Why would Melissa Cheyney, Wendy Gordon and other MANA executives spend 5 years hiding their own death rates if those rates showed homebirth was safe?
Can homebirth advocates offer any plausible reasons?
Author:Amy Tuteur, MD
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231 Responses to “A question for homebirth advocates”
Amy Tuteur, MD
Dr. Amy Tuteur is an obstetrician gynecologist. She received her undergraduate degree from Harvard College in 1979 and her medical degree from Boston University School of Medicine in 1984. Dr. Tuteur is a former clinical instructor at Harvard Medical School. She left the practice of medicine to raise her four children. Her book, Push Back: Guilt in the Age of Natural Parenting (HarperCollins) was published in 2016. She can be reached at DrAmy5 at aol dot com... More
Another bit of unicorn feces that has not been addressed is how they hide behind HIPAA and the need for signed informed consent from their clients in order to submit the data?? Nonsense. Does the CDC need a HIPAA release to publish anonymous data? Does a hospital need a HIPAA release to fill out a Birth Certificate? Did the CNM in Oregon who presented the MANDATED report to the state legislature need a HIPAA release?
No, the HIPAA BS is just flak to try to deflect well aimed SAMs. Don’t you think this discussion didn’t happen numerous times: “Mom, you know how mean the penocracy treated you after I dropped you off at the ER after your 8 hour failed second stage with a HBA2C of little Betsie Breech who only ended up weighing 8#12oz? (BTW, did the cooling treatment for that little variant of normal head bleed turn out OK – remember, I warned you to eat at least 6 portions of kale a day). Anyway, remember that HIPAA release I had you sign for the MANA study? Well, you know the penocracy is going to use your case to lobby against the HB movement and we wouldn’t want THAT, would we? Good, I thought so. Just sign here to withdraw your consent while I go get a couple of placenta pills. I know your PTSD from those mean doctors flares up when you go see Betsie in the NICU
My thoughts exactly. Every baby born in the hospital has birth certificate data available for research without needing consent or HIPPA release. Isn’t HIPPA restrictions if you want to may incidentally release personal information linking data back to a person. If you are just collecting data why are they stated some people didn’t sign HIPPA releases? Even Press-Ganey reports have a higher response return than 20-30%. And MANA midwives were collecting this data to promote their stance on Homebirth low interventions and I hope safety. They have an abismal return response then claim some poor return response is due to HIPPA. Why?
Northern Ireland has a population of 1.8 million.
There are between 50 and 100 legal terminations done here annually (serious risk to the life or health of the mother only, this currently does not include rape, incest or foetal abnormality).
There is mandatory reporting of the abortion stats.
I have concerns THAT data might be potentially threatening to patient confidentiality, because of the small numbers, the details given and the fact that everyone here knows everyone else’s business.
No so much with the MANA stats…big population, big geographic area, bare bones details made public.
I was just going to post asking a similar question. Wendy Gordon is claiming that the MANAStats project is “human research” and they need consent to submit data. I don’t think this is true, but I’m not sure. They are not doing any sort of intervention on the patients, they are just collecting data. I don’t think this has to go through any sort of IRB approval, but again, not sure. Can anyone speak to this with expertise? Also, if they are just submitting info and not publishing identifying data, HIPAA does not apply.
I’m sick of people hiding behind HIPAA.
Totally untrue, and I left a comment on the Sense and Sensibility post saying so. Patients need to give consent in order to participate in a study with an intervention. They also need to give consent to have their name or similar identifying info attached to their stats. But just plain unidentified observational stats? No way! Hospitals keep stats all the time. I myself am given quarterly feedback about my diabetes HbA1c stats, my blood pressure control rates, my STI screening rates, how my narcotic prescribing compares to other docs, really all sorts of outcome measures. This is standard practice. As a physician I am not allowed to opt out of this (and I wouldn’t want to). My employing hospital requires that the info be collected, given to me and that I read it. I am NOT ALLOWED to hide my head in the sand when it comes to quality measures.
Wendy Gordon knows this. She has a masters in public health. Public health research is all about these sort of observational unidentified stats. She is lying through her teeth.
MANA can’t even get their excuses straight. The reason they couldn’t require members to participate, as ‘splained to me by a MANA spokesperson last year, is that MANA is a voluntary membership organization rather than a regulating body. Which may be true, but it’s pretty funny to watch Wendy Gordon come up with other excuses.
Thanks. That’s what I thought. I mean, I didn’t have to get patient approval for the chart reviews for diabetes stats that I did for my ABIM Maintenance of Certification last year. Also, I don’t get approval for the PQRS reviews that I have to do on every single medicare patient.
You do need IRB approval to access and analyze medical records. However, once the data are compiled and stored in accordance with ethical guidelines, anyone can use the data without going through IRB a second time. If mana got IRB approval to collect them , researchers don’t need IRB to publish analyses. If they don’t have IRB, they shouldn’t be publishing with those data either.
The vast majority of homebirth midwives are not HIPAA covered.
What does that mean exactly? That most midwives do not have to maintain HIPAA privacy? Please explain.
HIPAA only applies to providers who take insurance, as I understand it. However, the concept of an obligation of privacy for health care providers far predates HIPAA, going back to, say, Hippocrates.
So, they aren’t affected by that law, but they still ought to keep their mouths shut where clients’ personal information is involved.
Basically, that’s it. HIPAA is a federal law. It defines covered entities, which essentially are those who transmit billing invoices to insurance plans electronically. If you aren’t a covered entity, HIPAA doesn’t apply to you.
Of course, the point is meaningless, since under HIPAA or under traditional privacy laws, a study of outcomes would always be allowed.
AAA, I don’t know about that. HIPAA makes us turn our paper charts over on any desk to prevent the reading of a name. It makes us have EMRs that have intricate security measures and tracking capabilities and polarized computer screens to prevent viewing of data by passersby. HIPAA makes us have to attend training seminars led by the hospital HIPAA Nazi so we don’t discuss cases in an elevator or hallway lest we be written up. HIPAA REQUIRES the law to be posted in the foyer. HIPAA LAW gives detailed provisions of how and where records are to be stored and what the mechanism is to release them to the client or designee. I really can’t see how licensed health care professionals which homebirth MWs so proudly claim to be, how they cannot be held accountable to these subsections – which are clearly not restricted to the electronic transmission of billing data.
You are a HIPAA covered entity, a provider who probably bills insurance. Once you are covered by the law, you have to comply with the law.
We are going down a rabbit hole in Wonderland now. I find it hard to believe that a crunchy granola lay midwife with placenta art pictures on her wall in Vermont has the capability to send an electronic bill to Vermont Medicaid for her home birth services. A typical billing service charges 5% and the logistics of doing it yourself are overwhelming. I would think there are provisions to paper file the 1500 form. And I think HIPAA kicks in the moment you bill the government or any other insurance OR PATIENT for your service. ALSO – how do HBMWs go about getting Prenatal Labs? CBC, blood type & Rh, Rubella titer, HBsAg, RPR and HIV. Glucose screens, gonorrhea, chlamydia and GBS tests? Ultrasounds? Are these simply not done? I know the state of Texas requires the RPR, HBsAg and HIV be done as part of prenatal care on every pregnant woman who gets prenatal care. OK, this is my point. The results of these tests are transmitted to the HBMW. The reports always have a confidentiality notice. So if, “Hi, Lotus, this is Primrose. I’m Kale’s mom. I was wondering if her tests came back. WHAT!?! NO! You mean she has syphilis AND gonorrhea AND she is HIV POSITIVE. OK, I’ll get some garlic cloves to put in her vagina, but I’m going to have to talk to Kale”. A HIPAA violation has occurred. The penalty is a $50,000 fine should Kale wish to pursue the case with (penniless midwife) Lotus.
Stick to medicine. You make a lousy lawyer.
Stick to law, you make a lousy human being
Hey, you two are on the same side of this debate, play nice, please.
I’m sorry, but you are just not correct about when HIPAA applies. Yes, if you are a “covered entity” HIPAA covers all sorts of things, not just things that are transmitted electronically. But to be a covered entity, you have to be a healthcare provider who electronically transmits health information in a “covered transaction.” Covered transactions are defined in the law and regulations as basically billing health insurance companies. PDF from the Department of Health and Human Services, which is responsible for enforcing the law, complete with citations to the applicable regulations:
http://www.hhs.gov/ocr/privacy/hipaa/understanding/training/coveredentities.pdf
CC: I guess you are right. I have had to sign HIPAA compliance forms as a condition to 1) get hospital privileges and 2) get on insurance provider panels. The litany of what are essentially “lay” midwives have neither hospital privileges nor are they typically on insurance provider panels. BUT, I think at least a dozen states now mandate that DEMs get paid by their state’s Medicaid – if they accept payment then HIPAA would apply. Again, MANA made a big deal of HIPAA compliance when it was not needed for the reporting of data, nor was it needed for an ethical review board. I think it is just flak to allow the MW to rescind reporting a bad outcome by persuading her client to withdraw her “informed consent”. What other explanation could there be?
