Melissa Cheyney and the Midwives Alliance of North America finally acknowledge their hideous death rates

Grieving family with an infant's coffin --- Image by © Leah Warkentin/Design Pics/Corbis

I told you so!

I’ve been writing about homebirth for more than a decade. For most of that time, the Midwives Alliance of North America (MANA) and Melissa Cheyney, the Director of Research for MANA have insisted that their data show that homebirth is safe.

In every category — with risks or without — homebirth increases the risk of fetal/neonatal death substantially and often enormously.

In the meantime, the publicly available data on CDC Wonder has made it possible for me to demonstrate that homebirth deaths rates have been 3-7X higher than comparable risk hospital birth. Amos Grunebaum, MD and colleagues have published several papers using the same data and confirming my analysis. The most comprehensive analysis of homebirth death rates was performed by Judith Rooks, CNM MPH for the state of Oregon. Rooks found that homebirth midwives had a perinatal death rate 800% higher than comparable risk hospital birth!

Now, MANA and Cheyney have finally relented and published their own data that shows that PLANNED birth at home or in a birth center (generally just a rented home without special equipment) in the US has death rates EVEN WORSE than we imagined.

The new paper is Perspectives on risk: Assessment of risk profiles and outcomes among women planning community birth in the United States to be published in Birth: Issues in Perinatal Care, the journal owned by Lamaze International.

The authors used the data generated by their own members:

Data on n=47 394 midwife-attended, planned community births come from the Midwives Alliance of North America Statistics Project. Logistic regression quantified the independent contribution of 10 risk factors to maternal and neonatal outcomes. Risk factors included: primiparity, advanced maternal age, obesity, gesta- tional diabetes, preeclampsia, postterm pregnancy, twins, breech presentation, his- tory of cesarean and vaginal birth, and history of cesarean without history of vaginal birth. Models controlled additionally for Medicaid, race/ethnicity, and education.

Ostensibly, the authors were attempting to determine appropriate criteria for allowing or risking out homebirths and birth center births.

They found:

The independent contributions of maternal age and obesity were quite modest, with adjusted odds ratios (AOR) less than 2.0 for all outcomes: hospital transfer, cesarean, perineal trauma, postpartum hemorrhage, low/very-low Apgar, maternal or neonatal hospitalization, NICU admission, and fetal/neonatal death. Breech was strongly associated with morbidity and fetal/neonatal mortality (AOR 8.2, 95% CI, 3.7-18.4). Women with a history of both cesarean and vaginal birth fared better than primiparas across all outcomes; however, women with a history of cesarean but no prior vaginal births had poor outcomes, most notably fetal/neonatal demise (AOR 10.4, 95% CI, 4.8-22.6).

The author’s definition of “modest” are quite different than mine. They found that for almost all outcomes, homebirth had a nearly 100% increase in fetal/neonatal death. Breech babies had a death rate 700% higher and attempted VBAC had a death rate more than 900% higher than that baseline death rate at homebirth (which is already higher than the hospital death rate).

Two charts provide the most important information.

The first shows absolute death rates:

IMG_2144

The death rate for first babies was 3.43/1000 and the death rate for second or subsequent babies was 1.03/1000. Compare that to CDC data that shows a hospital death rate of 0.36/1000 overall and 0.44 for first babies. In other words, homebirth had a neonatal death rate more than triple (200% increase) that of hospital birth for women having second or subsequent babies and 780% higher for first time mothers.

The second chart shows the increased risks of various pregnancy complications compared to the already elevated risk of homebirth demonstrated above:

IMG_2140

For example, attempted VBAC increases the risk by more than 10 fold. Twins increases the risk more than 3 fold. Breech increases the risk more than 8 fold. Postdates nearly triples the risk. Pre-eclampsia increases the risk more than 10 fold.

In every category — with risks or without — homebirth increases the risk of fetal/neonatal death substantially and often enormously.

What conclusions do Cheyney and colleagues reach?

The outcomes of labor after cesarean in women with previous vaginal deliveries indicates that guidelines uniformly prohibiting labor after cesarean should be reconsidered for this subgroup. Breech presentation has the highest rate of adverse outcomes supporting management of vaginal breech labor in a hospital setting.

