Is the American College of Nurse Midwives lying about the Cornell homebirth study, or merely ignorant of how it was done?

the truth or your story

In the past month, a variety of studies have been published that have shown unequivocally that homebirth increases the risk of perinatal and neonatal death. Even the data from homebirth midwives themselves shows that homebirth has a 450% higher death rate. This is bad news for homebirth midwives and supporters so they’ve embarked on an orgy of lying about what the various studies show, how they were done, and what they mean.

Perhaps I am naive, but I expected better from the American College of Nurse Midwives (ACNM). Unfortunately, they’ve jumped right into the muck. They are actively misleading both laypeople and reporters about the latest Cornell study, which showed that the risk of neonatal death at homebirth is 4 times higher than comparable risk hospital birth. Either they are deliberately lying or they actually don’t understand what they have read, even though it is quite straightforward.

A piece on Time.com about the new Cornell study includes the following claim:

In a response sent to TIME, the American College of Nurse-Midwives (ACNM) raises skepticism over determining the accuracy of the data that the study was based on. “Birth certificates are not always completely filled out, nor are they always filled out by the provider attending the birth. They are not always accurate, when compared to medical charts filled out by the attending provider,” they write. “The birth certificate data do not allow researchers to accurately separate out planned versus unplanned home births. We know that mortality rates are higher for unplanned home births, as they are more likely to involve emergency/urgent situations. The inability to separate these out casts doubt on the findings.”

But the study is NOT based on birth certificates, as the ACNM should know if they read the study, Term neonatal deaths resulting from home births: an increasing trend:

A retrospective cohort study using the CDC linked birth/infant death data set for term (>=37 weeks), >=2500 grams, singleton live births, excluding congenital anomalies from 2007 to 2009. Deliveries were categorized by setting: hospitals, birthing centers, and home as well as providers (midwives, doctors, and “others” for home births). Neonatal mortality (NNM) was defined as neonatal deaths up to 28 days after delivery. Hospital midwives served as reference. (my emphasis)

The CDC linked birth-infant death data set is NOT birth certificates, and is far more accurate than birth certificates alone. The birth and death certificates of each infant was linked to provide the maximum amount of information and to cross check the reliability of the data. So the ACNM is either lying about or ignorant of the source of the data and, therefore, the reliability of the data.

Moreover, since 2003 birth certificates have included place of birth, so no one is guessing where the babies were born. In addition, it is a legal requirement that the person who delivered the baby must sign the birth certificate. Any birth certificates signed by homebirth midwives must have been PLANNED, ATTENDED homebirths. While studies of birth certificates have shown that there can be errors in certain forms of data (e.g. maternal risk factors), they have never shown that the signature of the attendant is anything other than highly accurate.

The chief limitation of the CDC linked birth-infant data set is that it UNDERCOUNTS homebirth deaths because any babies who were transferred during a homebirth and were born and died in the hospital are erroneously removed from the homebirth group.

The bottom line is that the Cornell study unequivocally demonstrates that homebirth increases the risk of neonatal death by at least a factor of 4 and probably much more. The ACNM should apologize for making erroneous claims about the study and about the data … and they might consider studying up on the various forms of natality and infant death data since they appear, at a minimum, to be ignorant of the differences between them.

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  • Baffled

    I don’t know if this has been mentioned before–probably has, but has anyone seen the documentary “The Business of Being Born?” Absolutely fascinating and makes you have a distaste for the way western medicine has butchered the should-be natural process of giving birth. Dr. Amy, what’s your real beef with midwives? Personally I think someone with training similar to an OB who actually treats a woman like a human being and can deliver a baby very safely, is much better than an OB in a hospital who treats a woman like she has an infection in her uterus that needs all sorts of drugs and medication to get out and messes with the NATURAL PROCESS THE BODY IS SUPPOSED TO GO THROUGH. Also, why are c-sections elective surgeries????

