Posts Tagged ‘ACOG’

Time for ACOG and ASA to Change Their Guidelines! Eating and Drinking in Labor Should Not Be Restricted

October 27th, 2015 by avatar

“…The problem for anesthesiologists is that our practice guidelines on obstetric anesthesia are strongly worded, and state that women can not eat during labor. We can’t ethically design a large enough study to answer this question, so we will have to wait for expert opinion to change.” – Paloma Toledo, MD

Screenshot 2015-10-26 17.04.39Social media was all abuzz yesterday about information coming out of the American Society of Anesthesiologists (ASA) conference currently being held in San Diego, CA. Headlines everywhere screamed “Eating During Labor May Not Be So Bad, Study Suggests,” “Light Meal During Labor May Be Safe for Most Women,” and “Eating During Labor Is Actually Fine For Most Women.”  People chortled over the good news and bumped virtual fists over the internet celebrating this information.

The ASA released a press release highlighting a poster being presented at the ASA conference by two Memorial University medical students, Christopher Harty and Erin Sprout. Memorial University is located in St. Johns, Newfoundland, Canada. When a professional conference is being held, several press releases are published every day to advise both professionals and the public about news and information related to the conference. This was one of many released yesterday.

The student researchers suggested in their poster presentation that it may be time for a policy change. Their research indicated that, according to the ASA database, there has only been one case of aspiration during labor and delivery in the period between 2005 and 2013. That aspiration situation occurred in a woman with several other obstetrical complications. “…aspiration today is almost nonexistent, especially in healthy patients,” the researchers stated. The research was extensive – examining 385 studies published since 1990. Much of the research available supported the findings in the poster presentation/study.

The current policy of the ASA on oral intake in labor is that laboring women should avoid solid food in labor. You can read the ASA’s most current guidelines, published in 2007: Practice Guidelines for Obstetric Anesthesia An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia.  The American College of Nurse Midwives recommends “that women at low risk for pulmonary aspiration be permitted self-determined intake according to guidelines established by the practice setting.” They also conclude “drinking and eating during labor can provide women with the energy they need and should not be routinely restricted.”  American College of Obstetricians and Gynecologists recommends no solid food for laboring women and refers to the ASA guidelines.

I connected with Paloma Toledo, MD, an obstetrical anesthesiologist who is attending the ASA conference in San Diego to ask her what her thoughts were on this new research. “General anesthesia is becoming increasingly rare, so fewer women are at risk for aspiration, since most women will have neuraxial anesthesia for unplanned cesarean deliveries. The question is, is eating in labor unsafe? They do allow a light meal in the UK, studies have shown that eating does not adversely affect labor outcomes, and in the CEMACE data, despite allowing women to eat in the UK, there have not been deaths related to aspiration. I think a lot of women want to move away from the medicalized childbirth and have a more natural experience. Women want to eat, and I believe the midwife community has been encouraging eating in labor. The problem for anesthesiologists is that our practice guidelines on obstetric anesthesia are strongly worded, and state that women can not eat during labor. We can’t ethically design a large enough study to answer this question, so we will have to wait for expert opinion to change.”

Lamaze International released an infographic in July, 2014 covering this very topic. “No Food, No Drink During Labor? No Way!” and I covered this in a Science & Sensibility post sharing more details.  You can find all the useful infographics available for downloading, sharing and printing here.  Additionally, the fourth Healthy Birth Practice speaks to avoiding routine interventions that are not medically necessary, and it has long been clear that restricting food and drink in labor is certainly an intervention that should not be imposed.

It is important for birth professionals to recognize what the American Society for Anesthesiologists’ press release is and what it is not. We must not overstate the information that they have shared. Please be aware that this is not a policy change.

Hopefully, this will be a call to action by the ASA to examine the contemporary research and determine that that their existing guidelines are outdated and do not serve laboring and birthing people well, nor reflect current research.

Childbirth educators and others can continue to share what the evidence says about the safety and benefit of oral nutrition during labor and encourage families to request best practice from their healthcare providers and if that is not possible, to consider changing to a provider who can support evidence based care.


American College of Nurse-Midwives, (2008). Providing Oral Nutrition to Women in Labor.Journal of Midwifery & Women’s Health53(3), 276-283.

