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Rebutting Dr. Amy’s Information

Last night I wrote Homebirth vs hospital birth for the number cruncher and the famous Dr. Amy commented on the piece.

“Women choose to give birth in hospitals because they believe it is “safer” than birth outside the hospital. ” Birth in the hospital is safer. The only people who appear to be unaware of this are homebirth advocates. All the existing scientific evidence and the existing state and national data show that homebirth has an increased rate of neonatal death compared to hospital birth for comparable risk women. Sure, there are papers that claim to show that homebirth is as safe as hospital birth, but they do that by comparing low risk homebirth to high risk hospital birth, or low risk homebirth to hospital birth in decades past. The Johnson and Daviss BMJ 2005 study ACTUALLY shows that homebirth with a CPM in 2000 had a neonatal death rate almost triple that of hospital birth in 2000. According to the Linked Birth Infant Death 2003-2004 dataset recently released by the CDC, the most dangerous form of PLANNED homebirth in the US is homebirth with a DEM.

Dr. Amy has been debating homebirth on the internet for a while now so many people have had the opportunity to rebut her information.

On July 22, 2008, Anna Clark wrote a piece entitled Who’s Catching Your Baby? on RH Reality Check.  Many people, including Dr. Amy, commented and a really wonderful, but extensive, debate commenced.  A variety of people participated including an attorney with her Masters in Public Health, a MD, midwives of all backgrounds, and the Legislative Chair of the North Carolina Friends of Midwives.

The posts below demonstrate how the major arguments of her anti-homebirth campaign are just not true:

  1. her understanding and representation of DEM/CPM midwifery education;
  2. her interpretations and representations of neonatal mortality rates (and how the Amish population affects those rates) and;
  3. her interpretations and representations of the home vs hospital neonatal mortality rate data of the Johnson and Daviss BMJ 2005 study.

Since there are 56 comments on that piece, and not many people are willing to wade through all that, I’ve picked out the most interesting thirteen and have included them below.  It really is worth reading them all.  You be the judge.

Dr. Amy was the first to comment on the article.

************************************************************

The issue is safety

Homebirth advocates would like women to think that the issue is “choice” and that the AMA is attempting to “outlaw” homebirth. Neither of those things is true.

Why are homebirth advocates lying about this? As usual, it’s because the lie is so much better than the truth. Here’s what the AMA actually said:

1. Homebirth is not as safe as birth in a hospital or licensed birth center.

2. Midwives should be licensed to the standards of the American College of Nurse Midwives.

If homebirth advocates attacked the resolutions on what they actually said, they’d be forced into a discussion they would lose. Homebirth is NOT as safe as hospital birth. All the existing scientific evidence shows that homebirth has an increased risk of neonatal death. The Johnson and Daviss BMJ 2005 study that claims to show homebirth is as safe as hospital birth ACTUALLY shows that homebirth has almost TRIPLE the neonatal death rate as hospital birth in the same year. The ACNM standards for midwives ARE the appropriate standards. They are consistent with midwifery standards in EVERY other country in the industrialized world.

Homebirth advocates like to imply that homebirth midwives (direct entry midwives) are just like certified nurse midwives or just like European midwives. That’s not true, either. Homebirth midwives are a second, inferior class of midwives with far less education and training than ANY midwives in the industrialized world. American homebirth midwives would not be eligible for licensure anywhere else.

Homebirth advocates also neglect to mention that the Midwives Alliance of North America (MANA), the trade organization for direct entry midwives, has been collecting detailed safety statistics on homebirths since 2001. They have publicly offered those statistics to organizations that can prove they will used them for the “advancement of midwifery”. Even then anyone who is allowed to view the statistics must sign a legal non-disclosure agreement preventing them from disclosing any data to anyone else. It does not take a rocket scientist to surmise that MANA is almost certainly hiding the fact that their OWN data shows homebirth with a direct entry midwife to be unsafe.

The AMA opposes homebirth on safety grounds, and it opposes homebirth midwives because they don’t meet the world-wide standard for midwives. These are the real issues, the ones that homebirth advocates are trying to hide.

Submitted by Amy Tuteur, MD on July 21, 2008 – 8:38pm.

The Debate is Irrelevant

As it turns out, Amy, we are just weary of torturing the numbers with you. It was fun in 2006, but now it is mostly just tiresome (like the never ending repair of graffiti). You embrace Pang’s conclusion and flawed retrospective methods. We embrace the indifference in neonatal outcomes illustrated in Johnson & Daviss, but recognize that birth is not without risk. You exercise the Wonder Site without considering congenital anomalies and declare victory. We screen for congenital anomalies to assess the relative safety of the setting and the care provider and show equivalence in neonatal outcomes (see the query below). You declare women who extol their home birthing experiences as selfish competitive mommies. We weep for the mothers who birth alone because they do not have access to care. You celebrate the terrific obstetrical process capability we have today with C/S. We applaud the capability, but recognize that some mothers do not survive it and that some families lose their ability to create children because of it and consider that in the analysis of safety in light of the current C/S rate of 31%. Your advice to women concerned about the birthing process is to go find a concierge obstetrician who will nurture them like a midwife. We fight to assure that women who choose to birth at home have access to care.

The rhetoric is getting old, Amy. Compelling women to birth in hospital will not solve our problems. Addressing maternal health and access to care should be our focus (one element of this is the onerous environment in which obstetrics is practiced). Instead, we will all just dance this dance until women who choose to birth at home have access to care (because that is where we will land).

Russ

CDC Wonder Site results for white women, 37+ wks gestation, 20-45 yrs old, singleton, with congenital anomalies removed. Analysis basis inputs provided.

