The many deceptions, large and small, in the new MANA statistics paper

Eye looking thorough magnifying glass

Yesterday I gave a brief overview of the new MANA statistics paper (Homebirth midwives reveal death rate 450% higher than hospital birth, announce that it shows homebirth is safe) and pointed out that the fact that MANA waited 5 years to release the results demonstrates that Cheyney at el. have known for years that their death rates are hideous. It took them that long to figure out how to spin a death rate more than 5.5 X higher than comparable risk hospital birth as “safe.”

Today I’d like to take a closer look at the many deceptions, large and small, that Cheyney and colleagues have employed in writing a paper that has a conclusion directly opposed to the actual evidence.

But before we look at what Cheyney et al. wrote, it is helpful to consider what we need to know to make a determination of safety.

1. We need to know how many babies of the nearly 17,000 intended to be born at home actually died.
2. We need a comparison group. In this case, because we are looking at presumably low risk white women, ages 20-44, at term, with babies that are not growth restricted, the appropriate comparison comes from the Linked Birth Infant Death Files collected by the CDC. The database is publicly available on the CDC Wonder website. The death rate for the years 2004-2009 is 0.38/1000.
3. We CANNOT compare homebirth to out of date studies.
4. We CANNOT compare homebirth to other countries since the populations are quite different.
5. We CANNOT remove congenital anomalies from the homebirth group unless we also remove them from the hospital group.
6. We CANNOT assume that the fact that a baby died of a congenital anomaly at home means that it is a “lethal” anomaly. Many anomalies that inevitably result in death at home are highly treatable in the hospital.
7. We cannot remove breech, twins, VBAC, and other high risk conditions from the homebirth group because homebirth midwives are publicly on record claiming that these conditions are “variations of normal” and have lobbied across the country to have them included in homebirth midwives scope of practice.

When we compare the death rate at homebirth of 2.06/1000 with the CDC death rate for low risk white women, ages 20-44, at term, with babies that are not growth restricted of 0.38, we find that homebirth has a death rate 5.5X higher than hospital birth. In other words, the death rate at homebirth is 450% higher than comparable risk hospital birth. A third way of expressing this finding is as follows:

4 out of 5 babies who died at home could have been saved in the hospital.

In simple terms, the bulk of the MANA stats paper is a bald faced attempt to bury these results by inappropriately removing groups that should be included and then inappropriately comparing the results to papers from other countries.

At various points in the paper, Cheyney et al. remove congenital anomalies, remove breech, twins and VBAC. They proceed to compare the result to homebirth papers from the Netherlands and Canada. They ignore the CDC death rates for comparable risk white women during the same years; indeed, to read the paper, you wouldn’t know that the CDC death rates exist.

Their conclusion:

If you inappropriately remove anomalies, breech, twins and VBAC and compare the results to homebirth studies from other countries, our results aren’t that much worse; ergo homebirth is “safe.”

Cheyney at al. do provide data that should give everyone pause:

Of the 22 fetuses who died after the onset of labor but prior to birth, 2 were attributed to intrauterine infections, 2 were attributed to placental abruption, 3 were attributed to cord accidents, 2 were attributed to complications from maternal GDM, one was attributed to meconium aspiration, one was attributed secondary to shoulder dystocia, one was attributed to preeclampsia-related complications, and one was attributed to autopsy-confirmed liver rupture and hypoxia. The causes of the remaining 9 intrapartum deaths were unknown.

So out of 22 babies who died during labor (compared to a predicted rate of zero deaths in the hospital), 13 died of preventable causes. They died because they were too far from the personnel and equipment who would have saved them.

For the 7 newborns who died during the early neonatal period, 2 were secondary to cord accidents during birth (one with shoulder dystocia), and the remaining 5 were attributed to hypoxia or ischemia of unknown origin. Of the 6 newborns that died in the late neonatal period, 2 were secondary to cord accidents during birth, and the causes of the remaining 4 deaths were
unknown.

So out of 13 babies who died in the neonatal period, at least 9 died of preventable causes. They died because they were too far from the personnel and equipment who would have saved them.

In other words, out of the 35 homebirth babies who died, at least 22 died of obviously preventable causes.

The death rates in certain subgroups were astronomical.

(5 fetal/neonatal deaths in 222 breech presentations), TOLAC (5 out of 1052), multiple gestation (one out of 120), and maternal pregnancy-induced comorbidities (GDM: 2 out of 131;
preeclampsia: one out of 28

The authors are honest about the primary methodological limitation of the study. Data collection was voluntary and only 20-30% of CPMs contributed:

The main limitation of this study is that the sample is not population-based. There is currently no mandatory, reliable data collection system designed to capture and describe outcomes for all planned home births in the United States.We are also unable, for a number of reasons detailed elsewhere, to quantify precisely what proportion of practicing midwives of various credentials contributed data to MANA Stats between 2004 and 2009…

It is highly likely, therefore, that the 450% elevated death rate dramatically UNDERCOUNTS the real risk of homebirth.

Nonetheless, we can reach important conclusions. Despite the fact that the authors surveyed only a small proportion of practicing midwives, who submitted data that was not validated, and despite the fact that they authors performed a variety of maneuvers that violated basic standards of statistical analysis, and despite the fact that they were intent on concluding that homebirth is “safe” regardless of what the data showed, they actually showed that homebirth has a minimum rate of death 5.5X higher than comparable risk hospital birth.

We can also be sure that the authors understood that their data showed that homebirth has a horrifically high death rate, because they try to hide the number of deaths for the past 5 years, released the data only under pressure, and then proceeded to draw a conclusion entirely at odds with what their own data showed.

In addition, we can also conclude that homebirth is NEVER appropriate for breech, twins or VBAC.

Finally, we can come away from the paper with the horrifying realization that MANA has absolutely no idea what its own members are doing. There is no systematic attempt to determine if they are safe practitioners. To hear the authors tell it, they can’t even figure out how many practicing CPMs are actually submitting statistics, let alone whether those statistics are accurate.

When it comes to the safety of homebirth, the only question remaining is:

Who are you going to believe, MANA or your own eyes?

 

More on this study:

Homebirth midwives reveal death rate 450% higher than hospital birth, announce that it shows homebirth is safe.
Why did the Midwives Alliance of North America wait 5 years to publish its statistics?

  • Ash

    HOLY CRAP. I just realized a connection between these two reports of liver rupture. Looks like they are the same.

    “…one was attributed to autopsy-confirmed liver rupture and hypoxia.”

    Breech delivery with a CPM. See pages 7 and 8. Liver rupture. Apgar of 0 at one and five minutes.

    http://www.dhp.virginia.gov/Notices/Medicine/0129000032/0129000032Order09092008.pdf

  • Violette

    #4 (not comparing to other countries due to population differences) is one of the most compelling for me. It’s also the most frequently used by homebirth advocates. “Why is our maternal mortality so HIGH in comparison!!!” Possibly because we’re a country with a large population (roughly 1/3) who are medically considered obese, leading to countless healthy problems. We have a higher maternal mortality rate because we have higher rates of medical issues in our general population that will increase risks during pregnancy and delivery.

    • Karen in SC

      Also, twice in the recent past, death certificates made key changes that allowed deaths to be classified as “maternal death.” Dr. Amy did a blog post about it.

