Wednesday, March 19, 2014

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.


Sunday, March 16, 2014

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

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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.


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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)

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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.

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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


Friday, March 7, 2014

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


Wednesday, March 5, 2014

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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I have already dedicated two other posts to the MANA study. But I'm going to break it down even further. Women deserve to know the truth... and MANA won't share it with them.

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.

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

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 (which would have been the right thing to do). 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.

As I have written before, the authors of the MANA study did not provide a single comparison number for mortality rates in their study. Even for the studies they reference in the discussion, they did not list any mortality rates other than their own.

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 notethe 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 notein 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



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