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Cornell Study - 4x higher rate of death at Homebirth - Page 3

post #41 of 61

I wish there was a way to break down all the info from these studies to look at specific factors.  As mentioned above, the level of training of the midwives being one.  I have also heard of the horrible outcomes from studies looking at Oregon homebirths and then noticed in the MANA study that nearly 1/3 of the women were in the region of the U.S. that included Oregon. I'd love to see birth outcomes broken down by state (or at least by region).  I think it's important to know WHY the deaths occurred.  Were they due to a fear of transfer because of a hostile attitude toward homebirth and therefore mom and/or midwife waited longer than they should have to transfer?  Was it due to causes that could have been prevented had the midwife had certain medications or supplies?  That would be huge to know - some midwives carry oxygen, pitocin, etc. while others don't carry any of that.  All of those things are so important that I feel like these numbers tell us very little. To me, they tell us that we need to start looking more into what makes homebirth safe and what makes it unsafe so that everyone can make better decisions as to what is best for them.   

post #42 of 61
Quote:
Originally Posted by callieollie View Post
 

I wish there was a way to break down all the info from these studies to look at specific factors.  As mentioned above, the level of training of the midwives being one.  I have also heard of the horrible outcomes from studies looking at Oregon homebirths and then noticed in the MANA study that nearly 1/3 of the women were in the region of the U.S. that included Oregon. I'd love to see birth outcomes broken down by state (or at least by region).  I think it's important to know WHY the deaths occurred.  Were they due to a fear of transfer because of a hostile attitude toward homebirth and therefore mom and/or midwife waited longer than they should have to transfer?  Was it due to causes that could have been prevented had the midwife had certain medications or supplies?  That would be huge to know - some midwives carry oxygen, pitocin, etc. while others don't carry any of that.  All of those things are so important that I feel like these numbers tell us very little. To me, they tell us that we need to start looking more into what makes homebirth safe and what makes it unsafe so that everyone can make better decisions as to what is best for them.   


I wish I could give multiple thumbs up. 

post #43 of 61
Quote:
Originally Posted by callieollie View Post
 

I wish there was a way to break down all the info from these studies to look at specific factors.  As mentioned above, the level of training of the midwives being one.  I have also heard of the horrible outcomes from studies looking at Oregon homebirths and then noticed in the MANA study that nearly 1/3 of the women were in the region of the U.S. that included Oregon. I'd love to see birth outcomes broken down by state (or at least by region).  I think it's important to know WHY the deaths occurred.  Were they due to a fear of transfer because of a hostile attitude toward homebirth and therefore mom and/or midwife waited longer than they should have to transfer?  Was it due to causes that could have been prevented had the midwife had certain medications or supplies?  That would be huge to know - some midwives carry oxygen, pitocin, etc. while others don't carry any of that.  All of those things are so important that I feel like these numbers tell us very little. To me, they tell us that we need to start looking more into what makes homebirth safe and what makes it unsafe so that everyone can make better decisions as to what is best for them.   


I completely agree. I think someone should start a spinoff thread about looking at the recent studies and seeing what we can do to improve home birth outcomes.  I have wanted to start one for a week and just haven't had the chance.  Maybe someone can beat me to it :)

post #44 of 61
Quote:
Originally Posted by Pillowy View Post
 

 

So you would you like to see a study that broke down which births were attended by CNMs, CPMs, DEMs, LMs, and so on? What would you do with that information? If it was shown that those with more education and training - CNMs - had much lower death rates than the other midwives, would you want there to be regulations that everyone must meet that minimum standard before selling their services as a midwife?

Yes, I for one would.  In order for home birth to remain an option for American women we need to address the deficiencies of the education programs.  In order to do that we need to know what is working and what isn't.  And I don't think it has to be a CNM degree specifically.  In my state, NJ, we have the option of the CM, a direct entry program developed by the ACNM that allows a college graduate to get a masters in midwifery after bridging the gap in some health courses.  They then sit for the same exam CNMs take.  I also think that if we raised the bar for CPM training and required more standardized courses at college level we could improve outcomes (a&p, microbiology, pathophysiology, etc.). Midwives need to know what high risk looks like and what these diseases entail before they can call themselves "experts in normal birth"  I know some fabulous, well trained CPMs, but I have also been at conferences where everything is a variation of normal. 

 

I do not think that someone without verifiable, in depth education should be able to call themselves a midwife. 

post #45 of 61
I think it is 100% clear that mana has no interest in promoting practice guidelines, higher educational requirements or, risking out criteria.