      Another point is that other countries don’t have our system of certifying death, for pregnant woman and infants. So comparisons are hardly apples to apples.

    • PJ

      International comparisons in general tend to be difficult. It’s very hard to ensure that exactly the same things are being measured in exactly the same way. Maternal mortality in the US is driven by appallingly poor outcomes for African American women–this is the real scandal.

  • laylamm81

    I am confused about where the .38/1000 number came from. I’ve been looking, but I can’t find it. Can anyone point me in the right direction?

    • C T

      The CDC Wonder database. Use the restrictions that Dr. Tuteur gives: “low risk white women, ages 20-44, at term, with babies that are not growth restricted.”

      • Ash

        What are the search parameters?

        20-24 years, 25-29 years, 30-34 years, 35-39 years, 40-44 years
        White
        Non-hispanic white
        37-41 weeks (i decided to be more generous with the parameters here)
        2500-2999 grams
        all years of death

        i did not get .38/1000, so I am wondering what the search parameters should be

        • C T

          Only up to 2999g? That’s kind of small still. Play around with the parameters a bit more. It’s actually rather fun. 🙂

          • Ash

            Still can’t get even close to .38, although I am using only 2007-2009. I’m hating, but can anyone help me out with what parameters are being used?

          • Young CC Prof

            Try age at death, since we’re talking perinatal mortality.

          • Ash

            Age of infant, 0-7 days, mother: white, not hispanic, birth weight: 2500-3499grams, singelton, in hospital, years 2007-2010. This gets to .41, yes? Then adding high school and up, plus married gets to .39

  • CanDoc

    I’m shocked that the (reported) death rate is as low as it is. At 2.06/1000, it is a low enough number that I suspect it’s not going to sway many (if any) homebirthers into hospital birth… Because that translates to “99.8% of the time my baby won’t die!”

  • LMS1953

    “Medicaid reimbursements don’t cover the costs of homebirth, she said. Low-income Vermonters still must pay for much of the care out of pocket.

    “If we were only to take what Medicaid reimburses for us, no one would even make a living,” said Hamilton.

    Hamilton has colleagues in New Hampshire who have been less than thrilled with insurance coverage won in the Granite State.

    “A lot of them have given up taking insurance because you can’t survive,” she said.”
    ******************
    http://vtdigger.org/2011/05/17/vermont-bill-will-mandate-insurance-pay-for-home-births/

    Whoa, hold on a second here. When you take Medicaid reimbursement for services as a physician that IS ALL YOU GET. You are not allowed to balance bill. The reimbursement does NOT cover the cost of providing the service (ie, the pro rata share of overhead). Taking money from a Medicaid patient for a service that Medicaid covers is considered Medicaid fraud for which you can be expelled from the program and prosecuted with the possibility of fines and imprisonment.

    • Squillo

      Welcome the wild, wacky world of being treated like a professional, Ms. Hamilton. How do you like it so far?

      • Susan

        Applause.

    • Squillo

      Is Hamilton saying that homebirth midwives are balance-billing their Medicaid clients?

      • LMS1953

        Well, c’mon now. Placenta desiccation and encapsulation machines don’t grow on trees ya know?

      • Medwife

        Shee-it. And saying it like that… She truly seems not to realize she’s committing fraud.

        But… But Medicaid just doesn’t reimburse us enough to make a profit! Yeah lady. Welcome to health care.

    • An Actual Attorney

      Aren’t there fraud hotlines to report that sort of thing?

      • LMS1953

        Well, they could be saying that they DON’T accept Medicaid at all because of the low reimbursement rates that do not so much as cover the cost of providing the service. If you never at any time past/present/future accept Medicaid payment, then you can legally bill the patient your full charge. Now, if a male OB did that, he would be scourged, castrated and crucified with a plaque nailed over his head reading, “Behold, here hangs a penocrat who was in it only for the money”

        • An Actual Attorney

          That’s not how it reads. She says low income VTers still pay for MUCH of the care out of pocket. If she was saying she doesn’t take medicaid, then it would say MANY low income VTers still have to pay out of pocket.

          Now, I have seen plenty of my own quotes get messed up in the press, and plenty of quotes that were right but didn’t sound as clear in print as in my head. But if I read an incorrect implication that I was committing a crime, I’d make sure there was a major correction notice on the article.

          I’m pretty sure she’s saying she balance bills.

          • LMS1953

            I was just playing Devil’s …..er….Midwive’s Advocate trying to give her every benefit of the doubt. I read it precisely as you did. Please note the dates of the articles I have been posting from the Vermont situation. This one was 05/17/2011.

          • Karen in SC

            Anonymous form from reporting IRS fraud, like taking cash payments and not adding to income to be taxed.

            http://www.irs.gov/Individuals/How-Do-You-Report-Suspected-Tax-Fraud-Activity%3F

            I wonder if insurers issue 1099s to solo practitioners?

  • meg

    Being able to attribute a cause of death does not mean that that particular death was “obviously preventable”.
    By your logic we can always prevent placental abruption. How about meconium aspiration? Shoulder dystocia?
    And what magical solution does being in a hospital offer? Birthworkers can’t possibly assist a woman onto all fours, perform suprapubic pressure, rotate into the oblique or remove a posterior arm, unless they’re on a delivery ward, right?

    • Karen in SC

      Hospital teams (yes, more than one or two people) hold drills for SD. And when mec is noted, another team rushes in that is trained in neonatal rescusitation – trained, certified, and also practiced. Not magic, but a lot more reassuring that a midwife or two that maybe saw a video, maybe dislodged one shoulder, and forgot the oxygen tank.

    • Box of Salt

      meg “And what magical solution does being in a hospital offer?”

      A resus team for the baby, a blood bank for the mom, an OR for both. Oh, wait, that’s not magic – it’s medical science.

      Are those available at home?

      • Kory Oransky

        Based on my anecdotal evidence (which seemingly is the only authentic kind), nope, not available in my house.

        They were, however, available at the hospitals where I delivered my children.

        Could that be why we are all still here? Naaaaaaaah.

    • theNormalDistribution

      If the death can be attributed to a complication that could have been treated with a c-section, then yes. Yes it does.

    • Playing Possum

      Can’t prevent these things. Can predict them some of the time. Can intervene to minimise them most of the time. Can prevent secondary morbidity nearly all the time. The last one’s the big deal. They are going to happen no matter how much kale/ prenatal vitamins/ affirmations/ womyn woo is used. They are largely unmodifiable risks, and delivery suites do a lot to prepare for them when they happen (when, not if).

    • Petanque

      Just off the top of my head – they can offer several well-trained people who are experienced in recognising and acting on problems before they become serious, sterile equipment at the ready, and of course a surgical theatre that isn’t a car trip away.
      Effective pain relief is also nice too, it doesn’t have to be a “magical solution’ to be helpful and safe.

    • Trixie

      You use “birthworkers” as if that’s a real word.

    • PrimaryCareDoc

      Have you heard of C-sections?

      • Anj Fabian

        I have. Wonderful things. Saved my son’s life.

        Yet some people say “c-section” as if it was a dirty word.

        • Atom

          I was a breech baby, born c-section almost 40 years ago. I presume I was not held by my mother as much as I might have been those first few days. I can now blame all of my life’s failures on this.

