Homebirth increases the risk of a 5 minute Apgar score of zero by nearly 1000%

ECG Electrocardiogram

Two new papers shed light on the appalling outcomes at American homebirth.

The first paper is Apgar Score of Zero at Five Minutes and Neonatal Seizures or Serious Neurologic Dysfunction in Relation to Birth Setting by Grunebaum et al.

The authors used CDC data to assess birth outcomes:

Data from the United States Centers for Disease Control’s National Center for Health Statistics birth certificate data files were used to assess deliveries by physicians and midwives in and out of the hospital for the 4-year period from 2007-2010 for singleton term births (≥37 weeks gestation) and ≥2,500 grams. Five-minute Apgar scores of zero and neonatal seizures or serious neurologic dysfunction were analyzed for four groups by birth setting and birth attendant (hospital physician, hospital midwife, free-standing birth center midwife, and home midwife).

They found:

Home births (RR 10.55) and births in free-standing birth centers (RR 3.56) attended by midwives had a significantly higher risk of a 5-minute Apgar score of zero (p<.0001) than hospital births attended by physicians or midwives. Home births (RR 3.80) and births in free-standing birth centers attended by midwives (RR 1.88) had a significantly higher risk of neonatal seizures or serious neurologic dysfunction (p<.0001) than hospital births attended by physicians or midwives. (my emphasis)

In other words, homebirth increases the risk of an Apgar score of zero by nearly 1000%!!

5 minute Apgar score of zero

As the authors explain:

There is an identifiable pattern in these data for the outcomes of singleton term births: home birth is associated with a significantly increased risk of 5-minute Apgar score of 0 and neonatal seizures or serious neurologic dysfunction compared to hospital birth. When it comes to home birth versus hospital birth, setting is strongly associated with worse outcomes. The increased rate of adverse outcomes of home births exists despite the reported lower risk profile of home birth.13 The pattern for free-standing birth centers is also identifiable: this setting is associated with increased risk compared to hospital delivery, though not as high risk as home birth. When it comes to freestanding birth center versus hospital, setting is strongly associated with worse outcomes.

It is essential to note that these significantly increased risks of adverse outcomes from the setting of home and from the setting of free-standing birth centers reported here may be serious underestimations of clinical complications. (my emphasis)

The choice of an Apgar score of zero and the primary outcome measurement is particularly apt, since severe neurologic injury is particularly likely at homebirth, because homebirth midwives do not monitor the fetal heart rate appropriately. Hence the inordinate number of babies who drop dead or nearly dead into the hands of clueless homebirth midwives. Babies with a 5 minute Apgar score of zero include those that died intrapartum, but also those that were born without vital signs who were subsequently resuscitated by emergency personnel.

Interestingly the authors chose to use the MD group as the reference group despite the fact that it contains high risk women. I typically use the hospital based midwife as a reference since their are fewer high risk patients. Using that standard, homebirth has a risk of 5 minute Apgar score of zero that is 19X higher than low risk hospital birth!

The authors point out that all practitioner are REQUIRED to disclose this information to women contemplating homebirth, midwives as well as obstetricians.

The second paper is Selected perinatal outcomes associated with planned home births in the United States by Cheng et al.

The authors looked at birth outcomes from the year 2008.

There were 2,081,753 births meeting study criteria. Of these, 12,039 (0.58%) were planned home births. More planned home births had 5-minute Apgar score <4 (0.37%) compared to hospital births (0.24%; aOR 1.87; 95% CI 1.36-2.58) and neonatal seizure (0.06% vs. 0.02% respectively; aOR 3.08; 95% CI 1.44-6.58). Women with planned home birth had fewer interventions, including operative vaginal delivery, and labor induction/augmentation.

This is precisely what you would expect when mothers and midwives shun lifesaving interventions.

I’ve used the CDC Wonder data from 2003-2008 to demonstrate that in each year, planned homebirth with a homebirth midwives has a neonatal death rate anywhere from 3-7X higher than hospital birth. These new papers add valuable information by looking at severe neurologic outcomes as well and showing that such outcomes are much more common at planned homebirth.

I look forward to seeing how Henci Goer, Ina May Gaskin, Jennifer Block and other professional homebirth advocates attempt explain these statistics away. I’m guessing that they will be at a loss, and therefore simply ignore these hideous results.

  • open minded

    Here is one response by the home birth community and I am sure if I made any effort I would find more. Don’t be so closed minded to think they would not have any response. http://www.mana.org/blog/0/understanding-outliers-in-home-birth-research

    • KarenJJ

      Dr Amy recently discussed this article on the MANA blog.

      http://www.skepticalob.com/2013/09/the-new-mana-blog-the-gift-that-keeps-on-giving.html

      What makes you think people here are close minded as opposed to yourself?

    • Squillo

      While you’re questioning Amy’s closed-mindedness, you might ask MANA why they won’t publish any more comments on their post.

      • Amy Tuteur, MD

        It took MANA less than a full day to realize that no one was going to fall for their crap if allowed to read legitimate criticism. Therefore, instead of correcting the mistruths, half truths and outright lies that Wendy Gordon posted, they suppressed the comments.

        They KNOW their argument fatally compromised, but they will do whatever it takes to get their followers to believe it.

  • PrecipMom

    I’ve read the full study, and it’s not clear to me that breech presentation is excluded. I would be very interested to know if breech is there, and if so what proportion of these outcomes are from breech births.

  • Nunua

    To top all of this off, if your baby suffers an injury due to a homebirth gone wrong, your midwife likely has no malpractice insurance leaving you with a lifetime of crippling medical bills.

  • ratiomom

    The one thing I don`t understand about this midwifery mess is the position of the CNM`s professional organisations. What in the world is their motivation to keep associating with the CPM`s? CNM`s have invested a lot of money and effort in obtaining a real degree. Why do they encourage the public to perceive them as identical to a bunch of uneducated clowns? They have nothing to gain and their professional reputation to lose. Could one of the CNM`s on here enlighten me?

  • Deena Chamlee

    If the CM AMCB credential midwife was available in all fifty states and OOH births were attended by CNM or CM the data would be much different.

    When MANA created the CPM credential in the early 80’s they knew darn well it would confuse the public with the CNM credential. And when NARM set their standards so low not even requiring a high school education until 2012 it appears to me they were not concerned with outcomes.

    It appears they were concerned producing as quickly as possible as many CPMs and with taking over the midwifery homebirth market. And now since we have not confronted the issue, the issue has spread throughout America. The carnage that has resulted is absolutely devastating.

