MANA prepares to acknowledge the hideous death rate at homebirth

Lies Concept

Let me take you on a trip down memory lane.

I started writing about the Midwives Alliance of North America and their campaign to hide their death rates more than 5 years ago, back in August of 2006. My first major post on the issue was Research and special interests/the BMJ 2005 study in which I began an exploration of the fact that Johnson and Daviss were not forthcoming about their connections to the homebirth industry. Over the following year, I proceeded to analyze the BMJ 2005 study and demonstrate that it actually shows that homebirth with a CPM in 2000 had a death rate nearly triple that of low risk hospital birth in the same year. It took nearly 2 years, but Johnson and Daviss ultimately acknowledged that I had been right all along.

I first wrote about the fact that the Midwives Alliance of North America (MANA), the organization that represents homebirth midwives, was hiding their own death rates back in January of 2007. MANA has fought me every step of the way, denying, lying and doing whatever it takes to hide the fact that not only does the evidence show that homebirth with a homebirth midwife has a hideous death rate, but MANA has known that for years and done everything it could to make sure that American women did not find out.

That hideous death rate has been confirmed by 5 years of CDC statistics on planned place of birth, and most spectacularly by the horrific perinatal death rate of licensed Colorado homebirth midwives.

The mountain of statistics confirming the increased risk of death at homebirth is continuing to grow, and, as a result, it appears that 5 years of lying and denying on the part of MANA and homebirth midwives and their supporters is about to end. That’s the message I take away from the proactive attempts of the homebirth industry to minimize the significance of those deaths. Consider today’s post on Science and Sensibility by by Wendy Gordon, CPM, LM, MPH, MANA Division of Research, Assistant Professor, Bastyr University Dept of Midwifery (and placenta encapsulation specialist!), a woman who has been arguing with me in print about the data for more than 5 years.

The post talks about last week’s Institute of Medicine conference on birth settings and specifically addresses data that shows that planned homebirth has an increased rate of death. Instead of denying it, as Wendy Gordon has done in a variety of venues for more than 5 years, she actually acknowledges it and then counsels everyone to ignore it.

Gordon references the presentation by Dr. Frank Chervenak on CDC data:

Chervenak used his 12 minutes (out of 10) that were to be devoted to the hospital provider perspective for, instead, a rapid-fire display of “back-of-the-envelope” bar graphs attempting to show home/hospital differences in 5-minute Apgar scores using raw data drawn from birth certificates.

Chervenak slide

Gordon helpfully telegraphs the response that I suspect will accompany MANA’s defense of its horrific death rates:

1. It hasn’t been published!

Since it appears that some doctors are having a hard time getting their “research” on this topic published in peer-reviewed journals, they are presenting their data in settings that do not require peer-review, such as last year’s annual conference of the Society of Maternal-Fetal Medicine (the study still hasn’t been published) and this IOM workshop.

Of course, CDC data is published. It’s published by the CDC. It is valid even before it is included in a peer reviewed scientific paper. When the CDC publishes the number of people who died of lung cancer last year, that number is accepted, regardless of whether it ever appears in a scientific paper.

2. So what if the death rate at homebirth is much higher? The absolute number of babies who have died is small.

Let’s say that a person’s odds of getting struck by lightning in a heavily populated city are one in a million, and those same odds in a rural area are five in a million. These odds are called your “absolute risk” of being struck by lightning. Another way to look at this is to say that a person’s odds of being struck by lightning are five times higher in a rural area than in a densely-populated area; this is the “relative risk” of a lightning strike in one area over another.

A common approach of anti-homebirth activists is to use the “relative risk” approach and ignore the absolute risk, because it’s much more dramatic and sensationalistic to suggest that the risk of something is “double!” or “triple!” that of something else …

So after years of lying about the increased risk of death at homebirth, the homebirth industry is finally acknowledging that what I’ve been writing about the death rates has been true all along.

I find it quite amusing that Gordon and other homebirth advocates have suddenly discovered the difference between absolute and relative risk. The same people who have been howling about the “dangers” of epidurals (the risk of death from an epidural is less than the risk of being killed by a lightening strike), are suddenly insisting that the risk of death at homebirth, which is anywhere from 100 to 1000 times higher, is actually so small that you should ignore it.

3. Birth certificate data is unreliable!

Epidemiologists in the room were quick to step to the microphone for the open discussion part of the panel, pointing out the many flaws in Chervenak’s presentation. Marian MacDorman, Ph.D., senior statistician and researcher for the CDC’s National Center for Health Statistics, reminded everyone that birth certificate data is notoriously unreliable for neonatal seizures and low Apgar scores; this has been shown time and again for decades and had indeed been discussed earlier in this very workshop. More importantly, McDorman stated that data from birth certificates cannot be used to make comparisons between settings or providers…

I find that absolutely hilarious. Marian MacDorman, an editor of the Lamaze sponsored “journal” Birth, has published a number of papers based on, you guessed it, birth certificates. Infant and Neonatal Mortality for Primary Cesarean and Vaginal Births to Women with “No Indicated Risk,” United States, 1998–2001 Birth Cohorts is widely quoted in the homebirth community as demonstrating a 3X higher neonatal death rate (triple!) for elective C-section as compared to vaginal delivery. MacDorman and colleagues publicly revised the relative risk after others pointed out serious methodological flaws, but they still ended up claiming that C-section without medical indication has a 1.5X higher risk of neonatal death (nearly double!) than vaginal delivery. But birth certificates are notoriously unreliable for reporting risk factors, as I pointed out at the time.

Apparently MacDorman is trying to set a new standard for hypocritical behavior. She published at least 2 studies relying on birth certificate data, and in both studies, although the relative risk of neonatal death at C-section was supposedly nearly double or triple, the absolute risk was very small. Those studies are supposed to be valid, but the homebirth death rates are not?

After years of lying and denying, homebirth advocates are being forced to acknowledge the dramatically increased risk of death at homebirth.

There are two important messages to take away from this:

Homebirth (particularly homebirth at the hands of grossly undereducated and undertrained CPMs) dramatically increases the risk of perinatal death.

More importantly, professional homebirth advocates have steadily and repeatedly lied about the increased risk of perinatal death. They should never have been trusted before, and cannot be trusted now.

This is yet another reason why the CPM should be abolished. In addition to being undereducated and undertrained, the entire CPM industry is unethical, putting their desire for income ahead of their obligation to obtain informed consent. Not only have they let babies die, they’ve lied about it, too.

  • BeatlesFan

    Is it typical for mothers to be told their baby’s APGAR scores? I had both my children in hospital and I don’t know what the scores were for either of them. I would imagine my daughter’s were poor to middling since she came out the same awful shade of blue-gray as Rixa Freeze’s baby, although she didn’t need resus. She’s 15 days old with a clean bill of health so I know it doesn’t matter, but I am curious. Do parents normally have to ask?

