A flawed study published in “a second-tier journal”

That was the conclusion of Dr. Nicholas Fogelson about the much-publicized recent meta-analysis on home-birth, in a comment on Science & Sensibility’s post about it. [Honestly, I didn’t know that the AJOG was so poorly respected. Makes me rethink what studies I’d look at, if it was published there.] In the S&S post, Amy Romano questions whether the meta-analysis was even appropriate, in light of the huge de Jonge study of over 300,000 planned home births in the Netherlands. She writes,

Lack of statistical power could not possibly be the rationale for conducting a meta-analysis on the safety of home birth. [The de Jonge study] contributed 94% of the data on planned home birth in the meta-analysis (321,307 of 342,056 planned home births). That study found virtually identical rates of neonatal death in both the planned home and planned hospital births, with relatively narrow confidence intervals.

The blog “Birth Sense” has two posts on this study: a prologue of sorts and then a discussion of the 12 studies included in the meta-analysis. And despite Dr. Fogelson’s comment that AJOG is a “low-impact” journal, many news sources apparently didn’t get that memo, and had no problem trying to make a huge impact with the sensational headlines that “home birth is three times as deadly as hospital birth.”

I have read numerous blog posts and news articles about this study and will include links to them below, but I want to comment on some things. First, since the study isn’t going to be released for a few more months, I haven’t read it (I know it’s available by request, and I presume for a price or if you have a subscription), so I’m not sure what I can add to what those who have read it have said. In some ways, what I’ve read has raised more questions than answers. The main question is, what were the inclusion criteria? From some sources, I’ve discovered that the original study had to have been published in English (a common enough restriction — gotta make sure the doctors don’t get bogged down in any bad translations from reading foreign language studies!), and also to studies that reported outcomes of mothers and babies in both home and hospital births (apparently the reason why the Johnson & Daviss 2005 article on CPM births, published in the BMJ was not included — they didn’t have a hospital “control group”).  But I wonder, did they not have any exclusion criteria for the size? They included one study that had 5 women in each group — a total of 10 women studied! If I may say so, “Good grief, Charlie Brown!”

Additionally, they included the Pang study, which itself was flawed, in that it reported not only planned home-births (with or without a qualified attendant), but it also included unplanned home-births — this despite a title that declares that it looked at planned home births. Nor was the study limited to the “term” period, but included births as premature as 34 weeks. Since I don’t have the meta-analysis in front of me, I can’t say how heavily it influenced the conclusion, but “garbage in, garbage out” — if the data going into the study is wrong, you can’t reach the right conclusion.

In all meta-analyses I’ve read, there has always been a discussion of inclusion and exclusion factors; if there are others besides the ones I’ve mentioned above, I’d like to know — out of curiosity, if nothing else.

Some of the articles I’ve read have touched on problems researchers may have in reconciling different studies, which may all have different designs, or look at different populations, etc. Again, I don’t have the study, so I don’t know if Wax and associates looked at all the different factors and did an appropriate exclusion or analysis of differing studies. Some differences among studies that I can think of that might need some statistical calculation or exclusion of some births (which may or may not have been included in any of the cited studies), include prospective vs. retrospective study design; inclusion of term, preterm or post-term births; cross-over (women planning a home birth who transferred to the hospital, or women planning a home birth who gave birth precipitously outside of the hospital); whether babies with congenital anomalies were excluded; whether the mothers were properly matched in the groups — same general age, income, health, parity, etc.; whether twins or breech or post-term babies were included or excluded (many studies are limited by design to “singleton vertex babies from 37-42 weeks gestation”); cause of death (for example, excluding accidental deaths by smothering or car wreck would be a good idea, I’d think, if possible); whether there was a trained birth attendant; quality of the original study, and undoubtedly many other things I can’t think of.

