Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

Today's post on Science & Sensibility coincides with the release of a long awaited study looking at the home birth data collected by the Midwives Alliance of North America MANAStats project, 2004-2009.  Judith Lothian, PhD, RN, LCCE, FACCE reviews the research that examines outcomes of almost 17,000 planned home births in the United States.  To date, this is the largest dataset of planned home births available. Dr. Lothian takes a look at what the research found and helps S&S readers to understand the key points of the published paper.  - Sharon Muza, Community Manager, Science & Sensibility.

http://www.flickr.com/photos/wickenden/

http://www.flickr.com/photos/wickenden/

The American College of Nursing today announced the publication in the Journal of Midwifery and Women's Health of important new US research on the outcomes of home birth: "Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009". This research is important for two reasons: it adds to the increasing body of research that supports the safety of home birth for healthy women in the US, and it demonstrates the value and importance of the National Data Registry for Midwife-Led Birth, the Midwives Alliance of North America (MANA) Statistics Project 2.0 dataset(2). This is the first publication of home birth outcomes research in the US since 2005, nearly a decade. Just as importantly, it is the first major research study published using the MANA dataset.

Studying planned home birth presents unusual challenges. A randomized control trial is not possible because women are not willing to consent to randomization to home or hospital. Unlike other countries, data in the US are collected state by state and most birth certificates (the most common, although often unreliable, way to collect birth data) do not collect information about planned home birth. As a result, unlike in countries like the Netherlands, population based research is not possible. There is a need in the US for a system for universal maternity care data collection.  In response to this need, and the need for high quality data on midwifery outcomes, MANA in 2004 began the momentous work of developing a national data registry for midwife-led birth. The result is the National Data Registry for Midwife-Led Births, the Midwives Alliance of North America (MANA) Statistics Project 2.0 dataset.  A companion article in the same issue of the Journal of Midwifery and Women's Health is available to read more about the development and validations of the National Registry for Midwife-Led Births.

About the study

For this study, data were collected from 2004-2009 using the MANA Stats 2.0 Web-based tool. Midwifery participation was voluntary. Data were contributed by 432 different midwives: 20 to 30 percent of all active Certified Professional Midwives (CPMs) and a much lower percentage of active Certified Nurse Midwives (CNMs) contributed to the dataset. Other types of midwives who also participated included Licensed Midwives (LMs), Licensed Direct Entry Midwives (LDMs), Certified Midwives (CMs), and a small percentage of unlicensed direct entry midwives. The midwives obtained written informed consent from the women at the onset of care to contribute data, including outcomes, to the registry. It's important to note that women were entered into the registry by the midwives at the onset of care before outcomes were available. More than 95% of the women cared for by the midwives who participated in the registry provided consent. The sample for the study included all women who intended to give birth at home at the time they went into labor. The final sample of women was 16,924.

http://www.flickr.com/photos/eyeliam/

http://www.flickr.com/photos/eyeliam/

The women were mostly white, married, and college educated. Almost 2/3 of the woman paid for midwifery services out of pocket. The sample came largely from the Western United States.  Almost 78% of the women had previous babies (8% having had a previous cesarean) and a just over 22% were expecting their first babies. Some, but very few, of the women in the sample had complications or co-morbidities (for example, 1.3 % breech, 0.4% multiple gestation, 1.4% pregnancy induced hypertension, 0.8% gestational diabetes).

What follows is a snapshot of some of the most important findings of the study. The authors go into great detail presenting and discussing the findings and then comparing their findings to previous published studies of planned home birth. I encourage you to read the full article.

Study results

Almost 94% of the women had spontaneous vaginal births. There was a 5.2% cesarean rate and an 87% VBAC rate. Only 4.5% of the sample required oxytocin augmentation and/or epidural. Ninety two percent of the births were full term, 2.5% were pre-term and 5.1% were post-term. Less than 1% of the babies were low birth weight. There was an intrapartum transfer rate of 10.9%. Women giving birth for the first time were three times more likely to transfer during labor, most often for failure to progress. Postpartum transfers were 1.7% for women who gave birth at home. The most common reason (over 70%) was for complications related to hemorrhage and/or retained placenta. Neonatal transfer was 1.0% with the most common reason being respiratory distress or low Apgar.

In this sample, the rate of postpartum hemorrhage (defined as over 500cc in a vaginal birth and 1000 cc in a cesarean) was 15.4%, higher than previous research has reported. That said, the transfers for excessive bleeding were low. Active management of third stage is infrequent in this sample. The authors posit that without intravenous oxytocin administration, the 500cc benchmark for diagnosing hemorrhage may not be appropriate in this physiologic birth population.

The intrapartum neonatal death rate was 1.3 per 1000, consistent with rates reported in some studies, but higher than the rates reported in others. While the rate is still relatively low, it might, the authors suggest, be partially explained by a sample that included women who are at higher risk for adverse outcomes (multiple gestations, breech presentations, VBAC, gestational diabetes or pre-eclampsia). When these women were removed from the sample, the intrapartum death rate drops to 0.85 per 1000, a rate that is statistically congruent with rates reported in most studies, with the exception of large population studies in the Netherlands that report somewhat lower rates.(deJonge et al, 2009). The authors also note that the lack of an integrated system and possible delays in transfer may contribute to the small but somewhat higher rate of intrapartum neonatal death in the sample.

There was one maternal death in the study, as a result of a blood clot in the heart at three days postpartum after an uncomplicated pregnancy, labor, birth and postpartum.

Discussion

As in any research there are limitations. This is not a population based study. Not all midwives in the US contributed data to the registry. The births took place mostly in the Western United States. The women were largely white, college educated and married. Nonetheless, the findings make a major contribution to the literature on planned home birth supporting the findings of previous research conducted both in the US and in Canada, the Netherlands, and the United Kingdom (Johnson & Daviss, 2005; Janssen et al 2009; Hutton et al, 2009; Janssen et al, 2002; deJonge et al, 2009; Birthplace in England, 2011).

In spite of the meticulous development and validation of the dataset and the acknowledged limitations of the data, I suspect the usual naysayers will question the validity and the usefulness of the dataset. I suspect those opposed to planned home birth will exaggerate the implications of findings related, for example, to maternal bleeding in spite of the fact that almost no mothers required transfer or intervention, and point out the higher intrapartum neonatal mortality numbers than other studies have reported without discussing the fact that the increase is largely accounted for by infants of women at higher risk for adverse outcomes (pre-eclampsia, gestational diabetes, multiple gestation, VBAC,  breech). It is difficult for anyone to dismiss the importance of the overall excellent outcomes for both mothers and babies.

The excellent outcomes in this study, (with care provided mostly by CPMs & LMs, in a country that does not have integrated systems of care including seamless transfer and collaboration between providers, and with a sample that included women who are usually considered at higher risk for planned home birth {breech, VBAC, multiple gestations, pre-eclampsia, gestational diabetes}), should make us pause. Could it be that even for women with some risk factors, planned home birth could be as safe as hospital birth?  What would the outcomes be if we had an integrated system of care?

Personal "Take Aways"

  • The MANA dataset is an extremely valuable resource for researchers. Thanks to the work of MANA, the dedicated midwives who participate in the registry, and the women who consent to having their outcomes registered, we have further evidence, this time in the US, that planned home birth reduces interventions including cesarean, and has outcomes similar or better than planned hospital births. CPMs, CMs and LDMs, who are the largest group of midwives contributing to the dataset, deserve recognition and respect. The positive outcomes reflect the excellence of care that they provide for women. With the publication of this important study, and the publication of the companion article describing the development and validation of the dataset, hopefully, many more midwives, including CNMs and those who practice in other parts of the country, will be persuaded to contribute to the registry.
  •  I encourage you to share the findings of this study with the women you teach, talk to and touch. Most women will not choose home birth but knowing that women today give birth safely at home without routine interventions or tied to machines, and subjected to the ticking clock, should give all women a boost of confidence in their ability to give birth. And, it just might encourage some women to think about having a planned home birth.
  • We might think of a childbirth education registry. We have wanted high quality data for decades to track the outcomes of childbirth education. Perhaps this is a way to collect quality data?

Conclusion

This is a landmark study of US home birth. Hats off to MANA for its ground breaking contribution in collecting and providing data that will further advance our knowledge of planned home birth and midwifery.  Hats off to the dedicated midwives who contributed their outcomes to the dataset, and to the women who were so willing to share their information with the world. And, hats off to the dedicated researchers, Melissa Cheyney, Marit Bovbjerg, Courtney Everson, Wendy Gordon, Darcy Hannibal and Saraswathi Vedam who continue to contribute in groundbreaking ways to promoting and supporting normal, physiologic birth and the health and safety of childbearing women and babies. 

References

Birthplace in England Collaborative Group. (2011). Perinatal and Maternal Outcomes by Planned Place of Birth for Healthy Women with Low Risk Pregnancies: The Birthplace in England National Prospective Cohort Study, British Medical Journal 343, d7400.

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D. & Vedam, S. (2014). Outcomes of Care for 16, 924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. Journal of Midwifery and Women's Health.

