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Neonatal death rates after home births and a strange skeptic kerfuffle

If there’s a topic that I don’t write about much, it’s obstetrics. The reason is that it’s not a major area of my interest, and it’s not an area where I have as much expertise as I do in, say, cancer or even vaccines. My expertise in cancer comes from my career, of course, and my expertise in vaccines is self-taught through my 9+ years of blogging about it. Ditto my expertise in “complementary and alternative medicine” (CAM), also known as “integrative medicine,” about which I know quite a lot now. That’s probably why I didn’t pay much attention to a study that came out in late January from the The Midwives Alliance of North America Statistics Project, 2004 to 2009 (MANA). However, this study came to my attention due to a little blog kerfuffle going on between Dr. Amy Tuteur, who goes by the blog moniker The Skeptical OB (or Dr. Amy) and Jamie Bernstein over at Grounded Parents. Fortunately, the paper is available online; so we can all follow along, which allows me to do what I think best, discuss the paper first and then the blog kerfuffle, which, to be honest, I’m having a hard time figuring out why it’s become so vitriolic. It’s actually rather disturbing to see, given that the differences in position seem rather small. Going through it all, as painful as it is, might be educational. Besides, I’ve already pissed off one big name skeptic a couple of weeks ago. If I end up pissing off another one, it’s no big deal at this point, right?

Right.

Besides, one of the parties involved in this little dustup (which is, sadly, kicking up a fair amount of dust), Jamie Bernstein, who’s a friend of mine, asked me to look into the issue. At first I didn’t want to, but I changed my mind.

Before I go on, let me just say also that I tend to agree that most of the time home births are probably bad idea. There’s a lot of evidence out there that the risk to both mother and baby from home birth is significantly higher than it is in hospital. While it might be possible in highly selected cases to justify doing a home birth for low risk singleton pregnancies, it strikes me as way too risky to consider a home birth for higher risk, complicated pregnancies. Actually, this study suggests the same thing. Finally, I have noted that there is very much a cultish aspect that has grown up around home births, where the risks are downplayed and the “experience” is all. These are the areas where Dr. Amy, Jamie, and I generally appear (mostly) to agree, all the more reason why I’m puzzled by this whole thing.

The MANA study

First, let’s take a look at the paper. No, wait. First, let’s take a look at what MANA said about the paper in its press releases and fact sheets:

Safe Outcomes with Positive Benefits

  • High rate of completed home birth (89.1%)
  • High rate of vaginal birth (93.6%)
  • High rate of completed vaginal birth after cesarean (VBAC; 87.0%)
  • Low intrapartum and neonatal fetal death rate overall:
  • o 2.06 per 1000 intended home births (includes all births)
  • o 1.61 per 1000 intended home births excluding breech, vbac, twins, gestational diabetes, and preeclampsia.
  • Low rate of low APGAR scores
  • Extremely high rate of breastfeeding (97.7%) at 6 weeks

Few Emergency Transfers to Hospital Care

  • Primary reason for transport was “failure to progress.” Transfer for urgent reasons, such as “fetal distress” was rare.

Low Rates of Intervention

  • Cesarean section rate of 5.2%
  • Less than 5% used pitocin or epidural anesthesia

Sounds fantastic, doesn’t it? There’s just one problem, which has been pointed out by Dr. Amy, Jamie Bernstein, and Steve Novella. That problem is that, if you compare the death rates in the MANA study to publicly available death rates from other sources, the death rates in the MANA cohort are higher—and not just by a little. The issue behind the fracas is how much higher and in emphasis.

Actually, the better way to describe the problem with this study is that there is no control group. This is a single arm, prospective study. It’s good that it’s prospective, rather than retrospective, because it means that the data were all collected as patients were enrolled. However, it’s also important to recognize that this is not a typical group of pregnant women giving birth. As the authors themselves mention in the introduction that 1.18% of births in the US occur outside of the hospital, and, of those, approximately 66% are homebirths, for a total of 31,500 home births a year. This study examines 16,924 pregnancies, for a total of 16,984 neonates including 60 sets of twins, over birth years ranging from 2004 to 2009, which breaks down to around 3,385 births a year, a bit more than 10% of the home births estimated to have occurred in the US during this time period. That’s a significant sample, but it’s nonetheless a small fraction of an even smaller fraction of all the births that occurred in the US during that time frame.

That this is an unrepresentative sample is obvious just perusing the numbers, which are overwhelmingly white (92.3%) and college-educated (58.4% having completed a college degree, compared to 33.5% recently estimated for the general population). Basically, the numbers were what the press release/fact sheet listed above. Other important numbers were summarized here:

The overall death rate from labor through six weeks was 2.06 per 1000 when higher risk women (i.e., those with breech babies or twins, those attempting VBAC, or those with preeclampsia or gestational diabetes) are included in the sample, and 1.61 per 1000 when only low risk women are included. This rate is consistent with some published reports of both hospital and home birth outcomes, but is slightly higher than others. Because only 0.45 per 1000 separates these samples, further work is needed. These findings should, however, help to inform the process of shared decision-making as women talk with their providers about their own specific risk profiles, value systems and priorities for birth.

This leads the authors to conclude in their paper:

For this large cohort of women who planned midwife-led home births in the United States, outcomes are congruent with the best available data from population-based, observational studies that evaluated outcomes by intended place of birth and perinatal risk factors. Low-risk women in this cohort experienced high rates of physiologic birth and low rates of intervention without an increase in adverse outcomes.

Except, as Steve Novella pointed out, based on Dr. Amy’s calculations, the equivalent number for the overall death rate from labor through six weeks for planned hospital births is 0.38 per 1000. Now, I fiddled around with the CDC Wonder Database a while trying to see if I could replicate Dr. Amy’s number. I couldn’t. There are lots of settings in the Wonder Database, and I tried to match the cohort in the MANA study as well as I could. No matter how I tried to do it, my numbers came out around 0.5 per 1000 or I got a lot of “suppressed” data, which apparently means that there were too few to be considered valid. As far as I’m concerned, that’s close enough, as I didn’t have time to fiddle with the settings all night last night and unless Dr. Amy reveals the exact settings she used to get her number, there’s no way for me to easily replicate it easily. So, because it’s simpler, I’ll just assume she knew what she was doing and go with it. I also note that it’s not possible to get death rates for birth and the six weeks after birth using the MANA database, because the choices do not include the first six weeks. The ranges are (1) under one hour; (2) 1-23 hours; (3) 1-6 days; (4) 7-27 days; and (5) 28 to 364 days.

Be that as it may, for low risk pregnancies, the MANA death rate of 1.61 per 1000 is 4.2 times higher than the estimate provided by Dr. Amy from the CDC database of 0.38 per 1000. If we use my quick and dirty estimate of 0.5 per 1000, then that’s 3.2 times higher. Both of these numbers are within the range of what previous data have shown. For example, a meta-analysis from 2010 concluded that planned home births were associated with a tripling of the neonatal mortality rate. That’s, as I would put it, plenty bad, man.

Of course, there are problems with this comparison. We’re comparing apples and oranges in that there was no control group for the MANA study, and it’s always problematic to compare what is in essence such a highly self-selected group with population-based statistics. We have no idea if the MANA group was representative of women who choose home births, because it’s a group of women who not only chose home birth (less than 1% of pregnancies) but were also willing to sign the informed consent form to be in the study. Moreover, the error bars were large. Even when two groups are not easily directly comparable, as is the case here, a more than four-fold relative risk of death is definitely something to be concerned about, and it’s concerning that MANA does its best to de-emphasize it.

In its Consumer Considerations, MANA tries to downplay the risk, and, to be fair, it does have (somewhat) of a point in that it points out that what we are talking about are relative risks. As Steve Novella points out, when you look at a comparison of absolute risk, the difference between home birth and hospital birth is 0.123% (0.161% -0.038%), or 1.2 per 1,000, estimating that in the study population this amounts to 20 extra perinatal deaths. I liken this to the issue of mammography and an example I used before:

Essentially, mammography reduces the odds of a 60-year-old woman dying of breast cancer in the next decade by 30%. Sounds impressive, until you look at her absolute risk: by getting her annual mammogram, her chances of dying from breast cancer are whittled from 0.9% to 0.6%. Overall, for every 1,000 women in their 60s screened for breast cancer in the next 10 years, mammograms will save the lives of 3 people but 6 others will still die. (The numbers edge up or down in lockstep with a woman’s age.)

