No Matter How You Run The Numbers, The Result Remains the Same:

Homebirth, with or without a non-CNM midwife, is more dangerous than giving birth in the hospital.

Keeping in mind that homebirth midwives all claim to work with only low-risk women, lets look at the numbers I posted Friday:

“This Must Be a Joke” rants and raves in the comments of the previous post, calls me biased and stupid, and claims I shouldn’t have used the numbers from 32 weeks on. Other than the insults, she has a point. (I assume she is a she. If not, I apologize profoundly.) So I re-ran the numbers. Several times. Keep in mind that homebirth midwives all claim to work only with low-risk women. If women are having footling breech babies at home, it is only because some CPMs and DEMs lack the education and skill to diagnose the problem ahead of time and are shocked to see feet coming out first down the birth canal.  Or they believe that breech is just a “variation of normal” and low risk enough for birth at home. But I digress. We’ll compare the “other midwife” category (Notice this is midwives who are not CNMs we’re talking about here. There are no women in this category who intended to give birth with their OB at the hospital and somehow ended up giving birth with a midwife in their car on the way instead) with both the hospital numbers that include high risk hospital births — those attended by all hospital caregivers — and those that are only low risk, which are the births attended by CNMs.

Here are the numbers from 37 weeks on:

 hmmm. Looks like homebirth midwives are doing even worse in comparison to the hospital than they were in the 32 weeks-and-beyond numbers. How could that be? Because the 32 week numbers were increasing the hospital death rates! Once the pregnancy approaches term, hospital numbers improve, but it sure looks like the homebirth midwives don’t. Keep in mind, homebirth midwives claim to work only with low-risk women. But wait! These numbers include those babies born before 39 weeks. We all know those are slightly more dangerous than those born after 40 weeks. What happens if you throw out weeks 37 through 39?

 

Even WORSE numbers for homebirth! The homebirth death rate with an other-than-CNM midwife is now virtually TWO TIMES the higher risk hospital numbers, and more than three times the lower-risk CNM numbers. Keep in mind that homebirth midwives claim they work only with low-risk women. But wait, that 42nd week can get dicey! Totally ignoring the fact that most homebirth midwives claim there’s no expiration date on pregnancy, lets just take that out of the numbers. SURELY that must be the problem for homebirth midwives.

 

 

Hmmmm…nope!  While in all three cases above — while their numbers are slightly higher than CNMs working in the hospital — homebirth CNMs have a much more reasonable rate of death than other homebirth midwife death rates, which are yet again twice as high as higher risk hospital rates and more than three times as high as lower risk hospital rates.

Ahhh, but then we have another commentor, NaturalMamaNZ, who takes issue with my numbers. She complains that I have not properly accounted for confounding factors. Fair enough, she could be right. However, a confounding variable in this case would be high risk situations- but it’s quite an anomaly because midwives themselves accept high risk patients — all the while claiming to accept only low risk patients — and create high risk situations (remember, there’s no expiration date on pregnancy…) so there is really no way to seperate that from the data because that would be “cherry picking” good numbers, just like Johnson and Daviss did in NaturalmamaNZ’s favorite study. The data shows what it shows because of the current unregulation of midwifery and the carelessness in their want to accept patients of all levels of risk. Other confounding variables can easily be accounted for by changing the comparison groups to make them more alike. In this case, I changed the search criteria to include the same criteria Johnson and Daviss used – U.S. non-hispanic white neonates of 37 weeks + gestation. I further narrowed the criteria to women between the ages of 25 and 45 attended by the “other midwife” category, in order to remove any higher risk teen moms. I also only included those women with 12 years or more of education, meaning those who are, at a minimum, high school graduates.

 

 

 

WHAT? These numbers are even higher!!! Two times higher than the higher risk hospital births, the ones that include all caregivers, malpresentations, fatal birth defects, and so on,  and MORE THAN THREE times higher than those numbers for the low risk women who deliver with CNMs in the hospital.

But I can hear it now. “This must be a joke” will not stand for the fact that I left women up to age 45 in the group, because we all know they are higher risk. And those numbers include other potential confounders — single mothers, lack of prenatal care, twins, etc., etc. OK. Lets run these numbers, then: non-Hispanic white, singleton, 37 weeks + gestation neonates born to married women ages 25-39 with a minimum 12 years of schooling who started prenatal care before the 7th month of pregnancy. Surely these women — who are the epitome of the woman who hires a homebirth midwife in the US — will have stats that show that homebirth is safe!

 

I’m shocked. SHOCKED. (that’s sarcasm, for those of you who couldn’t tell. By the time I ran these numbers, I had ceased to find any of it shocking. I kept thinking I would be proven wrong with the next set, but alas, it wasn’t the case). These numbers are just as bad. Two times as high for the higher risk hospital births, and three times as high for the lower risk ones.

These numbers are sad. Yes, sad. They represent PREVENTABLE deaths.  Preventable by restricting the kinds of births that homebirth midwives can attend and requiring much higher standards for CPM/DEM education.  Or, better yet, doing away with CPMs and DEMs altogether and requiring a CNM to attend h0mebirths.

(Keep in mind that homebirth midwives claim they work only with low-risk women.)

190 thoughts on “No Matter How You Run The Numbers, The Result Remains the Same:

  1. I am so happy you did this! When I was posting this link(for which I eventually just got banned from 2 pages and defriended by some) these were the accusations I heard. Also I heard that you plagiarized the wax study, that the CDC wonder used the wax numbers, That Dr Amy would never support your numbers. And when I dared them to crunch the numbers themselves they responded with “man cannot be defined with quantitative measures” (my favorite)They are falling all over themselves to refute this. You have really shaken the NCB world with these posts!

  2. Again, this is SOOOOO misleading. You cannot have it both ways, I am sorry. You spend half your time complaining that midwives take on high risk patients and then you spend the other half of your time saying that homebirth is dangerous and that the numbers are for low risk women. That is a lie. These numbers include high risk, the Amish- many of whom choose homebirths and live in very rural areas. ( I should know btw, my inlaws live in Amish country and live an hour from a hospital, have up to ten babies into their forties and yes choose homebirth the vast majority of the time). You have religious people who won’t step into a hospital no matter what. These are RAW numbers. You cannot make assumptions based on them. Period. If you claim otherwise you are ignorant or you are lying, with all due respect. We have one study from this country that is backed up by ACOG, the Wax Study. Which tells us a hell of a lot more than some raw numbers including the most high risk of all patients doing homebirths. The results of the Wax Study states that the perinatal death rate for homebirth and hospital birth is EXACTLY THE SAME. Can you explain that to me? And since the perinatal death rate is the best measure of obstetric care according to the WHO- how can you explain that if your numbers are so accurate? And before you try to dispute the Wax Study, remember, it is supported by ACOG. You keep bolding that “homebirth midwives claim to only take on low risk clients”. But that is not true. The premise of the homebirth debate is that homebirth is safe for low risk clients NOT that midwives only take low risk clients. Everyone is aware that midwives take on high risk patients and THAT is the reason why we do studies that account for that and do not rely on raw numbers. Again, this simply tells us that high risk patients should give birth in the hospital. No numbers needed to figure that out.

    • Also, what about the poster who wrote she had crunched the numbers and when taking in account education there were no homebirth deaths. That is probably because the Amish have skewed the numbers. DO you know there are around 200,000 Amish living in this country? How many women choose homebirth a year? So, let’s say only 5% of the Amish homebirth- how many Amish women are giving birth at home? How may women in the US are giving birth at home? Any chance there numbers make a difference? I am going to go with, yes. Also, have congenital anomalies been removed from this data?

        • It is not grasping at straws. Let’s forget about the high risk women for a minute. Let’s pretend those high risk women don’t matter, don’t skew numbers. Let’s pretend the amish don’t skew numbers- let’s pretend, OK? If this raw data is so accurate why is the perinatal death rate the same in the Wax Study? Wouldn’t there be huge discrepancies there as well?
          I guess I need to ask. Are you trying to say this data proves homebirth is dangerous for low risk women? Because if you are saying that, you know you can no longer say that high risk women give birth at home.

          • Wait, I thought the Wax study was full of crap! Do you accept their findings or not? We know you’re grasping at straws if you’re trying to fall back on Wax.

          • I am curious – what is your issue exactly with the Amish? What did they do to you? Not “trust birth” enough? Please help me understand.

          • I never said the Wax Study is full of crap. I enjoy the generalizations that I am your typical “NCB” advocate though, just because I disagree that that your conclusions are based on concrete evidence.
            Here are a few comments from SMB- people that were debating w/Dr. A. about the CDC data base;
            Science based medicine, huh?
            I am truly stunned at the interpretations in this post and subsequent responses. It seems to me that a truly scientific inquiry would say “Direct entry midwives have three times the neonatal mortailty rate in 2003-2004 why could that be?”.
            1. What were the rates in other years? What was the trend across time?
            2. Could it be that they are untrained/undertrained? Could it be that DEM includes many types of midwives? Are there different outcomes between CPMs and other midwives?
            3. Is this increased rate a function of the small numbers, in which typically fluctuate wildly?
            4. Could the rate actually be higher and thus even more dangerous because DEM’s refer to docs?
            5. Could the rate be high because the Amish are a large contigent of homebirthers and have a higher rate of congenital issues?
            6. Is using type of attendant an acceptable proxy for place of birth?
            It it stunning to me that medical professionals do not ask these questions (and seek to find them, if they really care), and do not see that this single snapshot in time, cannot possibly give the answers that they are attributing to it. Stunning that they shout “Well, here is PROOF!” Stunning that they know so little about health surveillence.
            And this is a site called SCIENCE BASED MEDICINE?

            And:

            edgar,
            5. Could the rate be high because the Amish are a large contigent of homebirthers and have a higher rate of congenital issues?
            I think this definitely needs more looking into.
            The states with the worst stats also tend to be ones with Amish populations:
            Ohio: 1/1277 #1 in Amish population
            Pennsylvania: 8/3795 #2 in Amish population
            Indiana:1/201 #3 Amish
            Wisconsin 5/1845 #4
            Michigan 4/1617 #5
            Missouri 3/507 #6
            Tennessee 2/419 #12
            I believe there are only two states that have more than one death and are NOT Amish and that would be Texas and Utah. All the rest of the states that have had more than one death over three years all contain significant Amish populations (though when I ran the data initially, I didn’t include postdate pregnancies so there could possibly be more states with multiple deaths if you look at that.)

          • Also, Thank you for the avoiding the question but I think it does need an answer. Why does the Wax Study state that the perinatal death rate for home and hospital are equal? And you can’t dispute that, since that part especially was refuted by no one AND supported by ACOG. Look it up if you don’t believe me.

            I saw Bambi below posted that 20%-60% give birth in the hospitals. WEll, thank you Bambi!!!! That means 40%-80% give birth at home!! And the Amish ARE considered high rsik because they have so many babies and are far away from hospitals. I wonder what kind of midwife delivers babies for the Amish? I am gonna go with a Lay Midwife. So, with 200 thousand Amish living in the states and 40-80% giving birth at home- there is NO way they skew numbers. You are right. You are definitely right. ( that was sarcasm in case you missed it.)
            ps don’t forget to answer my Q about the Wax Study!! 🙂

  3. Awww look the NCB is all it’s a government conspiracy! They are out to get us because it’s including those damn Amish. Come on people, this is ridiculous! The point being made here is that even with the numerous scenarios played out too many babies are dying at home because of birth being attended by unqualified midwifes. Because their “low risk” mothers are not in fact low risk. I’m sure any one of you refuting these numbers are just as capable of going to the CDC and getting the numbers minus the Amish. Show us the numbers that say something different? And this Wax study, if it was so tell tale then why is the ACOG not saying homebirth is just as safe for low risk women as the hospital? Because they’ll lose a few patients? They aren’t saying that because as home birth is in this country it is not as safe as a hospital birth. And well if you want this all to be fair then I guess you need to tell MANA to release the numbers that they are holding onto. Numbers do not lie though. This here is the state of birth in this country. When will you stop making excuses and pointing blame? It’s the Amish fault, it’s the gypsies, it’s the government, it’s the doctors, it’s the insurance companies. No! It’s the improperly trained midwives in this country who are trusting birth to the point of killing mom and baby. But hey, at least you didn’t have a c-section. Congratulations for avoiding that nasty c-section scar. That should dry your tears at night, right?

