# New study showing homebirth increases risk of nenonatal death. Thoughts?



## loraxc (Aug 14, 2003)

FTR, I had a homebirth and would have another.

I realize this will probably be a controversial thread, but the MDC community should be aware that this study is out there. (An acquaintance who knows I homebirthed emailed it to me this morning.) I'm interested in discussing whether this study is flawed, whether it is politically motivated (probably!), but also whether it has something important to tell us.

"Home birth 'trebles risk of baby's death' "

http://www.dailymail.co.uk/health/ar....html?ITO=1490

"Home births are good for mothers but riskier for babies, says study"

http://www.guardian.co.uk/lifeandsty...h-babies-study


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## *MamaJen* (Apr 24, 2007)

We're talking about it over here: http://www.mothering.com/discussions....php?t=1239367

I got a copy of the original study, and wasn't terribly swayed by it. It's a meta-study, meaning it looks at a number of different studies from a number of different counties. Hence, the data is only as good as the original studies.

They looked at 342,056 planned homebirths, of which 321,307 came from a Dutch study which showed very high levels of homebirth safety. The other 20-odd thousand came from several other studies, some of which date back to the 1970s. They also didn't, as far as I can tell, include the North American Homebirth Study that showed good safety rates.

This is what I wrote in the other thread:
So basically, the bottom line in this study is they're showing a perinatal death rate of .07 for homebirths (229/331,666) vs. a .08 percent death rate for hospital births (140/175,443). Then they're showing a neonatal death rate of .2 percent (31/16,500) for homebirth, versus .09 for hospital (31/33,302).
That "three times as deadly" number comes from they're findings of nonanomalous noenatal death, where they're showing .15 percent (23/15,633) for homebirth, vs. .04 (14/31,999) for hospitals.

So basically, what that means to me is they were primarily using the Dutch study to find that perinatal death rate, which shows very similar mortality at home and in hospital. Then I guess that triple neonatal death rate was pulled from the other studies, many of which are pulled from the 1970s and 1980s.
***
So until I saw which studies had the high death rates, I wouldn't feel comfortable extrapolating too much from this analysis.


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## AlexisT (May 6, 2007)

I posted my thoughts on another thread. I am skeptical of this study. I don't think you can aggregate results from 7 different countries, in studies done over a 30 year span when obstetric practice changed quite a bit. The quality and size of the studies varies, too. I simply don't think it was well done--and I am far from a "homebirth advocate".


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## kittywitty (Jul 5, 2005)

http://www.theglobeandmail.com/life/...rticle1624918/


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## MammaB21 (Oct 30, 2007)

I have two counterpoints to that 'study' which to me are extremely important to consider. First of all, stating it the way the article does: 'infant death is "THREE TIMES AS LIKELY" in a homebirth', is misleading. While the sentence is true, they're talking about .03% and .3%. Both studies came back with an infant mortality rate of under 1% which is an extremely low risk either way. Certainly moms who chose homebirth are not endangering their babies.

Secondly, and the most important, is that the study doesn't provide any answers to where that extra percent is coming from. What is causing the increase in infant death at a homebirth? Which types of homebirths are being included in this study? Are we comparing strictly planned homebirths with an actively trained and practicing midwife in attendance? To me, that would be the only way I would ever take a study like this to heart. Otherwise, we're including all of the births that took place out of hospital. That would include planned and unplanned UC. It would include births that went too fast to get to the intended place of birth (ie: car births, parking lot births, births on the toilet). All of those have an increase risk of infection for baby due to birthing in a place likely to have higher exposure to bacteria. We would be including all the pregnancies that didn't have prenatal care. In those cases there could have been a problem with the baby that would have otherwise been detected and treated in a hospital setting. We would even be including the births in which there was a known problem with baby and mom decided to continue with her homebirth plans anyway. Think a heart problem that was not compatible with life. I know that in a case like that I would make the decision to birth my baby at home, possibly even if my prior plans had been a hospital birth.

Anyway, it saddens me that 'studies' like this are even out there when they are so utterly inconclusive. I'm also surprised that a doctor from the UK would take any study about homebirth done in the US seriously. There are so many other factors here that aren't being considered.


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## *MamaJen* (Apr 24, 2007)

Another thing to clearly point out: the cohort of 300,000+ homebirths showed very good safety rates, while the cohort of 15,000 homebirths showed bad safety rates.
Also, another thing I pointed out in the other thread -- in the planned hospital births, they showed a C-section rate of 9.3 percent. Of course most of you know that in America today, it's more like 32.5 percent.
And like a PP said, they don't specify if the births are midwife attended, which IMO makes a huge impact.


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## AlexisT (May 6, 2007)

Quote:


Originally Posted by *MammaB21* 
I'm also surprised that a doctor from the UK would take any study about homebirth done in the US seriously. There are so many other factors here that aren't being considered.

This part I can answer. The researchers were from the US. However, they didn't do a study per se: they did a meta-analysis of studies from the US, Canada, Australia, UK, Netherlands, Sweden, and Switzerland. It wasn't solely about home birth in the US. However, like I said, I don't see how you can achieve meaningful results by mushing together outcomes from completely different maternity systems.

My understanding is that all the studies were meant to look at planned home birth; however, the quality of the studies varied a lot. I know some of the US studies relied on birth certificate data, which isn't always reliable.


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## loraxc (Aug 14, 2003)

I thought the study was looking only at planned homebirths (excluded UCs, car births, etc.)

Quote:

So basically, what that means to me is they were primarily using the Dutch study to find that perinatal death rate, which shows very similar mortality at home and in hospital. Then I guess that triple neonatal death rate was pulled from the other studies, many of which are pulled from the 1970s and 1980s.
I don't quite follow, but are you saying that neonatal rate is drawing only from the US numbers, which are potentially very old? Can we then say that perhaps there was at one time a higher neonatal death rate for midwives (who did this include--trained people, anyone using the title?) in the US, but this is probably no longer the case?


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## *MamaJen* (Apr 24, 2007)

Quote:


Originally Posted by *loraxc* 
I thought the study was looking only at planned homebirths (excluded UCs, car births, etc.)


The study only looks at planned homebirths, but does not note if they were with a trained attendant. Basically, they could be treating a UC in a cabin in the wilderness the same way that they would treat a homebirth attended by a CNM one city block from a hospital.

Quote:


Originally Posted by *loraxc* 
I don't quite follow, but are you saying that neonatal rate is drawing only from the US numbers, which are potentially very old?

Basically, yes. It's hard to tell exactly where those high neonatal numbers are pulled from. That's the frustrating thing. They give a list of 12 studies they analyzed -- three from Canada (1998 - 1999; 2003 - 2006; and 2000 - 2004); two from the Netherlands (1990 - 1993 and 2000 - 2006); two from the U.S. (1976 - 1982 and 1989 - 1996, and note that the big North American homebirth study is not in there); two from the UK (1978 - 1983 and 1994); one from Western Australia (1981 - 1987), one from Switzerland (1989 - 1992) and one from Sweden (1992 - 2004).

By a huge amount, the biggest one is the recent Dutch study -- and we know that that study showed no higher mortality rates for planned midwife attended homebirths. That amounts to 321,307 of the 342,056 homebirths. The remaining 11 studies showed another 20,749 births.

To find the perinatal death number, which was similar to the hospital mortality rate, they combined six studies, for a total of 331,666 births. So obviously, the Dutch study and five others.
To find the neonatal death, which was higher, they combined the remaining seven studies, for a total of 16,500 births. The most significantly higher number was the nonanomolous neonatal death rate, which was pulled from 6 studies amounting to 15,662 births. There were 23 deaths in that group.

So basically, if the majority of those 23 deaths came from UCs in the Australian outback in 1980, that's not convincing data. If they came from Canada in 2004, that would be more alarming. Note that there is no US data less than 15 years old.


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## *MamaJen* (Apr 24, 2007)

Okay, so just for example: of the 20,749 births that were from the 11 studies other than the Dutch study, 30 percent (6,133) were from a 2002 study that looked at Birth certificates in Washington state from 1989 - 1996, and showed a high mortality rate for home births. Here's a strong critique of that study: http://www.lamaze.org/Research/WhenR...2/Default.aspx


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## loraxc (Aug 14, 2003)

Quote:

To find the neonatal death, which was higher, they combined the remaining seven studies, for a total of 16,500 births. The most significantly higher number was the nonanomolous neonatal death rate, which was pulled from 6 studies amounting to 15,662 births. There were 23 deaths in that group.
What was their justification for doing it this way?


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## *MamaJen* (Apr 24, 2007)

Quote:


Originally Posted by *loraxc* 
What was their justification for doing it this way?









I have no idea. Basically, it looks like they took five percent of their data, pulled a mortality rate from that, and sent out press releases saying that home birth it three times more dangerous -- based on that five percent break out group, despite the fact that 95 percent of the data showed similar mortality rates for home and hospital. I'm really baffled.


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## liz-hippymom (Jul 17, 2003)

Quote:


Originally Posted by **MamaJen** 
99 percent of the data showed similar mortality rates for home and hospital. I'm really baffled.

but that in its self is a problem, as the woman with "planned homebirths" are always low risk, whereas "planned hospital births" include both low risk and high risk woman. if homebirth were safer than the number should be lower for deaths, not higher.

and two times as high is twice as many dead babies. when your baby is one of then it matters.


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## Banana731 (Aug 4, 2006)

Quote:


Originally Posted by *liz-hippymom* 
but that in its self is a problem, as the woman with "planned homebirths" are always low risk, whereas "planned hospital births" include both low risk and high risk woman.

I have not read the study. Is that the case? I would find that surprising.


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## *MamaJen* (Apr 24, 2007)

Quote:


Originally Posted by *liz-hippymom* 
but that in its self is a problem, as the woman with "planned homebirths" are always low risk, whereas "planned hospital births" include both low risk and high risk woman. if homebirth were safer than the number should be lower for deaths, not higher.

and two times as high is twice as many dead babies. when your baby is one of then it matters.

I think you misunderstood what I was saying. They had 12 different studies. They grouped half of them into one cohort, amounting to 99 percent of the data (300,000+ births) and found similar mortality rates. Then they took five percent of the data (15,000 births) and found higher mortality rates. Three times higher in five percent of your total data is not twice as much.


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## sept04mama (Mar 3, 2004)

I just want to say that we shouldn't automatically discount EVERYTHING that is found to be (possibly) negative about homebirth. People need to be informed. I had a hard time researching the "cons" of homebirth when making my decision. I am glad we have an opposing view in this thread, even though most of us will still ultimately still choose homebirth.

I think possibly the reason it may be higher is that a lot of homebirths are postdate, which does include a higher risk of death for the baby. Maybe they took that into account, I don't know.

And Liz, yes, it *does* make a difference when yours is one of the babies who die. I would know.


