Thursday, February 6, 2014

MANA Won't Respond

photo credit Rajiv Patel

There is a lot of criticism out there about the new MANA study. A lot of questions, a lot of concern over the mortality rates, a lot of people speaking up. Just a look at the MANA press release and you can see some of the concerns (and that's with comments being moderated).... it's been a hot topic on Facebook, in the comments on different press releases, childbirth-related forums, etc.

And MANA's response?

(crickets chirping)

I can't help but wonder if they are doing this on purpose to avoid having to answer any of the hard questions. Are they hoping it will all just go away? The questions will just die out and they'll never have to respond?

The press releases and articles have been very careful to dance around the mortality rates, highlighting things like a low cesarean section rate and high breastfeeding rates, and assuring women that home birth is a safe option.... the responses I've seen so far from MANA and Wendy Gordon all seem so calculated, as if they planned them in advance... questions are dodged and when people continue to press them for answers, they just stop responding.

Does MANA plan to respond to the results of this study?

An excellent point made by someone in a discussion about this study was this: "The point of a study is not to pat each other on the back and say "Well done!". The point of a study is to add to the collective pool of information, to learn from it, to allow others to build on it and if you believe in evidence based care -- to help create evidence based models of care."

I could not agree more.

Here are a few questions I have about the study...

1. Why didn't the authors provide any numbers for comparison for the studies they reference? Here is what I am referring to in 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] " Readers are expected to wade through a bunch of different studies, searching for the information because the authors couldn't supply it. Why?

2. Why didn't they compare numbers to hospitals in the USA? The information is available on the CDC Wonder Database (I pulled them here). I cannot imagine a reasonable/acceptable response to be anything along the lines of "we don't know how reliable that data is" when the Wonder Database information is linked between birth and death certificates -- especially when they are asking people to trust information from their study where the data was self-reported. There is clearly literature and studies available regarding intrapartum mortality rates as well. Why didn't they include any of this information?

3. Here is what it says in the Discussion about higher risk pregnancies: "However, the safety of home birth for higher-risk pregnancies, particularly with regard to breech presentation (5 fetal/neonatal deaths in 222 breech presentations), TOLAC (5 out of 1052), multiple gestation (one out of 120), and maternal pregnancy-induced comorbidities (GDM: 2 out of 131; preeclampsia: one out of 28) requires closer examination because the small number of events in any one subgroup limited the effective sample size to the point that multivariable analyses to explore these associations further were not possible. It is unclear whether the increased mortality associated with higher-risk women who plan home births is causally linked to birth setting or is simply consistent with the expected increase in rates of adverse outcomes associated with these complications." It's a very open-ended way to leave that. A VBAC mortality rate of 4.75/1000, twin mortality rate of 8.33/1000, a breech presentation mortality rate of 22.67/1000. These numbers might just be "consistent with the expected increase in rates of adverse outcomes associated with these complications"? The safety of home birth for higher risk requires further examination. What are the steps they are going to take to look into this and further examine it? What do they recommend in the meantime to high risk pregnant women in that are planning a home birth?

What questions and concerns do YOU have about the study? What would you like the authors and/or MANA to answer?


  1. Why did it take so long for this study to come out?

  2. Does MANA plan on changing any standards of care or scope of practice guidelines based on this study - or any of the other study that just came out?

  3. I am an NICU nurse. I got to your blog from Dr. Amy. I wanted you to know how much I respect you. It takes a lot for someone to change their beliefs and even more for someone to be willing to examine the how and why behind those beliefs. You are a person of tremendous personal integrity and those kind of people are few and far between these days. Keep up the good fight.


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