Bin Liang, taking master of public health Curtin University of Technology Send response to journal: Re: Not only being afraid of death	In the article “Outcome of planned home births with certified professional midwives: large prospective study in North America” it suggests that only 1.7 deaths per 1000 planned home births, however among the 94.5% reported subjects, 1.3% had Apgar score below 7 at five minutes, and 2.4% were placed in the neonatal intensive care unit, moreover 0.5% of the newborns need urgent transfer to hospital.[1] In these situations, babies in danger are unable to receive effective treatments immediately which are available in hospitals, and this does pose a great threat on the babies' future health , such as higher risk of developing neurological disability in the future.[2] Reference: 1 Johnson K.& Daviss B. 2005, ‘Outcomes of planned home births with certified professional midwives: large prospective study in North America’ BMJ 2005; 330: 1416 2 Krebs, L., Langhoff-Roos, J. & Thorngren-Jerneck, K. 2001, 'Long-term outcome in term breech infants with low Apgar score--a population-based follow-up', Eur J Obstet Gynecol Reprod Biol, vol. 100, no. 1, pp. 5-8. Competing interests: None declared
Political Barriers to Accessing Care of Certified Professional Midwives in Illinois 17 June 2005
Michelle S. Breen, Vice-President, Coalition for Illinois Midwifery 60102 Send response to journal: Re: Political Barriers to Accessing Care of Certified Professional Midwives in Illinois	Thank you for publishing the prospective homebirth study by Kenneth C. Johnson and Betty-Anne Daviss. This study is especially important to advocates of the Midwives Model of Care in the United States. As a public health professional, grassroots organizer and homebirth mother, I intimately understand the value of this research. In Illinois, both licensed nurse-midwifery homebirth services and unlicensed direct-entry midwifery homebirth services are declining. Four thriving Illinois nurse-midwifery homebirth practices have closed or discontinued homebirth services in the past ten years. One of these practices, Alivio Medical Center, combined the services of nurse-midwives and direct-entry midwives to provide innovative and culturally-sensitive homebirth services for an underserved, low-income, low-literacy, Mexican- American, immigrant community (93% Medicaid patients) and was recognized by the American College of Nurse Midwives’ Kitty Ernst Award in 1998, and won the Unicef Safe Motherhood Initiative-USA Model Awards in 1999 and 2000. Additionally, seventeen Illinois direct-entry midwifery homebirth practices have closed following the issuance of cease and desist orders in 1997. These closing occurred for a variety of reasons, including the medical malpractice crisis and the issuance of cease and desist orders. The overall impact on families is a detrimental reduction of maternity care options. Legally recognized homebirth practices (nurse-midwifery and/or physician practices) are found in only 5 of 102 Illinois Counties. All of these practices are located in the northern half of the State. According to the Illinois Department of Public Health, in 2003, 738 Illinois births occurred without a trained birth attendant (neither a medical person nor a midwife). Families in Illinois are in need of greater access to maternity care options. Illinois midwifery advocates currently are seeking legislative change that will enable licensing of direct-entry midwives based on the Certified Professional Midwife credential. Passage of this legislation would bring Illinois into compliance with the recommendations of the American Public Health Association regarding access to direct-entry midwifery services. Thank you again for consideration of birth outcomes in jurisdictions in which the practice of Certified Professional Midwives was not well integrated into the health care system. This research may reassure legislators that families, choosing to birth at home under the care of Certified Professional Midwives, do receive necessary collaborative medical care and experience good birth outcomes even when this care is delivered within the context of an unsupportive health care system. Michelle Breen, MHS Vice-President, Coalition for Illinois Midwifery coodaa@aol.com Competing interests: None declared
Rethinking midwifery training to protect normal birth 17 June 2005
Mary Stewart, Team midwife BS7 9AH Send response to journal: Re: Rethinking midwifery training to protect normal birth	The elegant study by Johnson and Daviss is both welcome and timely. The recent publication of the NSF for Children, Young People and Maternity Services (DH 2004) highlighted once again the importance of promoting and protecting normal birth in a culture that seems to be increasingly driven by fear, technology and the market economy. Johnson and Daviss suggest that the most effective way of protecting normal birth is to encourage women to give birth in the place where it has happened for centuries and across cultures: the home. Equally significant, though, is the fact that the midwives in this study trained outside the mainstream, university and hospital- based system. There is currently no equivalent model of training in the UK but this study should give us pause for thought. As well as promoting home birth as a safe and viable option, perhaps now is the time for a revolution in midwifery training, and a move to an appentice-style, community based programme that values holistic, family-focused practice as much as it values academic credibility. Reference Department of Health (2004) National Services Framework for Children, Young People and Maternity Services: Maternity London: DH Publications Competing interests: None declared