    • Monica- it’s Sammy btw, you know I agree that homebirth isn’t right for everyone, that there are bad midwives out there and they need to be better regulated- there is more that I agree with than you might think. However, that does not mean it is OK to come to conclusions that support your agenda at any costs. Please, will some neutral person out there in the internet world please come on here and help me out here?? Raw data- raw numbers is not going to be the most accurate way to get answers. What if it was the other way around and the NCB’ers were using raw numbers to prove it was safe? You would never stand for that. The problem I have with this is that you and others are going to twist it around and say it proves homebirth is dangerous for everyone, even low risk women with a qualified attendant. You just do not have the proof to say that. I was not the one that came up with the “Amish skew the numbers” bit. I read that a long time ago when someone was debating Dr, A, someone who was NOT pro-homebirth( actually it was a guy that said he would never choose homebirth for his family, personally) someone who really understood statistics and reading numbers, he was the one who brought up the Amish and other factors. Dr. A, did not dispute it, that is why I believe it is significant. I have also read that congenital anomalies are included in the CDC numbers… I can’t and won’t accept these numbers unless an UNBIASED, neutral party totally agrees with them and doesn’t think the removal of high risk women would make a difference. Until then ,it is just an agenda to me, Sorry.

      • Sammy, I had a feeling that it was you ;). And as I’ve told you before, the point being made here and by others is that the only way home birth can be safe is if it is being done by trained professionals who are not unknowingly or knowingly and not caring taking on patients who are high risk. But we know there are many anecdotes out there of low risk women who have lost their babies. All could have been avoided if there were better standards in place for midwifes. Laws and regulations and that is all going to continue to happen and it’s going to continue to make home birth that much more risky for even the low risk women than it needs to be.

      • The bottom line is this: homebirth is NOT as safe as hospital birth. If you are a low risk woman with a competent midwife, your risk is lower than that of a high-risk woman with an incompetent midwife, but it is still not as safe as hospital birth. The reason for this is relatively simple – a low risk patient can become high risk in a matter of minutes, and not all complications can be risked out before or during labor. Let me give you an example. I was a totally low-risk patient. I didn’t have any issues like gestational diabetes or pre-eclampsia, my baby was head down, and I went into spontaneous labor at 38 weeks and 5 days when my water broke. By the time I arrived at the hospital, I was 9 cm dilated. I didn’t push until I felt the urge, had not drugs (not even a heplock for an I.V.), and I pushed in just about every position that you can imagine. My CNM described my labor as “textbook.” I delivered the placenta within minutes of my son being born, and then all hell broke loose. I began hemmorhaging. My husband was a medic in the navy, and he later told me that the only other person he had ever seen lose that much blood had died. My midwife sprung into action. While she began manual extraction of clots, she gave orders for me to be given a shot of pitocin and for an I.V. to be run. She quickly determined that my cervix was lacerated, and that I needed to go to the operating room immediately to be stitched up. Even with prompt care, had my hematocrit dropped one more point, I would have received a blood transfusion. Cervical lacerations are incredibly rare, but they do happen. If I had given birth at home, I would have been dead before they could have gotten me to the hospital. Unless your home is equipped with an O.R., a NICU, and a blood bank, there will always be some element of risk during a homebirth.

      • I think you are on to something about the Amish. I went to the CDC database and took out all states with significant Amish population as shown here:http://en.wikipedia.org/wiki/List_of_U.S._states_by_Amish_population I looked at all years, all causes of death, delivering between 37-41 weeks. Not in hospital other midwife had death rate of .94. An MD using the same criteria is .87. So there is, what, a 1.08% higher chance of death with a homebirth midwife than an MD if you live in a non-Amish state (math is not my strong suit so please correct me if I got that wrong).

        • Oh and if you take Idaho out along with the Amish states(since we all know Idaho is full of all sorts of crazies) birth actually becomes safer with a homebirth midwife at .82 than with an MD at .87.

          • About your amish theory: I live right outside amish country in ohio. They do utilize hospitals regularly. When I saw MFM at the local hospital, I would see Amish people there ALL the time. Amish babies are born in the hospital. At what rate, I don’t know, but this does prove that not all amish babies are born at home and the amish do turn to real doctors. Hell, the amish shop at wal-mart here and buy huggies diapers! Their horses and buggies are tied up outside. So, the amish do belong in your statistics! Nice try though!!

          • Yeah, but unless you have some actual statistics regarding Amish seeing OBs for their pregnancies, your anecdotes are pretty meaningless. For all you know, only 1% of Amish use OBs, leaving the other 99% to have homebirths. Absolutely meaningless if you don’t know what rate Amish have homebirths at.

            Do you have an alternate explanation for why when the Amish states are removed homebirth death rates become comparable to hospital?

          • I used from birth up to 27 days. What do you mean,by saying “nope”? Are you disagreeing with me looking at all causes of death?

            The thing is, the overall homebirth numbers are relatively small so any deaths impact their numbers greatly. So even if 60% of Amish are giving birth in hospitals, it just takes the other 40% having a few preventable deaths to throw off the national statistics and make them look horrible.

          • Idaho is full of crazies, which is why some areas have a +10% home birth rate with the panhandle having a 6% rate.

            Gotta love the science behind excluding states because they are “full of crazies” that will totally give you some sense as to the reality of a situation.

            and Idaho actually has some pretty strict home birth midwife licensure reqs (strict being relative of course).

        • If you are looking at all causes of death, you are looking at things such as congenital anomalies, infections, murders, diseases of the various systems, maternal disorders, etc. The causes of death that you need to be looking at are things such as birth trauma, respiratory distress, GBS, sepsis, malpresentation, birth/intrauterine asphyxia/hypoxia, etc. You cannot just use every single cause of death.

          • Why aren’t infections relevant? It sounds like you only want to look at factors that relate to homebirth death and not factors that might relate to hospital death (like infection). And I know I saw someone on here saying that babies with congenital anomalies are twice as likely to survive in a hospital so why are you suddenly so eager to remove those from the database?

          • If infection was higher at home than at the hospital, you guys should be fine with me leaving it in the numbers. I think this is funny that this post is titled “No matter how you run the numbers, the results remains the same” but try running the numbers excluding the Amish or including ALL causes of death and everyone is all “NOOOO you can’t run the numbers like that!!!” Neither of those things should be that unreasonable.

            It is very unfortunate that you all are just anti-homebirth, rather than wanting to arrive at the truth of the matter. There is a lot of improvement to be in homebirth midwifery, but how are you going to know the best way to go about making improvements if you are afraid of any data that doesn’t conform to your preconceived notions? There must be a reason the danger from homebirth disappears in the statistics when certain states are removed from the database. Maybe we need to look at what is going on in these states that make homebirth more dangerous there than in other states. That would certainly be more productive than this fear campaign designed to scare women away from homebirth.

  4. Oh well, still using the CDC wonder database. I wonder how many posts you’ll hang on that?

    Anyway, my question is: what is your agenda? Its hard to tell, because as the previous poster said there are some mixed messages going on. Is your mission to do away with the CPM credential (which, by the way, you get when you take NARM- there seems to be a misunderstanding about that on this site)? Or, do you want it to have more rigorous standards and be regulated. Do you want CPMs to be licensed, and be regulated by their states? Do you want it to be legally required for midwives to have some sort of disclosure agreement, where they list their experience level, risks of out-of-hospital birth, etc? (required in our state) You seem to value the CNM credential, though I’m not clear on how you feel about CNMs doing home birth- are you in favor of that or just think homebirth in general is too risky?

    I gather that many of you (or the women posting here) have been harmed in some way by choosing an out-of-hospital birth, and feel silenced or censored by the natural birth community. So maybe the purpose is more to provide a venue for being able to say what they want/need to say?

    I don’t ask to attack, but to see if we have any common ground. I know that many midwives want our profession to be regulated and professionalized. Speaking for myself, I chose the CPM over CNM route mainly because I didn’t want to get a nursing degree, but wanted to focus all of my learning on midwifery. Not less education in midwifery- I wanted more. And I didn’t want to avoid school-I do have a degree in Midwifery.

    Anyway- depending on what your actual agenda is- I think we could find a way to work together towards healthier moms and babies, and women making informed choices about their birth provider and place of birth.

    • I can’t speak for the author of this blog, but I personally want the CPM abolished. Midwives love to brag about the number of homebirths going on in Europe and Canada, but they fail to point out that the credentials of American CPMs are completely inadequate in comparison. NARM’s minimum requirements are a joke, and I see no reason why all midwives should not be held to the high clinical and educational standards of certified nurse midwives.

      In addition to abolishing the CPM, the following things need to happen to improve the safety of homebirth. It should be restricted to low risk women only (no breeches, multiples, VBACs, or women with pre-eclampaia, gestational diabetes, or other conditions). All midwives must be required to carry malpractice insurance. They should have clear criteria for transport (and actually use them), and their patients should pre-register at the hospital to ensure prompt care should a transfer be necessary. There must be real punishment for midwives who commit malpractice, and those who repeatedly demonstrate a lack of respect for the guidelines of their profession should be banned from practicing permanently.

      I personally would never choose a homebirth, but I support it as an option for women. What I cannot support is homebirth midwifery as it is in the United States today. Women and their babies deserve better than this.

    • Huh, for some reason, I didn’t see this comment until I came back here to look for another comment. Anyway, yes, I am *STILL* using the wonder database. It would be great if there were only RCTs regarding birth outcomes, but it’s impossible to do and get the numbers you need to show anything real. You NEED to have tens of thousands of births in order to show a pattern — anything less and the death numbers could be a fluke.

      As far as what I want…

      I don’t need to have the CPM credential abolished, but if it’s going to stick around, it needs to require a minimum of a Bachelor’s degree from an actual accredited university (i.e., not Birthingway, Aviva, National College of Midwifery, etc.), with the same science courses BSNs are required to take and pass with a B or better. If every CPM had the education that graduates from Bastyr have, I could be satisfied. I also want the NARM to reflect the same level of difficulty and accuracy as the exam that CNMs take. If the requirements for a CPM aren’t changed/made more stringent, then I do want the credential abolished.

      Other things I’m working for:

      1. Mandatory licensing. Those practicing midwifery without a license should be subject to criminal and civil liability.

      2. Adopt something similar to the Netherlands Obstetric Protocols for Antepartum, Intrapartum, and Maternal Postpartum Risk Assessment for homebirth. While the Netherlands numbers aren’t the best, their homebirth numbers are certainly better than ours. Adopting their protocols will give homebirth midwives a solid guideline to safely serve women and families and restrict them to the low risk births in which they are trained and specialize. Those who choose to attend high risk births in violation of these regulations should be subject to suspension and/or supervision and if appropriate (ie in the case of a death as a result of their violation), civil and criminal liability.

      3. Adopt an Infant Postpartum Risk Assessment Tool. The Netherlands protocols do not include comprehensive risk assessment for neonates, so such a tool could be composed by a team of GPs, OB/GYNs, pediatricians, and neonatal nurse practitioners.

      4. Immediately suspend the license of any DEM involved in a maternal or infant death or major injury, pending investigation. Midwives involved in fatalities and major morbidity must be investigated and must stop practicing until it is determined that she is a safe practitioner.

      5. After a second fatality or major injury, permanently revoke the DEM’s license if it has not already been revoked. A midwife might have one unlucky accident, but a pattern of incompetence, recklessness, or negligence must not be tolerated.

      6. Information about each DEM’s record made available to the public in a reliable online search tool. Patients must be able to see if their DEM has had malpractice suits, complaints in the last 10 years, disciplinary actions, suspensions, or other indicators of poor performance. I want this sort of thing available for OBs and CNMs as well.

      7. DEMs and birth centers must carry malpractice insurance. Malpractice insurance is simply part of the cost of doing business as a healthcare provider. It protects consumers and the State from shouldering the costs of DEM mistakes.

      8. Mortality and morbidity statistics must be tracked more carefully and made available to the public. If CPM is going to be a legitimate credential, it needs to be listed as a choice on birth certificate data. There must also be a spot for “planned homebirth” so that hospitals don’t get the blame for transfers that end in a death they could not prevent by the time it arrived. Morbidity data is not currently collected and it needs to be.

  5. But, but, but, statistics are part of the patriarchy and the male scientific system- so you cant trust them. HB is safe because I say it is! I have friends who had great HBs, who cares about the numbers?
    /snark/

  6. I WISH IT WAS A JOKE! Or a lie. Or purposely twisted.
    BUT ITS NOT
    These numbers aren’t made up, they are verified stats from CDC wonder.You can analyze the data too, there’s nothing hidden here. *If anything, these numbers are more conservative, as they do not account for all the HB transfers that ended in tragedy- those go into the hospitals stats.* These stats only count for babies that died at the house, not the ones who died but were delivered at the hospital, transferred late and came out brain dead and were removed from life support, etc. YES, these things happen, quite a bit, actually.

