Henci,
I didn't include the quote to what I was replying to in my last post.  I'll post again. 

Henci,

I'm not sure exactly why you are so offended.  Getting statistics from MANA who isn't exactly an objective party in the matter doesn't make much sense.  People don't like Dr. Amy because she wounds their pride but that doesn't mean what she says isn't worth heavy consideration.  I think she is completely straight forward and people don't like that and people would rather be flattered than know the truth.

Angela and Jenn: I moved the exchange of posts on the Grobman VBAC study from here to under the VBAC topic.

-- Henci

Just in case anyone is unclear on what the initial claim Dr. Amy made was and that she continues to make...I believe what Henci is referring to is Dr. Amy's repeated claim that homebirth has a 3 times greater neonatal mortality than hospital birth.  She got this from her calculation of a perinatal mortality rate of 2.7/1000 for homebirth vs. a neonatal mortality rate of 0.9 for hospital birth.  If someone were to challenge her to provide stats now to support the "3 times" allegation, I'm guessing she would cite the CNM in-hospital neonatal mortality rate (around 0.3?) from the CDC Wonder website. 

However, I'd counter that she does not have a fair comparison group because most CNM's are so very stringently controlled on the risk level of patient that they can accept (for example, many can not attend VBACs, or babies over a specific predicted size), so that the CNM patient risk profile does not match the the DEM patient risk profile at ALL.  There is also the issue with the CDC Wonder website that the data is reported as how the birth ended up, not how it was planned...which can really skew the data.  Specifically, many "out of hospital" births are planned hospital births--and these can be pretty high risk because they are often unattended and include people who really doesn't know what to do (just last week a story on the front page of my local paper reported on one such case where a mother birthing her 4th child while standing in a parking lot was assisted by a former maintenance man and another mother of 4...you'd think between 7 prior births those women would have a clue...but NO, they let the maintenance man tie off the umbillical cord with a scrap from a shirt--not necessarily a clean shirt!  And let me guess...in his haste to rip the fabric, he most likely bit it to start the tear rather than finding scissors...) if a risk were to develop during labor with a CNM, care would be transferred more quickly to an MD resulting in many poor outcomes getting shifted out of the CNM data (I had a client who THOUGHT she was going to birth with a midwife, but at the last minute the midwife called in an OB without consulting the mother to catch--or rather to use a vacuum that he barely got out of the package before the baby came out by maternal efforst alone after less than 10 minutes of pushing--because she suspected problems from a suspected big baby--despite the mother's previous history of not having a problem birthing a big baby--so that birth was listed as an MD birth).  This kind of transfer would be less likely to occur with out-of hospital DEM birth...but it does happen, so even for them, we are loosing the data on births that were intended homebirths, but transferred to the hospital. The CDC Wonder website...while intriguing...I feel has a lot of significant drawbacks when it comes to trying to compare different types of care providers.  But oh heck...lets have some fun here...

Using Dr. Amy's cherry picked "low risk" women--20-45 years old, white, singleton babies 37+ weeks, 2500+ g...here are some comparisons of neonatal mortality risk (per 1000) for the 2003-2004 data set:

MD in hospital: 0.61

"Other Midwife" in hospital: 0.36

MD out of hospital:  2.89

"Other Midwife" out of hospital:  1.15

OMG!  Look at that...it doesn't matter where the birth occurs, match the Dr. to the midwife, and the midwife has better outcomes!  We need to ban Dr's!  All births should be in the hospital with "other midwives" to acheive optimum neonatal mortality.

Ridiculous, right?  ;-)

To Maria:  Apologies, but Amy's stats have been rebutted ad nauseum in both this thread and at least one other thread on this Forum. She has shifted her ground now to the CDC data, but she lost all credibilility permanently when her initial accusation compared Johnson & Daviss' perinatal death rates (stillbirth + neonatal death) to neonatal death rates, and she refused to acknowledge this error when pointed out to her and went on repeating it. That tells you all you need to know about the honesty of her intentions and whether any more time should be spent trying to establish the validity of her claims. As the saying goes, "Fool me once, shame on you. Fool me twice, shame on me." If you want any further data from Amy, you will have to review this thread and the others (a search on "tuteur" should bring them up) on the Forum or go over to Amy's own blog.