    • KarenJJ

      I didn’t know until I found a folded up sheet of paper in my baby health book (government hands them out and they have growth charts in them and space for recording health nurse visits vaccinations). I just looked at them and my kids were 9/9 and 9/10 for their 1/5 minute scores. The 9/9 baby deteriorated in colour after that and had TTTN.

  • Sue

    Time for HB advocates to come clean.

    We know from the UK Birthplace study that, with fully trained MWs cooperating within the health system, tight risk-out and 40% transfer rate, the babies of first-time mothers still die at 3X the rate of similar hospital births (quite aside from hypoxic and physical injury).

    It comes down to this:
    1. HB carries an excess mortality for the babies of first timers, even under the best of circumstances;
    2. Following a successful vaginal birth, HB may be relatively safe PROVIDED that there is tight risking out, a cautious transfer rate, and is under the supervision of a trained midwife who works together with the hospital team.

    3. IN the absence of a fully trained provider, cooperating with a hospital team and working within tight guidelines for risk-out and transfer, HB carries an unacceptably high neonatal and maternal mortality and morbidity.

  • Captain Obvious

    http://highlandmidwife.com/blog/?p=113

    This lady is so wrapped up it is crazy. I was led here after finding her slamming a Homebirth gone wrong blog from 2006. Dr Amy chimed in and this “lady” challenged anyone to a Homebirth debate.

    • Bombshellrisa

      Crazy is SOOO right-from her “informed care” for midwife document “Malpractice Insurance: The midwife does not currently carry malpractice insurance due to the

      prohibitive costs which would have to be passed on to the clients.

      As a woman freely choosing midwifery care and out-of-hospital birth, I understand that (please initial):

      _______ I am ultimately responsible for the outcome of this pregnancy and birth.

      _______ My midwife is responsible for providing adequate clinical management of healthy,

      normal childbearing, as outlined in her training, credentials, and licensing.

      _______ The development of certain conditions during pregnancy, birth and/or the postpartum

      period may require the transfer of care to the medical system.

      _______ There are benefits and risks associated with labor and birth in both non-hospital and

      hospital settings.

      _______ The midwife carries certain emergency medication and equipment but cannot duplicate

      such services as are available at some hospital facilities, including continuous electronic

      fetal monitoring, Cesarean sections, or blood transfusions.

      _______ My midwife may not be able to accompany me into the hospital and/or birthing room in

      the event of a transport” Which basically says “I don’t have malpractice insurance, the care I give isn’t like what a doc can give and oh, by the way, I don’t go to the hospital with clients” And all this for only $3600, prepaid by week 36 of the pregnancy. http://www.highlandmidwife.com/docs/Financial.pdf

      • The last bit:
        “When the shit hits the fan, this midwife will be running for cover.”

    • Susan

      I really liked her business logo. I think you should steal it for your OB practice.

      (What on earth is it supposed to be? A satryr holding a baby?

      • Sue

        I really hope it doesn’t represent the fate of babies under her care.

        • Bombshellrisa

          Here are some comments from her guest book

          “Kristin and Lorri were great and very accomodating… They agreed to care for me even though I had 3 pre-term births previously (other midwives had declined to see me because of that)” So, I can tell already that they are not properly risking women out.

          ” It was soo incredible to have your confidence in my VBAC the entire time I was pregnant! I felt that during my pregnancy, labor and delivery-EVERYTHING was my decision and my choice.” An HBAC, again, not exactly risking women out.

          “Lorri made a “fertility tonic” for me, it has a blend of 27 or the best fertility herbs in it. She made it originally to help my husband and I conceive” Lorri owns an herbal shop. How nice of her to suggest a product she can sell them.

          ” I felt that there was a trusting caring relationship that was not there with any OB I had previously seen. After a 34 hour birth with 5 hours of pushing” 5 hours of pushing?

          “We tried a little bit of a blue and black cohosh tincture to try to help make my contractions effective and get the job done as I was eeking closer to 41 weeks.” This from a client http://joshandbrittanysthirdbaby.blogspot.com/

    • Bombshellrisa

      Here is the intro “I am Lorri Carr, a Direct-Entry Washington Licensed Midwife and Certified Professional Midwife, with experience that includes hospital births and clinical OB/GYN care. I am the only Licensed Midwife in Klickitat county, Washington, and the only obstetrical care available in Goldendale. In addition to complete prenatal care, home birth, and postpartum follow-up, I offer gentle and thorough gynecological care, nutritional analysis, and herbal remedies for my clients. I serve mothers from the Yakima Valley to the Columbia River Gorge into Oregon, with office appointments in The Dalles and Yakima.
      My job is to make certain that you are healthy and well-informed as well as completely supported, and that your care not only meets but exceeds medical standards, so you can experience the incredible joy of birthing your baby comfortably in your own home.”
      and more from her blog
      The midwives she is associated with are Sherry Dress (currently being investigated for practicing without a licence), Kristen Eggleston (under investigation), Marcille Petrilli (a traditional midwife, code for unlicensed but she has decided to submit her paperwork for her CPM), Shannon Bennet (who is not licensed and currently being investigated for practicing without a license) and PJ Jacobsen (a traditional midwife and lactation consultant, currently being investigated for practicing illegally without a license)

      • Spamamander

        Oh ffs she’s from my area. Like we aren’t already the meth and gang capital of the Pacific Northwest, we so need this reputation too.

        • Bombshellrisa

          I thought the Highway 18 corridor was the meth capitol of the Northwest (that would be my area).

  • Meagan

    So… Do I have this right?

    About 4 million babies are born in the US each year.

    Our Perinatal mortality rate is 4/1000.

    Now I have to do actual math, so I might get lost.

    …approximately 16,000 babies die during the perinatal period. Can that be right?

    I’m assuming the homebirth rate in the US is negligible to that figure. So if every child in the US were born at home… With a death rate 3 times higher…

    an additional 32,000 babies would die.

    5x is an additional 64,000.

    Can someone tell me if I’m figuring something wrong here?

    • R T

      Perinatal includes 5 months before birth so I’m not sure you are using the right term? You have to take into consideration our death rate includes very premature babies who end up not surviving so it wouldn’t jump up that much if all full term babies were born at home. It would certainly go up if ALL babies were born at home since micro and moderate preemies would die at home! It’s sort of hard to say exactly how many more healthy, full term babies would die at home without more information than what we have! Hence, the interest in MANA’s stats! Everyone can speculate but at this point the biggest database in the US isn’t available to anyone outside of a select few in the NCB community!

      • AmyM

        True, but we can look to our history, and to the current stats in developing countries to get an idea. If women have no access to medical help, then they are essentially “home-birthing” and I wouldn’t be surprised if the rate of neonatal/perinatal and maternal mortality and morbidity is pretty constant in such places.

        I think most Americans start off with more privilege anyway, so as a group, even if all Americans gave birth at home, but most had some kind of prenatal care, and a reasonable diet (as in not starving and access to clean water), their chances of good outcomes may be higher than say, some African or Middle-Eastern countries. Even the homebirthers find out where the hospital is, and though some go there way too late for the baby, the mothers generally survive.

