What MANA found; what MANA did.

Grieving family with an infant's coffin

The following is from a comment taking issue with Judith Lothian’s post on the Lamaze blog Science and Sensibility praising the MANA study Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. The authors claimed that the study shows homebirth is safe, but it actually shows that homebirth has a death rate 450% higher than comparable risk hospital birth.

This “study” brings up more questions than answers. And I hope MANA seeks to find answers – true answers, and not unfounded self-promoting headline – regarding the safety and risks of OOH birth…

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?

… The authors allude to insufficient collaboration between midwives and medical providers – is there any evidence in this sample to support this assertion? Case reviews of each incidence of perinatal death may illuminate this subject.

In this sample, was there any difference in outcomes between midwives practicing in states where CPMs are licensed and in states where they are not?

In this sample, were there individual midwives who had significantly higher perinatal mortality rates in their own practices? If so, what was there any common denominator among these types of midwives?

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.

100 Responses to “What MANA found; what MANA did.”

  1. manabanana
    February 3, 2014 at 10:47 pm #

    My prediction is that the next 5 years of MANA stats are even worse. As it was in 2009 (or 2010?) when a whole bunch of CPMs went to Canada for a breech conference – and came back ‘experts’ in vaginal breech birth. And then became even bigger promoters of vaginal breech birth.

    So, if MANA knew about these atrocious numbers in 2009 and did nothing… we’ll probably see even more hideous outcomes in the subsequent 5 years of data.

    Need I say how disgusted I am?

    • NoLongerCrunching
      February 4, 2014 at 8:37 am #

      I was wondering why they released 17,000 records rather than the 27,000… Could this be it?

      Btw, changed screen name from LynnetteHafkenIBCLC.

      • Squillo
        February 4, 2014 at 12:29 pm #

        They excluded stats from non-US midwives and women who transferred care before the start of labor.

        • staceyjw
          February 4, 2014 at 4:24 pm #

          Think of how many transfers of care were because of medical issues that came uo, like pre e, breech, GD, GBS, etc. Some MWs actually do care if mom is low risk, and some moms know medicxal issues require a CMN or OB.

          And still the numbers are bad.

  2. Sue
    February 3, 2014 at 4:32 am #

    It’s this very issue that inspired our letter to the Medical Journal of Australia – a report of outcomes (deaths) that were several times greater than for low-risk hospital births, with a conclusion that things were going well.

    Any other group of responsible health care professionals, having found this excessive death rate (and not even measuring hypoxic injury)) would be making recommendations for improvement.

    How about some basic ones:
    1. Only CNMs affiliated with hospitals can attend HBs
    2. Rule-out criteria must be adhered to, and transfer guidelines followed
    3. First-timers, breech and twins automatically excluded.

    • The Bofa on the Sofa
      February 3, 2014 at 8:10 am #

      Aren’t 2 and 3 redundant?

      • Sue
        February 3, 2014 at 11:45 pm #

        Sure. Repetition for emphasis.

    • The Computer Ate My Nym
      February 3, 2014 at 9:33 am #

      3 should also include VBACs. These rules wouldn’t completely eliminate the risk, but would drastically reduce it.

      • Jessica S.
        February 3, 2014 at 1:10 pm #

        I was just about to mention that, too.

      • Sue
        February 3, 2014 at 11:44 pm #

        Yep – forgot VBACs

    • LMS1953
      February 3, 2014 at 11:36 am #

      I have written about this concept before and I don’t want to be redundant. The problems with the HB situation in the US are too enmeshed with the incompetence and superstitious thinking of the lay midwives* who dominate it that we cannot begin to consider facilitating HB until they are banned. BUT, in countries such as Australia, the UK and the Netherlands where it appears pregnant women are willing to accept some rational restrictions on their “variants of normal” AND in the Third World imagine this —
      we use smart phone technology for something other than twittering and playing Angry Birds. There is absolutely no reason why a Bluetooth fetal heart monitor could not be attached to mom to not only provide intrapartum FHR monitoring but NST fetal surveillance for the late second and early third trimester high risk pregnancy to any woman anywhere on the planet. From an aborigine in Australia to grass huts in Africa to a kale farm in Oregon to a peat bog in Ireland. The telemetry could be monitored at the designated transfer center. There would be significant improvement in safety which would make the MANA reports even more hideous. Legislatures would be given evidence to ban the licensure categories of “lay midwives”. Considering the hubris of banning 16 ounce sodas, locking up formula in hospitals and onerous EPA regulations to protect the snail darter, I think a measure to protect a baby’s brain might have political viability.

