Showing posts with label Neonatal Death Rates. Show all posts
Showing posts with label Neonatal Death Rates. Show all posts

MANA's "Best Evidence" Shows Homebirth is Unsafe


Families thinking about home birth are often told, either by their midwives or by the blogs and websites that advocate for home birth, that "Birth at home is as safe or safer than the hospital." It is not. Every study on American home birth has shown it to have a significantly higher death rate than the hospital.

"But what about the studies on MANA's website?" some ask. That's a good question. On their website, the Midwives Alliance of North America has a section called "Research" in which they have six subsections (A-F) of studies which they say prove the safety of home birth.

Leigh Fransen, former CPM, LM, and part-owner of a birth center and author of the blog Honest Midwife, has gone through and helpfully summarized all of these studies.

After she finally read all of these studies after years of practicing as a midwife, what the data showed shocked her and eventually led her to leave the profession:

"The hours I had spent combing over all of MANA’s best evidence led me to this conclusion: nonhospital birth might be as safe as hospital birth, but likely only in health systems in which midwives are hospital-trained and well-integrated, and where exclusion criteria are strictly observed to permit only the lowest risk women to proceed. Nonhospital birth in the United States as currently practiced is responsible for lower numbers of interventions (such as cesarean section and medical pain relief) but a substantially higher risk of death or injury to the baby. 

Unbelievably, our 'own' evidence, upon close inspection, was almost unanimously against us."

You can read Leigh's summaries of all of the studies from the MANA website here:

Doing My Research
Section I: Meta-analyses and Systematic Reviews
Section II: RCTs and Section III: Cohort and Population Based Studies
Section III: Cohort/Population Studies Continued
Section III: Cohort/Population Studies (Re-Continued)
Section IV: International Observational Studies
Section V: Descriptive Studies
The MANA Study
The Other Side
My Days as a Midwife Close

In her post The Best Evidence MANA Does Not Want You To See, she writes:

"In my paper High Risk, I reviewed all the literature that the Midwives Alliance of North America (MANA) claims forms the “best evidence” for the safety of home birth. I found that most of the studies were either not applicable to the United States, did not address issues of safety, or actually demonstrated the opposite of what MANA claimed.

If MANA’s cherry-picked data paints a not-so-happy picture, wait until you check out what happens when you look outside of what MANA wants you to see. The literature on nonhospital birth in the United States is downright frightening. Despite what many midwives claim, these studies look at midwife-attended births, not accidental or unattended home births.

If you have had a nonhospital birth like I have, it is natural and normal to feel defensive about the safety of it. After all, to accept that you put your child at a substantial and unnecessary risk doesn’t feel good, even if you know that you made your decision out of love and a genuine desire to make a gentle, safe choice for yourself and your child. Sometimes knowing the truth hurts. I have accepted that my baby was one of the many lucky ones; I invite you to consider joining me in that realization."

Malpractice Insurance


When looking for a safe care provider for your birth, it is very important to find one that carries malpractice insurance.

Many home birth midwives do not carry malpractice insurance, reassuring their clients that they don't need it because "malpractice insurance only protects doctors so that they can keep practicing when they do something wrong."

In truth, malpractice insurance does not protect health care providers who make mistakes. It protects the families who the health care provider injures. Birth injuries in particular can be very costly and require expensive life-long care. If a family chooses a health care provider who carries malpractice insurance, and something goes wrong because of the health care provider, malpractice insurance will allow the family to be able to get the money they need to take care of the injury. If it's a hospital-based doctor or midwife who made the mistake, malpractice insurance will not protect them from the professional repercussions of their actions. Hospital-based care providers are overseen by boards of professionals who thoroughly review their actions; malpractice insurance doesn't protect them in any way from losing their hospital privileges or their license.

On the other hand, if a family chooses a birth center or home birth midwife who does not carry malpractice insurance, and something goes wrong that the midwife should have prevented, the family will have no venues for financial compensation. They will have to pay for the (potentially life-long) costs of the injury themselves. And the home birth midwife will have no professional repercussions, as she has nothing to stop her from taking on new clients without telling them of her past negative outcomes.

