A Letter from a Reader

Letters like this truly warm my heart <3 

(shared with permission)

Dear Doula Dani,

I just discovered your page yesterday after a friend of mine linked to it on Facebook. THANK YOU for being brave and willing to post facts even when they are unpopular.  I wanted to share my daughter's birth story with you.

*****

I was raised in the shadow of the story of my mother's successful unmedicated births and how she refused interventions (including ultrasounds) from medical professionals because she wanted to do things naturally and safely.  From elementary school on I knew that I wanted to -- in fact, needed to -- have an unmedicated birth because that was clearly the best, and safest, way to do it.

Fast forward to when I was pregnant with my first (and only) child. I planned to deliver in a hospital with an OB (as had my mother) but was extremely nervous to do so after reading things like Ina May's books and anything from Henci Goer that I could find. My husband flat out refused a home birth, which I thought was because he simply wasn't educated on these issues. Our compromise was a hospital birth with OB and doula.  I had developed a birth plan asking for nearly no interventions and felt nervous, but positive, about my upcoming unmedicated hospital birth.

I was devastated when my low-risk pregnancy quickly morphed into high risk pregnancy in the last trimester.  First, I developed gestational diabetes. I couldn't understand why this was happening to me because I'd been very careful with weight gain and nutrition. After more natural birth research, I was nervous the medical establishment was blowing the risks of GD out of proportion in favor of needless interventions. Thankfully, I was able to control GD with diet, which I could justify in my mind as not an intervention because it was "natural." Next, I tested Group B Strep positive. I was starting to worry my unmedicated labor and delivery was slipping away as I pictured myself tethered to an IV pole at the hospital. I called the hospital to make sure I could still use the birthing tub and sensed they were trying to hint that things might not go the way I hoped. My mom was skeptical of the need for antibiotics. She had never heard of a baby getting Group B Strep and didn't believe interventions would be necessary. I tried to research the issue myself and again found natural childbirth experts saying these risks were overblown by the medical establishment. I decided to get the antibiotics because I really didn't want to risk a serious infection to my baby (believe it or not I am actually quite risk averse) and because I thought I could still accomplish my natural birth goal (which I remained convinced was the safest and healthiest way to give birth).

The final nail in the coffin of my dream of an unmedicated birth was when my water broke at 38.5 weeks and I didn't go into labor for the next 12 hours. My water "breaking" was more like a slow leak, and it took me four hours to even realize something was going on. Thankfully, I eventually recognized what had happened and had the good sense to call the hospital. They told me to come right down and confirmed that my water had broken. I got started on the IV antibiotics right away and begged to be given time to go into labor naturally before pitocin was started (the rest of my water broken shortly before this). Pitocin finally started 12 hours after my water initially broke. I then endured painful contractions (and back labor) every two minutes for the next seven hours, determined not to have any more interventions. I barely progressed at all during this time and was only at 3cm seven hours after pitocin was started. I finally gave in and had the epidural (even the doula was recommending it by now) and fell asleep. Three hours later I was ready to push and delivered a healthy baby girl less than an hour later.

*****

The crazy thing about this birth story is that until I found your blog yesterday, I was convinced that my daughter's birth, if not a failure, was definitely not a success because it was not optimal. I thought that my daughter had not experienced the optimal entry into the world, because her entry involved medications, needles, and beeping alarms and machines. I desperately wanted to control the birth process to ensure optimal outcome, and almost lost sight of the fact that keeping mom and baby safe is the optimal outcome and sometimes involves interventions.

Reading your blog yesterday helped me let go of so many feelings of guilt and failure I still feel regarding my daughter's birth. I hadn't realized that I'd been misled, first by the inaccurate beliefs passed on to me by my mom and second, by the misinformation I read in Ina May's and Henci Goer's books. I fully support women's choice for unmedicated birth, but, crazy as it sounds, hadn't realized until I read your blog that "natural" does not always equal "safest."

Thank you for reading this and for continuing to do the important work you are doing. I will be recommending your blog to all my friends. 

Considering Home Birth?

Home Birth in the USA

There are some things you may not know about home birth in the USA. For example, if you were told that "home birth is as safe as hospital birth" then you need to know that is, in fact, not true... not in America... not even for low risk women. Here is some information regarding midwives, birth centers, home birth, studies, statistics, guidelines, and more, that you may find useful for learning more about home birth in our country. There is a lot to read here but it is important information in order for you to make a fully informed decision.

Let's start with an introduction for those who have never stopped by before. My name is Dani. I'm a birth doula and former home birth advocate. Here's my story:

What Drew Me to Home Birth and What Turned Me Away

* MIDWIVES *
One key issue with home birth here is the many different types of midwives we have in the USA: CNMs, CMs, CPMs, LMs, LDMs, lay midwives..... So many!! Each type has different standards for education and training (or no standards at all). Here is an easy-to-read series that touches on the three main types of midwives:

American Midwives series

Most home births in the USA are attended by a Certified Professional Midwife (CPM) or Licensed Midwife (LM) (CPMs and LMs are very similar). It's important to know that CPMs and LMs would not be able to be licensed in any other first world country. The standards simply are not rigorous enough. They are only legal in 26 states, do NOT earn hospital privileges as a part of their training process nor do they have any higher level education requirements -- as opposed to American CNMs/CMs and midwives in countries like the Netherlands, Canada and the UK. Safer Midwifery for Michigan has an eye-opening post that explains how little it potentially takes to earn the title “Certified Professional Midwife”:

CPM education: The bar is too low

Here is a great series exploring what it takes to become a midwife in other countries: The Education of Midwives Around the World

Many home birth midwives do not carry malpractice insurance. Why is insurance important? Insurance protects you. It means that if something happens that causes death or injury, you are able to have recourse and accountability. It means that if your child suffers an injury during birth, you can have compensation to help pay for life long care that may be needed.