One of the confounding factors that some of the articles I’ve read, is that some of the studies examined only the early neonatal period (up to 7 days), while others examined the full neonatal period (up to 28 days). Which reminds me of another factor I should have included in the paragraph above — perinatal deaths including stillbirths, and also possibly intrapartum deaths. Several of the writers have noted that the largest study, the Dutch study, was not included in the actual analysis of the most loudly trumpeted conclusion, namely, that home birth carries a 3x death risk for babies when compared to hospital birth. The largest study which had almost 95% of all of the births in all of the studies, and showed no difference for neonatal death, was excluded for the purposes of  neonatal death. It seems that it is because that study only went up to 7 days. Was there not some sort of statistical analysis that could be done to extrapolate deaths that may have occurred from days 8-28, so that this study could have been included? Or, an analysis that could have excluded deaths from 8-28 days in the other studies? As I said, I have more questions than answers. I’d love to read the study for myself (and the Birth Sense link has links to all 12 of the included studies — some of them are abstracts but some of them are the full studies, so I may start by reading those), but I wonder if any of the questions I have would be answered if I did read it.

Now for the links that I read, in addition to those I cited above (some of them include other links to other articles, as well) — obviously, most of them are going to be favorable to the “this meta-analysis is junk” viewpoint, but not all of them are:

Now for some links to other home-birth related stuff that is not about this flawed study:

  • The Unnecesarean’s blog post on a new study in this month’s issue of Obstetrics & Gynecology that says it’s important to distinguish between planned and unplanned home births [and I’m just in the mood right now, due to lack of sleep, to say cheekily, “and next, they’ll tell us that water is wet, and the sun is hot!” :-)]; but seriously, it’s because many times “unplanned” home births are to women with known risk factors that may cause problems with either themselves or their babies
  • the NHS write-up of the de Jonge (Dutch) home-birth study
  • High Tech vs. Nature’s Way,” an article from Minneapolis-St. Paul
  • The College of Physicians and Surgeons of British Columbia “Resource Manual” on planned home births

Ahhh, now I can close out some tabs on my browser.

Oh, and Dr. Amy, I’m pretty sure you’ve been waiting for me to write this up since I know you read me (not to mention you probably have “home birth” on your Google Alerts, and probably regularly add other keywords to make sure you don’t miss any internet discussions), so if/when you comment, just remember that you have to stay on topic. No cut-and-paste jobs like you usually do, m’kay? Oh, and before you bluster that the studies which showed that home birth is safe only in the countries of the study (like the Netherlands and Canada), because of how their midwives are integrated into the health system, I want you to answer a question: if that is true, why don’t you try to integrate midwives into the health system in America, rather than trying to elbow them out? That would solve that problem. 🙂

“We’ve never heard such a ruckus”

That was the quote from the Senate Chairman when talking about the recent Mississippi legislation (that died in committee), that would have made all non-nurse midwives illegal in our state. With over 5,000 phone calls, the response was unprecedented. While that may not seem like a lot of phone calls, apparently, it was! Considering that our whole state population is somewhere around 2.5 million, that is 0.2% of the population calling (assuming that each phone call was by a different person, which we know was not the case, since many people called every Senator, or at least, every Senator on the committee).

What started the bill? I’m not sure, but apparently, there was a midwife (perhaps living in Louisiana, perhaps just down in that area of MS) who attended a birth in which the baby died. It’s possible that it was just one of those things, but it’s also possible that she was not as well-trained as she could have and should have been. Since I know no details, and have only a rough idea of what happened, I most certainly cannot pass judgment. Regardless of what happened or “what might have been,” this case led the Board of Nursing to get with a legislator to introduce a bill to make non-nurse midwives illegal. As far as I know, nobody knew about it until it had already passed the House and was in the Senate. Then we spread the word, and “raised a ruckus,” and got it defeated. Yay!

Now, to work.

Last Tuesday, I was part of a group that met in Jackson to begin work on crafting our own legislation to introduce next year that will make CPMs recognized and licensed, and will create a review board to oversee them. I’m not totally sure how that will work, because I’ve just never dealt with that aspect of things before. However, there were some TN CPMs at the meeting that talked about how it worked in their state. You can join the Yahoo group MSFriendsofMidwives to see the latest version of the bill and to stay informed on the process.