Thank you for your article 18 June 2005
Anna F. Swisher, Lactation Consultant Texas 78729 Send response to journal: Re: Thank you for your article	Kudos to BMJ for having the courage to publish this paper! The unfortunate sequelae of interventions, e.g., elective induction, pitocin, epidural, and casearean for "failure to progress" happen everyday in American hospitals. The midwifery model of birth as normal, empowering, healthy, and joyful results in more positive health outcomes for both mothers and infants. Sadly, American physicians miss the spiritual and emotional aspects of human birth with the present medical model used in the United States. Women are disrespected and disempowered with a vague sense of disappointment that is not validated, but dismissed, because "you have a healthy baby, and that's all that matters." We have a lot to learn from our friends in other countries where midwifery and homebirths are the norm. Sincerely, Anna Swisher, MBA, IBCLC Texas Competing interests: None declared
Putting into practice 20 June 2005
Jane F EVANS, Independent Midwife AL5 1BG Send response to journal: Re: Putting into practice	How refreshing to read such a good piece of work about the safety of homebirth. The Question of wether breech births are low risk notwithstanding,let us hope that these findings are adopted and put into practice as rapidly as those of the Term Breech Trial (Hannah 2000)!! To that end I expect the announcement of the closure of a large Obstetric Unit with funds diverted to support homebirth within the next month. Reference Hannah M.E. et al. 2000. Planned Caesarean Section versus Planned Vaginal Birth for Breech Presentation at Term: A Randomised,Multi-centre Trial. Lancet. 356 (9239). 1375-83 Competing interests: None declared
Turning the Tide of Fear 20 June 2005
Lorna D Davies, Lecturer in Midwifery Christchurch Polytechnic Send response to journal: Re: Turning the Tide of Fear	Many thanks to Johnson and Daviss for an encouraging study that provides yet more firm evidence of the improved outcomes that are achievable when birth at home is made a realistic option for women. However, we must also recognise that the philosophy of both woman and attendant play a crucial role in the process. When a fundamental belief in the birthing process exists, on the part of both players, the outcomes are by current standards remarkable. With evidence like this to support the argument for planned and supported homebirth, we now need to concentrate on how we counter the current fear driven, blame focussed, risk managed care that is endemic in childbirth care provision throughout the western world and beyond. Many women and midwives, not to mention medical practitioners, are fearful of the process of birth and consequently reassuring them and ameliorating their fears is going to continue to be a long and uphill struggle. We need studies like this one to reaffirm the safety and economic viability of homebirth, in order to be able to validate the choice of planned homebirth, for low risk women at least. Thanks also to the BMJ for publishing the study. Competing interests: None declared
Great idea, but unfortunate methodology. 21 June 2005
Yogi Sehgal, Family Physician Sioux Lookout, Ontario, Canada, P8T 1A8 Send response to journal: Re: Great idea, but unfortunate methodology.	I like the idea of being able to offer home births, particularly in rural communities, where transfer distances to hospitals are usually quite short, and the mom with an emergent issue will get to the hospital before I will. However, this paper really does not provide good evidence of safety for all low risk women. As the authors acknowledge, there is a difference in the population of women undergoing home births and those choosing hospitals, both the ones recognized in the paper (i.e. educational level, ethnicity, etc.) and unrecognized (women get called "low-risk" that are not necessarily low risk in hospital, whereas midwives tend to be better at risk-stratification), and this is the one fatal flaw in this paper. There are also differences in rural versus urban outcomes that are not addressed. I do not know what the distribution of midwives geographically is. However, the numbers are at least present no to be able to provide mothers with an informed choice. As far as medical interventions go, I am astounded at the 33% episiotomy rate. I thought most communities had done away with this practice. The 3.7 versus 19.7 percent c-section rate has to be a reflection of the patient population, as, although I am sure there is a difference, that difference seems out of touch with the reality of the patients I see. Finally, why was "transfer to hospital" not considered a medical intervention? Bottom line, this information does not change my practice, but provides a little more information for patients in whom I share care who wish to have a home birth. Unfortunately, there are no midwives in Sioux Lookout, so, for logistical reasons, will continue to do hospital births. Competing interests: None declared