  • Courtney84

    I am reading the newest Jared Diamond book, The World Until Yesterday. He recounts another anthropologists experience with the Piraha tribe. they require the women to give birth unassisted on the beach because their culture highly values self reliance. The anthropologist, along with the tribe, listened to the woman cry out that the baby wouldn’t come, she was in pain, and after quite some time she started calling out that she was dying. When no one would go to her. The anthropologist started to head out to the beach, and the people called her back not allowing her to go to the woman. The anthropologist reports that the woman’s pleas for help grew more spaced, fainter, and then stopped. Intone morning the anthropologist went out to the beach and there the woman lied dead, her stomach swollen with her dead child.

    Other tribes are known to have their women practice unassisted birth, or birth with female attendants outside the camp, because the mother is expected to determine if the newborn is healthy and appropriately spaced from its next oldest sibling. If the mother determines the baby has a defect or is not healthy, isn’t spaced far enough from the next oldest sibling, or there are twins she is expected to kill the infant

    • Courtney84

      Don’t we all wish we could go back to a time when birth was so natural and peaceful?

      • Amazed

        No. Give me the noise and the raptors, I mean, doctors, in the hospital any day of the week and twice in Srnday.

        • Eddie

          Don’t forget about the machine that goes “bing!”

          • KarenJJ

            And drugs. Sweet drugs.

  • Dr Kitty

    OT 100 local people signed an open letter admitting either personally using illegal abortion pills or aiding others to obtain them, and basically challenging the prosecution service to come after them.

    This is in response to local politicians trying to shut down a private clinic offering non surgical abortions to women with LIFE THREATENING pregnancies.

    Meanwhile our health minister advises that pregnant women with mental health issues felt to be so severe that abortion may be warranted should be assessed by a consultant psychiatrist.

    The minister should be advised that I currently can’t get non pregnant actively suicidal or psychotic people assessed by a consultant psychiatrist, never mind one who doesn’t opt out on the basis of conscientious objection.

    I’m just so, so sick of this nonsense.

    No one should be forced to risk her life to carry a pregnancy against her wishes.

    http://www.guardian.co.uk/world/2013/mar/10/northern-irish-women-risk-jail-over-abortion-drug-use
    http://www.guardian.co.uk/world/2013/mar/12/northern-reland-debates-abortion

    • lacrima

      When I read “pregnant women with mental health issues felt to be so severe that abortion may be warranted should be assessed by a consultant psychiatrist”, I choked on my tea. The kid’s going to be matriculating by the time she gets in to see one.

      • Dr Kitty

        True dat!
        I can get an assessment within 24hrs for someone I’m really worried about by a “member of the unscheduled care team”- but that will be a psychiatric nurse, junior doctor or mental health social worker.

        We are far from the days when I can phone a friendly consultant or their secretary and have a patient added on to the end of the next day’s clinic list.

    • Sue

      Similar outrage from the anti-abortionists in Australia, Kitty – maintaining that women taking medical abortifacient out in an isolated community could bleed to death – not admitting that the risk of spontaneous miscarriage is the same. It’s a moral argument disguised as a safety one.

  • Lena

    The NGM has stated several times that she’s witness midwives lie about the results they give to MANA. If the numbers are so dismal when a significant number of midwives hide their bad outcomes, imagine how bad the real numbers must be.

    • Laura

      So, other than Barbara Herrera, the NGM, there must be other midwives who know about these gross malpractices and dangerous practices who are speaking out, no?

      • Practicing midwives almost never speak out. People have said that midwives have spoken to them in private.

        • Laura

          Surely the trauma of dead babies or horrendous outcomes would traumatize the integrity out of some midwives to speak up. But, it seems I’m wrong. I do admire Barb Herrera and her courage. I know she has taken a lot of abuse from her former midwife community for the stand she has taken.

      • Sue

        It’s time overdue for the professional and regulatory bodies for professionally trained midwives to speak out against the rogue practitioners. They reflect poorly on the entire profession.

        • KarenJJ

          “Power birthing” for example – can’t the midwifery body issue a warning against this practice? From what I can tell it’s extremely painful and can cause lasting problems.

          Don’t obgyn organisations issue statements on guidelines on practice? Do midwifery organisations do the same?

          • Sue

            Medical bodies do tend to issue guidelines and warnings, and generally make comment on community health care issues, more than nursing bodies do (I’m not sure why).

            I would love to see nursing academic and regulatory bodies take on the same roll. The message needs to get out: the rogues are creating bad press for the profession.

        • The Bofa on the Sofa

          It’s time overdue for the professional and regulatory bodies for professionally trained midwives to speak out against the rogue practitioners. They reflect poorly on the entire profession.

          But they ARE the “entire profession,” or at least a good sized chunk of it.

          I see midwives as a lot like chiropractors: if a defense of the profession consists of “they aren’t all crazy, there are some good ones” then there is a serious problem with that profession. It means that there are too many of the crazies, and the non-crazies don’t have enough power to swat away the crazies. When that is the case, it is the crazies who are in charge of the show. They are the show, and the sane ones are the sidebars.

          • Sue

            “But they ARE the “entire profession,” or at least a good sized chunk of it.”

            Not so much outside the US, BotS. IN Oz, HB is truly a fringe movement, involving MWs who are ex-hospital. Meanwhile, almost all (specialised nurse) MWs work happily in hospital L&D wards.

  • Aunti Po Dean

    some doctors are having a hard time getting their “research” on this topic published in peer-reviewed journals, they are presenting their data in settings that do not require peer-review

    Hilarious are the “trust birth”, breech birth conferences peer reviewed? Pot meet Kettle.

    • Sue

      (Pro Tip for Gordon: presenting at professional conferences is one of the methods of exposing your work to peer review.)

  • Aunti Po Dean

    “To return to the lightning analogy, it would be deeply disingenuous for a person to say that you shouldn’t move to a rural area simply because your risk of being struck by lightning is five times higher, without mentioning that at worst, that risk is five in a million. The ethics of this are further called into question when the person suggesting this is a trusted care provider, and is even worse when that person withholds all information about your option to move to a rural area — disregarding all of your other reasons for wanting to doing so — because they have decided that the risk of being hit by lightning there is too high for you.”

    She just doesn’t get it does she? What the ” trusted care provider” ie the CPM is doing is saying to the person wanting to move to a rural area ” go ahead and do it, it will be great” and at the same time not bothering to tell the person that there are any risks at all let alone 5 times the risk of death from lightning strike.

    • AllieFoyle

      And just how ethical (in this ridiculous, imagined scenario) is it for your trusted care provider to decide that you shouldn’t know about the increased risk of death in the first place?

      • Sue

        …and what’s the point of having that provider if they can;t give you expert advice?

    • LukesCook

      If being struck by lightning were the most serious risk attached to living in either a rural or urban area, and the respective benefits of each boiled down to a few minor differences in perceived comfort and convenience for at most a handful of days out of your entire life, then yes, I think the relative risks of being struck by lightning would weigh quite heavily in most people’s decision-making.

