Using data to expose the risks of home births Date: 06/06/14
Markian Hawryluk, a health reporter with The Bend (Ore.) Bulletin and an AHCJ Regional Health Journalism Fellow, describes how he took advantage of new data collected by the state of Oregon to shape an article that revealed high mortality rates for home births in his state. "If home birth were a drug," he wrote, "it would be taken off the market."
By Markian Hawryluk
I had been Interested in the issue of home births for years, ever since learning of the lax standards for midwives in Oregon. While beauticians and tattoo artists are regulated in the state, midwife certification is voluntary in Oregon, and even then, the hurdles for certification are rather minimal.
But with midwives largely operating outside of the established health care system, there was little more than anecdotal evidence to go on. That changed last year.
A doctor I’ve interviewed on other topics contacted me last October. He had been working shifts in the emergency room and was concerned by the number of “home births gone bad” that were showing up in the ER. The women, he said, for the most part were hoping to avoid a highly medicalized birth by choosing to deliver outside the hospital. Because they shunned even the most basic of screening tests, they often didn’t know they fell into any number of high-risk categories. When things went wrong at home or a birthing center, they would come to the hospital with both mother and baby in critical state. They ended up having a much more medicalized experienced than they would have had if they had gone through regular prenatal screening or even a birth at the hospital’s family birthing center.
Data, but it's not so simple
The doctor also pointed me to a report that had been released by the state with little fanfare, documenting the outcomes with planned out-of-hospital births. For the first time, I felt like I had a legitimate way to compare the safety of in-hospital and planned out-of-hospital births. As I dug into the data, however, I realized this would not be a simple comparison.
The state’s report stemmed from a failed attempt to pass legislation requiring mandatory licensure for midwives. The legislature had been shocked by the death of a newborn at the hands a midwife with minimal experience. But when they held hearings on the legislation, scores of midwives and mothers came out to protest the bill.
The legislators were successful in passing a change to the birth certificates, adding the question of the intended place of birth. This would turn out to be crucial. For years, the data on home births were muddled when mothers attempting home birth and their babies were transferred to the hospital when something went wrong. That artificially inflated the numbers of bad outcomes in hospitals and hid the true risks of home birth.
The question was added to birth certificates for the first time in 2012, and so last year, the state was able to publish for the first time the data on planned out-of-hospital births. Out of 2,021 births, eight babies died. That was twice the rate of infant deaths in hospitals for 2012.
But when I interviewed a nurse who had presented the state’s data to the legislature, I learned the hospital data did not separate the fetal deaths from congenital anomalies that happened before labor started. In fact, the data additionally showed a seventh death from home birth but researchers tossed that case because the death was due to a birth defect, not the process of labor itself. The true apples-to-apples comparison of death rates was much worse – five to six times higher for planned out-of-hospital births. She shared with me a working document that explained these differences in minute detail.
National data, local families
As I was working on the story, two national analyses of home birth outcomes were released. One was an analysis that matched birth and death records, but wasn’t able to account for hospital transfers. Another was data collected from a voluntary database of the Midwives Alliance of North America. I was also able to track down, through PubMed, additional studies looking at injuries to children during home birth, which helped flesh out risks beyond mortality.
We ran a query in the newspaper looking for families who had gone through home birth and were willing to share their stories. We had a flood of responses, but exclusively from supporters of home births. To get the alternative perspective, I tracked down an advocate who had testified in support of greater regulation. She put me in touch with a local woman whose son had developed cerebral palsy during birth. That mother connected me to a circle of women who had experienced tragic home births, and several of them agreed to talk to me.
One of our most difficult decisions was what to do with photos of babies who died during a home birth. The mother had forwarded me several more graphic photos which we clearly couldn’t use. There were two photos of the baby after his death that just looked like a peaceful sleeping baby. We decided against the close-up of the baby’s face and opted for a photo of the mother holding her lost son minutes after he died. It was one of the more powerful photos I’ve ever had with one of my stories.
The story ran in our four-color health magazine, Pulse, which is inserted in the newspaper each quarter, and also distributed to medical offices in the region. It allowed me to take a long-form approach, exploring in great detail, the data, the motivations behind seeking out home birth, and the tragic stories when these go wrong. The story garnered a lot of interest and predictably, a fair amount of debate in comments on the website.
Markian Hawryluk, is a health reporter with The Bend (Ore.) Bulletin and an AHCJ Regional Health Journalism Fellow. He has covered health policy for a number of publications, including American Medical News, Provider magazine and Health Industry Executive. He has won multiple awards in Oregon and the Pacific Northwest and was a Knight-Wallace Fellow.