Don’t just do something — stand there!

We’re used to the saying, “Don’t just stand there — do something!” and many times it’s true. Many times, however, it’s not. We value action — as measured by clichés like “He who hesitates is lost.” But we also understand the value of assessing a situation, to determine the best course of action — “Look before you leap.”

The father of a former coworker is a good example of not rushing into doing the first thing that pops into your mind. One time, there was a small kitchen fire that somehow started and caught the window curtains on fire. He rushed in, saw the fire, and pulled the curtains down. With his bare hands. Severely burning his hands, and if I remember correctly, requiring hospitalization. Far better would it have been for him to pause half a second longer, and grab a broom or some other object to get the burning curtains away from the walls and into the sink. Other similar stories abound of people throwing water on a grease fire, and spreading the fire instead of stopping it. They just reacted to the immediate situation… and reacted wrongly.

A great medical example is that of a nurse, pharmacist, or anyone else handling medication to double-check to verify that the medication they are dispensing is the medication they are intending to dispense to that patient. Or do an ultrasound to make sure that the baby really is breech before doing a C-section for a supposed breech baby (who may have flipped sometime in the past few minutes or few days).

Sometimes, it is better to pause, take a breather, and really think before acting. Or not to act at all.

What is commonly trumpeted by obstetricians is that maternal, neonatal and infant mortality dropped during the 20th century, for which they claim sole credit; what is not commonly told is that in the first part of the century, maternal and infant mortality increased under the care of doctors and particularly with births in the hospital. There are numerous quotes which demonstrate this, and show that it was known by some of “the powers that be” at the time, but I’ll just include a few [emphases mine]:

~ “Why bother the relatively innocuous midwife, when the ignorant doctor causes many more absolutely unnecessary deaths”. [1911-B; Dr.Williams,MD,p.180]

~ “In NYC, the reported cases of death from puerperal sepsis occur more frequently in the practice of physicians than from the work of the midwives’”. [Dr. Ira Wile, 1911-G, p.246]

And from the same source, later quotes from a 1975 study on the topic:

~ “Whether because midwives provided more skilled care or because obstetricians were too eager to interfere in labor and birth, obstetric mortality rates often rose as … midwife practice declined.” [DeVitt, MD; 1975]

And then from this document, quoting a conclusion made about midwives, a report presented to the White House,

“…untrained midwives approach and trained midwives surpass the record of physicians in normal deliveries has been ascribed to several factors. Chief among these is the fact that the circumstances of modern practice induce many physicians to employ procedures which are calculated to hasten delivery, but which sometimes result in harm to mother and child.

On her part, the midwife is not permitted to and does not employ such procedures. She waits patiently and lets nature take its course.”

While the doctors’ motto was, “First, do no harm,” the reality was that oftentimes, they caused harm by acting, when less harm would have come to mother and/or child had they not acted. “Well,” you might say, “that was then! A lot of things have changed since then.” Yes, and no.  Sometimes waiting patiently is still the best course of action:

Sometimes acting and intervening and speeding things up is the best course of action; but how often is slowing down and waiting on nature to take its course much better! When you have technology and gadgets and other things at hand, it’s easy to use them even when unnecessary. “When all you have is a hammer, everything looks like a nail.” And the ever-excellent quote from Jurassic Park via Jeff Goldblum, “Yeah, but your scientists were so preoccupied with whether or not they could, they didn’t stop to think if they should.”

First make sure you’re right, then go ahead. — Davy Crockett

Not just money

A recent article by Jennifer Block, author of the book Pushed which takes a close look at C-sections in America, highlights the disparity between what we as a country spend on maternity health care and what we receive, based on outcomes like maternal and neonatal morbidity and mortality and the premature birth rate. With a price tag of $86,000,000,000 in the year 2006, for an average cost of about $21,000 per birth, we should be getting better results than we are. I understand that a lot of that money goes to help babies who are born too early, and I don’t begrudge the amount it takes to save a life; however, I do wonder why we have so many babies being born too early. Why do we have such dismal results, when we spend so much? — according to the article, we spend twice per capita of what other countries spend, but we are far behind them when it comes to results.