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D. & Vedam, S. (2014). Development and Validation of a National Data Registry for Midwife-Led Births: The Midwives Alliance of North America Statistics Project 2.0 Dataset. Journal of Midwifery and Women's Health.

de Jonge,  B. van der Goes,  A. Ravelli, M. Amelink-Verburg , et al.(2009). Perinatal Mortality and Morbidity in a Nationwide Cohort of 529,688 Low-risk Planned Home and Hospital Births. British Journal of Obstetrics and Gynecology 16, no. 9, 1177-84.

Hutton, E.,  Reitsma, A., Kaufman, K. (2009). Outcomes Associated with Planned Home and Planned Hospital Births in Low-Risk Women Attended by Midwives in Ontario, Canada, 2003-2006:A Retrospective Cohort Study. Birth 36, no. 3, 180-89.

Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee Sk. (2009). Outcomes of Planned Home Births with Registered Midwife versus Attended by Regulated Midwives versus Planned hospital Birth in British Columbia. Canadian Medical Association Journal 181, no. 6, 377-83.

Janssen, P. Lee,S.,  Rya,E,  et al. (2002). Outcomes of Planned Home Births versus Planned Hospital Births after Regulation of Midwifery in British Columbia. 166, no. 3, 315-23.

Johnson, K. & Davis, B.A. (2005). Outcomes of Planned Home Brth with Certified Professional Midwives: A Large Prospective Study in North America. British Medical Journal 330, 1416-19.

About Judith Lothian

@ Judith Lothian

@ Judith Lothian

Judith Lothian, PhD, RN, LCCE, FACCE is a nurse and childbirth educator. She is an Associate Professor at the College of Nursing, Seton Hall University and the current Chairperson of the Lamaze Certification Council Governing Body. Judith is also the Associate Editor of the Journal of Perinatal Education and writes a regular column for the journal. Judith is the co-author of The Official Lamaze Guide: Giving Birth with Confidence. Her research focus is planned home birth and her most recent publication is Being Safe: Making the Decision to Have a Planned Home Birth in the US published in the Journal of Clinical Ethics (Fall 2013 ).

106 Comments

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30, 2014 07:00 AM by Geradine Simkins
Thanks for this great review Judith. I especially like the "personal take-aways" because they give us another lens through which we can think about the common narrative regarding childbirth in the US. And more importanly, as you mention--if all women, regardless of the birth setting they choose--are encouraged by these outcomes to be more confident in their innate abilty to give birth in a healthy unfettered way, then these studies on planned home birth can not only inform but inspire. We know that our US maternity care system is broken; we also have evidence that there are better ways to give birth that are safe, healthy, cost-effective and more satisfying.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30, 2014 07:00 AM by Robin Hutson
What an informative article that raises excellent points: such positive outcomes for mothers and babies without an integrated system begs the question how beneficial an integrated system could be? I hope that health policy decision makers who care about outcomes and cost pay attention! An integrated system would address so many aspects of our maternity care crisis in the US.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30, 2014 07:00 AM by Marinah Farrell
What a fantastic and well written article! The Midwives Alliance continues to work hard to demonstrate the safety of home birth and the realities of evidence based care. Thank you for highlighting and sharing such important findings today.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30, 2014 07:00 AM by Adrianna Costello-Martin
I love the idea of a childbirth education registry! I've been a CBE for nearly 18 years, and have seen first-hand the difference education makes. It is disheartening that only 25% of first-time moms take a CBE class (according to the Listening to Mothers Survey). I work at an OOH birthing center, and we starting requiring an independent CBE course for our first time moms and moms attempting their first natural birth, because we noticed our transfer rate for these women was higher than we (or they!) liked. Our rate of transfer for this group has gone down, and we believe education--really being prepared for the work of labor, with no punches pulled--makes a huge difference. Thank you for all your hard work. I can't wait to read the full study.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30, 2014 07:00 AM by Walker Karraa, PhD
Great review. But again the lack of any recognition of maternal mental health is a gap in the research design thatis cconsistent with birth based research paradigms. What is an outcome measurement without a measure of a woman's psychological well being. She could have had a "successful" vaginal homebirth and psychologically hemorraging. I am writing a chapter for a book dedicated to home birth to cesarean transfer. I have gathered research demonstrating midwives failing to provide mental health screening, psychoeducation, referral and a lack of knowledge about treatment that borders on professional incompetence. MANA has no position paper on mental health...despite the overwhelming evidence that depression and anxiety directly impact mother and baby antenatal and increase a woman's risk for preterm birth, IUGR--no core competency exists beyond a blurb about "emotions" in postpartum care. AC NM is the only midwifery training that mandates mental health core competency and addresses what the rest of science (medical, social, epidemiological, pediatric) has figured out: there is no maternal health without mental health. I'm disappointed that this was not noted in the review.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30, 2014 07:00 AM by Walker Karraa, PhD
And a registry that records physiology and ignores psychology? No data does not mean good data.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30, 2014 07:00 AM by Judith A. Lothian, PhD, RN, LCCE, FACCE, FAAN
This research reports on only some of the outcomes reported. It is worth finding out if any psychological outcomes are indeed included in the dataset. But, again this research did not report on all of the outcomes in the data set.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30, 2014 07:00 AM by Rachel Be
Thank you for this well written article and for addressing the need for an integrative health care system. It is an exciting day in the world of home birth advocates, thank you for contributing your voice.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30, 2014 07:00 AM by Catie M Mehl, LCCE CD(DONA) CLC
FTA: "As in any research there are limitations. This is not a population based study. Not all midwives in the US contributed data to the registry." Does the fact that participation was *voluntary* and that less than ? of home birth midwives in the US volunteered to be part of the study contribute to a selection bias? If participation had been randomized and participants not allowed to drop out for reasons other than leaving practice, could we possibly see different results?

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30, 2014 07:00 AM by Sarita Bennett
Wouldn't it be great if all CPM's and home birth midwives could contribute to the statistics project? It could happen if midwives - including home birth midwives - were accepted as crucial members of a well integrated and smooth maternity care team. Thank you so much for this well written information.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30, 2014 07:00 AM by Kimberly Wallace
Just not impressed. Too many limitations for people to get so excited about the "outcome". Where are the comparison to similar births in hospital? Agree with above poster.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30, 2014 07:00 AM by Wendy Gordon, LM, CPM, MPH
Every study has limitations. Unfortunately, the only national database that could be used for comparing hospital births is birth certificate data, and for many of the outcomes of importance here, birth certificate data has been shown to be very unreliable. There is no national database that accurately follows all women from where they *intended* to give birth at the time they went into labor, all the way through to the six-week postpartum visit. MANA Stats does, the birth center folks' database does, but general US databases are fractured and siloed so that these direct, matched comparisons of home to hospital birth outcomes at the national level simply cannot be done. Several other countries have comprehensive data collection systems that ALL providers use and that all link together, and these sort of higher-level comparison studies can be done. The US doesn't have this. It's a severe limitation. MANA Stats is a voluntary database, partly because there are a number of states in this country in which midwives could actually be prosecuted for attending a birth, and this contributes to a lack of safety when contributing data. So while there are limitations, this doesn't mean the data shouldn't be published.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30, 2014 07:00 AM by Catie M Mehl, LCCE CD(DONA) CLC
Wendy, I wasn't aware that researchers had to turn study participant names into the state. How would midwives in illegal states be prosecuted for turning in their data? Only 20%-30% of all US home birth midwives participated in this and, of those, 25% of contributors didn't participate continuously and not just because they were no longer practicing. And those that participated volunteered. These things matter. These things add validity to the data. I wanted this study to be awesome. I wanted this study to show that home birth in the US is just as safe as hospital births. But it doesn't. It says home birth with the midwives who chose to fully, 100% participate in this study does carry a higher rate of IP mortality but the absolute number is still low.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30, 2014 07:00 AM by Walker Karraa
It is interesting what studies are forgiven for their limitations, and others are crucified.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30, 2014 07:00 AM by Catie M Mehl, LCCE CD(DONA) CLC
I was thinking the same thing, Walker.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30, 2014 07:00 AM by Wendy Gordon, LM, CPM, MPH
@Catie Mehl allow me to clarify. Midwives may have a number of reasons for choosing not to participate, but there are many reasons why MANA Stats is and must be a voluntary dataset. Federal regulations around the participation of human subjects in research mandates that it must always be voluntary; people cannot be forced to participate in research. There are also laws regarding the use of protected health information in HIPAA regulations that prevent the disclosure of information about individuals. I agree with you, it *does* matter that the MANA Stats dataset is voluntary, and that is precisely why it is listed as a limitation of the study. MANA has been working for years to get more and more midwives to sign up, to create a culture of research in which midwives feel obligated to participate, and it's happening. But MANA has no way of mandating participation in this system for all midwives in the US. There are hospitals and practices that use electronic medical records and other databases for providing care, and their participation in that may be mandated for quality assurance purposes, but they cannot mandate that the data be used for research. That must always be voluntary, by federal law.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30, 2014 07:00 AM by Catie M Mehl, LCCE CD(DONA) CLC
Thanks for the answer, Wendy. And I am aware that they list it as a limitation but it isn't one being discussed in a way that it should be. If a hospital were to release data on outcomes but didn't require all of its care providers to report, only those that volunteered to have their stats counted, there is no way anyone in our community would accept those numbers. So why is it ok in this case? It shouldn't be.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30, 2014 07:00 AM by Ashley Rossi Lovell, LCCE
Why are the neonatal mortality rates reported in the results section (early and late) higher than the ones reported in the discussion section? In the results section, there are rates reported including congenital anomalies and without [early neonatal .88 and .41 for a total of 1.29/1000 when anomalies are included and .41 and .35 for a total of .76/1000 when they are excluded]. Then later, in the discussion, the total neonatal death rate is reported as 0.77/1000, and the discussion goes on to imply that that INCLUDES the anomalies. Why the discrepancy? I think most critics go straight to those newborn mortality numbers, and this is confusing to me.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30, 2014 07:00 AM by Judith A. Lothian, PhD, RN, LCCE, FACCE, FAAN
Catie, This is tricky. When birth takes place outside the hospital other factors come into play. As Wendy Gordon points out some midwives are reluctant to provide data when they are practicing "illegally". Others just aren't inspired or are too busy to do it. That aside, it's important to understand that there is NO totally reliable and perfect dataset related to home birth in the US. Birth certificate data are unreliable and do not, very often, distinguish between planned and unplanned home birth...and the outcomes, we know, of planned and unplanned home birth are very different. We evaulate the findings of any research based on the sample. These researchers clearly described the sample. We, as readers, come to our own conclusions about the findings based on what the researchers have provided us. My own take is that, although this is a sample that is not a population sample, largely Western US and white, married, highly educated women, the findings replicate those of other studies that are indeed population based. If the datset had been every midwife and every home birth in the US....would it have been more valuable? You bet! But we work with what we have. This is one study, of a large number of births in the US, that contributes to an ever growing body of knowlege about the safety of planned home birth. We look forward to more participation in the MANA registry. And we look forward to a national registy of all birth data and standard birth certificates that include information about planned place of birth.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30, 2014 07:00 AM by Gina Crosley-Corcoran, CD(DONA), MPH Candidate
Wendy, as a fellow public health scholar, I very much appreciate your take on this.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 31, 2014 07:00 AM by Catie M Mehl, LCCE CD(DONA) CLC
I appreciate your feedback and still feel that if this same study had come out but "home" was replaced with "hospital" and "midwife" with "hospital care provider" it would have been torn to shreds by our community. If we want to be taken seriously then we have to present serious research. This is only helpful for women who are looking to home birth with one of the midwives who participated fully in this study.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 31, 2014 07:00 AM by Walker Karraa, PhD
And I returned to this conversation to see still no discussion about mental health. The rest of the world gets it; and it would behoove childbirth lay professionals to get on board. Take a look at this piece out today: Why Shouldn’t This Bother Us? Mental Illness & the Global Burden of Disease http://wp.me/p2Xah3-hs

