A statistics professor analyzes the new paper from the Midwives Alliance of North America (MANA)

MANA stats paper

You may remember that Dr. Aviva Romm was in a bind over the hideous death rates in  the latest paper from the Midwives Alliance of North America, Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. When I asked her point blank about analyzing the MANA paper and the Grunebaum abstract, she dithered, claiming that statistics are too hard to understand.

I offered to find a statistics expert to analyze the papers for us, and Romm provisionally agreed. Then Brooke Orosz, PhD, a professor of statistics, volunteered to do the analysis and, as expected, Aviva Romm backed out. No professional homebirth advocate can afford to be part of an independent analysis of the data because they KNOW the MANA paper shows that homebirth has a hideous perinatal death rate.

Even though Dr. Romm has pulled out of the deal, Prof. Orocz has generously agreed to analyze the MANA paper. You can find the complete analysis here. I have slightly shortened it below.

The article, “Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009, by Melissa Cheyney, PhD, CPM, LDM, et al. The authors claim that this study demonstrates that midwife-led planned home birth can reduce interventions with “no significant increase in early or overall neonatal mortality.”

This document will analyze the following questions:

1) Was mortality elevated?
2) Was neonatal morbidity higher?
3) Was maternal mortality and morbidity higher?

All of these questions require an appropriate comparison group, and selection of this group is where difficulties arise. It is not appropriate to compare the home birth outcomes to all hospital births in the USA, as the home birth sample is considerably lower-risk.

The biggest difference is gestational age. Most neonatal deaths in the USA occur in severely premature babies, and very few of the MANA STATS home births involved premature or low birth weight babies, likely because most women who planned home birth and then developed preterm labor rapidly transferred to hospital care.

In addition, the MANA STATS mothers had fewer preexisting health problems, such as chronic hypertension…  (2) The racial makeup of the MANA STATS mothers was quite different from that of the USA as a whole, 92% White and only 3.1% Black or Native American women, who are at higher risk. Very few MANA STATS mothers carried twins, and none carried higher-order multiples.

1) Neonatal and Intrapartum Mortality

In order to find a suitable comparison group, I consulted the CDC’s Wonder Database of linked birth-infant death certificates. The MANA STATS group was predominately but not uniformly low-risk, so I chose to use as few conditions as possible.

…  99.2% of MANA STATS babies were over 2500 grams, so I eliminated low birth weight babies from the comparison group. Although the MANA STATS group was also low-risk in other ways, I did not add any further restrictions.

I then compared MANA STATS numbers to CDC numbers using an alternate hypothesis of increased death rates against a null hypothesis of equal or lesser death rates. Due to the small numbers, I computed p-values directly, with the binomial formula, rather than a normal distribution.

For babies born in a hospital during the period 2007-2010, weighing at least 2500 grams, whose mothers received some prenatal care, the neonatal death rate was 0.71 per thousand. When deaths due to congenital anomalies are excluded, the rate drops to 0.40. The neonatal death rate for MANA STATS babies was 0.77 excluding congenital anomalies (13 deaths out of 16,950 births) and 1.30 including congenital anomalies (22 total neonatal deaths). The neonatal death rate excluding anomalies was significantly higher in the MANA STATS group (p=0.01). In addition, the number of neonatal deaths attributed to congenital anomalies was higher than expected, although the statistical significance of this difference was marginal (p=0.04).

Additionally, there were 22 intrapartum deaths recorded in the MANA STATS data. Finding an appropriate comparison group is particularly difficult, as the CDC and many other health authorities do not record intrapartum deaths separately from other stillbirths.

The WHO  estimates the intrapartum stillbirth rate across North America as 0.3 per thousand. It is likely that the true number of intrapartum stillbirths among low-risk infants delivered in the hospital is considerably lower. However, in the absence of any other solid data, I will use the value 0.3 per thousand as a maximum reasonable estimate. The intrapartum death rate for MANA STATS sample was 1.30, which is significantly higher. (p<.0001, highly significant.)

So, for a comparable group of infants born in the hospital, with congenital abnormalities excluded, the combined neonatal and intrapartum death rate is at most 0.7 per thousand. The combined neonatal and intrapartum death rate for the MANA STATS group, with congenital abnormalities excluded, was 2.06 per thousand, which is significantly higher. (p<.0001, highly statistically significant.)

In other words, the expected number of deaths from causes other than congenital anomalies was at most 12, and the actual number of deaths was 35 (44 with anomalies included). It is clear that home birth substantially increases the risk of neonatal death and of intrapartum death.

Mortality by Subgroup:

In the conclusion, the authors state “However,the safety of homebirth for higher-risk pregnancies, particularly with regard to breech presentation (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) requires closer examination because the small number of events in any one subgroup limited the effective sample size to the point that multivariable analyses to explore these associations further were not possible.” [emphasis Orosz]

I strongly disagree with the italicized portion, particularly with regard to breech birth, the highest-risk subgroup. Out of 222 births, there were 5 deaths. This is a combined death rate of 22.5 per thousand, a number made even more shocking by the fact that breech position does not increase the risk of death at all among babies born in the hospital.

Disturbingly, the breech data were incomplete, as the authors explained: “There are 4 singleton pregnancies, 3 of which were breech presentations, for which all birth outcomes data are unavailable. These women began labor at home and then transferred to the hospital prior to birth. The midwives of record were contacted, and in each case the midwife did not accompany the mother, nor did the mother return to the midwife for postpartum care.” This missing data means that the breech death rate could in fact be as high as 36.0 per thousand, or 3.6%, which is similar to the breech birth death rate in the USA circa 1950.

Had those breech infants been born in the hospital, there is at least an 86% chance that all of them would have survived, probably higher, and a 99% chance that no more than one would have died. Instead, at least five and possibly eight babies died.

In addition, no information was available regarding neonatal or maternal morbidity in the breech birth group. Vaginal breech birth has been shown elsewhere to increase the risks of hypoxic brain injury and low APGAR in the infant as well as the risk of hemorrhage and perineal laceration in the mother. In short, breech position is a severe and unmanageable risk factor at home birth.

The TOLAC death rate was 5 out of 1052, that is, 4.75 per thousand. This is significantly larger than the hospital comparison rate of 0.7 per thousand even when controlling for multiple comparisons. (p=.006)

In fact, the combined death rate of every subgroup was higher than the hospital comparison rate, and the difference was highly statistically significant on all but the smallest subgroups. The lowest-risk subgroup was also the largest subgroup, that of multiparous women with no prior history of cesarian section. The combined neonatal and intrapartum death rate was 1.24 per thousand, (15 out of 12,088) less than twice the hospital comparison rate.

2) Neonatal morbidity.

Only 245 infants (1.5%) had a recorded 5-minute APGAR of less than seven. Nationwide, 1.1% of babies above 2500 grams had a low APGAR as per CDC birth data, so the rate among the MANA STATS babies is significantly higher (p<0.0001 per binomial test) but not drastically higher.

However, APGARs were unavailable for 401 newborns. This missing data is concerning, as newborn health is a key outcome, and the only recorded variable with a greater number of missing data points was maternal education. If all 401 of those newborns in fact had low APGARs, the true rate of low-APGAR births would be 3.8%, which is three and a half times the national average.

Alarmingly, of the 245 infants with low recorded APGARs, 69 were transferred to the hospital intrapartum, but only 66 were transferred postpartum, meaning that over 100 low-APGAR infants did not receive prompt medical attention.

3) Maternal Morbidity and Mortality

15.5% of the mothers in the MANA STATS group experienced a postpartum hemorrhage over 500ml, with 4.8% losing over 1000mL. Nationally, only 3.3% of vaginal births resulted in a postpartum hemorrhage exceeding 500 ml, with few exceeding 1000ml, and only 2% of cesarian births involved a PPH exceeding 1000 ml.(3) These nationwide numbers do NOT control for preexisting maternal risk factors, which are more prevalent in the hospital group as previously noted. Clearly, home birth substantially increases the risk of PPH.

Over 1,000 women attempted a vaginal birth after Cesarian. The number of uterine ruptures and hysterectomies was not reported.

The MANA STATS data recorded one maternal death during the study period, which is not inconsistent with the national maternal death rate. No conclusion can be drawn about the effect of home birth on maternal mortality.

Conclusion:

The mothers in the MANA STATS cohort experienced fewer childbirth interventions than comparable-risk women giving birth in the hospital.

However, the rate of intrapartum stillbirth or neonatal death was considerably higher, and the difference was particularly alarming among high-risk subgroups such as breech and VBAC. The incidence of low APGAR was significantly higher and may have been much higher. The risk of postpartum hemorrhage was substantially higher.