In other words, they attempt to minimize their own findings, despite the fact that they are uniformly terrible and often hideous. And these findings almost certainly UNDERESTIMATE the true death rate at homebirth in two critical ways: first, they compare complicated homebirths with uncomplicated homebirths, undercutting the impact of the fact that even uncomplicated homebirths have higher death rates than comparable risk hospital birth; second, this data is only a subset homebirths attended by members, voluntarily submitted by those members. The real death rates at homebirth are almost certainly even higher.

The bottom line is this: after years of denying that homebirth has a dramatically increased risk of fetal/neonatal death, Melissa Cheyney and MANA have finally admitted the truth. There is not a single category in which homebirth is a safe as hospital birth and in many cases, homebirth increases the risk of fetal/neonatal death by nearly 1000%!

Every American woman has a right to have a homebirth because she has the right to control her own body. But homebirth advocates should stop pretending that homebirth is safe. It is never as safe as hospital birth and generally far more deadly.

  • Platos_Redhaired_Stepchild

    These people are Certified Professional Midwives rather than Certified Nurse Midwives, right?

  • hmm hmm

    I’m so infuriated; IMO this amounts to research misconduct. Two questions

    1.) Has anyone corresponded with the VP Research or Office of the President at Oregon State about Cheyney? Is this the kind of research they want associated with their institution?

    2.) Who is the MD co-author on this paper (Lawrence Leeman)? [Actually scratch that, I just googled, and the third result is a youtube video he made on “how he came to take peyote”.

    Unbelievable.

  • Deborah

    These stats, awful as they are, are an absolute gift in being able to provide a snapshot into the past. They enable us to see just what birth was like for women and families before the advent of modern obstetrics. Anyone who wants to say “birth has always been safe and was ruined by medicalisation” need only to peruse this information to see how misinformed they are. To have produced these stats using randomised controlled trials would have been completely unethical as the medical profession, including properly trained midwives, already had this knowledge through decades of improved outcomes directly attributable to improved obstetric and midwifery practice.

    • Blair

      I am a pediatrician, and have been following the skeptical ob for some time, but have withheld comment, because I don’t think I could limit my responses to a reasonable amount. I have a copy of an article from the AAP’s Pediatrics journal from a few years ago, that I sometimes hand out to patients who are vaccine wary or want to consider home birth. It lists the causes of death of children worldwide based on age group, age <1,1-5, etc. #1 cause of death birth asphyxia/sepsis. Most of the other top causes vaccine preventable infections. For teenagers, dying in childbirth #11, if I recall, and dying from abortion #15 ish. I will find the article when I go to the office tomorrow. We had a twin, breech home delivery with first baby demise at my primary hospital a couple years ago. I believe doing home birth with twin, and breech is the medical equivalent of hooking Michael Jackson up to propofol all night–not just malpractice, but criminal

  • yentavegan

    Anecdotal evidence alert….I facilitate a breastfeeding support group. There are mothers who have been fitted for pessaries due to urinary incontinence. All have used midwives.

    • Eater of Worlds

      Were these homebirths in the US with midwives?

      • yentavegan

        Birth center births USA.

        • Eater of Worlds

          So probably mostly CPMs. Given how many you know have had these, do you think the midwives are letting the mothers labor too long, because it’s nacheral, right?

  • moto_librarian

    So here’s my question. We know that MANA has been sitting on this data for years, all while continuing to promote the safety of homebirth. Now that they have finally admitted that they have a hideous mortality rate, is there any legal recourse for families that have suffered? Does MANA itself have assets? Could they be found liable for fraud?

    • RudyTooty

      My guess is that MANA has $200K-$300K in assets.
      I’ve looked up their finances on Guidestar in the past, it wasn’t impressive.

      Short answer: there’s no money. MANA has enough money and influence to be dangerous, not to provide payout.

      Also, they believe what they promote. They 100% believe it. They believe CPMs are (well) trained, and home birth is safe (enough).

      Are you committing fraud if you’re delusional?