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 31, 2014 07:00 AM by Deena H. Blumenfeld, ERYT, RPYT, LCCE, FACCE
Thank you for this review of the MANA data set, Judy. I'm pleased to know, that even with the limitations of the information, it still points to safe and healthy outcomes for mothers and babies regarding homebirth. I also love your idea about tracking the outcomes of childbirth education. This data is much needed as well. I was talking to my husband about this months ago. I want to help make this happen.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 31, 2014 07:00 AM by Wendy Gordon, LM, CPM, MPH
@Walker Karraa, the MANA Stats registry does collect information regarding several perinatal mental health items. Those items were not explicitly reported in this study, but there is a rich dataset that is available to researchers. I encourage you to put together a research proposal and submit your application to MANA; I admire your passion and would love to see what you could do with it.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 31, 2014 07:00 AM by Katherine Dexter
@Robin Hutson Amen, Robin!

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 1, 2014 07:00 AM by Another Liz
This "study" brings up more questions than answers. And I hope MANA seeks to find answers - true answers, and not unfounded self-promoting headline - regarding the safety and risks of OOH birth. Here are some of my questions: In this sample, were there any differences in outcomes (perinatal mortality rate) between CNMs and non-CPMs? In this sample, were there conditions associated with a higher perinatal mortality rate, if so which ones (hmmm BREECH is sticking out for me), and how does MANA's professional guidelines reflect these increased risk of perinatal mortality? Does MANA reviews these findings, identify clear risk factors that increase risk of death, and set professional standards for safe practice - based on their own research? Why or why not? Where is the descriptive analysis of the deaths that occurred in this sample? What where the reasons for perinatal death? The authors allude to insufficient collaboration between midwives and medical providers - is there any evidence in this sample to support this assertion? Case reviews of each incidence of perinatal death may illuminate this subject. In this sample, was there any difference in outcomes between midwives practicing in states where CPMs are licensed and in states where they are not? In this sample, were there individual midwives who had significantly higher perinatal mortality rates in their own practices? If so, what was there any common denominator among these types of midwives? Let's start asking the hard questions. Let's start coming to conclusions about what makes midwifery and OOH birth safest and stop this nonsense of blind self-promotion. A group of health care professionals should adhere to ethical standards - first and foremost - to do no harm.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 1, 2014 07:00 AM by Ashley
@walker karraa I'm not a professional, "just" a mom. I found my CPM to be immensely helpful concerning my mental health. Each appt was an hour long and the care was very holistic. Having had other children, I didn't need as much education on pregnancy. She recognized the need to support my emotional health and met that need far above my expectations. The low client load, long appointments, and continuity of care led to enhanced psychological care. I saw a CNM for a hospital birth prior to my home births and I can say that while she did check in on my mental health, she was limited by appointment time and the nature of group practice. But even that experience provided more emotional support than an OB visit which primarily focuses on physical measurements.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 1, 2014 07:00 AM by Melissa Gibbons
@Another Liz, you raise some really good questions. Since you have so many I'll stick to just a few, specifically your question about conditions associated with higher perimortality rates. There were a small sample of breech and twin births included in th

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 1, 2014 07:00 AM by Catie M Mehl, LCCE CD(DONA) CLC
Wendy, did the law regarding participation change from 2000 to 2004? I ask because according to the secondary article about the development of the tool, for stats gathered in 2000 for the 2005 BMJ article participation was mandatory for all CPMs but clients still had to consent. From page 2: "In 1993, a group of midwife researchers within MANA, called theMANA Statistics Committee at the time, developed and piloted a data collection tool designed to help track demographic characteristics and pregnancy- and birth-related outcomes for midwife-led births occurring primarily in the United States. User feedback over the next 7 years led to several modifications, and theMANA Stats 2.0 paper data collection formresulted. In 2000, this formwas used for a year-long, prospective study of planned home births attended by certified professional midwives (CPMs) in North America. Data were collected on all CPM clients who consented to participate during the research year. Participation was mandatory for all CPMs, and results were published in 2005."

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 1, 2014 07:00 AM by Catie M Mehl, LCCE CD(DONA) CLC
And please know I'm honestly trying to learn and understand! :)

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 1, 2014 07:00 AM by Wendy Gordon, LM, CPM, MPH
@Catie Mehl, the federal laws around protection of human subjects in research, as well as HIPAA regulations, have continued to evolve and shift simultaneously. Honestly, I'm not your expert on that. I was not yet a midwife in the years leading up to and including the CPM study; research wasn't even a glimmer in my eye yet. :-)

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 1, 2014 07:00 AM by Ashley
Another Liz : This “study” brings up more questions than answers. And I hope MANA seeks to find answers – true answers, and not unfounded self-promoting headline – regarding the safety and risks of OOH birth. Here are some of my questions: In this sample, were there conditions associated with a higher perinatal mortality rate, if so which ones (hmmm BREECH is sticking out for me), and how does MANA’s professional guidelines reflect these increased risk of perinatal mortality? Table 5 gives info on the breakdown of death rates, including data on breech. The study also give this info on breech "When examining perinatal death rates among higher-risk women, the data suggest that compared to neonates born in vertex presentation, neonates born in breech presentations were at increased risk of intrapartum death (1.09/1000 vertex vs 13.51/1000 breech, P < 0.01), early neonatal death (0.36/1000 vertex vs 4.57/1000 breech, P = 0.09), and late neonatal death (0.30/1000 vertex vs 4.59/1000 breech, P = 0.08). ". Breech presentation is a higher risk than vertex, and I don't think anyone would dispute that. At the same time, I think midwives respect their clients' ability to research the risks and make their own decision based on that. There are some midwives who are not comfortable with breech presentation and will refer to an OB or more experienced midwife. There are other midwives who have a lot of knowledge and hands on training in breech birth. My midwife worked among the Amish for quite some time. The women she saw were having their babies at home, with or without a midwife. Obviously it was safer for these women and babies if a trained midwife was present, so she went. Perhaps if breech presentation were not an immediate c-section in the majority of US hospitals, the picture would be different. The SOGC (Canada) states, "Planned vaginal delivery is reasonable in selected women with a term singleton breech fetus." The US needs to make progress in this regard. We need to return to teaching vaginal breech birth in med school. We need to acknowledge that c-sections have risks to mom and baby, both short and long term. We need to give women all the information and provide real options for place of birth.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 1, 2014 07:00 AM by Ashley
@Another Liz, this research is a starting point. It is my understanding through reading all the articles on this study over the past couple of days that until now, there hasn't been a collection of data like this. MANA acknowledges the limitations to th