    • Squillo

      The solution a hospital offers for s/d–aside from c/s to prevent it–is resources. Practitioners who have drilled and attended real SDs. Practitioners who are experts in resuscitating and caring for very sick neonates.

      I went to an OB emergency drill at our public hospital last year. It used a robotic patient and included OBs midwives, L & D nurses, and pediatricians. None of the participants was aware of the nature of the drill–what the specific emergency was going to be–before it started. What came out in the debriefing afterwards (it was all filmed so they could assess performance) was how important everyone thought having a team was. Once the midwife called for help and the team responded, each individual took responsibility for one aspect of the emergency: helping deliver the baby; monitoring mom’s and baby’s vitals, recording the time; reassuring the mom and dad; and, once baby was out, resuscitating the baby while other members of the team attended to the family’s needs, physical and emotional.

      The original delivering midwife said something during the debriefing that stuck with me. She said that she had trouble getting her hands in position to deliver the shoulder, and that she was very glad that the other midwife was there to try, as she had smaller hands. There were also two OBs there to try, had neither midwife been able to manage it.

      So no magic, just a lot more resources–read: a lot more chances to save the baby–when things go south.

    • The Computer Ate My Nym

      “Birthworkers” (I won’t go into what image that phrase brings to my mind) often have never resolved a shoulder dystocia or even seen one resolved. They certainly don’t hold regular drills. Knowing the theory of how to do it isn’t enough. Not to mention that you can’t do a stat c-section at home if the various maneuvers don’t resolve the dystocia.

      As for placental abruption, frequent monitoring allows it to be found more quickly and having an OR down the hall as opposed to at a hospital “five minutes away” (plus getting dressed, traffic, getting registered and assessed, possibly pulling the OB off another case, possibly calling the OB in if it’s a small hospital, etc) allows for much quicker action in a situation where every second counts.

      Meconium aspiration is much easier to deal with when you have a team of pediatricians with rescus equipment, ranging from nasal syringes to respirators, on hand than at home, with a single midwife or maybe a midwife and a doula or apprentice, neither of whom has any experience with neonatal emergencies, even if they actually do have experience with obstetric issues.

      So, as everyone’s been saying, no magic, just lots of trained people with proper equipment for early detection and treatment of emergencies.

    • Amazed

      You seem to have your notions confused. “Obviously preventable” doesn’t mean that the potentially deadly event was in itself preventable. It means that at hospital, there are the people and equipment that would make the DEATH preventable.

      C-section is magic. I am here today, healthy and neurologically intact, because the magical hospital midwives realized they would need the magical doctor and he brought in the magical vacuum. Magic, I’m telling you!

    • LMS1953

      “The Pro-Home Birth Advocate Said What?”

      • ngozi

        Are you referring to the “My OB Said What?” website? Funny thing is, a good number of the complaints on that website are about midwives.

        • LMS1953

          Yes I am ‼️

          • ngozi

            I read that site a lot, and I have noticed (maybe I am wrong) that most of the comments aren’t from the doctor/OBGYN at all.
            I do wonder about some of what I am reading on there, but considering some of the experiences I have had at my own local hospital, I wouldn’t be surprised if most of what is alleged on that site is true.

          • ngozi

            I am sorry, I meant to say that most of the quotes women submit to the “My OB Said What?” website seem to come from midwives, nurses, ultrasound techs, etc…

    • PrecipMom

      Here is what you are missing:

      No, being in a hospital may not prevent a shoulder dystocia. It may not prevent meconium aspiration (although a timely induction reduces the risk of MAS.) It will not prevent a placental abruption, although it does mean that you have a shot in hell of being able to rescue that baby from the consequences of placental abruption. Being in a hospital means that if any of those things happen, you have access to the best resuscitative efforts.

      Maneuvers for shoulder dystocia can absolutely be done outside the hospital setting. But when that baby has been without oxygen for a few minutes, you may not be looking at a situation where first line resus is going to work. You may be looking at a situation where for that child’s neurological health you have a tiny window of opportunity to get the oxygen back to their brain. For that, if the baby is compromised enough, you need more than what is available in the home setting. You need a crash cart. You need access to intubation. Oxygen and De-Lee suction are not enough in those cases. And being in the hospital versus out of the hospital is the difference between life and death, between neurological health or brain injury from suffocating for too long.

      And yes, it is rare that you encounter something that severe that the first line is going to be useless. But it’s less rare than one might think, and it comes down to whether you think that baby matters. If that baby’s right to life and to health doesn’t matter, by all means, plan a home birth. But if you think that baby matters, and if you have the humility to accept that there is no reason why that baby won’t be yours, plan for birth in a setting where a baby born in that condition has a chance. That means in a hospital, really one with a NICU and with 24/7 in hospital obstetric and anesthesiologist coverage.

    • yentavegan

      In a hospital, with routine fetal heart monitoring, sometimes the doctors and nursers have enough information from that “intervention” to know that labor is not progressing smoothly. Not always, but in hindsight with EFM the decision to intervene and do a c/sec prevents a labor going bad from becoming a birth going deadly.

    • ngozi

      But midwives tell their clients/patients that if anything goes wrong that they are close to a hospital. If an emergency arrives I would rather be in the hospital than close to it. Just because you are 5 minutes away from the hospital does not mean that you will get the help you need in 5 minutes.

  • An Actual Attorney

    hmmm hmmm: I think it’s appalling to note that data capture for the variable “Method of Payment” was 99.96% (recorded in 16,917/16,924 cases), but for Apgars it was 38% (245/646) and neonatal transfer 54% (149/277) of cases.

    I just wanted to highlight that observation.

    • Anj Fabian

      That observation tells us that the the highest priority for a CPM is how she will get paid.

      Apgar? Meh. Not even half as important.
      Whether the baby was so ill that it needed hospital care? A little over half as important.

      But hospitals and doctors are in it for the money? My son’s discharge papers have the Apgar scores listed on them. His chart probably has them too. It’s as if the hospital thinks those numbers are important.

    • Becky05

      You’re misreading their chart. The number listed is the number of low APGAR scores, not the number reported. The denominator in both cases is 16984, and so they’re missing 401/16984 Apgar scores (still a substantial amount) and 128/16984 entries on neonatal transfer.

      • Anj Fabian

        Oops.

        So the data loss is smaller than we thought.

      • Hmm hmm

        Sorry I could maybe have expressed that better. I was trying to get a ratio of cases in which an outcome occurred to cases for which no data was provided. Regardless of the denominator, such a ratio could get us closer to estimating the extent to which events are underreported in the dataset and highlight the potential “worst case scenario” if all missing data were cases in which the relevant outcome (be it NICU admission or low APGARs) occurred. (For some variables the number of missing values exceeds the number of incidents reported).

        Secondarily, I think it highlights the data entry priorities of the midwives, since there are only a handful of cases for which payment method was unrecorded.

        Let me know if I’m making an error.

  • Guesteleh

    Over on TFB’s Facebook page, Wendy Gordon is saying you can’t compare the hospital death rate to the homebirth death rate because hospitals don’t record intrapartum deaths. I’m also seeing this being picked up on other sites as well. Can anyone address this argument?

