Planned home birth and neonatal death: Who do we believe?

The (in)famous Wax home birth meta-analysis hit the scene over a month ago. But the buzz doesn’t seem to be dying down. In the weeks since the original pre-publication and press release, editors at The Lancet and BMJ have both weighed in, and there’s a steady stream of media attention. While all of the media have dutifully quoted midwives in leadership positions saying the meta-analysis is flawed (an assessment with which I agree), I still keep coming back to the question I asked in my earlier post – did we need a meta-analysis to establish the neonatal outcomes of planned home birth? We had, after all, a very large, methodologically rigorous study on home birth safety involving over a half million women that was published less than 2 years ago. Won’t that suffice?

I had a chance to interview two of the researchers who conducted that study when I was in Vancouver for the Normal Labour & Birth International Research ConferenceSimone Buitendijk, MD, is Professor of Maternal and Child Health and Midwifery Studies at the Academic Medical Center of Amsterstam and heads up the Child Health Programme at the Netherlands Organisation for Applied Scientific Research. Ank de Jonge, the study’s lead author, is a practicing midwife with a PhD in public health who works at the Midwifery Science section within the EMGO Institute for Health and Care Research at VU University Medical Center in Amsterdam. I gained some new insights from them about their research and the Wax meta-analysis. Based on those interviews, and despite having written about the meta-analysis twice already, I thought it was time to ask anew: which is the “better” evidence for determining neonatal outcomes of planned home birth: the de Jonge cohort study or the Wax meta-analysis? Let’s have a look at some objective criteria and see how each study measures up.

Study size (home birth group):

  • Wax: 9,811
  • de Jonge: 321,307

That’s right, the Dutch neonatal mortality analysis is 33 times the size of the neonatal mortality meta-analysis. And believe it or not, this was BRAND NEW news to me that I didn’t realize until I spoke to de Jonge and Buitendijk. Although I had access to the full-text of the Wax meta-analysis and in fact looked critically at it (heck, I blogged about it!), I completely missed the fact that while the de Jonge study was “included” in the meta-analysis, it was excluded from the analysis of neonatal mortality, which was the major finding given so much attention by the media.  On the one hand, I’m pretty embarrassed to have made such a major error. On the other hand, it just underscores how misleading it can be for professionals or lay people to read headlines about a meta-analysis of “hundreds of thousands” of births finding triple the neonatal death rate.  Wax’s neonatal death data don’t come from hundreds of thousands of births at all. Not by a long shot.

Mechanism to ensure data were from planned home births:

  • Wax: mechanism varies across the included studies. In Pang et al., which contributed 63% of the home birth data and accounted for 12 of the 18 neonatal deaths in normally formed newborns, researchers relied on birth certificate data that did not differentiate between planned and unplanned home births, and assumed that any birth certificate for a baby born at home at or beyond 34 weeks, signed by a midwife, nurse, or doctor was a planned home birth, a method that has not been scientifically validated and has been widely criticized. Unplanned home births are riskier than planned home births with qualified attendants.
  • de Jonge: midwives routinely record the planned place of birth in a national perinatal database that covers 99% of births and is linked to another database of neonatal deaths by a validated method. Planned place of birth was unknown for 8.5% of the population, and the outcomes of this group were analyzed separately and reported.

Definition of neonatal death:

  • Wax: death of a live-born infant between 0 and 28 days
  • de Jonge: death of a live-born infant between 0 and 7 days (the World Health Organization definition of early neonatal death)

The appropriate definition of neonatal death has been a major bone of contention in the comments on this and other blogs that criticized the Wax meta-analysis.  Both 0-28 days (neonatal death) and 0-7 days (early neonatal death) are accepted definitions. Proponents of using early neonatal death argue that it is more sensitive to events occurring around the time of birth, such as hypoxic injury resulting from inadequate fetal monitoring or a sudden emergency like a cord prolapse or placental abruption. Indeed, some of the late (8-28 days) neonatal deaths reported in Wax resulted from sudden infant death syndrome, a condition that has nothing to do with planned place of birth. On the other hand, proponents of using 0-28 day mortality point out that some babies experiencing severe hypoxic injury in labor or birth may be kept alive for many days in a modern neonatal intensive care unit.  Their deaths should be counted as birth-related even if they don’t die as soon after birth.

Regardless of which is the more appropriate measure, I was shocked by something de Jonge and Buitendijk revealed in their interview. Wax never contacted them to ask for their 8-28 day mortality data. It is standard practice among researchers who conduct meta-analyses to contact the authors of the original papers to obtain unpublished data, clarify methodologies, or ask for data in a compatible format. One would think that if Wax was truly interested in whether planned home birth caused neonatal death up to 28 days, he would be very motivated to get his hands on the Dutch data set. And while de Jonge and Buitendijk told me that those data are not as complete as the early neonatal death data (because some pediatricians don’t reliably enter their patients’ data), they do in fact have the data up to 28 days and would have supplied it to Wax had he asked. Instead, they have done the analysis themselves and submitted it for peer review.  (Therefore, we’ll have to wait for the results.)

What were the characteristics of the population?

  • Wax – no requirements for home birth eligibility were defined for inclusion in the meta-analysis. Individual studies included in the meta-analysis varied in their mechanisms for determining eligibility. As noted above, the largest study that contributed the majority of neonatal deaths relied on birth certificates. Women with any of 18 medical conditions documented on the baby’s birth certificate were excluded. Neither the study authors nor Wax and colleagues comment on whether this is a reliable method for defining “low-risk”. (As someone who routinely completed birth certificates when I was practicing, my guess is that it isn’t.)
  • de Jonge – National guidelines (“Obstetric Indication List“) define who is eligible for primary midwifery care and home birth. These conservative guidelines ensure that the population of women having planned home births are healthy and at very low risk of complications.

The Dutch study has been criticized because it is, well, Dutch – midwifery and home birth in the Netherlands are highly regulated and integrated into the system, and there are clear eligibility guidelines. The same isn’t true of the United States, so we can’t generalize the results here or elsewhere where home birth is marginalized (e.g., Australia). What the Dutch study gives us, though, is a clear model to emulate in order to make sure home birth is as safe as it can be – regulate midwifery, provide continuity of care for women who need to be referred, and make sure only low-risk women are having home births. Instead of acknowledging this and moving forward to optimize safety, Wax and colleagues chose to mash together data from five different countries and four different decades with no attention paid to which women were and were not eligible and spit out an authoritative answer to the question, “Is home birth safe?” “Is home birth safe?” is a bogus question to which there is no answer. Context, training, system integration, and perhaps above all else the characteristics of the population matter. Any study worth its salt will describe these factors in as robust detail as is feasible. Combining and meta-analyzing data from dissimilar contexts may make sense in other areas of health care, but when context is everything, what’s there to gain?

A note about comments: please keep it civil and on point. I’m OK with debate, discussion, and disagreement. Name-calling, personal attacks, and other degrading commentary will be deleted or edited.

84 Comments

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by Carolyn Hastie
Congratulations Amy for a very clear, succinct and compelling review of the Wax meta-analysis. Shoddy research seems to be the hallmark of a section of the medical profession. The breech trial, the anaesthetist who falsified data ... The list goes on ... and now this!! My esteemed medical friends are, understandably, horrified. Thanks for your rigor and dedication. We are fotunate to have you shining the light on the truth.

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by FoxyKate
Who is this Wax person, anyway, with all of the comparisons of apples to hippopotamuses?

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by Amy Tuteur, MD
"Study size (home birth group): * Wax: 9,811 * de Jonge: 321,307" That's completely wrong. According to the Wax study: "A total of 342,056 planned home and 207,551 planned hospital deliveries were available for analysis." The Wax study INCLUDES the de Jonge study!

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by Amy M. Romano, RN,CNM
No, the neonatal mortality analysis does not include de Jonge. de Jonge data is included for other outcomes, for which no significant differences were found.

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by dave
@Amy Tuteur, MD I suggest you reread this article more carefully as it says: I completely missed the fact that while the de Jonge study was “included” in the meta-analysis, it was excluded from the analysis of neonatal mortality, which was the major finding given so much attention by the media. </quote.

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by Amy Tuteur, MD
"No, the neonatal mortality analysis does not include de Jonge. de Jonge data is included for other outcomes, for which no significant differences were found." But the deJonge paper does not measure neonatal mortality (death from birth to 28 days). So a more accurate representation of the study size for measuring neonatal mortality is: * Wax 9,811 * deJonge: 0 The Wax paper clearly shows how many studies of the 12 eligible study are include in measuring each variable. For example, when analyzing maternal complications, different studies measured different things. So in looking at specific complication (tears, etc.) only the subset of studies that ACTUALLY MEASURED the specific outcome were included. This procedure was followed for EVERY variable in the study. de Jonge did not include neonatal mortality (death from birth to 28 days) so it was literally impossible for Wax to include it. The Wax study is far from perfect, and I myself have criticized it. But what you have written is a misrepresentation of the study. The implication of your claim is that IF de Jonge had looked at neonatal mortality, homebirth would have had as low or lower neonatal mortality than hospital birth, but you don't know that; you CAN'T know that. It is entirelly possible that de Jonge left neonatal mortality (birth to 28 days) out of the study because it was much higher.

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by MAmomma
Soooo was the reason that they didn't include the deJonge data on neonatal mortality because they classified it as a shorter time window? It's too bad because with the number of homebirths there, it would definitely be good data to look at. I just don't see how you can compare the US to the Netherlands because the systems are so different, which is also why I can't fathom looking at a meta-analysis of homebirth as the end-all be-all study. And I like you Amy, would just like to optimize our options and care in this country! So frustrating!