    • KarenJJ

      Because sometimes they happen during labour and sometimes they happen when labour hasn’t yet commenced. Elective c-sections being those that happen before labour has commenced.

      Or did you think it meant that ‘elective’ means chosen without medical indication? Like ‘acute’ vs ‘chronic’, ‘elective c-section’ and ‘emergency c-section’ have medical meanings that might be different to what you might think.

      Keep reading baffled.

    • Amy Tuteur, MD
    • fiftyfifty1

      Dr. Amy has no beef with real University trained certified nurse midwives (CNMs) who follow sensible guidelines and provide safe births for healthy low risk women. What she is warning about is “Certified Professional MIdwives” or CPMs. These are lay midwives who have banded together and given themselves a title very similar to that of trained midwives in order to fool the public. Their death rates are up to 10x as high as for CNMs. They have no formal medical training, do not follow common sense safety guidelines and unlike CNMs are not eligible to practice as midwives in any 1st world country except the USA. Canada used to allow them but realized they were too dangerous and outlawed them. Dr. Amy is trying to get them outlawed here in the US as well.

      Did you know about this CNM/CPM difference? Wouldn’t you have liked to know that there is a type of midwife you could choose that has drastically better safety numbers? Why or why not?

    • fiftyfifty1

      I’ve given birth in the hospital twice: once with a CNM (certified nurse midwife) and once with an OB. Neither of them treated me like I had “an infection in my uterus”. However BOTH did test and pick up on the fact that I carried GBS in my vaginal flora. GBS is a type of bacteria that is totally normal in some women and doesn’t cause symptoms in the mom but can pass to the baby as it is born and can be fatal. Having GBS was a bit of a surprise to me because I have always been totally healthy in general as well as “down there”. I’ve never so much as had a single bladder infection or yeast infection. But anyway, they found I carried GBS, so I got an IV dose of antibiotics in both labors. I don’t like needles, but I’m a grown woman and I can handle my fears when I need to. For me, getting an IV was a small price to pay for saving my baby from the possibility of GBS sepsis. Google “Wren Jones” to hear the story of parents who followed their homebirth midwife’s advice and treated GBS with cloves of garlic in the vagina instead.

      • Houston Mom

        I was also GBS positive. The IV antibiotics were the first thing I asked for when I checked into the hospital. Strep B killed my sister-in-law’s first child. I was so relieved when the nurse started my IV.

    • manabanana

      Hi Baffled. Thanks for joining the conversation. I do not have as polarized views on the subject of midwives as some do here- though I do have concerns about midwifery in the US. I would much rather have this discussion among midwives – but MANA and my state midwifery organization like to censor the discussion. So until midwives are ready to have an open, critical conversation, I guess I have to revert to posting here.

      I never thought I’d see the day when I’d thank Dr Amy for posting some her her views… but I’m there.

      I don’t think BoBB is really going to influence anyone on this discussion board. I saw it when it came out in 2007 – while I was in the midst of attending births OOH and drinking the homebirth koolaid – and even then I found it misleading.

    • http://thefresstyler.blogspot.com/ Hannah

      The Business Of Being Born is propaganda, plain and simple. It is misleading and it is dangerous. Until modern obstetrics pregnancy and childbirth was the leading cause of death for women and babies routinely died at birth or as babies. Without fetal monitoring and venthouse delivery I would be dead or brain damaged, and my mother’s delivery with me went from normal to ‘get her out’ in a moment.

      Women are bring brainwashed to assume that birth is meant to be some herbal bath, scented candle and soft music experience when the truth is that no amount of trusting your body or bring treated like a unique petal is going to stop cord prolapse, placental abruption, cord wrap, shoulder dystocia happening unexpectedly. Save the performance art and spa experience for community college and Elizabeth Arden.

    • The Bofa on the Sofa

      Also, why are c-sections elective surgeries?

      Because waiting until it becomes an emergency is a bad approach.