    If you support HB, and believe women should have choices and give informed consent, this info is vital. You cannot be informed if you don’t know the facts. If a mom knows the risks, and still wants a HB, that is fine- but they deserve to have the info.

  7. Sammy, go to the CDC and look up the numbers. It really takes maybe 5 minutes. Congenital Anomalies have been excluded here. Did you bother to look at the COD’s listed here?? These are preventable deaths, things neonatologists have determined are preventable!

    Having done my own research on ICD 10 Q (Congenital anomaly section), it has shown that babies born outside of the hospital with congenital defects are at double the risk of dying from the defect than babies born in the hospital. I have not researched every defect though, so I don’t know the mortality rates for each one.

  8. The whole “it’s the Amish!” argument is confusing to me… If the causes of death you’re counting are separated out (asphyxia, problems with cord/etc.) what in the world does the mom being Amish have to do with the outcome? A dead baby is a dead baby.

    • The Amish argument is completely nonsensical and entirely grasping at straws. I love it, the rabid ncbers have a new caveat to add to their ever growing and contradictory list. Now living in a state that sports an Amish population is among them. Or Idaho LOL. If only I’d known that was what was going to make my home birth go horribly horribly wrong! Stupid Idaho!

      • It is not nonsensical. Do you realize that Amish people have an average of 7 children and will often have children up till their 40s? Plus, they live rurally so further away from the hospital. Once you are on your fifth pregnancy or past 35 years you become high risk, so there may very well be a lot of high risk Amish people having homebirths compared to the rest of the homebirth population.

        The fact is, if you do not live in an Amish state or Idaho, your baby is slightly safer with a homebirth midwife than an MD. How could that be if homebirth is intrinsically such a dangerous thing?

        • Oh yeah. How will we ever find 200,000 other people who have many pregnancies and live in the country and are older than 36. 300 million people and these 200,000 are throwing us off…They’re also all white. Did you mention that? Whites have better pregnancy outcomes…and other things that mean nothing really.

          • And I don’t want to hear any “300 million is the population of the whole country , not all the breeding women blah blah balh” Because under 200,000 is the population of the Amish, not the breeding amish…

          • MT- but we are not comparing the amish to 300 million people- we are comparing them to the 20 thousand who homebirth. The reason they could skew numbers is because a number of them are high risk- they will homebirth no matter what-if a baby dies it is god’s will, they also have many children and live in very rural areas. But let’s forget about the Amish. Obviously, no one here wants to accept they may play a part and in truth, I have no concrete evidence to back up the claim- I don’t know why everyone latched on to that one point. I made other valid points that were all ignored. The Wax Study, the fact that homebirth is supported by the American College of Nurse Midwives, the WHO, and the American Public Health Association. The fact that until 2003 there wasn’t even a option on birth certificates to put type of attendant or if the homebirth was planned or not. And lastly, these are raw numbers and they include high risk women and lay midwives. MT, I support you all and agree completely that all midwives should be better educated and regulated and insured. I don’t think any woman should have to lose a baby b/c they had an idiot midwife. I agree with you on those things.

          • We are not looking at 300 million homebirths. We are looking at 47,392 homebirths compared with over 11.5 million MD hospital births. Approximately 10% (4,842) of those home births are to people who have not attended high school, so are likely to be Amish or something similar. Interestingly enough, while 10% of homebirthers made it no further than the 8th grade, they had 20% of the homebirth deaths (13 out of 63).

            And again, take those Amish states out of the database and look at the other 32 states in the U.S. and the rates become very comparable. Look at the CDC database for yourself if you don’t believe me.

          • IA, YOu have no source that states midiwves will have to pay $60,000. DId you contact this company and ask? $72,000 is a shit load of money. Tehy do well and until you porve me otehrwise, I am not for one second going to believe that a midwife should have to pay that amount.

            Second Even if they do : This is how doctors do this type of thing 1)TAKE more clients. First rule of busisness (WE’ve already been over this`)B) Become part of a group and get a group rate. Midwives are the only group who don’t rell have to pay business insurence. I don’t hear you whining about how the poor plumber (who has actual employees) is going to make it.

            You’ve tried and tried but there really IS not excuse. I’ve had an answer for every one of your probles with it…what gives?

        • In other words, Amish make up, like .06% of the population but are having 20% of the homebirth deaths (assuming no high school education=Amish, which might not be such a big assumption seeing the only homebirth deaths to people dropping out before high school were in those states containing Amish people).

          • Saw that but it doesn’t change any of the stats I gave. Also doesn’t change the fact that if you look at the 32 states that have NO Amish people the death rate between midwives and MD become comparable. What is your explanation for that? If it was really true that any way you run the numbers the result remains the same then the homebirth death rate should not be dependent on having Amish containing states in the data. There are tens of thousands of homebirths taking place in the other 32 states, no reason we shouldn’t see a high death rate if homebirth is as intrinsically dangerous as you say.

          • Also, simply removing non high school graduates from the database wouldn’t account for people with similar life/religious philosophies as the Amish, but who obtain more education, like the Mennonites, for instance.

          • Even if it is true, and you haven’t told us which states you removed or what other parameters you used, you have no idea if the numbers are even related to the Amush. Correlation does not equal causation. It could be that those states happen to have particularly horrific midwives.

          • Heather, I gave all those details on my very first comment in your blog. I guess I will just copy and paste it since I don’t see any easy way to link to it.

            Before, I do, let me address your “correlation does not equal causation” comment. Don’t you think it’s a little late for that? Your whole entire post is assuming that correlation equals causation. You see a higher death rate associated with home birth and declare that it is directly being caused by CPMs/DEMs. So you don’t have any right to lecture anyone else about correlation not equalling causation.

            As for the higher death rate being caused by especially horrific midwives, who knows, maybe, especially seeing how it is unregulated or illegal in many of the states that have a higher rate. So the answer to that would be to make it legal and regulated, rather than pushing for it to be illegal in even more states. Look at the states that have a low home birth death rate and see what they are doing differently.

            Okay, here are my parameters:

            I went to the CDC database and took out all states with significant Amish population as shown here:http://en.wikipedia.org/wiki/List_of_U.S._states_by_Amish_population I looked at all years, all causes of death, delivering between 37-41 weeks. Not in hospital other midwife had death rate of .94. An MD using the same criteria is .87.

          • Who said anything about making homebirth illegal? We have never advocated that. We want to make it so that ill-trained, cowboy midwives who cause deaths through negligence are prosecuted severely, and we want higher clinical and educational standards for homebirth midwives, requiring either a CNM or having the same standards for CPMs. We want to stop homebirth deaths from being swept under the rug and families who suffer them to have legal recourse and renumeration. We want to raise awareness that homebirth as it currently stands in the US is NOT “as safe or safer” than hospital birth because of the wide variation in both training for homebirth midwives and laws from state to state. But no one said anything about making it illegal.

          • Yeah, maybe in theory you don’t want to make it illegal but I suspect if you were able to implement all the changes that you desired the end result would be the same thing.

            Let’s say you have your way and only CNMs with malpractice insurance can attend homebirths. What happens if the insurance companies all refuse to issue the CNMs malpractice insurance for homebirth? What happens then? In theory home birth is still legal, but in practice there is no way for anyone to engage it in legally. Do you have a solution for this problem?

          • CNMs currently have no trouble obtaining malpractice insurance for homebirths, and I have no reason to doubt that would change. Illegal midwives can’t get it, but it is even available to legally practicing CPMs as discussed on a recent thread here.

          • Do you have a source for your claim that CNMs have no trouble obtaining malpractice insurance? I have heard a lot to suggest it isn’t always easy to obtain depending on what location you are in.

            I mean, OBs are often not even covered for things like vaginal breech births in hospitals, so it seems strange to me that home birth malpractice insurance would be handed out so easily.

          • Often it is hospital policy due to malpractice insurance not covering it. It just seems wrong to me that the insurance company gets to decide medical policy.

            There are companies that supply insurance to midwives, but that doesn’t mean it is realistic to obtain it in all 50 states.

          • Ia, here is a company willing to give insurance to CNMs CPMS and the like. They ARE willing to insure them so now that goes out the window! Next you are going to say they can’t afford it, right? Well if they can’t afford it they need to charge more. That is the first rule of business, you need to make more then you spend. Now, please give me another reason why midwives can’t have insurence??
            http://www.cisinsurance.com/midwives/

          • I also feel the need to add that insurance co.s have the very very best risk assessment analysis workers in the known world. Why? Because they have to spend money if you screw up. They want to know how likely that is. IF insurance cos don’t want to insure you then WHY not? What is it that the insurances co know that you don’t. I mean, we know what it is, but you seem to argue it.If you are not likly to screw up then SURE they’ll insure you! They want your money!!
            The free market is one of the best tools we have to learning where real risk Vrs personal choice lies.

          • Insurance companies pay for the things that go wrong so yeah I’d say they do get to make those sort of decisions of what’s safest. Most OB’s don’t feel comfortable doing a breech birth anyways as they aren’t trained in it. Why do you think c-sections started becoming standard practice for breech? Because it was one of those things where there is a greater risk.

            As far as more CNM’s doing home birth goes perhaps they realize the benefits of having a hospital facility and OR just minutes from their patients door because they have seen how quickly a low risk birth can go bad.

          • That insurance company has a $250,000 pay out limit per home birth incident claim. Is that really sufficient? That is not going to go far at all for the life long care of a disabled child or paying expensive medical bills. Not to mention they have only been offering home birth coverage for two years and mention on their own website how it’s normal for companies to decide to withdraw homebirth coverage once the claims start coming in (I guess the implication is that they’re not like those other companies, but I’m not particularly reassured. Two years is not a long time.) There is just so much shady stuff that insurance companies do, like they have tried to charge OBs who work with homebirth CNMs an extra $12,000 a year. I am sure you would want homebirth midwives to be required to have OB supervision, but when the insurance companies try to discourage it through tactics like these, it doesn’t make me feel very confident about the future of home birth should the insurance companies be placed in charge of it.

            And to address your second point about breech birth, insurance companies are in it for the money. With malpractice lawsuits so extremely high, they have calculated it is cheaper to pay for all breeches to have c-sections than to have to pay out for any wrongful death suits. It is 100% a financial decision and 0% a medical decision. And just because it financially is in the best interests of the insurance company does not prove it is in the best interests of the patient. This isn’t medical, but think about the Ford Pinto. Ford calculated that it would be cheaper to not fix their exploding cars and settle the lawsuits from the family. So what a company decides is in its financial interests doesn’t prove that it is also in the best interests of the consumer. I don’t want to get into a debate about the safety of breech birth. I just think it is inappropriate that actuaries are making medical decisions seeing how their education involves absolutely no medical training.

          • Why do you care if it’s sufficant? If you had it your way they’d not be having insurence at all. Don’t tear up the company. They just offer something you said didn’t exist. You’re tying to lead me away form the point by trashing the insurence company. And it’s not going to work.

            They can get insured. The end. They need to be insured. The end. Now, back to you telling me why they cannot or should not be insured?

          • And to go ahead and trash your point one more time (so we can end this insurance company trashing) All insurance companies have to abide by the law and the regulations of the FTC. They can’t just charge some people more because they don’t like them. In order for them not to be sued for discrimination they must have numbers showing that midwives are more risky (in order to charge them more). They have to prove that, they can’t just say it. That would be illegal. A midwife would have a good case on her hands if they charged her more and could not prove why.

          • I never said that homebirth malpractice insurance did not exist. I just said I doubted it was easily accessible to midwives in all 50 states. I guess it gets back to what is the reason that you think it’s important for midwives to have malpractice insurance? If it’s to actually compensate the families when something goes wrong then $250,000 is not much (remember that the lawyer will take a third of that and then there will be other court fees) and do you even know how much the premiums for this insurance is? If they’re charging $60,000 a year then that is a total racket for something that would have a maximum payout of $250,000 per incident.

            I don’t understand this attitude of, as long as they have malpractice insurance, it doesn’t matter how crappy the insurance is. Doesn’t there need to be some kind of guidelines for what the insurance should cover?

            And yeah, actually in the case I mentioned where insurance companies were trying to charge OBs an extra $12,000 for working with midwives, it was overturned by the courts as they said it was not justified to charge that much extra. That’s not the point. The point is that insurance companies try to do all this shady stuff and court battles take time and money, which isn’t always something that midwives have. It’s not like you can just get it instantly overturned the second the insurance company tries something like this and in the mean time people have to live with the consequences.