Maria's confusion illustrates the serious problems someone like Tuteur causes for people who want to understand an issue outside of their sphere of expertise. They fall into the trap of thinking they are hearing a legitimate difference of opinion by experts of similar standing when they are not. You know this is so in Amy's case because of her continuing to repeat the same accusation after her basic error was pointed out to her--more than once, I should add. However, the result of her tactics is that those wanting to understand the issue may end up throwing up their hands in frustration, thinking neither side has the right of it or it's just too complicated for the nonexpert to understand. That's a win for the Tuteurs of this world. 

Her mud slinging also serves a purpose. Even if you try to ignore it or understand that it applies to her, it plants the pernicious idea that you can't trust anybody: everyone in the debate has an agenda and will cherry pick or distort data to support their position. Ernst's post suggests this. That's another win for the Tuteurs of this world.  

Amy's tactics achieve another purpose as well. They misdirect attention from much bigger issues with much greater impact on childbearing women. While everyone is in an uproar over the baby's safety in the tiny percentage of women who plan home birth, the focus is off the far greater dangers posed to the health and wellbeing of the millions of mothers and babies who undergo conventional obstetric management. You saw another example of this strategy in the Amer. College of Ob/Gyn's anti-home birth statement (no supportive data, of course) that came out after laceName w:st="on">RickilaceName> laceType w:st="on">LakelaceType>'s movie, the Business of Being Born, began making a splash. The point of the movie wasn't that every woman should birth at home, but the systemic problems with hospital birth that made home birth a good, if not a better, option for low-risk women. However, by shifting the ground to the irresponsibility of home birthers, they took control of the message and the grounds of the debate.

This brings me to one more related thing:  I moderate this Forum parttime. While my time and attention have been taken up with this discussion, I have been neglecting others who are posting on different topics. You all are free to continue the discussion, but I need to turn my attention to them.

-- Henci

Jenn:  Apologies, but I deleted the re-post of Tuteur's because it contained the same kind of objectionable and insulting language I just banned.

-- Henci

We'll have to agree to disagree on that one. My position is that I am willing to give anyone an opportunity to have their fair say, including an opportunity to rebut my arguments or those of other posters, but I am not willing to allow anyone to hijack this Forum with endless rants that, as you say, lack logic, maturity, or kindness. I also think Tuteur's rudeness, bullying, and personal attacks create an unpleasant environment that may discourage others from participating in the Forum or even following along. That may be a generational thing--I am currently 60--and maybe the younger generation isn't put off, but, then, I am the moderator, so I get to decide. And, of course, in support of my action, that kind of behavior violates the Forum's terms of use.  

-- Henci

Actually, both claims are both true.

Goer's quote from the WHO is out of date. The WHO said in April 2006:

Home-like settings for childbirth are associated with reduced likelihood of medical intervention. ... However, the evidence shows an increased risk of perinatal mortality, the reasons of which are not fully established.

Dr. Amy's quote is indeed from WHO, and certainly does not make Henci's "out of date," simply older.  I'll also point out that the quote Dr. Amy uses specifically refers to "home-like" settings.  The study upon which they base this conclusion looked soley at birth center births.   Who is to say that birthing in a birth center doesn't increase the risk of perinatal mortality over homebirth?  We really don't know.

Posted By Dr. Amy

As far as the NICE report is concerned, Goer didn't even answer the question. She was asked if NICE reports a higher rate of neonatal mortality at homebirth, and they do. From the same report that Goer quoted:

... intrapartum-related perinatal mortality (IPPM) for booked home births, regardless of their eventual place of birth, is the same as, or higher than for birth booked in obstetric units.

So the NICE report says that the perinatal mortality is the same as, or higher, than birth in a hospital.  I certainly think that people should be aware of this...but the statement isn't exactly rock solid.  Did they state "the same as" first because that was the statement they had more confidence in, or was "higher" stated last so that it would stick in the reader's mind?  I don't know.

Goer tried to sidestep the direct question that she was asked about DEM qualifications. American DEMs have less education and training than ANY midwives in the industrialized world. There's no denying it and she didn't deny it.

You were warned. You have flagrantly and repeatedly violated the Terms of Use for this Forum which forbid posting material that is, among other characteristics "defamatory," "abusive," or "harassing." You will be blocked from further posts on this site.

-- Henci  

I agree with Eema completely.

