The white woman’s burden is never ending. Now, apparently, it is the white woman’s task to teach her unfortunate sisters of color how they ought to give birth.

Let’s presume for a moment that the self-proclaimed “midwives” (CPMs) of the Big Push for Midwives aren’t simply interested in cynically plundering the Medicaid coffers and take them at their word:

A report released by the CDC today found a 29 percent increase in home births from 2004 to 2009. The rate of home births among non-Hispanic white women underwent a dramatic increase, while the rate for women of color decreased or remained stagnant, a trend that reflects racial and ethnic disparities in other areas of maternity care throughout the U.S…

Barriers to out-of-hospital maternity care include … laws or policies in all but 11 … states that deny Medicaid coverage for home births managed by Certified Professional Midwives.

The fact that women of color don’t choose homebirth is portrayed as an “ethnic disparity” in need of remedy. Never mind that women of color might actually be pleased with their own choices for childbirth. Or perhaps — here’s a mind-blowingly outrageous idea — women of color ought to be the ones whose views are respected and emulated. No, it’s far more satisfying to pretend that women of color don’t know what they really want until they are “educated” by their white sisters.

The blogger at Balancing Jane is typical:

… [T]he women who are likely to choose home birth are more likely to be highly educated, married, and white. In other words, the women who choose home birth are the ones who benefit the most from privilege in our society. To me, this means that these are the women who have the greatest access to information and the greatest ability to go against societal standards for birth through informed self-advocacy. …

Of course, that presumes that the women who choose homebirth are actually educated and they’re not. They are distinguished primarily by their gullibility. Most of what they think they “know” is factually false and their personal experience is so limited that they have no idea what childbirth is like when you don’t have immediate access to high quality medical care.

Therefore, Jane fails to consider an equally plausible alternative explanation:

Women of color might have no interest in the fads that preoccupy privileged white women. Possibly they have more important things to worry about. For example, they may have medical problems and risk factors that privileged white women do not have to contend with.

As Janelle Harris writes on The Stir:

… I can’t hop on this bandwagon that homebirth brings black women closer to our African heritage. I’ll immerse myself in a native language, I’ll shell out a few grand to fly to the mother continent and trace my Guinean roots. Heck, I’ve already dedicated thousands of dollars and thousands more hours studying our history for a master’s degree in African-American studies.

But if and when I ever find myself pregnant again, I’ll have my baby in a hospital, thank you very much. If something goes haywire — Lord forbid — I want all the bells and whistles of modern science by my side to save me or my child.

Harris points out:

I agree that we come from a society that likes to overtreat and overmedicate us for every bitty thing. But most of Black women’s issues lie not in the hospitalization during labor, but the health risks we suffer leading up to childbirth…

The Amnesty International report on maternal mortality emphasizes this point:

The US government’s failure to ensure that women have guaranteed lifelong access to quality health care, including reproductive health services, has a significant impact on the likelihood of having a healthy pregnancy and delivery…

Insufficient access to quality health care services over a woman’s lifetime means that women are entering into pregnancy with health conditions that are untreated or unmanaged. This poses added risks for both the woman and her child. For example, women who become pregnant with uncontrolled diabetes are more likely to have a miscarriage or develop pre-eclampsia.

But it is not simply that women of color suffer from lack of access to the technology employed to treat women with pre-existing medical problems and complications of pregnancy, the factors most associated with high rates of maternal death. Many women of color don’t have the same interests or priorities of white women who choose homebirth. Indeed, lower income women of all ethnicity don’t have the same interests and priorities of the relatively well-off women who choose homebirth.

That’s not surprising. Homebirth is like following Martha Stewart. It’s delightful to bake your own bread when you know that you don’t HAVE to bake your own bread if you don’t feel like it. Similarly, it seems delightful to privileged white women to avoid the hospital when they know that they don’t HAVE to avoid the hospital if they change their mind. For other women, who don’t have routine access to high quality medical care, who have medical risk factors, whose home is not a domestic paradise, who have enough unmedicated pain in their own lives that setting themselves the “goal” of enduring more pain without medication is unfathomable, homebirth is an affectation they have no interest in emulating.