The point is not to try to directly compare the numbers but to choose an example to illustrate a similar point, namely that when you look at absolute risks instead of relative risks, the perspective changes. I think it’s important in these studies always to include both numbers, the relative risk and absolute risk. None of this excuses MANA from using the graphs they did to try to downplay the even more elevated risk of infant death in infants presenting in breech position or women undergoing a vaginal birth after Caesarean section (VBAC), which were 5 out of 222 and 5 out of 1052, respectively. What is being weighed is whether the value of the experience of home birth is worth the roughly three- or four-fold increased risk of neonatal death, which translates to approximately an extra 1 in 1000 chance of the baby dying. I’m not going to touch that one with the proverbial ten foot cattle prod except to say I’d conclude: No.

Unfortunately, there are not a lot of high quality comparative data to use. A recent Cochrane review concluded that there is “no strong evidence from randomized trials to favor either planned hospital birth or planned home birth for low-risk pregnant women.” Of course, this is not surprising. Such a trial would be fraught with ethical difficulties, not the least of which because of data like the MANA data suggesting that home birth is almost certainly riskier than hospital birth. Moreover, from a strictly practical standpoint, I don’t see too many women being willing to be randomized either to hospital or home birth. Observational evidence is what we are going to have to use, because it’s highly unlikely that we’ll ever have decent evidence from a randomized trial. For some questions in medicine, it has to suffice.

The Kerfuffle

The entire blog kerfuffle that’s been intermittently flaring up boils down to a single graph and a single passage in Dr. Amy’s post about this paper. Given how much I harped on certain skeptics to provvide full disclosure, I will state right here, right now, that Jamie asked me to look at these posts. So I did. Now here’s the single graph:

And here’s the passage:

As the chart above demonstrates, the MANA death rate for the same years was 5.5X HIGHER. In other words, the MANA death rate was 450% higher than the hospital death rate.

On what planet is a death rate 450% higher than expected a safe outcome? Not on this planet.

MANA and homebirth midwives have been lobbying extensively for a scope of practice that includes breech, twins, VBAC, etc. Now they want to exclude those same births from their statistics. Even then, the MANA death rate is 4.2X higher than hospital birth. So even when homebirth midwives stick to low risk patients, homebirth has a death rate 320% higher than comparable risk hospital birth.

One thing that’s clear is that the figures of 2.06 per 1000 and 1.61 per 1000 were not in the MANA paper, at least not in that form. They were in that form in the Consumer Considerations page that I cited above. This clearly confused Jamie at the time because she couldn’t find the equivalent numbers in the paper. I must admit that at first it rather confused me a bit, too, as to how those numbers were calculated based on the figures reported in the paper. I had to figure it out by wading through the data and determining which numbers had been added together to come up with these figures. Be that as it may, Jamie was critical of Dr. Amy for the above passage, for these reasons:

Let’s leave this study for a bit and go back to the numbers Dr. Tuteur cites in her post. According to Dr. Tuteur, 1.6 per 1000 low-risk planned homebirths from the recent study resulted in neonatal death within 6 weeks of birth. Using CDC data, she also determined that the risk of neonatal death for low-risk white women in the US during the same years was 0.4 per 1000 births. She then points out that OMGZ YOU GUYS THAT’S A 5.5X INCREASE IN BABY DEATHS!

First of all, can I first point out that it’s a 4x increase, not 5.5x (1.6/0.4 = 4). Even comparing the homebirth cohort that includes high-risk births (2.1 in 1000) to the low-risk only CDC cohort (which is not a fair comparison for obvious reasons) would only result in a 5.25x increase in mortality. I seriously have no idea how Dr. Tuteur came up with 5.5x or 450% increase in mortality from the numbers that she cited.

I can find no flaw in this reasoning, and, had I noticed this first, I would have been far more snarky about it, because, well, that’s how Orac rolls. Dr. Amy should appreciate that, because she herself is often as sarcastic or more so than Orac is, only nowhere near as funny about it. Dr. Amy clearly did not do the right comparison, which would have been to compare low risk with low risk—by her own numbers. If she was so convinced that the figure of 2.06 per 1000 was the correct figure, then why did she include the figure of 1.61 on the graph and label it “low risk”? Moreover, her rationale makes no sense. After all, the statistics are right there, in the paper. True, they’re not in a nice table format, like most of the other statistics presented in the MANA paper. But they are there, so much so that Dr. Amy was able to come up with 2.06 and 1.61 out of 1000 numbers by adding together the appropriate figures. In any case, Dr. Amy attacked Jamie’s analysis as a “hatchet job.” Some of what she says makes sense, but I’m going to cite one thing that is a steaming pile of fetid dingo’s kidneys:

Clearly she never bothered to look at the CDC Wonder database, which contains an complete description of contents. I specifically noted that I looked at white women, 37+ weeks, 2500 gm babies.

No, Dr. Amy did not mention any such thing, at least not in her original post discussing the MANA paper. In any case, unlike Jamie, I did look at the CDC Wonder Database. I wasted quite a bit of my time fiddling around with it, trying to replicate Dr. Amy’s number. I couldn’t do it, because I was largely guessing based on what Dr. Amy said in her original post, “According to the CDC Wonder database, the neonatal death rate for low risk white women at term from the years 2004-2009 is 0.38/1000.” Nope, there’s nothing there about 37+ weeks or 2500 g babies. Armed with this new knowledge from Dr. Amy, I went back into the CDC Wonder Database, and plugged her figures in. That resulted in a mortality rate of 0.57 per 1000. At this point I was tempted to appeal to Dr. Amy for all of her other settings she used to search the CDC Wonder Database because I’m not getting the same number she is, and it’s not because I can’t figure out how to use the database. I use databases like this one all the time. But then I came across her a later analysis, I realized that the reason for the anomaly is probably because I didn’t exclude the ICD-10 code for major congenital malformations from the causes of death. So I did it again and came up with an estimate of 0.34 per 1000. That’s better, but still not identical to what Dr. Amy came up with. At least it’s now close enough that I’m not wondering as much as I was before what the heck was going on. Still, it would be nice to know the full settings used.

I don’t really want to go into the next phase of this little kerfuffle, which involves a statistics professor guest posting about the MANA study and a critique by Jamie, because this post has already grown too long, even by Oracian standards. Maybe if there’s interest on your part (and still on my part) I might take it on another time. Whatever mistakes Jamie might have made (and it’s clear that she didn’t find the figures used to come up with the aggregate estimated mortality rates of 2.06 and 1.61 per 1000), she didn’t deserve what came about a week ago, when this whole kerfuffle culminated in a rather amazing post by Dr. Amy that asked Can women be skeptics? In it, she says:

I’m beginning to wonder if there is a germ of truth to the claim that there are not more women in skepticism, because women are so anxious to avoid confrontation.

And:

You cannot be a skeptic and censor debate. Yes, you can remove racism and other evidence of hatred or discrimination. Yes, you can remove comments that are not on point. But you can’t censor comments that you don’t like and still call yourself a skeptic.

Say what?

Remember that there was a time when Dr. Amy was on Science-Based Medicine. It didn’t work out. You want to know the reason it didn’t work out? A certain guy that you all know and (hopefully) love described what happened in a comment:

Of course, Amy is free to present her side of the story as much as she likes on her blog. For now, we are going to take the high road and not get into a “he-said-she-said” sort of exchange. However, since Amy has cited our moderation policy as a reason for her departure, I no longer see a reason not to confirm that one unresolvable issue was that Amy strongly favored a more heavily moderated commenting system, and Steve and I were very reluctant to change our commenting policy. But the disagreement over the commenting system was certainly not only the bone of contention that we could not resolve.

Many of our regular readers will know who wrote that, but in the interests of full disclosure I’ll just say: Here’s another clue for you all. The walrus was Paul. No, wait, that won’t do. Besides many of my readers being too young to get that reference, it’s just another bad Orac joke. So instead let’s just say that everybody’s box of blinky lights wasn’t too far at all from that particular comment, lo, those four years ago. (Has it really been that long?)

In any case, Dr. Amy clearly left SBM in part because she didn’t like its free-wheeling, hands-off moderation policy (which is only marginally tighter than almost non-existent moderation policy here). I remember it well and could elaborate further, but I won’t, at least not without a very compelling reason. What was written then says enough for my purposes.

The bottom line according to Orac

Here’s what I don’t understand. A four-fold increase in mortality in planned home births attended by midwives, if accurate, is plenty bad enough. It’s more than enough to have grave concerns about the safety of even low risk births in the US. I say “if accurate,” because comparisons between two such different sources are always fraught with issues because we don’t know how comparable the groups are. However, a four-fold or five-fold increase in risk is enough that it starts to raise red flags, even accounting for the problems in comparing two different data sets.

