Wendy Gordon’s latest smear attempt

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You have to give MANA (the Midwives Alliance of North America) credit. Their motto appears to be: if at first you don’t succeed, lie, lie, again.

Clearly MANA is very worried in the wake of publication of the Grunebaum study that shows that homebirth increases the risk of a 5 minute Apgar score of 0 by nearly 1000%. Therefore, they’ve sent Wendy Gordon, CPM (and placenta encapsulation specialist!) to do what she can to discredit it.

No matter that it comports with the data from Oregon that shows that PLANNED homebirth with a LICENSED homebirth midwife has a death rate 9X higher than comparable risk hospital birth or that MANA has found that its own members have such hideous death rates that they have been desperately hiding them for years.

This is not about the truth, obviously. This is about tricking American women into ignoring horrific homebirth death rates, so any research that demonstrates the danger of homebirth must be discredited.

Wendy’s first attempt didn’t go so well. She was caught (by me) in a bald faced lie. MANA did not attempt to deny it, but, as it typical for them, they didn’t correct it, either. Apparently the entire attempt was not as successful as MANA would have liked. How can I tell? Within less than 24 hours, MANA felt the need to censor comments since the comments raised questions that MANA could not or would not answer.

Wendy’s second attempt, on the Lamaze blog Science and Sensibiity, tries to avoid the pitfalls of the first attempt. Instead of including the bald faced lie about the accuracy of Apgars on birth certificates, she simply linked to it.

She’s also made the smear considerably more vague, starting with the title itself, Flaws In Recent Home Birth Research May Mislead Parents, Providers. A more accurate title might be We hope that vague, unsubstantiated “flaws” that we’ve made up might be used to mislead others about the real dangers of homebirth.

The Grunebaum paper is well done and extremely difficult to undermine. There is simply no question that the data shows that homebirth raises the risk of a 5 minute Apgar score of 0 by nearly 1000%. The authors’ decision to use the 5 minute Apgar score of zero is truly inspired. Other research shows that homebirth has an appalling rate of intrapartum death, and not just any intrapartum death, but totally unexpected (“the heart rate was normal right up until the baby was born”) death. This is almost certainly due to failure to monitor babies appropriately during labor. The decision to use the 5 minute Apgar score of 0 means that we are looking at severe intrapartum compromise, almost certainly resulting in death.

Though the lay press has reported the results as an increased rate of stillbirth, and though the findings almost certainly do reflect an increased rate of stillbirth, the key point is that they reflect INTRAPARTUM stillbirth, not stillbirth before labor begins. How do we know that? Babies who die before labor begins don’t get birth certificates and they certainly don’t have 5 minute Apgar scores assigned, because Apgars are given only to babies believed to be alive prior to the moment of birth.

But rather than acknowledging that the decision to use the 5 minute Apgar score of 0 is one of the primary VIRTUES of the study, Gordon insinuates that it is a flaw.

When we examine a little more closely what it means to have a 5-minute Apgar score of zero, we might find that it does include some babies who died shortly after birth. We might also find a number of babies who had lethal congenital anomalies, who would not have survived no matter where they were born or who attended the birth; there may be important differences between home and hospital populations with regard to whether these anomalies were detected prenatally and whether parents changed their birth plans because of it.

The babies might have had anomalies! Duh! Of course they “might” have had anomalies. That doesn’t mean those anomalies were incompatible with life if the babies had access to lifesaving technology.

There may be important differences between home and hospital populations regarding anomalies! But there is NO EVIDENCE that there are important differences, so attempting to dismiss the findings on that basis has a whiff of desperation about it.

Wendy claims:

A rigorous study that actually examined deaths would have excluded births with outcomes that had nothing to do with place of birth or attendant.

No, rigor does NOT require excluding births with outcomes that have nothing to do with place of birth or attendant (“the baby would have died in the hospital, too”). Why? Because we are looking at the DIFFERENCE between outcomes BASED ON place of birth and attendant. If we subtracted all the deaths that “would have happened in the hospital, too,” the DIFFERENCE between home and hospital could be EVEN GREATER than if we didn’t subtract outcomes that were independent of place of birth or attendant, because the hospital death rate would be ZERO, since all the deaths in the hospital group “would have happened in the hospital, too.”

Either Wendy is hoping that homebirth advocates have poor basic logic skills or she herself has poor basic logic skills.

Here’s another whopper:

On the other hand, even a small percentage of misclassified outcomes in the home birth category have a dramatic impact. Because the number of home births in the U.S. is small, the inclusion of prenatal stillbirths, congenital anomalies and unplanned, unattended home births in the “home midwife” category is likely to have an appreciable effect on the negative outcomes examined here.

Is there any evidence that ANY of the 5 minute Apgars of 0 at homebirth were not 0? Is there any evidence that homebirth midwives signed birth certificates of patients who had unplanned homebirths? No, of course not. There’s isn’t a shred of evidence that even one midwife is accidentally recording that the baby she delivered had a 5 minute Apgar of 0 when it did not. Claims like these positively reek of desperation.

And yet another whopper:

I wrote my initial reaction to Grunebaum et al’s study last week when their press release came out. I expressed concerns about the low reliability and validity of birth certificates for drawing conclusions about rare outcomes. Grunebaum’s own data shows that over 10% of “home midwife” deliveries had no information on the birth certificate about the mother’s parity and had to be excluded from their calculations, while only 0.2-0.5% of hospital or birth center deliveries were missing parity data; this strongly suggests that something is amiss with the “home midwife” data.