In appreciation 21 June 2005
Kerry A. Dixon, CPM, LM, SNM graduate student Send response to journal: Re: In appreciation	Johnson & Daviss you hold out the light of truth. I am so proud my practice statistics contributed to the study. You both worked long and hard to give evidence to what we homebirth parents and midwives know in our hearts. I promise you will be immortalized as a reference in a multitude of research papers, for years to come. It is my fervent hope that policy-makers and insurers read and act on the findings. Congratulations to you both and thank you to BMJ for publishing. Kerry Dixon Competing interests: None declared
Physician Supports Home Birth 21 June 2005
Laurel L. Walter, MD, Family Physician Whole Health Family Practice 65203 Send response to journal: Re: Physician Supports Home Birth	Thank you for an excellent study confirming what so many smaller studies have shown regarding home birth. It was only as a consumer of midwifery care during my 3rd year of medical school, that I fully appreciated what this model has to offer. Now planning our 5th midwife attended home birth, I continue to see tremendous financial, emotional, and spiritual benefits to including home birth as an available option for all low risk women. As a family physician who has attended over 500 women in birth at hospitals, at birth centers and at home, I continue to offer the midwifery model of care for the cheif reason that it is the best model of care known for low risk women. When interventions are medically indicated, women can easily access the level of care they need at our excellent hospitals, yet midwifery is a felony in our state, limiting choices for low risk women. Families often drive over 2 hours to our center to find midwifery care, as we are the only free standing birth center in the entire state of Missouri, and one of few practices offering midwifery style care. Financial barriers also limit a family's choices due to the unwillingness of insurance companies and hospital owned Medicaid programs to cover services provided outside of the hospital. This continues despite the low costs of midwifery care, typically half of hospital based costs. If scientific evidence and sound financial decisions were guiding us, these barriers would be eliminated. It's time for American organized medicine to put financial and political interests aside, and adopt the policies that will enhance the choices and the health of childbearing families. It's time to accept what the data has clearly shown for many years, and incorporate midwifery and home based maternity care as the "gold standard" for the 90% of women who can remain low risk with this model of care. Recently published books such as "The Cesearean" by Michel Odent, MD, clearly describe what risks are posed by our current focus on medical interventions in normal birth and our skyrocketing Cesearean rates, approaching 60% in some Missouri communities. Continuing to over- medicalize childbirth will cost our society more than just health care dollars. It may be the biggest threat to the long term health of the next generation. Your study presents clear answers to the fears of physicians and policy makers regarding the safety of out of hospital birth, but the true test of science remains to be seen. Will we use the evidence to further the health of the next generation, or will we cling to our conventions for our own personal and professional benefit? Laurel Walter, MD Competing interests: None declared
The Fly in the Ointment 22 June 2005
Dav id A. Rivera, Physician Lombard Illinois 60148 Send response to journal: Re: The Fly in the Ointment	There is a contentious debate about home vs. hospital births in at least one online forum; the proponents reference Johnson and Daviss’ article as “proof” home delivery is safe. I do not mind if women chose home birth; however our pernicious legal system prevents me from ever considering the practice. I also refuse to back up midwives doing home deliveries for the same reason, unless I were granted blanket immunity against litigation for poor outcome. I’ve provided back up for a large midwifery practice doing hospital deliveries with excellent results and high patient satisfaction. Johnson and Daviss did not compare home delivery and hospital delivery outcomes. The study shows home birth outcomes in a low risk population are similar, but not superior, to hospital births. Hospitals and obstetricians do not have the luxury of eliminating high-risk patients; thus, the intervention rate will always be higher. That there were five intrapartum deaths demonstrates low risk can become high risk in a heartbeat. I have never had an intrapartum fetal death in 25 years of delivering babies. Home birth proponents appear to be more concerned with the psychosocial aspects of labor and delivery; obstetricians are more concerned with staying out of court. Both are valid interests, but I doubt one side will ever convince the other. D Rivera, MD Competing interests: None declared
