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    Find out what other moms-to-be are asking. Join in the discussion with Henci Goer, whose expertise is determining what the research tells us best promotes safe, healthy birth. If you would like to contact Henci outside of the Ask Henci forum, send an email to Goersitemail@aol.com.

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    Archived User

    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. 


    Henci, do you have more information about this? Thanks!

    maria.
    Henci Goer

    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  

    Archived User
    Thanks, Henci I figured as much, but unlike you, I do not have the info in y head nor at my disposal that quickly.
     

    maria.
    Archived User

    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.

    Archived User
    Oh, ok. It seems I'll have to look into it more myself. Thanks for the info anyways.




    Henci Goer
    Posted By n/a on 06/28/2008 3:18 PM

    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.

     

    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      

     

    Archived User
    Thanks, Henci, that clarifies a whole lot for me as it fits with other things I have read as well.

    Sorry to bring Dr. Amy here... this was a quote from her in a discussion online and I was wondering about it. The discussion is mostly a pissing contest between her and one other person, but I nonetheless want to look at everything Dr. Amy says for my own education.

    maria.
    Archived User

    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.

    Archived User
    Henci - you acknowledge that mid-wives have different training in each country. Are you familiar with the different requirements? Can you please detail what the differences are between American DEMs, CNMs and those certified/licensed in other industrialized nations? Also, I did note that you accused Dr. Amy of misinterpreting the WHO statement but clearly she included the "home-like setting" in her post and was transparent in including this in her post. Can you please explain to me how/why you believe she was misinterpreting the statement? The terms they use (as was included in her post) "home-like setting" clearly includes home births and birthing centers with a home-like setting as opposed to a hospital, correct? Do you believe that home-birth data as opposed to "home-like setting" would fare better if they were not lumped together? Do you have any statistics or data to support this?
    Archived User
    This conversation baffles me. Neither the WHO or the NICE has recommended against planned home births. The World Health Organization citation provided above discusses improving antenatal care. It does not discuss home births at all. It does refer to a Cochrane database article about home-like institutional birth settings (such as in-hospital birthing rooms or birth centers attached to hospitals). The Cochrane database article that actually discusses home births concludes that there is no evidence that hospital birth is safer than planned home birth. Here are the links to the Cochrane database articles. Cochrane database: Home birth compared to hospital birth http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000352/frame.html Cochrane database: Home-like versus conventional institutional settings for birth http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000012/frame.html Here is some links to the NICE (National Institute for Health and Clinical Excellence) Full clinical guidelines: http://www.nice.org.uk/nicemedia/pdf/CG55FullGuideline.pdf guidelines for patients: http://www.nice.org.uk/nicemedia/pdf/CG55FullGuideline.pdf NICE does not say that home births are dangerous. It does caution awareness that “if something goes seriously wrong during your labour (which is rare) it could be worse for you or your baby than if you were already in hospital with access to specialised care.” On the flip side if a labor and birth are normal, being in a hospital carries increased risk of interventions and subsequent complications of the interventions. So a mother planning a home birth is still stuck with the original dilemma, predicting whether she is going to have an uneventful birth (likely) or a complicated one (rare but possible). 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. As a physician myself, I am offended by Amy Tuteur’s paternalistic attitude. Flaunting the M.D. to bully readers into trusting to your words demonstrates desperation and a certain mean-heartedness that sullies the title for other physicians. Since most obstetricians lack any training in home births and have most likely never even seen a in home birth, the title of MD carries very little substance. It makes much more sense to discuss the risks and benefits of home birth with a birth attendant who has seen the ins and outs of such a practice. Today's patients, like any other consumer, demand transparency in their care and respect for their autonomy. We wish to make our own decisions about the type of care we receive including birth attendant and place of birth. ACOG also supports this approach, at least in theory if not in practice. See their excellent statement on the ethics of maternal care. http://www.acog.org/from_home/publications/ethics/co321.pdf http://www.acog.org/from_home/publications/ethics/co390.pdf Physicians may argue that patients cannot possibly learn all there is to know without becoming a physician themselves. On the other hand, I know very little about how to rebuild a car engine, but I can go to Consumer Reports or the NHTSA and make a choice based on reliability or gas mileage. We should have auditing organizations independent of care providers and payors, similar to the FEC. In this election year, we should all look carefully at how our government can protect consumer choice and consumer responsibility for their health and the health of their families. I recommend the book by Regina Herzlinger (coincidentally also from Harvard =) titled “Who Killed Health Care?” Tienchin HBAC mother and retired MD, FACS
    Archived User
    Neither the WHO or the NICE say that "home birth has an increased rate of neonatal death compared to hospital birth for low risk women." I can find no statement from the World Health Organization that describes home birth as having an increased rate of neonatal death compared to hospital birth. The statement from NICE: "There is a lack of good-quality evidence relating to women’s and babies’ short- or long-term outcomes for birth at home compared with hospital and there is no evidence on serious maternal morbidity and mortality. Limited low-quality evidence shows less intervention with a planned home birth compared with a planned birth in hospital. Transfer rates between home and hospital settings show great variation. While only three low-quality studies reported IPPM or intrapartum perinatal mortality rates, the findings suggest that there may be a trend towards higher rates when birth was planned at home. The unreliability of these data means that these findings should be interpreted with caution. Factors leading to the unreliability of the data include: • a lack of routine collection of data on place of birth • the mix of high- and low-risk women in the home-birth studies • the majority of women in these studies were self-selected populations, which questions the generalisability of the studies • inconsistent definitions • questionable relevance to the UK setting." Is the MANA data not published in the BMJ? http://www.bmj.com/cgi/content/full/330/7505/1416 But this only confuses a mother trying to make a decision. Because data from studies like these are collected, analyzed, and published by providers who have financial and personal investment in the outcome, she always feels that someone is pushing their agenda. A source of information that is somewhat more objective might be Childbirth Connection. http://www.childbirthconnection.org/article.asp?ClickedLink=252&ck=10145&area=27 What would really be terrific is for independent organizations who answer directly to the consumer, the patient/ mother/ client to provide an analysis of the immense information out there about pregnancy and childbirth. These centers would have an incentive to provide accurate and thorough information to the consumer because that is how they would stay in business. One model of this type is the "Center for the Childbearing Year" proposed by Raymond DeVries. http://docserver.ingentaconnect.com/deliver/connect/lamaze/10581243/v16n4/s8.pdf?expires=1214781533&id=44888322&titleid=10348&accname=Guest+User&checksum=BEE114ED9A0F06724724E7D92BDC23A9 Tienchin
    Archived User