American Society of Anesthesiologists Task Force on Obstetric Anesthesia. (2007). Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia.Anesthesiology106(4), 843.

Committee on Obstetric Practice. (2009). ACOG Committee Opinion No. 441: Oral intake during labor. Obstetrics and gynecology114(3), 714.

Singata M, Tranmer J, Gyte GML. Restricting oral fluid and food intake during labour. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD003930. DOI: 10.1002/14651858.CD003930.pub3.

Childbirth Education, Do No Harm, Evidence Based Medicine, Healthy Birth Practices, Lamaze International, Medical Interventions, Research , , , , , , , ,

Elective Induction at 40 Weeks? “Decision-Based Evidence Making” Strikes Again

July 14th, 2015 by avatar

Today on Science & Sensibility, contributor Henci Goer takes a look at a systematic review released in spring that examined the impact of elective inductions on the cesarean rate.  Sound analysis or a house of cards?  Looking closer at the studies reviewed provides insight into how the conclusions reached by the investigators might need to be examined more closely.  Henci does that in this review.  Have you read this new systematic review?  Did you come to the same conclusions?  I invite you to share your thoughts in our comments section below. – Sharon Muza, Community Manager, Science & Sensibility.

flickr photo by catharticflux http://flickr.com/photos/catharticflux/2710057340  CC licensed.

flickr photo by catharticflux http://flickr.com/photos/catharticflux/2710057340 CC licensed.

Yet another systematic review has surfaced “Induction of labor at full term in uncomplicated singleton gestations: a systematic review and metaanalysis of randomized controlled trials”  in which reviewers claim that electively inducing healthy women, this time at 40, not 41 weeks, offers benefits and doesn’t increase the cesarean surgery rate (Saccone 2015).

Let’s take a closer look.

Reviewers included five trials: three of them conducted in the 1970s (Cole 1975; Martin 1978; Tylleskar 1979), the fourth published in 2005 (Nielsen 2005), and the fifth in 2014 (Miller 2014). Already we have a problem. Induction management in the 1970s is sufficiently different from management today that results are unlikely to apply to contemporary care, but let’s get down to specifics. Two of the 1970s trials were deemed inadequate for inclusion in the Cochrane review of elective induction (Gulmezoglu 2012), and Miller 2014 is published only as an abstract. Quality systematic reviews exclude abstracts because they don’t provide enough information to evaluate the study. For these reasons, these three trials should be taken off the table..

That leaves us with the other two. Nielsen 2005 states in the title “Comparison of elective induction of labor with favorable Bishop scores versus expectant management: a randomized clinical trial” that it is confined to women with favorable Bishop scores. Anyone familiar with elective induction research should know that inducing when the cervix is ready to go won’t increase the cesarean rate compared with spontaneous onset, but inducing with an unripe cervix is a different story even when using cervical ripening agents (Dunne 2009; Jonsson 2013; Le Ray 2007; Macer 1992; Prysak 1998; Thorsell 2011; Vahratian 2005). As you move the induction date earlier and earlier, more and more women will have an unfavorable cervix, so including a trial limited to women with a ripe one will tilt the playing field in favor of induction. Furthermore, half the participants were multiparous women (113/226). Women with prior vaginal births will go on having vaginal births pretty much no matter what you do to them, which raises another point: inducing earlier means a higher percentage of the inductees will be first-time mothers because first time mothers tend to run longer pregnancies (Mittendorf 1990). Nulliparous women are much more vulnerable to anything that pushes them in the direction of a cesarean. That’s not all: The authors tell us that their hospital has a 7% cesarean rate for dystocia in women at term. If a hospital has a cesarean rate much higher than that—and many do—then results can’t be generalized to it, although, frankly, if the doctors are performing cesareans left and right, induction or spontaneous onset may not make much difference. In short, Nielsen (2005) doesn’t make a compelling argument for 40-week elective induction.

flickr photo by Selbe <3 http://flickr.com/photos/stacylynn/11944718954 shared under a Creative Commons (BY-NC-ND) license

flickr photo by Selbe < http://flickr.com/photos/stacylynn/11944718954 shared under a Creative Commons (BY-NC-ND) license