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by IndianaFran
@Amy Tuteur, MD "It is entirely possible that de Jonge left neonatal mortality (birth to 28 days) out of the study because it was much higher." Always hunting for the nefarious evil motivations of home birth researchers? As Amy R recounted from her personal contact with the co-author, the reason that late neonatal mortality was not included in the original de Jonge publication is that it is not collected in the same perinatal statistics registry, and is collected elsewhere in a fashion that is not as reliably complete. It's not like they had all the neonatal (0-28 day) data in one collection, and they intentionally "excluded" it. Even so, from published data we know that about 86% of all neonatal deaths in the Netherlands occur in the early neonatal period (0 - 7 days). So in effect, the figures on early neonatal mortality in the de Jonge study represent a rather comprehensive part of total neonatal mortality. It is indeed *possible* that this ratio may vary somewhat when considering only the low-risk pregnancies in the de Jonge study; it's also *possible* that it may vary somewhat between the planned home and hospital group. But while it MIGHT be true that including the deaths from 8 - 28 days could possibly affect the results of the de Jonge study (in either direction!), it's not very likely that it would change it by much. It's really not a huge leap to assume that the de Jonge results for early neonatal mortality are a close approximation for total neonatal mortality. Not a sure thing, but still a rather safe bet.

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by IndianaFran
my source for the 86% calculation: http://www.europeristat.com/bm.doc/european-perinatal-health-report.pdf see figure 7.4 on page 119. 6/7 of all neonatal deaths in the Netherlands take place in the early neonatal period.

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by b
From the DeJonge/Netherlands study “All neonatal care data from academic hospitals and about 50% of other paediatric data are entered in the paediatric register. Recently, these databases have been combined into one national perinatal database via a validated linkage method.22” See abstract of said alleged “validated linkage method”, below. In plain English, probably about half their baby death data is missing. The rest is not directly counted by place of intended birth at all, but rather guessed at by some poorly described modeling technique to link databases without unique identifiers. This isn’t a study at all!!! It is playing with SPSS waaaay too much. Can someone buy these guys a Wii? It is incredibly biased and hypocritical to spread propaganda that the Pang/Washington study (which showed at least twice the death rate) was invalid for allegedly having unplanned home births. A birth had to be full-term, occur at home (as opposed to on the way to the hospital or elsewhere) and with a licensed doctor or midwife, as per the study’s criteria and Washington State law regarding birth certificates. Unattended accidental births could not possibly meet this criteria, unless they just happened to have a midwife hanging around the house. Yet, this Grand Canyon sized flaw in the Netherlands goes without comment. http://www.ncbi.nlm.nih.gov/pubmed/19538407 J Clin Epidemiol. 2007 Sep;60(9):883-91. Epub 2007 May 17.Probabilistic record linkage is a valid and transparent tool to combine databases without a patient identification number.Méray N, Reitsma JB, Ravelli AC, Bonsel GJ. Academic Medical Centrum (AMC), Department of Medical Informatics, Amsterdam, The Netherlands. Abstract OBJECTIVE: To describe the technical approach and subsequent validation of the probabilistic linkage of the three anonymous, population-based Dutch Perinatal Registries (LVR1 of midwives, LVR2 of obstetricians, and LNR of pediatricians/neonatologists). These registries do not share a unique identification number. STUDY DESIGN AND SETTING: A combination of probabilistic and deterministic record linkage techniques were applied using information about the mother, delivery, and child(ren) to link three known registries. Rewards for agreement and penalties for disagreement between corresponding variables were calculated based on the observed patterns of agreement and disagreements using maximum likelihood estimation. Special measures were developed to overcome linking difficulties in twins. A subsample of linked and nonlinked pairs was validated. RESULTS: Independent validation confirmed that the procedure successfully linked the three Dutch perinatal registries despite nontrivial error rates in the linking variables. CONCLUSIONS: Probabilistic linkage techniques allowed the creation of a high-quality linked database from crude registry data. The developed procedures are generally applicable in linkage of health data with partially identifying information. They provide useful source date even if cohorts are only partly overlapping and if within the cohort, multiple entities and twins exist

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by Amy Tuteur, MD
"Even so, from published data we know that about 86% of all neonatal deaths in the Netherlands occur in the early neonatal period (0 – 7 days)." But that, of course, tells us nothing because most neonatal deaths occur in high risk groups (such as premature birth) that are explicitly excluded from the deJonge study. The point of my comment was to show that Amy Romano has deliberately misrepresented the Wax study. The numbers she quoted for neonatal mortality show that the deJonge study, far from including hundreds of thousand of women in calculating neonatal mortality (0-28 days), actually included ZERO! There is simply no excuse for making patently false claims like the deJonge study is 32 times larger than the Wax study. When it comes to the analysis of neonatal mortality (0-28 days), the deJonge study contains ZERO cases.

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by IndianaFran
@b "Unattended accidental births could not possibly meet this criteria,..." So, you're making claims about the Pang study that go beyond even the authors' own claims? "This study has several limitations that are related to the reliance on birth certificate data. These include the potential for misclassifying unplanned home births as planned home births and for misclassifying various outcomes and covariates." "We sought to minimize misclassification of intended location of delivery in this study..." That's *MINIMIZE* not *eliminate*. Even the authors admit that their methodology cannot categorize intended place of birth with absolute certainty. What do you know that they don't?

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by IndianaFran
@Amy Tuteur, MD "because most neonatal deaths occur in high risk groups (such as premature birth) that are explicitly excluded from the de Jonge study. " Sure. Yes, we know that a very small percentage of neonatal deaths occur among low-risk pregnancies. And we know that only a small percentage of all neonatal deaths are late neonatal deaths. So the likelihood that there exists a significant number of late neonatal deaths among low-risk pregnancies is a very very small likelihood. And if you had access to cause of death to eliminate late neonatal deaths related to accidents, respiratory and other infections acquired after 7 days, and other non-birth-related causes, that very very small likelihood becomes even smaller. I would still stand by my statement that "It’s really not a huge leap to assume that the de Jonge results for early neonatal mortality are a close approximation for total neonatal mortality. "

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by b
Indianafanny: "6/7 of all neonatal deaths in the Netherlands take place in the early neonatal period." That's unstandardized, (didn't we talk about this before?)try page 32 here. I'm glad you are using some of the links I gave you though. http://whqlibdoc.who.int/publications/2006/9241563206_eng.pdf Since the midwife databases (home or hospital), the OB databases, and the baby databases aren't linked in the first place, and a lot of the baby data isn't even in them in the first place, it has to be awfully hard to tell what perinatal factors are related at all by using those as this so-called "study" did. Oh, but they have a lot of subjects, so will ignore the fact the fact that they have no actual data. ; )

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by b
Amy Romona opined: "de Jonge: midwives routinely record the planned place of birth in a national perinatal database that covers 99% of births and is linked to another database of neonatal deaths by a validated method." There's no "perinatal database" RTFM. The entire thing was through statistical guessing linking Midwife to OB and then peds databases. There's no actual data in this so-called study!! Where babies that died were intended to be born in this is no more than a guess. From the J Clin Epidemiol. 2007 Sep;60(9):883-91. Epub 2007 May 17.Probabilistic record linkage is a valid and transparent tool to combine databases without a patient identification number.Méray N, Reitsma JB, Ravelli AC, Bonsel GJ. Academic Medical Centrum (AMC), Department of Medical Informatics, Amsterdam, The Netherlands. (document listed by DeJonge as the method they used) "All four perinatal caregivers create records in one of four independent registries: the registry of midwives (LVR1 or MR), of general practitioners (LVR-h), of obstetricians (LVR2 or OR), and of pediatricians (LNR or PR), respectively, with partial records in case of transfer. Because of privacy laws of the Netherlands, no unique personal identifier (of the mother or child) is available to combine records." And in case you weren't aware, there's no way to definitive validate anonymous databases, otherwise, ya know, they wouldn't be anonymous. Only a small percentage matched on a small set of variables, and only a very small percent of those were unique. The full text is up at science direct http://www.sciencedirect.com/ J Clin Epidemiol. 2007 Sep;60(9):883-91. Epub 2007 May 17.Probabilistic record linkage is a valid and transparent tool to combine databases without a patient identification number.Méray N, Reitsma JB, Ravelli AC, Bonsel GJ. Academic Medical Centrum (AMC), Department of Medical Informatics, Amsterdam, The Netherlands. "In absence of a large sample of validated pairs to independently estimate the awards and penalties, we used standard maximum likelihood techniques to estimate these weights from the data itself and to estimate the threshold" In other words, they guessed.

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by IndianaFran
@b The funny thing is that the 2006 WHO document you reference is exactly the same one I used as a source a few weeks ago to show that there are many other countries "in Europe" which have perinatal death rates greater than the Netherlands. And Dr T said that this information was "erroneous and out of date". So I guess now it is a reliable source after all..... And anyway, the data in that table is rounded up to the whole digit (per thousand), so it really doesn't contradict the numbers from the Peristat report (which is, incidentally, more recent, being based on 2004 birth data, as opposed to the WHO report which is based on data from the year 2000). And they both confirm that late neonatal mortality is a relatively small component of total neonatal mortality. And so does the updated WHO report using 2004 birth data which can be found at http://whqlibdoc.who.int/publications/2007/9789241596145_eng.pdf

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by Emily
She also said that Wax could have but did not attempt to get the 0-28 data from deJonge, and that such data is in the publication pipeline so we will have to wait and see what it says. Could you be any more uncharitable in your comments?

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by b
Ehhh, no it is about 3/4s in there vs. 6/7s. Since the DeJonge "study" is really based on statistical guessing as to which deaths were home vs. hospital, as opposed to anything that comes close to resembling real data, I don't think the the timeframe of follow-up matters anymore. To invent bizarre unlikely scenarios to suggest that studies unfavorable to midwives might have miscategorized some data and then embrace something like this that didn't even categorize data in the first place.....unbelievable. This is how a self-interested professional guild acts, and a guild that doesn't know much about science and research to boot.

