Excess Preventable Mortality?

One of the claims the anti-homebirth people (embodied in Dr. Amy Tuteur) make is that homebirth has a high rate of excess neonatal mortality which could have been prevented. Does it? From the CDC statistics, Dr. Amy has noted that the home births attended by “other midwife” have 1.15/1000 neonatal mortality, as opposed to hospital births attended by CNMs which have 0.37/1000. You can search my blog for other related posts, because I have written about this several times, but now I want to focus on one particular aspect — that of this apparent excess mortality being preventable.

For my purposes, I pull four causes of death from the CDC stats: anencephaly, thanatophoric short stature, Edwards’ Syndrome, and Patau’s Syndrome (in the “causes of death” codes, these are Q00.0, Q77.1, Q91.3, and Q91.7, if you wish to double-check me). Although there are many causes of death due to genetic or congenital reasons, these four all carry a near-100% neonatal mortality rate — that is, almost all of the babies born with these conditions die within the first 28 days, if they survive pregnancy and birth at all. (There may be other similar conditions, but these were the first that I found that all had this high neonatal mortality rate.) In fact, in quickly reading about these conditions, I discovered that in many cases, doctors refuse anything but palliative care (nutrition, hydration, etc.) for these infants, contending that any care such as surgeries is a waste of time, because they are believed to be hopeless and/or better off dead. Some even argue for euthanasia, just in case “natural processes” don’t kill these babies quickly enough.

So, being born in a hospital does not necessarily even lengthen the lives of these babies; and since stillbirths aren’t counted in these statistics, it’s anybody’s guess as to how many babies were conceived and were not aborted. (This website says that 95% of babies known [or suspected] to have anencephaly are aborted, while 55% of babies who are not aborted are stillborn. It also calls into question some of the accepted medical “facts” about anencephaly — that these babies can’t see or hear or feel — because of the life experiences of such parents. The longest-living baby with anencephaly in the U.S. is “Baby K” who survived two and a half years; and it’s possible that the true life expectancy of such babies is much longer than most doctors allow, if better medical care were given.) Most of these conditions can be suspected or known by prenatal genetic or ultrasound testing, and abortions are not counted in perinatal statistics, since they are intentional deaths, and perinatal mortality counts only unintentional deaths. What is not clear to me is if so-called “live birth abortions” or preterm inductions of labor are counted in these statistics if the baby survives the birth process and then is allowed to die without medical care; or if all of the preterm births in the statistics are from women who naturally went into labor prematurely.

Of the term group, the total neonatal mortality rate for just these four causes of death was 0.12/1000 in the CNM+MD+DO group, vs. 0.21/1000 in the “other midwife” group. Now, when I previously blogged about the high rate of definitely unavoidable or possibly unavoidable death in the “other midwife” group (including these deaths, as well as deaths due to conditions which may or may not be lethal depending on severity), Dr. Amy insisted that the inference she drew (that of DEM-attended home births having 2-3x the rate of neonatal mortality of CNM-attended hospital birth) were valid, and “the only people that don’t understand it” are home-birth advocates. I actually understand what she is saying very well, I just happen to disagree with her shallow assessment of the data.

Looking at just these four causes of death in the 37+ week group (for all women, not just non-hispanic white women giving birth to babies weighing 2500+ grams), the neonatal mortality rate in the CNM group is 0.06/1000, whereas in the “other midwife” group it is 0.21/1000. If there can be any sort of statistical inferences drawn from this, and since these deaths are unavoidable, it seems logical to assume that either more affected babies make it to term in the home-birth group (either because of a lower rate of abortion or preterm induction, or more women who choose hospital birth naturally go into premature labor), or more babies survive labor in the home-birth group. (It only makes sense that there would be a lower rate of abortion in women planning home-births, since many women cared for by midwives decline prenatal testing that can reveal an affected baby, so they would not have an abortion since they don’t realize their baby has a lethal defect, although even some nominally pro-life women will have an abortion or a “live-birth abortion” when faced with this news.) Dr. Amy either can’t or won’t understand these life-and-death issues, although they are plain to see. We know that a certain percentage of women will have an abortion when they find out their child has some birth defects, such as chromosomal abnormalities like Down’s, Patau’s, or Edwards’ Syndromes, or congenital birth defects like anencephaly. Many women will have an abortion if they merely suspect these conditions. But women who decline prenatal testing will not suspect that they are carrying such babies, and will not seek abortions.