I don’t presume to speak for women of color. They can speak for themselves without my help. And frankly, I don’t think the white women of The Big Push for Midwives actually care about women of color beyond seeing them as the way to secure access to Medicaid reimbursements. Nonetheless, I think the assumptions behind their publicity campaign are demeaning and wrong. It seems impossible for them to imagine that women of color are the ones who are truly “educated” about the reality of childbirth, and that privileged white women ought to be emulating them.

In the wake of the tragic death of homebirth advocate Caroline Lovell, there have been several nonsensical claims put forth by homebirth advocates battling to avoid cognitive dissonance. Analysis of these nonsensical claims reveals the same error at the heart of each: an inability to do 4th grade math.

Here’s Illithyia Inspired Birth Servant (don’t miss the picture of mom holding her blue, limp baby in water in the wake of her own homebirth):

I hold a sliver of hope that perhaps people might take from this weeks media that twenty mothers died after birthing in hospital last year and that something might be done about this. Wouldn’t it be wonderful if some attention were given to this pressing matter, hospitals forced to practice evidence based midwifery and medicine in every maternity ward so that hospital birth might one day be as safe as homebirth.

In her defense, she copied this inane “argument” direct from Homebirth Australia:

… Sadly many women died in Australian hospitals in childbirth last year – should we ban hospital births, too?” Michelle Meares, Homebirth Australia spokesperson said.

So let’s see if I get this straight: 20 is a bigger number than one so hospital birth leads to more deaths than homebirth? Do these women have any idea how foolish they look? Apparently not.

Therefore, in the interests of basic numeracy, I offer the following simple arithmetic lesson.

Let’s start with an example.

Approximately 12 people die from poisonous snake bite in the US each year. Approximately 520 women die from pregnancy and childbirth related causes each year. By the “reasoning” of homebirth advocates, pregnancy is more than 40 TIMES more dangerous than poisonous snake bites. Wow, who knew that pregnancy was so dangerous?

What’s wrong with this “reasoning”?

Comparing absolute numbers is inappropriate. The only valid comparison is that of rates. Rate, in this case, is the absolute number of people who died from the cause divided by the number of people who could have been exposed to the cause. Approximately 8,000 people are bitten by venomous snakes each year for a death rate of 1.5/1000. Approximately 4 million women are pregnant each year, for a death rate of 0.13/1000 (equivalent to 13/100,000). In other words, snake bite is 12 times more dangerous than pregnancy.

So let’s get back to maternal death rates in Australia. Yes, there were 20 maternal deaths in the hospital last year. Since nearly 300,000 women gave birth in the hospital, that’s a death rate of 6.6/100,000. There was only 1 maternal death at homebirth, but there were only 750 homebirths. That’s a death rate of 133.3/100,000. That’s a maternal death rate at home birth more than 20 TIMES HIGHER than the maternal death rate in the hospital.

We can refine our calculations further. Most maternal deaths in the hospital are due to pre-existing medical conditions or serious complications of pregnancy. The maternal death rate for low risk women is probably in the range of 1/100,000 or lower. According to homebirth midwives, this is the first maternal death in 15 years for a homebirth death rate of 9/100,000. Obviously, that is 9 times higher than the hospital death rate for low risk women. Any way you look at it, homebirth is more dangerous for mothers than hospital birth.

The “argument” advanced by Homebirth Australia doesn’t show that hospital birth is more dangerous than homebirth, but it does make the case that people who can’t even do grade school arithmetic should not be entrusted with the lives of pregnant women and their babies.

I’ve written extensively about the ignorance of American homebirth midwives (certified professional midwives or CPMs). It’s not surprising when you consider the pathetic nature of CPM training. Most CPMs have NO midwifery education of any kind. You can receive a “certification” after a program of unmonitored self-study.