Well done 23 June 2005
Pam D Stewart, Homebirth Midwife Maine, USA 04658 Send response to journal: Re: Well done	Reading through the BMJ article gave me goose bumps all over. I feel so proud of all the good work we have all done for birthing women through the years. I loved reading all that research jargon, all that technical language, all those charts and tables, and seeing that it verifies what we all know. I love imagining this article being in the hands of the public. And reading it, I felt intense gratitude to Ken Johnson and Betty-Anne Daviss for their tireless work in doing a thorough, careful and professional job of getting the word out in the medical community, even if it is perhaps through the back door of a British rather than an American journal. Competing interests: None declared
The General Practitioner / Family Doctor and home birth 25 June 2005
Assi Albert Cicurel, MD Israel Send response to journal: Re: The General Practitioner / Family Doctor and home birth	I want to thank the researchers for this important paper. For the past few years we have growing evidence for the safety of homebirth in low risk pregnancies. Medicalization of birth, as the medicalization of death and sexuality, are three extreme examples of the expansion of medicine into natural life events. Hospital medicine grasps the birth process as a medical emergency – a catastrophe waiting to happen. The caution of hospitals has increased in the last decades with malpractice litigation anxiety, giving birth to more and more intensive monitoring, medical and surgical procedures during the birth process. Primary care physicians, serving in the community, have a pivotal role in helping medicine learn its boundaries. Primary care physicians are playing this pivotal role by giving home based palliative care. It is now time to start helping the other side of life. How can we, as Primary care physicians assume our role in the birth process? 1.Physicians practicing good evidence based medicine must not avoid the evidence and offer homebirth as an option for low risk patients. 2.Primary care physicians should perform normal evidence based pregnancy preventive medicine and follow up, avoiding the growing amount of unproved tests and procedures available. 3.Primary care physicians may learn about the midwives in the community performing homebirths, and recommend experienced, responsible, and well trained midwives. We should also contact the midwives and discuss the details. Who examines the baby after birth? What type of follow up will the midwife perform? Who gives vitamin K and how? And more. We should be able to recommend a good midwife in the same way we help our patients find a medical specialist for consultation. 4.Primary care physicians can assume an active role by making a house call following the birth to examine the newborn and the mother. Birth is one of the blissful moments of life. By assuming an active role in the process of birth, we have an opportunity to share a happy, major life event with our patients. The evidence is here. The opportunity for change is here. We must not miss it. Competing interests: None declared
Re: Not only being afraid of death 25 June 2005
Sarah J Buckley, writer, mother, GP Anstead, Queensland 4070, Australia Send response to journal: Re: Re: Not only being afraid of death	Wen Bin Liang is concerned that babies born at home with low Apgar scores, or needing urgent transfer to hospital, may suffer long-term neurological disability because they are unable to receive effective treatment. Liang will be reassured to know that homebirth practitioners carry the equipment necessary for neonatal resuscitation, and newborns are usually well stabilised at home before transfer. However, this raises another important point in this debate: what is the impact of birth (and place of birth) on future development of the offspring? Unfortunately this aspect of obstetric care has been poorly studied, but the information that we do have raises serious concerns about the long-term impact of our current model of medicalised maternity care, and the high rates of medical interventions associated with its use.1 2 For example, Jacobson et al compared the rates of adult drug addiction between siblings born with and without exposure to opiates, barbiturates, and nitrous oxide in labour. Exposure to more than three doses of any of these analgesics was associated with an almost five times increased risk of drug addiction in adulthood.1 Caesarean section is another major birth intervention with poorly researched long-term implications for the offspring. Studies show that caesarean babies have lower levels of neonatal brain oxygenation,2 and slower neurological adaptation after birth.3-5 Animal studies have linked uncomplicated caesarean birth with abnormalities of dopamine pathways in adult rats and guinea pigs.6 Dysregulation of dopamine