In today’s guest blog, Skepchick’s resident stats junkie/guru, Jamie Bernstein, breaks down Dr. Amy Tuteur’s analysis of a recent homebirth study.
Trigger Warning for talk regarding neonatal mortality.
The relative risks of homebirths versus hospital births is an extremely contentious subject. Previous research, mostly done in European countries has shown an extremely small or even nonexistent risk of newborn death from homebirths relative to hospital births, however until recently there have been almost no good studies looking at the risks of homebirths for mothers in the U.S.
This week on the Skepchick backchannel, Julia mentioned that a new study was released this month by the Journal of Midwifery & Women’s Health on the safety of homebirths in the US. This study is being touted by Midwifery organizations as confirming the safety of homebirths. Julia also shared with us this post by Dr. Amy Tuteur from the Skeptical OB where she makes the claim that this same study, which supposedly shows how safe homebirths are, actually shows a 450% increase in newborn death rates from homebirths and confirms how unsafe homebirths really are. Like Julia, I had trouble understanding how two different people can look at the same study and yet come to completely opposite conclusions as to the results, so I thought it might be an interesting area to turn my statistical eye.
The main crux of Dr. Tuteur’s argument is the following:
According to Citizens for Midwifery:
The overall death rate from labor through six weeks was 2.06 per 1000 when higher risk women (i.e., those with breech babies or twins, those attempting VBAC, or those with preeclampsia or gestational diabetes) are included in the sample, and 1.61 per 1000 when only low risk women are included. This rate is consistent with some published reports of both hospital and home birth outcomes, but is slightly higher than others.
No, it isn’t “slightly” higher. It is MASSIVELY higher.
According to the CDC Wonder database, the neonatal death rate for low risk white women at term from the years 2004-2009 is 0.38/1000. As Judith Rooks, CNM MPH noted in her review of Oregon homebirths, intrapartum death among low risk babies is essentially non-existent in the hospital, so the neonatal + intrapartum death rate for the hospital is still 0.38
As the chart above demonstrates, the MANA death rate for the same years was 5.5X HIGHER. In other words, the MANA death rate was 450% higher than the hospital death rate.
She also includes this chart comparing the various death rates:
I clicked the link Dr. Tuteur gave where she got the Citizens for Midwifery quote but didn’t see anything with that quote or numbers on the linked page. I did download and read the study which these numbers supposedly came out of, though it’s worth noting that Dr. Tuteur wrote her post prior to the full paper being released.
I’m not really sure exactly where this quote came from and these numbers don’t seem to match anything in the study. My best guess is that the quote came from a press release or results summary. The stats she mentions (2.06 per 1000 risk of death for all births and 1.61 per 1000 risk of death for low-risk births) are not mentioned anywhere in the actual study, though that doesn’t mean they are not accurate.
Page 7 of the study lists the following fetal and neonatal mortality rates for the homebirth sample:
Intrapartum fetal death (after onset of labor but prior to birth): 1.30 per 1000
Early neonatal death (death after birth in first 6 days of life): 0.88 per 1000
Late neonatal death (death between 7 to 27 days after birth): 0.41 per 1000
However, these numbers include all births in the sample, not just to those of low-risk women. The study also listed the following mortality rates for births excluding lethal congenital anomaly-related deaths:
Intrapartum fetal death: 1.30 per 1000
Early neonatal death: 0.41 per 1000
Late neonatal death: 0.35 per 1000
These numbers still include high-risk births such as breech or twins, though. I was unable to find a low-risk birth stat comparable to the one Dr. Tuteur mentions in her post. I was hoping the stats she mentioned would be in the study so I would get some good confidence intervals to work with, but instead I’m just going to have to take Dr. Tuteur at her word and have to interpret the numbers without confidence intervals.
It’s worth mentioning here as well that the study in question did not compare risks in homebirths to that of a comparable hospital birth cohort. Instead, all this study did is look at a sample of almost 17,000 planned homebirths in the US in which they had lots of detailed information and then report on various statistics about those births.
Let’s leave this study for a bit and go back to the numbers Dr. Tuteur cites in her post. According to Dr. Tuteur, 1.6 per 1000 low-risk planned homebirths from the recent study resulted in neonatal death within 6 weeks of birth. Using CDC data, she also determined that the risk of neonatal death for low-risk white women in the US during the same years was 0.4 per 1000 births. She then points out that OMGZ YOU GUYS THAT’S A 5.5X INCREASE IN BABY DEATHS!
First of all, can I first point out that it’s a 4x increase, not 5.5x (1.6/0.4 = 4). Even comparing the homebirth cohort that includes high-risk births (2.1 in 1000) to the low-risk only CDC cohort (which is not a fair comparison for obvious reasons) would only result in a 5.25x increase in mortality. I seriously have no idea how Dr. Tuteur came up with 5.5x or 450% increase in mortality from the numbers that she cited.
Ok ok ok, but even assuming that Dr. Tuteur screwed up some of the basic math here, we’re still looking at a 300% increase in neonatal death rates for low-risk births. That seems pretty huge. However, take a look at those numbers again. One of the reasons they are reported as deaths per 1000 births is because the risks are too tiny to report as percentages. What we’re really looking at here is a risk of death increasing from 0.0004% to 0.0016%. This is a difference of 0.0012 percentage points. 0.04% to 0.16%. This is a difference of 0.12 percentage points. (Ed. note: minor math correction is fixed, thank you all for spotting this!) In other words, we are comparing an extremely small risk to a slightly higher extremely small risk. Plus, the smaller the risk, the bigger the sample size you need to detect any change in the risk. When dealing with percentages this tiny on a sample size of only around 17,000 births, it’s not clear that we can get enough accuracy to the 1.6 per 1000 number to even determine that it’s truly “bigger” than the 0.4 in 1000 number from the CDC.
All this is even assuming that the numbers Dr. Tuteur cites are comparable. The homebirth study looked at births for women who were planning a homebirth (regardless of where they ended up giving birth). All we know about the info Dr. Tuteur got from the CDC website was that it was for white women with low-risk births. This includes hospital births, homebirths, and births in locations other than the home and hospital (though she labeled them as hospital births on the chart she posted). Women who choose to have a homebirth are likely very different from all white women giving birth, so it’s not really a fair comparison. Plus, Dr. Tuteur doesn’t provide enough information to determine that the definitions are similar for things like “low-risk” and “neonatal death.” It is just not clear to me that these numbers are coming from sources that are similar enough that they can be compared to determine relative risk.
Rather than worry about what Dr. Tuteur wrote in her post, let’s talk a bit about the actual research done in the new Journal of Midwifery & Women’s Health study on U.S. homebirths and what they found in terms of upsides and downsides to having a homebirth.
Neonatal mortality rates for low-risk births were very low.
This study found that neonatal mortality rate for infants of parents who planned a homebirth in the first 33 days of life was 0.77 per 1000. This is similar to numbers found in homebirth studies done in Europe and is very low. This could be slightly higher than planned hospital births, but because the numbers are so close we can’t really tell for sure without a study that compares the cohorts while controlling for anything that may make the homebirth population different from the hospital birth population.
Neonatal mortality rates for high-risk births were inconclusive but worrying.
The study specifically mentions that breech births, TOLAC, multiple gestation and maternal pregnancy-induced comorbidities all seemed to have neonatal mortality rates that are in ranges higher than are typically seen in a hospital setting. However, due to the small overall population and the rarity of these conditions, there were not enough births presenting these conditions in the sample to say for sure. It’s also unclear whether the higher mortality rates are caused by the homebirth or by something else regarding the population of women that choose to have a high-risk homebirth. It’s possible, for example, that the type of women who chose to have a homebirth even though their pregnancy is considered high-risk may also be more likely to refuse medical interventions or drugs that could have helped their baby survive. Additionally, many midwifes will not do homebirths for high-risk births and it’s possible that the midwifes who do choose to deliver a high-risk birth in a home setting may be different from the midwifes who refuse to do so. Either of these situations makes this group extremely difficult to compare with mothers who choose a hospital birth. The question of whether the higher death rates are due to homebirths or something about the women and midwives who do high-risk homebirths is unclear at this point, but is still a cause to worry. A future study using a bigger sample and matched comparison group will have to be done to really understand the relative risk between home and hospital settings in high-risk births, but until a better study is done, it’s best to go with the best evidence we have now (however flawed) and assume that having a high-risk birth at home is a bad idea.
Many women who plan homebirths end up giving birth in the hospital.
In the study sample, 10.9% of women transferred at some point during labor to a hospital. Additionally, 1.5% of the women transferred to a hospital after giving birth. Of the newborns born at home, 1.0% of them were transferred to a hospital after birth. If you’re considering a homebirth, it’s important to consider that you could be one of the 1 in 10 women that end up having to transfer to a hospital partway through the labor process. Additionally, women going through their first birth were 3 times more likely to transfer than women on at least their second birth. This is probably because women who had a difficult first birth may be less likely to choose a homebirth for their subsequent births.
Women who planned for homebirth had low rates of oxytocin augmentation, cesareans, epidurals, and other interventions.
There were low rates of pretty much every type of hospital intervention. However, like the other items I mentioned it can’t really be compared with hospital births without a good matched comparison group.
Lots of women paid for homebirths out of pocket.
Just about two thirds of the women in the study who chose to have a homebirth paid for it entirely out-of-pocket. It seems that not all insurance companies cover homebirth and not all midwives accept insurance.
Conclusions based on this one study: The upsides to a homebirth could be lower rates of medical and surgical interventions and it’s probably just more comfortable being at home rather than at a hospital. However, there is a rather large risk that you may have to transfer to a hospital at some point during labor (which seems less comfortable than just going to the hospital in the first place). For low-risk births the neonatal mortality rate of having a homebirth is either negligible or slightly higher than that of a hospital birth, though because we’re talking relative risk it’s still quite low. For high-risk births there is some evidence that neonatal mortality rates could be much higher in a homebirth setting compared to a hospital. Additionally, homebirths may be extremely costly even if you have insurance.
Again, just to be clear, this is not a review of all the literature and is just my reading of this one study. So, how do two different people read the same study and come to opposite conclusions? The “homebirths are so safe” review by the Midwife Alliance of North America (MANA) focused on the low neonatal mortality rates for low-risk homebirths. They did mention that there were factors that could increase risk, but in my opinion did not give enough of a warning about the possible dangers of having a high-risk homebirth. The “homebirths are killing babies” review by Dr. Amy Tuteur was less “focusing on some parts of the study while downplaying others” and more just a sloppy and unscientific attempt at calculating relative risk by using two completely non-comparable data sources in order to scare readers away from homebirths.
Thank you so much for this, Elyse. Years ago I really enjoyed Amy Tuteur’s writing, but it became clear that she is an ideologue first. It’s so obvious it’s awfully hard to credit her perspective as an innocent mistake or a reasonable differing interpretation of data. This is especially bothersome because accurate information on birthing is crucial, especially among the set likely to choose home birth. Those you might call “medicine-skeptical” are overrepresented in the home birthing population and they are prone to falling for alt-med that’s either ineffective or dangerous. Of course, a great number of people choose home birth for perfectly rational reasons (comfort and control of your surroundings is a rational reason) and have read the literature. Many of my friends have done so, and they’re not anti-establishment woo conspiracists.
Amy Tuteur muddies the waters badly, giving the alt-med types examples of dishonesty and agenda-driven “data” by the medical establishment. When they criticize Tuteur for this, they’re fucking *right*. It’s too mild to call this “not helpful,” home birth is very vulnerable to potentially dangerous folk notions and outright pseudoscience that can harm or kill. Evidence-based critique is crucial if people are to have the information they need (and deserve) to make good choices. Tuteur fucks that right up.
Not for nothing, but this is a woman who defends male circumcision with the most tortured contrivances that don’t make sense on examination. I know that sounds inflammatory—and it is. I couldn’t believe it myself when I saw her doing it.
“This is especially bothersome because accurate information on birthing is crucial, especially among the set likely to choose home birth. Those you might call “medicine-skeptical” are overrepresented in the home birthing population and they are prone to falling for alt-med that’s either ineffective or dangerous. Of course, a great number of people choose home birth for perfectly rational reasons (comfort and control of your surroundings is a rational reason) and have read the literature. Many of my friends have done so, and they’re not anti-establishment woo conspiracists.”
Yes yes yes!!!! Thank you.
Thanks. I went into this with no agenda or ideology to defend. I was just really curious at how two completely different people could come to opposite results from reading the same study. If anything, as someone who puts a lot of trust in the medical establishment, I always just kind of assumed that homebirths were dangerous and possibly a crazy idea for someone to consider. Recently I read Emily Oster’s book “Expecting Better” and she said that she was surprised to find that the research showed that for low-risk births, homebirths were a safe alternative to a hospital birth. Even after reading her review, I was a bit incredulous because it just seemed…unintuitive. I went into this post deciding that I was going to just see where the data led and that’s what I did.
Frankly, Jamie, this is a hatchet job and a very sloppy one at that. I think you owe me an apology.
Let’s go through it point by point:
1. You wrote: “I clicked the link Dr. Tuteur gave where she got the Citizens for Midwifery quote but didn’t see anything with that quote or numbers on the linked page. I did download and read the study which these numbers supposedly came out of …”
How could you not find it? I gave an exact quote in my piece and linked to the place where the original can be downloaded? It is on page 3 of the 5 page CfM press release, the beginning of the second full paragraph. Please check to confirm.
2. You wrote: “I’m not really sure exactly where this quote came from and these numbers don’t seem to match anything in the study.”
Wrong again. On page 7 of the study, under the section Fetal and Neonatal Morbidity and Mortality, second full paragraph, last sentence: “When lethal congenital anomaly-related deaths were excluded (n = 0 intrapartum, n=8 early neonatal, n = 1 late neonatal), the rates of intrapartum death, early neonatal death, and late neonatal death were 1.30 per 1000 (n = 22), 0.41 per 1000 (n = 7), and 0.35 per 1000 (n = 6), respectively (Table 5).”
1.3+ 0.41+ 0.35 = 2.06
You quoted those exact numbers but never bothered to add them together to get the total.
3. You wrote: “First of all, can I first point out that it’s a 4x increase, not 5.5x (1.6/0.4 = 4).”
Except that the correct number of MANA deaths was 2.06/1000 not 1.6/1000.
4. You wrote: “I seriously have no idea how Dr. Tuteur came up with 5.5x or 450% increase in mortality from the numbers that she cited.”
That says more about you than about me. I explained how I got it in my post and I just explained it again.
5. You wrote: “What we’re really looking at here is a risk of death increasing from 0.0004% to 0.0016%. This is a difference of 0.0012 percentage points.”
No, that’s not what we are looking at. It is off by more than 100 fold. 0.4 deaths/1000 is 0.04%. You added in two extra zeros. The homebirth death rate was 2.1/1000, which is 0.21%. So the difference is 0.17%. That sounds like a tiny number, but when you are talking about thousands of births, it’s the difference between 4 deaths for every 10,000 babies born in the hospital and 21 deaths for every 10,000 babies born at home.
6. You wrote: “All we know about the info Dr. Tuteur got from the CDC website was that it was for white women with low-risk births. This includes hospital births, homebirths, and births in locations other than the home and hospital (though she labeled them as hospital births on the chart she posted).
Clearly you never bothered to look at the CDC Wonder database, which contains an complete description of contents. I specifically noted that I looked at white women, 37+ weeks, 2500 gm babies
7. You wrote: “This includes hospital births, homebirths, and births in locations other than the home and hospital (though she labeled them as hospital births on the chart she posted).”
Wrong again! I did not include locations other them home or hospital and label them hospital births. I don’t know where you got that idea.
8. You wrote: “Women who choose to have a homebirth are likely very different from all white women giving birth, so it’s not really a fair comparison.”
Really? White women who give birth in the hospital tend to be younger, poorer, of lower socio-economic class and more likely to smoke than the homebirth group, which means that the 450% higher homebirth death rate actually UNDERCOUNTS the difference in deaths between home and hospital.
Finally, you wrote: “The “homebirths are killing babies” review by Dr. Amy Tuteur was less “focusing on some parts of the study while downplaying others” and more just a sloppy and unscientific attempt at calculating relative risk by using two completely non-comparable data sources in order to scare readers away from homebirths.”
No, what’s sloppy and unscientific is your hatchet job. You are WRONG about the numbers, WRONG about the math, WRONG about the quotes, WRONG about the CDC Wonder database, WRONG about the differences between the home and hospital group and therefore, completely WRONG about your conclusion.
I hope youwill acknowledge these errors and correct them. And I’d like to see you apologize. It’s the least you can do after writing and publishing this “analysis.”
I had to make an account just to comment on this post because it is so unbelievably ridiculous. Thank you Dr Tuteur for coming here and defending your work, the fact none of the “skeptical” readers here has bothered to respond to your rebuttal, and instead go on their own little rants about how right the article ‘clearly’ is or how you are terrible (while citing no evidence), without bothering to fact check? It speaks volumes about their supposed skepticism. It took me 15 minutes to go through all of the claims made, your numbers and citations, and find them and see that they added up just as you said they did.
This article is nonsense and does a disservice to anyone interested in accurate analysis.
Dr Tuteur has earned a new reader after this garbage.
Thanks for your concern about there being a ton of errors in my post. I’ll go through these one-by-one.
1. Thanks for letting me know where that quote came from. I felt it was a waste of my time to click on every single link on the page you linked to and read everything on each page of those links. Instead I just read the study. I assumed the page you linked to must have changed since you first linked to it and made it less clear. I also assumed that it was a legitimate quote that I just didn’t know the source of. It would have been easier if your link went directly to the source, but understandable that pages on the internet get changed over time and what may have seemed obvious at the time you wrote your post wasn’t a couple days later.
2. I did add up the numbers from the study. However those were numbers for what the paper deemed as the “low-risk” cohort. In your post you said the 2.1 in 1000 number was from the cohort including high-risk births. I assumed you wouldn’t purposefully mislead. I apologize for making this clearly incorrect assumption.
3. I did do this calculation and in fact I wrote that in my post in the sentence after the one you just quoted. However, I didn’t believe you would possibly attempt to compare the cohort of low-risk-only hospital births to the cohort of low and high-risk homebirths because that would be purposefully misleading. Again, I apologize for making this clearly incorrect assumption.
4. I’m not really sure how this is a separate item. Please see my response to #3.
5. Yes! I really fucked this one up. I originally had a longer sentence that included the raw numbers and the percents. On a later edit I decided that was misleading my making the numbers seem smaller, excessively wordy, and more confusing for the reader, so I edited the sentence down. In doing so, I mixed up the numbers and didn’t notice my mistake until after the article was posted. The worst part is that the wrong numbers were extremely misleading making the risk seem orders of magnitude smaller than they really are. As soon as this was pointed out, I asked GP to fix it and posted my response in the comments. Unfortunately the GP admins were all busy yesterday with their kids and didn’t see my request for an edit until this morning. Had this been my own blog, I could have fixed it immediately but because it was just a guest post I don’t have access to edit the post directly. This doesn’t change any of my analysis because it doesn’t change any of the actual risk numbers. It was an editing error. I fucked it up. I’m sorry. I got it corrected as soon as I could.
6. I did look at the CDC Wonder Database. However, you have to set the parameters of which data you want. I was certainly not going to assume I knew the restrictions you used so I went with what you wrote in your post which was “low risk white women at term from the years 2004-2009.” I apologize if this was incorrect. Next time I’ll be sure to read your mind and know that you actually meant something that you did not write.
7. Again, see #6. I assumed that you provided all the restrictions you used in your database and was unable to read your mind and know that you used more restrictions than you wrote.
8. Yah. Those are all possibilities that may make the datasets not comparable along with like a million other possibilities I could think up. That’s why you’ve got to be really careful when comparing datasets from two different sources that are using non-comparable cohorts and different definitions.