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by b
For some reason Amy Romano keeps repeating this even though it isn’t true: “In Pang et al., which contributed 63% of the home birth data and accounted for 12 of the 18 neonatal deaths in normally formed newborns, researchers relied on birth certificate data that did not differentiate between planned and unplanned home births, and assumed that any birth certificate for a baby born at home at or beyond 34 weeks, signed by a midwife, nurse, or doctor was a planned home birth, a method that has not been scientifically validated and has been widely criticized.” They didn’t assume it, it is Washington state law. Maybe not perfect, but a bit better than trying to match up anonymous records two database away don’t you think? Since only 5% of births didn’t have APGARs, it is unlikely that there is much possibility for unattended births. http://apps.leg.wa.gov/RCW/default.aspx?cite=70.58.080 RCW 70.58.080 “1) Within ten days after the birth of any child, the attending physician, midwife, or his or her agent shall: (a) Fill out a certificate of birth, giving all of the particulars required, including: “ “6) If there is no attending physician or midwife, the father or mother of the child, householder or owner of the premises, manager or superintendent of the public or private institution in which the birth occurred, shall notify the local registrar, within ten days after the birth, of the fact of the birth, and the local registrar shall secure the necessary information and signature to make a proper certificate of birth.” Docs and midwives can't cert for births they don't attend. It might surprise some, but there are a number of people in this world who actually pay much more attention to the details and rules, and master and follow them.

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by Dallas Knight
Carolyn Hastie : Congratulations Amy for a very clear, succinct and compelling review of the Wax meta-analysis. Shoddy research seems to be the hallmark of a section of the medical profession. The breech trial, the anaesthetist who falsified data … The list goes on … and now this!! My esteemed medical friends are, understandably, horrified. Thanks for your rigor and dedication. We are fotunate to have you shining the light on the truth. It is a fairly bold and loose statement to say that "shoddy research seems to be the hallmark of a section of the medical profession". Research is always ongoing and in progress.

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by Midhusband
@b I am kinda thinkin' I am gonna regret jumping in here as "b" seems to have strong opinions and exhibits some proficiency in torturing studies. Nevertheless, I suppose trading rocks in the blogosphere is just as useful as anything else I might do just now. "b" - thanks for the link to the Washington statute language regarding the execution of the birth certificate. My personal opinion is that statute language means precisely bupkiss in assuring quality control over data collection when irregularities on the order of 0.001 can affect the outcome of a retrospective study and those filling out the birth record do not know it will be used for evaluation in the future. Pang is flawed and... your argument is irrelevant. You seem to criticize de Jonge as unreliable given the difficulty in using multiple databases and then assert that Pang must be considered good because you don't like de Jonge. I confess this line of reasoning might be too complex for me, but it is safe to say...your argument is irrelevant. In any event, if you are inclined to dismiss de Jonge, then we do not have much of a meta-analysis from Wax (with hundreds of thousands of births, albeit not associated with the subject neonatal mortality rate parameter in Wax that is the meat of this discussion) and we should just withdraw Wax Paper from the archive (and I agree with you on this). The only thing that Wax did was to breath new life into Pang which objective folks have judged as flawed. Your faithful midhusband, Russ

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by Midhusband
@Amy Tuteur, MD Greetings Amy, Boy, it feels like old times. I hope all is well with you and yours. I see in subsequent comments how your defense of the study size is defeated given that de Jonge is used for the perinatal mortality rate and not the neonatal mortality rate (which is the point of contention). Clearly, it is at best misleading to associate a study size containing hundreds of thousands of births with an elevated neonatal mortality rate in this study as AJOG has done in celebrating Wax Paper. You know, Amy, it does not bother me when a researcher makes an honest technical mistake, or fails to identify a shortcoming. I am really struggling to give Wax, et. al., the benefit of making an honest mistake. Cheers, Russ

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by Midhusband
@Amy Tuteur, MD Actually, Amy, asserting that de Jonge had 0 neonatal mortality rate data is incorrect. The 0-7 day data is clearly important and part of the neonatal period. Russ

Planned home birth and neonatal death: Who do we believe?

August 17, 2010 07:00 AM by Aly
Good job people; other than one comment from b, this discussion has been entirely on topic and civil! Nice to see actual evidence rather than pointless jabs. The authors of the study admitted that they could have included unintentional homebirths. Not sure what you're even arguing about there. In fact, Dr. Amy has often bemoaned the use of birth certificate data in studies of elective cesarean section. She knows darn well that b.c. data is notoriously inaccurate. I am actually rather suprised to see Dr. Amy defending Wax, she's usually pretty honest re: the shortcomings of studies. All of the media reports quoted the 500,000 subject number, then the neonatal mortality data. When in fact the neonatal mortality data was based on about a tenth of the original, or 50,000. What a bait and switch. The really bizarre thing is that every single one of the included 12 studies besides Pang showed no statistical difference between hospital and home. So yes, this meta is a regurgitation of Pang. Here's what the 12 studies conclusions in their abtracts show (and I've read about half of the studies in full): (the first six listed here were used in the neonatal analysis that showed the alleged doubling of mortality, while all 12 were used in the perinatal.) 4.Ackermann-Liebrich U, Voegeli T, Günter- Witt K, et al. Home versus hospital deliveries: follow up study of matched pairs for procedure and outcome. BMJ 1996;313:1313-8. CONCLUSION: Healthy low risk women who wish to deliver at home have no increased risk either to themselves or to their babies 7. Lindgren HE, Radestad IJ, Christensson K, Hildengsson IM. Outcomes of planned home births compared to hospital births in Sweden between 1992 and 2004: a population-based register study. Acta Obstet Gynecol 2008;87:751-9. CONCLUSION: In Sweden, between 1992 and 2004, the intrapartum and neonatal mortality in planned home births was 2.2 per thousand. The proportion is higher compared to hospital births but no statistically significant difference was found. Women in the home birth group more often experienced a spontaneous birth without medical intervention and were less likely to sustain pelvic floor injuries. 10. Woodcock HC, Read AW, Bower C, Stanley FJ, Moore DJ.Amatched cohort study of planned home and hospital births in Western Australia 1981-1987. Midwifery 1994;10:125-35. KEY CONCLUSIONS: Planned home births in WA appear to be associated with less overall maternal and neonatal morbidity and less intervention than hospital births. IMPLICATIONS FOR PRACTICE: whether these observed differences in intervention and morbidity have any relationship to the small, non-significant increase in perinatal mortality could not be determined in this study. Continuing evaluation of home birth practice and outcome is essential. 17. Janssen PA, Lee SK, Ryan EM, et al. Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. CMAJ 2002;166:315-23. INTERPRETATION: There was no increased maternal or neonatal risk associated with planned home birth under the care of a regulated midwife. The rates of some adverse outcomes were too low for us to draw statistical comparisons, and ongoing evaluation of home birth is warrant 15. Pang JWY, Heffelfinger JD, Huang GJ, Benedetti TJ, Weiss NJ. Outcomes of planned home births in Washington State: 1989-1996. Obstet Gynecol 2002;100:253-9. CONCLUSION: This study suggests that planned home births in Washington State during 1989-1996 had greater infant and maternal risks than did hospital births. 13. Koehler NU, Solomon DA, Murphy M. Outcomes of a rural Sonoma county home birth practice: 1976-1982. Birth 1984;11:165-9. Of the 273 who delivered at home, including 10 unplanned births, two were transferred to hospital for postpartum hemorrhage. One neonate was hospitalized for complications. The results of this study, as well as a review of the relevant literature, illustrate that, for a selected population, home birth is a reasonable alternative to hospital. 5. Shearer JML. Five year prospective survey of risk of booking for a home birth in Essex. BMJ 1985;219:1478-80. A higher rate of episiotomy and second degree tears and more Apgar scores of 7 or below were found in those who were booked for hospital. There were no perinatal deaths in either group. The results of this study showed no evidence of an increased risk associated with home confinements but indicated that there were fewer problems than were encountered in the deliveries in mothers confined in hospital. 6. Wiegars TA, Keirse MJNC, van der Zee J, Berghs GAH. Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands. BMJ 1996;313:1309-13. RESULTS: There was no relation between the planned place of birth and perinatal outcome in primiparous women when controlling for a favourable or less favourable background. In multiparous women, perinatal outcome was significantly better for planned home

Planned home birth and neonatal death: Who do we believe?

August 18, 2010 07:00 AM by Jennifer
@b- “Docs and midwives can’t cert for births they don’t attend. It might surprise some, but there are a number of people in this world who actually pay much more attention to the details and rules, and master and follow them.” Very interesting comment

Planned home birth and neonatal death: Who do we believe?

August 18, 2010 07:00 AM by B
Am I the only person who seems to think that a decent study on the safety of homebirth will remain elusive because of so many important variables and difficulties gathering accurate data using a more effective research design.

Planned home birth and neonatal death: Who do we believe?

August 18, 2010 07:00 AM by b
“My personal opinion” Such an objective reliable source. Let’s make public health policy based on it.; ) “ is that statute language means precisely bupkiss in assuring quality control” If you value your license and your livelihood the statutes that govern it are not bupkiss. Perhaps you think the people of Washington State are so dysfunctional that their police, social service and medical service people don’t mount a rather significant investigation as to the circumstances of a baby that dies outside a medical setting. Perhaps midwives who believe “they do everything the same as a doctor would” actually don’t even know about a all the rules and regs doctors have to apply in everyday practice. Maybe doctors have a lot more street cred with mothers because they can and do manage lots of very complicated information. I remember a “study” where midwives thought they had “proved” birth certs were inaccurate as to provider. When you read, you see that midwives simply don’t know basic federal guidelines about who get credit for the delivery. If the OB is physically present in the same room, it is considered theirs by law, even if a midwife catches. But, the midwives, were whining about how they didn’t get credit for THEIR deliveries. Too funny. “over data collection when irregularities on the order of 0.001 can affect the outcome of a retrospective study and those filling out the birth record do not know it will be used for evaluation in the future” No, the errors would have to be in the classification of deaths. There’s only a few dozen of those. The denominator has to be waaaay, waaaay, waaaay off to make a difference. If people on the midwifery side knew anything about math, science, or research that would be obvious. But, they don’t which is why they don’t see the problems in their so-called arguments and they can’t figure out why the average woman rejects midwifery. Most of the wrong classification would likely be in favor of the midwives -- not knowing an ambulance patient had really been an attempted homebirth with a midwife (because, ya know, I have heard they take off on you), a mom starts at home but the delivery actually happens in the hospital, it could be missed as homebirth. For errors you imply to be present and make a difference, there would have to be doctors and midwives all over Washington who go searching for dead babies outside the hospital. They would have to be stepping up to the plate, pushing police investigators and social workers out of the way to take credit for the death that was really an accidental home delivery that came faster than a pizza. They would have to lie on an official document and claim that THEY delivered them in the home and hang a sign on their backs saying “Sue Me and Take My License, Please!”. S’yeah right. “You seem to criticize de Jonge as unreliable given the difficulty in using multiple databases” Yes, I tend to think when the association between the cause (home vs. hospital) and the effect (death vs. living) was a complete and total fabrication and an invention and really just made-up data by the researchers, that’s a bit unreliable. I’m funny that way.