There is no transparency for home birth midwives. They do not have a publicly accessible board where any disciplinary measures would be listed. How do you know if your midwife has ever practiced negligently, resulting in the death or injury of a baby or mother? What is your midwife's real record? How can you verify it? How do you know for certain how many births she has attended? Far too many mothers have trusted their midwives, trusted the friendship they developed with their midwives, trusted their judgement and reputation, only to find out after a bad outcome that their midwife was less than forthcoming.


* BIRTH CENTERS *
Is a freestanding birth center safer than a home birth? That depends. In many ways, a freestanding birth center birth is just a home birth in someone else's home. What equipment does your birth center offer that wouldn't be available at home? Is the distance to the hospital closer? What types of midwives are running the center and who will attend your birth? The 2013 Birth Center study shows that out-of-hospital birth can be a reasonably safe option. However, it's important to know that this study does NOT reflect all birth centers in the USA. It was a select group of birth centers, majority of which were run by CNMs. The birth centers met certain criteria and were CABC-accredited. Out of 248 freestanding birth centers in the USA, only 79 were included in the study. Read more about the Birth Center Study here:

5 Things to Know about the Birth Center Study

* HOME BIRTH STUDIES AND STATISTICS *
Here are studies and statistics regarding home birth safety. It's important to look at studies done in the USA. Studies regarding home birth in other countries do not reflect home birth in America: different midwives, different health care systems. Outcomes will be better in countries where, for example, midwives have high standards for education and training and where the midwives have hospital privileges. These links are studies regarding home birth in America... and every single study shows a significant increase risk for babies born at home:

1. The 2014 MANA study, showing an increase risk of intrapartum and neonatal death of 3-5x for babies born to low risk women: Mortality rates from the new study by the Midwives Alliance of America 

2. Studies in the USA, current as of January 2014: Home birth studies 

3. 2013 studies (USA and internationally) and CDC data: 2013 Home birth studies and statistics 

4. The latest study on home birth in the USA (Feb 2014): New Cornell study shows home birth has 4x higher death rate than comparable risk hospital birth 

5. Risk of brain injury and home birth: Risk of anoxic brain injury is more than 18 times higher at home birth

* INFANT MORTALITY *
Advocates of the home birth movement use infant mortality to try to scare women away from our hospitals / maternity care.

Infant mortality is not the correct mortality rate to use to gauge safety of obstetrics / maternity care. Infant mortality is live birth through the entire first year. It does not include stillborn babies. It includes any and all deaths like accidents, disease, SIDS, etc that may happen day 4, day 204 or day 364... death at any time, for any reason for the first full year of life. Perinatal mortality is a much more accurate measure for maternity care (even the World Health Organization acknowledges this). It includes prematurity, fetal mortality (death of baby in utero), intrapartum mortality (death of baby during labor and delivery) and neonatal mortality (death of baby during first 27 days of life).

So why don’t the leaders of the home birth movement discuss perinatal mortality? Because the United States does very well with perinatal mortality, tied with countries like France and Japan, and actually better than countries like the Netherlands and the UK.

When will they stop trying to scare women using the wrong mortality rate?


* THE LIES AND MISINFORMATION *
Home birth in our country is sadly built on a foundation of lies and misinformation. An example is the press release written by MANA for the new MANA study: it's lies, cherry-picked info and misinformation. I shared more about this in an interview with SteadyHealth (as well as thoughts on HBAC/VBAC). To touch on this issue of the MANA study, I tried to put things into perspective:

"A home birth mortality rate of 1.62/1000 [from the new MANA study] for babies born to low risk women might not mean much of anything without having something to compare it to. 1.62/1000 just sounds low. However, when you compare it to the 2013 Birth Center study, for example, which has a mortality rate of 0.87/1000 for babies born to comparable risk women, then it makes you wonder why is the MANA study mortality rate twice as high?

These numbers all seem low, though. But it’s important to remember how many babies are born every year in the USA, specifically how many are born in an out-of-hospital setting. According to the CDC Wonder Database, in 2012 there were 38,997 midwife-attended out-of-hospital births - some in birth centers, some at home. So just for the sake of illustrating a point here, let’s round up to 40,000 births and let’s pretend they are all low risk women. According to the MANA study mortality rate of 1.62/1000, approximately 65 babies would die out of 40,000. According to the Birth Center study mortality rate of 0.87/1000, approximately 35 babies would die. According to the hospital mortality rate of 0.38-0.58/1000, approximately 15-23 babies would die. That’s a huge difference in the number of babies born at home that would not survive either childbirth or the first month of life. Now those mortality rates don’t seem so small.

What is home birth in America doing so wrong that their mortality rates are so much worse than hospitals and (certain) CABC-accredited birth centers? 1.62/1000 is the mortality rate for babies born to low risk women. This is not acceptable. Instead of addressing this issue and figuring out ways to make home birth better, safer they instead are spending their time trying to pull the wool over everyone’s eyes. They want people to think that 1.62/1000 is good. But it isn’t."

Read more here: SteadyHealth Interview

Another big source of misinformation is the popular film “The Business of Being Born.” Here is my critique of the film, which hits on misleading information that is widely shared, not just in this movie:

The Business of Being Misled

* GUIDELINES, EQUIPMENT & WHAT TO ASK YOUR MIDWIFE *
What makes home birth a reasonably safe option? Here are some guidelines:

Home Birth Guidelines for Safety

What equipment is available at home versus in a hospital?
Home vs Hospital: The Equipment

What questions should you ask your midwife?
Considering Out-of-Hospital Birth?

Have questions or more suggested reading material? Share in the comments below or here on Facebook:
https://www.facebook.com/douladanielle/posts/646718472063552

Not Buried Twice

Babies are dying preventable deaths... because of a deeply flawed home birth system. The time has come for change. And if we want change – if we want home birth to be a truly safe option – then it will have to be a consumer driven change. Women don’t deserve lies. Women don’t deserve the censored, twisted version of the “facts” about home birth. Women don’t deserve pseudoscience and misinformation. We deserve the TRUTH. We deserve the REAL statistics. We deserve the best care, accountability, and ethically driven care providers who err on the side of caution, not personal philosophy.