Notes Deaths Births Death
Rate
Certified Nurse Midwife 59 268602 0.22
Doctor of Medicine 1013 3117333 0.32
Doctor of Osteopathy 57 189133 0.30
Other 21 19143 1.10
Other Midwife 8 25702 Suppressed (0.31)
Unknown or not stated 4 9292 Suppressed

Dataset: Linked Birth / Infant Death Records, 2003-2004
Query Parameters:
Title:
Age of Infant at Death: Under 1 hour, 1 – 23 hours, 1 – 6 days, 7 – 27 days
Age of Mother: 20-24 years, 25-29 years, 30-34 years, 35-39 years, 40-44 years
Birthplace: All
Birth Weight: 2500 – 2999 grams, 3000 – 3499 grams, 3500 – 3999 grams, 4000 – 4499 grams, 4500 – 4999 grams, 5000 – 8165 grams
Delivery Method: All
Education: All
Gender: All
Gestational Age at Birth: 37 – 39 weeks, 40 weeks, 41 weeks, 42 weeks or more
Hispanic Origin: Non-Hispanic White
ICD-10 130 Groups: All
ICD-10 Codes: A00-B99 (Certain infectious and parasitic diseases), C00-D48 (Neoplasms), D50-D89 (Diseases of the blood and
blood-forming organs and certain disorders involving the immune mechanism), E00-E88 (Endocrine, nutritional and metabolic
diseases), F01-F99 (Mental and behavioural disorders), G00-G98 (Diseases of the nervous system), H00-H57 (Diseases of the eye
and adnexa), H60-H93 (Diseases of the ear and mastoid process), I00-I99 (Diseases of the circulatory system), J00-J98 (Diseases
of the respiratory system), K00-K92 (Diseases of the digestive system), L00-L98 (Diseases of the skin and subcutaneous tissue),
M00-M99 (Diseases of the musculoskeletal system and connective tissue), N00-N98 (Diseases of the genitourinary system), O00-O99
(Pregnancy, childbirth and the puerperium), P00-P96 (Certain conditions originating in the perinatal period), R00-R99 (Symptoms,
signs and abnormal clinical and laboratory findings, not elsewhere classified), U00-U99 (Codes for special purposes)
Live Birth Order: All
Marital Status: All
Medical Attendant: All
Month Prenatal Care Began: All
Plurality or Multiple Birth: Single
Race: White
Regions: All
States: All
Year of Death: All
Group By: Medical Attendant
Show Totals: True
Show Zero Values: True
Calculate Rates Per: 1,000

Submitted by Russ Fawcett on July 23, 2008 – 11:22pm.

Irony

The ultimate irony of the campaign to promote homebirth and license direct entry midwives will be to bring about the demise of direct entry midwifery.

Direct entry midwives and their supporters have successfully tried to confuse American women on two critical points:

1. Homebirth is KNOWN to increase the neonatal death rate
2. American DEMs are grossly undereducated and undertrained compared to ANY other midwives in the industrialized world.

The effort to license DEMs has already let to the national government’s collecting statistics on homebirth with a DEM. The first large data set already shows that homebirth with a DEM triples the rate of neonatal death compared to low risk hospital birth. This is consistent with all the existing scientific evidence on homebirth. Homebirth advocates will no longer be able to pretend to themselves or others that homebirth is safe.

MANA, the trade union for DEMs, has been successful up until now at confusing people about the education and training of DEMs. They created their own certification (“CPM”) which is so close to CNM (certified nurse midwife) as to create confusion. Homebirth advocates routinely cite the practice of midwifery in European countries like the Netherlands, without bothering to explain the American DEMs are nothing like Dutch midwives and would never be considered qualified in the Netherlands. Dutch midwives, like ALL other midwives in the industrialized world are hospital trained with extensive experience in managing complications. In contrast American DEMs never have any hospital training and receive degrees from correspondence courses.

MANA, the DEM trade organization, may continue to withhold the 7 years of safety statistics it has collected, but soon it won’t matter. The government is now involved and the truth can no longer be suppressed.

Here is an interesting fact to ponder:

Suppose that homebirth with a DEM were to increase from less than 1% of births (currently) to 10% of births. All the existing scientific evidence shows that homebirth with a DEM has an excess neonatal mortality rate in the range of 1-2/1000. That would mean 400,000 homebirths would lead to and excess 400-800 neonatal deaths per year. If homebirth with a DEM were to account for only 10% of American births, homebirth would become one of the leading cause of death of term babies in the US.

Submitted by Amy Tuteur, MD on July 24, 2008 – 6:40pm.

Great Zinger, Amy!

Well done.

Once again, however, I need to point out that your conceptual understanding related to the importance of licensing is flawed and your analytical projection is, well, just plain wrong.

On the subject of licensing, you need to understand that it serves a number of purposes. First of all, it promotes access. This is probably the element that most bothers you and your colleagues. I recognize that ACOG’s objective is to force women into the hospital by denying them access to care. This strategy is partially successful in that some women who do not have access to home birth midwifery care do settle for the hospital; however, some women birth at home unattended in the absence of midwifery care, and any excess bad outcomes associated with unassisted birth due to lack of access should be assigned to ACOG. Secondly, licensing allows the consumers to differentiate between credentialed and non-credentialed care providers. Thirdly, it provides a mechanism to assure the standards of care are maintained. In light of your long standing heartburn with the CPM’s training being largely in a clinical setting, I would think you would embrace the regulatory aspects of licensing. Also, it is a first step toward collecting state specific data. Whether you like home birth or not, and whether you like CPMs or not, everyone should support licensing as 1) women will choose to birth at home and they deserve access to care and 2) the CPM is the care provider that attends them. Also, Direct Entry Midwives have been licensed in the US since the late ‘70s and while some regulatory environments are better than others, it is generally considered beneficial. The only one that doesn’t really work at all is Delaware which requires a physician’s signature to obtain a license and ya guys won’t do it, so there is only 1 licensed midwife in the state. Without question, the midwives must be licensed for autonomous practice. One other thing to keep in mind is that contemporary licensing statutes tend to include provisions to protect any other care provider from any liability due to negligence on part of the midwife (even though this is largely for peace of mind for the obstetricians and hospitals as bad outcomes are rare and law suits are even more rare). To my knowledge, these provisions have not been exercised. In summary, licensing is the right answer from every perspective unless your objective is to deny women informed consent and sovereignty over their birthing decisions and constrain them to the hospital.

