Thursday, December 20, 2007

Spinning the data in Utah

I have written repeatedly about the fact that MANA (Midwives Alliance of North America) has created a huge database about homebirth deliveries, but refuses to release the data (Why is MANA hiding its data?). MANA is the organization that collected the statistics from the year 2000 that were used by Johnson and Daviss for the BMJ 2005 study. Indeed Ken Johnson is the former Director of Research for MANA.

MANA has continued collecting statistics since then. They now have a database that probably totals 30,000 homebirth deliveries. It is the largest database on the outcomes of homebirths and it could tell us a great deal about the safety of homebirth (or the lack thereof). Unfortunately, MANA has publicly announced that it will release the data only to organizations that will use the data for the "advancement of midwifery". Even then, organization members must sign a legal non-disclosure agreement promising not to reveal the data to anyone else. It does not take a rocket scientist to figure out that the data almost certainly shows that homebirth has an excess rate of preventable neonatal death, probably larger than the 1-2/1000 deaths that has been shown up until now.

We are, however, able to get a peek at a portion of the data. The state of Utah, as a condition of licensing direct entry midwives, has required that they submit their MANA statistics each year. Statistics collected over the first 18 months since the inception of licensing show a high rate of neonatal death. According to the 2006 and 2007 reports, there have been a total of 319 DEM attended labors and 2 neonatal deaths for a rate of 6/1000. That's 6 times higher than the neonatal death rate for low risk women in the US.

The dataset is small, and therefore, the results are not statistically significant. However, if the results in Utah accurately reflect the results across the nation, it is not surprising that MANA is not releasing its data; it would demonstrate conclusively that homebirth with a direct entry midwife is not safe.

Of course, Holly Richardson, the midwife who wrote the Utah reports downplays the neonatal deaths and their significance. The abstract of the 2007 Report of Outcomes of Utah’s Licensed Direct-Entry Midwives states:
The outcomes of Utah’s Licensed Direct-Entry Midwives for this time period are excellent. Necessary transfers to hospital were handled in a timely manner with good outcomes. LDEMs continue to have a remarkably low c-section rate(less than one-fifth the rate of other Utah providers). Outcomes of breech, twin, and VBAC deliveries were excellent. LDEMs appear to be using Pitocin safely and appropriately, with no injuries. Episiotomy is not being routinely performed (there were only three in this dataset). The condition of babies following their delivery by LDEMs is generally excellent with an average 5-minute Apgar score of 9.12 (out of 10), and their mothers fared equally well with all mothers well recovered at six weeks post-delivery.
The outcomes were excellent? Not exactly. The neonatal death rate was appalling high. That isn't even mentioned in the abstract! The information is buried in the last page of the report:
... The mortality rate for mothers was 0%, for babies 0.5% (1 baby). None of these cases of newborn complications were determined to be preventable or a result of inappropriate care provided by the midwife.
A neonatal death rate of 5/1000 is extraordinarily high. The death was not "determined to be preventable"? By whom? Where is that information? Why is the cause of death being withheld from us?

Hopefully, the legislators in Utah will ask these questions to determine whether homebirth with a DEM meets acceptable safety standards. Other states should follow suit. In states where DEM licensing is being debated, legislators should demand the MANA publicly release its nationwide statistics. In states where DEMs are already licensed, legislators should demand yearly updates on the outcomes of DEM attended homebirths. Women deserve to know this information and legislators can make it happen.

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