          • Midwives don’t have money? If they do a birth a month and charge $4000 they make $48,000 a year. That’s middle class. However 2 is more likely a number so that’s $96,000 per year. They charge YOU for the set up, rubber gloves and the like, they have no overhead. They usually don’t have any people working for them.
            SO now you are going to say they make only $3000 per birth
            $3000(2)(12)=$73,000 per year.
            $2000(2)(12)=$48,000 per year.

            I have totally supported my family of four on $25,000 and that includes insurance. PLEASE don’t tell me these women don’t have any money. They are not even on the poverty line. And many many of them charge more than $4000 per birth.

            Buy some damn insurance!

            Sorry this ended up lower than I thought it was. These comments are confusing

          • Aren’t we putting the cart before the horse by figuring out how malpractice insurance should be offered to midwives? Shouldn’t the guidelines for midwives be amped up excessively for education and licensing? Then once that is taken care of we can work on the insurance aspect of things? Because we all know that premiums go down with risk. So if CNM’s are performing homebirths given the education she will have her malpractice insurance will be cheaper than a CPM with considerably less education. Less risk = less cost.

          • Yeah, I have a hard time getting the comments in the right place too. I assume your reply was to me? I am kind of confused though, because how is a midwife going to afford paying $60,000 a year for malpractice insurance on a $73,000 salary? Speaking as a potential midwifery patient, I do not want to pay twice as much for a midwife just so she can have some malpractice insurance that might pay out less than couple hundred thousand dollars (after legal fees) on the one in a thousand chance that something goes wrong.

            Making midwifery twice as expensive is just going to encourage more people to UC and have more bad outcomes. It would be one thing if the insurance they were receiving was comparable to what OBs have, can you imagine an OB having a pay out limit of $250,000? This cis insurance company you linked to offers a limit of $1 million per incident for in hospital claims.

            I am sure there are some midwives out there that make $96,000 a year, but Google is telling me the average is more in the $60,000 range. When you say that they charge the patient for all the supplies, it is actually included in the flat fee that they charge. Also, don’t know how common this is but both midwives I worked with had billing/insurance people they had to pay. Another huge cost for some midwives would be gas, my last midwife would have patients that lived an hour or more away and she would go to their house for all their appointments.

            And I know you probably don’t really care about the Amish since they make up .06% of the population, but what would you do about them? A lot of them pay their midwives by bartering (giving them food or other goods). There is no way that these midwives are going to afford malpractice insurance. So what would you do? Arrest any Amish midwives practising without insurance and hope none of the Amish are desperate enough to try UC?

          • Something else occurred to me. You also want midwives to receive a lot more training. You want them to go to school for, what, 6-8 years? So you want to have medical professionals that spend at least 6 years training and then you want to pay them $26,000 a year? But you don’t want to make homebirth midwifery illegal, right? You just want to make it where no one would be able to and/or willing to become a homebirth midwife.

            Meanwhile, if malpractice insurance were required the insurance companies would be raking in millions only to pay out less than $200,000 to families whose babies were hurt (probably not even enough to pay for their medical bills, much less life time care). That just seems so backwards.

          • IA, YOu have no source that states midiwves will have to pay $60,000. DId you contact this company and ask? $72,000 is a shit load of money. Tehy do well and until you porve me otehrwise, I am not for one second going to believe that a midwife should have to pay that amount.

            Second Even if they do : This is how doctors do this type of thing 1)TAKE more clients. First rule of busisness (WE’ve already been over this`)B) Become part of a group and get a group rate. Midwives are the only group who don’t rell have to pay business insurence. I don’t hear you whining about how the poor plumber (who has actual employees) is going to make it.

            You’ve tried and tried but there really IS not excuse. I’ve had an answer for every one of your probles with it…what gives?

          • I have heard midwives say that malpractice insurance would be around $60,000 a year. The average for OBs is about $55,000 a year for malpractice insurance(this can be easily verified with google if you don’t believe me). I don’t see any way that they would charge homebirth midwives less than OBs, when supposedly all these studies show that midwifery is killing all these babies. Let’s be realistic here.

            I would like to contact the company directly to find out what they charge but I’m not sure the best way to go about it. I could pretend to be a midwife and make up information and see what kind of quote they give me. I just don’t know if they would investigate me first and find out that I wasn’t for real. I don’t know if it would work just to call them up and ask what they would charge in general. If you did that to a car insurance company they’d what to give you a specific quote based on your exact information. So what do you think would be better? Pretend to be a midwife and see what quote I get or admit I am just doing it for research purposes and say I just want a general range? In any case, I probably have to wait until Tuesday with it being a holiday tomorrow.

          • I wrote to the company asking for information as a licensed CPM in CA (the earlier discussion we had on this blog was about insurance in CA). I told them I’d been licensed for 3 years and never had a claim against me. This is what they quoted me:

            Based on the information provided in the premium indication questionnaire you submitted, we project annual premiums for a Full-time Home Birth practice, with $200,000/$600,000 limits as follows:
            Year*
            Premium
            1
            $13,034
            2
            $15,493
            3
            $17,485
            4
            $19,919
            5 and Thereafter
            $22,132
            *Premium projections are based on current rates, which may change over time. Policy issue and premium indications are subject to application and underwriting approval.

          • The reason it’s cheaper for midwives than MDs is because they’re (supposedly) taking on lower risk patients and don’t perform surgery. Not that hard to figure out.

          • Oh, good, Heather, that really helps to have those numbers. I am relieved to find out it is not $60,000 but I am kind of confused about why the numbers keep going up so much each year? Is that because they start you out with a big discount which gets smaller and smaller over five years? It just seems a little backwards because usually insurance gets cheaper the longer you are with them without having claims (though I am thinking of things like car insurance, maybe this is typical for malpractice insurance for all I know).

          • I assumed the numbers are going up each year because I told them I had been a midwife for 3 years, which is fairly new. They offer discounts to students and new midwives so that you can build your practice without having to pay the higher premiums while you don’t have as many clients. I don’t know that for sure, though, so I’ll email them back and ask!

          • Oh, so if you were to buy five years of insurance all at once it would cost a total of $22,000? So just around $4400 a year if you paid up front for five years?

          • If you would, Heather, also ask them what it would do to your rates if you had a single claim made against you? I would just like to be reassured that a midwife would not be put out of business because of one single claim that she may not have even been at fault for.

          • response from insurance lady:

            “You asked why premiums increase during the first 5 years of the policy. We offer a claims-made policy, and that is the nature of it – that it increases incrementally for the first 5 years. It remains the same from 5 years on unless there is a premium increase, but that has not happened for many years. As a matter of fact, we were permitted to give a 10% discount a few years ago.

            You receive a 10% credit for having a claims-free practice. If you have a claim, that credit is removed.”

            So basically, the incremental increase is just the way it’s done and the premiums increase 10% if you have any claims.

        • And maybe there is a reason for the insurance companies not covering vaginal breech births, or making the premiums too high for it to be cost effective for hospitals to allow it. Because it is NOT safe! But while it might not be fair that insurance companies make medical decisions it’s done all the time. As far as insurance not being available to midwifes in all states do you have any proof of that? Or is it more a matter of the cost will be too high for the midwife therefore causing them to raise their prices? Why shouldn’t they have insurance though? With or without a change in regulations at the very least why shouldn’t a midwife carry insurance? I need to have insurance to drive my car. A contractor even carries insurance. We’re talking about life and death situations in birth so midwifes if for nothing else but their own protection should become insured.

          • I just think if an OB decides vaginal breech birth would be best for her patient, it’s not right for the insurance company to be able to overrule that.

            I’m not making any claims to how hard or easy it is for midwives to obtain malpractice insurance. I have heard a lot of people say it was impossible in many places, but I don’t have any proof. Heather said CNMs had no problem obtaining it, so I asked to see proof of that. Nothing so far (though I know she is busy looking at the Amish data, so I don’t hold that against her).

            Whether or not a midwife should cover malpractice insurance is a different debate from what will happen if they are all required to carry it. I am afraid it would make midwifery illegal in many places if it becomes required and midwives aren’t able to obtain insurance. Heather and many others are insisting that the last thing they want to do is make homebirth illegal.

            I think you all have a lot of valid concerns, but so far I can’t get behind this movement because I fear it will ultimately end up in a lot of women being unable to obtain a homebirth with a midwife and I can’t get behind anything that takes away reproductive rights from women. Hopefully, someone will be able to fully allay my concerns about malpractice insurance.

            Isn’t malpractice insurance the reason why there are relatively so few CNMs doing homebirths? If that’s not the reason, what is?

          • “With malpractice lawsuits so extremely high, they have calculated it is cheaper to pay for all breeches to have c-sections than to have to pay out for any wrongful death suits.”

            Now with this theory then I guess ALL births would be better done via c-section because there’s less chance of a malpractice suit, right? Sure would stop the doctor who had delivered 50 babies in one night on 2 hours of sleep from messing up because all births would be scheduled. So I guess that makes more financial sense for the insurance company doesn’t it? There is a greater risk with breech. It is not just some variation of normal here. Especially since it doesn’t happen that often.

            Insurance companies have teams of doctors working for them to help them decide their policy. They aren’t just insurance adjusters making medical decisions with no medical background.

          • The reason many nurse-midwives don’t do homebirths is because they don’t feel comfortable practicing outside of the hospital, not because they can’t get malpractice insurance. They all have to have malpractice insurance to practice in the hospital, and it doesn’t keep them from practicing there.

        • Midwives don’t have money? If they do a birth a month and charge $4000 they make $48,000 a year. That’s middle class. However 2 is more likely a number so that’s $96,000 per year. They charge YOU for the set up, rubber gloves and the like, they have no overhead. They usually don’t have any people working for them.
          SO now you are going to say they make only $3000 per birth
          $3000(2)(12)=$73,000 per year.
          $2000(2)(12)=$48,000 per year.

          I have totally supported my family of four on $25,000 and that includes insurance. PLEASE don’t tell me these women don’t have any money. They are not even on the poverty line. And many many of them charge more than $4000 per birth.

          Buy some damn insurance!

  9. Becca Sue Congdon, you are right on. “Is This A Joke”, how do you think an Amish family would feel if they heard you say that it’s *their* home births that skew aaaaaall the numbers for everyone else? They are using the same midwives as everyone else, and quite often they are going to the hospital. They regularly seek the services of doctors who make house calls, or CNMs, and if they have problems, they don’t hesitate to avail themselves of hospital services including the NICU. They don’t just let their babies die– they are not adhering to NCB or home birth as an ideology. I wish you knew some Amish people, because you would eat your words and feel like a total ass. Not that this will get through to you, but for the benefit of other, more reasonable readers: http://amishamerica.com/amish-home-birth/

    • Well you know, the blacks are raping white women, mexicans are stealing your job, asians are doing your laundry, and amish are ruining your home birth. There is nothing bigoted about it, it’s just the facts! The shit stupid white people come up with will never cease to amaze nor disgust.

        • Wow, you sure showed me! Calling me out for making racial assumptions after I called myself out and amended my statement. You people are so stupid you have to have your insults handed to you apparently.

          What kind of failtastic teacher doesn’t know the definition of racism?

          • Yeah b/c you knew you couldn’t go back and delete the comment, that is the only reason why you “amended” your statement, Mary. You are obviously racist when you bring race into the equation.

          • Just because you can’t delete comments doesn’t mean I can’t. That may be your general course of action (delete anything that makes me look bad whenever I can!), but I found irony in my own hastily typed statement and called myself on it. That’s more fun than deleting.

            You’re just an idiot flailing for higher ground, and failing miserably. “Don’t look at me and my incredibly ignorant, bigoted statements about the Amish, look at Mary, she’s calling white people stupid! That’s TOTALLY RACISM!”

            And again, you don’t have even a basic understanding of what racism is. It’d be cute if it wasn’t so sad.

            I can concede when I say something painfully ironic, and I don’t need to delete it (I know, I know that’s breaking rule #1 of arguing on the internet, never admit when you’re wrong!). You on the other hand, well, you can just keep on flailing.

          • Yanno, given that What a Joke has now revealed that she believes in “reverse racism”, I wouldn’t say it’s inaccurate to characterize her as a stupid white person.