So I say that the evidence strongly suggests that the 0.21/1000 neonatal mortality rate in the “other midwife” group for these 4 conditions, as compared to the much lower rates in the term period of the CNM group, or the combined hospital-birth group, reflects the true incidence of mortality from these conditions, because the hospital-birth group has numbers which are artificially lowered because of abortion, or perhaps a higher rate of stillbirth.

It’s also possible that women who find out that their babies have a lethal genetic or congenital condition seek out midwifery care, or that women who are more likely to have an affected child seek midwifery care. For instance, if women are uncomfortable with prenatal screening (such as the risk of miscarriage for amniocentesis), but their doctors try to force it on them anyway (which happened to a friend of mine who ultimately chose a home birth), they may “jump ship” and just totally avoid the medicalization of both pregnancy and birth. Even though this friend gave birth to a perfectly normal child, she was nearly 40 so was at a much higher risk of having a baby affected by a genetic condition. But she didn’t want to be pressured by the doctor to take a test that she just did not want to do — she wouldn’t have had an abortion (although she is “pro-choice”), and her two other children had special needs, so she knew what she was getting into. There is also the possibility that women who find out that their babies are negatively affected are pressured by their doctors to abort (I’ve heard of women being forced to undergo psychological counseling because they refused an abortion), and they similarly “jump ship” to midwifery care, rather than to stay with the doctor who wanted them to murder their unborn child. Who can blame them? Would you really want to continue your pregnancy and give birth under the “care” of the man or woman who wanted your child dead?

But, even if there are cases not as extreme as that, if you find out during pregnancy that your baby is certain not to live, and is expected to die before labor, or almost certainly during labor, might you not seek to give birth at home without all the hospital intrusions and protocols? — at home, where you can call the shots? where you don’t have to worry about seeing dozens of other women in labor or with their perfect newborns, when yours has a lethal condition? where you don’t have to leave the hospital with empty arms, while everyone else goes home with a living baby? where you can spend as much time with your dying or dead baby as you want to, without being rushed by busy nurses who need to process your baby and paperwork?

So I say again, as I’ve said before, we need to look at the facts behind the bare numbers. The neonatal statistics don’t take into account abortions for known or suspected fetal anomaly; and I think it’s pretty obvious that home-birthing women are less likely to have an abortion than the hospital population. Babies who are known to be affected are also more likely to be born by pre-term induction (“just getting over with the inevitable”), which would cause a marked difference if you look at just term births. If 95% of the known affected babies in the hospital group are either aborted or induced pre-term, then very few make it to term, as opposed to most of the affected babies in the home-birth group. (Probably a slight exaggeration… for the point of clarity.) But this would definitely alter the statistics — and we see a difference in statistics in term births.

But these deaths are unavoidable, and the question concerns preventable neonatal mortality. There are only two things that would prevent the neonatal deaths of these babies born with lethal birth defects — their death prior to birth, either by abortion or stillbirth, or intense medical care to prevent their natural deaths from the numerous things that may be wrong with these babies (many affected babies have multiple abnormalities). Not all babies with these conditions die in the first 28 days, even without heroic measures. Some babies live much longer than expected, lasting even a few months or rarely a few years, with just a little bit of medical help (such as extra oxygen, if their lungs or breathing is affected).

But it is disingenuous to say that home-birth has a higher rate of preventable mortality when a great percentage of that excess mortality is not preventable.


19 Responses

  1. Kathy,

    You keep trying to slice and dice the data in ever more creative ways, trying to pretend that they show something different from what they clearly show. No matter how you try to manipulate, the most dangerous form of planned birth in the US is homebirth with a DEM.

    You’re in denial about the dangers of homebirth and I’m not surprised. Homebirth advocates are constantly prattling that “studies show” homebirth is as safe as hospital birth, when all the existing evidence ACTUALLY shows that homebirth increases the rate of neonatal death.

  2. Amy — tsk, tsk, tsk — you’re getting off-topic again!

    If I have made any errors in my post or in my logic, please point them out. If I am incorrect about the abortion, stillbirth, or neonatal mortality rate of these four conditions, feel free to post the evidence. If you find that I exaggerated the evidence about doctors encouraging abortions or pre-term inductions or refusal of any but palliative care for babies with these lethal birth defects, I welcome the correction. I am not unwilling to learn. You make a lot of noise arguing about the 2-3x neonatal mortality rate of home birth from the CDC stats, and I am merely pointing out that the NMR in “other midwife”-attended births for these four conditions is 3&1/2 times that of CNM-attended births. Why is that?

