Intended for healthcare professionals

Rapid response to:


Outcomes of planned home births with certified professional midwives: large prospective study in North America

BMJ 2005; 330 doi: (Published 16 June 2005) Cite this as: BMJ 2005;330:1416

Rapid Response:

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

2. Medwatch: the FDA Medical Products Reporting Program

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

Competing interests: No competing interests

09 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