      • DaisyGrrl
        February 3, 2014 at 12:12 pm #

        Don’t get your hopes up about midwives. In Ontario, Canada they are introducing birth centres run by midwives and touting the low-tech benifits of birth centre birth. No doctors or nurses! No EFM! But look – fireplaces and tubs! 10 minute transfers (yeah right)!

        In my city, the intention is to have 450 births a year attended in this setting now that the centre has opened its doors. It’s viewed as a cost-saving measure because these births are cheaper while making for a nicer environment for labouring mom. Meanwhile, OBs asked for money to build a world-class birthing centre next to the children’s hospital. Specialists, monitoring, NICU, dedicated ORs, the whole nine yards. I’m pretty sure they got shot down.

        • Jessica S.
          February 3, 2014 at 1:09 pm #

          Yeah, it’s a cost-saving measure until something goes terribly wrong, specifically something that would’ve been less of a crisis in a hospital, thus, I presume (although I’m not a doctor) would’ve cost less. Unless the baby dies, I suppose that may be “cost-saving”. Ugh, I feel horrible even jesting about such a thing. The costs, or potential cost-savings, aren’t worth the risk. There are some costs that can’t be measured.

          • LynnetteHafkenIBCLC
            February 3, 2014 at 1:12 pm #

            Even if all you care about is cost, it’s still not a good deal, given how expensive it is to care for a birth-injured child.

          • DaisyGrrl
            February 3, 2014 at 1:36 pm #

            Especially since we have single-payer insurance run by the government. They’re on the hook regardless.

          • LMS1953
            February 3, 2014 at 3:52 pm #

            Who says you have to take care of the child? Didn’t y’all have a well publicized case a couple of years ago where a child of Lebanese immigrant had a terminal genetic neurological disease? CanadaCare spent months trying to terminate the child, even refusing a merciful tracheostomy instead of months of intubation. IIRC, a hospital in St Louis eventually took the boy in transfer and gave compassionate end-of-life care. Please recall when Sebelius refused to allow the girl with terminal CF to get a lung transplant because she was only 12. She eventually got it – the first was rejected but she is thriving after the second. It’s easy to have “affordable” health care if you dump people off on an ice floe with a pound of whale blubber and a pat on the head.

          • Medwife
            February 4, 2014 at 3:45 pm #

            Ok, Rush.

          • Young CC Prof
            February 3, 2014 at 1:13 pm #

            You’re right, but actuarial models actually do put a price on human life. You add it to the loss of property and the direct and indirect costs of injury, and thus you can model the cost of a potential disaster and decide how much effort to put in to preventing it.

            In a world of limited time and money, it’s the rational thing to do.

          • DaisyGrrl
            February 3, 2014 at 1:50 pm #

            Interestingly, the Toronto birth centre only says it “has the potential” to save money. I guess they’ll find out soon enough if it’s true. The Ottawa centre, meanwhile, promises to transfer if there’s an abnormal fetal heart rate but doesn’t have EFM on site. I’m not sure how that’s supposed to work (any healthcare peeps able to explain?).
            I really hope there’s no disasters. Failing that, I hope that it doesn’t take too many disasters before they take risk more seriously.

          • Becs
            February 4, 2014 at 5:35 pm #

            It was decided not to have EFM at the birth centres. Why? Because if a midwife is recommending EFM the birth should probably take place in a hospital setting.

        • theadequatemother
          February 3, 2014 at 1:20 pm #

          Isn’t that birth center in reagent park (a socioeconomic ally disadvantaged area close to downtown to with really bad traffic?). Makes no sense to me…I would have put it next to Sunnybrook!

          • DaisyGrrl
            February 3, 2014 at 1:35 pm #

            The Toronto one is in Regent Park. The Ottawa one is in a not-so-great neighbourhood about a 10 minute drive from the closest hospital. But I’m sure the land was cheaper.