The purpose of the video and the #notburiedtwice campaign is to raise awareness. Planned home birth for LOW RISK women in the USA increases the risk of intrapartum and neonatal death at least 3-5 times compared to low risk women giving birth in a hospital. These are preventable deaths.

We are here to let those families know they are not alone. We support them. Their stories matter. Their babies matter. Home birth advocates are trying to silence them and pretend that their babies never existed. They try to bury these babies twice: once in tiny coffins in the ground, and a second time by erasing them from the public consciousness. We aren't going to let that happen. They won't be buried twice.

Be your own advocate. Don’t be fooled by good bedside manner. Don’t be fooled by the misinformation and lies. Learn the truth about home birth in the USA, learn the truth about the studies and statistics, read more here: Home Birth in the USA

For a quick breakdown of the numbers, comparing the 2014 MANA study (Midwives Alliance of North America), the CPM 2000 study (by Johnson and Davis, published in the BMJ), the 2013 Birth Center study (select CABC-accredited birth centers, majority of which were run by CNMs) and USA hospitals using CDC data, the mortality rates are as follows...

For each mortality rate below, it is intrapartum mortality (death during labor and delivery) plus neonatal mortality. And these numbers represent low risk women.

MANA study = 1.62/1000

CPM 2000 study = 1.70/1000

Birth Center study = 0.87/1000

USA hospitals (includes some high risk births) = 0.35/1000 - 0.55/1000

What does this mean?

Planned home birth has a mortality rate at least 3-5 times higher than hospital birth and twice as high as birth center birth (select CABC-accredited centers, that is).

For a more in-depth breakdown of the numbers and references, please click here.

****

The people in this video are real people, with real concerns, with real stories of loss, with a common goal to raise awareness and raise the standards for out-of-hospital birth. A big THANK YOU to everyone who volunteered to participate. A special thank you to the mothers of Gavin, Ligia, Brody, Magnus, Mary Beth and Clara for your continued bravery. I know it is not easy to speak up and share your stories – which is why many home birth loss mothers won’t speak up publicly. So thank you, thank you, THANK YOU.

To all of you watching? Thank you for doing so. Please share this video to help prevent more preventable loss, to honor those that have died and the families that mourn those mothers and babies, and to take a stand for a change that is greatly needed.

The idea for this video came to me after watching my friend, Megan, shared her home birth story on YouTube. After many hours of writing, assigning, organizing the layout, gathering and editing individual clips of footage, I handed it over to my friend, Nick Murphy, to edit and put it all together. Thank you so much, Nick! The “#notburiedtwice” campaign was started by Dr. Amy Tuteur, MD in the aftermath of the death of Gavin Michael. If you’d like to read more about when and why this campaign was started, click here: Let's Hold Them Accountable.

Gavin's mother shared her son's story, an attempted home birth, on a Facebook page dedicated to her son. Gavin died at 42 weeks, 2 days due to meconium aspiration. His midwife went online, asking in a public forum about the risks and for advice, after it was discovered at 42 weeks, 1 day that Gavin's mother didn't have any amniotic fluid. Read Gavin's story here: In Light of Gavin Michael

Clara's mother shared her daughter's story, an attempted home birth, on her blog. After two days of hard labor at home, Clara's mother transferred to the hospital, where they discovered there was no longer a heartbeat. Clara died at 42 weeks, 3 days due to meconium aspiration. Read her story here: She Was Stillborn

Mary Beth's mother shared her daughter's story, a home birth, on the website "Hurt by Homebirth." Mary Beth was born at 36 weeks, 5 days. She died approximately 7 hours later, due to prematurity. Her midwife failed to recognize clear signs that Mary Beth was not receiving enough oxygen and ignored the concerns by Mary Beth's parents. Read Mary Beth's story here: Mary Beth's Story

Brody’s mother shared her son's story, an attempted home birth after cesarean, as a guest post on the blog “TheNavelgazing Midwife.” Brody died during labor, while his mother was being transporting to the hospital, due to uterine rupture. Read Brody’s story here: Anna's Uterine Rupture Story

Magnus’ mother shared her son's story, an attempted planned breech birth at a freestanding birth center, on the website “Hurt by Homebirth.” She also created the website “Safer Midwifery forMichigan” as an educational resource for anyone considering the care of a midwife in Michigan, or anyone who has experienced negligent midwifery. Magnus died 13 days after he was born due to complications during birth when his head became entrapped and he was deprived of oxygen. Read Magnus’ story here: Magnus's Story

At this time, Ligia's parents would like the details of their daughter's home birth and death to remain private.

Do you trust birth? Do you believe what home birth advocates tell you about home birth safety? Do you trust your midwife? Do you believe your midwife is incredibly capable, experienced, amazing, ethical, trustworthy?

These women did. 

****

Not Buried Twice

We won’t let them bury you twice.

We aren’t going to let them forget.

Because you are profoundly loved.

And deeply mourned.

Because you mattered from the moment your mother found out about you.

And you will always matter.

More and more mothers, fathers and families are falling for the lies and misinformation.

More and more babies are dying preventable deaths.

More and more families are left with empty arms,

Broken hearts,

And wondering what just happened…

how did that happen?

Because they chose home birth.

Because people don't know the truth.

People don’t know how broken our home birth midwifery system is here in the United States.

Midwifery Today wants you to forget about Gavin Michael,

Deleting comments and banning anyone who asks about him.

But we aren’t going to let them forget.

We aren’t going to let them forget about my son, Gavin.

Or my daughter, Clara Edith.

Or my son, Brody.

Or my son, Magnus.

Or my daughter, Ligia.

Or any of the many other babies that didn’t need to die or who were needlessly injured during birth.

The Midwives Alliance of North America wants you to believe that home birth is just as safe as hospital birth.

But their own data shows that it is far from being “just as safe” as hospital birth,

Along with the data from every other study we have on home birth in the USA.