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## mwherbs (Oct 24, 2004)

the stats would include all "planned" homebirths- no matter the risk category- remember that OB's consider breeches and twins as high risk and I really don't see any way that they are keeping UCs out of the stats because they are planned homebirths- I will have to go to the med library and read their source studies- in the past the Pang study supposedly had stats on all planned homebirths in Washington but we know how that was off because the researchers use health department data on all births that did not occur in the hospital- so although the mws in Wa are licensed and it would be easy enough to collect that data directly - that is not the info the study used-


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## GuildJenn (Jan 10, 2007)

Quote:


Originally Posted by *Banana731* 
I have not read the study. Is that the case? I would find that surprising.

In the B.C. (Canada) study they only included women who met the criteria for home birth whether they delivered at home or not. (And yes in my province, Ontario, and in B.C. there are guidelines.)

However they also only went on the planned location - if a woman was having a home birth and transferred, that outcome counted as a home birth. Which seems fair because in that case the system works.

Anyways what I wanted to add to the discussion is that I think one of the big issues in neonatal death research in first-world countries today is that so many complications and issues now so rarely result in death that the stats can be confounding.

Lumping all complications together -- and putting the cut-off at 7 days for perinatal mortality -- means that it's hard to get a picture of which intervention "would have/might have/should have" helped.

So I don't find it surprising that perhaps particular complications would have better (or at least, not death) outcomes in hospital, and if the complications for the period of study tilted in that direction the study would show that.

It might be that homebirths have higher rates of neonatal deaths because hospitals can intubate newborns more quickly, for example. So you might have more babies surviving to 8 days in the hospital, taking them out of perinatal death stats.

Or conversely, if a study doesn't look at homebirths with a transfer, you could throw the stats in the other direction because more people who transfer will be in the middle of complications.

What I _personally_ would try to get (and have tried to get) from studies like that is a personal sense of where I stand.

If the fractional difference in risk in the meta-study were true, for example, and that _fraction_ were changing my mind about a homebirth, I think what it would be telling me personally is that I wouldn't be ready to be in a situation where there was a possibility that my choice to labour at home was the cause (however rare) of a loss.

In terms of policy, I don't think this study would be a good one to base public policy on because it is cross-country, and each country has a very different climate. In the US for example I am betting that there could be a small but significant number of women who hesitate longer before transferring because of insurance issues, whereas in Canada it's not as much of a concern so women who are homebirthing and find themselves in one of those rare situations might have a smoother transfer (and so better outcomes). Etc.


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## *MamaJen* (Apr 24, 2007)

So here's something really interesting. If you add up ALL mortality in the study, the hospital mortality rate is actually higher than the homebirth mortality rate (and yes, the studies did match low-risk births for the hospital cohort).

Perinatal mortality, home: 229/331,666
Neonatal mortality, home: 32/16,500
Perinatal mortality, hospital: 140/175,443
Neonatal mortality, hospital: 32/16500

Total mortality, home: 261/348,160 = .0007496, or .075 per thousand
Total mortality, hospital: 172/208,745 = .00082397, or .0824 per thousand

So there you have it.

(I'm actually very excited, because we just had a problem in my statistics class _exactly_ like this, and I'm a big geek and it's cool seeing a real world version of it.)

And one other thing -- that study of homebirths in Western Australia from 1985 - 1990 looks like it was used for a large portion of the data in the neonatal death category. That study showed abysmal mortality rates, along the lines of 7 per thousand. Which makes a lot of sense. Western Australia is enormously rural and has a high aboriginal population, you might be 1,000 miles from a hospital, it included high risk pregnancies attended by unqualified birth attendants -- pretty much everything you don't want to see in a homebirth, and not in line with how homebirths occur today in Canada or the UK or most of the US. I would be really interested in seeing the neonatal mortality rate with that study eliminated.


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## MidwifeErika (Jun 30, 2005)

Quote:


Originally Posted by *liz-hippymom* 
but that in its self is a problem, as the woman with "planned homebirths" are always low risk, whereas "planned hospital births" include both low risk and high risk woman. if homebirth were safer than the number should be lower for deaths, not higher.

While that seems like that should be the case, it really is not. I know of midwives who are willing to provide care to women with varieties of health issues so long as the women can get co-care or the midwife is able to consult on these issues. Also, many homebirth midwives provide care to women who are VBACs, advanced maternal age, multiples, breech, grand multips, postdates, etc. Each of these groups I would not consider "high risk," however there is a slight increase in risks for each of these groups.

Also, I am curious about when the planned birth location was taken into account. Does anyone know? Was it the beginning of care or was it at the time of labor?


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## Turquesa (May 30, 2007)

Quote:


Originally Posted by **MamaJen** 

Basically, yes. It's hard to tell exactly where those high neonatal numbers are pulled from. That's the frustrating thing. They give a list of 12 studies they analyzed -- three from Canada (1998 - 1999; 2003 - 2006; and 2000 - 2004); two from the Netherlands (1990 - 1993 and 2000 - 2006); two from the U.S. (1976 - 1982 and 1989 - 1996, and note that the big North American homebirth study is not in there); two from the UK (1978 - 1983 and 1994); one from Western Australia (1981 - 1987), one from Switzerland (1989 - 1992) and one from Sweden (1992 - 2004).


One of the major pitfalls of meta-analyses is that they often include even the crappy studies. As you previously mentioned, this study and this study are so flawed that not even ACOG reps cite them in their many statements against home birth.

Hence, we have this new "me-too" meta-analysis, which I consider to be little more than an attempt for ACOG and its minions to legitimize their relentless quest to force childbearing women into hospitals. In fact, they're gearing up to lobby against our birthing rights, (detailed in last link), so don't think the timing of this publication was an accident.

This "meta-analysis" is, in fact, only a "quasi-analysis" in that it cherry picks which studies to consider. The most pivotal study of them all was not welcome at the table.


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## loraxc (Aug 14, 2003)

Does this study include any explanation for their rationale on what studies to include?

Quote:

If you add up ALL mortality in the study, the hospital mortality rate is actually higher than the homebirth mortality rate (and yes, the studies did match low-risk births for the hospital cohort).

Perinatal mortality, home: 229/331,666
Neonatal mortality, home: 32/16,500
Perinatal mortality, hospital: 140/175,443
Neonatal mortality, hospital: 32/16500

Total mortality, home: 261/348,160 = .0007496, or .075 per thousand
Total mortality, hospital: 172/208,745 = .00082397, or .0824 per thousand
Do these numbers appear anywhere at all in the study? I sure would like to see why they didn't calculate it this way.


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## laughingfox (Dec 13, 2005)

Quote:


Originally Posted by **MamaJen** 
So here's something really interesting. If you add up ALL mortality in the study, the hospital mortality rate is actually higher than the homebirth mortality rate (and yes, the studies did match low-risk births for the hospital cohort).

Perinatal mortality, home: 229/331,666
Neonatal mortality, home: 32/16,500
Perinatal mortality, hospital: 140/175,443
Neonatal mortality, hospital: 32/16500

Total mortality, home: 261/348,160 = .0007496, or .075 per thousand
Total mortality, hospital: 172/208,745 = .00082397, or .0824 per thousand

So there you have it.











Quote:


Originally Posted by **MamaJen** 
To find the perinatal death number, which was similar to the hospital mortality rate, they combined six studies, for a total of 331,666 births. So obviously, the Dutch study and five others.
To find the neonatal death, which was higher, they combined the remaining seven studies, for a total of 16,500 births. The most significantly higher number was the nonanomolous neonatal death rate, which was pulled from 6 studies amounting to 15,662 births. There were 23 deaths in that group.

Sounds like they shuffled the studies in different configurations until they could flub it into looking like it "supported" their predetermined conclusion.

When all else fails, manipulate the data.


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## *MamaJen* (Apr 24, 2007)

Quote:


Originally Posted by *loraxc* 

Do these numbers appear anywhere at all in the study? I sure would like to see why they didn't calculate it this way.

Yes, the perinatal and neonatal numbers are listed in the main chart in the study. However, they didn't show that combined mortality rate, which is where you can see that the mortality actually higher for hospitals over homebirths. But getting that was just a matter of adding up the two numbers they did have for perinatal and neonatal mortality.
Now, there are some subtle differences between perinatal and neonatal mortality. Perinatal mortality goes up to 7 days, while neonatal mortality includes deaths up to 30 days, so it could pick up a situation where the baby was distressed during the birth but survived a few days. However, it also starts picking up things like SIDS, which aren't related to the birth at all. Some studies account for that, others I feel are not very careful about cause of death.
However, it's not like perinatal and neonatal are two totally different or unrelated numbers. There's more about them that overlaps then not.
They don't explain, unless I'm missing it, where the numbers for the neonatal mortality rate came from. But if they got those 15,000 births by combining the 1980s Western Australia study, the 1990s Washington birth certificate study and a couple of others, then I would find the results totally useless.

It would be a lot easier to discuss this study if it was readily available for everyone to read in its entirety. I feel like I'm not doing a very good job explaining this. Has anyone else actually managed to get a hold of a copy of it?


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## bailefeliz (May 27, 2009)

Seems to me that this meta analysis highlights, in all of its flawed glory, the complete vacuum on outcomes of OoH managed births. This is especially concerning given that many US LDM/DEM/CPMs insist on maintaining high risk conditions within their practice.

I hope that if nothing else this study and resulting controversy results in mandatory data collection on all OoH managed pregnancies/births.


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## Storm Bride (Mar 2, 2005)

Quote:


Originally Posted by *bailefeliz* 
Seems to me that this meta analysis highlights, in all of its flawed glory, the complete vacuum on outcomes of OoH managed births. This is especially concerning given that many US LDM/DEM/CPMs insist on maintaining high risk conditions within their practice.

I hope that if nothing else this study and resulting controversy results in mandatory data collection on all OoH managed pregnancies/births.

To what purpose? To prevent those of us who want options from having them?


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## AlexisT (May 6, 2007)

There should be better data collection, because so often, we simply don't have answers. However, "requiring better data collection" bumps into a whole host of issues.

The problem is that the places that have shown the most consistent safety records with regard to home birth do have stringent precautions. That can mean taking options away from some women. It also means that extrapolating the results to situations without those precautions is perilous. We don't know exactly how much each of those precautions contributes to safety. Maybe some of them are unnecessary; maybe some are fundamental. It would be difficult, and in some cases unethical, to study them. We're probably never going to be able to quantify the risk of an HBAC, or HB of multiples, because there simply aren't many of them, even if you could get the concept past an IRB.

Now, if a woman says, "home birth for me may pose a slightly greater risk but I'm willing to accept that", that's one thing. However, when we start including higher risk situations and saying that they're safe because of studies that did not include those conditions... then I think we're on trickier ground, and I do see people try to do that.


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## bailefeliz (May 27, 2009)

I believe that mandatory data collection is critical to provide true data on outcomes---Critical for true informed consent, for scrutiny of standards of practice, to be able to effectively evaluate safety---Ultimately to promote home birth if outcomes reflect positively as in the Dutch and BC studies.