    "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.

    Archived User
    It is unfortunate that the data for 2001-2007 is not available. I look forward to its publication. The data for 2000 published in the BMJ does not show that “homebirth with a CPM to have almost triple the rate of neonatal mortality as low risk hospital birth in 2000.” The BMJ article takes 5418 women who intended to birth at home at the start of labor. Out of these “five deaths were intrapartum and six occurred during the neonatal period. This was a rate of 2.0 deaths per 1000 intended home births.” Babies who die during labor and before birth are counted in intrapartum mortality rates. Babies born alive that die in the first 28 days of life are counted in neonatal mortality rates. So their home birth neonatal mortality rate was 6/5418 = 1.1 per 1000 births and their combined intrapartum and neonatal mortality rates was 2.0 per 1000 intended home births. Ideally, the mortality rate of a cohort who had planned hospital births would be compared to this group of 5418 women. In addition, factors other than place of birth that could change the mortality rate such as practice patterns, prematurity, etc would be similar in both groups of births. The authors of the BMJ article present several different sources for such a cohort to compare to their combined intrapartum and neonatal mortality rate. The combined intrapartum and neonatal mortality rates for hospital births ranged from 0.5 to 3.4 per 1000 births. Unfortunately the CDC National Vital Statistics Report on Infant Mortality Statistics from the 2000 period does not provide numbers for a matched cohort of births. The fact is that all the existing scientific evidence to date shows clinically undetectable differences in neonatal mortality rates between planned home birth and hospital births. No good data demonstrates that neonatal mortality is lower in hospital births compared to home births. Fortunately, no matter where a birth is planned, neonatal mortality is low. Unfortunately, for most families, scientific outcome measures are difficult to translate into a decision regarding where to birth. They have no way to measure what the local obstetrician’s or midwife’s neonatal mortality rates are. They may be exactly the same as those seen in published studies or they may be different. Tienchin
    Archived User
    Actually, the CDC does not provide the data. Link to the pdf file: http://www.cdc.gov/nchs/data/nvsr/nvsr50/nvsr50_12.pdf The Linked Birth/ Infant Death dataset for 2000 presents tables describing INFANT mortality data by a variety of maternal and infant characteristics. INFANT mortality rates include live born babies that died in the first year of life. Our discussion has been about NEONATAL mortality rates which include live born babies that died in the first 28 days of life. The BMJ article examines combined INTRAPARTUM AND NEONATAL mortality which includes babies that died during labor and live born babies that died in the first 28 days of life. The Linked Birth/ Infant Death dataset for 2000 has only one table, Table 6, with information regarding neonatal mortality rates. This table describes neonatal mortality rates based on race and gestational weight only. It does not subdivide neonatal mortality rates based location of birth, gestational age, or the presence/ absence of lethal birth defects. The CDC data presented in the Linked Birth/ Infant Death dataset for 2000 is not an appropriate cohort of births to compare to the MANA data published in the BMJ. Tienchin
    Henci Goer
    Posted By n/a on 06/29/2008 9:47 AM

    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.

