Who’s Catching Your Baby?


While another profession might have the popular reputation of being the world’s oldest, you can make a strong case that midwifery is a more realistic contender for that title. The tradition of caring for pregnant women and delivering babies in homes or community spaces is ancient the world over. And it’s present today, in the providers who practice within an American medical culture in which 99% of births take place in hospitals, presided by OB/GYNs.

Jessica Mattingly, a doula from Blue Springs, MO, notes that midwifery-assisted home birth can foster the understanding that "birth is a normal, celebrated, empowering experience for a woman and her family." And, she adds, "This is not done at the sacrifice of safety for mother and baby, but at the enhancement of it. Midwives and mothers can be and are able to identify the rare cases when medical intervention is needed and can seek collaboration and assistance."

The Fight for Licensure

While dozens of professions drew their numbers together in widespread licensing systems in the last century, midwifery was not among them. While the reasons for this are unclear, it may coincide with the rise of obstetrics in the early 1900s, which seemed to be a competitor to midwifery. The profession pitched more sanitary and better-educated doctors, and that message resonated. By 1955, one percent of American births took place at home, the same rate that stands today.

The lack of licensure is a sticking point for a profession that seeks to provide high-quality, evidence-based care to women, because midwifery skeptics point to it as evidence that the practice is unsafe and unpredictable. Critics claim that its apparent lack of regulation indicates that midwifery unnecessarily endangers both the mother and the baby.

Today you need a license in the U.S. to practice psychotherapy and cosmetology, to drive trucks and to be a mortician — but not to minister to laboring women in homes or in birthing centers. Or at least, not quite: Twenty-one states, including Wisconsin, Montana, and, very recently, Missouri and South Dakota, accept the certified professional midwife credential (CPM) for direct-entry midwife licensure. ("Direct-entry" means that standard midwifery training is recognized as sufficient to practice; the CPM isn’t expected to secure an additional medical degree.) CPMs are backed by the North American Registry of Midwives "to provide out-of-hospital maternity care for healthy women experiencing normal pregnancies," according to Steff Hedenkamp of the advocacy organization, The Big Push for Midwives.

CPMs complete training that lasts three to five years and requires hours in birth observations, classrooms, and clinics. CPMs also pass a national board exam that includes a clinical assessment, out-of-hospital training, and continuing education and re-certification every three years. The CPM is recognized by the American Public Health Association as a basis for licensure.

But while CPMs are certified in their profession and practice across the country, they’re not necessarily licensed. Licensure is up to boards that are set up on a state-to-state basis, and it is here that things get complicated. Certification by itself doesn’t offer legal protection or permission to practice. When a state makes licensing available, it protects the midwife from criminal charges for practicing, even at the highest CPM standards. It’s also likely to increase its number of active midwives, and those midwives will be more accessible to citizens via public awareness and, potentially, insurance reimbursement.

In more than half the U.S. states, midwives are vulnerable to prosecution for practicing medicine without a license. In 2006, an Indiana midwife who had overseen 1,500 births was prosecuted for just that when a baby she delivered didn’t live. The law that could have put her in prison for eight years, and ultimately put her on probation, still stands. Midwives who practice in the District of Columbia, Georgia, Hawaii, and many other states face the same threat. Yet they’re unable to receive licenses in states that don’t recognize midwifery as a viable profession and, rather, see OB/GYN care in hospitals to be the appropriate route for laboring women.

Traditional Medical Organizations Oppose Home Birth

At its 2008 annual meeting in Chicago last month, the American Medical Association passed a resolution opposing home birth. While it didn’t directly oppose direct-entry midwifery, it cited the "twenty-one states (that) currently license midwives to attend home births, all using the certified professional midwife (CPM) credential (CPM or "lay" midwives)…" as cause for its challenge to home birth.

The AMA resolution quoted the American College of Obstetricians and Gynecologists in saying that "the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex."

For its part, ACOG reiterated its opposition to home births last February:

ACOG acknowledges a woman’s right to make informed decisions regarding her delivery and to have a choice in choosing her health care provider, but ACOG does not support programs that advocate for, or individuals who provide, home births… Childbirth decisions should not be dictated or influenced by what’s fashionable, trendy, or the latest cause célèbre. Despite the rosy picture painted by home birth advocates, a seemingly normal labor and delivery can quickly become life-threatening for both the mother and baby.

While the AMA and ACOG are more accepting of midwives who work within hospitals, or in birthing centers that partner with OB/GYNs, the opposition to home births and "individuals who provide home births" equates into an invalidation of midwifery as a whole. Midwifery is fine, the implication goes, so long as it is safely within the realm of traditional hospitals, OB/GYNs, and nurses.

Physician disapproval of direct-entry midwifery assisting in home births resonates with the experience of California mother Alexis Aherns.

"When I told my final doctor later in the pregnancy that I was planning a home birth, he told me he didn’t recommend that, and added that he had seen plenty of women who made that choice show up with dead babies," Aherns said. "It was such a ridiculous statement that it actually didn’t even faze me." Despite her doctor’s predictions, Aherns delivered a healthy child at home with the assistance of a midwife.

ACOG’s position on home birth is one that Mattingly challenges as "terribly hypocritical and a violation of the ACOG Code of Professional Ethics which has as an ethical foundation ‘the respect for the right of individual patients to make their own choices about their health care."

The original AMA resolution last month cited the popularity of Ricki Lake’s recent documentary, "The Business of Being Born," which features her own birth experience as a catalyst for its resolution. Due to popular outcry, however, the AMA soon voted to delete references to Lake and the documentary from its resolution, while maintaining its opposition to home birth.

Though AMA, ACOG, and others skeptical of midwifery and home birth declare their concern for the well-being of the laboring mother and her baby, numerous reports indicate that home births are safe and minimally intrusive.

The British Medical Journal surveyed the 5,400 North American women who had home births with a CPM in 2005. No mothers died and five babies died, or .09 %. In context, the U.S., where nearly all births take place in hospitals, ranks 37th in world infant mortality; there are 6.37 deaths for every 1,000 live births, a rate behind South Korea and Cuba, according to the CIA World Factbook. The U.S.’s infant morality rate is second-worst in the developed world.

The journal survey also found that twelve percent of the home births were transferred to a hospital. Caesarean sections among these women were one-fifth the level of comparable groups who had hospital births.

A recent article in Florida’s St. Petersburg Times quotes the AMA’s citation of a study that compares a 1.7 per 1,000 death rate for babies born in hospitals and a 3.5 per 1,000 rate for those born at home. Home birth advocates charge that women should have the ability to choose what risks they want to face; many see the high rate of c-sections, drugs and labor inductions in hospitals as equally risky. They also point to other research that describes home births as being at least as safe as hospital births.

Doctors and Midwives React to the AMA

Dr. Henry Dorn of High Point, NC, is one OB/GYN — and former AMA member — who questions the recent obstacles to widespread licensure for midwives. Dorn operates a gynecology practice that offers midwifery services.

"I feel that (the AMA’s) statement may stem from a combination of ignorance or avoidance of the facts regarding out-of-hospital birth by skilled attendants, and perhaps a desire to protect the business interests of the physician community,"

Dorn said. "This is not to say that AMA members do not care for their patients’ best interests, but only that given the current medical climate, it would not be surprising to see those outside pressures affect [their] conclusions."

Dorn expects the resolution to "discourage another generation of doctors from considering alternatives to highly medicalized birth, as most feel that any statements by the AMA should be viewed as gospel."

Mattingly wonders if the root issue is that many doctors fear what they don’t know. "Very few doctors have seen a birth without any medical intervention," she said. That means, "Most have never ever seen a normal birth."

Despite its discouraging tone, Coral Slavin of Well-Rounded Maternity Center in Menomonee Falls, WI, thinks the resolution will have an unexpected effect.

"Ironically, I think that the AMA stand against out-of-hospital birth has only driven more people to view Ricki Lake’s documentary and spurred more questions. I don’t see how lawmakers morally could ban out-of-hospital birth without proof of the alleged dangers," Slavin said.

Dr. Elizabeth Allemann, a physician from Harrisburg, MO (she is not an AMA member) found another reason to be positive: "Honestly, there’s a little bit of a relief in having them actually make the statement. Now we no longer have to try to convince legislators that organized medicine is opposed to home birth and midwives, and can’t be a good-faith partner in designing legislation."

If Midwives and Physicians Could Collaborate

The stance the AMA and ACOG have taken against non-hospital births, alongside the de facto stance taken by states that don’t allow for midwife licensure, diminishes a culture of collaboration among doctors, midwives, and expecting women. While the two professional organizations detach themselves from CPMS, many midwives and home birth advocates recognize the important role OB/GYNs play in their vision for a renewed culture of birth.

Comparatively, home births are actively encouraged by U.K. governments, and in Edinburgh in particular. Nicola Goodall is an Edinburgh doula who reports that OB/GYNs and midwifes are partnering in an effort to respond to more babies being born than there are hospital units to accommodate them; Goodall said the collective goal is to increase home births by 800%. It’s an ambition that also translates into making midwifery an appealing and accessible profession.

"Midwives are registered here and they work alongside doctors and hospitals," Goodall said. "All women giving birth in the UK get midwifery care, but they may get it alongside doctors if they have a special need (such as) a medical problem like diabetes."

Stateside, many are working to diminish the unfriendly competition that dates back to the development of obstetrics one hundred years ago.

Steff Hedenkamp of The Big Push outlines the way the AMA and midwives could collaborate:

We welcome the AMA joining the Big Push as we work to bring together a national effort that is creating meaningful consumer protections and a new model for the U.S. maternity care system — one into which midwives are fully integrated. We welcome the AMA applying its vast resources to helping create a maternity care system that supports people from all walks of life from all over the U.S.

For their part, midwives often see the benefits of working with allopathic providers.

"We know that this partnership is needed to create that optimal environment for all mothers and babies," said Dr. Allemann.

For more information:
The Business of Being Born – Official Film Website
The Big Push for Midwives
American Medical Association Resolution 205: Home Deliveries
"A bundle of debate over giving birth at home" -St. Petersburg Times

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  • http://homebirthdebate.blogspot.com invalid-0

    Homebirth advocates would like women to think that the issue is “choice” and that the AMA is attempting to “outlaw” homebirth. Neither of those things is true.