  • Azuran

    OT – Just wanted to let you know that I had my (not so) little Potato last week. Long story short my water broke as I was going to bed in the late evening. I got induced the next morning because nothing was happening. By the end of the afternoon I was starting to have a fever and labour wasn’t progressing because baby’s head kept bumping against my pelvis so I ended up having a c-section.
    Little Potato was born perfectly healthy. Recovery has been hard for the first few days. Although a good part of it was probably just the state of absolute exhaustion I reached during labour. Not 100% yet, but It’s quickly improving now. Hospital staff and my family have been helping a lot in the last week.

    • Dr Kitty

      Congratulations on the little spud!
      Enjoy all the baby snuggles.

    • Sarah

      It will be hard. The first few weeks are rough. But congratulations!

    • Who?

      Glad the Spud is well and you are on the upswing. Those first few weeks are tough, or can be.

      Look after yourself.

    • yentavegan

      Mazel Tov! Welcome little Potato.

    • Inmara

      Congratulations!

    • MI Dawn

      Welcome, Little Potato! Glad you and baby are doing well. Rest as much as you can and let the family pamper you both.

    • The Bofa on the Sofa

      Little Potato was born perfectly healthy.

      How many eyes does it have?

      (come on, someone had to ask it)

    • Amazed

      Congrats! Welcome, not so little Potato!

    • MaineJen

      Welcome, little Potato!! And here’s hoping you have a speedy recovery. That sounds like a rough ride…

    • StephanieJR

      Congratulations!

    • Empress of the Iguana People

      Congratulations!! Sounds like what happened with my boybard.

    • fishcake

      Congratulations, Azuran! I hope you feel better very soon.

      By the way, your story sounds similar to mine. I remember feeling much improvement once I was able to take walks around the neighborhood. Of course, Baby loved it too.

    • myrewyn

      Congratulations and welcome to your Little Potato!

    • BeatriceC

      Congrats! I hope your recovery continues smoothy.

    • Christy

      Congratulations!

    • Karen in SC

      Congrats on the Little Potato!

    • moto_librarian

      Congratulations!!

    • Empliau

      Welcome Tot!

    • Gæst

      Congrats!

    • Box of Salt

      Congratulation to the whole family and welcome to the Potato!

    • SporkParade

      Congrats! Is a baby potato a “tater tot”?

    • mabelcruet

      Congratulations! If he was English, he’d be a ‘Spud’.

    • Platos_Redhaired_Stepchild

      Congrats & speedy recovery!

  • BeatriceC

    OT: Does anybody have access to “Trends in Neuroscience”? There’s an article I want to read, and while I have access to a lot of stuff, including “Cell” through MrC, this is not one I have access to. I’d like to read this one in full: http://www.cell.com/trends/neurosciences/fulltext/S0166-2236(16)30177-1

    • AnnaPDE

      How can we get in touch? My uni worked.

    • BeatriceC

      Deleted comment with personal info. Thanks for the person who helped!

  • Dr Kitty

    I be happy if the “as safer or safer than hospital” line would die already.

    “Much, much riskier than hospital, but entirely your decision if those risks are acceptable” just isn’t as sexy.

    • Merrie

      It’s predicated on the idea that “you might end up with an unnecessary induction, monitoring, or an unnecessary c-section” is the “unsafe” thing about hospital birth. Which is complete bs.

      • Young CC Prof

        Wanting to avoid a c-section if possible is reasonable, but most home-birthers radically overestimate the effect of birthplace on probability of c-section. The 2014 data set (17000 births) had a 5% c-section rate, but the overwhelming majority of the births were spontaneous term vertex labor in basically healthy women, and most were multips with no prior c-sections. Which means that, had all of them delivered in the hospital, the c-section rate would probably not have been much higher.

        And just to set the record straight, worrying about unnecessary
        monitoring makes you a princess, and induction of labor can be a good
        thing.

        • SporkParade

          I’m planning on getting induced if there is a next time. History of precipitous labor + not willing to risk giving birth at home = induction at the first sign it would be successful.

        • Kelly

          My induction was my best and easiest labor I have had and I did it all to protect the little terror I have running around now. Now I did get the ebil epidural before the ebil pitocin but I got to watch t.v. and relax with my husband before I pushed once and had a baby. How could you get more relaxed than that while having a baby? Even if it was a terrible experience, I did it because I developed a condition that could have killed her in the womb and thus I decided to use science to bring her out safe and sound. I just don’t get people at all.

