Dr. Amy calls in to the Kojo show

Yesterday, Washington DC based radio show hosted by Kojo Nnamdi explored the issue of homebirth:

A midwife in our region recently pled guilty to two felony counts in the death of a baby delivered at home. The case re-ignited a longstanding debate about “natural” versus “medicalized” birth. The American College of Obstetricians and Gynecologists note increased risks for both baby and mother in home deliveries. Natural birth proponents point to complications from hospital interventions that are often avoidable. We’ll explore the debate.

The guests included Mairi Breen Rothman, CNM; obstetrician David Downing, Brynne Potter, CPM, on Board of the North American Registry of Midwives (NARM); and Dr. George Macones of the American College of Obstetricians and Gynecologists (ACOG).

The discussion was exquisitely polite, with the participants talking past one another in an effort to get in their own talking points. No one questioned anyone on anything he or she said. Alerted about the show by a faithful reader, I called in. (You can read the complete transcript here.)


Here is Amy in Boston, Mass. Amy, you’re on the air. Go ahead, please.


Hi. I have a question for Brynne Potter about certified professional midwife. I’m wondering why the Midwives Alliance of North America, which is the sister organization of NARM, is hiding the death rates for the 23,000 certified professional midwife-attended home births that they have collected in their database.


OK. Well, I can sort of speak — I can certainly speak to that that the MANA dataset that, I think, Amy is referring to is a private dataset that is not CPM’s exclusively. It’s not certified nurse midwives exclusively. It is simply a voluntary collection of data that is not specific to death rates, but specific to all information. And that information is available. Researchers can apply for that information. But mandated reporting — and I’m really speaking back to what Dr. Downing was just saying — mandated reporting review of outcomes really takes places on a state level under licensure and regulation.

And I completely agree with him that one of the benefits of licensure in all 50 states is having the option to create integrated systems in which perinatal review can happen that includes home birth. And it’s not just a review of bad outcomes, it’s a review of all outcomes. And an opportunity to really know what’s going on and what’s happening with birth isn’t just going to be a benefit to be able to analyze how we can make birth safer, but to optimize what systems of care are gonna give women the most choices.


But I have to be more specific here, Brynne, because Amy specifically accuses your alliance of hiding the death rate of home birth. How do you respond to that?


Well, first of all, it’s not — she’s referring to the national midwifery organization, the Midwife she’s referring to the national midwifery organization, the Midwives Alliance of North America…


Oh, I’m sorry


…that I don’t represent. So I can’t really speak to a specific about some assumption of hiding. What I would say is that MANA’s — I know MANA stands ready to meet the needs of any reporting mandate. It is a private data set in which isolated cases of death would only be isolated cases similar to this case that we’re talking about today. We wouldn’t be able to make any extrapolation of a trend to homebirth. The only place we can do that is from the CPM2000, which was a cohort study that mandated all CPMs to report in prospectively all of their data for one year. And that study was published in the British Medical Journal, and it is absolutely in line with outcomes of all other published studies around homebirth, which is…

What can we learn from Potter’s attempt to avoid answering the question?

1. Potter was familiar with the existence of the database and the refusal of MANA to release the death rates.

2. She asserted that MANA is not obligated to release the death rates because the database is private. It is not; it’s been offered publicly, but that’s irrelevant in any case. MANA knows the death rates of CPM attended homebirth and is keeping that information from American women.

3. Potter implies that the fact that participation in the database was voluntary means that the results are unreliable. I agree that the database almost certainly under-counts the number of deaths at CPM attended homebirth. The real number must be appalling if MANA refuses to release its best case scenario death rates.

4. She tries to claim that it doesn’t matter because mandated state reporting would be more accurate. That’s true; of course, in states like Colorado with mandatory reporting of homebirth deaths, the death rates are extraordinarily high.

5. Potter claims that she cannot address the issue because she is on the board of NARM, the sister organization of MANA, not MANA itself; yet despite that, she is completely familiar with MANA’s stance and can’t offer any justification.

6. She offers the Johnson and Daviss BMJ 2005 paper which is based on the MANA statistics of 2000. She neglects to mention that the paper is a bait and switch comparing homebirth with hospital birth in years extending back to 1969. She conveniently neglects to mention (perhaps she does not know) that the death rate for CPM attended homebirth in 2000 was triple the death rate for low risk hospital birth in the same year.

Potter deserves credit for deftly refusing to answer the direct question and offering a variety of different obfuscations. She would not have gotten away with it if I had been allowed to respond.

Nonetheless, she (and MANA) would have been better served if she had simply pretended that she didn’t know that MANA was hiding the death rates from 23,000 CPM attended homebirths. In essence, she publicly acknowledged the existence of the database, publicly acknowledged MANA’s refusal to release the death rates, and publicly acknowledged that the database almost certainly under-counts the number of babies who died at the hands of CPMs

Of note, she didn’t offer anything remotely approaching a justification for hiding the death rates of CPM attended homebirths from the public.