With regard to your projections of a world in which 10% of births are planned home births with a CPM, we need to make a number of corrections. To begin with, it has already been demonstrated that your claims of 1-2 excess bad outcomes per 1000 births are incorrect. When the CDC Wonder Site data is screened for congenital anomalies, the neonatal mortality rate is indistinguishable for healthy women experiencing normal pregnancies. This is consistent with Johnson and Daviss’ findings. Furthermore, this terrific performance is in an environment in which there is very little infrastructure supporting planned home birth. Clearly claiming an excess mortality rate as high as 2/1000 is a gross exaggeration as the aggregate neonatal mortality rate in the CPM2000 study was 1.7/1000. To illustrate the flaws in your projection designed to scare and bully women into the hospital, let’s for talking purposes analyze an excess rate of 1/1000 in an evaluation of overall safety in the state of North Carolina. I prefer analyzing NC as I have a statewide evaluation of outcomes using the Perinatal Period of Risk Methodology.

To begin with, we have about 120,000 births per year in NC. Our overall perinatal mortality rate is about 12.5/1000 (http://209.217.72.34/VitalStats/TableViewer/tableView.aspx ). For anyone who is not familiar with the perinatal mortality rate, it is the number of deaths in the fetal period (from 20 weeks gestation, depending on convention) plus the intrapartum period (from the onset of labor until birth) and the neonatal period (from birth to 28 days post-partum). In NC we lose about 1500 babies a year. Applying Amy’s little experiment to NC, if 10% of women chose to birth at home with a CPM, that would translate into about 12000 planned home births per year. Using Amy’s (baseless, exaggerated and politically charged) value for excess bad outcomes of 1/1000, we would expect 12 preventable bad outcomes per year (out of 1500 total) due to the planned place of birth (we lose over a thousand lives every year to traffic accidents in NC). It is obvious that this hypothetical large home birth population would not significantly impact our overall perinatal mortality rate even with your inflated values. This simplistic view, however, is grossly inadequate to perform safety analysis.

Now let’s examine the sources of our excess bad outcomes during the perinatal period. The Perinatal Period of Risk Methodology is an analytical tool to assess outcomes in order to aid leaders in health policy on what actions to take. Premature, low birth weight babies (from 500-1500 grams) that do not survive after 24 weeks gestation are placed in the Maternal Health category. In NC, when the overall mortality rate is compared to a low risk group in this category, it is concluded that there are over 200 excess bad outcomes per year due to poor maternal health. We don’t really know how much of this hypothetical home birth group representing 10% of births in NC would be at risk for poor maternal health, but given we are performing a thought experiment, let’s assume it is representative of the overall population. So there is an opportunity to prevent 20 bad outcomes due to poor maternal health. We know that midwifery care is much more effective at promoting health than obstetric care. Let’s assume a 50% improvement resulting in the prevention of 10 bad outcomes due to poor maternal health. The overall perinatal mortality rate is now indistinguishable due to better maternal health offsetting Amy’s (baseless, exaggerated and politically charged) rate of excess bad outcomes of 1/1000.

Now let’s turn our attention to the mother. In the home birth group, we would expect a 4% C/S rate (480 total out of 12000 births). Had those women planned to birth in hospital, their C/S rate would have been 20% (2400). We know there is an excess rate of maternal deaths and hysterectomies due to C/S. Focusing first on hysterectomies (lost opportunity dead babies), rates of hysterectomy are approximately 0.03/1000 for vaginal birth, 0.6/1000 for the first C/S, 0.8/1000 for the second C/S and 5/1000 for subsequent sections. So, approximately 2000 sections are eliminated preventing the loss of fertility for 1-3 women every year. As an aside, one of the fastest growing segments of the home birth community are women who have endured C/S in the past and don’t trust that their birthing decisions will be respected in the hospital. As for maternal deaths, we know the rate of maternal deaths are under reported. In NC, the maternal mortality rate has been reported as 0.12/1000 during the 10 year period from 1987-1996. In addition to being underreported, it is likely higher today in light of the current C/S rate. We know that women undergoing C/S are 2 to 4 times more likely to die in childbirth than women who birth vaginally, so let’s say that the maternal mortality rate is reduced by 50% due to the reduced C/S rate and better maternal health. This hypothetical large home birth group in NC would then save one mother every other year or so. As we all know, the Golden Rule of Obstetrics is that the mother always comes first, so this is a significant difference.

There are myriad other defects in the bucket of morbidity associated with interventions and hospital birth (e.g. episiotomy, birth injury due to forceps and vacuum extraction, infections, etc…). Let’s not forget, also, that millions of dollars would be saved every year which will further improve the lives of the families of North Carolina.

So, what’s the conclusion in this Friday evening comprehensive analysis of safety in a North Carolina in which 10% of women choose to birth at home with an artificially high assumption on neonatal mortality? Well, it would be a terrific North Carolina that steadfastly supports and defends our mothers and families. In reality, as neonatal outcomes for planned home birth are indifferent to hospital for healthy women experiencing normal pregnancies, we would actually have better outcomes due to better maternal health, higher quality of care and reduced cost in this wonderful North Carolina in which 10% of women birthed at home and attended by trained, credentialed and licensed midwives.