Women considering home birth should be aware of these risks. Furthermore, the risk of death is increased for babies in breech presentations, and infants born to first-time mothers or mothers with a prior history of cesarian birth.

  • Amy Tuteur, MD

    They’re discussing the analysis on Metafilter:

    http://www.metafilter.com/137013/Is-Home-Birth-In-the-US-Safe

  • Starr

    As a Canadian Midwifery student I am really glad to get an analysis of this study from a statistician. While this study doesn’t compare to Canadian homebirth (for many reasons) I do think it speaks to how any birth professional needs to be properly trained to offer safe care.

  • Jocelyn

    I asked on MANA’s page what their response to this analysis is. “Citizens for Midwifery” responded: “The challenge with this analysis (and any analysis that uses CDC data) is that it is comparing medical records (MANAstats) to vital statistics/birth certificate data (CDC data). This means you are comparing apples to oranges. We’ve put together a fact sheet on understanding the flaws in vital statistics data that you might find useful here: http://www.cfmidwifery.org/pdf/Interpreting%20Home%20Birth%20Research%202014_2_6.pdf

    • Young CC Prof

      Death certificates are not accurate for capturing rare outcomes like death. Good to know.

      • Mer

        I went and read because of your comment, and Oh My God, they really do say that don’t they? I’m astounded!

        • Young CC Prof

          Technically they say birth certificates don’t accurately capture death, but the infant death database is made of death certificates which were linked to birth certificates for additional info.

          • auntbea

            ITS A GOVERNMENT CONSPIRACY AGAINST HOMEBIRTH! Speaking of which, this is which I find it odd that NCB’s and anti-vax are generally lefties. I trust (nay, ENCOURAGE!) the government to use my taxes, regulate air and water quality, and provide for the poor, but I don’t trust them to keep their data straight and provide accurate medical information?

          • Jessica S.

            You are singing my tune! I don’t get that. Or how NCBs/”crunchies” embrace gov data (or international, like WHO) for certain aspects – like breastfeeding – but insist it’s all a conspiracy with regards to vaccines. I guess everyone is prone to blindspots. Except me. That’s one of my most remarkable traits, how blameless I am.

          • Elaine

            I get the impression a lot of them are libertarians, actually. They don’t like to be told what they can and can’t do. To the extent that some of them are left-wing, it’s probably due to support for social services

    • Anj Fabian

      Bollocks. Hand waving. Don’t look behind the curtain!

    • Jocelyn

      Well, I’m afraid I ended up telling Citizens for Midwifery “Shame on you for lying to women about their safety and the safety of their children.” That’s what losing control looks like for me.

      • Amazed

        Sounds quite controlled, actually. Me, I wouldn’t dare go there. I won’t last a minute, given that I am really prone to losing control over their lies. Just look at my ramblings here.

        • http://kumquatwriter.wordpress.com/ Kumquatwriter

          PREACH.

    • Jill

      The MANA fact sheet says “However, removing those eleven percent of the births from the home
      birth sample makes any analysis based on these numbers unreliable. Some have said that this
      would only make the home birth outcomes look worse if those poor outcomes were correctly
      attributed to the home birth group, but the overwhelming majority of transfers in labor result in
      excellent outcomes, which also belong to the planned home birth group”

      Did they stop and think that perhaps the reason the transfer group had excellent outcomes might be because they were transferred, and that the excellent outcomes wouldn’t have happened in the home environment? They want it both ways… “Aw, we are penalized for those births that happen at home by accident, but wait, the ones we transfer to the hospital have great outcomes so we should also get credit for those outcomes!” Sorry, no.

      • Amy Tuteur, MD

        I don’t know if they are trying to trick people or they are simply so stupid that they don’t get it themselves.

        While the majority of transfers may have excellent outcomes, the death rate in the transfer group is typically FAR HIGHER than in the remainder who did not transfer since the incidence of life threatening complications is FAR HIGHER in the transfer group than the remainder who did not transfer. All the abruptions, fetal distress, cord prolapses, etc. that the midwives were capable of diagnosing are in the transfer group.

        I go back again to a point that every homebirth advocate, even the most ardent, can understand. If MANA’s data showed homebirth was safe, they wouldn’t have hidden the death rates for 5 years!

        • Ash

          Deaths and injury to women and infants don’t matter. Per self reporting of a small number of midwives, clients paid for services, breastfed, and did not get C-sections.

        • Squillo

          And they might have tried actually comparing it to hospital birth.

        • Michael Johnston

          You have responded very irresponsibly to this persons comment. If transfer to hospital when indicated is part of the planned process of home birth, than said transfers are properly part of the cohort.

          • attitude devant

            Sir, you have already led with the statement that you don’t know much about homebirth in America. It is not necessary to demonstrate.

            All levity aside, you really need to know that our homebirth midwives are completely different in traning (bad!) and practice patterns (they never met a mother who wasn’t a good candidate for home birth!) and regulation (there is none!) from midwives anywhere else in the world. So until you understand these things, please refrain from criticizing the owner of the blog.

            Thank you.

      • Michael Johnston

        Not at all. Transfer to hospital when circumstances indicate it is advisable is very much a conscious, intended, planned part of having a home birth. I can’t speak for Americans (the statistics can, and to understand this discussion in context you should compare the OVERALL morbidity/mortality rates for the US compared to the rest of the developed world) but in countries that properly manage health care in general and midwifery in specific, transfer to hospital when indicated is part of the process. As is the corollary — hospitals recommending families with home birth plans go back home after a risk assessment indicates an intervention is not warranted.

  • Melissa

    Geek Mom, is asking on Facebook, if there are any homebirth statisticians available to offer a rebuttal.

  • Amy Tuteur, MD
    • http://momofmanyfeet.wordpress.com Bambi

      Does his person not understand numbers?? Or grasp basic grammar??

      • auntbea

        I am not sure it is a problem of misunderstanding numbers. I think it is a problem of missing context. In part, because she is comparing a brief blog post to an academic paper, and insisting that there is justification missing from the former.

        • Anj Fabian

          I think we need to add the acronym:
          RTFSM (read the effing source material)
          to our lexicon

          The usual acronym is RTFM (read the effing manual) for tech types.

          The people who inspire these phrases are the ones who prefer to pestering people who know all the Things because THEY are the ones that either read the manuals or the ones who wrote the manuals.

      • Amy Tuteur, MD

        I’ve been out most of the evening and couldn’t respond. I just left the following comment on Grounded Parents (it’s in moderation):

        Frankly, Jamie, this is a hatchet job and a very sloppy one at that. I think you owe me an apology.
        Let’s go through it point by point:

        1.
        You wrote: “I clicked the link Dr. Tuteur gave where she got the
        Citizens for Midwifery quote but didn’t see anything with that quote or
        numbers on the linked page. I did download and read the study which
        these numbers supposedly came out of …”
        How
        could you not find it? I gave an exact quote in my piece and linked to
        the place where the original can be downloaded? It is on page 3 of the 5
        page CfM press release, the beginning of the second full paragraph.
        Please check to confirm.

        2.
        You wrote: “I’m not really sure exactly where this quote came from and
        these numbers don’t seem to match anything in the study.”
        Wrong
        again. On page 7 of the study, under the section Fetal and Neonatal
        Morbidity and Mortality, second full paragraph, last sentence: “When
        lethal congenital anomaly-related deaths were excluded (n = 0
        intrapartum, n=8 early neonatal, n = 1 late neonatal), the rates of
        intrapartum death, early neonatal death, and late neonatal death were
        1.30 per 1000 (n = 22), 0.41 per 1000 (n = 7), and 0.35 per 1000 (n =
        6), respectively (Table 5).”
        1.3+ 0.41+ 0.35 = 2.06
        You quoted those exact numbers but never bothered to add them together to get the total.

        3. You wrote: “First of all, can I first point out that it’s a 4x increase, not 5.5x (1.6/0.4 = 4).”
        Except that the correct number of MANA deaths was 2.06/1000 not 1.6/1000.

        4.
        You wrote: “I seriously have no idea how Dr. Tuteur came up with 5.5x
        or 450% increase in mortality from the numbers that she cited.”
        That says more about you than about me. I explained how I got it in my post and I just explained it again.

        5.
        You wrote: “What we’re really looking at here is a risk of death
        increasing from 0.0004% to 0.0016%. This is a difference of 0.0012
        percentage points.”
        No,
        that’s not what we are looking at. It is off by more than 100 fold. 0.4
        deaths/1000 is 0.04%. You added in two extra zeros. The homebirth death
        rate was 2.1/1000, which is 0.21%. So the difference is 0.17%. That
        sounds like a tiny number, but when you are talking about thousands of
        births, it’s the difference between 4 deaths for every 10,000 babies
        born in the hospital and 21 deaths for every 10,000 babies born at home.