        • LMS1953
          February 3, 2014 at 3:33 pm #

          Why would they want to go to the expense of building a world class high tech facility in Ontario, Canada when they can just dump the patients that need these services on any nearby city of 50,000 people in the US – and then brag about how wonderful and universally accessible and “free” the Canadian system is. A tad disingenuous, don’t cha think?

          • AlisonCummins
            February 3, 2014 at 3:48 pm #

            When this is done formally, the US hospital bills the Ontario government directly. When it’s done on an ad-hoc basis by Ontario tourists in the US, the US hospital will bill the canadian tourist who is then partially reimbursed by Ontario.

            This is actually a strategy for some high-cost services. If they generate high revenue, the US wil have a lot of them; in Canada with the smaller population and the lower density, it may sometimes be more cost-effective to outsource to the US. Say, for some cancer treatment. We maintain enough beds to meet our own needs most of the time, and when our capacity is exceeded we might outsource the overflow to the US.

          • LMS1953
            February 3, 2014 at 6:32 pm #

            That is still a whole lot cheaper than building a state of the art medical center and training and recruiting specialists (perinatologists, neonatologists, oncologists, thoracic surgeons) and all of the supporting staff and medical equipment. With the flux caused by the Affordable Heathcare Act, all of that may soon be in short supply in the US, so y’all might start working on a Plan B.

          • AlisonCummins
            February 3, 2014 at 6:59 pm #

            We do have all those things.

            What you need to keep in mind is that in Canada all hospitals are public, including the ones that our heads of government and movers and shakers of business use. If I think half-assed is good enough for “them” then half-assed is all that will be available for me when it’s my turn. So I need to think about my priorities when I vote.

            I’m not sure why you think that state of the art medical centres, perinatologists, neonatologists, oncologists and thoracic surgeons are nonexistent in Canada. We don’t use US overcapacity for everything, just to make the best use of our resources. It’s a little like a retailer outsourcing online support to India over the holidays. If contractors can cover the excess demand at Christmas there’s no point in staffing the retailer full-time year-round as if it were Christmas every day. Well, the US is Canada’s India. Sometimes we use you for outsourcing.

            If your overcapacity starts dwindling your prices will go up and it will make more sense to expand our local resources. At that point we will because it makes economic sense. Similarly, if a retailer’s demand is less bursty and is more evenly distributed throughout the year, they will have more full-time staff and less outsourcing.

            So don’t worry about us. We’ll be fine. We currently benefit from the inefficiencies of your system, but if you become more efficient we’ll adapt.

          • DaisyGrrl
            February 3, 2014 at 5:15 pm #

            Except both birth centres are in major cities with populations at/over 1 million. I know there are shortcomings in several other Ontario cities (as well as elsewhere in Canada), but these really are population centres that can support high-level care and serve as intake for low-density/lower-capacity populations. These cities have high-level maternity care – the doctors just want to give their patients the absolute best care possible.

            Regardless, that wasn’t really my point. My point was that if Canadian midwives with their university degrees (analagous to Australian/British/Dutch midwives) can’t be convinced to use EFM in a birth centre paid for by the government, then why would you expect CPMs to agree to remote real-time monitoring by an acutal health care professional? They eschew any sort of oversight except as a ploy to obtain Medicaid payments (oh no! government funded health care!). I think your idea would be a very cool use of technology but I think you’re overestimating the willingness of CPMs to submit to any meaningful supervision.

          • Becs
            February 4, 2014 at 5:31 pm #

            The reason why there is no EFM in these birth centres: because women who fall into the category of “recommended EFM” are encouraged to give birth in the hospital.

      • ihateslugs
        February 4, 2014 at 2:33 am #

        I think your reference to the superstitious thinking of lay midwives is really at the heart of why so many of them eschew technology. At the core of their message is the idea that birth is a normal, natural process that does not need to be “medicalized,” implying that the use of technology is entirely unnecessary, and to some midwives, even dangerous. If you’ve read enough natural childbirth literature, you’ll find repeated claims that continuous fetal monitoring is harmful, in that it leads to unnecessary sections based on transient and brief periods of heart rate change, which they claim are totally normal and of no significance.
        Furthermore, many midwives espouse concerns that both Doppler and ultrasound may have detrimental effects on the developing fetus, with some even claiming they lead to neurodevelopmental changes such as autism.
        These pervasive and philosophically based ideas are why I don’t think we’ll see a rush of DEMs eager to purchase the now available ultrasound apps/probes available to hook to smartphones, and why I suspect they wouldn’t be interested in an off-site heart rate monitoring center. (And this doesn’t even address the typical profile of a mother choosing an OOH birth, who often wants no trappings of modern medicine in their cozy birth nest.)
        Unless one has an appreciation for the true complications of birth, typically learned in a medical setting along with a deeper understanding of pathophysiology, you just don’t even know what you don’t know. They’ll never get it.

