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.

To be clear... I am not writing this in defense of ANYONE. Not Dr. Tuteur, not Professor Orosz, not Esther Inglis-Arkell. I'm writing this for the same reason I have been writing about the MANA study - almost constantly (yes, to the point of obsession) - since it came out: because women deserve the truth about what the data in the MANA study shows.

So here we go.... point by point.... why I think Ms. Bernstein was way off the mark.

Quotes from Jamie Bernstein's blog posts are in red; my responses are in black.

First up: Home Birth Safety and Risk

1. "I clicked the link Dr. Tuteur gave where she got the Citizens for Midwifery quote but didn’t see anything with that quote or numbers on the linked page. I did download and read the study which these numbers supposedly came out of, though it’s worth noting that Dr. Tuteur wrote her post prior to the full paper being released.
I’m not really sure exactly where this quote came from and these numbers don’t seem to match anything in the study. My best guess is that the quote came from a press release or results summary. The stats she mentions (2.06 per 1000 risk of death for all births and 1.61 per 1000 risk of death for low-risk births) are not mentioned anywhere in the actual study, though that doesn’t mean they are not accurate."

Is it really so hard to find? I clicked on the link provided by Dr. Tuteur, which takes you here:

Now, if I were looking for a quote from Citizens for Midwifery (CfM), my first instinct would be to click the link next to where I wrote "1." and if I couldn't find the quote there, I would click the link next to where I wrote "2."

(Awesome paint skills, I know)

Lo and behold, when I click on the link for the summary by CfM (next to where I wrote "1." in the photo), I find the exact quote that Dr. Tuteur referenced that Jamie Bernstein couldn't find: "The overall death rate from labor through six weeks was 2.06 per 1000 when higher risk women (i.e., those with breech babies or twins, those attempting VBAC, or those with preeclampsia or gestational diabetes) are included in the sample, and 1.61 per 1000 when only low risk women are included. This rate is consistent with some published reports of both hospital and home birth outcomes, but is slightly higher than others."

So she couldn't find that quote (seriously?) but Ms. Bernstein said she downloaded the study. You would think it wouldn't be hard for a "stats junkie/guru" to figure out what the overall death rate is with the study in hand but she is clearly someone who needs to have ev-er-y-thing spelled out for her. So, let's look at the study that Ms. Bernstein was able to figure out how to open.

Ms. Bernstein was able to find the mortality rates in the study and she included the numbers in her blog post:

"Intrapartum fetal death: 1.30 per 1000
Early neonatal death: 0.41 per 1000
Late neonatal death: 0.35 per 1000"

I'm not a stats guru. But if I were and if I were trying to find the "overall death rate" I'm pretty sure I would try and add up those three figures to see if those totals could give us the number we are searching for. Amazingly enough, that's exactly what happens. We get 2.06/1000.

"Thorough" is not a word that comes to mind when I think of Ms. Bernstein's ability to critique. Another perfect example:

2. "These numbers still include high-risk births such as breech or twins, though. I was unable to find a low-risk birth stat comparable to the one Dr. Tuteur mentions in her post. I was hoping the stats she mentioned would be in the study so I would get some good confidence intervals to work with, but instead I’m just going to have to take Dr. Tuteur at her word and have to interpret the numbers without confidence intervals."

Again, it is listed in the CfM summary that Dr. Tuteur linked to and again, all of this information is written in the study itself - confidence intervals and all. There is NO REASON a so-called "stats guru" should not be able to find the figures. The only thing that changes from the rates above is the intrapartum mortality rate for low risk women only, which is listed in the discussion of the study: 0.85/1000. Swap out the intrapartum mortality rate above that is for all risks (1.30/1000), replace with the low risk intrapartum mortality rate (0.85/1000) and we get low risk birth stat written up by CfM and quoted by Dr. Tuteur: 1.61/1000

Has this confused you? The point is.... had Ms. Bernstein simply clicked the link for the CfM summary or had she lived up to her title of "stats guru/junkie" and figured out how to add up the mortality rates, then the entire first portion of her critique would not exist.