    Why are homebirth advocates lying about this? As usual, it’s because the lie is so much better than the truth. Here’s what the AMA actually said:

    1. Homebirth is not as safe as birth in a hospital or licensed birth center.

    2. Midwives should be licensed to the standards of the American College of Nurse Midwives.

    If homebirth advocates attacked the resolutions on what they actually said, they’d be forced into a discussion they would lose. Homebirth is NOT as safe as hospital birth. All the existing scientific evidence shows that homebirth has an increased risk of neonatal death. The Johnson and Daviss BMJ 2005 study that claims to show homebirth is as safe as hospital birth ACTUALLY shows that homebirth has almost TRIPLE the neonatal death rate as hospital birth in the same year. The ACNM standards for midwives ARE the appropriate standards. They are consistent with midwifery standards in EVERY other country in the industrialized world.

    Homebirth advocates like to imply that homebirth midwives (direct entry midwives) are just like certified nurse midwives or just like European midwives. That’s not true, either. Homebirth midwives are a second, inferior class of midwives with far less education and training than ANY midwives in the industrialized world. American homebirth midwives would not be eligible for licensure anywhere else.

    Homebirth advocates also neglect to mention that the Midwives Alliance of North America (MANA), the trade organization for direct entry midwives, has been collecting detailed safety statistics on homebirths since 2001. They have publicly offered those statistics to organizations that can prove they will used them for the “advancement of midwifery”. Even then anyone who is allowed to view the statistics must sign a legal non-disclosure agreement preventing them from disclosing any data to anyone else. It does not take a rocket scientist to surmise that MANA is almost certainly hiding the fact that their OWN data shows homebirth with a direct entry midwife to be unsafe.

    The AMA opposes homebirth on safety grounds, and it opposes homebirth midwives because they don’t meet the world-wide standard for midwives. These are the real issues, the ones that homebirth advocates are trying to hide.

    • http://www.barenakedpundits.com invalid-0

      As the father of 3 healthy girls (1 born at home with a CPM, 1 born via c/s and 1 born through a medically managed hospital birth), an Ivy grad and a public policy professional I have both the experience and expertise to tell that your comments are well-designed, clinically dispensed and potentially compelling. Unfortunately, your sly rhetoric is little more than a pack of lies and half-truths unworthy of the oath you must have taken as an MD but have forsaken for arrogance or hubris. I pity you. Your brand of medical elitism is what drove my wife and I to research and conclude that midwives (CPMs and CNMs) are the prescription needed to deliver maternity care back to normalcy.

    • invalid-0

      It took less than a minute to find this information about an Amy Tuteur, MD. Posted on Henci Goer’s blog post. Enjoy…

      Ahh, I see you have run across Amy Tuteur, our very own Bill O’Reilley of the birth world. Like him, her intent is to steamroller you; any overlap with the facts in her rants is strictly coincidental.

      Some weeks ago, someone e-mailed me asking who she was. I said that I didn’t know, but it might be interesting to poke around on the internet and find out. A week or so later, my correspondent got back to me. She wrote that she could verify that Amy is a real person, but not that Amy is an M.D., much less an obstetrician. At least, she could find no license to practice medicine for Amy. My correspondent also found that some of Amy’s domain names are held publicly, but who holds the registration on homebirthdebate.com is not, which is something that can be done at an additional fee. This raises the question of why she would conceal the domain backer, especially since she has not done this with the others. She has also gone to the trouble and expense of copyrighting homebirth debate, which denies others access to the term. My correspondent speculates that Amy may be fronting a disinformation campaign. Blogs have become a common tool for this sort of thing. It’s an interesting, if somewhat paranoid, thought. If she is, an obvious suspect comes to mind for which entity might be backing her. It is certainly one that has deliberately spread disinformation in the past.

      My advice to you is the same as was given to me when she started posting on my Forum: Don’t feed the dragon. I had no idea who she was at first so I refuted her objections to a study showing that elective cesarean surgery increased the neonatal death rate. That segued into her criticisms of the MANA 2000 study, which I rebutted as well. If you look at the top of the topic list, you will see a link marked “search.” If you search this Forum’s posts on “Tuteur,” you should turn up our exchange and see my defense of these studies, and how I handled her. My strategy worked well. She hasn’t been back.

      — Henci

    • invalid-0

      Dr. Amy Tuteur, you need to do some SERIOUS homework. Hospital birth has been proven to be nowhere near as safe as homebirth. Check the facts!

    • invalid-0

      Dr. Amy I can just see you standing over a first time mom telling her all about the risks involved in her birth. Telling her how she in spite of the generations of successful birthing women she is a product of, would need to be monitored very closely. And how this is the most dangerous thing she will ever do. Well, your days are numbered because women are waking up. We know now that hospitals cause more problems than they prevent. Hospital birth is not safer unless we ignore your bad outcomes. The fact is OBs are surgical specialists. Who find it necessary to surgically remove babies over 30% of the time.

  • invalid-0

    The World Health Organization, the American Public Health Association, the Royal College of Obstetricians, and the Canadian organization of obstetricians all interpret the scientific data as supporting the safety of home birth. I happen to agree with them. Before I had my own baby at home, I researched the world’s literature regarding midwifery care. I was convinced that, for the safety of my baby, I should stay home with a midwife for labor and birth. Interestingly, neither the ACOG nor the AMA cited any scientific studies in their position statements. The Netherlands, with the best newborn and mother safety outcomes, embraces home birth with midwives. Women who birth outside a hospital, attended by a midwife have the best chances of success with breastfeeding and are happiest with their births. These outcomes matter, too.

    You gotta wonder–with science, justice, freedom, breastfeeding, maternal happiness, and cost savings on the side of midwives and home birth, just how long will money and “strong arm tactics” be able to maintain organized medicine’s near monopoly on birth?

    Elizabeth Allemann, MD

  • http://homebirthdebate.blogspot.com invalid-0

    Dr. Alleman,

    You are doing exactly what I have claimed. You are deliberately obscuring the difference between American direct entry midwives and all other midwives in the industrialized world.

    As you certainly know, American DEMs are grossly undereducated and grossly undertrained compared to certified nurse midwives or European midwives. American CNMs have university degrees and masters degrees in midwifery as well as extensive hospital based training in the diagnosis and management of childbirth complications. All other midwives in first world countries have university degrees and extensive hospital based training in the diagnosis and management of childbirth complications. In contrast, American DEMs have only high school diplomas, can attend DEM school by CORRESPONDENCE course and have NO training of any kind in the diagnosis and management of childbirth complications. American DEMs could not be licensed to practice midwifery in any other country in the industrialized world.

    “The World Health Organization, the American Public Health Association, the Royal College of Obstetricians, and the Canadian organization of obstetricians all interpret the scientific data as supporting the safety of home birth.”

    Interpret? What do you mean by interpret?

    The data is uniform and clear. As you know, there is not a single study that shows that homebirth is as safe as hospital birth for low risk women in the same year. All the existing scientific evidence shows that neonatal death rates at homebirth are generally TRIPLE the rate of neonatal death for low risk hospital birth. The US government has recently began collecting statistics about homebirth and the first dataset (available on CDC Wonder) shows that homebirth with a DEM is the most dangerous form of planned birth in the US!

    In order for women to make an informed choice about homebirth, they need to have accurate information about homebirth. There is simply no question that the existing scientific evidence shows that homebirth with a DEM has an increased rate of neonatal mortality. There is simply no question that American DEMs do not meet the qualifications for all other midwives in the industrialized world, and could not be licensed in any other first world country. American women deserve to know this basic information.

    • http://www.icanofnova.org invalid-0

      This seems less than compelling. I don’t know about you, but where I come from we’re not all of the white female demographic!

    • invalid-0

      I am confused how is 0.61 deaths per 1000 births TRIPLE 1.15 deaths per 1000 births. Moreover, by my calculations these rates are not statistically different.

      If you say that women should have unbiased statistics when contemplating a home birth, then you should present them in an unbiased, truthful manner.

      More than that, let the statistics stand for themselves and respect women’s ability to make educated and informed choices. Women don’t want to die in childbirth or have their neonate die anymore than you do!

      Women are more than capable of making their own choice about birth, weighing the risks and benefits. Many women desire home birth because they don’t want to expose themselves to the many unnecessary interventions that occur once checked into the hospital.

      Why is it that my many very educated friends have made comments like:

      “I waiting until the last minute to go to the hospital.”

      “The more I read [about childbirth in the US] the more I realize how useless my Ob is and how little I want to do with the medical establishment.”

      Then there is my friend with cerebal palsy who had natural childbirth about 5 years ago. All her doctor wanted to do was strap her to a bed when she was admitted in labor, although there were no signs of fetal distress or abnormal labor. Instead she had to push against those orders so that she could continue walking during her contractions as we her wish. The result was an uncomplicated, undrugged birth – despite her ob’s wishes.

      Why is it that women feel this way and have this experience? Why is it that women don’t trust their obs or the medical establishment? Why is it that the C-section rate in the US is among the highest in the world? Why is it that our neonatal mortality is also among the highest in the world?

      Maybe it would behoove you to contemplate these realities, instead of railing against a community that as a community actually respects women’s voice and choice.

  • invalid-0

    Has the US government data, posted by Dr. Amy, been published in a peer reviewed journal? Looks like it’s all based on birth certificates. Is it not? There’s a lot of problems with drawing conclusions based on birth certificate data, isn’t there? Isn’t that why researchers prefer prospective studies?

    • invalid-0

      Anonymous – You’re exactly right. (Here is the link to the query http://wonder.cdc.gov/lbd-icd10.html so everyone can search it for himself.)

      In 2003, of the 19 deaths, 4 were listed as being due to chromosomal abnormalities, 1 was due to encephalocele (part of the brain protrudes from the skull), 4 were due to heart defects, 1 was due to thanatorphic short stature (a rare genetic problem that affects 1/20,000-50,000 births, and is almost always fatal — either stillbirth or shortly after birth), 1 due to osteogenesis imperfecta, 2 to congenital diaphragmatic hernia, 2 due to “multiple congenital malformations” and 1 due to an unspecified congenital malformation.

      In 2004, of the 10 deaths, 1 was due to anencephaly (the brain does not develop normally, and has an almost-100% death rate in the neonatal period anyway), and 2 were due to other chromosomal abnormalities.

      While it’s possible they may have lived had they been born in the hospital, it’s impossible to know without knowing the cases, since many chromosomal and congenital birth defects are lethal, and birth place and manner have little or nothing to do with whether these babies survive or not.