  3. no longer drinking the koolaid
    February 2, 2014 at 11:07 pm #

    It is also interesting to me that the moderator of the MDCG list has posted the two articles. A discussion will usually ensue regarding the studies. Except for one comment, which was actually a quote copied from another list, no one has commented.

    When I have brought up the educational differences between CNMs/CM and CPMs/lay midwives I received a rather sharp rebuke that I should not bring the US midwifery communities arguments onto the lists. Judith Rooks, Kitty Ernst, and Susan Jenkins are all on the same list and no one is commenting.


    • areawomanpdx
      February 2, 2014 at 11:17 pm #

      I noticed the silence as well…it is something they would usually be crowing about.

    • no longer drinking the koolaid
      February 2, 2014 at 11:27 pm #

      And, BTW: apologies for poor grammar and syntax in the above message

  4. February 2, 2014 at 8:55 pm #

    OT but incredible story is developing in Victoria – the mother suffered a cerebral aneurysm Dec. 28 and has been declared brain dead since Dec. 29 – she was 22 weeks gestation at the time. She has been on life support and they are hoping to deliver the baby via cesarean @ 35 weeks. http://www.youcaring.com/help-a-neighbor/baby-iver-fund/133560 and http://www.timescolonist.com/donors-answer-man-s-plea-for-unborn-son-1.811300

    • Expat
      February 3, 2014 at 1:55 am #

      My neighbor, a single father, has the same story about his 9 year old daughter. Her grandmother is also my neighbor. They were jwalking along and talking and the mom just dropped and was never conscious again.

  5. Guesteleh
    February 2, 2014 at 7:46 pm #

    You know what’s amazing to me? The conversations on S&S, TFB and MDC are not monolithic cheerleading! There is a real debate going on! Women who support homebirth are criticizing MANA for spinning the numbers! This is very, very good.

    • February 2, 2014 at 8:57 pm #

      It proves what I knew all along: most of homebirth and midwifery are people like me, who had a reason (an understandable, but poor reason) for believing NCB nonsense make up the ranks of NCB. As the evidence piles up their ranks are finished. In fact, they make some pretty determined enemies by lying so often. I know I’m a thorn in Utah’s NCB movement’s side. They have made their facebook group private since I’ve exposed them via my safer midwifery in utah blog.

    • GuestingIt
      February 3, 2014 at 9:09 am #

      The skepticism NCBers usually reserve for OBs and hospitals (thanks to homebirth advoates) is now being aimed back at MANA. So ironic!

  6. MLE
    February 2, 2014 at 5:10 pm #

    Aaaarg! Comment in response to Doula Dani’s excellent critique:

    “So the neonatal death rate IS .76/1000? Wow. I am feeling extremely confident about homebirth now for low risk women. Those numbers are fantastic. Especially when you consider the 5% cesarean rate, the 95% breastfeeding rates and the low rates of vacuum and forcep assisted births. Think of how many women avoided unnecessary cesareans that could have possibly turned into uterine ruptures years down the line. It’s very possible that by choosing homebirth a woman’s future babies have been saved.”

    • MLE
      February 2, 2014 at 5:11 pm #

      (From rroonie at the science and sensibility link)

      • Karen in SC
        February 2, 2014 at 5:25 pm #

        But it’s not .76, it’s 1.61 isn’t it? And what was the transfer rate of those in the HB low risk category? Did that remove them from that group then?

        I agree, for low risk women screened by a strict criteria with appropriate prenatal care and tests, with CNMs only, with integrated care with OBs and hospitals, could have comparable care. But there will still be babies that die that could have been saved in a hospital, only far fewer of them.