The MANA study authors did not provide totals for the mortality rates. They should have. If Ms. Bernstein wants to critique anyone for omitting information, she should be placing blame on the authors of the MANA study for not spelling it out. If a "guru" can't figure out the total mortality rates, how will a lay person be able to figure it out?

3. "It’s worth mentioning here as well that the study in question did not compare risks in homebirths to that of a comparable hospital birth cohort. Instead, all this study did is look at a sample of almost 17,000 planned homebirths in the US in which they had lots of detailed information and then report on various statistics about those births."

That's it? That's all the slap on the wrist that MANA deserves for not including any numbers for comparing to hospital births? I cannot think of a single home birth mother that I know personally or even a single debate or discussion regarding home birth safety where this line hasn't been said "home birth is just as safe if not safer than hospital birth." Many, if not most, women choose home birth these days because they see it as an option of equal or greater safety. Why would MANA not make any comparisons at all? Why doesn't Ms. Bernstein recognize this as an issue? Why does it seem that over and over again in her critique that she lets MANA off the hook and is more than willing to give them the benefit of the doubt?

4. "According to Dr. Tuteur, 1.6 per 1000 low-risk planned homebirths from the recent study resulted in neonatal death within 6 weeks of birth. Using CDC data, she also determined that the risk of neonatal death for low-risk white women in the US during the same years was 0.4 per 1000 births. She then points out that OMGZ YOU GUYS THAT’S A 5.5X INCREASE IN BABY DEATHS!
First of all, can I first point out that it’s a 4x increase, not 5.5x (1.6/0.4 = 4). Even comparing the homebirth cohort that includes high-risk births (2.1 in 1000) to the low-risk only CDC cohort (which is not a fair comparison for obvious reasons) would only result in a 5.25x increase in mortality. I seriously have no idea how Dr. Tuteur came up with 5.5x or 450% increase in mortality from the numbers that she cited."

Dr. Tuteur compared CNM-attended hospital births to MANA study rate for all risks. As Dr. Tuteur's said: "According to the CDC Wonder database, the neonatal death rate for low risk white women at term from the years 2004-2009 is 0.38/1000. As Judith Rooks, CNM MPH noted in her review of Oregon homebirths, intrapartum death among low risk babies is essentially non-existent in the hospital, so the neonatal + intrapartum death rate for the hospital is still 0.38"

So we take the MANA rate for all risk (2.06) divide it by the mortality rate of 0.38 and we have 5.42.... and obviously, rounding that number gives us 5.5. You "seriously have no idea how Dr. Tuteur came up with 5.5x," Ms. Bernstein? Well, that doesn't shock me that you couldn't figure it out, actually. I don't think math is your strong suit. Or writing. Or reading. Or link clicking.

The risk is actually greater for babies born at home than that given by Dr. Tuteur because the rate she uses includes deaths resulting from lethal anomalies. These deaths are excluded from the MANA study rate.

As I quote above, Ms. Bernstein said "Even comparing the homebirth cohort that includes high-risk births (2.1 in 1000) to the low-risk only CDC cohort (which is not a fair comparison for obvious reasons)." So why did Dr. Tuteur compare the hospital CNM outcomes to the MANA study outcomes including low and high risk women? Well, we could always ask her (and by "we" I mostly mean Jamie, since she doesn't seem to be familiar at all with home birth midwifery). But as someone who understands how things work with home birth midwifery in our country, I'm going to answer with my own thoughts on the matter.

There are very few days (or hours) that go by that I do not see a home birth advocate or home birth midwife share something on Facebook, on a blog, in a forum, etc that aims to scare women away from and/or minimize the importance of screening measures: ultrasounds/technology are/is harmful, GDM testing is pointless for women who eat healthy, GBS screening isn't accurate, antibiotics will harm the baby's gut flora, babies come when they are ready, induction = bad, c-section = the worst, etc etc. Screening measures and proper monitoring are important. It's how care providers and pregnant women can be sure they are truly low risk - which is especially important for out-of-hospital births. Ensuring that a woman is low risk is part of the reason the Birth Center study has much better outcomes than the MANA study. But MANA and home birth midwives don't want to promote such practices as a whole. Screening measures are often optional if not discouraged in the world of home birth midwifery. How many women are giving birth at home each year thinking they are low risk but do not take the proper screening measures to make sure they actually are?