If we all believe in safety of home birth, and safety of US OoH birth practice, there should be no hesitation to establish mandatory data collection of all OoH managed pregnancies and births. That is simply putting the same expectation of accountability and transparency on Ooh birth as exists in hospital birth. I would view any hesitancy in data collection as troubling. Any professional working with families in so vulnerable a window as birth should want data to be able to provide best and safest care to clients.

And yes, yes, I believe the same for hospitals. It is clear to me that transparency IS evolving hospital practice, and that is a good thing. (ie--NIH VBAC consensus statement, in-hospital water birth, telemetry monitoring to facilitate mobility and unmedicated births with high risk conditions, etc.)


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## MyFillingQuiver (Sep 7, 2009)

Quote:


Originally Posted by *Storm Bride* 
To what purpose? To prevent those of us who want options from having them?









Exactly.

I'm not a MW or birth professional, but have dealt with over-zealous MD's, and suffered permanent injury from misdiagnosis during pregnancy..I understand what limited choices for birth can mean.

Legislation and regulation, IMHO, _rarely solves any issue_ without creating skyrocketing costs and complications on other levels. Even midwives who are not licensed or "regulated", place a huge value on health and welfare of mom and baby...of course, in any industry-including medical or MW, you have diabolically careless people..those people should be dealt with within the law, but requiring the hoop-jumping of over-regulation for MW's, leads to some of the same flaws we have faced in the Obstetrical community!

So many quality MW's, with years of healthy, safe, educated births have been pushed out by regulations and bans on their practices.

This is one where it combines being an educated consumer/client, and understanding that sometimes tragedy happens in good circumstances, is a balance we all who choose to birth in any place must face. (I have the utmost respect and humility for any of you who have experienced birth/neonatal loss-I certainly don't claim to know what that pain is, so I didn't want to sound cavalier about that aspect)


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## Storm Bride (Mar 2, 2005)

Quote:


Originally Posted by *AlexisT* 
There should be better data collection, because so often, we simply don't have answers. However, "requiring better data collection" bumps into a whole host of issues.

The problem is that the places that have shown the most consistent safety records with regard to home birth do have stringent precautions. That can mean taking options away from some women. It also means that extrapolating the results to situations without those precautions is perilous. We don't know exactly how much each of those precautions contributes to safety. Maybe some of them are unnecessary; maybe some are fundamental. It would be difficult, and in some cases unethical, to study them. We're probably never going to be able to quantify the risk of an HBAC, or HB of multiples, because there simply aren't many of them, even if you could get the concept past an IRB.

Now, if a woman says, "home birth for me may pose a slightly greater risk but I'm willing to accept that", that's one thing. However, when we start including higher risk situations and saying that they're safe because of studies that did not include those conditions... then I think we're on trickier ground, and I do see people try to do that.

The poster I was quoting seemed to specifically be talking about better data collection, for the purpose of cutting off women who are "high risk" ("risking out").

IMO, data collection in this area is a somewhat flawed concept right out the chute. There are just way too many factors involved in pregnancy and birth for data collection to be terribly meaningful.

I'm concerned about people comparing apples (singleton, vertex babies in mothers with no previous uterine surgery or health concerns) with oranges (breech, multiple VBAmC mama with health issues). However, the poster I was quoting talked about LDM/DEM/CPMs insisting on maintaining high risk "conditions" (ie. women) in their practice. It would appear she thinks that should stop.

I'm sick to death of other people thinking they should have the right to decide what happens to _my_ body. It makes me sick to my stomach that my failed HBA3C/stillbirth just adds to this crap...not only did my son die, but a bunch of nurses and doctors can sit back and blame "high risk" homebirth, and _none_ of what's happened to me in the hospital in my previous three births will ever factor into any of that.

If I'd known there were options, I would have never, ever, ever had a baby in the hospital...and maybe I wouldn't have all the issues I have, and maybe I wouldn't have my son's ashes on my bookshelf. But, the only part of that anyone would ever see in the records is that my homebirth ended in a dead baby.


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## Storm Bride (Mar 2, 2005)

Quote:


Originally Posted by *bailefeliz* 
I believe that mandatory data collection is critical to provide true data on outcomes---Critical for true informed consent, for scrutiny of standards of practice, to be able to effectively evaluate safety---Ultimately to promote home birth if outcomes reflect positively as in the Dutch and BC studies.

If we all believe in safety of home birth, and safety of US OoH birth practice, there should be no hesitation to establish mandatory data collection of all OoH managed pregnancies and births. That is simply putting the same expectation of accountability and transparency on Ooh birth as exists in hospital birth. I would view any hesitancy in data collection as troubling. Any professional working with families in so vulnerable a window as birth should want data to be able to provide best and safest care to clients.

And yes, yes, I believe the same for hospitals. It is clear to me that transparency IS evolving hospital practice, and that is a good thing. (ie--NIH VBAC consensus statement, in-hospital water birth, telemetry monitoring to facilitate mobility and unmedicated births with high risk conditions, etc.)

I've seen no evidence that transparency is evolving in hospitals (and I'm in BC, fwiw).

I'm not all that concerned about data collection, although it's really not as relevant as we'd like to think, imo. I do have concerns about the idea that "lay" midwives shouldn't maintain high risk conditions. That decision (who provides care to a "high risk" mom-to-be) shouldn't be the decision of any kind of regulatory body. I already ended up with one unnecessary surgery, because the local midwives weren't "allowed" to take my case. That disgusts me, personally and philosophically, and it disgusts me that people promote that, in the name of protecting women and babies.


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## MyFillingQuiver (Sep 7, 2009)

Storm Bride, I can totally relate to what you are saying. I have no desire for regulations to decide where I CAN birth. It's already gone too far! I was a birth choice ignorant young woman, and have a terrible story to tell in regards to my first birth..then I continued down that path. I ended up with a c-section for #3, (transverse lie) and a forced repeat for #4...when I sought out options, the hospitals were so limited. Just three years later I did have a VBA2C in a hospital-but it was hospital monitored and I had to be induced or schedule a section when I went to 41 weeks.

I had sought out MW care, but the recent licensure requirements in my state for MW's (that most rave about) meant, as a mom with 2 prior sections, they couldn't legally take me.

Now I have a MW for a homebirth, that is putting herself on the line for ME. She knows after 2 vaginal births, and then 2 c-sections (1 maybe needed, 1 definitely not) and a subsequent quick and easy VBA2C, I can have a vaginal birth like the next un-cut woman...but seriously, it's her on the line for me..where have those regulations gotten us here in my state? I would argue my risk is higher for a repeat serious intrauterine infection from a repeat section than it is for rupture-something the stats support, yet is considered highly dangerous apparently by the licensing body.

No thanks.


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## bicyclingbethany (Sep 11, 2009)

Studies can be flawed and biased.

I have found the Center for Disease Control's WONDER database immensely helpful in finding out data for myself. This is link to the Linked Birth/Infant Death Records in the United States.

http://wonder.cdc.gov/lbd.html

Here is the data I discovered for the 2003-2005 data set:
(Number of Infant deaths grouped by Birth Attendant and Birthplace)

*Certified Nurse Midwife:*
In Hospital= 158/802,574 rate of 0.20 per 1,000 live births
Not in Hospital= 16/28,030 rate suppressed

*Doctor of Medicine (MD):*
In Hospital= 3,209/8,939,831 rate of 0.36 per 1,000 live births
Not in Hospital= 16/7,252 (includes a delivery by a parent) rate suppressed

*Other Midwife:*
Not in Hospital= 35/38,483 rate of 0.91 per 1,000 live births

*Other* (this would include UCs and people who murder their neonates, but all categories have some cases of murder or neglect).
Not in Hospital= 58/20,814 rate of 2.79 per 1,000 live births

Groupings: I selected all characteristics of mother, only babies with a gestation of 37+weeks, 2500+ grams, from under 1 hour to 6 days old, all causes of death.

This, to me, is scary. If this is true, then midwives who practice out of the hospital really do have triple the neonatal death rate, here in the US. No studies from the 70s, just facts from a few years ago.


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## carriebft (Mar 10, 2007)

so your calculations there put CNM births out of hospital at .57 deaths per 1000, right?

what does "rate suppressed" mean?

Those numbers would seem to say CNMs are the "safest" kind of midwife to choose, but that hospital is still safer, correct?

and what flaws might there be in using a system like this to find data? deaths might not be birth related?


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## Storm Bride (Mar 2, 2005)

Quote:


Originally Posted by *bicyclingbethany* 
This, to me, is scary. If this is true, then midwives who practice out of the hospital really do have triple the neonatal death rate, here in the US. No studies from the 70s, just facts from a few years ago.

It's not that scary to me, because I have a pretty good idea of some of the hidden factors involved here. There is a _lot_ going on in the birth world that doesn't show up in the stats.

I attempted an HBA3C, and my baby died. That's exactly what the staff at the hospital saw, and that's how my case would show up in the stats. What _doesn't_ show up in the stats is the fact that _I_ refused to transfer, because _I_ was too afraid of the hospital, based on how I'd been treated there in the past. (And, for the record, there were staff at that hospital claiming that I didn't seem upset about my son, based on the fact that I was in shock from grief, and so spaced out from the anesthetic that I didn't even _remember_ being told that he'd died. Caring and compassionate birth professionals there, huh? So nice of them to assume that I just didn't care about my child, because I'd been attempting an HBAmC.)

Yes - if I'd had that baby in the hospital, he would have probably been born alive. They would have taken him by c-section before I even went into labour. Since we don't know why he died, I have no idea if he'd have survived for a week, a month, a year, lived out a normal life expectancy, or what. I don't know. I do know that he would have been a "success" for the hospital staff, but counts as a failure of high-risk homebirth.

I also know that the only way to have changed that would have been to physically force me into an ambulance. If that's what people want to see, in the name of better maternal health, then that's what they want to see. But, it scares me as much as an increased infant death rate does. The presence/absence or type of attendant, in my case would have made no difference.


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## sosurreal09 (Nov 20, 2009)

oh please women have been having their babies at home since the creation of humans! just b/c the hospital can cut a woman open to "save" a baby doesnt mean the baby will survive afterwards. IMO when its your time its your time i dont think homebirthing has anything to do with that.

also type of midwife does matter.


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## bicyclingbethany (Sep 11, 2009)

I'm very sad you lost your baby. ):

I agree with many folks on here- maternal care here in the US is sorely lacking in many areas. Respect for women, their choices, their bodies, etc all is in desperate need of improvement. If a woman makes a choice to birth at home no matter what, than that is her choice. But her choice affects many other people, not just her.

The CDC numbers are flawed- there are probably many births that have been recorded improperly. They do not tell us everything. I agree with this.

Because of various experiences, I have less and less faith in lay midwives. I believe there are many competent and capable midwives out there, don't get me wrong. But I believe there are many who are sadly incompetent and under-educated.