        • Gæst

          I understand wanting to avoid monitoring. The elastic straps used to hold the monitors in place were extremely itchy for me – I developed contact dermatitis from a pregnancy support belt that was made of the same material, and even though the belts weren’t on for that long, I had the same reaction. So very uncomfortable. I still did it, though.

    • Roadstergal

      Driving without a seatbelt is “as safe, or safer than” driving with one, if your definition has ‘red mark on chest’ and ‘death’ as equivalently bad outcomes.

      • Spamamander, pro fun ruiner

        This particularly hits home for me, as I was involved in a rollover accident with my car in December. The car landed on the driver’s side door after two rolls. I was wearing my seatbelt, and after a passer-by helped open the passenger side door I was able to climb out with help. I walked away with a bruised sternum and maybe some torn cartilage/ soft tissue damage. What COULD have been had I not been belted in …

        • BeatriceC

          I’m so glad you walked away with relatively minor injuries.

        • MaineJen

          Oh geez. That sounds terrifying

        • Roadstergal

          Whoa. Glad you came out in one piece!

      • TsuDhoNimh

        I was rear-ended by a larger vehicle and had a diagonal bruise across my chest from the seatbelt, with two much deeper bruises where the buttons on my shirt were under the straps. And bruises on my hipbones from the strap.

        I walked away from it, although I was walking stiffly for weeks.

        I don’t think I would have walked away from that experience if not for that nasty injury-causing seatbelt.

  • Sara

    I can’t believe this statement about breech being best managed in a hospital setting. It’s stated like that was not the recommendation prior to now, like this was a new finding, that no one had ever said anything like that until now. I can’t believe that the common conception in the midwifery world is that it would be okay to do a vaginal breech birth out of hospital.

    • Anonymous

      According to the birth nutters, breech is just a variation of normal

    • Young CC Prof

      Some midwives wouldn’t do it, but quite a few would. The story of Magnus Snyder is particularly telling.

    • When I was in the UK in the 70s, the ONLY women regarded as suitable candidates for home delivery were gravida 2,3, or 4; singleton vertex presentation, with no history of either medical or obstetric problems in the current or previous pregnancies, and no postdates. There were further criteria regarding the state of the house and social factors. A single blood count with a low hemoglobin was enough to disqualify a woman.
      It was, in fact, not easy for us students to find enough women who would have home births for our required course minimum. Nowadays, standards have been relaxed. But no responsible professional midwife would undertake a high-risk birth at home. She could lose her license. But, in the US, depending on where one is, “anything goes”.

      • MichelleJo

        That’s me! Homebirth survivor born in the 70’s, gravida 3, numbers 1&2 no complications. My brother, gravida 4, was also born at home.

    • Rose Magdalene

      I use to work for a non profit that amongst other things promoted natural childbirth/out of hospital birth and trained doulas. They def had a lala fairytale view of birth. One of my fb friends is a CPM I’ve known since my time working at that non profit. She’s always posting positive stories of home births of breeches and multiples. I like her as a person, but these posts drive the up a wall. Promoters of NCB/OOH birth, often times have no clue that what they are peddling is dangerous. And they actually believe that what they are pushing is saving mothers and babies. (I truly believed this when I was drinking the NCB koolaid.) They also tend to believe that CPM are better able to handle high risk vaginal births than OBGYN’s. CPM’s know magical positions and maneuvers, OBGYN’s only learn how to cut women open, blah, blah, blah. CPM’s are experts at normal birth they say, and breeches, multiples and post date babies are just variations of normal. Eye roll. The ideology is strong in the NCB community.

  • myrewyn

    Hooray for this! I do have a friend here who is about to give birth in a birth center and I’m worried for her… when she told me “good news! I got approved by my midwife for the birth center instead of the hospital!”, I’m sure I had to wipe the look of horror off my face and the only thing I could come up with to say was “how far will you be from a hospital??” All I know is it’s in SE Portland. Ugh.