I think that the biggest weakness we have to date in any comparison data of "out of hospital birth with a CPM" compared to "in hospital birth with a Dr or CNM" is a lack of a good comparison that starts at the beginning of prenatal care between the two groups.

The authors of the 2005 BMJ study have suggested that care with a CPM may reduce the rate of prematurity, and since complications associated with prematurity are a major cause of neonatal death in the US, that could significantly affect the comparison.  Dr. Amy asserts that there is no proof that care with a CPM reduces prematurity...and she is correct.

Further, I believe that the demographic choosing homebirth is more likely to include women attempting VBAC and grand-multiparas than the hospital birth population, which introduces risk.  Dr. Amy asserts that the hospital group would contain some levels of risk not seen in the homebirth group such as Gestational Diabetes and pre-eclampsia; however these women do often start in CPM care (and sometimes do remain, depending on the severity of symptoms) and so I think it is unwise to discount those risk factors in the "planned homebirth" population.

I wish there were a good way to do a study that matched women planning homebirth and planning hospital birth but eligible for homebirth at the start of prenatal care and follow them through birth to see outcomes.  Even better would be to follow them through to their second birth, since one of the claims of homebirth advocates is that birthing at home reduces the risk of primary cesarean--which if true, would reduce the risk to future pregnancies.  Such a trial would be extremely difficult and expensive though, and likely could only be done as a retrospective study.

Try that. I think the Forum software doesn't play as nicely with Macs as with Windows-based machines.

-- Henci

When I type my posts and hit for a new paragraph, the software automatically puts an empty line between the paragraphs. If that doesn't happen for you, or if it happens when you are typing a post but not in the uploaded version, try hitting   twice when you want a new paragraph.

-- Henci

You get one post and one rebuttal as follows:

1. You post on a new topic.
2. I respond.
3. You rebut.
4. I respond.

or

1. You respond to a post of mine or someone else's.
2. I respond.
3. You rebut.
4. I respond.

This provides a fair opportunity for you to make your case.

In light of what has gone on with this thread, I will add a new rule: You will respect my authority as moderator to declare a moratorium on a topic. I posted that there had been enough information and resource links on the issue of the MANA 2000 home birth neonatal mortality statistics for people to make their own evaluations. I could, of course, lock the thread so no one can post to it, but I'm not having a problem with anyone else, so rather than do that, I would rather handle the problem by dealing with you as an individual case. I am not singling you out. I would apply the same rules to anyone who behaves as you do, but so far, you are the only one.

-- Henci

Could you please explain the rules?

Dr. Ho asked for clarification of links that I provided and I responded with the clarification and the exact relevant quotes. Why did you delete that post?

Amy --

I have given you the rules for this site. They permit you to have your fair say. You may do as you please on your on website, but I will not allow you to hijack this Forum to use as another platform for your rants or to bully or attack me or others.  If you persist in flouting those rules--which, by the way, I would apply to anyone who behaves as objectionably as you do--you will be barred from posting in the future. It's your call.

-- Henci 

So here's where I am with this: Aside from responding to Amy's assertion that she is qualified to discuss mortality stats and I am not, I have deleted Amy's posts along with your responses to Amy's attacks on my integrity. (Apologies for deleting the responses, but it didn't make sense to leave them up after I deleted the rant.) I think there is enough information in this thread and the links and sources provided in the posts that anyone who wants to make their own evaluation of the Johnson and Daviss paper, can do so. Therefore, I would like first to thank those of you who contributed positively to the discussion and second to declare that we are done with the topic of the MANA 2000 stillbirth and neonatal mortality statistics.

-- Henci

Posted by Maria (above): I have yet to find where Johnson and Daviss admitted to have detorted the truth in the link you gave earlier. All I could find online was this http://understandingbirthbetter.com/section.php?ID=31&Lang=En&Nav=Section

Thank you, Maria! I just went to the page and read it through. Anyone who wants a calm, reasoned, scholarly explanation of the caveats of making appropriate statistical comparisons with the MANA 2000 study should follow your link. It does a better job of responding to Tuteur than I can do, which is not surprising since the author is an epidemiologist, and I am not.  

As for Amy's mention of other deaths that I omitted from my calculation, this is a prime example of how she misuses data. The "other deaths" were not neonatal deaths. They were intrapartum deaths and therefore were not relevant to a comparison with hospital-based neonatal deaths. Indeed, Amy's persistent confusion over what is encompassed by "neonatal deaths"--this is not the first time I have pointed this out to her in this Forum--brings to mind Andrew Zang's comment: "He  [or, in this case, she] uses statistics the way a drunken man uses lamposts--more for support than illumination."