function has been implicated, in human studies, with the development of schizophrenia, as well as substance abuse and attention deficit hyperactivity disorder.6 Other researchers have studied the effects of epidurals and pethidine, administered at term to rhesus monkeys, and found abnormalities in behavioural maturation during specific periods of infancy.7 Golub comments, “Probably the most widespread exposure of the developing brain to central nervous system agents occurs at birth.”8 Csaba’s research into hormonal imprinting raises more concerns about perinatal exposure to drugs and hormone-like substances.9 For example, he found that a single perinatal exposure to exogenous beta-endorphin altered adult sexual and aggressive behaviour in rats.10 This author states, “Perinatally, the first encounter between the maturing receptor and its target hormone results in hormonal imprinting, which adjusts the binding capacity of the receptor for life. In the presence of an excess of the target hormone or foreign molecules than can be bound by the receptor, faulty imprinting carries life-long consequences.”11 Hormonal imprinting effects can persist for three generations.12 New thinking about brain development emphasises the plasticity of the developing brain,13 and the vulnerability of the brain, during the prenatal period of neuronal mulitiplication, migration and interconnection, to irreversible damage.14 These findings add important information in interpreting Johnson and Daviss’ study. Not only are the babies represented here equally safe, in terms of mortality, compared to low-risk babies born in hospital; they may also have significant long-term neurological and developmental advantages because of their low rates of exposure to obstetric drugs and procedures. 1. Jacobson B, et al. Opiate addiction in adult offspring through possible imprinting after obstetric treatment. Br Med J 1990;301(6760):1067-70. 2. Isobe K, et al. Measurement of cerebral oxygenation in neonates after vaginal delivery and cesarean section using full-spectrum near infrared spectroscopy. Comp Biochem Physiol A Mol Integr Physiol 2002;132(1):133-8. 3. Kim HR, et al. Delivery modes and neonatal EEG: spatial pattern analysis. Early Hum Dev 2003;75(1-2):35-53. 4. Otamiri G, et al. Delayed neurological adaptation in infants delivered by elective cesarean section and the relation to catecholamine levels. Early Hum Dev 1991;26(1):51-60. 5. Vladimirova E, Smirnova EE. [The CNS status of newborn infants delivered by cesarean section (based on EEG data)]. Zh Nevropatol Psikhiatr Im S S Korsakova 1994;94(3):16-8. 6. Boksa P, El-Khodor BF. Birth insult interacts with stress at adulthood to alter dopaminergic function in animal models: possible implications for schizophrenia and other disorders. Neurosci Biobehav Rev 2003;27(1-2):91- 101. 7. Golub MS. Labor analgesia and infant brain development. Pharmacol Biochem Behav 1996;55(4):619-28. 8. Golub MS. Labor analgesia and infant brain development. Pharmacol Biochem Behav 1996;55(4):619-28, p 619. 9. Csaba G. Hormonal imprinting: its role during the evolution and development of hormones and receptors. Cell Biol Int 2000;24(7):407-14. 10. Csaba G, et al. Effect of neonatal beta-endorphin imprinting on sexual behavior and brain serotonin level in adult rats. Life Sci 2003;73(1):103- 14. 11. Csaba G, et al. Endorphin excess at weaning durably influences sexual activity, uterine estrogen receptor's binding capacity and brain serotonin level of female rats. Horm Metab Res 2004;36(1):39-43, p 39. 12. Csaba G, et al. Three-generation investigation on serotonin content in rat immune cells long after beta-endorphin exposure in late pregnancy. Horm Metab Res 2005;37(3):172-7. 13. Shore R. Rethinking the Brain: New Insights into Early Development. New York: Families and Work Institute, 1997, p 15. 14. Livezey GT, et al. Prenatal exposure to phenobarbital and quantifiable alterations in the electroencephalogram of adult rat offspring. Am J Obstet Gynecol 1992;167(6):1611-5, p 1614. Competing interests: I have attended home births as a GP and am the mother of four children, all born at home
Midwifery and uphill battles 1 July 2005
Christine F. Edie, Clinical pharmacist Cincinnati, Ohio 45208 Send response to journal: Re: Midwifery and uphill battles	I appreciated the article by Johnson and Daviss and will be submitting it forthwith to my third-party insurer as additional supportive evidence that they would be well advised to honor my midwives' claims for prenatal/obstetrical care. I, unfortunately, do not live in a "rural" or "underserved" area, which is apparently the only way they will reimburse for these services. Many responses have noted the battle involved with legislatures and medical organizations regarding midwifery, but the primary barrier I have experienced as a patient has been the refusal of my insurance company to reimburse for their services. Do I pay $2,000 out-of-pocket directly to my midwives or do I pay the one-time $20 co-payment for my first participating-provider OB visit? The options, or realistic lack thereof, give one pause. I chose to have my first child with midwives in a hospital (their consulting physician for their birthing center births resigned due to liability fears), delivered my daughter within 3 hours of being admitted (no tearing or episiotomy, thank you very much) and was ready to go home 8 hours after that, all with no drugs at all. How can an insurance company pass up an 11 hour hospital admit with no meds? Perhaps insurance companies, with much larger political action committees than midwives (!), can work to influence U.S. lawmakers in support of midwifery? Competing interests: None declared