Another reason is because too often high risk pregnancies/complications are brushed off and/or called "variations of normal." Need I remind you what happened on Jan Trittan's Facebook page when a 42+ week pregnant woman was discovered to have ZERO amniotic fluid and the midwife did not insist on an immediate transfer but instead asked for help on the internet. When the mother was finally transferred, at least 24 hours later, it was too late and the baby died. I can tell you for certain that this mother did not fully understand at all the risks of her situation -- it was clear her "professional" midwife did not even understand so how could she? The lack of informed consent is shocking. How many women are having high risk home births each year not understanding the risks of their situation because their midwife doesn't understand/know/acknowledge the risks?

And finally, the third reason is because hospital CNM outcomes do not solely reflect low risk outcomes. While the hospital CNM outcomes no doubt consist of mostly low risk women, there are high risk pregnancies in that mix.

Given these reasons, to me it makes perfect sense to compare the outcomes from hospital CNMs to the MANA study outcomes for all risks. Both figures include mostly low risk women but also include some high risk women.

5. "Ok ok ok, but even assuming that Dr. Tuteur screwed up some of the basic math here",

Dr. Tuteur didn't screw up basic math. Jamie Bernstein did.

6. "One of the reasons they are reported as deaths per 1000 births is because the risks are too tiny to report as percentages. What we’re really looking at here is a risk of death increasing from 
0.0004% to 0.0016%. This is a difference of 0.0012 percentage points. 0.04% to 0.16%. This is a difference of 0.12 percentage points. (Ed. note: minor math correction is fixed, thank you all for spotting this!) In other words, we are comparing an extremely small risk to a slightly higher extremely small risk. Plus, the smaller the risk, the bigger the sample size you need to detect any change in the risk. When dealing with percentages this tiny on a sample size of only around 17,000 births, it’s not clear that we can get enough accuracy to the 1.6 per 1000 number to even determine that it’s truly “bigger” than the 0.4 in 1000 number from the CDC."

I don't know if Ms. Bernstein would stick with this entire paragraph after fixing the math error she made. When she originally wrote this, you can see she was using numbers that were off by quite a bit. But maybe she would have. I suppose so since she changed nothing else except her "minor math correction." Regardless, she clearly is minimizing the risk of home birth here... and I have a big, big problem with that. "In other words, we are comparing an extremely small risk to a slightly higher extremely small risk."

Except that 1.6/1000 isn't small when it should be closer to 0.50/1000 (or lower) for low risk women. That is one whole baby per 1000 that dies needlessly. I know this baby. I know him by name. And I know her by name. The too many of them and their darling little faces. This "extremely small risk" pops up in my Facebook feed and I see this "extremely small risk" on a daily basis. And I don't know them all, or any where close to it, just some but too many. These "extremely small risks" are the babies whose stories aren't told because the moms think they were some flawed exception who did something wrong. Or because she was manipulated by her midwives to stay quiet. Or if their stories are told, they end up quickly deleted by moderators or buried in the back of posts in home birth support-only forums. Those moms are accused of fear mongering for sharing the stories. These tiny percentages are real little, very wanted babies and I can assure you, their moms all thought the risks were "extremely small." It may be easy to call it very small by someone who wants to minimize the risks as best as they can and who doesn't have a face to put to a number. It's a different story when that 0.16% becomes 100% of your child.

There are over 30,000 home births each year. That means over 30 babies die preventable deaths each year because they were born at home instead of in a hospital. Low risk moms. 30 full term, otherwise healthy babies. Does that seem small to you?

Is the sample size big enough from the MANA study? Maybe it isn't. Maybe it is. These numbers are nearly identical to the numbers from the CPM 2000 study, revealing the same mortality rates and the same preventable loss of life. There are several other studies available now regarding home birth in the USA. And each shows a similar (or higher) risk to babies born at home. If the sample size wasn't big enough, perhaps MANA shouldn't have published it all. But they did. So of course we will compare. It all just reeks of the same lame excuses over and over again offered by MANA, CfM and now Jamie Bernstein: ignore the bad stuff, you can't compare mortality rates to CDC data, the cohorts don't match exactly, sample size isn't big enough, ignore every comparison unless it makes home birth look good! 