My post was a review of one study, and a rather weak study at that (for all the reasons I mentioned in my post). I was hoping to spark a discussion here on the relative risks/benefits of homebirths. There has been some good discussion (like the commenters arguing whether or not less medical interventions should really be considered a benefit) but lately it seems that you and the rest of your anti-homebirth ideologues have taken over all potential discussion and refuse to debate actual facts. If you think that even a small base risk is not worth it, then go ahead and argue that. That is a perfectly legitimate argument and one I personally agree with. However, there is no excuse for manipulating data and fearmongering in order to make the risk seem even bigger than it is and I’m not going to apologize for calling you out on that.
Oh that is just pathetic. Just because you don’t understand the data doesn’t make it manipulated. The fact you don’t seem to understand that MANA’s data isn’t a study at all, let alone a ‘weak’ one speaks volumes about your capacity to even begin to interpret Dr Tuteur’s post, let alone he actual data or a real study.
I have more I want to say but cannot respond in full right, unfortunately. I want to say for now… this is not about people “refusing to debate the facts,” it’s that your facts were not straight and, as you stated here, based on a lot of assumptions.
I cannot speak for everyone commenting but I, personally, have huge issues with home birth in our country. I am not an “anti-homebirth ideologue.” I am not anti-home birth. I am a former home birth advocate and one of the reasons I have such issues with home birth in our country is the flawed, misleading and/or deceitful propaganda out there in support of it. I feel incredibly passionate about this for various reasons, some more personal than others. I personally know women who believed these lies and I am one of them…. I am in forums and in a community full of them… women who believe the lies. And it is especially horrible when you meet/know women who lost their babies at home births…. losses that were preventable. It is incredibly tragic. Yes, some women do know the truth about the risks. But many do not. MANA included NO comparison numbers, held onto this information for years and then brushed over everything with their press release. The risks are real and women deserve to see what they are, with comparisons.
I see your piece – which comes off as an attack with your tone and what assumptions you made, making Amy Tuteur look like a liar b/c you decided to make assumptions instead of real research – making it seem the risk is negligible, and it infuriates me. And this isn’t even something you are passionately connected to… and you wrote a piece full of errors – from math errors (thank you for fixing the decimal one) to your assumptions. Maybe I can connect you to a few of my friends who lost their babies at their home birth…. then maybe the numbers won’t seem so “negligible.”
OK, let’s see if I get this straight.
1. You couldn’t bothered to click on a link? Seriously?
You accused me of fabricating a quote because you couldn’t be bothered to click on the link that contained it?
2. You said that you didn’t know where the numbers came from. They came from the paper. Just because you don’t like them does not mean that you can imply that I made them up.
3. “I didn’t believe you would possibly attempt to compare the cohort of low-risk-only hospital births to the cohort of low and high-risk homebirths because that would be purposefully misleading.” Here’s a crazy thought: why didn’t you ask me why I performed the analysis the way that I did? Let me guess. You couldn’t be bothered
I would have told you that the reason that I include the high risk births is because what MANA writes in the paper is different from how MANA counsels patients. They tell patients that breech, twins and VBACs are “variations of nomal” and that’s why they should deliver at home. I figure that if they counsel the patients that these complications are low risk, they should be included in their stats.
4. See #3.
5. Yes, you acknowledged your mistake and corrected it.
6. It doesn’t matter whether or not you knew the restrictions. No matter how I restricted it, the women in the hospital group were HIGHER risk than the women in the homebirth group.
7. It has nothing to do with my restrictions. It is a characteristic of the database. Had you bothered to read the description, you would have known that other out of hospital births were not in the hospital group, but … I know … you couldn’t be bothered.
8. The hospital group is higher risk than the homebirth group for the reasons that I explained above.
Finally, you wrote: “there is no excuse for manipulating data and fearmongering in order to make the risk seem even bigger than it is and I’m not going to apologize for calling you out on that.”
By I did NOT manipulate the data. You didn’t understand what I did and you didn’t bother to ask. I did NOT make the risk seeming bigger than it is. In fact, I probably made it seem smaller. In 2012 the state of Oregon hired homebirth advocate Judith Rooks, CNM, MPH to review every homebirth in 2012 and compare it to low risk hospital birth.I used the same methodology she did. She found that homebirths had a 800% higher risk of death than comparable risk hospital birth (700% if you removed congenital anomalies from the homebirth group, but not the hospital group). My analysis is in keeping with every other analysis of homebirth in the US EXCEPT the paper written by MANA on its own statistics.
You need to correct the misstatements that remain above, and you ought to apologize for making them. Wait, let me guess. You can’t be bothered.
Ya, you know, it was really *hard* to click all those links and actually fact check the piece like I said I did, so instead of saying “I never looked for the quote” I said “I didn’t see” the quote. See, the first way of saying things makes me look like I’m lazy, while the second one makes her look like a liar! Obviously I picked the second one.
Saying, “I disagree with the fact that she added these numbers together” implies that we are two people who have a difference of opinion and saying “I’m not really sure exactly where this quote came from and these numbers don’t seem to match anything in the study,” makes her look like she just made up the numbers! So I did that second one. I hope no one notices! Actually presenting *two* points of view and justifying mine over hers is more trouble than this whole “skeptic” thing is worth.
As for any questions I might have about details, I won’t ask them before I publish! When called out on it, I’ll just say, “I’m not a mind reader,” because that will divert people’s attention from the fact that asking questions about details is a normal part of a journalist’s, or skeptic’s, work.
You know, nobody made you ‘analyze’ either the MANA data or the analysis of it. The reason why people look up to skeptics, or skepchicks, is they put in the work and do fact-checking. If you didn’t want to actually work to understand what you were talking about, you shouldn’t have done this guest post in the first place.
Here is my full response:
http://www.skepticalob.com/2014/02/grounded-parents-does-a-hatchet-job-on-my-analysis-of-the-mana-statistics-paper.html
I love that we have people here who can look at these things and actually dissect them in a way that is understandable and free of any agenda.
Thank you so much for posting this, and thank you to Jamie Bernstein for writing it. After I posted my own experience here of my family’s attempted home birth (over my objections), Dr. Amy talked past every point I made to bang her shtick drum, and (as I wrote in a follow up article) it struck me as VERY dangerous to approach this topic as an ideologue with a competing ideology instead of with impeccable use of data and methodology. We can’t claim to have the truth if we salad bar our data and fall into fallacies in the same way as those we seek to debunk.
Oh lord, I missed that Jamie Bernstein wrote this. Sorry Jamie! Awesome job.
Jamie, you may wish to check out the independent analysis of the MANA stats by Brooke Orosz, PhD that she performed to settle a dispute on the MANA stats by Aviva Romm, MD and myself.
http://www.skepticalob.com/2014/02/a-statistics-professor-analyzes-the-new-paper-from-the-midwives-alliance-of-north-america-mana.html
It is also worth noting that Dr. Romm refused to give her interpretation of the study claiming that statistics are just too hard.
The key point, however, is not that the magnitude of the difference in the death rates, but the fact that MANA is LYING about the meaning of their own statistics.
This data was collected 5 years ago and as far back as 2011, MANA was boasting about the low C-section and intervention rates in the homebirth group, while simultaneously refusing to release the death rate for the same group. The data were ultimately released in response to considerable public pressure, including a petition campaign demanding the release of the death rates.
If those death rates were really indicative of homebirth safety, why would MANA have hidden them for 5 years, while they were eagerly releasing just about every other piece of data from the cohort? The answer is that they wouldn’t have. Even MANA knows that this data shows that homebirth dramatically increases the risk of perinatal death. Please don’t be an apologist for their lies.
Leaving aside the fact that you just ignored everything Jamie wrote and have now shifted goalposts, I am curious about something you’ve posted. Who is Brooke Orosz? You say she gave an independent analysis, but you found this person. You say this person “volunteered.” How and under what circumstances? How do you know her?
See, you expect transparency from the people you’re arguing against, and yet you want us to take your word that this is an “independent analysis” by a stats professor who is a disinterested party. When I Googled Brooke Orosz, I see she is a professor at Essex County Community College, and I can find no faculty profile and no publication record (which isn’t surprising since she works at a community college, which is traditionally interested in teaching and not publishing). So, essentially, we know nothing of this person in order to judge whether or not they are truly independent. You simply want us to take your word for it. Forgive me if I am skeptical given your history of being misleading on this topic.
What do you think of Dr. Orosz’s math? Why complain about her place of employment or list of publications rather than address her argument? Her analysis is completely transparent. She shows her math step by step and provides rationale for any assumptions she makes or estimated values she uses. Let’s critique her WORK rather than try to discredit her as a person.
I’m not “complaining about her place of employment.” I’m saying that I have no way of judging whether or not she is independent as Tuteur claims. I will read through her analysis later when I have some time to spend on it. I’m not trying to “discredit her as a person,” whatever the hell that means. I’m asking for more information about who she is and why I should consider her analysis trustworthy and “independent” of any motive.
I also find it extremely hilarious that you lecture me on “discrediting her as a person” when you said this to Jamie below:
Pot, kettle, and all that.
Eer, not exactly. What you are attempting to do is poison the well. It doesn’t matter if it’s Dr Amy ‘s neatest friendsie if the data are accurate.
Yeah, it kind of does matter when the person is touted as an “independent” disinterested party. If Dr. Orosz does actually have some interest or is friends with Amy Tuteur, regardless of whether the interpretations are accurate or not, that means she’s not disinterested and an independent source of analysis as Tuteur is claiming. So, it does matter to me how Amy found this person to do this analysis because of the way Tuteur is trying to sell the analysis.
Well because presumably you are able to interpret the data she’s providing and come to that conclusion regardless of her affiliation. Barring independent knowledge of the person that says you should do otherwise, you should examine the data on their merit and come to a conclusion for yourself instead of instantly assuming, which you seem to be, that any affiliation, no matter how tenuous, negates what she’s saying.
I’m sure you could find her email and ask her.
With respect, I don’t see apologia in this post. I see a substantive statistical analysis of the various data, with reasonable conclusions regarding correlation and significance. Also, you seem to be doing a bit of “tu quoque” here, ignoring the refutation of your points by saying that the other guys lie.
Further, Dr. Orosz’s analysis demonstrates that you have drastically overstated the impacts, finding around 3x the likelihood of death compared with your claim of 5.5x. I am also curious why Dr. Orosz added neonatal and intrapartum deaths for the MANA stats, but did not add the estimate of .3/1000 intrapartum deaths in hospitals to those hospitals’ neonatal deaths. If this were added, it would reduce the increased likelihood of death to merely double, and a whole 1 out of 1000 births, which is not a lot, even if it is double.
I made a mistake here, misreading the numbers. Dr. Orosz did add neonatal and intrapartum deaths together, I was misreading the .7 number as without congenital, but that’s with congenital defects.
Mea culpa.
“Further, Dr. Orosz’s analysis demonstrates that you have drastically overstated the impacts, finding around 3x the likelihood of death compared with your claim of 5.5x”
If you were paying attention you would notice that Dr Orosz was intentionally more conservative when selecting the cdc comparison group, and the number STILL showed a 3x greater risk. Dr Tuteur actually used a comparison group closer to that of actual homebirthers, which is why the numbers are different. Even the cdc numbers are skewed in favor of homebirth though, because when the catastrophic transfers arrive (which happens at our hospital ALL the time) and the baby doesn’t make it because it is already too late, the death is counted in the hospital group.
“Even the cdc numbers are skewed in favor of homebirth though, because when the catastrophic transfers arrive (which happens at our hospital ALL the time) and the baby doesn’t make it because it is already too late, the death is counted in the hospital group.”
This bears repeating. I think a lot of people forget that if you transfer during a homebirth gone wrong (similar to the current debacle where the editor of Midwifery Today crowdsourced opinions and the baby ended up dying after an emergency c-section), that baby is not counted in the homebirth numbers, since they were born in a hospital, though that wasn’t the intended birthplace.
This is wrong, isn’t it? “What we’re really looking at here is a risk of death increasing from 0.0004% to 0.0016%. This is a difference of 0.0012 percentage points.”
0.4 in 1000 is 4 in 10 000, which is either 0.0004 or 0.04%, not 0.0004% so the difference is 0.12 percentage points.
Yes, exactly. The difference in risk is more than 1 death per 1,000 births for low risk women. Perhaps some women will think this risk is small. Some (like myself) will feel this risk is large. But prospective mothers deserve to be able to make up their minds themselves rather than have someone tell them that the risk is too tiny to worry their pretty little heads about. Especially because these results are not due to chance but are rather robustly statistically significant.
I don’t believe at any point I said that the risk was “too tiny to worry their pretty little heads about.” In fact I specifically mentioned that there may be a slightly higher risk with homebirths. For many women, any slightly higher risk to their child, even if very small, is not enough to outweigh the potential benefits of homebirths. Others put a different value on the risks and benefits. This is a personal choice based on personal valuation.
In other words, I completely agree with you and if anything I said in my post made it seem like I don’t, then I didn’t write it very well.
“Others put a different value on the risks and benefits. This is a personal choice based on personal valuation.”
I find it highly doubtful that most if any mothers-to-be think risking even a low chance of their baby dying in childbirth is worth the comforts of home and natural childbirth. And that is really what we’re talking about here, because the evidence shows that the only “benefits” of homebirth are personal comfort. The messages being broadcasted by numerous advocates of homebirth are that hospital births are more dangerous to the health of the mother and child. Women are choosing homebirth not because they value comfort over the life of their baby, but rather, because they are being fed misinformation.
I agree with Martha, and would add: 1. Homebirth advocates and midwives frequently understate risks of home birth and overstate the risks of hospital birth – mainly related to increased interventions, as if interventions will result in a less than ideal birth experience – obviously the worst thing possible *sarcasm*. 2. When women are fed a false notion of the benefits and risks, they are unable to make an informed decision about their care. Which, ironically is one of the very things that homebirth advocates claim will be lost in a hospital setting.
The issue isn’t that you said women’s shouldn’t care about a slightly higher risk, it’s that you are overtly defining 1/1000 to be a “slightly higher risk”, when in fact many people would classify that as much higher risk. Imagine you worked someplace where you saw 333 people perfectly healthy every day — as a bank teller, perhaps, or a museum guard — when all of sudden, every three days, someone just started dropping dead. Would you not find that troubling? If you don’t think that’s a lot of dead people, fine, but don’t assert on my behalf that isn’t a substantive increase.
Ah, beat me to it.
Of course, this still doesn’t necessarily mean the sample size was really large enough to detect statistically significant differences between the populations (though it is far more likely than in the .004%). Then again, for the confidence intervals to overlap they would have to be extremely large (what is the confidence interval for the CDC data?).
1.6 per thousand at 17k is ~27 total deaths, vs an expected ~7 for an equivalent number of hospital births. To me that seems like a large enough sample to detect some difference, but I am not a statistician. I am curious what studies MANA is citing that are “approximately equivalent” to the 1.6 number.
“1.6 per thousand at 17k is ~27 total deaths, vs an expected ~7 for an equivalent number of hospital births.”
This is the worst part. The heartbreaking, simple math of subtraction means that in this sample there are 20 babies who died who wouldn’t have, 20 families who have gone through the worst loss imaginable who shouldn’t have. And that is, presumably, with everything else going right, just because of location.
We cannot at all say that 20 babies died that otherwise would not have because this study did not have a comparable control cohort. All we can say is that there were a certain number of deaths in the homebirth population. The study had no hospital population. We can look at all births for a specific demographic that is similar-ish to the homebirth population (which is what Dr. Tuteur did) and see how many deaths are in that population. We can look at the differences between the two, but it isn’t really a fair comparison. In the absence of any better comparisons, which is the situation we are in now, we can say that homebirths may increase the neonatal deathrate by a small amount. We don’t know how big or small that amount is or whether it really exists at all, but we can say that it might exist. So, rather than “20 babies died when they didn’t have to” a more accurate statement would be “maybe up to 20 babies died when they didn’t have to, though the evidence so far is inconclusive.”
Alternatively, “up to 20 or more babies died when they didn’t have to, though the reporting is only 30% complete and the organization (MANA) by definition doesn’t have anything to do with planned hospital births so if you can’t use a comprehensive database like CDC for comparing neonatal mortality you can’t use any outside stat like average C-section or induction rate so this paper isn’t good for anything and why are we having this conversation?”
I don’t understand why you would argue CDC Wonder isn’t a good comparison when looking at the characteristics of the MANA numbers and using them to inform selection of CDC characteristics. Rates mean nothing without a comparison. What do you propose we use instead?
So what did you think of the Orsosz paper Jamie?
“maybe up to 20 babies died when they didn’t have to, though the evidence so far is inconclusive.”
Isn’t that bad enough? Isn’t this what should be emphasized considering that there is a huge movement out there convincing women that hospital birth is more dangerous than homebirth?
Seems like a lot of people are confused by the numbers. Let me try to clarify.
Putting a confidence interval on the CDC data would not be appropriate, as it is population data (on a very large population indeed) rather than sample data. The population I used is the over 15 million babies born in the USA between 2007 and 2010 who were born in a hospital and weighed at least 2500 grams. Of this population, 6006 babies died within their first 28 days of causes other than congenital anomalies, for a death rate of 0.4 per thousand. To see these numbers for yourself, look up the CDC Wonder database.
I then calculated the probability of 13 or more deaths in 16,950 births (MANA’s data) if the true death rate were actually 0.4 per thousand. It’s about 0.2, so yes, we have statistical significance. When we look at the combined neonatal and intrapartum death rate, the p-value drops to less than 0.0001.
Now, keep in mind that my comparison group was not really a fair comparison group. MANA’s mothers are much LOWER risk on average, wealthier, with more access to medical care, more likely to be married, less likely to be overweight or have high blood pressure at the beginning of pregnancy, and most (not all) of the women who developed serious complications during pregnancy transferred to hospital care. I did not attempt to build a truly fair comparison group, since that was impossible, instead I took a group which could not possibly be lower in risk than MANA’s sample.
Neonatal death in an infant of normal birth weight who is not suffering from fatal congenital defects is a very rare event. That a sample of only 17,000 such births shows a death rate significantly higher than the nation as a whole is seriously alarming.
Brooke Orosz
Yep, this is a rather embarrassing mistake. I was original doing things as decimals, then thought it might be confusing and switched to percentages and forgot to move the decimal. I’ve asked Elyse to edit the post (with proper mention of what the change was).
I read the Amy Tuteur piece, having been directed to it through some skeptical avenue or another (was it Reddit? In which case, partial mea culpa…), and thought just the same things outlined in this post. It’s particularly troubling that a skeptical physician (if that’s what she is) would use just the same sort of statistic-mongering that denialists and demagogues are known for. Calling an increase in the thousandths place “450%” is frighteningly disingenuous.
An increase in the thousandths place is tiny, unless you realize that 4,000,000 babies are born in the US per year. Then an increase in the thousandths place results in thousands more dead babies.
“What we’re really looking at here is a risk of death increasing from 0.0004% to 0.0016%.”
Umm no. Are we really supposed to trust your statistical analysis of these data when you can’t even convert fractions into percentages without getting off by orders of magnitude? Hint: 0.0004% is 4 per MILLION, and neonatal deaths are measured per thousand. You are math illiterate and you are trying to school us?! You give women in math a bad name.
“Plus, the smaller the risk, the bigger the sample size you need to detect any change in the risk. When dealing with percentages this tiny on a sample size of only around 17,000 births, it’s not clear that we can get enough accuracy to the 1.6 per 1000 number to even determine that it’s truly “bigger” than the 0.4 in 1000 number from the CDC.”
It’s “not clear” whether we can tell from these data whether the numbers are truly different and not due to chance?! Did you even try a statistical analysis? That’s what statistics are for, you see, to answer that question. That’s why you perforn the equations and see if the differences are statistically significant. You don’t just say gosh it’s “not clear”. Math is hard, I know, but what did you find Ms. Self-proclaimed Data and Stats Nerd?
lol u mad?
How original, bro.
Are you a sockpuppet?
No.
I am so sorry that I let down 51% of the population of the Earth because I didn’t do a statistical analysis on private data that I don’t have access to. I’ll turn in my data scientist resignation to my boss tomorrow.