It’s hardly surprising therefore that death rates at the hands of homebirth midwives are appalling. The latest data from the CDC (available on the CDC) Wonder website shows that homebirth with a non-nurse midwife has a neonatal mortality rate more than 7 times HIGHER than low risk hospital birth.

Licensed homebirth midwives in Colorado have a perinatal mortality rate that is appallingly high and has risen in every year since 2006 when licensing was enacted. The midwives have actually refused to release their death rate for 2010.

In Oregon, there have been at least 19 newborn deaths reported to the state over the past decade for a death rate more than 4 times higher than low risk hospital birth.

The Midwives Alliance of North America (MANA), the organization that represents homebirth midwives, has a database of 24,000 planned homebirths. They refuse to release the death rate. Even MANA knows that homebirth kills babies. They just don’t want American women to find out.

But evidently that’s not enough. In addition to presiding over the preventable deaths of low risk mothers, they’d like to try their hands at increasing the rate of preventable deaths of high risk mothers.

Consider this idiotic press release published by the Big Push for Midwives, the professional lobbying group trying to obtain state recognition (and therefore insurance reimbursement) for CPMs:

A report released by the CDC today found a 29 percent increase in home births from 2004 to 2009. The rate of home births among non-Hispanic white women underwent a dramatic increase, while the rate for women of color decreased or remained stagnant, a trend that reflects racial and ethnic disparities in other areas of maternity care throughout the U.S.

“Unfortunately, the women who could most benefit from out-of-hospital midwifery care are those who are least likely to have access to Certified Professional Midwives with the specialized training needed to provide it,” said Susan Jenkins, Legal Counsel for The Big Push for Midwives Campaign. “The CDC report and other research shows that babies born to women cared for by Certified Professional Midwives are far less likely to be preterm or low birth weight, two of the primary contributing factors not only to infant mortality, but to racial and ethnic disparities in birth outcomes.”

Just two short paragraphs, but a mountain of ignorance and illogic.

Jenkins boasts that babies born to women cared for by CPMs “are far less likely” to be premature or growth retarded. As my children would say: “Duh!”

CPMs, the so called “experts in normal birth” don’t take care of high risk women and both prematurity and growth retardation are high risk. No doubt the women cared for by CPMs are “far less likely” to have congenital heart disease, kidney failure or cancer, so perhaps CPMs would like to take credit for preventing those conditions, too. After all, if you are not constrained by logic or common sense, the sky’s the limit.

The concept that high risk women are “most likely to benefit” from CPM care is really breathtaking in its stupidity. Even the most cursory examination of neonatal and maternal death rates shows that these deaths are due to a LACK of technological interventions, nor a surfeit.

Let’s take a look at the leading causes of neonatal death. The following chart is adapted from Infant, neonatal, and postneonatal deaths, percent of total deaths, and mortality rates for the 15 leading causes of infant death by race and sex: United States, 2007:

Do CPMs know how to lower the incidence of congenital anomalies? No. Perhaps they know how to prevent pre-eclampsia, gestational diabetes or HELLP syndrome. No, they have no specialized knowledge in that area. Can they prevent abruption, vasa previa, or true knots in the umbilical cord? No, no and no. How about bacterial sepsis of the newborn? Hardly. The leading cause of infectious neonatal death is group B strep and many CPMs don’t treat it or employ bizarre “remedies” like garlic cloves in the vagina.

I can’t find a single thing on this list that CPMs, those self-proclaimed “experts in normal birth,” are educated or trained to prevent, manage or cure.

What about maternal mortality? Last week we looked at the leading causes of maternal ICU admissions.:

… The leading admission diagnosis for pregnant and postpartum women was maternal cardiac disease (36%). Maternal hemorrhage (both obstetric and nonobstetric) was the second leading reason for admission (29%). Hypertensive disease accounted for 9% of ICU admissions…

The majority of cardiac conditions prompting ICU admission resulted from cardiomyopathy. Acute complications associated with peripartum cardiomyopathy
comprised the majority of this group. Congenital heart disease is the underlying etiology for many of these valvular lesions and cardiomyopathies. Congenitally
acquired conditions were the second leading cause of maternal cardiac ICU admissions…

CPMs can’t prevent or treat peripartum cardiomyopathy, massive maternal hemorrhage or hypertensive disease. In fact, care by a CPM at home is more likely to increase death from these causes, not decrease it.