Clearly, the key intervention to protect our children is to not let them drive a car!!!! Here’s wishing you a terrific weekend, Amy.

Russ

Submitted by Russ Fawcett on July 25, 2008 – 10:30pm.

Dr Amy, You are incorrect

Dr Amy,
You are incorrect about ALL DEM training in the US. In Florida where DEM’s are Licensed Midwives they are required to attend a 3 year accredited program along with an extensive clinical component that requires attendance at 75 births, most CNM’s are only required to attend 25 births.

In addition to the 75 births, 50 of which must be primary management by the student midwife under direct supervision of either a Licensed Midwife, CNM, or OB, she must also perform at least 50 prenatal, postpartum, and newborn examinations. At least 4 of these must include continuity of care, meaning that the student provides prenatal, birth, postpartum, and newborn care to the same woman.

I did recieve an Associates in Science degree in Midwifery, which I am aware is NOT the same as the CNM required bachelors degree, but you cannot say that DEM’s do NOT have college degrees, my credits ARE transferable!

I had extensive education & training in the management of prevention of complications in addition to the diagnosis & management of complications. I am a specialist of NORMAL BIRTH, I had 3 years of clinical internship, and am highly capable of recognizing when a mom & baby need to be in the hospital and when transfer needs to happen. My hospital transfer rate is 10%, 99.9% of my transfers are non-emergency transfers, with a c/s rate of 6%, and NO neonatal deaths in over 300 births.

The State of Florida tracks statistics for it’s Licensed Midwives and as a state we have excellent outcomes!

2005 was the most recent posted data on the State of Florida Department of Health Council of Licensed Midifery website:

With 38 practicing Licensed Midwives (DEM’s)
18 provide homebirth, 20 work in birth centers
1069 women gave birth, 234 gave birth at home, 571 gave birth in a birth center, the others were transfered to the hospital.

138 women were transfered during pregnancy, 126 transfered during labor: of those, 264 gave birth vaginally, 3% of antepartum transfer had c/s, 6% of labor tranfers had c/s resulting in 99 c/s equaling an 8.5% c/s for women under the care of a Licensed Midwife.

7 women were transfered for postpartum complications, 11 babies were transfered after birth.
There were no maternal deaths, no infant deaths, only 1 fetal death at 29 weeks of pregnancy that was delivered at the hospital.

Timely Prenatal Care
with LM 96.86%
with all other Providers 95.3%

Adequate prenatal care
LM 74.35%
with all other Providers 76.12%

Births over 37 weeks
LM’s 95.29%
All other providers: 83.44%

Normal birth weight
(>2500 g)
LM 98.88%
All other providers 89.64%

Infants that Receive Healthy Start Screening
LM’s 50.15%
All other providers 26.99%

I think you are doing exactly what you are accusing other people of doing Amy, making blanket statements about something in which you do NOT have all the FACTS!

Licensed Midwife, CPM, DEM in Florida

Submitted by Anonymous on July 24, 2008 – 1:13pm.

Thanks for the statistics lesson Dr. Tueter!

I am confused how is 0.61 deaths per 1000 births TRIPLE 1.15 deaths per 1000 births. Moreover, by my calculations these rates are not statistically different.

If you say that women should have unbiased statistics when contemplating a home birth, then you should present them in an unbiased, truthful manner.

More than that, let the statistics stand for themselves and respect women’s ability to make educated and informed choices. Women don’t want to die in childbirth or have their neonate die anymore than you do!

Women are more than capable of making their own choice about birth, weighing the risks and benefits. Many women desire home birth because they don’t want to expose themselves to the many unnecessary interventions that occur once checked into the hospital.

Why is it that my many very educated friends have made comments like:

“I waiting until the last minute to go to the hospital.”

“The more I read [about childbirth in the US] the more I realize how useless my Ob is and how little I want to do with the medical establishment.”

Then there is my friend with cerebral palsy who had natural childbirth about 5 years ago. All her doctor wanted to do was strap her to a bed when she was admitted in labor, although there were no signs of fetal distress or abnormal labor. Instead she had to push against those orders so that she could continue walking during her contractions as we her wish. The result was an uncomplicated, undrugged birth – despite her ob’s wishes.

Why is it that women feel this way and have this experience? Why is it that women don’t trust their obs or the medical establishment? Why is it that the C-section rate in the US is among the highest in the world? Why is it that our neonatal mortality is also among the highest in the world?

Maybe it would behoove you to contemplate these realities, instead of railing against a community that as a community actually respects women’s voice and choice.

Submitted by Caitlin Shannon, JD, MPH on July 23, 2008 – 10:53am.

CDC Wonder statistics

Has the US government data, posted by Dr. Amy, been published in a peer reviewed journal? Looks like it’s all based on birth certificates. Is it not? There’s a lot of problems with drawing conclusions based on birth certificate data, isn’t there? Isn’t that why researchers prefer prospective studies?

Submitted by Anonymous on July 22, 2008 – 12:13am.

Re: CDC Wonder Statistics

Anonymous – You’re exactly right. (Here is the link to the query http://wonder.cdc.gov/lbd-icd10.html so everyone can search it for himself.)

In 2003, of the 19 deaths, 4 were listed as being due to chromosomal abnormalities, 1 was due to encephalocele (part of the brain protrudes from the skull), 4 were due to heart defects, 1 was due to thanatorphic short stature (a rare genetic problem that affects 1/20,000-50,000 births, and is almost always fatal — either stillbirth or shortly after birth), 1 due to osteogenesis imperfecta, 2 to congenital diaphragmatic hernia, 2 due to “multiple congenital malformations” and 1 due to an unspecified congenital malformation.

In 2004, of the 10 deaths, 1 was due to anencephaly (the brain does not develop normally, and has an almost-100% death rate in the neonatal period anyway), and 2 were due to other chromosomal abnormalities.

