Interpreting Evidence why values can matter as much as science de Melo-Martínde Melo-Martín and IntemannIntemann Perspect Biol Med Winter; 55(1): 59–70.

Home births: Official Stand נגד Australianand New Zealand Colleges of Obstetricians and Gynecologists American Medical Association (AMA) American College of Obstetricians and Gynecologists (ACOG) בעד United Kingdom’s Royal College of Obstetrics and Gynecology Royal College of Midwives, American Public Health Association American, Australian, New Zealand, and Canadian Colleges of Midwives

Why RCTs is unfeasible pregnant women are unwilling to be randomly assigned a place of birth regardless of their preference require either a large number of participants or a sufficiently frequent adverse outcome in order to show statistically significant differences between home and hospital births

Weaknesses observational studies selection bias—is it important in this case? confounding variables – skill of the birth attendant – differences in defining appropriate inclusion criteria for “low-risk” status – birth certificates that cannot reliably distinguish between high-risk, unplanned, unassisted home births and planned home births – inability to determine whether hospital transfers in home births occurred before or during labor

How should particular risks be weighed? how much weight to give to worst-case scenarios? – serious intrapartum complications may arise without much warning: cord prolapse, postpartum hemorrhage, or shoulder dystocia

value judgments also play a role in risk assessment what are the potential benefits of home birth? how valuable are those benefits? how serious are the adverse outcomes Are there equally good lower-risk alternatives available? Are there ways to manage or reduce existing risks?

Benefits giving birth at home familiar environment more control over the birthing process ability to choose decreased risk of obstetric interventions

Risk reduction vs risk avoidance strategies for managing emergency risks – ensuring adequate classification of low-risk pregnancies – providing appropriate transportation in case of emergencies

What is the nature of pregnancy and ?childbirth Opponents labor and delivery are intrinsically risky activities – hospital setting has already been established to be safe and best equipped to deal with medical emergencies – Note declining maternal and infant mortality since most births moved to hospitals pregnancy and delivery qualitatively different risks than other activities – any risk to the fetus, however small outweighs considerations that may be of substantial importance to the woman herself Proponents labor, and delivery for low- risk women generally safe Normal part of life that doesn’t require moving that activity to the hospital (e.g. eating/choking) decline in maternal and infant morality attributed to other factors

What counts as indicators of optimal care in the case of labor and delivery? What is significance of rates of obstetric interventions cesarean section Episiotomy epidural analgesia induction of labor electronic fetal monitoring

Do we need more research or do we need to discuss our underlying values?