Currently in Mississippi, there is only one CPM, although there are several out-of-state CPMs who serve various parts of MS, and many other midwives who could become credentialed and licensed. With licensure and certification not having been required to practice in MS, it could easily be seen by midwives as being an unnecessary use of time and money to get that piece of paper, when there was no risk to not having it and very little if any benefit to getting it. I suppose that saying that you’re a CPM might get you a few extra clients, but it wouldn’t alter your legal status, and you probably couldn’t file for insurance repayment either (I suppose it might be possible, but I highly doubt that without the legal recognition that insurance companies would recognize you either). Under the legislation that will be proposed next year, CPMs would be legally recognized, and current non-certified midwives who can demonstrate that they meet the NARM criteria would be grandmothered in.

So, benefits of the legislation would be that midwives who are currently operating legally and safely in the state will continue to be legal birth attendants, and will also be recognized by the state. I asked about legislation that would make Medicaid be able to pay for such midwives, and was told that the legislation doesn’t specify that, but once CPMs are recognized, that such a step may come in the future — I don’t know if it would need to be a law, passed through the state legislature, or if it’s just one of those things that once they’re legal, they can get set up to file claims, or petition Medicaid to recognize CPMs. Another benefit would be that with credentialing perhaps comes a higher degree of respectability and also recognition. There is a certain something that comes with proof that others recognize the work you’ve done, whether that’s proving you can survive med school and get M.D. after your name, or that you’re a certified piano technician, and become a member of the PTG.

One downside of this particular legislation is that it would make non-certified and non-licensed midwives illegal. Those working on the legislation believe that any measure that allows non-CPMs to practice would be defeated. I can see that, based on the bill that was just defeated, that would have made all midwives (except CNMs) illegal. Yet, midwifery has been unregulated for so long in our state, that I can also see that enough legislators might support the bill, even if it did not criminalize non-licensed midwives. But, it seems prudent to take the safe track. I do wish that legislation such as what is in Oregon could pass, with licensure being optional but having benefits; however, those with much more experience and knowledge about midwifery and legislation are making the suggestions, so I’m going along.

“Why would anyone not want certification??” I can think of a few reasons. Some just don’t like government interfering in your business — it’s simply a libertarian issue. “Government is there to keep the peace, and that’s about it — everything else should be left free and open,” some might say. With certification comes regulation — in some states, non-nurse midwives have become legal, only to be basically legislated out of existence by the laws that made it practically impossible to operate. It’s sort of like the hospitals that have labor tubs, but women can’t use them if their water is broken based on a theoretical but totally unproven risk of infection; and they can’t use them if their water hasn’t broken, lest their water break in the tub, and nobody know it. As long as rules and regulations are sound, then there is minimal problem with them; but when they get to be stupid and over-reaching, they can cause more problems than they solve. In Arizona, the law says that home-birth midwives cannot attend VBACs. If you agree that VBACs should not take place at home, then you’d probably agree that this is good legislation. However, if you think that the risk of adverse events is so small that HBAC is a reasonable choice for women to make, then you’ll probably disagree with the legislation.

John Stossel is in a series of articles discussing the downside of certification (not mentioning midwives at all, and only briefly mentioning doctors). Here are two articles, “The Right to Work,” and “Licensing Madness,” as examples. He makes a pretty good case that certification serves to protect established industries at the expense of those who are equally competent to provide certain services (braiding hair, yoga instructor, writing wills), but don’t have the money (or don’t want to spend thousands of dollars) to certify just for the right to do what they already can do, especially if they’re doing it on the side, or are starting to build up a business. He points out that market forces will serve to weed out incompetent florists at least as well as (if not better than) the lengthy and expensive certification process. When it comes to businesses such as these, I’d have a hard time coming up with a counter argument — the “risk” of a bad florist is that you waste $30 on an ugly flower arrangement, in which case, you’d go tell all your friends and family and neighbors and co-workers to avoid that flower shop, and the florist would soon go out of business. But an incompetent midwife may lead to dead or injured mothers and/or babies, so it’s easier to say that doctors and midwives and such should be regulated and certified.