     

    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



     

    Archived User
    Thanks, Henci. I will look at that study again. I just have got to get to the bottom of this one, lol. 

    It is confusing and upsetting when people look at one and the same study and come with different conclusions. It is infuriating especially when some of those  people also have low esteem for the lay person. When someone is so blatant about that, it is hard to trust anything they say. How words are used and tone of posts becomes very important.

    The truth is revealed, not just through the facts but also, when the facts are hard to see clearly, through the underlying respect or lack thereof in some cases.

    Thanks for your information and patience!

    maria.
     

    Henci Goer
    Posted By n/a on 06/29/2008 12:39 PM
    Henci - you acknowledge that mid-wives have different training in each country. Are you familiar with the different requirements? Can you please detail what the differences are between American DEMs, CNMs and those certified/licensed in other industrialized nations? Also, I did note that you accused Dr. Amy of misinterpreting the WHO statement but clearly she included the "home-like setting" in her post and was transparent in including this in her post. Can you please explain to me how/why you believe she was misinterpreting the statement? The terms they use (as was included in her post) "home-like setting" clearly includes home births and birthing centers with a home-like setting as opposed to a hospital, correct? Do you believe that home-birth data as opposed to "home-like setting" would fare better if they were not lumped together? Do you have any statistics or data to support this?
     
    In the U.S., CNMs or Certified Nurse-Midwives, get an RN first then go through a training program that certifies them through the American College of Nurse Midwives. The ACNM also started a few years ago--and I presume still has--a certification program for direct-entry midwives, meaning midwives who train to be midwives without the prerequisite of an RN. If I recall correctly, direct-entry midwives in their program receive a CM (Certified Midwife). The biggest and best known of the U.S. certification programs is through NARM, the North American Registry of Midwives, the organization to which I provided the link. NARM gives the certification "CPM" or Certified Professional Midwife. I'm on shakier ground here (perhaps someone more knowledgeable than I would like to chime in) but there is also an "LM" or Licensed Midwife, and I think these are midwives who have been certified by state programs. I do not have the details of training of midwives in developed countries. I wrote what I wrote in my response from my general knowledge gained from speaking with international activists for normal birth and from speaking abroad.
     
    I didn't accuse Amy of anything. She, although at the time I didn't know it was her, made the false statement that the WHO supports her claim that home birth increases the risk of perinatal death: "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." However, as I wrote in my response, when I tracked down her source quote, the WHO said nothing about home birth, but expressed a concern about in-hospital birth centers based on a systematic review. It is, to put it mildly, disingenuous, to say that the WHO indicts home birth, using the word "homelike" when, in fact the WHO does nothing of the kind. Home birth studies and studies of in-hospital birthing centers do not overlap, something I am sure Amy knows. They are not, in fact, ever "lumped together." As for data and statistics, there is a substantial body of well-done research into home birth concluding that a home birth with a qualified home birth attendant achieves equally good or better outcomes than hospital birth for low-risk women. The primary reason why is that healthy women at home and their babies are much less likely to be subjected to policies, practices, drugs, procedures, and restrictions that are ineffective and harmful than healthy women undergoing conventional obstetric management. If you would like to see the evidence for the safety and efficacy of home birth, Lamaze's Journal of Perinatal Education published the review project "Evidence Basis for the Ten Steps of Mother-Friendly Care" and the articles are downloadable for free. One of them is on out-of-hospital birth.
     
    I should also add that the systematic review of in-hospital birth centers has some weaknesses having to do with problems with the component studies on which it is based. I don't want to spend the time going into, but do not take it as gospel that in-hospital birth centers pose undue risk, or, at the very least, that all in-hospital birth centers increase risk.
     
    -- Henci
    Henci Goer

    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

    Archived User

    "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.

    Henci Goer

    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

    Archived User

    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.

    Archived User
    Ok, I have looked and looked but I cannot find where Johnson and Daviss acknowledged anything about their research being inaccurate. Would you please link me to this, Dr. Amy?

    Also, I thought it was not infant death that we needed to look at but neonatal death, death before 28 days. How does infant death rate say anything about homebirth?

    maria.


    Archived User
    Oh, disregard my last question, I read something wrong.

    maria
    Archived User

    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.