    • yentavegan

      You might want to share with your friend the facebook page of Justice for Vylette Moon. Birth center /CNM..

      • myrewyn

        I struggle with this with my friends. It’s tough when you know someone and you like them and (mostly) respect them but you have differing views on things like this. We could laugh off our differences on babywearing but worrying about her birth is different. I have friends here who have homebirths and one who is studying to be a midwife and mostly I keep my mouth shut :/

    • Bombshellrisa

      Even CNM run birth centers in a hospital or on it’s campus can be problematic. I just heard about a birth in one where the mother begged to be transferred to the main hospital for pain relief and was offered aspirin by her midwife and the midwife would not transfer her.

      • myrewyn

        The refusals to transfer care, whether from home or a birth center, terrify me.

        • Anna St

          Professional midwives should know where to transfer care, in Canada, it’s part of their education.

          • Bombshellrisa

            Canadian midwifery is very woo steeped. A woman at a birth center who is low risk but not tolerating the pain well and wishes to be able to go to the hospital shouldn’t have to beg a midwife to facilitate a transfer. I remember that there was a woman who died at a birth center in Quebec quite recently because her “educated” midwife didn’t risk her out.

      • Petticoat Philosopher

        That seems like a problem with the midwife though, not the fact that it’s a birth center. My friend (who had had an entirely uncomplicated, low risk pregnancy) had a good experience in a birth center on a hospital campus. She was also being attended by a CNM, who detected fetal distress early on in the labor and told my friend that she needed to be transferred, that the baby needed to come out right then. She was right on the campus, so she had her C-section right away. The umbilical cord had been knotted and if my friend had had a home birth, her otherwise healthy little girl would likely not have survived. An incompetent ideologue as a midwife could have had the same effect.

        I tell that story to anyone who starts yakking about how home birth is perfectly safe for women with uncomplicated, low-risk pregnancies. But, in that case at least, it seems like everything went as a it should have in that hospital birth center and that the close proximity to the hospital was enough, since she had a competent midwife. What’s scary is the idea that even a midwife who is an actual CNM, working at a hospital birth center (as opposed to some amateur who attends births miles away from a hospital, in or out of the home), could be as reckless and cruel as the one you describe. You’d like to think that someone who’s that mainstream wouldn’t do anything so horrible.

        So…just make sure the CNMs at hospital birth centers aren’t wacko dogmatists I guess?

        • KeeperOfTheBooks

          Pretty much.
          A SIL of mine is a bit into the natcheral stuff, which hey, if it floats her boat and is safe, good for her. She was leaning a little towards a homebirth until I mentioned, “y’know, at XYZ local hospital, so long as you and baby are good you can labor in a Jacuzzi, smell your essential oils, bounce on a ball, have the lights dim, dance, listen to music, whatever floats your boat–and if it all goes to hell, you can be in the OR having a C-section in about ninety seconds. And did I mention the awesome and free postpartum support group they offer every week, complete with coffee and pastries?”
          Being quite sensible, her response was essentially “oooooh, where do I sign up?”
          (Random side note: why don’t all hospitals offer that kind of support group? I know at least one mom whose life may well have been saved by that one. No judgment, no lactivism, just “hey, let’s all drink some coffee, coo over the babies, and talk to a counselor/social worker in an entirely informal setting.”)

          • BeatriceC

            That sounds like a truly baby (and mom) friendly hospital.

          • KeeperOfTheBooks

            It is. I so wish my OB delivered there, rather than the Gawdawful BFHI place at which he does deliver. When he retires, I’ll be really sad–but I’ll also be finding an OB who delivers at the other place!

          • Anna St

            Maybe if they were all like that, there would be less home births…

          • Bombshellrisa

            If there were less people emphasizing jacuzzis and dim lights and more who understood the value of safety over aesthetics, there would be less home births.

          • Roadstergal

            Fewer.

            Home birth is already a very small minority of births in the US. If the women involved were given proper risk/benefit information, rather than being sold on homebirth as ‘as safe, or safer than hospital birth,’ it would be even smaller.