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 1, 2014 07:00 AM by Jeff Olejnik
So many issues with this Homebirth survey. One main issue is transparency and misrepresentation. Quite frankly the data of the 20-30% reporting midwives shows an increase in adverse outcomes. But the press statement emphasizes the low interventions and successful prolonged breast feeding rates with no increase in adverse outcomes. Here is an excerpt from one blog of a women explaining how homebirthers make their decisions on their own research..."Ulitmately it is about KNOWING the risk. As long as we as women are willing to take it, let them. If a woman is smart enough to search out a home birth midwife then I expect her to do her own research on potential high risk issues she may be facing...". Yet if a women reads the press release and doesn't actually analyze the data, she may believe there is no added risk to Homebirth as compared to hospital birth. I have read comments trying to explain the higher risks at Homebirth because of congenital anomalies, unexpected premature deliveries, or attempting Homebirth too far from the hospital. Also comments about demanding doctors to start performing breech or VBAC deliveries more. Well Homebirth outcomes are as Homebirth outcomes are performed, same for hospitals. So according to this data, hospitals have better outcomes period. And according to this data some type of reform needs to be done limiting high risk deliveries from Homebirth or other reform to improve Homebirth outcomes. One comment stated MANA could have stated, "the risk of death at home birth is about 3 times as high as in a CNM birth center or hospital, but the overall numbers are low, and due to other benefits of homebirth, we still believe this to a be a good option for low-risk women". That would be a clear statement, and every mother could decide for herself if she is okay with that risk." This would have been appropriate for your press release so that women can decide if they want to accept that risk for the sake of lower interventions. It sounds like MANA published this press release to justify their choice for choosing Homebirth. But the data suggest MANA should be concluding that measures need to be put in place to make Homebirth safer.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 2, 2014 07:00 AM by fiftyfifty
@Wendy Gordon, LM, CPM, MPH "Federal regulations around the participation of human subjects in research mandates that it must always be voluntary; " No, federal regulations only mandate that *patient* participation be voluntary. In other words individual patients can choose to opt out. But Federal regulations do not prohibit professional organizations from requiring their members to participate in quality review. Hospitals require stats to be kept on their MDs and CNMs and this is entirely legal. But MANA doesn't meet the same standard.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 2, 2014 07:00 AM by OBPI Mama
@Wendy Gordon, LM, CPM, MPH HIPPA??? Where are HIPPA forms given in the state of Ohio with homebirth midwives? I didn't fill out any HIPPA forms, I know that! Why does my ex-midwife (and another 2 MANA midwives I know as well) share personal health information with other people? Generally confused...

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 2, 2014 07:00 AM by rroonie
According to a poster up above, the neonatal death rate for low risk women at homebirth (per the MANA stats) is.67/1000. Is this correct? The neonatal death rate for low risk women attended by CNMs in the hospital setting is somewhere around .4/1000. So we are basically looking at a difference of .2/.3. If you ask me those numbers definitely support homebirth as a safe option for low risk women. I think the question we need to ask is: Can homebirth in the US be safe? And if so, what guidelines should be followed in order to keep/make it safe? I feel confident that homebirth is in fact safe, as safe as hospital birth, as long as a specific protocol is followed. 1 Mother and baby must remain low risk and healthy 2. At least two experienced CPMs or CNMs at every homebirth 3. Every mother should have a back up OB 4. Each mother should be within a 15 minutes from a hospital 5. Swift transfer at first signs of trouble. First time mothers should proceed with extra caution when choosing homebirth and first time mothers should also be transferred immediately upon ANY warning signs. I can't get past this feeling that some people want- so desperately want - homebirth to be considered dangerous. They want bad stats. They WANT high death rates. They won't except any information that might show homebirth is actually a safe and valid option for many low risk women. But why? What is their personal stake in this and why do they not want to see women having healthy, safe homebirths? I don't get it. Women WILL continue to make this choice because it is so often a beautiful and healthy experience for the entire family. Why don't we all work together and integrate homebirth into our maternity care system? Homebirth isn't going anywhere. How about we do what we can to make it safer rather than fight the constant "home vs hospital" fight that gets no one anywhere?

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 2, 2014 07:00 AM by Wendy Gordon, LM, CPM, MPH
fiftyfifty : No, federal regulations only mandate that *patient* participation be voluntary. In other words individual patients can choose to opt out. But Federal regulations do not prohibit professional organizations from requiring their members to participate in quality review. Hospitals require stats to be kept on their MDs and CNMs and this is entirely legal. @fiftyfifty That is exactly what I said in a comment above, quoting myself: "There are hospitals and practices that use electronic medical records and other databases for providing care, and their participation in that may be mandated for quality assurance purposes, but they cannot mandate that the data be used for research. That must always be voluntary, by federal law." Not sure what your dispute is? It seems that we agree. The point is that collecting data for quality assurance and review is very different from collecting data for research purposes, and by federal law, the latter must always be voluntary.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 2, 2014 07:00 AM by Doula Dani
Why didn't they give any numbers when they compared to studies in the Netherlands and Canada, etc.? It seems very odd that they really want people to have to do their own searching to have ANY numbers for comparison. And, more importantly, why didn't they compare to the Birth Center study from 2013? The Birth Center study shows numbers for out-of-hospital birth here in the United States. I can't think of anything better to use for comparison. The main difference being type of care provider. In the Birth Center study mass majority are CNMs. In this MANA study mass majority are CPMs. Here are the numbers: Birth Center Study: Intrapartum mortality rate = 0.47/1000 Neonatal mortality rate = 0.40/1000 MANA Study: Intrapartum mortality rate = 1.30/1000 Neonatal mortality rate = 0.76/1000 Distance to the hospital might have *some* affect on the intrapartum numbers, but that might also not have any affect at all. Most home birth moms I know take distance to the hospital into consideration.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 2, 2014 07:00 AM by rroonie
So the neonatal death rate IS .76/1000? Wow. I am feeling extremely confident about homebirth now for low risk women. Those numbers are fantastic. Especially when you consider the 5% cesarean rate, the 95% breastfeeding rates and the low rates of vacuum and forcep assisted births. Think of how many women avoided unnecessary cesareans that could have possibly turned into uterine ruptures years down the line. It's very possible that by choosing homebirth a woman's future babies have been saved. Women's uterus' have been saved. That's not even mentioning the damage that was possibly avoided by not having to have a vaginal birth involving forceps and vacuums. As far as the intrapartum mortality rate goes, there could be a few different reasons. First of all Doula Dani, close to 1000 of the homebirth births were attended by unregulated, unlicensed DEMs. How do we know that all of the deaths, or even most of them, did not occur under their attendance? I also read that it was mandatory for Oregon midwives to participate. If this is true, Oregon midwives are probably the least regulated in the country and it's very possible that the deaths that occurred there skewed the stats. I would be curious to know how many deaths came from Oregon. And, Dani, if the deaths were due to poor transports, perhaps that means that all the anti-homebirth rhetoric that is all over the internet has created so much animosity and hostility that it is actually making homebirth MORE dangerous for women. If a woman arrives at a hospital and has to face an angry and hostile hospital staff that almost feels the need to punish the woman for choosing homebirth, that's not going to bode well for the baby, is it?

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 2, 2014 07:00 AM by rroonie
And this http://pushformidwives.org/wp-content/uploads/2011/09/Clinical-Experience-Comparison_2013.pdf This whole idea that CPMs are undertrained and undereducated is based on what information exactly?

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 2, 2014 07:00 AM by CRiley
@Doula Dani @Doula Dani- your comparison of neonatal death rates does not match those I am seeing. I believe you are mixing early neonatal death rates up with TOTAL neonatal death rates. Here's what I show when comparing the birth center study with the correct MANA Stats rate: - birth center early neonatal death rate: 0.40/1000 - MANA Stats early neonatal death rate: 0.41/1000

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 2, 2014 07:00 AM by DrDallas
@ Doula Dani, the Birth Center study actually found no differences in outcomes between CPMs and CNMs. The majority of freestanding birth centers in the U.S. are managed/staffed by CPMs, which makes sense given that CNMs are not trained as out-of-hospital

