The Delivery Debate

I made the decision to have homebirths with both of my children with a Certified Professional Midwife because of the large amount of studies I easily found on reliable web sites and in unbiased books. There is also an overwhelming amount of information from European countries that support homebirth with a midwife whose training is equivalent to CPMs. My first birth would have definitely been an unnecessary C-section if I had been in a hopsital and my second baby would have spent weeks in the NICU if I had chosen hospital birth.

"The 2000 BMJ data was collected by the authors of the study, Ken Johnson and Betty Anne Daviss. After collection, it took an expected five years for the data to be analyzed and published in a reputable journal."

You don't seem to understand. The data is ALREADY available. It is just not available to the public. It is only available to midwifery organizations who can prove they will use it for "the advancement" of midwifery. Even then, the people who will see the data must sign a legal non-disclosure agreement preventing them from revealing the data to anyone else.

Moreover, it did not take 5 years to analyze the data. According to the NARM (North American Registry of Midwives) Bulletin in January 2001, Johnson and Daviss were publicly presenting the data to other homebirth advocates and using it to lobby members of the American Public Health Association to pass a resolution supporting homebirth. That's LESS THAN A MONTH after full data collection was complete.

Johnson and Daviss are not independent researchers, either. Johnson is the former Director of Research for the Midwives Alliance of North America (MANA), and Daviss, his wife, is a homebirth midwife. NARM was intimately involved in the creation of the study and enforced the participation of the midwives. The project was funded with money from a homebirth advocacy foundation.

The same data has been collected in the same way every year since 2000. Not only has none of it been published, none of it is available to the public. It will only be released to persons who promise to use it for "the benefit of midwifery" and who sign a legal confidentiality requirement that prohibits them from sharing the data with anyone else. This strongly suggests that the existing data shows that homebirth is not as safe as hospital birth and that's why it must be suppressed.

from Amy Tudor: <<MANA is already collecting statistics on all CPMs and has been since 2000. The 2000 MANA data was the basis for the BMJ study. The data from 2001-2007, which is probably the largest existing database on homebirth, is being withheld from the public. >>

The 2000 BMJ data was collected by the authors of the study, Ken Johnson and Betty Anne Daviss. After collection, it took an expected five years for the data to be analyzed and published in a reputable journal. The new MANA web-based data collection system began in 2004 collecting raw data from participating midwives (CPMs, CNMs, and non-credentialed midwives). To publish research using that data, professional researchers must submit proposals to the Institutional Review Board. Raw data is released to the participating midwives and to participating state groups (which is why some states may publish their results). Otherwise, raw data for analysis and publication is only released to qualified researchers who have applied through proper channels.
Certified Professional Midwives have done an excellent job, evidenced both by the research cited in the British Medical Journal and also by the 22 state agencies that license CPMs in the US. Each year, more state legislatures recognize the benefits to their citizens of licensing Certified Professional Midwives to attend home births. Not only are outcomes equally as good for low-risk mothers whether birthing at home or in a hospital, but the lower rate of intervention in home births is safer for the mother and baby, and much more economical for those paying the tab. It is difficult to understand why any state legislature would continue to impose the higher risks of mandatory hospital birth on citizens who would prefer a natural, safer, home birth with a trained midwife.

<<Maybe it's not so ironic that here we are, 35 years later, fighting for the right to give birth in our own homes with the provider of our choice, in spite of the fact that this is the option that has kept humanity going and growing for all but the last 80 years of its existence.>>

S'Yeah.right. It kept us going...at a fraction of the planet's current population, because so many women and kids died. It kept us going... when, like my granma, women had over a dozen kids a piece so humans kept going even though we lost several of them. It kept us going....even though a lot of women didn't. Childbirth was to women what war was to men. Something that claimed a lot of young lives. And you didn't need abortion. Infanticide was quietly acceptable for any babies less than perfect. Simply unwanted ones could be abandoned at will.

Doncha miss the Good Ol Days.

Funny how a procedure with a 100% mortality rate got legalized in 1973. It was argued that abortions were happening illegally, and legalizing them would make them "safer." Maybe it's not so ironic that here we are, 35 years later, fighting for the right to give birth in our own homes with the provider of our choice, in spite of the fact that this is the option that has kept humanity going and growing for all but the last 80 years of its existence.

Russ is correct. The BMJ study published in 2000 includes only deliveries by CPMs, who had to participate as a condition of recertification under the North American Registry of Midwives. The MANA statistical project, which is ongoing, includes CNMs, CPMs and non-CPM midwives who deliver babies at home.

katie prown:

"168 babies were delivered by CPMs, while 29 were delivered at home by CNMs, with zero deaths in either group."

You need to provide a reference for that data. As far as I know, there is no published reference.

Is this part of the dataset that MANA is offering to midwives, but refuses to release to the public? Where else could you possibly be getting unpublished CPM statistics? If so, we can presume that you are quoting the unpublished data for 2000 because the years 2001-2007 show unacceptably high levels of neonatal mortality. That's precisely why MANA is refusing to release their data. They are sitting on what is probably the largest database of homebirth with a CPM (approximately 30,000 births) and almost certainly shows definitively that homebirth with a CPM has an excess risk of neonatal death.