Will you at lest correct the percentages in the post, and note the correction?
She has requested the corrections be made, she doesn’t actually have access to edit the article herself.
“private data I don’t have access to”
Well that would have been true if you had said it a month ago. MANA kept their data private for 5 years and only released it under pressure. But now you DO have access to it–it’s found in the very paper you are reporting on! As for the comparison group, it’s the CDC Wonder database and it is public. So no more excuses– have at it!
She wants to be a skeptic without actually doing the work of being a skeptic. It’s easier to imply that she couldn’t possibly know what she doesn’t want to investigate, especially if she can imply that people made up all the stuff she doesn’t understand.
If you want to play with the numbers yourself, look here: http://wonder.cdc.gov/lbd.html
And here: http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12172/full
I think everyone should play with numbers for his or her self, but I might possibly be biased.
Brooke Orosz
You don’t need access to the data to know whether you have a statistically significantly different result. You have a 95% confidence interval directly reported in the MANA stats paper and a standard error that is easy to calculate using binomial data like the CDC data — you can even do it online here: http://easycalculation.com/statistics/standard-error-sample-proportion.php. The approximate s.e. on Dr. Amy’s 0.4/thousand, using a n of about 1 million, is 0.02/thousand, so the 95% confidence interval is roughly 0.38-0.44 per thousand. So all we have to do is find the lower bound of the MANA estimate (0.75+0.11+0.07 = 0.93) and determine whether it crosses the upper bound on the CDC data. Answer: No. No it does not. Not even close. Ergo, statistically significantly different.
“Women who planned for homebirth had low rates of oxytocin augmentation, cesareans, epidurals, and other interventions.
There were low rates of pretty much every type of hospital intervention.”
Why exactly is that considered a good thing?
I understand why one would try to avoid a c-section, because that’s major surgery, but the rest?
Trying to achieve “less interventions” without talking about what those interventions are, what the risks and benefits are smells like “modern medicine is bad”. Suffering during birth is still sold to women as a goal, as necessary, as “beautiful”. Nobody would aim for “less interventions in tooth extractions” and list painkillers as an intervention.
But if they DO make that choice, it’s theirs to make. Presuming they were ALL duped is a little condescending.
Who did that?
Presume that all women were duped, I mean?
I’m against scaring women, against demonizing “interventions” (the dreaded “cascade of interventions”), against proclaiming that a birth without “interventions” like godsdamn pian relief is preferrable to one with “interventions”. Especially since those claims are often tied to possible (bogus) risks for the baby, which means that women are given incorrect information and scared away from the options they could have.
I had two births without pain relief (although I don’t qualify for the birth warrior badge. Both in hospital and both with other “interventions”) and I swear I would have been more than happy if I’d had the option of an epidural.
I’m all for giving women options, but I’m also for giving them accurate information without bullshit about why suffering needlessly is actually a good thing. I’m not Mother Theresa, after all.
Well, we certainly can agree that accurate information is very important.
If you can honestly read back the comment to which I replied and not understand how I got the impression that you think everyone who makes the decision not to try to have interventions has been fooled by the “‘modern medicine is bad’ smell” then I retract my statement.
You do realize that the answer to the issues in medicine today isn’t necessarily to stop (nopoo!! Ooo!!) washing our hair and start drinking kombucha right?
@sanatizedeeleventy With a bit of reading comprehension under your belt, you could at least *accurately* stereotype me. Let me know how that goes.
I wasn’t necessarily stereotyping you. I was stereotyping a large portion of the women who choose homebirth.
Oh well…carry on then! Stereotyping a “large portion” of people isn’t problematic at all!
Stereotypes are a function of our brain to interpret the huge amounts of information we encounter daily without having to devote an exceptional amount of resources to do it.
Stereotyping isn’t problematic unless you are discriminating based on them.
My comment was very tongue in cheek both times and you have interpreted quite defensively both times. I don’t discriminate based on shampoo or beverage choices. Rest easy.
No, I honestly don’t see that. Because the sentence I worte is this:
“Trying to achieve “less interventions” without talking about what those interventions are, what the risks and benefits are smells like “modern medicine is bad”.”
That sentence has a middle part which neatly explains in which cases I think it smells like “modern medicine is bad”: in cases where interventions are rejected because they are interventions. Not in cases where somebody decides that a specific intervention is not for them. I would personally never have chosen a water birth (which is an intervention, too, if you look at it), no matter how many women tell me how fantastic theirs was because I abhor bathtubs at the best of times.
If I wrote “Trying to achieve less abortions without talking about how reduce the need for abortions smells like anti-choice to me”, would you argue with me that “not all people who want to reduce abortions want to reduce access to abortions”?
So as I said, if you can’t catch that timber, I’ll retract the statement. I’m not going to tell you what you meant. 🙂
The problem, as I understand it, is that many times the interventions aren’t medically necessary or even necessarily for the comfort of the woman, but are meant to speed along delivery for the convenience of physicians. The same reason that giving birth in the lithotomy position is done, it’s not the best position to give birth in, it’s just more convenient for physicians than the woman. Giving birth on the back can, in fact, produce some of the complications that then require interventions. Look into the pitocin cascade or intervention cascade if you haven’t read much about it, it’s pretty fascinating and disturbing.
It cuts both ways. Giliell was kind enough to explain to me what I had stepped in on one of my first articles here as I explained without making it VERY clear that it was specifically my experience that doctors tried to schedule C-sections before shift changes. The “inconvenienced physician” is actually one of the most salient and cliche tropes in the home birth movement, and so even though stories like mine exist, they need to be considered in the larger mosaic of doctors who do have a patient’s best interests at heart.
Which is why I think it’s especially important to be very careful with data and its interpretation and not just line up on opposite sides of a trench and yell “Tastes Great!”/”Less Filling” at each other.
Ma yI ask you how many times you have given birth?
So, why do you assume to know better what the “best position for a woman to give birth” is than me, who would not have been able to remain in any other position than on my back?
Why do you think that women have no interest in speeding up birth? I kind of didn’t enjoy being in labour, so when I was given the option to get pitocin I was more than happy to have some.
Yes, I know, the dreaded “cascade of interventions”. The problem is that it’s a typical case of mistaking correlation for causation. The first intervention usually doesn’t cause the second one. It’s the first one failing that makes the second one necessary.
It is amazing how women who eschew modern medicine are defended tooth and claw while those of us who happily made use of the medical options we had and who were comfortable with the care we got are denied our agency, by men nevertheless.
Addendum: by “best positon” I don’t mean to generalize this for every woman. I’m talking about myself. I could have had a pool, a ball, and other options. Yet “lying on my back” was totally the thing for me.
I agree with pretty much everything Giliel has said.
Just my own personal observation (I know, not scientific, just anecdotal), I have not heard of a doctor pushing an intervention for their own convenience. I’m sure it happens sometimes, but not as much as the press likes to say. I have heard of women being bullied into not getting interventions though.
Also, the whole “most of these interventions are not necessary” comment makes me cringe. These decisions are made based on risk. For example, the average rate of stillbirth is about 1 in 1000. Let’s say you have a complication that makes it more like 5% for you, and an intervention will lower this risk. Some women (myself included) would choose this intervention. That means 95% of women in this situation really did not need this intervention (if they could read the future, that is). I was in this situation, and chose the intervention. But somehow I am considered a lesser mom/woman because I didn’t tough it out. (I don’t even want to start on the comments I received because I didn’t have a “natural” birth.)
I’d like to add that I have no problem if a woman chooses homebirth, fewer interventions, etc. But this shouldn’t be the ideal of womanhood. It should just be a choice.
I never said I “knew better,” I am referring to the physics and physicality of giving birth. When you push against gravity, it can make it more challenging. Also, I may not have given birth myself, but I know plenty of women who have, many of whom did not wish to remain on their backs strapped to a monitor but were not allowed to move from that position. I don’t have to have given birth myself to understand the various situations that women have experienced while giving birth.
Where did I say that? Oh, that’s right. I didn’t. My point is that many times women who do not want medically unnecessary interventions are given those interventions anyway for the convenience of physicians.
Sure, and that’s your right to make that call. Many women are not given that option and they are simply given pitocin without being told why or for what medical reason. I think we can both agree that women should be informed and allowed to make these decisions for themselves, yes?
That’s not how I understand it, do you have any information you can link to that has been able to determine this is the case?
That’s not AT ALL what is going on here. There are women who are just fine with biomedicine but yet who do not like the way that the biomedical system tends to treat women who are giving birth. Being critical of biomedicine is not the same thing as eschewing it.
This is just every trope out of the business of being born and every homebirth echo chamber and not necessarily a reflection of reality. Not to mention the naturalistic fallacy. Oh and you made the claim you must provide the evidence. So please feel free to prove that epidurals lead to pit which leads to a cesarean. (Hint: they don’t)
Laying down to birth isn’t much of a fight against gravity (and isn’t just a physician-borne thing)
… if you were giving birth upside down on the other hand….
I have seen the Business of Being Born, but this is information I’ve learned from reading academic sources in medical anthropology, not from homebirth websites or documentaries.
I’m not sure where you think I have made an appeal to nature in there, but I am not making an argument that giving birth in one position or another is more natural and therefore better. I’m arguing that there are physical reasons that it could be more beneficial for certain positions over others. And since you asked for evidence, here you go: summary of evidence on birthing positions, with studies that suggest giving birth in an upright position can actually speed up labor (thus perhaps negating the need for pitocin). But, ultimately, women should be giving birth in positions that they are most comfortable in (which I’m pretty sure Giliell and I agree on).
Most of what I know about this subject comes from reading work by medical anthropologists such as Robbie Davis-Floyd (Birth as an American Rite of Passage), Brigitte Jordan (Birth in Four Cultures), as well as articles and studies by other anthropologists like Carolyn Sargent, Claire Wendlan, and Ellen Lazarus that I can think of off the top of my head. I’d appreciate it if you’d stop pretending as if you know where I have gotten my information from. I also asked Giliell for that information in good faith because it’s quite possible there are sources she knows of that I am unaware of.
Um I don’t pretend anything. O.o.
Here you may find this analysis interesting
http://theadequatemother.wordpress.com/2012/02/15/epidurals-and-progression-of-labour/
Also, there is evidence that epidurals slow the active phase of labor, for example this study by Alexander et al. So, when a woman is given an epidural, it can slow the labor, for which the response is pitocin to speed it up, which is how the cascade of interventions begins.
I am genuine when I ask for evidence that points in different directions that the cascade of interventions is actually confusing correlation with causation. If you have it, I am interested in seeing it because it would go against all sorts of other stuff I’ve read on the topic.
Well thanks for going in the direction I knew you would. 😉
Thanks, I’ll read that article and look into his sources and stuff when I have some time, probably not until this weekend.
And whoops, did not mean to assume the author was a man. I don’t know their gender. 😉
“I never said I “knew better,” I am referring to the physics and physicality of giving birth. When you push against gravity, it can make it more challenging”
You said “it’s not the best position to give birth in”. Obviously, the best position to give birth in” is the one where women are safe and “comfortable”* in. So, you excluding that position means that you apparently know better than those women for whom “lying flat on my back so I wouldn’t have to fight against gravity pulling down 180lb of me was totally cool”.
The other birth positions are only “superior” if you exclude the factor “what the woman prefers”.
” I think we can both agree that women should be informed and allowed to make these decisions for themselves, yes?”
Yes.
“.My point is that many times women who do not want medically unnecessary interventions are given those interventions anyway for the convenience of physicians.”
“The problem, as I understand it, is that many times the interventions aren’t medically necessary or even necessarily for the comfort of the woman, but are meant to speed along delivery for the convenience of physicians.”
” it’s just more convenient for physicians than the woman.”
1. Could you please define “necessary” and “unnecessary”? At what percentage of risk does an intervention become necessary? Since 98% of babies born to women with Strep B in their vaginas don’t contract Strep B, is it a necessary intervention to given them all antibiotics or an unnecessary one? Are epidurals necessary or unnecessary?
2. Do you notice a pattern?
You claim that all those things (that may or may not be necessary or optimal. I am the first to agree that there is still plenty of room for improvement in maternal care) are done because suddenly OB/Gyns and midwives only think of their own sefish convenience. These are the people we trust with our birth control, our abortions, our pre-natal care, our cancer screenings, but suddenly at the point of giving birth they turn into people who no longer have our best interest at heart but who solely look for their own convenience? You don’t even leave room for them being honestly mistaken.
“Also, there is evidence that epidurals slow the active phase of labor, for example this study by Alexander et al. So, when a woman is given an epidural, it can slow the labor, for which the response is pitocin to speed it up, which is how the cascade of interventions begins.”
You know, this doesn’t even make sense when compared to your previous comments.
1. The study was very small. 220 and 214 women in each group is not a very large sample, but even if we with that, it doesn not support your conclusions. To claim that this leads to pitocin and the “cascade of interventions” is not part of that study, it’s a leap you’re making. You have also not given evidence why birth without pitocin is supposedly preferrable to birth with pitocin.
2. Given that you argued that interventions happen mostly for the convenience of the medical personel, this doens’t make sense. If epidurals lead to longer labour lead to pitocin leads to other interventions lead to c-sections then for their own damn convenience the medical professionals should be the ones who should try to keep women from epidurals and pitocin in the first place. Because why have 10 hours of labour with frequent check ups on the patient and lots of work only to have to go for a c-section in the end anyway when it’s actually so much more convenient to have 5 hours of labour during which a midwife can do the work?
*I’ll give comfortable scare quotes because it’s hard to be comfortable while being in severe pain
Giliell, this is the last time I’m going to engage with you on this thread. You are misreading what I’m saying (or outright ignoring it) to try to make a point, and I’m just really not interested in continuing a conversation with you if you’re going to continue doing that.
I clarified that what I meant by “best” was the physical issues that can arise from giving birth on one’s back. I then gave a link to an article that describes in detail why this is the case and said that ultimately women should give birth in whatever positions are comfortable for them. You and I do not actually disagree here, but you keep insisting that I am pretending to know better, when in reality I am re-stating what other women have said and what the research on birthing positions says.
I already did define it, you just choose to ignore it. I said “medically necessary/unnecessary.” That adjective is important. And I cannot give a blanket statement about which interventions are medically necessary/unnecessary because they are dependent upon the circumstances of the individual person giving birth. When you ask “are epidurals necessary or unnecessary?”, that is a loaded question that is actually quite meaningless devoid of any context.
So, here is an example of you putting words in my mouth (again). Show me where I said interventions happen because “suddenly providers think of their own selfish convenience.” What I said was that there are cases where interventions occur not for a medical reason but because of physician convenience, whether that’s because they are about to get off their shift or because it’s more convenient access for a woman to be in the lithotomy position. It does not necessarily imply selfishness–often the convenience is just part of the way they are trained, it is ritualized behavior that they do not question.
I’m not sure what you mean by I don’t “leave room” for them being honestly mistaken. I did not say anything remotely like “all interventions happen because providers are selfish assholes.”
Once again, you are misreading what I wrote. The study I cited was an example of how the use of epidurals can lengthen labor. Look closely at how I phrased that paragraph:
“Also, there is evidence that epidurals slow the active phase of labor, for example this study by Alexander et al. [In other words, here is one example of evidence that epidurals slow the active phase of labor.] So, when a woman is given an epidural, it can slow the labor, for which the response is pitocin to speed it up, which is how the cascade of interventions begins.”
I did not say that that study was about the cascade of interventions, I said that there is evidence that epidurals slow labor, which is the event that leads to the cascade of interventions. Someone else has posted a link to an article that critically assesses the cascade, and I will read it and the attending literature when I have some time. But do not misrepresent what I have written.
I never, ever claimed that. I said that “many interventions happen,” not that “interventions happen mostly.” There’s a clear distinction in meaning between those two phrases. Many does not imply a percentage, it just implies that it is common. Perhaps it is less common today that it was 15-20 years ago when a lot of the literature I’ve read was written, which is something that I will have to read up more on. But, I am not saying that interventions “mostly happen” for physician convenience. So, once again, please stop misrepresenting what I’ve said.
I think there’s a multitude of reasons that these sorts of things happen, and I’m not going to sit here and try to give you one neatly-wrapped answer as if I could cover all the possible reasons and nuances in a blog post comment. People have spent entire careers writing about the issues within the US medical system, I couldn’t possibly do the topic justice here. But, again I will point out, that just because people like myself are critical of the medical system in the US it doesn’t mean we “eschew modern medicine.” For me, it means I want the system to work better and have better outcomes for people. There is something inherently privileged about being able to sit in a place that views the biomedical system in such a benevolent light as many within the skeptic community seem to do.
Giliel, I quite agree.
Agree wholeheartedly. Even with a certified nurse midwife for my last birth, I was shamed for electing an epidural. I was induced at 37 weeks for pre-e and HELLP and went through 12 hours of pitocin labor before asking for the epidural. The epidural enabled me to have a vaginal birth.
I’m going to have to side with Gilliel on this one. Interventions are not the villain here. The basic reality is that hospital birth is safer than home birth. If something goes wrong at home, you’re likely screwed. As for the math of “risk of death increasing from 0.0004% to 0.0016%”: Simple enough. 0.0016/0.0004=4 which means a 400% increase. Bottom line,
To be picky, it’s actually a 300% increase. Alternately, you could say that the risk at homebirth is 400% that of hospital birth.
Seriously, quit putting words in my mouth. I never said interventions are the villain.
I said unnecessary interventions for the convenience of physicians and often despite the explicit wishes of women are the villain, and that it happens too often. That’s all. I know interventions are sometimes medically necessary, and I am not talking about those.
As for the math, Jamie is aware of the issue with the percentages in her post and will issue a correction when she’s done with work.
“Unnecessary interventions for the convenience of physicians and often despite the explicit wishes of women.” Right but there is significant disagreement about how often that actually happens.
And that’s certainly a conversation we could have. But that’s not people are trying to argue with me about.
I will argue that point with you. I disagree with you completely.
So the absolute risk is low…does that make those unnecessary deaths ok? Does it make it ok that MANA attempted to white wash the dangers of homebirthing? In case you aren’t aware, the position of the SOB is that CPMs be abolished and we develop a similar model as Canada, not that homebirthing be made illegal. Further increasing safety would be to go to an accredited/attached to a hospital birth cenfer, if birthing the ‘hospital’ way isn’t desired. I think supporting those two things to offer women ‘choice’ is far superior to supporting non regulated midwives who are killing babies unnecessarily, through negligence or ignorance in the name of choice. That would be like supporting back alley abortion over legal abortion in the name of choice, which is asinine.
This comment covers most of my response to this article. I don’t see how any of the benefits of homebirth outweigh the life of any one woman or dearly-wanted child. Although I usually hate Dr. Tuteur’s abusive tone (I thought what she wrote on the thread of chrisbrechteen’s article was just cruel and unhelpful to anyone, especially considering that his experience sounds like what would have happened if CPMs were abolished and his low-risk partner had instead attempted a homebirth with a CNM). That said, she’s the loudest voice out there fighting against a Natural Childbirth movement that seems benign in moderation, but in its extremes is dangerously anti-science. Women can’t be expected to be experts or to spend countless hours wading through tons of stats and research trying to find out what is safe, especially when misinformation can be incredibly persuasive and pervasive. We simply need policies that best promote women’s health, period.
But this issue really hits home for me. When I was pregnant with my second child I called the very reputable Birth Center, staffed with Certified Nurse Midwives, where I had my first child’s prenatal care. Since I’d had an emergency c-section with my first, I was not eligible to receive care with them with my second because I was now “high risk.” I was just calling for referrals for good CNMs who work in hospitals. The idiot on the phone’s (not a CNM) first suggestion was a list of CPMs that are willing to do VBAC homebirths (because of course no CNMs do that.). That should not be legal. That is not good medicine or public policy. Had I taken that route my daughter and I would be dead since I did have the oh-so-rare uterine rupture that is feared by any woman attempting a VBAC. Thankfully I was at a hospital with a CNM – perfectly in line with policies advocated by Dr. Tuteur, but not by the many many advocates of homebirth. So I’ll give Dr. Tuteur a little leeway, because she’s fighting for a worthy cause that doesn’t have enough strong advocates.