They are only a certification group focused on obtaining legality of practice and insurance reimbursement for what are essentially lay/non-professional practitioners.

Unless the acnm takes up the banner and seperates itself from mana, this is going to be a fight for appropriate standards conducted on a state by state level by individual citizens groups who are aware of issues/risks and have the time and money to pursue the issue legislatively.
post #46 of 61
Thread Starter 

What I do know is that for my next pregnancy, if I choose homebirth, I am hiring a CNM or CM (if not an OB). With all this data that's recently been released, and what I've learned about the educational differences & requirements for CNMs and CPMs (and DEMs), I can't bring myself to think about hiring a CPM. Some are great, some are obviously not great, and there is almost no way to tell the difference beforehand. CNMs and CMs have a high bar of education they must fulfill. CPMs and DEMs have all sorts of different educations and levels of experience.

post #47 of 61
Quote:
Originally Posted by Buzzbuzz View Post

I think it is 100% clear that mana has no interest in promoting practice guidelines, higher educational requirements or, risking out criteria.

They are only a certification group focused on obtaining legality of practice and insurance reimbursement for what are essentially lay/non-professional practitioners.

Unless the acnm takes up the banner and seperates itself from mana, this is going to be a fight for appropriate standards conducted on a state by state level by individual citizens groups who are aware of issues/risks and have the time and money to pursue the issue legislatively.

 

MANA has no interest in promoting practice guidelines, higher educational requirements or risk-out criteria for OOH birth. I agree with that.

 

BUT - because there's so much smoke and mirrors in the world of OOH midwifery, I feel the need to clarify MANA's role.

 

MANA is not a certification group. NARM is. (However inexorably these two organizations are linked - they are different and separate.)

 

Side note: MEAC creates standards for midwifery education for certified professional midwives, however. NARM does not require MEAC accreditation for sitting for the certification exam. Just sit with that detail for a minute.

 

MANA represents "all" midwives - and this includes DEMs who have no certification what-so-ever. (Hard to issue professional standards when the organization doesn't actually represent any profession.) MANA calls this 'innovative.':

"MANA is unique and innovative in that it is the only professional midwifery organization in the U.S. that is inclusive of all midwives regardless of their educational route to midwifery."

 

Technically the National Association for Certified Professional Midwives is the professional organization for professional midwives equivalent to ACOG or ACNM or AAP.

It looks like MANA wants to be the voice of the 'profession of midwifery' and but not actually function as a true professional organization. Not sure what NACPM is doing.

There are lots of interlinking of groups in midwifery. OOH midwifery in particular, is really a very small population, and they seem to create new organizations every couple months -

Whether this is intentional or not, it produces the following effect: 1) creates the illusion of the profession being larger than it is, 2) confuses the issue of which organization is responsible for what.

 

ACNM dwarfs MANA, NACPM, MERA, CfM, AME, MEAC, NARM, FAM, MAMA, the Big Push, in size and is primarily concerned with the issues that concern the overwhelming majority of its membership - which is CNM/CM health care services provided in an in-hospital setting.

 

That said, there appear to be a few MANA sympathizers with high profiles at the ACNM at the moment, and it's unclear if these individuals' opinions truly reflect the opinions of the majority of the ACNM membership.

 

IMO MANA should be the professional organization for CPMs. But they aren't. And that causes confusion, and creates and sustains a lack of accountability for midwives.

post #48 of 61
Thank you for that clarification!

Would it be fair to categorize mana as a advocacy group and view their health and safety claims through that lens?

In that case safety claims from mana would be the equivalent of the California raisin board advertising "our studies show that people who eat raisins once a week are less likely to suffer from depression! Buy raisins today!"
post #49 of 61

I sometimes wonder if the home birth midwives anecdotes about the docs being hostile is more their perception than an actuality. On one of the lists I belong to a non-CNM/CM was looking for advice and an interpretation of a surgical report. The reason she was asking the docs on this list is because her local environment was hostile to OOH midwives. The docs strongly encouraged her to call the OB who had done the original C/sec and dictated the report.

 

The midwife finally did talk with the "hostile" doc and found her very kind. Their discussion was very informative for the midwife. She decided, based on the surgical report and the conversation with the OB that this woman was not a candidate for a home VBAC. The OB agreed to accept the woman as a VBAC candidate.