    Archived User
    I don't mean to offend....but that just made no sense. If you're only allowed one reply, and you didn't want to reply to Maria to waste that one reply by answering her very good questions (I've been waiting for the responses myself), then why did you just reply in a manner that only advertises your own blog (by what you just said, wasting your one response) and doesn't answer the questions? I don't think that Henci meant one response EVER, I think she meant you're allowed one response for each question/topic, provided they are respectful responses. I'm thinking I may not be the only one waiting for the answers to Maria's questions, so can you please post them here? They've been the foundation of your debate, and I'd like to know where the research is.
    Archived User
    I don't think Henci would delete a post with a link to where you get your information from, Amy. Only bullying and posts which detort the truth from what I understand. So please, post that link and the exact quote. 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
    Someone posted this in the comments of the Baltimore article. It seems to refute adequately what your point of contemption is.

    Also, I have been looking at the WHO report and I can also there not find anything that confirms what you write. Pleas quote where you found this, what page, the full paragrah etc.

    I have tried reading your blog, Amy, but the tone of it is quite agressive and it honestly diminishes the validity of your points in my opinion. I thought upon reading the first page that I would find some good unbiased information, just as I find here, but upon following the debate link, I was appalled by the animosity of people, including yourself. I do not like going to your blog nor do I like referring people to it. To each their own I guess.

    maria.
    Henci Goer
    Posted By n/a on 07/02/2008 9:48 AM

    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.

    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  

    Archived User

    '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.

    Henci Goer

    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

    Archived User
    The link Amy Tuteur provided to CDC Wonder does not provide an appropriate cohort of births to compare to the MANA data.

    Our original discussion was about finding an appropriate cohort from the year 2000 of planned HOSPITAL births to compare to data on planned HOME births published in the BMJ.

    The CDC Linked Birth/Infant Death dataset for 2000 does not provide neonatal mortality rates based on planned HOSPITAL births.

    The link http://wonder.cdc.gov/lbd.html navigates to a page that allows us to select one of three databases: Linked Birth/Infant Death Records with ICD 10 codes for 1995-1998, for 1999-2002, and for 2003-2004. It does not allow the user to select for data from 2000 alone.

    Then we can separate the data out by maternal and infant characteristics. The data is not available by place of birth. The CDC Wonder link does not provide any information about hospital birth neonatal mortality rates in 2000.
    Archived User
    Yes. Johnson and Daviss do not use the neonatal death rate in the hospital group in 2000.

    The NEONATAL death rate includes live born babies that died in the first 28 days of life.

    In their BMJ article, Johnson and Daviss examine the COMBINED INTRAPARTUM AND NEONATAL death rate which includes babies that died during labor and live born babies that died in the first 28 days of life.

    The COMBINED INTRAPARTUM AND NEONATAL death rate for planned home births in the BMJ article was 2.0 / 1000 in 2000.

    The COMBINED INTRAPARTUM AND NEONATAL death rate for planned hospital births in the BMJ article was drawn from ten sources with rates ranging from 0.5 to 3.4 / 1000.

    See Table 4 at http://bmj.bmjjournals.com/cgi/content/full/330/7505/1416?ehom

    No. The neonatal death rate published by the CDC for white women with 2500+ g babies was 0.9/ 1000 in 2000.

    See Table 6 at http://www.cdc.gov/nchs/data/nvsr/nvsr50/nvsr50_12.pdf

    Tienchin
    Henci Goer
    Posted By Amy Tuteur on 07/06/2008 4:08 AM

    maria:

    "Henci has also explained her point of view."

    Unless and until you study some basic statistics, you will not understand the rules of statistical analysis and therefore you will not understand that Johnson and Daviss are flagrantly violating those rules.

    Anyone who does not understand the difference between between intrapartum deaths (stillbirth) and neonatal deaths (commonly defined as born alive and dies between birth and 28 days), which Amy clearly does not, is either unqualified to discuss mortality statistics or intentionally misleading people for reasons of her own.

    -- Henci



    Henci Goer

    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

    Henci Goer

    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 

    Archived User

    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?