    How does one stop it? That is the question that all of us need to be asking ourselves.

    • Lisa from NY

      My friend had an HB with a CNM. Even so, she lost so much blood she went into shock and almost died before she made it to the hospital.

      Not a single CNM has bags of donor blood on hand, and a PPH can happen without warning.

      • Renee

        Had she used a CPM she would be dead.

      • theadequatemother

        wasn’t she the 50 yo having the HBAC? Shouldn’t she have been risked out in the first place?

    • Renee

      First- Push to get the CM legal in all states, which shouldn’t be too hard if you all want to do it. Do this while still collaborating with CPMs.

      Then make a push for CNM/CM as the minimum standard for MWs, and lobby insurers and Medicaid to only pay for CNM/CMs.

      During a set period of time, you could offer a CM by case review, and exam and practical skills test, to qualified CPM/LDEM/unlicensed MWs. This would keep out killers. You could offer scholarships and free classes and educational credits for those who cannot pass, and help them get their CM. Putting a hand out to help all those that want to improve will be vital to getting less push back from CPMs. You will see who is lazy and unwilling to learn from doing this. This will also need to have funding behind it, which could be done through fees or federal monies.

      Then, make it known that only CNM/CM are MWs, whether with press releases, or legal actions, both, or other. Doesn’t matter how. They need to be differentiated. Let the others call themselves TBAs, whatever. I personally don’t care what the others want to call themselves, so long as it is NOT MW.

      I would also require all HB MWs to have malpractice, and this can be done by creating a buying co-op to help cut fees. It is not too costly right now (4-5k a year for a CA licensed CPM), so its more a matter of needing to have it. This will keep out hobbyists that only do a few births a year. If there are good MWs that cannot afford it, for whatever reason, you can offer scholarships to them, or fundraise for them. I figure if MWs that KILL can get 10-30k, people can raise money to pay the equivilent in insurance costs for select MWs.

      • Deena Chamlee

        Its not that easy. CM is a graduate degree and they do not think like us. Many do high risk obstetrics OOH and refuse to practice any other way. We were educated and trained in two totally different belief systems.

        • Renee

          I know the difference in philosophy, and agree it won’t be easy. Honestly, I think the philosophy IS *THE* problem! You must take a stand against non-evidenced based practices. (I know YOU are!) Once you get to what actually works, there is not a whole lot of variation.

          I do think there WILL be those who refuse to come along, and refuse to stop doing breech, VBAC, etc. Those ones CAN, and should, be marginalized by a strong group of certified professionals. They can also be made less dangerous by taking away their titles of MW and their insurance and Medicaid pay outs, which can happen if you make CM the standard.
          Just think of other professions that do not allow such things.

          FOr an example- I am in solar, and other than non specific, electrical/plumbing standards, there were NO national standards for solar electric OR hot water installers when I started 10 years ago. The states, and each city (!) had their own patchwork rules (if any), which was a MESS. Many of us saw very dangerous PV installations, but could do nothing to stop the installers. We worried there would be electrical fires and deaths, since the industry was booming and new businesses were starting all the time. Luckily, we could go to city fire/ building/ electrical inspectors for help, which fixed individual systems, but left the dangerous installers intact.

          Seeing the need for qualified workers in this boom industry, a group stepped in about 8 years ago and created national certifications, standards, and rules, which at first, pissed SO MANY people off! Tests, number of hours, and proof of work, were required in order to be certified, which quickly became a standard buyers and investors wanted to have. Holy crap were people mad! My boss, a 20 yr veteran, failed her first test, and I was appalled! We hated this standard and railed against it, as did many veteran contractors. It split the industry. The group were called opportunists, told “who the hell are you?” and so much worse.

          However, a few years later, after the bugs were ironed out, tests were revised, and we started to see the benefits, most people came on board. Its never been mandatory, and is still pretty new, but has made a big difference already. Those that didn’t go along were marginalized- no federal jobs, no jobs with investment funds, no work on big projects or in certain cities. Someone MUST be certified to lead those jobs now. This also gave workers clear rules to go by, which has helped installation across the board.

          We had it easy- there were no consumers demanding unskilled PV electricians, nor were there extreme philosophical differences. Homeowners could still do their own work on their own homes (though resale is an issue). Not every crew member needed certified, just the head installers- though it quickly became a way for workers to get ahead, and now you can find whole crews that are certified in this way.
          What we have in common is that there were other standards we could look to, and piggyback on. You DO have standards in the CM.CNM, and practice protocols! There WERE also older installers that didn’t think it was fair, and who didn’t feel they needed to take a test. (They either quit, or got on board.)

          I know there ARE CPMs that are really good, or want to do better, and either didn’t know how, or just haven’t had to (why get a degree if you do not have to?). There are also so many hobbyists, that decided to “catch babies” after having a HB but never looked further into education than a PEP. This needs to end

          It HAS to be done, one way or another, because LIVES are at stake.

          • Bombshellrisa

            Someone was saying that the pass rate for certification was 20% first time around for electricians. Is that true?

          • schnitzelbank

            It’s shocking, isn’t it?
            [thank you, thank you, I’ll be here all week, please tip your waitress]

          • Lizzie Dee

            To some extent, I fell foul of the “Why get a degree if you don’t have to?” approach, so I get it.

            The American system of education is a lot different to ours so experiences are not directly transferable, but I was a high school drop out from a working class background at a time when that was not that unusual. I worked alongside people who had degrees doing much the same job, and that mindset made some sense. When I returned to education, I realised how wrong it was. The purpose of a proper education ought to be to make you much more aware of what you DON’T know, and at best, how to rectify that. Qualifications in themselves are not much use if they lead to closed minds or an unwarranted sense of superiority.

            When it comes to self-styled midwives – if you have attended a few or many births where nothing went wrong, confidence in your own abilities can be a bit of a problem. Educating those who find facts inconvenient when set against a more appealing ideology isn’t foolproof, either, and if the people doing the educating are cracked then the qualification isn’t going to make a whole lot of difference. I am not anti-midwife, I am not anti the “midwifery model” that says a woman’s feelings are important – I am definately anti woo. In my book, anyone fervently supportive of homebirth is suspect. (Some) women want them, they should have proper care – but no idea how you sort the good from the bad. You don’t do it by shrugging off disasters, that’s for sure. Some kind of legal framework that puts the menaces out of business seems more likely to be effective than appeals to anyone’s better nature.