While it’s possible they may have lived had they been born in the hospital, it’s impossible to know without knowing the cases, since many chromosomal and congenital birth defects are lethal, and birth place and manner have little or nothing to do with whether these babies survive or not.

What is *far* more likely is that these home-birthing women chose not to have any prenatal testing done (including ultrasounds), and did not know their babies were affected prenatally. Since most women who go to doctors do have these tests, they know their babies cannot survive or will survive with severe disabilities. Many of these women (even if they are nominally pro-life) choose an abortion or pre-term induced delivery (aka “life-birth abortion”) rather than carry the child to term and risk the uncertainty of stillbirth, intrapartum death, or neonatal death. (Check out http://www.BeNotAfraid.net for women who have not chosen abortion even when faced with the heart-breaking prenatal diagnosis [some of which were wrong].)

I’m actually unsure where Dr. Amy got her figure of 1.15/1000, because when I put in those criteria, I got 29 deaths out of nearly 30,000 births in the home-birth set, which is 0.98. When I realized there is a “non-hispanic white” in addition to “white” It dropped 2 deaths and about 4,000 births, for 1.05. (I’m assuming that when she says “20-45″ that she means 20-44, because it goes “45-49″, but this discrepancy may be where she gets her 1.15.)

However, of the 29 deaths, 20 of them were due to congenital defects or genetic problems — all of which may have been hopeless cases, regardless of birth place. It just can’t be known without investigating each of the deaths. When you perform the same query Dr. Amy did, except take out cause of death due to congenital and chromosomal abnormalities or defects, you get the following death rates per 1000:

CNMs: 0.25
MDs: 0.33
DOs: 0.34
other midwife: 0.34

You will have to figure the “other midwife” death rate, because of the small number, the rate is suppressed. Oh, yeah, homebirth is risky. Not!

I will also point out that the database lists “other midwife” as the birth attendant for over 5,000 in-hospital births at 37+ weeks, that there were 82 out-of-hospital Cesareans performed, and that CNMs performed some 6,000 in-hospital C-sections. Except that direct-entry midwives don’t attend hospital births (which is one reason for the difference in training they get, compared to other countries’ midwives), C-sections always take place in hospitals, and CNMs don’t do C-sections. So I’m unsure how accurate the data are.

Submitted by Katsy on July 23, 2008 – 9:32am.

That ALSO show that homebirth increases the risk of death

“When you perform the same query Dr. Amy did, except take out cause of death due to congenital and chromosomal abnormalities or defects, you get the following death rates per 1000:

CNMs: 0.25
MDs: 0.33
DOs: 0.34
other midwife: 0.34″

What you’ve just shown is that homebirth with a DEM has the same neonatal death rate as low, moderate and high risk hospital birth with an MD, (including all pre-existing medical conditions, and all possible pregnancy complications). That’s yet another indication that homebirth has an excess rate of preventable neonatal death. For an accurate comparison, you need to go back and pull out all the pre-existing conditions and pregnancy complications in the MD group (and the CNM group) and recalculate. When you do that you find that the neonatal death rates per 1000 are:

CNMs: 0.21
MDs: 0.24
other midwife: 0.34

No matter how you slice and dice the data, the conclusion is still the same. The most dangerous form of planned delivery in the US is homebirth with a direct entry midwife.

Submitted by Amy Tuteur, MD on July 23, 2008 – 11:03am

Um, yeah

Dr. Amy, you said that legalizing non-nurse midwifery will ultimately bring about the death of it. Why, then, do you not support such legalization in the states that do not yet have it? Isn’t the end worth it, in your eyes?

Besides, I think I pretty easily showed that so much of the “excess” neonatal mortality rate is, at most, 0.09/1000, excluding genetic and birth defects. (And that’s without doing any statistical calculations to determine if the rate is significant or possibly only due to chance.) It also includes the 4 deaths from the possibly higher-risk 42+ week group. Unless, of course, going post-term is *not* a risk factor. It confuses me, to speak plainly, because I always assumed you would think post-dates is not low-risk, yet you included it in the so-called low-risk births you culled from the CDC stats. Excluding the 42+ week births actually makes the “other midwife” statistic the lowest NMR!

How can that be?? I thought that “no matter how I sliced and diced the data” that such births were the riskiest form of planned birth! But in all seriousness, if 400,000 women chose home birth, at an apparent 0.09/1000 excess NMR, that would be an excess of 36 deaths, not 400-800 per year. If there were a current rate of 1% (40,000 births), there would be an excess of 3.6 deaths per year.

You’ve stated “the issue is safety”. Is it? Really?? Look at the data for 2004: there is an excess of neonatal death of 3-4/1000 for both maternal smoking and being unmarried. Instead of roaming the blogosphere trying to convince some 20-40,000 women to give birth in the hospital, why not spend that time convincing just 1,000 women to give up smoking? You’d be likely to be more successful, while ostensibly saving as many babies’ lives!

This study found there to be a nearly three-fold neonatal mortality rate when comparing C-sections to vaginal birth (1.77 vs. 0.62); and even when excluding certain risk factors such as congenital anomaly, the difference was “reduced only moderately.”

Considering that a woman who chooses a home birth has probably less than a 5% chance of ending up with a C-section (typically about a 10% transfer rate, and most don’t end up with a C-section), compared to a 23.6% chance at a hospital, that makes a C-section about 5 times as likely to happen at a hospital for low-risk women. So, if these hypothetical 10% of low-risk women chose home birth, and reduced their chance of a C-section to 1/20 instead of 1/4, then there would be only 20,000 C-sections, instead of 100,000. Also, reducing “moderately” the figures in the above-mentioned study (to exclude fetal anomalies, etc., giving C-section a hypothetical 1.4 NMR instead of 1.77), the excess 80,000 “unnecesarians” would yield an excess 62 neonatal deaths. (There would be a predicted 1.4/1000 for 100,000 C-sections, or 140 deaths, vs. 28 deaths out of the 20,000 C-sections; plus 0.62/1000 for the 300,000 or 380,000 vaginal births.) So, even if home birth yields an excess of 0.09/1000 deaths for low-risk women, and 36 babies out of a hypothetical 400,000 died, over 62 others would live that would have died, because they had been born by C-section.