-- Henci

'which calculates to 1.1/1000"

Those are not the only deaths. However, even if you restrict the deaths only to those 6, that still means that the neonatal death rate at homebirth in 2000 was triple that of the neonatal death rate at hospital birth in 2000 (0.34/1000), just as I have claimed.

Thank you for providing the results of this data query. Six newborns of the 5418 women intending home birth at the start of labor died in the neonatal period in the Johnson study, which calculates to 1.1/1000. 

-- Henci  

maria:

"Would you please link me to this, Dr. Amy?"

I'm not ignoring your questions, maria. Henci Goer has limited me to only one response on this blog and I am saving the response for her.

If you'd like to find out more, a great deal more, you can visit my blog Homebirth Debate (homebirthdebate.blogspot.com). You can post as many questions as you want there and I will try to answer them all.

As I said originally, the complete dataset can be found at CDC Wonder http://wonder.cdc.gov/lbd.html. The dataset can be queried to find out the neonatal death rate for white women, 37+ weeks, 2500+ gm, with singletons who delivered in the hospital in 2000, which was 0.9/1000. Johnson and Daviss have already publicly acknowledged this on their website Understanding Birth Better.

If you prefer, we can remove lethal congenital anomalies. There were 1863 deaths, of which 1001 were due to lethal congenital anomalies. That means that the neonatal death rate for hospital birth in 2000  (white women 37+ weeks, 2500+ gm singletons) was 0.34/1000.

Really, Amy, your playground bullying tactics don't cut any ice with me. I spelled out the rules for this Forum. If you send a link to the CDC document you claim states that having a DEM increases risk of perinatal mortality, I will not delete your post, and I'll follow up on it.

-- Henci

"I hit the CDC's most recent report on perinatal mortality in 2003. If you know Tuteur, you will not be surprised to hear that it says nothing about care providers."

Have you no shame?

You already deleted the link to the data, so that you could pretend it was never posted here. Now you arbitrarily pick a completely unrelated paper and claim the data is not in there. No surprise since it is a paper about something else entirely.

Looking for something else to respond to a post on another thread, I hit the CDC's most recent report on perinatal mortality in 2003. If you know Tuteur, you will not be surprised to hear that it says nothing about care providers.

-- Henci

My bad for not getting back to this Forum sooner. The last time you posted to this Forum, I set ground rules for you: you would have your opportunity to state your case and make one rebuttal to my response, and then we were done. I'm going to reinvoke that rule and delete all of your posts that appear after this one.

1. You have provided no source for the allegation that the CDC reports a higher perinatal death rate at home births. I have tried various search combinations, but I am unable to find your source. If you write back with the source so I can review it, I will not delete your post, and I will respond to it.

2. You have supplied no information about the training of DEMs or how it compares unfavorably with the training of other midwives--not that such a comparison would be useful or valid for the reasons I stated in my first response to you, namely, In what country? Under what circumstances? What are the specific defects of DEM training? Appropriate training would vary according to the midwife's scope of practice and the conditions under which she works. To repeat, the key issue is whether a midwife with NARM certification, that is, a "Certified Professional Midwife" or CPM, has the requisite knowledge, skill, and experience to properly care for women planning home birth. If you perceive flaws or weaknesses in the training, by all means list specific deficiencies, and, again, I will not delete your post, and I will ask a guest expert to respond. If not, then please cease to malign DEMs. I would also add that midwifery training to work in hospitals would not adequately prepare a midwife to work out of hospital.

3. I will not rehash the argument over the Johnson and Daviss study. My response is elsewhere on this Forum.

4. I have no problem correcting what I have said if someone presents facts that contradict it or a reasoned argument why I am wrong. You have never done either. In this case, I was lazy in that I was repeating what I have read and heard. I will add, though, that the singleton preterm birth rate and low birthweight rates are on the rise and that the overuse of cesarean surgery is playing a role in this.