 

The midwife came back to the list to report this. I think she understood that the environment wasn't hostile, it only seemed that way because that's what she believed it to be. Once she showed her willingness to work with the OB and not be hostile herself, the patient benefited. And now this midwife has an OB she can consult in the future for other situations.

post #50 of 61

The birth certificate data collects reports by place of birth (hospital, birth center, home birth, other), and it also collects the attendant data (MD, DO, CNM/CM, Other Midwife, Other). The study however extracts place of birth data. This means that the study is comparing the outcome of births delivered by midwives in hospitals, all CNM, against homebirths delivered by CNM, CM, and other midwives. For one, this somewhat nullifies the argument of comparison of the most appropriate setting for birth since the data isn't comparable since all midwives in hospitals have to be CNM (or they do at least where I'm at). I'm not saying that hospital midwives still wouldn't show up tops; just that the data isn't comparing the same thing,

post #51 of 61
Quote:
Originally Posted by Pillowy View Post
 

What I do know is that for my next pregnancy, if I choose homebirth, I am hiring a CNM or CM (if not an OB). With all this data that's recently been released, and what I've learned about the educational differences & requirements for CNMs and CPMs (and DEMs), I can't bring myself to think about hiring a CPM. Some are great, some are obviously not great, and there is almost no way to tell the difference beforehand. CNMs and CMs have a high bar of education they must fulfill. CPMs and DEMs have all sorts of different educations and levels of experience.

 

Another option is a CPM who has graduated from a MEAC-accredited program and attained her CPM that way, not the PEP process. 

post #52 of 61
Quote:
Originally Posted by phathui5 View Post

Another option is a CPM who has graduated from a MEAC-accredited program and attained her CPM that way, not the PEP process. 

That distinction is pretty opaque to consumers, and it's not clear from tge study whether it results in safer practices or better outcomes. For me at least, it's a problem that midwifery organizations have been so open for so long - if the barriers to entry are sufficiently low, entry is meaningless. (Edited to remove parenthetical that I actually can't find the backing link for.)

Which programs are MEAC certified?
Edited by MeepyCat - 2/25/14 at 5:37am
post #53 of 61
Thread Starter 
Quote:
Originally Posted by kimgeik View Post
 

This means that the study is comparing the outcome of births delivered by midwives in hospitals, all CNM, against homebirths delivered by CNM, CM, and other midwives. For one, this somewhat nullifies the argument of comparison of the most appropriate setting for birth since the data isn't comparable since all midwives in hospitals have to be CNM (or they do at least where I'm at).

 

I disagree with the idea that the study isn't measuring the overall safety of the place of birth, since the midwives in the hospital are CNMs and the midwives at homebirth don't have to CNMs. Many of us who have had homebirths or are considering homebirth have used or have considered using a CPM. Non-CNMs deliver most homebirths. So the comparison makes sense.

 

We're comparing the overall safety of hospital birth with the overall safety of homebirth. A comparison between CNM hospital births and CNM homebirths would be great, but that's not what we're looking at here, and not the reality of most homebirths.

post #54 of 61

If you would like to read a statistical analysis comparing the two studies being discussed that has been done. The analyst is a Ph D and a professor of statistics. She volunteered for this after hearing that Aviva Romm and Dr. Amy had had both agreed that this would be helpful.

This is posted on Dr. Amy's site. There are a few comments by her, but the majority is the statistical analysis. If you would rather not hang out on her site reading the whole thing, there is a link on the page that takes you directly to the document.

http://www.skepticalob.com/2014/02/a-statistics-professor-analyzes-the-new-paper-from-the-midwives-alliance-of-north-america-mana.html

post #55 of 61

The CDC categories for birth attendent are MD, DO, CNM, other midwife, and other. It is abundantly clear that anyone giving birth out-of-hospital with an attendant in the "other midwife" category intended to give birth out-of-hospital. The hospitals are the ones getting screwed with the numbers for transfers. People who plan a homebirth transfer to the hospital for two reasons: pain relief and something abnormal/going wrong. This group is going to have a much higher rate of mortality/morbidity than either your run-of-the-mill hospital birth or your planned homebirthers that actually gave birth at home. If anything, Missy Cheyney in her role of homebirth advocate should be wondering why, when you take a bunch of emergencies and thrust them into hospital hands and hospital statistics, are homebirth numbers still so bad? 

post #56 of 61

One thing I'm curious about in this study is why the large difference in outcomes between homebirths and freestanding birth center births? I would think that they'd be very similar as they both have very similar set ups. Just in one case, the laboring woman is going to the midwife and in the other, the midwife comes to the laboring woman. Why should the outcomes be so much worse if the midwife comes to the laboring woman? They both use the same tools and sometimes even the same midwife. It makes me wonder what other differences existed between these two groups. 

post #57 of 61

The difference is the type of midwife and the restrictions on practice. Freestanding birth centers in the US that are part of the AABC (American Association of Birth Centers) are mostly staffed by CNMs and they have strict rules regarding who they can accept and transfer of care. Most homebirths in the US are attended by CPMs and other lay midwives. There is little to no oversight and no standard of care. Even when it is CPMs staffing the birth centers, they still have to follow the stricter birth center rules.  They will often risk patients out of the birth center and in to homebirth. Eeek! 

post #58 of 61

Small correction to the comment about birth centers. I am a CNM and ran a birth center until 2013.