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 2, 2014 07:00 AM by Jesse Garon
@Wendy Gordon, LM, CPM, MPH Given how bleak the outcomes are, for breech and TOLAC especially, did it at any point become an ethical consideration for MANA to hold onto this data since 2009? I am wondering if women had had access to your data on CPM attended home birth breech deliveries, specifically the very high death rates as compared to hospital birth, if they might have reconsidered attempting out of hospital breech births. Or if some of your members, knowing the high likelihood of poor outcomes, would have transferred care to an OB for a breech baby. A few more babies might be with us today if this information had become available earlier.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 2, 2014 07:00 AM by Doula Dani
Dr Dallas - there may be more CPM birth centers in the US. But they didn't use data from *all* birth centers for this study. They used select birth centers. It is written in the study. Majority of the centers used were CNM run, a small percent were CPM run, a smaller percent were combination of CPM/CNM run. Criley - both neonatal mortality rates I listed are total neonatal mortality rates (early plus late). The Birth Center study listed other rates so readers could compare rates. To compare to US hospitals, they used CDC vital statistics and used the neonatal mortality rate for all babies born to all races at a weight of 2500 grams or more. This rate includes lethal anomalies and all high risk pregnancies. It was 0.75/1000.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 2, 2014 07:00 AM by rroonie
Doula Dani- that is impossible. The neonatal death rate for black babies in the US is approximately 10/1000. There is no way .75/1000 is the rate for high risk pregnancies AND women of all races.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 2, 2014 07:00 AM by Doula Dani
0.75/1000 is correct. You can see for yourself in the Birth Center study in the discussion area. Or you can see it for yourself through the paper where they got the rate: http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_06.pdf Go to page 21, under all races, 2500 grams or more then look under the Neonatal column and you will see 0.75. It is not solely high risk. It includes high risk. So it is low risk and high risk. And includes lethal anomalies, too. I'm not sure where the 10/1000 comes from but I would guess that it is live births for African American babies regardless of gestational age.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 2, 2014 07:00 AM by rroonie
Dani- you did not add them all together. You ONLY took the rates for 2500 grams to 2900 grams. When you add up all the different weights of 2500 grams and above you get somewhere around 5/1000. That's a neonatal death rate of 5/1000 not.7/1000. A neonatal death rate of .7/1000 is extremely low. It's a very good indicator of the safety of homebirth for low risk women.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 2, 2014 07:00 AM by Doula Dani
No that is incorrect. Please look where it says 2500 grams or more. It is the 11th line down. Then go to Neonatal column. It says 0.75

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 2, 2014 07:00 AM by Christina Moody
@douladani You asked why the MANAstats was not compared to birth center study. A comparison between the two would not be comparable as the birth center study had zero breechirths, zero multiple births, and a small handful of VBACs. In order to make a

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 2, 2014 07:00 AM by Doula Dani
@Christina Moody The Birth Center study actually does have breech and VBACs. It is incorrect to use the .85/1000 intrapartum for comparison to that study. And I also do not know why they excluded pre-e deaths to get to that number of .85/1000. Are they saying that a midwife did not know the signs of pre-e? Or would a midwife just ignore them? That makes no sense to not include that death. It seems as though the authors and others that facing all the criticism of this study really, really do not want women to look at numbers to compare. There is an excuse for everything. "you can't compare to this b/c of ____, you can't compare to that b/c _____." They just want women to take their word for it and not look at the numbers. For those that are willing to do the work and find the numbers to compare, they can see for themselves. But it is a pity that the authors didn't do the courtesy of making it easier for women who are seeking to make informed choices. Regardless, they should have used this study as a comparison. Why would they not? It is published in the same journal? They used studies based out of Netherlands and Canada but why not the Birth Center study? And again, why didn't they show any of the numbers so women could see directly the differences in the rates. In other studies, like the Birth Center study, the rates are given in the discussion so women can clearly see. You have to search through studies to find the numbers and for those that don't know where to look, they won't be able to make a comparison. Here are some numbers for anyone who wants to compare: Neonatal (TOTAL... meaning early plus late): MANA study = 0.76/1000 (excluding lethal anomalies) Birth Center study = 0.40/1000 (excluding lethal anomalies) USA hospitals = 0.75/1000 (for all races, all babies over 2500 grams, *including* lethal anomalies and high risk) Intrapartum: MANA study = 1.30/1000 Birth Center study = 0.47/1000 Now someone might not think these numbers show much of an increase risk, as the numbers all look quite small. But to someone else, they might look at it and see that difference is too significant for them. That is up to each woman to decide for herself but she is entitled to having the information. Here is the Birth Center study: http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12003/full#b42 Here is the Vital Statistics paper: http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_06.pdf

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Jesse Garon
@Christina Moody That's not correct. Why would you only look at intrapartum deaths? The intrapartum death rate for MANA does not compare favorably to any other studies out there, anyway. The total death rate excluding high risk in this study is 1.61.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by rroonie
Dani- go to page 21, you will see that you are only taking into account the neonatal death rate for 2500 grams or more.. next on the list is 2900 grams to 3400 grams and it continues down the line. The neonatal death for 2900 grams to 3400 grams alone is over 1/1000. You need to take them ALL into account. You are incorrect. Go see for yourself.. scroll down and see. What is your stake in this and ask yourself why you want homebirth to be "dangerous". Have you bought into the belief and now you are desperate to prove that your belief is true? Well, it's not. It just isn't. The mortality rates for low risk women giving birth at home is low. We see this time after time after time. The MANA stats show it, the study on birth centers in the US show it, the studies from Canada and the UK show it. It's woman's choice. Just let it go.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Sal Morgan
@Jeff Olejnik I agree Jeff, and the words "it adds to the increasing body of research that supports the safety of home birth for healthy women in the US" I find very telling. Does MANA want women to have accurate information about home birth, or only information which supports the safety of home birth? I have several family members who have birthed at home (two since 2009), and although all went well I am sure they were not made aware of the increased mortality rate relative to hospital birth before they went ahead.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by rroonie
You also need to add in post neonatal death rates. Together the total is somewhere around 3/1000. For low risk women at homebirth the total is .7/1000 and that includes a percentage of premature births. The CDC data for low risk women does not include premature births and their total neonatal death rate is approx. .6/1000. Face it, Dani, the neonatal mortality rates are the same between homebirth and hospital birth. And if Christina is correct and the intrapartum death rate for low risk women is .85/1000 ( and does that include the premature births? I would bet that it does if the neonatal death rate includes them) that is not much of a stretch from the Birth Center study intrapartum rates of .47/1000. No matter how you twist the numbers, the differences are tiny. And the homebirth numbers include unregulated and unlicensed midwives. The final conclusion seems pretty clear: homebirth is a safe option for low risk women. Homebirth has a higher mortality rate for high risk women. I don't even think we needed a study to tell us this, but at least now we can put the homebirth debate to rest.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
rroonie - the fact that you cannot grasp this shows how little you know what you are talking about. No, you do NOT add post neonatal death rates. We are looking at NEONATAL death rates. Early neonatal + late neonatal = TOTAL neonal, which are the numbers I gave. My numbers are correct. Postneonal means AFTER the neonatal period. Here is copy and pasted from the Birch Center study, since you do not understand how to read the information on the Vital Statistics paper: "The US neonatal mortality rate in 2007 was 0.75/1000 for newborns weighing 2500 g or greater."

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
Christina Moody - The Birth Center study actually does have breech and VBACs. It is incorrect to use the .85/1000 intrapartum for comparison to that study. And I also do not know why they excluded pre-e deaths to get to that number of .85/1000. Are they saying that a midwife did not know the signs of pre-e? Or would a midwife just ignore them? That makes no sense to not include pre-e deaths. It seems as though the authors and others that are facing all the criticism of this study really, really do not want women to look at numbers to compare. There is an excuse for everything. “you can’t compare to this b/c of ____, you can’t compare to that b/c _____.” They just want women to take their word for it and not look at the numbers. For those that are willing to do the work and find the numbers to compare, they can see for themselves. But it is a pity that the authors didn’t do the courtesy of making it easier for women who are seeking to make informed choices. It makes no sense they did not offer the Birth Center study for comparison. Why would they not? It is published in the same journal? They used studies based out of Netherlands and Canada but why not the Birth Center study? Here are some numbers for anyone who wants to compare: Neonatal (TOTAL… meaning early plus late): MANA study = 0.76/1000 (excluding lethal anomalies) Birth Center study = 0.40/1000 (excluding lethal anomalies) USA hospitals = 0.75/1000 (for all races, all babies over 2500 grams, *including* lethal anomalies and high risk) Intrapartum: MANA study = 1.30/1000 Birth Center study = 0.47/1000 Now someone might not think these numbers show much of an increase risk, as the numbers all look quite small. But to someone else, they might look at it and see that difference is too significant for them. They ARE statistically significant. The increase risk is 2.7 times greater for intrapartum deaths reported in the MANA study. It is up to each woman to decide for herself what she wants to accept for the level of risk but she is entitled to have the information. Here is the Birth Center study: http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12003/full#b42 Here is the Vital Statistics paper: http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_06.pdf

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by rroonie
Ok Dani, you are right, I suppose. But did you notice that the neonatal mortality rate for white women was .72/1000? That's for low risk women too because the neonatal mortality rate for all risk level white women is approx. 4/1000. It shows that in the first chart I believe. So, basically, what's your point?

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Jesse Garon
@rroonie Her point is that if you use the Birth Center study as a benchmark for out of hospital birth among low risk women in the US, MANA's numbers are not so great by comparison.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by rroonie
Really? How so? The neonatal rates are almost identical. It's the intrapartum rates that are higher for homebirth.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
No. The rate of 4/1000 is neonatal mortality rate for ALL babies born at ANY gestational age. So any baby that is born alive, no matter how premature, no matter how little they weigh. For 2500 grams or more for only white women, the number is even smaller than 0.75/10000. It is on the same page in the Vital Stats paper.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by rroonie
Also, the MANA stats include premature births, the low risk hospital birth stats don't.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by rroonie
It clearly shows for white women with babies 2500 grams or more the rate is .72/1000.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by rroonie
Again, no difference. Are we squabbling over .1/1000??