5. I have nothing to apologize for. It is a fact that no one can find evidence that you currently hold a license to practice medicine. One correspondent who tried to get background information on you found that the holder of your domain name is hidden, something that, according to this same poster, costs more and is not usual practice. Your website appears as a "sponsored site" when searching on certain topics, which I would expect--although this is speculation--probably costs a pretty penny. If any of these statements are factually incorrect, let me know, and, as before, I will not delete your post. Meanwhile, putting these facts together, it is not unreasonable to speculate that you are backed by an organization, ACOG being the most likely candidate, although it escapes me why you would want me to apologize for that. I, for example, am pleased and proud to be an independent contractor with Lamaze International.

Finally, thanks for the free promotion. Two new posters to this Forum found out about it via your posts on your website.

-- Henci

"In addition to the immediate causes of neonatal and maternal morbidity and mortality, delayed causes of death and injury to mother and infant such as suicide, substance abuse, or homicide are often not discussed. As a facilitator of a postpartum group, I believe that these problems can be traced in part to the mother’s birth experience and how that experience affects her perception of her mothering capabilities. In effect, the future life and death of each infant may depend on the empowerment of the infant’s mother through her birth experience."

Do you have any research to support this claim? I find it extremely hard to believe that suicide, substance abuse and homicide can be attributed solely to a mother's birth experience.

Those claims were mine. Maria quoted them without attributing them to me.

Ms. Goer, you did not manage to rebut either claim, both of which are quite simple:

1. The CDC says homebirth increases the risk of neonatal death

2. US DEMs (including CPMs) have less education and less training than ANY midwives in the industrialized world.

Marsden Wagner himself acknowledges that the CDC strongly disagreed with him on his personal opinion that homebirth is safe. He writes about it proudly in his chapter, Confessions of a Dissident, in the book Childbirth and Authoratative Knowledge by Brigitte Jordan.

Moreover, you did not even address the latest CDC statistics from the linked Linked Birth/Infant Death 2003-2004 dataset. The data show that homebirth with a direct entry midwife has double to triple the neonatal death rate as hospital birth for low risk women.

And as long as we are discussing this issue, I will mention two additional points that you have never addressed:

1. MANA (the Midwives Alliance of North America) has been collecting safety data on homebirth since 2001. They have publicly offered the data to those who can prove they will use it for the "advancement" of midwifery. Even those people must sign a legal non-disclosure agreement preventing them from revealing any data to anyone. In contrast, the US and state governments make all birth data available each year on the internet. MANA's data almost certainly show that homebirth with a CPM has a much higher neonatal death rate.

2. Over a year ago, we argued about whether Johnson and Daviss used the correct comparison group in the BMJ 2005 study. I said that the correct comparison group was low risk hospital births in 2000. With that comparison (which Johnson and Daviss left out of the paper), they had ACTUALLY showed that homebirth with a CPM had a neonatal death almost triple that of hospital birth. You gave all sorts of excuses as to why they didn't need to use that group. Johnson and Daviss have since publicly acknowledged on their onw website that I am correct. You have not acknowledged it, and instead (as far as I can tell) deleted the posts you wrote in support of the wrong control group.

3. Maria pointed out to you in another post that the World Health Organization 2006 report on perinatal mortality (which shows that the US has a lower rate of perinatal mortality than Denmark, the UK and the Netherlands) and that this cannot be reconciled with your public claims that the US has a higher rate of perinatal mortality than other first world countries. Fortunately, you now acknowlede that the US perinatal mortality rate is comparable to other developed countries.

Finally, I would appreciate it if you would stop insinuating that I am not who I say I am,  that I do not have the credentials I list in my CV (Harvard '79; BU School of Medicine '84; Boston's Beth Israel Hospital internship, residency, staff appointment OB-GYN, Brigham and Women's Hospital staff appointment, Harvard Medical School Instructor in Clinical Obstetrics and Gynecology) or that I am in the employ of ANY organization. A public apology for your completely baseless, fabricated accusations would be appropriate.  If you promote such obvious and easily checked falsehoods about me, people might begin to think you are using the same tactic to promote homebirth.

In case you refuse to post or to delete this entry, readers can find it on my website.

The link you inserted for the WHO quote did not work, but I tracked down the quote by searching on the terms "World Health Organization" "April 2006" and "home-like." Those who know you will not be surprised to hear that you misinterpreted the WHO statement, which is about "home-like settings" in hospitals not home births. The WHO sources its statement to

Hodnett ED et al. Home-like versus conventional institutional settings for birth. The Cochrane Database of Systematic Reviews, 2005, 1, article number CD000012.