You can say the mantra of "birth is safe, birth is normal" as much as you want, but it doesn't mean nothing bad will happen. 1 out of 12 women die from pregnancy or childbirth in the developing world. This cannot be entirely blamed on poor nutrition.
Midwives have so much to offer in terms of improving maternal and infant health- better prenatals, better nutritional guidance, less interventions, more breastfeeding support- but there are too many midwives out there who genuinely do not know how to handle obstetric emergencies. Or could handle them if they do. But I am continuing to see midwives who are overly confident in the birth process and do not perform even basic care during labor because of this.

Here in Texas a baby died because the midwife wanted to deliver him, even though he was breech and she never had ANY clinical experience with this. Another baby died in utero because the midwife failed to take maternal vital signs and make an accurate judgment based on clear signs of fetal distress.

Scary, all around. I am afraid to birth anywhere, quite frankly.


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## liz-hippymom (Jul 17, 2003)

Quote:


Originally Posted by *MyFillingQuiver* 







Exactly.

I'm not a MW or birth professional, but have dealt with over-zealous MD's, and suffered permanent injury from misdiagnosis during pregnancy..I understand what limited choices for birth can mean.

Legislation and regulation, IMHO, _rarely solves any issue_ without creating skyrocketing costs and complications on other levels. Even midwives who are not licensed or "regulated", place a huge value on health and welfare of mom and baby...of course, in any industry-including medical or MW, you have diabolically careless people..those people should be dealt with within the law, but requiring the hoop-jumping of over-regulation for MW's, leads to some of the same flaws we have faced in the Obstetrical community!

So many quality MW's, with years of healthy, safe, educated births have been pushed out by regulations and bans on their practices.

This is one where it combines being an educated consumer/client, and understanding that sometimes tragedy happens in good circumstances, is a balance we all who choose to birth in any place must face. (I have the utmost respect and humility for any of you who have experienced birth/neonatal loss-I certainly don't claim to know what that pain is, so I didn't want to sound cavalier about that aspect)

here is the thing- _without_ accurate and reliable studies one cannot be an educated consumer. i feel very duped after losing my daughter, due to an ill-trained CPM. and i felt a second devastation when i took it to the "regulating board" who merely slapped her on the hand, despite finding her negligent.


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## GuildJenn (Jan 10, 2007)

Quote:


Originally Posted by *anielasmommy09* 
oh please women have been having their babies at home since the creation of humans! just b/c the hospital can cut a woman open to "save" a baby doesnt mean the baby will survive afterwards. IMO when its your time its your time i dont think homebirthing has anything to do with that.

also type of midwife does matter.

You know, I just took a 15-minute break to consider whether it was my responsibility to answer this post or not.

And I guess I kind of think that as that 1:10,000 parent, it kind of is. I realize this is a statistical discussion. But there are still people behind the stats.

So - in my case, everyone knew at a certain point that a c-section would save my daughter's life. However, one wasn't available right then. During the four days that she survived I held her as she had seizures, gazed into her reflex-less eyes, held her for 8 hours as she fought to take every breath slower and slower, washed her body after she died, dressed her for her funeral, and buried her.

I write all that out because your statement that "when it's time it's time" is very easy to say when it's not your baby. My daughter was -- officially, by autopsy -- a strong and healthy baby until she was deprived of oxygen.

This was a very natural process. So is CP, in that situation.

Does that mean I think every birth should take place in a hospital? No, not at all.

But I do think that people need to understand what risk assessment and good decision making mean in labour. It does not serve the homebirth community to ignore risk and throw up hands and say "what will be will be." At the individual level of course parents are free to choose that. But to put air quotes around "save" is a little over the top.


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## liz-hippymom (Jul 17, 2003)

Quote:


Originally Posted by *bicyclingbethany* 
I'm very sad you lost your baby. ):

I agree with many folks on here- maternal care here in the US is sorely lacking in many areas. Respect for women, their choices, their bodies, etc all is in desperate need of improvement. If a woman makes a choice to birth at home no matter what, than that is her choice. But her choice affects many other people, not just her.

The CDC numbers are flawed- there are probably many births that have been recorded improperly. They do not tell us everything. I agree with this.

Because of various experiences, I have less and less faith in lay midwives. I believe there are many competent and capable midwives out there, don't get me wrong. But I believe there are many who are sadly incompetent and under-educated.

You can say the mantra of "birth is safe, birth is normal" as much as you want, but it doesn't mean nothing bad will happen. 1 out of 12 women die from pregnancy or childbirth in the developing world. This cannot be entirely blamed on poor nutrition.
Midwives have so much to offer in terms of improving maternal and infant health- better prenatals, better nutritional guidance, less interventions, more breastfeeding support- but there are too many midwives out there who genuinely do not know how to handle obstetric emergencies. Or could handle them if they do. But I am continuing to see midwives who are overly confident in the birth process and do not perform even basic care during labor because of this.

Here in Texas a baby died because the midwife wanted to deliver him, even though he was breech and she never had ANY clinical experience with this. Another baby died in utero because the midwife failed to take maternal vital signs and make an accurate judgment based on clear signs of fetal distress.

Scary, all around. I am afraid to birth anywhere, quite frankly.









well said


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## Turquesa (May 30, 2007)

Quote:


Originally Posted by *bailefeliz* 
If we all believe in safety of home birth, and safety of US OoH birth practice, there should be no hesitation to establish mandatory data collection of all OoH managed pregnancies and births. That is simply putting the same expectation of accountability and transparency on Ooh birth *as exists in hospital birth.*

Really? When I tried to call both of my local hospitals and ask for their cesarean rates, both got extremely evasive and gave me the run-around. By stark contrast, I asked my CPM about rates of transfer, episiotomies, cesarean deliveries, etc., and got a detailed list of up-to-date stats.

The CDC and state health departments collect the same data from both entities, and virtually all of that comes from the application for birth certificates that are submitted to state departments of health. While the 2000 certificate applications are more detailed, many states are still using the 1989 applications, which don't call for a lot of information about births or interventions.

Right now, The Coalition for Improving Maternity Services is trying to gather aggregate, facility-wide data of intervention rates in hospitals for all 50 states. And believe me, there is tremendous resistance from doctors and hospitals.

Another case in point? Hospitals in New York are required by the Maternity Information Act to produce such data and make it available to all women. Some years ago, they were caught red-handed not complying with their legal obligation.

Finally, here is another piece worth reading on the problem.

Do you have any evidence to support the notion that midwives are opaque in their practices and hospitals are transparent? I guess I'm not seeing it...


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## bicyclingbethany (Sep 11, 2009)

Turquesa said:


> Really? When I tried to call both of my local hospitals and ask for their cesarean rates, both got extremely evasive and gave me the run-around. By stark contrast, I asked my CPM about rates of transfer, episiotomies, cesarean deliveries, etc., and got a detailed list of up-to-date stats.
> 
> I hear this from many women. Honestly, I don't know of any large business I could just call up and demand statistics for. Most of these numbers, such as the rate of cesarean deliveries can be found on state government websites.
> 
> I mean, if I'm some medical assistant hired to answer phones and direct calls, would I know the episiotomy rate of the hospital? No way. I would pass on the call to someone who may know this off-hand, who might then continue to pass it on. Not many folks would know these stats, and we all know how difficult it can be trying to obtain specific information from ANY bureaucratic-type enterprise. This isn't perfect, but it's not shocking or necessarily "evasive".


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## bailefeliz (May 27, 2009)

Quote:


Originally Posted by *Turquesa* 
Really? When I tried to call both of my local hospitals and ask for their cesarean rates, both got extremely evasive and gave me the run-around.

I just posted on the other thread related to this...I am not so good at this discussion forum business.

I agree turquesa, that there must be transparency with hospital care. As I posted on the other thread:
In my State, institution specific method of delivery (c/s rates) are published quarterly in Vital Statistics. My institution totals following rates monthly: c/s (differentiating primary from repeat), successful VBAC, water birth, epidural use, assisted delivery, etc. True, one may not get the numbers from the unit secretary, but can get rates by asking for the nurse manager. This transparency is common in my region, as evidenced by chart below:

http://oregonianextra.com/olive-spec...omparison.html

Mortality information by type of provider is also available through vital stats, but erroneous in that not everyone can sign death certificates, and OoH transports (most sentinel events) are then folded into hospital numbers. Currently, outcomes related to OoH birth management are completely unknown--and from these threads, it is clear it is a national issue.

In my opinion, we need data.


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## bailefeliz (May 27, 2009)

Oops--here is a link that will work (i hope):

http://oregonianextra.com/olive-spec...omparison.html


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## MammaB21 (Oct 30, 2007)

[/QUOTE]I mean, if I'm some medical assistant hired to answer phones and direct calls, would I know the episiotomy rate of the hospital? No way. I would pass on the call to someone who may know this off-hand, who might then continue to pass it on. Not many folks would know these stats, and we all know how difficult it can be trying to obtain specific information from ANY bureaucratic-type enterprise. This isn't perfect, but it's not shocking or necessarily "evasive".[/QUOTE]

I have to disagree with this. The information should be readily available. Maybe one simple transfer to the billing and coding department or records department and anyone there should be able to do a quite search to get those stats. Being unwilling to look for the information is different from honestly not having it available. Hospitals need to be making it easy for their staff (and public) to get this information. And I would expect to be able to call any large business and ask for stats or information. I would expect to be warmly guided to the information I was seeking in order to better make a consumer decision. Hospitals aren't exempt from customer/client care.


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## alegna (Jan 14, 2003)

Quote:


Originally Posted by *bicyclingbethany* 
Most of these numbers, such as the rate of cesarean deliveries can be found on state government websites.

If you find them, I am in search of true c-section stats (not uncomplicated first time c-section, TOTAL) for hospitals in TX after 2004. 2004 seems to be the last time those were released. The ones from 2004 have been out for at least 3 years now, you'd think they could put out some updated ones by now.

-Angela


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## bicyclingbethany (Sep 11, 2009)

Here are the primary c/s rates for Texas in 2007. This is not the total like you wanted, but it is more recent.
http://www.google.com/url?sa=t&sourc...fiozKVD7ZsxBCg

Also, this is a good starting point: http://www.ourbodiesourblog.org/blog...-rates-by-hosp

I agree that this info should be easier to find and more accessible. But I have NEVER dealt with any phone tree that was a simple and painless process- from my university to my internet company. Hospitals SHOULD be different, but it's silly to hold them to a standard that not even for-profit companies can attain.

Now, where can I find the total perinatal death rate for all CPMs in Texas? Where can I find all Texas CPMs' episiotomy rates? NOWHERE. Not unless I call up every single midwife in the state and ask her. I think this is what a PP was arguing- hospital transparency isn't the best, but it is better than we have for CPMs.


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## liz-hippymom (Jul 17, 2003)

Quote:


Originally Posted by *bicyclingbethany* 
Here are the primary c/s rates for Texas in 2007. This is not the total like you wanted, but it is more recent.
http://www.google.com/url?sa=t&sourc...fiozKVD7ZsxBCg

Also, this is a good starting point: http://www.ourbodiesourblog.org/blog...-rates-by-hosp

I agree that this info should be easier to find and more accessible. But I have NEVER dealt with any phone tree that was a simple and painless process- from my university to my internet company. Hospitals SHOULD be different, but it's silly to hold them to a standard that not even for-profit companies can attain.