I can’t decide whether Jenkin’s inane boast is the result of ignorance or mendacity. Can she and the homebirth advocates of the Big Push for Midwives truly be so ignorant as to think they can take credit for preventing complications simply by caring for only uncomplicated patients? Or is this yet another bold faced lie told in attempt to increase CPM reimbursement, neonatal and maternal well-being be damned?

I guess the real reason doesn’t matter. In either case, CPMs have demonstrated once again that they lack the basic education (and reasoning ability) to be entrusted with the lives of pregnant women and their babies.

Blogger now redirects everyone to an in country website that, for some reason, doesn’t include the comments. I learned last night that it won’t happen if you add /ncr to the url, so it would be www.skepticalob.blogspot.com/ncr

ncr stands for “no country re-direct”

Everyone knows that evolution is based on the principle of “survival of the fittest.” What does that mean for childbirth?

It means that by definition not everyone survives. Lots of people die. In the case of childbirth it means high levels of neonatal and maternal mortality.

So contrary to the inane babbling of NCB and homebirth advocates that women’s bodies are perfectly designed to give birth, no one’s body is perfectly designed for anything. There is a tremendous amount of genetic variation, there are many competing environmental pressures and the environment can change over time. Simply put, human existence is a competition and many drop out and die along the way. That applies to childbirth just as to any other aspect of human existence.

For example, there is tremendous genetic variation to the onset of labor and there are risks and benefits to each variation. Consider the onset of labor. The range of normal is extremely wide. In human pregnancy (average length 40 weeks) labor can start normally anywhere from 38-42 weeks, and onset is not restricted to the normal range. Premature birth is quite common and post mature birth is hardly rare.

Contrary to the nonsense spouted by NCB and homebirth advocates that babies “know” when to be born, there are advantages and disadvantages to birth at any possible gestational age. Babies born at earlier gestational ages are smaller and therefore more likely to fit through the mother’s pelvis. Yet babies born at earlier gestational ages will be less likely to have mature organ systems, and therefore more vulnerable to illness and death. On the other hand, babies born at later gestational ages are more robust, but they are also larger and might not fit through the mother’s pelvis or might outgrow the ability of the placenta to supply them with oxygen, and die before labor even begins.

And birth doesn’t depend only on the baby. It also depends on the mother. The maternal pelvic dimensions are determine by a wide array of genetic factors, each independent of the others. Moreover, a pelvic structure that is beneficial for birth may be suboptimal for maternal survival in the non-pregnant state. A wide maternal pelvis is ideal for childbirth, but limits maternal mobility and therefore the ability of the mother to outrun predators and to keep up with her tribe.

It isn’t simply the expulsion of the baby at birth that is affected by maternal genetic variation. If the mother’s blood type and the babies blood type differ (and both are determined independently), the mother’s immune system can attack the baby’s blood cells and kill the baby.

Pregnancy produces a variety of metabolic changes in the mother, some of which may be deleterious to the baby, the mother, or both. Gestational diabetes increases the risk of neonatal complications and the risk that the baby will be too big to fit through the maternal pelvis. Pre-eclampsia and eclampsia can kill the baby, the mother or both through a series of complex metabolic changes that affect everything from blood pressure, to blood clotting, to maternal seizure threshold. Just as subclinical sickle cell trait confers an evolutionary advantage in surviving malaria, but clinical sickle cell disease is a killer, subclinical variations of pregnancy complications probably also confer an evolutionary advantage, but clinical manifestations can and do kill.