      • theNormalDistribution

        This, Alan. This.

        • You guys need to step back and get some perspective. “Most people’s decision making” *already* leans away from HB–in fact, that is a vast understatement. You on this blog act like HB poses a much higher risk to the lives of American children, both in relative and absolute terms, than it even comes close to doing.

          You’re discussing a parallel to lightning here. When there is a thunderstorm, I don’t let my kids go outside to watch it on the porch as many other families do. I don’t let them use or stand near the sink, or even go near a window. Most parents aren’t this cautious about lightning, but I don’t condemn them or insinuate that the caregivers of kids who tragically die from lightning strikes are tantamount to murderers.

          • KarenJJ

            “Most parents aren’t this cautious about lightning, but I don’t condemn them or insinuate that the caregivers of kids who tragically die from lightning strikes are tantamount to murderers.”

            What if someone was telling them that storms were beneficial and that a beautiful storm experience of standing them under a tall tree during a lightning strike meant that you would love them more?

            They’d be a bit gullible, yeah? If their kid was then killed by a lightning strike, you’d point out that it was a bit daft tethering the kid to the tree to start with? Or if not to them personally, to others that might think it was a good idea to tether their kids to tall trees during lightning storms. If they went on to say that sometimes people are killed by lightning that aren’t tied to tall trees, you’d try to figure out how to say ‘true, but it was probably not a great idea from the get go and highly likely what killed your kid in this case?

          • I think tethering them to tall trees is sliding into hyperbole; but there are definitely people who like to go out on the porch and watch lightning with the family. And of course there are many others who don’t bother to stay clear of windows, open doors, and sinks or tubs.

          • KarenJJ

            I was thinking along the lines of deliberately putting them into a more risky situation.

          • Homebirth isn’t the problem. NCB, and its completely insane ideology which has spread rather too widely into the mainstream is the problem.

            There will always be those who will opt for homebirth, whether from fear of hospitals or a mistaken assumption that having a baby is no big deal. For most sane people, the benefits – small – will be outweighed by the risks – devastatingly awful if your luck runs out. What NCB is doing is pretending there are no risks, and the vastly better outcomes that obstetrics (and interventions) have brought about lends a surface credibility to the lies they tell.

            In Nature, large numbers of women and babies die horrible deaths. Fit, healthy, low risk women. Looking at stats from as recently as the 1950s ought to make that obvious , or the figures from countries where obstetrics aren’t available – but who is looking? The myth of birth being beautiful, safe and empowering is just too appealing – why spoil it by getting real?

            Civilisation does bring in additional risks like driving, and quite a few others. With those though, you do not have some mad ideology playing the risks and their consequences down. People can weigh the risks and benefits rationally – as they could with childbirth if NCB stops going in the wrong directionfor reasons that have little to do with the welfare of women

          • You make some valid points in your first three paragraphs. I don’t agree with your last paragraph though. I think when you see statistics like the average–average!–American driving over a thousand miles per month just to commute to work, dovetailing with horrific levels of suburban sprawl coupled with a lack of sidewalks or public transit, that we are collectively the victims of a “mad ideology”.

            Getting back to birth, though, what I would like to see is more birth centers, more midwives like the one in the NPR story, and less of both the “classic” hospital birthing experience and also less of NCB madness like “power birthing” (shudder) that I just this morning learned about from a comment on this blog.

          • AllieFoyle

            You clearly have a passion for the problem of excessive driving in american culture. I think it might be a better use of your time to start your own dedicated forum and discuss it there rather than awkwardly trying to insert the issue into discussions where it’s just not germane.

            Also, birth centers that aren’t attached to hospitals aren’t really an improvement over HB in terms of access to resources in emergency. It’s just HB somewhere else.

          • Maybe you and Dr. Amy could debate that point:

            http://www.skepticalob.com/2013/01/new-birth-center-study-does-not-show-what-its-authors-claim-it-shows.html
            “The study found that birth in accredited birth centers was very safe”

            And I did not bring up driving in this thread so accusing me of awkwardly trying to insert it is just a bit off target. The comment I was directly responding to included the following, which was the first mention of driving in this thread:

            “Civilisation does bring in additional risks like driving, and quite a few others. With those though, you do not have some mad ideology playing the risks and their consequences down.”

          • R T

            The natural birth center he is referring to is inside the UCSD hospital. http://health.ucsd.edu/women/child/facilities/Pages/center.aspx

  • So they get no credit for releasing the data? If they were as 100% unethical as described, wouldn’t they have stonewalled this for eternity?

    I do think the risk is too high for my comfort level. But you still can’t dismiss the magnitude of absolute risk and focus only on relative risk. Going back to car trips again, because they have a good quantified relationship between miles driven and fatalities: if X = 3Y, then driving X miles with your kids in the car subjects them to three times as much risk of death as driving them Y miles. But we don’t freak out if someone drives their kids to the park they like better three miles from home instead of the perfectly acceptable one a mile away.

    Let’s say Average Alicia births in the hospital as average people tend to. She drives a minivan and puts about the average mileage on it per year of 13,000 miles and change. (We’ll assume that whatever mileage the minivan is being driven without kids in tow is made up for by the kids riding in other vehicles.). Crunchy Cassie prefers homebirths but also drives a minivan. She only drives it about 8,000 miles per year, though.

    Odds are strongly in favour of both Alicia’s and Cassie’s kids making it to age 18. All else equal, though, whose kids have the statistically *better* chance? Yup, Cassie’s. But where are the blogtivists trying to get parents to drive their kids around less? We did see one commenter here say something along those lines, but that is the only case I have ever seen–at least based on child safety, as opposed to the environment or something else.

    • Amy Tuteur, MD

      Alan, people might be more willing to listen to you if you’d bother to read the post before mouthing off about it. MANA hasn’t released their death rates. They are preparing for the time when they will be forced to release them.

      • “Forced” the way Nixon was forced to release his tapes, Saturday night massacre be damned? I did read your post, and that was not the interpretation I took from it. What agency, court, or administrative entity is doing the forcing? Is there a subpoena?

        And please: you, and most people here, would not listen to me if I were literally the Oracle at Delphi, LOL.

        • Anonomom

          >And please: you, and most people here, would not listen to me if I were literally the Oracle at Delphi, LOL.

          Why do you think that is?

          • Sullivan ThePoop

            Probably because everything he says is most likely 1/2 true at best and wholly ridiculous.

          • Certified Hamster Midwife

            I just don’t take anyone who ends sentences with “LOL” seriously at all.

          • Very snobbish of you, LOL. 😛

          • Certified Hamster Midwife

            ಠ_ಠ

          • KarenJJ

            Now that brings back memories.

          • Victoria

            WWED? What would Eyes do?

          • Unlike some others here, I don’t care to engage in speculative armchair psychoanalysis, sorry.

          • Sue

            No Alan, you seem to prefer speculative armchair obstetrics, infant feeding and parenting.