7. "All this is even assuming that the numbers Dr. Tuteur cites are comparable. The homebirth study looked at births for women who were planning a homebirth (regardless of where they ended up giving birth). All we know about the info Dr. Tuteur got from the CDC website was that it was for white women with low-risk births. This includes hospital births, homebirths, and births in locations other than the home and hospital (though she labeled them as hospital births on the chart she posted). "

Wrong. That is just flat out wrong. In the CDC Wonder Database, you can sort based on location and based on provider. The numbers, from the CDC, provided by Dr. Tuteur are for hospital births only.

8. "This study found that neonatal mortality rate for infants of parents who planned a homebirth in the first 33 days of life was 0.77 per 1000. This is similar to numbers found in homebirth studies done in Europe and is very low. This could be slightly higher than planned hospital births, but because the numbers are so close we can’t really tell for sure without a study that compares the cohorts while controlling for anything that may make the homebirth population different from the hospital birth population."

Nope. Not slightly higher. They are twice as high. (0.38/1000 for hospital and 0.77/1000 for home) Ya know, if we weren't talking about babies it might not be such a big deal to me.

Ms. Bernstein, why didn't you look at the intrapartum mortality rates? Maybe because if you would have, you would have seen a very substantial increase risk for babies born at home. Or maybe because if you wanted to, you'd have to click a few more links to gather that information. So hey, just ignore it!

9. "Additionally, many midwifes will not do homebirths for high-risk births and it’s possible that the midwifes who do choose to deliver a high-risk birth in a home setting may be different from the midwifes who refuse to do so"

Where is she getting this information? How does she know how many home birth midwives will or will not take on clients that are high risk? How many home birth midwives does she know or even know of ? Why is she using the word "midwifes" and not the word "midwives"? High risk home birth midwives are not hard to come by here in the USA. So to me, this looks like an assumption from someone who doesn't know what they are talking about.

10. "Conclusions based on this one study: The upsides to a homebirth could be lower rates of medical and surgical interventions and it’s probably just more comfortable being at home rather than at a hospital.  However, there is a rather large risk that you may have to transfer to a hospital at some point during labor (which seems less comfortable than just going to the hospital in the first place). For low-risk births the neonatal mortality rate of having a homebirth is either negligible or slightly higher than that of a hospital birth, though because we’re talking relative risk it’s still quite low. For high-risk births there is some evidence that neonatal mortality rates could be much higher in a homebirth setting compared to a hospital. Additionally, homebirths may be extremely costly even if you have insurance.
Again, just to be clear, this is not a review of all the literature and is just my reading of this one study. So, how do two different people read the same study and come to opposite conclusions? The “homebirths are so safe” review by theMidwife Alliance of North America (MANA) focused on the low neonatal mortality rates for low-risk homebirths. They did mention that there were factors that could increase risk, but in my opinion did not give enough of a warning about the possible dangers of having a high-risk homebirth. The “homebirths are killing babies” review by Dr. Amy Tuteur was less “focusing on some parts of the study while downplaying others” and more just a sloppy and unscientific attempt at calculating relative risk by using two completely non-comparable data sources in order to scare readers away from homebirths."

And here we have her conclusion where she minimizes the risks of home birth (again) and calls Dr. Tuteur "sloppy and unscientific." It's no wonder MANA tweeted this post by Jamie Bernstein: it makes home birth look good and it attacks the credibility and analysis by the most outspoken advocate we have for our cause.

What is "sloppy and unscientific" is when someone writes a critique that is full of errors, that is lacking the most basic of math and reading skills, and minimizes risks that have been found with the data in this study by other professionals - actual experts - to be very real and far too high. What is even sloppier is when multiple people point out the errors and the author does nothing to fix them. Jamie Bernstein is just as guilty as MANA is for trying to sweep the horrible results of this study under the rug and as far as I am concerned, just like MANA, she has blood on her hands for doing so.