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
I'm not looking at low risk hospital stats. When it says "2500 grams or more" it means any baby, regardless of gestational age, regardless of risk or complications, even including lethal anomalies, ANY baby that weighs at least 2500 grams is included.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
You can use the .72/1000 number if you'd like. It actually is more accurate. But I was using 0.75/1000 since it includes ALL races and the MANA study, though primarily white women, does have other races in the study.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
I posted a long comment to explain some points but it is awaiting moderation still... I posted it last night. I'm going to break it up into smaller comments:

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
Christina Moody – The Birth Center study actually does have breech and VBACs. It is incorrect to use the .85/1000 intrapartum for comparison to that study. And I also do not know why they excluded pre-e deaths to get to that number of .85/1000. Are they saying that a midwife did not know the signs of pre-e? Or would a midwife just ignore them? That makes no sense to not include pre-e deaths. It seems as though the authors and others that are facing all the criticism of this study really, really do not want women to look at numbers to compare. There is an excuse for everything. “you can’t compare to this b/c of ____, you can’t compare to that b/c _____.” They just want women to take their word for it and not look at the numbers. For those that are willing to do the work and find the numbers to compare, they can see for themselves. But it is a pity that the authors didn’t do the courtesy of making it easier for women who are seeking to make informed choices.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
Here are some numbers for anyone who wants to compare: Neonatal (TOTAL… meaning early plus late): MANA study = 0.76/1000 (excluding lethal anomalies) Birth Center study = 0.40/1000 (excluding lethal anomalies) USA hospitals = 0.75/1000 (for all races, all babies over 2500 grams, *including* lethal anomalies and high risk) Intrapartum: MANA study = 1.30/1000 Birth Center study = 0.47/1000

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
Now someone might not think these numbers show much of an increase risk, as the numbers all look quite small. But to someone else, they might look at it and see that difference is too significant for them. They ARE statistically significant. The increase risk is 2.7 times greater for intrapartum deaths reported in the MANA study. It is up to each woman to decide for herself what she wants to accept for the level of risk but she is entitled to have the information. Here is the Birth Center study: http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12003/full#b42 Here is the Vital Statistics paper: http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_06.pdf

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
Now someone might not think these numbers show much of an increase risk, as the numbers all look quite small. But to someone else, they might look at it and see that difference is too significant for them. They ARE statistically significant. The increase risk is 2.7 times greater for intrapartum deaths reported in the MANA study. It is up to each woman to decide for herself what she wants to accept for the level of risk but she is entitled to have the information.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by rroonie
But what's the point? .72/1000 is an extremely low number. Are you trying to claim that homebirth is dangerous because the total neonatal death rate at homebirth is .7/1000? Do you really think there's a huge difference between .4/1000 and .7/1000? I will go out on a limb and say that if you told women: "If you give birth at the hospital you have a much higher chance of cesarean section and a mortality rate of .4/1000 and if you give birth at home you have a very slim chance of cesarean section and a mortality rate of .7/1000." Women who wanted to choose homebirth still would. The difference in mortality rates is slight and the benefits to being at home are obvious. Also, the MANA homebirth stats include premature births. So, without those the numbers would probably be lower. 2% of the homebirth numbers were premature births. The low risk hospital births do not include any black women and the homebirth numbers do. The homebirth numbers include births attended by DEMs who are unregulated and unlicensed. Let's put it this way: if you told women who birth in the hospital that if they accepted the epidural the mortality rate would increase from .4/1000 to .7/1000 do you think women would all start having natural births? No. They wouldn't. Women would still take their epidurals. Would you judge those women as selfish or would you accept that their needs matter too? Why not try and see it from their perspective. What if someone tried to force YOU to birth at home, if you were afraid and not comfortable there? Basically, you and others are trying to force women into the hospital through shame and humiliation and judgement. You are not trying to make it illegal but you are hoping that you can name call if women decide they want to homebirth. That's bullshit.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
rroonie - you can look at the numbers and make any sort of decision you'd like. The differences in the neonatal rates is smaller but to some, it might matter. Just b/c it doesn't matter to you, doesn't mean it won't matter to others. The intrapartum mortality rate difference between the two studies is actually startling in my opinion. That is probably why they did not compare the two studies in the discussion. Because that is a large difference. Your baby is 2.7 times more likely to die during labor at home with a CPM than in a Birth Center with a CNM.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
And don't make any such assumptions about me. Your comment does not make for respectable and productive discussion. If a woman wants to have a home birth, that is her choice and not something I would mock and I would not "name call." I just believe she is entitled to making an informed decision on the matter.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by rroonie
I apologize, Dani. It's frustrating because the vast majority of people who debate against homebirth DO like to name call, shame and judge. They like to use choice words such as "narcissistic, selfish and stupid." Are you saying that you don't join in on these judgements? You don't silently like comments that shame women? I'm only asking that you be honest with yourself. A few years ago some data came out that showed that elective c-sections had a neonatal mortality rate of 1.7/1000. Yet, homebirth opponents are ADAMANT that elective c-sections should be an option for women and that they should not be judged for that choice. The "debate" over elective c-sections pretty much ended then and there and yet the homebirth debate rages on. Anyway.. Please remember that you are not comparing CPM assisted homebirth and CNM assisted birth centers births. You are comparing CPM attended homebirth AND unregulated, unlicensed DEM assisted homebirth that include premature births with CNM and CPM birth center births. That is what is being compared.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Jeff Olejnik
@rroonie Please provide citation of that CS neonatal mortality rate of 1.7/1000.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
Thank you for the apology. I can understand your frustration. My issue is not with the women choosing home birth. My issue is with those "at the top." This whole MANA study is really bringing out the worst sides to people I actually respected. I am saddened to read Penny Simkins press release. I have loved her and her books. I take two of them with me to every birth I attend as doula! But now her press release... ugh.... she just lost so much credibility. It all seems like such a desperate attempt by some of the very influential, "big names" in home birth trying so hard to defend this and cover up the truth of these numbers. I have seen and been apart of many conversations that are going on all over the internet about this. If they just would have been honest with the press release and information about this study, if they would have offered rates for comparison, they could have at least walked away with their dignity. Yes, the information would scare some away from home birth but not everyone. But now, who knows how many it will scare away b/c of the lack of honesty and integrity that has been displayed in attempt to cover up what is true: home birth means an increase in neonatal and intrapartum mortality rates. I do not shame the women that choose home birth. I have BEEN that woman. I just have such issues - such frustration - with those that are trying so hard to pull the wool over the eyes of women that are only searching for real information to make informed choices.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by HUH???
Not going to get into a debate here but to those talking numbers the home birth and birth center numbers should/ will NEVER include premature babies because PREMATURE births are not attended at home or in a birth center. If they are included in a study it is because care was transferred which means that the newborns morbidity/ mortality will ALWAYS be counted by the hospital.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
And also, rroonie - yes it is possible that some of the deaths were to babies born under the care of DEMs. But it is also possible that they may not have had any deaths from DEMs. We can't make assumptions. The DEM group is a small percent of the births. And I did not see any deaths that were due to prematurity.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
In another online discussion that I commented on, Judith Rooks (CNM, MPH) and Wendy Gordon (CPM, MPH) discussed intrapartum mortality rates. Judith Rooks provided some very good, very telling information about hospital intrapartum mortality rates. She said that they are very rare in hospital settings. Very informative comment. Here is the end of the comment to quote Judith Rooks exactly "Intrapartum fetal death rates in hospitals have declined consistently since the late 1970s consequent to ever-expanding use of electronic fetal monitoring combined with increasing rapid access to cesarean sections for fetal distress from asphyxia. All of these studies are referenced in the attached paper. The most recent large, reliable studies of intrapartum fetal deaths in hospitals in developed countries now range from 0.1 – 0.3/1000 births." Wendy Gordon did not dispute these numbers. Those numbers include high risk and low risk pregnancies (and I believe lethal anomalies, too). So using those numbers and comparing them to the MANA study we have this: Intrapartum mortality rate: MANA study = 1.30/1000 Hospitals = 0.1/1000 to 0.3/1000 That means a baby at a home birth is 4 to 13 times more likely to die at home birth than in the hospital.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by rroonie
Ugh. I wrote out an entire comment that didn't post. Ok, let's go over numbers: MANA: early neonatal death rate: 0.4/1000 + late neonatal death rate .3/1000 + intrapartum mortality rate (for low risk women) .85/1000 = total mortality rate is 1.6/1000 Low risk Hospital birth : early neonatal death rate .38/1000 + late neonatal mortality rate 0.3/1000 + intrapartum mortality rate 0.3/1000 ( I found source which I will link below that claims that 0.3/1000 is the lowest intrapartum mortality rate available. I'm going to take that over one person's comment. Total mortality rate for low risk hospital birth= 1/1000 So we have a difference of 0.6. That's not huge. And considering that 8% of the homebirth women were black and could skew numbers, considering that 1000 of the 17,000 births were attended by unregulated and unlicensed DEMs AND the 2% of the homebirth births were premature births that may or may not have been removed for the stats, I think a difference of 0.6/1000 is not bad at all. The risk of birthing at home if one is low risk is only slightly higher at home and possibly not higher at all. We really do need more information

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
No your adding incorrect numbers. Not at my computer right now, will comment later during my kiddo nap time :)

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by HUH???
rroonie : So we have a difference of 0.6. That’s not huge. And considering that 8% of the homebirth women were black and could skew numbers, WHERE DID YOU GET THAT % FROM?