    • Trixie

      I’ll let a pro tackle the stats, but is she seriously arguing that there’s a black hole of time for which the CDC does not count deaths? Isn’t it more likely that intrapartum death is so rare within hospitals today that it’s basically nonexistent? It seems like she’s trying to cast a shadow of doubt on the hospitals to distract from the fact that their study showed so many intrapartum deaths.

      Also the Science and Sensibility article portrayed the intrapartum statistic as if it was the entire death rate.

      • Guesteleh

        Wendy Gordon Midwife The CDC wonder database is only giving you the numbers for neonatal deaths. They are missing the intrapartum deaths that happen in the hospital. Intrapartum deaths that occur in the hospital are not reported in the CDC data.

        • Guesteleh

          ^^^That’s one of her posts on TFB’s page, there’s lots more where that came from. But people are very politely arguing with her and backing it up with numbers, so that’s good.

          • Amy Tuteur, MD

            Someone should ask Wendy why, if the MANA data shows homebirth is safe, they hid it for the past 5 years.

          • Squillo

            Someone should also ask her why she and her co-authors didn’t consider death an adverse outcome.

          • Box of Salt

            And what they think “no conflict of interest” means.

    • Squillo

      That’s kind of funny, because one of the references in the MANA paper (The UK Birthplace study) includes intrapartum deaths.

      • wilsonofprussia

        CDC Wonder does not include interpartum death in the linked birth / infant death file. Therefore it isn’t appopriate to add intrapartum death with neonatal death to one group to compare to another.

        • auntbea

          Our best evidence suggests that IP death rate in the hospital is essentially zero. If you add an IP rate of zero to the neonatal death rate, you get….the neonatal death rate. So using the neonatal death rate as a sum of IP and neonatal death is not inappropriate.

          • wilsonofprussia

            Where is this evidence?

          • wilsonofprussia

            My point is that the CDC does have a fetal death file but it isn’t linked to the birth/infant death file. Intrapartum deaths are there. Intrapartum death are not in the Wonder data so it isn’t appropriate to add intrapartum death to neonatal for one group for an overall death rate of 2.06/1000 and compare it to the neonatal death of .3/1000. If we are calling out folks for misleading others then fair is fair. A comparison of neonatal death rate of 1.3/1000 is still concerning compared to .3/1000 and is a more approriate comparision of like to like. I don’t know know where 2.06/1000 came from unless it also included intrapartum. I am interested in seeing more data/evidence on intrapartum death rates. Please share your best evidence. Thanks

    • Susan

      Huh? Hospitals don’t record intrapartum deaths? Oh please. On the other hand…. there are just exceedingly freakishly rare because we know when the baby is dying… unlike homebirth.

      • Jessica S.

        / Yeah, what she said. 🙂 I should’ve read your reply first!

    • Jessica S.

      I think I’ve read Dr. Amy, and other professionals here, explain that intrapartum deaths are very rare in hospitals and so when they happen, they are likely to be investigated on a case by case basis. What I gather, again from what I’ve picked up here, is that with the constant, regular (an accurate!) monitoring of the baby in the hospital, if there is a sign of distress, they get that baby out ASAP, thus no surprises, even if the baby doesn’t survive. I’m explaining this really poorly, I’m sure, so I hope someone else more qualified can answer!

      • Informed Mother

        Oh of course, it “rarely” happens so we can assume that it happens more often in home births than at hospital. You do realize that the numbers for home births are tiny. And there are no statistics to compare them to. “Dr” Amy has been very disingenuous here.

        How about highlight the ACTUAL comparisons:

        0.41/1000 early neonatal death rate in the MANA study compared to 0.46/1000 early neonatal death rate from national data;
        0.35/1000 late neonatal death rate in the MANA study 
compared to 0.33/1000 late neonatal death rate from national data.

        There is no national data on the intrapartum neonatality rate, so we cannot compare that to the MANA data.
        Now do you understand why this study validates homebirth? And yes, myself and many homebirthers and most midwives agree that breech and multiple births etc are best performed in a hospital. Homebirth is a reasonable and safe choice for a low risk woman, that is as safe and frequently safer than hospital.

        • Squillo

          Do your hospital stats include neonates who died from congenital anamolies?

        • ronadair

          Aaaaaaaand, no responses. Great questions, though, and I was wondering the same things. Go figure.

      • Informed Mother

        Also, I just want to make clear when we talk about “intrapartum deaths” these are stillbirths. Sadly they happen in all medical settings.

  • LMS1953

    Early in my career, about 25 years ago, I had my first experience with a lay MW attending to a HB. I got a phone call one Sunday night from her. We had attended a Michel Odent conference on “rebirthing” and “natural birth” and she assumed she would get a sympathetic ear from me. I took the transfer in the context that I was on call and by EMTALA Law, I had no choice. Her client was at 40w 3d. She was doing a home TOLAC. She was breech. She had SROM for 24 hours. She was stuck at 8 cm for 6 hours. Now, any of these factors would have been, by itself, an indication. The constellation was astonishing. She came in with her client and was gracious enough to translate why I thought a C-section was indicated. She delivered an 8#12oz baby. Mom and baby did fine. The charge for a self-pay C/S (with no prenatal care was $1200. To show her gratitude, mom sent me, each month, a check for $5.00. I relocated about 5 years later. But, I figured she would just now have retired her bill. Ahh, the warm glow of gratitude!

  • manabanana

    It’s a shitty study.

    Ahem, “study”

    • Anj Fabian

      My question is what is the data loss?
      __ women were enrolled.
      __ women had incomplete data submitted.

      What does THAT pie chart look like?

      • AlisonCummins

        I’m not seeing the pie chart? I see five tables and a figure, but no pie chart.

  • LMS1953

    Here is a newspaper link that delves into the waist deep unicorn shit:

    http://vtdigger.org/2012/01/11/blue-cross-blue-shield/

    • Houston Mom

      Wow the penocracy comment from Katherine Hikel MD

      • Guesteleh

        Quote in the article:

        “For some reason, insurance companies feel like they’re in the position that they need to screen providers,” Cohen said. “They’re basically validating only conventionally trained providers.”

        • Young CC Prof

          Actually examining what you’re paying for before you pay for it? Requiring malpractice insurance so that, in the event of a dreadfully expensive provider screwup, they can file a subrogation claim rather than eating the costs themselves?

          Oh, those evil insurance companies. What fresh devilry will they devise?

          • pit bull owners have the same whine when they hear that their dogs aren’t covered or that it will cost more than other dogs. Insurance companies just do the math on these things, they don’t give a damn if its nice or not.

          • thepragmatist

            I’d like to see one of our stat crunchers do the math on that one: is homebirth safer than pitbulls? (Self-disclosure: I owned a cross that people used to avoid for fear, who was actually the sweetest, stupidest dog I’d ever had and worked with me as a service dog until his death last year.

          • Young CC Prof

            What measure of harm do you want? I suspect actual deaths caused by pit bulls (or dog attack in general) are pretty rare. Dog attacks can cause serious injury but usually aren’t deadly.

            Also, the thing about pit bulls is that ones who were treated normally from birth don’t hurt people. It’s deliberate abuse that turns them into killers. (Some horrible human beings do this on purpose because they want a brutal dog.)