        • Amazed

          I, for one, stand behind the theory that the Oracle of Delphi was one seriously drugged lady (well, a score of ladies but still). So yes, I probably wouldn’t listen to you. You don’t want to be the Oracle of Delphi, Alan. And we don’t believe in oracles, anyway. Try with facts: they are trying to negate the results that are still to be released. Doesn’t take an oracle to conclude that there is something that they don’t like there, even when said results have been only submitted voluntarily.

          • And I said anything contradictory to that when? Easy to dismiss someone when you continually distort them into a crude strawman.

    • AllieFoyle

      Can you read or are your functions limited to extended, tedious bloviating?

      They *have not* released the data.

      • Then I guess It was premature of Dr. Amy to write:

        “So after years of lying about the increased risk of death at homebirth, the homebirth industry is finally acknowledging that what I’ve been writing about the death rates has been true all along.”

        Note the present tense. You can’t have it both ways; one good nitpick deserves another.

        • AllieFoyle

          Someone with your standardized test scores ought to have better reading comprehension. They are tacitly admitting that the death rate is higher and are attempting to change the conversation so that the focus is on something else, anything but death rates. They have not actually released those rates yet.

          • Sullivan ThePoop

            LOL! Standardized test scores? Please tell me you are kidding and he did not really share something so inconsequential to life.

          • Bombshellrisa

            Yes. No kidding. Apparently it was to help us to understand that he is capable of opining about the topics on the blog.

          • Durango

            Oh, STP, it was HI-larious. I did literally laugh out loud.

    • suchende

      Don’t worry, we city-dwelling parents are smug enough about not driving our kids around and all the other advantages we give our kids over suburban plebes. We don’t need a whole new blogging community to pat each other on the back over it.

    • MLE

      Nevermind that they didn’t release the data – when they DO release it, they will get just as much credit as the murderer who admitted it.

    • Sue

      Alan – I’m not sure that it’s worth replying, because you seem to have a contrary view on almost everything. But, anyway:
      1. This is an OB’s blog about obstetrics. Somebody else who is a road safety expert can do a blog on road safety; and
      2. Although there are cumulative statistics that make up the road toll, the deaths INCLUDE the people drink driving, not wearing restraints, driving drugged or unlicensed. If someone chooses to do one of these things, then they are culpable. The additional risk of driving to the park while driving safety, all wearing restraints, is negligible.

      • And you don’t think there are widely varying factors in homebirth that get lumped together in that one number? No difference in the risks women are willing to take, no difference between midwives in terms of competence and prudence? I accept that even with the most competent, prudent midwife, homebirth will be riskier than hospital or birth center birth. But the disparity will not be nearly as great.

        I also think you are neglecting the fact that when you pack the kids in the minivan and head for the park across town instead of the one nearby, you are increasing that relative risk regardless of how careful you are, just because you share the road with others who may be drunk, or texting, or whatever.

        BTW, a suggestion: if you don’t think it’s worth replying to me, just don’t, and leave it at that. The have-it-both-ways “you’re not worth responding to, but…” routine is lame.

        • Sue

          AGAIN, Alan – READ before you speak.

          The 3X figure for first-timers comes from the UK Birthplace Study, with standardised health service midwives and tight risking out and 40% transfer. You are wrong, again.

          • Maybe take your own advice. There was nothing about “3X” in the comment you responded to.

          • Eddie

            Question: What does a 40% transfer mean? Does that really mean that 4 in 10 of those deliveries started at home but ultimately occurred in the hospital?

          • Becky05

            Yes. The Birthplace study looked at intended place of birth at the beginning of labor. 36-45% of first time mothers were transferred to the hospital during labor or after delivery. Even then, they had a higher adverse outcome rate than first time mothers in the hospital. http://www.bmj.com/content/343/bmj.d7400

          • Eddie

            Thanks for linking to the study. Wow, they consider even an epidural to be an “intervention” and then proudly report that interventions are so much lower at HB. With that definition, no duh! The average person who only reads the results will think an “intervention” must be a bad thing.

            For those in the know … is it normal in medical literature to report an epidural as an “intervention,” or is that an effort to conflate pain relief with actual interventions like a C-Section? In other words, is this study being deliberately misleading in that respect, or is this the normal way these statistics are reported?

          • Becky05

            I’ve seen other examples of listing an epidural as an intervention, or of studies considering lowering the rate of epidurals to be a good thing, but many of those were by authors with a pro-natural childbirth bias.

        • Sue

          “you’re not worth responding to, but…” routine is lame.

          I know it serves no purpose for you, but it’s useful for other readers to see the errors in your argument. But thanks for the advice. Much appreciated.

          • If it’s useful for other readers, yadda yadda, then it IS worth responding to. You remind me of the classic scene in the movie Fargo when Steve Buscemi is irritated at how taciturn his travelling companion is, and petulantly declares:

            “Oh, fuck it, I don’t have to talk, either, man! See how you like it.”
            [they sit in silence for a few seconds]
            “Just total fuckin’ silence. Two can play at that game, smart guy. We’ll just see how you like it.”
            [a few more silent seconds pass]
            “Total silence.”

            L-O-fucking-L.

    • T.

      I reiterate my belief you have a lot of free time on you hands.
      Care to try a hobby?

      • Already have several, thanks all the same.

  • Squillo

    I find it utterly astounding that Gordon can write with a straight face:

    The MANA Stats web-based system was touted by attendees as the best data collection system for home birth outcomes.

    And:

    We believe that there is potential for there to be more movement in the next 30 years than there was since the last IOM workshop on this topic 30 years ago, particularly because of the availability of high-quality datasets such as MANA Stats (primarily planned home births) and the American Association of Birth Centers’ Uniform Data Set (primarily planned birth center births). As the stewards of the largest database on midwifery care and outcomes of normal physiologic birth in the home setting, the DOR encourages researchers to apply for the MANA Stats data to conduct this important research (application information at mana.org/DOR).

    Availability? [Cue sound of birds chirping.] There has yet to be a single paper published using the data they’ve been making “available” for how many years now?

    Anyone else wonder why they didn’t present their robust data at the same conference at which Gordon excoriates Chervenak for using “back-of-the-envelope” stats?

  • Squillo

    A few months ago, MANA was crowing on its Twitter feed that they were about to publish their “benchmarking data” (and were very careful to repeat that phrase) in a peer-reviewed article that would show “results similar to CPM 2000 data.” I wonder if Gordon’s quick-step is related to the putative article.

  • No one has commented on that slide yet…

    Some People Say that midwives don’t accurately assess or record Apgar scores, but this is the first time I’ve seen it in numbers.

    In the hospital, about 4% of babies are given a perfect, 10 out of 10 Apgar.
    At home, over 40% of babies are given the same score. That’s a ten fold increase. It’s stunning.

    The total number of 9 and 10 point Apgar scores is similar at about 90% for hospital babies and about 96% for home birthed babies.

    Pity it doesn’t include all Apgars, including the 1 and 5 minute scores.

    My son had scores of 1 and 8 for the 1 and 5 minute. Born almost completely flat, was successfully resuscitated. All thanks to the right people, the right training and the right equipment.