Silence of the lions 9 July 2005
Marsden G. Wagner M.D., Former Director of Women's and Children's health, WHO 123 Sherman Ave, Takoma Park. Maryland, 20912 USA Send response to journal: Re: Silence of the lions	When a study is published with scientifically valid evidence against an important position of a clinical group, clinicians have two common reactions: ignore the study and hope it goes away; torture the data until it confesses to what they want it to say. It is instructive to observe who has and who has not responded, to date, to the study of planned home birth by Johnson and Daviss. The largest group of responders consists of midwives and other supporters of the demedicalization of birth. This group recognizes the excellence of the methodology, the importance of the findings, and the consistency with the existing weight of evidence. The second largest group of responders is primary care physicians, some of whom are generally positive about the findings while others try to torture the data to justify running from the heresy of agreeing to health care which is not in some kind of medical setting: “this information does not change my practice”. Then we have the silence of the lions: why are the obstetricians not responding? With one possible exception, there are no obstetrician responders to a study with major implications for obstetric practice. And the one physician responder who may be an obstetrician rejects supporting planned home birth, even if safe, because of the “pernicious legal system”. Fear of litigation is a highly selective excuse used by some obstetricians when there is something which is not obstetrician-friendly such as planned home birth (over which they have no control and no profit). But when there is an obstetrician-friendly intervention they want to promote such an misoprostol induction of labour, they don’t mention fear of litigation even though there have been dozens of cases of litigation in the U.S. after adverse outcomes following misoprostol induction. (1,2,3) It is doubtful there will be obstetrician responders to this study because of their hope that by ignoring it, this study will go away. On the other hand, when a retrospective study (4)incapable of separating planned from unplanned home birth was presented in the U.S. suggesting home birth may be unsafe, the American College of Obstetricians and Gynecologists (ACOG) issued a press release the next day citing the study as indicating the dangers of home birth. Since for many years ACOG has had a published opinion (with no citations from the literature) that home birth is not safe, an opinion which attempts to deny women a legitimate choice of place for giving birth, ACOG’s rush to cite the flawed study is explained. And their silence in the face of the present outstanding study by Johnson and Daviss of the safety of home birth is to be expected. One responder questions how quickly the findings of this study will impact on the maternity care systems, citing the rapidity with which the finding of the Hannah trial (5) changed the management of breech birth. But surgical breech birth is obstetrician-friendly and planned home birth is not, seriously threatening the likely impact of the Johnson-Daviss study in countries such as the U.S. where organized obstetrics is a major impediment to the demedicalization and humanization of childbirth. 1) Wagner M Adverse events following misoprostol induction of labor, Midwifery Today, 2004; 71: 9 – 12 http://www.midwiferytoday.com/articles/cytotecwagner71 2. Medwatch: the FDA Medical Products Reporting Program http://www.fda.gov/medwatch/safety.htm Druginfo@cder.fda.gov 3. Searle Pharmaceutical Co., Searle Drug Experience Reports 4) Pang J et al, “Outcomes of Planned Home births in Washington State: 1989 – 1996” Gynecology and Obstetrics, 100(2) 253-59, 2002 5) Hannah ME et al, Planned cesarean section versus planned vaginal birth for breech presentation at term: A randomized multi-center trial. Lancet 356 (9239), 1375-83, 2000 Competing interests: None declared
Billions Saved: An Opportunity to Use Health Care Dollars More Wisely 15 July 2005