The answer, according to Ms. Block, is to increase the number of midwives, both in and out of hospitals. She notes that 100 midwives saved the state of Washington an estimated $2.7 million over the course of two years; which also reminds me of this midwife I’d previously read about, who works in Washington, D.C., and keeps her funding by noting how much money they have actually saved by going low-cost and low-tech, while getting results that are twice as good as average.

Part of the reason for the midwives’ good results is the much lower use of C-sections, which are expensive, especially when compared to out-of-hospital vaginal birth (mine cost about $3000 apiece for all prenatal care and everything). When a midwife attends a home birth, all the care is included in a single fee, rather than billing for the monitoring of the baby, the after-baby care, the postpartum checkups, etc. One thing that surprises me about getting a bill from the hospital is that often that’s not all there is to it — there’s one from the doctor, the anesthesiologist, and the hospital, and possibly extras for other services rendered, depending on the circumstances.

But hospitals are reluctant to use midwives. Some hospital-based midwives are not allowed to attend out-of-hospital births lest they lose their privileges at the hospital. Despite the fact that you get more for less with midwives, and especially so in an out-of-hospital scenario. But, insurance companies don’t pay for a midwife to “labor-sit” — it’s not “billable” like the use of technology. So it would cost hospitals more to have one-on-one care with laboring women (which they can’t bill, but which shows much better outcomes for mother and baby), than it is to hook the women up to ten kinds of machines (which are billable, despite some questions about their actual efficacy in reducing negative outcomes for mother and/or baby).

Ask Dr. Amy

Here are questions that have come to my mind that I would like Dr. Amy, or anyone else who knows the answer to them, to answer. Most of them I’ve previously asked, but I’ve either gotten no answer, or have not gotten a satisfactory answer. Some of them I may be asking for the first time.

1. Since a “debate” is supposedly honest and fair, isn’t it unfair to have you being the “moderator” of the Homebirth Debate blog/website? Isn’t that rather like Michael Savage or Michael Moore running a political debate? or like Adolph Hitler, Joseph Stalin or Mao Tse-tung running a religious debate?

2. Since a “debate” is supposedly honest and fair, isn’t it dishonest of you to delete comments with which you disagree?

3. Why do you delete so many comments? I’ve personally had so many of my comments deleted that I made a habit of saving my posts, so I could quickly re-post them. And I’ve heard from many others who likewise have had their comments deleted once posted. About how many comments per day do you delete, anyway? Why? — Is it because you can’t answer them?

4. Why do you require home-birth advocates to back up everything they say, when you and your minions rarely do? In fact, I’ve almost never seen you quote any study or link to any study which indicates what you say — you basically say, “Believe me, I’m a doctor,” whereas when we make similar claims, you say we have to cite sources before you believe us. Isn’t that an untenable double standard?

5. When home-birth advocates do back up what they say, with studies published in notable journals such as ACOG’s Green Journal, why do you then say that we don’t have the right to quote such studies, and demean our understanding of plain, written English?

6. Why do you take so many things out of context? For instance, back in December or early January, which was about the last time I took you up on your blog, I had just started this blog, and you checked it out, pulled a fragment of a sentence about breech birth out of what I had written, and mocked me on your blog, though what I had said was backed up by recent research: what you left out was “in the absence of these factors” but kept in “breech birth is safe.”

7. When I posted a few breech birth studies from the 80s on your blog, you said that was too old, and that many larger and more current studies showed the reverse. What are they? I’ve found many studies, from the year 2000 and onward, that demonstrate that automatic C-section is not evidenced-based. Where are the studies you mentioned?

8. Is the current 30% C-section rate outrageous or not? You said it was in a comment on another blog a couple of years ago — do you still hold to that opinion? Why or why not?