No, Wendy didn’t express her concerns, she LIED about the reliability of Apgars scores on birth certificates, and supplemented that lie with a deliberate misrepresentation of a paper on birth certificate reliability that shows THE OPPOSITE of what she claimed it showed. Her misrepresentations were publicly pointed out in the comment section and she NEVER DENIED them.

Wendy is so desperate to smear the paper that she cheerfully smears homebirth midwives along with it. They are such slobs that they didn’t include parity on the birth certificate. I don’t doubt that midwives are sloppy in their record keeping, but that doesn’t mean that they sloppily wrote that the 5 minute Apgar score of the baby they just delivered was 0.

Wendy can’t resist logical fallacies, either. She trots out a loaded question just like the classic “have you stopped beating your wife?”, a “question” based on a foregone conclusion that may be completely false.

The fact that these authors were clearly warned about the low quality of their data regarding both low Apgar scores — and especially seizures — but chose to push ahead with publication without addressing them, suggests other motivations.

The authors were never warned about the low quality of their data since their data is high quality. To the extent that they were warned about anything, they were warned that homebirth advocates were fully prepared to LIE about the quality of the study’s data. True to the warning, Wendy is lying about it now.

Give it up, already, Wendy. At this point, you are just destroying your own reputation and that of MANA. The Grunebaum paper is a high quality paper that presents accurate data on an excellent metric (the 5 minute Apgar score of zero). It comports with the CDC data, the Oregon data, and the fact that MANA has refused for years to release their own death rates.

Homebirth kills babies who didn’t have to die. I know it, you know it and MANA knows it. Your desperate attempts to hide the truth from American women don’t smear the papers you criticize; they smear the organization that you represent.

  • Dr Kitty

    “Low is low” isn’t going to work.
    A vast body of comprehensive medico-legal law already says that even if a risk is in the order of 1 in 10,000 if it is serious, and a prudent patient would want to know, it should be part of an informed consent.

    HB midwives can present the data as AR or RR or however they want, but they need to present the data, and they can’t keep saying “as safe or safer than hospital” when evidence no longer supports that.

  • I don’t have a creative name
    • Jocelyn

      Yeah, that’s a “Well, duh.”

  • Jennifer2

    Entirely OT, but saw a flier for “The Perfect Storm” at daycare drop-off this morning. Here’s the website and Facebook page. Predatory woo at its finest.

    https://m.facebook.com/pages/Well-Adjusted-Products/178987935519448?id=178987935519448&refsrc=http%3A%2F%2Fwww.google.com%2F&_rdr

    http://www.welladjustedproducts.com/shop/perfect-storm-handouts

  • Sue

    If there’s ANY APGAR score that would have excellent inter-rater reliability, it would be ZERO, no?

  • Kell

    a few days ago i signed up to renew my NRP (neonatal resuscitation program). there were two options to click on when signing up, the class for hospital workers: the complete class which reviews and tests on all 9 lessons in the book, and a shorter class for midwifes attending home deliveries which covers lessons 1-4 and 9. Yikes! Me a NICU RN who works in a non-delivery hospital, that only attends a few deliveries a year when she gets called out as a part of a transport team to hospital that is uncomfortable with a delivery they have suddenly found themselves apart of is more trained in neonatal resuscitation than a midwife who attends to 100’s of homebirths a year?? As i flipped through my book a realize its because I have the equipment (and comfort level) to carry out lessons 5-8 (intubations, low lying umbi line placements, epi administration, needle decompression) and they don’t. So when a homebirth midwife explains to parents that he/she is certified in NRP do they explain that they only studied half the course? Well half plus lesson 9. You know what lession 9 is? “Ethics and Care at the End of Life”

    • Antigonos CNM

      A homebirth midwife will be lucky to do 100 deliveries a year. More like a maximum of 50. Physically, it is extremely difficult to do more than that, not to mention that the demand is small enough that such a midwife might go months without a client.

      • Squillo

        This is what I really don’t get about homebirth midwifery in the U.S. If you’re working without a net, wouldn’t you want to have the best possible training and the most possible experience in handling complications and doing resus?

        Selecting an “expert in normal birth” is like getting on a jet whose pilot has read the book about flying without autopilot but who’s never actually done it. And jets crash many orders of magnitude more seldom than births go wrong.

      • Kell

        Yeah I really have no idea how many they do, I just chose a number without thinking. Point is they are at the deliveries of many more babies then I am!

  • Squillo

    You’ve got to have a look at Gordon’s latest comment in response to someone asking her to comment on Judith Rooks’s work.

    • Guesteleh

      For those of us who are statistics-impaired, can you explain what’s crocky about Gordon’s comment?

      • auntbea

        1) She claims the Grunebaum study and the Rooks study cannot be compared because the latter studies death and the former does not. As if a five-mute Apgar of zero were not somehow a measure of likely death.

        2) She says Rooks exaggerated, and the likelihood of death at homebirth is ONLY two times higher. Oh well!