Now, where can I find the total perinatal death rate for all CPMs in Texas? Where can I find all Texas CPMs' episiotomy rates? NOWHERE. Not unless I call up every single midwife in the state and ask her. I think this is what a PP was arguing- hospital transparency isn't the best, but it is better than we have for CPMs.

again, well said!


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## Climbergirl (Nov 12, 2007)

This was the exact words I got about VBAC success rates for my local hospital. I was speaking with the birth advisor whose job is to talk to women about their specific issues and the hospital services.

"I'm glad you called me. I spoke with our director of perinatal services, Terry Francis, who said that there are no true statistics for VBAC success rates. There are too many variables to be considered. It's best that your ob, whomever you select, determines that you are a good candidate for having a successful VBAC attempt."

I asked her how many woman come in planning a VBAC actually get one. Honestly, they have a ton of regulations related to a VBAC patient, so they should know the outcome of that planned VBAC. I am a Quality Engineer, so this seems incredibly odd that they aren't looking at how well they are doing. I know the medical device company I worked for had to!

I think the info needs to be better for both hospitals and midwifes. But sometimes I wonder how my birth is recorded. I almost died 5 days post-op and had complications after my c-section. Was that considered "live baby, live mama"? How do we know how many of those moms and babies were in the ICU or NICU and almost did not make it?

I wish the system was better in general.


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## flitters (Sep 18, 2003)

Quote:


Originally Posted by *bicyclingbethany* 
Hospitals SHOULD be different, but it's silly to hold them to a standard that not even for-profit companies can attain.

I somewhat agree with what you are saying here, but wanted to clarify that not all hospitals are non-profit:

http://en.wikipedia.org/wiki/Non-profit_hospital

"In 2003, of the roughly 3,900 nonfederal, short-term, acute care general hospitals in the United States, the majority-about 62 percent-were nonprofit. The rest included government hospitals (20 percent) and for-profit hospitals (18 percent)."


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## triscuitsmom (Jan 11, 2007)

Quote:


Originally Posted by *bicyclingbethany* 
I'm very sad you lost your baby. ):

I agree with many folks on here- maternal care here in the US is sorely lacking in many areas. Respect for women, their choices, their bodies, etc all is in desperate need of improvement. *If a woman makes a choice to birth at home no matter what, than that is her choice. But her choice affects many other people, not just her.*

The CDC numbers are flawed- there are probably many births that have been recorded improperly. They do not tell us everything. I agree with this.

Because of various experiences, I have less and less faith in lay midwives. I believe there are many competent and capable midwives out there, don't get me wrong. But I believe there are many who are sadly incompetent and under-educated.

*You can say the mantra of "birth is safe, birth is normal" as much as you want, but it doesn't mean nothing bad will happen.* 1 out of 12 women die from pregnancy or childbirth in the developing world. This cannot be entirely blamed on poor nutrition.
Midwives have so much to offer in terms of improving maternal and infant health- better prenatals, better nutritional guidance, less interventions, more breastfeeding support- but there are too many midwives out there who genuinely do not know how to handle obstetric emergencies. Or could handle them if they do. But I am continuing to see midwives who are overly confident in the birth process and do not perform even basic care during labor because of this.

Here in Texas a baby died because the midwife wanted to deliver him, even though he was breech and she never had ANY clinical experience with this. Another baby died in utero because the midwife failed to take maternal vital signs and make an accurate judgment based on clear signs of fetal distress.

Scary, all around. I am afraid to birth anywhere, quite frankly.

For the first thing I bolded... this is true no matter what decision you're making here though. It shouldn't be the factor on which people base their decisions (unless of course they want it to, but not because someone else thinks it "should").

For the second... I don't see anyone saying that bad things don't happen or that babies don't have bad outcomes or even die... or for that matter mothers don't either. Birth is safe, most of the time it doesn't require anything that cannot be easily provided. But that isn't always true and it doesn't matter who you are, what your risk factor is, where you are birthing or who you have with you sometimes it will go wrong. That doesn't mean we shouldn't try and take steps to lower the number of times it does but what exactly that looks like won't be the same for every single situation.


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## Storm Bride (Mar 2, 2005)

Quote:


Originally Posted by *bicyclingbethany* 
Hospitals SHOULD be different, but it's silly to hold them to a standard that not even for-profit companies can attain.

Now, where can I find the total perinatal death rate for all CPMs in Texas? Where can I find all Texas CPMs' episiotomy rates? NOWHERE. Not unless I call up every single midwife in the state and ask her. I think this is what a PP was arguing- hospital transparency isn't the best, but it is better than we have for CPMs.

I wouldn't be all that interested in the hospital rates, and I wouldn't even look rates for _all_ the CPMs (don't think they're actually called that here) in BC. I'd be interested in the rates for the individual provider I was interviewing/seeing, and her backup, in the case of midwife (if I go into hospital in labour, I just get whoever is on duty, so I wouldn't see any point in having all the stats for everybody, unless I could kick one out).


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## alegna (Jan 14, 2003)

Quote:


Originally Posted by *bicyclingbethany* 
Here are the primary c/s rates for Texas in 2007. This is not the total like you wanted, but it is more recent.
http://www.google.com/url?sa=t&sourc...fiozKVD7ZsxBCg

Also, this is a good starting point: http://www.ourbodiesourblog.org/blog...-rates-by-hosp

I agree that this info should be easier to find and more accessible. But I have NEVER dealt with any phone tree that was a simple and painless process- from my university to my internet company. Hospitals SHOULD be different, but it's silly to hold them to a standard that not even for-profit companies can attain.

Now, where can I find the total perinatal death rate for all CPMs in Texas? Where can I find all Texas CPMs' episiotomy rates? NOWHERE. Not unless I call up every single midwife in the state and ask her. I think this is what a PP was arguing- hospital transparency isn't the best, but it is better than we have for CPMs.

Right. Totally different numbers. I want the total section rates like they've put out in the past. They're not making them public any more.

And fwiw my understanding is that Certified Midwives in TX do NOT cut episiotomies. They are not allowed to.

-Angela


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## Turquesa (May 30, 2007)

The latest data that I can find for Texas is 2004. One of you Texans should call your Department of Health and ask why similar reports are no longer being released.


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## Turquesa (May 30, 2007)

Quote:


Originally Posted by *MammaB21* 
I would expect to be warmly guided to the information I was seeking in order to better make a consumer decision. Hospitals aren't exempt from customer/client care.









:

Quote:


Originally Posted by *bicyclingbethany* 
Most of these numbers, such as the rate of cesarean deliveries can be found on state government websites.

Most? Not true at all. Not even close. Here is a list of all of the states with links to their departments of health. You probably don't have all day to visit all 50 websites, but I can guarantee you that only a handful of them provide aggregate, facility-level (i.e. by each hospital) data on intervention rates-NY and MA because their legally forced to. As Bailefeliz mentions, Oregon has cesarean rates (and some home birth data), and I know that Utah provides some data.

The closest that other states may get is to list cesarean rates by county. But even that doesn't put enough in context.

But even in these states, rather than being buried in a government website, the data needs to be made accessible in hard-copy form to _all_ maternity care clients of _any_ birth setting. Period. This is required (albeit not complied with) in New York State.

Also, even though cesareans are the most serious intervention, there are more interventions that need to be listed, and it's hit-and-miss as to which states publish data on forceps deliveries, episiotomies, etc.

Quote:


Originally Posted by *bailefeliz* 
I just posted on the other thread related to this...I am not so good at this discussion forum business.

LOL! It's not you. I'm kind of hoping the mods merge the two threads. So we're not clicking back and forth.

Quote:


Originally Posted by *bailefeliz* 
In my State, institution specific method of delivery (c/s rates) are published quarterly in Vital Statistics.

You are very lucky indeed. I'm surprised that your state midwifery board doesn't collect such data. On THAT I agree that there should be more transparency. MWs in my region are voluntarily transparent, but that can't be counted on everywhere.

Legally, it will depend on where you live, and then it will depend on who volunteers the any information. This is why I cannot support a sweeping statement about how hospitals are somehow more transparent than midwifery services.

You might check out the Coalition for Improving Maternity Services (referenced above). I know that they are trying to collect nationwide, facility-wide data on all hospitals, birthing centers, and homebirth services. I applaud the effort. Women deserve to know regardless of where they have their babies.

What happened to Liz-Hippymom's baby is unconscionable. (Liz, if you're reading this, I hope you report her to your State Midwifery Board if you haven't already.)

For every story like Liz's there are other tragic stories of a hospital birth gone awry. And to bring this thread back on topic to the meta-analysis







, I think that's why we're all responding based on our gut feelings and personal prejudices; most of us haven't yet read the meta-analysis, am I right?









Finally, I'll say that Liz's story is why as a consumer, I fight for midwifery licensure. The cause isn't just for NCB advocates to feel all happy and chipper; rather, it ensures greater accountability for midwives who, like doctors, have their bad apples among them.


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## bailefeliz (May 27, 2009)

Seems to me we need a national perinatal registry--where ALL prenatal clients are registered at their first prenatal visit with basic info (gravity, parity, prev c/s?, EDC, etc.--high risk conditions input as pregnancy progresses if/when they arise, data input after birth. I am talking every client of every OB, CPM, CNM, MFM, FP, LDM, DEM, Naturopath.

Then we could know true outcomes, including mortality/morbidity, and intervention rates related to provider type, region, etc.

Transparency would bring accountability to all aspects of maternity care.

It would ultimately save the failing American health care system----as I believe would evolve practice all around for the better----higher levels of safety, lower rates of intervention.


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## mwherbs (Oct 24, 2004)

Liz-hippymom has complained to the board and the hearing has been done- resulting in "a slap on the wrist"- i imagine they do not require peer review - which would have been a bit more helpful atleast in illuminating how other midwives would handle the situation and why and could also make recommendations like more education ...
the results/actions of the board is published on line- although the most recent actions are not there so you can see lists of results /sanctions against midwives - there is also published online lists of actions on other professions-

I have read the full text of the article and will have to re-read, probably the most compelling reply I have read was written by 2 of the authors of one of their reference articles that was information mined-
they mention things like 1/4 -4801 of the home births had no recorded attendant- so could be any type of birth from accidental to intentional UC

- I also see that the info in the Netherlands is client coded pretty much as bailefeliz recommends as a solution - and I talked with a mw I know in Oregon who volunteered her time to number crunch for the health department because they had collected a bunch of data that they never had the money to look at or publish- so she did do that for 5 years- and she looked at the published data having LDMs listed in the attendant slot in hospital - her best guess is that represents mom's provider- not who was the birth attendant as the hospitals in Oregon do no allow LDMs as attendants.


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## bailefeliz (May 27, 2009)

Data (fetal death certificates, essential to assess outcome) from Oregon DHS, Vital Stats, is entirely flawed because of data input errors by the admission of the Director or DHS.