9. Should women be allowed to try to give birth vaginally after a previous Cesarean? Why or why not?

10. If yes, then why do you not start a blog on “VBAC debate”, like you have on homebirth? — afraid too many MDs and OBs will get on, and you can’t shut them up by saying, “I’ve got a medical degree and you don’t, so you have to believe everything I say”?

11. Is there anything that ACOG has said that you disagree with?

12. Are the following low-risk or high-risk: breech vaginal births, post-term births, and twins?

13. Why do you insist on saying that the mortality rate reported in the Johnson & Daviss study is neonatal, when it is a combined neonatal and intrapartum?

14. Are intrapartum deaths reported in government statistics? If so, where?

15. Are not intrapartum deaths a subset of stillbirths, in that the baby died during labor was born dead?

16. What is the intrapartum death rate for the year 2000? Or any year? I require facts, not surmises.

17. When a lethal fetal anomaly is discovered during pregnancy, what percentage of mothers have an abortion and/or preterm induction? (many people report a 95% termination rate for cases such as Down Syndrome and other fetal anomalies, which would significantly alter the rate of lethal anomalies in babies born at or after 37 weeks)

18. Is it not true that there are significant difficulties in reconciling prospective and retrospective studies, such as the BMJ study and the government vital statistics report?

19. Is it not true that one of the deaths in the J&D study was to a non-white woman, so it (and all other non-white births) must be excluded when attempting to compare it to neonatal death rate among white women in the National Vital Statistics Report?

20. Is the intrapartum mortality rate or the neonatal mortality rate presented in the prospective J&D study statistically significant, when compared to the retrospective NVSR? (please provide your reasoning and calculations)

21. Are the numbers from the CDC 2003-2004 statistically significant, or should other calculations be used to determine statistical significance?

22. In this post of mine, I showed that, according to the CDC 2003-2004 statistics, women who gave birth at home had 3.5 times the rate of babies with 4 lethal birth defects at 37+ weeks, compared to women who had a CNM in the hospital: 0.21/1000 vs. 0.06/1000. You said that could “easily be due to chance,” in a comment. Does that not mean that there are calculations and other things that must be done to determine if the overall death rate is also not “easily due to chance”?

23. Considering that the home-birth set had over 3x the number of babies with 4 selected lethal birth defects, why don’t you ever mention that when you launch into your diatribes against home-birth, but instead act as if it is statistically significant, never delving into the causes of death?

24. In the CDC stats, there are some 20 neonatal deaths attributed to factors with codes beginning with Q. Is it not a fact that sometimes babies die of these conditions even when born in the hospital? — that some of these conditions may be so severe that no amount of medical care can save severely affected babies?

25. Is it not necessary to know the severity of these cases, in order to determine whether these Q-coded deaths could have been prevented by immediate medical care, in order to say that the deaths of these babies was “preventable”?

26. There are several inaccuracies or at least questionable entries in the CDC stats — “other midwife” being the birth attendant at a hospital; CNMs performing C-sections, etc. — what happened? Several thousand typos? Shouldn’t the inaccuracies be questioned and verified before being quoted as being statistically significant? Isn’t it possible that some of the deaths were coded wrong? If so, that wouldn’t change the hospital statistics too much, since there are about 8 million births over the course of the two years; but there are only about 40,000 home-births in that same time, so one death in the home-birth group would make a bigger change than it would in the hospital-birth group.

27. While most births will occur before the end of 42 weeks, even without medical intervention, some women do not naturally go into labor at this time. Since the CDC stats group all births that occur from the start of week 42 until… whenever — it’s not listed — could be 50 weeks as far as we know — all in one category, isn’t it possible that there were some babies who had moved into the high-risk category for being post-dates, post-term, and/or post-mature, and probably should have “risked out” of home birth, yet were born at home? Wouldn’t that skew the results for babies born just in the term period?