    • I am not “judging” the Amish. It’s a fact that they are more high risk because they have so many children, live in rural areas and many of them travel by horse and buggy and won’t transfer to the hospital. I remember my father in law telling me how he got a call in the middle of the night and a young amish man needed him to give his wife a ride to the hospital because some dangers popped up while she was in labor. It was 4 in the morning and my father in law drove two hours to get her to the hospital. Luckily she was OK but that is only because they know my inlaws well and somehow got to a phone in time and got to the hospital in time. This was a twenty year old girl too. The older ones are more of the staunch homebirthers( from what I have been told by my inlaws- they are literally surrounded by the Amish out in the country) and would not have chosen to go to the hospital. They believe if a baby dies it is God’s will. Just like they believe if they get killed while riding in their horse and buggy it is God’ will. They only ask you replace the horse if you crash into them and kill a family member with your car. It is religious ways that make them see the world like that. You have to consider the fact they will skew numbers especially when they have SO many babies!!

      • “You have to consider the fact they will skew numbers especially when they have SO many babies!!”

        Clearly what a population of less than 250,000 does is statistically significant within a population of 300,000,000. If every Amish person in the world had a baby right. this. minute. they would make up a tiny % of births in the US each year.

        Your anecdotes are boring and irrelevant.

        • Are you that dense? We are not talking about hospital births- remember? We are talking about homebirths and the number of women who do that is very, very small in comparison. What- 20,000 women homebirth a year- or is it even less? So if 40-80% of Amish women choose homebirth and there is 200 thousand Amish living in the US- you are telling me the Amish are insignificant in this conversation? Really? A large portion *of* the people choosing homebirth every year are Amish, Mennonite, and religious groups who can definitely be seen as more high risk because of lifestyle choices and religious beliefs as the commenter below pointed out. That is the problem with raw numbers and that is why ACOG or the CDC didn’t crunch the numbers themselves, release them and make a big whooha about how crazy dangerous homebirth is. People that understand how to analyze numbers and statistics would laugh at this, that’s why. It proves nothing.

          • What part of Amish don’t send their children to high school and thus are not part of the numbers above do you not understand? ALL of the amish have been removed. ALL. Drop this idiotic argument already.

          • Fail, nearly 40% of the homebirth deaths that take place in states that contain Amish people are to people who haven’t attended any high school. This is compared to 0 homebirth deaths to 8th grade drop outs in the rest of the United States.

          • Damn. I didn’t see Fail say anything about hospital birth. I saw fail mention the population which , sadly I must admit I just said somewhere above. Still true though, and still has nothing to do with the hospital.

  10. Oh, I just love when I find someone that says it so much more eloquently than I ever could. Here is part of a comment from someone who is debating Dr. Tuteur on her analysis of the CDC statistics in 2004 and 2005:

    The largest flaw is the assumption that restricting the selection of hospital births to 37+ weeks of gestation, 2500+gram BW, white women, maternal age 20- 44, and further restricting to CNM-attended births, somehow yields a “low-risk” group that can be statistically compared to the self-selected cohort of women who choose homebirth with a non-nurse midwife. Dr Tuteur claims “The risk profile of CNM hospital patients is slightly higher than that of DEM patients” but this is an assertion without evidence. It is true that in an ideal world, all home birth clients ought to be at low risk. But the retrospective statistics capture results from the real world, and in the real world in the United States, some women choose home birth even though their risk profiles might be less than pristine.
    Let me anticipate your response that this is evidence that home-birth midwives are incompetent because they cannot or do not screen their clients appropriately. Leave aside the ethical dilemma presented by abandoning a client who resists a recommended referral or refuses transfer; those are issues to pursue in another thread. They have no relevance at the moment to the issue of proper statistical matching. In order to draw a valid conclusion, you need to select a comparative cohort that matches the home-birth cohort as it actually exists in real life.
    I assert that your choice of cohort matching is flawed in serious ways.
    First, take note of the fact that in the CNM hospital cohort, approximately 5% (25,000 of 560,000) of your group consists of grand-multiparas. (women who have already had at least 4 children). In the out-of-hospital, other midwife group, the proportion is 21% (7500 of 35,000). This is on its face an independent confounding factor, which you have neither acknowledged nor adjusted for. But it also strongly suggests other demographic differences which were mentioned upthread by heyunyi, the fact that specific religious subgroups (Amish, Mennonite, certain offshoots of LDS and Seventh Day Adventists, and others) are far overrepresented in the homebirth group. While religion on its own is not a medical risk factor, isolated cultural subgroups can and do have many lifestyle factors that impact overall health.
    Any serious analysis of raw birth statistics must at a minimum acknowledge the existence of such factors, in order to correctly match them.
    Second, let’s take a closer look at the hospital cohort as well, to see what hidden confounders may be present. For rough analysis purposes, I have selected the state data for Indiana and Pennsylvania to compare against each other. For the record, this is not cherry picking. I selected these states because on the surface, you might expect them to have similar results. They are both middle-size states, with populations that are roughly balanced between large urban centers and many rural communities; there are few truly remote areas where distance to medical care is a large factor; among the white population already selected for, the ethnic profiles seem relatively comparable; income and socioeconomic factors are also relatively comparable. Now, I am not trying to make the case that these populations are totally identical, I am just pointing out that they are more similar than, for instance Massachusetts vs North Dakota or Mississippi vs Wisconsin.
    That said, let’s look at neonatal mortality among hospital births, all providers (already limited by the same exclusion criteria in the original post) – the last column is neonatal mortality per 1000:
    Indiana (18) In Hospital Total 132 168,019 0.79
    Pennsylvania (42) In Hospital Total 140 268,838 0.52
    (For the record, this difference is statistically significant at the 95% confidence level – CIs are 0.66 – 0.92 for IN and 0.44 – 0.60 for PA, in other words, the difference in neonatal death rate cannot be attributed to chance).
    There are three plausible explanations for this difference. (1) Differences in quality of care (2) differences in underlying risk level (3) some combination of the above.
    Now, if some hypothetical person (not I) were to apply the same standard of evidence as Dr Tuteur uses in her analysis, that person might say that the excess deaths in Indiana were the result of incompetent hospital practitioners, or incompetent hospital practices, since our prior restrictions (BW, gestation etc) have allegedly leveled out risk. While we can’t rule that out entirely, it would seem highly unlikely that the overall quality of hospital care in Indiana can explain this result, since hospital practitioners in Indiana are trained to the same standards as elsewhere.
    Perhaps the Indiana statistics look worse due to contamination by home birth transfers? That explanation fails, because Pennsylvania has a higher proportion of out-of-hospital births than Indiana (3.2% vs 2.4%), so if hospital mortality rates were affected by home-birth transfers, it would affect Pennsylvania results more than Indiana’s.
    So we are left with the conclusion that even after restricting birth statistics by race, age, gestational age, and birth weight, we still do not have a homogeneous level of underlying risk factors. At this point, we don’t have the tools to identify exactly what those factors are; as a resident of Indiana, I think it would be important to do further research. If it were possible for Indiana hospitals to achieve the same results as Pennsylvania hospitals, then approximately 50 deaths could have been prevented in Indiana over 3 years, which is incidentally a larger number than the number of deaths attributed nationally to homebirth over that same time.
    But I digress; what is clear is that any serious cohort analysis for underlying risk factors is lacking in the orginal presentation at the top of the post.
    And there is a third major flaw in this analysis introduced by restricting the cohort to CNM births. CNMs are not evenly distributed about the country. CNM-attended births as a proportion of all vaginal births range from 0.7% in Arkansas to 35.9% in New Mexico. http://www.midwife.org/siteFiles/news/TrendsinCNMBirthsfromJF07JMWH.pdf
    Generally speaking, CNM births are more common in the Northeast and west coast, and least common in the midwest and mountain states. The result is that when you restrict your hospital cohort to CNM births only, you have introduced a serious geographical skewing, oversampling from areas where the underlying risk factors are smallest, and drastically undersampling from the regions where they are greater. Therefore any national cohort of CNM births is inherently biased toward good outcomes.
    And finally, there is the unexamined issue of data quality. In a closer look at the IN/PA results referenced above, I noticed a specific peculiarity in the out-of-hospital data.
    Indiana (18) Not in Hospital Other 8 2,023
    Indiana (18) Not in Hospital Other Midwife 1 205
    Pennsylvania (42) Not in Hospital Other 2 634
    Pennsylvania (42) Not in Hospital Other Midwife 8 3,820
    I’m not focusing on death rates now, the numerators are too small to be useful. I am focusing on the number of reported births. Now the “other” category of attendant is clearly a catch-all. It includes births which were unattended, attended only by untrained bystanders, husbands, partners, relatives, whatever. At least some of these were unplanned. But what catches my eye is the huge difference in the way the “other midwife vs other attendant” numbers are hugely unbalanced when comparing IN to PA. Indiana has ten times as many births recorded by “other” than by “other midwife” (CPM or other DEM). In Pennsylvania, the numbers are skewed 5 to 1 in the OTHER direction. I don’t claim to have a complete picture of home birth in Indiana, but I am close enough to it to know that Indiana is not a hotbed of “trendy” unattended childbirth (UC), and I highly doubt that a huge number of Indiana women who intend hospital birth are having trouble getting to a hospital on time. What I do know is that the legal environment for non-nurse midwives in Indiana is very hostile. What I strongly suspect, from the above numbers, is that there is a considerable number of midwife-attended homebirths in Indiana, where the birth certificate data, later registered by the family, does not reflect the midwife’s attendance. We can only speculate whether the “true” neonatal death rate would be better or worse with more accurate reporting. And we can only speculate to what extent this may be true in other areas. Any discussions of the legal and ethical import of this can be put aside for now, because again I am focusing on the validity of the statistical analysis. It is clear (at least to me) that the accuracy of the original dataset is questionable, and given that the homebirth numbers are relatively small, we should be somewhat skeptical of accepting the calculated mortality rates as accurate.
    And I haven’t even touched on the issue of homebirth-tranfer-to-hospital vs CNM-transfer-to-MD. A serious statistical analysis would at least discuss some plausible estimate of the number of cases which are missing due to these factors.
    So in summary, Dr Tuteur’s analysis of CDC statistics is flawed in these ways:
    It is based on data where the underlying data quality is questionable for one cohort.
    It fails to identify or discuss demographic factors which make the homebirth cohort unique.
    It fails to evaluate or adjust for known confounding factors.
    It uses a geographically skewed hospital cohort for comparison.
    It fails to account for missing data due to transfer of care.
    It is clear that the original statistical presentation in this post falls far short of anything resembling scientific evidence. And, in my opinion, it is unprofessional to use throw-away lines to dismiss the results of other serious researchers, and at the same time feature this sort of crude statistical analysis as being relevant. What’s also missing is a serious discussion of the legal and ethical obstacles involved in doing any valid scientific research on homebirth in the US.
    If we are truly discussing science based medicine, then we should expect all evidence provided to meet the standards of science. (Thank you T- for your presentation of the Cochrane summary). I would hope that when we see future posts regarding specific childbirth practices, they will spend more time on an unbiased review of published valid research as a starting point, rather than a much later unannotated offhand reference to “all existing scientific studies”.

    • “retrospective statistics capture results from the real world, and in the real world in the United States, some women choose home birth even though their risk profiles might be less than pristine.
      Let me anticipate your response that this is evidence that home-birth midwives are incompetent because they cannot or do not screen their clients appropriately… those are issues to pursue in another thread.”

      This is that thread, genius.

      • Leave aside the ethical dilemma presented by abandoning a client who resists a recommended referral or refuses transfer; those are issues to pursue in another thread.
        I like how you left that part out. And ignored every other valid point but oh, well, what are you gonna do, right?

        • Midwives have no ethical obligation to provide inadequate care to women, and it’s not what is being discussed here. I reject out of hand that Ms CPM should continue providing care to Ms Gestational Diabetes because, well, Ms Gestational Diabetes really really wants her to.

          The piece had no valid points in this discussion other than the one I quoted.

          • There is nothing unethical about refusing to help someone harm themselves. Don’t make it out to be like these women are heros. If you know that a client is doing somthing stupid you don’t stand around and watch. You call the freaking ambulance.

  11. I have read many of your posts and am worried a little about some issues you have not addressed. Much of the writings here are about showing how bad homebirth is yet your blog title states that you are blogging for better birth. How about looking at the c section statistics and how WHO promotes that only between 10-15% of all birth should be via c section including elective but that there are hospitals that have well over 30% even 40% of births via c section. Im a mum of two both c section and I find the rapid growth of this more alarming then homebirth. Im scared that when my daughter births there will only be one option and that will be surgery, I want her to be able to chose. Please expand you subject matter and give all the information not just the data that supports your beliefs!

    • Yes, Heather! Your next post should be about the origins of that figure! You can talk about the evidence behind it (*smirk*), the wisdom of having recommended c-section quotas (*snerk*), the WHO’s statements about that figure (LOL) and Marsden Wagner’s qualifications to set the WHO’s recommendations for obstetrics (ROFLMAO).

