Friday, January 31, 2014

New MANA Study Shows Increase Risk for Babies Born at Home



photo credit Michael Macfeat

So MANA has a new study to offer to look at home birth safety. All over the web it is being shared as proof that home birth is safe for babies… especially for those who read only the MANA press release and not the actual study.

This makes me so sad and so frustrated. So many women look to MANA - Midwives Alliance of North America - as a good source for home birth information and it just disgusts me how much that organization continues to lie, mislead, and tries so hard to pull the wool over women's eyes.

It is important to note the authors of this study are huge CPM/LM supporters (2 of the six are CPMs themselves and five of the six are on the MANA Division of Research Coordinating Council) so this is hardly unbiased. The information used for this study was on a VOLUNTARY basis and was SELF REPORTED by the midwives. From the study “Participation in the project was voluntary, with an estimated 20% to 30% of active CPMs and a substantially lower proportion of CNMs contributing” Just a couple of the many red flags…

A very interesting post written by a CPM/LM offers up some very interesting insight into how midwives submitted data for this study. They could submit data after the birth was over, which means they could select which births to include and which not to include. Click here to read it

For a more in-depth look at the MANA numbers, click here to read my series.

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Here is the new MANA study:


Let’s look at some numbers from the MANA study:

Intrapartum mortality rate = 1.30/1000

Neonatal mortality rate (including lethal anomalies) = 1.29/1000

Neonatal mortality rate (excluding lethal anomalies) = 0.77/1000

(Intrapartum mortality rate refers to babies that die during the process of labor and delivery. Neonatal mortality rate refers to babies that were born alive but die within the first 27 days of life.)

They were very sneaky in the study not to show numbers for comparison. They did not include hospital numbers for births in the USA. They compared to home birth outcomes in Netherlands and Canada and admit the mortality rates are higher in the MANA study but did not give any numbers. To quote the study: "The intrapartum fetal death rate among women planning a home birth in our sample was 1.3 per 1000 (95% CI, 0.75-1.84). This observed rate and CI are statistically congruent with rates reported by Johnson and Daviss[4] and Kennare et al[30] but are higher than the intrapartum death rates reported by de Jonge et al,[10] Hutton et al,[12] and Stapleton et al.[14] " So if you want to compare, you need to do some digging.

So let's do some comparing.

Now if you do look up in the CDC Wonder Data base for 37 weeks and greater, 2500 grams and great, white women (b/c it's over 92% white women in the MANA study), singleton, then you get a number that is closer to .38/1000 for hospital birth neonatal mortality rate with a CNM -- which is a closer comparison. This number for the hospital group includes lethal anomalies, so keep that in mind! This shows a risk of three times greater for babies born at home. I did a more in-depth look at the hospital numbers, click here to read it.

An easier way to get a good feel for this is using the CDC numbers from Vital Statistics, instead of going the CDC Wonder database route - because the Wonder Data Base can be a little confusing. If you read the Birth Center study (link below) that came out in 2013, they used the neonatal death rate of 0.75/1000 for hospital births to show a comparison, which comes from the CDC Vital Statistics and that number reflects ANY baby weighing over 2500 grams born to mothers of all races (so premature babies, lethal anomalies, *all high risk* pregnancies, women with no prenatal care, etc.... all risks and complications). Here is the vital statistics study where the 0.75/1000 neonatal mortality rate comes from:


Go to page 21, under all races, 2500 grams or more then look under the Neonatal column and you will see 0.75

So comparing that hospital neonatal death rate of 0.75/1000 to the neonatal death rate from this MANA study of 1.29/1000, including lethal anomalies since they are included in the hospital numbers, it, again, shows an increase risk to babies born at home. Keep in mind, that hospital rate includes ALL risks and complications, all races, even premature babies, any baby born that weighed over 5.5 pounds.

Now here is the Birth Center study. 


This study is based off of select Birth Center births in the United States and majority of the births centers included in this study were run by Certified Nurse Midwives (CNMs).... compared to the MANA study, which is mostly CPMs.


Intrapartum Motality Rate:
Birth Center study = 0.47/1000
MANA study = 1.30/1000

That is 2.7x greater risk reported in the MANA study.

Neonatal Mortality Rate (total neonatal, early plus late, for each):
Birth Center study = 0.40/1000 excluding anomalies
MANA study = 0.77/1000 excluding anomalies
Almost two times greater risk. 