Consider something as common as postpartum hemorrhage. The most common cause of postpartum hemorrhage is uterine atony, failure of the uterus to contract strongly after the placenta has been expelled. Prolonged labor is a risk factor atony, and the length of labor is determined not merely by maternal factors like the strength of contractions and the size of the maternal pelvis, but by fetal factors like the size of the baby and its position as it enters the pelvis. It is the interplay between these maternal and fetal factors that determine whether a fatal hemorrhage will occur after birth, not some mystical “perfection” of the process that can be relied upon to provide the desired outcome.

Survival of the fittest means exactly what it sounds like: only the fittest will survive and the rest will die. Being the “fittest” in a given environment depends on a complex interplay of multiple genetic factors, each of which is independent of the others. Just like a human being isn’t “perfectly designed” to outrun every predator, every human being (mother or baby) is not perfectly designed to survive pregnancy and childbirth.

Human beings have survived and thrived thus far because of technological interventions. We can’t outrun every predator, but we can create spears to kills predators from a distance and we can make fire to ward off predators that we cannot see in the dark. I haven’t noticed anyone claiming that authentic human existence requires returning to the savannah, giving up fire, and putting aside our spears.

We cannot control climate, or our vulnerability to severe climatic conditions, but we can create clothes to hold body heat, houses to shelter us, and central heating to warm us. I haven’t noticed anyone claiming that authentic human existence requires shedding our clothes, leaving our houses and huddling in caves.

We cannot depend on every baby to fit through a maternal pelvis, every pregnancy to last for the optimal length of time, and every mother to withstand the metabolic extremes that may be caused by pregnancy. Yet I have heard NCB and homebirth advocates prate that authentic childbirth requires vaginal delivery, “unhindered” labor regardless of timing, and an acceptance of every maternal metabolic change no matter how deranged.

The hallmark of human evolutionary success is the development and deployment of technology. In this environment, that’s what makes people fit. Rejecting that technology, and demonizing it as unnecessary and inauthentic is the ultimate in foolishness.

The fittest mother is not the one who rejects technological interventions; the fittest mother is the one who employs any and every technological intervention that can potentially enhance her child’s survival. Anything less is the intellectual equivalent of prancing around naked in a snowstorm while rejecting houses, central heating and even fire as unnecessary technological “interventions.” It’s extremely painful and a quick way to an unnecessary death.

Re: Inquiry into Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 and two related Bills

I write to express my concern about the above bills. I understand that these bills will enable Medicare funding, access to the Pharmaceutical Benefits Scheme and professional indemnity premium support for midwives providing care for women to give birth in hospital. Medicare funding for midwifery care is long overdue. It is not acceptable however to exclude homebirth from this funding and indemnity arrangement…

On a personal note, I am quite shocked and ashamed that homebirth will no longer be a woman’s free choice in low-risk pregnancies… I feel the decision to outlaw homebirth’s is contrary to women’s rights … Please find a solution for women and babies who homebirth after this date as their lives will be in threat without proper midwifery assisstance. And as a homebirthing mother I will have no choice but to have an unassisted birth at home as this is the place I want to birth my children.

Yours sincerely,
Caroline Flammea, Nick Lovell and daughter Lulu Lovell.

*****
Caroline Emily (Flammea) Lovell

LOVELL (nee Flammea). – Caroline Emily 15.07.1975 – 24.01.2012 Passed away suddenly after giving birth to a beautiful baby girl. Beloved daughter of Jadzia (Jade), loving wife of Nick and exceptional mother of Lulu and Zahra. You taught us how to love Always in our hearts

*****

Does anyone know any new Mums in the Melbourne area?? Please share this post:

“Are there any mothers in the Melbourne area, who could be part of a milk tree? A woman named Caroline died this week while giving birth to her second daughter, Zahra, at home. And the family is seeking donated milk to help bubba along.

If you can help or know someone who can, please contact Eve …
.
And please send your love & thoughts to Carolines family 3yr old Lulu, 5day old Zahra & husband Nick.”