If those midwives transmit information to Medicaid electronically, they are covered entities and must abide by HIPAA provisions.
You’re right, though–HIPAA is a giant smokescreen with regard to this study.
It only applies to “covered entities” who transmit health information electronically for certain purposes. It essentially means providers who bill electronically, health plans, pharmacies, etc. who receive patient information electronically.
Lots of homebirth midwives don’t do that, so they’re not covered under the law.
Strictly speaking, they absolutely *should* maintain patient privacy, but not all of them do.
You may hate the heck out of the HIPAA compliance specialists, but as a patient, I am far more comfortable with my health care knowing that my embarrassing questions about cancer treatment and my sex life, or my complaints about my first post-partum shit, aren’t going to brighten up anyone’s day in the elevator.
MDC’s birth professionals forum used to occasionally have a midwife or doula drop in with complaints about clients. They never believed they were violating patient privacy until a few people offered to send links to their patients. And named the patients to prove it could be done.
I want to answer this question. Because I have given birth at home. I have attended other women’s births at home. And I have trained to be a home birth midwife.
I can’t say that as of TODAY I am a home birth advocate. But I definitely was one, once upon a time.
I will say that AT NO POINT did I ever want faulty data or conclusions guiding my decision making to give birth at home, or to recommend home birth to anyone. I will say that I’ve always believed that ALL WOMEN deserved to understand the risks of OOH birth, and to understand that there are certain risk factors that INCREASE risks of death when delivering at home.
I am not a leader in the midwifery community. I am not a MANA executive.(Though, I have been a MANA member – until recently – I cannot stomach MANA’s deceit any longer.) When I’ve asked questions regarding safety or home birth deaths among my midwifery peers, I’ve been patted on the head and told to go back to my “you’re not yet a midwife yet” corner to sulk in my inadequacy.
I know there are more home birth deaths than what are reported. I know that all home birth mothers do not post their heartbreaking stories on their blogs for the world to read. I know how ‘professional’ midwives hush each other and censor any discussion about deaths that happen among themselves.
I DON’T KNOW WHY the MANA midwives, the MANA BOD, the MANA executives are engaging in this charade. I hold myself to higher standards.
I sought out a profession – and believed – for a short period of time that there was professionalism among midwives – CPMs. There are schools, there’s credential. CPMs are licensed in my state. These are the trappings of professionalism. But these people are not, as a group, professionals. At all.
The latest press release from MANA claiming home birth is safe, when the data shows otherwise – is a perfect example of their utter lack of professionalism.
I’m disgusted. I’m beyond disgusted. And I’m not coming to this from the outside. I’m on the inside. I’ve got a half a dozen CPMs phone numbers in my cell phone right now. Any one of them could call me to ‘decompress’ about a birth. I know about their (non-existent) risk-out criteria, I know first hand about what they consider “low-risk” and appropriate for OOH birth. I know their superstitions surrounding “allopathic medicine” and how they neglect to provide basic, evidence-based care to their clients.
I want to know this answer, too, Amy. Why are they hiding this data? It is so sickening. How do the authors of this ‘study’ sleep at night? I could not.
What a testimonial! Thank you! If you are interested, you might read Doula Dani’s similar journey of belief change on her blog, What Ifs and Fears are Welcome.
Don’t look back in hindsight and say woula-coulda-shoulda.. go forward with your education and become a certified nurse midwife! You can add so much to your chosen vocation just by going through the proper professional established channels.
Thank you.
For demonstrating the integrity MANA lacks and the graciousness to talk about your experiences.
I just read the study analysis by Judith Lothian in Science and Sensibility and her lack of ethics is shocking. Her commentary is supposed to be a “take away” summary for women considering homebirth. Any summary of the MANA data must include a warning about the breech death rate. Women deserve to have this info highlighted. They deserve to know the extreme risk they are taking-it’s not just a big relative risk, it’s a big absolute risk. This is one thing I thought everyone, homebirth advocate or not, could agree on: BREECH BIRTH IS EXTREMELY DANGEROUS AT HOME.
But no, she doesn’t even mention the extreme risk in this sub-group. She doesn’t mention the death rate at all but rather explicitly *encourages* women with breech to reject the label of “high risk” and implies that they are as safe at home as in the hospital!
“The excellent outcomes in this study . . . with a sample that included women who are usually considered at higher risk for planned home birth {breech, VBAC, multiple gestations, pre-eclampsia, gestational diabetes}), should make us pause. Could it be that even for women with some risk factors, planned home birth could be as safe as hospital birth?”
How can she possibly sleep at night after this? Doesn’t she think women deserve to know? This woman is a cheerleader for the Grim Reaper.
How can these people sleep at night? I ask myself the same question.
And then they imply that more study of breech home birth should be necessary because the numbers of breech home birth were low. Yeah, real ethical. Let’s just sit around for 10 more years and watch more babies die.
Yeah they claim the sample size it too small to make a valid comparison. But it is not too small. That’s what we have statistics for, to tell us whether a difference in outcomes is likely due to random chance due to a small sample size or whether the differences are real. The statistical analysis has been done and it is statistically significant. THE RISK IS REAL.
Yes, the analysis has been done. I did it my own self, it took me five minutes, and yes, I’m a mathematician. The sample size is small, but the outcome absolutely is statistically significant and practically significant. Failure to act on these results is entirely unethical.
Did MANA even consult a statistician in putting this thing together?
They have Other Ways of Knowing
I know. So anti-feminist!!!
I once raised a fairly straightforward statistical point on science and sensibility and was told Wendy Gordon has extensive training. Either that is a lie or there is a prof somewhere who should really not be passing himself as a statistician.
They do not understand that there is a difference between “small sample size” and a “sentinel event”. For example, the OB in Corpus Christi Texas who fractured the baby’s skull and severed the spinal cord with the inappropriate use of forceps should not be able to plead “small sample size”. But that is EXACTLY what the DEMs are doing.
That hospital in Massachusetts that had two maternal deaths in a short period. It’s only two. It’s unusual, but maybe they were just really unlucky. Maybe. There’s an investigation underway anyway, to find out whether it was bad luck or systemic problems.
The Navelgazing Midwife did a post where she wrote about googling “breech homebirth” and all the listings were stories about death. It wasn’t scientific but it led her to write a very good post about NOT trying a breech birth at home.
To all women who applauded Judith Lothian – hey ladies, you’re welcome to volunteer your breech babies for such a study. I won’t volunteer mine.
I wonder how many of these would really do it and how many would only welcome research with OTHER women high-risk babies as unwilling participants.
Fiftyfifty1 – such a great point you bring up. They cite the UK studies with low risk pregnancies, highly trained providers and well integrated collaboration and transportation to get the camel’s nose under the tent. Next thing you know the camel is taking a variation of normal dump on the rug.
A while back, it was felt that a frank breech, making normal progress in labor, with an experienced and well trained obstetrician in attendance, could safely deliver vaginally in a hospital setting. Nope. The risk is too great. But a DEM should be “credentialed” to do it?? Right – just trust birth.
But CPM feel they can deliver footing breech equally safe now.
I cannot believe how women can be this stupid as to fall for that when they have the actual numbers and then, when things go south, either claim, “It wasn’t the homebirth!” or say “I didn’t know!” This is one of the cases when numbers are loud and clear.
I know I sound like I’m blaming the victim here but it just looks so clear to me. Everyone who cannot make the simple calculation that 5 out of 222 is 1 of every 44 people they meet in their lives and that it is measured in percents is not an “educated mama”, she’s an illiterate who should have never graduated from elementary school.
As a mother that had breech baby those numbers just make me sick…they make me see red. 5 babies dead and why? Because their mother didn’t want the dreaded c-cestion that is the standard of care in the hospitals! It was my first baby and i was nervous heading into the OR as I had never had surgery or been sick enough to be in hospital, but it didn’t matter. My baby mattered. I trusted the professionals to take care of us…and they did.
That baby has given my family so much joy. Actually, he pretty much makes everyone he knows smile! I can’t imagine not having him. I can’t imagine anything would have ever been more important than him. He was meant to be here and those babies were too!
I’m not a math person, but when I think of around 200 people I think about my high school class…that would mean that 5 of the people I graduated with would have dead baby.
Do we have 40 breech babies around here?
Mac is one, my wife is #2.
Breech moms chime in.
Just think – if we have 40 breech babies here, then 1 would be dead if they were at home…
Young CC Professor is number 3.
And complete breech rather than frank, with asymmetric growth restriction, hence Baby Prof was at particularly high risk of getting his poor head stuck.
I had two breech babies. One was a c-section, the other a precipitous delivery on route to a planned c-section. One of the scariest moments of my life until I heard her cry and knew her head was out.
I have one
Both of my nieces, and both of my BFF’s babies, were breech.