Why aren't homebirth midwives and homebirth advocates honest with women about the risks?

I am so pleased to see an article about CPMs. It is a great idea to use the CPM as the national credentialing standard to provide women who are choosing homebirth with safe, qualified care providers. It's amazing as advanced as the US is that we are so far behind on safe, relevant and benevolent maternity care...

In the year 2000 in Wisconsin???again, the only year for which we have data to distinguish among CPMs, ???Other Midwives??? and ???Other??????168 babies were delivered by CPMs, while 29 were delivered at home by CNMs, with zero deaths in either group.

373 babies were delivered at home by ???Other Midwives,??? a category that includes planned unassisted births as well as births managed by non-CPM midwives. There were 2 deaths in that group.

264 babies were delivered at home by ???Other,??? a category that also includes planned and unplanned births with no attendant present, as well as births managed by non-CPM midwives. There were 3 deaths in that group.

Yes, the numbers are small, small enough that we could reasonably expect to see no neonatal deaths in any of the categories. Nevertheless, of the 637 babies delivered at home by non-CPM midwives and lay people in the year 2000 in Wisconsin, there were 5 deaths.

It???s precisely because I care about the safety of mothers and babies that I???ve been working to promote CPM licensure???as a volunteer, I might add. And for the record, I???m not a midwife myself.

Regardless of what the medical lobby has to say about it, families in every state will continue to choose home birth, very often for religious, cultural or financial reasons (the majority of CPM patients in the year 2000 were on Medicaid or uninsured). These families deserve access to licensed and regulated providers whose education and training qualifies them as specialists in safe out-of-hospital maternity care.

Without state licensure that requires out-of-hospital midwives to meet national credentialing standards and to follow national standards of care, anyone can claim to be a midwife, and families have to take it on faith that their midwife is appropriately educated and trained to deliver babies at home. I think most people would agree that mothers and babies deserve better than that.

<<And in the year 2000 in Wisconsin, CPMs had a neonatal mortality rate of zero, while "Other Midwives" had a neonatal mortality rate of 11.83 per thousand.>>

Do you know what people with perfect data are called in science? Fakers. No one has a death rate of zero. Either you don't have a large enough sample or people are not reporting things accurately as you allude to in the rest of the post.

More importantly, it is perinatal death rates, not neonatal that are important in assessing birth options. Do you even know the difference without googling it? If lay midwives have problems, they probably won't be able to get the child out in time and it will be recorded as a stillbirth. Take a few more that are born live and but they don't have a a clue as to what to do, but just call them stillborn. Pretend the CPM wasn't there and deny involvement when there is a death. Poof. Away goes your neonatal death rate.

The fact you could post these statements and think they actually support your position, to not realize you have holes you can drive a truck through speaks volumes about the complete and udder lack of scientific knowledge of you and your group.

Again, the more you say, the more it seems like the only "option" is to improve things (read pocketbook) for your members at pregnant women's expense.

Women and babies lives on the line.

You don't seem to care one bit. It's not something for my grandma's farm neighbor women to do because it is more interesting than "Welcome to Wal-mart" and lets them buy more Longaberger. It's not something for bored urban/suburban housewives to do when the last kid is in school and there's too many bills.

When pregnant women are disgusted by the hospital model, the thing to do is fix it. Not give them cheap imitation of what they are trying to get away from.

katie prown:

"And in the year 2000 in Wisconsin, CPMs had a neonatal mortality rate of zero, while "Other Midwives" had a neonatal mortality rate of 11.83 per thousand."

Do you have a citation for that claim?I have never seen any published data that shows that CPMs in Wisconsin had a neonatal death rate of zero in 2000.

"The fact is, the categories of "Other Midwife" and "Other" are absolutely meaningless,"

Your backpedaling is not particularly compelling. It was YOU who claimed that we should look at the statistics for Wisconsin as confirmation that homebirth is safe, before you found at that the statistics for Wisconsin showed homebirth to have triple the neonatal death rate of hospital birth.

Let's take a look at another state you touted: Utah. You don't seem to be familiar with the statistics from that state, either. Utah's statistics also show a higher rate of neonatal death. It is more than triple the expected rate of neonatal death for low risk women in the hospital.

The state of Utah, as a condition of licensing direct entry midwives, has required that they submit their MANA statistics each year. Statistics collected over the first 18 months since the inception of licensing show a high rate of neonatal death. According to the 2007 report, there have been a total of 225 DEM attended labors and 1 neonatal deaths for a rate of 5/1000.

Homebirth advocates are routinely dishonest about these bad outcomes. Holly Richardson, the midwife who wrote the Utah reports downplays the neonatal death. She actually asserts that the outcomes were "excellent" and that the " mortality rate for mothers was 0%, for babies 0.5% (1 baby)." A neonatal mortality rate of 5/1000 is not excellent, it is 5 times higher than expected!