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
The numbers you are pulling aren't correct. You cannot exclude pre-e. That is ludicrous and makes no sense that they did that. A skilled midwife would know the signs. That's the whole point of this study, it shows the safety (or lack there of) of home birth and the skill of the attendants. You keep wanting to throw in there that some of the births were attended by DEMs yet you have NO idea if there were ANY deaths at all by DEMs. You can try and do all the twists you want to the numbers, that is your choice. But facts are facts and numbers are numbers. 1.30/1000 is the intrapartum mortality rate listed in the Abstract of the study and in the full text of the study. It IS the intrapartum mortality rate. A comparison of hospital rates with the Birth Center study and the MANA study is below. I am not separating early and late neonatal for any numbers. Neonatal numbers below are EACH for TOTAL neonatal (early plus late). * MANA STUDY: Intrapartum mortality rate = 1.30/1000 Neonatal mortality rate (excluding lethal anomalies) = 0.76/1000 * BIRTH CENTER STUDY: Intrapartum mortality rate = 0.47/1000 Neonatal mortality rate (excluding lethal anomalies) = 0.40/1000 * HOSPITALS: Intrapartum mortality rate = 0.1/1000-0.3/1000 Neonatal mortality rate (*including* anomalies, low risk and high risk; all babies of all races born at 2500 grams or more) = 0.75/1000 * TOTAL MORTALITY RATES: MANA study = 2.06/1000 (excluding anomalies) Birth Center study = 0.87/1000 (excluding anomalies) Hospital = 0.85/1000 to 1.05/1000(*including* anomalies, low risk and high risk; all babies of all races born at 2500 grams or more) Keep in mind, the hospital numbers would be even lower if lethal anomalies were excluded and if it reflected *mostly* low risk and *mostly* white women women, as the other numbers do. Those are the rates.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Ashley
Other factors to consider when comparing MANA Stats study and the birth center study: * VBACs in the birth center study: 56 (0.3% of the sample) * VBACs in the MANA Stats study: 1052 (8% of the sample) * breech births in the birth center study: 25 (0.2%) * breech births in the MANA Stats study: 222 (1.3%) The Birth Center study indicates that most of their breeches were transferred before labor started, primarily because known breech deliveries are expressly forbidden by AABC rules. They transferred another 63 women with breech babies when they arrived at the birth center in labor, and didn't have to count their outcomes in their stats because they weren't "admitted" to the birth center. Meanwhile, in the MANA Stats study, 118 of the 222 breech babies were transferred to the hospital in labor, but ALL of those outcomes are counted in the planned home birth stats.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
There aren't any deaths in the MANA study that are due to uterine rupture. How do we know the 3 deaths that happened to VBAC moms were due to complications of the VBAC if no deaths are due to uterine rupture?

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
Excuse me, I'll rephrase my question so it makes better sense. How do we know the 3 deaths that happened to VBAC moms were due to complications of the actual VBAC? How do we know one of the VBAC moms wasn't the shoulder dystocia death? How do we know one of the VBAC moms wasn't one of the cord accident deaths? How do we know one of the VBAC moms wasn't the liver rupture death? It is incredibly possible - since uterine rupture is not listed as the cause for ANY fetal deaths - that the VBAC deaths were completely unrelated to the fact that the mom had a previous cesarean section.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
If you want to exclude breech and twin deaths from the numbers, then OK. I can see how that would be useful. That would make the intrapartum mortality rate for the MANA study 1.06/1000. Still much higher than the Birth Center study and hospitals.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Ashley
You bring up a lot of good questions about what we know and don't know about the VBACs in the MANA Stats study, but the point was that there were almost none in the Birth Center study. If we're trying to compare two birth settings and draw conclusions about the PLACE of birth, then the women in those two groups should be as comparable as possible. So to recap: MANA STUDY: Intrapartum mortality rate = 0.85/1000 Early neonatal mortality rate (excluding lethal anomalies) = 0.41/1000 BIRTH CENTER STUDY: Intrapartum mortality rate = 0.47/1000 (this rate was calculated to not be statistically different from the MANA study) Early neonatal mortality rate (excluding lethal anomalies) = 0.40/1000 - essentially the same as the MANA study HOSPITALS: Intrapartum mortality rate = ??????????? (no actual data) Early neonatal mortality rate (term pregnancies) = 0.46/1000 The providers should be similar as well, but we don't have any information in either study about who the care providers were that were associated with the adverse outcomes. The Oregon analysis you keep referring to showed deaths attributed to providers other than DEMs, including a CNM. Perhaps the adverse outcomes in this MANA Stats study were shared among various types of providers as well. But that wasn't the point of the study. The point was to look at location of birth, NOT type of provider as you suggest. There is no data here to support your assertion that the type of provider was associated with intrapartum or neonatal deaths.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
I didn't refer to the Oregon study at all. Please tell me why pre-e and GDM deaths should be excluded when comparing to the Birth Center study?

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Jesse Garon
@Doula Dani Some of the "unknown" deaths could be from uterine rupture, though, right? Since that diagnosis wouldn't have been made until the mother was presumably at the hospital?

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
Response to Jesse and Ashley - the VBAC deaths were likely due to the VBAC. I don't know. This study has so many holes it's ridiculous. And MANA wants to call breech, VBAC, twins, etc all variations of normal and totally fine for home birth but the numbers clearly show otherwise. They want it both ways! They want to exclude high risk from the numbers yet don't encourage proper screening and risking out. The IP mortality rate is 2.85/1000 for VBACs. Insane. Are they saying anything about this? Are they bringing up how HBAC is clearly a very high risk for the baby? And breech is even worse!! Any statement you'd like to make, MANA? Sweeping those deaths under the rug, saying they shouldn't be counted is a slap in the face to the families of those babies. They matter. Their deaths should be included. I mean, hey why stop at excluding VBAC, twins, breech, GDM and pre-e?? Some of the unknowns might have been due to high risk as well, so let's exclude those too. And the liver rupture, had the mom had ultrasounds that might have been detected beforehand that their was a liver issue. So that could have been high risk, too. We probably should just exclude all except the placental abruptions and cord accidents!! NO. Wrong-o. The intrapartum mortality rate is 1.30/1000. Even if a potential home birth mom wants to exclude high risk, and wants to take the proper screening measures to make sure she stays low risk, she still has a higher risk than in the hospital or a CNM birth center.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Wendy Gordon, LM, CPM, MPH
@Doula Dani, I'm catching up on your conversation here and I'd like to clarify something. My lack of response to my colleague Judith Rooks' comment on another site should not be taken as implicit agreement with her position. After taking the initial position that intrapartum death rates were zero, she has subsequently begun a literature review and changed her assessment, which she has shared with me. I look forward to reviewing it, and, with her permission, sharing my feedback. In the meantime, I would suggest that you read the MANA paper again. All relevant numbers are reported, with and without exclusions of higher-risk births. For mothers who fall into a higher-risk category as outlined clearly in the paper, the higher-risk outcomes may be most applicable. For mothers who have none of the named factors, the lower-risk outcomes would be more applicable. I imagine that this kind of transparency is appreciated by those who are actually making these choices for themselves; I applaud that the birth center study was similarly transparent about how their numbers were arrived at; and I look forward to the day when mothers will have actual data on rates of intrapartum death in U.S. hospital settings with which to compare.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Judith A. Lothian, PhD, RN, LCCE, FACCE, FAAN
I have followed the posts for the last few days with some concern. I am thrilled at the interest in home birth research but worry that there is a confusion on the part of some readers on what good research entails. This is a well designed study. The data set is not perfect. No data set is. MANA and the researchers spell out the limitations. The researchers clearly describe the sample. Our responsibility as consumers of research is to look at the findings in light of the sample and the design. And, very importantly, we need to evaluate the findings in light of the findings of other studies. This study's findings support the findings of other studies done outside the US that support the safety of home birth. The sample included higher risk women than we usually see in home birth data sets. Taking the neonatal outcomes of higher risk women of the analysis, the outcomes are comparable to previous studies. The researchers make note of this. This study makes an important contribution in the literature on home birth. Like any other study it will need to be replicated.. In the final analysis it is the weight of the evidence that counts. And this research contributes to a larger body of evidence that does support the safety of planned home . I encourage the readers of this blog to read the original articles and the articles that are referenced for a more complete description of previous findings. I suspect that a careful reading of the original research may clarify concerns and settle some doubts.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Doula Dani
Wendy - just as I am closing my computer for the day you are joining, which is a bummer for me. I will be back tomorrow to see if the discussion continues. Thank you for commenting. So can you be clear, do you agree or disagree using 0.10/1000 to 0.30/1000 for intrapartum mortality rate for hospitals? Also, the numbers that are unfortunately missing from the study are the comparison numbers. The authors refer to several studies without providing any numbers at all from those studies. Do you know why that is? Can you share here what the numbers are for the studies for us all to see? This is what I'm referring to from the Discussion in the study "The intrapartum fetal death rate among women planning a home birth in our sample was 1.3 per 1000 (95% CI, 0.75-1.84). This observed rate and CI are statistically congruent with rates reported by Johnson and Daviss[4] and Kennare et al[30] but are higher than the intrapartum death rates reported by de Jonge et al,[10] Hutton et al,[12] and Stapleton et al.[14]" I think reading the study is very informative, though there is quite a bit of missing data (the missing data noted at the end of each table is what I am referring to). But it is important for readers to have numbers for comparison. To an expert, an intrapartum mortality rate of, say, 5.43/1000 is obviously high. To a lay person, it might not mean much without something to compare it to. Thank you!