This brings us to the last trial, Cole (1975). Investigators allocated healthy women either to induction at 40 weeks (111 women) or 41 weeks (117 women). As with Nielsen, half the women had prior vaginal births. Despite being healthy, 22 women were induced for “obstetric complications” (undefined) in the 41-week induction group before reaching 41 weeks. If their doctors induced labor because they had concerns, then this would likely put the women at heightened risk for cesarean. Another 32 women were induced for exceeding 41 weeks. This means that overall, nearly half (46%) of the comparison group didn’t begin labor spontaneously, which would mask any association between induction and cesarean. Leaving the induction vs. spontaneous onset issue aside, the U.S. cesarean rate in the early 1970s was around 5%, which means it was a rare woman who would have one regardless of circumstances. Again, not exactly a strong case for inducing at 40 weeks.

What about the benefits? The best reviewers can come up with are a clinically meaningless reduction in mean blood loss (-58 ml); a lower rate of meconium-stained amniotic fluid (4% vs. 14%), not, mind you, a reduction in meconium aspiration, and therefore clinically meaningless as well; and an equally meaningless reduction in mean birth weight of -136 g (5 oz). If they had found something more impressive, surely they would have reported it.

Really? This merited a pre-publication media blast? Because it amounts to a textbook example of “garbage in, garbage out.” I can see only three possibilities to explain it: either 1) the authors and peer reviewers at the American Journal of Obstetrics and Gynecology (AJOG) don’t know as much as they should about what constitutes a quality systematic review, 2) they are so steeped in medical model thinking—“How early can we get the baby out of that treacherous maternal environment?”—that their judgment is compromised, or 3) we have a “pay no attention to what’s behind the curtain” effort to promote elective induction. I don’t know which is the more troubling, but if it’s the last one, the sad thing is that because it’s got the magic words “systematic review,” “meta-analysis,” and “randomized controlled trials” in the title, it’s likely to succeed.


Cole, R. A., Howie, P. W., & Macnaughton, M. C. (1975). Elective induction of labour. A randomised prospective trial. Lancet, 1(7910), 767-770.

Dunne, C., Da Silva, O., Schmidt, G., & Natale, R. (2009). Outcomes of elective labour induction and elective caesarean section in low-risk pregnancies between 37 and 41 weeks’ gestation. J Obstet Gynaecol Can, 31(12), 1124-1130.

Gulmezoglu, A. M., Crowther, C. A., Middleton, P., & Heatley, E. (2012). Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev, 6, CD004945.

Jonsson, M., Cnattingius, S., & Wikstrom, A. K. (2013). Elective induction of labor and the risk of cesarean section in low-risk parous women: a cohort study. Acta Obstet Gynecol Scand, 92(2), 198-203. doi: 10.1111/aogs.12043

Le Ray, C., Carayol, M., Breart, G., & Goffinet, F. (2007). Elective induction of labor: failure to follow guidelines and risk of cesarean delivery. Acta Obstet Gynecol Scand, 86(6), 657-665.

Macer, J. A., Macer, C. L., & Chan, L. S. (1992). Elective induction versus spontaneous labor: a retrospective study of complications and outcome. Am J Obstet Gynecol, 166(6 Pt 1), 1690-1696; discussion 1696-1697.

Martin, D. H., Thompson, W., Pinkerton, J. H., & Watson, J. D. (1978). A randomized controlled trial of selective planned delivery. Br J Obstet Gynaecol, 85(2), 109-113.

Miller, N., Cypher, R., Pates, J., & Nielsen, P. E. (2014). Elective induction of nulliparous labor at 39 weeks of gestation: a randomized clinical trial. Obstet Gynecol,132(Suppl 1):72S.

Mittendorf, R., Williams, M. A., Berkey, C. S., & Cotter, P. F. (1990). The length of uncomplicated human gestation. Obstet Gynecol, 75(6), 929-932.

Nielsen, P. E., Howard, B. C., Hill, C. C., Larson, P. L., Holland, R. H., & Smith, P. N. (2005). Comparison of elective induction of labor with favorable Bishop scores versus expectant management: a randomized clinical trial. J Matern Fetal Neontal Med, 18:59-64.