        • MLE
          February 2, 2014 at 8:12 pm #

          Agreed as well. I just don’t care for the whole attitude that the death rate isn’t that terrible no matter what it is and somehow a 95% breast feeding rate should be prioritized above life.

          • Young CC Prof
            February 2, 2014 at 8:19 pm #

            Also, like most breastfeeding studies by lactivists, ignores the whole correlation vs causation thing. Women who choose home birth are probably strongly motivated to breastfeed and would have done so no matter where they delivered.

          • Amazed
            February 2, 2014 at 8:41 pm #

            Do these women know that dead babies have a breastfeeding rate of 0,000%? I swear, some of them make me wonder.

          • LynnetteHafkenIBCLC
            February 2, 2014 at 9:03 pm #

            I wouldn’t be at all surprised if some of the moms either lied or fudged the breastfeeding information, given the shame that population would feel if they needed to supplement or quit.

          • MLE
            February 2, 2014 at 9:19 pm #

            Oh yes, I am shocked that some women actually reported that they weren’t breast feeding. I can only imagine how bad it must have been for them to be willing to admit it.

          • Trixie
            February 3, 2014 at 7:01 am #

            Considering that 15% of them had significant blood loss, I’d imagine there were some suffering from supply issues related to that, no?

          • LynnetteHafkenIBCLC
            February 3, 2014 at 7:03 am #

            Yep, and there is no end to the medical conditions that could be underlying, since it’s doubtful any bloodwork was done prenatally.

          • Mel
            February 3, 2014 at 8:08 am #

            Before I started hearing about NCB, the statement “A living baby is far more important than breast-feeding” appears so obvious that I wouldn’t have thought anyone would need to state it.

        • lucy logan
          February 3, 2014 at 2:49 pm #

          what this shows is that natalism is the primary central principle of homebirth. not only is birth womans natural and defining function but her “future fertility” namely her ability to have more than 3 or so kids, is more important than her life, an the life of her already term or near it child. this is extremely reactionary stuff. right now having more than 3 kids is an unusual choice and more than 4 statistically marginal. i personally see no reason it shoud be otherwise, but NCB is not much more than a cover for quiverfull antifemininsm.

  7. Guesteleh
    February 2, 2014 at 4:39 pm #

    Judith Rooks just posted this comment on the Feminist Breeder’s FB page:

    Someone sent me a copy of the conversation that is going on here about the intrapartum fetal death rate in hospitals in developed countries. Intrapartum fetal deaths are so rare that there are relatively few studies with data about them. Missouri may be the only US state that routinely collects data to distinguish antepartum (AP) fetal death (before the onset of labor from intrapartum (IP) fetal deaths (during labor before the birth). In a study of 2,721 stillbirths from 20 – 43 weeks gestation in Missouri from 1989-1997, 86% of the fetal deaths were antepartum (having occurred before the onset of labor); only 14% were fetal deaths during labor. Other studies have also found that only about 15% of all fetal deaths at term occur during labor; the others occur before labor starts. My full report includes a table that summarizes findings from studies of IP fetal deaths during low-risk births in hospitals in the United States in 1980, from Missouri from 1989-1997, the United Kingdom in 1998, Scotland from 1988-2007, and conclusions from a systematic review of the literature on stillbirths published in leading English-language medical journals from 1995 – 2005. Intrapartum fetal death rates in hospitals have declined consistently since the late 1970s consequent to ever-expanding use of electronic fetal monitoring combined with increasing rapid access to cesarean sections for fetal distress from asphyxia. All of these studies are referenced in the attached paper.

    The most recent large, reliable studies of intrapartum fetal deaths in hospitals in developed countries now range from 0.1 – 0.3/1000 births.

    (basically seems to be a bitchsmack to Wendy Gordon)

    • Squillo
      February 2, 2014 at 4:52 pm #

      Gordon’s response (I shit you not):

      And let us not lose sight of the main findings of the authors of this Missouri study, which is that there are shameful racial disparities in fetal deaths for black women as compared to white women (whose outcomes weren’t so great either).

      You mean those black women that are being so well served by homebirth midwives?

      • Amy Tuteur, MD
        February 2, 2014 at 4:53 pm #

        Gordon would have been better served to keep her mouth shut. She just makes herself look desperate to change the subject.

        • Squillo
          February 2, 2014 at 4:59 pm #

          I rather imagine she is.