          • Michellejo

            Great comparison!

          • schnitzelbank

            Likewise, birthing industry reform could benefit from just looking at reunified Germany. When E and W merged, there was a huge cluster across all labor and industry. Standards, education, infrastructure, and practices in every single certified profession were vastly different. Plumbers, teachers, physicians, no one was exempt from having to negotiate changes. Mostly, the East had to retrofit, adapt, educate, and certify to Western standards. It took a good ten(ish) years to see the changes completed. But it happened. I think the midwifery council could benefit from communication with the Germans on this!

      • fiftyfifty1

        “Do this while still collaborating with CPMs.”
        No.

  • mostlyclueless

    Can you link to any rebuttals from the natural childbirth advocates? I don’t follow their blogs but I am really curious how they’ll respond to this…the first study in particular seems pretty damning.

    • Renee

      They won’t rebut this. They ignore such things.

      • LovleAnjel

        Or they will emphasize the reduced rate of interventions as a desired outcome.

  • Charlotte

    I’m glad it included data about birth centers. I always knew homebirth was safe, but I had no idea that a birth center wouldn’t be. I had actually wanted to give birth to my first baby in one, and it wasn’t until I began reading this blog that I realized how bad an idea that would be.

    • Allie P

      Birth centers are the equivalent of giving birth in “someone else’s house.” A friend of mine had a failed TOL “Bradley Birth” at one of these places and after 42 hours of labor (only intermittent monitoring) her husband broke down and asked for a transfer. You know what ended up happening? HE had to call an ambulance and she was transferred to a rural hospital (we live in DC, but the birthing center was out in the middle of nowhere, maryland) where she had an emergency c-section. They were 90 minutes from their home. Thankfully, the baby is fine, but it was a nightmare.

      • Laural

        There is a difference in kinds of birth centers; accredited birth centers have very good safety records. Non-accredited birth centers are like giving birth in someone else’s house.

  • MaineJen

    That seems pretty ironclad data. And exactly what I’d expect to see considering that hospital CNMs really ARE taking on only low-risk patients, as they should, whereas homebirth CPMs will take anybody who can pay, and damn the risk. And this is the result.

    • Lisa from NY

      In New York, there are lots of CNMs taking on anyone who can pay for an HB. There is no oversight whatsoever.

      • Kalacirya

        I’d love to know more about the outcomes from the CNM down the road from me, I was so disappointed when she popped up.

        • Certified Hamster Midwife

          Is this the CNM who presided over this birth?http://www.skepticalob.com/2013/01/yes-the-baby-died-but-my-homebirth-midwife-was-awesome.html

          I live near you….we should compare notes.

          • Kalacirya

            I see from the blog that the midwife was named Michelle. Are we talking about Michelle Doyle? If that’s the case, that is exactly the quack that opened up shop down the road from me. We also have another set of midwives, CPMs, downtown: http://www.heartspacemidwifery.com/about.html

          • Certified Hamster Midwife

            Yes, that is the one. Her record is good on paper but there are surely some close calls she doesn’t advertise.

          • Kalacirya

            Well she does craniosacral therapy and homeopathy, that’s all I need to know. I have no respect for such a practitioner, because even if they have the degree under their belt, I can have no faith in their critical thinking skills. I bet this woman lives in the natural health section at Honest Weight. Blergh.

          • Certified Hamster Midwife

            The natural health section at the co-op has SOME remedies that are actually effective! You know, tea tree oil. And valerian root supplements. And senna laxatives.

            Then there are the rows and rows of homeopathic remedies and treatments for made-up diseases (candida)… Probably stuff for adrenal fatigue, too. I’ve never looked.

          • Kalacirya

            Did you know that they have a homeopathic section in the pet wellness area? Stuff like that makes me wonder why I’m a member.

          • Certified Hamster Midwife

            I know someone who does pet reiki. Pet. Reiki.

            And you’re a member too? I used to stock dairy but I haven’t worked there since 2008 or so. I was working 60 hours a week and couldn’t get it together to even work monthly. The new store makes me so happy I should go back to working even though I don’t live walking distance anymore.

            She was probably so well-meaning but, you know, misguided. At least things like acupressure make sense because rubbing things tends to make them feel better.

            I got introduced to EFT (tapping on meridian points to help minimize negative thoughts) and I struggle with how much bullshit it sounds like but how immensely helpful it is to me. “Well, performing a repetitive motion while thinking about upsetting things must do something neurologically…” I think, while avoiding rolling my eyes reading websites on the subject.

          • Kalacirya

            I worked there in 2009-2010, but don’t do it any longer. Graduate school plus a part time job during classes doesn’t give me enough time for it. The new store is nice though.

          • Certified Hamster Midwife

            I joined while in grad school. I had too much unstructured time and I needed to go throw boxes around after a day interning and learning how to be a bureaucrat. I still enjoy shopping there….but haven’t been to any membership meetings in a very long time.

          • Something From Nothing

            They also say elimination of whooping cough, etc by taking placenta medicine is possible. Do these idiots know how dangerous that misinformation is? And the ones who pay the price are children? I have to stop reading this stuff… It makes me crazy.

  • Jeteset

    is there no amount of data that will cause the legislature to act? how much are these NCB lobbyists getting paid anyway?

  • Expat

    I love these articles as a rebuttal to the: “but all Dr. Tuteur does is take the cdc data and use it to support her claims. She doesn’t publish her analysis in peer reviewed journals, so what she says doesn’t count” Well, here you have it, somebody who took the cdc data and published a subset of it in a peer reviewed journal, and what does it say? The same thing that Dr. Tuteur has been saying: homebirth isn’t safe for babies. Take that Jennifer Block.

  • Deena Chamlee

    I have just shared this with the ACNM Oregon Affiliate. The authors did not differentiate between CPM and CNM care. And I anticipate there will be more studies that do the same in the future.

    We do not have any common ground with CPMs with these types of outcomes. CNMs need to be denouncing unacceptable care in OOH settings. If we don’t the profession of midwifery will be significantly marginalized.

    The entry to practice into the profession of midwifery needs to be graduate prepared providers. Any other type of provider is not warranted. We have allowed this to go on long enough. CNM’s need to stand up and say no more!

    • The Bofa on the Sofa

      Considering that the bulk of HBMWs are CPMs and hospital MWs are all CNMs, there isn’t going to be a lot to learn from further scrutiny there. Perhaps in the the birth centers.