Still, there are probably some very good healers that could not be certified because they are alternative practitioners. For example, Chris Gardner, who wrote the book The Pursuit of Happyness, which was also a movie by the same name with Will Smith playing him, has an interesting history. If you remember the movie, he became a stockbroker while being homeless much of the time, with his son in tow. That’s only part of the story. When he was in the Navy and for several years afterward, he worked for and with a doctor. While my memory of what all he did is a little fuzzy, he had “great hands,” meaning, he was proficient in the medical work he did. He never went to one class of med school, but he had what it took to do what he did, including operate on people, teach med students how to do the right things — he even had work published in medical journals! But, because he wasn’t a doctor and hadn’t gone to med school, what would have been a promising medical career was necessarily stopped. He didn’t have enough money to become a doctor, and the doctor who employed him couldn’t afford to pay him more. “So, big deal — that’s just what you’ve got to do to become a doctor! We can’t have just anybody calling himself a doctor!” Well, true, but this also kept him from applying his skills and healing a lot of people. Sure, it kept some quacks out of the business of medicine, but it probably keeps some who would be very good doctors from doctoring.

There are definite upsides and downsides to this. Regulation helps to keep bad practitioners from starting a business, although it does not entirely eliminate bad practitioners. However, nothing can. While capitalism is a strong influence in keeping bad practitioners out of business (because people will not willingly spend their money on bad goods or services), they can for a time prosper. And if they’re schmaltzy enough, may be able to keep people blind to their incompetence or poor products or services to stay in business for a while — Bernie Madoff was a master at this (of course, he also blinded them with greed, which is another tangent and topic entirely). We’ve all known people who were certified, licensed, bonded, insured, and/or regulated who were really bad practitioners of their craft or trade. It happens. There are bad apples in every barrel. Regulation can make it so that people don’t have to do their own work to make sure people are really competent, which can be a good thing, or a bad thing if they are lulled to sleep and think that everyone who produces a piece of paper is competent.

As you can see, I’m conflicted about this — mostly because if you’ve got a bad midwife, we’re not talking about losing a little bit of money by not being more conscientious, but perhaps losing your baby’s life. Given enough time, the truly bad will probably be eliminated simply by market forces, but what may happen during that time? How many babies may die? Not something to be talked about lightly. However, we cannot protect people from themselves. Some people are going to choose things that others may think are “woo” (acupuncture, acupressure, magnets, copper, feng shui, craniosacral therapy, chiropractic care, herbs, vitamins, supplements, etc.) — we can’t stop them from doing that. And if a woman thoughtfully considers the matter, and chooses a non-certified midwife, or even just has a few friends over to attend her birth, can we really stop her? Should we? At what point does “society” get to dictate who attends her birth? Recently, there has been a national conference on VBAC (which since you’re birth junkies, you’ve probably heard about, unless you’ve been living under a rock). A similar argument has emerged from the pro-VBAC community, namely, that women have the right to choose how to give birth, and should not be forced into a C-section, even if there is a risk of uterine rupture and perinatal mortality. Does someone else get to choose how women give birth, or is that something that each woman should be able to choose for herself?

I think highly enough of women and our intellect to say that if a woman understands that she is hiring as a midwife someone who has only attended ten births, hasn’t really read too much about birth complications, and has never handled a postpartum hemorrhage or a “slow to start” baby, or any other complication, that she should still be allowed to hire that midwife, knowing the risks. I would want someone more qualified than that, but some women are comfortable with that level of skill and knowledge. Unless the midwife misrepresents herself or her skills, then I just don’t see that “we” should try to save the woman from herself. Others may disagree — it comes down to where on the “libertarian” continuum you find yourself.