        • February 2, 2014 at 5:47 pm #

          JR: Intrapartum fetal death is extremely rare in the hospital. Here is clear statistical evidence.

          WG: WHITE PRIVILEGE! You’re racist!

          Makes total sense.

          • Amazed
            February 2, 2014 at 5:55 pm #

            Go to scienceandsensibility.org and enjoy the last two posts. The poster thinks MANA’s neonatal death rates are fantastic and that pushformidwives.org is an unbiased source. Oh, and a scientific one, too.

            I fear to imagine how many women will be taken by such comments and “stats”. That’s the trouble with Google University: it gives masters to those who should have never gotten a high school diploma (oh the irony with the tightened requirements for CPMs! They now want a high school diploma from Google masters! The outrage!)

          • Trixie
            February 2, 2014 at 8:03 pm #

            I’m reminded of Dreah Louis’s account of how racist her CPMs were.

          • February 2, 2014 at 8:06 pm #

            Yeah. But THAT ISN’T WHAT THE DISCUSSION IS ABOUT. It’s totally irrelevant to the topic at hand.

          • Trixie
            February 2, 2014 at 8:11 pm #

            Oh, I COMPLETELY agree. Don’t get me wrong. Just pointing out that Wendy doesn’t have a leg to stand on claiming that hospitals are racist.

      • areawomanpdx
        February 2, 2014 at 11:20 pm #

        My favorite was the commentor who pointed out that if Wendy Gordon thinks the outcomes in that study were bad, she must think those in her own were horrific, since they were much higher…

    • Amy Tuteur, MD
      February 2, 2014 at 4:52 pm #

      And term babies make up only a small fraction of those stillbirths, so the intrapartum stillbirth rate for term babies in hospitals is substantially lower than 0.1-0.3/1000.

      • Squillo
        February 2, 2014 at 4:56 pm #

        Not to mention that the data is 17-26 years old. And the midwives in MANAStats have yet to catch up with it.

    • PrecipMom
      February 2, 2014 at 6:43 pm #


      Anyone else popping popcorn and waiting for Wendy Gordon to say something even more embarrassing?

      • LynnetteHafkenIBCLC
        February 2, 2014 at 6:55 pm #

        I was waiting for Judith Rooks to weigh in. I’d love to hear more from her, and from other CNMs with ethics.

        • Trixie
          February 2, 2014 at 7:27 pm #

          I was momentarily confused until I realized Judith Rooks and Judith Lothian are entirely separate people.

    • Mel
      February 3, 2014 at 8:16 am #

      Which makes sense. My husband was born in late 1980. He had a nuchal cord wrapped 3x around the neck. During transition, it became clear that he was in big trouble as shown by EFM. They were trying to get an OR ready when my MIL managed to deliver my husband in her words “two really, really hard pushes”. (FYI: She is very clear that she’d have preferred a CS…..)

      If my MIL had delivered at a closer, rural hospital without EFM, my husband would have died.

      • Fuzzy
        February 4, 2014 at 5:59 pm #

        My daughter was delivered by high forceps due to the inavailability of a csection. She could not descend without distress d/t a 3x nuchal cord. We would not have been monitored if one of the corpsmen had not wanted to try out his new monitor.

    • The Computer Ate My Nym
      February 3, 2014 at 9:40 am #

      Wasn’t there a recent study comparing home to hospital birth that found basically a zero intrapartum fetal death rate, as fetuses in distress are monitored in the hospital and generally delivered by stat c-section prior to death if they come in alive? Can anyone remember which study this was or if I’m making it up and/or misremembering?

  8. Dr Kitty
    February 2, 2014 at 3:19 pm #

    I was having such a good weekend too (Six Nations Rugby- Ireland won) and then you have to bring me down with that graphic…

    Keep it up.

  9. Amy Tuteur, MD
    February 2, 2014 at 2:40 pm #

    It seems to me that in the nearly 8 years that I have been writing about homebirth, MANA has never issued a single recommendation designed to improve safety. Can anyone else think of any safety recommendations that MANA has issued?

    As far as I can tell all MANA has done is argue strenuously that women have the right to choose unsafe birth.

    • Squillo
      February 2, 2014 at 3:05 pm #

      How many practice bulletins has ACOG released related to OB? How many clinical bulletins has the ACNM?