        6.
        You wrote: “All we know about the info Dr. Tuteur got from the CDC
        website was that it was for white women with low-risk births. This
        includes hospital births, homebirths, and births in locations other than
        the home and hospital (though she labeled them as hospital births on
        the chart she posted).
        Clearly
        you never bothered to look at the CDC Wonder database, which contains
        an complete description of contents. I specifically noted that I looked
        at white women, 37+ weeks, 2500 gm babies

        7.
        You wrote: “This includes hospital births, homebirths, and births in
        locations other than the home and hospital (though she labeled them as
        hospital births on the chart she posted).”
        Wrong
        again! I did not include locations other them home or hospital and
        label them hospital births. I don’t know where you got that idea.

        8.
        You wrote: “Women who choose to have a homebirth are likely very
        different from all white women giving birth, so it’s not really a fair
        comparison.”

        Really?
        White women who give birth in the hospital tend to be younger, poorer,
        of lower socio-economic class and more likely to smoke than the
        homebirth group, which means that the 450% higher homebirth death rate
        actually UNDERCOUNTS the difference in deaths between home and hospital.

        Finally,
        you wrote: “The “homebirths are killing babies” review by Dr. Amy
        Tuteur was less “focusing on some parts of the study while downplaying
        others” and more just a sloppy and unscientific attempt at calculating
        relative risk by using two completely non-comparable data sources in
        order to scare readers away from homebirths.”

        No,
        what’s sloppy and unscientific is your hatchet job. You are WRONG about
        the numbers, WRONG about the math, WRONG about the quotes, WRONG about
        the CDC Wonder database, WRONG about the differences between the home
        and hospital group and therefore, completely WRONG about your
        conclusion.

        I
        hope you will acknowledge these errors and correct them. And I’d like
        to see you apologize. It’s the least you can do after writing and
        publishing this “analysis.”

        • Hmm hmm

          Your comment above is visible on the groundedparent (barf) website. For now.

          • KarenJJ

            Well, they are meant to be skeptics and that means that they should be able to admit where they are wrong and make a correction and acknowledge any editing to the original article. I’ll be interested how they manage this one, considering how they were unable to grasp the fundamentals.

          • KarenJJ

            OK couldn’t resist and joined up and commented. It will hopefully be an interesting discussion to follow.

        • Danielle

          I think someone just got owned.

        • auntbea

          Damn. I had to go to bed last night, but was planning to post something this morning. Now I guess I can just go back to my regularly scheduled programming.

        • LibrarianSarah

          I also noticed that no one had the stones to reply to your comment. I am getting increasingly disillusioned with skepchick. I like the idea with combining skepticism with feminism but godless bitches does it better.

      • KarenJJ

        Wow. I’ve not been following skeptic sites for a while, but it looks like Grounded Parents are all meant to be skeptics. And they are concerned about tone in the comments? Really? And Dr AMy’s position on circumcision is relevant, how? That was one of the most unskeptical pieces of skeptic writing I’ve read. Very embarrassing for them, especially when they couldn’t do the percentages correctly and couldn’t work out the numbers.

        I was a big fan of the skeptic movement when I first found it, and then got bored because skepticism didn’t go into the sort of topics I found interesting (parenting and childbirth). So now they have a site for it, but they still can’t use skepticism on childbirth.

        Ironic, up the top they have a trigger warning about the discussion of neonatal mortality and then completely play down the actual risk of neonatal mortality. Do they even realise that those numbers are actual babies that could have survived with better care? Probably not because their numbers were so wrong and so far off the mark…

        My “favourite” quote from that article:
        “She then points out that OMGZ YOU GUYS THAT’S A 5.5X INCREASE IN BABY DEATHS!”

        No words.. I just don’t know what to say here. Were they trying to be funny?

        • auntbea

          Sarcasm is the hallmark of a truly incisive take-down.

        • fiftyfifty1

          “That was one of the most unskeptical pieces of skeptic writing I’ve read. Very embarrassing for them”

          Yes, really embarrassing. Unfortunately this level of reporting is common on Skepchick. They think they can substitute a sassy attitude for the hard work of real analytic thought.

          • auntbea

            Is this true? That’s problematic for several reasons, and not only because they serve as the voice of “female” skepticism.

          • fiftyfifty1

            Well most of their articles are better than this one (how could they be worse?). And I don’t have the background to judge their science articles outside of medicine. But way too often I read their bio/health posts and find very shallow analysis and sometimes even pretty obvious mistakes. I’m frequently disappointed, even though I typically agree with them politically. It’s extremely embarrassing to me that this is supposedly the female voice of skepitcism.

  • The Bofa on the Sofa

    So here and there, folks have referred to the 4 “lost” cases (3 of which are breech) where the midwife had absolutely no information about the outcome after transferring to the hospital. The usual perspective has been “yeah, right, we all know what happened there” (and Brooke refers to them in her write up).

    I think, to be fair, we can’t assume that there was actually a bad outcome with the birth itself, but I also say that doesn’t matter. What we CAN safely assume, I think, is that the parents were so completely disgusted with the care provided by those “midwives” (I’d hate to imagine that there was multiple offenses for a single midwife) that they didn’t even want to get have any further contact with them.

    And I have to say, I don’t see that as any less of an indictment of the profession than even the terrible results. That you have midwives who are dumping patients off at the hospital and have treated them so poorly that the patients want nothing to do with you is not a good thing.

    If I were part of this profession, that would cause a serious double take. Those midwives have a serious issue, and if you, as a profession, aren’t concerned, then you have a serious problem.

    Thinking about this has been bothering me a lot lately.

  • Gene
    • Amy Tuteur, MD

      Fabulous!

    • Danielle D.

      This is good. I09 is full of science fiction and science junkies, who tend to enjoy data like this & tend to remember and repeat what they know. You can tell as much from the comments.

      • Danielle

        BTW, in case anyone misunderstands: I mean “junkie” as a complement. I09 is written for people like me.

        • Gene

          It’s my spouse’s go-to for geek news. Seriously, this story is really spreading. Amy, there is another post on Sermo as well (by enbastet) discussing legal ramifications of a CPM and malpractice. I’d post here, but the site is only for physicians.

          • auntbea

            Can you post a synopsis?

          • Gene

            Basically, someone who is both a physician and a lawyer was posting his thoughts on malpractice and CPMs and what would, legally, constitute malpractice by a CPM. The issue is that even though a CPM calls herself a “midwife”, she cannot be held to the medical standards of a physician or even a CNM because she is, in fact, neither. Her education is not equivilent to a CNM’s (let alone a physician’s). So if a physician, a CNM, and a CPM all did the exact same thing, the physician and CNM may have committed malpractice, but the CPM would not have since she is being held to the standard of her “specialty”.

            The poster bases this on a case from 2002 in which a midwife (CNM) was found to not have committed malpractice because “A nurse-midwife is not judged by the standard of care for ob/gyn physicians.” So, in effect, a CPM who has LESS education than a CNM could not be held to a CNM’s higher standard of care. In effect, even though a CPM talks the talk (we are TOTES like CNMs and way better than physicians), they cannot be held to that standard of care and would not be committing malpractice. It’s a scary thought.

          • Karen in SC

            But they’re experts in normal birth!

          • auntbea

            Well, but why is it not practicing medicine without a license? (A question to which you may or may not know the answer.)

          • fiftyfifty1

            Creepy! So unless you go with the highest level of education/training you won’t have much recourse if your provider gives bad care because, basically, “Who can expect a midwife to provide as good of care as a doctor”. wow.

          • Melissa

            In deciding if a practitioner has committed malpractice you look to see what the standard is for that profession. If it is a doctor you look at other doctors and find out what they would do in a similar case. And professional guidelines are a good way to determine this. ACOG says don’t to VBAC unless you have facilities where a C-section can be done. If a doctor does VBAC in a patient home the court will find that is outside the standard of care and is malpractice.

            Tort law is based on the idea that people should be liable for the harms they cause only if they are negligent in what they are doing. If a doctor is following all the guidelines then even if theres a bad outcome because of those guidelines, he shouldn’t be held responsible (although maybe the people who make the guidelines should).

            MANA has no professional guidelines or recommendations. Midwives tend not to testify against one another. Therefore there is no standard of care that a midwife can violate, making it impossible to get a malpractice claim. (I think that there may be a potential contract claim but I need to do more research into fraud)

    • Mac Sherbert

      And the typical crowd is already on scene. I like this post.