Out-of-hospital birth, especially with a non-nurse midwife, isn’t just as safe as hospital birth.

Not here in the USA.

Not even for low risk women.

It’s far riskier.

And people deserve to know that.

But they don't want you to know that.

They don’t want you to know how risky it is.

They don’t want people to know about the loss.

The preventable loss.

They don’t want you to know about our heartbreak.

Your precious, perfect little bodies have already been buried once.

And they are trying to bury you a second time,

by erasing your very existence.

But we aren’t going to let them.

You will not be buried twice.


Please share this video to help raise awareness, using the hashtag #notburiedtwice
Here is the video link: http://youtu.be/CRhkZKUNyMY

Trust Birth

Lisa trusted birth... and lost her baby due to shoulder dystocia
Liz trusted birth... and lost her baby due to placental abruption
Sara trusted birth... and lost her baby due to breech presentation head entrapment
Anna trusted birth... and lost her baby due to uterine rupture
Peyton trusted birth... and lost her baby due to placental abruption
Dhanya trusted birth... and lost her baby due to shoulder dystocia
This mama trusted birth... and lost her baby due to cord prolapse
Danielle trusted birth... and lost her baby due to low fluid which led to meconium aspiration

Sadly, I could go on and on. And on.

The above listed were planned freestanding birth center and home births. These women trusted birth. Yet birth betrayed them. Instead of a healthy thriving child, birth left them with empty arms.

Homebirth After C-Section A Gamble - SteadyHealth Article

I was recently interviewed by SteadyHealth. Very nervous but excited to share this. :) Here is a sneak peak from the article:

You were once a homebirth advocate yourself. Can you describe what led you to change your mind?

It was a combination of factors. It started with being involved in an emergency home birth transfer as a doula. From there, it just took off into several different avenues, searching for answers to the mounting questions and concerns I had. The process and the aftermath have made me a much more skeptical person. In the end, I realized I was duped by all of the home birth propaganda. I realized I only had part of the story when we were hoping/planning for our home birth.

MANA Study Part 4: Vaginal Birth After Cesarean

You are reading Part 4 of my MANA study series. Click to view:

MANA Study Part 1: Intrapartum Mortality Rates

MANA Study Part 2: Neonatal Mortality Rates

MANA Study Part 3: Total Mortality Rates

MANA Study Part 4: Vaginal Birth after Cesarean (currently reading)

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April 4, 2017 Update: a new study from the Midwives Alliance of North America (MANA) confirms that attempting a VBAC at home comes with a much higher risk of neonatal death. The study Perspectives on risk: Assessment of risk profiles and outcomes among women planning community birth in the United States looked at planned, midwife-attended births in a home or freestanding birth center. In the study, they use the term LAC (Labor after Cesarean) instead of using the term TOLAC or attempted VBAC.
Rates are as follows for women attempting birth at home or freestanding birth center:
Women with prior vaginal birth, no cesarean history: 1.03/1000
Women attempting VBAC with prior vaginal birth: 1.27/1000
Women attempting VBAC without prior vaginal birth: 10.2/1000

Yes, you read that outrageously awful rate correctly: 10 neonatal deaths per one thousand!

Compare those rates to USA hospitals: 
Hospital CNMs (lower risk pregnancies) = 0.35/1000 to 0.55/1000
Hospital MDs (higher risk pregnancies) = 0.43/1000 to 0.63/1000
Hospital attempted VBACs* = 1.3/1000
Hospital repeat cesarean = 0.5/1000

* The hospital attempted VBAC group includes a higher risk group of women. It includes women with and without prior vaginal birth, with and without higher risk medical conditions and also includes fetal deaths - death of baby in uterus prior to onset of labor from 28 weeks gestation and beyond. Fetal deaths were not included in the home and birth center rates above (meaning, the rates would be higher for the home and birth center births if fetal deaths were included).

****

For today's post I am discussing VBAC, HBAC and the MANA study outcomes for HBACs. Let's first lay out the different acronyms:

VBAC -- Vaginal Birth After Cesarean
HBAC -- Home Birth After Cesarean
TOLAC -- Trial Of Labor After Cesarean
ERCD -- Elective Repeat Cesarean Delivery
RCS -- Repeat Cesarean Section

TOLAC refers to all women who have had a previous cesarean section (or more than one) who attempt a vaginal birth. The outcome for TOLAC may be vaginal birth (VBAC) or it may be repeat cesarean section. TOLAC therefore includes outcomes for both.

ERCD refers to all women who decided to forgo an attempt at vaginal birth. ERCD is a bit of a deceiving term. While a cesarean section in this group is labeled as “elective” it also includes women who medically needed cesarean sections for reasons aside from having a previous cesarean section (which would mean it is not actually an elective cesarean section). Because women with chronic illnesses, or other such medical contraindications for TOLAC, are lumped into the ERCD group, the risks of ERCD may be overestimated.

**** 

I'm briefly going to discuss various aspects surrounding VBAC before discussing the startling increased risk for babies born at home to mothers attempting a HBAC.

Jamie Bernstein Got It Wrong

I'm going to switch gears for a moment from discussing the MANA study to something else. Well, sort of.

I thought about writing this post earlier this month but ended up changing my mind. So instead, I've been spending (too much of) my free time, trying to fight for what (I believe) is right in comment sections where this issue has been discussed. That has proved to be far too exhausting and frustrating..... so instead of pulling my hair out over this issue, over and over again, I am just going to write the darn post.

What am I referring to here? That would be the two blog posts written by Jamie Bernstein for Grounded Parents. I will link to the blog posts, only because I am legally required to do so since I am using quotes from the posts -- but not because I want to send any traffic to that site. Because I don't.

MANA Study Part 3: Total Mortality Rates

You are reading Part 3 of my MANA study series. Click to view:

MANA Study Part 1: Intrapartum Mortality Rates

MANA Study Part 2: Neonatal Mortality Rates

MANA Study Part 3: Total Mortality Rates (currently reading)

MANA Study Part 4: Vaginal Birth After Cesarean

****

Now it's time to put together what we know and figure out the total mortality rates. This is intrapartum mortality plus neonatal mortality. It's important to look at the total mortality as it really gives more complete picture.