Planned home birth and neonatal death: Who do we believe?

August 18, 2010 07:00 AM by b
@Jennifer "I would like to read more about birth certificates, birth certificate verification, data collection and the like, especially how it relates to out of hospital birth and concerns that the citizenry “pay[s]… attention to the details and rules, an

Planned home birth and neonatal death: Who do we believe?

August 18, 2010 07:00 AM by paule bezaire
"who do we believe". that's right. many of us believe what we want to believe. we trust women's bodies ~ or not. and even in front of all the evidence in the world, we may not change our views. but through educating young women, and telling them the TRUTH, that MOST of the time, birth is NOT a medical event, maybe there's a glimmer of hope that they will learn to trust their bodies, which will be the best outcome for them. AND perhaps, through teaching them their RIGHTS (my body, my birth, my baby), we will empower them to say NO to birth attendants of ANY KIND who just need to control. thank you for your highlights, and pointing out this and that. it will make sense for whomever wants to read it, and it won't for whomever doesn't want to believe it. that's fine. it's part of our freedom: to believe the truth or to keep on with the lies. blessings on your work.

Planned home birth and neonatal death: Who do we believe?

August 18, 2010 07:00 AM by b
@aly "Good job people; other than one comment from b, this discussion has been entirely on topic and civil!" Midwifery definition of uncivil = showing that your data was fabricated. "The authors of the study admitted that they could have included

Planned home birth and neonatal death: Who do we believe?

August 18, 2010 07:00 AM by Amanda
@b: "If people on the midwifery side knew anything about math, science, or research that would be obvious. But, they don’t which is why they don’t see the problems in their so-called arguments and they can’t figure out why the average woman rejects midwif

Planned home birth and neonatal death: Who do we believe?

August 18, 2010 07:00 AM by Nicholas Fogelson, MD
I'm so glad to see that this discussion has focused on the data and its validity rather than degenerating into something else. Maybe its the cool lime green colored background :) Clearly the De Jonge data, which was collected in a country with a large organized homebirth system, cannot be extrapolated to the United States. Clearly the fact that De Jonge left out days 8-28 deaths is an issue, and very likely explains the difference between De Jonge and Pang. Many babies with hypoxic injuries die after 7 days. In my experience this has been the rule rather than the exception, when neonatal resucitation is available. Modern pediatric technology can keep an infant alive for just about as long as the parents care to continue. The death of these infants is usually because support is withdrawn, and in many cases it takes more than 7 days to reach that point. Clearly Pang's methodology also has some problems. The most important line in the whole piece is this "“Is home birth safe?” is a bogus question to which there is no answer." I could not agree more. The whole concept of safety of childbirth, in any environment, is flawed. Bad things can happen in childbirth, just as they can happen crossing the street. The question is whether birth environment has a clinically important impact on outcomes in low risk pregnancies. This will always be hard to answer, as to the 99.9% that do fine the difference wasn't significant, but if there is an attributable risk, the 0.1% that hits it will see that risk in special significance that cannot be described in mathematics. Wax has published a meta analysis which has some strengths and weaknesses. It does show an increased neonatal death rate for homebirth. Those that are against homebirth will taut it, those that support homebirth will attack it. This is nothing new. This type of post-hoc research commentary is part of the process of scientific discovery, and has gone on with every major paper that anyone ever cared about. The most important part of all of this is that both Wax and DeJonge showed that homebirth is largely safe. There may be a few more bad outcomes in the homebirth groups depending on how you look at the data, but when you consider the number of births we are looking at, the absolute number is so very few that the argument is a little ridiculous.

Planned home birth and neonatal death: Who do we believe?

August 18, 2010 07:00 AM by Jennifer
@Amanda- You might expect this kind of bias from someone with an interest in the collection and analysis of birth data. Before 1986, people didn’t get a Social Security number until around age 14. By 1990, the age was lowered to 1 year and now parents app

Planned home birth and neonatal death: Who do we believe?

August 18, 2010 07:00 AM by Jill Herendeen
I thought the meta-analysis was supposed to be published in Sept....have you read the whole thing yet?

Planned home birth and neonatal death: Who do we believe?

August 19, 2010 07:00 AM by Katrina
@Nicholas Fogelson, MD Thank you! You put things in perspective quite perfectly!

Planned home birth and neonatal death: Who do we believe?

August 19, 2010 07:00 AM by katie
@Katrina :like:

Planned home birth and neonatal death: Who do we believe?

August 19, 2010 07:00 AM by b
@Nicholas Fogelson “Clearly the fact that De Jonge left out days 8-28 deaths is an issue, and very likely explains the difference between De Jonge and Pang. “ This criticism was originally raised by yours truly and is out of date, my friend. The big

Planned home birth and neonatal death: Who do we believe?

August 19, 2010 07:00 AM by b
“Giving birth in an institution allows for cleaner data and facilitates tracking, which helps prevent fraudulent claiming of dependents. Which, of course, helps our country’s bottom line financially.” LOL. I will file that in the same file as fallacy “hospitals make more money from c-sections”. No, there is no Federal Bureau of Unclaimed Tax Deductions. The government doesn’t fly around in its black helicopters looking for families that didn’t get a social security number for junior and therefore can’t claim him as a deduction. And since Medicaid pays for half of births, wouldn’t the govt. look in to saving money by pushing homebirth? Since midwives can only convince a teeny, tiny fraction of women to fall for their deception, in fact, they have turned their focus to government officials. They are trying to highlight the cheaper rates and hide the ultimately higher costs of later medical care from the disasters they cause and intangible human costs that women will bear. But, wow. LMAOROTF That’s the most entertaining conspiracy theory I’ve heard in a long time. The Social Security Pension Fund and the math geeks starting in the 1930’s have been conspiring for decades to make women birth at hospitals. Today, I would think they would just be conspiring to make them birth --- anywhere, since it will go broke soon without tons more taxpayers. Next Lamaze will be warning pregnant women about the hidden dangers of retirement communities and nerd glasses. Tell me please, is the Illuminati in this story, somewhere? How about the AARP? Keep baby close....BUT AWAY FROM GRANDMA!!!! The Industrial-Medical-Geezer-Geek complex. The Business of Being Old. “The idea that women who give birth outside of institutions and the notion that midwives are lawless rule-despisers working off-the-grid is old. Really old.” Old? Not to the scores of Americans that had their right to unrestricted foreign travel taken from them until recently because of the massive fraud of some midwives. Not to the kids who grow up with druggie mothers because they birthed with a midwife they knew she would not report them to social services, the way the hospital would. Not to the kids with non-fatal handicaps who die because their moms birthed with a midwife to prevent medical care that would save them, so they didn’t have to raise a handicapped kid.

Planned home birth and neonatal death: Who do we believe?

August 19, 2010 07:00 AM by Midhusband
@Nicholas Fogelson, MD Greetings Nicholas, I appreciate your thoughtful remarks. This is more of a management problem than a problem in evaluating the studies. A comprehensive safety assessment of these two different models of care (the setting is just one attribute) would need to include maternal mortality in addition to perinatal mortality, peripartum hysterectomy, hypoxic events leading to long term disability, bad outcomes in future pregnancies associated with uterine scars, postpartum depression and a whole host of relevant dependant variables. What we know is that planned home birth, attended by a skilled midwife, is a valid choice and we should manage it. You pointed out that extending de Jonge to the U.S. may not be appropriate because the Netherlands has a long history of supporting home birth and I agree with you. In the U.S., we have made every effort to marginalize women who would make this choice by denying them access to care and disenfranchising the midwives who serve them. We might very well expect to see a slightly higher risk of a bad outcome in the U.S. as compared to the Netherlands because of this. Here are actionable steps we can take to fix the situation and achieve the same outstanding performance as the Netherlands: 1) License and regulate Certified Professional Midwives in all 50 states, the District of Columbia and Puerto Rico as the CPM is the primary care giver to women who choose the home setting for birth in the U.S. The CPM is authorized to practice in 26 states (licensed and regulated in 24) and regulatory oversight is key to assure access and performance. I should say here, and this is important, that regulatory oversight must not be used as a means to deny women autonomy in their birthing decisions. 2) Retire mandatory written practice agreements between Certified Nurse Midwives and physicians as a condition to practice. In addition, intentionally produce CNMs with the training they need for the home setting and autonomous practice. 3) Assure reimbursement for planned home birth (Medicaid and private insurance). 4) Standardize guidelines for intrapartum transports and assure that all members of the healthcare team are trained to understand how to manage these events. 5) Cultivate liability options such as a) no fault remedies, b) binding arbitration, c) limits of liability, etc...by installing pilot programs in every state as the Childbirth Connection suggests in their Blueprint for Transforming Maternity Care document. I would also hope that successful programs could be enlarged to improve the environment for physician led care in the hospital setting. I would hope that managing the medico-legal environment better would reduce interventions and improve safety. This might actually moderate the accelerating rates of planned home birth. 6) Engineer systems to monitor performance of planned home birth and adopt best practices as they are identified and confirmed. We have some work to do, Nicholas, and much of it needs to be done in each state's General Assembly. Best, Russ Russ Fawcett Vice President & Legislative Co-Chair North Carolina Friends of Midwives

Planned home birth and neonatal death: Who do we believe?