    • WHO no longer recomends 10-15% c-section rates. When they did the number of dead babies went up. That is not their current recomendation. But thanks for playing!

    • You see Bambi! Can you imagine how many babies died in the Amish Community with her as their midwife?! But you can’t compare that with a low risk mom and a qualified CP. That is what we are wondering- is homebirth safe for low risk moms with qualified providers, who transfer when they become high risk? Your midwife should have had you go to the hospital, she was obviously negligent. I agree that midwives need to be regulated, specifically b/c of what happened to you. I don’t agree that we can say homebirth is dangerous for low risk women, though. That question has yet to be answered.

      • “That is what we are wondering- is homebirth safe for low risk moms with qualified providers, who transfer when they become high risk?”

        It’s great that you’re wondering that, however the numbers presented in the last two posts aren’t even beginning to field that question. The numbers are reflecting real world home birth as it is in the US. If it makes you feel better you can pretend they are all high risk breech and that the numbers do not apply to you in any way, that your theoretical midwife really is safe and not one of those irresponsible ones you read about online.

        The numbers are debunking the claim that home birth is inherently safer than hospital birth, not whether or not it can be safe for some women some of the time, until it’s not safe and then those women are quickly rushed to the hospital. You have been arguing ad nauseum about lots of things that are completely OT to the posts. You can whine until the cows come home about the statistical validity of the numbers and whether or not they represent the relative risk of home birth for white 26 year old atheists named Susan that live in New Mexico. Go ahead, we’ll sit here and wait. At the end of the day these are still the death rates and they are still unbelievable and unnecessary.

        • I am so tired of this BS. I am only going to say this one more time because you all have an agenda and you will shut your ears and close your eyes no matter what anyone says to you. I have seen it countless times, all over the internet. The premise for homebirth is that it is safe is when the women are low risk, they have a qualified attendant- a CPM ( I know what you think of CPM’s but they DO have more skill than a lay midwife) and when they are transferred when they become high risk. You can’t include high risk women in your numbers that use midwives across the board, never transfer or aren’t able to and then say those numbers prove homebirth isn’t safe- period! How difficult is this for you to grasp? Yes, midwives could be better regulated but what is the point of this post? To win? Do you even care about women or is this just about “See!! Hahaha!! We are the better than you because we gave birth in the hospital!!” Enough with the BS of actually wanting to help women because your ONLY agenda is win at all costs.

          • We are well aware of what the home birth ‘argument’ is. We are concerned about what home birth midwives are actually doing, in the real live world with real live women. Why is that so difficult for you to grasp? Be outraged at the midwives for putting women in danger, and killing babies in ridiculous numbers. Don’t be mad at us for pointing out that they are doing it.

          • To add, you really are just laughable. It’s really telling that rather than being outraged by the number of deaths that are completely unnecessary, the disparity between home and hospital, you’ve spent a dozen posts whining that those deaths “don’t count” and otherwise trying to exclude them. Those dead babies don’t matter. Those dead babies didn’t deserve better. Those dead babies don’t count. Only the dead babies of an imaginary perfect group of women count, and until someone comes up with the numbers for that imaginary perfect group of women that don’t live in Idaho, aren’t amish, etc. midwives can continue with their unsafe practices that result in needless death and you’ll blithely add as an after thought ‘well sure there could be more regulation’.

            You lambaste us for having an ‘agenda’ while you’re so buried in your own that you can’t grasp the basic premise of the posts in the first place because you’re too busy reacting with rage that anyone could possibly be questioning home birth.

            The agenda here has been spelled out to you numerous times. We don’t care if home birth is safe for some women some times. Many people here HAD and will continue to HAVE home births. We aren’t trying to stop you from having your home birth. We are trying to stop UNSAFE PRACTITIONERS FROM PRACTICING. How many times in the above post is it bolded that midwives claim to only take low risk women?? Did you read the post in the first place? You can’t have it both ways. You can’t argue that home birth is safe with all of these numerous caveats, midwives are A-OK, and then when it is clear that midwives aren’t holding up their end of the bargain and are not risking people out, identifying problems, transferring etc say “oh well those people don’t really count.”

            If you cared about women and babies you wouldn’t be putting all of your energy into attempting to exclude and explain away their bad outcomes, you’d be fighting to have their midwives held accountable. Go ahead and keep spouting off drivel about ‘winning’.

          • Fail- if you have read, I AGREE with you about the midwives. I agree with all of you a lot more than you know or think. I am not an NCB advocate. I have never advocated for homebirth, the most I have ever done is explain that I had valid reasons for choosing homebirth that maybe some other posters here could verify b/c I don’t want to go into it. I took every possible precautionary measure when choosing HB and was given excellent care by my midwives- it just makes me believe that there are other women like me out there- that choose HB because of some very personal reasons that include their past history and the last thing they need is someone to use this misleading data to tell them they chose homebirth because they want ” to be trendy” and could give a sh** about their baby’s life. I was born by c-sections- I see nothing wrong with them, even when women choose elective sections. I am all for epidurals- I don’t think anyone should have to go through pain if they don’t want to. I don’t think doctors or hospitals are evil, as I wrote above, i come from a long line of doctors and actually have had all great experiences with them. I have full empathy for any woman that lost her baby during HB, don’t think she should be silenced and I think those midwives should be held accountable for murder. The only thing I don’t agree with, is using raw data to prove a point. I don’t think it is accurate. I would thnk the exact same thing if NCB’ers were using numbers to prove any sort of their agenda as well.

          • “The only thing I don’t agree with, is using raw data to prove a point. I don’t think it is accurate.”

            You have failed to provide a single reason why the raw numbers inaccurately show midwives have an unacceptably high death rate compared to the hospital. You have argued ad nauseum that the numbers can’t reliably predict risk for low risk women which is completely OFF TOPIC AND IRRELAVENT.

            If you agree with so much then stop making so many inane off topic arguments. Midwives. Are. Killing. People. They claim to only take low risk patients. Again, how many times is that bolded in the OP? Did you read the OP? IF they are only taking low risk patients then the numbers are terrifying on their face. I don’t think any of us believe they are only taking low risk patients though.

            IF THEY ARE NOT taking only low risk patients….

            DO YOU NOT SEE THE PROBLEM?

            In EVERY SINGLE GROUP OF PEOPLE that Heather selected for home birth with ‘other’ midwives had a higher death rate. Stop whining about whether nor not those women were “really” low risk, or god forbid…amish… and pay attention to the giant god damned elephant in the room: The ill trained midwives causing deaths.

            The data is not misleading, it’s clear as fucking crystal: Midwives are not holding up their end of the ‘it’s safe for low risk women’ bargain.

            Now please, take your defensive, hysterical rantings elsewhere. No one cares why you have home births or how many doctors you know. Read the posts carefully and respond to what they actually say, rather than grasping at straws in a vain attempt to further your own self serving agenda.

          • You are talking about the world as it would be ideally (well trained accountable care providers, low risk clients)

            This post is about how the world actually is. With the current system we have in place in the United States (randomly trained unaccountable providers, clients of variable risk) it is incredibly more dangerous to have a baby with a non-CNM midwife at home.

            We know that the system we have now is unsafe. Want to get numbers on how safe CPMs are at home? Apply for the MANA data. Want to know how the numbers are for regulated accountable midwives attending low risk women? Make midwives accountable and enforce risk criteria.

            Also stop blaming the Amish for poor stats for the following reasons: 1. Many midwives serving the Amish communities are CNMs (Penny Armstrong being the most famous) so they weren’t included in this data. 2. The Amish are not a homogenous group and accept varying amounts of medical care. 3. The hospital deaths also include people who refuse care or who just hit the crack pipe/were just hit by a car/ shot in the head by their boyfriends/pounded back a 6 pack a day/work in a chemical factory (but are 39 weeks and still considered by Birth Certificate stats to be ‘low risk’ see link) and so on and so forth.

            The bottom line, birth certificate data is not the most reliable, but its limitations affect both data sets (other midwife and non-other midwife), and what we see here is something rather alarming that warrants further investigation. So quit blaming the Amish and do some investigating. You could start with Colorado stats (mandatory reporting) or use softer data from MANA. You could then compare that to truly low risk data from CNM attended births at accredited birth centers (which unlike MANA data, is published).

            http://www.cdc.gov/nchs/data/dvs/birth11-03final-acc.pdf (see what is considered ‘low risk’. There is no place to mark off for serious trauma, drug use, alcohol use among other things)

      • Until we get the unqualified midwifes out of the mix though Sammy, I don’t think we can actually answer the question you want answered. You’re asking if home birth a less safe option than hospital birth with a qualified midwife and low risk women, but you see that’s not what we have out there doing home births. Now I know you did have a good bunch of CPM’s who did your home birth, but given the laws right now there is way too much room for bad ones out there so you will never get the answer to the question you are looking for without a major overhaul of the midwife system as a whole.

        • My point is, is that no one can answer this question. Ask any non-biased, articulate, thoughtful person this and they will say the same. Even people who are against homebirth have come out and said time and time again we don’t have enough information to prove it one way or another. I am not saying homebirth is safer than going to a hospital. I don’t believe that. I am frustrated when people twist the truth to further an agenda b/c it helps no one. It only alienates the two sides even more, creates more women to homebirth and doesn’t solve the problem. The problem, 1st, is all the lay midwives running around. Florida does not have the problem other states do because they are much better regulated. When a preventable death happens it becomes serious business and those midwives aren’t going to be working again. The very first thing to push for at least, is to have all midwives regulated to the same standard as Florida midwives. Midwives there also receive longer and more rigorous training, as far as I know. I think it is safe to say that when high risk women choose to to give birth at home with a lay midwife it is pretty dangerous, right? No one thinks those specific women and their situations could possibly be skewing the data? It doesn’t take much. The numbers for homebirth are small and yet we are talking about a difference in deaths of .6/1000 compared with 1.2/1000. What is the absolute risk being taken here, especially if you take into account the high risk women? I don’t think this post is demonstrating the truth at all. It’s really too bad that the focus can’t be on something more positive, like how to fix the problem. Where are all the posts about solutions?

          • The solution is so simple, we don’t need a whole post about it: If you want the safest birth environment, give birth in the hospital.

            We are talking about 1-3 days of your life spent in conditions that are not exactly to your liking. Giving birth in the hospital is not a lifetime comittment. If your baby dies at home for causes that would have been preventable in the hospital, well that is not osmething that will ever go away 🙁

          • Sammy, this is not twisting the numbers. This is showing that home birth midwives claim to only take on low risk patients and yet the numbers are still greater than the hospital numbers. That is exactly what it says here. In bold I don’t know how many times it says midwifes take on low risk patients. You can’t make the numbers show what you want them to show because midwives are taking on cases they shouldn’t. That is what you are failing to see here. It’s not trying to make you feel all warm and fuzzy about your successful homebirth. It is showing you what your risks are. You are taking a much greater risk having a home birth here in the US. It doesn’t matter if you are low risk or not it’s still a risk because you are birthing with someone who doesn’t have the proper experience or education. That is what these numbers are showing. The NCB community screams that it is safer or as safe as a hospital birth all. the. time. This shows that that is not the case. That is the bottom line here. Instead of wasting your time fighting these numbers Sammy why don’t you try to help us make people aware of the dangers that are out there and help to get properly trained midwives performing home births so we can have the numbers that you want to see?

          • Sammy-Just so you know, I am one of those that is not quite sure about homebirth, but I’m more along the lines that we don’t have enough information to say much. What we can say from the cdc stats that in some instances homebirth appears to be more dangerous, but it is hard to nail down exactly what those instances are unless we conduct better research(which is just not out there). The cdc stats are interesting and provide a jumping off point of where to start research, but they just don’t cut it for me.

            What I would like to see is much better research done that helps us to look at what is really safe and what is not. I also think that it is possible that homebirth could be safe under certain circumstances, but that is also hard to define. What I do find interesting about the cdc stats is that those numbers also vary by state….so somehow some states do better than others regarding homebirth.

            For me(a non-homebirther, labor and delivery nurse, soon to be CNM student), I want more info before I state point blank that homebirth is not safe. If I were to choose homebirth at any point(which I see as uhlikely) I would want a CNM(because I know her education and that she has quicker access to the hosptial), and I would want to live close by a hospital.

            Homebirth is not necessarily my area of interest, but if it were, I would much rather like to look at solutions to the issues addressed than bicker over cdc stats that don’t really give us a good research base to rely on.

        • Exactly Sammy, only detailed studies can answer specific questions about birth. Stats from the CDC can only give very broad, non specific answers.