The CDC published an update on homebirth today. Entitled Home Births in the United States, 1990–2009 and written by MacDorman, Mathews, and Declercq, the data brief noted:

• After a decline from 1990 to 2004, the percentage of U.S. births that occurred at home increased by 29%, from 0.56% of births in 2004 to 0.72% in 2009.

• For non-Hispanic white women, home births increased by 36%, from 0.80% in 2004
to 1.09% in 2009. About 1 in every 90 births for non- Hispanic white women is now a home birth. Home births are less common among women of other racial or ethnic groups.

• Home births are more common among women aged 35 and over, and among women
with several previous children.

• Home births have a lower risk profile than hospital births, with fewer births to teenagers or unmarried women, and with fewer preterm, low birthweight, and multiple births.

• The percentage of home births in 2009 varied from a low of 0.2% of births in
Louisiana and the District of Columbia, to a high of 2.0% in Oregon and 2.6% in Montana.

But there’s one thing that the data brief didn’t mention at all: exactly how many of those babies died?

The authors managed to analyze homebirths by race. They managed to analyze homebirth in each and every state. They managed to analyzed the risk profile of homebirths. But somehow they couldn’t manage to check the neonatal death rate for homebirth located on one of the CDC’s own websites. They are curiously silent on the most important thing we need to know about homebirth: is it safe?

Had MacDorman et al. bothered to look, they would have seen that the most recent CDC data shows that homebirth with a non-nurse midwife has a neonatal mortality rate 7.7 times higher than comparable risk hospital birth!

This extraordinarily high death rate is all the more remarkable because it actually under-counts the homebirth death rate. That’s because homebirth transfers ended up in the hospital MD group and were not counted in the homebirth group. The real number of homebirth deaths is almost certainly significantly higher.

While MacDorman et al. were busily analyzing the state level data, they could have learned that in the state of Colorado, which has licensed homebirth midwives since 2006, the homebirth death rate has exceeded the death rate for the state as a whole (including premature babies and pregnancy complicati­ons) in every single year since and has risen in every single year since 2006, The death rates are so appalling that the homebirth midwives of Colorado refused to release the death rates for 2010. Or they could have learned that the state of Oregon has had at least 19 reported neonatal deaths in the past 10 years for a rate that is more than 4 times higher than the death rate for comparable risk hospital birth.

Every major news outlet has reported on this CDC data brief, and curiously, not one bothered to ask how many of the homebirth babies died. A few news outlets made vague pronouncements that homebirth might double or triple the neonatal death rate, but not a single one bothered to find out what actually happened in the group that MacDorman and colleagues studied.

I’ll admit that I’m pretty frustrated by the fact that MacDorman et al never bothered to look at the neonatal death rate, or looked at it and didn’t bother to report it. Who really cares that the homebirth rate rose an additional 9% since 2008? Yet somehow MacDorman thought it was critical to report on that. Everyone needs to know how many of those babies died, yet MacDorman couldn’t be bothered to report on that.

And I’m also pretty frustrated by the mainstream media. There are no questions, no probing, and no investigation into the number of babies who died. It’s as if they don’t exist. Journalists just collected opposing viewpoints and wrote “balanced” articles that inexplicably left out the most important issue. And while journalists interviewed midwives and obstetricians, not a single one thought to interview a pediatrician or a neonatologist to determine whether the people who actually care for babies think about the dangers of homebirth to babies.

I’m afraid that the only thing that will shake journalists out of their complacency is the death of a celebrity’s baby at homebirth. Sooner or later that is going to happen, and journalists will “discover” that babies have been dying preventable deaths at homebirth all along. Until then, they won’t ask the difficult questions; they’ll simply accept what they read in press releases and reprint them wholesale.

As I’ve written about repeatedly, natural childbirth and homebirth advocates have made a fetish of maternal mortality. They’re not actually DOING anything about maternal mortality, but they are complaining about it and insinuating (or even claiming) that modern obstetrics is responsible for maternal deaths and that midwifery care would lower maternal mortality. But as a paper in the forthcoming issue of Obstetrics and Gynecology reveals, the keys to lowering maternal mortality involve MORE interventions, not fewer.