August 19, 2010 07:00 AM by Jennifer
@b- I was baiting you with SSA history from your web site. This is more than I could have asked for: "Not to the scores of Americans that had their right to unrestricted foreign travel taken from them until recently because of the massive fraud of some

Planned home birth and neonatal death: Who do we believe?

August 19, 2010 07:00 AM by Amanda
@Jennifer Wow. It was clear that 'b' was clearly losing his/her composure over the course of these posts, but holy smokes ... @Midhusband Russ, thank you for this comment. Probably the most useful one of the whole lot.

Planned home birth and neonatal death: Who do we believe?

August 19, 2010 07:00 AM by Is politically invented “risk” in birth defining the rights of childbearing women? (Part
[...] have already broken down the methodological flaws of the Wax meta-analysis into comprehensible nuts and bolts so I won’t expound upon its junk science here,  suffice it to say the authors’ [...]

Planned home birth and neonatal death: Who do we believe?

August 20, 2010 07:00 AM by Aly
"Brownsville midwife Margarita Garcia-Rojas, 61, filed 3,400 birth certificates between 1985 and 1996." I've always wondered if the paranoid rantings against midwives on Dr. Amy's site and elsewhere were related to racism and stereotypes of granny midwives. b is confirming that for me a little bit. I can certainly understand being against homebirth, but the frenzy of some of these anti-midwife screeds is just wierd, and interesting in a historical context.

Planned home birth and neonatal death: Who do we believe?

August 20, 2010 07:00 AM by B
@ Nicholas Fogelson "The most important line in the whole piece is this ““Is home birth safe?” is a bogus question to which there is no answer.” I could not agree more. The whole concept of safety of childbirth, in any environment, is flawed. Bad th

Planned home birth and neonatal death: Who do we believe?

August 20, 2010 07:00 AM by b
@jennifer “@b- I was baiting you with SSA history from your web site.” So, in other words, you are now claiming you were doing something sneaky to victimize women. And then you rant for an entire post that midwives are falsely accused of doing sne

Planned home birth and neonatal death: Who do we believe?

August 20, 2010 07:00 AM by b
@Midhusband "August 19th, 2010 at 17:40 | #39 Reply | Quote @Nicholas Fogelson, MD Greetings Nicholas, I appreciate your thoughtful remarks. This is more of a management problem.... Here are actionable steps we can take to fix the situation and ...." Hey, great. Not only to do midwives deceive and victimize women, but the men are in charge of everything!! ; )

Planned home birth and neonatal death: Who do we believe?

August 20, 2010 07:00 AM by Jennifer
@b- Keep backpedaling, please. I do feel bad about baiting you and I'm sorry. Amanda is right. You've been losing your composure and now you're dropping anecdotes as your proof. Why is someone from the Social Security Administration running around all ove

Planned home birth and neonatal death: Who do we believe?

August 20, 2010 07:00 AM by Midhusband
@B Thanks B, Yes, I think we will agree on many things and below are a few thoughts. Training - I think it is best to establish training requirements based upon the scope of practice and the job description as opposed to what other countries do that intentionally produce credentialed home birth midwives within the bricks and mortar university setting. I really can't speak to the scope of practice for midwives in the UK or the Netherlands, but I think we can discuss the CNM & the CPM. A key thing to understand is that the CNM has a much broader scope of practice than the CPM and the CNM is designed to operate in the hospital setting with all the associated complexities. The CNM provides primary care for women, primary gynecological care, she has prescriptive authority, she may provide primary elder care - she does many things in addition to providing care for women during the childbearing year. Indeed, she may be the primary care provider for women from their first cycle to their dying day. The CPM scope of practice is limited to maternity care for healthy women experiencing normal pregnancies during the childbearing year, and so it is not justified to simply hold all midwives to the same training requirements when they do not have the same scope of practice. It is interesting, here in my state, we have CNMs with Associate Degrees in nursing and the CNM certificate, 3 year RN degrees and the CNM certificate, and now a Masters degree in nurse-midwifery will be required for entry into the CNM profession. Shall we require that all CNMs who do not hold a graduate degree (with decades of experience) return to school? Clearly, the answer is no. One thing to keep in mind is that the CPM credential is accredited by the National Commission for Certifying Agencies (irrespective of pathway) which also accredits the CNM credential. In judging the adequacy of the credential and pathways to achieving it, I submit it is best to look at performance metrics such as outcomes and maternal satisfaction as opposed to what might be considered customary for CNMs, engineers and attorneys. We are comfortable with performance, and the credential, as evidenced by the results of the CPM2000 study (Johnson & Daviss) and many years of experience. As we are talking about the adequacy of the Portfolio Evaluation Process (P.E.P.) pathway to obtaining the CPM, which is a very formal apprenticeship program, let me draw your attention to many other apprenticeship programs registered with the Department of Labor in the Tar Heel state: http://www.nclabor.com/appren/trades/apprenticeable_occupations_900.pdf Note how many specialized jobs of moderate scope in the healthcare fields are produced via an apprenticeship model. Now we need to put our manager's hat on for a minute. As PEP trained CPMs are the primary caregiver to women who choose a home birth in the U.S., states that do not license and regulate PEP trained CPMs for home birth will then have elevated rates of planned unattended home birth, they will not manage intrapartum transports, continuity of care is compromised, the midwives will not be regulated and consumers will not be protected from a midwife who does not maintain the standard of care. It is clear that we need to address today's problems today, and install increased requirements when there is justification in the context of a multi-generational program plan. Free-Standing Birth Centers - I agree with you. Unfortunately, the trend in my state is to close small facilities in favor of concentrating maternity care in large facilities with increased capability. There seems to be a lot of consolidation going on and there are many obstacles in front of a midwife of any credential who considers such a venture. All the best to you, B, Russ

Planned home birth and neonatal death: Who do we believe?

August 21, 2010 07:00 AM by b
@russ "4) Standardize guidelines for intrapartum transports and assure that all members of the healthcare team are trained to understand how to manage these events." What exactly are you looking for here? This shows a lot ignorance of the health car

Planned home birth and neonatal death: Who do we believe?

August 21, 2010 07:00 AM by b
") License and regulate Certified Professional Midwives in all 50 states, the District of Columbia and Puerto Rico as the CPM is the primary care giver to women who choose the home setting for birth in the U.S. .....I should say here, and this is important, that regulatory oversight must not be used as a means to deny women autonomy in their birthing decisions." In Oregon, this seems to have morphed into "have your cake and eat it too". In other words, they licensing to get access to insurance and to help get the patients via the impression of the state's seal of approval. They want all the benefits. But, they don't people to actually be able to complain about them to the state licensing board!! More sacrifice of women's rights to midwives. http://www.oregonlive.com/news/index.ssf/2010/07/homebirth_conflict_escalates_o.html

Planned home birth and neonatal death: Who do we believe?

August 21, 2010 07:00 AM by Article Round-up for Pregnancy, Birth and Beyond - Inspired Birth Professionals
[...] Planned home birth and neonatal death: Who do we believe? by Science & Sensibility. [...]

Planned home birth and neonatal death: Who do we believe?

August 22, 2010 07:00 AM by Midhusband
@b Greetings Anony-b, Well...it looks like it is just you and me now. I confess that I had resigned myself that I was not going to respond to you as your inflammatory remarks are actually helpful to me as folks who might casually wander upon this thread would likely favor our more temperate words. As I was cutting the grass yesterday (something we XY types are fond of doing when there is not much on ESPN or the beer inventory is low and in between telling women how to give birth), I decided it is time to engage you. I must point out that there is a bit of a mismatch in this contest. You are entirely anonymous, b, and free to say whatever you like with no accountability, while I am accountable for my words. Why don't we make it more fun and you can tell us who you are with all of your outstanding credentials. What do say, b? Amy was never anonymous. Anyway, here are my thoughts on your most recent remarks... Anony-b said - "You sound like the people who work for public relations for British Petroleum. Victims can’t have the damage they suffer limited, why should those responsible get limits? Limits on intangible damages have been criticized as sexist, so no surprise they are embraced here. " Nope, I don't work for BP and I am not in Public Relations. Clearly, you did not understand the message I sent. Let me suggest you read it again. I am not advocating for limits of liability, or any other model, but rather I am suggesting we do what the Childbirth Connection suggests and deploy pilot programs to cultivate options that may provide improvement. My personal opinion (FWIW) is that there is indeed a crisis in the medico-legal environment in maternity care that needs attention. Defensive medicine has resulted in 1 of 3 women concluding her pregnancy in abdominal surgery. While I am thankful that the OBs are as good as they are at C/S (and this procedure does save lives), I am in the camp that believes this elevated rate is a problem. Also, tort based remedies are only 60% efficient in distributing funds to families awarded a judgement, while administrative programs are 90% efficient. I tend to believe we can better support the families in crisis, and reduce the pressure on the good folks working in maternity care, with alternative models all at the same time. Perhaps you think the existing tort based model is perfectly fine, but I think you are in the minority on this. Anony-b said - "In Oregon, this seems to have morphed into “have your cake and eat it too”. In other words, they licensing to get access to insurance and to help get the patients via the impression of the state’s seal of approval. They want all the benefits. But, they don’t people to actually be able to complain about them to the state licensing board!!" First of all, let me suggest you slow down and review your posts more carefully before releasing them. You make a lot of mistakes in putting your words together which does not help you develop credibility. This is true in your comment posts and your blog as well. As for the Oregon issue, the experience from around the country is that the vast majority of complaints against licensed midwives arise from healthcare providers in the hospital who are hostile to home birth after an intrapartum transport. It is very rare (but it does happen) in which a client/consumer enters a complaint. Nevertheless, the fundamental purpose of licensure is to protect consumers from midwives who do not maintain the standard of care and so processing complaints is a key part of regulation (which is why every state has a Board of Medicine to address issues with incompetent physicians). I don't have enough information to know if the midwives' suit is correct, but I do know that harassment exists, and so I am looking forward to knowing the results of this litigation. Take care, Anony-b, and I look forward to your response. Russ

Planned home birth and neonatal death: Who do we believe?