As I have done with the previous two posts, I'm going to compare numbers a few different ways. I'll use the same information I did for intrapartum and neonatal comparisons plus I am adding in one more study, the CPM 2000 study, for total mortality comparisons. I'll explain why when I get there. So here they are again:

1. The MANA study - planned home births with a midwife in the USA, attended mostly by CPMs, LMs and LDMs (Certified Professional Midwives, Licensed Midwives and Licensed Direct-Entry Midwives)

2. The Birth Center study - planned births in select CABC-accredited birth centers with a midwife in the USA, attended mostly by CNMs (Certified Nurse Midwives)

3. The CPM 2000 study - planned home births with a CPM (Certified Professional Midwife)

4. USA hospitals - births in hospitals in the USA


ALL RATES DISCUSSED BELOW EXCLUDE ALL LETHAL ANOMALIES. The exception is the hospital group. Excluded from the hospital group are congenital malformations, deformations and chromosomal abnormalities from the hospital group. This may not include all lethal anomalies, as some may be labeled as something else, like cardiac disease, for example.

****

First, let's compare the MANA study to the Birth Center study.

Total Mortality Rates, all risk:

MANA study = 2.06/1000

Birth Center study = 0.87/1000

For every 10,000 babies born at home, 20-21 babies will die. 

For every 10,000 babies born at a CABC accredited birth center, 8-9 babies will die.

As I mentioned previously, a part of this increase is due to the fact that the MANA study has more high risk pregnancies than in the Birth Center study. Let's compare low risk only.

Total Mortality Rates, low risk:

MANA study = 1.62/1000

Birth Center study = 0.87/1000

Why is a home birth two times more likely to end in death of a baby? The birth center studies is freestanding birth centers. These are two studies that look at out-of-hospital birth in the USA... why is there such a big difference?

For every 10,000 babies born at home to low risk mothers, 16-17 babies will die.

For every 10,000 babies born at a CABC accredited birth center, 8-9 babies will die.

What does this comparison show us?
1. It shows the increase risk to babies born out of a hospital to high risk mothers (2.06/1000 compared to .87/1000.... insane)
2. It shows the increase risk to babies born out of a hospital under the care of a non-nurse midwife (1.62/1000 compared to .87/1000... not acceptable)

(as I explained above, majority of the midwives in the MANA study are non-nurse midwives; majority of the midwives in the Birth Center study are nurse midwives)

****

Now I will compare the MANA study to the CPM 2000 study. Why am I doing this? Because one of the defenses I have seen many, many times now is that home birth advocates are trying to blame the unlicensed midwives that took part in the MANA study for most or all of the bad outcomes. There are 971 births that were under the care of unlicensed midwives in the MANA study. So I am comparing the MANA study to the CPM 2000 study to see if that may potentially be the issue. Here are the outcomes:

Total Mortality Rates, all risk:

MANA study = 2.06/1000

CPM 2000 study = 2.0/1000



Total Mortality Rates, low risk:

MANA study = 1.62/1000

CPM 2000 study = 1.7/1000

As you can see, the mortality rates are nearly identical. 100% of the outcomes in the CPM 2000 study are Certified Professional Midwives. Are unlicensed midwives solely to blame for the bad outcomes in the MANA study? Or can we compare both the MANA study and the CPM 2000 study to the outcomes of the Birth Center study and conclude out-of-hospital births with non-nurse midwives substantially increase the risk of death for a baby? That's how it looks to me but you are free to interpret it however you'd like.

****

Finally, I will compare the MANA study outcomes to hospital outcomes. Since I used two different cohorts for hospital births, I will compare both.

Please note: The hospital CNM group is mostly low risk women; the hospital MD group is low risk and high risk. MD refers not only to OB/GYNs but high risk pregnancy specialists, such as perinatologists and even other medical doctors who may deliver babies, even on rare occasions (such as ER doctors).

This first comparison has the hospital cohort that is a closer match to the MANA study cohort. I defined it in my post regarding neonatal mortality rates.

Total Mortality Rates:

MANA study = 2.06/1000

MANA study, low risk only = 1.62/1000

Hospital CNMs = 0.35/1000 to 0.55/1000

Hospital MDs = 0.43/1000 to 0.63/1000

Even compared to the hospital MD group - which has a higher percentage of high risk pregnancies than the MANA study - the risk is greater for babies born at home. Comparing low risk home birth to mostly low risk hospital birth and it is a risk of death 3-5x higher for babies born at home.


This next comparison has the hospital cohort that is much, much broader which gives MANA the advantage, as the MANA study includes an all-around much lower risk group of women in this comparison.

Total Mortality Rates:

MANA study = 2.06/1000

MANA study, low risk only = 1.62/1000

Hospital CNMs = 0.38/1000 to 0.58/1000

Hospital MDs = 0.52/1000 to 0.72/1000

Comparing all risk home births to all risk hospital births, a baby is 1.5 to 4 times more likely to die at home. Comparing low risk home births to mostly low risk hospital births, a baby is 3 to 4 times more likely to die at home.

Again, these figures give MANA the advantage as it includes a higher risk group of women for the hospital outcomes:

For every 10,000 babies born at home, 20-21 babies will die. 

For every 10,000 babies born at home to low risk mothers, 16-17 babies will die.

For every 10,000 babies born to mostly low risk mothers in a hospital, 3-6 babies will die.

For every 10,000 babies born to women of all risk in a hospital, 5-8 babies will die. 

I am going to make one final comparison, using the most recent figures I just outlined (with the hospital cohort that gives MANA the advantage with the lower risk group of women). I am going to compare hospital CNM outcomes to MANA study outcomes for all risk. I am doing so for three reasons:

1. The hospital CNM numbers are not strictly limited to low risk outcomes, like the MANA study low risk outcomes are. There is no way to completely filter out all high risk pregnancy outcomes from hospital data. While it is unlikely that any breech births or twins births are included in the hospital CNM outcomes, it is possible. Regardless, hospital CNMs care for mostly low risk women, but they do not care for only low risk women.