    • http://thefresstyler.blogspot.com/ Hannah

      Also, I might have a c-section as an elective surgery. I have major issues with pelvic instability from an injury that leaves me far more susceptible to uterine prolapse. If the choice is between baby being cut out and my uterus following her out, I will pick the former thanks, and I will schedule it in advance as I damn well please.

      People are sad for me as though not having my baby emerge from the glory of my lady garden is some tragedy that precludes me from ever truly being a mother. Yeah, this girl ain’t drinking that koolaid.

  • An educated mother

    Dr. Amy, how can you disregard the findings of the Cochrane Review (the gold standard for evidence based care) which states that most women should be offered and encouraged to ask for midwife-led continuity care models? Most being low to moderate risk women? OBs should always be involved and care for women with high risk factors. Or how can you disregard the World Health Organizations strong stance supporting and requesting more midwives in the world? It seems that you even disregard your own board’s (ACOG) opinion which says Certified Nurse-Midwives and Certified Midwives are “experts in their field in their respective fields of practice and are educated, trained, and licensed, independent providers…”. I am left no other option than to believe that you are on an independent quest to go against all the leading recommendations in the world and ignorantly promote lies to win people over to your viewpoint. When you actually back up your statements with facts then people will listen. Otherwise you sound like a fool.

  • theNormalDistribution
    • Jessica S.

      Unbelievable. I don’t even have the words to fully express my disgust.

    • thepragmatist

      While I actually LIKE the quote, my personal experience of being obsessed with breast-feeding led to a starving baby. There are things to be obsessed about… and then there are things to be pragmatic… I don’t think there is anything I am “obsessed” about when it comes to parenting, other than making sure my son is safe and able to express who he is in the world. How that happens is irrelevant and actually, it’s counter-productive at the best of times, to ever get “obsessed” about the minutia of parenting. As for stealing images, I’m not shocked. At all.

      • AlisonCummins

        New parents are commonly obsessed and irrational. It’s their job to be hypervigilant. That’s the only way infants survive.

        It’s the job of experienced parents to give the new parents the space they need to do their jobs and to try to redirect harmful obsessing into more productive channels. If you hadn’t had any problems breastfeeding, making that your obsession would have been fine. If you hadn’t been obsessed with breastfeeding you would have been obsessed with something else.

        I don’t have a lot of problems with new or newly expecting parents obsessing irrationally and not having a good view of the big picture. They’ve got another twenty years to find the big picture and in the meantime minutiae may be all they can handle. If they want to get together and obsess, fine. Reality will give them perspective all by itself. It doesn’t need my help. Your baby went hungry, you noticed, you called in your resources, you fixed it, you realigned. All went as it should.

        What is more concerning is when the “experienced parents” play a role in promoting this narrow focus. That is not appropriate.

        • Young CC Prof

          I confess to being a little obsessed with feeding. We mix formula with a scale and graduated cylinder because we decided the scoop in the can and the line on the bottle weren’t precise enough. And when we think he needs a bigger bottle, we add a single extra gram of formula powder and another 6 mL of water to the recipe.

          *Facepalm*

          • AlisonCummins

            Sounds good to me!

            He’s still very new. During the first six weeks he’s changing all the time: he doesn’t have a “normal.” In a couple of months you’ll be able to look at him or listen to him and know something’s off and what it probably is. You can afford to be sloppy with things because if there’s a problem you’ll know about it.

            Now? You’ve got your rule book and you follow it precicely. That makes one less thing you have to worry about. Whatever’s going on at any particular moment, it’s not a problem with the formula mixing. Excellent!

          • Siri

            That’s beautifully written, Alison! I recognise everything you say. When my first baby was a month old, I travelled across the country with him to visit my mum for Christmas. I had this idea that all his clothes needed to be washed on 60 degrees; if my mum (who thought I was wasting electricity) snuck his stuff in a 40 degree wash, I would fret and fume and secretly rewash it at the correct temperature. If she picked up a garment, decided it didn’t need washing and put it back on the clean pile, I would fret and fume until I could retrieve it and wash it.