    I’d like to see the average CPM come close to that.

    • PoopDoc

      I’ve never attended a birth with an honest to god Apgar of 10… My brother got one, but it was a joke. The pediatrician in attendance was one of my dad’s old army buddies.

      • Sullivan ThePoop

        They gave my oldest daughter a 10 and my youngest a 9+, whatever that means. Although it must be kind of arbitrary because my son was given a 6 at 1 minute and a 9 at 5 minutes because he wasn’t breathing, but he was never completely blue. My nephew was given a 7 at 1 minute and he was completely blue then at 5 minutes he was still given a 7 but was no longer blue. My nephew was admitted to the NICU for a couple of days, my son wasn’t. His parents could have gotten the 1 minute wrong though.

      • CSM

        Ha, I’ve never seen a 10 either. It’s usually the color that’s always off.

        • Disgusted

          They didn’t tell me what my son’s was, but he had white extremities (pinkish face), yelled once then was quiet – although he did squirm and kick a lot while they were taking his footprints. NICU was in the room to be sure everything was okay. He has to go into the incubator for a while before I held him – I think we were having failing placenta issues (2 weeks post date, pre-eclampsia, late decels the last few minutes of second stage). But then he was perfectly healthy. He’s a perfectly healthy 17 year old today. Anyway I guess that score would have been – what? 5? 6?

    • Aussiedoc

      I’ve given one 10 at one minute in my entire career. It was a caesar for severe maternal pneumonia, bub came out screaming the place down and about 40 degrees and this astonishing shade of pink. Poor thing was absolutely scalding!

      Other than that I never have. Colour usually isn’t quite right.

      • KarenJJ

        Does that mean there’s such a thing as ‘too pink’?

        • Aussiedoc

          It means there’s a limitation to the APGAR score. Somebody resuscitating properly shouldn’t be thinking in those terms anyway. APGARs are assigned in retrospect to consider long term outcomes.

          So, yes, this baby was a 10. Still ended up needing resp support at ten minutes.

    • Sue

      AFAIK, it’s not the CPM babies that are different, it’s that the minutes are much longer…

    • KarenJJ

      Either:

      1. Babies born at home are amazingly alert and healthy.

      2. All babies look pink and glowing by candlelight.

      3. These midwives don’t know how to assess AGPARS.

      It certainly casts doubts on homebirth advocates claiming that their babies had great AGPAR scores.

      • Renee Martin

        Based on all the HB pics they post, the MWs are simply clueless. I have never seen so many blue, gray, limo, lifeless babies as “Happy, successful, empowered HB!” babes.

      • The Computer Ate My Nym

        I’d say the baby in the picture shown in the linked article was an 8 at best based on skin tone. The poor thing was gray/blue all over. Maybe some pick blotches, but certainly not body completely pink.

    • Mrs. W

      I’ve come to the conclusion my daughter’s APGARS are likely wrong – she wasn’t breathing at all for the first minute (so not crying), needed NARCAN and resuscitation and was given a 7 for the 1 minute APGAR and a 10 for the 5 minute APGAR…..cord gases were 7.0.

      • Out of curiosity, I did a quick superficial read on Virginia Apgar. It became obvious to me that her researches stemmed from seeing a LOT of babies born in poor condition. Her system was meant to be a way of figuring out which resuscitation techniques were rapidly effective, and which not. Needless to say, her method met with opposition – but it does seem that like present company, she was motivated by trying to identify and alleviate problems – not invent a gold star system for aspiring birth goddesses. She was one of those heroic people who put a lot of effort, mid 20th century, into improving things enormously for mothers and babies – with the rather unfortunate unintended result that 21st century mothers can assume birth is now safe and foolproof.

        It took ten minutes for my first daughter to make it to 7 – starting from one. She’d pinked up by then – with a lot of help; muscle tone was awful, breathing wasn’t great. She’d certainly get full marks for screaming! But really, those 10s are about as reliable as the NCB version of “low risk”.

    • Susan

      One ten in twenty years here too. There wasn’t a shade of blue on the baby. It was odd.

      • ersmom

        1 perfect 10 in 10 years as an OB here…with about 1500 deliveries under my belt. That’s like 125 CNM years! 😉

        • Sue

          or about a millennium in LM/CPM years

    • ‘Nother Lawyer

      This was my very first thought. There is no way CPMs have seen enough births to be able to accurately assess.

  • CarolynTheRed

    Maybe I’m dim, but I don’t get the high Apgar distribution slide. Can someone explain?

    • True 5 minute Apgar scores of 10 are rare. The slide shows an apparent and huge bias for home birth attendants. Or lying. It’s difficult to say which it is.

      I think it may be scored this way for HBs: “Any obvious problems? No? It’s a ten.”.

      The usual point off is for color – the hands and feet are often pale due to poor perfusion.

      • Bombshellrisa

        Now think of all the pics and videos of the waterbirth babies. Even Rixa Freeze’s baby, not crying, not moving, not breathing and pale. How many of those bluish babies are given a 10?

        • Remember it’s the 5 minute score.

          Immediately after birth, you are looking at the 1 minute score. A lot can happen in a few minutes.

          • Aunti Po Dean

            Yes but I think the point is that if we know that the mortality rate is higher it stands to reason that the morbidity rate (need for resus) is higher too. So if the Apgar is 10 so much more often at home than hospital then either the midwife is lying, doesn’t know how to score an Apgar (distinct possibility too) or the very fact that you are born at home gives you a perfect Apgar cos we all know that homebirthed babies are born peacefully and without problems most of the time.

          • Amazed

            Hey, blue-grey is a natural colour! A full 11 out of 10! Dolhpins are blue-gray. Waterbirth, remember? Elephants are grey. Ina May and her lauded analogy? Anyone coming with more gray analogies? It’s so natural. Pity they can’t actually put a full 11, so they have to go for 10.

          • Amazed

            Blue, blue, my world is blue… you know who the performer was? I can’t remember. Anyway, that might be an appropriate refrain for many homebirth mothers who claim that their children are their world.

          • Victoria

            Eiffel 65? We’d need a morose emo version of it though for the homebirth crowd. Peppy Eurodance and blue babies is very incongruous.

          • Amazed

            Very incongruous, indeed. THe more I think about it, the more I think it’s a perfect fit. Red, red, my eyes are red… Scary.

          • ersmom

            Damn you, for now I have an earworm!

          • anonymous

            Dolphins are blue-grey–lol!

          • Amazed

            Aren’t they? Well, they look blue-grey to me. But that’s okay. They are dolphins. A perfect APGAR score for colour. When babies receive said score for being blue-greyish, though, I get worried.

      • Sue

        You guys just don’t get it! The Lay MWs’ APGAR (APpropriate Guess At Result) goes up to eleventy!

        • Guestll

          *dead*

    • Gene

      Out of the hundreds of deliveries I’ve attended, I don’t think I’ve awarded more than a scant handful of 10s at five minutes (and none at 1 minute). The vast vast vast majority of pink screaming healthy newborns still have a bluish tinge to their feet and hands. One off for color is a nine.