28. In ACOG’s statement on the Supreme Court’s decision to uphold the Partial-Birth Abortion ban, Douglas W. Laube, MD, MEd, ACOG president, is quoted as saying: “It leaves no doubt that women’s health in America is perceived as being of little consequence…. We have seen a steady erosion of women’s reproductive rights in this country. The Supreme Court’s action today, though stunning, in many ways isn’t surprising given the current culture in which scientific knowledge frequently takes a back seat to subjective opinion.” Why is it that ACOG is so concerned about a woman’s right to legally end the life of the child she carries in her womb, but stands against her right to legally give birth to that child in the manner of her choosing?

29. ACOG has placed “‘Lay’ Midwives and Home Birth” in the second spot of its State Legislative Issues 2008 — why? You say it’s because of “safety” concerns. I think that’s a load of bull, and I’ll tell you why: the numbers just don’t add up. Even if your grossly inaccurate figures about the “excess rate of preventable mortality” were correct, which they’re not, at most, outlawing home birth completely would potentially save 80 babies’ lives per year. Maternal smoking and unmarried mothers are each associated with approximately 4/1000 greater neonatal mortality, and affect 400,000+ and 1.3 million+ babies, respectively, per year, or over 7500 dead babies that would have lived had their mothers not smoked or been married (I know these categories are not mutually exclusive, so there is undoubtedly some overlap).

30. I assume you’re a member of ACOG — could you tell them that on the page I just linked to, that they need a spell-check and/or an editor? I’d point out the error to you, but it’s pretty obvious.

31. You’ve complained about “defensive medicine” and the high C-section rate being due to OBs unwilling to take chances with letting labor continue normally; but the current laws make that reality. In a post you had a couple of months ago about C-section rates, in the ensuing discussion, the topic turned to this topic. Susanne complained that midwives just complained about the high C-section rate while making no efforts at altering legislation, and sneered at them for not helping. I don’t mean to sound sarcastic, but does ACOG really need the help of midwifery organizations such as NARM and MANA?

32. Has any midwifery organization tried to block legislation that is designed to make the malpractice system more fair or generous to doctors?

33. Doesn’t ACOG have something like 50,000 members who are all doctors and therefore probably earn at least six figures every year? Do they need the help of midwives, who are a fraction of the number, and make a fraction of the income, in order to pass this legislation?

34. If midwifery organizations hop on board with the medical liability reform, and throw their huge financial resources (one source said that a Wisconsin midwifery organization had a grand total of $3,000 for its lobbying budget, when the bill finally passed, but I guess every penny counts!) into the ring, would ACOG support home-birth midwives with their legislation, or at least not try to block it? After all, if midwifery organizations didn’t have to fight for survival, they would have more resources to help their brother obstetricians.

35. Why is it that promoting laws banning CPMs and home-birth is #2 on ACOG’s legislative agenda, when it affects so few people, while defensive medicine — particularly the outrageous C-section rate and the medically inappropriate forced repeat C-section instead of allowing VBACs — is way down at #5, under “medical liability reform”?

36. Previously, you’ve said that a 30% C-section rate is at least twice what it ought to be. How did you arrive at that conclusion? Do you still hold to that conclusion? Why or why not?

A World Apart

One of my fellow childbirth educators (actually a co-moderator on my independent childbirth educators email list) has recently come back from another trip to Sierra Leone. Her group is called Midwives on Missions of Service, and their goal is to reduce maternal and infant mortality by improving the standards of care pregnant women get.  They are currently focusing on Sierra Leone, which has the worst or among the worst rates of maternal and childhood mortality in the world.

Click here for the (very short) update on their most recent trip. Go read it and then come back.

If you want more a in-depth look at previous trips into Sierra Leone, you can click here.

I’ve explored much of the “Global Midwives” website, although it’s been several months ago, and I was deeply impressed by the depth of poverty and the paucity of infrastructure (like decent roads) and health care in Sierra Leone (nicknamed “Salone”). This latest update broadens my understanding even more. This is “the hungry season” in Salone. We don’t even know what that is! These women were going all day without food, not having enough food to bring with them to these classes.