So why does Dr. Amy have to make a questionable comparison—and, contrary to her defense of it, it is dubious—to get the risk up only to a 5.5-fold increase? I don’t know. Compare low risk to low risk or all births to all births, but don’t compare low risk to all births. I could understand the temptation if it meant the difference between a four-fold and a twenty-fold increase, but making a big deal out of the difference between a 4.2-fold and a 5.5-fold increase in the risk of neonatal death strikes me as pointless, given the size of the confidence intervals involved. We’re all agreeing that there appears to be a significantly elevated risk of neonatal death due to home births. We’re all agreeing that the mortality rate for breech presentation and other high risk pregnancies appears to be elevated in the MANA data to a very worrisome degree, making MANA’s lobbying for a greater scope of practice for midwives to include these sorts of high risk pregnancies a policy to be opposed until there is evidence showing that their outcomes are equivalent. If this argument isn’t about how many angels can dance on the head of a pin, it’s not too far off from that.

So why all the vitriol from Dr. Amy? (Yes, it’s mostly coming from her.) It doesn’t make sense to me, particularly her bringing gender, rather than data, into the issue with her unnecessary insinuation that some women can’t be skeptics because they’re too touchy-feely and concerned about not offending—after her demands for an apology. Being civil and being a skeptic are not mutually exclusive. In other words, you don’t have to be a jerk to be a skeptic, although clearly some skeptics are jerks at times, this box of blinky lights included, and some are jerks much of the time. Moreover, one can’t help but note that Steve Novella came to the same conclusion that Jamie did long before I looked into this matter; yet I haven’t seen him criticized the way Jamie was.

I suppose Dr. Amy won’t be happy with me for writing this. I rather expect that I’ll be accused of standing up for a friend (as if this were a bad thing), that somehow I don’t “understand” the data; that I’m too stupid to figure out how to replicate Dr. Amy’s search of the CDC Wonder Database, and the like. So be it. It’s not as though I haven’t endured far worse criticism over the years, sometimes even from people on “my” side. Who knows? She might even convince me that she’s right and I’m wrong. Data can do that.

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

413 replies on “Neonatal death rates after home births and a strange skeptic kerfuffle”

For someone who’s big into disclosing Conflicts of Interest, you wait an awful long time, about 3000 words in, to admit that you have a big beef in this fight yourself beyond “one side asked me to look into this”. Puts the whole well argued part above in a cloud that wasn’t needed.
Not arguing the rest, I’d say any evidence of a 100 % increase would be plenty to persecute every “planned home birth” for child endangerment.

Except that I don’t have a big beef in this fight. I know Jamie Bernstein. She asked me to look into it because she wondered if she was wrong. We’re not close friends, but we have met before a few times and we do know each other. We correspond sometimes about various skeptical issues. When I’m in Chicago, I like to hang out with the Chicago Skeptics if I have a chance, and she’s usually there when that happens. That’s about it.

As for that stuff with SBM from four years ago, it’s ancient history. Everyone involved has moved on, and I hadn’t really even given a thought to it until I became aware of this kerfuffle. Indeed, I never would have even mentioned it if Dr. Amy hadn’t written that ridiculous post about some women “suppressing” criticism because they don’t want anyone offended, and the reason it’s so far in is because, well, it’s not really that important to the overall issues I was discussing. Rather, it was simply a point worth knowing if someone has accused someone else of suppressing debate through overly vigorous moderation of comments.

If it makes you happy, I’ll add a mention that Jamie’s a friend of mine early on. You’re actually probably right. I probably should have mentioned it right off the bat, but I don’t think I needed to mention the SBM thing right off the bat because, well, it’s such a minor part of the post as far as I’m concerned.

Orac…The reason people in the SOB camp are getting pissy is because Jamie was sloppy and also misrepresented 3 different people’s positions. Dr Amy, Dr Orsosz and Esther Inglis-Arkell, the author of the i09 paper. She also hid behind moderation as GP quit allowing many comments pointing out her errors through. None of the ones I saw were abusive or violated the TOS. And obviously GP loves this click bait as they’ve posted shitty little responses to continue fueling the fire as well.
Not gonna lie, not impressed with them. I also agree that Dr Amy hurt her credibility by doing the math the way she did, but supporters of homebirth wouldn’t find her credible if she said water was wet, either. Either way, the conclusion is the same. Does that excuse it, nope. But there’s serious issues with homebirth in the US that deserve addressing. One unnecessarily dead baby is too many.

Further I find it very fascinating she asked her to mighty mouse for you and you agreed. Hmm. I have a huge nerdcrush on you and may have done the same, but I wouldn’t expect you to actually do it.

For whatever it’s worth, my essay was directed NOT at Bernstein, but at the absurd assertions of certain home birth advocates, such as, “The MANA paper proves home birth is safe,” and “The MANA paper proves home birth after Caesarian is safe.” (Yes, I’ve seen the first repeated over and over again, including in the mainstream press, and the second repeated several times.)

Going to do something actually useful now, y’all have fun.

Oh my comment is so full of errors…’I find it very fascinating she would ask you to’ is what it should say.

One thing that’s clear is that the figures of 2.06 per 1000 and 1.61 per 1000 were not in the MANA paper, at least not in that form. They were in that form in the Consumer Considerations page that I cited above. [Emphasis mine.]

FYI the link to the PDF in the bolded words (just below the text you cite from Dr Tuteur’s post, itself below the graph) is borked.

Dr. Amy is well known not only for vicious personal attacks on everyone who disagrees with her, but for making putative statements of fact that are unsupported or outright false. She probably objected to a moderation policy that did not allow her to delete comments that pointed out her numerous errors.

I think it’s worth asking why studies from European countries in which home birth for low-risk women is much more common do not show a similar increase in neonatal or early mortality. Is this a question of correlation in America not being causation, or are the Dutch, etc. doing things better than we are, in which case we should adopt their practices?

You’re certainly right that home birth seems unwise for high-risk women. However, women with breech or twin babies or prior C-sections who choose that option relatively often do so because they are afraid of being subjected in hospitals to coerced and outright forced Cesarean sections. What someone like Mu who would throw all home-birthing women in prison misses is that women, as well as babies, have legitimate interests. While hospitals might be slightly safer for babies in the short term (ignoring the later allergies, etc. associated with unnecessary C-sections), they are a lot more dangerous for women. At some hospitals more than a third of all women giving birth are subjected to major abdominal surgery, with significant physical and financial consequences, and a third of those will have some level of complications. For the entirely child-centered, growing up poorer because a hospital bankrupted your parents also has potential health implications in a country like ours. These unwise home births would be discouraged if hospitals would cease decreeing that VBACs or vaginal breech births are not “allowed” and threatening to get court orders to strap women down for unwanted surgeries.

I do think Dr. Amy is quick to attack anyone who criticizes her at all, but that is part of her style. I didn’t read too much about the argument, but if I was on the receiving end of Dr. Amy’s wrath over something so little I probably would have let it go.

The reason people in the SOB camp are getting pissy is because Jamie was sloppy and also misrepresented 3 different people’s positions. Dr Amy, Dr Orsosz and Esther Inglis-Arkell, the author of the i09 paper.

The only “sloppiness” I saw from Jamie was in her not being able to reconstruct how the mortality figures of 2.06 and 1.61 per 1000 were derived. I admit in my post that I had trouble initially reconstructing them myself. So I’m not sure how “sloppy” that was.

She also hid behind moderation as GP quit allowing many comments pointing out her errors through.

Citation needed. Specifics matter.

I was on the receiving end of Dr. Amy’s wrath over something so little I probably would have let it go.

As I almost certainly will do if she attacks me for this post; that is, unless she can demonstrate concretely that I’m definitely wrong about something. And unless, of course, I’m in a cranky mood when I see it. 🙂

Part of the problem is that two different questions are being asked. The first is, “what is the added risk of homebirth per se?” Answering this question requires holding the risk of the pregnancy constant and just analyzing the effect of place of birth. The second question is, “what is the risk of homebirth as practiced?” This means determining the difference between what the risk of neonatal death at homebirth SHOULD be and the risk of neonatal death AS IT IS. If homebirth is safe, the risk of death should be similar to the risk of death of low-risk women in hospital birth. That’s because safe homebirth requires risking out women with complications. The fact that high-risk women are still in the homebirth sample is part of the reason homebirth in the US is particularly dangerous. Taking them out of the sample, therefore, could be seen as artificially reducing the real risk of homebirth.