      • Deena Chamlee

        Small percentage of homebirths are done by CNMs and a larger percentage are done by CNMs in birth centers.

        The bottomline is if we want to preserve the integrity of the profession we must separate ourselves from poorly educated, poorly trained, individuals with GED or high school education who are calling themselves professionals.

        In fact a high school education was only required by NARM in 2012. Thus, there are individuals out there calling themselves “midwife” who have not graduated from high school.

        • The Bofa on the Sofa

          Small percentage of homebirths are done by CNMs and a larger percentage are done by CNMs in birth centers.

          Yes, that is what I said.

          The bottomline is if we want to preserve the integrity of the profession
          we must separate ourselves from poorly educated, poorly trained,
          individuals with GED or high school education who are calling themselves
          professionals.

          Yes, this is what we have been telling you for the last couple of days.

          • Deena Chamlee

            I know you guys woke me up. The ACNM must address things and take an extremely strong stand. Because if we don’t it will not bode well for the profession.

          • The Bofa on the Sofa

            Well good luck on ya, Deena, but I am going to say now, I will not be surprised if you run into a ton of resistance. I have to say, and I hope I’m wrong, I fear that there aren’t really such big differences between the attitudes of the CPMs and your CNM colleagues, and too many CNMs will simply deny that there is a problem, just as the CPMs do.

            You’ve heard the stories, just as I have, of the quack CNMs around, and the extent to which they are accepted. They are far, far too common. They, and their friends, will fight you the whole way.

          • Deena Chamlee

            If others do not wake up from the codependent relationship that exist the profession will be marginalized.

            I had the Affiliate ready to take action because of the outcomes. And we tried but got no where except for mandatory license.. So I think you are wrong about my colleagues.

          • Renee

            All it takes is a dedicated few.
            Good progress IS being made right now in OR, it can happen elsewhere too.

          • Good luck! I agree with Bofa, don’t be surprised if you hit very stiff resistance. Still, I hope you can change things.

    • Lisa from NY

      In New York, we only have CNMs (as far as I know), and I have heard of pretty horrible outcomes, too. A baby can get stuck if the mother gained too much weight during pregnancy, for example. A midwife can’t do a C in an emergency, even if she is a CNM.

      B&H is based in New York, and they insure their own employees. They stopped covering HBs for a reason.

      • PrecipMom

        No, we have CMs too, at least up here. They’re licensed and they’re still toxic.

    • Sue

      Deena – I wouldn’t you agree that home birth is inherently more risky, no matter who the provider is? The UK Birthplace Study showed that, even with mainstream midwives, tight risk-out criteria and a 40% transfer rate, first-timers still had 3X excess neonatal mortality.

      Even if you have two CNMs and an OB at the home, you don’t have a resuscitation team, a blood bank or an operating theatre.

      Sure you can minimise risk at home by having at least two CNMs who are accredited with the local hospital, a minimum standard for prenatal care and testing, strict risk-out criteria (no primips, twins, breech, PIH, diabetics) and liberal transfer policy, but there will always be unforeseen complications.

      Personally, I would accept homebirth under these specific circumstances as a reasonable alternative ONLY if the parents understand and accept that risk explicitly.

      • Lizzie Dee

        This may be my silliest question yet, but what does “understanding the risks” mean? We all take risks, all the time, but only by putting them out of mind. I am absent minded crossing roads; if I stopped to contemplate the risks, I’d never step of the pavement. I definitely favour making the risks of homebirth very clear and explicit, but while you have NCB all over the web doing the opposite, a general perception that the hazards of childbirth are a thing of the past, how? The large majority happy to “risk” hospital birth also know that a straightforward birth is a reasonable expectation but take a different approach to a small risk. It must be attitudes to the BENEFIT that makes people stay at home. And most of us can’t see what that benefit is.

        • theadequatemother

          its not a silly question. Most people are not good at understanding risk…and especially not good at factoring in consequences to their risk assessments.

  • Captain Obvious

    Didn’t the research on CEFM show that CEFM did not decrease the risk of CP, but that it did decreases the risk of intrapartum stillborn and also decrease neonatal seizures?! And Homebirth midwives do not use CEFM. I wonder if Homebirth midwives used CEFM if that would help decrease their poor outcomes :-/

    • Expat in Germany

      but, but -studies- show that intermediate ascultation is just as good as CEFM!!! and if you use CEFM it will cause an unnecesarean!

    • Lisa from NY

      What good would it do?

      Let’s say the baby is in distress and not responding well to the contractions. How long would it take for the woman to get out of the birthing pool, put on her clothes and get to an ambulance to go to the hospital? Then she gets to the hospital, it would be another hour until she would get the baby out. Would the baby be okay?

      • Captain Obvious

        First off, my comment was mostly snark. Just associated the similar outcome of intrapartum stillbirth and neonatal seizure to both not using CEFM and Homebirth midwives.
        Secondly, most labors converted to cesarean are for category 2 tracings that are not true emergencies. These are the ones midwives still feel comfortable watching and wait until it truly becomes category 3 IMO. These probably could have enough time to get to the hospital. But you are right, a true bradycardic episode of fetal distress will not make it from home, sometimes cannot even avoid some injury just from across the hall.

  • attitude devant

    What really is mind-boggling to me about this research is that I have always assumed that the midwives lie about their Apgars. I don’t assign Apgars myself, the baby nurse does, and I would never ever challenge his/her assessment. It’s a point of professional honesty and rigor. But the midwives? They lie about everything else. Why are they not lying about this? Or are there more bad Apgars than they let on?

    • Therese

      I’m sure they lie about plenty of their Apgar scores but it would probably seem silly to lie about a 0 at 5 minutes. It’s not like you can lie and say, oh, no baby was really a 7 because obviously it wasn’t, you wouldn’t have called 911 if it was (please don’t tell me there are midwives out there that wouldn’t be calling 911 for a 0 apgar at 5 minutes). I guess you could lie and add on a point or two and say the apgar was 2, but that is still horrendous so what would be the point? That’s not going to really make you look any better as midwife. I would imagine the scores they lie about are the babies who are doing marginally okay or better because no one is going to contradict them on those.

    • fiftyfifty1

      Maybe in cases where the baby dies they *want* the Apgars to have been zero, just the same way that Australian midwife wanted the Apgars to be zero. They want a stillbirth baby, not a baby that died after birth that they can get in trouble for.