Many home birth midwives without malpractice insurance cannot be sued if they have a negative outcome, because very few lawyers will take on a lawsuit against them if they don't carry malpractice insurance. There just isn't enough money in the midwife's bank account to make the lawsuit worth it to the lawyer. And if a lawsuit is successfully brought and won against them, they can just declare bankruptcy, use a new name and continue practicing. One birth center in Michigan did just that.

In a report comparing different state midwifery laws, "Do State Midwifery Laws Matter?", the data shows that requiring midwives to carry malpractice insurance cut the rate of newborn deaths in half. Women and children benefit from midwives carrying malpractice insurance - and they benefit a lot.

If your midwife does not carry insurance because the cost will cut into her profits, she has weighed the pros and cons of not carrying malpractice insurance, and decided that the benefits to her outweigh the risks to you.

Babies Die in Hospitals Too

Yes, they do.

Most babies that die at hospitals cannot be saved despite all of equipment there just for them, and the training and skill of the teams working so hard to save them.

Some babies die at hospitals because of mistakes or negligence.

But.

Whatever the reasons babies die at the hospital, *more* babies die at home. Every study on US home birth has found significantly increased rates of death for babies born at planned, midwife-attended home births than those born at the hospital.

When understanding this point, it's very important to look at the rate. Some people only look at the absolute numbers, and are confused. "But 1,000 babies died at US hospitals last year, and only 100 died in home birth, so doesn't that mean home birth is safer?"

No. Here's why:

Let's say 100 million people go to the library this year, and 14 die while they're there. And 20 people hike Mt. Everest, but only 1 of them dies.

If you're just looking at absolute numbers, you would conclude that going to the library is more dangerous than hiking Mt. Everest, because 14 people died instead of 1.

Now, if you're looking at rate, you'll see that going to the library has a death rate of 0.00000014, while hiking Mt. Everest has a death rate of 0.05. That means hiking Mt. Everest is 357,143 times more dangerous than going to the library. And you understand that by looking at the rate.


According to one of the latest, best studies on US homebirth, the rate of death for newborns born at US hospitals with midwives is 3.1 deaths per 10,000 births. That same study found that the rate of death for newborns born at planned, midwife-attended home births is 13.1 deaths per 10,000 births. So, the rate of death is four times higher at home birth - meaning that home birth is four times more dangerous than hospital birth.

Babies die in hospitals, too. But they die four times more often at home birth.

The Qualifications of US Home Birth Midwives

In trying to understand why the risks of home birth are so elevated compared to hospital birth, it's important to understand the "qualifications" of home birth midwives.

There are several different types of midwives in the United States and if you're not familiar with all of them their titles can sound similar and confusing. CNM, CPM, CM, DEM, LM...what's the difference? As Danielle Repp explains in her series "American Midwives": 

"There are two midwifery certifying bodies in the USA: American Midwifery Certification Board (AMCB) and North American Registry of Midwives (NARM). The AMCB is considered the Gold Standard for midwifery certification and is the certifying body for Certified Nurse Midwives (CNMs) and Certified Midwives (CMs); NARM is the certifying body for Certified Professional Midwives (CPMs). Licensed Midwives (LMs) also fall under NARM as it is the NARM entrance exam they take. Specific requirements for LMs may vary by state in order to take the exam."

"So in short, midwives in the USA basically fall into one of these three categories:
1. AMCB certified
2. NARM certified
3. Uncertified"

She continues:
 
"1. Certified Nurse Midwife (CNM)"

"Certified Nurse Midwives (CNMs) are some of the most highly skilled and educated midwives in the world. The Certified Nurse Midwife is one of the only types of midwives in the world that requires a nursing degree. The CNM also holds a master’s degree as the minimum level of educational requirement (some have doctoral degrees). CNMs must complete their education through an ACME-accredited midwifery program (ACME = Accreditation Commission for Midwifery Education). Once completed, they can apply to take the AMCB certification exam."