        3) She keeps talking about how the absolutely low number of deaths means you can’t make meaningful statements comparing place of birth because low is low. But we CAN provide a clear and meaningful answer — homebirth death rates are less low than hospital death rates — in the form of relative risk, which is the statistic Rooks provided.

        4) She is bemoaning the small sample. While it is true that small samples can are more likely to produce wrong estimates by chance, there are statistically checks and corrections, which Rooks used appropriately. The sample is not the largest sample in the world, but it is large enough to give us a confident estimate of the relative risk of homebirth.

        • Karen in SC

          If she is bemoaning the small sample, she needs to whip out the MANA stats to refute.

          As if….

          • Squillo

            But that won’t be large enough, according to Gordon. The MANAStats contain 24,000 homebirth records. The Grünebaum study contains >60,000, and yet, that sample is apparently too small to draw any meaningful conclusion.

        • Squillo

          Bingo.

          Re # 4, the very study she is critiquing in the post had a homebirth sample size of >60,000, and a total OOH sample size of >100,000. She doesn’t like the results of that either.

          Johnson & Daviss, which MANA cites as evidence that outcomes for CPMs are as good as in-hospital outcomes, had a sample size of 5,418.

          So basically, there’s no study with a sample size large enough to support the idea that homebirth isn’t as safe as hospital birth, but when the study is favorable, it becomes so. By magic.

        • Bombshellrisa

          And someone here crunched the numbers and you know what is only two times more dangerous than having a homebirth in Oregon? Climbing Mt. Everest. I would love to hear Wendy Gordon’s spin on that

    • theadequatemother

      also: “Community Manager, Contributors (guest and regular) and Commenters shall abide by the following policies in their interactions on this blog site: All blog post articles designed to present statistical information or offer best practices advice for maternity care professionals must be consistent with up-to-date, evidence-based research and/or be consistent with Lamaze International’s Six Healthy Birth Practices.”

      so if you have evidence and it doesn’t jive with Lamaze’s six healthy birth practices don’t bother posting it.

      If you have ideas that coflict with evidence but that do jive with Lamaze’s six healthy birth practices pontificate away sistah!

    • Amy Tuteur, MD

      Wendy Gordon is simply pathetic. Her desperation is truly amazing to behold. And her willingness to ignore and suppress the truth about homebirth deaths is grossly unethical. But of course, MANA itself is grossly unethical.

    • auntbea

      It’s a giant logic pretzel. Extra knotty.

  • Amy M

    http://mamabirth.blogspot.com/2013/04/getting-honest-about-midwifery-and.html?m=1

    OT: The above is a half-assed attempt by an NCB community leader (?) to say that they really are “evidence-based” and “natural birth isn’t best for everyone (but it is for most people)” and “stop coming to me with medical questions because if your baby dies I don’t want to be held responsible.”

    • melindasue22

      I don’t read it that way. It sounds like an honest attempt to call out her fellow NCBers for being too dogmatic. And the medical advice thing, she truly does sound appalled that people would seek medical advice from her. Humans aren’t perfect we can be contradictory at times but she does seems sincere.

      • Amy M

        I read it that way at first, but then I read the comments and her response to the navelgazing midwife, whose comment has evidently been removed (possibly by navelgazing midwife herself). After reading the comments, it kind of soured me and came across as less sincere as I originally read it. Maybe that’s me just being biased and it is really meant to be an attempt to build a bridge, in which case, good…first steps are important.

        • Antigonos CNM

          Could you give a precis of what NGM wrote?

          • Amy M

            I don’t know, it was removed, but I can put what the response by “mamabirth” was.

            Re- NGM- For the record I have always “spoken my truth”- ALWAYS.
            I
            have NEVER told people to “trust birth” blindly. (I have notice though
            that people read what they want to, not my thoughts.)I have shared this
            same message (poking fun or finding the flaws in the natural birth
            community) at least a dozen times in the last two or three years.
            Sometimes with attempted humor, sometimes not. Sometimes in an entire
            post, sometimes as a disclaimer.

            I was never a black and white
            “trust birth” and I and frankly, I don’t know how you got that idea or
            why you ever “stopped sending people to me”. Nor am I moving towards
            the middle. I am the same person I ever was with the same opinions.

            And
            to be honest- I don’t really want your endorsement just like I don’t
            want it from Dr Amy (she even wrote a blog post about how I had
            integrity). I get the feeling you are one of those people who like
            me…as long as I say what you want me to say. Now you like me- because
            you happen to agree with me this time. I only want friends who like me
            even when they DISAGREE with me.

            Your cruelty to a mom who shared
            a birth story on this blog was deeply embarrassing(for you) and spoke
            volumes about your character.

            I don’t know if you are a
            “pariah” in the natural birth community. But I can tell you (since you
            want me to be truthful) that I don’t care for your blog because you are
            mean. Pure and simple- you are mean to people who disagree with you. I
            have seen you attack women who have unassisted births- thoughtful,
            seemingly kind, and aware women who choose unassisted birth (or go
            overdue, or have their babies at home, or, or, or). Yet you smugly
            attack them and cite their lack of education and your wisdom.

            I
            have seen you be mean to women on this very blog because they had a
            birth that you deemed unsafe (even though all was fine and you didn’t
            know the facts) and seen you condemn midwives when you know very little
            of the story.