      • Dr Kitty

        Although 5 minute Apgar=0 does not necessarily mean stillbirth.
        There could have been respiratory or circulatory efforts at some point within the 5 minutes.

        • Lizzie Dee

          Wouldn’t you get at least a 1 for some sign of life? As far as I remember, my daughter’s were 1,3,5,7. No seizures as far as I know, (Which isn’t very far – her notes got “lost”) CP. I read somewhere yesterday that a score of above 7 does not necessarily rule out CP.

          Nobody much wants to talk about brain damage, do they? In my book, death is much worse, but it is not unmentionable or unimaginable. Bit difficult to romanticise or offer consolations. Sorry: not implying that is what loss mothers do, far from it usually, but what do you put in your signature for spastic quadraplegia? There doesn’t seem to be many on MDC.

          • Dr Kitty

            5 minute APGAR is just that- the score at 5 minutes.

            It is a snapshot of what the child is like at 5 minutes, not what the child has been like in the preceding few minutes, so you wouldn’t get a retrospective point for some gasps or a faint pulse at 2 minutes if there was none at 5 (or at least not the way I was taught).

        • fiftyfifty1

          Sure, not all babies with a 5 minute Apgar=0 are stillbirths. But all stillbirths have a 5 minute Apgar=0.

    • MomAnd Midwife

      AD, I am assuming that you work in the OB dept, but if I am incorrect, please forgive. That being said, are you saying that you have NEVER seen a delivery team fudge APGAR scores after an unexpected outcome at the nurses’ station of the L&D or nursery, once everyone is stable? Because during my inpatient care time, I certainly did! So many times I couldn’t even give an accurate assessment, honestly. And timing the Apgars was never truly done well, during my first decade in the hospital…it seemed as if almost every 1 minute assessment was done within seconds of birth, until handy little timers were added to the baby warmers. A full, PPV resusc can happen before 1 minute, and baby receive 8, 9 scores. My assistant’s primary roll during those moments after birth is accurately noting times for my apprentice and I to evaluate Apgars, in my home birth practice.

      Please don’t make such sweeping generalizations.

      • attitude devant

        No apologies necessary. Let’s unpack what I said: I don’t assign Apgars; the nurse or team taking care of the baby does. I have never challenged an Apgar assigned by them. That’s what I said. It’s true. And yes, you can have a kid who’s looking iffy at birth who’s squalling 60 seconds later. That’s how resus works if the kid’s not too acidotic and you’re doing a proper NRP. All well and good.

        As for midwives? I’ve been taking HB transports for decades and I’ve seen so much lying that I’ve stopped being shocked by it. I’ve seen midwives change due dates so they don’t have to refer out a 43-week patient (I often have access to early u/s, so yes I do know). I’ve seen them ‘forget’ records and then drop off pristinely white copies that have clearly just been created. I’ve had patients tell me they’ve been ruptured for four days but the midwife told them to say 12 hours. I’ve had midwives claim “the baby just flipped to breech” during the second stage (as IF!). I’ve had midwives claim they weren’t at a birth when another midwife says they were. So, yep, homebirth midwives lie. A lot of them lie and they lie about a lot of things.

        Not all homebirth midwives lie. Maybe you don’t lie. Good on you. Instead of getting all huffy with me, why don’t you call out your sisters on the behavior that gives the lot of you a black eye? Because until you start policing each other I don’t trust you—until you prove to me you are trustworthy.

        • attitude devant

          I should make it clear, Mom and Midwife, that I am very suspicious of anyone practicing in unsupervised settings, no matter what their education or orientation. The temptation to cut corners, to shade truth, to bend rules is soooo great. I think having other eyes on our work is a tremendous boon to patient safety and quality care. So, I’m not persecuting midwives; I am an equal opportunity cynic.

        • MomAnd Midwife

          I, too, have seen plenty of my colleagues lie about their clients histories, and it is abhorrent. I’ve seen it from the student midwife perspective ~ literally, my very first home birth ~ and from my years as an L&D nurse. I was the “friendly” RN, to whom the truth would be shared, and boy, was I put in unbelievably awkward positions.

          I WANT there to be a good mechanism to police all providers, because otherwise, we get Rowans, Valeries, etc creating havoc for all of us ethical, responsible, intelligent home birth providers. There are a couple of things in the works, on my state level and nationally, that I, of course, cannot discuss here. But, midwives are certainly NOT alone in the potential for piss-poor care and deceptive charting, which is my original thought with this study. I do like your term, below, of “equal opportunity cynic;” I would describe myself the same.

          It is interesting that ACOG has started a well-organized, well-funded attack against home birth providers, complete with two studies in a week and several reckless legislative attempts in long-standing regulated states.

          • KarenJJ

            “It is interesting that ACOG has started a well-organized, well-funded attack against home birth providers,”

            And so they should be, right? With results and outcomes as described, plus your own descriptions above, reckless homebirth providers should feel under attack. Indeed, I well imagine that ethical, responsible, intelligent homebirth providers such as yourselves are absolutely horrified at the incompetent, irresponsible and unethical behaviour shown by several homebirth providers. I imagine someone like yourself would be right behind legislation that would prevent this type of midwife from practising and sullying the profession of miwifery.

          • MomAnd Midwife

            Clearly, Karen, you are unaware of the reckless bills introduced into both the TX and SC State houses that would have set midwifery back decades. I am all for legalization of, and oversight for, CPMs and LMs. But the SC bill literally would have legalized “lay persons” to act as midwives, who, by definition, have no formal training. I am not interested in starting a fight over the quality of CPM education. However, the Reps who introduced these bills are both known to be in the back pocket of the AMA, and ACOG. If NC had oversight, or if Utah did not have voluntary licensure to be legal, perhaps Rowan and Valerie would have been less likely to practice. And I know of other midwives in illegal states who are also being prosecuted as well. One state recently gained licensure of CPMs and oversight by physicians, where a midwife is linked to at least 2 newborn deaths prior to legalization. I am well-connected within the hierarchy of The Big Push for Midwives, and feel as if I am doing all I can at this time to obtain licensure in all 50 states, which should come with oversight by a joint midwifery/MD/consumer panel.

          • KarenJJ

            How does it set it back decades? As far as I can tell, homebirth midwives in the US are already decades behind the rest of the western world. I’m not familiar with the legislation being introduced. I live in a country where I have access to a free homebirth programme available via the government and backed up by the main maternity hospital with two educated and licensed midwives attending each homebirth. Well I would have access, but I am immediately risked out of that programme due to underlying issues and having had a c-section. Which is as it should be.