            My fifth occasionally gets clean clothes – you know, Christmas, his birthday, mother’s day.

          • AlisonCummins

            And every day you could know that you’d done at least one thing right: his clothes had been washed at the correct temperature. That’s very reassuring to a new parent.

          • Box of Salt

            You’re lucky you’re formula feeding. Since I was BFing, my scientific training compelled me to weigh the baby, which required buying a baby scale (we started off using our food scale, but it only went to 11 lbs including the extra tray the baby was trying too squirm off).

          • Young CC Prof

            Actually, I kind of want a baby scale also. He’s so little! Five weeks old and only now really fitting his “newborn” clothes. For a couple weeks there, we swaddled him instead of dressing him because nothing fit.

        • araikwao

          One upvote is not enough for this ^^

  • Sue

    HB MW’s questioning charting accuracy? LOLing.

  • Trixie

    Geradine Simkins in the S&S comments seems to be trying a new gambit: alleging that the decision to home birth with a CPM isn’t just about the risk at birth, because their model of care has improves safety for mother and child throughout the entire “childbearing year.”
    http://www.scienceandsensibility.org/?p=7895&cpage=1#comment-124079

    “Thanks Barbara–a very articulate and thoughtful commentary on “risk” and the ethical principles of “autonomy”–the right to self-determiantion in medical decision-making. I often feel the bottom line of the controversery about home birth and midwife-guided care is contained in this nugget from your commentary: “That is precisely what midwifery has been throughout time and across place: the development of a body of knowledge and skilled craftsmanship to navigate the dangers of childbirth. All of that knowledge was discounted with medicalization.” Medicalization, indeed! I imagine most people in the U.S. can see that the “medical delivery business” has changed the character of the health care industry to focus less on “health” and “care” and more on “industry.” It requires consumers of health care to be vigilant regarding their choices of birth place and birth practitioners, and well-infomed regarding making decisions for themselves & their familes. Your piece puts “risk” and “decision-making” regarding the safety of planned home birth in the context of the larger issue–and the imperative–of truly ensuring safety for mothers & babies in the childbearing year. Thank you”

    • Squillo

      A lot of sound and fury signifying nothing.

      • Anj Fabian

        I see paranoia.

        • An Actual Attorney

          It’s not paranoia if they are out to get you. In this case, they == the truth.

    • Squillo

      And I like how she conflates homebirth and midwife-guided care. It ignores the vast majority of CNMs/CMs who don’t do homebirth and, as far as I know, are still midwives.

      • Amazed

        Medwives, you mean…

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

      I think she’s full of “dangerous bullshit” and “desperate reframing.”

    • Susan

      So that means home birth is safer because any baby that can survive it is stronger? Huh?

  • Squillo

    As childbirth educators and birth professionals who work with expectant families, it is critical that we remain up to date on the newest data and research available on a wide variety of topics. When we have current information, we are then able to share this information with the families that we work with in relevant ways. Today, I would like to bring to your attention to the most fundamental, yet comprehensive data available about birth in the United States. 2012 date was released last month by the Center for Health Statistics. The National Vital Statistics Report “Births: Final Data for 2012” is a gold mine of information for those of you who are interested in the state of births in the USA.

    From the 1/28/Science and Sensibility blog [emphasis mine].

    • fiftyfifty1

      Yep, it’s “fundamental” and “comprehensive” and “a gold mine”….unless the data say something bad about homebirth in which case I change my mind, it’s all “unreliable”.

      • Squillo

        Kind of like the WHO: good when they recommended a c/s rate of 15% or lower, bad when they recommend vaccination or active management of the third stage of labor.

        • Jessica S.

          Bullseye!

    • thepragmatist

      And they accuse US of cherry-picking data and data sets. LOL!