            No- if you are disliked it is not because you speak truth. It is because you speak with cruelty.
            (I
            feel the same about many of the “trolls” in among the NBC. I recognize
            their hurt and their bad experiences and the lack of perfection in
            midwifery AND the truth in their words- but I will never endorse their
            methods of bullying and hate.)

            Truth- I still think natural
            birth is better. I am not ashamed of that truth. Truth- I still
            realize that it isn’t always possible. (To me- to recognize that
            interventions are needed is OBVIOUS and COMMON SENSE and I believe I
            have always had common sense.) I have always known that. If people
            like you believe I felt otherwise, well, you interpreted me incorrectly.”

            I thought all of them were big fans of each other (navel gazing midwife, and mama birth), so the in-fighting is confusing to me.

            Like I said, I am wont to take anything those people say with a grain of salt, so maybe she is sincere, and not just paying lip service. If so, I retract my snarky comment, since it was uncalled for, and appreciate that someone who is generally a fan of natural birth can accept that natural birth is not always possible or desirable.

            The rest of the comments read like all of the other comments on those types of blogs: “you are SO right!’ “You go, mama!” and that type of sentiment, with little discussion like we have here.

          • Antigonos CNM

            Thank you. There are still areas in which I disagree with NGM, but she has matured and changed during the years I’ve followed her blog, and she often makes excellent points. In recent times she has come to see that direct entry midwifery [she is a CPM, btw, who, at one point, thought seriously about becoming a CNM, but she isn’t young and her health is not so good] is seriously lacking in many respects.

      • auntbea

        That’s what I thought, until I read the poem “Medwife” a few posts later.

  • Lisa from NY

    OT: An old neighbor of mine died last week at 55 with cancer. Instead of doing chemo, she opted for a natural remedy which did nothing.
    Had she done chemo, she would have been alive now.

    • Mishimoo

      I’m sorry for your and the family’s loss, preventable deaths are awful.
      Hazarding a guess at the remedy – laetrile/”Vitamin B17″?

      • Lisa from NY

        I think she did the Alkaline PH route, because that’s the one cure touted in the “literature”. She was under the care of a alternative medicine practitioner, though.

        • Lisa from NY

          But I can’t ask her because she is dead. I only know this from a friend of hers who did not probe for details.

          • Mishimoo

            It takes a special kind of greed to prey on people with cancer, it disgusts me. I wish that providing accurate information about the lack of efficacy of the alternative treatments didn’t feed right into the sales pitch.

        • Sue

          “Alkalinisation” is currently fashionable for all sorts of things, but shows a gross misunderstanding of physiology. Next to the preservation of sodium concentration, tight control of pH is one of the strongest physiological influences. Unless your pH is held between the tight range of 7.35 to 7.45 – controlled by breathing and kidney function, you get very sick.

    • Burgundy

      I lost a close relative due to the same reason 2 weeks ago. She had breast cancer and refused chemo. She went to a “Chinese Herb Specialist” for treatments. The crack told her that she was free of cancer 6 months ago but turned out her cancer advanced from stage 1 to stage 4 within 2 years. We are having a hard time dealing with it. I hate people who play doctors with people’s live, like CPMs or the so called “natural remedy specialists”.

      • Bombshellrisa

        We have lost loved ones to these “cures”-for my husband, both of his parents (one to “The Greek Cancer Cure” and the other to “natural remedies” instead of medicine after an MI with a history of diabetes and high blood pressure). It’s the worst to see the ones you care about denying themselves and you the chance to have more time together because they want to do things “naturally”.

  • fiftyfifty1

    Come on MANA, do the right thing. Release the mortality stats.
    Isn’t there even a single brave and honest person within MANA?

    • Bambi Chapman

      No

  • auntbea

    In the comments, one Darla Torrez, CPM wrote,

    “being a state licensed CPM means I am uncredentialed, unskilled, and obviously illiterate.”

    Now, obviously this was sarcasm on her part, and I have taken it thoroughly out of context. But still. A thing of beauty.

    • The Bofa on the Sofa

      “being a state licensed CPM means I am uncredentialed, unskilled, and obviously illiterate.”

      Although it does not mean that, the problem is that it also does not mean she’s not.

      • Kerlyssa

        A-men to that.

      • Sue

        Yep – that’s the point, really. There appears to be no correlation between the possession of CPM and skill or literacy.

    • Antigonos CNM

      She’s literate to the extent that she could write that sentence. More than that, I really couldn’t say.

      It’s not enough to be “credentialed”, it depends entirely on who is doing the credentialing. I could undoubtedly become a PhD from a diploma mill without difficulty but so what? that, and 5 cents, as the saying used to go, will get you on the Staten Island Ferry.

      Skills? The sad fact is that about 85% of deliveries can be done by a 5 year old cretin. It is that other 15% that’s a killer, more or less literally. To which skills does Torrez specifically refer? I can knit beautiful baby blankets — isn’t that a skill?

      So what she thinks is sarcasm may not in fact be anything more than a statement of fact–that is how much her CPM is really worth.

      • Amazed

        Sometimes I wonder about lay midwives… I know the prevalent opinion here is that they are overestimating their own abilities and I share it. But maybe deep down they know they are not equal to OBs/hospitals. Why else would they hysterically compare themselves to OBs/hospitals, sans the dreaded C-section?