I have 3 friends in my social circle (that I know of) who were breech and delivered by c-s. Another was delivered by c-s because her older brother had been breech and a c-s and VBAC wasn’t really a thing back then. She went on to have a breech baby herself last year. So that’s 5 that I’m aware of.
Actual Kid was a footling breech. Jammed that toe down in my cervix. Planned CS and he’s the joy of my life.
Yikes! Hope his toe nails weren’t jagged. 😀
Son #1 was transverse. I had a cs with no problems, and 11 years later I have a healthy, wonderful child. Oh, the horror of interventions.
Breech wife, my husband was footling (second twin).
He was an emergency section. Prolapsed cord, had to be resus’d. Would have died at home.
1 breech son… he was much more comfortable to be pregnant with butt down vs. head down… even though he was 10lbs.3oz. Failed ECV and wonderful c-section.
my sibling and the sibling’s offspring were both breech. My sibling was small and was a premie, the offspring was almost 11 pounds. I would have hated to have a homebirth with an 11 pound breech baby.
My baby is currently breech at 36+5 weeks. Will attempt ECV next week and if it doesn’t work, scheduled c-section at 39 weeks. Looking forward to having a healthy baby, however she comes.
My sister and I were just talking last night about how many women we know who would have been dead, or had dead babies, or both if it weren’t for c-sections.
Best wishes for an easy healthy delivery and a quick recovery. Whichever way it goes.
Thank you! I am a little nervous about a possible c-section, but when I really think about it I am more happy to be meeting my wee one soon regardless of how she comes out.
5 out of 222 plus 3 who transferred to the hospital and were “lost to follow up”. Lost to followup my ass! Lost to followup happens in long term studies where 10 years later somebody has moved away without leaving a forwarding address. “Lost to followup” doesn’t happen with a birth. That midwife knows the mom’s phone number and could call her to find out the outcome. It doesn’t take a rocket scientist to realize that those babies are either dead or mangled. So it’s 8 out of 222. That’s 1 out of every 28 breech babies at home! How do you like those odds Judith Lothian!? Go ahead, keep telling women to birth those breech babies at home!
1 out of 28. That’s more than 1 dead baby in my class at elementary school. That’s about 2 in my current bloody zumba class. God, it might be the baby we’re all joking will be born dancing because the mom is growing right in front of us.
Judith Lothian is a criminal. Yes, a criminal. Fifty, do you believe that she isn’t just as aware as us about those odds? But hey, what’s almost 30 % of dead babies against almost 100 % of payment for those babykillers.
Or maybe the moms wised up and want nothing to do with Midwife and won’t respond to her calls.
In any case, I agree that common sense and reading between the lines lead one to believe those three babies didn’t have a good outcome.
Hey, if there are 222 questions on the test and you only miss five, that’s still totally an A.
That’s kind of how they see it!
Only, I never studied 9 months for ANY test. Lazy as hell, I know. If I read 9 months for whatever exam they throw at me, 24 hours of every day, you can be sure I’ll be furious if I miss 5 questions. And that’s about a test, not a baby I supposedly want alive and healthy.
It’s of a piece with the arguments presented by Wendy Gordon and another MANA Spokesperson in response to the low-apgar study back in September.
Gordon wrote:
This research stands in sharp contrast to a large and growing body of research that shows that, for low-risk women with a skilled midwife in attendance, home birth is a safe option for newborns with lower rates of interventions and complications for mothers.
When a commenter asked how MANA defines low-risk, their spokesperson wrote:
There’s a lot of questions about what low-risk means. Some define low risk as a head-down, singleton baby born before 41 weeks. Others have varying definitions including some VBACs under certain conditions, or women in the 42nd week of pregnancy. This is part of the issue when looking at the data – we are debating whether or not women should have home birth, rather than looking at what circumstances pose a higher or lower risk.
If you don’t actually have a definition of low-risk, then it is, by definition, a meaningless concept.
If “low-risk” is whatever the midwife says it is, then it is nothing.
Low-risk = “I know nothing bad will happen to me.”
As the billboard that I drive by on my way to pick up the kids, “‘It won’t happen to us’ is not an emergency plan”
There is no cake. The cake is a lie.
The communications plan seems to be: “Homebirth is safe for low-risk women. But we’re not going to define low-risk.”
The only way to define low risk is retrospectively. Everything else is a natural and widespread optimism based in wishful thinking. I would have no problem with people choosing homebirth if the slogan was “Homebirth is safe if nothing goes wrong..the list of things that can go wrong is depressing and if your luck runs out you are f.. ed. Then I wouldn’t have to wince every time someone says “I know the risks.” No. You are unlikely to have any real idea.
“The only way to define low risk is retrospectively”
I agree with your post in general, but you are wrong about the designation of low risk being retrospective. Risk, by definition, is prospective. We CAN sort women ahead of time into groups based on risk factors. Some are low risk, some are high risk, some are extremely high risk. But NONE are “no risk”. And the stakes are high. For those on the wrong side of chance, the price is extreme. A dead baby is just as dead if it is born to a low risk mom as to a high risk mom.
I don’t agree re: prospective vs retrospective. I tell my patients that the diagnosis of “NORMAL PREGNANCY” is made at the 6 week post partum visit. The HBMWs aren’t going to accept ANY risking out assessment. Nor will their clients. Yet they will have no problem shoving the UK safety study in our faces.
It’s a matter of definition. Risk, by definition, is a matter of probability, and is thus prospective.
If the rates were the same for the other 75% of CPMS who didn’t report (and let’s face it, they’re probably worse) — that’d be 20 dead breech babies who didn’t have to die. Then imagine all the babies that have died in the 5 years since that they’ve been sitting on the statistics, many of whose parents might have made the decision to birth in a hospital if they knew the actual odds.
In the comments on the S&S article, Wendy Gordon is claiming that the reason participation in the study was so low is because so many midwives are practicing in states where CPMs have to operate underground and so midwives feared prosecution if they kept track of their stats or something. Because, you know, it’s all the states’ fault. Home birth midwives would just love to be completely transparent if given the chance.
Also a giggle to see TFB call herself a “fellow public health scholar.”
http://www.scienceandsensibility.org/?p=7869
There were a few bits that leapt out at me, including such gems as:
– “A randomized control trial is not possible because women are not willing to consent to randomization to home or hospital.” (Let’s just pretend that it’s a matter of consent rather than ethics.)
– “In this sample, the rate of postpartum hemorrhage (defined as over 500cc in a vaginal birth and 1000 cc in a cesarean) was 15.4%, higher than previous research has reported. That said, the transfers for excessive bleeding were low. Active management of third stage is infrequent in this sample. The authors posit that without intravenous oxytocin administration, the 500cc benchmark for diagnosing hemorrhage may not be appropriate in this physiologic birth population” (I really can’t see why they think they’ve spun this as a positive thing.)
– “I suspect those opposed to planned home birth will exaggerate the implications of findings related, for example, to maternal bleeding in spite of the fact that almost no mothers required transfer or intervention…” (I don’t need to, the problem is pretty clear from your findings.)
– “The MANA dataset is an extremely valuable resource for researchers.” (Yes, in that is shows exactly what not to do and how interested DEMs and CFMs are in positive cashflow rather than positive outcomes for mothers and babies)
– “I suspect those opposed to planned home birth will exaggerate the implications of findings related, for example, to maternal bleeding in spite of the fact that almost no mothers required transfer or intervention…” (I don’t need to, the problem is pretty clear from your findings.)
Of course, we would have absolutely no reason to suspect that proponents of home birth would underestimate the risks and exaggerate the benefits. Only the penocracy would present their position with such self-serving manipulation.
That conclusion about maternal bleeding makes me so mad! They don’t care about the mother’s hemoglobin count after the birth, or a week after the birth, or even a month after the birth!!! Any breastfeeding problems in an anemic mother will get blamed on something else, probably.
But OMG that baby just HAS to get some extra milliliters of blood from the cord, even though after a few months, any effect is gone!!
One of the things I disliked about my hospital births was the blood taken before and after. I hate getting blood drawn, BUT I knew the reason why and it was really not a big deal.
Remember how “delayed cord clamping” is so important because it might decrease the risk for anemia months down the road?
“The authors posit that without intravenous oxytocin administration, the 500cc benchmark for diagnosing hemorrhage may not be appropriate in this physiologic birth population”
English to English translation: We did bad on this measure and we’ve decided that the easiest way to improve is just to say that bad is good.
Trixie, thanks for that terrific link.
http://en.m.wikipedia.org/wiki/Home_birth
When in doubt, go to Wikipedia. There seems to be some confusion about intrapartum fetal death. Wiki talks about IPPM= intrapartum-related perinatal mortality. In homebirth there are cases where the baby has a heart beat when labor starts and does not at delivery. This is infinitesimally rare in a hospital. What does happen in a hospital is that a compromised baby is born and goes on to die within the first day/week and counts as a IPPM.
http://en.m.wikipedia.org/wiki/Home_birth
OK, here goes. There are about 4,000,000 deliveries in the US annually. The home birth rate is 0.72%. So, over 5 years there have been about 144,000 homebirths. The MANA study reported on only 17,000 of them = 11.8%.