      What is *far* more likely is that these home-birthing women chose not to have any prenatal testing done (including ultrasounds), and did not know their babies were affected prenatally. Since most women who go to doctors do have these tests, they know their babies cannot survive or will survive with severe disabilities. Many of these women (even if they are nominally pro-life) choose an abortion or pre-term induced delivery (aka “life-birth abortion”) rather than carry the child to term and risk the uncertainty of stillbirth, intrapartum death, or neonatal death. (Check out BeNotAfraid.net for women who have not chosen abortion even when faced with the heart-breaking prenatal diagnosis [some of which were wrong].)

      I’m actually unsure where Dr. Amy got her figure of 1.15/1000, because when I put in those criteria, I got 29 deaths out of nearly 30,000 births in the home-birth set, which is 0.98. When I realized there is a “non-hispanic white” in addition to “white” It dropped 2 deaths and about 4,000 births, for 1.05. (I’m assuming that when she says “20-45″ that she means 20-44, because it goes “45-49″, but this discrepancy may be where she gets her 1.15.)

      However, of the 29 deaths, 20 of them were due to congenital defects or genetic problems — all of which may have been hopeless cases, regardless of birth place. It just can’t be known without investigating each of the deaths. When you perform the same query Dr. Amy did, except take out cause of death due to congenital and chromosomal abnormalities or defects, you get the following death rates per 1000:
      CNMs: 0.25
      MDs: 0.33
      DOs: 0.34
      other midwife: 0.34
      You will have to figure the “other midwife” death rate, because of the small number, the rate is suppressed. Oh, yeah, homebirth is risky. Not!

      I will also point out that the database lists “other midwife” as the birth attendant for over 5,000 in-hospital births at 37+ weeks, that there were 82 out-of-hospital Cesareans performed, and that CNMs performed some 6,000 in-hospital C-sections. Except that direct-entry midwives don’t attend hospital births (which is one reason for the difference in training they get, compared to other countries’ midwives), C-sections always take place in hospitals, and CNMs don’t do C-sections. So I’m unsure how accurate the data are.

  • invalid-0

    I’m not a doctor and I’m not a midwife. I am a teacher and a mother who has experienced birth in the hospital with both an ob and a CNM. I’ve also experienced birth at home with a CPM.

    I know that some in the medical community ridicule the education of CPMs. CPMs can get their education from an accredited school or they can work through the required curriculum with an approved preceptor. What we were taught in my education classes was that the most effective way to learn was hands on with a one-on-one teacher to student ratio. It seems to me the student midwives who learn this way are getting an optimum education. They have to pass the same national exams as those who graduate from the college programs. If the instruction wasn’t adequate, they wouldn’t be able to pass the tests.

    My personal experience with a CPM was wonderful. She spent much more time with me during my prenatal visits addressing issues that were never covered by my other care providers. I’m talking about things like severe leg swelling. My doctor told me this was just a part of pregnancy. Because we didn’t address the problem, it developed into toxemia which was treated by inducing labor and nearly turned into a C-section.

    My home birth midwife told me that the leg swelling was not normal and suggested a change in my diet and the addition of B vitamins. This worked wonders for me and I had a much more comfortable pregnancy and an amazing birth. I was not lucky. I was very blessed to have a skilled midwife (who learned her craft from other midwives). With her encouragement and guidance, I took much better care of myself and my baby and I reaped the rewards of a beautiful birth experience.

  • invalid-0

    Amy,

    Aside from the fact that you are grossly misquoting and twisting the scientific evidence to suit your one-man-band effort to discredit Certified Professional Midwives, we’re all so curious about who you are.

    Where do you practice? What experience do you have with research? What are your research credentials? What are your research/academic affiliations? In short, aside from misquoting others’ statements and engaging in unsupported conjecture, what credentials do you have to back up your opinions?

    Oh, and by the by, if you can tear yourself away from your solo efforts backed by Big Medicine to stamp midwives and home birth from the earth, do tell what you and them are doing to *fix* the critical problem in our society where nearly 1 in 3 American women are going through major surgery to give birth, but only a fraction of them are “high risk.”

    Other than bashing the science-backed profession of Certified Professional Midwives with your club of lies, tell us what you’re doing to improve our current U.S. maternity care system. Explain what your doing in light of a two-year review of the science behind maternity care that indicates that the common and costly use of many routine birth interventions, such as continuous electronic fetal monitoring, labor induction for low-risk women, and cesarean surgery, fail to improve health outcomes for mothers and their babies and may cause harm.

    Other than shoveling your horse manure all around the blogosphere, tell us what you’re doing when faced with this research that also finds that harm is caused by routine use of intravenous fluids (IVs), amniotomy (breaking the bag of waters), withholding food and water from women in labor, and episiotomy (http://www.medicalnewstoday.com).

    And truly, if as you so falsely assert every time the wind blows, CPMs are such back-asswards health professionals, do tell us why the American Public Health Association (APHA) recognizes the CPM training and clinical skills assessment process as the basis of a national certification program for licensing midwives who provide out-of-hospital maternity care services.

    Help us understand why states are increasing passing legislation to license CPMs, and why no state has ever reversed its decision to license CPMs. Also, please expound on why no state has reported an excess of damaged babies after permitting CPMs to practice or that all states reporting results have described favorable outcomes for mother and baby, and reduction in expense to the state for initial and follow-up care. Please pontificate on why eight of the ten best states in perinatal mortality license CPMs.

    But you won’t go there, will you? My guess is the AMA and ACOG only pay you enough to buy and beat the one-note drum you’ve got … and because they can’t generate any answers to what they’re doing to fix the crisis, neither can you. So all you have is this feeble, tedious, obvious attempt to discredit midwives and the consumers who choose them.

    Hey, I know: request a pay raise from Big Medicine (the AMA is a *$280 Million* organization after all), and maybe you’ll be able to talk about the other multiple aspects of improving birth in our society … oh, but that couldn’t be. You wouldn’t know how to talk about anything other than “me-Amy-you-second-class-inferior-midwife-because-I-say-so.”

    But the good news? There is only one of you, (funny how *no* other MDs show up in blogs other than you to talk about this issue) and there are THOUSANDS of us and our numbers are growing … us being consumers and midwives (increasingly Certified Nurse Midwives (CNMs) … now doesn’t that just bite your bippy!?) … oh, and chiropractors, and naturopaths, and acupuncturists, and nurse practitioners, and massage therapists and childbirth educators, and lactation consultants, and doulas, and, and, and … and everyone who says “AMA/ACOG: BACK OFF. NOW.”

    Amy, we know who you are. We’re just not that impressed.

    As one of my mentors always says, “If you don’t have any solutions to the problem, get OUT of the way of those of us who are actually doing the work to fix it.” Beep, beep lady.

    Steve U. in NY

    • invalid-0

      YAY for Steve U.!

    • invalid-0

      Yes!, thank you Steve!

      I couldn’t have said it better! WOOOHOOO!

  • invalid-0

    I think everyone would agree that all birth entails risk, at home or in the hospital, with any type of qualified caregiver. Arguing about which caregiver or setting works best is beside the point.

    A pregnant woman has as much right to choose her caregiver, her location and her “treatment” as a woman who is not pregnant.

    Currently, many good women unintentionally bog the debate down by arguing about hot button issues, like which setting carries more risk and whether unmedicated birth benefits the baby.

    If all American women could recognize the need for truly comprehensive education about all their options, and ask with one voice for all those options to be available to them, legally and without stigma, then we could all make our choices without defending them by attacking others.

    First we need to convince women that they have choices, that they should not automatically do what the doctor says and that they are responsible for educating themselves thoroughly so they can choose the risk that they can live with.

    • invalid-0

      this is great post, and I am very happy to see something thoughtful on the topic rather than the same old studies and personal attacks.

      I suspect you are never going to convince medically trained doctors that home birth is safe, so why keep attacking ACOG? ACOG consistently stands up for women’s right to choose. They are the only organized medical society that does, so why alienate them? If you are interested in reproductive rights, ACOG is your friend not your enemy. Please see their website about the recent Bush policy about contraception. I am a member of ACOG and I have received many email alerts over the past few days on this topic.

      Also how do the lawyers not get involved in this argument? When my insurance carrier tells me I can not offer VBAC and vaginal breech delivery to my patients, who is to blame? As long as traditional inpatient obstetrics is dominated by the fear of lawsuits, unnecessary c-sections and inductions will continue. Also any women that attempts a home delivery and has a complication will not get the care they need if they go to a hospital. No doctor will want to be involved in these cases due to the legal risk.

  • http://www.drshelleybinkley.com invalid-0

    The AMA’s statement against home birth is somewhat analogous to the American farmers saying they don’t recommend people growing their own vegetables. It’s a silly statement and can’t be enforced. It merely casts the AMA as a self-serving organization, rather than a patient-centered one. Instead, perhaps they should have called for a well-designed study in the United States comparing home birth to in-hospital birth.

    People who choose home birth are not going to be swayed by an AMA statement, and it may indeed have the opposite effect. There are some well-researched studies that support the safety of home birth when attended by skilled birth attendants.

    The research actually shows that under the right circumstances in low-risk women home birth is as safe and possibly lower risk than in-hospital birth.

    My book, DIY Baby! Your Essential Pregnancy Handbook contains an entire chapter devoted to an intelligent discussion of the pros and cons of home birth.

    I take the approach as a physician that I want the best outcome for my patients and rather than cast judgement about their choices, I prefer to offer them as much information as possible so they can make intelligent, well thought-out decisions.

    Shelley S. Binkley, M.D.
    Certified by the American Board of Obstetrics and Gynecology,
    Fellow, Amercian College of Obstetrics and Gynecology.

  • http://homebirthdebate.blogspot.com invalid-0

    Dr. Binkley,

    The AMA said made two specific claims:

    1. Homebirth is not as safe as hospital birth.

    2. Midwives should be have education and experience at the level required by the American College of Nurse Midwives.

    What specifically are you disagreeing with?

    Are you suggesting that there is scientific evidence that shows that homebirth with a DEM is as safe as hospital birth for low risk women in the same year? If so, please share the scientific citation, since I am unaware that such information exists.

    Are you suggesting that the level of education and training required for ALL other midwives in the industrialized world is not necessary? Do you think that England, the Netherlands, Canada, Australia, etc. are overeducating and overtraining their midwives? Please explain why you believe that American DEMs, who could not meet the licensing requirements for any country in the first world, should be considered adequately educated or adequately trained.