What makes me so, so angry with MANA, with the study authors, with CfM and with many others out there - all who have their own clear personal gain for protecting the reputation of home birth midwifery - is that they won't simply acknowledge the truth of this study and the truth of every other study done on home birth in America.

I have no idea if Jamie Bernstein has anything personal to gain or not by writing up her poorly executed critique but clearly, I am just as angry with her as well. I have left plenty of comments stating my issues, I have even corresponded with her privately (we, oddly, have a mutual friend on Facebook). We had a fairly civil private conversation but after I shared information regarding intrapartum mortality rates, she banned me. I feel she must have some motivation to try and discredit Dr. Tuteur, Prof. Orosz and Ms. Inglis-Arkell, to try and minimize the risks of home birth, to try and cover up the real results from the MANA study.

To her, to MANA, to CfM, and yes, even to Grounded Parents and anyone else who supports this nonsense I say: Do the right thing, help mothers to make informed choices! Statistics aren't the bottom line but they matter - even a little bit - to plenty of women. Women deserve the truth and yet they are being fed lies by the people/establishments they trust the most. It's maddening, to put it mildly.


I need sleep. Apologies for typos. It's 12:30am and way, way past my bedtime. Up next - when I have the energy - I'll tackle Jamie Bernstein's second post for Grounded Parents, where she tries to critique the analysis done by statistics professor Brooke Orosz, PhD. Spoiler alert: Jamie Bernstein's piece is an utter mess. Unless, of course, you like lies and strawman arguments.


On to the next.

Ugh. I'll be honest. This is so "yesterday's news" I just don't even want to. But I said I would so I am! So now on to Jamie Bernstein's second post for Grounded Parents.

Again, Jamie Bernstein's quotes are in red; my responses are in black. Here we go:


One More Homebirth Risk Analysis

"I feel like it’s my duty to step in and provide a little more thoughtful review."

If by "thoughtful" she means "useless" then yes, that's exactly what she provided.

"So, how do I know that i09 did not bother to read the study or the Skeptical OB post? Their title was “Statistics Professor Challenges Midwives’ Math on Home Birth Safety.” There are so many things wrong just in this title that it’s hard to even know where to begin. First of all, let’s take the term “midwives’ math.” i09 also doubled down on this in the first sentence of their post which started out with “Recently a group of midwives published a paper about birth outcomes for home births…” If i09 had actually bothered to google the authors of the supposedly overturned study, they would have seen that the authors are medical anthropology researchers at Oregon State University. The head author is also a registered midwife in addition to being a medical anthropology professor, though that’s hardly “a group of midwives.”  (Note: I’m not linking to the authors’ bios for their privacy and protection)."

There are so many things wrong in just her opening paragraph. First, if Ms. Bernstein had actually bothered to Google the study authors then she would see that not just one of the authors is a midwife, but three of the authors are midwives. Let's look at the authors, shall we?

1. Melissa Cheyney – Certified Professional MIDWIFE and Chair of the MANA Division of Research
2. Marit Bovbjerg – Director of Data Quality for the MANA Division of Research
3. Courtney Everson – Director of Research Education for the MANA Division of Research
4. Wendy Gordon – Certified Professional MIDWIFE and Director of Social Media for the MANA Division of Research
5. Darcy Hannibal – a home birth mother
6. Saraswathi Vedam – Certified Nurse MIDWIFE and Senior Advisor for the MANA Division of Research

So three of the six are midwives, five of the six are the board of the Midwives Alliance, and clearly, all six are home birth midwifery advocates. The title of the io9 piece written by Esther Inglis-Arkell is absolutely fitting.

Ms. Inglis-Arkell left a comment for Jamie on her post and it is worth sharing: "While Jamie is correct that the headline doesn’t entirely sum up the group of professionals evaluating the MANA data, given that three of six authors were midwives, analyzing data from a midwives’ organization, and commissioned by that organization, I think the term “midwives” is a fair term for a headline. Jamie does not mention the fact that in the post, I write, “A group of PhDs and midwives analyzed the data and concluded, in a paper published in the Journal of Midwifery and Women’s Health.” In other words, I do bring up their academic credentials just as I brought up the credentials of Dr. Orosz."