Yes, very true. I am on many natural parenting boards and the advice given to women about how to get a VBAC is irresponsible.
I am so disappointed in Grounded Parents for this.
I’m not a parent (yet, I hope it’s just yet), though I desperately wish I were. The thought of losing a much-wanted baby at birth, what should be the happiest day becoming the worst, is devastating even as I sit here at my computer.
I read here (and elsewhere) quite a bit about pregnancy, birth, and parenting because it is interesting to me, but also because it has been occupying my idle thoughts for a couple of years now. I was so happy when GP became part of the Skepchick network, because there would be more of a chance for science-based discussions of all aspects of parenting, but this undermines all confidence I had in finding such a place here.
This is not a good skeptical post. It is at best a shallow skim into a deep and complicated topic. For a more well-trod analogy, this is the equivalent of looking at the arguments “vaccinate your baby because it will prevent horrible diseases” and “don’t vaccinate your baby because autism” and concluding “don’t vaccinate your baby because they might get a fever after unless there’s maybe an outbreak happening in your area.”
I know how hard it is to really apply skepticism to a topic that seems like you’re already being skeptical about. I watched that goddamn documentary Business of Being Born and thought I was so damn smart and skeptical for seeing how things really were. I had such cognitive dissonance reading the Skeptical OB it was visceral–it honestly hurt to read post after science-based post and realize how easily I’d been swayed by wooy naturalistic fallacy bullshit because I though I was so clever and against the grain.
Maybe there is a lot to fix about hospital births, though I think a great many are doing that anyway (some too far IMO) in response to competition and patient/parent requests. But there is so much more to fix about home birth in the US before it becomes as remotely safe as the hospital or even home birth in other developed countries, starting with who is qualified to be a provider.
I expected better, though I did finally get a posting account to say so, so congrats, I guess? Unfortunately I don’t know that I can stick around anymore.
To be fair to Jamie, this is a critique of the SOB’s analysis of one study, not a review of all the homebirth evidence out there. That said, please stick around! We have a variety of perspectives here at GP. I’m pretty strongly anti-homebirth myself, but I’ve really enjoyed this piece and the ensuing discussion in the comments.
Ok, yes, what Jenny said.
Jenny was the one who called me out on the G.P. backchannel and let me know that my first post about my partner insisting on a home birth was missing a big part of the picture about the intense pressure from the other side NOT to have interventions–which I find equally objectionable. And Em wrote a fabulous article repudiating the idea of natural birth as somehow “better.” I myself have had my position shift to simply being aware that 1) Body autonomy is very important and 2) some voices in this dialogue are presenting the anti-homebirth side (which I agree with BTW) with fallacies and bias–which makes it vulnerable.
I don’t think the issue of body autonomy is an issue here. Nobody on either side of this issue is advocating laws that would stop a pregnant woman from freebirthing if she wants to. The issues are over whether the information being put out there to help women decide how to handle pregnancy and birth is often inaccurate, and that many of the laws and policies in place in the United States might be putting women at risk by allowing lay midwives to provide poor care that lacks the standards and consequences (for them) that doctors and nurse midwives face.
I 100% absolutely agree that that’s what the issue SHOULD be, and I absolutely and emphatically encourage the bad information to be debunked. (One of the reasons I think it’s SO important to “play fair” with data and be above reproach in our intellectual integrity.) In as much as that IS the argument, I put on my foam #1 glove and cheer.
However, if/when I read an actual thread like this one, what jumps out at me is the sense that “if any mother were REALLY informed, she would make the same risk assessment that we would!” The sentiment that even a small statistical risk is “too much” is all over this thread. And while I want to be absolutely clear that I agree with that sentiment, I also think that there is a danger in advancing an argument that any decision is “wrong” or “clearly uninformed.”. We don’t always pick the statistically safest course for everything we do–even when it comes to our kids. Risk assessment is something we all do. I also personally feel like “think of those poor lost babies” has a particularly ominous echo when coupled with denigrating a woman’s decisions about her body.
I think both sides hear things the other side doesn’t say. You said: “Nobody on either side of this issue is advocating laws that would stop a pregnant woman from freebirthing if she wants to.” and I absolutely agree with that (well, mostly), but I also haven’t met a single home birth advocate opposed to better midwifery training or a more accurate understanding of home birth risks. (I’ve met a midwife who didn’t think it was necessary, but not who was opposed to it.) I live on the Berkeley boarder of Oakland, so I have had the chance to talk to dozens of people on both sides since I found out this was a huge issue.
I really do hope we can bring to light the risks, dispel misinformation, and maybe even get some legislation for better midwife training. I can’t underscore enough how much I agree with you (all of you) about that. That’s why I think it’s extra important for skeptics to be skeptical with intellectual rigor, and not merely set themselves up as an opposing ideology with equal proclivity for fallacies and sloppy thinking.
So you’ve never met a cpm of lay midwife or birth advocate against higher standards of care? I have. Check out mothering or midwifery today or one of the hundreds of homebirthing groups on Facebook. They claim that regulation and licensure eliminate choice.
Further when it comes to the dead babies it’s not only that they’re dead. It’s that they’re dead unnecessarily. It’s that even though many of those deaths are through neglect or ignorance there is no recourse. It’s that children who are severely brain damaged or physically damaged through the actions or inactions of the midwife won’t get the care they need because lay midwives and cpms often don’t carry insurance. There’s so much to this that you are basically dismissing with that comment.
Yes we all do risk assessment but how do you expect women to do that when the information simply isn’t there? Or if it is, as in the case of this recently released paper, the information is touted as saying something other than it does? They get away with it because most people aren’t actually good at this sort of risk assessment and most people can’t actually read a study. Or don’t even bother to and simply take the headline at face value. The other thing is that you can see actions against a doctor or midwife and even their statistics as far as c sections and such. Even where they graduated from and how long they’ve been in practice. Cpms and lay midwives are pretty much impossible to assess in that way. There are great cpms and horribly negligent or even abusive cpms and the huge problem is is that it’s almost impossible to figure out which is which.
I also didn’t see where anyone said if the mom was really informed she would make the same choice as me. I chose to birth in a hospital but I support homebirthing with a CNM or at am accredited birth center. I do think women take unnecessary risk by choosing cpms or lay midwives but like I said, they have no way to really know what their risk is.
@sanatizedeeleventy I think this comment really crossed my personal line of overly-combative, so this will be my last reply to you. You talked past just about every anti-home birth point I made and your reply PERFECTLY illustrates what I’m saying about presuming that anyone who has made a different choice is uninformed or misinformed or duped or stupid because they “don’t bother” or “can’t read a study” or “can’t possibly know.” (How is it that WE know if the information is unavailable?)
All I’ve said throughout this thread is that it is dangerous to be sloppy with our argument because it sets us up as just an alternative ideology instead of the truth, and that more training and more information is good, but that respecting a decision once made is also important. I didn’t want my partner to have a home birth. She did. We ended up transferring and having a c-section and it was awful every step of the way, but I never presumed her decision was uninformed.
I’m sorry you feel that we have more disagreement than overlap in our viewpoints.
” I also haven’t met a single home birth advocate opposed to better midwifery training or a more accurate understanding of home birth risks.”
Really? Then how come there’s this deafening silence from the homebirth advocates on the bogus credentials of CPMs? Those people are not considered adequately trained in ANY other western nation.
Where is the demand from the homebirth movement that all midwives need to carry insurance?
Why is the biggest advocacy group MANA obviously OK with its members caring for high-risk women such as twin births, breech babies and VBACs?
They may not often ague actively against regulations, but that’s sure a hell lot of dogs that didn’t bark ever.
I’m sorry you feel it was overly combative as I don’t feel I was really taking that position with you. I think you’re reading what I’m writing in a different tone than I am and I’m not really sure in what way I can change that to make it more palatable to you.
I also think we have an overlap in our position, and much more so than disagreement. Perhaps it’s because I’m on my phone and typing on it is an honest pain in the ass, perhaps it’s because I’m very dry, perhaps in just awful at conveying meaning but I do not think I was being combative or saying that we are in complete disagreement.
In any case I’m sorry you feel that way. If you felt like telling me why I strike you as being combative to you I can work on that. I also will say I think you’re a bit sensitive to disagreement, or at least that’s how it’s coming across.
@Giliell I honestly don’t think anyone could answer that question. It’s sort of part of the problem that taints the whole issue. If you want my personal OPINION, it is because this has become a pro vs. anti debate with fanatics on either side instead of a careful quest for truth. But maybe they all just secretly hate babies.
Certainly the groups guilty of that are part of the problem, and I wouldn’t argue otherwise. But they should be called out by name. Lumping all home birth advocates together because they aren’t vocal enough in their objections to something they may not perceive as an issue carries its own set of problems. That’s why I’m such a fan of transparency and why I think to GET that transparency we can’t play fast and loose or fall into traps like generalizing, assuming motive, ad hominem, and such.
All I can tell you is that with the exception of one midwife who thought she had “quite enough training” I have personally not spoken to anyone who when asked “Do you think midwives should have more training” or “Do you think accurate statistics are important in making an informed decision for a home birth” have said no.
sanatizedeeleventy Okay, fair enough. If you want to know the exact phrase it was “So you’ve never met a CPM….” That in reply to a thread where I said I HAD met a midwife who didn’t want any more training so it seemed not only kind of “Gotcha” but also a little talking past. Plus some of your other replies in other places have been pretty snarky, you’ll agree. I didn’t get the feeling there was good faith communication going on, but if I’m wrong about that, I apologize.
Generally my feeling on this thread is that people have SUCH strong feelings that they perceive the need to do advocacy. (I can hardly blame them for that–look at some of the stories! And this is just one article on one blog!) So I’ll go on for four paragraphs about how I want more transparency, higher standards, how my own experience with home birth was awful, and it seems like the replies are engineered only to figure out where to work in another talking point.
I’ve seen my partner shamed for having a C section and for not having one sooner. I’ve seen her shamed for choosing home birth and for not having the midwife break her water before just transferring. I’ve watched her be called names by both sides from “toddler” to “stupid” to “a credulous idiot.” I don’t think it requires ignoring the sins of the home birth advocates to acknowledge that anti home-birthers could be playing a cleaner game. (Which again, I WANT because I want them to pwn face, kick ass, and take names.)
This is such an empty criticism. You have not even discussed one particular aspect of this article. All you’ve done is complain that it’s contra to what Amy Tuteur has told you and so therefore it must be wrong.
You say “this is not a good skeptical post.” Why not? What is it, exactly, that is unskeptical about it? If you expect anyone to take you seriously, you may wish to actually comment on the content of the post rather than trying to guilt trip GP into only talking about things in ways that don’t disappoint you.
My criticism was that it was a shallow dip into a complicated topic. I don’t find it skeptical because it doesn’t address the immense body of literature and history around the issue. I suppose this could be a problem with blogging, though I have seen some superb scientific blog posts. Perhaps I don’t think it is possible to have an agenda-free but truly informed opinion about a contentious subject.
How do you analyze one evolution paper on its merits without looking at how it fits into the previous literature? How do you address the bad science claims of an anti-vaccination group without a good understanding of the pro-vaccine evidence?
The article is too thin and trying to cover too much. And it comes off as backbiting within skepticism rather than really applying some good science to the sloppy work in the paper.
I see the pro-home birth and anti-vaccine proponents in the same light (and the Venn diagram of these groups shows considerable overlap), an to be so good one one and not go good on the other is distressing.
Urgh, I’m sorry for all the typos in the last sentence. I had cookies in one hand and a keyboard in the other.
For clarity: “and to be so good on one and not so good on the other is distressing.”
It seemed to me that the thesis of the article was pretty clearly about one study–specifically how two people can use the same study to come to different conclusions.
I think a lot of what has gone on in the comments here amounts to advocacy, and I can see why feelings run very hot–just some of the personal stories on this thread reveal how close to home it hits. But if a study or conclusion doesn’t slam dunk a particular narrative, people get very anxious. And it seems to me that the author’s point seems to be we HAVE to be better than that.
Sure, but that’s just it–how useful is that? It’s obvious why a home birth advocacy group and a home birth non-fan obstetrician could look at the same paper and come to different conclusions. Especially with a paper that, hmm, meticulously massaged, and the off the rails spin it got in the NCB world.
But as was noted downthread, which was somewhat of an epiphany for me, this is less a skeptical activism blog and more a skeptic…community? introspection? blog. This is different to Skepchick, whence I came, so I need to recalibrate my expectations I suppose.
Are you asking me how useful intellectual rigor is? (Or am I misreading?)
Because at this point, both sides have now accused the other of being sloppy with data and massaging the stats to suit their agenda. So I think it is PARTICULARLY useful–here, and in the issue at large. If data don’t support our narrative we can’t just accuse the other side of lying and call it a day. I personally want home birth to be demonstrably dangerous so I can show my partner, and I never have to go through one again, but that doesn’t mean an exercise in examining statistics that might be less dramatic than I hope isn’t a useful one.
I believe you are misreading. I heart intellectual rigor. I do it for a living.
I also read and analyze papers for a living, so I know that:
a) It’s tough to put a single paper in context without some knowledge of the context.
b) Regardless of the ultimate conclusion (which incidentally seemed to be “a pox on both your houses”), the analysis in this article was not well done and clearly showed lack of contextual knowledge.
I don’t know about the actual data in the paper–I read the corresponding methodology and validation paper as well and aside from a poor effort to track down missing numbers and an overall low participation rate it seemed sound–but the paper itself is massaged in the sense that it is veeery cautious to say as little as possible before sneaking what they want to be the takehome message in at the end. This I will expound on a bit, since science literacy is my real ideology.
This is the actual title of the paper: Outcomes of Care for 16,924 Planned Home Births in the
United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009
This is the Citizens for Midwifery headline that was being passed around: New Home Birth Study from the MANA Statistics Dataset Shows That Planned Home Birth with Skilled Midwives is Safe for Low-Risk Pregnancies
Big difference.
They say things like this: “Rates of spontaneous vaginal birth, cesarean, low 5-minute Apgar score, intact perineum,
breastfeeding, and intrapartum and early neonatal mortality are all consistent with reported outcomes from the best
available population-based observational studies of planned home and birth center births.” Comparing home birth to home birth, but don’t mention rates for hospital birth.
Oh, but they don’t have a problem showing how “great” their rates of intervention are compared to hospitals: “Only 4.5% of the total MANA Stats sample required oxytocin augmentation and/or epidural analgesia, which is notably lower than rates of these interventions reported more broadly in the United States (26% for oxytocin augmentation
and 67% for epidural analgesia). Rates of operative vaginal birth and cesarean are also substantially lower than those reported for hospital-based US samples (1.2% vs 3.5% and 5.2% vs 32.8%, respectively).”
Finally this bit: “Low-risk women in this sample experienced high rates of normal physiologic birth and very low rates of operative birth and interventions, with no concomitant increase in adverse events.” Death is an adverse event. They cannot actually say that with a straight face, because they never compared home birth death to hospital death to show that there wasn’t an increase (likely because there *is* an increase).
Much as it pains me to admit, given my career choice, any jackhole can get a paper out make unsupported claims if they’re crafty enough. As an advocate for science literacy I look at many papers and go: WAT. This is one of them.
I’ll be honest. I can’t even pretend to keep up with all that.
But if you have statistical mathy numberizing criticism to the analysis of the OP, that’s awesome. I thought she made a good point about why the study was a little disingenuous from one side and downright sloppy from the other, but I’m not a mathematician. It seemed to me like your primary umbrage was that it didn’t advance the correct narrative. But if your criticism is based on content, then I’m going to put on my foam #1 glove and cheer you on!
It’s really hard to word this question without sounding like an asshole, so I’ll say upfront that I’m actually interested in clarification, not assholery, but: Is it hard to follow because I haven’t done a good job of being clear or because tackling a scientific paper isn’t part of your toolset?
If the former, that’s a good thing to know because I’m not used to talking to a more general audience and I thought I’d picked out some of the most egregious examples of manipulation for illustration. I want to do better, though.
If the latter, I would–with respect to how difficult navigating the landmines of parenting is anyway and with as much gentleness as I can put into text–suggest that the average person trying to make these critical decisions doesn’t have that toolset either, and are relying on an authority of some kind to give the proper information with which to make those decisions. The biggest pitfall is choosing where to put your trust. I choose science-based authority because it is the most likely to self-correct and will constantly re-evaluate best practices, and it helps that I can go directly to the primary literature with extensive training in a scientific and analytical toolset.
Skepticism and science is good for taking down charlatans and peddlers of pseudoscience of all stripes. MANA is one of these, and I cringe that they are considered a respectable authority when there is little to no self-correction, re-evaluation, or attempt at setting best practices.
If you take the time to disclaim a question like that, I think it’s generally going to land softly. No offense taken.
I don’t know if you did a good job of clarifying or not. I’m an English Major. I did quite well in my math classes but my last one was seven years ago, and it was called Math for Liberal Arts. My final was an oral presentation on fractals. So it’s been a very long time since I had to evaluate numbers.
So you’re right. I read the conclusions and I can follow the language pretty well, but I can’t check the math and I do have to choose who I trust in that regard. But I also choose “drink” from multiple sources and read the comments and pay attention to who watches the watchers. That’s why I was (initially) excited about this post. I thought people were going to talk about THIS study and THESE results and be skeptical even against the narrative they want to be true. (That *I* want to be true.) And it’s why I was so disappointed to see it become another battleground where the slightest inward facing criticism is seen as a weakness of message. Rather than “this isn’t accurate, and here’s why” we got “how could you!?” Well, to me “how could you” is a simple matter of being a skeptic. You are willing even to check your own assumptions.
To be frank, my colleagues ARE science based. And they’re good at math. And they’re writers so they can explain it to me in a way I can parse. And they represent a diaspora of opinions on this and many other issues. They’ve checked me a few times on some of my own assumptions. I trust them. Mostly though I trust them to admit if they are wrong when mathy folk start crunching numbers. I think it’s unfortunate that some voices turn this into a warzone instead of a discussion. But I’ve seen particular voices who are more interested in an agenda than integrity in this issue, and have demonstrated simply abysmal reading comprehension. Which is a pity because I don’t trust THEM to read with impartiality, and I would want to check if they told they’d seen a study that water was wet.
But as I said, I have nothing but curiosity to see where this goes from here. I just wouldn’t want people NOT to discuss it simply because it might reveal something we don’t WANT to be true.
I just want to add one last thing and then I think I need to stop (at least until next time). There isn’t a paper outcome that I “want” aside from “not being a shitty paper”. I don’t have a horse in this race. I’m not pregnant nor have I ever had a baby, so I don’t have any choices to make soon or defend. My mom had four kids without complication and dang near thought she’d have the last at home (though she didn’t), so it’s not like I haven’t been around some alt viewpoints. If this paper (and the recent preponderance of other evidence) had actually shown no change in risk of death between hospital and home it would be like “oh, carry on then”. Personally, I’d probably still go to the hospital for some sweet, sweet pain relief, but if others wanted to stay home, more power to them.
I wasn’t upset that this paper might show something I didn’t want (I’d already read it anyway), I was upset that the article here did not do a good job of analyzing either the paper itself or SOB’s response, especially since it was the first time I’d seen the topic really tackled in depth here. I don’t mind at all a level-headed reining in of overstepped criticism, but this article was not doing that.
Anyway, to next time.
Please keep in mind that Grounded Parents is not a single entity. There are about 30 of us bloggers, and this is a guest post. Perspectives are bound to be diverse. Personally, I want nothing to do with homebirth. I think the movement surrounding it takes maybe a grain of truth (which could be from now or 50 years ago) about what’s wrong with hospital birth and turn it into a tinfoil hat crusade. They shield dangerous midwives, crow “trust birth” and sometimes even eschew ultrasounds. It’s repulsive. I wasn’t happy to see anything here that might be construed as “homebirth isn’t so bad!” because there’s a lot wrong with homebirth and those who advocate for it, but I do think it’s worth taking a look at the information we have so that we as skeptics don’t come off as sneaky as the birth zealots. There’s plenty more to say about this topic, so I’m sure that you or anyone else feeling disappointed by this piece or previous homebirth coverage will eventually see something more to your liking.