Sorry, but I don’t buy it. Fair comparisons involve comparing groups as close to each other as possible. If you leave out VBAC, breech, gestational diabetes, etc. in one, you have to compare it to a group in which those are excluded as well. That’s how we do it in the cancer world; I don’t see any compelling reason it should be different in obstetrics.

“The only “sloppiness” I saw from Jamie was in her not being able to reconstruct how the mortality figures of 2.06 and 1.61 per 1000 were derived. I admit in my post that I had trouble initially reconstructing them myself.”

MANA intentionally made these numbers hard to find. They set a trap for journalists and Jamie fell right in. Somehow this is seen as a blemish on Dr. Amy’s credibility. Rather it should highlight to everyone how MANA tried to mislead anyone looking into these stats.

I have to say that staking your flag on comment moderation policies as the dividing line between being and not being a skeptic is pretty shaky. I would think that there were far more important dividing lines.

Especially since the “censoring debate” bit is obviously false. It’s not like Dr Tuteur was prevented from airing her opinions on her own blog, which is, at minimum, what I would expect if she was actually being “censored”. Indeed, it’s not like everything she posted at GroundedParent was summarily removed by moderators, for that matter, including her presumably original comment which described Jamie’s analysis as a hatchet job.

I saw this back when it first exploded, too, and wondered what the stink was about. After all, Jamie came to the same conclusions as Dr. Tuteur: home births have an apparent increase in risk over hospital births, but more study is needed because of the severe limitations of the study. Dr. Tuteur did make conclusions based on an inappropriate comparison of groups. Her response to the criticism was confusing for its level of outrage and personal attacks.

I followed this a little bit, but had a different interpretation. I had the feeling Jamie was being a bit disingenuous in her criticism. For example:

“First of all, can I first point out that it’s a 4x increase, not 5.5x (1.6/0.4 = 4). Even comparing the homebirth cohort that includes high-risk births (2.1 in 1000) to the low-risk only CDC cohort (which is not a fair comparison for obvious reasons) would only result in a 5.25x increase in mortality. I seriously have no idea how Dr. Tuteur came up with 5.5x or 450% increase in mortality from the numbers that she cited.
Ok ok ok, but even assuming that Dr. Tuteur screwed up some of the basic math here […]”

To me, this is unfair. She uses 0.4 as the low-risk, while Amy used 0.38, and then claims that 2.1/0.4 gives 5.25, while Amy’s calculation seemed to be 2.06/0.38 = 5.42. Yes, it’s not quite 5.5, but close enough that most people would recognize that Amy was rounding up (that question of whether that was a fair comparison, however, is a valid).

Then she says thing like:“it’s not clear that we can get enough accuracy to the 1.6 per 1000 number to even determine that it’s truly “bigger” than the 0.4 in 1000 number from the CDC.”, “It is just not clear to me that these numbers are coming from sources that are similar enough that they can be compared to determine relative risk.”, “due to the small overall population and the rarity of these conditions, there were not enough births presenting these conditions in the sample to say for sure.”, “A future study using a bigger sample and matched comparison group will have to be done to really understand the relative risk between home and hospital settings in high-risk births, but until a better study is done, it’s best to go with the best evidence we have now (however flawed) and assume that having a high-risk birth at home is a bad idea.”

Jamie directly attacks Amy’s credibility. She does admit she does not know the literature on this topic (neither do I, for that matter), but she makes claims about the validity of the comparison as if she had the knowledge to do so.

Jamie concludes by downplaying the increase in risk seen from Amy’s analysis of the MANA study (and contradicting her ”birth at home is a bad idea”): “For low-risk births the neonatal mortality rate of having a homebirth is either negligible or slightly higher than that of a hospital birth” and by attacking Amy’s credibility once again: “The […] review by Dr. Amy Tuteur was […] just a sloppy and unscientific attempt at calculating relative risk by using two completely non-comparable data sources in order to scare readers away from homebirths.”

Then, in response to the analysis by Orosz, Jamie make the following claims: “but I’m not even sure why we are at the point of comparing them when I’m not even yet convinced that the cohorts are similar enough to be compared.”

If fact, it should be obvious that both her articles are based on this kind of arguments. Jamie is clearly arguing from ignorance. Just because she does not know if the values are comparable, it does not mean they are not, and that no one could possibly know. She clearly does not know, yet makes apparently absolutely no attempt to find out form an independent expert. I don’t want to sound as if the question of the comparability of the groups is not important and worth debating, but when I read Orosz’s analysis, it seem to my non-expert eyes that she made every attempt to favor homebirth in her choice of groups, and still showed significant increases in risk for home birth. In fact, Jamie seems to stubbornly persist in her ignorance in spite of multiple calls from Amy and other to ask for expert and independent opinion on this topic.

Jamie then continues with: “I’m going to give my opinion here if only so everyone will stop making assumptions […] it seems as though there is either no increased risk or a very small increased risk to having a homebirth in a low-risk birth situation” and “Again, this is my personal opinion and based partially in data, partially on guessing and assumptions regarding data I don’t have or doesn’t exist, and partially based on my personal valuation.”, and concludes with “However, there is no reason to mislead on the real risks. If you are against homebirths and you think that any possibility of a risk is not worth taking, then argue that without resorting to inflating the numbers.”

To me, Jamie came across as biased and unable to challenge her assumptions. Jamie acknowledges that “[MANA] did mention that there were factors that could increase risk, but in my opinion did not give enough of a warning about the possible dangers of having a high-risk homebirth.”, but does not seem to understand that this is done on purpose. She asks not to “[resort] to inflating the numbers” (which is a strawman), but fails to realize that what Amy is trying to do is prevent MANA from deflating the number. MANA don’t appear to want women to know about the risks of homebirth. Again, this is not my field of research, but it is particularly telling to me that MANA chose to compare their data to nothing else. It seems logical to me that most researchers would have found the best possible comparison group, and then discussed the possible biases associated with this chose. Is this really unreasonable?

Again, maybe Amy’s comparison of low risk birth in hospital to high risk at home is debatable, but Jamie’s articles went beyond that. To me, in that process, she lost a great deal fo credibility for anything else of value should could have said.

In case anyone read this far, I apologize for the long comment.

Edouard Brière-Allard

I find it amazing that she asks if women can be sceptics.
Seriously, isn’t that already a given? What makes her assume otherwise? Also her statements about censorship and her past history.

@Edouard

When I read it, the impression I got was that Jamie’s primary criticism is that you can’t make the conclusions that Dr. Tuteur when there are so many unknown variables that could make the comparison at best misleading.

Keep in mind, she agreed with Dr. Tuteur that homebirths did appear to have an increased risk and that the MANA study probably could not be generalized to the greater public.

As a follow up to my comment in #7, it turns out the link to the Consumer Considerations fact sheet is given correctly earlier in the OP.

Feel free to disregard #7!

And I used to agree with you, but have since changed my mind. (Just FYI, I run experiments in the social sciences, so I am not a total blowhard here.) The compelling difference between a cancer study and this one, is that in a cancer trial, the personnel (or at least their training) involved with control and treatment are the same. The accidental inclusion of more high-risk people in one group or the other is based on chance, and the only thing that varies is the treatment itself. In homebirth, the treatment of “homebirth” is a compounded: you are varying the place of birth, but also the training of the personnel in the treatment group. More importantly, the existence of high-risk people to the treatment group is not random, but directly related to the (lack of) training of the personnel in the treatment group: it is therefore PART OF the homebirth treatment. You can separate out the two parts of the treatment by looking at low-risk hospital vs. low-risk homebirth (place of birth treatment), and low-risk hospital vs. full-sample homebirth (combined place of birth and personnel treatment). You could probably even subtract one from the other to get the personnel treatment. But it is not inappropriate to look at the risk of “homebirth” as the combined risk of both place and personnel.

EBA (#17) did a much better job making the points I was trying to. Thanks so much!
Orac how do you want me to prove my claim of censorship? There are screen caps on the Facebook group for Dr. Amy, would you like me to email them to you?