Again, currently, at least in my State, there is no data on LDM/CPM/DEM outcomes. There is a high suspicion that rates are unacceptably high for perinatal death within OoH birth management. The only way anyone currently knows of a sentinel event is if someone--hospital or family member--reports to the Board of licensure. That is less than ideal for obvious reasons. As Lix-Hippymom has so bravely and eloquently demonstrated, it is excruciating--and humiliating-- on many fronts to stand up and report in the face of such extreme loss. Complaints to the Board are also necessarily protected--so public cannot know of incidence of adverse outcomes unless a final order is issued--which can take years. Even then, in Oregon, when one does a license inquiry on a licensed midwife on an individual who HAS had a disciplinary action related to egregious management--"none" appears in the history of disciplinary action window. ????

i do not blame the midwives in my State for the current mess. The State clearly needs to step up around the charge of providing public safety related to practice of State licensed practice.

This meta analysis simply highlights the need for mandatory data collection in my mind so consumers can truly make an informed decision--now completely elusive.


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## bicyclingbethany (Sep 11, 2009)

Angela- Just FYI, CPMS can and do cut episiotomies here in Texas. I had one!

PP whose name I don't remember- Texas has released data more recent than 2004, and I posted the link to 2007 primary c/s data in my previous post.

Well, I guess we can all agree from this- no one is crunching enough numbers and no one is being transparent enough!


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## Storm Bride (Mar 2, 2005)

Quote:


Originally Posted by *bailefeliz* 
Seems to me we need a national perinatal registry--where ALL prenatal clients are registered at their first prenatal visit with basic info (gravity, parity, prev c/s?, EDC, etc.--high risk conditions input as pregnancy progresses if/when they arise, data input after birth. I am talking every client of every OB, CPM, CNM, MFM, FP, LDM, DEM, Naturopath.

Then we could know true outcomes, including mortality/morbidity, and intervention rates related to provider type, region, etc.

Transparency would bring accountability to all aspects of maternity care.

It would ultimately save the failing American health care system----as I believe would evolve practice all around for the better----higher levels of safety, lower rates of intervention.

That sounds a bit scary, really.

I have my records from my first four "births". _None_ of them is accurate. Not one. I'm not just talking about the BS assessment of my motives and emotional state and all that. I'm talking about claims that I was informed about medications that I wasn't informed of, mis-statements about the weight and gender of my babies, misstatement about presentation of one of my babies, incorrect number of previous pregnancies, etc. It's not one set of records. There are errors in _all_ of them. Punching some stuff into a database sounds good...but I'd want to see some really serious measures in place to ensure accuracy.

And, all that being said...it's still not enough, because birth isn't just about gravity, parity, previous c/s, due dates, etc.

I know how my entire history would look if it were chopped into numbers for statistical purposes, and it's _wildly_ misleading, even without the errors in my records. There's a lot more to what's going on than the numbers.


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## *MamaJen* (Apr 24, 2007)

I've read the full study and posted my thoughts about it. (I'm not a professional statistician, but I am studying it at the graduate level.) There were 12 studies amounting to 342,056 homebirths. Most of those came from a recent large-scale Dutch study. A very large portion of the data, when you eliminate the large Dutch study, came from two outdated and/or badly designed studies -- rural western Australia in the 1980s, and birth certificates in Washington state. They also didn't include the north American midwife study.
They also used a very small portion of the data, just five percent, to break out that triple neonatal mortality rate. I believe that they did it this way because some studies expressed the mortality rate as perinatal deaths and some of the other studies expressed it as neonatal deaths. The Dutch study had 300,000 + homebirths, and the perinatal death rate in this study (which showed similar safety to hospital births) had 300,000+ homebirths it pulled from. The neonatal death rate came from just 15,000 births.
So I'm assuming -- and they never actually say which studies were used to generate the neonatal deaths, so this is just an assumption -- I'm assuming that they pulled the perinatal death rate from the Dutch study and a few others, and the neonatal death rate from the remainder of the studies. But we don't know which studies. The way they aggregated their data is exceptionally murky.
If it shows that births in rural Australia in the 1980s had a high neonatal mortality rate, I don't find that relevant to our current situation in the UK, Canada or most of the U.S.
Here's my thoughts on it: It is a tragedy when any baby dies, and it is especially a tragedy when a baby dies from malpractice, at home or in the hospital. I want American midwifery to be legalized, regulated and monitored, because I think that produces the best safety outcomes. I believe American midwifery could be safer, both in the states where it's not yet legislated, and in the states where it is legal. But I believe that overall, knowing that birth anywhere always carries risk, homebirth with a qualified provider, in a low risk pregnancy, and with systems in place in case of transfer, is relatively safe. I believe it carries a different set of risks than hospital birth.
I also believe that there are so many things that are deeply wrong and non-evidence based with the way babies are born in hospitals today. Mothers are put through a huge amount of unnecessary morbidity, injury and trauma because so many practices are not evidence based. I truly, in my heart, believe that the state of obstetrics in America today is a violation of human rights.
Would less babies die if we gave every single pregnant woman a C-section at 38 or 39 weeks? Possibly. You could make a case that doing that would actually reduce the total rate of infant mortality. However, you would wind up with a whole lot of other costs -- actual financial costs to taxpayers and insurers, as well as health costs to the mother, and emotional costs. Is it worth it to give 5,000 women unnecessary C-sections to save one baby? That's the way that you have to think about it if you're looking at it from a true public health perspective.


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## Storm Bride (Mar 2, 2005)

Quote:


Originally Posted by **MamaJen** 
Here's my thoughts on it: It is a tragedy when any baby dies, and it is especially a tragedy when a baby dies from malpractice, at home or in the hospital. I want American midwifery to be legalized, regulated and monitored, because I think that produces the best safety outcomes. I believe American midwifery could be safer, both in the states where it's not yet legislated, and in the states where it is legal. But I believe that overall, knowing that birth anywhere always carries risk, homebirth with a qualified provider, *in a low risk pregnancy*, and with systems in place in case of transfer, is relatively safe. I believe it carries a different set of risks than hospital birth.

re: the bold. Does that mean you also support forcing high-risk women into hospital-based care with an OB? That seems to a sentiments that's popping up here a lot, and I want to make sure I'm reading it right.

The _only_ thing that made me high-risk was the fact that an OB cut me open, after I'd said "no" when I was 24 years old. That was it. I've never had a single health problem during pregnancy - not once, not ever. Even the death of Aaron was more complicated than it would look in studies (contributing factors included the fact that my labour stalled when CPS* intake worker showed up at my front door while I was naked in a birth pool in my living room). So, because I'd been...well, basically assaulted...by an OB once, I should have no legal choices, except to subject myself to that again, or not have any more kids?

I'm just trying to clarify if we're really saying that we want to protect women, babies and midwives, by forcing certain women into hospitals, because that's what it sounds like.

*They're not called CPS here, but I don't know the current name of the agency and I figure everyone here understands "CPS".


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## *MamaJen* (Apr 24, 2007)

Quote:


Originally Posted by *Storm Bride* 
re: the bold. Does that mean you also support forcing high-risk women into hospital-based care with an OB? That seems to a sentiments that's popping up here a lot, and I want to make sure I'm reading it right.

Absolutely not. I believe in a woman's determination over her own body. But things like twins, breech, high blood pressure, HBAC/VBAC etc add additional risk to homebirth. I passionately believe in the concept of informed consent. I think women deserve to have an accurate assessment of those risks, and make their own decision. And of course, a midwife would choose or not choose to attend that birth.
The problem is that I really don't think we have clear information on what that risk is. Is it one in a hundred? One in a thousand? One in ten thousand? It's hard to do risk assessment when you don't have good information. 100 percent chance of a C-section in the hospital, with all the related risks or a ...what? chance of a bad outcome at home.
If I was carrying twins or a breech baby or something similar, I would spend a long time on the decision making process, and honestly I don't know which birth setting I would wind up choosing, but I would still want to have the right to make that decision.
I know the state does things to legislate safety. We have to wear seatbelts, only surgeons can perform surgery, etc. Depending on the level of risk, I think reasonable people could disagree on whether or not midwifes should be prohibited from attending "high risk births" (and just defining that would be a huge effort.) I personally don't think midwives should be prohibited from, say, delivering a breech baby, though there are reasonable arguments to be made for the other side.


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## triscuitsmom (Jan 11, 2007)

Quote:


Originally Posted by *Storm Bride* 
Punching some stuff into a database sounds good...but I'd want to see some really serious measures in place to ensure accuracy.

I agree. Even if it were doable I don't think it's ever going to be truly accurate... and if it's not truly accurate then what is the point?

I have the long form birth certificate for my oldest son. It lists the "details" of birth. Here we fill out the form ourselves, and I did it online and I'm 100% sure that *I* didn't make any mistakes as I still have the print out confirmation. There is also the same information sent in by the care provider.

The doctor listed on his form as the delivering attendant I never even met. It is quite possible that it was one of the OBs on call that day, but I have the names written down of the attending OB, the resident who actually caught him, plus my own midwife and none of those people is on the birth certificate as the delivering attendant. So if we were doing statistics by care provider my statistics for his birth (vaginal, no episiotomy or tearing, healthy baby with good APGARs, no forceps etc etc) would be going under someone who was definitely not even in the room.

Plus his gestational length was wrong. He was born at 43 weeks, 2 days. It *is* possible that I ovulated a day or even a couple of days later as I wasn't tracking that. But there was *one* experience where I could've gotten pregnant. We're talking months before that if it wasn't then. And after he was born before I could've gotten pregnant after that one time. But his birth certificate says 40 weeks, 3 days. Why does it say that? Because a (non first trimester) ultrasound said I couldn't possibly be as far along as I was. Despite the fact that I was a sexual assault survivor who was not partnered. I'm not guessing what lead to his conception. And yet I had an OB look me in the eye and say "Sometimes women are wrong about these things, you just don't understand." And my hospital records say that "Patient presented thinking she was 43 weeks but she was wrong about her dates and they were adjusted to reflect 40 weeks". (not that exact wording but you get the point)

I have no confidence that you can get truly accurate statistics for stuff like this. There are just too many variables involved I think.

ETA: I meant to also say that he was a 43 weeker who was healthy. No breathing problems, APGARS were 8/9/9. Strong all through labour. There *are* risks to going to 43 weeks. But he is an example of a baby who was fine. Better than fine even. But he's not included in the statistics for truly postdates babies as a success because an OB that believes in an inexact science (ultrasound) above all else.


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## *MamaJen* (Apr 24, 2007)

Oh, yeah. I've mentioned this before, but I want to stress again that this study showed a 9.3 percent C-section rate.
In America nowadays, it's what, 32.5 percent?
I think that's just another indication of how this study doesn't portray our current reality.


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## kittywitty (Jul 5, 2005)

Quote:


Originally Posted by **MamaJen** 
Oh, yeah. I've mentioned this before, but I want to stress again that this study showed a 9.3 percent C-section rate.
In America nowadays, it's what, 32.5 percent?
I think that's just another indication of how this study doesn't portray our current reality.