    • invalid-0

      The one thing “Dr. Amy” a.k.a. the ACOG/AMA, doesn’t realize is that most Direct Entry Midwives actually have WAY more midwifery training that our counterparts the CNM’s.
      In Florida, the state that I attended midwifery college in, we are required to have 900 hours in the classroom and 900 hours clinically. We must observe 25 deliveries and manage 50, along with hundreds of prenatal, postpartum and newborn visits. My wonderful CNM friends will all tell you that their programs didn’t come close to the same requirements.
      The Direct Entry programs here in Florida are also 3 years in duration and are based on the European programs. In fact the school I graduated from, the International School of Midwifery modeled their program after programs in the UK.
      Direct Entry Midwives with this type of training are just as qualified as nurse midwives to care for patients.
      Perhaps “Dr Amy” should do her homework before spouting of at the mouth about things she isn’t informed enough about!

  • http://www.allaboutpasorobles.com invalid-0

    Give incentives for doctors to attend home births. If enough doctors are willing to do it then I think there would not be this constant battle.

    I know doctors who have lost their privileges at hospitals because they attended home births. And you say they don’t like midwifery because it is not safe? Hogwash.

    By the way, doctors do not “deliver” babies. Mothers do.

    greg

    • invalid-0

      Greg — women in approximately half of all U.S. states have no access to licensed home birth providers, and you know very well that docs don’t want to do home birth for $2,000 or so for all the prental care and birth, total. when they can get far far far more than that at the hospital. Plus, safe home birth requires careful attention by the care provider, and doctors want to come in the last 5 minutes only. Plus, doctors have absolutely no training in natural childbirth; how could women manage a home birth with a doctor ignorant of how to support them through unmedicated labor? And then when the doctor forces the woman onto her back and brutally drags the baby out of her, hurting the baby (doesn’t happen w/a midwife btw), how can the baby be safe?

      I’m disappointed that this is your answer the lack of access to licensed home birth care.

  • http://www.ncfom.org invalid-0

    Thank you Ms. Clark for the thoughtful essay. Kudos to Dr. Dorn, Dr. Allemann and Dr. Binkley for supporting a woman’s right to birth as she chooses and to assure she has access to care.

    This is very simple. Some women will choose to birth at home. We know it is a perfectly valid choice and these families deserve access to care and licensing assures the standards of care are maintained. There are very few physicians who will attend women who birth at home. Of the ~11000 CNMs in the US, only about 100 attend women who birth at home. The primary healthcare professional attending these families, and the only credentialed caregiver explicitly trained in the home setting, is the CPM. There are approximately 1400 CPMs serving women who choose to birth at home and the community of practice is growing at a steady rate year after year.

    I absolutely support vigorous discussion on the subject of safety (informed consent is absolutely key), but it really bothers me when this most vocal adversary knowingly misuses the data. This has been debated for years and Amy knows darn well that just looking at stats for White Women is not appropriate. The data on the CDC Wonder site for white women birthing with Other Midwife will include the Plain folk which represents ~10% of the home birth population with higher incidence of congenital anomalies. Also, risk profiles are not the same and we know that there are women with known breech presentation who are birthing at home as they will not be supported in a vaginal breech birth in hospital. I think it is terrific that obstetrics has advanced such that planned C/S is likely the safest option for breech presentation, but when women run out of options in the hospital they will look for options elsewhere. Indeed, Schlenzka observed better outcomes for midwife attended Out-of-Hospital birth even with elevated risk factors. We know that the incidence of low birth weight babies is lower for midwife attended planned home birth due to better maternal health. We know the C/S rate is reduced by a factor of 5 which will result in fewer hysterectomies and maternal deaths. The incidence for all of these bad outcomes is very low, but it is simply argumentative to claim that hospital birth is safer for healthy women experiencing normal pregnancies.

    On the subject of training, a comparative evaluation was recently performed by the Director of our University CNM Program and presented to a legislative study committee. This assessment compared the minimum clinical requirements to obtain the CPM credential, the CNM credential and the CM credential (the ACNM version of the Direct Entry Midwife). The conclusion was clearly that the clinical requirements are comparable for care during the childbearing year. More importantly, the CPM credential is accredited by the National Organization for Competency Assurance (NOCA) which is the same organization that accredits the CNM credential.

    It is clear that the leadership of the ACOG/AMA has lost all perspective and I find their priorities in establishing their agenda remarkable. In my state, we lose ~1500 babies per year during the perinatal period. The biggest source of excess bad outcomes is poor maternal health resulting in over 200 excess bad outcomes per year. A conservative estimate for the total number of bad outcomes for women who choose to birth at home is 3-5 per year from all causes and largely not preventable. Furthermore, 8 of the top 10 states in perinatal mortality license CPMs and there are women who are birthing unassisted because they do not have access to midwives.

    Assuring women who choose to birth at home have access to care is just a go-do-it. Advancing access to the Midwives Model of Care is good policy and will promote improved maternal health. It is also important for the safety of these families that transfers of care are efficient and unobstructed when obstetrics is indicated which can only happen with licensed midwives.

    I’m finding that the legislators tend to see the logic in all of this and that the obstructionists must resort to strong-arm tactics to delay the inevitable (access to licensed midwives). It’s funny, if the Medical Societies were to actually support this community they would find allies in their initiatives to address the environment in which obstetrics is practiced. Instead their leadership is entrenched and we will bump heads in front of the General Assembly and the media and they will lose.

    Russ Fawcett
    Legislative Chair, North Carolina Friends of Midwives

  • http://homebirthdebate.blogspot.com invalid-0

    You copied Henci Goer’s post but you did not copy what followed, including:

    “Ms. Goer, you did not manage to rebut, either claim, both of which are quite simple:

    1. The WHO says homebirth increases the risk of neonatal death

    2. US DEMs (including CPMs) have less education and less training than ANY midwives in the industrialized world.

    Marsden Wagner himself acknowledges that the WHO strong disagreed with him on his personal opinion that homebirth is safe. He writes about it proudly in his chapter, Confessions of a Dissident, in the book Childbirth and Authoratative Knowledge by Brigitte Jordan.

    Moreover, you did not even address the latest CDC statistics from the linked Linked Birth/Infant Death 2003-2004 dataset. The data show that homebirth with a direct entry midwife has double to triple the neonatal death rate as hospital birth for low risk women.

    And as long as we are discussing this issue, I will mention two additional points that you have never addressed:

    1. MANA (the Midwives Alliance of North America) has been collecting safety data on homebirth since 2001. They have publicly offered the data to those who can prove they will use it for the “advancement” of midwifery. Even those people must sign a legal non-disclosure agreement preventing them from revealing any data to anyone. In contrast, the US and state governments make all birth data available each year on the internet. MANA’s data almost certainly show that homebirth with a CPM has a much higher neonatal death rate.

    2. Over a year ago, we argued about whether Johnson and Daviss used the correct comparison group in the BMJ 2005 study. I said that the correct comparison group was low risk hospital births in 2000. With that comparison (which Johnson and Daviss left out of the paper), they had ACTUALLY showed that homebirth with a CPM had a neonatal death almost triple that of hospital birth. You gave all sorts of excuses as to why they didn’t need to use that group. Johnson and Daviss have since publicly acknowledged on their onw website that I am correct. You have not acknowledged it, and instead (as far as I can tell) deleted the posts you wrote in support of the wrong control group.

    3. Maria pointed out to you in another post that the World Health Organization 2006 report on perinatal mortality (which shows that the US has a lower rate of perinatal mortality than Denmark, the UK and the Netherlands) and that this cannot be reconciled with your public claims that the US has a higher rate of perinatal mortality than other first world countries. Fortunately, you now acknowlede that the US perinatal mortality rate is comparable to other developed countries.

    Finally, I would appreciate it if you would stop insinuating that I am not who I say I am, that I do not have the credentials I list in my CV (Harvard ’79; BU School of Medicine ’84; Boston’s Beth Israel Hospital internship, residency, staff appointment OB-GYN, Brigham and Women’s Hospital staff appointment, Harvard Medical School Instructor in Clinical Obstetrics and Gynecology) or that I am in the employ of ANY organization. A public apology for your completely baseless, fabricated accusations would be appropriate. If you promote such obvious and easily checked falsehoods about me, people might begin to think you are using the same tactic to promote homebirth.”

  • invalid-0

    Stay tuned for more fact checking….. but meanwhile check this out. Again, took less than a minute.

    From a post from Women to Women Childbirth Education
    July 10th 2008
    Homebirth Debate
    Some people might call it merely “skewing the information”, but she (Amy Tuteur) repeatedly says that the Johnson & Daviss CPM Home-Birth Study (published in the British Medical Journal in 2005, undertaken in 2000) shows a 2.5/1000 neonatal death rate, but that only happens if you count the intrapartum deaths as live births. However, intrapartum deaths are by definition stillbirths; and stillbirths are by definition *not* included in the NMR, but that doesn’t stop her from saying that these intrapartum deaths should be counted as NMR because they would have been born alive had they been in the hospital. (Oh, did I mention she sometimes confuses herself with God? Actually, from some of her comments, I have reason to suspect she’s an atheist or agnostic, and she’s extremely demeaning to those who mention religion at all, specifically jumping down the throat of someone who said that the female body is “designed” to give birth — she took offense because she believes in the blind chance of evolution and bristled at the term “design.” I’m not meaning this in a flaming way to anyone who may also be atheistic, agnostic, or believe in evolution, just showing that she can’t even respect religious beliefs or differences…. or at least, not as long as they’re espoused by pro-home-birth people.) I repeatedly asked her for stats that showed what the intrapartum death rate is in hospitals, because it isn’t mentioned in the Vital Statistics Report (intrapartum deaths would be a subset of stillbirths), but of course she never provided any evidence to back it up. And one of those intrapartum deaths happened because of AROM in the hospital. But that shows that homebirth is risky, right?)

  • http://homebirthdebate.blogspot.com invalid-0

    “When you perform the same query Dr. Amy did, except take out cause of death due to congenital and chromosomal abnormalities or defects, you get the following death rates per 1000:
    CNMs: 0.25
    MDs: 0.33
    DOs: 0.34
    other midwife: 0.34″

    What you’ve just shown is that homebirth with a DEM has the same neonatal death rate as low, moderate and high risk hospital birth with an MD, (including all pre-existing medical conditions, and all possible pregnancy complications). That’s yet another indication that homebirth has an excess rate of preventable neonatal death. For an accurate comparison, you need to go back and pull out all the pre-existing conditions and pregnancy complications in the MD group (and the CNM group) and recalculate. When you do that you find that the neonatal death rates per 1000 are:

    CNMs: 0.21
    MDs: 0.24
    other midwife: 0.34

    No matter how you slice and dice the data, the conclusion is still the same. The most dangerous form of planned delivery in the US is homebirth with a direct entry midwife.