    Archived User
    lol........ Maybe I'm missing it completely but he didn't ask for clarification. He posted the links that we've been asking for you to post. And then you refuted his well written piece with nothing but accusations and nothing to prove what you are saying, followed by a link to your own blog, again. (This message is hereafter directed to Tienchin.) Thank you, Tienchin for your post. It is exactly what I wanted to see. It feels like to me that these numbers really aren't a fair comparison to each other because there are entirely too many variables in the first place. What I wish these studies included was perhaps quality of prenatal care. I've been running this through my head time and time again while watching this conversation and it feels like these studies are simply looking at the wrong things. It seems rare to me that a neonatal death be directly linked to the actual birth when it gets as far as 28 days after, so how can that be used? (Or maybe there are factors that I'm not aware of?) That said, I don't think that these comparisons can be fairly used for either side of the debate. If there is proper prenatal care in a low risk woman, and proper monitoring during labor, it seems to me that an intrapartum death would be unlikely both at the hospital and at home for any other reason beyond a complication that would have ended in death anyway. A well trained midwife will see that there is a problem in time to transport the laboring woman while (if necessary) an operating room can be prepped for cesarean. If the woman is within an adequate amount of distance of the hospital, it doesn't seem to me that there would be any difference at all between hospital and home because even if she were in the hospital there would be a wait for the OR to get prepped. So really, the only difference that I can see is the type of fetal monitoring being used. A doppler doesn't print out a pretty piece of paper like a TOCO does, but you can still monitor the heart rate well, even during a contraction. In a hospital, they would basically do no differently than they would do at home, they just have more gadgets and infections laying around. So, if you have a well trained midwife, and you're within, lets say, a half hour of a hospital (enough time to prep the OR), and you've done well to take care of yourself and get adequate prenatal care.....what exactly is the advantage of a hospital birth? Because for me, those numbers say nothing. Tienchin, I think my question is what is the general consensus of what can be done better for a low risk, well prepared woman in labor in a hospital? I can't remember if I read that you are an advocate of home birth or not. I live in a state that outlaws home birth, and we now have a growing culture of unassisted births, which actually makes me a little scared. I think that home birth is a beautiful thing, but unassisted birth is not the way to go! I can understand the apprehension that may surround the idea of home birth, but I also feel that a woman's right to choose where she births should be number one. I don't know how it is that lawmakers can interfere with that.
    Archived User
    I'm so sorry for my huge paragraphs replies. I can't figure out why my paragraphs don't space right.
    Archived User
    Thanks, Tienchin! This is very helpful!
    maria.
    Henci Goer
    Posted By Amy Tuteur on 07/07/2008 3:10 AM

    Could you please explain the rules?


    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

    Henci Goer
    Posted By Angela Simpson on 07/07/2008 8:25 AM
    I'm so sorry for my huge paragraphs replies. I can't figure out why my paragraphs don't space right.



    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

    Archived User
    I actually do do that, but I'm thinking that it might be my browser playing tricks on me. I use a Mac, and typically use Safari when I'm on the forum. I'll try in firefox next time, I think.
    Henci Goer

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

    -- Henci

    Archived User
    Nope, it doesn't! I use Firefox now and it is fine.
    maria.
    Archived User
    I would really like an independant party to look at this. I mean, it would be nice if this could ne hased out once and for all.
    maria.
    Archived User
    I am a general surgeon in California currently working as mother. I had my now five year old by cesarean for breech and asystole with an attempted external version with my obstetrician friend. I had my now three year old in water at home with a midwife with my obstetrician friend as my backup.

    I think studies can be interpreted in different ways. I was merely pointing out the data. The reason you were not sure which side I was one is because I am not on the home birth or the hospital birth side. I am on the mother’s side.

    Some events that happen during labor and birth are not resolved immediately after birth. Sometimes babies survive for weeks or months on life support only to die later. Researchers have different time periods (infant, neonatal, intrapartum, perinatal mortalities) because they are trying to answer different questions, and sometimes they disagree on which time period to use. Sometimes there is no right answer.

    Prenatal care and its effectiveness or ineffectiveness have been studied. Studies are inconsistent in part because the purpose of prenatal care is not consistent. Is the goal a lower maternal/ neonatal mortality rate? Or breastfeeding success? Or avoiding repeat cesarean sections? See the Cochrane database at: http://www.ncbi.nlm.nih.gov/pubmed/17636711?ordinalpos=9&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

    Although you may not perceive any difference in monitoring between a home and a hospital, those who feel they “do it better” have very strong beliefs about how intrapartum and neonatal mortality is affected by location of birth and birth attendant. For some, being ten minutes from the hospital is too far. For others, an hour is close enough.