2. This shows why it is necessary for women to take proper screening measures to ensure a mother is low risk for out of hospital births. If she is high risk she should either switch to a hospital CNM or MD where proper monitoring/care for her high risk pregnancy can continue as it should to ensure the safest outcome for mother and baby. If a mother's low risk status is assumed and not confirmed with the necessary/recommended screening measures, she may actually be high risk but may think she is low risk.

3. If your home birth midwife brushes off your high risk pregnancy and/or refers to it as a "variation of normal," you are taking a big risk and you need to be aware of the odds.

Total Mortality Rates:

MANA study, all risks = 2.06/1000

Hospital CNMs, all risks = 0.38/1000 to 0.58/1000

This means a baby is 3 to 6 times more likely to die at home. That is an additional 15-18 babies per 10,000 that die at home under the care of a midwife that would have lived had they been born in a hospital under the care of a CNM.

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Conclusion: 
There currently are over 30,000 home births every year in the USA. This means, for women who are truly (confirmed) low risk, each year at least 31-41 babies die at home births that would have lived had they been born in a hospital. For high risk women, each year at least 29-34 babies die at home births that would have lived had they been born in a hospital.

The safest place of birth for a baby is in a hospital. For babies born outside of the hospital, it is important that their mothers be low risk (throughout pregnancy and during labor/delivery) and that the attendant be a Certified Nurse Midwife who practices under the guidelines set forth by CABC-accredited birth centers.



References:

1. MANA study: http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12172/full

2. Birth Center study: http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12003/full

3. CPM 2000 study: http://www.bmj.com/content/330/7505/1416

4. USA hospital neonatal mortality rates: http://wonder.cdc.gov/

5. There are two sources I have used for hospital intrapartum mortality rates:

    a. 0.3/1000 is from The World Health Organization:
http://whqlibdoc.who.int/publications/2006/9241563206_eng.pdf
(see Table 7.1 on page 21)

    b. 0.1/1000 to 0.3/1000 is from Judith Rooks:
Here are screen shots of a public, online discussion between Judith Rooks, CNM, MPH and Wendy Gordon, CPM, MPH.

As you can see, Wendy Gordon - one of the authors of the MANA study - did not dispute the rates provided by Judith Rooks. Neither Judith Rooks nor Wendy Gordon commented again after that. Eventually the thread - posted on the public Facebook page of an outspoken home birth advocate (The Feminist Breeder) - was deleted by the page admin.

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MANA Study Part 1: Intrapartum Mortality Rates

MANA Study Part 2: Neonatal Mortality Rates

MANA Study Part 3: Total Mortality Rates

MANA Study Part 4: Vaginal Birth After Cesarean

MANA Study Part 2: Neonatal Mortality Rates

You are reading Part 2 of my MANA study series. Click to view:

MANA Study Part 1: Intrapartum Mortality Rates

MANA Study Part 2: Neonatal Mortality Rates (currently reading)

MANA Study Part 3: Total Mortality Rates

MANA Study Part 4: Vaginal Birth After Cesarean

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Neonatal refers to the newborn period of life, specifically the first month. Neonatal mortality rate refers to the death of a baby any time after live birth and through the first 27 days. If a baby dies prior to labor or prior to birth, the baby will not be included in the neonatal mortality rate. Only babies born alive but die some time in those first full 27 days are included in the neonatal mortality rate.

Neonatal mortality rates can be broken up into early neonatal (death in the first week) and late neonatal (death after the first week but before the 28th day). I will be looking at TOTAL neonatal mortality rates, which is simply early neonatal mortality plus late neonatal mortality.

The overall neonatal mortality rate for the United States is 4/1000 (4 deaths for every 1000 live births -- which is the same neonatal mortality rate as Canada). This rate is includes all gestational ages (including extreme prematurity), all risks, all complications, lethal anomalies, etc. For obvious reasons, this is not the correct comparison to the MANA study neonatal mortality rate.

Just as I did for the comparison of intrapartum mortality rates, I am going to compare the neonatal mortality rates from 3 different data sets:

1. The MANA study - planned home births with a midwife in the USA, attended mostly by CPMs, LMs and LDMs (Certified Professional Midwives, Licensed Midwives and Licensed Direct-Entry Midwives)

2. The Birth Center study - planned births in select CABC-accredited birth centers with a midwife in the USA, attended mostly by CNMs (Certified Nurse Midwives)

3. USA hospitals - births in hospitals in the USA


First, let's look at comparing MANA to the Birth Center study.

Here are the neonatal mortality rates, both rates are excluding anomalies:

MANA study = 0.77/1000

Birth Center study = 0.40/1000

That is an increase risk for babies born at home of just shy of two times. Small yes, but per 10,000 it is an additional 3-4 babies that die at home births during the neonatal period.

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Now, let's compare to hospitals using the CDC Wonder Database. Since it is impossible to get an exact comparison group for hospital births, I will use different hospital groups for the comparison: one that is as close of a match as I can get to the MANA study, and one that is broader. I will define each of them below.

In the first comparison, I will try to match the MANA study as close as possible. So the search results will be based off of the following criteria:

Years 2004-2009 (same as the MANA study)
White Women (92.3% of women in the MANA study were white)
Singles and Twins (small percent were twins in the MANA study, the rest were singletons)
37 Weeks and Above (97.5% of women in the MANA study were 37 weeks and above)
Birth weight of 2500 grams or more (99.2% of babies in the MANA study were 2500 grams & up)
Excluding most lethal anomalies*

*Excluded are congenital malformations, deformations and chromosomal abnormalities from the hospital group. This may not include all lethal anomalies, as some may be labeled as something else, like cardiac disease, for example.

My search includes everything else... all ages (maternal), all education levels, all marital statuses, etc.