So, the current neonatal mortality rate in babies born to low-risk women by (many times unnecessary) C-section is almost doubled that of the same hypothetical group that chooses a home birth.

Safety? Yeah, right.

Submitted by Katsy on August 2, 2008 – 12:43am.

Amy, Amy go away … take your lies and slither away

Amy,

Aside from the fact that you are grossly misquoting and twisting the scientific evidence to suit your one-man-band effort to discredit Certified Professional Midwives, we’re all so curious about who you are.

Where do you practice? What experience do you have with research? What are your research credentials? What are your research/academic affiliations? In short, aside from misquoting others’ statements and engaging in unsupported conjecture, what credentials do you have to back up your opinions?

Oh, and by the by, if you can tear yourself away from your solo efforts backed by Big Medicine to stamp midwives and home birth from the earth, do tell what you and them are doing to *fix* the critical problem in our society where nearly 1 in 3 American women are going through major surgery to give birth, but only a fraction of them are “high risk.”

Other than bashing the science-backed profession of Certified Professional Midwives with your club of lies, tell us what you’re doing to improve our current U.S. maternity care system. Explain what your doing in light of a two-year review of the science behind maternity care that indicates that the common and costly use of many routine birth interventions, such as continuous electronic fetal monitoring, labor induction for low-risk women, and cesarean surgery, fail to improve health outcomes for mothers and their babies and may cause harm.

Other than shoveling your horse manure all around the blogosphere, tell us what you’re doing when faced with this research that also finds that harm is caused by routine use of intravenous fluids (IVs), amniotomy (breaking the bag of waters), withholding food and water from women in labor, and episiotomy (http://www.medicalnewstoday.com).

And truly, if as you so falsely assert every time the wind blows, CPMs are such back-asswards health professionals, do tell us why the American Public Health Association (APHA) recognizes the CPM training and clinical skills assessment process as the basis of a national certification program for licensing midwives who provide out-of-hospital maternity care services.

Help us understand why states are increasing passing legislation to license CPMs, and why no state has ever reversed its decision to license CPMs. Also, please expound on why no state has reported an excess of damaged babies after permitting CPMs to practice or that all states reporting results have described favorable outcomes for mother and baby, and reduction in expense to the state for initial and follow-up care. Please pontificate on why eight of the ten best states in perinatal mortality license CPMs.

But you won’t go there, will you? My guess is the AMA and ACOG only pay you enough to buy and beat the one-note drum you’ve got … and because they can’t generate any answers to what they’re doing to fix the crisis, neither can you. So all you have is this feeble, tedious, obvious attempt to discredit midwives and the consumers who choose them.

Hey, I know: request a pay raise from Big Medicine (the AMA is a *$280 Million* organization after all), and maybe you’ll be able to talk about the other multiple aspects of improving birth in our society … oh, but that couldn’t be. You wouldn’t know how to talk about anything other than “me-Amy-you-second-class-inferior-midwife-because-I-say-so.”

But the good news? There is only one of you, (funny how *no* other MDs show up in blogs other than you to talk about this issue) and there are THOUSANDS of us and our numbers are growing … us being consumers and midwives (increasingly Certified Nurse Midwives (CNMs) … now doesn’t that just bite your bippy!?) … oh, and chiropractors, and naturopaths, and acupuncturists, and nurse practitioners, and massage therapists and childbirth educators, and lactation consultants, and doulas, and, and, and … and everyone who says “AMA/ACOG: BACK OFF. NOW.”

Amy, we know who you are. We’re just not that impressed.

As one of my mentors always says, “If you don’t have any solutions to the problem, get OUT of the way of those of us who are actually doing the work to fix it.” Beep, beep lady.

Steve U. in NY

Submitted by Steve U. on July 22, 2008 – 2:06am.

Access to Care – It’s Just a Go Do It

Thank you Ms. Clark for the thoughtful essay. Kudos to Dr. Dorn, Dr. Allemann and Dr. Binkley for supporting a woman’s right to birth as she chooses and to assure she has access to care.

This is very simple. Some women will choose to birth at home. We know it is a perfectly valid choice and these families deserve access to care and licensing assures the standards of care are maintained. There are very few physicians who will attend women who birth at home. Of the ~11000 CNMs in the US, only about 100 attend women who birth at home. The primary healthcare professional attending these families, and the only credentialed caregiver explicitly trained in the home setting, is the CPM. There are approximately 1400 CPMs serving women who choose to birth at home and the community of practice is growing at a steady rate year after year.

I absolutely support vigorous discussion on the subject of safety (informed consent is absolutely key), but it really bothers me when this most vocal adversary knowingly misuses the data. This has been debated for years and Amy knows darn well that just looking at stats for White Women is not appropriate. The data on the CDC Wonder site for white women birthing with Other Midwife will include the Plain folk which represents ~10% of the home birth population with higher incidence of congenital anomalies. Also, risk profiles are not the same and we know that there are women with known breech presentation who are birthing at home as they will not be supported in a vaginal breech birth in hospital. I think it is terrific that obstetrics has advanced such that planned C/S is likely the safest option for breech presentation, but when women run out of options in the hospital they will look for options elsewhere. Indeed, Schlenzka observed better outcomes for midwife attended Out-of-Hospital birth even with elevated risk factors. We know that the incidence of low birth weight babies is lower for midwife attended planned home birth due to better maternal health. We know the C/S rate is reduced by a factor of 5 which will result in fewer hysterectomies and maternal deaths. The incidence for all of these bad outcomes is very low, but it is simply argumentative to claim that hospital birth is safer for healthy women experiencing normal pregnancies.