          • The Bofa on the Sofa

            I know the part about “there are no bad dogs, only bad owners” but when Paris Hilton’s chihuahua goes beserk, it ain’t taking down the family.

            Meanwhile, Marmaduke can cause serious injury just by being happy.

          • Young CC Prof

            Heh. I lived with that dog for a year, the one that could cause injury just by being happy. Friendliest creature on the planet, hardly even barked. 150 pound Saint Bernard. She said “hello” by putting her front paws on your shoulders, which could knock you over if you weren’t expecting it.

          • The Bofa on the Sofa

            When we got our first dog from the shelter, we went into a pen with a Dane, and he did that (put his paws on my shoulders). He stood a full foot taller than me.

            I’m not a big guy by any means (average) but that was one massive dog. We didn’t adopt him, but I still remember him pretty clearly (black and white Dane).

          • The Bofa on the Sofa

            There are something like 5 million pit bulls in the US. There are an average of about 20 pit bull caused deaths each year. That puts the rate at 1/250K PER YEAR. Most of the victims (something like 2/3) are adults.

            It is hard to otherwise define the denominator. I found a source that gave me 4.5 million dog bites a year. There is also a claim that pit bulls constitute 4% of the dog population.

            If we assume that pit bulls are no more likely to bite than other dogs, than that would make it 180000 pit bull bites a year. If 20 of them lead to death, we can say that the risk of death from being bitten by a pit bull is 1 in 9000. According to Dr Amy, childbirth death risk is 1/2500.

            Therefore, to the best I can figure, childbirth is more risky, at least in terms of death, than being bitten by a pit bull.

            Now, being bitten by a pit bull is going to have a range of injury associated with it, and is, possibly, by definition, causes injury, so we can’t really compare that, but as for death, pit bull bites are safer.

            Then again, no one would ever consider a pit bull bite to be “safe.” With all the debate about the dangers of pit bulls, no one is excusing a dog that bites.

            Yet, as far as death goes, it’s safer than childbirth.

        • anion

          Well, in my opinion it IS “totally inappropriate” for insurance companies to dictate who they’ll reimburse for medical services. I firmly believe this is inappropriate, because it keeps me from getting paid by insurance companies to sing soothing songs, wave my hands around, and think really hard about “health,” when everyone with a brain knows that is a perfectly legitimate and effective cancer treatment.

          It’s not *fair* that I can’t get paid for doing that just like people with real medical knowledge get paid for actually curing diseases and helping people! Why can’t *I* get paid for whatever I wanna do? Why are the insurance companies keeping me from getting rich? Why are they so mean? Why do they insist on only paying for services performed by legitimate professionals that have a good chance at not killing mothers and babies?

          That’s why I’m rooting that insurance companies will be forced to pay for any service anybody wants to provide, effective or not, done by actual professionals or not. I have my “Professional Organization” all set up (it’s called THAW, for Think Health And Wave) and I am, of course, a highly respected member. As soon as those pesky insurers start accepting the New Medical Paradigm I have discovered, myself and the other members of THAW–and, of course, every other loon on the freaking planet with an internet diploma and an acronym they pulled out of their butts–can start boasting about taking insurance just like real legitimate healthcare providers do! And then the consumer will have even LESS idea what’s safe and effective and what isn’t, and even LESS recourse if something goes wrong, and the insurers can go out of business when people sue them for hooking them up with loons like me, and people can die or be maimed! Ha ha! It’s win-win (well, it’s win-win for me. It’s lose-lose for everybody else. SUCKERS!)

          Free THAW! Force insurers to pay for hand-waving and thinking hard TODAY!

          • AlisonCummins

            It’s a real thing, and it’s called Health Freedom.

          • Trixie

            I just read a post about a reiki practitioner who is pissed that insurances won’t cover reiki.

          • R T

            Reiki was a provided service during my months, off and on, in the PSCU during my pregnancy. They also offered massage, mani/pedi & facials etc. It might not have been directly billed to my insurance as Reiki, but I’m sure it got snuck into the bill somehow!

          • At one point in my career, the hospital I was working for went into bankruptcy and closed, so I lost my job, and the chances of finding another midwifery position were slim. Discussing this with the head of the nurses’ union, herself not only an experienced RN, but a PhD in nursing, I was amazed that she seriously suggested that I “retrain” to become a reflexologist. She really thought that was a form of science.

        • Playing Possum

          Isn’t it just so mean how they require their providers to be demonstrably effective and non injurious?!?! How dare they want value for $$ and to minimise expensive, devastating complications?!?!

          Insisting that health care companies take on the risk of untrained practitioners, is like telling them they should also take on the risk of a bigmouth but not at all medically trained friend who has an opinion on everything. Yup, you have a right to get your healthcare from whoever you want, but nobody should have to support your choice unless it’s safe, cost effective, and done by specifically trained and – oh no – VALIDATED practitioners.

      • Squillo

        That was hilarious.

    • Squillo

      To recap:

      CPMs want to be receive third-party reimbursement, just like other medical professionals. But they don’t want any of the pesky regulations that other medical professionals in an acute-care setting are subject to.

      Got it.

  • LMS1953

    Oops, I forgot to post the link to the law

    http://www.leg.state.vt.us/docs/2012/Acts/ACT035.pdf

  • LMS1953

    OK, if you want to know why MANA just now, please review this Vermont Law passed Oct 1, 2011 to be phases in until Oct 1, 2011. As a condition of CPM/DEM licensure they were MANDATED TO FILE their stats via MANA. That the legislature mandate taxpayer subsidy WITHOUT KNOWING perinatal outcome is beyond reprehensible

  • So apparently there was a lot of deception about how these statistics were collected in the first place.

    http://navelgazingmidwife.squarespace.com/navelgazing-midwife-blog/2014/1/31/my-take-on-the-mana-stats-study.html

    • LMS1953

      Terrific link! I think MANA just now published the data as a quid pro quo for the Vermont Legislature to have mandated their payment by Medicaid and private insurance. Why is this not prosecuted as Medicaid fraud?

  • LMS1953

    I’d bet it was GDM trying to VBA2C an 11 pound baby. GDM is associated with an increased thoracic and abdominal girth. She might have gotten by with the head and perhaps shoulders but got hung up at the thorax and abdomen to result in rupture of the liver.

    • melindasue22

      I was wondering about that.

  • Therese

    So what is up with the study’s claims that their rates are similar to the rates found in other studies in other countries? Is that even true? I find it difficult to believe that these other countries’ rates could be similar to U.S. homebirth mortality rates.

    • Becky05

      Well, one of the studies they cited as having similar intrapartum mortality rates was a study of South Australian homebirths which found that homebirths had an intrapartum mortality rate seven times that of hospital birth. They didn’t include that note in the discussion. Also, it is difficult to show statistical significant differences in mortality even with very different numbers because the mortality rates are so low, you need very large sample sizes that aren’t often found.

      • Mishimoo

        Because when one hears the word ‘Australia’, one automatically thinks ‘safe’

        • LMS1953

          Especially when they say things in that disarming accent of theirs, “Put another baby on the barbie for me, will ya, mate?”

          • Mishimoo

            No, no, the correct phrases are: “She’ll be right mate, no worries!” and “She’ll be right mate, no sweat!”

          • araikwao

            This Aussie does not identify with “no sweat” as a local idiom – I thought that was American.