2004-2006:

2007-2009:

Neonatal mortality rates for hospitals based on this search criteria are:
Medical Doctor = 0.33/1000
Certified Nurse Midwife = 0.25/1000

Please note: The hospital CNM group is mostly low risk women; the hospital MD group is low risk and high risk. MD refers not only to OB/GYNs but high risk pregnancy specialists, such as perinatologists and even other medical doctors who may deliver babies, even on rare occasions (such as ER doctors).

Comparing this similar hospital group to the MANA study and we have the following for neonatal mortality rates:

MANA study = 0.77/1000

Hospital CNMs = 0.25/1000

Hospital MDs = 0.33/1000

MANA study rate is 3 times greater than the hospital CNM rate and 2 times greater than the hospital MD group. Per 10,000 it is an additional 5-6 babies that die at home births during the neonatal period, compared to the hospital CNM group; compared to the hospital MD group, per 10,000 it is an additional 4-5 babies that die at home births during the neonatal period.

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CDC neonatal mortality data is very accurate, despite what MANA and Citizens for Midwifery have claimed (I will get to that in another post). However, birth certificate data isn't perfect. We are potentially sacrificing the high accuracy the more search criteria we use. So that is why I will do another comparison with hardly any criteria selected.

The rates below are based on the following:

Years 2004-2009
Birth weight of 2500 grams or more
Excluding most lethal anomalies*

*Excluded are congenital malformations, deformations and chromosomal abnormalities from the hospital group. This may not include all lethal anomalies, as some may be labeled as something else, like cardiac disease, for example.

My search includes everything else... all races, all ages (maternal), all gestational ages, all singles and multiples, all education levels, all marital statuses, etc.

2004-2006:

2007-2009:

Neonatal mortality rates for hospitals based on this search criteria are:
Medical Doctor = 0.42/1000
Certified Nurse Midwife = 0.28/1000

Please note: As I stated above, the hospital CNM group is mostly low risk women; the hospital MD group is low risk and high risk. MD refers not only to OB/GYNs but high risk pregnancy specialists, such as perinatologists and even other medical doctors who may deliver babies, even on rare occasions (such as ER doctors).

Comparing this similar hospital group to the MANA study and we have the following for neonatal mortality rates:

MANA study = 0.77/1000

Hospital CNMs = 0.28/1000

Hospital MDs = 0.42/1000

MANA study rate is just shy of 3 times greater than the hospital CNM rate and just shy of 2 times greater than the hospital MD group. Per 10,000 it is an additional 4-5 babies that die at home births during the neonatal period, compared to the hospital CNM group; compared to the hospital MD group, per 10,000 it is an additional 3-4 babies that die at home births during the neonatal period.

Again we are seeing an increase to babies born at home compared to hospitals, even when we are looking at a much higher risk hospital group for comparison.

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At least 5 babies from the MANA study that died during the neonatal period were due to hypoxia or ischemia. This basically means those babies were deprived of oxygen at some point. I cannot help but wonder how many of these 5 cases (and potentially more) were due to lack of proper monitoring during labor, especially during second stage (pushing).

For a look at the intrapartum mortality rates, click here.

Up next, I will put it all together and we can look at the total mortality rates.


References:

1. MANA study: http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12172/full

2. Birth Center study: http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12003/full

3. USA Hospitals: http://wonder.cdc.gov/

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MANA Study Part 1: Intrapartum Mortality Rates

MANA Study Part 2: Neonatal Mortality Rates

MANA Study Part 3: Total Mortality Rates

MANA Study Part 4: Vaginal Birth After Cesarean

MANA Study Part 1: Intrapartum Mortality Rates

You are reading Part 1 of my MANA study series. Click to view:

MANA Study Part 1: Intrapartum Mortality Rates (currently reading)

MANA Study Part 2: Neonatal Mortality Rates

MANA Study Part 3: Total Mortality Rates

MANA Study Part 4: Vaginal Birth After Cesarean

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All over the web the new MANA home birth study 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.

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 and the one not involved with MANA is a home birth mother). 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

So let's look at the study. Let's pull out the information and let's do what MANA doesn't want you to do: compare it to other outcomes. If they did want you to make comparisons, they would have done you a favor and included rates so you could see. Mortality rates aren't going to mean much of anything unless the reader has a really good grasp of what is acceptable and what is not for mortality rates in first world countries, specifically in the USA. So we need to be able to compare to make sense of them.

Intrapartum mortality rates are up first.

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"Intrapartum" means during labor and delivery. Intrapartum mortality then refers to death of a baby during labor and delivery. This means the baby was confirmed to be alive at the onset of labor but was born still.

I am going to compare the mortality rates from 3 different data sets:

1. The MANA study - planned home births with a midwife in the USA, attended mostly by CPMs, LMs and LDMs (Certified Professional Midwives, Licensed Midwives and Licensed Direct-Entry Midwives)

2. The Birth Center study - planned births in select CABC-accredited birth centers with a midwife in the USA, attended mostly by CNMs (Certified Nurse Midwives)

3. USA hospitals - births in hospitals in the USA


Let's get started.


Here are the intrapartum mortality rates:

1. MANA study = 1.30/1000

2. Birth Center study = 0.47/1000

3. USA Hospitals = 0.1/1000 to 0.3/1000


Please note: the hospital rate is for any gestational age, any and all risk -- extreme prematurity, no prenatal care, any and all risks and complications, etc.

As you can see, the risk of death for the baby during labor and delivery is significantly higher in the MANA study. The MANA study rate is 3 times higher than the Birth Center rate; the MANA study rate is 4 to 13 times higher than the USA hospital rate.

Part of the reason the intrapartum mortality rates are higher in the MANA study compared to the Birth Center study is because the home births in the MANA study include some high risk pregnancies, where majority of high risk pregnancies in the Birth Center study were risked out.