My question is, what is the statistical validity of data that is 1) voluntarily reported, 2) collected by “professionals” with markedly deficient training who 3) have a vested financial interest in having the data interpreted in the best possible light which 4) accounts for less than 1 in 8 of the cohort? Is this what passes for EVIDENCE BASED MEDICINE??
Does anyone seriously believe that if 7/8 of the homebirth cohort was included in the data set that the hideous risk WOULD NOT BE WORSE?
I like how Wendy is saying in the comments “for many of the outcomes of importance here, birth certificate data has been shown to be very unreliable.” Umm, like deaths from homebirth transfer being counted in the hospital column since intended place of birth isn’t caught in every state’s recording?
Generally, death is captured accurately.
But birth certificates don’t record whether the mother had an epidural. That’s clearly more important, given its top billing in the summaries.
I thought that intended place of birth wasn’t always captured accurately. Isn’t that why Oregon had to mandate a change on their birth certificates to obtain the numbers that Judith Rooks analyzed?
No. (And I was being facetious, of course; birth certificates don’t capture death. That’s the death certificate that’s linked to the birth certificate.)
I don’t know offhand how accurate bc info is for birth attendant, but insofar as it is inaccurate, it’s far, far more likely to be skewed in favor of homebirth midwives (or unattended birth).
D’oh. Thanks for pointing that out. I obviously don’t know what I’m talking about and re-reading what I wrote, I clearly need to think more before I post. 🙂
A tip of the cap to a Catie Mehl who has commented to the spin article:
“I appreciate your feedback and still feel that if this same study had come out but “home” was replaced with “hospital” and “midwife” with “hospital care provider” it would have been torn to shreds by our community. If we want to be taken seriously then we have to present serious research. This is only helpful for women who are looking to home birth with one of the midwives who participated fully in this study.”
Catie, that was perfectly stated! Thank you.
It doesn’t matter why. When 70-80% of the cohort refuses to participate, it’s not longer a study, it’s a non-random survey.
When 70-80% refuse to participate in the study billed as “the largest analysis of planned homebirth in the U.S.”–and conducted by their own professional advocacy organization– you know exactly how committed they are to safety.
You know you are in trouble when your target audience sees through your crap and calls you on it.
From one commentor:
“Does MANA reviews these findings, identify clear risk factors that increase risk of death, and set professional standards for safe practice – based on their own research? Why or why not? …
Let’s start asking the hard questions. Let’s start coming to conclusions about what makes midwifery and OOH birth safest and stop this nonsense of blind self-promotion. A group of health care professionals should adhere to ethical standards – first and foremost – to do no harm.”
Dr. Amy, your posts on this study have been great and I look forward to your further commentary. This study is disturbing on so many levels. The breech results are horrifying even to my non-mathematical mind.
I would love to see a post addressing the shortcomings of the study in terms a layperson can understand. For example, there have been a number of comments about the idea of a randomized study being the gold standard for a study like this. I’ve read posts of yours before that explain the ethical limitations of studies involving childbirth and what we can learn from them regardless. But even the author of the S&S article seems to think that a randomized study could be done if not for obtaining consent.
So my question for such a post would be: How should a study of homebirth in the US be designed in order to accurately capture outcomes? How was this study designed and what are the shortcomings in the data collection and analysis? What results can we trust and what results are missing that you would expect to see in a study of the comparative risks of providers and locations? If we can get all kinds of information from CDC datasets, why can’t MANA provide similar quality datasets without consent from the care providers and patients? As a lay person who knows very little about science and medicine, these are the types of questions that present a barrier to me to fully understand this MANA study.
The problem is that for every person who actually reads the study and comes away with questions, there will be a hundred who read the press release (or the article written by the journalist who just read the press release and got a quote from each “side”).
But Dr Amy, they are not healthcare providers. They are birthworkers. It’s birth they serve – not babies, not mothers and definitely not health.
That speaks volumes about their ethics. Volumes.
Is Gordon too stupid to realize that, or is she counting on everyone else to be?
Tell me, Ms. Gordon, would they be afraid if they thought their stats would reflect well on them?
She does that ‘public health scholar’ crap to people about obesity, too. She has no clue what she is talking about.
Hahahaha…”Wendy, as a fellow public health scholar, I very much appreciate your take on this.” Why? Wendy is playing damage control when the data suggests risks, when she should be postulating how to make Homebirth safer. Yet Gina appreciates her take on it? Gina could step up and throw in some public health personal trade-offs to the lower interventions at the risk of morbidity and mortality that some people may be willing to take, or suggest some limits on low risk definitions, but doesn’t. I only hope Gina’s complete disregard for safety by rubber stamping MANA’s press release despite the data somehow limits her hirability there in Illinois.
Gina appears to be confused between the words “student” and “scholar.”
‘Scholar’ did used to be synonymous with ‘pupil’. My mother speaks very quaint English and uses it to mean schoolchild. Does sound rather grandiose coming from Gina haha
I would hope that the amount of BSC she has unleashed on the interwebz over the years would also limit her hirability.
I find it rather telling that in the MDC thread about Dr. Amy’s comments on the MANA study all the detractors want to complain incessantly about Dr. Amy’s attitude and tone and what a big “meanie” she is. Several intelligent posters keep trying to direct the conversation back to the study, the data, the numbers, the risk. “What does it matter her tone of voice – what do the numbers show?” They ask. And are faced with “but she hurt my feeeeelllliiiinnngggsss!!!!” Waaaaa!!!!
Showing, in yet another blantant way – that what matters to the NCB, homebirth movement is the woman’s/mother’s feelings and emotions and how she experiences the thing – not what is scientifically, factually true about the risks to her baby’s life.
I don’t even mind the way they give their own feelings higher priority. What I do mind is their pathetic attempts to prevent others from reading Dr Amy. They take the risk (to their babies, not their feelings!), OK. But then they try to stop others from learning about the risk, so they cannot decide not to take it if they so chose. This, ladies, is not OK. A big no no.
I find it disgusting how they not only make the choice for themselves but try to make the choice for US, as well – you, me, Young CC Prof and every woman here. They have already decided that we should not read Dr Amy because they cannot bear us making another decision and not mirroring their own choice back at them. Talk about cowards who are not as sure of themselves as they try to show.
I agree. The OP even said something to the affect of “If you’re planning a homebirth don’t read this because it will make you feel bad.”
Dead babies make me feel bad. But hey, I have been mean all my life. My mother even lovingly calls me her “Little Sour Pookie.” Yeah, I know I am setting myself up with that one…
For those of us who reside in the USA, I wonder if it’d be useful for us to write to our representatives and senators asking for mandatory outcomes reporting for DEMs and CPMs. I don’t think it means much but it’s an uphill battle here, and no one is recognizing the dangers of these professions if there’s no statewide data, even if the data is poor quality.
In my state, the laws for midwives appears to be as follows: midwives may administer oxygen, oxytocin, IV fluids, vitamin K, eye prophylaxis, “d other
drugs or procedures as determined by the department.” No healthcare provider can be held liable for injuries caused by the midwife (funny, it appears the midwife cannot be liable as well) It does not require midwives to hold a nursing degree, enter into agreements with another healthcare provider, and does not allow the midwife to use vacuum or forceps. Informed consent must include the midwife’s training&experience, if the midwife has liability insurance, and a protocol for medical emergencies (“Call 911!”)
I am looking at the laws for Oregon state and they at least have “absolute risk factors”
Vermont passed a law in October, 2011 MANDATING that DEMs be reimbursed for home birth services by Medicaid and private insurance. Contemplate that. With NO KNOWLEDGE whatsoever of the hideous risk of home birth, the Legislature was so infested with the woo that they passed this law. The stupid morons passed the law. They have a religious belief in the “natural”, the homeopathic”; the magical power of water and kale, unpasteurized milk and two X chromosomes.
The blood of these senseless deaths rests on the hands of the Vermont legislature. Of course, they are too stupid to have any reasoning powers to understand this. Hit ’em where it hurts. Boycott Vermont maple syrup and cheddar cheese – seriously, it is the only thing these blithering idiots would understand.
1.) You do realize that Vermont’s infant mortality rates have declined since the legislation passed? 2.) Can you provide an example of any other studies where the data collected is available to the public before the study is published? I can’t. And MANA is still collecting data. This is an ongoing study. The next 5 year data set includes more detail. 3.) You can complain about CPMs all you want but it doesn’t change the fact that homebirth is legal for women in all 50 states. If more CNMs were attending these births then CPMs wouldn’t be in demand. The fact that states like Maryland would rather a women go unassisted that have ANYONE there to care for her is speaks volumes about how “concerned” they are for that mother and child’s safety. You all can continue this “my way or the highway” mentality but you don’t need to act surprised when women hit the road.