"Certified Nurse Midwives are licensed and have prescriptive authority in all 50 states (and other territories of the USA). The educational and clinical skills training of the CNM not only includes pregnancy and birth care but also primary care for women throughout life, reproduction, infertility, newborn care, andent of sexually transmitted diseases."

"2. Certified Midwife (CM)"

"The Certified Midwife (CM) credential has existed since 1994. The CM is the direct-entry version of the CNM. While CMs do not need to have a nursing degree, they must take all of the nursing school pre-requisites (such as anatomy, physiology, microbiology, etc) and must receive a bachelor’s degree and master’s degree. The CM’s educational and clinical skills training is similar to the CNMs, as it again not only includes pregnancy and birth care but also primary care for women throughout life, reproduction, infertility, newborn care, and management of sexually transmitted diseases."

"3. Certified Professional Midwife (CPM)"

"The Certified Professional Midwife credential ... was developed as a direct-entry route to become an out-of-hospital midwife. CPMs are not authorized to work in a hospital setting."

"Certified Professional Midwives do not have any degree requirements. The only educational requirement is to have a high school diploma, which was not a requirement until September 1, 2012."

"The Portfolio Evaluation Process (PEP) is a popular route to become a CPM. It is an apprenticeship where the student midwife follows and learns from a preceptor midwife. After attending 40 births (and the prenatal exams leading up to it), the student midwife can qualify to take the NARM exam. Anyone with a desire to become a midwife can seek out a preceptor. Half of CPMs have earned their credential through the PEP route."

"Another route to become a CPM is to graduate from a Midwifery Education Accreditation Council (MEAC) school. There are nine MEAC schools in the USA, some of which award certifications, some diplomas and some degrees."

"CPMs ...do not have prescriptive authority in any states (in certain states, CPMs are able to obtain certain medications, such as Pitocin, Cytotec, antibiotics, etc but CPMs cannot write prescriptions). CPMs also would not qualify to practice midwifery in other developed countries due to the lack of formal education requirements; the CPM requirements also do not meet the International Confederation of Midwives (ICM) standards."

The above was all from Danielle Repp's series American Midwives, part 1, part 2, and part 3; emphasis mine.

Due to the variation in types of training accepted to become a CPM, some CPMs might have enough education to meet the ICM minimum standards. However, the CPM credential itself does not require it, and ACOG estimates that "possibly as many as two-thirds of CPMs do not meet the ICM standards."

I want to repeat - Certified Professional Midwives - the kind of midwives that attend the majority of the home births in the United States - do not have any educational requirements other than a high school degree. And if they became a CPM before 2012, they don't even need that. They don't need to take anatomy, or physiology, or immunology, or even basic college biology.

And do you know what's even worse? In some states, midwives do not have to have any qualifications at all to practice. None. The state where I spent my college years - Utah - has voluntary licensure, which means that if a midwife simply decides that she'd rather not be licensed by the state, she has no educational requirements, no limits on her scope of practice, and no accountability for her actions. This satirical website points out the weaknesses in such a system.

Here are a couple charts that explain the difference between the midwives who work at doctors offices and in hospitals (CNMs) and the majority of home birth midwives (CPMs, LMs, lay midwives, etc.):


via
via


Now, if you think you'll be safe at home birth if you choose a CNM instead of a CPM, think again. Researchers in 2009 found that home birth with a CNM had twice as many babies die than hospital birth with a CNM. An even more recent study published in 2016 found that babies born to CNMs and CPMs at home birth died three to four times more often than babies born at the hospital, with no statistically significant difference between home births with CNMs or CPMs. Even if your midwife is a CNM instead of a CPM, you still won't be able to tell at home if your baby is being deprived of oxygen, you won't have an operating room if it becomes urgently needed, and you won't have a neonatal resuscitation team with all of the equipment that might be needed to save your baby.