  • Susan

    I am very much an outsider to the CNM world but I have observed a few things over the years. One is that they do try to be inclusive with the term midwife. So much so, that often, I feel they are ashamed of the “nurse” in CNM. Not all, but some. The thing is that those that are most drawn to the academic type positions may from my observation be the same people who attempt to be the most open minded about home birth. I know that someone like Antigonos or the other actual CNMs who post hear can speak to whether my observations are true or if it just happens to be the CNMs I know. I know some great CNMs, some of whom have attended and support homebirth. There are politics at work here and I think it’s getting in the way of CNMs admitting to the real difference between them and CPMs. It’s more than the RN, it’s the real education.

    • The Bofa on the Sofa

      We’ve had the discussion many times about why in the blazes the CNM is so accommodating of CPMs.

      No one has figured it out.

      • Susan

        It’s something about the sort of person who is drawn to academics being the sort of person who is going to give the most consideration to being open minded about home birth. I think. But, with all this new data a choice needs to be made if these people need to be brave enough to say they were wrong.

        • theNormalDistribution

          I don’t know… If that were the case, wouldn’t that theory apply to OBs as well?

          • The Bofa on the Sofa

            I don’t think there is any reason to think that academics are, on the whole, less interested in making things as good as possible.

            Sure, there are going to be the occasional ones who’s interests are “integration” of methods (you see that with doctors in faculty positions, for sure), etc, but the bulk are going to be mainstream.

            And that is what worries me. The attitudes you are seeing ARE mainstream in the CNM world.

          • Susan

            I don’t know. I know when I was considering becoming a CNM one of them warned me that I would have to pretend to be more woo tolerant than I am to survive midwifery school.

          • The Bofa on the Sofa

            I don’t think CPM is (just) about woo, it’s mostly general incompetence.

            Why would an academic CNM have any patience for a practitioner who has little more than a high school diploma? Why would an academic CNM be less likely to think that a nursing degree is necessary?

          • KarenJJ

            Hannah Dahlen is an Australian example of this.

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

            Woo has heavily infected medical schools, as well. Orac writes about it.

            What I do think is a common pitfall among academics is the idea that they have the tools to be experts — about everything, not just about their particular field of expertise, whereas the hoi polloi need direction and instruction. Therefore, academics often act rather stupidly because of their inflated idea of their own abilities.

          • Susan

            I am curious Antigonos if my perception that the ACNM may be more pro homebirth because there is an overrepresentation of woo tolerance in CNM academia is fact or just my impression?

          • KarenJJ

            Just curious, but what do academic nurses study? Because I see the nuts and bolts of medicine being studied by scientists and doctors. Nurses I see more of as the patient experience side of things? Would that be correct?

            If that’s so I’m baffled by people like Hannah Dahlen pushing vaginal birth (through her Normal Birth directive in NSW, Australia) over patient experiences.

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

            I could write a book about nursing and what it includes. The profession is very, very different from the public perception. When I trained, about 1/3 of the class dropped out because they’d had no idea the amount of science they’d have to learn: they thought it was mostly about TLC. In my first year, I studied anatomy and physiology, microbiology, chemistry, psychology, sociology, nutrition, basic nursing skills [procedures]. Second and third year were more specialized: med-surg, peds, OB, OR, etc.. In my day, after the first 6 weeks, we worked half day and had lectures as well. By our third year we were competent to run wards. Nowadays, the clinical experience is much more limited and the classroom time vastly expanded [padded, some might say], and new graduates are thought to need at least a year to become fully-rounded nurses. I’m not sure this is actually an improvement. Most of the bridging courses At Your Cervix took prior to beginning her CNM Masters’ course were nonsense.

            Both doctors and nurses are trained to certain disciplines of thought — but not the same discipline. In a sense, doctors are detectives: identify the illness, order the treatment. Nurses are more problem-solvers: we are confronted with a patient who has an illness which manifests itself in certain ways, how do we implement the necessary treatment? Doctors MUST rely on nurses’ observations as well as their performance; nurses need doctors whose knowledge base is, while much the same as nurses, in far more depth. And someone has to be in charge of the ship — even if the captain knows the mechanics of the engine, someone has to stoke it while the navigator points it in the right direction.