Jane (#8) the difference is EU and Australia only have one type of midwife and they are university trained and work within the medical system. In the US we have CNMs and CMs, which are university trained (and attend about 20% ) of out of hospital birth, and CPMs and other lay midwives who attend the rest. The CPM credential only requires a high school diploma, 40 attended births (and you don’t have to be the primary midwife for all of them) and passing a multiple choice test to be certified. Further this certification can mean little or nothing as there’s varying though generally little oversight, no requirements for risking out or transferring patients and little accountability when they do fuck up. Most don’t carry malpractice insurance. They don’t have any hospital privileges and often don’t work with physician or CNM oversight.
Many homebirth advocates claim homebirth midwives only take low risk patients and risk out patients once they stop being low risk. This is pproveably false simply by a quick look at MDC, midwifery today or Jan Tritten’s Facebook pages or the homebirth board on babycenter. Women with GBS, for example, are often advised to shove a clove of garlic into their vagina to ‘prevent’ GBS exposure to the newborn.

The reason our data are so poor is because we have a second subpar class of midwives who attend homebirth.

I would be careful about prosecuting mothers for birth choices. Criminal law is a very heavy handed weapon, and should be used carefully for personal medical choices. As Orac points out, it’s not clear the increase in risk here for low birth – while a powerful argument against choosing that choice and powerful justification for carefully regulating it – justifies classifying it as the negligence or recklessness necessary for a criminal trial.

The gender comment above is extremely troubling. And thanks for walking through this, Orac.

Well, whenever Dr. Amy is involved there will likely be vitriol! I think a lot of it this time was that Jaime’s post was very sloppy and seemed to be implying Dr. Amy quoted something which didn’t exist when really Jaime just hadn’t looked very hard for it. There were also the politely worded corrections that were deleted and the refusal to fix any mistakes apart from a simple and obvious math error.

The statistics professor eliminated the code for congenital anomalies to get her higher number, but Dr. Amy did not. The reason Dr. Amy’s numbers were so low were because she looked at only white women since there were so few black women in the MANA statistics and she chose certified nurse midwives on the basis that they would have a lower/more comparable risk profile since there were few risk factors in the MANA group. The numbers including OBs would include type I diabetes, morbidly obese mothers, a higher percentage of breech presentation, and many other high risk mothers who would not have had homebirths. She posted a video showing how to get her numbers (http://www.skepticalob.com/2014/02/calculating-neonatal-mortality-using-the-cdc-wonder-database.html), though she must have done some math beyond that since the CDC wonder database won’t allow the date range she be used to be looked at all in one piece.

Dr. Amy’s numbers are not quite the right comparison group either since breech births and would almost certainly be risked out of CNM care and some other conditions that MANA midwives may not even test for. I understand why she did it though – she was making a point that MANA midwives keep saying breech is just a variation of normal and perfectly safe to deliver at home and gestational diabetes is no big deal and no real reason to test for it and inserting garlic in the vagina is an appropriate way to deal with the risk if GBS, so she’s going to take them at their word and consider these all low risk and so compare them against hospital low risk. Which, it is a good point, and she said clearly what she was doing, but she should have made her point and talked about what the actual risk for truly low risk women might be and how each risk factor effects things.

The absolute risk of homebirth is still low, but each perinatal death is a tragedy, and much of the risk could be ameliorated by proper training and licensing of midwives which would allow them to be better integrated into the overall system. Also there is a big factor of honesty, which seems to be Dr. Amy’s main point – how can MANA announce these numbers, which they have sat on for years, and claim they show homebirth is as safe as hospital birth? Also, then absolute risk for some situations such as breech birth is not at low, and MANA has known this for years, but still harped on about “variation of normal” and encouraged them to happen at home, How is that informed consent?

There are well respected “elder” midwives who do not believe in carrying medication to slow/stop hemorrhage – just stick some herbs or a bit of placenta under mom’s tongue, and it will do just as well! There are those who discourage ultrasounds (might cause cancer… or autism!) and believe that as long as the umbilical cord is not cut, there is no reason to worry and rush to resuscitate a baby who hasn’t taken a breath yet because they will still be getting oxygen through it. How many babies died or were brain damaged (another study showed homebirth babies were something like 16 times as likely to end up in the NICU getting cooling therapy to try to preserve brain function) because the midwife didn’t realize the placenta was already detaching and not supplying oxygen? Absolute risk being low or not, there is just no excuse for that sort of incompetence.

I know Dr. Amy’s stuff was a little confusing since she posted about in about a zillion posts in a short period of time, but if Jaime was going to take issue with her work, she really should have taken time to click on all of them and at least skim. Jaime’s post was quite lazy and a bit insulting, and Dr. Amy is super touchy and likely to go off on people, so there you have it, drama.

Jane: I noticed that no one has responded to your question about studies in Europe concerning midwives. The population of midwives in Europe and the United States are not comfortable. The closest comparison to midwifes in Europe are probably certified nurse midwifes in the United States. However, homebirth thing is mostly the territory of certified professional midwives (whose minimum training requirement is a high school degree) and direct entry midwives who have no formal training whatsoever.

@Jane,

If really looked at the perinatal mortality rates of homebirths in Europe, especially UK and the Netherlands you’d need to reconsider your statement that they don’t show an increased risk.

You also need to consider the fact that the United States does not have the strict licensing requirements or strict definitions of risk that European countries do. IE, in some US states it’s legal for someone with just a high school education and some online courses to treat a VBAC twins pregnancy.

You state that 1/3 of women in some hospitals are subjected to a C-section. You should be aware that this includes planned, high risk, and repeat C-sections. The rate for an unplanned section is more like 1/5 in the US.

Now, I fiddled around with the CDC Wonder Database a while trying to see if I could replicate Dr. Amy’s number. I couldn’t.

What search terms and limitations were you using or do you think should be used? I like playing with CDCWonder database and could try to reconcile the numbers if you’re interested.

Orac: When blogging on something another skeptic has written, if there’s any confusion whatsoever about what you’re reading, do you contact them and try and clarify this before you write your post? After going and reading all the posts around this issue it’s certainly appears that Ms. Bernstein did not do this initially. And prior to her response Dr. Teuter, does not appear to have tried to make contact either. However, after having your post criticized as inaccurate and manipulated, I can see how one might respond less than “politely”.

Did you read the comments? Did you read the many people who listed multiple errors made by Jamie?

Not fair to compare high-risk homebirth to low-risk hospital birth? Not fair? It’s more than fair. Homebirth midwives claim that they only take low-risk women. They claim that high-risk is just “a variation of normal”. That’s their selling point. So, not high-risk enough to take them and their money but too high-risk to be included in the stats? Having one’s cake and eating it, too?

To me, this alone is the hardest of all arguments against homebirth midwives. How is pointing out their imcompetence and lies unfair?

I cannot believe Jamie Bernstein didn’t know this. Everyone who took the time to read more than one of Dr Amy’s posts knows it’s her main beef with homebirth. For this, and the reasons others have posted, I call her work sloppy.

I’ve written it many times over Dr Amy’s blog: you can’t have it both ways. Either midwives are so incompetent that they cannot recognize high-risk when they see it, so they are guilty, or they are knowingly taking high-risk women (deceiving most of them that they are not high-risk but just experiencing “a variation of normal”) and they are guilty.

Either way, I cannot see why we shouldn’t accept midwives at their word and their very own PR: each woman they take is low-risk, so she should be included in the stats.

Cannot overstate this, but it isn’t just an issue of absolute risk of this or that. Its an issue of preventable death. A baby dying is an agonizing thing to go through, but what is worse is when you know it could have easily been prevented. Midwives lie about their numbers. They will never say “its slightly more risky than hospital birth”. They tell you its actually safer than giving birth in the hospital (or exactly as safe). Then there is the shameful issue of MANA making absolutely no recommendations based on their ‘study’ (a non random survey with a 30% reporting rate) even though it showed that the rates of death for breech/twins/vbac were totally unacceptable by anyones standard. They just don’t care. This survey was the best possible scenario and it STILL shows an increase in death. That should be deeply concerning to anyone who is concerned about getting to the truth of the matter here. The real numbers are much worse, I’m sure.

As someone else linked, Amy Tuteur also made a video on her site to show exactly how she got the numbers.

I know, I know. I’m at work right now and haven’t had a chance to look at it. It’s really a fairly minor point, given that I came up with a number pretty close to hers after I fiddled around some more and excluded congenital malformations, as I discussed in my post.

I’ll leave this comment here since it was ignored by Jamie and moderators over at GP (as were pretty much all of the comments that pointed out issues and/or Jamie’s obvious errors).

Alli (comment on GP) said “I’ve been trying to think of how to explain why I didn’t and still don’t find Dr. Tuteur’s comparison misleading, and I think I finally put my finger on it–it’s really a comparison of home versus hospital *midwifery* care.”