    Since it is not because of the care they receive after birth, it seems obvious that for whatever reasons, more babies in these four groups are born at home than are born in the hospital. I can come up with several reasons that may affect it: 1) fewer abortions; 2) fewer pre-term inductions; 3) fewer pre-term births; 4) fewer stillbirths; 5) more women choosing a home birth with a known lethal defect. Since the CDC stats do not show these things, it cannot be proved. What can be shown, however, is that these deaths are not preventable — no matter how much you try to ignore the cause of death and the near-100% neonatal mortality of these conditions. The only thing that keeps babies with these conditions from becoming neonatal mortality statistics is their in utero death, or intense medical care (or a fluke) that keeps them living longer than 28 days.

    I read of a study (haven’t blogged about it yet because I can’t find the original) that looked at how the abortion rate has affected neonatal mortality, and if you look just at the NMRs of countries like France and Ireland, it appears that Ireland is horrible compared to France. However, Ireland, being strongly Catholic with very restrictive rules on abortion, has a much higher number of babies with known congenital or genetic defects than France. They have a higher NMR than does France. But that doesn’t mean that it’s more dangerous to be born in Ireland than in France; rather, it’s more dangerous to be a fetus in France than in Ireland, because you’re more likely to be killed before birth in France than to die after birth in Ireland.

    Again exaggerating for clarity, we could reduce the neonatal mortality rate to zero by increasing the abortion rate to 100%, but that’s just playing with numbers, not improving care for the babies that make it out alive. France has decreased their neonatal mortality for babies with knowable congenital or genetic defects by increasing their abortion rate. The numbers look better because intentional deaths are not counted in statistics with unintentional deaths; but the reality is that Ireland has a standard of care similar to France — but just looking at numbers doesn’t show that, because it doesn’t take into consideration deaths due to abortion or stillbirth.

    Again, if you have anything to add to the discussion or any correction of anything I have said, feel free to respond. But if you are just going to make the same tired old arguments without any evidence that you make everywhere else, I will not allow it.

  3. “it seems obvious that for whatever reasons, more babies in these four groups are born at home than are born in the hospital.”

    Only in this particular dataset, and that could easily be random. In order to draw that conclusion, you’d need to present large surveys that showed that there are higher rates of congenital anomalies among women choosing homebirth. I’ve never seen any evidence of that.

  4. So now you are saying that this dataset is not large enough to draw statistical conclusions from it? That these 30,000+ midwife-attended home births versus 8,000,000 hospital births are not large enough? You need larger studies? Then it must also be that we would need larger studies to conclude that your statements about the home-birth neonatal mortality rates are accurate and of statistical significance. If it could “easily be random” that these particular conditions happened 3.5x more often in home-births in this dataset, then why could it not “easily be random” (and not statistically significant) that home-birth has a higher apparent NMR by these stats?

    Also, since you used to practice obstetrics, perhaps you could clarify something for me. In the case of a pre-term induction, a.k.a. a “live birth abortion” — an induction such as I mentioned in the post in which the baby is intended to die during or soon after the birth, just without the stigma (?) of abortion, or for whatever reasons a woman might do it — if the baby is born alive and allowed to die “of natural causes” within a few hours of its birth, would it be counted in these statistics — would it be given a birth certificate and a death certificate? Above, I questioned whether all of the preterm births were unintentional or whether some were intentional. Perhaps you could clarify that, since that is a point that is unclear to me. I know that “true” abortions would not be counted; and I know that unintentional preterm births would be counted, but this is a gray area, since the baby is frequently born alive but with the intention of its death.

  5. “So now you are saying that this dataset is not large enough to draw statistical conclusions from it?”

    No, I’m saying that it is not large enough to draw the conclusion that you want to draw about the incidence of congenital anomalies among women who choose homebirth.

    “In the case of a pre-term induction, a.k.a. a “live birth abortion””

    I’ve never seen such a thing. In my state (as in most states) that is illegal.

  6. Great article, my friend!! You rock!!!!!!

  7. “No, I’m saying that it is not large enough to draw the conclusion that you want to draw about the incidence of congenital anomalies among women who choose homebirth.”

