Reply




We thank Ms Cohain for her letter on our article on 5-minute Apgar scores of 0 in relation to birth setting and attendant. Ms Cohain makes 4 points by way of criticism. All fail to be persuasive.



  • 1.

    Ms Cohain says: “The article claims that hospital births resulted in 0.16 stillbirths per 1000 full-term births after 37 weeks, which means the perinatal mortality rate of the United States 2007 through 2010 would have been 0.2/1000 instead of what it was: 7/1000.” Our article reported on the 5-minute Apgar score of 0, not the stillbirth rate. In addition, stillbirths are but 1 component of the perinatal mortality rate, which also includes neonatal mortality, which we did not report in our article. The comment shows that Ms Cohain has a basic misunderstanding of perinatal outcomes.


  • 2.

    We do not understand the relevance of Ms Cohain’s comment about prematurity rates. Our inclusion criteria of ≥37 weeks’ gestational age and ≥2500 g birth weight without twins explicitly exclude premature deliveries. The supposed 17% prematurity figure appears nowhere in our article.


  • 3.

    According to Centers for Disease Control and Prevention data that we reported there were a total of 60,296 home births that fulfilled our criteria of singleton term birth, birth weight ≥2500 g for the 4-year time period. It is unclear where Ms Cohain found the supposed 29,000 home births. If this number was taken from somewhere as a 1-year number it is even less clear why she would think that simply multiplying a 1-year number and dividing it by the number of midwife births for 1 year would show the accurate number of births for a 4-year period. This comment shows a basic misunderstanding of data analysis.


  • 4.

    We agree with Ms Cohain that at home births both umbilical cord prolapse and shoulder dystocia can be causes of Apgar scores of 0 and stillbirths. But those 2 causes of Apgar scores of 0 and stillbirths are preventable with planned hospital births, where there is ready access of cesarean delivery as well as a team to manage shoulder dystocia. We strongly disagree with Ms Cohain that these are the “…only 2 possible emergencies that have been documented to cause intrapartum stillbirth at planned attended homebirths of low-risk births.” In addition to these 2 preventable causes of stillbirths there are multiple other potential reasons and causes for low Apgar scores of 0 and stillbirths, including but not limited to prolonged pregnancy, which is preventable with planned hospital birth and induction, and placental disease, cord anomalies, and infection. This comment questions her lack of a basic understanding of obstetrics or the risks in homebirths.



We close by emphasizing that clinical judgment about the safety of home birth requires rigorous adherence to the discipline of evidence-based reasoning. This is an intellectual and moral standard from which Ms Cohain appears to have liberated herself. In doing so, she displays an egregious failure of professionalism.

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May 11, 2017 | Posted by in GYNECOLOGY | Comments Off on Reply

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