          • Mishimoo

            It was around in the area my Dad grew up in (Mackay), and also part of a Don Spencer song from when I was a kid.

          • Playing Possum

            No wuckas!! Although in SA where I trained, it was ‘shizbee right’.

          • araikwao

            Or South Australia jokes, perhaps? 😛

          • Playing Possum

            Hehehe. Go for it. I’m not going to admit what state I’m in now (or which state I’m from), that would be a big ‘kick me’ sign on my back.

            Gotta love Radelaide though. Baking summers, terrible water … Lisa Barrett …

          • Petanque

            Snowtown . . . .

          • KarenJJ

            Poor old Snowtown. I knew it well before it became notorious for being too close to the highway.

          • araikwao

            Ah, regional differences, of course. Can I start making Queenslander jokes yet? 😛

          • Mishimoo

            Go for it, we’ll just keep dominating Origin 😛

          • araikwao

            I’m from Victoria, so I don’t care. I only speak AFL 😉

          • Mishimoo

            In that case, how about that awesome streak the Lions had a few years ago? Oh wait… lol

          • KarenJJ

            She’ll be apples?

          • The Computer Ate My Nym

            Likewise, don’t say “we’re all rooting for her”. It’s my understanding that that means something else in Australia.

          • araikwao

            And I will not talk about wearing thongs for the same reason!;

  • LMS1953

    Could someone please clear up this confusion I have. I was under the impression that CNMs, as a condition of their licensure, could ONLY practice in a hospital or birth center setting under the supervision of a doctor. Now I read posts where CNMs attend to home births. Which is it? Does it vary state by state? The last I checked, ACOG published an opinion that obstetricians should NOT back up HB (for good reason as the maliciously withheld MANA stats show.

    • Varies state by state.

    • Squillo

      A few states prohibit it, but most states allow CNMs to do homebirth. In practice, though, it can be hard for them to do it because many states require a written collaborative agreement with an MD, and a few require “physician oversight” specifically. It’s hard to find MDs who will agree to that.

      • LMS1953

        Thanks. I would imagine if the physician charged a retainer fee (if for no other reason than to cover the higher malpractice premium – heaven forfend if she/he actually seeks compensation for their skill and expertise), there would quickly follow censure/fine/license revocation for “fee splitting”. The point is probably moot now anyway since on page 29,832 of ObamaCare there is a subsection that mandates that we provide such coverage. Ya gotta read it to find out what’s in it.

    • Trixie

      In my state, largely due to the Amish and Mennonite population, there are CNMs who do home births. The best group of them also has hospital privileges as well as an accredited birth center. The Amish will home birth with underground midwives if they don’t have this option, or at least enough of them will. But the CNMs have enough credibility in the community that they have nudged our local population of Amish into better prenatal care, hospital care if needed, and they generally have good outcomes. But it’s worth noting that the Amish also will not carry health insurance, or sue.

      ETA and they do have collaboration agreements with an OB group.

  • Joe Smith
    • Anj Fabian

      If Jennifer Margulis’ mother was still alive, she’d probably cringe. Her mother was a scientist, a brilliant, accomplished scientist.

      Jennifer is an ideologue.

    • Amy M

      Yeah, she didn’t mention the deaths either…she was more concerned with lack of interventions and breastfeeding rates. Sigh.

      • Atom

        Well, that’s what matter’s right?

        And Dr. Brogan has also been promoting vaginal garlic on her facebook page. You can’t make this stuff up. Sigh indeed.

  • hmm hmm

    I think it’s appalling to note that data capture for the variable “Method of Payment” was 99.96% (recorded in 16,917/16,924 cases), but for Apgars it was 38% (245/646) and neonatal transfer 54% (149/277) of cases. This highlights the real priorities of the midwives “participating” in this study (I use quotes because their participation was obviously highly selective) and speaks to both the questionable integrity of the dataset and the ethical integrity of the data collectors.

    The missing data in this study is ridiculous and inexcusable and I hope that Amy will devote an entire post to this topic on its own. In some cases the number of missing cases for a variable exceeds the number of recorded values. For example, one table reports there are 109 cases of NICU admission and missing data for 128. It’s obvious that certain variables were simply not entered and particularly those that illustrate bad outcomes. Thankfully though, we have a reliable dataset on method of payment used!

    And BTW, how is it possible for a care provider not to know whether their patient has been admitted to an ICU, especially in a setting like pregnancy care and delivery where a midwife is supposedly following a patient closely? The only conclusion is that these cases were deliberately withheld from the dataset.

    • LynnetteHafkenIBCLC

      Unbelievable. Good catch. There are so many appalling little details in this paper.

      • Are you nuts

        Too bad most people will just read the headline and move on without asking questions.

    • Guesteleh

      Or that the midwife did a dump and run at the ER and never contacted the family to find out what happened.

    • anion

      Yes, some “personal, one-to-one nurturing and care,” huh?

  • LMS1953

    The nauseating thing is that the Vermont Legislature two years ago had the DEMs ride in on their high horses and unicorns and bought all the woo. They MANDATED that state Medicaid and private insurers such as BC/BS pay DEMs for their HB services. Remember, only Vermont and Oregon DEMs were required by MANA to report their data. Thus, MANA intentionally withheld data from the Vermont Legislature which could be prosecuted as fraud and intentional deception for the sole purpose of assuring financial gain. I think we should find a HB mom in Vermont with a tragic story and the courage to file a class action lawsuit for the purpose of banning the licensure and most certainly the use of taxpayer money to pay for the services of DEMs. The legislators who voted for it should be subject to censure as well. Since it is in New England, a day in the stocks in the city square would be fitting to get the message across to the crunchy morons in Vermont who would sacrifice their offspring at the altar of Woo.

    • attitude devant

      Same damn thing happened in Oregon. Missy Cheyney was 1) a professor in a state-funded university, 2) the Chair of the DEM board, and 3) running MANA research. There was also a state requirement to share the data, and she stonewalled every step of the way. In other words, she KNEW how bad it was, LIED about why she wouldn’t share it, and she’s OBFUSCATING the truth now. How that isn’t fraud involving state and federal dollars I do not know.

      • Jane Lucas

        But of course the authors had no conflicts of interest to disclose.

      • LMS1953

        Who would have “standing” to file suit in either Oregon or Vermont?

        • Houston Mom

          Do you mean a suit vs MANA or the state? I thought someone had sued Oregon and the case was dismissed because the state has sovreign immunity.

  • Squillo

    There is currently no mandatory, reliable data collection system designed to capture and describe outcomesfor all planned home births in the United States.

    And yet, it is possible to have a mandatory data collection system for all CPM-attended home births in the U.S. NARM did it in 2000 for the Johnson & Daviss study. One wonders why they didn’t continue.

    • attitude devant

      Perhaps because that study showed a three-times increase risk in death when compared with a contemporary hospital population?

      • Squillo

        You think?

  • The Bofa on the Sofa

    Can anyone address the bolded part

    “For this large cohort of women who planned midwife-led home births in the United States, outcomes are congruent with the best available data from population-based, observational studies that evaluated outcomes by intended place of birth and perinatal risk factors. Low-risk women in this cohort experienced high rates of physiologic birth and low rates of intervention without an increase in adverse outcomes.”