  • invalid-0

    Below is the result I obtained when I queried the CDC Wonder Statistics for the year 2003-2004:

    Attendant Deaths Births Rate per 1,000 births
    CNM 909 308113 2.95
    MD 25361 3571460 7.10
    DO 1069 185981 5.75
    Other 352 19711 17.86
    Other Midwife 52 17786 2.92
    Unknown/missing 116 9004 12.88
    TOTAL 27860 4112055 6.78

    Obviously there are limitations to interpreting these statistics.

  • http://homebirthishealthy.org invalid-0

    One problem with birth certificate data is coding. For example, for many years in IL, student nurse midwives were coded as “other midwife”. Home birth activists discovered this when trying to figure out the why approximately 1000 births annually, attended by “other midwife,” occurred in hospitals.

    Carefully designed and executed prospective studies are need to get at these answers.

  • http://homebirthdebate.blogspot.com invalid-0

    “For example, for many years in IL, student nurse midwives were coded as “other midwife”

    But that didn’t happen here, since the attendant was the person who signed the birth certificate and student midwives aren’t allowed to sign birth certificates.

    “Carefully designed and executed prospective studies are need to get at these answers.”

    Funny you should mention that. The Midwives Alliance of North America (MANA), the DEM trade organization, has collected detailed safety statistics on CPM attended homebirths since 2001, but they are hiding the results. They have publically offered the statistics to organizations that can prove they will use them for the “advancement of midwifery”. Even then, before being allowed to see the statistics, you must sign a legal non-disclosure agreement which prohibits you from sharing any data with anyone else. MANA is hiding its OWN safety data! It does not take a rocket scientist to suspect that MANA’s own data shows that homebirth with a DEM increases the risk of neonatal death.

    All the existing scientific studies (including the Johnson and Daviss BMJ 2005 study) already show that homebirth has an increased rate of neonatal death. The latest CDC statistics merely confirm that.

    People keep trying to change the subject, and I’m not suprised since there is no data to support their position. The fact remains (and despite 20 comments, no one has presented ANY data to show otherwise), all the existing scientific evidence, and the CDC data show that homebirth with a DEM increases the rate of neonatal death. The only people who appear to be unaware of this are homebirth advocates.

    • invalid-0

      How is it that some 6000+ hospital births took place with “other midwife” in attendance?

  • invalid-0

    It’s not just my opinion. Other groups who are really good at looking at data have made recommendations based on the scientific evidence. Of course midwifery organizations such as ACNM (American College of Nurse Midwives), MANA (Midwives Alliance of North America), NACPM (National Association of Certified Professional Midwives),CfM (Citizens for Midwifery) CIMS (Coalition for the Improvement of Maternity Services) and the Big Push for Midwives advocate for midwifery care in hospitals, birth centers, and in homes. Midwives would be expected to believe in midwives. But there are neutral organizations which support midwifery care and out of hospital births. The APHA (american public health association): “Therefore, APHA
    Supports efforts to increase access to out-of-hospital maternity care services and increase the range of quality maternity care choices available to consumers, through recognition that legally-regulated and nationally certified direct-entry midwives can serve clients desiring safe, planned, out-of-hospital maternity care services,” WHO (world health organization) outlines care for pregnancy around the world (http://whqlibdoc.who.int/hq/2007/WHO_MPS_07.05_eng.pdf): Scroll down to page 4 to see who they recommend should provide the care–its midwives or people with “midwifery training” in EVERY situation involving a pregnant, birthing, or postpartum woman. NEVER a doctor without a midwife, even when the woman has become very very sick.

    The RCOG (The Royal College of Obstetricians and Gynecologists) and the RCM (Royal College of Midwives)–groups in England have this to say about home birth and midwives:
    “The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that
    labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.1–3 ”

    Unlike the ACOG statement and the AMA resolution, these organizations quote many scientific studies. I call that “interpreting the data”, maybe I’m not using that term correctly, but I sure agree with these expert groups in their conclusions. They spend a lot more time studying studies than I do.

    To quote a more powerful expert: I recently had the privilege to attend the birth of a physician (the mother is a physician–we shall see what the baby becomes) who is very familiar with all these studies and the arguments about what they mean. She pushed out her son into a tub of water, greeted him joyously, and moved to her bed to nurse. Three hours later as I was waving goodbye from the doorway of her bedroom, she said “This changes everything!” Indeed.

    Elizabeth Allemann, MD

  • invalid-0

    I have had the pleasure to work with midwives of several different types of training: CNM’s, CPM’s, and NC’s (no credentials). I have not worked with CM’s so I won’t speak of them except to presume they have excellent training as well.

    I can make this generalization:

    All of these midwives emerge from their training filled with enthusiasm, lots of book learning and relative inexperience. Like all new professionals, they are eager to consult, ask for advice, and to have help as they continue to learn as they practice. As years and births go by, they become more seasoned. Physicians are like this, too.

    Apprenticeship seems to lead to lots of hands-on confidence and a little less confidence with the “quote the latest article” type of debate and those who go to a school emerge with lots of confidence on the latest science and less confidence with the hands-on stuff. There were similar issues as I compared community-based residencies with university-based residencies.

    CPM’s and CNM’s and NC’s in my experience have similar training and preparation for their work. In today’s maternity care crisis, we need them all.

    Elizabeth Allemann

  • http://homebirthdebate.blogspot.com invalid-0

    Dr. Alleman,

    You titled your first comment “Data Support Midwives”, but you haven’t presented ANY data.

    I pointed out that there is not a single scientific paper that shows homebirth to be as safe as low risk hospital birth in the same year. You have not offered any data to contradict that claim. I also supplied the data from the CDC 2003-2004 linked birth-infant death dataset that shows that the most dangerous form of planned birth in the US is homebirth with a direct entry midwife. You have not offered any data to contradict that claim, either.

    It does not matter who does or does not support homebirth. It only matters what the evidence shows and you have supplied no evidence.

    “CPM’s and CNM’s and NC’s in my experience have similar training and preparation for their work.”

    But they don’t. Certified nurse midwives have university degrees, masters degrees in midwifery and extensive hospital based training in the diagnosis and management of childbirth complications. Certified professional midwives have high school degrees, can attend midwifery school by correspondence course, cannot transfer to another university because credits from most midwifery schools are not accepted by other universities, are required to attend only 20-40 deliveries, and have no training in the diagnosis and management of complications.

    American CPMs do not have enough education or training to be licensed in the Netherlands, the UK, Australia, Canada, ANY first world country. Why shouldn’t CPMs meet the SAME standards of ALL other midwives in the industrialized world?

  • http://www.ncfom.org invalid-0

    As it turns out, Amy, we are just weary of torturing the numbers with you. It was fun in 2006, but now it is mostly just tiresome (like the never ending repair of graffiti). You embrace Pang’s conclusion and flawed retrospective methods. We embrace the indifference in neonatal outcomes illustrated in Johnson & Daviss, but recognize that birth is not without risk. You exercise the Wonder Site without considering congenital anomalies and declare victory. We screen for congenital anomalies to assess the relative safety of the setting and the care provider and show equivalence in neonatal outcomes (see the query below). You declare women who extol their home birthing experiences as selfish competitive mommies. We weep for the mothers who birth alone because they do not have access to care. You celebrate the terrific obstetrical process capability we have today with C/S. We applaud the capability, but recognize that some mothers do not survive it and that some families lose their ability to create children because of it and consider that in the analysis of safety in light of the current C/S rate of 31%. Your advice to women concerned about the birthing process is to go find a concierge obstetrician who will nurture them like a midwife. We fight to assure that women who choose to birth at home have access to care.

    The rhetoric is getting old, Amy. Compelling women to birth in hospital will not solve our problems. Addressing maternal health and access to care should be our focus (one element of this is the onerous environment in which obstetrics is practiced). Instead, we will all just dance this dance until women who choose to birth at home have access to care (because that is where we will land).

    Russ

    CDC Wonder Site results for white women, 37+ wks gestation, 20-45 yrs old, singleton, with congenital anomalies removed. Analysis basis inputs provided.

    Notes Deaths Births Death
    Rate
    Certified Nurse Midwife 59 268602 0.22
    Doctor of Medicine 1013 3117333 0.32
    Doctor of Osteopathy 57 189133 0.30
    Other 21 19143 1.10
    Other Midwife 8 25702 Suppressed (0.31)
    Unknown or not stated 4 9292 Suppressed

    Dataset: Linked Birth / Infant Death Records, 2003-2004
    Query Parameters:
    Title:
    Age of Infant at Death: Under 1 hour, 1 – 23 hours, 1 – 6 days, 7 – 27 days
    Age of Mother: 20-24 years, 25-29 years, 30-34 years, 35-39 years, 40-44 years
    Birthplace: All
    Birth Weight: 2500 – 2999 grams, 3000 – 3499 grams, 3500 – 3999 grams, 4000 – 4499 grams, 4500 – 4999 grams, 5000 – 8165 grams
    Delivery Method: All
    Education: All
    Gender: All
    Gestational Age at Birth: 37 – 39 weeks, 40 weeks, 41 weeks, 42 weeks or more
    Hispanic Origin: Non-Hispanic White
    ICD-10 130 Groups: All
    ICD-10 Codes: A00-B99 (Certain infectious and parasitic diseases), C00-D48 (Neoplasms), D50-D89 (Diseases of the blood and
    blood-forming organs and certain disorders involving the immune mechanism), E00-E88 (Endocrine, nutritional and metabolic
    diseases), F01-F99 (Mental and behavioural disorders), G00-G98 (Diseases of the nervous system), H00-H57 (Diseases of the eye
    and adnexa), H60-H93 (Diseases of the ear and mastoid process), I00-I99 (Diseases of the circulatory system), J00-J98 (Diseases
    of the respiratory system), K00-K92 (Diseases of the digestive system), L00-L98 (Diseases of the skin and subcutaneous tissue),
    M00-M99 (Diseases of the musculoskeletal system and connective tissue), N00-N98 (Diseases of the genitourinary system), O00-O99
    (Pregnancy, childbirth and the puerperium), P00-P96 (Certain conditions originating in the perinatal period), R00-R99 (Symptoms,
    signs and abnormal clinical and laboratory findings, not elsewhere classified), U00-U99 (Codes for special purposes)
    Live Birth Order: All
    Marital Status: All
    Medical Attendant: All
    Month Prenatal Care Began: All
    Plurality or Multiple Birth: Single
    Race: White
    Regions: All
    States: All
    Year of Death: All
    Group By: Medical Attendant
    Show Totals: True
    Show Zero Values: True
    Calculate Rates Per: 1,000

  • http://www.icanofnova.org invalid-0

    I’ll comment with quotes from others and then with one quote from myself.