Prysak, M., & Castronova, F. C. (1998). Elective induction versus spontaneous labor: a case-control analysis of safety and efficacy. Obstet Gynecol, 92(1), 47-52.

Saccone, G., & Berghella, V. (2015). Induction of labor at full term in uncomplicated singleton gestations: a systematic review and metaanalysis of randomized controlled trials. American journal of obstetrics and gynecology.

Thorsell, M., Lyrenas, S., Andolf, E., & Kaijser, M. (2011). Induction of labor and the risk for emergency cesarean section in nulliparous and multiparous women. Acta Obstet Gynecol Scand, 90(10), 1094-1099. doi: 10.1111/j.1600-0412.2011.01213.x

Tylleskar, J., Finnstrom, O., Leijon, I, et al. (1979). Spontaneous labor and elective induction – a prospective randomized study. Effects on mother and fetus. Acta Obstet Gynaecol Scand, 58:513-518.

Vahratian, A., Zhang, J., Troendle, J. F., Sciscione, A. C., & Hoffman, M. K. (2005). Labor progression and risk of cesarean delivery in electively induced nulliparas. Obstet Gynecol, 105(4), 698-704.out

About Henci Goer

Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach She is the winner of the American College of Nurse-Midwives “Best Book of the Year” award. An independent scholar, she is an acknowledged expert on evidence-based maternity care.


ACOG, Cesarean Birth, Childbirth Education, Do No Harm, Evidence Based Medicine, Guest Posts, Medical Interventions, New Research, Research , , , , , ,

Great Line-up of Plenary Conference Speakers and President’s Desk Updates

May 14th, 2015 by avatar

lamaze icea conf 2015Today on Science & Sensibility – news you can use!  Plenary speakers have been announced for the upcoming conference and Robin Elise Weiss, Lamaze International’s Board President has a new series of informative videos called “From the President’s Desk” that you will want to check out.  Read on for information on both of these topics.

Lamaze/ICEA Joint Conference News

Lamaze International and the International Childbirth Education Association (ICEA) just announced their plenary (general session) speaker line up for the joint Lamaze/ICEA 2015 conference at Planet Hollywood, Las Vegas on September 17-20.  Four speakers will address the entire conference in general sessions and I am very much looking forward to listening to their presentations along with the many concurrent sessions that will be offered over the four days of the conference.

ICEA and Lamaze celebrated their 50th anniversaries together in 2010 in Milwaukee, WI with a well attended “mega-conference” that had great energy and educational offerings and I expect that this conference will be just as big and wonderful.  Bringing together two leaders in childbirth education to hold a joint conference means that all attendees will benefit in numerous ways.

The theme of the Las Vegas conference is “Raising the Stakes for Evidence Based Practices & Education in Childbirth” and I know that educators, doctors, midwives, doulas, L&D nurses, IBCLCs and others will come together and take advantage of this joint conference to network, learn, receive contact hours, and socialize with other professionals.  Maybe, even win a little at the blackjack tables or take in a great show.  Las Vegas is a great venue for this conference, offering a wide variety of locales, activities and nightlife to enjoy outside of conference  hours.

This year’s plenary speakers

camman head shot 2015William Camann, MD
Director of Obstetric Anesthesia, Brigham and Women’s Hospital,  Associate Professor of Anesthesia, Harvard Medical School

Presentation: What does the informed childbirth educator need to know about labor pain relief in 2015?



combellick head shot 2015Joan Combellick, MSN, MPH,CM
PhD Student, NYU College of Nursing
Midwife, Hudson River Healthcare

Presentation: Watchful Waiting Revisited: Birth Experience and the Neonatal Microbiome



Joseph head shot 2015Jennie Joseph, LM, CPM
Co-Founder and Executive Director
Commonsense Childbirth School of Midwifery

Presentation:The Perinatal Revolution: Reducing Disparities and Saving Lives through Perinatal Education and Support



mcallister head shot 2015Elan McAllister
Founder, Choices in Childbirth

Presentation: No Day But Today





Concurrent sessions

Watch the website for soon to be released information on concurrent speakers and their topics.  Concurrent sessions will fall into one of four categories:

  • Evidence-Based Teaching and Practice
  • Using Technology and Innovation to Reach Childbearing and Breastfeeding Women
  • New and Emerging Research in the Field of Childbearing and Breastfeeding
  • Challenges of the Maternal Child Professional

Preconference workshops

Additionally, there will be two preconference workshops available for a small additional fee.  These 4 hour workshops allow you to really immerse yourself in the topic and leave with concrete skills applicable to your work with childbearing families.