      “My daughter was born at home, and has turned out to be amazing. Granted, her mom and I went to classes, her mom ate really well, and was low-risk. I think if one is well-prepared, eats well, and is low-risk, home births are fine.”

      Yeah, well my c-section babies turned out to be extra awesome! I was so prepared for them and educated about the procedure, there wasn’t any way the c-section wouldn’t turn out great. So,everyone should have c-sections!!!! (Snark).

      • Karen in SC

        I hope the regular readers there know an anecdote from data. In fact, it might be fun to just reply “anecdote” to each of those posts. Or maybe even “anecdotes aren’t evidence.”

      • Danielle

        There are also a bunch of posts point out that in their family’s case, the expected baby was much safer in the hospital.

        • The Bofa on the Sofa

          I liked the comment that said that the real issue is not the absolute risk, but that the original authors had the nerve to claim that there was no increase in adverse effects. IOW, Missy, you lying sack of shit.

          A lot of commentors jumped on that, how the actual results of the study did not support the authors’ conclusions.

    • Ash

      I am trying really, really hard to not “rage respond” to some of the commenters on that io9 post. I feel like this http://imgs.xkcd.com/comics/duty_calls.png

      • Young CC Prof

        I feel like that all the time.

    • Amy Tuteur, MD

      Now it’s being linked from Jezebel.

  • guest

    I know everybody has a lot on their plate right now, but this is the official press release issued by the University of British Columbia. med.ubc.ca/u-s-home-births-found-to-have-low-intervention-and-mortality-rate/

    • Stacy21629

      Shame shame…They didn’t even MENTION the breech deaths or any other increased risks. What a crime against mothers and babies to pass on this drivel.

    • birthbuddy

      Seriously? This drivel will now be quoted far and wide as gospel and used to justify introducing homebirth programs. It will be held up as evidenced based medicine’ from a reputable university. What about the increased PNM and 15% PPH rate for goodness sake?

    • Young CC Prof

      Thanks for the heads up

    • auntbea

      Does this change the legal ramifications at all? This is an official medical organization providing dangerous medical advice, based on faulty research. Do they have liability if someone suffers a bad homebirth outcome as a result?

    • areawomanpdx

      Wow, Missy Cheyney is so intellectually dishonest. In that article, she’s quoted as saying we need to mo e the discussion away from whether or not low risk women should be allowed to give birth at home. That has NEVER been the discussion. The discussion is whether ill-trained midwives should be allowed to attend births at home, and whether women are being properly informed of the risks.

    • Jocelyn

      I just sent an email with this analysis and the others Dr. Amy has done, as well as the Cornell study that came out at the same time. I also explained about MANA’s vested financial interest in home birth. Hopefully they’ll listen.

    • http://momofmanyfeet.wordpress.com Bambi

      That is disgusting.

  • guestposter

    “February 18, 2014

    Nope. I had three c/s and the maternal death rates on fourth cesareans vs. Vbac was my deciding factor. Slightly higher death rate of baby? Sorry buddy. The duty I have to my existing children and my life both come before a new baby. I don’t expect everyone to make decisions with that same paradigm, but wanted to share that I don’t think the same way. (Btw my hba3c was the most awesome thing I’ve ever done.)”

    - http://www.improvingbirth.org/2014/02/versus/#comment-4601

    Whoa. At least her hba3c was awesome.

    • Anj Fabian

      If she was really devoted to her living children, she would have opted for a tubal ligation with #3.

      It’s always safer for a woman to not be pregnant.

      • Karen in SC

        I know! We stopped at two because of risks due to my age. And I love big families but ended up starting too late. Turned out our family size is perfect for us!

      • LibrarianSarah

        To be extra safe she should have had her husband get a vasectomy. It is safer for men to get clipped than it is for women.

    • Young CC Prof

      Right. So you compared the OVERALL death rate of VBAC to the specific death rate of a 4th c/s and on the basis of that decided HBAC was your safest option.

      Conditional probability matters, folks.

  • KAndrews

    I wish we knew how many of the babies that died had injuries or brain damage

    • Stacy21629

      I know…I was thinking just the other night about that and the breech deaths in MANA’s study. So 222 breechs. 5 deaths. That’s roughly 2%. A 50% C-section rate. Let’s assume with a 2% death rate there’s a 5% brain damage. 7% injuries/death, 50% C-sections…so <50% of women with breech babies manage a healthy vaginal home birth. So NOT what I would consider a "variation of normal".

  • Stacy21629

    It’s working…found this on MDC in the thread about the Cornell study. Keep at it Dr. Amy and Dr. Amos!!!

    “What I do know is that for my next pregnancy, if I choose homebirth, I am hiring a CNM or CM (if not an OB). With all this data that’s recently been released, and what I’ve learned about the educational differences & requirements for CNMs and CPMs (and DEMs), I can’t bring myself to think about hiring a CPM. Some are great, some are obviously not great, and there is almost no way to tell the difference beforehand. CNMs and CMs have a high bar of education they must fulfill. CPMs and DEMs have all sorts of different educations and levels of experience.”

    • Trixie

      Link?

      • Stacy21629
        • Melissa

          Some of the other comments in that thread are just rage inducing. “It makes me wonder about outcomes other than death. A baby who was the victim of a placental abruption may die at home, but the same baby in a hospital may live…and live forever.severely.brain damaged. Maybe saving a life with medical heroics is the right priority, but I’m not sure.”

          The undercurrent of eugenics in a lot of the NCB is terrifying. Some babies are meant to die. Better dead at home than to have some type of birth defect and live. Don’t vaccinate, and if your immune system is good enough you’ll be fine. It’s gross.

          • Stacy21629

            Agreed. That and the comments of “well, the mother should have done her own research” or “we have to honor the mother’s decisions”.
            Eugenics and victim blaming. Hallmarks of the NCB movement.

          • Comrade X

            I think fake “midwives” like these should be totally open with prospective clients about their eugenicist views.

            “I am not here to make sure you give birth to your baby as safely as possible. I am here to facilitate you undergoing a eugenic test by withholding proper medical care from you and your child. If you and your child are evolutionarily worthy, you will survive this process. If you are unworthy, one or both of you will die. Are you ready to face the test?”

            I think with that kind of “Running Man” honesty, there are very very few women who would gleefully sign up.

          • KarenJJ

            Exactly how I’ve come to think of what they are trying to do and why they think vaginal birth is an “achievement” to be proud of. If they pass the test they can then go and celebrate with their paleo donuts.

          • The Computer Ate My Nym

            Even leaving aside the eugenic aspect, for the moment, they don’t seem to have thought this through: The deaths during childbirth are frequently due to hypoxic encephalopathy, usually related to prolonged delivery. If a baby was born in the hospital, most likely the signs would have been seen earlier and there’d be no damage at all. But even supposing that a hospital can only incrementally improve the situation such that a baby that would die in a home birth would have major damage in a hospital birth. What about a baby with major damage at a home birth? She or he might have only minor damage at a hospital birth and one with minor damage might be 100% fine. So, even accepting the “better dead than damaged” assumption, having the baby in the hospital is a better risk.

          • Young CC Prof

            Remember the study about how home birth increases the risk of needing cooling therapy for HIE 18 times?

        • Danielle D

          On a positive note, a number of posters to that thread correctly read the numbers and the faulty rationale in the paper. Even for the one protested, “well, all the hospital can do for me is turn a death into a very adverse brain damage outcome,” the important question of whether the hospital can lessen the severity of bad outcome has been raised. She doesn’t know a theoretical home birth emergency leading to death would result in “severe brain damage in the hospital. It might. Or the child might well survive with no problems at all, or mild disabilities. Time factor alone makes the possibility of any given emergency being more adverse if the emergency begins at home.

          And most people, when push comes to shove, are desperate to see that baby stay alive–even when risk of disabilities is present.

          • Stacy21629

            And that’s the thing, isn’t it – you never know exactly what the outcome will be until afterward. I will admit it – not currently faced with the prospect of caring for a disabled child, I don’t think I could manage it. But in the instant, when my baby’s life is on the line – do EVERYTHING. I’ll deal with the ultimate prognosis later.

    • Medwife

      Once she figures out how few CNMs deliver at home because they find the risks unnacceptable/can’t get an OB to back them because OBs find the risks unacceptable, I hope she finds her way to the hospital.

  • MLE

    Donna on the Midwifery Today FB page is asking for a list of “concerns.” I outlined the basics around both the situation itself and Jan’s response but could use backup.

    P.S. Dr. Orosz’s work is awesome.

