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."

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.

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. 

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:

• Term neonatal deaths resulting from home births: an increasing trend – Study from 2014 that found a death rate 4 times higher at home birth than hospital birth
• Oregon Study – Study from 2012 that found a death rate 8 times higher at home birth than hospital birth
• Infant outcomes of certified nurse midwife attended home births: United States 2000 to 2004 – Study from 2010 found that home birth with CNMs had 2 times more deaths as the hospital, and home birth with CPMs had 3.5 times more deaths than the hospital 
• MANA Study - Study published in 2014 by the Midwives Alliance of North America that found a death rate 5.5 times higher at home birth (for breech babies the death rate was 28 times higher)
• Home birth and risk of neonatal hypoxic ischemic encephalopathy – Study that found that home birth babies suffer 17 times as many brain injuries 
• Selected perinatal outcomes associated with planned home births in the United States – Study that found that 3 times as many babies born at home have seizures
• Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting – Study that found almost 4 times as many babies born at home have seizures, and 10 times as many babies born at home have a five minute Apgar score of 0

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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Why international studies do not show American home birth is safe

Home birth in the United States is very different from home birth in other developed countries.

Different Midwives

In countries like Canada, the UK, and the Netherlands, the midwives have much higher educational standards than US homebirth midwives. They must have a university degree, they meet the standards set forth by the International Confederation of Midwives, they are integrated into the health care system, and they have hospital privileges.

Most home births in the United States are attended by Certified Professional Midwives (CPMs) or Licensed Midwives (LMs). Neither CPMs nor LMs would be able to practice in any other developed country; their educational standards are just too low. They do not have to have a university degree (if a midwife became a CPM before 2012, she doesn't even need to have a high school degree), their credential does not meet the standards set forth by the International Confederation of Midwives, they are not integrated into the health care system, and they do not have hospital privileges.

Certified Nurse Midwives (CNMs), which do attend some home births in the United States, are much more similar to midwives found in other developed countries. Like the midwives found in the UK, Canada, and the Netherlands, they must have a university degree, they meet the standards set forth by the International Confederation of Midwives, they are integrated into the health care system, and they are (usually) able to obtain hospital privileges.

This helpful chart from "American Home Birth" illustrates the differences between the types of midwives:

Different Systems 

In addition to the differences between American midwives and the midwives found in Canada, the UK, and the Netherlands, the home birth systems are completely different.

In Canada, the UK, the Netherlands, and other developed countries home birth is integrated into the main medical system. Midwives are highly regulated and have accountability for their actions and outcomes.

If a woman wants to have home birth, she is assessed by a care provider to make sure that she is "low risk." "Low risk" means she does not have risk factors such as a previous cesarean, twin (or other multiple) pregnancy, breech baby, previous postpartum hemorrhage, and much, much more. These things are not just "variations of normal" - they are complications that increase the risk to woman and baby during pregnancy and labor. The risking out criteria is quite extensive, to make sure that only the lowest-risk women are attempting home birth.

If a woman develops risk factors any time during her pregnancy or labor, her care is transferred to an OB and she delivers in the hospital. The transfer rate is quite high - about 40% in the Netherlands. A high transfer rate is the sign of a good home birth system - it means the midwives are recognizing risk factors and taking them seriously. Transferring is to keep the woman and her baby safe, as they are no longer safe attempting a home birth with their risk factors.

In the US, home birth is not integrated into the main medical system. There are almost two systems - the hospital system, and the home birth system. Home birth midwifery laws are determined on a state level, and there is an incredible amount of variation between the states. In general, accountability of out-of-hospital midwives is very low.

In the United States there are no national risking out criteria for women attempting home birth, and the states that do have legally required risking out factors have very few of them. Here is a chart that compares the Dutch risking out criteria to Oregon's risking out criteria: Dutch Homebirth Standards vs. Oregon Homebirth Standards. And most states have even less risking out criteria than Oregon.

In most states where midwives can legally attend out of hospital births, they are free to take on women of any risk, and pride themselves on their low transfer rates - even though a low transfer rate is a sign that a midwife is either missing risk factors or ignoring them.

For all of these reasons - poor education, training, regulation, and accountability of US midwives, and the large differences in the US homebirth system compared to the homebirth systems in other developed countries - one cannot use studies from other countries to prove that home birth in the United States is safe. One must use home birth data from, and only from, the US to determine safety of home birth in the United States. 
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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. 

• MANA Study – This is the study mentioned above, released in 2014 by the Midwives Alliance of North America. It found a death rate 5.5 times higher at home birth (for breech babies the death rate was 28 times higher)
• Term neonatal deaths resulting from home births: an increasing trend – Study from 2014 that found a death rate 4 times higher at home birth than hospital birth
• Oregon Study – Study from 2012 that found a death rate 8 times higher at home birth than hospital birth
• Birth Outcomes of Planned Home Births in Missouri: A Population-Based Study – Study from 2011 that found that home birth resulted in a 5 times increase in neonatal seizures, and an 11-20 times increase in intrapartum (during labor) deaths.
• Infant outcomes of certified nurse midwife attended home births: United States 2000 to 2004 – Study from 2010 found that home birth with CNMs had 2 times more deaths as the hospital, and home birth with CPMs had 3.5 times more deaths than the hospital 
• Neonatal Mortality of Planned Home Birth in the United States in Relation to Professional Certification of Birth Attendants – Study published in 2016 that found babies born to CNMs and CPMs at planned home births died three to four times more often than babies born at the hospital, with no statistically significant difference between CNMs or CPMs at home
• Home birth and risk of neonatal hypoxic ischemic encephalopathy – Study that found that home birth babies suffer 17 times as many brain injuries 
• Selected perinatal outcomes associated with planned home births in the United States – Study that found that 3 times as many babies born at home have seizures
• Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting – Study that found almost 4 times as many babies born at home have seizures, and 10 times as many babies born at home have a five minute Apgar score of 0

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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