Or to put it another way, the state of Maryland recognizes the autonomy of doctors and the CNM’s who work side by side with them to give low risk mothers the option of certified midwife care. But CNM’s want to protect their professionalism and therefore they have chosen to deliver in hospitals rather than put themselves in a place where there is no medical back up on hand,
I used to want to attend home births. Then I got my master’s, got licensed, and started to work in a hospital. In other words I met reality. And now I know I dodged a bullet- and not just me, but maybe a baby I might have let die at home.
Maryland. What an interesting example you chose. Do you realize that last year they announced their lowest infant mortality rate ever?
Infant mortality declines every year worldwide and nationwide. Has infant mortality declined faster than the national average in Vermont, or slower?
@ Mntn Momma: 1) You do realize that “infant mortality rates” have no pertinence with prenatal care and perinatal/neonatal mortality. I know y’all like to tout that the US infant mortality ranks somewhere between Bangladesh and the Belgian Congo, but the perinatal/neonatal stats are among the best in the world.
2) you want an example, you want an example. YOU CAN’T HANDLE AN EXAMPLE! I think you yourself gave one in your first sentence. The CDC provides the “data” before the placenta can be desiccated sand encapsulated. An Oregon CNM presented 2012 “data” to the state legislature in Oct 2013 that showed a hideous perinatal/neonatal death rate for home births in Oregon. You DO realize that there is a difference between “data” and a “study” don’t you? No, as a MANA supporter you obviously don’t. MANA had to “study” 5 years of their (corrupted) “data” for 5 years before they could put a bullshit spin on it and release it so it could be “studied” in an honest and unbiased fashion. As a result hundreds of babies died or suffered permanent brain damage as a result of hubris such as yours.
But the reason CNMs don’t attend these births is because they recognize the dangers associated with them, and therefore won’t take the risks. And that is with THEM attending.
Therefore, the obvious solution is to let less qualified people do it. Because, you know, that’s always the best approach to use when the best qualified refuse to do it – bring in an amateur.
Can you provide an example of any other studies where the data collected is available to the public before the study is published?
Off the top of my head? Pretty much everything collected by the NCHS.
Public opinion polls. Election results. Highway fatalities. Crime rates.
A mother going without care in childbirth says more about her concerns for her child’s safety than it does about anyone else’s.
I think this is a great idea.
YES. Dear God, yes. I’ve been brainstorming ideas for weeks! I was thinking Change.org, but have yet to really peep it out…
Also, I have heard that Congress members generally give a lot of weight to letters that are written in local papers (letters to the editor). I don’t think the average congress person checks everything on change.org, but they do run through constituent correspondence with aides.
Love it. I’m going to do some research today and tonight. My father in law is actually Dept. Attorney General of my neighboring state. He may have some good ideas too.
Part of me wants to go undercover and infiltrate the homebirth community in the midwest and make my own little documentary…
Gained some clarity on a snowy run this afternoon. As much as I’d like to go under-cover and infiltrate the homebirth circles of the midwest, gathering the craziness to nicely present to the peeps representing us on Capital Hill, I think there’s a better way.
So, the hospital I work for is devoted to research. They want us all to participate in research projects, and in order to support us, we have a Research Integrity Department just for bone-heads like me who want to do a little investigation.
So, the Research Integrity Dept. has a Federalwide Assurance (FWA) with the Department of Health and Human Services, in which they assure all research projects are conducted in accordance with Federal regulations. Whatever THAT means! (I kid, I kid.)
I do have a point. I promise. And that point is, I went ahead and scheduled an appointment to brainstorm ideas. I’ll meet with someone the week of the 10th.
So, I obviously want to look into homebirth disasters, and I’m going to go on a run tomorrow with my OB and we’re going to kick some ideas around. BUT….if anyone has any suggestions or guidance….lemme know! Luckily, the first meeting is super informal because they know we’re not researchers and just have ideas. In fact, the link to schedule an initial appointment is entitled, “I have an idea.”
How cool is that?
So, if anyone has input, let me know and I’ll give you my email address. I’m also happy to give more details on where I work, etc., would just prefer to do so privately.
Thanks peeps!
Can you do a post that has a list of all the NAMES of the babies from HB deaths during the period after 2009, when this data was collected, but not shared? I have a feeling many of those moms would not have taken the chance had they seen the data, and MANA didn’t allow them too. I am sure some would have still went ahead, but they were denied all the info to make the choice, but the very group that claims they are all about moms.
Those are NAMES and families that were destroyed. MANA needs to see it. The bloods is on their hands.
I also liked Trixie’s idea of an empty kindergarten classroom.
I am thinking of those 5 dead breech babies out of 222. When I was in high school, there were 22 students in my class. There were six classes for each grade. If we take the students for every 2 years, we’ll have 264 students. Hell, that would make more than 2.5 dead students out of all those who enrolled in my one time school a year if we accept that they were all breech.
It defies belief. 5 out of 222 is SUCH a big number. I cannot believe it gets swept under the carpet the way they’re doing it at our favourite loony haunt… and some other places.
It really is horrifying. (Watching my husband cuddle my newborn baby, breech until he was calmly delivered by c-section.)
And of course, we don’t know how many of the 222 suffered hip dysplasia, brain injuries from oxygen deprivation, or other unknown injuries from midwives trying to yank them out.
All completely unnecessary. Boggles the mind.
Ah but we know the percent of midwives who got paid! Let’s keep an eye on what’s important.
I lose my calm and all vestiges of class (I know, I know I don’t have much of that when it comes to those clowns but still!) when I think that those “midwives” who killed those 5 babies and damaged who knows how many of the other 217 actually got paid for their so called services. When I think of OBPI mama, I always remember how grateful she was to her midwife and how she could not recognize the latter’s failures in years. God knows how many mothers like her think the world of their midwives because they managed not to kill the baby but only maim it which the mothers interpreted as saving it.
So happy for you and your healthy C-section family.
Oh my gosh, yes. I think a LOT of homebirth moms believe as I did. Even ones who’s babies were brain-damaged… “At least they’re alive!”
I remember midwives helping me along with that attitude by sharing with me the “what if I got an inexperienced resident!” could have beens… Now I don’t know how resident stuff works in OB wards, but the Children’s Hospitals I take my son to always have residents paired up with senior staff… Of course, I had to find this out because of what happened to my son… Sigh.
Somehow, the fact that you and moms like you were led to think so sounds particularly horrifying to me. It’s as if you were purposefully led into developing the Stockholm syndrome and hailed those who maimed your babies as the heroes in the fairytale (actually, a horror tale but without your knowledge).
I am sorry if what I’ll write next sounds too repellent. If you’d like me to, I’ll remove it. But from your words, you and moms like you look like mind rape victims.
Amazed, have you been around long enough to have read Dr. Amy’s post about the ebook, From Calling to Courtroom? I recommend it highly for a further look into the lay birth attendant’s mindset.
Karen. I read it. It’s just… I don’t know. Each time I read a mother explaining her journey into this warped world, it looks more horrible to me. Strapped of all humanity.
I remember something that happened about 20 years ago. We were visiting my aunt’s family in their village and were about to leave the next day. They were trying to make us stay but my parents were like, no, not possible, as much as we’d like to. My cousin (then 4) looked at my dad and said, “Uncle, if you love me, you’ll stay.”
Long story short, we stayed. And the very next day my father cut his hand with the axe very badly. My cousin felt so guilty for needling him into staying.
I repeat, she was 4. And she was in no way to blame for a man of 40 making a decision. I am revolted by the way grown-ups make and execute plans to escape responsibility for something they did with their own two hands.
There is a mom in the February birth club that is furious her doctor won’t do a vaginal breech birth, I hope she doesn’t try at home…. at least no one agreed with her so she called everyone mean. By the way how is your recovery? Considering an elective CS at 39 weeks based on doctor’s advice from yesterday.
Umm, I know you didn’t ask about my recovery, hope you don’t mind that if I jump in.
Mine went a lot better than I ever thought it would. You will need to do everything you can to get the rest you need. My only problem was I was in a lot of pain after the CS and didn’t know why. Nurses kept giving me pain meds. They thought I was ok because I was passing gas. Turned out my pain was constipation and the pain meds were useless. If I had of known that a BM would have made me feel so much better (I was miserable for one while) I would have begged for an old-fashioned enema!!
I believe some women do have an awful experience with their CS, but I didn’t.
It’s mainly being recommended for psychological/anxiety issues – also I am worried I may be more at risk for really bad tearing, but it’s a unique situation so there is no medical data on it at all. I am not crazy about the idea of being awake during surgery, but I like that everything will be planned, I’ll know what’s going to happen, I won’t have to worry about going overdue, and I won’t have to recover from an emergency c-section after hours of labor if labor doesn’t go well (either for physical reasons or because I have a panic attack in the middle and it stalls).
I’m leaning towards going with the CS right now.
I had a higher risk of tearing, precipitous birth or loss due to early cervical dilation and premature rupture of membranes, slow healing of tears, etc. due to my joint condition, but didn’t have any issues despite persistent OP babies. I was probably just lucky, so if a caeserean seems like a better option for you, take it if you can.