Yes yes YES. Thank you for spelling it out better than I did.

Women choosing to have a high risk home birth is one thing…. but women unknowingly having high risk home births is another… women who *think* they are low risk. As I have said before, I can’t help but wonder if the pre-e and GDM moms in the MANA study knew ahead of time of their issues… specifically the pre-e and GDM moms who ended up losing their babies due to their high risk issues. Did they know? Were they screened? Did their midwives just miss or ignore or dismiss the red flags?

I watched on youtube a breech home birth… an ACCIDENTAL breech home birth. I was FLOORED! The mother had no clue and when the midwife found out the baby was breech, there was no discussion of risks, there was no talk of transfer…. nothing. Just the discovery of breech baby and then kept right at it. So much for informed consent! The shocking part is that it is really not shocking anymore. B/c THAT is home birth in our country. It is a lack of informed consent, lack of screening, lack of monitoring, lack of acknowledging the real risks in high risk situations.

Until there are changes made to home birth in our country to ensure that it is for TRULY low risk women only, then a woman has no idea what kind of midwife she is getting, no idea if she’ll be getting informed consent, no idea if she will be getting the truth about the importance of screening measures, no idea if she’ll be properly monitored, etc etc etc.

I wish I knew how many women have home births each year who think they are low risk but are actually high risk.

**

That was my GP comment. And I just want to add…. I just received an email this morning from a friend. Her friend was planning a home birth with midwives. This woman suffered a catastrophic outcome b/c her midwives lied about her screening results!! This woman DID take her screening measures to ensure she was low risk… and she WAS high risk. And had NO CLUE b/c her midwives didn’t tell her the test results. This just happened in the last week.

This is home birth in America! A woman choosing home birth, thinking she is a good, low risk candidate, may have no idea her pregnancy is high risk by the time the birth rolls around. THIS is why comparing hospital midwife-attended births to all-risk midwife-attended home births is reasonable.

And just a side note… not all of the births in the hospital CNM group are low risk. Some hospital CNMs see certain types of high risk patients.

We can’t easily directly compare home birth in the US to hospital birth, but we can compare the perinatal mortality rate for the US to home birth in Canada. Canadian perinatal mortality for home birth was 0.35/1000 in this study from 2009.

http://www.ncbi.nlm.nih.gov/pubmed/19720688

Canadian midwives with hospital privileges, significant education and appropriate risking out have excellent outcomes. Why isn’t anyone asking why Canadian home birth is coming in with much better safety rates even compared to the low risk MANA cohort? I think it is fairly clear that American home birth is vastly less safe than home birth practiced in other countries.

“I know, I know. I’m at work right now and haven’t had a chance to look at it. It’s really a fairly minor point, given that I came up with a number pretty close to hers after I fiddled around some more and excluded congenital malformations, as I discussed in my post.”

It’s not a “minor point” though. Don’t you see? You are calling out someone else’s credibility by leading your readers to think that Amy Tuteur may have lied or manipulated or whatever to get those numbers b/c you (and Jamie) can’t seem to figure out how Amy T got those numbers. Why didn’t you just ask her?

Jamie’s two posts on GP were very lazy and full of errors. THAT is what people – myself included – had issues with. She was making strawman arguments, twisting things around, etc… it seemed like she was trying very hard – pulling whatever stunts she needed to – to make Amy Tuteur and Brooke Orosz look sloppy/wrong. It was not skepticism.

The problem with all of this Grounded Parents debacle, is there just seemed to be a personal vendetta about Dr. Amy and in many ways further gives ammunition against what Dr. Amy discusses. Yes she can be over the top opinionated (but believe it or not I’ve been following her for 5 years (same amount of time I have been reading your blog) and have seen a softer side from her too), but you know what, when other non-CPM midwife studies come out it seems those rates are often similar to what Dr. Amy has posted. Perhaps the math is slightly off, biostatistics is not an easy subject and I’m sure even experts get things wrong from time to time.

You know what though, I have seen Dr. Amy make corrections, I have seen her take certain tone-related comments seriously and I have seen her drop certain contentious subjects all together (she had a post about parenting outside the standard nuclear family 5 years ago, one I didn’t agree with and hasn’t brought it up again). Yes, she’s contentious, but she’s consistent and pretty accurate overall.

I have also seen her time and time again stand up for the woo that has infiltrated Prenatal, birth and infant care, much of which is infuriating, sanctimonious, full of shaming, and can be extremely dangerous to the women and children. My brother and his wife had prenatal classes at one of the top science-based hospitals in Canada, and some of what he saw made his jaw drop at how woo-ey it was.

Grounded parents had some much material to work from when doing posts about homebirth, pregnancy and infant care, but they chose to publish an article bashing another skeptic. At the end when Elyse said that she’s no longer anti-homebirth due to some of its activist (Dr. Amy), it was beyond infuriating to a mom who has seen more and more woo come into parenting practices since I had my own child 8 years ago. To me, Jamie and Elyse could have used Dr. Amy’s comment section to call her out instead of a blog post that in the end had homebirth midwives promoting it.

I’m actually quite sick of the stupid dispute. Again, there is so much woo in the Natural Childbirth Community that can be addressed. Do I think it’s okay for skeptics to disagree? Sure, but I suspect there is a lot more to this than just numbers. Needless to say out of the first few posts from Grounded Parents on the subject of birth I have been disappointed.

To Dorit’s comment in #25: I don’t think anybody, and certainly not Dr. Amy, has advocated for removing or prosecuting a mother’s choice to have a home birth. The issue is whether a second, uneducated class of home birth midwives (not CNMs) should be allowed to charge quite a bit of money to attend homebirths in a professional capacity. All over the US, CPM and lay midwives avoid prosecution or any sort of penalty for presiding over the deaths of babies and mothers who would have lived if not for their incompetence. They usually have no insurance. If they want to charge money to provide midwifery services, then they should be held accountable for their outcomes the way any actual medical professional would. Right now, that is not the case.

It’s not a “minor point” though. Don’t you see? You are calling out someone else’s credibility by leading your readers to think that Amy Tuteur may have lied or manipulated or whatever to get those numbers b/c you (and Jamie) can’t seem to figure out how Amy T got those numbers. Why didn’t you just ask her?

What nonsense. (See, I can be like Dr. Amy when I want to be.)

I was simply pointing out that a full list of all the parameters is necessary for anyone to replicate such a search, and at the time I didn’t know where to find that list. When I came close to her number on my own, I was satisfied that nothing obviously weird was going on and explicitly said so in my post. Did you bother to read that part?

So I missed that Dr. Amy had made that video. It was easy to do. Mea culpa. You’re making the proverbial mountain out of a molehill.

ANH – Sorry, there’s no justification for limiting the discussion of C-sections to “unplanned” C-sections. Some of the women who avoid OBGYNs do so because they are justifiably afraid of being told that they must have a C-section; those would be considered “planned”. Others are justifiably afraid that they will be coerced to submit to electronic fetal monitoring, which has no apparent benefit but greatly increases the C-section rate. There are some hospitals where the C-section rate is far higher than one-third. That’s not “necessary” by any standard.

The study cited by PrecipMom shows that home birth need not be dramatically more dangerous for low-risk babies than hospital birth – and may even be less dangerous when all the downstream consequences of excess interventions are considered. Those American midwives who are doing worse need to do better.

As to the counting or noncounting of deaths due to congenital anomalies: Such deaths may not be preventable no matter where delivery is. More, some parents may in fact not feel that perinatal death of a severely malformed fetus is a worse tragedy than a long NICU stay, torturous for the baby and psychologically and financially devastating for the family, followed by death or institutionalization. The goal of reducing the death rate to zero is neither possible nor necessarily beneficent.

@Doula Dani

leading your readers to think that Amy Tuteur may have lied or manipulated or whatever to get those numbers

I don’t see Orac implying any such thing. They based their analysis on Dr. Tuteur’s original article about the MANA study. That article did not state what criteria she used, nor did it include a link to the video she subsequently made showing what she did. It’s great that she eventually explained how she got the numbers she got, but she should have either explained in the original post or added a link to the video. She didn’t. Instead, she included an abbreviated description that was insufficient to duplicate her results.

As a layperson looking at the vairous posts, if I wanted to double check what people were saying and see how they arrived at the calculations and comparisons they did, that’s a bit thing to leave out.

Dorit #25:

I would be careful about prosecuting mothers for birth choices. Criminal law is a very heavy handed weapon, and should be used carefully for personal medical choices.