August 22, 2010 07:00 AM by Nicholas Fogelson, MD
Midhusband>> As for the Oregon issue, the experience from around the country is that the vast majority of complaints against licensed midwives arise from healthcare providers in the hospital who are hostile to home birth after an intrapartum transport. And why do you think that is? It usually because the transport happened way too late and put the woman and fetus are far more risk than the OB felt was justified. Some of this comes from differing expectations of what is appropriate, but a lot of it comes from completely screwed up transfers. In my career, I would say that at least 25% of hospital transfers were associated with some sort of negligent practice on the part of the midwife. I don't take it personally, as they have a different training than I, but it does make for some bad feelings. Some OBs do take it personally, and try to fight back. Here's just a few examples 1) Midwife transfers patient postpartum, saying she is bleeding postpartum and she can't stop it. She has been massaging the uterus and it stops for a bit but it keeps coming after that. The patient is in hypovolemic shock and is pouring blood from her vagina. Exam shows she has a massive sulcus tear up to her cervix with an arterial bleeder. Pt requires many units of blood and general anesthesia to repair the tear, which was completely missed by the midwife. 2) Midwife sends a patient in in her husband's car, saying she has been 8 cm for 12 hours. On exam the baby is frank breech. Midwife didn't come with the family, and told the husband it was because "she was just going to stay at the house and clean up." 3) Midwife brings in patient with huge posterior laceration saying she can't fix it. Exam shows that she has sewn the vagina nearly shut and still has not encircled the bleeders. Entire 'repair' is removed and fixed. Midwife watched the repair, and based on comments clearly had no idea what the anatomy was that needed to be repaired. The 'repair' she tried to do also was with the completely wrong type of suture. 4) Midwife transfers a patient who has been complete for 6 hours without descent. By leopold's the baby is huge and the patient's blood sugar is 180. Midwife and patient insist that she she is not diabetic because a fingerstick blood sugar early in the pregnancy was normal (rather than a far more sensitive glucose challenge test). Midwife actively influences the mother to not accept an insulin drip to control her sugars prior to delivery, says it will hurt the baby. Baby eventually delivered by cesarean, 11.5#. 5) Midwife transfers a mother with a stuck breech with head entrapment. Baby has an agonal rhythm and cannot be resucitated postpartum. Infant dead in labor room. Ask any OB and they can give you more examples. I try not to bring these up because there are midwives that do a good job and make appropriate transfers. But many don't, and many don't accept what they do not know. They transfer too late, and sometimes don't even come with the patient to give a proper report. By doing this they undermine any good feelings between midwivery and obstetrics, and turn some OBs into absolute midwife haters. If CPM are ever going to get real acceptance, this kind of shit needs to stop, or the people who do it need to be pushed out of practice.

Planned home birth and neonatal death: Who do we believe?

August 22, 2010 07:00 AM by Midhusband
Great Day in the Morning, Nicholas !!! I sense some frustration here... First of all, as long we are telling stories, let's talk about gross negligence for a minute. Check this out... http://fayobserver.com/Articles/2010/03/31/987295 I must confess that I have never heard of a midwife inducing a non-gravid woman and then sectioning them only to find out the uterus is without the products of conception (because there never were any). To be fair, this spectacular event also illustrates the systemic problems with maternity care these days in addition to real issues of human performance with physicians. I can produce hundreds of women who will describe significant deficiencies in the practice of obstetrics. Does that mean obstetricians are incompetent as a profession given that 80% will be sued for malpractice during their career? Of course not. This does bring up an important aspect of the dynamics here. The hospitalists only see the transports and while most of them are not urgent, some of them are. I tend to agree that there are different thresholds for escalation of intervention (which is why there is a dramatic difference in C/S rate), and that is why the studies are useful in counting outcomes. You seem to have passed judgement on the CPM and I am sad for that. The vast majority of CPMs are competent and maintain the standard of care, day-in and day-out, (just like you do). Just like there are incompetent physicians, there are midwives who should not be practicing, and that is why regulation is so important. Russ

Planned home birth and neonatal death: Who do we believe?

August 22, 2010 07:00 AM by Aly
"But many don’t, and many don’t accept what they do not know. They transfer too late, and sometimes don’t even come with the patient to give a proper report. By doing this they undermine any good feelings between midwivery and obstetrics, and turn some OBs into absolute midwife haters." Gee, maybe it's because they get treated like shit when they get there, get threatened, sued, and even *jailed.* I have NEVER heard of a midwife sexually assaulting a patient, getting a court order to FORCIBLY cut a woman open for cesarean section, or threatening a woman bodily harm if she does not cooperate. Does this excuse the midwifery behavior you mention? Absolutely not, particularly the dumping of patients that generally happens in states ACOG has worked to keep ooh midwifery illegal. Besides that, the other behaviors are from lack of training, not malice, as obs do. And don't tell me Obs don't screw up, or cause dead or brain damaged babies. Better training, more regulation, I agree. But obstetricians absolutely cannot ignore their own culpability here. There will always be women who want to homebirth for whatever reason, whether you like it or not. We need 1)better training of cpms, no doubt. 2) formal obstetrician backup in hospital. 3) careful screening of homebirthing mothers 4) informed consent. I do believe midwives might even be more scorned and hated than Muslims, by people who have no concept that there are moderates and extremists in EVERY group. (That's true of obs-moderates and extremists-, but there's no movement to eliminate them either, unless you count malpractice insurance skyrocketing!). Sigh.

Planned home birth and neonatal death: Who do we believe?

August 23, 2010 07:00 AM by Nicholas Fogelson
@Midhusband >> You seem to have passed judgement on the CPM and I am sad for that. Not really, but I can see from an OB's perspective how so many OBs can be so anti-midwifery. Even if only 1 in 50 transfers are like this, its enough to hurt relations terribly. I agree that regulation is necessary and there needs to be standards of education that CPMs should meet. Right now its far too fractured, and in many states completely unregulated.

Planned home birth and neonatal death: Who do we believe?

August 23, 2010 07:00 AM by Nicholas Fogelson
>> We need 1)better training of cpms, no doubt. 2) formal obstetrician backup in hospital. 3) careful screening of homebirthing mothers 4) informed consent. Agreed >> I do believe midwives might even be more scorned and hated than Muslims Its interesting that you compare midwives to a religious affiliation.

Planned home birth and neonatal death: Who do we believe?

August 23, 2010 07:00 AM by Aly
Trying to post without links (besides one, these are all non birth/midwife websites): Did I mention I hate anecdotes? It's not right to condemn all obs based on these stories anymore than it is to do the same against homebirth midwives. But as long as we're sharing horror stories, I know you have wondered why some women are scared to death of obstetricians. The funny thing is, it's obs who are getting sued right and left for killing babies, and lawyers claim it's because doctors refuse to police themselves and get rid of the bad apples. Sound familiar? Chicago police officer versus fired and fined obstetrician: Refusal of cesearean, has vaginal delivery, woman loses her baby for 3 years after hospital calls cps: Obstetrician disappears after ordering pitocin, baby dies: Two teachers die, 15 days apart, same hospital, after c-sections: Medical Kidnapping: Rogue Obstetricians vs. Pregnant Women: ob/gyn sexual assault: Comments from physicians: Physician (to a patient who was expressing discomfort over a vaginal exam): “Come on, now, you’ve had something a lot bigger than my finger in there! How’d you ever manage to get pregnant if you can’t put up with this?”

Planned home birth and neonatal death: Who do we believe?

August 23, 2010 07:00 AM by b
@russ “Greetings Anony-b,” Oh, no, you have me mistaken with your friend Anony-B (big B that is). That’s OK. We look so much alike that I mistook myself for her. Or maybe your other friend Anony-bennifer or your other friend Anony-bmanda, or pre

Planned home birth and neonatal death: Who do we believe?

August 23, 2010 07:00 AM by Midhusband
Nicholas Fogelson :@Midhusband >> You seem to have passed judgement on the CPM and I am sad for that. Not really, but I can see from an OB’s perspective how so many OBs can be so anti-midwifery. Even if only 1 in 50 transfers are like this, its enough to hurt relations terribly. I agree that regulation is necessary and there needs to be standards of education that CPMs should meet. Right now its far too fractured, and in many states completely unregulated. So, Nicholas, do you know why CPMs remain unregulated in about half of the US? That's right!! You guessed it - the leadership of each state's medical society exerts their considerable political leverage in the General Assembly objecting to it. They cannot separate their objections to planned attended home birth from the need to regulate the midwives. We just completed a substantial project at the request of the General Assembly for the stakeholders to propose a licensing methodology to regulate CPMs in our state. Just about everybody (and their lobbyist) was there. The fundamental message from the Medical Society was... Home birth is a bad idea and don't do anything to make anything other than a bad idea. I found it remarkable. Our argumentation was compelling and the physician participants even acknowledged it, but nevertheless they ignored the request of the General Assembly and elected not to participate. The irony is profound. Russ

Planned home birth and neonatal death: Who do we believe?

August 23, 2010 07:00 AM by Augusta Cherri, LCCE
Profound, indeed. I am always shocked by physicians who stand against midwifery presumably because it makes women babies less safe. Yet when you start talking about ways to make it safer, they do not want to participate. The argument always comes back to, "We want women to have choices and participate in their healtcare, so long as they choose hospitals and physicians." Do they want women to be safer or not?

Planned home birth and neonatal death: Who do we believe?

August 23, 2010 07:00 AM by Augusta Cherri, LCCE
Sorry for the typos.

Planned home birth and neonatal death: Who do we believe?