  • Movement in Birth (AM)
  • Social Media Smarts: Strategic Online Marketing for the Busy Childbirth Professional (PM)

Early bird registration is open until August 1, 2015, so registering now allows you to save money on the conference fees and make your travel and hotel plans now.  Look for interviews with the plenary speakers over the next few months on Science & Sensibility.

 From the President’s Desk

Board President Robin Elise Weiss, Ph.D, has recently made a series of short and useful videos for Lamaze International on several topics.  The video series is called “From the President’s Desk”. Released to date are several on cesareans;

Robin’s newest video discusses the recently released ACOG committee opinion “Clinical Guidelines and Standardization of Practice to Improve Outcomes“. This video helps both birth professionals and consumers to understand how pushing for the best evidence based care can result in both pregnant people and their babies having improved outcomes.  ACOG wants to be able to offer best practice to those receiving care from its members, and consumers can help by sharing their desire to receive care in line with recommended guidelines.

Head over to Lamaze International’s YouTube Channel to see all the offerings, share the relevant videos with your students and clients and subscribe to the channel so that you don’t miss any of the releases.

2015 Lamaze & ICEA Joint Conference, ACOG, Cesarean Birth, Childbirth Education, Conference Calendar, Conference Schedule, Continuing Education, Lamaze International, Lamaze News , , , , , , , , , , , ,

Celebrate International Day of the Midwife! ACOG Calls for Universal ICM Standards

May 5th, 2015 by avatar

Lamaze and Midwives IDM 2015Lamaze International and Science & Sensibility join with other partners around the world to celebrate International Day of the Midwife.  This global celebration is observed every year on May 5th and was officially recognized by the International Confederation of Midwives in 1992. (Read Judith Lothian’s report from the 2014 ICM Congress here.) This year’s theme is “The World Needs Midwives Today More Than Ever.”

Key midwifery concepts and model of care

Key midwifery concepts as defined by the International Confederation of Midwives describe the unique role that midwives have in providing care to women and families:

  • partnership with women to promote self-care and the health of mothers, infants, and families;
  • respect for human dignity and for women as persons with full human rights;
  • advocacy for women so that their voices are heard and their health care choices are respected;
  • cultural sensitivity, including working with women and health care providers to overcome those cultural practices that harm women and babies;
  • a focus on health promotion and disease prevention that views pregnancy as a normal life event;
  • advocacy for normal physiologic labour and birth to enhance best outcomes for mothers and infants.  (Fullerton, Thompson & Severino, 2011).

ACOG advocates universal standards



On April 20, 2015, the American College of Obstetricians and Gynecologists (ACOG) endorsed the International Confederation of Midwives education and training standards and suggested that this criteria be adopted as the minimum requirements for midwifery licensure in the United States.  ACOG “advocates for implementation of the ICM standards in every state to assure all women access to safe, qualified, highly skilled providers.” In the same document, ACOG calls for a single midwife credential.  Currently, in the USA there are certified nurse midwives (CNM), Certified Midwives (CM) and Certified Professional Midwives (CPM) and they all have different core competencies and educational requirements.  You can read the entire ACOG statement here.  This document is meant to accompany their Levels of Maternal Care statement that I wrote about in a previous blog post.  Both of these recent statements signify a recognition that families have choices about the type of health care provider they receive their maternity care from and that more and more families every year are choosing midwifery.