More excellent articles that explain the disparity between US home birth midwives and US hospital midwives and the home birth midwives in other countries can be found here:

The hypothetical situations you can imagine when you think about home birth midwives' lack of education and regulation - like, "If I have an emergency during labor at home, will my midwife know what to do? Will she have the skills and training to save my baby?" - clearly actually happen at home, as we can see from the numbers. With home birth midwives, three times as many babies die. With home birth midwives, seventeen times as many babies have brain injuries. These are the numbers that result from the faulty regulation and extremely low educational requirements required of US home birth midwives.

The Coalition for Safer Home Birth

In response to the increased death rates at home birth and the lack of regulation and accountability of home birth midwives, an citizen-led organization called the Coalition for Safer Home Birth has formed. The Coalition is made up of home birth families, doctors, midwives, and advocates who wish to make home birth safer in America.

https://www.change.org/p/state-legislators-protect-mothers-babies-make-home-birth-safer

To draw our lawmakers' attention to the laws that would most improve the safety of home birth in the United States, the Coalition for Home Birth has started a petition on Change.org.

The petition endorses the following regulations for midwives:

1. Require a License
2. AMCB Certification
3. Malpractice Insurance
4. Low-risk Scope of Practice
5. Report Outcomes to the Public
6. Integrated System of Care

You can sign it here: Change.org: Protect Mothers & Babies - Make Home Birth Safer

We need to improve our home birth system! Please read and sign the petition, and use it as a guide for pushing for a better system in your state.

Home Birth After Cesarean (HBAC)


What is an HBAC?

A vaginal birth after a previous cesarean section is called a VBAC. A home VBAC is often called an HBAC - home birth after cesarean.

Are HBACs riskier than hospital VBACs?

HBACs have nearly four times the newborn death rate that hospital VBACs have. VBACs attempted in the hospital have a neonatal mortality rate of 1.3/1000; this means that one baby will die for about every 800 hospital VBACs attempted. VBACs attempted at home (HBACs) have a neonatal mortality rate of 4.75/1000; this means that one baby will die for about every 200 HBACs attempted.

Why are VBACs considered "high risk"?

In other countries where home births are well-integrated into the medical system and they have regulated risk assessment criteria, having a prior cesarean section means you will be "risked out" of having a home birth. Your pregnancy and labor are considered "high risk." Why is that?

Well, one of the biggest reasons having a prior cesarean section makes you high risk is the increased chance of uterine rupture. In the place where the uterus was cut during the prior cesarean delivery, a scar has formed. The stress of stretching out during pregnancy and then undergoing labor can cause the uterus to tear open at the scar. This is called uterine rupture, and it is a life-threatening event for both mother and baby.

For women who have never had a cesarean section, the uterine rupture rate is only 0.012%, or 1 in 8,434.  For women who have had a previous "classic" cesarean section (vertical cut on the uterus), the uterine rupture rate is 2-11%, or at least 1 in 50 (and possibly as high as 1 in 9). For women who have had a previous low transverse cesarean section (the most common kind of cesarean), the uterine rupture rate is 0.5-2%, or about 1 in 200 (but possibly as high as 1 in 50).

What are the signs of a uterine rupture?

Signs of a uterine rupture include abnormal patterns in the baby's heart rate, tachysystolic contractions (that means where the contractions are one right after the other), vaginal bleeding, shock, prolonged labor, and abdominal pain, but by far the most consistent sign of a uterine rupture is abnormal patterns in the baby's heart rate. The absolute best way to watch for this sign is with continuous electronic fetal monitoring, which can only be done in the hospital.

http://reference.medscape.com/article/275854-overview#a5

Some women have been told that even if they have an VBAC at home, they will definitely be able to tell if they have a uterine rupture because they will experience abdominal pain. But as you can see from the above chart and reference, only one out of every four women who have a uterine rupture experience abdominal pain. Abdominal pain is specifically pointed out as being "an unreliable and uncommon sign of uterine rupture."