  • An Actual Attorney
  • fiftyfifty1

    What is notable about Dr. Orosz’s analysis is how conservative she chose to be when picking a comparison group. She eliminated only 2 groups from the overall CDC database: babies under 2500 grams and babies born to women who had received no prenatal care at all. This was because over 99% of the MANA babies weighed over 2500 grams and because 100% of the MANA patients had received prenatal care.

    Besides these 2 restrictions she did not take ANYONE else out of the CDC database. Teenagers? Crack addicts? Twins? Malpositions? Diabetics? Smokers? Prison inmates? Grandmultips? Illegal immigrants? Schizophrenics? Morbid obesity? VBACs? HIV? Nope, she didn’t eliminate ANYONE from the hospital group based on ANY of these risk factors.

    At every step of the way, she gave MANA the advantage.

    And still MANA’s numbers are atrocious. And *statistically significantly* atrocious.

    • Jessica S.

      On a side note, somewhat unrelated, after reading the suggestions from all those midwives re: no fluid, I wonder if their clients would be better off with no prenatal care!! :)

      • fiftyfifty1

        “I wonder if their clients would be better off with no prenatal care”

        This is an excellent question and an extension of the question of: Does having a midwife at your homebirth improve safety or not?

        The numbers that we have from Oregon indicate that having a UC (a.k.a. “freebirth”/planning to give birth at home without a midwife) is no more unsafe than having a homebirth attended by a midwife. And perhaps having no pre-natal care at all is no worse (maybe even better!) than having some quack push stevia on you.

        • The Computer Ate My Nym

          FWIW, the CDCWonder neonatal mortality data for married white women giving birth at 2500+ grams, 38+ weeks shows “other midwife, out of hospital” to have a mortality of 1.28 and “other, out of hospital” to have a mortality of 2.46. Of course, that includes unplanned delivery at home, delivery by the paramedics, etc, so it’s hard to tell for sure, but at the very least it doesn’t prove that UC is as safe as attendance by a CPM.

          Is the Oregon data publicly available? I’d be curious about it.

      • Stacy21629

        I would think that a primip experiencing a prolonged labor would be more likely to get “scared” and go into the hospital. Whereas her CPM would say “oh, it’s a variation of normal” and keep her home 48hrs more until the baby was dead.

    • Stacy21629

      I noticed that as well. Not even a qualification for race when 90+% of homebirths are white and outcomes for other races tends to be worse.

    • Young CC Prof

      You know what the minimum necessary restriction is to get numbers better than MANA? Eliminate babies under 1500 grams (very low birth weight). That alone gets you down to about 2/3 of their death rate.

  • anion

    Thank you, Dr. Orosz!

    So, about the APGAR scores:

    “Alarmingly, of the 245 infants with low recorded APGARs, 69 were transferred to the hospital intrapartum, but only 66 were transferred postpartum, meaning that over 100 low-APGAR infants did not receive prompt medical attention.”

    I wonder… I could be very wrong here, and I realize I’m making an assumption, but the first thing I thought of was how many of those transfer babies wouldn’t have survived birth had they not reached the hospital before being born? In other words, if not for that wicked modern medicine and/or those unnecessary c-sections–if the mothers of those babies had just gone on “trusting birth”–I imagine at least some of those babies would have been stillborn or died shortly after birth. I also wonder how many of them, if any, sustained neurological (or other) damage, since the MANA stats completely ignore that outcome. How many of the postpartum transfers sustained such damage, and how much of that could have been avoided with immediate medical attention from trained professionals?

    I know there’s no way to know, but the thought is chilling, isn’t it?

    • LMS1953

      Anion, I catch your drift. What drives me batty about working with CNMs (CNMs, not CPMs) is their notion that the baby is doing fine and is “tolerating labor” and you can go on and on and on and baby will do fine, until there is some catastrophic fetal heart rate pattern that makes you intervene AND that such intervention can be done in timely enough fashion that baby will be just fine. That is bull. A baby in a laboring womb is a drowning victim. EVERY contraction restricts utero-placental blood flow. CO2 progressively accumulates. Acidosis progressively develops. Hypoxia encroaches. By the time the ominous tracings occur, there has already been organ damage. You have to stay “ahead of the curve”. I think it is completely senseless to have a woman push for more than 3 hours. If the baby hasn’t delivered by 3 hours, it is ridiculous to think that she “is making progress”. The only progress you will ever see past that point is descent of banana headed caput with cervical edema and vulvar swelling. But I have had CNMs blithely observe a 4 hour or 5 hour or EVEN longer second stage saying “the baby is doing fine, and the labor is making progress, I think a couple more hours of the Hokey Pokey ought to do it”. Bull

      • http://www.antigonos.blogspot.com/ Antigonos CNM

        Again, this is a matter of education. Where I studied midwifery, no primip pushed for more than 2 hours; no multip for more than one, without bringing the on-call doctor into the case.

        • Medwife

          My guidelines are the same, for patients with no epidural. They get another hour if an epidural is in place.

      • Jocelyn

        Yes yes yes! That is EXACTLY what happened to my sister. The CNM encouraged her through 4 1/2 hours of pushing because the baby was “making progress.” Uh, right. Maybe a millimeter or two. When a doctor was finally consulted and pulled my nephew out with forceps, the baby was blue, not breathing, and with an Apgar of 3. My sister got a 3rd-degree tear, as well.

  • Captain Obvious

    This! This should have been MANA’s press release conclusions.

    • http://whatifsandfears.blogspot.com/2012/12/the-business-of-being-misled.html Doula Dani

      I posted it on the MANA Facebook page (as did others) and on the MANA press release but my comment still hasn’t been posted yet.

      • manabanana

        How about “Evidence-Based Birth”?
        You’d think that page would be interested in EVIDENCE.

        • http://whatifsandfears.blogspot.com/2012/12/the-business-of-being-misled.html Doula Dani

          Yes, I forgot to add that I posted it there earlier today!

  • hurricanewarningdc

    Brava to Ms. Orosz, but my problem with the work: Numbers are just so mind-boggling, especially for people who already avoid thinking. If MANA and its fans cannot comprehend simple common sense, then we have no hope that they’ll consume a scholarly paper. Further, in the end, the NCB reader will say “meh, 2 versus 5 babies… death is natural.” Sure, they may have to drop the “babies die in the hospital, too” garbage (not that they will), but the total number (regardless of what we can learn from the statistics) is still small enough for them to ignore. They’ll continue to say “it won’t happen to me” because that’s what they wish to believe.

    But please understand that I’m very appreciative of the effort. For moms who are “doing their research” and who are willing to glance away from the midwife industry propaganda, this may be the counterpoint that saves a llfe. I hope so. Again, thank you for trying.

    • Medwife

      They’ve already had access to the lite/minimal numbers with biased conclusion version.

      • Anj Fabian

        First impressions, dammit.

        Studies show (they do) that first impressions are hard to dislodge, even when people are exposed with information that contradicts the initial message.

    • theNormalDistribution

      I think the real issue here isn’t that moms do their research, learn the reality, and then conclude that “meh, it’s only 2 babies vs 5, I’ll take my chances”. Given, some of them will, and that’s their right. But the misinformation is so rampant and pervasive, I think it’s safe to say that despite their “research”, most women who get involved in the NCB culture don’t actually understand the reality of the risks they’re taking. And of those women, most of them, if truly informed of the risks, would not opt to take them.

      It’s not MANA who we need to inform. Their heads are in the sand because ignoring the truth puts money in their pockets and food on the table. It’s not even, really, the women who are into the woo, although plenty of women who were into the woo have been swayed by Dr.Amy’s constant assault with facts and numbers. I’d like to think that there are enough reasonable people in the world that continually pushing the issue in the public sphere will eventually result in reforms.

      • Stacy21629

        This is so true. I was 100% immersed in woo when I had my son at home. I had read TONS of “hospital horror stories” and “done my research”…I had no clue. I hadn’t read a single homebirth horror story or looked at real, critical evidence. I’m thankful now that I have…but most people go to places like MDC for their “research” and are completely in a bubble when it comes to objective evidence.

        • Guesteleh

          Speaking of MDC, the whole Jan Tritten mess hasn’t been posted over there. Anyone want to give it a shot?

          • Stacy21629

            Someone needs to put up this new analysis as well. There’s already a thread for the MANA stats. It’s been…curiously….quiet since it was started. Originally there was a long, fast-moving thread that degenerated into a Dr. Amy hate fest and a well-known CPM calling her a Nazi. Then that was closed under the reasoning that there should be a thread just for the paper itself…so someone started one and it’s crawled along and has dropped from the top. Funny how folks LOVE to bash Dr. A…but don’t actually want to discuss science associated with homebirth.