I completely agree, and from what I’ve read at Dr Tuteur’s blog, so ddoes she. But of course it’s different from holding homebirth midwives accountable for malpractice.

@Orac

One thing I noted when this all blew up was that Jamie acknowledged that while she didn’t know how Dr. Tuteur came up with her numbers, she did take them at face value as validly derived.

And also, there’s a huge intersection between the home birth midwifery movement and the anti-vaxers. It’s often the midwife who first convinces a mother not to vaccinate herself during pregnancy for flu or pertussis, and then not to give the baby Hep B or vitamin K (which I realize isn’t a vaccine, but it is an injection) at birth. The real reason is that a lay midwife isn’t allowed to give those injections in most states, so rather than send her client to a doctor, she convinces her that it’s not necessary if you just eat enough kale. This is the same reason lay midwives tell clients to stick raw garlic in their vaginas instead of obtaining antibiotics for Group B Strep.

I would like to add comments regarding other topics addressed by Orac.

First, the insults flying in this debate. Orac said “So why all the vitriol from Dr. Amy? (Yes, it’s mostly coming from her.)”. Frankly, I think you are wrong. Jamie made it clear in her articles that she though Amy was either lying or incompetent (see previous quote or full article), and supplemented that with comments like this one (see comments, first article by Jamie): “I assumed you wouldn’t purposefully mislead. I apologize for making this clearly incorrect assumption.” Although Amy was attacking, I feel she was only responding in kind to what Jamie was saying. Not necessarily mature, but that’s her style. I would not expect her to start being nice when people insult her knowledge or credibility.

Second, for your claim that Amy made “unnecessary insinuation that some women can’t be skeptics because they’re too touchy-feely and concerned about not offending”, I think you are misinterpreting what Amy was trying to do. Here are some other quotes from that post:

“It’s hardly news that the skeptic community is dominated by men. Part of the reason is pure, old fashioned gender discrimination and harassment. Apparently some male skeptics feel threatened by women and want to frighten and harm them.”

“Women are not less logical than men. Rationalism is not the province of men alone. Women are perfectly capable of succeeding in the hard sciences and do so every day.”

“I’m beginning to wonder if there is a germ of truth to the claim that there are not more women in skepticism, because women are so anxious to avoid confrontation.”

“So can women be skeptics? Of course they can. They have the same ability to succeed in science as men, the same ability for rational thought as men, and the same inherent ability to give as good as they get in free-wheeling debate.”

I don’t see much wrong with this, or the rest of Amy’s post. It’s true that Amy did go on to insinuate that Skepchick in particular could be was one of those that was “so anxious to avoid confrontation”. I don’t even think Amy herself believes this, and I have not seen Jamie make tone arguments. I saw it as a way for Amy to try to get Jamie to respond intelligently to her criticism. It was my impression that Grounded Parents and Jamie were perfectly happy to let the matter drop and keep their arguments from ignorance intact. Amy, on the other hand, has a dog in this fight. She wants the risks of homebirth with lay midwives to be recognized so that women can make informed choices. It appears that she chose to attack Jamie’s credibility as a skeptic to get her to look at the issue and correct her mistakes (the issue of whether or not this tactic was necessary or useful is debatable).

Thirdy, you mention people of treating Jamie differently than Steven Novella because she is a woman. You write: “Moreover, one can’t help but note that Steven Novella came to the same conclusion that Jamie did long before I looked into this matter; yet I haven’t seen him criticized the way Jamie was.”

Here are Steven’s conclusion:
“The MANA data is legitimately concerning. Trying to whitewash such results paints MANA in a very bad light. If they wish to promote midwifery they need to be honest about and own those results, and explain why they believe homebirths are still a reasonable option.”
and Jamie’s conclusion:
“For low-risk births the neonatal mortality rate of having a homebirth is either negligible or slightly higher than that of a hospital birth, though because we’re talking relative risk it’s still quite low. […] [MANA] did mention that there were factors that could increase risk, but in my opinion did not give enough of a warning about the possible dangers of having a high-risk homebirth.”

Steven and Jamie conclusion are different enough, in my opinion, to justify the different response from Amy. Steven said this data is troubling and demands accountability, while Jamie does not recognize the dishonesty of MANA and still thinks homebirth from lay midwives could be safe. That being said, I would not be surprised if some of the difference in treatment from the community at large (i.e. not Amy) could be attributed to sexism.

Again, sorry for the long post, but I felt the quotes were necessary.

Edouard Brière-Allard

PrecipMom:

As this OP and comment thread is about a blog scuffle between authors who self-identify as skeptics, specifically regarding analysis of the MANA study, I can’t see that the Canadian/BC study is pertinent. (*)

That said, it certainly would be worth bringing up with MANA.

(*) To be clear, the study you linked to is specific to British Columbia and probably cannot be compared to other provinces; I believe someone upthread (or maybe it was someone on the GP thread?) may have already mentioned that provincial standards for midwifery vary.

I have been a regular follower of Dr. Amy’s blog for a while, so I am familar with her arguments on the grounds of infant mortality. However, I’ve started to notice that she devotes very little time to discussing maternal mortality and maternal health and satisfaction outcomes. From the limited data I’ve encountered (from sources that I have no doubt may be biased) homebirth (or at the broadest, midwife-assisted birth) results in lower maternal mortality and greatest maternal satisfaction after the experience.

I can appreciate that Dr. Amy goes to great pains to emphasize that she supports women’s rights and reproductive rights. However, it seems like she sometimes gets very close to the “do what’s best for your unborn baby” line of argument that is so prevalent among repro-rights opponents.

The largest question I always toss about in my head is whether or not it is acceptable in some form for an expecting woman to prioritize her own experience as paramount during birth. Is the rather obvious increase in infant mortality an acceptable tradeoff to create an experience that will be more satisfying and enjoyable to the mother?

I’ll also note that Jamie also pointed out some of the flaws and weaknesses of the MANA study.

“There are some hospitals where the C-section rate is far higher than one-third.”

If anyone needs an example of the kind of clueless and biased reasoning that homebirth advocates so often indulge in, look no further than jane. Pointing to the rate of CS of this or that hospital without thinking that those can be first rate medical centers where high risk cases converge…

Todd and Orac:

Dr. Tuteur said in her post “the neonatal death rate for low risk white women at term from the years 2004-2009 is 0.38/1000”

Based on that, I would perform the following search:

White women
Singles (no twins or higher orders)
37 weeks and above
Birth weight of 2500 grams or more
Live birth through 27 days (the neonatal period)
Years 2004-2009

(a preterm and/or IUGR baby would not be low risk)

Which gives 0.38/1000 for the hospital CNM group – which is mostly low risk women.

I understand it wasn’t spelled out exactly in that particular post by Dr. Tuteur, which is why I still don’t understand why – if someone wants to write an analysis or criticism – why not be thorough and just ask the author how they got the numbers?

@Trixie 43: I was replying (belatedly, and without making that clear) to comment 1 – but now that you mention it, I may have misinterpreted the comment: It may have referred to prosecuting the midwife rather than the mother. I think your other points are well taken.

In re comment #45 by jane,
1. A woman who is afraid of C-section and tries to avoid it by seeking a non-medically trained midwife may be getting the option she desires, but may not be getting the medical care she needs. It is not valid to hide that critical difference.
2. Similarly, “excess” intervention is a medical judgement that should be made by medically trained personnel.
3. One major problem with your concluding paragraph
calling for allowing newborns with major congenital defects to die is that a non-medically trained midwife might not know what effective medical treatments are available. Given the already woo-filled nonsense suggested by non-medical midwives I have read just in the comments to this post (anti-vaccine, anti-vitamin K, anti-antibiotics, not revealing high risk test results), I would not want to allow a layperson to give life or death medical advice.
4. Furthermore, (yes, this last is a stretch) it would be fairly easy for an individual to claim that an infant’s death was due to a treatable congenital abnormality rather than malpractice.

@Doula Dani

I agree that it would have been better for Jamie to do her due diligence and ask Dr. Tuteur how she got her number from WONDER, but it is still a fair criticism to say that Dr. Tuteur should have spelled out what she did in her original post. A layperson may guess what variables constitute low-risk, but they would, at best, be guessing at what Dr. Tuteur selected and could end up including or leaving out certain groups that should have been left out or included. It’s a criticism we level at anti-vaxers regularly when they make some claim: show your work.