Sometimes CPMs and other home birth midwives claim that they have "better training" than nurses or doctors to detect uterine ruptures. This is not true. It may be possible for a home birth midwife to detect a uterine rupture with a doppler if they are listening for longer intervals than normal and at the exact same time as the rupture, but it's highly unlikely they will catch the rupture right away. It's also a myth that being at home with a midwife will prevent a rupture. It will not. Uterine ruptures occur at the same rate in the hospital and out; it's just far more likely at home that the rupture will go undetected until it is too late for the baby.


If the uterus ruptures, how long do you have to save the baby?

When the uterus ruptures, the biggest risk to the baby is lack of oxygen. Essentially, the baby cannot breathe, and the placenta is no longer providing them with oxygen. They are suffocating. A cesarean section needs to be performed immediately to save the baby from brain damage or death. Several studies have shown that you have at most about 18 minutes to deliver the baby after uterine rupture before certain brain damage or death. You can see those studies here and here.

Many families planning home birth are comforted by the fact that "we live just five minutes from the hospital" in case anything goes wrong. But living five minutes from the hospital means you are at least thirty minutes from an emergency c-section, as this post explains: Five Minutes to the Hospital.

VBAC at the hospital vs. VBAC at home, a summary

At the hospital: A woman is attempting a VBAC with continuous electronic fetal monitoring, the best way to detect a uterine rupture. She does, indeed, rupture. The baby's distress is detected almost immediately and the doctors can act immediately to save the baby's life and brain function.

At home: A woman is attempting a VBAC and the baby's heart rate is being checked every fifteen minutes with a doppler. The midwife checks the baby's heart rate. It sounds good. A few minutes after she checks, a rupture occurs. Fifteen minutes later, she checks again. This time she can tell the baby's distressed. They call the ambulance, which takes a few minutes to arrive and another few minutes to get to the hospital. Some more time (we'll estimate 15 minutes) is spent getting the mom ready for an emergency c-section. By this time, the baby's been without oxygen for over 30 minutes and is most likely lost or at the very least severely brain damaged.


VBACs are classified as "high risk" for a reason. 

https://www.facebook.com/groups/birthaftercsectionfacts/

Home Birth Death in Hawaii

A newborn died last Wednesday as the result of an attempted home birth in Hawaii. From the Hawaii Tribune Herald

"One obstetrician said that Wednesday’s death had taken a toll on hospital staff, especially because of the fact that it was another in a disturbing trend."

“'This is an ongoing problem here. … Within the last five years, I’ve seen at least three dead babies from home births, and just a week ago I took care of a patient who nearly bled to death after a home birth,' the doctor said. 'All of the obstetricians here have had similar experiences. And in all of these situations, the standard of care of obstetric practice was not followed by the practitioners. I believe that all of these bad outcomes could have been avoided if good practice patterns were actually followed.'”

"The obstetrician said that state law does not require licensing and oversight of midwives and other practitioners that aid in the home birthing of babies, which can lead to dangerous situations."

“'You need a license to be a plumber, you need a license to be a carpenter, you need a license to cut hair in the state of Hawaii. You do not need a license to deliver a baby,' the doctor said. 'I have had multiple occasions where babies died, and did not need to die, and there are no repercussions for the people who misled these patients.'”

Read the full article here: Hawaii Tribune Herald: Death of newborn rekindles home-birth debate

Doesn't the US have a high infant mortality rate?

Home birth advocates often say that hospital birth is clearly unsafe, as the "United States has one of the highest infant mortality rates in the world."

The problem is that infant mortality is not how you measure obstetric safety.

Infant mortality includes all deaths from birth to one year of age. This makes it a measure of pediatric care, not the safety of obstetric care.

According to the WHO, the best measure of obstetric care (care during pregnancy, labor, and delivery) is perinatal mortality, which it defines as deaths from the 22nd week of pregnancy to the 7th day of life. And the United States has one of the best perinatal mortality rates in the world, lower than Denmark, the UK, and the Netherlands.