On the subject of training, a comparative evaluation was recently performed by the Director of our University CNM Program and presented to a legislative study committee. This assessment compared the minimum clinical requirements to obtain the CPM credential, the CNM credential and the CM credential (the ACNM version of the Direct Entry Midwife). The conclusion was clearly that the clinical requirements are comparable for care during the childbearing year. More importantly, the CPM credential is accredited by the National Organization for Competency Assurance (NOCA) which is the same organization that accredits the CNM credential.

It is clear that the leadership of the ACOG/AMA has lost all perspective and I find their priorities in establishing their agenda remarkable. In my state, we lose ~1500 babies per year during the perinatal period. The biggest source of excess bad outcomes is poor maternal health resulting in over 200 excess bad outcomes per year. A conservative estimate for the total number of bad outcomes for women who choose to birth at home is 3-5 per year from all causes and largely not preventable. Furthermore, 8 of the top 10 states in perinatal mortality license CPMs and there are women who are birthing unassisted because they do not have access to midwives.

Assuring women who choose to birth at home have access to care is just a go-do-it. Advancing access to the Midwives Model of Care is good policy and will promote improved maternal health. It is also important for the safety of these families that transfers of care are efficient and unobstructed when obstetrics is indicated which can only happen with licensed midwives.

I’m finding that the legislators tend to see the logic in all of this and that the obstructionists must resort to strong-arm tactics to delay the inevitable (access to licensed midwives). It’s funny, if the Medical Societies were to actually support this community they would find allies in their initiatives to address the environment in which obstetrics is practiced. Instead their leadership is entrenched and we will bump heads in front of the General Assembly and the media and they will lose.

Russ Fawcett
Legislative Chair, North Carolina Friends of Midwives

Submitted by Russ Fawcett on July 22, 2008 – 9:56pm.

Interpreting Data

It’s not just my opinion. Other groups who are really good at looking at data have made recommendations based on the scientific evidence. Of course midwifery organizations such as ACNM (American College of Nurse Midwives), MANA (Midwives Alliance of North America), NACPM (National Association of Certified Professional Midwives),CfM (Citizens for Midwifery) CIMS (Coalition for the Improvement of Maternity Services) and the Big Push for Midwives advocate for midwifery care in hospitals, birth centers, and in homes. Midwives would be expected to believe in midwives. But there are neutral organizations which support midwifery care and out of hospital births. The APHA (american public health association): “Therefore, APHA
Supports efforts to increase access to out-of-hospital maternity care services and increase the range of quality maternity care choices available to consumers, through recognition that legally-regulated and nationally certified direct-entry midwives can serve clients desiring safe, planned, out-of-hospital maternity care services,” WHO (world health organization) outlines care for pregnancy around the world (http://whqlibdoc.who.int/hq/2007/WHO_MPS_07.05_eng.pdf): Scroll down to page 4 to see who they recommend should provide the care–its midwives or people with “midwifery training” in EVERY situation involving a pregnant, birthing, or postpartum woman. NEVER a doctor without a midwife, even when the woman has become very very sick.

The RCOG (The Royal College of Obstetricians and Gynecologists) and the RCM (Royal College of Midwives)–groups in England have this to say about home birth and midwives:
“The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that
labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby.1–3 ”

Unlike the ACOG statement and the AMA resolution, these organizations quote many scientific studies. I call that “interpreting the data”, maybe I’m not using that term correctly, but I sure agree with these expert groups in their conclusions. They spend a lot more time studying studies than I do.

To quote a more powerful expert: I recently had the privilege to attend the birth of a physician (the mother is a physician–we shall see what the baby becomes) who is very familiar with all these studies and the arguments about what they mean. She pushed out her son into a tub of water, greeted him joyously, and moved to her bed to nurse. Three hours later as I was waving goodbye from the doorway of her bedroom, she said “This changes everything!” Indeed.

Elizabeth Allemann, MD

Submitted by Elizabeth Allemann, MD on July 23, 2008 – 7:59pm.

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10 comments to Rebutting Dr. Amy’s Information

  • Well, you’ve shown that you are very good at cutting and pasting, but you’ve simply proved my point. The only people who appear to be unaware of the fact that all the existing scientific evidence shows that homebirth increases the risk of neonatal death are homebirth advocates.

    You will note, by the way, the Dr. Alleman has never denied the validity of my statistical analysis. She’s never addressed the point and simply tried to change the subject to her opinion and other people’s opinions.

    If the best you can do is quote made up junk from other homebirth advocates, you’ve conceded my point.

    Dr. Amy, The statement you originally commented on was a quote from an article written in the Journal of Perinatal Education. I’m not interested in debating you over something that someone else said. I cut and paste because I don’t want to spend my day debating you. You and I are not going to convince each other to change our views, so I find continuing this conversation with you as fruitless. Besides, anyone who can read can see that it wasn’t made up junk. Enjoy your Sunday, Jen

  • Congrats, Jen! Being spammed by Dr. Amy is akin to drawing the ire of the entire ACOG, so that’s a big feat. It has been said by people more wise than me that if you’re not making “them” angry you’re not yelling loud enough.

    Unfortunately, now you are drawn into a potentially career-consuming debate about statistics and the manipulation thereof with this woman who has PLENTY of time to do such things (especially since she doesn’t practice anymore). I trust your comments will satisfy your readers and you won’t have to go into this over and over again when it is clear that you will not be changing her mind, as she won’t be changing yours or any other minds which have been opened to critical thinking.