Ms. Bernstein's final sentence makes NO SENSE ((Note: I’m not linking to the authors’ bios for their privacy and protection).). There is no need to protect the privacy of the study authors. Please. This is public information! Anyone at all who can access the internet can pull up the study with the authors names right at the top of the study. The credentials for each author are listed right by their names and Ms. Bernstein said in comments of the article "I do know about the different types of midwife certifications" so it's hard to figure out why she wrote this opening paragraph at all and why she wanted to pretend the authors names aren't public information other than because she was flat out lying.

Several people (myself included) pointed this out to her in the comments. She made no changes.

"Also, if they’d read either the “Midwives’” study or the analysis that they wrote their entire post on, they may have realized that no one is actually challenging anything. The Journal of Midwifery and Women’s Health study did not attempt to make any relative risk comparisons between homebirths and hospital births. All it did was look at data from about 17,000 planned homebirths in the US and report on outcomes for those births. "

Wrong. The MANA study authors didn't just "look at data from about 17,000 planned homebirths." They didn't just serve up the data and say "hey, here are the outcomes!" No. The used the information to make comparisons and draw conclusions. The used different studies from other countries to make comparisons for mortality rates (though, they omitted each of the rates.... conveniently). They also compared intervention rates and cesarean section rates to hospitals in the USA using CDC data. They didn't compare mortality rates from home to hospital... they should have... but they didn't. Regardless, this wasn't just a collection of data. They used the data to draw comparisons and conclusions, including the conclusion that "Low-risk women in this sample experienced high rates of normal physiologic birth and very low rates of operative birth and interventions, with no concomitant increase in adverse events." What Dr. Tuteur, Professor Orosz, myself and others are doing is drawing the appropriate comparisons by comparing to hospital data to show the MANA study conclusion is wrong. There is an increase in adverse events for babies born at home.

"In this case the cohort groups are very different. They contain completely different types of people and do not even use the same definitions for very simple things like what counts as a hospital birth. In the case of intrapartum death, we don’t even have any cohort comparison group at all. Even so, this is the best data we’ve got. We can compare the numbers to get some rough estimates on potential risk increases, but to claim that “home birth substantially increases the risk of neonatal death” is absolutely not supported by the data."

Ms. Bernstein goes on and on for several paragraphs about not having a comparable control cohort. What she clearly missed (though I don't know how) is that Prof. Orosz gave MANA the advantage with the rates she used for the hospital cohort. The hospital cohort is a higher risk group of women than that in the MANA study. Her intrapartum mortality rate is an estimate for any and all pregnant women (regardless of gestational age, risk, lethal anomalies, etc). The results from the analysis by Prof. Orosz were 0.7/1000 for the hospital cohort and 2.06/1000 for the MANA study. If we were looking at a hospital cohort that was a closer match to the MANA study cohort, the difference would be even more substantial... the hospital total mortality rates would be under 0.7/1000. Prof. Orosz concludes "It is clear that home birth substantially increases the risk of neonatal death and of intrapartum death." That conclusion is supported by the data.

"At one point she discusses breech births. In the homebirth cohort there were 5 deaths in 222 breech births. There were also a handful of breech births in which there was missing data. Prof. Orosz explains:
Disturbingly, the breech data were incomplete, as the authors explained: “There are 4 singleton pregnancies, 3 of which were breech presentations, for which all birth outcomes data are unavailable. These women began labor at home and then transferred to the hospital prior to birth. The midwives of record were contacted, and in each case the midwife did not accompany the mother, nor did the mother return to the midwife for postpartum care.” This missing data means that the breech death rate could in fact be as high as 36.0 per thousand, or 3.6%, which is similar to the breech birth death rate in the USA circa 1950.
In other words, Prof. Orosz is assuming that in all cases in which outcomes were missing for mothers who transferred to a hospital with a breech birth, the newborn died, though she gives no evidence for why this may be true. She then adds in these supposed deaths in order to come to her conclusion that 3.6% of the breech homebirths resulted in the death of the infant."

This goes on and on for another several paragraphs where she even accuses Prof. Orosz of manipulating the data. And all of it is complete nonsense.