        When I read Antigonos and some other midwives who post here, I see women who are comfortable with who they are and what they do. They don’t seem unwilling to err on the side of caution out of fear that they’d be displaced by the OB in the ER. They don’t seem to feel the urge to denigrade obstetrics and obstetricians because they know that they have place in birth and it’s important enough as it is. Darla and some others – it’s as if they are constantly trying to inflate their worth/self-worth in the eyes of NCBs/their own eyes because deep down, they are not certain of how much they are worth,

        • Antigonos CNM

          I think it is also because they either deliberately believe, or are unable to accept, that so much CAN go wrong. You don’t expect a brand-new car to spend all its time in the garage; you don’t expect planes to fall out of the sky [especially the one you’re flying in]. When you really think of the POTENTIAL for birth to become lethal, it is very scary.

          I never felt comfortable doing home births because I knew what could go wrong [and I was in a system which was well prepared for emergencies]. It usually didn’t; with one exception all the home births I did went swimmingly, but having seen, over the years, in hospital, all the varieties of complications, you cannot pretend that it can’t happen.

          Most homebirth midwives have attended so few births that they have just been lucky not to have witnessed a lot of things every hospital nurse, doctor, and midwife has seen.

          • Amazed

            You’re probably right. But my, each time I see a midwife who screwed up featured in the news, her age is somewhere between my mom and my grandmother. How could a woman of such age not remember the times when midwives and doctors could often do very little but watch as the disaster unfolded? The old women I know are not above reminding their daughters and granddaughters what it used to be like. I was present when a friend of mine expressed a wish to give birth in a private clinic that had less resources but was otherwise more comfortable and relaxing. Her mom said, basically, “Child, I know it’s a very special time for you. I know you want the best for you and the baby but listen to me: go to the obstetrics unit. You’d better have the best care available to both of you, just in case.” Boy, was she glad later when “in case” turned to be an emergency and she was in the poor furnished non-private hospitals! There was no music, no TV either, the sheets were old, it was noisy and unpleasant, the food sucked. But they were there – the specialists and the equipment. And in the long run, that was all that mattered.

            How could have these women forgotten so easily?

          • Young CC Prof

            Some of them never knew in the first place. Some families were just lucky that way. We actually don’t have any obstetric horrors in the last few generations. (Dead children, yes, enough to make us profoundly pro-vaccine, but no dead newborns or mothers.) That’s probably why my mother is so vulnerable to the natural-childbirth rhetoric.

          • Amazed

            Sounds logical. Yet out of the old women I know practically everyone knew someone who had either a tragedy or a lucky escape. Midwives live in birthing circles and even now, they have more touch with death. How can they dismiss and forget it is beyond me.

          • KarenJJ

            My guess is that these women also remember some of the old-style doctors that didn’t practise with the professionalism and bedside manner that they mostly do today. Mum’s obgyn was condescending, lied on her medical chart and told her off for being a ‘naughty girl’ when she fell pregnant when it was believed that Dad had fertility problems (he did, but not as bad as suspected and we all inherited Dad’s rare genetic mutation). She complained to the medical board, but is very much on the side of “doctors are assholes”.

            They also are from a time when it was much more rare for a woman to have a career and at a later stage of life when they were looking for something else outside the home, they were probably looking for a career that gave a professional prestige with a low barrier of entry.

            Another guess is that some of these women have issues with their sexuality but due to religious/cultural/financial reasons have stayed in heterosexual marriages and have been doing “women’s health care” for an outlet. There is something ‘off’ with some of these women.

  • Allie P

    “there may be important differences between home and hospital populations with regard to whether these anomalies were detected prenatally and whether parents changed their birth plans because of it.”

    Yes. Chances are that pregnancies attended by homebirth midwifes are less likely to detect anomalies, and that if they did by chance manage to do so (rather than talking their patients out of screenings and tests), do so, patients were MORE likely to transfer to the hospital for the births. How is “Well, we’re unequipped to detect anomalies that need to be serviced with life saving interventions at the hospital” a selling point? I mean, seriously? If someone tells me it’s not fair to judge the quality of the medical service they provide on the grounds that they can’t provide adequate medical service, I ask them to show me to the door.

    And the “may be miscalculating the Apgar is another laugh riot. How many times have dead and dying babies been given “perfect” Apgard by ill-trained midwives. We’ve seen it on this blog time and again. If the HBMW are calculating the Apgars wrong, it’s that they probably aren’t giving 0s or other low scores to babies who deserve them, all those babies who they think “just need to pink up a bit” but really need NICU, stat.

    • Antigonos CNM

      I don’t know whether the ” there are more anomalies (incompatible with life) in homebirths” is really relevant. The absolute numbers of women choosing home birth are so low, and the total of anomalies in the total population of women giving birth is low enough that I would expect that we would be thinking in fractions of one percent for homebirths in which the baby has a previously undiagnosed anomaly which is fatal. To me, this is a red herring.

  • The Bofa on the Sofa

    I like the part about the common lack of parity: “You can’t use birth certificates to assess midwives, because a very large number of midwives can’t fill out a birth certificate properly.”

    Not really instilling confidence in the system.

    • Jennifer2

      Yeah, if you can’t fill out a birth certificate properly, you maybe shouldn’t be holding yourself out as a health care professional.