    Is this “deception” or is it straight out lying?

    • Squillo

      MANA has a history of not including death as an adverse outcome.

      • Anj Fabian

        For home birth, that’s an expected outcome.

      • An Actual Attorney

        It can’t be adverse if it just wasn’t meant to be.

    • Amy M

      By “adverse outcomes”, I think they mean “C-sections” and “pitocin.”

    • AlisonCummins

      Lying.

  • The Computer Ate My Nym

    Just for fun, I ran a CDC Wonder search for 2007-2010, white women with at least a high school degree, giving birth at at least 39 weeks gestation (not excluding post-dates), with babies at least 2000 grams in weight, delivered by vaginal delivery, and excluding congenital anomalies. Rate of death in hospital delivered by MD or CNM, 0.10 per 1000. In other words, 10 per 100,000, which is actually lower than average maternal mortality. For other midwife, not in hospital, the rate increases to 0.75 per 1000–7.5x higher. This is the very lowest risk group I could come up with. And it is very low risk–but a much higher risk at home.

  • Staceyjw

    Withholding this info is so amazingly unethical, even for a group known for their misleading info.

    Even if you assume low risk moms would have gone ahead anyway, think of the babies that would still be alive, just from sharing the stats on breech, twins, and HBAC. We need a list of their names to send to Missy.

    HB moms deserve better! they deserve true informed consent, the very thing they deny the hospital provides. I think some of the low risk moms would have bailed out as well.

    • The Computer Ate My Nym

      And yet they wiggle out of even a recommendation that breech and other high risk births not be considered candidates for home birth. If an OB found that one of their practices was leading to a mortality rate of over 2% in breech babies, they’d change it immediately! But MANA can’t even conclude that breech births are high risk and should be delivered in the hospital. Their claim that there isn’t enough data to draw a conclusion falls flat given the term breech trial. There is enough data and more!

  • AlisonCummins

    Question: why assume no intrauterine growth retardation? Homebirth midwives have no way of detecting that so cannot risk those pregnancies out even if they want to, which we know they don’t. Or can they?

    • Squillo

      I agree.

    • Young CC Prof

      Sometimes measuring the fundal height is a clue. Of course, my fundal heights were perfectly normal, even as my son measured 4 weeks behind by sonogram.

  • PrecipMom

    Can someone explain the liver rupture? I don’t understand how that would happen. Livers don’t just randomly rupture, do they? What is the rest of that story?

    • attitude devant

      My guess (an educated one) is extreme trauma at delivery. A shoulder dystocia, a bungled breech. Something like that. Pretty horrible, no?

      • The Computer Ate My Nym

        I was wondering whether there might be some complication like hydrops fetalis enlarging the liver and making rupture more likely. This is totally speculation but given that at least some CPMs don’t do Rh screening or RhoGam…

        • Trixie

          I don’t know why this still surprises me, but dear God, no Rhogam?

          • Rabbit

            Because vaccinations are bad, don’t you know. Full of chemicals. Humanity got along just fine without Rhogam and Vitamin K shots. [/bangs head against desk]

        • OBPI Mama

          That is unnerving. My midwife did give me a rhogam shot after my son’s birth. She got it from some black-market lady in Western USA… Should I be weirded out?

          • fiftyfifty1

            Yes you should be weirded out. Sorry.

          • An Actual Attorney

            You got a black market injection of something that is (if it was what was claimed) a blood product???

          • Elizabeth A

            Yes. Yes, you should be weirded out.

            You have no way at this juncture of knowing that the shot contained the intended medication, and even less way of knowing that the medication was uncontaminated, and stored correctly.

          • OBPI Mama

            I believe it contained the right medicine because I’ve been able to have 3 other babies (2 more with + blood types). It looked like new packaging when she opened it… The midwife had said it’s from a nurse out west who is sympathetic to the underground work homebirth midwives have to do. Ick. Still weirded out.

          • The Bofa on the Sofa

            You dodged a huge bullet.

            Just because it did turn out ok this time does not mean that getting a vital medication from a “black market lady in the western US” is not a really, really bad idea.

            The correct response is, “Wow, that was seriously bad. I really got lucky.”

          • OBPI mama

            That is so creepy. I, honestly, at the time didn’t know one lick about the rhogam shot. The midwife let me know she was able to get one (and told me the above). I had no idea it was a blood product even. Yes, dodged a huge bullet. Everytime I hear something new about a dangerous thing she did, I am so humbled.

          • Box of Salt

            OBPI mama, did she give you the paperwork that’s supposed to go with the RhoGam?

            I was also given wallet card because if you’ve received RhoGam your blood may not type correctly (+ antigens that aren’t your own are present). Did she give you one of those?

          • The Computer Ate My Nym

            I’m glad you’re ok and everything went well, but I’M weirded out by the idea that this is going on in the US. It’s a pooled blood product! AIII!! Very glad you’re ok!

        • C T

          It was finding out that some CPMs claim that RhoGam is unnecessary that finally made me realize that they are horrible “care providers.” I have a distant cousin who had two children that required blood transfusions while still in the womb because of Rh problems. I get the RhoGam shot faithfully myself.

      • PrecipMom

        That’s what I was thinking, particularly in conjunction with the hypoxia.

      • Captain Obvious

        Yes, I agree. The midwife probably squeezed the baby’s belly that hard to help deliver the baby, she caused internal liver rupture.

    • areawomanpdx

      Maybe HELLP?

      • Amy M

        HELLP affects the mother’s liver, not the baby’s.

        • areawomanpdx

          Ahh, I thought she was talking about the mother. Ya, that makes no sense.

    • Anj Fabian

      Omphalocele – results in organs being outside the baby’s body. Vaginal birth is very risky.

      • The Computer Ate My Nym

        But diagnosable by ultrasound (which NCB discourage) and at least sometimes treatable, though it does carry a grim prognosis, from what I understand.

    • Houston Mom

      Apparently CPR can be a cause http://www.ncbi.nlm.nih.gov/pubmed/18432557

  • Staceyjw

    A big point here is that if you rupture at home, baby WILL DIE. Period.

    The rate for VBAC rupture is 1 in 200, but deaths are a small number of these when in the hospital (where this stat originated) This is how HBAC is sold- rupture risk may be higher, but few babies die.

    This proves HBAC is nothing like VBAC, as if 1 in 200 ruptured as expected, and 5 died, that means 0 survived! It doesn’t get better if there are more ruptures, because that would mean something was happening to increase that risk as well.

    The stats for breech and multiples is not one bit surprising. VB for breech is risky even in a well equipped hospital, and twins are always a risk. Doing these things at home should be criminal negligence for any provider that does it.

    • auntbea

      Good catch.

    • thepragmatist

      That terrifies me! VBAC at home is something our midwives want and sneakily try to do anyway, and it upsets me whenever I know a friend has, “by accident”, had a home VBAC, which does happen frequently enough. And one day soon, judging by how many woman I know birthing at home, somebody’s baby is going to die on the alter of VBAC, if it hasn’t quietly happened already.

  • Amy M

    I would hope it would bother more people in the homebirth community that so much is unknown. Why don’t they know what happened? If these midwives are the medical professionals they sell themselves as, they should damn well know what happened to their patients. Professionals don’t just lose that much data. Professionals don’t just fail to follow up with their patients.