      • Sullivan ThePoop

        Both of my daughters were completely pink and everyone in the room commented on it both times, not to mention with my youngest people that were not there at the time but took care of me later also made comments about that and how she gave a dirty look to whoever gave her the heel prick, but didn’t cry.

  • Mrs. W

    I think part of the answer is that it has to be more expensive to lie about your product and it’s safety than to tell the truth about it. In short – I think when it comes to products aimed at women’s health (or anyone’s health) there should be an obligation to not only collect information on the safety and efficacy of the product, but to publicly report that information and demonstrate that the relevant information has been disclosed to the patient making the choice. The tobacco industry is regulated. The alcohol industry is regulated. The pharmaceutical industry is regulated. So why is homebirth and alternative medicine allowed to just run wild maiming and killing people who are thinking they are buying one thing but getting an entirely different thing? Government needs to step up to the plate and give women and their babies the same protection that they give users of tobacco products, alcohol products and pharmaceutical products – government needs to protect the right of the consumer to be informed about the product they are buying, particularly when that product might have adverse health consequences for either themselves or their children.

    • AllieFoyle

      Couldn’t agree more. Absurd that there aren’t more consumer protections in place. It’s an issue of health and disability; life and death.

  • PrecipMom

    So, MANA, what you’re willing to say is that the extra babies per thousand who die because they were born too far from medical care don’t matter. You’re willing to egg women on because the odds are low on an absolute level even though you *know* there will be more women with empty arms because those mothers trusted you. But that extra baby and his or her mother doesn’t matter to you. Thanks for the honesty at least!

    Well, that extra baby or two per thousand matters to me. And it matters to more home birth mothers than you realize. Thank you for the clarity of telling us that if our babies die it’s a tolerable risk to you for *what* benefit exactly?

    • Squillo

      In other words, “Don’t worry your pretty little heads about a few more dead babies.”

    • mollyb

      Exactly. But the dangers of formula–no matter how slight or, you know, “made up” DOES matter.

    • Certified Hamster Midwife

      To be honest, it reminds me a little bit of car manufacturers continuing to manufacture vehicles with known defects instead of changing the design in production and recalling those already sold because it was cheaper to pay out wrongful death lawsuits than to halt production and change the car.

      It’s not a perfect analogy. The cost for birth attendants, who do spend a lot more time with their clients than most doctors and get to know them better, is largely emotional. But maybe it’s easier to grieve a lost baby once or twice in your career than it is to admit that entire career is wrong, that you were wrong, that your wrong beliefs have harmed your clients.

  • Renee Martin

    And to think, MANA stats are voluntary, but they still couldn’t keep a lid on the death. Imagine had they been required to report, and actually checked for accuracy. I look at their “data” like “believe half of what you see, none of what you hear”. Reading former CPMs, and former CPM apprentice, blogs really showed me how much they lie. (grey baby that doesn’t cry? Apgar 9!)

    Can’t wait until Oregon HB data hits the public. I know its being collected, they changed their birth certificates last year. Sadly, those stats will leave out a significant amount of deaths, as intrapartum deaths at home, and stillbirth due to poor care, don’t get birth certs. Babies like Shahzad wouldn’t have been added in the number. MWs once again get a pass for being extra negligent- bad enough to kill before baby even comes out.

    • anonomom

      Will it count planned homebirths that result in an emergency transfer to the hospital that ends in a bad outcome due to the delay in treatment?

      • Jessica

        When you fill out a birth certificate in Oregon, you are asked whether the birth was a planned homebirth. DHS should have a better sense of how many babies born in a hospital ended up there as a result of a transfer. I don’t recall whether the form asks for details surrounding a transfer, as I had not planned a homebirth so I moved on to the next question.

      • Renee Martin

        Yes, this is it’s strength- no longer will HB transfers be counted in hospital stats.
        If there was a way to track the intrapartum deaths (baby is alive, then dies during labor), and the stillbirths from poor care (ie: 42weeks, baby dies before labor starts) , then it would be helpful. AFAIK, this isn’t happening.

        • Dr Kitty

          So, easy fix, you need a spot on the death certificate and stillbirth certificate for “had you planned a homebirth”.

  • moto_librarian

    The relative risks of homebirth don’t seem too high until you end up on the wrong side of the statistic. It amazes me that HB advocates are so callous about the deaths of much-wanted children. This attitude further demonstrates just how unprofessional many CPMs and DEMs really are. Rather than attempting to tighten up their educational and clinical requirements and implementing a process that would weed out bad midwives, they simply write off these babies as the cost of doing business. It is disgusting. The only acceptable credential for midwifery is the CNM, period. These other credentials are simply a pale imitation, and the sooner that they are abolished, the better off all birthing women and their children will be.

    • The Bofa on the Sofa

      The relative risks of homebirth don’t seem too high until you end up on the wrong side of the statistic.

      The problem is the characterization of the absolute risk as “low.” In what respect is a 4/1000 mortality rate considered low? It’s low compared to having a heart attack (160/1000), but compared to anything that we do in our lives, that number is HUMUNGUS! Even if it is 4/10000, it is very large compared to our every day activities. For example, the chance of a drunk driver dying in a car accident is something like 2/million (for every million times someone drives drunk, 2 people die). The same death rates apply to skydiving and scubadiving, two activities that are generally considered high risk.

      Here is one that I have always been trying to figure out (and don’t have time today). What is riskier? Childbirth? Or running a race in NASCAR?

      Some preliminary info: 24 official “nascar” drivers have been killed in the history of the sport. This includes major and minor circuits.

      Now for races: I haven’t had too much time to look, but it looks like there has been something like 10 000 NASCAR races that have been run. Currently, NASCAR runs 43 drivers in each, but I don’t know if that has always been the case in all series in history. Let’s say the average is 35 drivers. As such, the death rate would be 24/350 000, or 7/100 000.

      Recall that maternal death rates in the US are about 11/100K.

      In other words, having a child is about as dangerous as driving a race in NASCAR.

      Now that’s historical, including times when safety standards were not in place, and NASCAR is a lot safer now.

      It really appears to be that being born is the most dangerous thing you ever do in your life, and giving birth is the second.

      But these are “low absolute risks” right?

      • auntbea

        I like these stats, Bofa. Post some more!

        • Sue

          (I want to know both relative and absolute risk of driving under the influence of heroin while covering one eye and texting.)

          • auntbea

            I would like to see those texts.

          • Eddie

            Isn’t that where the texts from “texts from last night” come from?

      • Eddie

        What a *fantastic* analysis! And every time there is a death in NASCAR, they look at what needs to change to make it safer. They don’t just shrug and say, “Well, it’s an inherently dangerous sport.” Unlike *some* of the hard core home birth advocates.

        • Bombshellrisa

          Or even worse say ” some drivers aren’t meant to live”.