            There is no legalization of CPMs and lay midwives where I live. They don’t exist here, they don’t exist in the UK and they don’t exist in the Netherlands.

            Why are you so keen to license a type of substandard midwife that is not educated or experienced enough to practise anywhere else in the developed world and certainly wouldn’t qualify as a homebirth midwife where I live?

          • MomAnd Midwife

            The scope of practice of a CNM in my state (and most others in the US) does not permit home birth. I have a BSN, and so I would have actually had to spend LESS time in a Master’s program to obtain my CNM than it took me to pursue my LM and eventual CPM. But, I wanted to attend home births. And, like it or not, a segment of the population will ALWAYS seek home birth; they will UC if there are no skilled providers to attend them.

            I would love to see a system here similar to Canada, where the midwifery training includes cross-training in home, birth center, and hospital settings, allowing midwives to care for women in all locales. At least, this is my limited understanding. But for now, the US is so far away from this model, and not, from my perspective, because the midwives or consumers are not interested. OBs, ACOG, AMA, health insurance carriers, and hospital systems have a vested interest in keeping midwives, and the families we serve, in the perceived “fringe.” And this is not paranoia, AD…this is documented amongst private info from multiple sources that I am not at liberty to share.

          • Karen in SC

            I have a totally opposite view of those on the “fringe.” Homebirth will always be a choice, but let it be a choice with no implied approvals from government by licensing undereducated lay midwives. Let it be truly a “fringe” (or accidental) choice.

          • Eddie

            Why would the AMA or ACOG be interested in allowing lay midwives to practice? How could this possibly benefit them?

          • MomAnd Midwife

            They don’t have an interest, Eddie. But, by making regulations so very restrictive that it would have been an effective ban on licensed, professional midwives, they would eliminate the growing competition we represent.

          • KarenJJ

            How many obgyns are sitting about with nothing to do because a small but increasing number of women have been choosing to give birth outside of hospital?

            Or is it because they are seeing outcomes like above and more pelvic floor damage from long births and poor outcomes from homebirth midwives?

            I don’t understand why you feel the need to push for licensing underprepared miwdives that are not allowed to practise anywhere else. CPMs can’t practise in the UK or the Netherlands where homebirth is more prevalent.

            Where I live I have access to a government funded homebirth program (ie it’s free for me). Two university educated, licensed midwives attend each homebirth and it is backed up by the main maternity hospital. Women are screened to be low-risk (ie no twins, breech etc, could be transferred to hospital as soon as things start changing for the worse).

            Is that the type of homebirth vision that you have for the US – ie similar to the UK, the Netherlands, Canada , NZ and Australia? Is that what the Big Push is aiming for? In that case, isn’t ruling out non-conforming midwives that lack the experience and education to be high performing midwives a part of achieving that aim?

          • Deena Chamlee

            License of poorly educated individuals will not change outcomes. And midwifery needs to get on the same page where education and regulation is concerned.

            Have all CPMs and LMs become CMs. Then license CMS in all fifty states and lets move toward a highly educated and regulated profession across all three venues.

          • attitude devant

            Not quite sure how two articles in an INDEPENDENT scientific journal (you do realize that AJOG and ACOG are two completely separate entities, don’t you? And that ACOG does have a journal, but it’s not AJOG?) constitutes an attack…. Paranoid much?

      • Amy Tuteur, MD

        I worked at very busy hospitals, and during the time I was there, nearly 100,000 babies were born and I never saw, or even heard of. anyone changing Apgar scores.

        That’s the beauty of a teaching hospital. So many people are involved and have access to the record that any changes would be noticed and reported within hours if not sooner.

        • attitude devant

          When I was on teaching faculty one of our residents assigned his own Apgars on a very depressed baby. The nurses said 0, 1, 5 and he dictated 1, 5, 8. He couldn’t change the birth cert or the delivery log, because those were in the purview of the nursing department, but he dictated his own and wrote them in his note. Well the smackdown from the department faculty (including me) was so immediate and so pronounced that I’m sure he never forgot it. So, yep, in decades of practice, that’s the only time I ever knew of any such thing—-and it wasn’t tolerated.

        • MomAnd Midwife

          My years at the teaching hospital were the ones where the deceptive charting was least likely, I do agree with you on that one.

  • theadequatemother

    It drives me nuts when people say that homebirth is “as safe as” or “safer than” hospital birth. It appears to me that they arrive at this conclusion because they lump things like labour augmentation, c/s and instrumental delivery into “complications and bad outcomes.”

    I see it like this:

    HOME = higher likelihood that baby will die, or suffer brain damage. Lower likelihood of some maternal outcomes like episiotomy or instrumental delivery or cs.

    HOSPITAL = lower likelihood that baby will die or suffer brain damage. Higher likelihood of interventions like episiotomy, instrumental delivery, cs (and some outcomes that it seems only NCB zealots passionately care about like continuous monitoring, or epidurals).

    So I think it is clear, at least to me, that the tradeoff is that homebirth lowers minor morbidity in the mother and replaces it with major morbidity in the baby through a lack of timely intervention. It is only if you don’t separate the balance sheet between mom and baby and fail to weight these outcomes according to their severity that you can possibly arrive at the (erroneous) conclusion that it is “as safe as.”

    That is why I think the brave choice, the selfless maternal choice, is to have your baby in the hospital. Because sure, maybe there is slightly more morbidity for mom…but she will most likely recover and the trade-off is a greater chance of a healthy alive baby…and babies that die intrapartum or sustain brain damage have no hope of recovery.

    • Laura

      Well-stated. I think this is the crux of the matter very well summed up.

    • Courtney84

      This is really nicely said.

      Is exactly how mybusband and I feel. We’ve already heard comments from well intentioned family and friends about planning a natural birth and minimizing interventions. My husband just cuts people off at the pass by stating, “our biggest concern is minimizing high impact risks. We are fine with minor complications if it minimizes the already low risk that the baby will die.” People seem stunned, but haven’t had any come backs yet.

    • fiftyfifty1

      “maybe there is slightly more morbidity for mom…”
      Although morbidity is in the eye of the beholder to some extent. I loooooved by c-section. I would by no means consider it a morbidity to me.

      • theadequatemother

        I agree with you. But maternal morbidity has been measured in a particular way now that it’s almost gospel…and the cs rate is part of that and considered “morbid” not just by NCB types but by admin and maternal outcome researchers too.