    As far as a general consensus, I don’t know of one. Perhaps obstetricians believe that the advantage of a hospital birth is that they are there, along with all the equipment and personnel with which they are comfortable. In fact, most people have some element of this. If you plan a home birth, is your backup plan to go to the most rural hospital without a neonatal intensive care unit? Or is it to go to the hospital with a perinatologist on call 24/ 7? Are you more likely to take the words of an obstetrician or a mother more seriously? Is not having a continuous fetal monitor only ok if you have a Doppler? Or is a fetoscope enough? All of us participate in the idea that doctors know more than us and that technology and science make things safer. Some less than others. Robbie Davis-Floyd says it best in her book Birth as an American Rite of Passage with her discussion of our societal values of paternalism and technocracy.
    http://www.amazon.com/Birth-as-American-Rite-Passage/dp/0520229320/ref=sr_1_3?ie=UTF8&s=books&qid=1215502269&sr=1-3

    Tienchin
    Archived User
    WOW doesn't get more "independent party" than that, I feel! Thank you so much for your well written response. What a breath of fresh air compared to the beligerence that's been delegated before this point. And I agree wholeheartedly that its the mother's decision and that decision should be supported by all, particularly legislation. Its a shame that there are too many variables in the studies to make them truly reliable. But see, I don't believe that Mother Nature ever intended birth to be a scientific study with the hopes that women will trust their bodies and intuitions to guide them to the right decisions. Just my opinion though
    Archived User
    I think Dr. Amy's blog postings and online commentary lack elegance, rhetorical style, maturity, kindness, and even really much logic. I think she belittles her readers openly and all women in more subtle but repetitive ways. I am grateful she is no longer practicing medicine.

    But Ms. Goer, your responses to her weaken your case. She should be allowed to flog herself on an unlimited basis and you should let her.  Limiting her expression only makes you look defensive.
    Archived User

    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.

    Henci Goer
    Posted By n/a on 07/07/2008 10:39 PM

    "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."

    You're joking, right?

    YOU decided that there is "enough" information and resource links. What do you think is going to happen if there are more? Do you expect people to fall down dead from information overload?

    There is absolutely no legitimate reason to limit the presentation of relevant information. The ONLY reason to limit the presentation of relevant information is to prevent people from finding out the truth.

    I have no need to continue this discussion. I think I have made my point and hammered it home repeatedly. I only dropped in because you wrote about me personally and you lied. I honestly cannot believe that you were so careless. It is so easy to find out the truth about me and my credentials, but you never even bothered. Your contempt for the truth about something so obvious and easily checked should be a warning to others about your contempt for the truth about obstetrics.



    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  

    Archived User
    Posted By Dr. Amy on 06/28/2008 3:18 PM

    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.

    The education required by NARM is certainly less than other midwives.  However, there are many individual midwives who have credentials far exceeding those required by NARM.  I think it is worth-while to push for more stringent requirements.

    Archived User
    Henci, Thank you. I agree completely that Amy needed to be moderated, particularly considering her disrespectful tone toward not just you, but advocates of home birth in general. You simply deleted the posts that included repeated information or blatant attacks on you. This forum, and you as its moderator, reflect Lamaze's values and you simply did what you needed to. I applaud you for your restraint, because I probably would have been a bit less tactful in my responses. haha Seriously, though, I'm happy to see her gone, for good. She did nothing to promote a polite and balanced debate, which is something that I actually enjoy.

    I do have a question unrelated to that though. I read recently somewhere that a study was done that concluded in only 0.7/1000 attempted VBACs resulted in rupture (or maybe it was .07%?). Has anyone else read this too, and if so, where did you find it??? I'm having a hard time finding it again.
    Archived User
    (sidenote--I just used HTML tags to space my paragraphs. hooray it worked!!!!!!)
    Henci Goer
    Posted By n/a on 07/08/2008 1:54 PM
    I think Dr. Amy's blog postings and online commentary lack elegance, rhetorical style, maturity, kindness, and even really much logic. I think she belittles her readers openly and all women in more subtle but repetitive ways. I am grateful she is no longer practicing medicine.

    But Ms. Goer, your responses to her weaken your case. She should be allowed to flog herself on an unlimited basis and you should let her.  Limiting her expression only makes you look defensive.


    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

    Archived User
    Posted By n/a on 07/06/2008 4:44 AM
    The link Amy Tuteur provided to CDC Wonder does not provide an appropriate cohort of births to compare to the MANA data.

    Our original discussion was about finding an appropriate cohort from the year 2000 of planned HOSPITAL births to compare to data on planned HOME births published in the BMJ.

    The CDC Linked Birth/Infant Death dataset for 2000 does not provide neonatal mortality rates based on planned HOSPITAL births.

    The link http://wonder.cdc.gov/lbd.html navigates to a page that allows us to select one of three databases: Linked Birth/Infant Death Records with ICD 10 codes for 1995-1998, for 1999-2002, and for 2003-2004. It does not allow the user to select for data from 2000 alone.

    Then we can separate the data out by maternal and infant characteristics. The data is not available by place of birth. The CDC Wonder link does not provide any information about hospital birth neonatal mortality rates in 2000.
     