    Of course WE know why they don’t “know”—if reporting is voluntary, why not just “lose” the information on the poor outcomes, the ones where the midwife ditched and moved to another state, but does it never occur to prospective clients to ask these questions?

    I suppose in some cases, they might really not know, because they have no way of properly monitoring or assessing an unborn fetus, or recognizing various problems that do arise. If the midwife drops the woman off at the hospital and disappears, she might really have no idea what went wrong. Still, if she was a true professional, she’d stick around to find out.

    • I am sure there is a significant number of “midwives” out there who simply don’t keep records of any sort, beyond noting in a diary that “X went into labor around 4 p.m. and gave birth later in the evening”. And maybe not even that.

    • Staceyjw

      What’s the excuse for not having a real, nationwide, data collection system? Isn’t that what MANA stats is suppose to be? Weren’t several states relying on them to collect the data for them? Guess that was a big fat FAIL, so when are those states going to wise up, like Oregon did, and start collecting their own stats?

      I sure wish moms could sue MANA for hiding these risks.

      • Squillo

        There’s no excuse. NARM did it in 2000.

        I suspect the answer would be similar to the excuse Melissa Cheyney gave for not supplying MANAStats data to the state of Oregon: Midwives would be afraid.

    • T.

      They have a curious, fatalistic mentality. We collect data to do something with them, to make sure there are less death, or disabilities. They don’t believe it is possible to reduce those, so why keep data? Just for the fun of it? If a baby died well it was meant to. Nothing could be done. Pass on!
      It is sickening. And very pre-scientific.

      • KarenJJ

        That’s the impression I get. That this data was collected to match a foregone conclusion. They never planned to do anything with it (ie improve practices) apart from “proving that homebirth is safe”.

  • OBPI Mama

    The image in my head is horrific… Ex-midwives and assistants and a mass of women standing infront of each other, hiding dead babies behind them, while they smiling and eerily tap their fingers together waiting for new babies to maim and murder. 🙁 This is so upsetting.

  • attitude devant

    So here is a college professor, tenured at a state institution in the Anthropology department, deliberately obfuscating the findings of a major study. Wow. Just wow.

  • Tired Momma

    Let’s not forget that this whole study was done by MANA, an organization that has its whole financial stake in homebirth. They need to keep the money flowing. Mortgage Companies don’t take placenta pills for payment.

  • Amazed

    Haha, homebirthing bitches are at it already. Never mind the dead and disabled babies, let’s rant at Dr Amy! I’ve been waiting for their howls.

    http://www.mothering.com/community/t/1396708/this-dr-amy-tuteur-woman-drives-me-crazy

    And bunny627 wrote an essay in college that rebutted Dr Amy’s slams against homebirth and got an A!

    Bastyr does have some high standards, it seems. That’s if bunny627 college degree wasn’t in embroidering (cloths, not mothers!).

    • Captain Obvious

      And Lady Cat, the group owner of BabyCenter’s Homebirth board apparently shut down the thread about MANA’s study because her thread is a support board, not a debate board. Fingers in ears, lalalalalala

      • Amazed

        I must admit that with every study coming out and every thread coming to “Dr Amy is meeeeeen, see what she’s saying!” or being locked, I’m finding it harder to sympathize to those who sing lalalala and then, when all the hell breaks lose run for the hospital bleating “Doc, help!” like the good little sheeple they mock us for being.

  • Trixie

    Did anyone post Navelgazing Midwife’s take yet? Rather informative of the rigorous standards for data collection that MANA held its midwives to. http://navelgazingmidwife.squarespace.com/navelgazing-midwife-blog/2014/1/31/my-take-on-the-mana-stats-study.html

    • Guesteleh

      The study says they enrolled the clients before they knew the outcome of
      the births, but I beg to differ. They may do that now, but back when I
      was doing them (2004-2009), we didn’t even fill out the paperwork until
      the woman was past six weeks postpartum. In fact, we used to sit with a
      pile of charts in our laps and fill out stat sheet after stat sheet,
      some women even a year (or more) postpartum. At that time, the stats
      were filled out on paper and sent in, so I know we weren’t
      supposed to send in any statistics before the woman was six weeks
      postpartum. I can’t imagine we were the only ones that did it that way.

      • areawomanpdx

        So are they lying about their collection methods, or did they just not mention that in the paper? I would think the journal that published the study might be interested in this information.

      • Squillo

        Moreover, the client can revoke consent to have her data included at any time.

    • auntbea

      I’m frustrated that she says she would welcome a *real* study on homebirth. Those studies exist. They all say the same thing. WE ALREADY KNOW THE ANSWER TO THIS.

      • Trixie

        Okay, but look, if you’ve read her story, she’s come a long way and has done something almost no other CPM has been willing to do — admit she was wrong and had no idea what she was talking about when it came to some of the deliveries she did.
        I think what she means by real is a study where all the CPMs had to report all their data. That one has not been done yet.

        • auntbea

          I know she’s come a long way. And I know she changed her mind based on evidence, including that from Judith Rooks. So, why would she treat this like an open question?

          • Trixie

            I’m not reading it like she thinks it’s an open question at all. I think she’s saying she knows that the data used in the study is junk, and the real numbers are far worse. And that she’d like to see a study capture that.

          • Guestll

            NGM has one foot in evidence-based, the other still in the woo. Can’t quite shake her belief that HBAC is A-OK, because, as she’s stated repeatedly on FB, she’s never seen a rupture (and the only ruptures she’s seen were primips with Pitocin!)

            I really want to like NGM, but I can’t. She’s either pandering to her audience, or she’s very confused.

  • AllieFoyle

    How can this even be considered a legitimate scientific study when the results were reported voluntarily?

    Just imagine trying to pass off safety information about a medical procedure or a new pharmaceutical based on information from voluntary reporting.

    “Um, hmm, no, I don’t think I’ll fill out the report on *that* particular case.”

    or

    “Everything went well that time; I’ll definitely send in that report!”

    It’s not remotely scientific. How can you draw any legitimate conclusions from a study like this…other than the obvious one that the people presenting it are either unethical, don’t understand statistics, or both?

    • Trixie

      Sort of reminds me of that study of the Webster technique where chiropractors who did the technique mailed back surveys saying it worked.

    • Staceyjw

      Even so, the stats are awful. I have heard that MWs were encouraged to send in just the good results.

      I bet the MWs that participated actually think their numbers are good, they are just that ignorant.

    • AlisonCummins

      Except that even with this bias, it still shows a high risk. That’s suggestive.

    • Squillo

      Technically, they’re supposed to log data for every client enrolled (unless the client revokes permission.)

      Whether or not this happened… well, there’s a fair amount of missing data.

  • guest

    Keep up the great work Dr. Amy. I am disgusted at MANA but I am always reassured when you tear them to shreds as they so deserve.

  • MANA – where ideology comes first.

  • lola

    I wonder how many of the “unknown” are actually postdates? There doesn’t seem to be a category for that, or am I missing something? We’re all familiar with the whole library book comparison.

    • Anj Fabian

      If this study was an encyclopedia, it is missing over half the volumes.

    • Staceyjw

      I bet many of them. Post dates loss is the most common reason for the HB deaths I hear about by far.