Reading what it’s like in Salone is almost like looking into another world — I can only imagine what it would be like to actually be there. These Sierra Leoneans are illiterate and ignorant, but intelligent and eager to learn. They are excited about learning just the basics of health care, and putting into practice things they’ve learned about prenatal and postnatal care.

While some might denigrate these “Traditional Birth Attendants” or speak poorly of the ignorance that they still have, it is important to remember that even if these TBAs do not have the skill level attained by doctors, midwives, nurses, or any other trained health personnel in developed countries, the knowledge and education by MOMS staff is a huge improvement over what they had — which was essentially no knowledge whatsoever.

In the U.S. and other developed countries, we take for granted things like food, medicine, clean water, hospitals, paved roads, easily accessible transportation (most of us have our own cars, or there is safe, reliable public transportation), ambulances, etc. It would be easy for us to throw up our hands and say “It’s no use — what’s the point?” But these midwives are saying, “It’s a big job, we’d better roll up our sleeves and get to work!”

Remember “The Serenity Prayer”?

God grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference.

These women may not be able to build good roads to make it easy for people to drive to the nearest health clinic or hospital (something which now takes many hours’ of walking, or perhaps even days); they may not be able to magically make food to grow, or make the water clean and safe; they may not be able to train these women to perform C-sections, but they are “changing the things they can.”

This work is worth supporting: you can donate money or things, or if you are qualified, you can volunteer to help their work.

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.

Should it be Illegal for Pregnant Women to Smoke?

Some time ago, the American College of Obstetricians and Gynecologists and the American Medical Association released statements decrying home birth, ostensibly for reasons of safety. This “safety” is typically quantified by mortality and morbidity, which is why the ever-vigilant Dr. Amy travels the blogosphere preaching her gospel of “home birth with a DEM has 2-3x the rate of mortality as low-risk hospital birth.” I’m planning another post in the near future on that, but here is one post in which I take on that statement, if you’re interested.

But, just for the sake of argument, let’s say that Dr. Amy is right (which she’s not). She consistently says that the Johnson & Daviss CPM home-birth study shows 2.6/1000 neonatal mortality (although it includes intrapartum deaths), compared to 0.9/1000 in the hospital for low-risk births (which she defines as births to white women at 37 or more weeks gestation and 2500 grams of birthweight, although that is not necessarily an accurate comparison). She also says that the CDC stats show that home birth with “other midwife” has a neonatal mortality rate of 1.15/1000 vs. a CNM rate of 0.37 (although she deliberately ignores the higher rate of babies that were born with lethal birth defects like anencephaly). She says, “The issue is safety.” Is it really?

Let’s pretend she’s right, though, and say that planned home birth has, say, a 1.5/1000 neonatal mortality vs. 0.6/1000 for a similar low-risk group who have planned hospital births (just picking a number in the middle of the above-mentioned numbers). This would mean that for every 1,000 babies born at home, 1 more would die in the planned home-birth group as opposed to the hospital-birth group. (Just to remind you, even though I don’t agree with this assessment, these numbers also don’t take into account serious morbidity — injury that the baby sustains during or after birth.) But let’s say that the 2.6 as opposed to 0.9 is correct — that would mean that the “excess mortality rate” would be 1.7. So, the worst-case scenario is 1.7/1000.

The U.S. government gathers statistics about births and deaths, and here is the link to the report on the year 2000. If you go to the 11th page of this PDF file, you’ll see infant mortality rates by maternal race and various characteristics (like gestational age at birth, birthweight, infant sex, etc.). I want to draw your attention to two different characteristics, near the bottom of the page: marital status and maternal smoking. While these data are separated by maternal race, they do have them combined into “all races.” If you look at “marital status,” you’ll see that unmarried women have an infant mortality rate 4.5/1000 more than married women (probably due to the higher socioeconomic status of married women vs. single mothers). If you look at maternal smoking, you will see that smokers’ infants die at 4.2/1000 more than babies born to non-smokers. A big factor in this is prematurity, which as everyone who has ever read a pack of cigarettes knows, the surgeon general warns that pregnant women who smoke increase the risk of preterm birth, low birthweight, and infant mortality.