        • Sue

          Well said, Eddie. Medicine is always working to minimise errors and improve outcomes, whereas lay midwifery (and most “alternative” therapists) think their practice is just perfect and always will be. They defy the normal human desire to keep improving.

    • Certified Hamster Midwife

      See my comment above about the Ford Pinto.

      I love the Ford Pinto trope.

  • quadrophenic

    Isn’t relative risk precisely what women need to know when deciding where to give birth? If I’m shopping for say a carseat, and I’m comparing safety studies (not that information is presented this way for carseats) and I find out that carseat A is associated with 3 times more deaths or serious injuries than carseat B, that information is much more useful to me than a stay like 1 in 10,000 children die or are seriously injured in carseat B. Because I don’t have a choice about whether or not I have to occasionally drive somewhere and use a carseat, but I do have a choice as to which carseat to use.

    Basically, once you get pregnant and decide to keep the child, you don’t have a choice whether to give birth or not. So absolute risk goes out the window – you’re going to give birth somewhere and you’ve got to determine what is the safest option. I suppose if you were questioning whether or not you should get pregnant at all then absolute risk may be an issue.

    • The Bofa on the Sofa

      Remember, the “absolute risk is too small to worry about” argument is just as much a justification for drunk driving as it is for HB (moreso, actually, since driving drunk has an absolute risk of death that is 50 times less than that of the MOTHER dying in childbirth, and the risk of just getting in a drunk driving accident is 30 – 40 times less than the CHILD dying in birth).

    • Eddie

      It’s not true that you must choose the absolutely safest option. What if you choose a hospital that is convenient for you — or that is covered by your insurance — only to find out that a different hospital has half the death rate? Does that make you a bad mother? No. The absolute risk matters as well. Fully informed consent in these situations requires explanation of absolute as well as relative risk.

      If relative risk is so important that no-one should ever be able to choose HB, then no woman should get an epidural or have an elective CS either, because it increases her relative risk. Which is obviously a decision I don’t agree with!

      Again, relative AND absolute risk are both important. Any discussion that only focuses on one of the two is not telling the whole truth.

      • LukesCook

        Risks, relative or absolute, must also be weighed against benefits. It’s irrational to accept a higher risk for little or no benefit.

        An elective CS, for example, may increase some risks but also increases others. As was pointed out in the comments to the recent post on c-sections, it is entirely rational to accept a small increase in maternal morbidity (especially of a transient nature, like a blood transfusion) in exchange for a decrease in the risk of the baby dying or being permanently disabled.

        • Eddie

          Absolutely. Maybe I wasn’t clear enough. What I was saying is that I do NOT agree with the idea that NO woman should get an epidural or elective CS. That is, the decision should be between a woman, her family, and her doctor. Those are the people best positioned to know the risk/reward.

          My wife *loved* the epidural and the pain relief it brought during the birth of our youngest. I’ve known more than one family who chose an elective CS, for quite a variety of reasons, some medical (huge baby, small mother) and some not (wanting a positive horoscope for the baby, and thus picking a specific day of birth). I didn’t judge any of them.

        • thepragmatist

          And furthermore, MRCS in essence eliminates the risk of emergency c-section in labour, which is a riskier mode of birth for both mother and baby. The riskiest, statistically, in terms of maternal morbidity/mortality. The 10-20% chance of emergency surgery during labour and delivery was another big reason I had a MRCS. The risk of MRCS vs planned vaginal delivery in women who have 2 or less children as far as I can see is LESS for everyone involved, if you account for the fact that emergency c-section should be a risk of planned vaginal birth, statistically. At the least, a wash. Provided we’re talking about women choosing to have a small number of children. I would not have chosen to have MRCS if I wanted more than two. And in time, as technology gets more advanced, those accruing risks in each additional pregnancy/surgery may be mitigated, too.

  • Amy Tuteur, MD

    A special PS for homebirth advocates: I told you so!

  • theadequatemother

    Once again the NCB and homebirth advocates demonstrate the double standard they have for evidence – based on confirmation bias.

    If the study supports what they already believe it’s a great study.

    If the study doesn’t support what they already believe, it’s a deeply flawed study that no one should pay attention to.

    • Amy Tuteur, MD

      For people like Wendy Gordon, Melissa Cheyney and Marian MacDorman, it’s not confirmation bias. It’s a deliberate attempt to take away women’s right to informed consent by hiding and misrepresenting the scientific evidence.that is required for informed consent.

      • AllieFoyle

        Right. At what point do their arguments cross the line from fuzzy statistics into deliberate obfuscation of important information? And isn’t it, well, paternalistic of them to suggest that women not concern themselves with silly old things like death rates?

        • Amy Tuteur, MD

          They crossed the line 5 years ago and have been crossing it on a daily basis ever since. They’ve displayed “conscienceness of guilt” about what they have been doing, by publicly denying that they are hiding high homebirth death rates.

          They’ve hidden the deaths rates precisely because they understood that many women would never choose homebirth if they knew that MANA’s own data showed that the death rates were higher. They further understood that their income would be compromised by the knowledge and they valued their income above the lives of other women’s babies.

          CPMs are not and have never been midwives. They are “birth junkie” hobbyists who refuse to accept any standards, and refuse to accept the consequences of their actions.

          They remind me of the folks at Ford who promoted the Pinto even after learning that it exploded when subjected to a minor rear end accident. The Ford executives made the deliberate decision that it was “less costly” to let people die than to redesign the car. At MANA, it is “less costly” for them to let babies die than to insist on standards and accountability.

          • Ibanezsrx

            The Pinto case is even more disgusting with more details. I’ve seen this used as a case study a couple times in the MBA. Not only did the executives decide the value of a human life, but Ford’s engineers developed a rubber bladder that would prevent fuel leakage in the event that the gas tank ruptures in a collision it was rejected. I believe that this fix would have cost roughly $7 but the company decided on absolute sales price and profit margin for the project. They would neither absorb the $7/car cost or pass it along to the consumer.

            There are predictable outcomes when you put ideology over reality.

          • Eddie

            I could be wrong, but I believe the *part* cost was around $7. The labor costs and other costs would have been much higher. And of course some value has to be put on human life. Otherwise no product would be safe enough to sell. The problem is not when a company puts a price on human life. It’s when the price is set too low.

          • KaernJJ

            It’s a price that has been climbing higher and higher. I’ve worked in a dangerous industry (underground mining) and the insurance premiums are incredibly high (millions of dollars a year ten years ago). Insurance premiums could be reduced if the company qualified under ‘super safe’ guidelines (walkways were colour coded, hot taps given a cautionary label, LTI tracked, mandatory PPE etc etc).

            If CPMs were required to have malpractice insurance, they would either quickly conform to safer guidelines or go out of business.

          • Sue

            Every industry except non-science-based health care seems to work towards improving standards and minimising risk. Smart people naturally want to do better.

          • KarenJJ

            And yet saying this is ‘meen’.

          • Certified Hamster Midwife

            I made the Pinto comparison before I even scrolled down to this comment. Gosh, I thought I was so clever.