In re my comment #57, point 2, ideally the decision should be made by the parents, in consultation with medically trained personnel who have objectively laid out all of their options for medical intervention with clearly stated risks and benefits. I realize this is an ideal, but going 100% the opposite way into blind avoidance out of fear is just plain ignorant and dangerous.

@ Todd,
You are right that Dr. Amy should have put in an explanation or a link to other posts showing how she got the numbers, at least retroactively, once she realized people were confused. But leaving it out was an oversight, not a deliberate attempt to hide a faulty comparison. Jamie’s accusation that Dr. Amy was being deliberately misleading is what people are upset about.

Todd,

I agree. It would have been much easier to understand and would have alleviated a lot of confusion if it were better spelled out in that particular post by Dr. Tuteur.

@yizz

Regarding the WONDER figures, Jamie did not suggest that Dr. Tuteur was being misleading. She took her at her word. The bit where she used the word “misleading” was in reference to how Dr. Tuteur added the numbers from the original study, and that’s afternoting in the original post that “The stats she mentions (2.06 per 1000 risk of death for all births and 1.61 per 1000 risk of death for low-risk births) are not mentioned anywhere in the actual study, though that doesn’t mean they are not accurate.” and that “those were numbers for what the paper deemed as the “low-risk” cohort. In your post you said the 2.1 in 1000 number was from the cohort including high-risk births.”

The “misleading” comment was perhaps ill-advised, but I didn’t read it as a serious accusation, in light of how Dr. Tuteur closed her response:

No, what’s sloppy and unscientific is your hatchet job. You are WRONG about the numbers, WRONG about the math, WRONG about the quotes, WRONG about the CDC Wonder database, WRONG about the differences between the home and hospital group and therefore, completely WRONG about your conclusion.

“…ideally the decision should be made by the parents, in consultation with medically trained personnel who have objectively laid out all of their options for medical intervention with clearly stated risks and benefits”

Ideally, parents who then ignored the advice of medically trained personnel and rejected medical intervention despite being advised of the increased risk, would be politely but firmly turned down by every midwife in their area.

EBA,

Thank you for taking the time to lay it out there so well. I hope everyone reads your comments.

Imagine for a moment that a bunch of chiropractors got together and formed a professional lobbying group to defend lax regulations on their profession. Then imagine that they had a survey (that they misleading called a study) about outcomes, a survey that was filled out after the fact on a totally voluntary basis. Only 30% filled out surveys and no explanation was given for the other 70%. Lets imagine that the survey still showed that there was an increase in danger to patients over getting a massage. Imagine the lobbying group published the numbers without any oversight or peer review from another group, and put it out with a press release that outright lies about the data.

….Then imagine that skeptics fell all over themselves bickering about if how so and so blogged about it was misleading or not instead of focusing on the fact that cherry picked data STILL shows an increase in danger, which could lead one to reasonably conclude that the real numbers are much worse.

Well, that’s the difference between skeptics and quacks. We care about how the numbers are derived and want it to be done correctly. It matters to us.

Jane,

If you want to take issue with modern obstetrics you can do it with Dr. Amy on her blog. She’s addressed these points, even if you don’t like her answers.

Your argument amounts to absolving midwives of responsibility for their professional decisions. Hospital policies explain, in part, why there is demand for high risk deliveries. It does not explain or excuse midwives’ willingness to perform them. How many of these midwives will say, “You can have a home birth, but a C-section in the hospital is safer, even if your first choice would be a hospital vaginal birth”? They don’t. Professionals have a responsibility to recognize the limits of their competence even when patients demand more.

The reasons other countries have better results have been addressed by Dr. Amy. The midwives are better trained, integrated into the system, and don’t perform high risk births.

The “misleading” comment was perhaps ill-advised, but I didn’t read it as a serious accusation, in light of how Dr. Tuteur closed her response:

No, what’s sloppy and unscientific is your hatchet job. You are WRONG about the numbers, WRONG about the math, WRONG about the quotes, WRONG about the CDC Wonder database, WRONG about the differences between the home and hospital group and therefore, completely WRONG about your conclusion.

Indeed. Dr. Amy’s response was completely overwrought and far out of proportion to any perceived “offense,” particularly the persistence of it over multiple posts. Then when she brought the whole issue in of “some” females (translation: Skepchicks) being unable to be good skeptics because they are too averse to confrontation, that topped it off.

Amy just wrote a response to this on her blog.

I figured she would. I’m only surprised it took her a whole five or six hours. If I decide to respond right away, she’ll respond again immediately. We’ve seen this pattern play out in this unfortunate kerfuffle. If I don’t respond right away, she’ll probably write a taunting post claiming I’m “afraid” of her or finding some other thing to attack over. So I’m in no hurry to respond because she can always bury me in posts; there’s nothing to be gained by getting into a pissing match. Instead, I’ll respond in my own time on my own schedule.

Thought you might need this: http://youngsgifts.com/images/at_home/emergency/704-443064.jpg

Hardly.

Jane

ANH – Sorry, there’s no justification for limiting the discussion of C-sections to “unplanned” C-sections. Some of the women who avoid OBGYNs do so because they are justifiably afraid of being told that they must have a C-section; those would be considered “planned”.

This is something I can comment. The wife of my best friend is an epidemiologist surveying the needs of C-Sections and she is responsible for a lot of epidemiological data (meta-analysis) which should affect the needs of C-Section because the data show that after a few years, pregnant woman don’t always need a C-Section after having one for the first pregnancy.

http://www.ncbi.nlm.nih.gov/pubmed/?term=St%C3%A9phanie+Roberge

Alain

But it is not inappropriate to look at the risk of “homebirth” as the combined risk of both place and personnel.

Of course, that’s not what she did, at least not as explained in her very first post. Certainly she mentioned nothing of this. Let’s go back to what she did say:

No, it isn’t “slightly” higher. It is MASSIVELY higher.

According to the CDC Wonder database, the neonatal death rate for low risk white women at term from the years 2004-2009 is 0.38/1000. As Judith Rooks, CNM MPH noted in her review of Oregon homebirths, intrapartum death among low risk babies is essentially non-existent in the hospital, so the neonatal + intrapartum death rate for the hospital is still 0.38

As the chart above demonstrates, the MANA death rate for the same years was 5.5X HIGHER. In other words, the MANA death rate was 450% higher than the hospital death rate.

On what planet is a death rate 450% higher than expected a safe outcome? Not on this planet.

MANA and homebirth midwives have been lobbying extensively for a scope of practice that includes breech, twins, VBAC, etc. Now they want to exclude those same births from their statistics. Even then, the MANA death rate is 4.2X higher than hospital birth. So even when homebirth midwives stick to low risk patients, homebirth has a death rate 320% higher than comparable risk hospital birth.

Nope. No mention of isolating place and personnel in her original post. She’s still wrong, as far as I’m concerned. In fact, now that I think about it, she’s even wronger. The Wonder database doesn’t allow one to look up the six week mortality, which is what the MANA paper reported. So Dr. Amy compared four week mortalities (which the Wonder database does let one look up) to six week mortalities in the MANA study. It probably doesn’t make a huge difference, but it’s just another way these figures are not easily comparable.

Then when she brought the whole issue in of “some” females (translation: Skepchicks) being unable to be good skeptics because they are too averse to confrontation, that topped it off.

This is particularly ironic in light of the amount of confrontation, flame wars, dealing with unsavoury behaviour, etc. that Skepchick and its affiliates have been through on matters pertaining specifically to feminism.

On the matter of comments policies, which Dr Tuteur specifically brought up, I would put forth Skeptical Science (*) as an inexact parallel: Skeptical Science has a stringent comments policy – in fact IMO it is far more stringent in several respects than Skepchick and a very active set of moderators who enforce it. (It’s also an inexact parallel because, as far as I am aware, most of the Skeptical Science writing team do not self-identify as skeptics the way that, say, Orac, the Skepchicks, or members of JREF do.)

So if Skepchick is insufficiently skeptical because of the specifics of their comments policy, what of Skeptical Science?

Skepchick comment policy.

Skeptical Science comment policy.

(*) For those unfamiliar with the site, Skeptical Science discusses climate science, and has an extensive collection of self-styled “skeptic” arguments against the science that it refutes, with reference to the existing body of evidence. Skeptical Science updates its articles and publishes new content on the basis of new research on a regular basis.

Is there any consideration for the added risk of transporting a laboring mother from wherever she is (home) to the hospital? It would seem that there’s an occasional baby born in traffic, plus inevitable traffic accident related injury and death.

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