Fair enough. I guess between “the midwives don’t actually believe in the woo they still peddle so that makes it okay” and now this I was getting a vibe I really don’t like. I’ve also seen way too many otherwise smart and critical people (and I count myself among them, so it’s not a slam on them) buy the “home birth is as safe or safer” line because it does seem at first blush like the more skeptical impulse (most babies *are* born in hospitals so questioning that is in the minority).
But the numbers are growing, and they’re growing in part because are groups pushing that home birth is very safe when more studies have been coming out showing the opposite. As people interested in science and true skepticism we should be the ones going “whoa, do you have actual evidence for that safety claim?”
So here (the paper, not this article) is the home birth group’s best effort at evidence and their headlines and conclusions are wildly out of line considering the actual content. I would have hoped this site’s response, even as a conglomerate, would be more along the lines of “are you kidding me with this sloppy ass data?” regardless of what SOB or whoever is doing.
I think this is a good critique. I really enjoy reading all the Grounded Parents articles, but mostly because the people writing here are secular parents, which is to say parents with which I can easily relate. Coming here to read the articles on Grounded Parents feels a lot like going to a virtual meeting of my local secular humanist chapter, which is to say, a club of like-minded individuals sharing, discussing, and sometimes debating, but only within a certain scope of unspoken agreement. If most of the readership is coming here for the same reasons, then the function of this site is more a forum for discussion, not activism. The discussion taking place in this thread is pretty great, even if the article itself leaves much to be desired, and that’s worth something.
Have you seen these two pieces by Jenny?
http://groundedparents.com/2013/12/17/fck-the-birth-experience/
http://groundedparents.com/2014/01/18/what-to-expect-when-you-have-a-baby-in-portlandia/
I think you make a very good point, and I feel encouraged that someone is actually asking for more on this topic because it really is a matter of life and death. This (homebirth in general, not necessarily this study) is definitely something I want to write about once I work through my mental backlog. Thank you for speaking up.
I had missed those (it’s been an interesting winter), so thank you. I’ll have to catch up on the video later, but the Portland piece was interesting (though I wanted moar!). It’s also interesting that this post generated far more discussion. Whether that was because it was longer, had more direct analysis to bite into, or was simply more controversial I don’t know. Probably a combination. For funsies I skimmed a few more of the top 10 baby cities in Jenny’s Portlandia link and each one had some kind of daft, off-hand but ill-thought out comment as part of the criteria for selection. Each one could have been an article of its own–is this popular baby-having-related fad/trend/study actually full of shit and if so how bad does it smell?
Anyway, I’m glad you pointed me to other perspectives and look forward to more. Especially now that I have my shiny new login account. 😉
I have to say this is some wacky math going on here…. I’ve compared the MANA study to the Birth Center study and to the CDC Wonder Database (I posted screen shots on my blog if you’d like to see). Both show a significant increase risk to babies born at home.
The Birth Center study is made up of mostly CNMs (Certified Nurse Midwives). The MANA study is made up mostly of CPMs (Certified Professional Midwives). Here are the numbers for comparing the two:
Intrapartum Mortality Rate:
Birth Center study: 0.47/1000
MANA study: 1.30/1000
(That is 2.7x greater risk reported in the MANA study)
Neonatal Mortality Rate (this is TOTAL neonatal period for each):
Birth Center study: 0.40/1000 excluding anomalies
MANA study: 0.76 excluding anomalies
(Almost two times greater risk)
TOTAL MORTALITY RATES (intrapartum plus neonatal):
MANA study = 2.06/1000
Birth Center study = 0.87/1000
A baby born at home is 2.4 times more likely to die than baby born at a CABC accredited birth center. This means for every 10,000 babies born at home, 12 babies will die that would have lived had the mother been under the care of a midwife at a CABC birth center. A part (though not all) of this increase is because most CABC accredited birth center will risk women out who are no longer considered low risk. A low risk woman should take proper screening measures to ensure she remains low risk if you want to consider the rates that reflect low risk women only. To look at low risk comparison, we have:
TOTAL MORTALITY RATES for LOW RISK (intrapartum plus neonatal):
MANA study = 1.61/1000
Birth Center study = 0.87/1000
A home birth is then just shy of two times more likely to end in the loss of life of a baby than if the baby were born at a birth center with a CNM. This means for every 10,000 babies born to low risk moms at home, 7 babies will die that would have lived had the mother been under the care of a midwife at a CABC accredited birth center. SEVEN!! 7 full term, otherwise healthy little babies. 🙁
When I compared to the CDC Wonder Database, I found numbers very similar to what Dr. Amy Tuteur found as well (again, I have screen shots if you are interested, so you can see I did this myself, just in case anyone thinks I copy and pasted from someone else):
Hospital MD neonatal mortality rate = 0.62/1000
Hospital CNM neonatal mortality rate = 0.38/1000
(CNMs will care for mostly low risk, which is why their numbers are lower. The MD group is low risk and high risk. These numbers include lethal anomalies.)
Now to compare… ALL numbers below include lethal anomalies:
MANA STUDY:
Intrapartum mortality rate = 1.30/1000
Intrapartum mortality rate for low risk only = 0.85/1000
Neonatal mortality rate = 1.29/1000
HOSPITALS:
Intrapartum mortality rate = 0.1/1000-0.3/1000
Neonatal mortality rate for low risk = 0.38/1000
Neonatal mortality rate for low risk and high risk = 0.62/1000
TOTAL MORTALITY RATES (intrapartum plus neonatal):
MANA study = 2.59/1000
MANA study for low risk = 2.14/1000
Hospital rate for low risk = 0.48/1000 to 0.68/1000
Hospital rate for low risk and high risk = 0.72/1000 to 0.92/1000
A low risk baby is 3 to 4.5 times more likely to die at a home birth than in the hospital. This means for every 10,000 babies born at home (to LOW RISK mothers), 15-17 will die that would have lived had they been born in the hospital. That is so sad 🙁 Now, even worse, if a pregnant woman planning a home birth does not take screening measures recommended to make sure she is low risk throughout her pregnancy and just assumes she is low risk (or if her known high risk pregnancy is not referred out and simply referred to as a “variation of normal”), then you are looking at comparing the low risk hospital numbers to the numbers in the MANA study that represent all women, which would mean a baby is 4-5.5 times more likely to die at home vs in hospital. This means for every 10,000 babies born at home, 19-21 will die that would have lived had they been born in the hospital.
The agenda of Dr. Amy and her followers is obscene. How could anyone blame Aviva Romm for not partaking in Dr. Amy’s charade? OF COURSE she was going to ask a friend to analyze the data. Anyone who read the interpretations can easily tell how biased it is. First and foremost, if you go by what Dr. Orosz stated, homebirth is safe for low risk women who have previously given birth. She pointed out that the mortality rates for these women was 1.2/1000 compared to 0.7/1000 for hospital births. There is NO statistically difference there. So, if Dr. Orosz was truly unbiased, she would have pointed that homebirth was unsafe for high risk women, less safe for first time mother who are low risk and safe for low risk women who have given birth before (and have never had a C section). This supports every other study ever done on homebirth!!! A subset of women can safely give birth at home. They are the healthy low risk ones who have normal pregnancies and uneventful former pregnancies. It’s disingenuous to say the least, to lump all women together; low risk and high and determine that homebirth is dangerous for all. It’s simply not honest. The birth center study published a year ago makes it very clear that one CAN give birth safely outside of a hospital. The key is that the mother must be low risk, attended by experienced midwives and close to a hospital. As far as Dr. Amy goes, she KNOWS she is pulling a fast one but doesn’t care. Even Dr. Orosz proves that. Dr. Amy never includes intrapartum deaths when she compares home and hospital so instead of comparing 0.7/1000 (the accurate number) she uses 0.38/1000. Dr. Orosz states the the intrapartum mortality rate in the hospital is 0.3/1000 not zero. So, there is one lie. Secondly, Dr. Amy compares the low risk hospital group to the high risk homebirth group. She knows she is blatantly deceiving people but doesn’t care. I would hardly call her a skeptic. The intrapartum mortality rate for low risk women at homebirth is 0.8/1000 not 1.3/1000. It’s important that that is made clear. And lastly, and this is something that no one ever brings up. 1000 unlicensed, unregulated DEMs included their births ( and presumably) deaths in the MANA stats. That could very, very easily skew the results. Even if five deaths occurred under the care of 2 DEMs it would be enough to skew the results and make homebirth look worse. The argument that should be made is this: Is homebirth safe for low risk women attended by CPMs and CNMs? We already can assume that homebirth is dangerous for high risk women and we can also assume that homebirth is dangerous when the midwives who are attended births are unlicensed DEMs with little to no experience. So until that stats from DEMs are removed, I don’t think we will have accurate homebirth numbers at all. And even with DEMs included, we can safely know that low risk women in the USA can give birth at home safely if they have already had at least one uneventful birth and pregnancy.
I’m surprised you didn’t call her dramy. @@ what does any of that have to do with the very real documented risk of homebirthing with a cpm?
Why is the writer of this article confused by the fact that Dr Amy was looking at low risk births on the CDC to get a comparison group?
In the article the writer has stated “These numbers still include high-risk births such as breech or twins, though.”. I don’t live in the US, but regarding the government funded homebirth programme where I live midwives can only attend low-risk births. Any issue such as breech, twins etc is referred on to an obgyn. Is this different in the US? What happens to the number of neonatal deaths when the breech/twin pregnancies are removed from the overall sample in the paper?
@Alli, please do stick around. This is the beauty of Grounded Parents. I’m a Grounded Parents writer, and I disagree with most of this article. Respectful discussion about this topic is a worthwhile outcome. Dr. Amy can be very harsh, but I agree with most of her points. I must admit, I haven’t read most of the comments, and skimmed others. That said, this issue hits home with me as well. I had very low-risk pregnancies with both my kids. I am pretty sure my oldest wouldn’t have survived birth without the wonderfully-skilled forceps delivery I had. Of course, I probably would have been fine with a home birth with baby #2. But I sure as hell loved my epidural. Furthermore, I doubt my 2nd degree tear would have been repaired so beautifully by a midwife.
I think what makes this so emotionally charged is that childbirth stories are both a bonding mechanism and an in-group/out-group litmus test for new mothers. I’ve already seen evidence in this comment thread, where someone claims rock-star status by going “all-natural.” Which implies that other women, whose pregnancies are different, or whose babies are at risk, or whose hips are narrower, or whose babies are larger, or whatever, who do avail themselves of pain management are not stars at all. What happens on the ground is that the self-described rock stars shame the women who didn’t give birth “correctly,” and this becomes a gateway for pressuring vulnerable parents into refusing vaccines and other forms of medical care. The also parallels to the way vaccine deniers self-ascribe rock-stat status for refusing vaccines.
You’re right, it’s totally fucked up that women are shamed by anyone for how they choose to give birth. But I think your comment is a bit one-sided. People in this very thread are also implying that women who choose to give birth at home for whatever reason are not informed of the risks and that their choices are wrong because they are making irrational choices. In essence, they are also shaming women for choosing to want a birth experience (whatever that may mean), for not wanting certain interventions unless absolutely necessary, for not wanting pain meds, and saying things like women who want to give birth at home “eschew modern medicine.” It goes on on both sides of this topic, unfortunately.
I will totally cop to thinking that homebirth is by and large irrational. For women with low evident risk, with an actual certified trained nurse midwife with privileges at a nearby hospital, I think it’s within the realm of risk that an otherwise rational person might accept if they feel strongly about the birth experience (something else I don’t understand as evidenced here – http://groundedparents.com/2014/01/10/the-best-laid-birth-plans/). Putting the experience above having a healthy baby and pushing to avoid intervention at all costs, however, is something I don’t understand at all.
I think you’re going a little beyond the argument to suggest that people are criticising women who don’t want pain meds or interventions, however. What people are criticizing is the idea that echewing pain meds or avoiding interventions is somehow morally or otherwise superior, which is an incredibly common attitude that several of us have discussed over the past couple months here.
I agree that the idea that giving up pain meds or avoiding interventions is somehow superior is horseshit. But I don’t think I’m reading into people’s arguments that they feel superior to women who give birth at home.
When you say things like “putting the experience above having a healthy baby,” you set up a false dichotomy. Plenty of women have a healthy baby at home and have the birth experience they want. Of course, plenty of women have a healthy baby in the hospital with pain management and interventions and are perfectly content with that experience, too! But just because you “don’t understand” it does not necessarily mean that their reasons or motives are irrational. And, let’s be honest, within skeptic circles, rationality is moralized and often treated as a means of asserting superiority over others.
Well, I could pretty effectively argue that even having children is pretty irrational in this day and age, so that’s where I’m coming from there – we all make choices that are seemingly irrational based on the fact that they are something we want, not necessarily something we need or even the best possible choices in a given situation. You are assuming a judgement related to the term “irrational” that isn’t necessarily there. But yes, when women fight tooth and nail to have home-vbac, I think that’s putting the experience they desire over the risk to them and their baby. I’m not suggesting they shouldn’t have that choice because frankly, I don’t have a strong enough horse in the race to defend that.
“I agree that the idea that giving up pain meds or avoiding interventions is somehow superior is horseshit.” Me too. I also agree with the idea that we shouldn’t shame each other for birth choices. That’s what I was trying to get at. I’m totally guilty of rolling my eyes and assuming that homebirth is another component of the crank magnetism that includes homeopathy, anti vaccination, etc. I’ll check that.
The problem IMO is that some women conflate childbirth method with social status and therefore with self-worth.
I totally empathize with women who want that experience- I tried for it, after all. What I hate is how midwives have free reign to lie about how safe home birth is. I’ve looked for a midwife that says that homebirth represents an increase in risk (even ‘a slight’ or ‘an insignificant’ increase in risk), and there aren’t any. They tell you its safer than the hospital more often than not, which is just nonsense. How is it possible to make an informed choice when everyone involved in it is willing to tell outright lies? I also don’t think most women know how completely unaccountable midwives are in the US, or that midwives will support each other first and abandon grieving families who are hurt by negligence. Even midwives who risk out patients will rally behind their ‘sisters’ at the expense of a family that is burying a newborn. You can google “our sisters in chains” if you want to see this dynamic in action.
Don’t be fooled into thinking this is about women choosing this or that, its about our tolerance for charlatans and fraudsters to have access to new targets. I don’t think its something society should tolerate.
@ksenapathy- you loved your epidural? What if data came out that showed that epidurals increased risks to your baby, small risks, but still increased risks? Would you forgo epidurals for all further births? Would you birth your future babies in birth centers where women have equal mortality rates to hospitals but much lowered use of interventions such as epidurals? How would you feel if an outspoken former midwife and her followers commented on every single article posted on the internet making sure to yell very loudly, “EPIDURALS KILL BABIES!!!!!” Would you think they really cared about stopping women from using epidurals because they were worried about babies or do you think it would be because they enjoyed being sanctimonious about a choice that really has zero affect on them? What if data showed that formula increased risks/death for babies? Would you quit your job and stay home for an entire year to nurse your baby? I think it’s pertinent that some of you ask yourself this question. It’s very easy to condemn women who choose homebirth when YOUR choices aren’t restricted or judged in the least. It’s so easy to point your fingers and call women selfish isn’t it? But I wonder if you would give up epidurals or formula if the tables were turned. Ask yourself. Really ask yourself.
“It’s very easy to condemn women who choose homebirth when YOUR choices aren’t restricted or judged in the least.”
Are you seriously suggesting that women who chose epidurals or other interventions or who choose to utilize formula (which is not an exclusive proposition, might I add) are *NOT* judged for those choices?
Although to be totally fair, I should acknowledge that both homebirth and extended exclusive breastfeeding are certainly considered more unusual and therefor judgement worthy by society at large, as opposed to online parenting discussions. My experiences in being shamed for c-sections and formula supplementation, notwithstanding…
The question, Em, is SHOULD you be? The answer is simple: NO. Absolutely not. It’s wrong either way.
@anthropologist underground, you are showing your bias. Do you honestly not see the ‘mainstream’ women shaming the women who homebirth? Shaming happens all around. In this thread. Everywhere and from all sides. There is a lot of shaming of homebirth women but that somehow is acceptable, isn’t it?
YOU’RE SHOWING YOUR BIAS!! 11
@mmella – I don’t personally attack anyone. I don’t prefer to tell home birthing moms that homebirth kills babies. On the other hand, I do often say that there is a minimum of threefold likelihood that a baby born at home will die. Data is data. I personally think compassion is better than shaming. Then again, I can see Dr. Amy’s motivation for her harshness.
I find it rather interesting that you automatically assume that women who are pro-hospital birth also formula-feed. I breastfeed, and work from home most days (check out some of my articles on Grounded Parents like this one: http://groundedparents.com/2014/02/21/all-natural-wool-over-my-eyes/?utm_source=rss&utm_medium=rss&utm_campaign=all-natural-wool-over-my-eyes ). However, I don’t breastfeed because evidence says it’s better, but because I am PRIVILEGED enough to have the job flexibility and financial freedom to make those choices. But, I digress. I loved my epidural. I only wish it had worked the whole time both times 🙂
If I could “Like” this comment, I would. 🙂
@ksenapathy, but there ISN’T a three fold increase. Here, look closely:
total mortality rate for low risk hospital birth: 0.7/1000
total mortality for low risk birth center birth: .9/1000
total mortality for low risk homebirth (after previous low risk pregnancy: 1.2/1000
total mortality for low risk homebirth including first time mothers: 1.6/1000
total mortality for high risk homebirth: 2/1000
High risk homebirth is 3x more dangerous. Is it really that difficult to be honest and specific? Or is it just more fun to claim that homebirth in general is bad bad bad? Homebirth is NOT the issue here. One can have a safe OOH birth, Dr. Amy herself has conceded that much. Can we stop already with exaggerations and mistruths? I wouldn’t be surprised to learn that the main problem with homebirth is that doctors and hospitals refuse to make the transition from home to hospital more smooth. And Dr. Amy’s rhetoric is not helping matters there. There’s no doubt about that. And the homebirth numbers are not limited to CNMs and CPMs, which they should be. They include midwives of all experience and education levels. So the true risk for low risk mothers under the care of a truly experienced and education midwife(s) is not known and is surely lower than what we see here.
mmella,
Here are the numbers:
A low risk woman should take proper screening measures to ensure she remains low risk if you want to consider the rates that reflect low risk women only. To look at low risk comparison, we have:
TOTAL MORTALITY RATES for LOW RISK (intrapartum plus neonatal):
MANA study = 1.61/1000
Birth Center study = 0.87/1000
That is an additional 7 babies per 10,000 that will die. These are low risk moms and healthy little babies that die preventable deaths. The Birth Center study was mostly made up of CNMs. The MANA study was mostly CPMs.
Comparing to hospitals:
Hospital MD neonatal mortality rate = 0.62/1000
Hospital CNM neonatal mortality rate = 0.38/1000
(CNMs will care for mostly low risk, which is why their numbers are lower. The MD group is low risk and high risk. These numbers include lethal anomalies.)
Now to compare… ALL numbers below include lethal anomalies:
MANA STUDY:
Intrapartum mortality rate = 1.30/1000
Intrapartum mortality rate for low risk only = 0.85/1000
Neonatal mortality rate = 1.29/1000
HOSPITALS:
Intrapartum mortality rate = 0.1/1000-0.3/1000
Neonatal mortality rate for low risk = 0.38/1000
Neonatal mortality rate for low risk and high risk = 0.62/1000
TOTAL MORTALITY RATES (intrapartum plus neonatal):
MANA study = 2.59/1000
MANA study for low risk = 2.14/1000
Hospital rate for low risk = 0.48/1000 to 0.68/1000
Hospital rate for low risk and high risk = 0.72/1000 to 0.92/1000
A low risk baby is 3 to 4.5 times more likely to die at a home birth than in the hospital. This means for every 10,000 babies born at home (to LOW RISK mothers), 15-17 will die that would have lived had they been born in the hospital. 15-17 babies!! Low risk moms. 15-17 babies that die preventable deaths.