Without a source for the NICE statement, I will not venture to comment on what you are likely to have taken out of context or misrepresented except to say that it hardly seems likely that U.K. health care policy would promote home birth if it posed excessive risk, which, of course, it doesn't. 

Finally, the blanket accusation that U.S. direct-entry midwives have less training than other midwives in industrialized countries requires no denial because it is fatuous. The person who made it offered no comparison data to substantiate the claim. In fact, it would have been impossible to do so.  Midwifery training varies from country to country as does scope of practice. In many countries, midwives do not function independently but under the supervision of obs who set policies and make medical decisions. In some countries, they function the way intrapartum nurses do here and don't even catch babies. The training needed for practice in these situations is different than that needed by a midwife working independently who takes full responsibility for her clients. What is more, other than in the Netherlands, midwives are almost always trained to conduct hospital births exclusively, which is a whole different animal from home birth. To sum up, there is nothing to "deny" because the accusation has no substance. The real question is, "Do certified U.S. direct-entry midwives receive adequate training to properly care for women intending home births and their infants in the antepartum, intrapartum, and postpartum periods?" To answer it, one has only to show that the NARM certification process for midwives is rigorous and thorough and that to achieve certification, a midwife must demonstrate that she has the requisite knowledge, skill, and experience to care for women appropriately at out-of-hospital births. End of story.

-- Henci      

Actually, both claims are both true.

Goer's quote from the WHO is out of date. The WHO said in April 2006:

Home-like settings for childbirth are associated with reduced likelihood of medical intervention. The evidence shows that the number of spontaneous vaginal births is higher, breastfeeding initiation more common and maternal satisfaction better in home-like institutional birth settings compared to conventional institutional settings. However, the evidence shows an increased risk of perinatal mortality, the reasons of which are not fully established. Thus, there is an increased need for monitoring early signs of complications in these home-like settings. (my emphasis)

As far as the NICE report is concerned, Goer didn't even answer the question. She was asked if NICE reports a higher rate of neonatal mortality at homebirth, and they do. From the same report that Goer quoted:

... intrapartum-related perinatal mortality (IPPM) for booked home births, regardless of their eventual place of birth, is the same as, or higher than for birth booked in obstetric units.
* If IPPM is higher, this is likely to be in the group of women in whom intrapartum complications develop and who require transfer into the obstetric unit...
* When unanticipated obstetric complications arise, either in the mother or baby, during labour at home, the outcome of serious complications is likely to be less favourable than when the same complications arise in an obstetric unit.

Goer tried to sidestep the direct question that she was asked about DEM qualifications. American DEMs have less education and training than ANY midwives in the industrialized world. There's no denying it and she didn't deny it.

Both statements are gross falsehoods. Here is a quote from Care in Normal Birth: A Practical Guide, which is published by the WHO:

So where then should a woman give birth? It is safe to say that a woman should give birth in a place she feels is safe, and at the most peripheral level at which appropriate care is feasible and safe (FIGO 1992 [FIGO is the international Ob/Gyns professional organization]). For a low-risk pregnant woman this can be at home, at a small maternity clinic or birth centre in town . . . (p. 12)

World Health Organization. Care in Normal Birth: A Practical Guide. Geneva: World Health Organization; 1996.

And here is a quote from Sheila Kitzinger, writing in this year's March issue of Birth:

In September 2007 the UK National Institute for Health and Clinical Excellence (NICE) issued clinical guidelines on intrapartum care of healthy women and their babies during childbirth. Under "key priorities" it stated: "Women should be offered the choice of planning birth at home, in a midwife-led unit or in an obstetric unit." Information suggests that for "women who plan to give birth at home or in a midwife-led unit there is a higher likelihood of a normal birth, with less intervention" (p. 77).

Kitzinger K. Letter from Europe: home birth reborn. Birth 2008;35(1):77-8.

As for the canard that U.S. direct-entry midwives are poorly trained, a perusal of the North American Registry of Midwives (NARM) website gives the lie to that.

-- Henci  

1. Homebirth increases the risk of neonatal death. This is accepted and acknowledged by the WHO, the CDC, NICE (The National Insitute for Health and Clinical Excellence), a healthcare watchdog in the UK, among other major health organizations. 

2. American direct entry midwives have less education and training than any midwives in the industrialized world.