That’s what we like – a fully informed woman choosing what is best for her body!
I feel like I am going to be so nervous either way that at least with the c-section if I do get really nervous I won’t have to physically do anything you know? Early on I thought I could handle labor but my anxiety has just gotten really bad these last few weeks.
You didn’t ask me, either, but I’m hoping it’s still okay for me to jump in. 🙂
I loved both my c-sections! Recovery was easier than I expected; the first day or two was difficult, yes, but not impossible, and after those first few days I felt okay–the pain meds really helped.
I was nervous before the surgery, of course, but my beloved OB and the lovely anesthesiologist were very reassuring and kind; the anesthesiologist held my hand through a lot of it. Getting the spinal done was nerve-wracking a bit, but not especially painful (surprisingly; it did hurt, but no more, really, than any other needle). And once it was in I felt like I was floating. The whole thing was pretty exciting, really. My husband got to take pictures of the baby’s head once it was out both times, and then you hear the cry, and everyone in the room cheers. (BTW, for my first, my OB asked my husband if he wanted to see my uterus, and showed it to him and explained all the parts. I’m still mad Hubs took no pictures. So if that’s something that might interest you, say something beforehand! 🙂 I may be very odd, but how often do you get to see your own internal organs?) They gave the baby to my husband so I could see her and kiss her, and then he went off with her (both of mine are girls) for bathing and all that other stuff.
I was in recovery longer with #2 than #1, but both times the nurse(s) was kind and caring. My husband was allowed to come visit me there, and with my second they let our three-year-old come in very briefly.
The worst parts of the whole thing for me were:
1. The first time they made me stand up. Make sure you hold a pillow to your stomach, to help support it. Go slow!! You don’t have to leap out of the bed, you can take your time.
2. The first shower. They make you do it, and it’s nice to have one, but it’s uncomfortable–not painful, but uncomfortable. The nurses or you should make sure you’ve just taken your pain meds before you go in, for maximum effectiveness.
And even those moments weren’t so awful. And yeah, at both hospitals they wouldn’t let you leave until you pooped, so if you’re having trouble say something and they’ll give you a laxative or stool softener.
IV fluids may make you swell a bit, so be prepared. They made me take my wedding ring off, which didn’t thrill me (I understood, but it made me sad), but it was kind of nice to have Hubs put it back on me later; he said the same thing he said when we got married, which made it a really sweet moment.
You’ll want a Boppie or other kind of pillow to put on your stomach/lap when you hold the baby.
In my experience stitches are more comfortable than staples. You’ll probably also be more comfortable in your maternity underwear for a while, since the waistband is above the incision. The incision will feel kind of numb and occasionally tingly as it heals.
Really, I’d say after the first week I was feeling almost normal, and after the second I felt mostly normal. I walked a little hunched over for a couple of days, but again, that wasn’t for long, and wasn’t a big deal.
People refer to it as “major surgery,” and it is because it’s an abdominal surgery. But I had emergency surgery for a ruptured ulcer a few years ago, and compared to that the CS recovery was a cakewalk. It’s really not that bad, I swear; I know a few CS moms and all of us agreed it wasn’t anywhere near as horrible as we’d been led to believe, and all of us were feeling pretty good within a few days. Most of us didn’t completely finish taking our pain meds, even, and had a couple left over at the end.
I went through labor with my first; my doctor offered me VBAC for my second but I said no way. I was very happy with both of my sections, and would have done it again without question. My scar is barely visible now.
Really, both were lovely experiences overall.
Best of luck to you!
I had three C/Ss, within the space of 3 1/2 years, and no problems with any of them. Indeed, I flew from Israel to the US with my firstborn when he was 10 days old, as my mother was terminally ill and desperately wanted to see her first grandchild.
My daughter had a C/S for primip breech; is now hoping that the doctors won’t suggest VBAC for #2 — her experience was as positive as mine was.
The first poop after my c-section was like the birth experience I never had. Omg was I happy when that sucker was finally born.
I know – trust pooping!
After my c/sec I asked for and received Ensure with something added to help form soft stools. It was my magic elixir! They had to get it from the geriatric ward!
No Colace?! Those pain meds (the opiates anyway) were slowing your gut down, too. Post partum pooping ain’t easy, no matter where the baby came out.
Kind of disappointed the nurses were clueless.
I feel pretty good at this point (4 weeks.) I definitely did need help for at least 2 weeks, but I only really felt badly while in the hospital. Incision is already starting to fade, and I have only a very small area of numb skin. Overall, it was, as other C/S moms said, “Not awful.”
Just remember, when it’s time to get out of bed, roll on to your side and push up with your arms. Don’t try a sit-up type maneuver!
Yes we do. All of those outcomes were included in the study. If you want to be taken seriously you should understand the controls of the study you are bashing.
Show us! Where? Please quote!
You didn’t read the whole thing, did you? Did you skip the tables?
This reads like gibberish to me. Explain it like I’m five. What are the “controls” of the “study” you’re talking about?
And there were three breech babies who transferred to hospital where we “don’t know” the outcome. We don’t know if they lived or died.
It gets worse… I think we can safely add them to those 5.
God, I was friendly with at least half the students in my year. Imagine losing someone you’re friendly with and someone you know. Every. Year.
Those aren’t just numbers that “are not really about me”. They can translate into numbers from the life of any of us as it is.
Or if they are permanently brain-damaged, as Dr. Amy has pointed out.
Or the one baby whose penis had to be amputated because it was whacked by the mother’s pelvis.
Yes we do know that. Those outcomes were included.
And if you want to talk about penis mutilation, let’s talk about the thousands of circumcision complications that happen annually at the hands of doctors
What does circumcision have to do with the conversation at hand? Nothing. We are discussing home birth with CPMs.
Yes we do. The study followed through to six weeks. It took all transport information into account and the outcome was attributed to the midwife who had transported and not the hospital or doctor
Table 5 of the study – note a:
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.
Becky is correct. We don’t know how these births turned out. I can’t say I think much of a midwife who doesn’t know how her dump and run at the hospital turned out.
No, according to the study there was data missing on four hospital transfers, no outcome data at all. The midwife didn’t go with the mother to the hospital and there was no follow up afterwards.
I stole that from a blog post by — I think — a nurse who was talking about the number of children who die of the flu each year being equal 6 kindergarten classes. But, the comparison is apt in this case, also. Since I was in my son’s kindergarten class this week, it really stuck with me. All those great kids.
Here it is. http://shotofprevention.com/tag/nurses-who-vaccinate/
Thank you for this I had no idea there were so many fatalities! Just the other day my SiL pooh-poohed influenza vaccines on the basis that she and her children got the jab and still came down with the flu shortly afterwards. I mumbled something like I think they only vaccinate against the most common strain going around so their getting sick doesn’t prove they don’t work but I was not confident talking about it because I know so little. I also doubt very much that what they had was really the flu.. very mild if it was.
I will share this with her.
All the more reason to get vaccinated in, like, late August or early September before there’s any flu going around. You’ve got plenty of time to develop full immunity before flu season hits. The flu vaccine has 3 strains, but this year there were some new varieties that had 4.
And you don’t really get the benefit of the shot for about two weeks.
My kids got their mist in October. I think middle child has flu now; or possibly an unnamed virus. All I can think is “Thank goodness she got the vaccine, I don’t need worse than this.”
Anecdotally, a friend’s kids both got the flu (confirmed by blood test). Oldest child with no vaccine was down for 5-6 days, younger child had been vaccinated and was sick for 1.5 days. And not as badly.
Pink/Baby Blue/Black bumper stickers and ribbons in honor of the babies who died at home birth. Bumper sticker: “Instead of trees, whales and snail darters, try saving a baby instead”
Having just taken my kid to her first day of full time school, I think this image is horrific.
That information would be unethical to share. If any of the parents came forward, it would not be, but we don’t know which deaths talked about online are represented in the stats since participation was not mandatory.
I don’t think that’s what staceyjw meant. Of the families who have come forward, whose names are known — what are the names of the babies that died after MANA should have been releasing the data.
Dr. Amy, one thing I’ve been puzzling over is this: where are the antepartum deaths? I think LOTS of things midwives do would lead to a higher antepartum stillbirth rate, but I don’t see it addressed in the MANA report. Why would they not include that in their stats?
They cannot even track the normal stuff well, and you think they are going to track this? I am sure those will be in the hospitals count.
Their response is that antepartum would be a matter of prenatal care, not place of birth and they can only study one question at a time.
So wait another 5 years and maybe we’ll see that study.
I was wondering this as well. How many babies under the care of midwives were stillborn due to inadequate antenatal assessment? Say the client shows up at her 41 week appt and there are no heart tones. This would likely fall in the “planned hospital birth” category, and not contribute to the midwives’ death rate. Most of the time these types of births fall into “we don’t know why this happened” category – and the mother is induced in the hospital. These should be included in the midwives’ stats. I agree.