        • fiftyfifty1

          I wonder how they measure things in countries where C-section is not considered a morbidity but rather a reasonable, viable choice e.g. Italy, China, Brazil.

    • B/c they look at infant mortality rate… b/c they don’t know the leading causes of death that lend to our higher maternal mortality rate… b/c of Ina May, Ricki Lake, Sarah Buckley, mothering dot com, childbirth connection… b/c of the Johnson and Davis BMJ article… b/c they are told to “look at the Netherlands!”… b/c sadly, “midwife” is a title that literally any woman can give herself….. b/c everything being thrust at women who are considering an unmedicated birth is telling them that US hospital setting is not safe and home birth is. As Dr. Amy has said it, “they don’t know what they don’t know.”

      BTDT…. 🙁

    • thepixiechick

      Hell yes TAM!

  • Susan

    Curious Amy? When a new study comes out supporting home birth it appears that the mainstream press picks it up quickly? I just looked to see if there was anything else out for the public about this.

    • Renee

      I noticed this! How can we balance it out?

      • Certified Hamster Midwife

        Do the journals that run these stories put out press releases on them?

        • Squillo

          It’s usually the institution(s) the researchers are affiliated with. None of the U.S.-based affiliated institutions for either study (Cornell, Baylor, Columbia, UCSF, OHSU) appears to have done a release. It’s possible they still will, but they tend to pick and choose whatever they think will get the most media attention.

          • nomorequestionscatherine

            I would think this could get quite a bit of media attention if they put the word out. My guess is they don’t want to deal with/manage the zealous NCB and general public backlash it would lead to.

          • Lizzie Dee

            The image of an infant with an Apgar of 0 at five minutes might just focus attention. The risk of a dead baby is both awful and abstract, maybe “natural” in a weird, distant, won’t happen to me way. Not much that is natural about the idea that you could spend the rest of your life caring for a damaged child.

          • Squillo

            In my experience, the institution doesn’t have to deal with the public reaction much–they’re just happy to get the media coverage. It’s possible the PIs didn’t want to do it.

            Maybe I’m wrong, but homebirth doesn’t actually seem to be hugely mediagenic at the moment. There have been some pieces in recent years in Time and the NYT, but overall, I see little about it in the media in contrast with, say autism or vaccines, anyway, where any little study seems to get covered. Moreover, this result doesn’t represent a major newsworthy shift–it reinforces what ACOG etc. have said for years. It would be more newsworthy if it wend against the “dominant paradigm.”

  • Renee

    I also wonder if the non accredited BCs are dragging the numbers down for the accredited ones? The accredited ones are suppose to be very good, are the all mixed together? If so, the good ones also bring the numbers UP for the non accredited ones.

    • Ob in OZ

      That is like saying that there are a few Doctors who are not as good and hurt the hospital statistics. We are all in it together. The difference is that when there is a Doctor involved, we do something about it, and there is nowhere to hide. How many Birth Centres that “underperform” try to do better, and see what the better ones have that they don’t?

      • Renee

        I agree, it is that there are 2 standards for BCs- accredited, and none. Mixing the 2 makes it harder to see where the problems lie.

  • Sedi

    They will say that it’s not necessarily about outcome but about a woman’s right to choose where she gives birth. So we’re back to the c’est la vie, some babies aren’t meant to live etc. line. That’s why it’s exhausting, there’s an answer for everything meanwhile babies and families suffer so that these women can feel powerful.

    • Women might have a right to choose, but they also have the right to informed consent and the right to adequately trained and qualified care providers.

      • attitude devant

        While I am an ardent supported of women’s rights, I think the shunning of care that can improve neonatal outcomes for trivial reasons is outrageous and obscene.

        • Renee

          Like refusing the vit K shot? Or Rhogam? Or, well, any of the woo….

        • I agree AD – and that needs to be the social message, right now the social message is that elective cesareans are to be criticized and disdained and home birth is to be applauded…

        • Susan

          Well said AD! I support their right to make an outrageous and obscene choice and our right to criticize the choice! How is your lawsuit going anyway Amy 🙂

        • yentavegan

          ” the shunning of care” YES that is the correct terminology.

        • Sedi

          I just think that the moment there is an uncomfortable finding re the safety of homebirth the immediate response is ‘but women have the right to choose….’. Yes, fair point, women have every right to choose however, on what information are they basing that choice? On information which is essentially ideology served up by university of google…..

      • Eddie

        That’s how I see it precisely. There is always the right to refuse any offered treatment. But this doesn’t mean that any old person should be allowed to provide medical care.

    • realityycheque

      Honestly, with that said I’m sure that if women truly understood the risks, significantly fewer would be attempting homebirth.

      They can’t say, “It’s a woman’s right to choose!” whilst influencing her opinion with heavily biased, warped information and telling her that hospitals are evil and will psychologically damage her/bring harm to her child.

      I believe a lot of women choose homebirth because they truly believe that it is “as safe or safer than hospital” and through fear that being in a hospital will lead to psychological damage/bonding issues and a potentially harmed baby.

      I really think it would be a minority of women who would still choose homebirth if they FULLY understood the risks and weren’t getting all of their “information” from biased, misleading sources.

      • Lisa from NY

        They believe that EVERY MOTHER AND BABY gets a staph infection in the hospital, and half of them die.

  • Renee

    I think the MD group IS a great comparison because we all know that HB is NOT low risk anymore. HB SHOULD be “low risk”, and if it was, the hospital MW and HB MW would have the same numbers- of the hospital would be worse (HB is safe or safer, amirite)?

  • Expat in Germany

    It also looks like the first time moms fare better under an MD than under a hospital midwife.

    • Renee

      Not surprising, given the “no intervention” attitude of many MWs and the people that choose them.

    • I think being primaparas in itself should be considered a risk factor.

  • Expat in Germany

    both papers say that out of hospital birth is worse, but their umbers don’t really agree. Any guesses?

    • Expat in Germany

      oh, the selection criteria. The top one takes everybody and the bottom study only counted low risk people?

    • The Computer Ate My Nym

      They didn’t use the same baseline data either. The top one looked at 2007-2010, the bottom only 2008.

  • Susan

    How they’ll explain it away…. they can’t use the “it includes unplanned homebirths” so they will use….”well, it’s fine if you don’t include Portland!”

    • Squillo

      If they were unplanned, then how did the midwives know to show up? Must be that speshul midwife intuition.