My letter to my fellow Mississippians and my state Senators

My note on facebook which I slightly altered into a letter to the Mississippi Senators:

I was shocked to find out today that HB 695 which would amend current Mississippi state law to restrict the practice of midwifery to only Certified Nurse Midwives (CNMs) has passed the House and is in the Senate. This is a historic and unwelcome revision of long-standing Mississippi law which has always allowed for the free practice of midwifery.

There are only about 25 CNMs in the state (as of 2008) [Update – someone told me that there are only 2 CNMs that she knows about, both hospital-based and in the far South], and most serve the lower third of the state. This leaves the rest of us without the benefit of a legal home-birth attendant. Tennessee, Louisiana and Arkansas allow for CPMs (Certified Professional Midwives), and some may even allow for non-certified or “lay” midwives to legally practice (as current Mississippi law does). When I was pregnant with my son, now three years old, I was unable to find a local Mississippi midwife close enough to attend my birth, so chose a CPM from Tennessee. If this bill becomes a law, I fear that that option will no longer be available. What then? My choices will be limited to an unassisted birth or giving birth in a hospital.

A midwife is a safeguard of normal birth — monitoring the mother throughout pregnancy, just like a doctor (only better), and monitoring the mother and baby throughout labor. In most hospitals, this one-on-one labor care is nonexistent, replaced by machines monitoring the mother and baby, with nurses checking in only rarely. Sure, it’s more cost-effective since there can be a higher patient-to-nurse ratio, but it’s not better! With the close “with woman” care that homebirth midwives can give mothers, they can pick up on indications that labor may not be progressing normally, and take steps to put it back on track at home, or make an appropriate and timely transfer to the hospital.

Without homebirth midwives, women such as myself will be forced to give birth at home without a midwife in attendance, or to give birth in substandard conditions in a hospital. There are no baby-friendly hospitals in Mississippi. Our fair state consistently ranks at the bottom of most health criteria, including breastfeeding (see also this link). Home-birth is very “baby friendly” — what we need is more encouragement for women to have home birth, not less! This is just one of many benefits to babies of home birth. Among the many benefits to mothers are a much lower rate of interventions, including C-sections, epidurals, inductions, augmentations, episiotomies and vacuum- or forceps-assisted births.

Home birth is not for everyone. Many women would not choose it if they could; and some who want to give birth at home have risk factors that cause them not to be good candidates for a home birth, so give birth at a hospital. Yet most women are low-risk, and about 90% of women who plan on giving birth at home do so (and only a very small minority of the 10% who transfer to hospitals do so in an emergency; most are calm, routine transfers for pain medication or labor augmentation).

CNMs are wonderful — I had one during my first pregnancy (I lived in Illinois then). CPMs are likewise wonderful — I had one during my second pregnancy. As far as practice style went, there was no difference. The main difference between CNMs and CPMs is that CNMs are Registered Nurses who go on to complete midwifery training — training which is very similar if not identical to the midwifery training that CPMs complete.

With midwives already in short supply, changing the law to an even more restrictive one will be counterproductive. If you care about home birth, midwifery, the right of mothers to choose where and with whom to give birth, or just plain don’t like government interference, please contact State Senators and urge them to vote against this legislation! And for good measure, contact Representatives and express your disappointment that this bill passed.

Thank you.

And some links on this issue — the “Big Push for Midwives” facebook profile page and a page to sign up for updates; and a facebook group to keep everyone abreast of the situation in Mississippi.

Mississippi Midwives Facebook Group

If you’re on facebook, you can join this group to keep up with the latest news on the legislation to outlaw non-nurse midwives.

If you know of any other groups or organizations, big or small, official or unofficial, please let me know so we can join forces. Thanks!

Making Mississippi Midwives Illegal

I was horrified to find out that a bill has passed the Mississippi House of Representatives, and was sent to the Senate, to make CNMs the only legal midwives in Mississippi. My state was one of the few that was “alegal” — there was no language specifically protecting or prohibiting non-nurse midwives.

