Saturday, March 16, 2013

Dear Legislators...Data Matters

Dear Legislators,
The Big Push for midwives is funding lobbyist work aimed at licensing CPMs and out-of-hospital (OOH) midwives all over the country.  Michigan is no different.  The political landscape is heated with arguments of choice, erroneously exaggerated cost savings, and supposed safety.    In this letter, I would specifically like to address the issue of safety as it pertains to data.  

In Michigan's case, I'm tremendously concerned about the startling lack of data as it relates to legislation and potential law.  At present, the State of MI does not collect any data on outcomes in planned out-of-hospital birth.  There is no analysis or approximation of safety, deaths, or injuries.  It is therefore extremely difficult, and even more importantly, irresponsible, to make assumptions about the safety of OOH birth.

Other states have taken a proactive initiative to purposefully collect data on outcomes before further making decisions on licensing, standards of practice, and educational requirements.  These states were uncomfortable with legislation licensing OOH midwives without the data to back up claims of safety, and rightfully so.  They demonstrate responsible legislative process, and intend to base potential laws upon evidence.  

    "In 2011 the Oregon House Health Care Committee amended the direct-entry 

    midwifery —“DEM”—law to require collection of information on planned place 
    of birth and planned birth attendant on fetal-death and live-birth certificates 
    starting in 2012.

    Oregon now has the most complete, accurate data of any US state on outcomes 
    of births planned to occur in the mother’s home or an out-of-hospital birth center."

In March, 2013 the state of Oregon released their data collected on OOH birth deaths (not just limited to DEMs, but including all OOH births and outcomes).  (Note: this does not include injured babies or babies that died interuterine, such as post dates babies, etc.)  The statistics for OOH birth in Oregon are startling to say the least, coming in at a whopping 8 times more dangerous than hospital birth.  The report was compiled by a well respected midwife, and advocate for OOH birth, Judith Rooks, CNM.  

     "My name is Judith Rooks. I’m a certified nurse-midwife, a past-president of the 

     American College of Nurse-Midwives, and a CDC-trained epidemiologist who has 
     published three major studies of out-of-hospital births in this country.

Ms. Rooks states in her review:

    "...out-of-hospital births are not as safe as births in hospitals in 
    Oregon, where many of them are attended by birth attendants who 
    have not completed an educational curriculum designed to provide all 
    the knowledge, skills and judgment needed by midwives who practice in any 
    setting...currently the collective practice of these midwives is not safe enough."

Sound familiar yet?  

A Deadly Trend
Oregon's data is not alone.  In 2012, Colorado released data on planned out-of-hospital births to find that home birth was over 11 times more dangerous than hospital birth.   Midwives Washington has collected research on this very topic in recent years from a variety of states and sources.  No state that has taken the responsibility to collect their own data, has found that birth attended by a midwives in the OOH setting, to be anywhere near as safe as a hospital birth.  It's important to note here that this is separate entirely from CNMs (and CMs in some states) who are delivering babies in hospitals and hospital-run birth centers. 

The deadly trend in licensing dangerous care providers without doing adequate research, is costing lives...not offering better options.  Michigan legislators have a responsibility to pay close attention to the mistakes other states have made, the data they have collected, and to refrain from putting lives at greater risk. 
What's going on in MI, and why does this data matter here?? 
There are several reasons every Michigan citizen should be alarmed.  We will focus on two here:

1) MI does not even bother to collect data on outcomes, and has no evidence or basis for claiming OOH midwives are safe.  Without data we cannot adequately predict safety, nor can we appropriately draft legislation that would improve safety. 

2) MANA's (Midwives Alliance of North America) lobbyists are working hard to push legislation
to license the same kind of OOH midwives in MI, as you see in these other studies.  They are making claims that cannot be backed up with facts to persuade legislators...such as, "home birth is as safe or safer than hospital birth."  Current MI bills regarding OOH midwives fall far short of improving safety.  Instead, the root issues that pervade OOH birth are being manipulated for the advantage of the midwives themselves, not the safety of the people they serve. 

MI Legislators must look closely at trends and data in other states.  Nowhere have they licensed OOH midwives, saved money, and had outcomes remotely close to safe. In fact CPMs, or the lesser educated DEMs/lay midwives, would not be considered competent to practice in any other first world country.  Let's not cost more lives, let's draft legislation that would actually make OOH birth safer instead of worse.  Before legislation goes anywhere on this issue, we need data and evidence on which we base those decisions. It is unethical to draft any law or legislation without data behind it, and our legislators have an obligation to draft responsible law.  After all, lives are at stake.  These are not just numbers and data, these are children whose lives were cut short. 

What About "Choice"? 
Frankly stated, out-of-hospital birth should be an option.  The data presented here is not intended to be an argument to eliminate OOH birth, nor was that the message of Judith Rooks in her report.  The data demonstrates an appalling track record, indicating need for better guidelines in educational training and practice for OOH midwives.   

Other countries have successfully embraced midwifery outside hospital walls as an alternative for low-risk pregnancies.  Unfortunately, many OOH midwives in MI pride themselves on normalizing high risk, and ignoring risk factors all together.  Other countries have determined minimum standards for educational training that far surpass that of standards set forth in the US for midwives practicing OOH.  These countries also have specific risking out criteria, transfer of care protocols, and they collect data on outcomes to properly evaluate safety in practice.  Embedded in these systems of midwifery are mechanisms for accountability, and reliable structures for safer OOH birth options, neither of which is the case in Michigan. 

Please take time to consider the responsibility that rests upon your shoulders as leaders in our great state.  Govern with a conscience, take the time to gather all the data you need to inform legislative efforts, and require mandatory reporting of outcomes.  Mothers and babies deserve safe options in birth, and there is a way to preserve choice while improving safety.  We count on you to protect the people of this state.  

Most Sincerely,

The Team at Safer Midwifery for MI
Other Links:

The Politics of Midwives, Medicaid, and Money (Post coming soon)  


  1. Data does matter! I'd like to see data from New York state (where only CNMs and CMs are licensed to legally attend home births) and Florida (where licensed CPMs have a strict set of exclusion criteria and must carry malpractice insurance.)

    It would be interesting to see how/if the data from the these states reflects the more stringent licensing requirements.

  2. Do you have a source for the CO data? I know Dr. Amy has a post and I'd like something more official or from a more neutral source. I'm not saying I don't believe it, I do.

  3. Sorry if this is published twice...

    Do you have a source for the CO OOH mortality rates? I know Dr. Amy has a post on it but I'm looking for something official or from a more neutral source. Not that I don't believe it, I do.

  4. Hi Catie,

    There is a page on the Colorado Midwives Association website that discusses MW statistics. Click on "Resources," then "Homebirth Safety in Colorado."

    Also, the state filed a report on CO LMs which can be found on the Dept of Regulatory Agencies:

    I hope this helps.