Homebirth advocates cannot be trusted on the issue of safety. You were wrong about Wisconsin, you were wrong about Utah and you are wrong about the safety of homebirth.

Re: Wisconsin. The point is that the year 2000 is the only year in which it's possible to distinguish between CPMs and "Other Midwives," a category which does, in fact, include unassisted and unplanned home births, as well as deliveries by non-CPM midwives.

And in the year 2000 in Wisconsin, CPMs had a neonatal mortality rate of zero, while "Other Midwives" had a neonatal mortality rate of 11.83 per thousand.

The fact is, the categories of "Other Midwife" and "Other" are absolutely meaningless, which is why the Bureau of Vital Statistics is revising them. Many parents who plan to have unassisted births check off "Other Midwife" out of fear of being accused of child endangerment. And plenty of non-CPM midwives, whose numbers have dwindled thanks to our new law, check "Other" out of fear of being arrested for practicing illegally.

Apples and Oranges. Check back after we've had a few years of birth certificate data that accurately reflects each category of birth attendants responsible for managing out-of-hospital deliveries in Wisconsin.

>>>Posted By: Amy TuteurMD @ 02/23/2008 4:23:58 PM
>>Comment: bobpine2:

>>"Why don't you address the huge rate of preventable maternal deaths in hospitals?"

>>>Because there is no "huge rate" of preventable maternal deaths in hospitals. Moreover, the most common causes of >>>maternal death are pre-eclampsia and hemorrhage and neither can be successfully managed at home


oh no, no, no. There's no problem.

Even though ACOG admits it.
http://www.acog.org/from_home/publications/press_releases/nr11-30-05-2.cfm
http://www.medscape.com/viewarticle/520168_3

Even though the CDC has had a goal of cutting the rate in half.
http://www.csctulsa.org/images/CDC%20Strategies%20to%20Reduce%20Pregnancy%20Related%20Death%202001.pdf

Even though the US ranks 41st in maternal mortality rates.
http://www.msmagazine.com/news/uswirestory.asp?ID=10601


Or maybe severe hypertension, hemorrhage and the like can't be managed FROM home either (by the doctor). And maybe primary care doctors (like your average OB/GYN) don't do all that much better at managing complex medical emergencies. Maybe both US midwifery and obstetrics are obsolete in the 21st century.

Moms deserve better than either one.

:

"Why don't you address the huge rate of preventable maternal deaths in hospitals?"


The infamous Amy-without-a-license countered:
<<Because there is no "huge rate" of preventable maternal deaths in hospitals. Moreover, the most common causes of maternal death are pre-eclampsia and hemorrhage and neither can be successfully managed at home.>>

No, no, no. There's no problem. Even though ACOG admits it. Even though the CDC has had a goal of cutting the rate in half. Even though the US ranks 41st in maternal mortality rates.

Or maybe its because severe hypertension, hemorrhage and the like can't be managed FROM home (doctor or patient). And maybe primary care doctors (like your average OB) don't do so well at managing complex medical emergencies. Maybe because the current hospital model for obstetrics is obsolete in the 21st century.

http://www.acog.org/from_home/publications/press_releases/nr11-30-05-2.cfm
http://www.medscape.com/viewarticle/520168_3
http://www.csctulsa.org/images/CDC%20Strategies%20to%20Reduce%20Pregnancy%20Related%20Death%202001.pdf
http://www.msmagazine.com/news/uswirestory.asp?ID=10601

Worse still is the lack of training and expertise in the very thing they are there for ??? medical emergencies in pregnancy. Direct entry midwives or CPM are no different than what my grandmother did. She called the farm lady up the road who had 10 kids. Nurse midwives know enough to be dangerous. Women get a false sense of security of medical rescue in an emergency.

OB/Gyns are primary care doctors. If you have massive bleeding, severe hypertension, or surgery unpregnant, you will get immediate, specialized care from a doctor that deals with that crisis extensively and frequently. If you are a dying pregnant woman, it is amateur hour. An average OB sees ???death???s doorstep??? cases once in a Blue Moon. No where else in medicine are critically ill patients treated by primary care doctors. Life-threats in pregnancy are seen by docs with infrequent exposure to them and inadequate experience with their treatment.

Women should not have to take risks to avoid unwanted intervention during normal birth.

We shouldn't have to make choices between terrible alternatives. We need promote the Laborist model. That would be a new specialty where doctors are in house 24/7 in shifts. They are highly trained in only on labor and deliver. They are more practiced and therefore more effective (and most of all AVAILABLE) in emergencies of labor and delivery. A laborist would be LESS likely to do unnecessary interventions and sections because they are more familiar with variations of normal labor and not ordering things to cover their butts when practicing medicine over the phone. Laborist maternity wards would easily allow other birth attendants, natural childbirth and the like for uncomplicated births. But, it gives the skilled, readily accessible emergency back-up that the others promise, but do not (excuse the pun) deliver.

Moms are People Too. Let's not choose between bad options. Let's demand good ones. Support Laborists as a new specialty and the standard