          • Young CC Prof

            In my city, there are hundreds, perhaps thousands of people who want to be nurses but can’t pass the algebra, chemistry and anatomy prerequisites.

            Believe me, I know. They’re in my algebra classes, sometimes over and over.

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

            Since I’m not in the US, I really can’t answer that, alas.

          • Susan

            Meanwhile the hoi polloi is being humbled by clinical practice on a daily basis. Humbled as in aware of their own limits.

          • fiftyfifty1

            “And that is what worries me. The attitudes you are seeing ARE mainstream in the CNM world.”

            Yep, and that’s why I now tell my patients to stay away from them. Until they clean house, they are not to be trusted.

          • manabanana

            As someone who currently works in a large obstetrics practice with dozens of CNMs who work along side physicians. I respectfully disagree.

            No, these are not mainstream attitudes among CNMs. Most CNMs are busy with their practices and caring for their patients, and they give relatively little thought to OOH birth practices. OOH birth is truly a fringe activity. I have witnessed nothing but evidence-based practices employed by the CNMs with whom I work. No crystals, no cinnamon candy, no ‘trust-birth at all costs’. Please don’t malign real professional healthcare providers in your efforts to shed light on OOH midwifery in the US.

            That said, I’m not sure who is doing ACNM’s PR. I anticipate some pushback shortly from some of the more reasonable, level-headed ACNM members.

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

            I think ACNM is trying to hedge its bets — and be all things to all people, certainly not alienate members if at all possible. Remember that even CNMs are not universally accepted yet.

          • manabanana

            I am fortunate to work in an environment where CNMs are (rightfully!) recognized as professionals.

            I think the ACNM’s reluctance to emphasize the difference between CNMs/CMs and ‘other’ midwives is a mistake. It may not be ‘nice’ – but there are some very important distinctions that should be clarified.

            And it does ACNM no favors to have the public grouping CNMs with all other midwives.

          • Susan

            I honestly don’t have a sample size large or broad enough. It’s an impression. OBs come from another world of being a men’s powerful profession that is now mostly women. Nurses have a history of having to fight tooth and nail for every bit of respect we get. We are still, mostly, a women’s profession. How each profession might view midwifery is quite different. And, therapeutic touch was a NANDA approved nursing dx when I graduated. As in, there is too much woo tolerance in nursing.

          • theNormalDistribution

            I would guess the woo tolerance in nursing and woman-centric professions is more of a factor here than CNM’s “being drawn to academics”. If anything, you could say that the sort of person who is drawn to academics is going to be, in a sense, the least open minded… because they will have learned to be more critical of the ideas they hear. There is less of an “anything goes and everyone’s opinion is valid” attitude among more highly educated people than in the general population.

      • C T

        I suspect that part of it is because CNMs tend to have an inferiority complex in relation to MDs in the USA. To most people in the USA, an MD is the “REAL baby doctor” because the USA doesn’t have the same well-established tradition of nurse-midwifery as Canada/Australia/etc. To protect against being relegated to lower status than they merit as highly-trained specialist nurses, CNMs will tend to try to protect the reputations of all midwives. After all, you can’t trust the average American to know the difference between a CPM and a CNM.
        Also, I think enough of them have had conflict with OBs that they don’t feel safe siding with OBs against CPMs for fear of losing some of their own “turf” (i.e., licensing allowing them to attend homebirths and birth center births in some states, hospital privileges for anything other than completely unproblematic births, etc.). The more freedom CPMs have, the less anyone is going to scrutinize what CNMs do and try to impose limitations on them.
        Finally, just like some medical doctors, some CNMs buy into extreme NCB beliefs.

        • LMS1953

          CT – very well said and oh so true! Most CNMs are Ina Mae wannabes – she is their patron saint.

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

            I’m not. And that hasn’t been my experience — rather, it is the CPMs who idolize Gaskin.