      • Antigonos CNM

        In the UK, keeping records is a legal responsibility of midwives. Their registers can be summoned for examination at any time. I don’t know if ANY state in the US has such a requirement or whether record-keeping is left to the discretion of the midwife.

        • Anj Fabian

          Left to the discretion in practice. I believe in theory, midwives are supposed to keep complete and proper records. I don’t believe they are audited except rarely. The birth center that was shut down recently ought to be audited as part of the investigation.

          • Antigonos CNM

            It would be interesting to know exactly where each state in the US stands on this. Given that ALL forms of midwifery are still illegal in a few states, one has to assume that in those states, there are no legal requirements for record-keeping.

          • FormerPhysicist

            Perhaps, though you can never be too sure with the crazy patchwork of laws. There *is* a legal requirement to pay taxes on illegal income, for instance.

          • KarenJJ

            Even CNMs? I thought CPMs and lay midwives weren’t always legal but that CNMs were fine.

          • Antigonos CNM

            I stand corrected — there have been some changes since I last checked. However, on the “Citizens for Midwifery” website, it is stated that “While CNMs are legal in all states, the need for doctor collaboration or practice
            agreements means most CNMs are vulnerable to the ability of doctors to terminate
            or refuse to participate in practice agreements with midwives, and their ability
            to influence hospitals to refuse privileges to midwives (who in many cases are competing
            for the same clients as the doctors are).” At Your Cervix, a newly-graduated CNM in Pennsylvania, has been looking for a job for more than half a year, in spite of the fact that she also has nearly 10 years of experience as a registered nurse in L&D.

            Currently, CPMs are licensed to practice in only 28 states, and “CMs” only in 3.

            A CNM can’t, AFAIK, just tack her diploma and license on the wall, and open her own office or clinic. Not all insurance companies are willing to insure midwives working outside of hospitals, either.

    • auntbea

      I tried to make this point in the comments and got…well, I don’t really know what I got. Hard to read the wall of huh?

    • Antigonos CNM

      Or they don’t fill a birth certificate out at all. I remember that, during the Viet Nam War, it was fashionable to give birth “outside the hospital” just to avoid having Jr’s existence documented, lest 18 years hence, he should be eligible for the draft, should it still be the law. Considering that there ARE states which do not legally permit midwifery, in those states, if a midwife would write a birth certificate, she could be prosecuted [assuming someone noticed; and I think they would, these days, with Social Security numbers being assigned at birth instead of age 16]

  • Captain Obvious
    • Karen in SC

      Blatant “feel good” fluff. Another post I saw but didn’t waste time reading was “Lose Your Fear of Labor.”

      • T.

        In science, feeling “warm and fuzzy” often means being WRONG.

        • LibrarianSarah

          I don’t when I made a bacteria glow in dark back in college I got a warm and fuzzy feeling. I was all like “stand back I’m doing science!’ and then science happaened and it was awesome.

          • T.

            I stand corrected. This kind of warm and fuzzy is good 🙂

            But the one who cames from the “if I think positive nothing bad will happen!” mentality is not, I thinl

          • EmbraceYourInnerCrone

            I like to refer to that mentality(nothing bad will happen if I think positively enough!) as “Clap harder!” in reference to the part in the Peter Pan play where the audience has to prove they believe in fairies by clapping, to save Tinder Bell (clap or the fairy gets it!)

            I guess my mom didn’t BELIEVE hard enough when she hemorrhaged when in labor with my brother…

          • The Bofa on the Sofa

            “Clap or the fairy gets it”

            Awesome

    • Lisa from NY

      “Most midwives bring emergency medical equipment to births including oxygen tanks, pitocin, syringes, etc, but because of the quality of care they provide, they are much less likely to need to use these tools than an OB.”
      Can I puke now?

      • Antigonos CNM

        Well, they are certainly less likely to know how and when to use them — assuming they have all this reputed equipment, etc. And again, there’s no mandatory standard or protocols for use.

      • t.

        I can bring emergency medical equipment around if I wish. Doesn’t mean I know when or how to use it but hey, I can.

    • PrimaryCareDoc

      My eyes started bleeding after the fourth “mama.”

  • Squillo

    Gordon writes:

    Epidemiologists and birth certificate scholars have made their concerns about reliability and validity exceedingly clear in an enormous body of literature over the last few decades, and in fact, expressed these concerns directly to Frank Chervenak (co-author on this study) earlier this year when he presented this very data at the Institute of Medicine’s workshop onResearch Issues in the Assessment of Birth Settings (IOM & NRC, 2013, p.143).

    Here’s what the report she cites says:

    With respect to the 5-minute Apgar scores reported by Chervenak, [Marian] MacDorman wondered how well lower Apgar scores were reported, given the poor reporting of higher Apgar scores. MacDorman mentioned her own unpublished 2009 data, which linked birth and death certificate data on infant mortality by place of birth and provider.

    That is the only mention of the validity of birth certificate Apgars in the report. If there are other “epidemiologists and birth certificate scholars” claiming otherwise, perhaps Gordon could cite them.

    So we have MacDorman’s “wondering” based on unpublished data versus the conclusions of a pair of peer-reviewed studies that found near-perfect reliability with regard to Apgars.