    But… it *is* large enough to draw the conclusion that home birth has three times the NMR of hospital birth, simply because 1.05 is almost 3x 0.38? Despite the fact that about 1/3 of that 1.05/1000 is due to unavoidable congenital anomalies, as opposed to 0.02/1000 in the CNM group?

    What I am saying about this is that in this group, the incidence of lethal congenital anomalies is almost twice that of the hospital group as a whole, and over three times that of the CNM group. You go around and talk everywhere about homebirth having a 2-3x death rate of hospital birth, and you pull out the CDC stats and brandish it about like it’s statistically significant, and *now* you’re saying that we have to determine the statistical significance of it? *Now* you’re wanting to say that the incidence of these congenital anomalies could “easily be random”? Well, these congenital anomalies carry with them a near 100% neonatal death rate; therefore, these excess deaths could “easily be random”, according to you. Which proves my point very nicely.

    Have you done the statistical calculations of the CDC stats to determine if the apparent difference is statistically significant? What, pray tell, are the results? I assume you can evaluate the claims and evidence you put forth, to see if the results are significant or if they are, in fact, random.

    I’ve made no secret of the fact that I do not have a background in statistics, which is why I’m looking at these stats from this angle. I suspect the difference is not significant — especially since by excluding unavoidable deaths in these 4 categories removes 1/3 of the NMR in the “other midwife” group.

    When you look at the other “Q” causes of death, I think it is fair to say that many of these conditions may be lethal depending on severity — like osteogenesis imperfecta — usually not lethal, but one form has a 100% mortality rate (at least by the end of the 1st year, but not necessarily in the neonatal period). It’s treading shaky ground to start postulating about whether this heart defect or that one could have been prevented in a hospital birth, because there can be severe or mild cases in conditions such as encephalocele (I’ve previously blogged about this and included a link in which a baby lived several months with this condition, after the parents refused abortion); congenital diaphragmatic hernia (I just came across a blog in which the woman was diagnosed with an affected fetus; her doctor recommended abortion due to the severity of the case, and she is refusing — preferring to love her baby and let her live as long as she can, even knowing that there is a high likelihood her baby will die soon after birth); and hypoplastic left heart syndrome (this mother refused a pre-term induction, such as I mentioned above, when she received this prenatal diagnosis, and declined heart surgery for her child when told he would most likely not survive it, taking him home to die naturally within a week or two — doctor’s best prognosis — a year later, he is doing well, his HLHS has corrected itself without surgery, although a couple of other heart defects did require surgery). Also, at some point several months ago, I read the blog of a woman who had an abortion by pre-term induction after receiving a negative prenatal diagnosis. The baby was born alive but premature, which is what they expected, and the parents held him until he died. She counted herself a good Christian, and although she is still against abortion for other reasons, she chose to terminate her pregnancy rather than carry a child to term that she was told would probably die in utero. Then there is this story in which a woman was scheduled for an induction termination at 31 weeks, within minutes or hours of receiving a lethal diagnosis, although she was so shell-shocked from the diagnosis, she didn’t even really realize what she was doing. When the induction didn’t work, she went home to continue the remainder of her pregnancy. In fact, I came across a great many stories of women who were offered preterm inductions when they received a negative prenatal diagnosis – including one article in which it was claimed that some Catholic hospital was doing it, circumventing the Church’s teachings on abortion and right-to-life issues, and possibly in opposition to the new federal “Born Alive Infant Protection Act.” I’ve searched and searched trying to find better statistics on this, but they’re buried and/or obtuse; however, something like 2000-3000 abortions are performed every year after 20 weeks of gestation. I would presume that the majority of these would be done in response to a negative prenatal diagnosis — giving time to get the results back from an amnio or routine 18-20 week ultrasound. Considering that there are over 1 million abortions committed every year, this is a small percentage. However, most of the abortions done in this time are dilation and extraction abortions, or are called induction abortions, or a few other names. While certain abortions insure that the fetus is dead prior to its extraction (by dismemberment, in some cases, or injecting digoxin into their hearts to kill them); in the cases I’ve mentioned above of failed preterm inductions in which the mothers decided to go full-term, the fetus was obviously not killed prior to the beginning of the procedure. One British study found that about 10% of such abortions resulted in a live birth, which is why many American abortionists will “dig” babies, to make sure they don’t have “the dreaded complication” of being born alive. However, in cases in which the baby was wanted prior to its negative prenatal diagnosis, this may come too close to outright murder in the eyes of the mother, but she can handle a preterm induction and allowing the baby to then “die of natural causes” when born too early. It may be illegal, but from what I’ve seen, it’s not necessarily uncommon.