          • KeeperOfTheBooks

            Quite possibly. There is, though, the factor that this hospital is freaking HUGE and is in one of the largest cities in the US, and as such, can offer more than Podunk Regional Medical Center which is going to have less money and resources to set that kind of thing up. Understandably, PRMC is going to focus what money and resources they have on things that will improve the “live babies and moms” line vs the nicer-but-less-necessary stuff.

        • Bombshellrisa

          The midwife I described is a CNM who also delivers at the main hospital. Both the woman who gave birth and her husband are traumatized by what happened.

          • myrewyn

            If she had hospital privileges that makes it even worse! Why not transfer??

          • Anna St

            Maybe because some people hate hospital environnement…. Our birthing center (in Canada) is very cozy and very close to the hospital. I’m traumatized by hospitals (had an operation without anaesthesia as a child) and for me, a birthing center is much better. Obviously, everybody hopes for the best. But if there’s a problem, you don’t have to walk, they put you on a stretcher, call the hospital before so they can get ready for you (they have an agreement with them) and that’s it.

          • Poogles

            Ok, but that doesn’t really apply to this situation – the mother *wanted* to transfer to the hospital (where the midwife has privileges) for pain relief and the midwife refused. That is completely unacceptable.

          • Anna St

            I guess it’s no different than people who are traumatized by hospital births. Unfortunately, incompetent professionals can be found anywhere.

          • Bombshellrisa

            It’s completely different. The midwife was not incompetent, she was cruel and controlling.

      • KeeperOfTheBooks

        That’s as disgusting as it is unethical. UGH!

      • TsuDhoNimh

        The midwife WOULD NOT? I don’t think the midwife has the legal authority to refuse pain relief to a patient, or refuse a transfer to somewhere that pain relief can be given.

        • Bombshellrisa

          She “steamrolled” over the husband trying to get help for his wife and dismissed the laboring woman’s cries and the fact that she was vomiting and shaking.

          • Box of Salt

            Please tell us there’s going to be a lawsuit over this.

          • Bombshellrisa

            This birth happened last week. The person works with my husband. My husband congratulated him and basically the guy started talking about how baby is beautiful and perfect, but he and his wife are upset about how they were treated. My husband called me while he worked to tell me about this. The couple’s first baby was born in a regular L&D, with epidural pain relief. The wife ended up with midwives this time because of a change in insurance, and the hospital recently opened a CNM run unit. Not sure if there was a language barrier issue(English isn’t the first language of the woman who gave birth) but I do think that her being a WOC was a factor in her treatment. I gave my husband a rundown of who the couple should contact to complain. I hope they act on this.

          • Box of Salt

            Oh my. Please let us know if there is anything we can do to help.

    • fishcake

      What I tell my friends who want to give birth at home, when they say “it’s fine, we’re 10 minutes away from the hospital,” is: “you might know you should transfer, but you might detest having to move, even walking to the car.”

      Why not just go to the hospital where you’ll be able to stay put, and not have to leave the building until you’re going home with your newborn?

      • Roadstergal

        If there’s anything that makes the experience of going to the hospital easier, it’s being in the midst of active labor. :p

  • Empress of the Iguana People

    I doubt it’ll make much impression on my CNM friend. She’s still pretty enamoured of all the sparklies they threw at her in her master’s classes a couple years ago. She’s working at a birth center in Amish territory

    • Heidi_storage

      Oh, well. Even a woo-y CNM is better than a CPM.

      • Empress of the Iguana People

        True

      • no longer drinking the koolaid

        Don’t count on that. The “woo-y” CNM may have more schooling, but that doesn’t mean she isn’t totally in sync with the lies that CPMs and other lay midwives tell. Again, ask Magnus’ mom.

        • The Bofa on the Sofa

          IN PRINCIPLE the CNM should at least have the basic medical training.

          However, as you note, CNMs that do homebirths are doing it because they have the type of mindset that makes them ignore actual medical risks.

          I still think their medical training makes them better, but they are still unacceptable IMO. They are ideologists.

      • RudyTooty

        I disagree.
        I think they can be more dangerous.
        People trust them more, because they’re nurses and nurse-midwives, and they hold the authority and knowledge and seem more respectable and more skilled.

        CPM, CNM or OB/GYN is going to be up sh*t creek without a paddle in a home setting. It’s a low-technology, low-resource, low-skilled-staff setting.