August 23, 2010 07:00 AM by Aly
>> I do believe midwives might even be more scorned and hated than Muslims DR. F: Its interesting that you compare midwives to a religious affiliation. Sure, there are some midwives with religious like philosophical beliefs. I've made clear in the past that I don't agree with ideological commitment to either extreme. Some obstetricians have an equally tenacious ideology that pregnancy is a disease and technology is supreme. The only difference is that midwives don't try to force their beliefs on anybody else, while obstetricians have taken a political and medical policy of forcing their "religion" on society as a whole. In addition to forcing individual women to undergo surgery with court orders. Kind of like the difference between Unitarians and fundamentalist Christians. ;-) My only philosophy is evidence based medicine and that benefits and risks of medications and procedures should be weighed objectively based on science and not anecdotes (on either side). That's about medicine and health in general, not birth specifically. And that no matter how misinformed I personally think unassisted birth or elective cesareans are, women ultimately have complete control over their bodily integrity.

Planned home birth and neonatal death: Who do we believe?

August 24, 2010 07:00 AM by B
@ Midhusband "Training – I think it is best to establish training requirements based upon the scope of practice and the job description as opposed to what other countries do that intentionally produce credentialed home birth midwives within the bricks

Planned home birth and neonatal death: Who do we believe?

August 24, 2010 07:00 AM by B
@ Aly "My only philosophy is evidence based medicine and that benefits and risks of medications and procedures should be weighed objectively based on science and not anecdotes (on either side). That’s about medicine and health in general, not birth spe

Planned home birth and neonatal death: Who do we believe?

August 24, 2010 07:00 AM by Midhusband
B :@ Midhusband “Training – I think it is best to establish training requirements based upon the scope of practice and the job description as opposed to what other countries do that intentionally produce credentialed home birth midwives within the bricks and mortar university setting.” But the scope of practice is the same for any midwife working in a hospital or in a home – they must be able to provide high standard pre-natal care and assess risk for labour, they must be expert in low-risk physiological birth, and expert at recognizing medium and high-risk situations that need transfer to hospital, as well as providing top-notch transfer care and excellent communication and co-operation with attending ob-gyns. I hope you aren’t suggesting that the high standard university-level midwifery education, including practical training components, that midwives receive in Canada, UK, Netherlands etc. is over-kill for their scope of practice. Hi B, The assertion that the scope of practice of the US CNM & the CPM is not the same originates from testimony given by the Director of our university based nurse-midwifery program as she argued for the adequacy of apprentice trained CPMs for their scope of work. I agree that a normal prenatal exam delivered by a CPM may be considered as identical to that delivered by a CNM, in addition to many other tasks. The point here is that the CNM has a much broader scope of practice than the care of healthy women during the childbearing year (not to belittle this aspect in any way - we think it is of prime importance). Of course I am not criticizing the training requirements established in the countries you site. I have no basis to criticize them nor intention to do so. I think it is terrific that the infrastructure exists there to actually produce credentialed midwives to meet the home birth demand (more or less) with that pathway as we don't here. Producing home birth midwives is something that the architects of the training program need to be intentional about, and we don't tend to do that in the university setting here. My argument is against the bias that says university training is the only confident training. This is not true for professions of moderate scope - particularly when they are specialized. Did you review the link to the registered apprenticeship programs I provided? I suggest embracing the notion that apprenticeship training is adequate for specialized professions of moderate scope, or don't think about it very much the next time you get on an airplane... ;-) I have no objection to producing midwives of any credential. I would have no objection to requiring a Doctor of Nursing for midwives as long as we produce enough of them (but I would wonder about the motivation for doing that). When we have serious issues with access to care (and all the associated implications), we need to focus on the fundamentals of adequacy of training and then assure performance through regulation. Russ

Planned home birth and neonatal death: Who do we believe?

August 24, 2010 07:00 AM by B
@ Midhusband I think the university is exactly the right place to teach midwifery including a long practical period for hands-on experience. University midwifery programs do not contain only academic courses and there should not be a stereotype that t

Planned home birth and neonatal death: Who do we believe?

August 24, 2010 07:00 AM by Aly
"I don’t think anyone needs a Masters degree to be a midwife, but they certainly should have a Bachelors degree with excellent academic and practical skills upon completion of the program. You’d likely find that nurses and doctors would be more cooperative working with midwives if they had at least the same education and qualification level as nurses. " I agree, but don't necessarily think it has to be a nursing degree. The CM route available in one or two states seems to be enough. A college degree, hospital training, low and high risk training, etc, are a must., as well as a strict midwifery board for oversight.

Planned home birth and neonatal death: Who do we believe?

August 25, 2010 07:00 AM by B
I agree too, not a nursing degree, but I just meant similar standard of education.

Planned home birth and neonatal death: Who do we believe?

August 25, 2010 07:00 AM by Kathi Wilson
As a university educated midwife in Ontario, I'd like to make a couple of comments. One is that a university midwifery program needs to be built from the ground up. One of the issues that we saw with a CM educated midwife that moved up here was that the program she went through appeared to be a condensed nursing program with midwifery crammed into the second half or so, which seemed to leave some gaps. The program here (which is responsive to external input regarding its functioning) has a core academic program with sciences (a & p, repro, pharmacology, etc) and then extensive clinical placement (over 50% of the program, with a minimum requirement for births attended in both home and hospital settings). Midwives are expected to be competent in both hospital and home settings, and competence includes extended skills like managing women with epidurals and induction/augmentation. Midwives are expected to have entry-level competence upon graduation (something that is also different from other jurisdictions), but there are restrictions in their first year of practice regarding requirements to work only with experienced midwives for mentoring purposes. Re: the conversations around transfer. I believe that one of the reasons that our outcome data in Ontario and BC regarding homebirth are so good is because midwives must, by regulation, function in both settings -- there is no home/hospital birth midwife divide. Because we can still look after women post-transfer (and most often do) at the hospitals where we are privileged, we are less reluctant to transfer if we (or the woman) need or want to. Further to that, even if a transfer is for a more emergent reason, we are, by and large, respectfully received, and so there's little fear of hostile reception. Because our consultants know us (and I think this is *so* important), they have far more trust in our clinical skills/knowledge and that we are not bringing in disasters to dump on their doorstep. When the impediments to good transfers are reduced or eliminated, then it's less likely that bad ones are going to occur.

Planned home birth and neonatal death: Who do we believe?

August 26, 2010 07:00 AM by B
@Kathi Wilson Thanks for explaining the system in Ontario and British Columbia Kathi. It sounds fantastic to me!

Planned home birth and neonatal death: Who do we believe?

August 26, 2010 07:00 AM by Midhusband
@B I need to ask a favor of you. It is really easy and not very complex. It doesn't cost anything and it is the right thing to do... Please don't use the words "Lay Midwife". There is no place for those words in professional conversation - particularly in reference to CPMs. The word "Lay" means untrained and so using it in reference to midwives who invest 3-5 years in a clinical setting learning their trade, and whose credential is accredited by the National Commission for Certifying Agencies (who also accredits the CNM credential) is not only incorrect, but is really offensive. To make the distinction between a credentialed and non-credentialed midwife, the appropriate and respectful words to use are "Traditional Midwife" when referring to the latter. I trust this is not a big inconvenience for you. Now, on to the few things we disagree on... B said - "I think the university is exactly the right place to teach midwifery including a long practical period for hands-on experience. University midwifery programs do not contain only academic courses and there should not be a stereotype that they are theory only programs. " OK. I respect your opinion. I am not of the opinion that a university based program is a theory only program. I do believe an apprentice trained CPM is likely more capable of managing a home birth operation upon entry than a CNM, simply because she has been doing the specific job for a number of years. B said - "How strange that teachers from primary school to college and university-level are expected to study at university-level, but midwives who may deal with life and death situations where some medical knowledge is necessary are only expected to have high school diplomas and a certificate from a midwifery school below university-level, especially ones that teach pseudoscience like homeopathy, aromatherapy, reiki etc." Well, I think I will just refer you back to the many professions in which an apprenticeship program is considered adequate, many of which have safety significance. My concern, which you kind of touched upon, is performance variability among preceptors. Recently, NARM increased requirements to be a preceptor that equates to an additional 2 years of practice after being credentialed before being qualified to serve as preceptor. In any event, requirements will continue to evolve, but, at the end of the day, it is licensure and regulation that assures performance and protects consumers. B said - "I don’t think anyone needs a Masters degree to be a midwife, but they certainly should have a Bachelors degree with excellent academic and practical skills upon completion of the program. You’d likely find that nurses and doctors would be more cooperative working with midwives if they had at least the same education and qualification level as nurses." I agree that a graduate degree is not required to produce high quality midwives. I am not so confident that university degrees will improve the relationship between the hospital staff and the midwives as home birth CNMs also struggle in this regard. Please note that there are many CPMs who hold undergraduate degrees, graduate degrees, nursing degrees, associates degrees... in addition to the CPM credential. So, many conform to what you have described as your preference, yet it seems judgement has been passed. B said - "@&$ (offensive language deleted) midwives scare the wits out of me. I read Gloria Lemay’s site and she implied that one young woman died from post-partum hemorrhage because her baby was not with her nursing right after birth. I tried to comment how ridiculous that was but it was never published. Midwives who can spout such nonsense are a danger to birthing women. We all know that nipple stimulation triggers uterine contractions, but serious pph cannot be solved by a breastfeeding baby! Complete ignorance about medical facts." OK. I don't judge OBs by the spectacular few, but if those concerns are paramount for you then you must be a strong advocate for regulation as the CPM is indeed the primary care provider to women who choose home birth in the US whether they are regulated or not. Can we produce credentialed home birth midwives better than we in the US produce them today? Sure we can. The best we can do today to manage planned home birth is to regulate CPMs irrespective of pathway. Ten years from now it may be different. Russ

Planned home birth and neonatal death: Who do we believe?

August 26, 2010 07:00 AM by Midhusband
@Kathi Wilson Hi Kathi, The Ontario program sounds terrific (I travel there on occasion and I adore the people). I have a few questions for you... 1) From the time folks first started working on developing the program, how long did it take until it was active? 2) What did you do in the interim until the program was in place? 3) Do you produce enough home birth midwives from the program to meet the need? 4) Prior to the training program and licensure, what was the environment like? 5) Can you describe how many midwives are practicing who were not trained in the program? Best, Russ

Planned home birth and neonatal death: Who do we believe?