They are not counting stillbirths? When they encourage going postdates?
I give up.
Follow the money.
OT – http://www.huffingtonpost.com/2014/01/30/united-arab-emirates-breastfeeding-law_n_4689740.html?ir=Women
With the debate of Islam and Middle Eastern culture aside… you’d think American women would not be supportive of breastfeeding legislation but I was fairly shocked to find, on a breastfeeding group I’m part of on Facebook, that women are highly supportive of this. Disgusting! And I’ll be deleting myself from this group after I’m done with the debate. I’m completely fed up with lactivism, homebirth woo and all the other natural “philosophies” spreading around. Not entirely because of the philosophies themselves but more so because of the psychotic proponents.
Not surprising. It would be interesting to know what Americans as a whole think of such legislation, not just BFing activists, of the variety like those in the FB group you mentioned. I don’t want to lump ALL pro-BFers together; I’m sure there are plenty that think a law mandating compliance would be too much. At least I hope! I always find it amusing when the same “let’s force everyone to do ABC” are appalled at say, universal health care or mandatory vaccines. Especially the latter, b/c it often shows how they like to pick and choose which CDC/WHO stats they like and which they don’t. But again, NOT every single advocate of BFing fits that mold. The rabid ones just happen to have the loudest bark, too!!
Well, I think most Americans are sensible, at least enough that they would be horrified at a law like this. One of the most horrid parts of the law are that if the woman cannot or won’t breastfeed, she can not only be sued by her spouse but her baby will have to have a wet nurse. I couldn’t believe how many people were supportive of those clauses. But I know that this tiny group of lactivists only represents a very small percentage here in America…. for that, I am thankful!
Me, too!!
Ugh, so nutty. A law like this might make some sense where I am from where water contamination is a concern (I think Dr Jeevan has expressed some horror that women choose not to nurse) but not in the UAE or US.
IDK, lots of American women think banning BC and abortion is fine, and others think making hospitals push BF and deny MCRS is a good thing.
They are against anyone taking away THEIR choices, but they have no problem taking away others rights.
I was pleasantly surprised that everyone who posted about it on my Baby Center due date board was against it.
Well after reading Navelgazing Midwife’s article, I think maybe for all we know they were still trying to collect all of the older data before they went to online submission.
There are only two states where DEMs were mandated by MANA to report their data: Vermont and Oregon. That makes up the bulk of the stats and even those were sketchy. I am not sure about Oregon, but back in October, 2011, the Vermont Legislature passed law that did two things: 1) it mandates that Medicaid and private insurance pay DEMs for home birth services; 2) it mandates that DEMs report their stats. Well, the DEMs were delighted with the first part, but were predictably pissy about the second that caused the high horses and unicorns in their stables to whinny and neigh.
I think, as stated earlier below, they hid their stats as long as possible hoping they would get better and to brainstorm to see how they could change atomic spin to turn black into white. Notice that a CNM in Oregon presented the data back in October to the Legislature and now MANA came up with a similar report. My guess is that the Legislatures were putting a great deal of pressure for MANA to release the data (which they had MANDATED) and that legislative repercussions were threatened if they did not – such as revocation of licensure categories for DEMs and revocation of prior mandates for the payment of home birth services by Medicaid and private insurances.
So in MANA’s belated data release, we get the real stats for Vermont and Oregon, which we know were REALLY bad for Oregon, mixed in with incomplete, self-reported data from 48 other states, which incomplete data most likely leaves out a disproportionate number of really sad outcomes…after all, in the minds of some CPMs, such tragedies are probably “homebirth attempts but hospital births then deaths”, not “homebirth deaths”, because the mom “gave up on the process” (and, incidentally, “fired” the midwife) and went to the hospital where her damaged child finally got sectioned out and then died when taken off machines a few days later. From what I’ve read, there seems to be a pattern of “dumping and forgetting” by midwives after bad outcomes. It’s always more fun to remember–and report!–successful homebirth stories.
And that’s why I’ll continue to believe the CDC numbers over MANA’s.
Well, as “real” as they could get them at the VO Unicorn Ranch. I think the reporting was still selective and incomplete. BUT, those two states MANDATED such reporting. Failure to do so should be cause to revoke DEM licensure with such punishment as is accorded for “practicing medicine without a license”. Then we would hear wails against the penocracy.
I ran a CDC wonder search on Oregon and Vermont alone just to see what the comparison would be. There weren’t large enough numbers to get an estimate from the CDC site, but using very loose criteria (age 15-49, all races, all marital states, all educational status, GA at least 34 weeks including unknown) I got 1.12 per 1000 for MD/in hospital and 12 out of 3831 for out of hospital/other midwife. That is, about 3.13 per 1000. Oregon and Vermont both have at least some level of regulation of midwife practice. Home birth with DEM is legal and insurance pays for it. If it’s safe anywhere, it should be safe in these two states. The fact that we still see this close to 3:1 ratio…
EXACTLY, Nym. If that is as good as it gets in Unicorn Land where the bags of oats are bottomless and woo flows through the troughs, just imagine what the stats are elsewhere.
Vermont and Oregon did not make up the bulk of the data. They did not use state forms to get their information. Also, you should know that the Midwives Alliance of West Virginia (made up of mostly CPMs and DEMs) tried to get legislation passed last year to create a mandatory days registry for home births through the state
and they were sadly shut down and told it wasn’t necessary.
Bah, I don’t think this is all that worthwhile of a tack.
To me, the more interesting question is, if homebirth is “safe”, then what is “unsafe”?
Because if you actually look at objectively, there aren’t many things that are less safe than childbirth, much less homebirth.
Yesterday, we came up with climbing Mount Everest and running for president. Attempting to climb Mount Everest has about a 10x greater chance of death. Never came up with an exact answer for running for president, but best estimates are that the chance of death is less than 5x that for childbirth.
Remember, they are trying to sell this as “absolute risk”, so the concept of “safer” and “less safe” aren’t relevant, except in comparison to homebirth. If homebirth is “safe” then, in order to be “unsafe” something has to be less safe than homebirth.
This is REALLY hard, if you look at it on a per event basis. It doesn’t do any good to look at annual risk of, say, failing to wear your seatbelt, because that is the cumulative risk for probably 1000 different events. If you get in the car and drive to work, what is the risk if you don’t wear your seatbelt? Tiny, tiny, tiny. Now, you do that every day for a year, that risk adds up, but for any single event, it’s nothing. Probably a thousand of times safer than childbirth, I would think.
So if homebirth is safe, what is unsafe?
Crab fishing in the Bering Sea, perhaps?
Not per day. A day spent crab fishing is about 100 times safer than a day spent giving birth, IIRC.
Note that the annual risk is comparable to the risk of childbirth.
Right, so the most dangerous job that an american might have is about as dangerous as having a baby a year.
Now THAT is funny!
I would say that the risk an obstetrician takes of getting sued for the outcome of a delivery is comparable to the risk of perinatal/neonatal mortality in a home birth. And the risk of physician suicide from job related stress is comparable to the risk of maternal mortality at home birth.
Receptive intercourse with an HIV+ male partner? It’s safe for vaginal sex — only a 1/1,000 chance of transmission per act of intercourse. Less safe for anal sex but I don’t know how much less safe.
Sharing needles with an HIV+ partner is definitely unsafe.
http://goaskalice.columbia.edu/confused-about-hiv-transmission-statistics
HIV infection is different though, because it can be managed. 20-year old gay men in North America have a life expectancy of 77 years whether they are HIV+ or not. http://www.healthline.com/health-news/hiv-life-expectancy-for-americans-with-hiv-reaches-parity-121813
Dead women and babies are just dead.
Not everyone understands statistics, Bofa, but everyone understands a cover-up.
Have we compared this to the risk of being a soldier in a combat zone?
I think that would vary drastically with the nature of the conflict.
US Military death rates per 100,000 active duty between 1980 and 2010 varied from a low of 43 in 1989 to a high of 1,953 in 2007.
https://www.dmdc.osd.mil/dcas/pages/report_number_serve.xhtml
0.43 per 1,000: safe!
20 per 1,000: not safe!
My guess is that early on the true believers held back the stats believing that they were an aberration and the numbers would get better as HB spread and HB midwives gained more experience catching complications. Then, the better, newer numbers would take the edge off the bad ones and paint an overall good picture. But it seems the opposite has happened and they’ve been scrambling to keep a lid on it ever since they realized that the terrible rate of outcomes wasn’t getting better and never would. Deaths are becoming more frequent and the circumstances even more tragic as riskier and riskier HBs are being attempted against all common sense or rational judgment. And of course, it’s the true believers themselves who prevented these hoped for better outcomes from being possible by discouraging and opposing meaningful education and certification, hospital transfers, and interventions once the transferred patients arrived at the hospital.
It’s such a sad state of affairs and I can’t really wrap my head around it.
It would be fascinating to see ALL the data they currently have separated out by calendar year. Sure, scrub the heck out of the data to protect whoever, because what I really want to see is the trends.