      How many has MANA? As far as I can tell, they don’t even have a single page on their website devoted to clinical practice or quality improvement. (In the “Resources” section, however, they do have a page on birth photography.)

      • Young CC Prof
        February 2, 2014 at 3:34 pm #

        Alternative medicine’s proponents always criticize “conventional” medicine by saying that its practitioners keep changing their minds.

        They fail to understand that that’s the whole point of science, to continually seek out more data and to change practices on the basis of new information.

        • Sue
          February 3, 2014 at 4:39 am #

          Yep – it’s known as Continuous Quality Improvement.

        • Comrade X
          February 3, 2014 at 11:49 am #

          Yeah, it’s the same with rabid religious fundamentalists.

          “Science changes its mind all the time….we haven’t changed our mind in thousands of years” – Guys, that’s not a plus point. Sensible people change their beliefs given new information.

      • Amy Tuteur, MD
        February 2, 2014 at 3:51 pm #

        I believe that ACOG has around 142 practice bulletins, plus many more clinical opinion papers.

        ACNM has approximately 11 clinical practice bulletins.

        MANA has none.

        • Squillo
          February 2, 2014 at 4:07 pm #

          Wait, you mean the organization whose mission statement says its “a professional membership organization that promotes excellence in midwifery practice” and is dedicated to “improving outcomes for women, babies, families, and communities” hasn’t issued a single paper for members to help them improve clinical practice?

          Perhaps their motto should be: “Meh. Good enough.”

          • Karen in SC
            February 2, 2014 at 4:11 pm #

            Yeah but they have FB groups, like that defunct one, Elder Midwives. Isn’t that good enough? Recommending blowing cinnamon candy breath into the nose of a mother bleeding out?

          • Trixie
            February 2, 2014 at 5:47 pm #

            They’re pioneers in the field of hatting-induced PPH.

          • Maria
            February 2, 2014 at 4:18 pm #

            My impression is that if MANA started issuing practical, evidence based guidelines for their members to adhere to in order to improve care and outcomes, they would be chastised for medicalizing birth or for taking away women’s choices in how they “experience” birth. They probably fear losing members by being labeled as Medwives.

          • Squillo
            February 2, 2014 at 4:25 pm #

            And yet, they love to trot out places like the Netherlands as birth-Nirvana, where midwifery is “fully integrated into the system.” Which means they have not only guidelines, but mandatory regulations governing their scope of practice.

            Professionalism: it’s a bitch.

          • Maria
            February 2, 2014 at 4:39 pm #

            Well said. They compare apples to oranges and do not see the hypocrisy of it all.

          • The Bofa on the Sofa
            February 2, 2014 at 4:47 pm #

            Yep. “Studies show that with properly selected, low-risk women in the presence of extensively trained midwives with full hospital access, it can be as safe as being in the hospital.

            Thus, that justifies CPMs taking on anyone anywhere.”

          • Squillo
            February 2, 2014 at 4:58 pm #

            It helps to avoid defining “properly selected”, “low-risk”, or “extensively trained.”

          • Durango
            February 2, 2014 at 5:30 pm #

            Or even “good outcome”

          • Elaine
            February 3, 2014 at 10:34 am #

            There is a group of CPMs in my area who have been around since the 70s (not all the same people, but as of a few years ago the since-deceased founding midwife was still doing deliveries there). We interviewed with them and one thing that put me off was their insistence that they aren’t medical practitioners. They seemed to view what they do as fundamentally different. The mom still takes “responsibility” for how her birth turns out. She still has to do her “research”. I think they see themselves more as consultants or assistants to the mom. As a medical practitioner myself I’ve learned that with knowledge and licensure comes responsibility, and I can’t disclaim that by expecting my patients to know what I know. I am held to accountability by my profession, not by my patients being expected to “do their research”. This was one of several factors that made me decide not to use this group. I don’t know if other CPMs take a similar tack but I wouldn’t be surprised.

          • Comrade X
            February 3, 2014 at 11:48 am #

            Yeah, I’ve never quite understood that. If it’s still up to me to do “research” equivalent to being a sodding professional myself, and anything that goes wrong will be “my fault”, what exactly is the point of paying these people in the first place?