          Many studies have been done showing the safety of homebirth in the right circumstances with strict protocol. What CDC stats do show us is that protocol is not being followed, and with such unregulated midwifery in the US it’s no surprise.

          Lumping all midwives together, like this blog has done, is not accurate AT ALL, because there is such a diverse range of midwives in the US. Until there is more regulation on midwife education & practice, there’s no way we can lump them all together & make assumptions about them.

          Studies from other countries who do have much more regulated midwifery systems show fantastic results for midwives, with less unnecessary intervention, less morbidity, & equal or less mortality.

          One thing we can be sure of in the US, is when considering homebirth stick to CNM’s & strict risk assessment.

          • Really, what is so hard to understand about this post? As the midwife system here in the US is right now a woman can’t actually feel that it is as safe or safer than a hospital birth! With regulation and better education for midwives that doesn’t mean it couldn’t be a safe option, but as it is now the numbers show it is not as safe or safer than the hospital. That is what it’s saying.

  12. There are roughly 261,150 Amish in the US (http://amishamerica.com/how-many-amish-live-in-north-america/), so I think once you remove the number of children, men, and women who are not child bearing and then with that take figure 40% of those give birth at home I doubt you will have enough to completely skew the system. Even guessing half the population is of child bearing years (which is a huge assumption) 261,150/2=130,575*.40=52,230

  13. All of this hilarious arguing aside, let me just go ahead and shoot the whole “amish” argument in the foot right now. Those without 12 years of schooling were excluded from the above numbers and the midwives still had significantly higher death rates.

    Since you all are experts on the Amish because your sister in law’s cousin’s uncle lived near some, you’ll know that the Amish strongly discourage high school attendance.

    So even if the Amish really were roaming the prairies in statistically significant numbers, nearly all would be excluded because they are strongly opposed to high school and beyond.

    Straws: you’ve got lots.

    • Okay, so I ran the numbers only including the states that contain Amish. Of the 33 deaths that occurred 13 of them were to people with an 8th grade education or less. So it definitely appears that people with no high school education are overly represented among homebirth deaths in Amish states.

  14. “I don’t agree that we can say homebirth is dangerous for low risk women, though. That question has yet to be answered.”

    Sammy, you can disagree ’til the cows come home and you will still be wrong. Your glowing opinion of homebirth and lay midwives, combined with what looks like a deep desire to justify/be congratulated for your own choices, does nothing to disprove the very real fact that homebirth in the US as it is currently is NOT as safe as hospital birth. Are there good outcomes for some women, some of the time? Well sure! Does that mean the practice is safe, especially given the huge crapshoot that is hiring a homebirth (non-CNM) midwife? Heck no. Hospital numbers with CNMs (and those evil OBs!) are in fact much better than the supposedly “low-risk” home births. The end. You really cannot argue about that. The question of whether homebirth is as safe as hospital for low-risk women is moot– the numbers say it’s far less safe. Maybe someday when we have all midwives holding CNM degrees, carrying malpractice insurance, carrying practically an ambulance-full of emergency equipment, then we can talk safety. Until that day, Sammy, you are still wrong, and homebirth with American homebirth midwives is substandard care and reckless behavior. Shame on you and everyone else who put your own desires ahead of your child’s safety. I include myself in that chastisement, as I used to buy into the bullshit too. Why don’t you have the guts to open your eyes and change your tune when presented with overwhelming evidence that contradicts your delusions????? Don’t answer that. You’ll make my head hurt. I really can’t take much more drivel today.

  15. This is beautiful work, Heather. Sadly it shoots right over many people’s heads because they simply do not have enough education and numeracy to understand how statistics are computed and how the analysis of stats works. They don’t know what questions to ask or how to ask them because they are ignorant. Thus they cling to their beliefs about placenta encapsulation, positive thinking, and the evils of Idaho.

    • Seriously? Do you understand that controlling for variables is part of the scientific process? If homebirth deaths are linked to certain extremist attitudes that are only present in certain parts of the country, that is extremely relevant.

      I would really love to hear an explanation for why homebirth with a midwife becomes slightly safer statistically than with an MD if you look at the 31 states that do not have Amish and are not ID. If you really cared about women and babies that is what you’d be looking at, rather than making fun.

  16. Ok- So, I took your advice and decided to look up the data myself. Now, i don’t claim to be an expert in analyzing data- and correct me if I am wrong but when I looked up CDC births, I came across this link:
    http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_11.pdf

    Well, what I discovered was that until 2003 ALL OOH births included those that were unplanned. In 2003, they decided to make a change in reporting and made an option of adding planned and unplanned births on the birth certificates. Still, it seems that only 19 states did this so we are still left w/31 states that include those unplanned homebirths. If you read the analysis, it clearly states that unplanned homebirths are going to be high risk and will ultimately, make homebirth look bad. I was also surprised to learn that the WHO, the American College of Nurse Midwives and the American Public Health Association all support homebirth.
    I’m sure this will be disputed and ignored but I am only trying to make sure the information you have provided here is accurate.

    • Sure. Except I didn’t use the numbers for all out of hospital births. The number is on the chart so you can see what it is, but I’m using the numbers from the “other midwife” category. You don’t have a midwife at your homebirth unless you plan it.

    • Not only that, but as you can see in some cases, the rate of death in the “other midwife” category is actually higher is some cases than the rate for all ooh births!!

    • Let me add there is no way to remove the unplanned homebirths from the numbers during those years because there was no option to state whether or not the birth had been planned or unplanned. So ( please correct me if I am wrong or missing something) the years 1999-2002 must be excluded, right? And even then, years 2003-2006, still contain unplanned homebirths for 31 states. Have I missed something because this is a pretty huge factor-?

      • Please explain to us all how you can have a midwife at an unplanned homebirth. Again, I didn’t use the numbers from the “all homebirths” category, which you could very clearly see if you’d even looked at any of the charts.

        • Ahh- OK, yes that makes sense. That is why I asked, if I am missing something, please tell me. Why would Dr. Amy only analyze the data from 2004 though? Whenever I have seen her use the CDC data to prove homebirth is dangerous, I have only seen her crunch numbers from 2004-05. You would think she would do what you did, right? That she would use all those years, other than just one year? I am not being snarky and I really do want to know what the evidence shows based on the most accurate data. This just seems really fishy to me. Can you at all see where I am coming from? I am no expert in this kind of thing- I know there are people out there that have a much better understanding of this data than I do. You really believe this is accurate? How is it possible that the “other midwife” would have a higher death rate then births that are unattended or attended by a taxi driver or husband? Especially, when we have a study that has some flaws but no one has disputed the finding that the perinatal death rate was the same for homebirth and hospital birth. ( Wax Study again- based on half a million women, I believe). This just does not add up. The Wax Study would have demonstrated what these numbers reveal, IF these numbers were accurate- correct?

        • Tsk, tsk. Heather, you have no way of knowing that women giving birth in gas station restrooms or in the car on the way to the hospital are not attended by midwives. Obviously, ignoring this enormous cohort of women seriously undermines the validity of your analysis.

        • She’s so worried about the unplanned home births skewing the home birth stats (and will boldly state you can’t (can’t!) extricate those numbers while clearly having no god damn clue what she is talking about), but is completely unconcerned about the home birth stats skewing the hospital statistics. Every woman that has a botched home birth that ends up delivering a dead baby at the hospital, despite potentially days of completely inadequate care at the hands of a midwife, is counted in the hospital stats. THOSE numbers cannot being extricated. But oh no no, she doesn’t have an agenda at all!

          • That is the point, FAIL- thank you for making it for me. These numbers prove nothing- actually you are right, homebirth could be more dangerous than these numbers demonstrate or it could be less dangerous. That is why we don’t use raw numbers to come to conclusions, we use peer reviewed studies. If it has not been peer reviewed, it’s not taken seriously, especially not by someone who claims they are a skeptic. That’s just general knowledge.
            Here, it might help to read this from other, more qualified people..

            Differing views have been expressed by the American Public Health Association(“Recognizing the evidence that births to healthy mothers, who are not considered at medical risk after comprehensive screening by trained professionals, can occur safely in various settings, including out-of-hospital birth centers and homes”)

            the American College of Nurse Midwives (“Despite a plethora of published papers on related topics, there are very few studies that isolate DEM practice as a variable. The outcomes documented in the literature are mixed, with some investigators reporting better than average outcomes among women attended by direct entry midwives, while others document better outcomes provided by physicians and/or nurse-midwives. It is difficult to draw a conclusion from these studies”)

            the Cochrane Collaboration (“No strong evidence about the benefits and safety of planned home birth compared to planned hospital birth for low-risk pregnant women.“) http://www.cochrane.org/reviews/en/ab000352.html

            One more thing. In 2003 the birth certificate was revised and among other things, this was the year that an option to include your birth attendant was added to the birth certificate. So, before this date, birth certificates included unattended births and they did not reveal who attended the birth. That must be the reason why Dr. Tuteur did not analyze the numbers till 2004.
            ‘In 2003 the US standard birth certificate form was revised to include place of birth and attendant at birth. In both the 2003 and 2004 Linked Birth Infant Death Statistics, mention was made of this data, but it was not included in the reports. Now the CDC has made the entire dataset available for review.’

  17. My final and last post. I think it is sad that we can’t debate and be respectful of one another. I can’t believe how many people resorted to name calling and ad hominem attacks- is it really necessary to be this way? We are adults here, I don’t see the point in taking down to that level. If I came off as a bitch, and I’m sure I did at some point and I know I was snarky at some points too, I apologize for that. I am not going to behave that way in the future.

  18. Even supposing this completely ridiculous blaming of the Amish was totally true, and it is the Amish insistence on having babies at home that skews neonatal death rates upward, that alone is proof that having babies at home is a risky act. This whole exercise you apologists are doing in picking straws – “well its because of uneducated women – older women – high risk women” etc – proves the point exactly that MANY WOMEN SHOULD NOT HAVE BABIES AT HOME. Most of them, in fact, since the more factors you’ve listed here, the more you’ve left out… most women who exist. No “older” women (maternal age has been steadily rising in the US), no women with health problems, no women over a certain BMI (that has been steadily rising also), no women under a certain education level, etc., etc., you’re left with about 5-10% of the population who are “low risk” and you still can’t prove they won’t have a 3x higher chance of having their babies die at home with some poorly trained midwife who “trusts birth”.

    • Try going to the CDC database and look at the 32 states that don’t have Amish. Choose babies born 37-41 weeks, all causes of death, deaths between birth-27 days. The home birth death rate in those states is very comparable to the MD/hospital death rate in the same states. I’m still waiting to hear an explanation for how this could be so if homebirth is just so inherently risk across the board.

      • Actually, I’m working on it right now, and finding this isn’t actually true. I’ll post it when I have it finished. The gap is a little less, but not nearly “comparable,” and it is only in the MD/DO category, which are obstetricians who care for all the high risk pregnancies, and not the hospital death rate. Not only that, but we shouldn’t be comparing homebirths with only physician births, as they shouldn’t be comparable, and I haven’t done that in any of these comparisons. I’ve used overall hospital rates and CNM rates. Homebirth women should only be low risk, and that is what homebirth midwives are claiming they are.

        • If you get to throw in CNMs in the hospital birth rate, I should get to throw them in with the home birth rate. Interesting, doing that I’m coming up with an exactly identical rate of .84.

          Where are you seeing midwives claim that only low risk women do homebirths?

          I think it’s silly to pretend that all homebirths are done by low risk women when you know that is not true. But hey, whatever makes your stats say you want them to say, right?

          • Hahaha, what? First of all, we should be comparing midwives with midwives, period, which is why the other midwife category should be compared to CNMs and not doctors. The only reason the other comparison has been made here is because the first one is SO BAD for the other midwife category. It’s like an add on. Not only are they worse than the low risk category, where they should be comparable, but they’re even higher than ALL hospital mumbers, which include high risk. That’s the whole point. Secondly, we all agree that out- of-hospital CNM numbers ate reasonable. The ones in question are the other midwives, which is why their numbers must be examined separately.

          • Oops, my reply to you ended up on the bottom of the page.

            Here is some more of the person’s comment that is relevant: First, take note of the fact that in the CNM hospital cohort, approximately 5% (25,000 of 560,000) of your group consists of grand-multiparas. (women who have already had at least 4 children). In the out-of-hospital, other midwife group, the proportion is 21% (7500 of 35,000). This is on its face an independent confounding factor, which you have neither acknowledged nor adjusted for.

          • Oh, yeah, one more thing I wanted to ask you. Surely you would admit that the CDC database is useless for evaluating the safety of giving birth with a CPM, right? Seeing how unlicensed midwives and licensed are all lumped together as “Other Midwife”.