The intrapartum deaths due to high risk pregnancies in the MANA study are as follows:

BREECH = 3 deaths
VBAC = 3 deaths
TWINS = 1 death
GESTATIONAL DIABETES MELLITUS = 2 deaths
PREECLEMPSIA = 1 death

The VBAC, breech and twins births were planned. However, I can't help but wonder if the GDM and PRE-E deaths were known/planned. It is absolutely possible that the GDM mothers were never screened for GDM and/or that symptoms for the complications were either ignored or missed by the midwife. It is absolutely possible that symptoms for pre-e were ignored or missed by the midwife. If the symptoms were ignored or missed for these high risk pregnancies, then it does not make sense to exclude them. However, for the sake of giving MANA the benefit of the doubt, all high risk pregnancy related intrapartum deaths are excluded for the rate below.

Here are the intrapartum mortality rates for low risk women (the MANA rate is the only one that changes):

1. MANA study = 0.85/1000

2. Birth Center study = 0.47/1000

3. USA Hospitals = 0.1/1000 to 0.3/1000


Please note: as I mentioned previously, the hospital rate is for all gestational ages, all risk factors and complications. For intrapartum mortality rates for full term, low risk women in hospitals, it is likely closer to 0.1/1000 or even lower than that.

Again, as you can see, the risk of death of a baby during labor and delivery at home is still significantly higher even for low risk women.

Another way to look at this information, is simply moving the decimal over to look at rates per 10,000 instead of per 1,000.

MANA study = 13/10,000

MANA study low risk women = 8.5/10,000

Birth Center study = 4.7/10,000

USA Hospitals = 1/10,000 to 3/10,000

Meaning:

For every 10,0000 babies born at home, 13 babies will die during labor and delivery.

For every 10,000 babies born at home to low risk women, 8-9 babies will die during labor and delivery.

For every 10,000 babies born at a CABC accredited birth cennter, 4-5 babies will die during labor and delivery.

For every 10,000 babies born in hospitals including all gestational ages and all risks, 1-3 babies will die during labor and delivery.


Please note: in order for women considering home birth to be certain of their low risk status, they should take all screening measures and have all necessary monitoring through pregnancy and through labor/delivery to ensure she is actually low risk and remains low risk up until the baby is born.


References:

1. MANA study: http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12172/full

2. Birth Center study: http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12003/full

3. There are two sources I have used for hospital intrapartum mortality rates:

    a. 0.3/1000 is from The World Health Organization:
http://whqlibdoc.who.int/publications/2006/9241563206_eng.pdf
(see Table 7.1 on page 21)

    b. 0.1/1000 to 0.3/1000 is from Judith Rooks:
Here are screen shots of a public, online discussion between Judith Rooks, CNM, MPH and Wendy Gordon, CPM, MPH.

As you can see, Wendy Gordon - one of the authors of the MANA study - did not dispute the rates provided by Judith Rooks. Neither Judith Rooks nor Wendy Gordon commented again after that. Eventually the thread - posted on the public Facebook page of an outspoken home birth advocate (The Feminist Breeder) - was deleted by the page admin.

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MANA Study Part 1: Intrapartum Mortality Rates

MANA Study Part 2: Neonatal Mortality Rates

MANA Study Part 3: Total Mortality Rates

MANA Study Part 4: Vaginal Birth After Cesarean

Tragic Death of Baby

Something happened on Friday that definitely deserves a lot of attention: A baby died a preventable death because the midwife did not understand the risks involved in the particular situation.

This was broadcast for everyone to see on Facebook. It started with this initial question, sent via private message to Jan Trittan, the editor of Midwifery Today, who then posted it on her page:

As you can clearly see, the midwife did not fully understand the risks of the situation ("what do we truly feel are the risks"). You can also clearly see that she has not transferred care to a physician ("we're in a state with full autonomy for midwives and no transfer of care regulations past 42 weeks").

If a pregnant woman's hired professional care giver is unaware of the risks, how does the pregnant woman know the risks? This midwife clearly doesn't want to acknowledge that this mother is in any danger at all, even saying "technology isn't perfect" as if a BPP done on two separate occasions, both indicating ZERO amniotic fluid, would be incorrect (again... this is not a matter of a BPP indicating LOW amniotic fluid, it indicated ZERO amniotic fluid BOTH times). Can we honestly believe this mother has any idea of the risks involved in her situation?

At 42 weeks 3 days, the baby died:

The baby died from meconium aspiration. How does that happen? There are factors that each individually increase the chances of meconium aspiration and sadly this mother had several factors:

Postterm
Low amniotic fluid (and in this case, even worse, she had NO amniotic fluid)
Placental insufficiency

Based on current research, an induction at 41 weeks (or shortly after) not only would have greatly increased the chances that this baby would have survived, but it also would have decreased the chances that this mother would end up with a c-section.

An immediate transfer of care at 42 weeks 1 day when it was initially known that there was no amniotic fluid would have also yielded a live baby. Or at 42 weeks 2 days. Clearly, going in at 42 weeks 3 days proved to be one day too long.

I have had a pit in my stomach since I watched this all unfold on Friday on Facebook. It almost seemed a like an awful prank. What midwife would do such a thing? What professional wouldn't understand the risks? What professional would seek advice on Facebook and ask others to share "opinions/stories" to help them make their decisions?

A petition has been started and I have already signed it, and I hope you will as well. Sign for this mother, because she was not given true informed consent and is now left with the loss of her child. Sign for this baby, because he or she was not given the best chance at life. Sign for the family of the mother/baby, who will also forever grieve this loss. Sign for this midwife, because her actions were beyond negligent and she should be held accountable. Sign for the current and future clients of this midwife, who deserve to know who they are hiring.

Please Sign This Petition

Update your Facebook and/or Twitter status with this hashtag: #notburiedtwice to raise awareness for the loss of this baby.... another preventable loss at the hands of a negligent midwife.

The thread was, of course, deleted. I took over 65 screen shots (including the two posted here) as I was participating in the discussion but did not get all of the comments. However, they were all captured. To view the full Facebook thread, it is available here: The Internet Never Forgets