  8. “even some nominally pro-life women will have an abortion or a “live-birth abortion” when faced with this news”

    I wasn’t aware that delivering a baby early due to a known fatal birth defect was illegal, as one commentor has suggested? I read a blog once written by a Christian woman who was VERY pro-life who found out her third baby had a fatal birth defect which included heart defects and also an inability to produce amniotic fluid (which was apparently pretty painful for the mother as well–as I can imagine!). Since she had at least one previous cesarean, she chose to birth this baby via cesarean at about 31-32 weeks…which would be beyond the point of “viability,” and since no overt means were used to kill the baby, I suppose it wouldn’t be considered an abortion? But since yes, nothing was done to help the baby–including giving any oxygen, I would consider this to be very close to abortion. Not that I’m judging the woman mind you…I’m not in her shoes, and can’t imagine the agony she went through over this decision.

    The family held the baby for I think it was less than 2 hours before the baby died.

    This to me is very clearly an example of the kind of thing you are talking about…how this kind of birth defect simply doesn’t make it to term in the hospital birthing population. And certainly if it were to make it to term, it would be unlikely to be in CNM care–would have been transferred to OB care once the suspicion of a birth defect was confirmed.


  9. Yes, that’s what I was trying to figure out — this “gray area” between outright abortion and live birth with the expectation of death. Just inducing or sectioning a woman early is not illegal — there are many cases of this that spring to mind when the mother’s or baby’s health is clearly affected — complications of diabetes, high blood pressure, eclampsia, or some other thing on the maternal side; as well as cases in which the baby’s health is suffering — perhaps a placental abruption, IUGR, or some other thing like that.

    But these are done with the idea of preserving the mother’s or the baby’s health or life. Most of the cases I read about of pre-term inductions had nothing to do with the mother’s life or health, and it was not done to save the baby’s life either, but rather to hasten his or her demise.

    I am not an expert on abortion law, but I do think that many states have at least some restrictions on late-term abortions, either after 24 weeks (viability) or in the 3rd trimester, or something. So, in those states, these inductions would not be counted as abortions, although the end result is the same. A minor quibble, in my opinion.

    In some of the stories I read, the women who received a poor prenatal prognosis were strongly pressured to have an abortion within a few days or weeks, because they were nearly to the point of abortion not being a legal option. One woman who had steadfastly refused an abortion breathed a sigh of relief after reaching 25 weeks, since she felt like she would no longer be pressured to have an abortion. At her first appointment after that cut-off point, however, her doctor suggested a pre-term induction. I guess it’s a legal gray area, although perhaps the federal BAIPA clarifies that… maybe.

  10. […] In this post of mine, I showed that, according to the CDC 2003-2004 statistics, women who gave birth at home had 3.5 […]

  11. I want to make sure I really understand what you are saying here. In this particular study, a significant number of the infant deaths were due to conditions which would have resulted in death even if the baby had been born in the hospital? So how can these deaths be considered evidence of increased danger to the baby from home birth? That makes no sense at all, unless I am misunderstanding what you are saying.

    The speculation as to why more babies with these conditions are being born at home is interesting, but not relevant to the argument. Home birth cannot be considered relevant to a death which would have been equally certain in any other birth setting.

  12. Yes, that’s exactly my point. There were over three times as many babies who were born at home who had these particular conditions, compared to midwife-attended hospital births. These 4 causes of death have nearly 100% mortality in the first month of life, regardless of birthplace. Yet Dr. Amy (the first commenter, who is well known for her anti-homebirth stance) consistently uses the raw numbers or statistics to say that these numbers “prove” that homebirth is risky. You are right that it makes no sense at all to try to do so, and that it can’t be relevant when the outcome would have been the same regardless of birthplace.

  13. Thanks for summarizing so neatly. I notice that Dr. Tuteur didn’t have an answer to the actual question being raised. Her only response seems to be statistical: your particular statistical analysis is not a valid one. But she doesn’t say why not.