  • Amazed

    Someone is at it. Congratulations, Jan and co. You’ve been whining for ages that obstetricians won’t pay attention to you. Here, now you have some first class attention on your very own page.

    Amos Grunebaum: Jan Tritten has been conveniently absent for many days now as above said she is “away from the internet since Friday afternoon”. That attitude is the same as “taking the Fifth”. She is refusing to answer everybody’s concerns on the ground that her responses might tend to incriminate her. That is her legal right. And her refusal to answer shows more likely than not that she is guilty of something associated with the crowd sourcing on facebook and the baby’s death. .

    • http://kumquatwriter.wordpress.com/ Kumquatwriter

      Must have already been deleted, is there a cap?

      • Amazed

        When I tried to come back to make one, it was already missing. Damn it, it was mere moments between the two.

        I have no worries, though. He’s now officially pissed. I don’t think he’ll just go away because they really, really want him to.

        • Guesteleh

          He’s someone who has the stature and credibility to lobby lawmakers, not to mention rally his colleagues in ACOG to take a stronger and more vocal stance against homebirth. I really wonder what kind of phone calls and emails he’s generated over the past few days.

          • Amazed

            Yeah. As I said, first-class attention. Now, it looks like they don’t want it, after all. Won’t they make up their minds already? Huh?

          • KarenJJ

            Maybe they should integrate lay midwives into the hospital setting (thinking of the scenario out loud – not actually recommending this!). Having to do things that are hospital policy, like coordinate with other staff and expertise (like obgyns and anaesthetists), going to weekly meetings and also giving informed consent. And if something goes wrong they can stand up in front of their colleagues and discuss what went wrong with their care. Explaining your advice to a mother and how it ended in a preventable death to someone like Dr Grunebaum would put most of these midwives off trying to be ‘integrated into the medical system like in Europe’.

          • Amazed

            Yeah, that’s a good scenario. After all that happened in the last few days, though, I am quite sure Dr Grunebaum would rather take a stake to defend his practice, his colleagues, his malpractice insurance, and the standards of his profession with than breathe the air in the same room with them. If anything, their last backpedaling ensured that no adequate physician would go near them, let alone back them up.

            I wonder… If doctors are in the pocket of Big Pharma, whose pocket the loon who recommended Stevia is?

          • KarenJJ

            Yes, I’m pretty sure he’d rather stick a fork in his eye then fill his clinic with puffed-up hippies that like lecturing people on using cinnamon to stop haemorrhages and stevia for increasing fluid.

          • Jocelyn

            Big Sugar. Or would that be Big Non-Sugar?

      • Stacy21629

        I saved it as a PDF at 3pm :)

    • HillieOnTheBeach

      Somehow I think that for the most part, if Jan Tritten’s standing in the midwife community drops like a lead balloon, it won’t be so much because she was part of this tragedy but more likely because of the embarrassing inconvenience she imposed on them all.

      As if that wasn’t enough, the credulous and cynical speed with which many of them jumped on the “doctor did it” bandwagon should scare the living daylights out of anyone considering CPM assisted homebirth.

      • auntbea

        She obviously isn’t prepared for prime-time politics. Her first action should have been to blame the post on a rogue staffer who has now been fired.

      • PrimaryCareDoc

        Yup. And this should also give serious, serious pause to ANY doctor that agrees to be backup to an OOH midwife.

    • PrecipMom

      Yeah, I’m definitely a Grunebaum fangirl at this point.

      This case has made me so furious. So insanely unprofessional.

    • Blamed Stacey

      I am thankful for the attention, but it sure does seem like no one gave a crap until a man in authority decided it was a problem……

      • Amazed

        Quite right. But it’s quite understandable. Us, they could and did blow away as Dr Amy’s minions, Dr Amy’s clones and Dr Amy’s whatever. With the man in authority, it’s quite clear that he’s his own man. And he isn’t an unlicenced “Dr”, so everything they used to discredit Dr Amy is now back to bite them in the ass.

        • Guesteleh

          Amy is a retired clinician and a blogger. Amos Grunebaum is head of obstetrics at one of the most prestigious teaching hospitals in the country and regularly publishes in peer-reviewed journals. No disrespect to Amy but in terms of credentials, Grunebaum is way harder to blow off and dismiss.

          • KarenJJ

            Doesn’t stop those fools from trying though, does it? Are they still deleting his posts (I don’t get on to facebook much). Because, yes, that should convince him that the CPM credential is a professional and worthy qualification.

          • Amazed

            Exactly!

  • http://safermidwiferyutah.wordpress.com/ Safer Midwifery Utah

    Why don’t people like aviva romm understand that going “I was mistaken” is a lot less horrible in every imaginable way than digging yourself in deeper or trying to ignore it?

  • Amazed

    It’s been so quiet at the MT page since the link to this analysis was posted. I think that, for a while, they’ll be stunned. They might have actually believed it’d show otherwise.

  • PrimaryCareDoc

    So, it took Dr. Orosz what, a week to perform this analysis? And MANA claims it took them five years and that’s what delayed the release of information.

    • Jocelyn

      Well, to be fair, my math teachers could always do the math problems way faster than the remedial learners, too.

      • The Bofa on the Sofa

        No offense to anyone, and not to diminish the significance of this post, but what she’s done here is nothing all that crazy hard. It’s pretty much standard fare for statistical analysis.

        As she notes, the hardest part of the problem is determining the proper comparison group. From there, it is pretty much straight from a standard social science statistics course, and any of many here could do the calculation.

        • PrimaryCareDoc

          Right. And that’s the point. MANA could have done this in no time flat. Instead they sat on the results, claiming they were “analyzing” them.

  • The Computer Ate My Nym

    Thank you for performing this analysis, Prof Orosz. Would you be interested in publishing it in a peer reviewed journal? The most obvious would be as a letter to JMWH, but it’s not clear to me that they would be interested. Perhaps to one of the OB/GYN journals as a letter or brief report?

    • Medwife

      JMWH should DEFINITELY PUBLISH THIS. I dearly hope the author submits it. That’s what data analysis looks like.

  • CelinaA

    They didn’t even bother to report uterine rupture? As for all the VBAC attempts, did they rate how many women went on to have vaginal births?

  • Brooke Orosz

    Thank you for publishing this

    • Amazed

      Thank you for volunteering to perform this analysis and going on even after Dr Romm (that’s Miss Vivi of the tiny hurt feelings, for those who read my previous comments on her) flounced.

    • Montserrat Blanco

      Thank you very much for the analysis.

  • disqus_ok9xndxFPu

    I do not disagree with your points, however, I do have to ask if Prof. Orocz has any professional biases that we should know about that could have informed Romm’s opinion. If, for example, Orocz has published other documents supporting science-based medicine, Romm may have erroneously assumed Orocz was biased– or, I suppose, if Orocz had personal experience with homebirth, she could be biased for real.

    • Jocelyn

      Dr. Romm said she would not go forward with the analysis because she believed Dr. Tuteur was not courteous enough towards her: http://www.skepticalob.com/2014/02/aviva-romm-is-in-a-bind-over-the-hideous-mana-death-rates.html. She stated no objection to Orocz,

    • Brooke Orosz

      My prior formal publications are in pure mathematics, and I have some less formal publications in mathematics and statistics teaching. The last thing I published in medicine was related to technical aspects of certain mammogram techniques, in 2001. I have no personal experience with home birth, positive or negative, nor does anyone close to me, although I am now strongly opposed to it!

      Feel free to Google me if you wish, but spell my name correctly. It’s an s, not a c.

      • MaineJen

        Thank you for the analysis, this was so valuable!

      • The Bofa on the Sofa

        In case anyone wonders, Brooke Orosz has a PhD from CUNY. The title of her thesis was “Problems in additive number theory” working with Melvyn Nathanson

        Yep, that’s pretty much pure math

        • Jules

          Prof. Nathanson from Lehman? I just took a stats class with him this past semester. Small world :)

          • The Bofa on the Sofa

            That’s who signed her thesis as the chair of her committee.

          • Brooke Orosz

            Yup, Nathanson from Lehman. A fine mathematician and a marvelous teacher.

        • Trixie

          She’s got a pretty hefty YouTube channel, too!

      • http://whatifsandfears.blogspot.com/2012/12/the-business-of-being-misled.html Doula Dani

        Dr. Amy – perhaps add this information to the introduction above, so readers can see this is an unbiased analysis.

        Really great information here. Thank you!!

        • http://kumquatwriter.wordpress.com/ Kumquatwriter

          Agreed. Right up top.