 

AABC is a trade organization. Birth centers can be members just like they can join the local chamber of commerce. They can operate the birth center any way they wish, sticking with only low risk women or taking on high risk women if they want. I am not sure the ratio of CNM only to non-CNM (LM, DEM, CPM) run birth center, or those that have a mix of providers. Although most birth centers are run by CNMs.

 

However, the stricter guidelines that you mention are part of being a credentialed birth center. That is not done through AABC, but through the CABC, an independent and separate organization.

 

The difference between the home birth numbers and the birth center numbers is not the place of birth, but the education level of the midwife doing births in that place. CNMs have a deeper, broader education and a higher proportion of CNMs work at birth centers than at home. More non CNM midwives, with a less extensive education do home births.

 

If all midwives had a university level education with at least part of their clinical experience in hospital, I can almost guarantee that the home birth numbers would improve in terms of safety. There will always be those outlaw midwives who are arrogant enough to believe they can and should handle anything at home.

 

Edited because I forgot to include this link from AABC that came out last week. http://www.birthcenters.org/content/position-statement-birth-center-quality

post #59 of 61
Quote:
 Which programs are MEAC certified?

 

Here's a link to a list of MEAC-accredited midwifery programs.

 

There are nine.

Basytr

Birthwise

National College of Midwifery

Maternidad La Luz

Nizhoni

Birthingway

Florida School of Traditional Midwifery

Midwives College of Utah

National Midwifery Institute

 

What I find interesting about MEAC is that they are very careful to not assert that an accredited education is in any way superior to the PEP process. If anyone can find a statement to that effect on the MEAC website, I'm interested in seeing it!

 

In fact, more often than not, I hear midwives saying that the apprenticeship  model is the only 'pure' model of midwifery training, and that those midwives who entered practice through a formal program have inferior training.

 

It would be nice for CPMs to develop some consensus regarding what type of training produces the most competent, safe and skilled practitioners. Until then that happens (when pigs fly?), it is very hard for the consumer to rely on the CPM credential to convey to them any level of standard or training or competency.

post #60 of 61

I was reading an old paper by Judith Rooks, CNM and a home birth supporter. She explained that one of the reasons there can't be unity in midwifery is that the organizations representing the lay midwives (CPMs, DEMs, LMs, etc.) don't have internal unity.  They can't agree on a standard for education, standards for practice,  guidelines or ethics. I know there are some within the lay midwife community who feel that they would like to see these developed. It is difficult to have a vocation become a profession without standards, guidelines, ethical considerations, standardized education, etc.

I think where the lay midwife groups are failing is that they have tipped in favor of protecting their members, and potential members and this means they have tipped away from protecting the public interest. One of the acts of a professional organization is to maintain their own privileged and powerful position. It is a very delicate balancing act, but I think the actions of the lay midwifery organizations, including journals representing them, have tipped in favor of self interests.

I am a home birth midwife myself. Almost always when I am with a group of other OOH midwives and we start discussing risking out (twins, breeches, VBACs, high risk conditions), almost every single time, the first thing I hear is, "If I did that, I wouldn't have any business." 

 

There is a new study from the CDC that came out last week showing that the homebirth rate continues to rise although it is still less than 2 %.  I would be interested to know how the number of midwives compares. If there has been a greater growth in the number of midwives than there has been in the number of women seeking home birth, that means that the pool  of women who are appropriate candidates for home birth (no identifiable risk factors) is being shared by more midwives. However, not all women who could have a home birth are choosing to do so. Thus midwives are taking on riskier women because they need to be able to make a living. Having standards and guidelines that limit the women they can accept into care would have a direct financial impact on the members, and potential members, the lay midwifery organizations represent. It is in the self interest of these organizations not to have standards and guidelines. Doing so would make an already weak organization even weaker as they appear to change from protecting the self interest of the members to protecting the interest of the people they serve.

 

 

 

 

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