            You are right about the inferiority complex RNs of the old diploma programs have about MDs, which is what spawned the whole academic nursing path, so that nurses could also have a string of initials after their names, and it influenced the early US CNMs to the point that they demanded the right to perform certain kinds of procedures that midwives traditionally did not, to “show” their “equality” with doctors. But one has to remember that barely 50 years ago, a nurse’s status legally was quite different: I remember when nurses were first regarded as responsible for their own actions. When I entered nursing school, a nurse was expected to follow orders, and in the case of a mistake, the DOCTOR who gave the order was liable, not the nurse. As a result, most nurses were made to feel inferior most of the time: “Just do what I say” they were told by doctors.

          • KarenJJ

            That was my mum’s experience with nursing too. It was an eye opener when she upgraded her nursing skills to degree level 15 years later by doing a bridging degree for practising nurses (see CPMs! Other countries can do this!) and they were taught to have evidence for what they do and also taught to stand up to poor practices from other medical professionals (including doctors) and that they were also responsible to report on negligent care.

          • FormerPhysicist

            Hmm, I’ve seen a lot of nurse practitioners who I really like and trust. But when my OB sent me in overnight to L&D for observation for Pre-E, and to do the c/s in the first available slot in the morning, the ‘kindly’ older nurse took me off the monitor because it was uncomfortable and I wouldn’t have it at home. Contravening the doctor’s orders. And – what do you know, while she wouldn’t believe me when I said my backache felt like labor, it was and then there was a bit of a mad scramble to get my doctor in on time. I have to wonder if those few hours might have made a difference to my health. I’m NEVER coming off blood pressure medication in this life.

            My point – I think it’s while turf battles are bad, some nurses really do overstep.

          • http://thefresstyler.blogspot.com/ Hannah

            From what I’ve heard from some of my friends who have birthed in Australian midwife care, this is not at all uncommon. Based on anecdata, of course, it seems like a lot of midwives there are pushing a particular agenda. Two of my cousins were allowed to fruitlessly labour for days, were repeatedly sent home for not being in active labour, and ended up with emergency c-sections. In one case, all my cousins husband had to say when a obstetrician was called in was ‘please save my wife’. In both cases they were assured this was all natural. I have lots of friends who were repeatedly sent home for days by midwife care in Australia and it seems there is a similar issue in the UK.

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

      I find it an unwieldy mouthful to always have to describe myself as not only “certified” but as a “nurse” midwife. Here in Israel it’s a lot easier: the term “midwife” legally means “certified nurse midwife”. There isn’t any other legally recognized kind. And when I was in the UK, although the official designation was State Certified Midwife [SCM], at that time the ONLY programs to study midwifery were open only to holders of the SRN [State Registered Nurse -- RN in the UK means "Royal Navy"] qualification, so the word “midwife” had only one meaning.

      The whole history of midwifery in the US is entirely different from that of Europe’s, and that’s a big part of the problem. When I left the US in 1974, there were only two schools of what we today call “certified nurse midwifery” in the country — one was [and is] the Frontier Nursing School in Kentucky which was training midwives to work in rural areas not served by OBs. Midwifery was not integrated into mainstream medical institutions, while in the UK and Europe, midwives were. Ask a European today who delivered your baby, and if she says “Dr. Jones”, the rejoinder is “What went wrong?” but in the US that’s the norm for normal births. My own alma mater, Beth Israel Medical Center in NYC, had just hired its very first CNM about the time I went to Cambridge, and BIMC was regarded then as being quite avant garde in some of its policies. She was on staff, did not have her own caseload, and had quite a few problems competing with the interns and residents for deliveries, IIRC.

      NON-professional midwifery, however, was present from almost the beginning, and no one ever thought, during the frontier years, of trying to regulate it, largely because American women, or at least those who could afford it and had access, preferred doctors, even GPs, to deliver them. This was because, in the 18th century, it became fashionable for European aristocrats to retain the services of an “accoucheur”, and American women loved keeping up with Lady Jones across the Pond. The “granny” midwife, almost by definition, was for the poor and the disadvantaged, so there wasn’t any need for her to be well-educated.