Exactly. And here it's at over 39% just at the local hospital. I just want to give a big







to you, Jen. This study is seriously flawed in every way. And everyone keeps concentrating on homebirth mortality but ignoring the tripling of neonatal and maternal death rates from c-sections which happen in hospital and the many many deaths and complications from hospital births. My son was one of those (he luckily lived, but no thanks to the hospital which made the complications). Everything has risks in life-I just wish that American midwives were covered by insurance, regulated and certified, and made more available for women both in hospital and in home.

Storm Bride, I agree with you, too. I did not have a c-section, though they tried their hardest to force me-thank the gods for parents who threaten litigation when you're too exhausted to think and surgeons who are decent human beings and not the "cut em open no matter what" type. But since I had a myomectomy, I have had to fight literally tooth and nail for a decade now because of our screwed up system. I've been mistreated, assaulted during birth even after refusing things...for me the only safe place,except for arising complications, obviously, is out of hospital. Because I know what it's like to be treated less than human otherwise.


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## Storm Bride (Mar 2, 2005)

Quote:


Originally Posted by **MamaJen** 
Absolutely not. I believe in a woman's determination over her own body. But things like twins, breech, high blood pressure, HBAC/VBAC etc add additional risk to homebirth. I passionately believe in the concept of informed consent. I think women deserve to have an accurate assessment of those risks, and make their own decision. And of course, a midwife would choose or not choose to attend that birth.
The problem is that I really don't think we have clear information on what that risk is. Is it one in a hundred? One in a thousand? One in ten thousand? It's hard to do risk assessment when you don't have good information. 100 percent chance of a C-section in the hospital, with all the related risks or a ...what? chance of a bad outcome at home.
If I was carrying twins or a breech baby or something similar, I would spend a long time on the decision making process, and honestly I don't know which birth setting I would wind up choosing, but I would still want to have the right to make that decision.

Okay. Fair enough. The mantra of "low risk" women is just getting to me a bit.

Quote:

I know the state does things to legislate safety. We have to wear seatbelts, only surgeons can perform surgery, etc. Depending on the level of risk, I think reasonable people could disagree on whether or not midwifes should be prohibited from attending "high risk births" (and just defining that would be a huge effort.) I personally don't think midwives should be prohibited from, say, delivering a breech baby, though there are reasonable arguments to be made for the other side.
I'm not actually a big fan of legislation for one's own safety (eg. seatbelts) as opposed to legislation to protect third parties (eg. having to prove you _can_ do surgery before you're allowed to do surgery).

In the case of birth, it's even more complicated than that, because defining risk is really slippery. I know that coping with doctors caused me a _huge_ amount of prenatal stress. I actually put off seeing the GP about an OB referral with dd2 for months, because I just couldn't face it...and that was knowing that I was going to have a c-section in the end. Every visit was just a huge ball of stress. (You know...the _only_ high blood pressure reading I've ever had during a pregnancy was while the GP was talking about how she would "manage" my labour when I was intending to VBA2C. The doctor commented herself that my bp was high, while talking about this, and took a new reading - it was normal - at the end of the visit, because of that. If just talking about all the restrictions and "requirements" could affect my blood pressure, what would the actual experience have done for me??)

The "pure numbers" approach to all this really worries me. I know we need quantifiable data, but...it's only part of the picture. The impact on quality of life (for both moms and babies) gets lost in the shuffle when we focus on the numbers.

I don't want any of my children to ever lose a baby. I truly wouldn't wish that experience on my worst enemy. But...I also don't want my girls to go through what I went through in my pregnancies prior to that. And, according to the numbers, I went through four near-perfect "births"...healthy mom (hahahaha - but we're not talking about reality - we're talking about what's on paper or in a computer), healthy babies, great apgars, good recoveries - you name it. They were _perfect_...and I wouldn't wish them on anyone, either. Someone looking at the _numbers_ wouldn't see a problem at all.


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## Surfacing (Jul 19, 2005)

subbing to come back later and read


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## loraxc (Aug 14, 2003)

Quote:

It is a tragedy when any baby dies, and it is especially a tragedy when a baby dies from malpractice, at home or in the hospital. I want American midwifery to be legalized, regulated and monitored, because I think that produces the best safety outcomes. I believe American midwifery could be safer, both in the states where it's not yet legislated, and in the states where it is legal. But I believe that overall, knowing that birth anywhere always carries risk, homebirth with a qualified provider, in a low risk pregnancy, and with systems in place in case of transfer, is relatively safe. I believe it carries a different set of risks than hospital birth.
I also believe that there are so many things that are deeply wrong and non-evidence based with the way babies are born in hospitals today. Mothers are put through a huge amount of unnecessary morbidity, injury and trauma because so many practices are not evidence based. I truly, in my heart, believe that the state of obstetrics in America today is a violation of human rights.
I wish I could put this in my sig! ITTTTTA. Great post.


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## alegna (Jan 14, 2003)

Quote:


Originally Posted by *bicyclingbethany* 
Angela- Just FYI, CPMS can and do cut episiotomies here in Texas. I had one!

PP whose name I don't remember- Texas has released data more recent than 2004, and I posted the link to 2007 primary c/s data in my previous post.

Well, I guess we can all agree from this- no one is crunching enough numbers and no one is being transparent enough!









Fascinating! Last I read the regulations they were specifically forbidden from cutting episiotomies as they were considered surgery. When I read up on it they were actually forbidden basically from cutting anything but the cord. But it has been a few years since I read up on it.

And the problem is that now the only TX data being released is info that can't be used to extrapolate full C-section stats nor can it be compared with previous information









-Angela


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## Turquesa (May 30, 2007)

Quote:


Originally Posted by *bailefeliz* 
Data (fetal death certificates, essential to assess outcome) from Oregon DHS, Vital Stats, is entirely flawed because of data input errors by the admission of the Director or DHS.

I'm not sure I understand this sentence.







So your Pubic Health Division is admitting to inputting flawed data?

Quote:


Originally Posted by *bailefeliz* 
Again, currently, at least in my State, there is no data on LDM/CPM/DEM outcomes. There is a high suspicion that rates are unacceptably high for perinatal death within OoH birth management.

All that I can find for your state's birth outcomes, as referenced in a post above, is whether women had cesarean or vaginal births....basically the same data that you provided earlier. So it isn't fair to say that there are "no data on LDM/CPM/DEM outcomes" because the data does account for planned home births and freestanding birth centers (the latter named by facility). So it looks like docs and mw's are getting pretty equal treatment.

I could find no facility-wide data for neonatal mortality, not for hospitals or OOH midwives. If you could link me to some that would be great. Otherwise, with regard to neonatal mortality rates with OOH midwives, "speculation" might be a better word than "suspicion." Forgive me for belaboring this topic, but I'm just not seeing how there's less transparency for OOH mw's than there is for in in-hospital maternity care providers.

I do agree with you that complaint-filing should become an easier process.


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## Climbergirl (Nov 12, 2007)

Storm Bride,

You are absolutely right about records being a mess. Mine are seriously off. My doula took notes and when you compare her notes to my medical records, none of it makes sense. So, either the nurse was lying (possible) or doing a poor job with her data. In my mind, either one should be against the law in my opinion.

For example, my little c-section baby was also diagnosed as having shoulder dystocia. That really makes no sense (the baby is either in or partially out - and to put the baby back in is pretty risky). Or they seriously screwed up. I will never know.

Yes, it takes more effort and time to have accurate records. I worked for a medical device company and the cost and time we had to spend to accurately record every little thing was mind boggling. And yet, the place where our products were used are held to much less of a standard.

Maybe things will be better for my children. I certainly hope so!


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## MidwifeErika (Jun 30, 2005)

Quote:


Originally Posted by **MamaJen** 
Oh, yeah. I've mentioned this before, but I want to stress again that this study showed a 9.3 percent C-section rate.
In America nowadays, it's what, 32.5 percent?
I think that's just another indication of how this study doesn't portray our current reality.

I think this is really important to see. We are kind of running off in many different directions in these two posts about this topic instead of really discussing the actual meta analysis.

I appreciate everything you have posted MamaJen!


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## mwherbs (Oct 24, 2004)

I agree it was a relief to read *MamaJen*'s posts before I was able to get my hands on the article and I could not put it better than she has after reading it-
thanks for all the work-


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## GuildJenn (Jan 10, 2007)

Quote:


Originally Posted by *MidwifeErika* 
I think this is really important to see. We are kind of running off in many different directions in these two posts about this topic instead of really discussing the actual meta analysis.

I appreciate everything you have posted MamaJen!

But it does make sense when you take into account that they took all the high-risk pregnancies out of both groups.

I don't know. I am not impressed by the meta-analysis, but the homebirth community's immediate dismissal doesn't make me any more comfortable about evidence-based medicine on either side.


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## laughingfox (Dec 13, 2005)

I just went to the CDC website and looked up _all_ infant births/deaths for 2003-2005 (the most current available), sorted by medical attendant and birthplace..
http://wonder.cdc.gov/lbd.html1 (such a huge amount of information available there, and you can group it in dozens of different ways)
MDs in hospital showed a death rate of 7.15 per thousand (OB's are lumped in with MDs, AFAIK)
CNMs in hospital: 2.88 per thousand
CNMs out of hospital: 2.70 per thousand
"Other Midwifes" out of hospital: 3.84 per thousand

The highest death rate shown, oddly enough (not counting the "unknown/not stated" category), is MDs _out_ of hospital, at 29.36 per thousand.


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## Twinklefae (Dec 13, 2006)

Quote:


Originally Posted by *laughingfox* 
I just went to the CDC website and looked up _all_ infant births/deaths for 2003-2005 (the most current available), sorted by medical attendant and birthplace..
http://wonder.cdc.gov/lbd.html1 (such a huge amount of information available there, and you can group it in dozens of different ways)
MDs in hospital showed a death rate of 7.15 per thousand (OB's are lumped in with MDs, AFAIK)
CNMs in hospital: 2.88 per thousand
CNMs out of hospital: 2.70 per thousand
"Other Midwifes" out of hospital: 3.84 per thousand

The highest death rate shown, oddly enough (not counting the "unknown/not stated" category), is MDs _out_ of hospital, at 29.36 per thousand.

No, that makes perfect sense - MD's out of hospital would mostly be unplanned, emergency type births, not excluding high risk mothers and without any equipment to help a lot of the time. Hurricanes, planes, black outs, etc.


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## bicyclingbethany (Sep 11, 2009)

Laughingfox-

What search criteria did you use?

ETA: If you don't change the criteria, then you choose babies who died 20 weeks or less gestation to 364 days old. These extremes obviously have little if nothing to do with the birth attendant.

Try babies 37+ wks gestation to 23 hours old and see what you get.