So, if ACOG and the AMA want to outlaw home birth because of the “safety issues”, or as Dr. Amy puts it, 2-3x the neonatal mortality (which at most equals 1.7/1000), why not start with something more easily changed, which would affect a larger number of women and babies? Let’s say that 1.7 is accurate — heck, let’s even go all the way up to 2/1000; and there are at most 40,000 women who intentionally give birth at home with a midwife (although the CDC statistics only record about 15,000 women per year). That means that at most 80 babies would be affected. But (according to page 12 of the PDF), there are 1,347,069 babies born to unmarried women every year (at 4.5/1000 excess infant mortality), or 6,061 babies who die that would have lived had their mothers been married. Also on that page, are the numbers for smokers — 425,107 (at 4.2/1000 excess mortality), or 1785 dead babies because their mothers smoked. (If you look at just black women, you’ll see that smoking raises the rate from 12.7 to 19.8/1000!)

So, if ACOG and the AMA really have issues with safety, why do they not throw their powerful lobbying muscle behind reducing the number of women who smoke or who have children out of wedlock? When was the last time you saw anything on the national news from ACOG or the AMA decrying out-of-wedlock births? Oh, sure, they kick and scream and turn blue and foam at the mouth when Ricki Lake releases The Business of Being Born and is vocal about home birth; but when celebrity women like Camryn Manheim, Jessica Alba, Jodie Foster, Halle Berry, Susan Sarandon, and Madonna all have babies “without the benefit of marriage”, the only thing anybody talks about is “who’s the daddy?” When Dan Quayle took “Murphy Brown” to task for having a baby out of wedlock, he was roundly derided on all sides. Yet looking at the plain statistics, we see that “regular folks” have an increase in infant mortality, even if wealthy celebrities do not.

So, I ask again, as I did in my title — if home birth should be outlawed or warned against on every corner, with ACOG and the AMA issuing seriously-worded press releases about the risks of home birth because Ricki Lake made a movie about it (except they forgot to put in any data supporting their claims….) — where is the foaming at the mouth when higher-profile celebrities — world-famous celebrities, in fact, like Madonna — flaunt their single motherhood, and do everything shy of making a movie about it? Where is the outrage by the doctors for the “attention in the media by celebrities having” out-of-wedlock births which are statistically at least twice as risky as even the direst home-birth predictions, and are also have some 33x the rate of occurrence of home-births throughout the United States every year? Where are the press conferences deriding maternal smoking, and the press releases by these organizations announcing an attempt at legislation making maternal smoking illegal?

Until these doctors begin to attack real and serious risks, I cannot take them seriously when they scream that they do not support home birth because of potential safety reasons. And I wonder how anybody can take them seriously, when they put forth so much effort to stop home birth which is already so rare (less than 1% of all the births in the United States, although making home-birth midwifery illegal is the #2 legislative priority for ACOG), and do so little to stop maternal smoking (12% of all births, with a 10.7/1000 overall infant mortality rate) and unwed motherhood (1/3 of all births, with a 9.9/1000 overall infant mortality rate).

Open letter to ACOG and the AMA: GET REAL!

Meaningless Statistics

I’ve been thinking about statistics and mortality — maternal, neonatal and infant. I’ve previously blogged about the CDC stats for 2003-2004, available on the Wonder query, where you can find the cause of death for every infant whose death is recorded, from birth up through age one. What I wonder, though, is whether these statistics even have meaning, or if they are too narrow for real purposes. You see, there is only one cause of death allowed on the death certificate — even if the baby or mother died for a variety of reasons, or a compounding of factors.