        Training and skill and expertise cannot change your location.

        If CNMs use risk-out criteria conservatively, and they have good collaborating relationships with hospitals and reasonable distances for allowable births to the hospital, they can demonstrate better outcomes.

        But many homebirthy CNMs embrace the same ideology as CPMs. And I believe this makes them more dangerous, because they’re more deceptive.

        • Heidi_storage

          I see your point, but they actually are more skilled and knowledgeable, and so might be able to handle sticky situations better than a CPM who can only tell the mother to think orgasmic thoughts.

          • swbarnes2

            So you have a situation that 95% of CNMs would say “This is bad, let’s get to the hospital”. Well, the 95% of CNMs who would make that call already work in hospitals. Only about 5% of CNMs work outside of hospitals. A CNM who does homebirth is almost certainly operating on the fringe of her profession. You can’t count on her doing everything she was trained to do.

            Then remember, there isn’t a gigantic demand for homebirths. It might be hard to make it financially if you turn away a bunch of women up front, and risk out more as you go along.

  • Merrie

    They don’t seem to realize that an AOR of >1 means that the behavior is more dangerous. An AOR close to 2 means almost double the risk. “Modest” increase indeed.

    • Sheven

      I guess it illustrates why it doesn’t work to characterize a risk with words when you can use numbers. If a risk of a procedure is one in a million and it’s doubled, I could say the increase is staggering (double the risk!) and I could also say the increase is tiny (one more person per million procedures!).

      • Merrie

        That’s true. But a lot of people are idiots about statistics any way you slice them. They think that because there are multiple ways to state them, there’s no objective truth. Like “Oh, the statistics may say that, but we all know that statistics are lies”.

        • Sheven

          Yeah. What’s more worrying is that people tend to think of small risks as nonexistent, especially when they are pumped full of confidence due to rhetoric and anecdote. A hypothetical risk of one in a thousand risk of death, for example, sounds like nothing to parents until you point out that that means four thousand US babies would die each year and their baby is as likely to be one of those deaths as any other baby.

          • Mel

            The way I explain my viewpoint to people is that when n=1 and I am the one, I see the statistic as being either 0% or 100%. Yes, there might be a 1/1000 risk of death at a population level – but for me personally it’s either 0% or 100%. Since I am highly risk adverse, I usually assume my risk is 100% and work to make choices that reduce the problems associated with the risk.

          • Petticoat Philosopher

            Ha, I am the same way and always have been. This is one of those issues that really highlights stark differences in people’s personalities. I remember being an adolescent and having adults try to hammer into our heads over and over again that trying heroin or driving drunk EVEN ONCE can kill you (or others, in the case of the latter.) Some people seemed to respond with “Eh, what are the chances, that won’t happen to me.” Whereas what I got out of it was “That will DEFINITELY happen to me!” So I needed no convincing to stay away from hard drugs or to be super hard line about being stone cold sober every time I get behind the wheel. (And I was also that person who would take someone’s keys and not give them back if they’d been drinking, no matter how much of a stick in the mud they thought I was.) All my life I’ve heard people talk about how young people think they’re immortal and I’m like “What? I cannot relate to that at all.” lol

            It also means that I’ll probably never go bungee jumping or sky-diving, which many people say are a blast. But since I don’t particularly get why the sensation of free-falling is particularly enjoyable (I don’t really like rollercoasters), I don’t feel like I’m missing out too terribly by being as risk-averse as I am.

          • Christy

            You are not alone!

          • Young CC Prof

            To put it in another context, the murder rate in the USA is about 5 in 100,000 per year.

            That’s the same as a 1 in 1,000 risk of murder over 20 years. And yet people worry about being murdered!*

            *Murder risk is NOT equitably distributed across the population. Some people are at much higher risk than others, and their fears are legitimate. Some people are at lower than average risk and spend too much time watching the news.

      • The Bofa on the Sofa

        How about if something has a risk of 2 in 10 million, but then increases to a risk of 20 in 10 million. Are you concerned about the factor of 10 increase? Or do you dismiss it as being an absolute risk of 2 in a million?