    You are right that you can't do the query on place of birth in 2000. You can in 2003 and 2004 though. But there is the rub...it is simply "place of birth" not "planned place of birth." 12% of women who start labor planning to birth at home end up transporting to the hospital...and likewise a certain percentage of women who plan to birth in a hospital will accidentally birth out of the hospital--happened to one of my clients with her second baby (ironically she had a lot of stress over her hospital choice because the hospital she'd used for her first baby closed its maternity ward during her second pregnancy, and she just wasn't sure she was going to like the alternate...turned out her labor went too fast for her to get to either of the hospitals). Also, there is a significantly larger number of women in the "other midwife" category than one would expect based on the 2005 BMJ study...which leads to the logical conclusion that many of those births were not attended by CPM's, but may have been attended by women with very little formal training. In my state, because of the Amish and Mennonite population, there are a lot of lay midwives who I'm told would not pass the NARM exam to get the CPM designation. This has made efforts to get legislation for licensure difficult. Amy believes of course that licensure will be the downfall of CPM's because she thinks it will expose them as being substandard care providers. I believe the opposite--that licensure will allow CPM's to be less hesitant to transfer care when it is meritted, thus increasing the safety for women and babies.
    Henci Goer

    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

    Archived User
    "I am not willing to allow anyone to hijack this Forum with endless rants that, as you say, lack logic, maturity, or kindness." Thank you for this. I have too often seen list owners who are unwilling to delete nasty posts or ban abusive people all in the name of "free speech"; which is why I do not go on most boards. As a result of this contortion of the definition of "free speech", boards are taken over by these psychologically-challenged people. I am 34 and it puts me off. My argument always is: "if you are teaching a class, would you allow an overly-obnoxious student who seeks to dominate the class to remain unchecked in the name of free speech?" Your allowing Tuteur to post at all is generous. If she thinks that you are so wrong, let her post on her own blog
    Archived User
    Oh and for the record, I found this site through Tuteur's blog, which I found through her posts on our alternative weekly and I did not read for very long at all (I saw more than enough after 30 seconds). So you may be getting more people to your site through her linking to you, which, if that is true, is peachy, IMHO.
    Archived User
    Ok, I posted this to a prof. in statistics and here is his response:


    The study I am looking at is this study:
    http://www.bmj.com/cgi/content/full/330/7505/1416
     
    The following explanation was given by Johnson and Daviss about their study:
    http://understandingbirthbetter.com/section.php?ID=31&Lang=En&Nav=Section
     
    Some people say they have used the wrong comparison groups and that the correct comparison would prove that homebirth has triple the neonatality rate of hospital birth. 
     
    ***
    OK, here’s my take on it…
     
    When I read the executive summary of the BMJ, I was struck by it’s modest claims in the results.  By modest, I mean that it essentially reported the percentages of differing outcomes within it’s own data set.  It was the conclusion, however, that struck me: it claims that their study group was similar to a group not in the study, namely, low risk hospital births in the US.
     
    That seems to be the basis of the criticism.  The comparison group has one obvious difference that masks for lots of other potential discrepancies: it was retrospective data.  The authors of the study actually point this out in the study, however, so, to me, it isn’t fair to fault them for making the comparison.  Perhaps they could have added a footnote to the conclusion in the exec summary, but that’s a bit picky.  The disclaimer is clear in the discussion section:
    “Regardless of methodology, residual confounding of comparisons between home and hospital births will always be a possibility. Women choosing home birth (or who would be willing to be randomised to birth site in a randomised trial) may differ for unmeasured variables from women choosing hospital birth….”
     
    Consistent with this disclaimer, the biggest factor (in my opinion) is the demographics of their study group.  This is visible in Table 1, which shows the characteristics of the mothers in the two groups:
    -          More women above the age of 25
    -          Likelihood of having already given birth is much higher
    -          Typical education levels are higher
    -          95% had partners—which I would wager is significantly larger than the comparison group, whose rate is reported as N/A
    Their study group is a self-selecting subpopulation of women—they are different from other women in ways that move them to choose a birth method that is out of the “main stream.”  This fact alone (supported by the items I just listed) suggests to me that they were better prepared for birth, and more aware of risks and of ways to handle them.
     
    They did attempt to sort the data from the Nat. Center for Health Stats into “low risk” mothers, in order to make a better comparison.  Assuming that sorting method valid, they arrive at the result that their group is, essentially, equivalent to the in hospital “low risk” group.  Not shocking, given the kind of mom in their population.
     
    I hope this is helpful.
    ***

    Now my question is, what numbers did Amy Tuteur use to come to her comparison of homebirth being triple the risk of hospital birth. Where can I find these numbers and how are they a better comparison?