This is a strawman argument. Prof. Orosz did not assume those newborns died. She brought up a true and valid point that they could have died.

"Later, she does the same “assume all missing data is the worse possible outcome” trick when discussing the APGAR scores for the homebirth newborns. APGAR scores are commonly used immediately after birth to determine the health of the baby. The higher the score, the more signs of health the newborn is showing.
Only 245 infants (1.5%) had a recorded 5-minute APGAR of less than seven. Nationwide, 1.1% of babies above 2500 grams had a low APGAR as per CDC birth data, so the rate among the MANA STATS babies is significantly higher (p<0.0001 per binomial test) but not drastically higher.
However, APGARs were unavailable for 401 newborns. This missing data is concerning, as newborn health is a key outcome, and the only recorded variable with a greater number of missing data points was maternal education. If all 401 of those newborns in fact had low APGARs, the true rate of low-APGAR births would be 3.8%, which is three and a half times the national average.
No. Just no. Just because a baby’s APGAR score is missing in the dataset doesn’t mean it was a low score. Maybe some of them were, but we don’t know because they are missing. That’s kind of what “missing” means. Unless you have a really good reason to assume that all missing data = worst case scenario, you cannot just make that assumption."

She did it again. Another strawman argument from Ms. Bernstein. Again, Professor Orosz did not say the missing APGARs were most certainly low APGARs. She said they could be - it's a valid point.

"In the piece I wrote last week I did not provide my personal opinion but there seems to be a lot of assumptions about it, pretty much all of them wrong. I’m going to give my opinion here if only so everyone will stop making assumptions. My personal opinion is that from what I’ve seen of the data reported on in the Journal of Midwifery and Women’s Health along with the CDC data as reported by Prof. Orosz and reviews of other studies I have read in various places (such as Emily Oster’s book Expecting Better, which I highly recommend) it seems as though there is either no increased risk or a very small increased risk to having a homebirth in a low-risk birth situation"

If you can't see the increase risk, Ms. Bernstein, then it's because you either don't want to or because you are not actually a "stats guru" at all. Dr. Tuteur, Professor Orosz, Dr. David Gorski and Dr. Steven Novella are just some of many experts who found the MANA study outcomes to be incredibly concerning, finding the mortality rates too high even for low risk women.

This second post Ms. Bernstein wrote is paragraph after paragraph of utter nonsense. If she deleted her two strawman arguments, deleted the false information, and deleted where she wrongly accuses Professor Orosz of manipulating data, then her blog post would consist of nothing. And we'd all be better off for it.

I hope no mothers-to-be who are considering home birth read her posts and are fooled by what she had to say. If there are, my hope is they will at least read the comments where it is quite clear the many mistakes Ms. Bernstein made.


  1. Thank you thank you thank you!! Jamie Bernstein's piece is just one huge argument from ignorance that gives MANA way too much benefit of the doubt and none to the person erring on the side of caution.

    I was happy too see that apparently she's not managed to impress very many of the skeptics who know her in person I'm the Chicago area.

  2. I would have been humiliated to realize I had made an error doing basic math when I claimed to be a stats guru. That isn't like a typo. In her head she did the "math" and that's what she came up with. That would be enough for me to discredit anything she says related to numbers. Hopefully most will not take her seriously.

  3. I could not believe the audacity of the woman in her subsequent post and her comments. Let alone the fact that her laziness to click to a link should be a huge red point regarding everything she writes.

    I'm ready to give her a leeway for the error in basic maths. I am, however, not ready to give her a leeway for not checking what she wrote. I am stunned at how many of the so called skeptical people waved her laziness and incompetence away. I wonder whether they would dare present such a research to their bosses! Actually, I'd like to see the boss who'd smile and say, "Right, there was no need to make the colossal effort with the link."

    No wonder MANA loved her post. Thank you for taking the time to expose her lack of standards.

    By the way, it's Queen of Meen here, aka Amazed from the SOB.

  4. Jamie in short, is not a stats guru, but a biased propaganda artist who has a soap box but cannot do math or research.
    I almost feel sorry for her, to embarrass herself so bad, in public, forever. Who would hire someone that that?


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