        • The Bofa on the Sofa

          I would add in more information about how Brooke got involved. You state that she “volunteered” but that doesn’t really explain how she learned about the problem in the first place. It SOUNDS like she is a friend of yours, so you’d want to clear that up.

          • guest0815

            is she the poster “young cc prof” by any chance?

          • The Bofa on the Sofa

            Don’t know, won’t ask, but…

            if that is the case, you have to worry about the appearance of partiality. Hard to claim that you have an “objective analysis” by a regular at SOB.

            Not that I consider any of it a fault of the analysis (the work stands on its own) but it gives opponents easy grounds to dismiss it.

            Although, as I’ve said many times, it’s just math, so what’s there to dispute?

          • AlisonCummins

            Doesn’t matter. The point is that it’s math, all the inputs are public, the author has a public face and a reputation to preserve and anyone can check the work. If Dr Aviva Romm had wanted to participate in the choice she had that option. If she wants to ask a friend of hers to redo it she still can.

          • guest0815

            I think it does matter. The main criticism by the NCB crowd is not how to calculate p values, but rather the choice of comparison group. If Dr. Romm had the analysis redone by a friend of hers using a different comparison group (one that is more favorable to them), we would immediately question the impartiality of that choice.

            Now I think it’s hard to argue that the wonder database is not the correct comparison group, but it would be a stronger point coming from someone who is not a reader of this blog.

            (Then again we’re arguing with ideologues who have foregone conclusions on this anyway, so it probably won’t make a difference either way…)

          • The Bofa on the Sofa

            Yep.

            That is why I referred to the “appearance” of partiality.

            Brooke claims she had no personal experience with HB, and that is true, but that doesn’t mean she comes at this with no bias.

            Yes, the work stands for itself, but it’s certainly not an independent analysis.

            Again, that doesn’t make it wrong, but it does give them grounds to dismiss it out of hand.

          • Brooke Orosz

            Let ‘em come up with their own comparison group. So long as it’s drawn from reasonably recent US data and not chock full of micropreemies, it’s going to produce pretty similar numbers.

            I did very little screening: Hospital births over 2500 grams. Some folks claimed that gestational age as listed on birth certificates is unreliable, so I didn’t use that. Weight is a simple measurement, therefore more reliable. I also eliminated babies whose mothers were known to have received no prenatal care.

            And that breech death rate still looks hideous when compared to, say, the USA’s overall neonatal mortality (preemies and all) or even perinatal mortality rate. Or to the total INFANT mortality. In Mississippi.

          • Comrade X

            Yup – you were INCREDIBLY conservative in choosing your comparison groups. Positively humongously GENEROUS to MANA. And the numbers still came up dreadful. I don’t care if you’re Dr Tuteur’s MUM – the numbers you worked with are a matter of public record, it can be easily checked that you did not falsify or otherwise nefariously manipulate them. The calculations you performed are openly available and replicable by any qualified person with a pocket calculator and a small notepad.

            Sorry fake “midwives”, time to play the ball and not the man.

          • AlisonCummins

            Right, so let’s see how long it takes them to come up with their own statistician and comparison group that makes home birth look much safer.
            Or not.

          • Amy Tuteur, MD

            Yes! I’m very grateful that she volunteered.

    • GuestB

      I have a stupid question: How is supporting science based medicine a bias?

      • Irène Delse

        Only in the minds of MANA execs?

      • Jocelyn

        Because you’re closing your mind to the secrets of the universe and “other ways of knowing.”

      • Stacy21629

        Because that’s the entire basis of the NCB/homebirth/antivax movement’s “legitimacy” – complete and total denial of science based medicine.
        They have no standing without first tossing out science based medicine.

      • KarenJJ

        Wouldn’t it pretty hard to find a Professor in a hard science that isn’t biased by science?

  • areawomanpdx

    Thank you so much for arranging this analysis! I have one question. In the comparison numbers, Dr. Orosz used hospital births attended by all care providers, correct? I would be interested in a comparison to CNMs delivering in the hospital. My guess is that the difference would be even greater.

  • http://kumquatwriter.wordpress.com/ Kumquatwriter

    Just saw this on Jan’s Facebook page. ETA my bad, it went up in January. That doesn’t make it any less repulsive.

    • Medwife

      Oh yeah, there’s a big thread that has a lot of super magical twin home birth stories.

      • Jocelyn

        Ugh. I want to vote that down, not because I don’t like your comment, but because I don’t want to think about how many risky deliveries they’re encouraging other women to take.

      • anion

        I bet they’re not asking Dreah Louis to share hers.

      • KarenJJ

        I could write the article for them!
        —–
        If you have a patient with a pregnancy with multiples, it is no longer low risk and should be referred on to an obgyn. It’s how all those midwives in other countries like Europe with homebirth that is more integrated into the medical system practice midwifery. All pregnancies should have an ultrasound to confirm that pregnancies are singleton pregnancies before continuing with planning a homebirth.

        Easy – took me five minutes. And yes, I know ‘Europe’ isn’t a country, but I like to use the same terminology they do and get down with the ‘homies’….
        Right, well, that’s Midwifery Today’s editorial content taken care of for another month. They just need a few really, really big pictures to pad out the rest.

  • Ash

    Thanks to Brooke Orosz, PhD, for this analysis.

    Question for y’all: If I wish to send a letter to a newspaper, gov’t officials, etc asking for increased regulation of HB midwives, what would you propose? My state requires licensing as a CNM or CPM. However, there are no other regulations such as prohibiting HB for multiples. Do I start with the “soft stuff” like asking that all HB midwives have to submit stats to MANA or propose regulations such as not allowing HB for multiples, etc, like some other stats? I don’t know if it’d be more effective to start with incremental changes.

    • Anj Fabian

      My gold standard is that all midwives be registered, licensed, have mandatory reporting of all outcomes and carry malpractice insurance.

      Carrying malpractice insurance requires all of the others, so if you wanted to pick one that would be perfect.

      If I couldn’t get the insurance, mandatory reporting would be my second choice because if the midwives have stellar results, then great. If their results are poor, then obviously changes need to be made.

      However, without mandatory reporting, midwives can make any claims they like, lie as much as they like and legislators will have no other source of information to base their decisions.

      • Anj Fabian

        The mandatory reporting is to the STATE, not to any other organization no matter how “independent” it is.

        I’d make an exception if the organization is JCAHO.

        • KarenJJ

          And published online. At least, that’s what happens where I live in Australia.

      • Anj Fabian

        I believe that these are the same standards that other countries suck as UK, Canada and Australia use.

    • AllieFoyle

      I’d emphasize the need for informed consent so that women know unequivocally when they choose it that HB is statistically riskier and that the risk is especially elevated in certain situations.

      I’d also advocate for stricter training, licensing, and practice standards as well as mandatory outcome reporting, liability insurance, meaningful oversight with mechanisms for discipline and investigation of complaints and poor outcomes.

      • GuestingIt

        Informed consent is of course important, but it might be toothless when legislated, e.g. if the informed consent form is written by midwives as it was in FL.

  • Karen in SC

    Has MANA also lied about rates of PPH?

    • Anj Fabian

      Midwives often minimize the impact of PPH. Severe PPH can adversely limit breast feeding, and can lead to breast feeding failure.

    • Amy M

      Estimating blood loss at home, by eye, isn’t easy, and I would suspect they lowball it. How many stories have we read where the mother passes out from blood loss, but doesn’t go to the hospital or get much in the way of care from the midwife? Especially, if the baby isn’t doing well, and is demanding attention. If the mother is passing out, she’s lost a lot of blood, almost certainly more than 500ml or whatever they usually claim, but often the mothers don’t seem all that fazed by it.

      • Amy M

        http://icpa4kids.org/fr/Wellness-Articles/if-i-were-at-homei-would-have-died-the-trouble-with-extrapolating-hospital-birth-events-to-homebirth/Toutes-les-pages.html

        Here it is. I guess Dr. Amy did a post on this a few years back: http://www.skepticalob.com/2011/07/napalm-grade-stupidity-of-erin-ellis.html

        If you try to link to the original through the SOB post, it won’t go. I believe the one I linked on top there has been edited , and the parts about the “hormonal bubble” have been downplayed. (see the author’s note at the bottom)

        • Amazed

          Erin Ellis, the author of this lunacy, is one of those expressing sympathy for poor Jan. I’ll have to check whether she was one of the Facebook advisors.

      • Mac

        Mom’s aren’t fazed because they don’t know. When I had my last c-section my nurse was little concerned I was bleeding too much and warned me to let her know how I was feeling and if it increased. I was like I’m on it, I feel fine really. She said for some reason women won’t mention the bleeding….they will just pass out. Anyway, from my conservation with her I figure most women don’t understand how blood loss makes you feel, and how much is too much.