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## liz-hippymom (Jul 17, 2003)

Quote:


Originally Posted by *laughingfox* 
I just went to the CDC website and looked up _all_ infant births/deaths for 2003-2005 (the most current available), sorted by medical attendant and birthplace..
http://wonder.cdc.gov/lbd.html1 (such a huge amount of information available there, and you can group it in dozens of different ways)
MDs in hospital showed a death rate of 7.15 per thousand (OB's are lumped in with MDs, AFAIK)
CNMs in hospital: 2.88 per thousand
CNMs out of hospital: 2.70 per thousand
"Other Midwifes" out of hospital: 3.84 per thousand

The highest death rate shown, oddly enough (not counting the "unknown/not stated" category), is MDs _out_ of hospital, at 29.36 per thousand.

those rates don't shock anyone else?
Lay midwives have a much higher rate of death than CNMs in or out of the hospital. of course obs have the highest rate they are the ones with all the high risk patients, all the preterm babies, all the no prenatal care-show up to deliver mamas. but obviously- from these numbers- lay midwives are NOT as safe as they could be-
its the difference of getting a masters degree (cnms) or doing a modular based training and observing 100 births (texas standards).


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## CherryBomb (Feb 13, 2005)

Quote:


Originally Posted by *GuildJenn* 
I don't know. I am not impressed by the meta-analysis, but the homebirth community's immediate dismissal doesn't make me any more comfortable about evidence-based medicine on either side.

Agreed.


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## laughingfox (Dec 13, 2005)

Quote:


Originally Posted by *Twinklefae* 
No, that makes perfect sense - MD's out of hospital would mostly be unplanned, emergency type births, not excluding high risk mothers and without any equipment to help a lot of the time. Hurricanes, planes, black outs, etc.

There are homebirthing MDs who do it on purpose. I had one for DD1's birth.
I've known of 6 or so homebirthing MDs(counting my state and the one next to me) and there are MDs who work in birth centers, also. Unfortunately, it's hard to tell what's going on with those numbers without more specifics.

Quote:


Originally Posted by *bicyclingbethany* 
Laughingfox-
What search criteria did you use?

I looked at "Linked Birth / Infant Death Records for 2003-2005 with ICD 10 codes", then chose "Birthplace" from "Group Results By", and "Medical Attendant" in the first line that said "Or".
I left the other criteria set at "None" under the first part for grouping results, and I left everything else in its default "All" setting to show all results at once.

Quote:


Originally Posted by *liz-hippymom* 
those rates don't shock anyone else?
Lay midwives have a much higher rate of death than CNMs in or out of the hospital. of course obs have the highest rate they are the ones with all the high risk patients, all the preterm babies, all the no prenatal care-show up to deliver mamas. but obviously- from these numbers- lay midwives are NOT as safe as they could be-
its the difference of getting a masters degree (cnms) or doing a modular based training and observing 100 births (texas standards).

There are no records on the CDC website for CPMs specifically (which are not the same as "lay" midwives, since they are licensed). I'd like to see how/if the numbers would change if that bit of data was collected.
Anyone can check the "other midwife" box on a birth certificate in my state (and others as well, I imagine), so accurate numbers are not gathered for CPMs.


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## MidwifeErika (Jun 30, 2005)

Quote:


Originally Posted by *GuildJenn* 

I don't know. I am not impressed by the meta-analysis, but the homebirth community's immediate dismissal doesn't make me any more comfortable about evidence-based medicine on either side.

I haven't seen anybody immediately dismiss it. Perhaps I am missing something? I have seen midwives discussing it amongst themselves on facebook or in forums or people discussing it here as well and trying to get a full picture of what was included for data and trying to understand it.


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## Turquesa (May 30, 2007)

Quote:


Originally Posted by *laughingfox* 
"Other Midwifes" out of hospital: 3.84 per thousand

Do these rates control for the type and training of "other midwife?" I also wonder if unplanned and unassisted births get lumped into that number. Please, I'm not dismissing the data. Just seeking clarification.


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## laughingfox (Dec 13, 2005)

Quote:


Originally Posted by *Turquesa* 
Do these rates control for the type and training of "other midwife?" I also wonder if unplanned and unassisted births get lumped into that number. Please, I'm not dismissing the data. Just seeking clarification.

To the best of my knowledge, there are no controls in place for "other midwife"; I believe this info is largely gathered from birth certificates. With a limited number of boxes to check, it's probably somewhat open to interpretation when it's self-reported by folks who don't really "fit" into any of the boxes. I'd bet a lot of stuff gets lumped in with "other midwife".

I was just posting those numbers because the in hospital/out of hospital numbers for relevant scenarios showed a different picture than this study/analysis did.
Sorry for the tangent, OP!


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## mwherbs (Oct 24, 2004)

so I have been involved or attending births since the 80's and communicate with midwives all the time not just where I currently live but across the country- we have talked about deaths and complications and discuss what has happened in their region- so saying that mws have 3x the death rate did not make any sense to me and I knew that there had to be some other manipulated info going on sounded similar to the Pang study which was gleaned from Wash. State birth cert info so every birth that was documented as out side the hospital was atributed to midwife attendance- also very recently I had discussed transfer rates and death rates in 2 states with midwives who had looked at/compiled the raw data that their health departments had gathered- and they said the mortality rates were lower than the state rates-- I was looking specifically for any info related to vitamin K- which is what prompted my inquiry- so I have alot of reasons to doubt the info

looked at the references- they used the Pang study as their meta analysis data from the US---


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## triscuitsmom (Jan 11, 2007)

Quote:


Originally Posted by *mwherbs* 
so every birth that was documented as out side the hospital was atributed to midwife attendance

And this I think we can all probably agree is a huge problem.

I'm a UC supporter as a birth choice. That being said I think even a planned UC where something goes wrong would be safer with a trained attendant there most of the time. Usually nothing goes wrong, and when it does it can usually be handled fairly easily, but there are definitely times where having trained eyes and hands can make all the difference in safety.

And that is just planned UC. The difference in safety between unplanned UC and just about anything else is going to be huge. It's true that you get the babies that just come fast for well nourished, healthy Moms where babe is in a great position and it just happens. Even still who knows who is around to help that could do damage by their lack of knowledge (pulling on cord comes to mind immediately). It's also true you get the Moms who for whatever reason safety wise shouldn't plan a UC, or possibly even an out of hospital birth and they still sometimes for a myriad of reasons deliver outside of the hospital too.

That's not a true representation of having a midwife there to support and assist.


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## S.Elise (Jul 1, 2009)

The Big Push just emailed this out:

International Expert Calls Study Deeply Flawed
and Politically Motivated

FOR IMMEDIATE RELEASE

WASHINGTON, D.C. (July 7, 2010) - As New York and Massachusetts moved to pass pro-midwife bills in the final weeks of their legislative sessions, the American Journal of Obstetrics and Gynecology fast-tracked publicity surrounding the results of an anti-home birth study that is not scheduled for publication until September. Described as unscientific and politically motivated, the study draws conclusions about home birth that stand in direct contradiction to the large body of research establishing the safety of home birth for low-risk women whose babies are delivered by professional midwives.

"Many of the studies from which the author's conclusions are drawn are poor quality, out-of-date, and based on discredited methodology. Garbage in, garbage out." said Michael C. Klein, MD, a University of British Columbia emeritus professor and senior scientist at The Child and Family Research Institute. "The conclusion that this study somehow confirms an increased risk for home birth is pure fiction. In fact, the study is so deeply flawed that the only real conclusion to draw is that the motive behind its publication has more to do with politics than with science."

Advocates working to expand access to out-of-hospital maternity care questioned the timing of AJOG's public relations efforts on behalf of a study that won't be published until next fall.

"Given the fact that New York just passed a bill providing autonomous practice for all licensed midwives working in all settings, while Massachusetts is poised to do the same, the timing of this study could not be better for the physician groups that have been fighting so hard to defeat pro-midwife bills there and in other states," said Susan M. Jenkins, Legal Counsel for The Big Push for Midwives Campaign. "Clearly the intent is to fuel fear-based myths about the safety of professional midwifery care in out-of-hospital settings. Their ultimate goal is obviously to defeat legislation that would both increase access to out-of-hospital maternity care for women and their families and increase competition for obstetricians."

The United States recognizes two categories of midwives: Certified Nurse-Midwives, who are trained to practice in hospital settings and who also provide primary and well-woman care, and Certified Professional Midwives, who undergo specialized clinical training to provide maternity care in out-of-hospital settings. Research consistently shows that midwife outcomes in all settings are equivalent to those of physicians, but with far fewer costly and preventable interventions, including a significant reduction in pre-term and low birth weight births, and as much as a five-fold decrease in cesarean surgeries.

The Big Push for Midwives Campaign represents thousands of grassroots advocates in the United States who support expanding access to Certified Professional Midwives and out-of-hospital maternity care. The mission of The Big Push for Midwives includes educating state and national policymakers about the reduced costs and improved outcomes associated with births managed by CPMs in private homes and freestanding birth centers. Media inquiries: Katherine Prown (414) 550-8025, [email protected]


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## MegBoz (Jul 8, 2008)

Quote:


Originally Posted by *stella.rose* 
The Big Push just emailed this out:

International Expert Calls Study Deeply Flawed
and Politically Motivated

FOR IMMEDIATE RELEASE

Thanks for posting!

I wanted to share on Facebook, but the release is a PDF!

http://www.thebigpushformidwives.org...awed_Study.pdf

They really should have an HTML version for sharing.


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## [email protected] (Jun 12, 2005)

See if either of these work, and thanks for spreading the word!

http://tinyurl.com/256gbwk
http://tinyurl.com/mx5zp5

The full headline is:

OB/GYN Journal Fast Tracks Anti-Home Birth Study in Advance of Pro-Midwife Legislation
International Expert Calls Study Deeply Flawed and Politically Motivated

Katie


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## bailefeliz (May 27, 2009)

Quote:


Originally Posted by *Turquesa* 
I'm not sure I understand this sentence.







So your Pubic Health Division is admitting to inputting flawed data? (

Sorry I am just now responding, Turquesa. Was internet free for a bit (blissful--I highly recommend it







)

But, yes, the Public Health Division issued a statement of apology for erroneous numbers due to data input problems after an investigation was requested because of published numbers putting LDM fetal death rate at 4-10 X higher than all other providers. All data was thrown out as a result.

So we still do not have true data. We DO know number of fetal deaths, and we know # of TERM fetal deaths (48 total for my State for 2006---for an overall rate of 1:1000). This, of course, includes all cases of women presenting to their provider with an already demised neonate, and/or extremely sick mamas and babies. Much more concerning in my mind are cases of term *intrapartum* fetal death of otherwise healthy babies. It is so rare that it is hardly mentioned in the literature, that I can find. (Please share sources if you have any!) The only study I found puts rate of term intrapartum perinatal death overall at .3:1000--very rare. I am concerned that this rate is higher in OoH birth management in the US. And I believe that more conservative risk screening would diminish higher rates of term loss, as demonstrated in the BC and Dutch studies.

I continue to think mandatory data collection is the only way for us to discover true outcomes, critical for true informed consent. In my mind, nformed consent is a fallacy without provider specific regional data.


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