      • The Bofa on the Sofa
        February 2, 2014 at 4:11 pm #

        (In the “Resources” section, however, they do have a page on birth photography.

        In the words of the crane in the book “Are You My Mother?”, “SNORT!”

    • no longer drinking the koolaid
      February 2, 2014 at 5:47 pm #

      A good part of the problem with MANA is that it is a weak organization. There may be midwives within the organization that want to see things handled more professionally, but they are outnumbered by the ones who like to say they are already professional, or that such standards are unneeded.

      If they begin to talk about setting standards, they are at risk for losing many of their members and further weakening the organization. There is a group of lay midwives here in Michigan who have vowed to fight any attempt by the FOMM or Michigan Midwives Assoc. to pass licensing laws for CPMs and lay midwives. If it is happening here, then it is happening in all 50 states.
      Although MANA should have guidelines and standards, they don’t dare. And they have no way to convince their diverse membership otherwise.

      • Squillo
        February 2, 2014 at 6:04 pm #


        Professional medical societies get a little pushback every time they publish a clinical guideline because those guidelines get used by plaintiffs’ attorneys to bolster assertions that a defendant physician violated the standard of care. And yet, they continue to publish them because, presumably, the majority of members believe it’s the right thing to do.

      • KarenJJ
        February 2, 2014 at 10:51 pm #

        Like herding cats… What is the point of joining MANA?

        • no longer drinking the koolaid
          February 2, 2014 at 10:58 pm #

          So the membership can say they belong to a “professional organization”. They want to be considered professionals, but do not want the accountability that goes with the responsibility.

    • Comrade X
      February 3, 2014 at 11:44 am #

      Women DO have the right to choose unsafe birth. People DON’T have the right to get paid for being skilled safety-ensuring professionals when they’re absolutely NOT.

  10. Trixie
    February 2, 2014 at 2:14 pm #

    So with TOLAC, about 1/200 died — isn’t that almost exactly consistent with what we know about rupture risk in TOLAC? Although it doesn’t look like we can see how many TOLACs experienced uterine rupture.

  11. Captain Obvious
    February 2, 2014 at 1:54 pm #

    Melissa Gibbons responds that MANA’s “professional” guidelines recommends transferring care in the case of known multiples or breech. Then Ashley comes in and really states how MANA’s guidelines are being followed in that midwives respect their client’s ability to research the risks and make their own decision based on that. So which is it? And if MANA’s midwives are not following their guidelines, what accountibility and sanctions do they risk?
    There are so many anecdotal stories of women preaching women are aware of the risks before they choose Homebirth. That may very well be for that particular woman, but I believe many out there are “researching” blogs the echo their desires, like the now MANA press release, only to be shocked when something bad happens.

    • Squillo
      February 2, 2014 at 2:24 pm #

      What professional guidelines is she referring to? The only guidelines I can find on the website are these: http://www.mana.org/pdfs/MANAStandardsQualificationsColor.pdf

      The words “breech” and “multiple” don’t appear anywhere in them; in fact, there are no specific risk factors mentioned at all.

    • The Bofa on the Sofa
      February 2, 2014 at 4:09 pm #

      hen Ashley comes in and really states how MANA’s guidelines are being
      followed in that midwives respect their client’s ability to research the
      risks and make their own decision based on that.

      What risks? I though there were no increase in adverse events in HB with a CPM?

      But Ashley seems to suggests there are risks involved but that people accept them? Does that mean she doesn’t agree with the conclusions?

  12. Anj Fabian
    February 2, 2014 at 1:50 pm #

    Was this tracked?
    “The authors allude to insufficient collaboration between midwives and
    medical providers – is there any evidence in this sample to support this

    Did CPMs list who was their back up OB? Who provided the prenatal care? If any?

    • LynnetteHafkenIBCLC
      February 2, 2014 at 2:03 pm #

      If this was anything more than an attempt to blame others for the deaths, I will personally eat a placenta.

      • Anj Fabian
        February 2, 2014 at 5:33 pm #

        I will join you in that meal.

    • The Computer Ate My Nym
      February 2, 2014 at 2:21 pm #

      It should have been. If it wasn’t, it should be from now on. Given that their current hypothesis is that insufficient collaboration was a major risk factor, they’re obliged to track collaboration from now on.

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