The paper is Preventing Maternal Death: 10 Clinical Diamonds by Clark and Hankins. The authors write:

The death of a mother during or after childbirth is one of the most tragic events in medicine. We have identified 10 specific recurrent errors that account for a disproportionate share of maternal deaths, primarily related to pulmonary embolism, severe preeclampsia, cardiac disease, and postpartum hemorrhage. Attention to these principles and the development and adoption of local or regional clinical protocols that address these issues will help reduce the likelihood and effect of error and of maternal mortality.

What is a clinical “diamond”?

In medicine, a clinical pearl is a short aphorism meant to assist the clinician faced with a complex clinical situation in cutting to the essence of the matter and making a correct decision… Such “pearls” are intended to be default approaches of high value and low risk that the wise clinician will automatically incorporate into practice as a matter of course, barring some exceptional clinical circumstance.

… We present here 10 such aphorisms, elevated to diamond status by virtue of their ability to prevent what is perhaps the most tragic event in all of medicine and by their universal applicability to nearly every patient, every time.

They are:

1. A pregnant woman with acute chest pain should have an immediate CT angiogram
2. A patient with preeclampsia and shortness of breath should have a chest X-ray immediately
3. A hospitalized patient with preeclampsia and a systolic blood pressure of 160 or a diastolic pressure of 110 should receive an IV antihypertensive within 15 minutes
4. Angiographic embolization should not be used for acute, massive postpartum hemorrhage
5. Any woman with cardiac disease gets a maternal–fetal medicine consult
6. If more than one dose of medication is needed to treat uterine atony, go to the patient’s bedside until the atony has resolved
7. Never treat “postpartum hemorrhage” without simultaneously pursuing an actual clinical diagnosis
8. A postpartum patient who is bleeding or who recently has stopped bleeding and is oliguric, should not receive diuretics
9. Any woman With placenta previa and even one previous Cesarean should be delivered in a tertiary care hospital
10. Every labor and delivery unit should have a recently updated massive transfusion protocol

In other words, to prevent maternal death from pulmonary embolism, severe preeclampsia, cardiac disease, and postpartum hemorrhage, we need increased use of technology, more treatment with medication, more direct physician supervision and access not only to blood banking but to massive transfusion protocols.

In contrast to the insinuations (or claims) of NCB and homebirth advocates, the solution is NOT “trusting birth,” unhindered birth, birth affirmations, nutrition, supplements, chiropractic or indeed ANY care that is exclusive to midwifery.

Maternal mortality is a serious problem that requires serious solutions. NCB and homebirth advocates (like Ina May Gaskin) who exploit this issue for personal gain (and who simultaneously make no concrete efforts to treat it) are worthy of nothing but contempt.

Maternal mortality has dropped 99% in the past 100 years. A maternal death is now, fortunately, a rare event. Attention, therefore, is shifting to maternal morbidity, in particular, life-threatening morbidity. The results of a new study are instructive.

Near-Miss Maternal Mortality: Cardiac Dysfunction as the Principal Cause of Obstetric Intensive Care Unit Admissions by Small et al. will be published in the February 2012 issue of Obstetrics and Gynecology. The title gives away the principle finding; heart disease is the most common cause of maternal ICU admission.

The study took place at Duke University from January 2005 to April 2011. There were 19,575 births and 5 maternal deaths for a maternal mortality rate of 25/100,000. That is approximately double the US maternal mortality rate, but that is only to be expected in a tertiary center that receives the most complicated cases from the surrounding area. There causes of the five maternal deaths were: two from metastatic cancer, two secondary to cystic fibrosis, and one the result of sepsis.

The authors then looked at maternal admissions to the intensive care unit:

Ninety-four obstetric patients—five per 1,000 deliveries—were admitted to ICUs. Eight declined participation in the study. Eighty-six patients were included in this analysis.