      • Susan

        Antigonos I love reading your posts!

  • hurricanewarningdc

    Is this correct? “The chief limitation of the CDC linked birth-infant data set is that it UNDERCOUNTS homebirth deaths because any babies who were transferred during a homebirth and were born and died in the hospital are erroneously removed from the hospital group.” Did you mean from the “homebirth” group at the end?

    • Amy Tuteur, MD

      Sorry. Fixed it.

  • Rabbit

    “The chief limitation of the CDC linked birth-infant data set is that it UNDERCOUNTS homebirth deaths because any babies who were transferred during a homebirth and were born and died in the hospital are erroneously removed from the hospital group.”
    Did you mean erroneously removed from the homebirth group? OR erroneously added to the hospital group?

    • Mel

      Each home birth could cause both to happen. For example, a LD nurse posted about a midwife who came with a mom whose baby’s head had been entrapped for 20 minutes. An emergency CS was performed, but the baby was dead.

      The baby’s death would have been listed as a hospital birth since the CS was performed at the hospital. This would artificially inflate the hospital death rate since the attempt at home birth lead to the baby’s death, not the delivery at the hospital.

      Since that death was counted as a hospital death, it was also removed from the home birth category – even though the lack of medical skills/equipment at the home birth directly lead to the death of the baby.

      As a statistical effect, the removal of the birth from the HB cohort would be a larger effect on the total HB rate than on the hospital rate, but it would theoretically affect both.

      • Mac Sherbert

        And then later they use that c-section to show how dangerous they are!!! It’s like some kind of mad cycle.

        • Young CC Prof

          Or, say, the near-fatal c-section on the NCB fan who delivered in the hospital, but delayed intervention until it was “absolutely necessary,” six hours after the doctor first recommended it.

      • Jessica

        And this is why it pays to require information on planned place of birth, as Oregon does.

        • Susan

          California also requires planned place of birth.

  • http://shameonbetterbirth.wordpress.com/ Shameon Betterbirth

    If I had to bet its a problem with whoever is in charge of responding to the press instead of the ACNM as a whole. Maybe you should email them?

    • Staceyjw

      NOPE. I wish this was true. While many CNMs are awesome and against lay MWs taking patients, just as many want to protect the “sisterhood”. They the the tradition of MWery seriously, and see law MWs as part of providing care to women.

      That CPMs harm and kill in such great numbers often comes as a surprise to them. I know that the CNM that presented the data here in Oregon was pretty shocked at the bad numbers- no one thought it would be so bad.

      I have no clue why they back CPMs other than they are women and want to support other women, and they see HB MWs providing something valuable they cannot-HB. Some even lament their degrees (!) and day Lay MWs are superior.

      Thankfully many are awesome. but they are too busy to play politics.

      • Medwife

        I found this discussion really late, but here’s what I think. I think there is an idea at the top that trying to include CPMs rather than alienate them is going to lead to their being more educated, less dangerous. I know some of the higher ups in ACNM. Most CNMs want a system like the rest of civilization- one kind of midwife, a university-trained one.

        • fiftyfifty1

          “trying to include CPMs rather than alienate them is going to lead to their being more educated, less dangerous.”

          Sadly, the evidence shows just the opposite–but yet they don’t reevaluate their position of support.

          • Medwife

            I agree with you.

      • fiftyfifty1

        “Thankfully many are awesome. but . . . ”

        This is an example of one of Bofa’s observations. If you find yourself saying some variation of “they’re not all bad” then you know the profession has a serious problem with quality.

        I want to trust CNMs. I used to. I’m a physician who chose CNM care for my first pregnancy. But seeing what I’ve seen since, I would never again recommend them. They are badly in need of cleaning house.