Part of the problem with home birth midwifery is that screening measures aren’t always taken (and in many cases, are not encouraged) to ensure a low risk woman remains low risk. If a pregnant woman planning a home birth does not take screening measures recommended to make sure she is low risk throughout her pregnancy and just assumes she is low risk (or if her known high risk pregnancy is not referred out and simply referred to as a “variation of normal”), then you are looking at comparing the low risk hospital numbers to the numbers in the MANA study that represent all women, which would mean a baby is 4-5.5 times more likely to die at home vs in hospital. This means for every 10,000 babies born at home, 19-21 will die that would have lived had they been born in the hospital.
Y’all, I have my first sinus infection, so I can’t really engage much here. My hubby is picking up kiddo from preschool, and coming home to stay with the children while I see the doc. (Pity me!!) All I’m going to say is that I have an excellent OB in my family, as well as other doctors. They’ve explicitly told me that no matter how skilled and trained a birth attendant is, birth simply isn’t as safe at home or out of hospital. Even if actual doctors were willing to attend OOH birth, if something goes wrong, the minutes it takes to transport to the hospital can mean death.
Like others have said, as long as this reality is transparent to a pregnant mom, it’s up to her what she does. It’s that transparency that’s, dangerously, missing. Women are misguidedly believing that home birth is as safe. IMO, to say that better training and education from midwives will cure the problem is totally disingenuous. The transparency can be communicated with compassion and kindness, or harshness. I’ll stay on the compassionate side. That said, Dr. Amy has every right to be harsh. In fact, she’s just posted a rebuttal to this very article here: http://www.skepticalob.com/2014/02/grounded-parents-does-a-hatchet-job-on-my-analysis-of-the-mana-statistics-paper.html
I must vehemently disagree with you about having “every right to be harsh.” Amy and her followers are bordering on harassing Jamie on Twitter, and I think everyone involved with this network should be really fucking disturbed by the kinds of behaviors Amy (and her followers) engages in considering the same type of shit happens to many people who write for this network. It’s extremely discouraging to see someone posting here in encouragement of Amy’s tactics. We can all disagree and have a conversation about this topic, but to be supportive of those types of tactics is disgusting.
And, it’s not compassionate to support her harshness. You don’t get to pretend to be above it all while promoting that kind of stuff.
She’s harsh because she feels so deeply for parents whose babies have DIED because of misinformation. These are babies, not statistics. Many if not a majority of women who have lost their babies would honestly say they wish they had only been informed. I stand by my position that transparency is imperative. I myself will not name call, and in that sense I guess I’m at least tactful, if not compassionate. She has reasons for her harshness. I wouldn’t say some of the things she does if I were her. I don’t encourage her tactics, but I also don’t condemn them.
Why don’t you tell us what YOU would do if someone wrote a sloppy piece filled with factual errors and math errors about your work?
Have you bothered to compare what I wrote in my comment about her hatchet job with what Jamie wrote? Did you find the quotes she said didn’t exist? Did you do the addition to get the number that she complained she didn’t understand?
I know that you WANT to believe that homebirth is safe, but you really shouldn’t avoid checking the claims just so you won’t learn something that doesn’t support your world view.
And please don’t assume that women are fragile flowers and can’t be subjected to the requirement that what they write is truthful. Jamie went after me personally. I have defended myself; you haven’t bothered to check my defense; and Jamie is nowhere to be found.
The worst part, though, is that you have ignored the central problem. MANA lied in its own paper about its own results. That deprives women of the opportunity to make an informed decision about homebirth.
What might be of interested to people is this post on exactly how MANA collected their stats:
http://navelgazingmidwife.squarespace.com/navelgazing-midwife-blog/2014/1/31/my-take-on-the-mana-stats-study.html
“As we know, the statistics gathering was completely voluntary. I knew several midwives who never did the stats; a few that did. And this was just in one city! How can anything really be known by such skewed statistics (if you even want to call them that anymore)? And I am sure that midwives with a bad outcome just didn’t finish that woman’s stats. It would have been encouraged in the culture. So that so many did send in negative outcomes lets us know how bad the perinatal mortality and morbidity rate really was. ”
This is incredibly important to note. With hospital births and the CDC births, you can’t just choose to not send in your bad outcomes. You can’t just choose to make things look better because you’re under pressure to do so by your colleagues.
This right here is probably the most damning thing yet, to my mind. All of the statistical analysis and debate in the world doesn’t mean much if there’s no rigor in the collection of data to begin with.
Another thing to point out about the homebirth movement – because there is often no regulation, there generally isn’t a postpartum transfer protocol. A baby deprived of oxygen for a certain amount of time we know will often exhibit learning disabilities or other issues. These could take years to pop up, so if a toddler is a bit behind or an elementary student is struggling, there’s no way to correctly attribute this to homebirth. In a hospital, you would be whisked off to the NICU, and then there would be extra monitoring to ensure that these babies are meeting developmental milestones and getting help if they aren’t meeting them. There are some truly horrific homebirth photos of limp blue babies where the caption is “Apgars of 10!”, when that’s clearly not the case. What happens to these kids?
Anecdote alert – I do know a baby who passed away due to a botched homebirth. Except… they were rushed to the hospital and given a crash caesarean (this is what most people picture when they hear the term “emergency” caesarean. The mother had a vertical incision since there was no time to do the bikini cut that is typically performed now.) So know that baby is in the caesarean stats, not the homebirth ones. He probably went 18 minutes without oxygen, and stayed for several weeks in a NICU, then was sent home. He died as a result of birth injuries, and needed to be tube fed the entire time since he could never suckle. Since he held on long enough to pass the 28 day mark, he’s now in the infant mortality stats. This baby will not be attributed in homebirth stats.
Another note about statistics – when I was pregnant with my younger son, it was determined early on that it was a twin pregnancy. Like a large percentage of twin pregnancies, it naturally “reduced” to a singleton. Depending on which stage of the pregnancy this occurs, sometimes there is evidence of the deceased fetus on the placenta when you give birth. I was warned that if this happened, to expect to fill out the paperwork for a stillbirth. Why? Because of the regulations in my province, any fetus born after 20 weeks gestation, regardless of the gestational age of the fetus, is counted as a stillbirth. So a fetus that passed at 12 weeks but was expelled from the uterus at term with the living baby counts in the “stillbirth” numbers. I don’t know if it’s the same in the states, but this could impact hospital stillbirth stats.
MANA’s numbers are the definition of cherry picked. Voluntary surveys filled out after the fact, with a 30% reporting rate.
…yet there is *still* an increase in mortality in the home birth group. That should be extremely concerning to anyone who looks at the numbers. Taking them at face value is not wise or advisable.
For all the people complaining about Dr Amy using sensationalized language I see basically no one complaining about MANA lying outright in their press release about their numbers. They said that there was a low intervention rate with no increase in negative outcomes, even though the paper clearly shows an increase in death. I guess death isn’t a negative outcome?
Then there is the fact that MANA kept these numbers secret for a long time. I was pregnant during the period of time that they could have released these numbers and chose not to. Did I not deserve to know about them?
Then there is the fact that MANA has absolutely refused to make any recommendations based off the paper, even though the numbers for breech birth specifically show an unacceptably high risk by anyones standards. They don’t care about safety, they care about making midwives look good. And this website has blindly decided that it was a good idea to support their mission.
This is one of the biggest issues I have from people who defend what MANA did. When they finally released their numbers which showed an absolutely hideous death rate (particularly with breech, vbac, multiples), what did they do about it? Did they then start telling women about it? Did they revise their practices to make recommendations as to which women should be risked out? Did they advocate for more education for their members in order to attend home births? Did they do anything at all that you would expect an organization which regulates healthcare providers to do?
MANA literally has no safety standards of any kind. MANA insists that it is up to each midwife to determine for herself what she will and will not take on. There’s no such thing as a health organization that doesn’t have safety standards. MANA is not a health organization; it is lobby for increasing homebirth midwife income and it is important that people understand that.
Can you imagine grounded parents writing an article about seat belt use and risk that was like this post? Where they discuss how seat belt advocates are simply sensationalizing the numbers to scare people, because the the absolute risk of dying in a car accident is low for just about everyone on any given car ride? That would never happen because most of us know that it isn’t about absolute risk, its about PREVENTABLE deaths happening. Nothing is worse than someone losing their life and realizing that it didn’t have to happen. Imagine if every time a toy was recalled there was a grounded parents article published pointing out how many people successfully used the product without injury or death, instead of focusing on the obvious once again- preventable deaths are a tragedy, and a product recall is infinitely more preferable than knowing that only a few people will die from a defective product. Home birth is that defective product, it has inherent risk that should not be ignored.
Can I imagine a blog of skeptics saying “This issue is very important and we need good data to refute the other side and this study might be suspect, so let’s talk about that”?
Yes. I can imagine that.
That’s not what happened though. They took the numbers at face value and declared “hey its just a little less safe!”. Its irresponsible. Using a recalled product is usually just a little less safe than not using it, but most people are totally unwilling to take the chance. How is this any different?
I was reluctant to answer this because it seems pretty clear from some of the replies you’ve given here and over at SkepticalOB that you are essentially going to conflate any criticism of a study and any position beyond total contrition with “home birth advocacy”. This despite the fact that the MOST extreme “home birth position” by any Grounded Parent writer, or indeed on this entire thread, calls for better standards of care, more transparency of the risks, and the radical notion that mothers should then be respected for what they choose to do with their bodies. However, I didn’t want to leave your comment floating because it’s a terrible analogy.
The difference is we wouldn’t be talking about a recalled product. We would be talking about ONE study over the efficacy of a recall. We would be saying, essentially, “this product needs to be recalled, and we all agree with that, BUT this study might not be the best way to prove that, and if we’re going to convince people to stop using the product, we may need a study that works better.”
That’s how it’s any different.
How dare you, Dr. Amy. How dare you attack the writer of this piece when you are NOTORIOUS for lying, twisting numbers, twisting facts and pitting women against each other to push your own agenda. This isn’t about life and death for you. God only knows what it’s about, but it’s surely not that. If you were truly about making birth safer you would take a totally different approach and I think you know it. Have YOU retracted your ‘450% deathrate increase’ blog post? You purposely left out intrapartum mortality rates that Dr. Orosz stated was 0.3/1000. What about that? Did you edit that piece? And do you have no shame? I agree with Will. You sick your followers on anyone who disagrees with you and have them bully and intimidate people until you get your way. It’s incredible, actually. Someone needs a put a stop to it.
@douladani- you are just trying to confuse anyone who is following along. Stop making things so complicated. They are actually quite simple.
Total mortality for homebirth for low risk women who have had a previous pregnancy (AS STATED BY DR. OROSZ): 1.2/1000
Total mortality rate for low risk birth in the hospital: 0.7/1000
Total mortality rate for low risk birth center birth (Dr. Amy states on her blog that accredited birth centers are very safe): 0.9/1000
Conclusion: There is NO statistical difference between homebirth, accredited birth center birth and hospital birth if the mother has had a previous healthy pregnancy and is low risk. That is VERY different from all the comments here that claim homebirth is dangerous and kills babies. That is a bald faced lie. ******If you are a low risk, healthy women who has had at least one uneventful pregnancy, homebirth IS SAFE for you, with NO statistical difference in mortality rates*********** In addition, women who choose homebirth will undoubtably avoid having an unnecessary C section. Once you have a scarred uterus birth becomes much more dangerous for you and your baby so choosing homebirth has a lot more to it than a ‘beautiful experience’. Stop with the sanctimommy finger pointing and shaming.
And lastly, and most importantly, many commenters have mentioned that MANA stats are cherry picked. I disagree. ALL midwives in the state of Oregon had to participate in this study. Oregon has the WORST mortality rates for homebirth in the country. Their midwives are the least regulated in the country. Many of them are unlicensed, uneducated midwives who believe too much in the ‘trust birth’ mantra. Everyone agrees that Oregon needs major changes. So, we can be sure that the state of Oregon did not help the MANA numbers and therefore do not clearly demonstrate the true risk of giving birth at home. With almost 1000 unregulated, unlicensed midwives participating in the MANA stats, the numbers are unquestionably worse then those of licensed CPMs and CNMs. Unless you want to argue that education and experience has no bearing on mortality rates.
If by confusing people you mean that I am trying to tell the truth so women can make informed choices, then sure, I’m “confusing” people.
My numbers are correct. Let me know what you think I have listed incorrectly.
Home birth increases risk of death.
Using Dr. Orosz analysis it also shows increase risk, even for low risk. Where do you live that home birth is promoted as safe ONLY for low risk and ONLY for second time moms?? Even then, with all those stats gymnastics you want to do, it STILL shows increase risk. At least 5 babies that die preventable deaths. Dr. Orosz used only 2500 grams or more so she was very generous in MANAs favor in her comparison, but when comparing more closely to the women that are having home births, the risk is even higher. As I stated earlier, a low risk baby is 3 to 4.5 times more likely to die at a home birth than in the hospital. This means for every 10,000 babies born at home (to low risk mothers), 15-17 will die that would have lived had they been born in the hospital.
No matter how you slice it, it is an increase risk. Whether it’s 5 babies or 15 or 21 or more, those are preventable deaths happening at home births. And that is awful.
MANA should have been honest in their press release. They should have offered numbers for comparison so women could make informed choices. They should have released this study long before they did. But they didn’t. Because they are an organization lacking integrity and honesty and they care more about home birth and home birth midwives than they do about babies living. They should have said “our numbers show an increase risk to babies but we believe it has other benefits, such as a lower c-section rate and intervention rates” or something along those lines. But they did not. They chose to lie and try to fool women.
@doula dani Sigh. I am using Dr. Orosz’s numbers. You know, that unbiased source? Are you accusing Dr. Orosz of lying? Of twisting the numbers to make homebirth look better? I find that strange since Dr. Amy posted her analysis and all the people who follow her blog support it. In her analysis, she claims:
Total Mortality for low risk women who have had one previous pregnancy and give birth at home: 1.2/1000
Total Mortality for low risk women who give birth in the hospital: 0.7/1000
NO statistical difference, doula dani. And homebirth has the added benefit of avoiding an unnecessary C-section. After one C section you have a 1/200 chance of a uterine rupture!! That is much more dangerous than a TOTAL mortality rate of 1.2/1000!!!!! Do you not consider these things at all? Do the FUTURE babies of women matter at all?? In addition to that, and something that you refuse to acknowledge, 1000 unregulated DEMs participated in the MANA study. That means one thousand midwives who could have 10 births under their belt participated in this study. Do you think that clearly reflects the true mortality rate of a low risk woman who is attended by a CNM or CPM who has 5- 10 -15 years experience? You want to desperately claim that homebirth is dangerous but that statement is neither factual nor honest. Homebirth is dangerous under certain circumstances. Homebirth is safe under certain circumstances. Why don’t we do a women a favor and make it clear what those circumstances are? Clearly, YOU enjoy giving birth in the hospital but hospital birth is not for everyone. If a woman can have a safe out of hospital birth, and giving birth at out of hospital is what puts her mind at ease, then let’s help her have that safe birth. I wonder if all the women commenting against homebirth, I wonder how THEY would feel if people tried to take away their rights to have an epidural or maternal request C section. I wonder how they would feel if they were forced to give birth at home and in birth centers with no pain medication. And I wonder how they would feel if the women who enjoy giving birth without pain meds told them, “It’s not about YOUR experience. What about your BABY’S experience? This isn’t about YOU, it’s about your BABY.” So easy to say when your choices aren’t the ones being judged. I would bet my life that every single woman on this thread who is anti-homebirth would still choose an epidural, still choose a hospital, still choose a C section, even if data came out to show that the mortality rates were slightly increased for these things. And it’s not because these women are ‘selfish’ it’s because they are humans with emotions and needs and they matter. They matter just as much as their baby does. So keep shaming women if you want, but try to imagine if it was the other way around. And try to accept the fact that homebirth IS IN FACT SAFE under certain conditions. If accredited birth centers are safe, which are no different than homes, than the difference lies in two things: the experience of the care provider and the risk profile of the woman. If one can have a safe birth in an accredited birth center, they can have a safe birth at home following the same protocol.
“And homebirth has the added benefit of avoiding an unnecessary C-section. After one C section you have a 1/200 chance of a uterine rupture!! ”
What is the probability that a woman with a prior history of successful vaginal delivery, no major illnesses or complications, and a singleton full-term cephalic fetus (that’s our lowest-risk homebirth scenario) will wind up with a c-section if she delivers in the hospital?
Pretty small, actually. Much smaller than the national rate, and smaller than the primary c-section rate for first time mothers.
I will reply in full later… I have no time right now, unfortunately.
I did not say Dr. Orosz was lying, nor did I insinuate it. Her analysis was fantastic. Your comparison is not accurate because you are using a very select group, the lowest of low risk, for the home birth group and comparing it to a higher risk group in the hospital. 1.2/1000 mortality does not apply to home birth as a whole – it is a select group. 22% were first time moms and that number is only rising for first time moms giving birth at home. No where is it promoted that home birth in the USA be limited to or recommended for second time moms only. Please point to me where you see that recommended. Thank you.
Even then, using 1.2/1000 for non-first time moms (with previous vaginal birth(s), that is) who are low risk and comparing to .7/1000 shows an increase risk. That is 5 babies that die per 10,000. 5 babies that die preventable deaths at home.
As I said, Dr. Orosz was generous (in MANAs favor). She only looked at babies 2500 grams or more for the hospital set. If it was a group of women that matched the MANA set more closely, that number representing hospital birth mortality — .7/1000 — would be even lower (especially if comparing to low risk moms who have had at least one previous vaginal birth, as you are using for the MANA study). So, even more babies would die preventable deaths at home, even for moms who have had a previous vaginal birth and who are low risk.
“Total Mortality for low risk women who have had one previous pregnancy and give birth at home: 1.2/1000
Total Mortality for low risk women who give birth in the hospital: 0.7/1000
NO statistical difference”
Yes, statistical difference. Dr. Orosz mentioned so in her analysis and I just did the numbers for funsies to corroborate. You might not consider that difference meaningful from a personal decision-making standpoint*, but it is most certainly a statistically significant difference.
*Personally, I do think it’s meaningful, especially since it’s a difference that gets even larger when you remove primiparas from the hospital group as well. A proven pelvis will be less risky in both scenarios.
So what about all the unnecessary deaths of future children due to unnecessary C sections? Do those babies’ lives not matter?? 4 million women give birth in the US every year. ONE in THREE of those women give birth by C section. Even if only 1% of the C sections were not necessary, that still results in a large number of deaths for future babies. And the risk of uterine rupture increases to 1 out of every 26 women if she has had 2 C sections and the increase just keeps growing with each one. If you choose homebirth there is almost a zero chance of having an unnecessary Csection. So if you end up with one, there was no avoiding it.
So giving birth at home does save lives in it’s own way. There are benefits for low risk women giving birth at home, even if you choose to ignore them. Instead of scare mongering all women away from homebirth, why don’t you focus on the facts? The facts are CLEAR that homebirth is not safe for women with twins, breech babies and previous C sections. There is not much to argue there. It is not factual to say that homebirth is dangerous for low risk women. The differences from this flawed data are not statistically significant. And no, Dr. Orosz IS comparing low risk to low risk. You are really insulting her by saying otherwise. The total mortality rate for low risk women in the hospital is 0.7/1000. That’s according to Dr. Orosz- ya know, the unbiased source?!
And AGAIN, the MANA stats include data from 1000 unregulated direct entry midwives that do not have the education or experience to safely provide care to women. ( Do you disagree with that?) If you are going to advocate for anything, advocate that DEMs become illegal.