For instance, take a baby who was born with Down Syndrome, and because of that genetic defect also had a fatal heart defect. When the baby dies, is the cause of death listed as being due to Downs or the heart defect? — it can’t be listed as both! What about babies that are born premature and end up dying from a lung infection because of their prematurity — is the cause of death listed as prematurity or infection or something related to the lungs? This may have a big impact when looking at small statistics, such as those in the home-birth set. If a breech baby died from birth asphyxia because of complications with a breech vaginal birth, is it coded “birth asphyxia” or “complications from breech birth”? The first makes it look like home birth has excess neonatal mortality in low-risk women; the second makes it clear that this birth is in the higher-risk breech group. While most breech babies will do just fine being born vaginally, some will not.

I will also note that there were several babies born in the 37-42 week group that listed as the cause of death “extreme immaturity”! At term?

Maternal mortality is another term that I have the same difficulties with. You might think that all “maternal mortality” is just “women dying in childbirth”, like what used to happen in the “Dark Ages,” before clean water, antibiotics, blood transfusions, etc. — back when women had vitamin deficiencies that caused pelvic deformity, and doctors proudly refused to wash their hands, and even gloried in their bloody clothes! (Some of these things are still factors in maternal mortality in poor countries around the world.) But maternal mortality includes deaths of women during pregnancy or up to six weeks (or 1 year, depending on the definition) of the end of pregnancy, regardless of how it ended — miscarriage, abortion, stillbirth, or live birth. I don’t think abortion should be counted with maternal mortality; because it’s more precisely “anti-maternal” — it’s the refusal of a woman to become a mother to that child. I’ve read recent statistics that half of Romania’s maternal mortality is due to abortion (which ends about half of all pregnancies there), even though it is legal. “Unsafe abortion” is the fifth leading cause of maternal mortality worldwide, according to the World Health Organization. But, it is counted, so what I want or think doesn’t matter. That’s life.

I know someone who had a near-lethal complication from her C-section (which was necessitated due to preeclampsia that threatened her life or health as well as that of her baby) — her incision became horribly infected; and she also developed blood clots in her legs, which could have traveled to her heart, lungs, or brain and killed her or seriously disabled her. If she had died, would her C-section have even been implicated? Her “cause of death” would have been listed as “infection,” or possibly “stroke” or “heart attack from blood clots”. But the infection was because of the C-section; and the leg clots developed due to being immobile because of the C-section and subsequent infection (having to stay in bed in the hospital). So, had she died, only the immediate cause of death would have been listed, and not the true cause, the underlying reason, which was “complications from a C-section.”

And there is this article, in which the author demonstrates a deliberate under-reporting of maternal mortality, by coding abortion deaths as being due to some factor — any factor — other than abortion:

Furthermore, the cover-up of abortion-related deaths has actually been furthered by the World Health Organization’s coding rule number 12 of the International Classification of Diseases. This rule requires that deaths due to medical and surgical treatment must be reported under the complication of the procedure (embolism, for example) and not under the condition for treatment (elective abortion). According to researcher Isabelle Bégin:

In effect, this makes the “abortion” category a “ghost” category under which it is simply impossible to code a death due to abortion.

If this is true of abortion, I can only assume it to be true of all other types of maternal mortality. The CDC admits at least a 30% under-reporting of maternal mortality (although they don’t specify anything about the unreported or underreported deaths). But when statistics have no meaning, because the true cause of death is vague, obscure, or outright denied, how are things supposed to get any better? If we don’t know the reasons why women or babies die, how can we keep it from happening?

Finally, a few different doulas and childbirth educators on one of my email lists have said that stats at their local hospitals are similarly “scrubbed” as regards C-sections. At first, I wondered how that could happen — after all, it’s “vaginal birth” or “C-section” right? Well, one woman said that if there was a placental abruption, then that is what is put down — “PA” — not C-section. So, the C-section rate looks lower than it really is.