August 26, 2010 07:00 AM by Kathi Wilson
It was actually a very fast (relatively speaking) turnaround from the universities being granted the program to its inception. I don't know precisely, but I'm thinking not much more than a year. The program actually began prior to legislation (it started in 1993 and midwifery was not formally enshrined in legislation and funded by the province until Jan 1 1994). All midwives who had been practicing prior to legislation had to undergo a program of evaluation and upgrading in order to become registered (there were about 60 midwives in that group). I, personally, was apprenticing at the time that the program for "grandmothering" began, but did not have the numbers needed to do that, so applied to the first university class and was accepted. All midwives in Ontario are "homebirth" midwives. Our regulatory college requires that all midwives attend and be competent at births both at home and in hospital -- midwives cannot choose to be one or the other. We are required to submit "active practice" reports every 5 years that demonstrate minimum numbers attendance in each setting. It's difficult to assess how many women who want homebirths are unable to access midwifery care, although in most places demand exceeds supply. We are roughly capped in the numbers of women each full-time midwives provides care to in a year -- usually each midwife has 40 - 50 primary clients/year. Approximately 2% of babies in Ontario are currently born at home (overall, not just midwifery clients, and the rates within practices varies. My practice runs at about a 20% homebirth rate. Midwifery in Ontario was never illegal, but rather alegal. Prior to legislation in 1993, there was no legislated midwifery in Canada; however that has changed over the last decade and a half, with only a couple of remaining Atlantic provinces not having regulation (which will likely change). Although midwives never faced prison in this province, there was certainly a good deal of suspicion and hostility, but there was also a very active consumer lobbying group that arose in the early 80's that worked alongside some sympathetic high-profile supporters to accomplish legislation. That was also spurred by a couple of coroner's inquests in midwifery baby deaths that led to recommendations that midwifery be regulated and legislated. Don't know how many precisely who are currently practicing who have not gone through the university program. Many of the original 60 have retired, but we do have a very active "bridging" program to evaluate and integrate midwives who have had formal training in other jurisdictions, which is a year-long program administered by one of the universities. There are currently about 500 midwives now practicing in Ontario, and I would hazard a guess that maybe 1/4 of them have come through the bridging program. Many of those have trained in the Middle East (many from Iran), UK and the USA (both CNMs and CPMs). Hope that answers your questions! Kathi

Planned home birth and neonatal death: Who do we believe?

August 28, 2010 07:00 AM by B
Midhusband (Russ) said, "B said – “@&$ (offensive language deleted) midwives scare the wits out of me." Lay midwife is not an expletive just because you don't like the term. Please do not edit my comments to imply that I was using an expletive. I'd expect a professional not to play such games. Russ, I certainly hope that you take a look at midwifery programs worldwide, especially in other countries with successful homebirth infrastructures and outcomes and see what the gaps are between current CPM training and that midwifery training. A large gap in curricula and apprenticeship should tell you something.

Planned home birth and neonatal death: Who do we believe?

August 28, 2010 07:00 AM by Midhusband
Well, B, we certainly have managed to push each other's buttons, haven't we...I do regret that. Maybe we should walk a mile in each other's moccasins for perspective. I am simply arguing from a perspective similar to this recent, and outstanding, Time article. http://www.time.com/time/magazine/article/0,9171,2011940,00.html Unfortunately, the entire article is not yet available online, but the fundamental message is go license CPMs. If I could snap my fingers and install the Ontario program, with regulation, and sufficient quantities of midwives, I would do it in a heartbeat. If I think about what it would take to do that, I think of the following process steps... 1) advocate until a target university is charged with designing a program and activating it (3-5 years) 2) activate the program (1 year, but I think that is extraordinary) 3) graduate the first class (2-4 years depending...) 4) continue to produce midwives until the production rate offsets the attrition rate and growth in demand (2-4 years?) Note that we would also have to assure that the licensing statute does not require a written practice agreement with a physician - the CNMs have been trying to change that for decades. At this point, we can establish the new program as minimum required for entry. So, if we start today, maybe we could achieve the transition in 8-14 years depending upon success. We need to address the safety issues today by regulating CPMs which is what every state that manages midwifery care in the home setting has done. We know the training model is adequate, even if others may be evaluated as better. Evolving to a university based program should be put in the context of a Multi-Generational Program Plan. We should not let the perfect be the enemy of the good. Russ

Planned home birth and neonatal death: Who do we believe?

August 29, 2010 07:00 AM by IndianaFran
@b "I mean, c’mon, why doesn’t any one address this" because your argument contains so many falsehoods that it is hardly worth it. "There’s no “perinatal database” RTFM." Yes, there is: http://www.perinatreg.nl/home_english "The LVR1, LVR2 and LNR registries are linked to one combined PRN-registry." You are trying to make an argument regarding the methodology by which the registries were linked. However, making the claim that the linked registry does not exist is an argument not worth having. "There’s no actual data in this so-called study!! " Again, of course the data exists. The existence of the data does not depend on your acceptance of the way the linkage was accomplished. "It is a couple of midwives that used a completely invented connection between homebirth and its outcomes." No, it's not. The data linkage was performed by a different group of researchers, including epidemiologists and statisticians. One of the co-authors of the de Jonge paper was also involved with the data linkage project (ACJ Ravelli). She is an epidemiologist, not a midwife. Her contribution to the de Jonge paper was most likely related to her knowledge of the creation of the data linking methods. And then there are your repeated disparaging references to "they just guessed", "invented connections", "fabricated links". A group of specialists in epidemiology, medical informatics, and public health developed a sophisticated method for linking the Dutch obstetrics, midwifery, and pediatrics registries. They published their methods and results in several papers in peer-reviewed journals of epidemiology and medical informatics. Their primary result and conclusions: "Independent validation confirmed that the procedure successfully linked the three Dutch perinatal registries despite nontrivial error rates in the linking variables. Probabilistic linkage techniques allowed the creation of a high-quality linked database from crude registry data. The developed procedures are generally applicable in linkage of health data with partially identifying information. They provide useful source date even if cohorts are only partly overlapping and if within the cohort, multiple entities and twins exist." The linked registry has been used by other groups of researchers as the basis for a number of other peer-reviewed publications, besides the de Jonge study. So, on the one hand, we have the opinions of a wide range of specialist professionals, who submit their work to peer review, whose product is considered to be a high-quality database suitable for further peer-reviewed work. On the other hand, we have a random internet individual who disagrees with their methods and results. I submit that if you want to undertake a serious criticism of the combination of probabilistic and deterministic record linkage techniques used to create the Dutch Perinatal Registry, this is probably not the right forum. And I'm afraid that "in other words, they just guessed" does not constitute a serious criticism. And your approach is certainly not strengthened by the inclusion of outright falsehoods.

Planned home birth and neonatal death: Who do we believe?

August 29, 2010 07:00 AM by B
I'm all for changes, even if they take time, as long is isn't a case of maintaining the status quo because it is easier and pisses less CPMs off.

Planned home birth and neonatal death: Who do we believe?

August 30, 2010 07:00 AM by Tatiana

Planned home birth and neonatal death: Who do we believe?

August 30, 2010 07:00 AM by Tatiana
That was supposed to be a trackback.

Planned home birth and neonatal death: Who do we believe?

September 4, 2010 07:00 AM by Tiny
As long as modern obstetrics continues its assault on women through the use of practices that are based in $$ rather than in evidence-based medicine, I am thankful that we have well-trained home birth midwives available. For those women that are unlikely or unwilling to go to the hospital, I am thankful that we have the same. For those women that have precipitous labors and refuse induction, ditto... Life is not perfect. Planning is not perfect. While I support those that find the hospital their most comfortable place for birth, we must take care not to alienate those that find otherwise --- at the risk of creating more of a problem than we solve. And certainly OBs cannot at this time claim to be problem free, what with all the absolutely unnecessary c-sections, epis, inductions, managed labors and tests that do not have reasonable research evidence to back them up. That said, I also support excellent training for home birth attendants -- ideally a combination of coursework and hands on practice. That is what we have in the CPM credential. In my state, a vast majority of the CPMs have BA/BS degrees or higher. And most have years of observation and hands-on work before they attempt the credential process. Just like any medical personnel, it makes sense to shop around. I will certainly point out that it is way more likely to have an OB with serious issues still practicing, since there is no required reporting that the consumer has access to. The anecdotes of negativity can go both ways, from the woman who dies of intestinal perforation from her c/s to the postpartum hemorrhage. It would be so nice if people could step back and realise that women are people who deserve choices, not just vessels for a child. PTSD and trauma can be avoided in all settings, when care is appropriate for each individual, and guided by a combination of empathy, compassion, caring, and evidence-based medicine. Demonizing either side, or deciding that one side is somehow intrinsically of more value or has intrinsically better outcomes is childish.

Planned home birth and neonatal death: Who do we believe?

May 28, 2012 07:00 AM by Is Home Birth Safe in Canada?
[...] whether meta-analysis is even the right tool for examining home births. She also discusses how misleading the paper is regarding the data used to calculate neonatal deaths, just as the authors of these letters to the [...]

Planned home birth and neonatal death: Who do we believe?

April 1, 2013 07:00 AM by Is politically invented ?risk? in homebirth defining the rights of childbearing women? (Partÿ1)
[...] have already broken down the methodological flaws of the Wax meta-analysis into comprehensible nuts and bolts so I won’t expound upon its junk science here,ÿ suffice it to say the authors’ [...]

@Nicholas Fogelson, MD Nichola

August 22, 2015 07:00 AM by Jennifer Moyer
@Nicholas Fogelson, MD Nicholas Fogelson, MD, respectfully, I would agree that there are numerous midwives who are not as well educated as they should be, there are also a lot of midwives who have gone through intense and rigorous training so we may serve

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