    1) The resolution did not offer any science-based information for the AMA’s anti-midwife or anti-home
    birth position.
    “Maternity care is a multi-billion dollar industry in the United States,” said Steff Hedenkamp,
    Communications Coordinator for The Big Push for Midwives. “So it’s no surprise to see the AMA join the
    American College of Obstetricians and Gynecologists in its ongoing fight to corner the market and ensure
    that the only midwives able to practice legally are hospital-based midwives forced to practice under
    physician control. I will say, though, that I’m shocked to learn that the AMA is taking this turf battle to the
    next level by setting the stage for outlawing home birth itself—a direct attack on those families who choose
    home birth, who could be subject to criminal prosecution if the AMA has its way.”

    2)- (CNN) — An estimated 2 million babies die within their first 24 hours each year worldwide and the United States has the second worst newborn mortality rate in the developed world, according to a new report.
    –(Since less than 1% of births in the US are home births. It would seem those deaths are occuring in hospitals with highly educated doctors and nurses.)

    3) Don’t let schooling interfere with your education.
    Mark Twain

    4) My experiences between a hospital managed birth and a home birth are vastly different. My hospital birth was emotionally and physically scarring. My OB was highly educated yet sorely lacking in understanding of normal unmedicated birth.
    My subsequent home birth which were assisted by 2 CPMS and 1 Doula that were all college educated, experienced in normal birth including VBACS (which are, sadly now, becoming the norm) and came highly recommended, made my hospital birthing experience in comparison seem barbaric!
    I recommend that all childbearing aged women do the research on their own, seek out groups who support their view of normal birth (I did with ICAN- a non-profit organization.) and find qualified, experienced and recommended birthing professionals.

  • invalid-0

    Dr Amy,
    You are incorrect about ALL DEM training in the US. In Florida where DEM’s are Licensed Midwives they are required to attend a 3 year accredited program along with an extensive clinical component that requires attendance at 75 births, most CNM’s are only required to attend 25 births.

    In addition to the 75 births, 50 of which must be primary management by the student midwife under direct supervision of either a Licensed Midwife, CNM, or OB, she must also perform at least 50 prenatal, postpartum, and newborn examinations. At least 4 of these must include continuity of care, meaning that the student provides prenatal, birth, postpartum, and newborn care to the same woman.

    I did recieve an Associates in Science degree in Midwifery, which I am aware is NOT the same as the CNM required bachelors degree, but you cannot say that DEM’s do NOT have college degrees, my credits ARE transferable!

    I had extensive education & training in the management of prevention of complications in addition to the diagnosis & management of complications. I am a specialist of NORMAL BIRTH, I had 3 years of clinical internship, and am highly capable of recognizing when a mom & baby need to be in the hospital and when transfer needs to happen. My hospital transfer rate is 10%, 99.9% of my transfers are non-emergency transfers, with a c/s rate of 6%, and NO neonatal deaths in over 300 births.

    The State of Florida tracks statistics for it’s Licensed Midwives and as a state we have excellent outcomes!

    2005 was the most recent posted data on the State of Florida Department of Health Council of Licensed Midifery website:

    With 38 practicing Licensed Midwives (DEM’s)
    18 provide homebirth, 20 work in birth centers
    1069 women gave birth, 234 gave birth at home, 571 gave birth in a birth center, the others were transfered to the hospital.

    138 women were transfered during pregnancy, 126 transfered during labor: of those, 264 gave birth vaginally, 3% of antepartum transfer had c/s, 6% of labor tranfers had c/s resulting in 99 c/s equaling an 8.5% c/s for women under the care of a Licensed Midwife.

    7 women were transfered for postpartum complications, 11 babies were transfered after birth.
    There were no maternal deaths, no infant deaths, only 1 fetal death at 29 weeks of pregnancy that was delivered at the hospital.

    Timely Prenatal Care
    with LM 96.86%
    with all other Providers 95.3%

    Adequate prenatal care
    LM 74.35%
    with all other Providers 76.12%

    Births over 37 weeks
    LM’s 95.29%
    All other providers: 83.44%

    Normal birth weight
    (>2500 g)
    LM 98.88%
    All other providers 89.64%

    Infants that Receive Healthy Start Screening
    LM’s 50.15%
    All other providers 26.99%

    I think you are doing exactly what you are accusing other people of doing Amy, making blanket statements about something in which you do NOT have all the FACTS!

    Licensed Midwife, CPM, DEM in Florida

  • invalid-0

    The AMA and ACOG’s recent resolutions against home have propelled U.S. women and their families to greater action in order to achieve legal and safe access to out of hospital birth. We are pushing to reclaim normal birth. We are pushing against the increasing rates of c-section and induction, which have resulted from the increasing medicalization of birth. We are pushing to birth in the location of of our choice. We are pushing for legislation to protect the birth provider of our choice. My state, NC, currently denies licensure for the only health care providers trained in out of hospital birth (CPMs.) My state also has numerous counties without obstetrical care. In counties where maternity care is provided, many have poorly staffed clinics. Women have to wait for weeks for an appointment to see a maternity health care provider. CPMs are willing to travel many miles to provide quality health care to their clients. CPMs provide prenatal care, care during labor, and post partum. They create relationships with their clients and with their families during lengthy and thorough prenatal visits. Our mothers and babies deserve the safe and excellent care provided by CPMs. They also deserve to benefit from positive relationships between midwives and hospital staff in case transfer of care is necessary. At a time when more and more obstetricians are trying to leave the field of birth, we need to find ways to increase access to care, not deny it. We need more midwives. We need not criminize them. It is inevitable that North Carolina and eventually other states who deny licensure will have to license CPMs. Families throughout the U.S. will continue to push for this change until it happens.

  • invalid-0

    A correction to my last post: CPMs are not the *only* providers trained in out of hospital birth as I stated, though it’s the credential with which I’m most familiar. Obviously as the excellent post from the licensed CPM, DEM in Florida and Dr. Alleman show, there many excellent qualified home birth providers with a variety of training. Again, U.S. families need access to ALL these excellent maternity health care providers.

  • http://homebirthdebate.blogspot.com invalid-0

    The ultimate irony of the campaign to promote homebirth and license direct entry midwives will be to bring about the demise of direct entry midwifery.

    Direct entry midwives and their supporters have successfully tried to confuse American women on two critical points:

    1. Homebirth is KNOWN to increase the neonatal death rate
    2. American DEMs are grossly undereducated and undertrained compared to ANY other midwives in the industrialized world.

    The effort to license DEMs has already let to the national government’s collecting statistics on homebirth with a DEM. The first large data set already shows that homebirth with a DEM triples the rate of neonatal death compared to low risk hospital birth. This is consistent with all the existing scientific evidence on homebirth. Homebirth advocates will no longer be able to pretend to themselves or others that homebirth is safe.

    MANA, the trade union for DEMs, has been successful up until now at confusing people about the education and training of DEMs. They created their own certification (“CPM”) which is so close to CNM (certified nurse midwife) as to create confusion. Homebirth advocates routinely cite the practice of midwifery in European countries like the Netherlands, without bothering to explain the American DEMs are nothing like Dutch midwives and would never be considered qualified in the Netherlands. Dutch midwives, like ALL other midwives in the industrialized world are hospital trained with extensive experience in managing complications. In contrast American DEMs never have any hospital training and receive degrees from correspondence courses.

    MANA, the DEM trade organization, may continue to withhold the 7 years of safety statistics it has collected, but soon it won’t matter. The government is now involved and the truth can no longer be suppressed.

    Here is an interesting fact to ponder:

    Suppose that homebirth with a DEM were to increase from less than 1% of births (currently) to 10% of births. All the existing scientific evidence shows that homebirth with a DEM has an excess neonatal mortality rate in the range of 1-2/1000. That would mean 400,000 homebirths would lead to and excess 400-800 neonatal deaths per year. If homebirth with a DEM were to account for only 10% of American births, homebirth would become one of the leading cause of death of term babies in the US.

    • invalid-0

      Dr. Amy, you said that legalizing non-nurse midwifery will ultimately bring about the death of it. Why, then, do you not support such legalization in the states that do not yet have it? Isn’t the end worth it, in your eyes?

      Besides, I think I pretty easily showed that so much of the “excess” neonatal mortality rate is, at most, 0.09/1000, excluding genetic and birth defects. (And that’s without doing any statistical calculations to determine if the rate is significant or possibly only due to chance.) It also includes the 4 deaths from the possibly higher-risk 42+ week group. Unless, of course, going post-term is *not* a risk factor. It confuses me, to speak plainly, because I always assumed you would think post-dates is not low-risk, yet you included it in the so-called low-risk births you culled from the CDC stats. Excluding the 42+ week births actually makes the “other midwife” statistic the lowest NMR!

      How can that be?? I thought that “no matter how I sliced and diced the data” that such births were the riskiest form of planned birth! But in all seriousness, if 400,000 women chose home birth, at an apparent 0.09/1000 excess NMR, that would be an excess of 36 deaths, not 400-800 per year. If there were a current rate of 1% (40,000 births), there would be an excess of 3.6 deaths per year.

      You’ve stated “the issue is safety”. Is it? Really?? Look at the data for 2004: there is an excess of neonatal death of 3-4/1000 for both maternal smoking and being unmarried. Instead of roaming the blogosphere trying to convince some 20-40,000 women to give birth in the hospital, why not spend that time convincing just 1,000 women to give up smoking? You’d be likely to be more successful, while ostensibly saving as many babies’ lives!

      This study found there to be a nearly three-fold neonatal mortality rate when comparing C-sections to vaginal birth (1.77 vs. 0.62); and even when excluding certain risk factors such as congenital anomaly, the difference was “reduced only moderately.”

      Considering that a woman who chooses a home birth has probably less than a 5% chance of ending up with a C-section (typically about a 10% transfer rate, and most don’t end up with a C-section), compared to a 23.6% chance at a hospital, that makes a C-section about 5 times as likely to happen at a hospital for low-risk women. So, if these hypothetical 10% of low-risk women chose home birth, and reduced their chance of a C-section to 1/20 instead of 1/4, then there would be only 20,000 C-sections, instead of 100,000. Also, reducing “moderately” the figures in the above-mentioned study (to exclude fetal anomalies, etc., giving C-section a hypothetical 1.4 NMR instead of 1.77), the excess 80,000 “unnecesarians” would yield an excess 62 neonatal deaths. (There would be a predicted 1.4/1000 for 100,000 C-sections, or 140 deaths, vs. 28 deaths out of the 20,000 C-sections; plus 0.62/1000 for the 300,000 or 380,000 vaginal births.) So, even if home birth yields an excess of 0.09/1000 deaths for low-risk women, and 36 babies out of a hypothetical 400,000 died, over 62 others would live that would have died, because they had been born by C-section.