Five interesting facts about midwifery

  1. There are approximately 26,000 midwives in the USA.  This number includes Certified Nurse Midwives, Certified Midwives and Certified Professional Midwives.
  2. Midwives practice and catch babies in hospitals, birth centers and in families’ homes.
  3. Midwives who are educated and regulated to international standards can provide 87% of the essential care needed for women and newborns. (UNFPA, 2014)
  4. 11.3% of all babies born in the USA in 2013 were caught by midwives (Martin, Hamilton, Osterman, et al. 2015)
  5. Approximately 0.6% of all midwives in the USA are male. (Pinkerton, Schorn, 2008)


How are you celebrating International Day of the Midwife in your community and in your classes?  Have you reached out to the midwives in your community and let them know that they are appreciated?  Take a moment to do so and join Lamaze International in thanking midwives for helping families have safe and healthy  births.


Fullerton, J. T., Thompson, J. B., & Severino, R. (2011). The International Confederation of Midwives essential competencies for basic midwifery practice. An update study: 2009–2010. Midwifery, 27(4), 399-408.

Martin JA, Hamilton BE, Osterman MJK, et al. Births: Final data for 2013. National vital statistics reports; vol 64 no 1. Hyattsville, MD: National Center for Health Statistics. 2015.

Pilkenton, D., & Schorn, M. N. (2008). Midwifery: a career for men in nursing.Men in Nursing Journal, 3(1), 32.

UNFPA. The State of the World’s Midwifery 2014. A Universal Pathway. A Woman’s Right to Health. United Nations Population Fund, New York; 2014

Breastfeeding, Home Birth, Midwifery, Uncategorized , , , , , , , , ,

Henci Goer – Fact Checking the New York Times Home Birth Debate

February 26th, 2015 by avatar
home birth

© HoboMama

An article in The New York Times Opinion Pages – Room for Debate was released on February 24th, 2015.  As customary in this style of article, the NYT asks a variety of experts to provide essays on the topic at hand, in this case, the safety of home birth. Henci Goer, author and international speaker on maternity care, and an occasional contributor to our blog, takes a look at the facts on home birth and evaluates how they line up with some of the essay statements. Read Henci’s analysis below.  – Sharon Muza, Science & Sensibility Community Manager

As one would predict, three of the four obstetricians participating in the NY Times debate “Is Home Birth Ever a Safe Choice?“assert that home birth is unacceptably risky. Equally predictably, the evidentiary support for their position is less than compelling.

John Jennings, MD president of the American Congress of Obstetricians & Gynecologists, in his response- “Emergency Care Can Be Too Urgently Needed,” cites a 2010 meta-analysis by Wax and colleagues that has been thoroughly debunked. Here is but one of the many commentaries, Meta-Analysis: The Wrong Tool Wielded Improperly, pointing out its weaknesses. In a nutshell, the meta-analysis includes studies in its newborn mortality calculation that were not confined to low-risk women having planned home births with a qualified home birth attendant while omitting a well-conducted Dutch home birth study that dwarfed the others in size and reported equivalent newborn death rates in low-risk women beginning labor at home and similar women laboring in the hospital (de Jonge 2009).

The other naysayers, Grunebaum and Chervenak, in their response – “Home Birth Is Not Safe“, source their support to an earlier NY Times blog post that, in turn, cites a study conducted by the two commentators (and others) (Grunebaum 2014). Their study uses U.S. birth certificate data from 2006 to 2009 to compare newborn mortality (day 1 to day 28) rates at home births attended by a midwife, regardless of qualifications, with births attended by a hospital-based midwife, who almost certainly would be a certified nurse midwife (CNM) in babies free of congenital anomalies, weighing 2500 g or more, and who had reached 37 weeks gestation. The newborn mortality rate with home birth midwives was 126 per 10,000 versus 32 per 10,000 among the hospital midwives, nearly a 4-fold difference. However, as an American College of Nurse-Midwives commentary on the abstract for the Society for Maternal-Fetal Medicine presentation that preceded the study’s publication observed, vital statistics data aren’t reliably accurate, don’t permit confident determination of intended place of birth, and don’t follow transfers of care during labor.

