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Jan 21, 2010

The AMA says we are "shooting the messenger" re homebirth critique

Further to the posts below on the homebirth study, the AMA has sought right of reply. Dr Andrew Pesce, for those who haven't been following the story thus far, is the president of th

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Further to the posts below on the homebirth study, the AMA has sought right of reply.

Dr Andrew Pesce, for those who haven’t been following the story thus far, is the president of the AMA (which opposes homebirth), an obestetrician and gynaecologist, one of the reviewers of the new study, and also the author of the MJA editorial on the study.

He writes:

“Home birthing is a controversial issue in Australia and this week’s debate around the South Australian study is proof of this.

As would be expected, both sides of the debate put their cases strongly and passionately.  Unfortunately the passion sometimes gets in the way of the facts and the evidence.  Melissa Sweet’s critique of my editorial in the Medical Journal of Australia is a case in point.

My editorial was primarily about the politics of home birth.  Most neutral commentators have commended me on the balance of the editorial.

As AMA President, I transparently declared a potential conflict of interest based on the policy of the AMA.  I presume the College of Midwives, which strongly advocates for home birth and the role of private midwives, has similarly declared its potential conflict of interest in their complaint to Media Watch.

But let’s look at the study itself.  All the results mentioned are accurately reported, relevant and statistically significant.

The seven-fold increased risk is a statistical prediction of the most likely risk according to the data.  It is arrived at after exclusion of babies dying from congenital abnormalities and other conditions before the onset of labour.  The fact that it is statistically significant – despite relatively low numbers of planned home birth – is of more concern, not less.

The overall rate of perinatal deaths was not different, but only if you ignore the fact that a larger number of women planning to give birth in hospital have risk factors and complicated pregnancies.

When adjusted for prematurity and low birth weight, the overall perinatal mortality rate for all pregnancies planning a home birth was double that of planned hospital birth.  This difference did not reach statistical significance, but it is here that the relatively low numbers make the study’s findings unable to detect a statistically significant difference at this level of risk.

The study identified the same contributing factors that were found in a previous larger Australian review (Bastian H, Keirse MJNC, Lancaster PAL. Perinatal death associated with planned home birth in Australia: population based study. BMJ 1998; 317: 384-388).

The Bastian study found poor adherence to risk assessment, lack of monitoring of foetal wellbeing and delayed response to emerging complications in home births.

Incidentally, that study was actually designed under the auspices of, and funded by, Homebirth Australia, but the results are now repudiated by that organisation.

If a justification is needed for the AMA highlighting the concerning results of this study, it is that home birth advocates continue to deny the higher risks of current home birth practice, and the need for adequate risk assessment and management.

And, to be fair, my editorial did mention the lower intervention rates, the similar rate of post partum haemorrhage and other favourable outcomes of home births found in the study.

My point that the decisions regarding government policy regarding home birth should be based on evidence (light) rather than political pressure (heat) paraphrases the view apparently endorsed by Ms Sweet at the conclusion of her piece.

But what is the evidence for Ms Sweet’s claim that the MJA’s inclusion of an editorial by the AMA President has slanted media coverage?  There was not one mainstream media organisation that did not give coverage to criticism of the study (and the AMA) by home birth advocates.  Rather than slanting the story, my editorial provided an opportunity for home birth advocates to put their case.

As for the AMA media release, it does what any media release is meant to do: it emphasised the key messages around the AMA’s position on home birth.  By the same token, the media releases from midwives and home birth advocates state their position.

The AMA media release says clearly that the AMA supports women having choice about where they have their babies.  The AMA media release stresses the need for evidence and safety.  There is balance – far more balance than the commentary on this important issue that is found on home birth websites.”

• Dr Andrew Pesce is President of the AMA and a practising obstetrician and gynaecologist at Westmead Hospital in Sydney

Meanwhile, Croakey has just caught up with the 22 Jan issue of Australian Doctor, which has a page one story on related issues, including details of a study of the first 100 births through the St George Hospital Homebirth Program in NSW, published in the Australian and New Zealand Journal of Obstetrics.

The story says the study has reported “reassuring outcomes” and that “a growing number of obstetricians are calling for more support for safe homebirth models despite the AMA’s resolute opposition to the practice”.

Professor Michael Chapman, who has been involved in the St George program, is quoted saying that homebirths involving experienced midwives following strict hospital transfer protocols were appropriate for a small group of low-risk women who preferred to give birth at home.

He said: “Homebirth conducted in a random disorganised manner with independent midwives and patients who are pushing the boundaries of safety have given it a bad name. But in a controlled environment, I do believe the risks are minimal.”

Update: The AMA has been in touch to advise that Dr Pesce was a reviewer on this paper as well.

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