      So, the current neonatal mortality rate in babies born to low-risk women by (many times unnecessary) C-section is almost doubled that of the same hypothetical group that chooses a home birth.

      Safety? Yeah, right.

  • invalid-0

    to say thank you to all who have commented thus far. RH Reality Check was created to act as a bridge to connect professional advocates, providers, online news readers, bloggers, activists and all who wish to join in the conversation about reproductive and sexual health news and information.

    I am awe-inspired by the conversation and appreciate the time, energy and passion you are all contributing in an effort to exchange information and vet the rhetoric put forth by some who do not wish the information to be out there and shared.

    As a long time reproductive health advocate and mother of two – both born with the help of CNMs and doulas in a birthing center – I was immediately struck, after their births, by how similar and yet disconnected the reproductive health discussion around abortion & contraception as compared to maternal health, childbirth and pregnancy are. If we do not ensure, across the board, that women have the access to care, information and services they need, we are compromising women’s health and lives. The decision to birth with a particular provider, in a particular location should be left to the woman, her family and the care giver they choose.

    We know from having battled the anti-choice forces for years that they will come up with anything and everything to support their ideology rather than work to address the real, critical issues: improving maternal health, ensuring access to care, and guaranteeing women’s human rights are respected by allowing for freedom of choice.

    Thank you all for visiting and participating in the discussion! I hope some of you will consider pitching us stories on the issues for which you advocate and those we cover, as well as signing up for our daily emails to continue participating as a valued member of our community!

    Amie Newman

    Managing Editor, RH Reality Check

  • invalid-0

    What the medical community is either ignoring or missing is that “consumer-driven health-care” is finally hitting their OBGYN community and hitting them hard.

    Pregnant women are demanding birth in the facility and with the provider they choose. With skyrocketing c-section rates, terrible mortality numbers, and ridiculous hospital policies, women are demanding and choosing an alternative to birthing in hospitals.

    Instead of recognizing this demand, the AMA – and it appears from these posts, Dr. Amy – are trying to bully women into believing that the only place to birth a baby is in a hospital under their control. What they don’t understand is that by the stance they are taking, they will continue to alienate more and more women, such as myself.

    From my experience, very few OBGYNs have even seen a birth take place anywhere other than a hospital, yet they are ready to attack it. Perhaps if more OBGYNs opened themselves up to witnessing midwife care and homebirths/birth center births, we could all start a dialog on how to PARTNER TOGETHER to move maternal care into a positive direction and lead the world instead of ranking so low.

    We need midwifery AND OBGYNs. AMA AND ACOG: Let’s start working together and stop the nonsense of “outlawing” birth that doesn’t line your pockets. Let the politicians and police take care of the real “outlaws”, and get back to focusing on babies.

  • invalid-0

    Dear Sylvia,

    Thank you for your graciousness and humility in issuing a correction. Your statement about CPM’s being the only maternity care professional with home birth experience was close to true and I knew what you meant. It is true that CPM’s are the only professionals REQUIRED to train outside the hospital. Some CNM’s and even fewer physicians are witnesses to home birth or birth center births in their training. I was FORBIDDEN to attend home birth and discouraged from speaking with home birth families when I was in training. CPM’s deserve to claim that they have the only credential which ensures the public that they have had training in out of hospital birth.

    Elizabeth Allemann, MD

  • invalid-0

    Well done.

    Once again, however, I need to point out that your conceptual understanding related to the importance of licensing is flawed and your analytical projection is, well, just plain wrong.

    On the subject of licensing, you need to understand that it serves a number of purposes. First of all, it promotes access. This is probably the element that most bothers you and your colleagues. I recognize that ACOG’s objective is to force women into the hospital by denying them access to care. This strategy is partially successful in that some women who do not have access to home birth midwifery care do settle for the hospital; however, some women birth at home unattended in the absence of midwifery care, and any excess bad outcomes associated with unassisted birth due to lack of access should be assigned to ACOG. Secondly, licensing allows the consumers to differentiate between credentialed and non-credentialed care providers. Thirdly, it provides a mechanism to assure the standards of care are maintained. In light of your long standing heartburn with the CPM’s training being largely in a clinical setting, I would think you would embrace the regulatory aspects of licensing. Also, it is a first step toward collecting state specific data. Whether you like home birth or not, and whether you like CPMs or not, everyone should support licensing as 1) women will choose to birth at home and they deserve access to care and 2) the CPM is the care provider that attends them. Also, Direct Entry Midwives have been licensed in the US since the late ‘70s and while some regulatory environments are better than others, it is generally considered beneficial. The only one that doesn’t really work at all is Delaware which requires a physician’s signature to obtain a license and ya guys won’t do it, so there is only 1 licensed midwife in the state. Without question, the midwives must be licensed for autonomous practice. One other thing to keep in mind is that contemporary licensing statutes tend to include provisions to protect any other care provider from any liability due to negligence on part of the midwife (even though this is largely for peace of mind for the obstetricians and hospitals as bad outcomes are rare and law suits are even more rare). To my knowledge, these provisions have not been exercised. In summary, licensing is the right answer from every perspective unless your objective is to deny women informed consent and sovereignty over their birthing decisions and constrain them to the hospital.

    With regard to your projections of a world in which 10% of births are planned home births with a CPM, we need to make a number of corrections. To begin with, it has already been demonstrated that your claims of 1-2 excess bad outcomes per 1000 births are incorrect. When the CDC Wonder Site data is screened for congenital anomalies, the neonatal mortality rate is indistinguishable for healthy women experiencing normal pregnancies. This is consistent with Johnson and Daviss’ findings. Furthermore, this terrific performance is in an environment in which there is very little infrastructure supporting planned home birth. Clearly claiming an excess mortality rate as high as 2/1000 is a gross exaggeration as the aggregate neonatal mortality rate in the CPM2000 study was 1.7/1000. To illustrate the flaws in your projection designed to scare and bully women into the hospital, let’s for talking purposes analyze an excess rate of 1/1000 in an evaluation of overall safety in the state of North Carolina. I prefer analyzing NC as I have a statewide evaluation of outcomes using the Perinatal Period of Risk Methodology.

    To begin with, we have about 120,000 births per year in NC. Our overall perinatal mortality rate is about 12.5/1000 (http://209.217.72.34/VitalStats/TableViewer/tableView.aspx). For anyone who is not familiar with the perinatal mortality rate, it is the number of deaths in the fetal period (from 20 weeks gestation, depending on convention) plus the intrapartum period (from the onset of labor until birth) and the neonatal period (from birth to 28 days post-partum). In NC we lose about 1500 babies a year. Applying Amy’s little experiment to NC, if 10% of women chose to birth at home with a CPM, that would translate into about 12000 planned home births per year. Using Amy’s (baseless, exaggerated and politically charged) value for excess bad outcomes of 1/1000, we would expect 12 preventable bad outcomes per year (out of 1500 total) due to the planned place of birth (we lose over a thousand lives every year to traffic accidents in NC). It is obvious that this hypothetical large home birth population would not significantly impact our overall perinatal mortality rate even with your inflated values. This simplistic view, however, is grossly inadequate to perform safety analysis.

    Now let’s examine the sources of our excess bad outcomes during the perinatal period. The Perinatal Period of Risk Methodology is an analytical tool to assess outcomes in order to aid leaders in health policy on what actions to take. Premature, low birth weight babies (from 500-1500 grams) that do not survive after 24 weeks gestation are placed in the Maternal Health category. In NC, when the overall mortality rate is compared to a low risk group in this category, it is concluded that there are over 200 excess bad outcomes per year due to poor maternal health. We don’t really know how much of this hypothetical home birth group representing 10% of births in NC would be at risk for poor maternal health, but given we are performing a thought experiment, let’s assume it is representative of the overall population. So there is an opportunity to prevent 20 bad outcomes due to poor maternal health. We know that midwifery care is much more effective at promoting health than obstetric care. Let’s assume a 50% improvement resulting in the prevention of 10 bad outcomes due to poor maternal health. The overall perinatal mortality rate is now indistinguishable due to better maternal health offsetting Amy’s (baseless, exaggerated and politically charged) rate of excess bad outcomes of 1/1000.

    Now let’s turn our attention to the mother. In the home birth group, we would expect a 4% C/S rate (480 total out of 12000 births). Had those women planned to birth in hospital, their C/S rate would have been 20% (2400). We know there is an excess rate of maternal deaths and hysterectomies due to C/S. Focusing first on hysterectomies (lost opportunity dead babies), rates of hysterectomy are approximately 0.03/1000 for vaginal birth, 0.6/1000 for the first C/S, 0.8/1000 for the second C/S and 5/1000 for subsequent sections. So, approximately 2000 sections are eliminated preventing the loss of fertility for 1-3 women every year. As an aside, one of the fastest growing segments of the home birth community are women who have endured C/S in the past and don’t trust that their birthing decisions will be respected in the hospital. As for maternal deaths, we know the rate of maternal deaths are under reported. In NC, the maternal mortality rate has been reported as 0.12/1000 during the 10 year period from 1987-1996. In addition to being underreported, it is likely higher today in light of the current C/S rate. We know that women undergoing C/S are 2 to 4 times more likely to die in childbirth than women who birth vaginally, so let’s say that the maternal mortality rate is reduced by 50% due to the reduced C/S rate and better maternal health. This hypothetical large home birth group in NC would then save one mother every other year or so. As we all know, the Golden Rule of Obstetrics is that the mother always comes first, so this is a significant difference.

    There are myriad other defects in the bucket of morbidity associated with interventions and hospital birth (e.g. episiotomy, birth injury due to forceps and vacuum extraction, infections, etc…). Let’s not forget, also, that millions of dollars would be saved every year which will further improve the lives of the families of North Carolina.

    So, what’s the conclusion in this Friday evening comprehensive analysis of safety in a North Carolina in which 10% of women choose to birth at home with an artificially high assumption on neonatal mortality? Well, it would be a terrific North Carolina that steadfastly supports and defends our mothers and families. In reality, as neonatal outcomes for planned home birth are indifferent to hospital for healthy women experiencing normal pregnancies, we would actually have better outcomes due to better maternal health, higher quality of care and reduced cost in this wonderful North Carolina in which 10% of women birthed at home and attended by trained, credentialed and licensed midwives.