As it happens, we have a study that is accurate and allows us to do both those things. The Midwives Alliance of North America study reports on almost 17,000 planned home births taking place between 2004 and 2009 (Cheyney 2014b), and therefore overlapping Grunebaum and Chervenak’s analysis, in which all but 1000 births (6%) were attended by certified or licensed home birth midwives. According to the MANA stats, the newborn death rate in women who had never had a cesarean and who were carrying one, head-down baby, free of lethal congenital anomalies was 53 per 10,000, NOT 126 per 10,000. This is less than half the rate in the Grunebaum and Chervenak analysis. (As a side note, let me forestall a critique of the MANA study, which is that midwives simply don’t submit births with bad outcomes to the MANA database. In point of fact, midwives register women in the database in pregnancy [Cheyney 2014a], before, obviously, labor outcome could be known. Once enrolled, data are logged throughout pregnancy, labor and birth, and the postpartum, so once in the system, women can’t fall off the radar screen.)

We’re not done. Grunebaum and Chervenak’s analysis suffers from another glaring flaw as well. Using hospital based midwives as the comparison group would seem to make sense at first glance, but unlike the MANA stats, which recorded outcomes regardless of where women ultimately gave birth or who attended them, hospital-based midwives would transfer care to an obstetrician when complications arose. This would remove labors at higher risk of newborn death from their statistics because the obstetrician would be listed on the birth certificate as the attendant, not the midwife. For this reason, the hospital midwife rate of 32 per 10,000 is almost certainly artificially low. So Grunebaum and Chervenak’s difference of 94 per 10,000 has become 21 per 10,000 at most and probably much less than that, a difference that I’d be willing to bet isn’t statistically significant, meaning unlikely to be due to chance. On the other hand, studies consistently find that, even attended by midwives, several more low-risk women per 100 will end up with cesarean surgery—more if they’re first-time mothers—then compared with women planning home births (Romano, 2012).

Hopefully, I’ve helped to provide a defense for those who may find themselves under attack as a result of the NY Times article. I’m not sanguine, though. As can be seen by Jennings, Grunebaum, and Chervenak, people against home birth often fall into the category of “My mind is made up; don’t confuse me with the facts.”

photo source: creative commons licensed (BY-NC-SA) flickr photo by HoboMama: http://flickr.com/photos/44068064@N04/8586579077


Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. (2014). Development and validation of a national data registry for midwife-led births: the Midwives Alliance of North America Statistics Project 2.0 dataset. J Midwifery Womens Health, 59(1), 8-16. doi: 10.1111/jmwh.12165 http://www.ncbi.nlm.nih.gov/pubmed/24479670

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. (2014b). Outcomes of care for 16,924 planned home births in the United States: the midwives alliance of north america statistics project, 2004 to 2009. J Midwifery Womens Health, 59(1), 17-27. doi: 10.1111/jmwh.12172 http://www.ncbi.nlm.nih.gov/pubmed/24479690

de Jonge, A., van der Goes, B. Y., Ravelli, A. C., Amelink-Verburg, M. P., Mol, B. W., Nijhuis, J. G., . . . Buitendijk, S. E. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG 116(9), 1177-1184. http://www.ncbi.nlm.nih.gov/pubmed?term=1177%5Bpage%5D+AND+2009%5Bpdat%5D+AND+de+jonge%5Bauthor%5D&cmd=detailssearch

Grunebaum, A., McCullough, L. B., Sapra, K. J., Brent, R. L., Levene, M. I., Arabin, B., & Chervenak, F. A. (2014). Early and total neonatal mortality in relation to birth setting in the United States, 2006-2009. Am J Obstet Gynecol, 211(4), 390 e391-397. doi: 10.1016/j.ajog.2014.03.047 http://www.ajog.org/article/S0002-9378(14)00275-0/abstract

Romano, A. (2012). The place of birth: home births. In Goer H. & Romano A. (Eds.), Optimal Care in Childbirth: The Case for a Physiologic Approach. Seattle, WA: Classic Day Publishing.

Wax, J. R., Lucas, F. L., Lamont, M., Pinette, M. G., Cartin, A., & Blackstone, J. (2010). Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol, 203(3), 243.e241-e248. http://www.ajog.org/article/S0002-9378%2810%2900671-X/abstract

About Henci Goer

Henci Goer

Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach She is the winner of the American College of Nurse-Midwives “Best Book of the Year” award. An independent scholar, she is an acknowledged expert on evidence-based maternity care.  



Babies, Evidence Based Medicine, Guest Posts, Home Birth, Maternal Quality Improvement, Maternity Care, Midwifery , , , , ,

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