Here is a question for you: the study on accredited birth centers shows that one can have a very safe birth in an accredited birth center. (Even Dr. Amy admits this on her blog). Accredited birth centers are still free standing birth centers. They are NOT within hospitals and as many advocates of homebirth suggest for women who homebirth,they are probably within 15 minutes of a hospital. So clearly, it is not necessary to be within a hospital to give birth safely. Which concludes that out of hospital birth is safe under certain conditions. Well, what are those conditions? We know that the care providers in accredited birth centers are a mixture of CNMs and CPMs ( mostly CNMs). We know the women who give birth there are all low risk and we know that they are most likely within 15 minutes of a hospital and may possibly have OB back up. Therefore we CAN advocate for safe homebirth as well.
We should advocate that only low risk women give birth at home and preferably those who have already had one healthy pregnancy. However, if a first time mother still wants a homebirth she should be able to but should understand the benefits vs drawbacks (no chance of an unnecessary C section, increased risk to first child-perhaps). We should advocate that all women receive back up care from an OB and register at a hospital, just in case. We should advocate that all women who choose homebirth be no more than 15 minutes from said hospital. We should advocate that it’s important to transfer at any sign of trouble.
It’s entirely possible for women to have options. @doula dani you are refusing to see the big picture and you are narrowly focusing on assumptions rather than the actual reality or truth. The risk of giving birth at home, IN TRUTH, is different for every single woman. That’s why it’s so false and misleading to claim homebirth has 3 or 4 or 5 time higher mortality rate. That is NOT TRUE ACROSS THE BOARD. You are going to tell me that a second time mom who is young, healthy, who lives close to a hospital and is registered at that hospital, who has received blood work and ultrasounds, who has received care from an OB and two experienced midwives during her whole pregnancy will have the same risks as a woman who has GD, who has never had an ultrasound or seen an OB, who lives 45 minutes from a hospital, who has ONE direct entry midwife who has 1 year experience, who believes whole heartedly in the ‘trust birth’ mantra, who never really knows her accurate dates and goes past 42 weeks pregnant?? You think those two women have the same chance of their baby dying? You see, THAT is how you are being dishonest. There is a difference between the two and you need to acknowledge it if you honestly claim to care about women.
I came upon this post and found the discussion interesting … both sides. However, when I read your comments the numbers did not seem match the statistical analysis I went and read. First as everyone, including Dr. Orosz, has noted, an analysis like this is difficult/limited due to unavoidable differences in populations. In Dr. Orosz analysis she notes frequently that she is using the estimates for factors in the hospital group that would, if anything, tend favor the MANA group (understandable benefit of the doubt, since this is not an actual control group, but rather a best estimate) These factors included a generous estimate of hospital inter partum mortality and low birth weight as the only “high risk” factor filters for the hospital group. Dr. Teuter, on the other hand, seemed to use less favorable, but still reasonable estimates. There is nothing wrong with this, but it is why doing multiple analyses and reporting a range of possible results would be best. Also, while Hospitals are mandated to report all deaths, this is not true for CPM’s or DEM’s … except in Oregon and Colorado, I believe. As has been noted this study was voluntary with only 30% participation. It has been noted in many studies in the past, when reporting is voluntary, negative outcomes, tend to be significantly under reported.
After going back to the original statistical analysis, it appears you are comparing apples to oranges. Your quote of a totally morality risk of homebirth of 1.2/1000 for low risk multiparous homebirths (which appears to include only neonatal deaths … not inter partum) and then proceed to compare to the hospital rate of 0.7/1000, which includes primips and multips and includes inter partum deaths. In Dr. Orosz summary, the rates were: hospital 0.7/1000 and for homebirths 2.06/1000. You also repeatedly state that these differences are not statistically significant. In your opinion, these findings may not be clinically significant, but the p values in Dr. Orasz report appear statistically significant.
Lastly, your focus on very low risk, multiparous births delivered by CPM’s (not DEM’s) is a straw man. The group that published this data, MANA, supports both CPM’s and DEM’s, as well as homebirths for primips, twins, VBACs (even x2 or 3) and breech births. Additionally, they are opposed to requirements for universal training standards, insurance requirements to protect their patients, restriction on their practice to low risk patients or increased regulatory scrutiny of negative outcomes to bring them in line with other providers of care to pregnant women.
C-sections are higher risk *for moms*, and lower risk *for babies*. There is a wealth of data demonstrating that. If there is an increase in mortality for c-sections its maternal mortality, not perinatal mortality.
What are all of these deaths by unnecessary section that you speak of? I just check the CDC Wonder database. The only exclusions I did were pregnancies over 39 weeks and singletons. I did not take out higher risk ethnic groups. All babies over 2500 g- that includes the macrosomic babies. No maternal health conditions removed.
The mortality rate was 1.98/1000.
So, just about the highest risk group of term pregnancies you could choose. And the mortality rate was STILL lower than the MANA stats death rate of 2.1/1000 for all homebirths.
Ugh… this is awful. I just got done writing a post for a different article where I tried to explain that I felt many authors on this site were making sweeping, negative generalizations about women who were interested in “natural” childbirth, and how frankly unwelcome it makes me feel. Now here we are doing it again. Trying to lump everyone who wants to have an unmedicated birth together as science hating, woo-filled, irresponsible parent is shitty. And yeah, that’s how it feels.
Are there problems with the “natural birth movement”? Yes, many! I want to see them fixed! Are there issues that shouldn’t be poo-poo’ed away regarding how a lot of women get treated in a modern medicine model? YES! And I want those fixed too!
There have been a lot of posts on this site about the authors being judged harshly and treated badly for having a c-section, or an epidural, or not breastfeeding. I support every one of those choices and would not try to shame you for them. Now here many of you are trying to shame me for mine.
I’m not going to engage on this thread… it is really hostile here.
I DO want to wholeheartedly thank Will and chrisbrecheen for saying some of the things I would want to say myself and pointing out some of the strawmanning happening.
I’m not lumping everyone together. I think the reasons to try to have a NCB are totally legit. I tried for one, and it was a disaster, and that is when I found out that home birth midwives are preying on women who have legitimate concerns about their birth experience. I did a series on The Business of Being Born on my ex-home birthers blog, and over and over again I see the same thing- they point out a problem in hospital birth, and then say midwives are the answer without providing any evidence that midwives or out of hospital birth would actually solve the problem. A big reason why my out of hospital birth was so awful was because the midwives did things to me without my permission, something that was a main concern for me as a survivor of sexual violence, and when I tried to reach out to the NCB community for help there was none. Everyone has defended the birth center and midwife, and thats how I found out what they are selling is a lie. They only pretend to care until the check clears. They will lie in court or to the police for each other, and pretend like negative outcomes never happened. Read ‘from calling to courtroom’ if you don’t believe in the depth of the depravity of the home birth midwifery community, its a guide on how and when to lie to avoid being accountable for deaths and other problems. THAT is what I care about- women who want a NCB being preyed upon by charlatans. THAT is the issue.
There isn’t any one here who doesn’t agree with every point you’ve just made. There isn’t anyone here who wants midwives to spread bad information.
If you think there is, I challenge you to read just a little more closely.
I really wanted to thank you for this comment. When multiple readers from another blog come to defend “their” writer it can charge the atmosphere of any thread, and sometimes it feels a little futile to bother engaging in such high levels of vitriol. Your comment made me feel a little better and a lot less like I was screaming into a windstorm.
Another perspective (after getting bogged down in these comments for a good half hour): I work in a country where the maternal mortality ratio is +300/100,000 and the neonatal is 14-19/1,000 (depending on source). Yet over 90% of births are in medical facilities. The key problems are a high HIV burden, late accessing of antenatal care (usually 20 weeks or later) and medical personnel – primarily nurses as there’s a chronic shortage of doctors – failing to follow clinical protocols during the ANC process or at delivery.
Our statistics on home births are impossible to compare to hospital deliveries as they range between horrific (poor women giving birth at home without medical attention because the nearest clinic is hours away over rutted roads and no-one has a car while the ambulance takes about 14 hours to arrive – if it ever does, or the local clinic refuses to help because it’s 2pm and the nurses want to finish their paperwork and go home), and fantastic (rich women with excellent ANC access who have highly qualified midwives attending and a private ambulance just minutes away).
So I look at the MANA/for or against home birth debates and can only wish we were at that point.
This comment is to the discussion in general because I think there’s some apples-to-oranges discussion, especially in the idea that the answers lie in the math.
Where the numbers come from and what they actually represent are not something you can get at by *just* looking at the math. The social science aspect of this is what complicates it. Doing studies in the social sciences is extremely difficult in part because of the many variables that need to be controlled and in part because, for example, you can’t tell women where to give birth. You can only analyze after the fact the choices they do make. Even in a single study in which homebirth and hospital birth groups are included, controlling for variables is so difficult that the data need to be analyzed very cautiously.
In this case, we have comparisons made between data that don’t even come from the same study, so no variables are controlled between them. It’s like having a study without a control group. The numbers that result don’t really support any conclusions. At most, they support further study that is controlled.
Jamie’s analysis of the numbers included separating out low risk and high risk as much as was possible to do within the study rather than lumping them together. She didn’t lump them together because she was assuming good faith on Tuteur’s part that she wasn’t comparing both low- and high-risk homebirth with low-risk hospital birth. This is just aside from the fact that the hospital stats aren’t comparable to the homebirth stats except in the sketchiest way because they aren’t from the same study so the variables are not controlled in the same way.
Tuteur’s numbers do reflect this lumping together. So the math for both is correct as far as the decimal numbers.
So the math isn’t really the issue in either article. The source of the numbers is. Numbers don’t exist in a vacuum.
In the end, honestly, I think the MANA study is almost useless because it doesn’t have a hospital group to compare to. I say “almost” useless because it does at least provide more information to work with going forward, and it demonstrates the need for studies that are more comprehensive.
I should also add that since people can’t exactly wait around to make childbirth decisions until proper studies are done, studies that are difficult to do and take forever to do properly, I have no issue with making the argument that no amount of additional risk is worth it, without having to say I absolutely know that these numbers are certain. That is one of the arguments that I think we should be making, rather than fudging toward a certainty that isn’t there just because we believe the cause to be just.
Thank you, Melanie. I think that perspective is important for the discussion, and it was lost.
Thank you for putting out your neck to post this.
This is only reinforcing how much I think this article was a poor skeptical post and not a great exercise in critical thinking, even as it tries to look like one.
“She didn’t lump them together because she was assuming good faith on Tuteur’s part that she wasn’t comparing both low- and high-risk homebirth with low-risk hospital birth.”
She may have assumed in good faith, but she didn’t read very well, because Dr. Tuteur did the comparisons both ways: low-risk home (as it should be) vs. low risk hospital (as much as you can since there isn’t the option to screen out breech and VBAC in the CDC data), as well as all-risk home (as it is actually practiced in the US) vs. low risk hospital. For whatever reason Bernstein focused on the latter and made it sound like that was the only comparison done, even though she used the same graph as her illustration.
Further, this one paper from MANA is not brand new information, and this is where the lack of awareness of or address to context is critical for the overall picture. Numbers are important in the sense that they give a magnitude to the difference in risk. Just arguing that there is an additional risk in anything doesn’t add much; it is the idea of how much additional risk that helps inform a person’s decision. And there have been several different kinds of studies, all quite recently, that do have as close to apples to apples as you can get without doing a highly unethical RCT:
https://olis.leg.state.or.us/liz/2013R1/Downloads/CommitteeMeetingDocument/8585
A comparison at the request of the state of Oregon looking at all hospital and out of hospital births births in the state in 2012 showed a 3 to 8-fold increase in perinatal death depending on the type of out of hospital provider. (And mentioned in GP’s own Jenny Splitter in a previous article.)
http://www.ajog.org/article/S0002-9378%2813%2900641-8/fulltext
2013 study using a standardized certificate of live birth showed a 9-fold increase in a five minute APGAR score of 0 (highly correlated with neonatal death and a good metric for indicating that something is very wrong).
http://www.ajog.org/article/S0002-9378%2813%2901604-9/fulltext
2013 study (unpublished poster presentation at a professional conference) at a hospital that is the primary referral center for therapeutic cooling for neonatal hypoxic ischemic encephalopathy (brain damage due to lack of oxygen at birth) showed a 17 to 31-fold increase in babies presenting hypoxic injury with need for cooling therapy following home birth. The difference is greater when looking at babies being born vaginally, because in the hospital most of these babies in trouble are spotted and a C-section is done quickly.
http://www.ajog.org/article/S0002-9378%2813%2901155-1/fulltext
2014 study using the CDC’s linked birth/death certificate data showed a 3-fold increase in neonatal mortality in home birth attended by a midwife.
These studies are all as apples to apples as it ethically gets, and they all point to a significant problem with home birth in the US as it stands. This consensus, and yes the magnitude of the difference, should make anyone considering a home birth extremely wary. There may be providers who do everything right, but that is often not apparent until after the fact. Until the standards are consistent and the midwives properly trained and educated (CNMs or CMs only, none of this DEM or CPM nonsense), following appropriate protocols, and integrated into the hospital system for quick transfer of care, birth at home is, as a whole, far more dangerous than birth in a hospital.
Bernstein’s article makes a mess of the preponderance of data (mostly by failing to address it and doing a shoddy critical reading job of what she did address) and IMO did a huge disservice to skepticism that was mitigated only by the ensuing discussion.
I already answered this below. Jamie’s post is NOT about whether or not there is risk in homebirth. It is about two different people reaching two different conclusions on one study and how that could happen. I realize that you really want this post to be about something different than it is, but you’re judging it based on this different post in your head, so of course it’s going to fail to be that post. That’s not what it is intended to be.
As I said below, Tuteur’s focus in her title, in her all caps and boldface, and in her data is on the conclusions she reached from a faulty and misleading comparison. She chose that focus. That is the conclusion Jamie is addressing. That is the conclusion that is wrong. The graph shows the low-risk number from the MANA study. In Amy’s one line about the rate for low risk excluding breech, etc., she provided no data. Just a relative risk rate (which itself, just in that one line, is ANOTHER example of a misleading use of data, not to include the absolute risk when you provide a relative risk rate). You think it was unfair for Jamie not to include that in her data analysis when there was no data to include and when it had nothing to do with the conclusion Jamie was addressing. Had she included it, it would have been another example to criticize in Dr. Tuteur’s post. Is that really what you want?
“Just a relative risk rate (which itself, just in that one line, is ANOTHER example of a misleading use of data, not to include the absolute risk when you provide a relative risk rate).”
Except that she already provided the absolute rates for each risk category in the quote from CfM, which stated 1.61 deaths per thousand for low risk and 2.06 per thousand for all risk. Those were the numbers from which she calculated relative risk. Those were the same numbers from which Bernstein herself calculated the relative risks (though I didn’t like her excessive rounding–significant figures are significant for a reason and small changes in rounding can compound to large errors in calculation).
I just don’t think this kind of “why are these two perspectives different?” analysis is useful in a vacuum. This topic is too deep for such a shallow skim, which is why I spent some time trying to explain where this study fits in context.
I think we might be talking about two different things, then. The MANA low-risk rate includes VBAC, multiples, breech, etc. Near the end of her post, Dr. Tuteur gives us a rate if we compare just low risk without those but she gives just a relative risk number, not an absolute risk. That’s what I thought you were saying Jamie should have mentioned.
You may be right about the topic being too deep to be used for this kind of analysis. It seems that tackling these issues with the number interpretation in a broader context, though, would have been too broad for a blog post and detracted from the point of avoiding these kinds of mistakes in our use of homebirth data, which is important.
No, the MANA all risk includes VBAC, breech and such, but the low risk specifically excludes them. Not that the paper itself includes these numbers, and they (MANA) do most of their description of the total sample and some parsing of complications in the discussion,* they don’t provide the numbers for the different risk categories clearly in the paper.
“The overall death rate from labor through six weeks was 2.06 per 1000 when higher risk women (i.e., those with breech babies or twins, those attempting VBAC, or those with preeclampsia or gestational diabetes) are included in the sample, and 1.61 per 1000 when only low risk women are included.”
This is the quote where both Dr. Tuteur and Bernstein got the MANA numbers for their respective calculations of relative risk for each category (though Bernstein, as I said, with inappropriate rounding).
*Though their conclusions are along the lines of “the death rate is higher because the mean medical system makes mothers afraid and midwives feel bad” rather than “don’t do high risk births at home, midwives!”
Urg, my kingdom for an edit button.
I agree that doing a broad perspective and a narrow analysis at once would be difficult and unwieldy. If it was a matter of GP having done this issue in depth previously, an article applying an added layer of statistical analysis and compare/contrast would likely have gone down a lot smoother. As it has not, and as home birth hasn’t gotten the same rigorous treatment in skeptical circles as something like anti-vaccination, I don’t think it does as much good without the same base of “okay, here’s what we know and accept” to point to before doing so.
Melanie, you said this far better than I ever could! This is an area in which a lot of uncertainty exists and if anything that means we should be having more discussion about how we’re going to value risks and benefits in the face of that uncertainly. Like you, I think think that most home births are probably done unnecessarily because the actual risks aren’t being taken into consideration. I think there are times when taking the possible extra small risk may be worth it for some people(for example people without insurance or people who have severe anxiety in hospital settings, or people who live in places where it is difficult to get to a hospital). Others may not think it’s worth it even inn those situations. But we can’t even have this conversation until we have some idea what the risk is. Making blanket statements that home births are bad no matter what and manipulating the numbers to make it seem more dangerous helps no one.
“But we can’t even have this conversation until we have some idea what the risk is.”
Well, what about Amos Grunebaum’s recent peer-reviewed study that did not use MANA data at all but found an increase risk of death on the same order as what Dr. Tutuer is claiming? What about the numbers from the state of Oregon where all planned homebirths are by law reported? The stats there were commissioned by the state through a 3rd party who concluded homebirth death rate was 6-8x higher than comparable risk hospital birth. What about Colorado’s numbers or California’s? Do we have enough idea of the risk now? What level of proof do *you* feel we need to have before we can “even have this conversation?”
“In this case, we have comparisons made between data that don’t even come from the same study, so no variables are controlled between them. It’s like having a study without a control group. The numbers that result don’t really support any conclusions. At most, they support further study that is controlled.”
This comment shows a misunderstanding of biostatistics. Having a study with an intervention group and a control group that come from the same study is indeed one way of designing a study. But that is far from the only valid way of designing a study that will give us information that we can trust. Another excellent way is to use population data as our control group. Often, using population data as the control group yields conclusions that are *more* trustworthy because the population data is so very large (huge in this case). Because of its size, population data doesn’t have a confidence interval–it’s not a sample from the population, it IS the population. So it’s perfectly valid to compare a large subsample of the population (~17,000 homebirths) to the population as a whole (CDC Wonder database). If the subsample comes back showing worse outcomes (as it did here), we do need to ask ourselves if the subsample might have been higher risk to begin with. Looking at MANA’s own description of their homebirth mothers, however, should put this concern to rest. Women who chose to homebirth with MANA were much *lower risk*: less likely to be first time moms, less likely to have any underlying health condition, less likely to be poor, less likely to have a breech, twins or a prior c-section, more likely to be white, married and at term rather than pre-mature. When women start off lower risk than an average woman from the population but despite that have their babies die at a higher rate, this is important. Especially since the numbers are robustly statistically significant.
And this isn’t the first study to show this same increase in death. If you are worried that Dr. Tutuer has somehow tainted the analysis, or if you are worried that MANA’s data cannot be trusted, you may wish to check out Amos Grunebaum’s recent independent study (and all his data is drawn from a single database if that somehow still matters to you). His conclusion is the same: homebirth increases death risk considerably, nearly the same magnitude as what Dr. Tutuer concluded.