Rondi E Anderson, Director of Midwifery Salem Hospital, Salem Massachussetts, 01970 Send response to journal: Re: Billions Saved: An Opportunity to Use Health Care Dollars More Wisely	Johnson and Daviss have made a long awaited, difficult, and extremely significant contribution to the obstetric literature. In a day when health care contributes 15% to the crippling national debt the United States is facing, an authoritative article supporting a health care choice that is both satisfying to the families and has the potential to markedly impact health care debt is a important beacon of a direction that is not only sane but likely imperative. The United States currently has a debt of 7.800,000,000,000. Thirty billion of that is from childbirth (1). Privately insured and uninsured families struggling under the burden of health care expense from rising health insurance cost and for the growing number of uninsured, hospital bills. In addition large corporations are being threatened by bankruptcy in part from the cost of health insurance for employees. The one health service that every family needs deserves further attention. In research published in 1999, we found that the average uncomplicated vaginal birth in the United States cost 68% less in the home then in the hospital (1). This reduction in fees is because of the elimination of hospital fees and the significant reduction in medical intervention including cesarean section shown in this, as well as other studies (2,3,4,5). If all low risk women in the United States began labor with the intention of giving birth at home with a midwife, there would be an average saving of 3,600 dollars per birth, which would save the United States and private insurers 14 billion dollars per year(1). This saving would occur without increase in risk to mother and baby--thus allowing the United States to devote more resources to other urgent priorities. It behooves those in power over public health decisions to educate the health care community and the public to stop the unnecessary use of financially burdensome over hospitalization that has no over all health benefit, and support the implementation of regulations and health care delivery systems that support midwives and home birth. References 1. Anderson RE, Anderson DA. The cost-effectiveness of home birth. J Nurse Midwifery 1999;44: 30-5.[CrossRef][ISI][Medline 2. Johnson K.& Daviss B. 2005, ‘Outcomes of planned home births with certified professional midwives: large prospective study in North America’ BMJ 2005; 330: 1416 3. Anderson RE, Murphy PA. Outcomes of 11,788 planned home births attended by certified nurse-midwives. A retrospective descriptive study. J Nurse Midwifery 1995;40: 483-92.[CrossRef][ISI][Medline] 4. Murphy PA, Fullerton J. Outcomes of intended home births in nurse- midwifery practice: a prospective descriptive study. Obstet Gynecol 1998;92: 461-70.[Abstract/Free Full Text Competing interests: None declared
Are trials of place of birth feasible? 22 August 2005
Soo M Downe, Professor of Midwifery Studies University of Central Lancashire, PR3 2LE, Denis Walsh, Fiona Dykes, James G Thornton, Andrew Symon, Gillian Gyte, Elizabeth Key and Michelle Mossa Send response to journal: Re: Are trials of place of birth feasible?	A number of the respondents to a recent epidemiological study of place of birth published in this journal1 noted the potential for bias in non-randomised studies in this area. Others indicated that randomised trials of place of birth would be difficult, if not impossible. We have been working on this problem for some years now. To date, members of our group have completed one early feasibility study, two meta-analyses, one meta-synthesis, and an ethnographic study. We conclude that it is possible and appropriate to undertake trials in this area, as long as they are based on a clearly defined hypothesis that accommodates the complexity of place of birth. Our studies indicate that phase one and two pre-trial work is required to establish the proportion of women who would agree to be randomised, the impact of preference, the level of equipoise amongst professionals, the important outcomes to be assessed, and techniques for overcoming the problems of interpretation and generalisibility when units have the same title (‘birthcentre’, ‘hospital maternity unit’) but differ subtly in the care provided, or in local philosophies and beliefs about childbirth. We are aware that other researchers are also addressing some of these issues, including the definition of birth centres, and the factors that influence women’s choice. This preparatory research being undertaken by our team and by other colleagues is particularly timely in the UK in the light of recommendations supporting women’s choice of place of birth in the Children, Young People and Maternity Services National Service Framework2. We believe that a randomised trial of place of birth based on the MRC guidance for trials of complex interventions3 is now essential, especially following the important findings of Johnson and Daviss that out -of-hospital birth is potentially beneficial for some women and babies. References 1 Johnson K.& Daviss B. 2005, ‘Outcomes of planned home births with certified professional midwives: large prospective study in North America’ BMJ 2005; 330: 1416 2. DH and DES 2004 National Service Framework for Children, Young People and Maternity Services. Department of Health, London 3 Medical Research Council 2000 A framework for development and evaluation of trials of complex interventions to improve health. MRC, London Competing interests: All authors are engaged in research relating to place of birth. They have no other competing interest