    • Mr.G

      I was at the conference in March in DC. MacDorman’s criticism of the study and using Apgar scores was much, much stronger and totally off the truth. She blatantly lied about the evidence and disregarded her own papers. Then, when the written report comes out those lies were removed because she realizes more than Wendy does that in writing her comments would have appeared even more lunaticky and would have exposed her even more as what she really is: Me a Frawd Too.

      • Squillo

        So Gordon is relying on the unpublished remarks of a single epidemiologist based on her unpublished data?

        I’m shocked. Shocked!

  • auntbea

    “I’ve also written previously about the dangers of reporting relative risks (“ten times higher!”) without acknowledging that the absolute risk of the complication is actually very, very low…Some of the raw numbers that Grunebaum reports in the study are so low…that it is hard to imagine how practitioners could use this information to draw any meaningful conclusions whatsoever about
    clinical practice.”

    Translation: It is totally uncool of them not to present the results in a way that would prevent us from drawing any meaningful conclusions about the safety of homebirth.

    • Squillo

      If that’s the case, it will be equally hard to draw any meaningful conclusions from the MANAStats data and the peer-reviewed! studies they’re promising. They only contain 24,000 homebirth records. This study had >60,000 (>100,000, if you count freestanding birth centers, which Gordon apparently doesn’t.)

  • KarenJJ

    Geez these guys are clowns. Stop pretending and get a real job!

  • Dr Kitty

    “There may be important differences between home and hospital populations with regard to whether these anomalies were detected prenatally and whether parents changed their birth plans because of it”

    This is Chutzpah!

    What we KNOW as a fact is that women who choose HB may decline antenatal investigations. For that reason one would expect there to be a higher rate of fatal foetal anomalies in the HB group, because many people who ARE given such diagnoses choose to end the pregnancy, often in such a way or at such a gestation that APGARS and birth certificates don’t factor in at all. Almost all hospital deliveries of babies with fatal anomalies will be to parents who a) are aware of their baby’s diagnosis and b) have chosen not to interrupt the pregnancy early.

    If parents do have such a diagnosis antenatally, very, very few will decide to deliver at home, under MW care. The reason being that almost every parent in that position holds onto some shred of hope that the tests were wrong and things are not as bad as the doctors predict. Those parents choose hospital, because if there is ANY chance of saving their child, they’ll take it.

    Wendy is trying to have her cake and eat it, essentially saying that yes, HB increases your chances of having an unexpected fatal birth defect, but that actually somehow makes the appallingly high death rates OK, because those babies were meant to die, and they probably made up most of the HB deaths.

    • Squillo

      In other words, it increases the chances that an unexpected birth defect will be fatal.

    • auntbea

      I don’t actually think she was being that deliberate. I think she was just throwing out all the sources of measurement error she could think of, because she actually believes that debunks the study. My undergraduates do the same thing, because they are impressed with how easily they can make what sounds like a Very Serious Critique without needing to expend much mental energy at all. They get sad when we get to the part of class where we learn that measurement error is not the same thing as bias and they are going to have to work a little harder with the analysis.

  • Squillo

    While Gordon was busy not mentioning Northam & Knapp (who put reliabilty of birth certificate Apgars at again 91-100%) this time, she also neglects to mention DiGiusppe & Aron 2002, which found that agreement between birth certificates and medical records was “almost perfect” for Apgar scores.

  • Squillo

    Gordon writes:

    Even if every single one of those babies had a 5-minute Apgar score of zero, Grunebaum’s rate of zero Apgars in the hospital would increase from 0.25/1000 to 0.49/1000. In reality, only a very small proportion of home birth transports actually do result in such an adverse outcome, and thus essentially have a negligible effect on hospital outcomes.

    On the other hand, even a small percentage of misclassified outcomes in the home birth category have a dramatic impact.

    Translation: If you could correctly attribute transfers, our crappy outcomes would look even crappier.

  • Antigonos CNM

    Alas, the Big Lie can be surprisingly effective. People, or a lot of them, anyway, will believe what they want to believe, not necessarily what is correct.

    • araikwao

      Yes, conspiracy theories are key to a lot of belief systems – anti-vax, sCAM, anti-GMO, home birth..

  • PeepsGottaRight

    When do we start the legislative effort to open MANA’s little shop of horrors? Wendy ~ Publish the death statistics. People have a right to know!

  • Squillo

    the key point is that they reflect INTRAPARTUM stillbirth, not stillbirth before labor begins. How do we know that? Babies who die before labor begins don’t get birth certificates and they certainly don’t have 5 minute Apgar scores assigned, because Apgars are given only to babies believed to be alive prior to the moment of birth.

    That was my thought, too, but Grünebaum et al. note in the limitations section of the study:

    [I]t is not possible to know from the CDC data whether a 5-minute Apgar score of 0 was effectively a stillbirth that occurred antepartum or intrapartum.

    • Antigonos CNM

      In which case the only births which could be included in the study must have had at least one documented FHR during labor itself. And that, in the hands of an untrained, or badly trained, midwife, can be deceptive. I’ve had several patients who presented with what appeared to be FHRs of 160 but in reality had maternal pulses of 160 and FHRs of 80. You’ve got to be sufficiently aware to take the maternal pulse, too — and I would not take it for granted that all homebirth midwives are that aware.

      • Squillo

        To make sure I’m understanding correctly: In order for a neonate to have a recorded 5-minute Apgar and be issued a birth certificate, there had to have been one or more FHR noted intrapartum, which would mean it had to be an intrapartum stillbirth?