    Clearly, the key intervention to protect our children is to not let them drive a car!!!! Here’s wishing you a terrific weekend, Amy.

    Russ

  • invalid-0

    If a home birth patient is transfered to the hospital for complications she most certainly WOULD get treated by the staff ob on call in that hospital!
    The fact that you would even suggest she would not be treated makes me cringe! It is not true.
    I am very sorry for the medical community that they are so worried about their malpractice insurance they would put that first before patient care. But the fact that you would try to imply that a woman who attempts a home birth would not receive the same care if transfered to hospital is abusive and untrue!
    Because of the medical communities’ stance on VBAC, some women only have the choice to home birth or to arbitrarily sign on for a repeat surgical procedure to cut down on the ob’s risk. Does that sound like ACOG is giving these women a choice?

  • invalid-0

    you missed the point. The insurance carriers and hospitals are telling their doctors they can not do VBACs, not the “medical community.” Every bad outcome from an attempted VBAC or an attempted home delivery is guaranteed multimillion dollar verdict against the doctor. Why would an ob risk her career and practice in these situations?

  • invalid-0
    • invalid-0

      Unfortunately, this story and many like it are not rare…

      http://www.caringbridge.org/visit/kaitlynlee
      This is a memorial website for my daugher Kaitlyn who died at 3 years of age from the injury she sustained at birth-in a hospital by doctors who should know better.

  • invalid-0

    It might be worth pointing out that midwives sucess rates SHOULD be considerably higher than hospitals because they generally work only with women whose pregnancies are not considered high risk.

  • invalid-0

    …not all women who choose home birth *are* low risk. Some midwives may attend births of twins, or breech births, or post-term births, etc.

    If you look at the home birth stats, 19 deaths are due to congenital anomalies and genetic defects (which very easily could be not related to birthplace at all). Of the remaining 10, one of those deaths is due to diaphragmatic hernia (which is unlikely to have been affected by place of birth); and four of the remaining deaths were in the 42+ week group, which is at higher risk for problems with post-maturity. Three of the four deaths were due to birth asphyxia (most likely due to aging placenta), and one was to a generic “labor complication.” Since the “42+ week” group isn’t broken down, it’s impossible to tell how much after 41 weeks they are.

    Looking at births from just 37-41 weeks (same low-risk group as above, with deaths due to congenital anomalies, genetic defects and “outside causes” [homicide, accidental death, etc.] removed), the “other midwife” death rate is 0.17/1000, for CNMs it’s 0.22/1000 and for MDs it’s 0.32/1000.

    Looking at deaths due just to infectious/parasitic diseases, pregnancy, childbirth and the puerperium, and certain conditions in the perinatal period (I leave in the infections because babies are more likely to catch an infection in a hospital than at home with just family around, instead of hundreds of people in one building, and possibly dozens of caregivers, not to mention the multitudes of sick people that go to hospitals), the “other midwife” rate is 0.13/1000, for CNMs it’s 0.14/1000, and for MDs it’s 0.20/1000.

    The fact that some midwives may in fact attend higher-risk births is a very important reason to have a study that matches a group of midwifery clients to those attended by doctors. For one thing, many women who seek home birth are unlikely to have abortions for religious reasons (the Amish, for example) but are more likely (due to generations of intermarriages) to have babies with birth defects. They are also more likely to have large families, and the risk of neonatal death increases with 5+ children. Just as women who seek home birth tend to be white (93% compared to 79% in the CNM & MD births), they also tend to be less likely to smoke, which in itself is a risk factor in preterm birth and neonatal death. There may be other factors.

    Preferably, this matching would begin in the early part of pregnancy, to see how pregnancy outcomes might differ between the groups, if at all. For example, how many women risk out of the midwife-attended group during the course of the pregnancy? Are there any differences in the rates of perinatal death or stillbirth? Or inductions or C-sections? Of episiotomies and NICU admissions?

    And these questions of strict mortality and morbidity do not even take into account maternal satisfaction, breastfeeding rates, and family concerns (having older children there to welcome the new baby, not having the mother taken away from her other children, not having the new baby taken unnecessarily from his or her mother, etc.), and many other things.

    Having low rates of infant death at home births of low-risk women just adds to the other benefits of home-birth.

  • invalid-0

    so if I understand your stats – more than 50 % of the 19 deaths could have been avoided by in hospital birth?

    “Aging placentas” can be detected by ultrasound. “Birth asphyxia” could be detected by continuous monitoring during labor. Diaphragmatic hernia can be fixed by surgery in the newborn period.

  • invalid-0

    It’s anybody’s guess whether any of the deaths due to congenital anomalies or genetic defects could have been prevented by having been born in the hospital. Only by going through them on a case-by-case basis can it be determined if any of the deaths were at all affected by place of birth. (Of two home-birth deaths I’m personally aware of, one was due to multiple congenital anomalies — a hopeless case, despite being in the hospital for most of her 3-day life; and the other due to a malformed heart — the baby died on the operating table at 3 weeks of age, but otherwise would have lived beyond the neonatal period only to die at a projected 6-8 weeks of age — the surgery was his only hope, but he didn’t have good odds of surviving it, which he didn’t.) Most cases of Down Syndrome (using this as an example, since it is a common genetic occurrence) are not lethal; but sometimes the genetic defect can cause a lethal heart defect or some other lethal anomaly. Just because a woman who carries such an affected fetus chooses to give birth at home does not make home birth “risky”, in the sense we are using it, especially for normal babies.

    Many home-birthing women choose to avoid all prenatal testing including ultrasound and genetic testing; therefore, they will not have an abortion for known fetal anomaly, simply because the defect is unknown until birth. Therefore, it is more likely for babies in planned home births to have defects, because they are not aborted, whereas some in the planned hospital births would be. It is possible that for these at-risk babies, that having been born in a hospital would have helped; it’s also possible that nothing could have been done.

    If you look at the baby who died diaphragmatic hernia, the death occurred within an hour of its birth. It’s possible the baby was rushed to the hospital and an immediate operation was performed and he or she died on the operating table; it’s also possible that even immediate surgery would not have helped.

    I agree with what you say about aging placentas being detectable by ultrasound; and here’s where it gets a little sticky. Many women who choose home birth will refuse ultrasounds or any other test or intervention, even when they go post-dates. Since 3,000+ births happened in the 42+ week home-birth group with only 4 deaths (plus 2 more for anencephaly and a genetic defect), the odds are still pretty good for nothing to go wrong, but it is a riskier proposition. Continuous monitoring may help, but there are still babies in the hospital group who died of birth asphyxia, so it is not a 100% guarantee.

    There are some cases when women should definitely go to the hospital. Most women don’t meet those criteria. There are some women “in the middle”, with some people thinking they should birth in the hospital, while others think it’s safe to birth at home. To further compound the problem, there are some unsafe or less-safe midwives who will resist a transfer even when they should go to the hospital (there are bad apples in every profession); and there are also some women who will absolutely refuse to go to the hospital (perhaps for religious convictions, if nothing else), even when it is evident that something is wrong and the midwife strenuously urges the mother to transfer.

    I guess to sum up what I’m saying, there’s more to the stats than meets the eye. My knowledge of home birth is such that I can see “behind the scenes” as it were. I’ve heard and read many stories which show a broad range of experiences that confirm what I have written above. How much this affects the question of the safety of “other midwife” and home birth remains debatable. From looking at the details of the statistics — such that I can find, especially the cause of death for home-born babies — I still see that home birth is safe for low-risk women and babies.

    If some people are concerned about women choosing home birth, I suggest that the better way to deal with the situation is to see why women choose home birth, and to see what they can do at hospitals to make them more attractive than home for birthing. Instead of legislating away a woman’s choices, they should actually **listen** to women and respect them enough to be accommodating to their desires, instead of just ignoring them like second-class citizens, whose desires and wishes are unimportant, compared to doctors and hospitals and protocols.

  • http://www.icanofnova.org invalid-0

    That was beautifully put.

  • http://floridnightingale.blogspot.com/2008/06/sexism-and-dangers-of-exclusionary.html invalid-0

    Birth attended by a certified nurse midwife is safer than the other options. CNMs have graduate degrees (mostly master’s) and many hours of clinical practice. Soon, all CNMs (like other advanced practice nurses) will have doctoral preparation. CNMs embrace parental choice and do not perform surgery. They’re expert at use of non-pharmacological, non-invasive techniques. They also have either collaborative relationships with MDs or their own privileges to admit a woman to a hospital in an emergency.

    Like others, I am skeptical of any organization that is unwilling to share its data – what could the lay midwives have to hide?

  • invalid-0

    I, too, don’t like that MANA won’t release the stats, but considering how Dr. Amy (and undoubtedly others) have skewed all other stats and data, I don’t blame them for being cautious. Look at what she did with the Johnson & Daviss BMJ study, as well as the 2003-2004 CDC stats — saying that it’s the fault of midwives for happening to attend the births of so many babies who had congenital/genetic problems, all the while knowing that many of these babies, and perhaps all of them, could not have survived regardless of where they were born. She persistently says the intrapartum deaths are actually live births and therefore neonatal deaths; and she frequently asserts that all women who give birth at home are definitely in the low-risk category, when we all know that that is not always the case. As I pointed out previously, there are some women who will give birth at home even if they are not technically “low-risk”, but in fact give birth to breech babies, twins or triplets, post-dates babies, as well as typically being older and of higher birth order. All of these things can skew stats, and she knows it. But she insists on painting a very bleak picture of giving birth at home. I can guarantee that if she had her claws on MANA stats, she would conveniently forget to say any of the possible risk factors or other confounding factors that might make it appear that home birth has an excess of neonatal or perinatal deaths.

    So, while I don’t like that MANA isn’t more forthcoming, I understand it, since I’ve been the victim of Dr. Amy’s convenient cut-and-paste jobs where she makes it appear that I’ve said something I didn’t. If she can do that to little ol’ me, what would she try on MANA?

    However, if you exclude 42+ week births, and deaths due to congenital/genetic problems, the CNM & “Other midwife” stats are identical.

  • invalid-0

    We don’t know about the MANA stats. That’s just Amy’s speculative claim. Call MANA to find out about it. We do know that — in general — data is usually only shared with legitimate researchers, and it’s very clear that Amy is no such thing!

    She should have been on the cover of Al Franken’s book, Lies (and the Lying Liars Who Tell Them).