    I think in the end, on one hand, eventhough this study has lots of merrit, the homebirth advocates should maybe not take it as a decisive study about the safety of homebirth, as they tend to do now, saying 'see!'
    However, I do not think Amy's claims are grounded either so I would like to present to this prof. the numbers Amy is talking about and see what he comes up with.

    Henci, would you please refer me to where I can find the numbers Amy is talking about? My apologies if they are posted here before!

    Thanks!
    maria.

    ps: I asked two other people knowledgeable in statistics to look at this and I am waiting for their responses as well.
    Archived User
    Silly question, perhaps: but how can you think Amy is wrong (or right) if you don't understand the study yet?

    You've got the process backwards: you have come to a conclusion and now you look for evidence to support it.  But it's supposed to work the other way; you are supposed to understand the subject ad the evidence before you come to a conclusion on it.
    Archived User
    I am trying to understand it. I thought I understood it, but I am looking at it again, trying to be open to the study's possible flaws and its implications. There seems to be two ways of looking at this study depending on where you stand in the debate.

    I don't understand your question. I am not looking for evidence. I am looking to understand how Amy comes to her conclusion and others come to theirs. This is why I posted my question to some people knowledgeable about statistics and not involved in birth like I am (or Henci or Amy for that matter). Just curious what they thought is all and I thought others may be interested as well.

    I personally do not care either way how accurate this study is. I birth unassisted.

    I hope this answers your question.
    Henci Goer

    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 Ricki Lake'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

     

    Archived User
    Posted By Henci Goer on 07/09/2008 2:49 PM

    ... 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.  



    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?  ;-)

    Archived User
    Maria,

    You can continue to search for proof that the home birth neonatal death rate is triple that of hospital births, but you won’t find it. It doesn’t exist.

    Keep two things in mind when reading “debates.”

    1) You do not have to prove the opposite in order to disprove the other.

    2) If you suspect you are being duped, you are probably right.

    If you follow a link and do not find what you are seeking, then it is not there. Not even in invisible ink that only MDs and statisticians can read.

    Tienchin Ho MD, FACS, HBACM
    Archived User
    Thanks, Jenn. That puts it all together nicely for me.

    Henci, I apologize for continuing to bring this up. I do this not because I do not trust you, but because I want to understand Amy's claims. Not because I think she is right (her behavior would be an indicator that she is not!) but because I need to understand it for myself. I think my confusion is with the fact that I could not find where she got her numbers and a lot gets lost on me when numbers are presented back and forth. And *blush* I was too lazy to read it all through to find the info.

    Jenn's little summary has helped clarify things however.

     
    Henci Goer

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

    -- Henci

    Archived User
    I'm not exactly sure why you were offended at that post.  This seems pretty reasonable.  It doesn't make any sense that MANA 2000 would be a source for finding objective information since they have a vested interest in homebirth being portrayed as safe.  Dr. Amy is right.
    Archived User
    Posted By Henci Goer on 07/08/2008 2:28 PM
    Posted By n/a on 07/07/2008 10:39 PM

    "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."

    You're joking, right?

    YOU decided that there is "enough" information and resource links. What do you think is going to happen if there are more? Do you expect people to fall down dead from information overload?

    There is absolutely no legitimate reason to limit the presentation of relevant information. The ONLY reason to limit the presentation of relevant information is to prevent people from finding out the truth.

    I have no need to continue this discussion. I think I have made my point and hammered it home repeatedly. I only dropped in because you wrote about me personally and you lied. I honestly cannot believe that you were so careless. It is so easy to find out the truth about me and my credentials, but you never even bothered. Your contempt for the truth about something so obvious and easily checked should be a warning to others about your contempt for the truth about obstetrics.



    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  

    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.

     

    Archived User

     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.

    People don't like Amy because they (and I) think she's a nutjob.  She ignores anything that doesn't support her opinion and refuses to acknowledge when she's wrong.  I've seen her caught red-handed making unsubstantiatable claims on her blog and when called out on it, she refused to acknowledge the lie.  When called out again, she attacked the poster's mental capacity in a snide manner, still not apologizing for the fact that she lied

    Are you aware that she linked to a grieving mother's blog (the woman was blogging about the death of her baby after a homebirth) and that croanies from Amy's site went to this mother's blog and harassed her?  One visciuosly attacked her two months after her baby's death and basically called her a murderer.  Amy only took the link down after many other grieving mothers went to her site and begged her to.  She also trolls parenting sites like BabyCenter and MotheringDotCom to find bad outcomes to post about to support her claims.  She has no class, cherry picks what information she gives out, and doesn't respond to points that contradict her.  That's why I give what she says no credence whatsoever.


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