        • Antigonos CNM

          If a woman is laboring in hospital, there is going to be not only a note made of an FHR — taken by a nurse/midwife with either an old-fashioned fetoscope like the Pinard, or more likely with a Doppler, there will also be a fetal monitor strip. This constitutes real evidence that the fetus is alive after the onset of labor.

          At home, you MAY have a competent midwife, who has her own Doppler [and possibly a witness who sees it being used and hears it so that you aren’t taking the midwife’s word] but you almost certainly are not going to have a fetal monitor which prints out. Or you may have an incompetent midwife who THINKS she heard an FHR, or maybe doesn’t even listen but takes the mother’s word that she’s feeling fetal movements. This seems almost incredible, but since there are midwives who pride themselves on being absolutely non-interventional in any way whatsoever unless invited to do something by the laboring woman, nothing can be taken for granted. And, during labor itself, it isn’t uncommon for fetal movements to be reduced or even absent, so that the fetus might or might not be still viable. You may think that this level of insanity is beyond even the weirdest of “midwives” but I don’t think it can be discounted entirely. We’ve seen that midwives can be duplicitous and that at least one book instructs them how to lie. In hospital there are always others around; in the home environment, who knows what’s going on?

          Frankly, I doubt the statistics would be much different, even if it were possible to really observe all homebirth situations with complete accuracy. But there probably are some — at least a few — homebirths which are designated intrapartum deaths but which are actually antepartum deaths.

          • Amy M

            Especially in those “my baby will come when he is ready, and he wasn’t ready until I was 43 weeks pregnant” cases.

        • auntbea

          I think I am more confused now.

          • Squillo

            If you find no heartbeat during labor and the baby is born dead, it’s a stillbirth and no birth certificate is issued and no Apgar assigned, if I understand Amy and Antigonos correctly. So none of the births included in the study, with Apgars of 0, could have been stillbirths.

            Which seems to contradict what Grunebaum says in the limitations section of the study.

            Or am I confused?

          • auntbea

            See? Confusing. I think the answer is that there *could* be a mistake, with a “heartbeat” found for babies who are actually no longer alive. Unlikely in a hospital, but possible with a midwife who doesn’t know how to find a heartbeat. So there may be antenatal deaths erroneously classified as intrapartum deaths in the HB group, which would be artificially inflating their mortality rates. Essentially, the defense is (once again) their own incompetence

          • KarenJJ

            The more they try to defend themselves against the poor data coming out the more unprofessional and incompetent they look. It’s really starting to get embarrassing for them.

            The “but we’re just kind hearted little women working away at helping women” line is not going to work for them for long I hope.

          • anion

            The more they try to tighten their grip the more star systems–sorry, facts–will slip through their fingers.

            (Sorry, couldn’t resist.)

          • The Bofa on the Sofa

            Wow, that’s some serious PCM credit, there. Given the name “anion” and a great use of a Princess Leia reference, you have little more to do than apply. You clearly have the skills needed to be an outstanding PCM.

          • anion

            Well, I try. 🙂

          • kumquatwriter

            Do! Or do not. There is no try!

          • Squillo

            It wouldn’t inflate their mortality rates–dead is dead– but it would mean that some of the deaths were possibly unrelated to quality of care. Of course, it could also mean that a death that would otherwise end up in the “home” column ended up in the “hospital” column, if the midwife heard what she thought was a FHR, then transferred when it’s “lost” later on. How many of those have we read about recently?

            Either way, the inability to differentiate between an antepartum and intrapartum stillbirth is a limitation to the study, as the authors note.

          • Squillo

            What’s confusing me is the idea that the data Grünebaum et al. used contains stillbirths. The various states’ definitions of live birth require some signs of life–respiratory effort, voluntary movement, pulsing umbilical cord. If a baby is truly stillborn–i.e., shows no signs of life after expulsion from the womb–does it receive a birth certificate and 5-minute Apgar? If not, it would seem to me that these have to have been excluded from the study. Yet the authors note that the possible inclusion of stillbirths is a limitation.

          • Dr Kitty

            Squillo, sure a macerated stillbirth that was obviously some time antepartum won’t get APGARS, BUT few health care workers will see a lifeless baby and call it quits without trying CPR.
            Even if they never get a pulse or a breath, most would do several minutes of CPR before calling it, and so yes, there will be stillborn babies with birth certificates and APGARS.

          • Squillo

            Thanks, that’s helpful to know.

      • Lisa Cybergirl

        Can a baby be alive with a zero Apgar?

        • Young CC Prof

          Technically, no, since zero Apgar means the no heartbeat, but some babies with low or zero Apgar can be revived. Just as with adults with no pulse, whether revival is possible depends on how long since the heart stopped and why it stopped.

        • Antigonos CNM

          If the Apgar is really zero at 5 minutes, no. At 1 minute, it is highly unlikely, but if resuscitation can establish a heartbeat, it might be possible to save the baby [who would be very sick initially; requires intubation and ventilation, etc. and IMMEDIATE transfer to NICU.

          In a homebirth situation the odds are virtually nil. Even in hospital, with a trained team in the delivery or operating room, working on the baby from the moment of birth, the odds are very bad. Every SECOND counts.