    Keep up the good work!

    Dr. L

    Dr. L, I agree, one can burn up so many hours of ones life going back and forth with someone who thinks different… and for what? My objective is not to convince anyone that homebirth is best or to convince someone to have a VBAC. If someone wants a hospital birth or a repeat cesarean, that is their decision and there is support all over the internet and “in real life” for those decisions. This site provides information and support for women who want to VBAC, homebirth, HBAC, have an unmedicated birth, or for people who are curious why the heck anyone would want to do any of those things. There are websites for debate, this is not one of them. Best, Jen

  • I’ll have to ping this over at my blog. I wish I had the time and energy to read the entire post and comments at rhrealitycheck, so thanks for excerpting some of it. FACT: women will continue to birth at home. If the medical community is so hot and bothered by it, then my suggestions are: (1) clean up your own backyard, (2) reduce the unnecessarian rate, (3) HELP improve maternal-fetal healthcare REGARDLESS of birth venue. That should keep you pickles busy for a millennium!

    “Clean up your own backyard.” EXACTLY! When I was planning my HBAC, and having moments of fear and doubts, I kept wishing that I could go to the hospital, have my privacy, have my CPM midwife, have my freedom, let labor take its course, and yet have all that equipment available if the crap hit the fan. But the way that ACOG, AMA, insurance companies, OBs, and hospitals have it set up, that scenario is impossible. So right now, all birthing woman have to make the decision – home or hospital. And there are risks to both scenarios. And neither scenario is perfect, but, obviously for me, I think home is closer to perfect than hospital. Maybe someday CPMs will be able to work in hospitals in conjunction with OBs, but be the sole caretaker of individual patients, be able to call the shots, and be able to call in the OB when the situation calls for it. But I won’t hold my breath for that to happen. And, I’m very happy that I was at home. I would not have been able to have the birth I did if I had gone to the hospital. No way. Best, Jen

  • Sairah

    I just read your blog, and I have to wonder why it matters whether people choose to have homebirth or hospital birth. Over here, it’s pretty much an either/or situation, and it’s whatever is the best for the mother to give birth comfortably.
    I don’t know much about the statistics for over here either, but I’m assuming that the risk is the same wherever the baby is delivered because the mother is relaxed, and the midwife is fully qualified, and will always transfer you to a hospital should you need it.
    I don’t see why there isn’t more choice in that regard where you are.

    Sairah, What country are you in? I think here it’s really a matter of economics, insurance, and the medicalization of birth. Both OBs and midwives are vying for the same clients and so they are competing. It would be ideal if homebirth midwives and OBs could work together, midwives consulting OBs on issues and having a supportive contact at a hospital when they do transfer. But then it’s a matter of insurance companies. Many insurance companies will drop coverage if they learn that their OB is attending, or consulting on, homebirths. However, there are a handful of doctors that attend homebirths and/or have birth centers in the USA, but they are very few and far between. And then you have the fundamental difference in how midwives vs. OBs practice in the States, which makes it very difficult to find an OB who “thinks like a midwife” to consult/work with. What have your birth experiences been like? Best, Jen

  • KJ

    Isn’t our little Amy just the most adorable thing? It’s a pity that now most of the birth community has figured out her tactics and are calling her on her sh#t. It’s going to be not as much fun for her now that the word is out and she’s yesterdays blognews.

    I just counted up on my fingers the number of women I’ve personally influenced to have a homebirth. Actually I had to use more than my fingers, as it’s well over two dozen.. and I’ve only been spreading the word for a few years. Now, multiply that word-of-mouth campaign exponentially by all the homebirthing families in the US and my goodness! Homebirth is GROWING. And this is what really gets sweet little Amy in a knot. Because no matter how tasty those checks from AMA/ACOG are, they have already seen the writing on the wall, and they are going DOWN.

    KJ, “In real life,” I have personally influenced two, a third is pregnant and planning a homebirth, and a fourth is not pregnant, but is considering a homebirth. Yes, our troops are out there. And our own victories are the greatest testament to what birth can be. Best, Jen

  • JustaMom

    I giggle everytime I read a Dr. Amy comment, It seems that she quotes the same 2 or 3 studies each time she encounters someone who DARES to discuss the safety of homebirth. And she seems a bit bitter that she can’t get her hands on that MANA research. It’s becoming less and less funny though…now it’s just old and boring and…well sad.

    Justamom, As the posts above show, the information she is using on her anti-homebirth campaign is just not true: her statements about DEM/CPM midwifery education, her statements about neonatal mortality rate, and her interpretation of statically indifferent data. All not true. Best, Jen

  • I wonder if Dr. Amy knows that a growing number of people, not even “homebirth advocates” but people with brains, are recognizing her as nothing more than an overzealous spammer with too much time on her hands. Not one person I have talked to has taken her seriously.

  • Miko

    How about people like “Dr” Tuteur actually do something to address the issues that are driving women away from the hospitals?

    Oh wait, its too easy to sit back and sling mud from behind a blog, The “debate” on the “Homebirth Debate Blog” is really just a forum where women can go back and forth about how “horrible, selfish and unstable” women (who choose homebirth, or hell, even unmed vaginal birth) are.

    Amy, if you want to present FACTUAL info, get educated and do so. Stop pushing your own agenda and personal issues.

  • Ha Ha Ha Ha…. the Dr has become her own worst enemy.

  • AustinMom

    It’s funny how Dr. Amy says “The only people who appear to be unaware of the fact that all the existing scientific evidence shows that homebirth increases the risk of neonatal death are homebirth advocates.” Does she know that these home birth advocates include organizations like RCOG, RCM, APHA, and all the typical pro-midwife groups? It’s sad that pretty much the only organization that doesn’t support home birth is ACOG. Why do women choose to listen to just one group, when everyone else says differently?

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