  14. Thanks, Kathy, for shedding some light on these numbers. Very interesting, and even more interesting is Dr. Tuteur’s non-responsiveness. That clears up just as much for me.
    Dr. Tuteur’s statement about home birth being 2-3 x more dangerous than hospital birth has made me look and look into this issue, because of course, on the surface, she appears to be right. However, the 1% percent of homebirthers can never really be compared to a hospital group, and this posts sheds light on that. Refusing tests to show abnormalities like the ones you mention are a big part of home birthers’ philosophies I would say and thus the numbers are quite significant.
    No slicing and dicing to me at all.
    Anyway, thanks again. I am slowly going over your other posts about this subject because it is haunting me.
    ps. I linked you on my blog 🙂

  15. Dr. Amy Tuteur wrote: “The second problem is that the vast majority of the deaths are due to congenital anomalies. Indeed a full 55% of the deaths in the C-section group are due to “congenital malformations, deformations and chromosomal anomalies.” When congenital anomalies are removed, the neonatal death rates for vaginal delivery drop to 0.33/1000 and for C-section 0.76/1000. Obviously, none of the babies with congenital anomalies were low risk.”

  16. MinorityView,

    Thanks for the link! It does appear that Dr. Amy says that babies born with anomalies are not low-risk, which means that such babies ought to be excluded from any group which is supposed to be “low-risk.” Interesting.

  17. Good rationalizing, Kathy! Keep up the good work!

  18. Except there’s one big problem.

    What midwives claim are “fatal” anomalies and “unpreventable” death they really arent’. They are, apparently, just kids with minor problems that the midwife had no clue how to treat.

    If you look at the infamous Daviss/Johnson study, two of the three anomalies don’t have extremely high death rates in the first place. Second, those 2 also can’t be found in the year 2000 CDC deaths!

    Ditto for most of the other excuses. The numerous claimed early SIDS deaths also don’t appear in the year 2000 national death stats either. On top of that, the early, early SIDS most midwives claim doesn’t occur in nature.

    And FYI, the overall infant death rate is about 3.5/4.0 per thousand. The intrapartum rate was 1/1000 which is 10 times higher than low risk hospital.

    To drop the majority of your deaths as “unavoidable” with self-reported data is a fraud.

    Maybe we should avoid midwives because they seem to cause all this early SIDS and fatal anomalies!

    • Facts, please?! Citations? Any data, other than your word?

      Plus, please try to stay on topic. This post is dealing with one aspect of neonatal/infant mortality — that of babies born with lethal anomalies. You don’t know that these babies you’re discussing weren’t some of the rare ones whose anomalies are in fact fatal. It makes perfect sense to me that since most home-birthing women likewise eschew ultrasounds, that they would have fewer interventions during pregnancy (including abortion and pre-term induction) that might lower the term death rate. What I pointed out in this post is that for some reason, women who gave birth at home with “other midwife” as the attendant had a 3x incidence of these lethal anomalies. Why? I gave a few reasons in the post, including the less likelihood of them even knowing the potential prenatal diagnosis, therefore no abortion. I’ve read numerous other stories in which women have aborted or been pressured to abort for lesser diagnoses. If you take a population with zero abortions, they are bound to have more children born with anomalies than in a population with any abortions, much less a high abortion rate for fetal abnormality. As I said either above or in a different post or comment, Ireland does not have legal abortion while France does; Ireland has a higher neonatal mortality rate, which might lead one to conclude that it is more dangerous to be born in Ireland, when the reality is, it’s merely more dangerous to be a fetus in France. Ireland has good postnatal care — it’s just that more babies are born with worse problems due to the illegality of abortion.

      The CDC stats are interesting. If you want to start throwing accusations about what is or is not in them, I’ll point out that there were absolutely no babies born at home who subsequently died of hypothermia, but there were some in the hospital-born group. There were no babies born at or after term who died due to being preterm or of extreme immaturity/prematurity in the home-birth cohort, but there were some in the hospital cohort. In the 2003-2005 stats, iirc, there were no babies born at home who died of SIDS, yet there are numerous hospital-born babies who died of SIDS.

      Please tell me where you get your stats for “the overall infant death rate” of 3.5-4/1000 — what years, what group, what numbers? Throw me a bone, here.

      Also, I’m extremely curious where you find the intrapartum death rate — I’ve looked a long time for any study or, well, really anything that notes an intrapartum death rate of any sort. I would *love* to have something concrete to point to.

      Yeah, I’m really sure that midwives are fraudulently reporting anencephaly as the cause of death. It’s so easy to mistake that diagnosis! Gimme a break.

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