Home > Academic OB/GYN Podcast > Academic OB/GYN Podcast Episode 28 – Journals for December 2010

Academic OB/GYN Podcast Episode 28 – Journals for December 2010

Journals for 2010 with Nicholas Fogelson and Paul Browne.  Topics include NICHD Strip Classification, Oral vs Intrauterine Progestins for Hyperplasia, Fetal Lung Maturity Outcomes Less than 39 Weeks, Congenital Toxo and more!

Academic OB/GYN Podcast Episode 28 – Journals for December 2010

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  1. December 30, 2010 at 5:29 pm

    Say, Dr. Fogelson, I meant to leave you a comment on your last podcast but it slipped my mind. I was looking forward to hearing your comments on homebirth because you’ve seemed fair-minded about out-of-hospital birth in the past. I was surprised by the inference that women who have babies at home might be inconsistent or even negligent about follow-up pediatric care for the baby (an idea floated in response to the Wax meta-analysis, I believe — in particular the findings re: neonatal mortality).

    I would suggest that the most likely explanation for that difference is Wax’s inclusion of the 2002 Pang et al. study, which failed to distinguish planned attended homebirth from unplanned or unattended homebirth. (Oh, and that California study, from the days when mothers dodged saber-toothed tigers during labor — what was up with including that one?) While there’s a subset of homebirthing women who eschew routine pediatric care, they’re a small minority. I’ve had 2 babies in the hospital and 3 at home, and I got much more careful follow-up on that front from the homebirth providers: they made sure the babies were scheduled for well-child exams according to the doctor’s preferred timetable.

    Enjoyed the podcast despite the quibble.

  2. December 30, 2010 at 5:58 pm

    There’s always room for quibbling! No question though that a population of infants that are immediately seen by a pediatrician whether the mom likes it or not is going to get more consistent pediatric care than a population that requires maternal action to get prompt pediatric evaluation.

    • December 31, 2010 at 6:41 am

      Hold on, though: I thought the podcast speculation was that sick babies might be slipping through the cracks once they were past the perinatal period, as an explanation for Wax’s (dubious) report of increased rates of neonatal but not perinatal death. Home-born babies are examined immediately after birth by the birth attendant — part of their skill set is assessing the newborn and referring to peds as appropriate. Anecdotally, my CNM did a much more thorough exam than the clearly sleep-deprived peds resident who assessed my son after my last hospital birth.

      In my first comment I was talking specifically about care during the remainder of the neonatal period. Once a mother is discharged from the hospital, she’s on her own as far as arranging outpatient care for the baby. A mother who has delivered at home is usually in regular contact with her midwife, who will be asking many questions about the baby — including whether the baby has seen an MD.

      The more plausible explanation for Wax’s findings, IMHO, is the use of a substantially different dataset in the analysis of perinatal mortality. Sloppy data in, sloppy findings out.

      • December 31, 2010 at 12:20 pm

        I think you make an incorrect assumption when you state that a homebirth attendant is going to pick up the things that a pediatrician will, but perhaps you think differently. Pediatricians do train for years to find these small things. CNMs, awake or not, have minimal training in pediatrics.

  3. December 31, 2010 at 6:47 am

    PS I do appreciate your open-mindedness about homebirth. Happy new year to you!

  4. January 16, 2011 at 10:18 am

    Okay, I went back to the podcast and listened again to the bit that had been niggling at me. You guys said that families might not get adequate “immediate or delayed pediatric care,” and I was responding to the “delayed” part — which I interpreted as a hypothesis that homebirth families aren’t following up with peds after the perinatal period. That isn’t what I’ve seen in the corner of the homebirth community where I hang out, though it’s certainly possible for folks whose orientation is more toward the unassisted end of the birth preferences spectrum.

    It seems to me that the question of adequate newborn exams in the immediate postpartum period is a different issue, since it’s more about provider training than maternal motivation. I don’t have the clinical peds experience to guess how often a CNM might miss something life-threatening, but the idea that this would pose a serious threat to home-born babies doesn’t seem to be borne out by the literature. (I just looked back at the causes of death listed in the Johnson & Daviss CPM study, and at the ’96 study by Ackermann-Liebrich et al. in which babies were examined initially by midwives and then by pediatricians on day 3. I tried to look at the Janssen studies, which I think would also be useful but something weird is going on with the CMAJ site.) I’m curious about the perspective of the CNM who commented on the previous podcast, since she routinely examines babies born at home who are compromised as a result of congenital anomalies.

    A disadvantage of leaving a comment a few weeks after listening to a podcast is that the details blur. I forgot that you had responded specifically in the podcast to people (like me) who are skeptical about the article selection strategies used in the Wax paper. I suppose I might be biased, but OH I am not a fan of the Pang study. Advance planning and skilled assistance are cornerstones of safe homebirth, and in my view it’s ill-advised to extrapolate from a study that didn’t distinguish reliably between planned attended homebirth and unplanned, unattended homebirth.

  5. January 16, 2011 at 11:39 am

    >> I don’t have the clinical peds experience to guess how often a CNM might miss something life-threatening, but the idea that this would pose a serious threat to home-born babies doesn’t seem to be borne out by the literature.

    “Serious threat” means so many things to so many people. Outcomes are going to be good for the vast majority of cases no matter where birth happens and who attends it, because overall most births go well without intervention.

    At a fundamental level, I think that homebirth providers overestimate their ability to deal with difficult situations and their likelihood of recognizing rare but dangerous problems. This isn’t malicious – its natural. There is a strong bias in us all called availability bias – our inability to recognize something that we are not familiar with. When providers with less training estimate their ability to deal with problems they overestimate it because they are substantially less familiar with rare but serious problems that would require more advanced expertise. Ergo, the misconception that a CNM is going to be as acute at picking up a problematic child as a pediatrician. Given that they have a miniscule amount of experience and training in congenital problems compared to the pediatrician, there is no way this the case.

    On the other hand, physicians are far more aware of what they do not know, because they know more. For example, a general pediatrician, despite his or her broad knowledge in pediatrics, is quite able to admit that they would be less likely to pick up a rare congenital heart anomaly than a pediatric cardiologist. The pediatricians advanced knowledge of the issue actually makes them more aware of what differentiates them from the super-expert.

    I am aware of lots of diseases that I am not expert in, and thus recognize that I am not likely to diagnose them when presented with them. Had I not known about them at all, they wouldn’t even be in my world of consideration, thus leading me to overestimate my ability to diagnose disease. I think this is what is happening with lay midwives and some CNMs, and in combination with resource availability issues, is why homebirths are marginally more dangerous for mother and infant than in hospital births.

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