      • Anj Fabian

        That wasn’t an actual midwife! It was a friend. Or maybe a passing stranger who happened to walk into a strange castle in the middle of a stormy night…

        • Squillo

          Or a doula, or a “traditional birth attendant….”

          • KarenJJ

            Sure, call yourself doula or traditional birth attendant. At least people will hopefully realise you’re not a midwife.

          • Squillo

            Nah. That’s just what you call yourself when the authorities make those pesky inquiries about dead babies.

        • fiftyfifty1

          “Or maybe a passing stranger who happened to walk into a strange castle in the middle of a stormy night…”
          I actually have read this exact scenario. The passing stranger got caught in the storm while he was out riding horseback. He took refuge in the ruined mansion only to find a woman in labor! He delivers the baby safely! Later he and the (single) mom fall in love and marry.

      • Bombshellrisa

        Or they were Skyping through the labor and the midwife decided to come over “as a friend”.

  • I would fully believe this is a gross underestimation of low APGAR scores in the Homebirth group….in part because I think midwives are ‘generous’ in how they count – math and colour determination might not be their strong suits.

    • Renee

      I wonder how they got the agars from the HB MWs. I cannot believe they reported them because who collects data from CPM/DEMs? Considering all the blue and grey babies that had a 9 APGAR on HB videos, for a baby to get a 0 must be really horrible.

      • theadequatemother

        I think that the data collected by the CDC is probably that mandated on the paperwork that accompanies a birth (ah bureaucracy) I filled out a lot of birth record forms, mandated by the province, during medical training. They must be filled out by the doc or midwife and include 1, 5 and 10 minutes apgars as well as date and time, weight, gender and I think mother’s age at time for birth etc. It sounds like the kind of data that the govt would collect (in this case the CDC) on all births.

      • yentavegan

        All those blue/grey babies being celebrated on homebirth youtube videos are cringe worthy. I have seen all 5 of my babies moments after birth and none looked as limp, struggling or sickly coloured as those homebith infants.

  • ol

    These papers shows not only the real rate of low Apgar score but the role of the selection: when it is strict and based on medecal knowledge, the death rate is not so obviously high, when it is partly based on the homebirth advocate’s view on birth the difference is high.

  • The Computer Ate My Nym

    This data contradicts the claims made based on neonatal mortality that home birth is not riskier for women who have had babies already. The risk is less and perhaps enough that there isn’t a clear difference in mortality but the greatly increased risk of apgar of 0 at 5 minutes shows that there is an increased risk for babies born to women who have had a previous (presumably normal) birth.

  • KarenJJ

    “I look forward to seeing how Henci Goer, Ina May Gaskin, Jennifer Block and other professional homebirth advocates attempt explain these statistics away.”

    Well you see it’s the hats…

    • Lisa from NY

      But they don’t have to mention these studies at all. The people in the woo only read what’s on the NCB web sites.

    • Antigonos CNM

      I think they will, if they address the issue at all, try to claim that Apgar scores are really entirely subjective, and therefore irrelevant. Or that homebirth midwives grade more strictly than in hospitals which means that hospital births are only scored zero in “extreme circumstances”. Or something equally confusing.

      • Susan

        Yes, an Apgar score of zero is very subjective :). A friend of mine makes a joke when she teaches NRP “I can count to zero doctor”… maybe no signs of life at five minutes will be explained as acceptable because the cord is still attached and seizures are a variation of normal? If the study doesn’t support homebirth it’s because ACOG the obstetrician’s trade union and “Dr” Amy somehow rigged it…..sisters in chains unite!

        • Susan

          Someone, probably, will say seriously, that it’s ONLY the homebirth midwives who are respecting a woman’s right to a vaginal breech, twin, or post dates birth at home, and HER right to the lower rate of intervention at home trumps the mythical rights of the baby, and that since it’s the sisters in chains that are taking back a woman’s right to physiologic birth where SHE wants it that IF there is an increased risk to the baby it’s the mother’s right to take that risk. I had an argument with someone on Mothering that was pretty much saying that…

          • Renee

            I get this argument, and if someone actually knows the risk, and STILL wants to take it, thats their prerogative. The problem is that most moms that HB think HB IS safe, you know “safe or safer”. The MWs lie, and the moms don’t believe anyone that disagrees.

            So called MW that take those moms OOH should NOT be considered MW. Thats the other issue. Unqualified laypeople are giving themselves a title they do not deserve.

          • Susan

            I agree with you.

    • AmyM

      Did you see that one of those anti hatting-chatting-patting loons is now offering a 40$ class to explain how hatting, chatting and patting can cause PPH?

    • theadequatemother

      I’ve seen a lot of “explaining away” lately based on contamination of HB MW data by high risk cases (breech, twins, VBAC), even on MDC. It appears that some HB supporters think the data only looks bad because not all women and pregnancies taken on by HBMW are low risk…they remain feeling blissfully protected by the fact that their own pregnancy is singleton cephalic presentation. They will most likely use the argument that the groups in the study are apples to oranges and hence there is no way to “know.”

      Other than the mystical womyn’s intuition that HB is as safe as.

    • Sue

      We need an equivalent term to ”mansplaining”, to describe people who comment about stuff they know nothing about. Maybe ”laysplaining”?

      (Disclaimer – no generalisations intended about men or non-medical people – only those who ‘splain stuff they don’t know about)

      • Eddie

        How about missplaining (but should there be one or two s’s?) I do like “laysplaining” though.

        • Lizzie Dee

          One S. Though with two it did bring to mind the young women who have not yet had children who explain to us all how it should be done. And the experts on the Brewer Diet who have never seen Pre-Eclampsia because the diet cures it.

          I am baffled by people who are Certain of their Rightness. A personality trait, obviously. But not, I think, one you and I find appealing, Eddie.

          • Dr Kitty

            I love the people who have “never seen” Pre-eclampsia, and then tell use that “of course” they don’t dip urines, check BPs or check blood counts, because those are all unnecessary tests.

            In other words, you can’t find what you don’t look for.

      • realityycheque

        +1 for laysplaining here!

  • Rachel Mills

    Well, they could always continue to insist that absolute risk remains “low”. Which is fine until its your baby that dies the completely preventable death…

    • Kalacirya

      I always love this. When it comes to breastfeeding, the tiniest of changes in the odds ratio or relative risk will excite them, even if the absolute difference is very very small. But when it comes to negative outcomes, the hand waving starts.