So does the United States really have one of the worst obstetric systems in the world? No. It has one of the best.
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The Johnson and Daviss Study


As I discussed in the last post, we can only use studies that use home birth data from the United States to determine whether home birth in the United States is safe.

And when you look at that data, you find that every study on planned, midwife-attended home birth in the United States shows that significantly more babies die at home birth than at hospital birth:


Other than those listed, there is one more major study on home birth in the United States. It is called "Outcomes of planned home births with certified professional midwives: large prospective study in North America," it was published in 2005 by the authors Johnson and Daviss, and it claims to have found that planned home birth had "lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States."

The problem is, the data didn't actually show that.

When analyzing the number of interventions for their study, Johnson and Daviss compared numbers from home birth in the year 2000 to hospital births in the year 2000. But then when looking at mortality (death) rates, they compared the home birth numbers from 2000 to hospital numbers stretching all the way back to 1969, when death rates in the hospital were much higher.  After doing this, they said that found a neonatal death rate of 2.7 per 1000 for home births and 2.6 per 1000 for hospital births.

When it was pointed out to them that the data actually showed a hospital death rate of 0.9 per 1000 in the year 2000, meaning that their study really showed home birth had 3 times the death rate as hospital birth, the authors admitted that the hospital death rate in 2000 was indeed 0.9 per 1000. They claimed that the data wasn't available to make the correct comparison at the time of their study, even though it was available since 2002 and their study was published in 2005.

After admitting the correct hospital neonatal mortality rate in 2000 was 0.9 per 1000, they then tried to claim that home birth in 2000 *actually* had that same death rate. They did this by excluding groups of deaths from the home birth data that they did not exclude from the hospital data. If those same groups were excluded from the hospital data, the hospital death rate would drop down to 0.34 per 1000 - still showing the same conclusion: three times as many babies died at home birth than at the hospital.

Why would Johnson and Daviss go to all these lengths to claim that the data showed home birth is safe, even when it didn't? Well, the reader might be surprised to know (since they did not disclose it in their paper) that Johnson used to work for the Midwives Alliance of North America, and Daviss is a homebirth midwife.
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Is Home Birth in the United States Safe?


One day, I decided to type the question "Is home birth safe?" into Google. I tried two variations - "Is home birth safe?" and "Is homebirth safe?"

In an excellent example of why we shouldn't trust everything we read on the internet, for both searches the "Google Answer Box" at the top of the page quoted an article by the Midwives Alliance of North America, which said: "In today's peer-reviewed Journal of Midwifery & Women's Health, a landmark study confirms that among low-risk women, planned home births result in low rates of interventions without an increase in adverse outcomes for mothers and babies."

The problem? This is a lie. Every study done on planned, midwife-attended home birth in the United States - including the study quoted in the answer box - has found significantly increased rates of babies dying at home birth. 


The study quoted in the Google Answer Box, titled "Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009" and done by the Midwives Alliance of North America, found that the rate of newborn death at homebirth was 5.5 times higher than the newborn death rate at hospitals. 

And the worst part? The MANA study relied on voluntary, self-reported numbers from home birth midwives. With obvious personal interests in making the numbers look better, is is likely that many negative outcomes were not reported by midwives. In all likelihood, home birth has even worse outcomes than found by their study.

Here's a break down of the numbers from the MANA study: 

The CDC Wonder Database (an excellent, extremely accurate source of information) shows that for the years of the study (2004-2009), the neonatal death rate for babies born in the hospital to a comparable sample group was 0.38/1000. The "MANA Home Birth Data 2004-2009" for that same time period found that "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."

That overall death rate - 2.06 deaths per 1,000 - is 5.5 times higher than the comparable hospital death rate, 0.38 deaths per 1,000. The death rate found for only low-risk home births - 1.61/1000 - was still 4.2 times higher than the hospital death rate. 

The study done by MANA, which they claim shows home birth is safe, shows that 4 to 5.5 times more babies die at home birth than at the hospital. 

Home birth in the United States is not safe.
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