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


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.

"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 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

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


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.


1. MANA study:

2. Birth Center study:

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

    a. 0.3/1000 is from The World Health Organization:
(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.


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


  1. Excellent! Thank you for this analysis.

  2. This was from a note that Rebecca Dekker of Evidence-Based Birth posted on her Facebook page:

    "The in-labor stillbirth rate was 1.3 per 1,000 for the entire sample, excluding fatal birth defects. It was lower for both low-risk women (0.85 per 1,000) and women who had given birth before (0.84 per 1,000), and higher for first-time moms (2.92 per 1,000), breech presentation (13.5 per 1,000), and VBAC attempts (2.85 per 1,000)."

    I assume that the 0.84 per 1,000 for primips/multips includes all risk groups, which makes me wonder what the intrapartum death rate would have been for primips/multips who were truly low-risk (not VBAC, not twins, not breech, not GD, not preeclampsia). It sounds like homebirth *could* have relatively less risk for such women, and I imagine that risk would go down even further if they were attended by a truly capable provider, i.e. a CNM or MD/DO with hospital privileges.

    That said, the risk category for everyone else is just so much higher. Homebirth "safety" guidelines should clearly state that FTMs and everyone in higher risk categories should be strongly advised to birth in the hospital.

    1. Yes, I agree about the guidelines. I believe that you are correct and that the rate for (truly) low risk multips would be even lower.

      It is unfortunate the many holes there are in this study. I cannot help but wonder if things were left out on purpose. When they list all of the intrapartum deaths, they did not mention which ones happened due to certain high risk pregnancies. They list the GDM deaths and the pre-e death but did not list which ones were the VBAC, breech and twins deaths. Why not? That makes no sense. It makes me wonder if some of the high risk pregnancies were actually doubled up... like perhaps one of the VBAC deaths was labeled a GDM death... meaning they potentially subtracted two deaths instead of one when calculating the low risk IP rate... which would mean the rate for low risk women would be higher if that was the case. It might not be the case. But it just doesn't make any sense that if they know a baby died due to complications of breech/twins/VBAC, why wasn't it listed? Also, they didn't note if there were any uterine ruptures in the VBAC group. This information should be known. Even if there were zero uterine ruptures, they should list that information. VBAC moms deserve to know how many ruptures there were, regardless of positive or negative outcome. That number could be zero or that number could be 20 or whatever. Who knows? Why isn't it listed? There are 11 intrapartum transfers for which the data is not availabe... were any of those ruptures?

      So many holes....

    2. Well, it isn't actually a "study" anyways. I'm no sociologist, but as a historian, I have always been told that any "study" where the participants are self-selected isn't worth much. This was more of a survey than anything else, and there was nothing to stop midwives from simply not reporting the bad results. I was pretty amazed that there were a few cases where the outcomes were unknown because the pt transferred to the hospital in labor and the midwife never followed up with her pt. A provider who doesn't follow up with her pt? Yikes.

    3. If I could like your comment I would do so a thousand times.