While it’s too late to contact the Representatives (I emailed mine anyway), you can email the Senators and ask them to vote against it. Even if you’re not from Mississippi, I would still appreciate a show of support for CPMs from citizens of other states. There are almost no CNMs in Mississippi anyway — none that I know of in the top half, perhaps the top 2/3 of the state; when I had Seth, my midwife (a CPM) was from Tennessee — I don’t know how that might affect midwives crossing state lines. Currently, CPMs are illegal in Alabama, but some Tennessee CPMs have set up a “birth house” just over the border to accommodate women who don’t want to give birth in the hospital, but live close enough to the border to drive there in labor.

My mind is still reeling — I feel like I’m writing pretty scattered, here — hopefully you can find the coherent thought in it, though.

I have nothing against CNMs — I had a CNM attend the birth of my first baby. This isn’t some sort of turf war — just trying to keep alive the only form of midwifery available in my area.

Please share the word, too, if you will. Thanks!

Update: — I just noticed that some of the email addresses of the Senators are incorrect — two at least are misspelled (one “seante” and another “.us” instead of “.gov”), and one email address was listed as the same address for at least 3 different Senators. Sandra has commented below with a list of email addresses which appear to be correct, so you may want to use those instead. The first list is by district whereas Sandra’s list is alphabetical, so you should probably use one of the other and not both, in order to make sure you get them all.

2nd Update: — if you’re on facebook (and maybe even if you’re not), here is a post I wrote that I hope was a little more collected, outlining why I support home birth. It is what I used as the base for my email to the Senators (mostly changing the end from “please contact” to “please vote against this bill”). Feel free to pass it around and use what you want from it in your own emails if you wish. I don’t know if emails make more impact if they’re similar or if they’re all unique (probably the latter), but if you don’t have time to write a response of your own, I don’t mind if you use portions of what I’ve written and make it your own.

3rd Update: — if you’re on facebook, you can join this group to keep up with what’s going on. If you know of any other groups (large or small, official or unofficial) that are involved in defeating this bill, please let me know, so we can join forces.

Another good hospital birth story

J’s birth. Enjoy.

Mary Breckinridge, the first American CNM

At a time when maternal mortality was 800/100,000 and infant mortality claimed one in ten lives, Mary Breckinridge was a true life-saver. She established Frontier Nursing Service in 1925, which brought quality care to rural (and typically, impoverished) Kentucky women. Frontier still trains nurse midwives. Here are a few articles about Mary Breckinridge, in honor of National Midwifery Week:

In many ways, Ms. Breckinridge was to nurse-midwifery what Ina May Gaskin is to non-nurse midwifery. Most of us are probably more familiar with Ina May than Mary Breckinridge, for many reasons — we home-birthers tend to hire CPMs rather than CNMs (who many times cannot legally attend home births); we’ve read her engaging books; she’s still alive and giving interviews, and working hard promoting midwifery and awareness of maternal mortality, etc. But there are many similarities between the two women — both saw a need and filled it; both popularized midwifery; it’s possible that without Mary Breckinridge, there would be no “CNM” at all, and perhaps without Ina May Gaskin there would be no CPM either. There have been many other influential figures, and many other necessary players, in the realm of midwifery; but in each of these cases, they were at least the starting point in their respective fields, and in so doing, saved midwifery and/or home birth. In some ways, Ms. Breckinridge had a harder role, perhaps, living at a time when doctors were on a full-court press to eliminate midwives as dirty and incompetent (in contrast to their sterile hospitals and/or sterile technique, in addition to their high-falutin’ education). The fact that maternal mortality increased with the increase in hospital births was not widely known; and the fact that these “dirty” and “incompetent” midwives had lower maternal mortality attending home births than doctors attending home births; and home birth had lower maternal mortality (and morbidity) than hospital birth, was actively suppressed by obstetricians of the day, in their PR campaign to drive out midwives and midwifery. For a woman to consciously and willingly step into a demonized role, roll up her sleeves, and get to work, should be recognized and given full credit. In some ways, I think it might be like the wife or daughter of a plantation owner going to live in a slave hut, and working the fields, instead of living a pampered life of ease and enjoyment.

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