        It’s the difference between the risk of dying driving sober vs driving drunk (on a per 8 mile drive basis)

        • Roadstergal

          And that brings up the other parts of the equation – what is the tradeoff, and what is the risk to self vs others? I’m very willing to take that kind of risk with my own life for something fun, but not for someone else’s life for something not fun. So on the homebirth side, it’s the question of who else bears the risk (baby), and what the tradeoff is (often a fear of procedure X, so wanting to be as far as possible from where procedure X is done).

          (Not saying that drinking isn’t great fun – I mean driving drunk.)

    • Heidi_storage

      Yes, but as Sheven points out the absolute increase matters, too–and in this case, it is high enough even for multiparas that I would be scared of attempting homebirth if I weren’t already. (Also, does this paper examine the rate of brain injury among neonates delivered at home vs. in the hospital? I bet those ORs are really appalling.)

  • Sheven

    It’s going to be interesting to see what happens next.

  • MaineJen

    “But aside from that, Mrs. Lincoln, how did you enjoy the play?”

  • TsuDhoNimh

    Wow … what shook this loose?

  • Amy M

    Well now that these data are published, what effect do you think it will have on homebirth in America? (I don’t know, I’m asking).
    I’m wondering how people like Henci Goer will interpret this data and present it to readers who almost certainly won’t read the original. Or even if they did read the original, can they really interpret the data?

    Will this be more likely to cause American CPMs to risk more women out? The consequences of a birth disaster, for American home birth largely rests on the shoulders of the woman who gave birth (and her family), so there’s still little motivation for CPMs to take risks seriously.

    I am hopeful that the home birth community will take the words of Ms. Cheney seriously, since she is an authority they recognize. Unless they just shun her for saying bad things about home birth.

    Don’t get me wrong, I’m glad they were finally honest about this data, I just hope it actually makes a difference with how home birth is done in the US.

    • Christy

      People tend to hear what they want to hear, so I don’t know how much this will affect the home birth rate. I do have some hope that it will at least lead to risking out more women.

    • Roadstergal

      I dunno. From the excerpt, they played it more as “HBAC is great for women who have had previous VD!” And then they say that trying to VD a breech should be done in a hospital, without mentioning that breech VD is v v dangerous even in the hospital… it really seems to be trying to bury all of the homebirth death in tables. Going the Birthplace Study route – hey, the rates of death are small, no matter where you are. I mean, a study that showed double the neonatal death rate at home for primps, and the spin was “Birth is safe no matter where you are.”

      Again, the dad from the Holy Grail. “Let’s not bicker and argue about who killed who…”

      • Anj Fabian

        I loathe the Birthplace Study.

        It should be taught in statistics class. Give students a list of routine statistics to find. Better yet, give the study to read as homework and make “Find the stat.” a pop quiz.

        • Dr Kitty

          The birthplace study is useless.
          The data was grouped in such a way that neonatal death and less than 24hrs in NICU with TTN and no longterm effects were essentially weighted the same and an uncomplicated CS with a healthy mother and baby was seen as a bad outcome in and of itself.

          • Young CC Prof

            The Birthplace study buried the actual numbers of deaths in an appendix in a separate file. I know because I dug it up once upon a time.

            Still, the UK Birthplace study had essentially the same number of low-resource births as MANA’s 2014 data, roughly 17000. Birthplace recorded 11 deaths, MANA recorded 44. (Which they buried by slicing and dicing into subgroups, two here, three there, and oh yeah the ones with congenital anomalies don’t count.)

            So yeah, the American midwives are being far more irresponsible.

      • Eater of Worlds

        Isn’t a woman allowed to refuse a c-section regardless if the baby is in danger, or heck her own life is in danger? They allow women to refuse blood transfusions, even if they will die othewise. So theoretically a woman could have a vaginal breech birth at a hospital.

    • Bombshellrisa

      A local CPM links the MANA stats on her website and says that they are “proof” that home birth is safer than a hospital. If she couldn’t do math before , she won’t be doing any now. (It should also be noted that she links to a bunch of papers from Canada, Britain, Australia and New Zealand to back up her claim that homebirth is safe. All the papers are from 20 to 30 years ago and older).