I understand there is a “bigger story” behind homebirth that a look at the numbers alone misses. There are many personal reasons that women choose a homebirth. I know this because I was raised in a homebirthing family. I understand homebirth’s aesthetic appeal and am part of the cultural group that has embraced it. But now that I’m older I can also see what else it is: it’s pseudoscience. My parents are also anti-vaxers–that’s also pseudoscience. Skeptics fight against the pseudoscience of the anti-vax movement. When there are deaths from vaccine-preventable illnesses, skeptics don’t throw their hands in the air and say “well there was no randomized control group for the kids who got sick, so we can’t draw any conclusions, we need more study before we will know” nor do we say “well it’s still fine not to get your kids their shots because the risk of dying is very tiny”. No, we analyze the numbers and speak out against the anti-vax movement. Homebirth data show that having your baby at home is RISKIER than choosing not to vaccinate your baby. Why the double standard I wonder?
Fair enough. I did not know population data could be used to that degree of confidence. So you can enter the exact same variables from the MANA study into the database for the comparison?
I stated clearly that I *don’t* think we wait for perfect studies to advocate against homebirth. My point is that we don’t fudge the numbers or pretend there’s a certainty that isn’t there. The same goes for advocating for vaccines. I don’t pretend there isn’t any risk involved. The argument I make is that the much greater risk involved is with not vaccinating, and on schedule, and explain why.
The double standard, if anything, is that it’s somehow okay to fudge the numbers with homebirth in a way that I don’t see people doing with vaccines (although maybe they do–I’m sure there’s a Facebook meme contingent out there doing so). It’s okay for Dr. Tuteur to compare low- and high-risk homebirths to low-risk hospital births because of what she says about MANA’s counseling practices, as she notes above. That’s fudging the numbers. And it’s unnecessary. The case against homebirth, even with the need for more studies and better studies, is strong enough that we can state it as it is, and certainly mention these other factors, such as MANA’s counseling practices, without artificially including them in the data.
Similarly, the tactic of using large percentages to refer to increases in very small numbers is also one I think we can do without in our advocacy. It’s no different than when anti-vaxxers talk about, say, the 900% increase (or whatever huge number) in TOXINS in combined vaccines when we’re talking about very, very small quantities, especially compared to what a baby’s body encounters daily.
Striving to be cautious about claiming certainty, transparent about the data we’re using, and avoiding misleading uses of numbers is important no matter what we’re talking about. And I say that as someone who has to catch herself constantly on these things, overstating my case because something is so important to me. I get that we all or most of us probably do this. I don’t get defending it as somehow okay to do.
Melanie,
I think the problem here is that we have people with experience interpreting biostatistics talking to people without that experience. It sets us up for a lot of misunderstandings. Here’s a quick example: your use of the term “degree of confidence”. This actually means something in statistics speech (similar to the p value) whereas I bet that you meant it to mean simply “level of trust”. See, a misunderstanding already.
Likewise the use of percentage increases (e.g. 400% increase). Expressing numbers this way is common in biomedical literature. Laymen might see them as “scare tactics” or “manipulative” but to researchers and doctors these are an accepted factual way of expressing numbers. If we didn’t think about relative risk and always just thought of absolute risk, we wouldn’t make recommendations at all. The chance that your kid will die of measles if you don’t get him vaccinated is far less than one in a million. The chance that your kid will die if you lay him down to sleep on his tummy instead of his back are teeny in absolute numbers, but big in two important ways: the relative risk and the total number of dead babies in the population if a lot of people start put their baby stomach-down. Percentage increases are important. They show us clearly when we have a “defective product” or inferior practice.
I understand that as a layman it might be hard to trust Dr. Tutuer because of her tone and also because I don’t think she’s the world’s best explainer. Some of her comparison choices can be baffling and thus seem underhanded if you don’t have the medical training to understand why she makes them (and she doesn’t explain it well). An example is when she compares the homebirth death rate for high risk pregnancies like breech to the hospital low risk rate. The reason for this comparison is 2 fold: 1.homebirth midwives do tell their patients it’s “just a variation of normal” and 2. If you give birth to your breech baby in the hospital by C-section, as is the standard OB recommendation, your chance of coming home with a live healthy baby, despite your “high risk” pregnancy is no different than for a mom with a low-risk vertex (head down) baby. The chance of your baby dying is well less than 1/1000, while it’s as high as 3/100 for homebirths. Many high risk conditions become low risk *if you use modern medicine*.
Anyway frustration with this article was that Jamie bills herself as being someone you should trust when it comes to stats, and then tells everyone that her conclusion is that it’s impossible to draw any conclusion, when actually the numbers are robust. I myself am a physician, not a statistician, but it’s clear to me that Jamie is coming at this as a layman and is totally over her head with this.
I was responding to your comment that the CDC database does not require confidence intervals, but I could have misunderstood what you meant with that. Can you explain how either misunderstanding specifically affects or changes any of the points I’ve made? Otherwise, I’m not really seeing the point of bringing it up other than to make this about me, not the subject at hand.
I don’t argue that percentage increases and relative risk are completely invalid or that they aren’t used in the biomedical literature. In epidemiology and in public health, at the very least, however, using percentages to describe very small numbers is cautioned against. For other laypeople like me, here’s an accessible explanation that even uses infant mortality as an example: http://www.in.gov/isdh/23986.htm. (Do a search in the page for “rule of twenty” to get to the section I’m talking about.)
I think you’re making some assumptions and reading incorrectly between the lines with me, not only with the assumptions about my understanding but in your earlier comment about understanding the homebirth culture, which seemed to imply that that I’m pro-homebirth (but maybe that’s my false assumption :-). The homebirth culture is completely foreign to me. I’ve had to work to understand where people are coming from on that, and frankly, I’ve made little progress. I also have no issue with tone. I defend PZ’s tone on atheism regularly. It takes all kinds of tones to reach different audiences.
The problems I have with Dr. Amy’s work are the problems I’ve explicitly stated, her manipulation of numbers. I completely understand why “low-risk” in homebirth is not always genuinely low risk. That does not make it okay to say, well, they are dishonest about their numbers, so I’ll be dishonest with mine. What you do is you compare low risk to low risk, then add in the discussion that the risk of homebirth is likely to be even higher when you take into account these factors. You don’t just decide to change the numbers. Not only that, she did this and presented the numbers without even telling us that she did this except in this comment section. I can’t believe I have to spend this much time arguing that this is wrong.
Jamie is a statistician. She has a master’s in public policy, economics, statistics, health policy, science policy, and energy policy. So can we dispense with making this about arguments from authority that distract from the issues at hand and focus instead on the arguments themselves?
I really appreciate the time you’re taking here to discuss this in good faith, FWIW. I do want to save you time in arguing that homebirth is risky and why because I already agree with you on that. I’m kind of puzzled by the assumption in these comments as a whole that being critical of Dr. Tuteur’s work somehow equates with being pro-homebirth or an apologist or something. For me, aside from the ethics involved, this is about being able to provide credible, honest information to people who are already often mistrustful of medicine. Being cautious about the claims we make doesn’t mean not making any claims at all. It just means doing so honestly.
“So you can enter the exact same variables from the MANA study into the database for the comparison?”
You can enter many of the variables into the CDC Wonder database but not all. For the ones you can’t enter (certain lifestyle factors) we can be confident that the MANA patients have the edge based on the demographics that they themselves have released. MANA’s homebirth cohort has a much healthier baseline lifestyle on average than the general population (diet, exercise, married or stable partnership, non-smoking).
I echo Dr. Orosz’s encouragement to check out the CDC Wonder database. It’s very cool! It’s one of those great things, like public libraries, that we can be really proud of our government for giving us.
I do think it is ethical to compare low risk hospital to all risk at home births. It is hard for someone who is not in the home birth community to understand why. In the home birth community, it is not uncommon at ALL for screening tests and ultrasounds to be discouraged. It is not uncommon that twins, breech and other high risk pregnancies to be called a “variation of normal.” It is not uncommon in the home birth community that low risk is *assumed* instead of *confirmed*. So it actually IS fair to compare low risk hospital birth (where measures are taken to confirm the pregnant woman is actually low risk) to the home birth data that represents ALL risks. If a low risk home birth woman DOES take measures to ensure she is truly low risk, then yes, she can look at the low risk numbers. However, many women who assume their low risk status will still look at the low risk numbers… and that is obviously not correct. Ultrasounds, GBS testing, GD testing, etc are so often deemed unnecessary or “too risky” in the home birth community. So while, yes, to an “outsider” it can look like Amy Tuteur is manipulating the data but to anyone who understands home birth in America, it is not a manipulation at all.
I can’t help but wonder how many high risk pregnancies were known ahead of time versus those that were just missed by the midwife due to lack of screening or lack of understanding the signs of certain complications… especially the breech, pre-e and GDM deaths.
Even then… when comparing low risk to low risk… it is still a substantial risk for babies born at home.
What you are describing is not that it’s ethical but that being unethical is justified. Manipulating numbers is not ethical. If we really want to convince people, many of whom already have a mistrust of medicine, it is even more important to be trustworthy.
EXACTLY my point. Compare the low risk to low risk. Then in the discussion, talk about the additional factors you point out that make the risk likely to be even higher.
“Compare the low risk to low risk.”
Dr. Tuteur actually does do that. She does both: low risk home (as it should be practiced) vs. low risk hospital and all risk home (as it is actually practiced) vs. low risk hospital. Bernstein’s article focused exclusively on the latter while ignoring the former, much to the detriment of her argument IMO.
Jamie’s thesis is “how can two different people look at this study and reach different conclusions.” The title of Tuteur’s article is focused on the 450% she derived from comparing high- and low-risk homebirth to low-risk hospital birth. The bulk of Tuteur’s post and all the supporting data she includes are about this conclusion. She has one line where she tells us the increased risk of low-risk homebirth without breech, etc., to low-risk hospital without any of the supporting data she used to reach that conclusion. Do you really think it’s unreasonable given Jamie’s thesis and Tuteur’s own focus and use of data for Jamie to have focused on the 450% and related data in her post?
I do think it’s unreasonable, because she doesn’t acknowledge it at all (despite using and not explaining the exact same graph in her post), in fact makes the same calculation herself and acts like Dr. Tuteur made a sloppy math error, and strips all the nuance out of a very nuanced post.
Bernstein’s article was messy, came off rushed and ignorant, and made a lot of assumptions that expose her lack of research. It’s a pretty terrible showing of skepticism. By contrast, here’s a good one: http://theness.com/neurologicablog/index.php/death-rate-for-home-births/
You seem to be conflating personal ethics with scientific ethics. You may think it’s fair, and maybe it is personally, but comparing two studies (one of which is known to be deeply flawed) isn’t a scientifically ethical basis for medical claims.
What about it was nuanced? The all caps (and misleading) MASSIVE? The boldface for the most misleading line in the post? Using a misleading percentage as the title? I think we have different definitions of nuanced. She went out of her way to highlight conclusions she reached dishonestly.
The graph doesn’t show the low-risk comparison that Tuteur made later in her post. That has no data in the post to support it, as I said. It shows the low-risk number from the MANA study. Jamie isn’t using the graph to do anything in her post. It’s there to show that Amy included it. I was actually kind of surprised Jamie didn’t discuss how the graph itself was misleading. (Do a search for “misleading bar charts” for examples of manipulating scale to make small differences seem large).
Dr. Tuteur’s post is a “What Not to Do When Interpreting Numbers” on multiple levels, but Jamie calling her out on that is the problem. I don’t get it. At all.
I don’t understand about the graph–it has bars for hospital low risk, MANA low risk, and MANA all risk. Personally, I’d have set the hospital rate to 1 and shown the others as a fold change, which is a valid point, but each rate is there.
Dr. Tuteur writes about where she got her numbers, the differences between the hospital and the two risk categories in the MANA paper, spends some time on the push home birth midwives are making to expand their scope of practice, and discusses the truly frightening death rate for breech at home. Only one of those things was mentioned in the article, though all of it is relevant to the difference between MANA declaring home birth safe and SOB declaring it unsafe.
silverfeather13 wrote:
“There have been a lot of posts on this site about the authors being judged harshly and treated badly for having a c-section, or an epidural, or not breastfeeding. I support every one of those choices and would not try to shame you for them. Now here many of you are trying to shame me for mine.
I’m not going to engage on this thread… it is really hostile here.”
In general when people want to make choices that differ from mine it’s none of my business. When they make stupid or dangerous choices that will run the risk of harm to themselves alone, I would warn them but if they are competent adults it’s still not my business to stop them. We have perfectly clear evidence that homebirth is several times more dangerous to both infants and mothers (especially the former) than hospital birth. Even the MANA study shows that, and it was a self-selected groups of providers voluntarily reporting (would you report your disasters if you didn’t have to do so? The real perinatal mortality rate will be higher in all likelihood that shown in this paper.) Given that we are now talking of people making bad choices that run risk not only to themselves, but to their babies that have no say in the decision. It seems right to me that we should speak up a bit more loudly. And when it comes to egregiously bad choices, such as breech, twin, primip, VBAC at home, I think shame IS appropriate. I would actively stop a parent from harming their child – I’m certain you would too. I would speak up if they let their child do something dangerous – and so, I hope, would you. Why wouldn’t we do the exactly same just because the child is in utero? For untrained people to encourage and facilitate high-risk deliveries at home shows either great callousness or great ignorance, and I would do more than shame them. They deserve prosecution. I used to deliver in a rural hospital with no anesthetist, no surgeon/OB, and no blood bank. An hour’s drive to those things won’t work for a cord prolapse or a PPH. I saw my predecessor’s deliveries scissoring down Main Street, those that had CP mildly enough to be able. I stopped it as I knew it wasn’t safe enough. I was not prepared to live with the knowledge that I had caused such things. I simply hope that others have the decency and the foresight to see what they are letting themselves in for and understand their own limitations when they make these choices. Hostility – nothing personal; I just have a thing about people who are careless with the lives of others.
NO, I don’t agree that this is comparable.
I will always speak up against bogus claims, quack medicine and extremely risky things like home-VBAC. But I would never ever agree with intervening in a woman’s decision in childbirth, even if it kills herself or the baby. Because forcing medical treatment on somebody is just plain wrong. And it has happened before and it is still happening.
What I absolutely support is banning pseudo-midwives (CPMs) from comercially treating women. Because medical care is something that belongs into the hands of trained professionals who are insured and who can be held accountable.
This. All of this.
Also keep in mind, the most hideous risk factor in the MANA study was breech position, with a death rate in excess of 2%. In hospital birth, breech position does not increase the risk of death or serious injury to the child at all. It’s a complication, but one that is easily managed with a nice calm planned cesarian birth. In the hospital, breech means zero extra risk to the child, and only a very remote extra risk to the mother. So yes, outcomes for full-term breech babies should be compared to the outcomes of low-risk hospital birth.
Gestational diabetes, preeclampsia and attempted VBAC are considered risk factors in hospital birth, but all are more common in the general population than in the MANA trial. Now, if someone wants to compare risk factor by risk factor, that might be interesting.
Never did say a thing about forcing medical treatment on anyone. I understand the issue of consent and deal with on a daily basis. I merely said I would shame them for damaging and killing their babies by virtue of making dangerous choices.
You didn’t MERELY say shame. Actually you literally said: “I would do more than shame them.” You added prosecution and “actively stop[ping]” as well. Short of performing the medical procedure on someone against their will, how is that not “force”?
Please read for comprehension. I said I would shame the parents, but “For untrained people to encourage and facilitate high-risk deliveries at home shows either great callousness or great ignorance, and I would do more than shame them.” – this applies to their attendants, the CPMs, and I went on to say I would prosecute them. You shouldn’t get your knickers in a twist about imagined enforced medical procedures when there is nothing further from my mind.
Fair enough, but I got the same impression as Gilell, and both of us use reading comprehension skills every day. My knickers aren’t “in a twist.” If you’d like me to break it down, the quote you posted didn’t say anything about CPMs or attendants, and withOUT that disclaimer, “untrained people” could absolutely apply to mothers. Since that’s the group you had last been talking about, it’s not an unfair inference.
I’m glad you clarified it. Thank you.
Well, I think that after clearing up that misunderstanding we’re all on the same side: medical care belongs into the hands of trained medical professionals.
I’m just back from a trip to the ER. I’m glad nobody tried convinc me of the benefits of pain or something like that.
While it is quite possible that Dr. Amy rushed through the numbers and gave an inaccurate analysis (I actually wrote this before reading all the comments, I guess this has been cleared up), there are many studies out there from credible, medical journals which do back up the fact that homebirths are riskier (the AAP, the ACOG, AMA), than hospital births. You can argue/debate about exactly how much more of a risk they are and when they are riskier, but short of all the moons and stars lining up for a completely trouble free pregnancy, the risks of childbirth directly related to amount of access to conventional medicine (technology, trained medical staff) is exponential. And even at twice or 3X the rate of death of hospital births, that’s still significant, IMO.
But Jamie is right, obtaining clear data is difficult to come by, however, there does seem to be more open-mindedness for homebirthing across the medical profession for women who are at low risk, perhaps because it costs so much less, I don’t know.
The problem I have with the whole low risk thing is — you just never know. Further, I honestly don’t know how many homebirth deaths fail to be reported as some homebirthing proponents are so anti-medicine that they only see midwives during their pregnancy and not doctors.
The additional moral dilemma for me is even if there is a similar risk between LOW RISK pregnancies (again, hard to measure — I thought I had a low risk pregnancy until I landed in the ER), I’m not sure how promoting homebirth is more empowering for women. (And I’m not suggesting anybody here is saying that.)
One (and I stress “one”) of the reasons the U.S. has a higher infant mortality rate is that physicians/hospitals tend to take a more heroic effort to save gravely sick babies, coupled with how we report prenatal deaths. This luxury of modern medicine is a choice that should be given to all women, IMO, with the understanding of the very real, potential risks for those who choose to forgo conventional, medical intervention from the beginning.
It is a very sad, sad state that we are in with home birth here in the USA — it is unlike any other developed country out there. It is a confusing system to navigate, it is made up of many different types of midwives all with different levels of training and education, different midwifery organizations and governing bodies, a lot of misleading information and tactics (using infant mortality instead of perinatal mortality, is just one example)… it is a community where concern and questions and dissent is deleted/censored… a community where hospitals are made out to be horrible and evil, bashing OBs is the norm, and yet, any mention of bad home birth outcomes and a woman is accused of fear mongering (incredible double standard)… accountability and transparency are nonexistent… these are all things I learned firsthand as a home birth advocate (and there is even more). And these are reasons why I am a FORMER home birth advocate.
The MANA study is flawed for many reasons. For one it is self reported. This home birth midwife explains how midwives could submit information on births after the fact, thereby having the ability to select which births to submit and which not to submit. Worth a read: http://navelgazingmidwife.squarespace.com/navelgazing-midwife-blog/2014/1/31/my-take-on-the-mana-stats-study.html
The time length it took MANA to release this information was 5 years. How many women gave birth in those 5 years that deserved to see this information? Why did it take so long? For comparison, the Birth Center study took 3 years to publish the study after all the data was collected (study period ended 2010; study released January 30, 2013). The MANA study took 5 years to publish after all the data was collected (study period ended 2009; study released January 30, 2014). Why did it take so long? And why did they release other information from the study but didn’t release mortality rates until later?
The comparison numbers were completely absent in the MANA study. Even for the studies they reference for comparison, they did not put the mortality rates from those other studies in the discussion. So if anyone wants to see what the other mortality rates are, they have to look up the study themselves. Why? Why would they leave that information out?
Why didn’t they compare to hospital data? They use CDC data IN THEIR STUDY to compare for interventions and c-sections. Why didn’t they use the CDC data to compare for mortality rates? The 2013 Birth Center study — from the EXACT SAME JOURNAL — compared to the CDC data for mortality rates. Why didn’t the MANA study?
Most women that I know personally or with whom I have discussed home birth online in forums, on Facebook, on blogs, etc almost ALWAYS say they are having a home birth because “studies show home birth is as safe if not safer than hospital birth.” It’s what I used to believe as well! There is not a single study done on home birth in the USA supports that idea, though. The only people who support that idea is MANA and NARM and Business of Being Born and midwives and anyone else who earns money from home births or who has been misled about the truth.
I feel like this conversation has lived a tortured like and it is time to put it out of its misery. I am closing comments. You may continue discussing this on your own time in your own space.