TOTAL MORTALITY RATES (intrapartum plus neonatal):

MANA study = 2.06/1000
Birth Center study = 0.87/1000

A baby born at home is 2.4 times more likely to die than baby born with in a CABC accredited birth center. This means for every 10,000 babies born at home, 12 babies will die that would have lived had the mother been under the care of a midwife at a CABC accredited birth center. A part (though not all) of this increase is because most CABC accredited birth center will risk women out who are no longer considered low risk. A low risk woman should take proper screening measures to ensure she remains low risk if you want to consider the rates that reflect low risk women only. To look at low risk comparison, we have:  

TOTAL MORTALITY RATES for LOW RISK (intrapartum plus neonatal):

MANA study = 1.62/1000
Birth Center study = 0.87/1000

A home birth is then just shy of two times more likely to end in the loss of life of a baby than if the baby were born at a CABC accredited birth center. This means for every 10,000 babies born to low risk moms at home, 7 babies will die that would have lived had the mother been under the care of a midwife at a CABC birth center. 

Both of these studies show the safety (or lack thereof) of out-of-hospital births in the USA. Keep in mind again, the Birth Center study was majority CNMs (Certified Nurse Midwives); the MANA study was majority CPMs (Certified Professional Midwives).

Edit 02/03/2013:
In another online discussion about this study, Judith Rooks (CNM, MPH) and Wendy Gordon (CPM, MPH) both discussed intrapartum mortality rates in hospitals. It was a very informative discussion. Judith Rooks provided some information and numbers regarding the rare occurrence of a fetal death during labor and delivery in a hospital (intrapartum fetal death). To quote her exactly, she said "Intrapartum fetal death rates in hospitals have declined consistently since the late 1970s consequent to ever-expanding use of electronic fetal monitoring combined with increasing rapid access to cesarean sections for fetal distress from asphyxia. All of these studies are referenced in the attached paper. The most recent large, reliable studies of intrapartum fetal deaths in hospitals in developed countries now range from 0.1 – 0.3/1000 births."

Wendy Gordon, one of the authors of the MANA study, did not dispute these numbers. Those numbers include high risk and low risk pregnancies in hospitals. So using those numbers and comparing to the MANA study we have this:

Intrapartum rates:

MANA study = 1.30/1000

Birth Center study = 0.47/1000

Hospitals = 0.1/1000 to 0.3/1000

That means a baby is 4 to 13 times more likely to die during labor and delivery at a home birth than in a hospital. 

And sadly, who knows what the real numbers are for the MANA study because of so much data is missing and again, the fact that this is self reported.

For a more in-depth look at the MANA numbers, click here to read my series.








7 comments:

  1. Another criticism of the "study". Worth reading.

    http://theness.com/neurologicablog/index.php/death-rate-for-home-births/

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  2. It is sad to see the press release by Geradine Simkins for MANA. And the comments are so ignorant of the actual data. "...This is not 'home' vs 'hospital'. This is a study that supports the fact that low-risk women can deliver safely at home if they so choose without raising their risk of unwanted outcomes..."
    Good job with this post and good job with comment on other blogs discussing this important issue.

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    Replies
    1. I tried to post a comment on the MANA press release but they did not allow it to be posted. Go figure.....

      I hope more women look at the Birth Center study for comparison. Makes it very clear the difference a competent care provider can make.

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    2. I commented on that MANA site as well. I was fair, saying women have the right to birth at home as long as they have proper informed consent of the risks. I see the data and if a woman still really wants to accept those risks, then fine. But MANA delayed the release of that data and then glossed over it in their press release. They offered no comparison hospital stats and conclude Homebirth is safe. I have seen their comments and other sites comments proclaiming this study as a victory. It is, but not how they are thinking of it. The study shows an obvious increase risk. Now women attempting Homebirth need to be told these risks. Now MANA censored your comment as well as mine, people should know that as well. That says a lot about MANA. Keep up the great work.
      Jeffrey Olejnik MD FACOG

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  3. What scares me even more than these numbers from MANA is the fact that this is self-reported and only contains about 30% of the data. How many more deaths are likely hidden in the 70%?

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  4. Thank you so much for slogging through the numbers and being so compassionate and kind w/your explanations. People who are fence sitting about home birth can use some kindness when deciding what to do.

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