… African American women comprised the largest population admitted to the ICU (45%). Significant differences were found by race and ethnicity in the following variables: parity, BMI, and marital and insurance status. African American (mean 35) and Hispanic women (mean 36) had significantly higher BMIs than white women (mean 28). African American and Hispanic women were also more likely to have Medicaid or no insurance and were more likely to be unmarried and multiparous.

The following table shows the reasons for ICU admission.

The authors write:

… The leading admission diagnosis for pregnant and postpartum women was maternal cardiac disease (36%). Maternal hemorrhage (both obstetric and nonobstetric) was the second leading reason for admission (29%). Hypertensive disease accounted for 9% of ICU admissions…

The majority of cardiac conditions prompting ICU admission resulted from cardiomyopathy. Acute complications associated with peripartum cardiomyopathy
comprised the majority of this group. Congenital heart disease is the underlying etiology for many of these valvular lesions and cardiomyopathies. Congenitally
acquired conditions were the second leading cause of maternal cardiac ICU admissions…

The findings of this study are notable for the following:

1. Race is a major risk factor for near-miss maternal mortality.
2. Obesity (BMI greater than 30) is a major risk factor for near-miss mortality.
3. The leading cause of near-miss mortality is cardiac disease.
4. Infection and bleeding account for only one third of the near-miss events.

This paper demonstrates that near miss-maternal mortality, like maternal mortality, is the result of complex medical and non-medical factors. Both race and maternal BMI appear to play important roles. Pre-existing medical conditions account for a substantial proportion of near-miss maternal mortality. The traditional causes of maternal mortality and near-miss mortality have been eclipsed by cardiac complications of pregnancy.

In other words, contrary to the claims of natural childbirth and homebirth advocates, maternal mortality and near-miss maternal mortality are not related to obstetric interventions. The most common risk factor is pre-existing maternal health issues. Women with serious medical problems (including obesity) prior to pregnancy are the ones most likely to develop life threatening medical problems during pregnancy and childbirth.

Today’s post is brought to you by the student midwives writing on the website sponsored by the Royal College of Midwives. It is an object lesson in what happens when student midwives (and many graduate midwives) are confronted with scientific evidence that does not support their pre-existing beliefs. It’s not a pretty sight.

Here’s the question posed by the OP (original poster):

article stating 2 in 3 babies stillborn at home could have been saved in hospital

Just wondering what your views are on this article. http://skepticalob.blogspot.com/2011/12/2-out-of-3-babies-who-die-at-homebirth.html

Now let’s look at the reasoned discussion that follows, the careful reading of my post, the examination of the underlying scientific literature (the Birthplace Study), and the mathematical analysis of the data.

P:

Dr Amy talking about things she doesn’t understand again

V:

This woman does my nut in

Li:

I really don’t understand the idea “0 out of babies Bjorne in hospital could of been saved at home’ she seems be choosing to ignor all the evidence re hospital birth being more likely to led to intervention and then all the associated risks off that…

Does rub me up the wrong way when people who should know better choose to take one small piece of evidence and ignore the rest

Lo:

Only read a tiny bit so far but I’m puzzled by “3 times (200%)”. Can someone explain this to me? 1 times 1 is 1, which is 100% of 1. So presumably 200% of 1 is 2, and therefore three times 1 is 300%? If that makes any sense.

R:

I agree.

S:

Dr. Amy’s blog is a waste of time, she likes to skew numbers and reports, while ignoring any evidence that what she is saying isnt true. Homebirth in the USA is not as safe as other countries, however painting homebirth in general with the same brush is irresponsible. Esp considering the USA’s high mortality rates.

B:

Was going to read this then saw who wrote it and changed my mind.

M:

Agreed, I don’t need the anger in my life from reading posts by this woman. Gets me worked up just thinking about it!

Original poster:

yeah it is an absolute load of rubbish but i thought it would bring an interesting discussion/debate which hasn’t happened… as everyone thinks exactly the same lol x

And that’s how student midwives handle information that challenges pre-existing beliefs. Very instructive!