  19. This was in someone else’s comment here, have you read it?

    And there is a third major flaw in this analysis introduced by restricting the cohort to CNM births. CNMs are not evenly distributed about the country. CNM-attended births as a proportion of all vaginal births range from 0.7% in Arkansas to 35.9% in New Mexico. http://www.midwife.org/siteFiles/news/TrendsinCNMBirthsfromJF07JMWH.pdf
    Generally speaking, CNM births are more common in the Northeast and west coast, and least common in the midwest and mountain states. The result is that when you restrict your hospital cohort to CNM births only, you have introduced a serious geographical skewing, oversampling from areas where the underlying risk factors are smallest, and drastically undersampling from the regions where they are greater. Therefore any national cohort of CNM births is inherently biased toward good outcomes.

    • Ahh, but I have not ONLY restricted my hospital cohort to in-hospital CNMs. The numbers are there for all hospital births as well. The hospital numbers are still twice as high when you take into account all births — even the high risk ones!! — and that’s not considering that homebirth transfers before birth that end in death are counted in the hospital stats. However, it seems that your friend is wrong that using only CNM numbers would be biased toward better outcomes.

      For the dataset (that I just happened to have up on my screen, no other reason) including non-Hispanic singleton White neonates between 37 and 40 weeks with prenatal care starting before the 3rd month, mothers between the ages of 20 and 39 with more than 12 years of school, the CNM numbers broken down by region are as follows:

      Northeast: 75667, death rate 0.34
      Midwest: 52,287, death rate 0.57
      South: 96,508, death rate 0.56
      West: 66,402, death rate 0.44

      It looks like the South, which has the highest risk factors and where your friend claimed had the lowest number of CNMs, actually has the highest number of CNMs and the second highest death rate, effectively skewing the numbers HIGHER for CNMs.

      • But the South also has a lot more births than the other regions, over twice as many as took place in the Northeast, for instance. So the overall percentage is still going to be lower.

        Here is a different way to look at it. I took the 5 states with the best health outcomes and the 5 states with the worst health outcomes according to the The Commonwealth Fund Commission’s “Scorecard on Health System Performance”. 6 best states were Vermont, Hawaii, Iowa, Minnesota, Maine and New Hampshire. 6 worst states were Mississippi, Oklahoma, Louisiana, Arkansas, Nevada and Texas.

        I took CNM births in the best 6 compared with overall hospital births, 53,899/648,918. Which works out to 8% of all hospital births being done by CNMs. The 6 worst states had 68,917 / 2,466,145 so a rate of about 2%. So essentially four times as many CNM births happen in the healthiest 6 states as compared to the least healthiest 6 states. So I would have to think that would skew the numbers and make CNMs look better than they would if it was more geographically standardised.

        • OK, so tell me what it is that is making birth less safe for educated white women in the less healthy states? Because we’ve controlled for race and socioeconomic status, which is ostensibly the problem in the south. But I can easily (ha ha — it takes me forever because I triple check everything) run the numbers separately for each region. My guess is that the proportions remain the same.

          • I’m not sure I understand your question. Are you implying that it is only black people or uneducated people that have poor health outcomes? That an educated white person will statistically have the same health outcomes regardless of whether they live in Mississippi or Vermont? Not sure if that is true. Have there been any studies done on this?

          • I didn’t ask if minorities and poor people had worse health outcomes than white educated people. I asked if all white educated people statistically had the same health outcomes regardless of where they live.

            And really, the assumption that someone has 12 years of school=economically well off is really bothering me too. I understand that statistics show the more education you have the more money you make over a lifetime, but there are still plenty of poor people with 12 years of education. There are plenty of poor people with 16 years of education. Someone with 16 years of education might not have even earned their bachelor’s, seeing how the average student takes like 5-6 years. I can’t believe you think you can include only high school graduates in your data and exclude minorities and assume you have excluded all poor people. Because white high school graduates with no college education are never poor, right?

          • I never said I excluded all poor people. The point of narrowing the focus was to get a more homogenous group of people. People who’ve at least graduated from high school and are white are *more likely* to have better health outcomes.

          • Yeah, but that doesn’t mean there still CAN’T be wide geographical differences, even among white high school graduates.

          • Sure, which is exactly why I asked your for your explanation of what it is that is making birth less safe in some geographical areas. Is it the air in Louisiana?

          • Do you really not understand that people with poor health are more likely to have poor birth outcomes? Or is it that you don’t understand what factors would be causing white people to have poor health?

            Here you go from this website http://snrs.org/publications/SOJNR_articles2/Vol10Num01Art05.html:

            Mississippi has high rates of adult health problems including the highest rate of obesity and high prevalence of chronic illnesses such as diabetes, hypertension, cardiovascular disease, cancer, and renal failure. Mississippi is also burdened with some of the most challenging social determinants of health such as poverty, lower education levels, poor health literacy, unemployment, and single parent households. All of Mississippi’s 82 counties contain areas federally designated as medically underserved with startling numbers of healthcare professional shortages.

            Do you see how some of those things might affect people’s health which then affects their birth outcomes?

        • Oh, wait, you’re probably going to come back and try to say you excluded every single unhealthy person because a CNM only treats low risk people.

          Well, my answer to that would be that people with chronic diseases are only the tip of the iceberg. What you don’t see is all the of the people who are not healthy but have yet to develop an official disease. You cannot compare a fit, non-smoking person who eats a healthy diet to one who is unfit, smokes and eats a lot of junk food and expect them to have the same birth outcomes. So any time you are oversampling (by four times as much) among the former, it is going to skew the results.

          That’s why scientists rely on peer reviewed studies, rather than just raw data. For people who pride themselves so heavily on doing things the scientific way you would think you’d understand this.

    • also, I’m still working on the Amish data — I haven’t forgotten it. My computer froze up yesterday and I lost everything that I’d plugged in halfway through, so I gave up and took my kids for a hike.

  20. Actually when you do play around with the parameters nurse midwives do have lower mortality at homebirths than in hospitals. Here’s the chart:
    http://www.facebook.com/photo.php?fbid=281699798513380&set=a.259497457400281.83485.159375377412490&type=1&theater

    These were the parameters:
    Delivery Method: Vaginal
    Plurality or Multiple Birth: Single
    Birth Weight: 1500 – 4999 grams
    Gestational Age – new: 37 – 40 weeks
    Age of Infant at Death: 0- 23 hours
    Age of Mother: 20-34 years
    Race: White
    Hispanic Origin: Non-Hispanic White
    Education: 12 – 16 years and over
    Month Prenatal Care Began: 1st – 3rd month

    Many other studies confirm that homebirth is safe as long as risk assessment is followed. Now it’s a matter making sure those risk assessments are followed, with stricter protocols & more consultation with other medical professionals.

    • Yes, because babies making it past 23 hours means that homebirth is safe. I guess if they suffer through 24 hours and then die, it’s certainly for some reason other than what happened at their birth.

      The point, which several people don’t seem to be getting here, is that RISK ASSESSMENT IS NOT FOLLOWED HERE IN THE US. Non-nurse midwives are pushing and pushing to be allowed to do riskier and riskier births at home, not asking for restrictions and care guidelines.

      • The point, which several people don’t seem to be getting here, is that RISK ASSESSMENT IS NOT FOLLOWED HERE IN THE US.

        We’re missing your point because all this time you’ve been insisting the point was that homebirth midwives only work with low risk women.

        • Because that’s what the midwives keep claiming they are taking on is low risk patients. I think that’s pretty clear in this post. If they were just taking on low risk patients, then these numbers wouldn’t be what they are. But then again I suppose low risk is open for interpretation. It doesn’t seem there is a clear consensus of what low risk is.

      • Heather, I just said that – r e a d. And I’ll rerun the number past perinatal, I think I’ve done it before & the numbers weren’t much different.

        If we’re going to talk about homebirth then let’s talk about it honestly – in the right circumstances homebirth is safe. But by the look of the stats, risk assessment & protocol is not being followed to ensure safe homebirth. But that doesn’t nullify the fact yes homebirth can be safe.

        Instead of preaching your ‘homebirth is dangerous’ mantra, strongly reiterate the specific circumstances inwhich homebirth IS safe. A hell of a lot of people would be more willing to listen to you than they do now. Abrasive posts have a way of alienating people.

        • If there right circumstances were happening here NaturalMama then I guess this wouldn’t even be an issue now would it? Why is that flying over your head here? Numerous times in this post she says that homebirth midwives say they only take low risk patients. The thing these numbers is showing is that not all homebirth midwives are taking low risk patients. And it’s not because of the Amish or because of one particular state that these numbers are the way they are. It’s because lay midwifes are trying to play hero to women who think all doctors are out to cut you open and all hospitals just want to give you interventions. So they are “coming to the rescue” and instead killing moms and babies.

        • Also, how are you getting numbers like 0 and 1? When I ran it, I didn’t get zero for any of them, which the database shows when you tell it to “show zero values.” All I’m getting is “suppressed value,” which means it is somewhere between 1 and 9. The CDC doesn’t want people searching it to be able to figure out the details of a small number of births, because they don’t want you matching the births to ones you know about in real life.

          • I don’t know why I’m getting the numbers & you’re not, down the bottom have you checked the boxes saying ‘show suppressed or zero values’?

            Monica, we’re well aware midwives are taking on high risk patients & not sticking to strict protocol that would make homebirth safe. Never mind the whole midwife system is unregulated.

            I’ll say it again, r e a d it this time:
            “Now it’s a matter making sure those risk assessments are followed, with stricter protocols & more consultation with other medical professionals.”

      • I reran the CDC numbers to include deaths from 0 – 6 days old. Results:

        CNM hospital – .26 per 1000
        MD hospital – .34 per 1000

        CNM home – .23 per 1000
        MD home – 1.37 per 1000

        Note CNM’s have a LOWER mortality rate at HOME.

        The data is also from the years 1999 – 2006 (before 1999 they didn’t seem to document place of birth) with these parameters:

        Plurality or Multiple Birth: Single
        Delivery Method: Vaginal
        Age of Infant at Death: Under 1 hour – 6 days
        Birth Weight: 1500 – 3999 grams
        Gestational Age – new: 37- 40 weeks
        Race: White
        Hispanic Origin: Non-Hispanic White
        Age of Mother: 20-34 years
        Education: 12 years – 16 years and over
        Month Prenatal Care Began: 1st – 3rd month

          • Fantastic! Not a single person here has said it’s not safe to give birth at home with a CNM, as has been reiterated over and over and over and over and over again. We are making the argument that it is not safe to give birth at home with CPMs and lay midwives here in the US.

          • Really Heather? Maybe you need reminding of what you wrote in your post “Friday Fallacy: Babies Die in the Hospital, Too” :
            “And with Certified Nurse Midwives? It’s better, but still one-and-a-half times the rate with CNMs in a hospital! So babies do not die at the same rate in the hospital as they do in homebirth.”

            I reran the numbers specifically to counteract that statement, to show that even with the CDC stats homebirth with low risk criteria has LESS mortality than hospital births. I’m glad you at least half arse acknowledge it in this post.

          • I’m not advocating that CNMs not be allowed to attend homebirths; I think they are perfectly legitimate homebirth care providers, which I have stated over and over on this blog. However, saying that it’s safer with them is ingenious. Do you really think that women who choose a homebirth are going to agree to an induction after 40 weeks or to make sure their child doesn’t grow too large to stay in your parameters? Hardly.

          • We have no idea what ALL homebirthing women would choose to do. Yes we know of some radicals, doesn’t give usu the right to judge an entire group of people.

            Using the CDC data, the only 2 factors that make a significant difference are race & education. Birth weight, gestation, plurality etc, none of it makes homebirth more dangerous than hospital birth – only race & education level.

          • I just ran the stats including all education levels & races, & all other parameters. The rates jumped up for all types of birth attendants as expected.

            CNM’s hospital = 1.04
            CNM’s home = 1.08

            Pretty similar huh. So no matter what paramters, CNM’s in the US continue fare the SAME whether at home or hospital.

        • Also, I have had both boxes checked (show zero/show suppressed values) the whole time. It will show the suppressed values between 10 and 19 if you check the box, but not those less than 10.

  21. Lol, Heather I can’t believe you said Johnson & Daviss was my favourite study – what a crock. I’m happy to concede that 3 of the deaths they excluded should have been included to give a more accurate number. Besides, I don’t expect non-CNM midwife figures for perinatal death to be good in the US anyway, the system is too unregulated, you have a mixed bag of midwives of different education levels.

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