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 3, 2014 07:00 AM by Jeff Olejnik
Judith or Wendy, please comment on the Cornell study just published that seems to have similar data but a different conclusion on safety for Homebirth.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 4, 2014 07:00 AM by Sarah
I've been looking at the stats more closely, too, and I have to say, they paint a pretty disturbing picture of neonatal death in homebirth in the US. It seems quite Orwellian to me that the press releases (and MANA in general) are stating otherwise. This debate about intrapartum death statistics seems specious at best. Though the CDC does not officially record these numbers, all indications from other studies that have addressed this indicate that intrapartum death in the hospital is very rare, as cited above, somewhere along the lines of 0.1-0.3/1000 across all gestational ages and including lethal anomalies. The Birth Center study cited above shows a 0.47/1000 IP death rate, still more than 2.5x lower than the MANA set. But let's, for a moment, leave aside the disturbing IP stats, which represent a staggering HALF of the homebirth deaths in the MANA set. If you compare the MANA stats for early + late neonatal death rates (leaving in lethal anomalies, because hospitals leave these in, too) then you have 1.29/1000. If you search the CDC stats for ALL hospital births 34+ weeks (late preterm and beyond) the numbers are 1.06/1000. Think about this. The hospital set includes EVERYONE who gives birth late preterm and beyond. All races, all medical complications, all risk levels, 40+% living 200% poverty line or below (covered by Medicaid), women with autoimmune diseases, clotting disorders, substance abuse problems, teen mothers, women with growth restricted babies or babies with severe infections or non-lethal defects found in utero, women who stayed on bedrest in the hospital to barely make it to 34 weeks, a 4x higher rate of late preterm birth than MANA's set, 7x higher rate of twins, several times higher rate of pre-e (3.4% in US vs. 0.2% in MANA set), GDM (2-25% in US vs. 0.8 in MANA set) and all the complications listed in the MANA data. If you compare this to the MANA set of almost all white, mostly married, majority highly educated, mostly healthy and low risk women and pregnancies, AND you exclude HALF of the homebirth deaths, then the numbers are ALMOST as good. And this is with voluntary reporting of only 20-30% of the homebirth data. Why are we celebrating this? If I was considering homebirth, if you told me that the chances of my baby dying were 2.5x higher than ALL the babies born 34+ weeks in the hospital, and as much as 4-5x higher than women of comparable risk at term, that would make my decision for me. Other women would look at the absolute risk, consider the benefits and make a different choice. The point is, we deserve to be informed and not misled by statistical gymnastics.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 4, 2014 07:00 AM by Another Liz
Were any of the concerns voiced in these comments addressed when the article was peer-reviewed prior to publication? As far as excluding "higher-risk births" from the data, I don't understand the rationale for this, because the midwives in my area - who are licensed CPMs - readily admit and advertise that they attend breech, VBAC (usually up to VBA2C is the standard), and twin deliveries OOH. If, to these professional midwives, this is low-risk and appropriate for OOH care, why exclude the outcomes of these higher-risk, planned OOH deliveries? These births aren't 'whoopsies, we didn't know'. These were planned home births with CPMs. It is entirely appropriate to include the data from these deliveries. What, exactly, were the authors of this 'study' attempting to measure? Outcomes of planned homebirths with midwives - as they were practicing during the study period? Or outcomes of just *some* planned homebirths with midwives- specifically, those with the better outcomes?

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 4, 2014 07:00 AM by Another Liz
On a side note, I would like to thank Science and Sensibility for publishing readers' comments - and not censoring this discussion. I am truly grateful that this webpage allows an open exchange of ideas, questions and critical examination of the topic at hand.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 4, 2014 07:00 AM by Jesse Garon
@Wendy Gordon, LM, CPM, MPH So, you're still not willing to answer the question about why it took 5 years to release this data, during which time homebirthing moms did not have accurate statistics on which to base a decision? Are you implying that there's a massive CDC coverup to sweep huge amounts of intrapartum death under the rug in hospitals?

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 4, 2014 07:00 AM by Jeff Olejnik
Interesting correlation with EFM use and intrapartum deaths. Many Homebirth advocates refuse EFM because they feel it causes too many interventions that result in cesarean. I have even read where Homebirth advocates state EFM has never shown any benefit. I am aware that it was once thought EFM would help significantly decrease CP rates. It hasn't. But there are several studies that show it has decreased the intrapartum death rates (mortality) and have decreased the neonatal seizure rates by half (morbidity). Now hospitals tend to use EFM and their intrapartum death rates are low, while Homebirth midwives don't use EFM and have the above intrapartum deaths rates. ACOG puts out practice bulletins and committee opinions to guide practice. Wouldn't it be nice for MANA to simply be honest about the data and then provide some new practice guidelines for Homebirth midwives to follow to improve outcomes. I would be impressed. Too many women considering Homebirth are already commenting on line how safe Homebirth is based on MANA's press release statement. This feels so negligent to me.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 4, 2014 07:00 AM by Another Liz
Negligent. That would be one word for it. And since CPM licensing laws are often written - quite intentionally - to not require any sort of liability insurance, how can any midwife be found negligent for care she does or does not provide? And what if the negligence originates from the professional organization representing these midwives? Perhaps the defense of the midwife in this case would be: "I was abiding by the practice standards set forth by my professional organization." Who is accountable? "Wouldn’t it be nice for MANA to simply be honest about the data and then provide some new practice guidelines for Homebirth midwives to follow to improve outcomes. I would be impressed." Yes. I would be impressed too. This type of action is long overdue.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 4, 2014 07:00 AM by hmm hmm
Like others, I will look forward to Wendy Gordon's response. From a quick read of recent posts on this thread, and in order to help her in responding, here are the questions outstanding that have been asked of her to which she has yet to address: 1. Does she agree with using a IP mortality rate for hospitals between 0.1 and 0.3 per 1,000? 2. Why did MANA wait 5+ years to publish these statistics given that they published all of the other relevant variables from the same dataset years ago? (And while we're at it, when can we expect to see the data from 2009-present?) 3. Why were comparison figures from relevant studies so blatantly left out of the manuscript?

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 4, 2014 07:00 AM by Sharon Muza, BS, LCCE, FACCE, CD(DONA), BDT(DONA), CLE
What a fantastic response and discussion in the comments section! But at the risk of going in circles and repeating the same back and forth that has happened in the more than 100 comments posted, making it hard to follow discussions and responses, as community manager, I am going to ask for further comments to be either those sharing NEW information that has not been previously discussed or that the conversation be directed to the MANA blog (http://www.mana.org/blog) after reading the postings there. Our readers are educated and understand how to evaluate research, and Science and Sensibility has some additional tools to help those that want more information about understanding research. http://www.scienceandsensibility.org/?p=7718 And I would also like to express a great deal of gratitude to Judy Lothian for all her effort and time to write this review and share with readers.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 4, 2014 07:00 AM by Midwest Midwife
I am a CPM who is growing increasingly uneasy and angry with MANA, NARM my state MW org. and the homebirth community in general. It is very simple. No studies have been perfect, but few show anything other than a large increase in relative risk. Efforts to restrict midwives to low-risk births, or to even *define* risk are dismissed or fought against by my community. Experienced, sane, midwives quit. New midwives take huge risks and idolize cowboy-midwives. I will say it: too many babies have died in my community. (Incidentally, none of those babies were counted in these stats - only one midwife in my community files them.) This is not how this data should be spun. NARM and MANA need to be calling for standards, accountability, more education, stricter protocols, mandating data collection and (actual) informed consent. I wish there was an organization (who wants to start one with me?) that pushed for meaningful, national, evidence based reform of our fractured midwifery system.

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

February 12, 2014 07:00 AM by A Slightly Twisted Fairy Tale » Lamaze Seminar (2/1/14-2/3/14) With Judith Lothian and Allison
[…] Ph.D., R.N., Associate Professor in the Graduate Dept. of the College of Nursing at Seton Hall, lends a powerful voice in the MANA stats debate and provided a presence of deep knowledge to impart to the gathering. At […]

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