I would not be surprised at all if there were odd spikes as particularly active midwives who ignored known risks caused adverse outcomes to jump.
Home birth is uncommon enough that if the data was presented with only the state given, it would be obvious where the worst outcomes were concentrated. It might also drive a wedge into the midwifery community as midwives clamored “I am not responsible for those outcomes! It wasn’t me. It wasn’t us.”.
Which leads to the question:
If it wasn’t you, who was it?
Someone knows. Someone knows very well who the bad actors are.
That’s a good point. Yes, some home birth deaths are caused by sudden mishaps in previously normal labor, but it really seems like the majority are caused by failure to risk-out before delivery or failure to transfer when clear signs of a problem appear.
Home birth can’t be made as safe as hospital birth, but I think it could be a lot better than it is.
Perhaps a good benchmark would be the numbers for accredited CNM birth centers? I have a relative who is planning to deliver at one, and at an ultrasound, when a minor but potentially concerning anomaly was discovered, they immediately referred her to an MFM at a large teaching hospital. The MFM will decide, with more monitoring as the pregnancy continues, if she needs to be risked out and deliver at the hospital, or if she can continue at the birth center. That is how out of hospital birth ought to work.
Actually, my younger brother was born at a birthing center. And they risked out! Ultrasounds weren’t commonly done in those days, but they did all the usual tests. My mother claims they made her do the GD test twice. They also had an on-call pediatrician to examine the babies after birth and confirm they were healthy.
My mother was absolutely low risk–second birth following an uneventful pregnancy and a relatively easy first birth. I still don’t think I would make that choice, but it’s not crazy.
“Home birth can’t be made as safe as hospital birth, but I think it could be a lot better than it is.”
We actually know just how safe it can be made. That’s the UK Birthplace study. It was done in ultra-low-risk women. It allowed NO women with ANY history of ANY complication or risk factors in this pregnancy or any other pregnancy. It insisted on compliance with ALL appropriate prenatal tests. Births were attended by TWO cnm-level midwives who had hospital privileges. Midwives were required to transfer if ANY sign of a problem including meconium, malposition, prolonged rupture of membranes, slow progress, elevated temperature, questionable heart tones. There was a dedicated ambulance service and women far from the hospital were not allowed to participate.
Results showed that in multiparous women, the risk of the baby dying was not statistically different from in a UK hospital. But note that the UK doesn’t have terrific perinatal mortality rates to begin with–the USA is better.
In first time moms the rate of the baby dying was nearly 3 times that of in the hospital! And this is even with them transferring at the first sign of any suspected problem: 40% of first time moms were transferred.
So there you have it. In a perfect homebirth world, a ultra-low-risk woman on her 2nd, 3rd or 4th baby with a history of all easy uncomplicated prior births is a decent candidate as long as she is attended by 2 midwives with advanced university training and hospital oversight and is willing to transfer at the first sign of trouble and is willing to accept the statistically tiny chance of freak occurrences like cord prolapse, abruption etc.
It was Portland, obviously. If you leave out Portland, home birth in Oregon is safe, Babies in Portland missed the memo on how to be born.
Aside from the obvious issue of treating birth as a normal physiological event where the mother just needs moral support (how’s that working out for mothers and infants in Afghanistan?), there’s a very real financial disincentive to be honest about the stats.
If I’m a midwife and I’m short on clients, I’m likely to take on a high-risk client because the absolute risk is still low and I need to pay the rent. If things go south, I still get to be a midwife and the midwifery community will support me. No malpractice insurance means I don’t have to worry about being sued (I’m judgement proof because there’s no money in taking me to court). The risk is entirely on the client.
Additionally, midwives are competing for a very small piece of the childbirth pie. There are only so many people who will take the risk of an out of hospital birth, even with the notion of it being as safe or safer. The folks at MANA are lobbying for licensure and insurance reimbursements all over the place. If legislatures and insurance had hard evidence of the risks, they’d be less likely to play ball. And if the percentage of people willing to give birth out of hospital is small, then the percentage of people financially able to self-pay and willing to be attended by an unlicensed attendant is even smaller.
If MANA can’t make midwifery pay for its members, then MANA doesn’t receive membership dues. Without pressure from clients, legislatures and insurance to make midwifery safer, midwives will not work to make midwifery safer because it is not in their financial interest to do so. I’ll be very interested to see what Oregon does in the coming years in response to the growing pile of evidence that non-CNM midwives are unsafe.
tl;dr: I don’t think CPMs will take safety seriously until it hits them in the wallet.
Not to mention, many probably underreport their income quite a bit.
I think you really nailed it.
Even the CNM that supports HB and LDEMs, and presented the deplorable OR stats, has said that the CPM “credential” wasn’t meant to be permanent. It was supposed to be a stop gap, temporary measure in order to get lay MWs up to speed, and totally educated.
I think the hope was the others like OBs and hospitals would be more willing to work with them, and transfer care from them, if they were legitimate. They wouldn’t have to hide, be illegal, or drop moms off and run, once licensed. Insurance would pay, and MWs could afford to improve their education and their tools. ALL this should have led to improvements, or so they thought.
Now, I think the CNM I mentioned may have thought that the other MWs would improve, and I am sure the other CNMs that support CPMs, might also believe this, but the CPMS themselves? No way were they trying to go the hard route of a real degree when they could catch babies without it. All the legitimacy didn’t improve anything, it just made them even bolder, and duped more moms.
For this reason, I can see thinking the first year or two would be a fluke, with following years improved as more CPMs got integrated into the “system” (the system they despise, and still blame). I know that CNM was surprised by the horrible numbers. The CPMs are too ignorant to think they are bad.
The big problem is that they all believe that birth is a normal event, that is safe if left alone, “birth is safe, interference is risky”. This premise is so false, that no measures can fix it until the mindset changes. Efforts at licensing, malpractice coverage etc, are pushed in hopes of slowing the harm of their philosophies.
I don’t know why it was ever OK to have non CNM MWs, and why they would let other women claim the title they worked do hard for, but thats another argument.
It seems to me that the outcomes for MWs and HBs are getting relatively worse in more recent years, as they get more and more careless, including in the types of patients they accept.
it’s the typical mommyupmanship crap, with the more dangerous you can do, the better it is.
I am sure the last few years are the worst yet.
I agree. And the midwives are holding conferences that reinforce the idea that breech, HBAC, twins are variations of normal and discussing the positive side of their practice. They don’t seem to be talking of the risks and the downsides of their practices and nobody is making them. Or if they try to they are “mean”, running a “witch hunt” etc.
Same pigheadedness as the doctors of old.
In our country, where we have well-trained midwives, there are those in the NCB camp who are concerned about the medicalization of Midwifery and birth. So they are choosing to be unassisted homebirthers. Basically, they are women who are signed on with a midwife but oops, the baby came too soon to call the midwife. (Not really, they choose not to call them). Now, if the mother does end up transferring or has a baby die, I wonder if that will be added on the midwifery statistics or not. I have been at UC support meetings and they really do believe the risk is minimal.
One of my colleagues who worked closely with the authors told me the original idea was to show a trend of improvement, just as you suggest above. But that’s not what the numbers showed.
Their new strategy seems to be to try to cast doubt on the CDC’s and hospitals’ statistics. As if to imply that MANA does a better job of data collection.
The idea made me laugh out loud.
Voluntary reporting that netted them what ridiculously small percentage of the total data?
From The Feminist Breeder (via FB): According to consensus data, the early neonatal (>7 days) death rate for white women was 2.9 per 1000 live births. Considering that 99% of babies are born in hospitals, I’d like to understand how the hospital neonatal death rates are supposedly so low. The problem is that there’s no standardize national reporting system for this data so people use the data that suits their purposes.
What’s “consensus data”?
Nope, no standardized system. Every year, 4 million birth certificates and 2.5 million death certificates are just filed in the circular file, there’s no way they’re codified and shared here: http://www.cdc.gov/nchs/nvss.htm
The CDC data is NOT merely death data. It comes from the LINKED birth-infant death files, which means that every single death has been matched to it’s corresponding birth certificate.
There is absolutely nothing wrong with US reported neonatal mortality statistics. Moreover, the same data is kept by the CDC for homebirths with non-nurse midwives as well, and from 2004-2009, homebirth death rates varied from 3X – 7.7X higher than comparable risk hospital birth.
And it has the advantage of recording virtually every birth and associated neonatal death in the nation. Not just, oh, say… 20-30% of them.
I think the Feminist Breeder failed out of her MA in public health program.
I might be wrong about her leaving the program but I’m pretty sure GOMI mentioned her failing epidemiology and statistics.
Why am I not surprised.
I don’t even understand this.
Um…maybe because nobody enjoys being caught out in a glaring error – or (say it softly) blatant lie?
And because the echo chamber needs to be shielded from any hint of cognitive dissonance
And the other question:
What about the other years’ data they haven’t released yet?
What years did they release?
years 2004-2009
That would be no, no they can’t.