        • Medwife

          I have definitely had women start gushing in a very notable (to the rest of the room) fashion without the bleeder blinking an eye.. Postpartum women are usually asymptomatic until they truly enter hypovolemic shock.

          • Amy M

            Wow, really? I had a pph, but it was crazy-sudden, like I stood up, and lost so much blood I started losing consciousness immediately (on a nurse luckily), but I had been sitting (and evidently blocking the flow/clots) and there was no blood anywhere before that. It was apparent to me that it was bad, from the reaction of the nurse, and the gajillion other people who suddenly turned up in the room to help.

          • Medwife

            For example: “oops, I think I peed!” I pull back her sheet, bloods gushing like a faucet.

          • fiftyfifty1

            ” Postpartum women are usually asymptomatic until they truly enter hypovolemic shock.”

            I want to clarify Medwife’s words here. Women often are asymptomatic at the time of the bleed. But even if you don’t feel bad from a postpartum bleed at the time, you pay for it in the weeks after birth by feeling anemic, low energy, short of breath etc. right when you are needing to care for your baby. That’s why the high MANA numbers of postpartum bleeds above 500cc are concerning–women pay the price.

          • Medwife

            Yes, thank you, I mean _in the moment_ they may not feel or look like they are losing a lot of blood until they’ve lost a horrendous amount (not necessarily true, esp if they started out anemic). They sure do feel it in recovery. And it can basically prevent them from breastfeeding.

          • Mac

            So, staying in the hospital after birth is safer for both the mom and baby. At home at mom might lose too much and never know it unless or until she passed out. Plus,you would think the NCB crowd would be all over something that might cause a mom not to be able to breastfeed.

          • Young CC Prof

            Of course, many naturalists don’t believe there IS anything that can cause a mom not to be able to breastfeed, other than sabotage by Big Formula’s minions and selfishness. See the absurdities posted this week on an old breastfeeding post…

      • realitycheque

        Pardon my ignorance, but how is blood loss estimated in the hospital?

        • Amy M

          I don’t really know, but they often put chux pads down, I suppose they could weigh the pad. Clearly if the woman is losing consciousness that’s an indication that she’s lost a lot of blood. I know in my case, size of clots was an indication, but not everyone has clots. Someone who isn’t ignorant, can you tell us?

          • Mishimoo

            As far as I know, they weigh the chux pad. My EBL was 200mL for the last two, I can’t remember what it was for the first.

          • gtrslingermama

            Had a severe hemmorage from a miscarriage. My pups was 32,,and bp 80. It was like a faucet and had to go to the emergency room. I went thru numerous chux pads and filled up the container on the wall. They started me on pit but I was still bleeding out and my bp was super low. Then they put methergen in my IV HOLY SHIT!!! I was curled up in the fetal position and convulsing (it was worse than when I was in labor with my baby and the epidural wore off). I don’t remember how much blood I lost but it was enough that I had to sign a release for a transfusion and they were asking if my husband if he was my blood type. This was just a mc that happened at 6 weeks of pregnancy. Can’t imagine a pph!

          • Medwife

            How awful. Question- did they really give you methergine IV?

          • gtrslingrmama

            Yes they did…How I know was they told me when they injectes it. Then they sent me to the maternity ward to recover once I was stable (luckily no babies were there at the moment bc that would have emotionally wrecked me). Anyhow the nurse was about to give me more methergen (in pill form) and I told her no please bc of of the experience I had had downstairs in the ER. She was in shock and thought I was confused and then she checked my charts and there it was. I think the folks in the ER were really fearful I might die and were scrambling to help me. The good thing is the methergen actually did its job and stopped the bleeding. It just sucked going thru it.

        • fiftyfifty1

          It’s a combo of things. Weighing Chux is one of them. If there is a puddle on the ground, you can mop it up with a pre-weighed towel and weigh that. But on top of the weighed things you have to add more, because not every drop of blood gets weighed. This is where you get training in medical and nursing school. When you are a medical student, they have you add up your estimation out loud (“The chux give us 200 and I see a spot over there that is about 100 and another over there that is 50″ etc.)and then they point out to you what you have missed (“You forgot that spot over there, and that towel, and look at this clot”). But all of this still is prone to human error, so that’s why they test your hemoglobin after the birth (typically first thing the next morning) to make sure you have not lost more than they thought you did.

          • realitycheque

            Thanks! :)

      • Anj Fabian

        I was googling today and in an issue of MT, someone claims that the doctors doing the usual (pitocin, gentle traction on the cord to facilitate the delivery of the placenta) violently tears the placenta away from the uterus causing PPH.

    • Amazed

      OBPI mama comes to mind. If she reads this, I’d like her to post once again of just how her midwives estimated her blood loss. Chilling.

    • auntbea

      They tried to change the threshold at which blood loss was considered severe, by pointing out that they don’t send women to the hospital at that value. So, in other words, because they don’t send people to the hospital at level X, level X must not be that bad.

  • Lawyer Jane

    This is impressive work. I think you have laid the groundwork – now you need to go on to step 2, which is influencing public policy.

    • Amy Tuteur, MD

      Influencing public policy is the long term goal, but the more immediate goal is simply to demonstrate that homebirth has a horrible death rate and that homebirth midwives have no safety standards.

      Homebirth is a fringe practice; less than 1/2% of women choose it. Why then have homebirth midwives been able to make as much progress with legislators as they have? Because homebirth advocates are one issue voters and, thus far, satisfying them has been a win-win for state legislators. Homebirth advocates will vote for you if you push their legislation and no one else will be angry with you because the average voter doesn’t care.

      It seems to me that it is critically important to expose homebirth midwives as the lay birth junkies that they are. Then fewer people will support them and there will be less pressure on legislators to kowtow to them.

    • areawomanpdx

      There are many of us who have been trying to influence public policy, but Dr. Amy is right: OOH birth supporters are loud, obnoxious, and well organized, which legislators care far more about than they do actual evidence. They will show up in a cloud of matching t-shirts, breastfeeding babies, and patchouli, holding signs and chanting while doctors and nurses will sign a letter. They will pack a hearing room while average citizens will sign an online petition. Their tactics are simply more effective at this point. Unfortunately, legislators have the same piss-poor science education as the rest of Americans, and they will be more swayed by the many handwritten letters describing beautiful water birth experiences than they are the hard data of this analysis. If we want to win legislatively, we need to be better organized and willing to get out and testify. Asking for a meeting with your legislator to present the information in person will be more effective than sending an email. We need huge numbers of people who are as appalled by deaths of babies and who are as willing to put their money and time where their mouth is as these homebirth midwives and their supporters are passionate about keeping their right to make money killing babies.

      • Mac

        Will need LOTS of letters to make a difference. My rep is so overwhelmed with NCB support letters that I was sent a form letter thanking me for voicing my support for the CPM bill when I clearly laid out why I was against it!!! Grrr…still writing my response to that.

    • auntbea

      Political change takes time. In the meantime, our goal is to spread accurate information so that women can access something other than woo.

  • auntbea

    I would have liked an explanation of power, i.e. role of both sample size and effect size in our ability to calculate statistical significance. To be able to say that a difference is unlikely to be due to chance, you need a large sample OR a large effect or both. The difference the death rate for breeches is HUGE: therefore you don’t need a very large sample to be confident that it’s real.

    • fiftyfifty1

      Yeah, isn’t it pathetic that this needs to be spelled out for people? I mean, it’s fine that the general population doesn’t know this, but for supposedly trained medical professionals (like Aviva Romm) to say it is “too hard” and the samples are “too small” to be able to make a comparison–wow!

      • auntbea

        First rule of academic publishing: whenever the findings don’t go your way, suddenly develop insufficient power!

  • moto_librarian

    I was going to post this link on Dr. Romm’s FB page, but alas, I am banned from commenting. Anyone else want to do it?

    • GuestB

      Done

      • GuestB

        Got a screen shot on my phone because I’m sure it will not last long. Just realized someone else posted it as well. The more the merrier, I guess.

  • Anj Fabian

    Anyone want to post this link as a comment to all the posts that are saying “This study shows how safe home birth is!” ?

  • moto_librarian

    Thank you Dr. Orosz! There are a lot of Dr. Amy haters out there, but maybe some of them will come to their senses when they see that an independent statistician comes to the same appalling conclusions.

  • Anj Fabian

    I welcome any criticism from other statisticians.

  • Alenushka

    Thank you Dr. Amy and D. r Orosz. I am glad I took statistics class 2 years ago.