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> Academic OB/GYN Podcast, BMJ, Green Journal, Grey Journal, Journal Articles > Academic OB/GYN Podcast Episode 27 – Articles for November 2010
Academic OB/GYN Podcast Episode 27 – Articles for November 2010
Dr Paul Browne and I discuss articles from the Green and Grey of 2010, along with some interloping BMJ articles. Topics include The Big Homebirth Studies, The Goodness of Databases, Single Site Laparoscopy, and Reducing Induction before 39 weeks.
Academic OB/GYN Podcast Episode 27 – Journals for November 2010
Categories: Academic OB/GYN Podcast, BMJ, Green Journal, Grey Journal, Journal Articles
Academic OB/GYN 
I appreciate your guys thoughtfulness on the home birth subject – heck, your willingness to discuss it -without much palpable bias- at all. As an American home birth provider, however, I think an important piece of the puzzle is missing, both in data analysis and in your conversation. It is truly the definition of a confounding variable…
My practice does over 450 births per year, more than 80% of them out of hospital (home or birth center) and more than 70% of our families are Plain. For us Amish and Mennonite but for other American midwives I know well, also Mormon, Jehovah’s Witness, Brethren, Pentecostal, Orthodox Jewish, Hutterite, Moravian, as well as a zillion new conservative Christian / Eevangelical / Enigmatic faiths, survivalist separatists, ETC. Not to mention the other huge percentage of out of hospital birthers – the families who choose unattended birth, with no care provider in attendance at all. These all go into the data set the same….
With only 1-2% of American women choosing to birth out of hospital, please acknowledge and understand what high percentage the above groups represent in that small statistic. I feel like the admonishments against out of hospital birth – well intended by people such as yourselves – are directed only to the other small (but increasing) percentage of out of hospital birthers: the highly educated, upper middle class, professional couple (choosing a professional midwife with an established system of consultation, collaboration, referral and effective transport systems). Because the other groups? Mostly don’t particularly value those things in a provider.
So, the counfounders… I’m here to tell you: most of the women falling into the above groups require pressure to obtain even “baseline” labs. Most would not consider having an ultrasound even with indication. Most will not call “early” in labor (if that’s even a possibility, as most are grand multips). Most won’t call when their water breaks, rather when labor starts (perhaps a significant amount of time later), no matter how thoroughly we counsel them. Most, if pressured into routine testing, unwanted ultrasounds, mandated repeat c/sections, risking out of out of hospital birth by responsible midwives for medical reasons, etc — WILL transfer to unlicensed providers with different comfort levels or choose unattended birth. By no means do I mean to malign such choices; indeed I support each families right to reproductive choice in the matters, legally and philosophically, even if they are choices I would not make as a mother or as a midwife personally.
Let me review a few of my practice’s outcomes. Again, we are a large, well respected, primarily out of hospital group of CNMs. All of us have Masters, all have previously worked in hospital for significant amounts of time, we have practice guidelines mostly based on ACOG standard of care, we all have hospital privileges, and have strong relationships with our back up physicians. But in the past four months, we have had 4 neonatal deaths. HORROR! Screams the inelegant database and it’s followers. All four were Amish, two delivered in hospital and two at home (though all intended out of hospital) none desired prenatal ultrasound, all had the same congenital defect (EVC dwarfism), none consented to post mortem autopsy and all died soon after birth. Is that REALLY labeled a congenital defect / unpreventable death in the database, without diagnostic ultrasound or autopsy? Yet all had chest circumferences less than 11 cm, polydactaly, various other anomalies which are hall marks of this mostly lethal anomaly which burdens Amish families heavily.
I think of two other of our IP deaths potentially considered preventable. One was a grand multip with a known breech, scheduled for C/S at 39 weeks. (Though it should be said we all argued for sooner delivery given mom’s history of PROM with every delivery but the OB group refused). SROM’d at 38 weeks, went immediately to hospital, fatal undiagnosed cord prolapse. “Planned” home birth with her intake visit of course. Next one, 2nd baby, breech, scheduled for c/s – started labor, called midwife who was to meet her at hospital, delivered precipitously within 30 minutes of onset of labor, head entrapment unresolvable for 25 min by EMT – baby died of HIE at 3 days after life support removed. Of course, a literal home delivery (they got baby out eventually) and also a planned home birth before breech was known.
I just wish there was a way to streamline the data we’re talking about here so we can have a real conversation about relative risks. Presently I think it’s not that meaningful. Obviously we all know there can never be a “gold standard” study when it comes to birthing as no one will consent to randomization. And our data collection tools, for the reasons mentioned, are so far less than ideal. What’s the answer? How to truly compare apples with apples?
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My point, which I failed to make in the prior post is that all 6 of these deaths were labeled “potentially preventable” by our local Child Death Review Team. This review cannot occur by policy sooner than 12+ months after its occurrence. And ONLY the hospital births (exact same resuscitative care, same lack of diagnostic US or autopsy) were labeled “natural deaths”. THAT is bias, and that is our database to date. 😦
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You make an interesting point about “potentially preventable” death of an infant that had a lethal anomaly. We tend to malign those who fail to diagnose things promptly, even when that failure to diagnose has no impact on the final outcome. Is that fair? I’m mixed on it. Early diagnosis does lead to improved outcomes with many anomalies. When there is a significant fetal anomaly that goes undiagnosed, overall that’s a bad thing, even if it was an untreatable anomaly. I say that because until that baby is born, we don’t know what that anomaly really is, and in my physics ruled brain that baby is a veritable Schroedinger’s Cat. It isn’t anything yet – its either a severe anomaly or it isn’t. It could as well have been a transposition of the great vessels that would have required immediate intervention to survive.
I think if one chooses not to do antenatal anomaly screening one just takes those risks, and this is what some populations choose to do.
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I can’t wrap my brain around the Schroedinger’s Cat thing. Is it like saying a tree is both a tree and a table in potentiality?
I think the first step in improving the meaningfulness of birth outcome statistics is to remove all congenital anomalies from all data sets, which would seem obvious but it’s not always happening. I had a 4 hour old baby die after being born at home, transported at 1 hour for respiratory distress and in NICU with full care for 3 hours. Mom was GBS positive, ruptured 3 hours, and had two antibiotic doses at home. Cause of death was listed as “Sepsis” but three weeks later cord blood analysis revealed baby had a congenital syndrome that is ALWAYS lethal. But I’ll bet you that stat will be a strike against home birth in some future study.
You might be interested to read about some of the anomalies our families are burdened with here http://www.clinicforspecialchildren.org/CSC/Research.html This is literature from our local amazing and wonderful Clinic for Special Children run by the brilliant Dr. Holmes Morton.
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Thanks for your thoughts and detailed comments.
You make a lot of great points. There is a lot of heterogeneity in the population of women who seek out-of-hospital birth. Some avail themselves of the care of certified nurse midwives that typically takes all the safeguards an obstetrician would, and others choose to avail themselves of a care from folks that are of a more inconsistent level of training. I say ‘inconsistent’, as I think it is unfair to malign all direct entry / lay midwives, as I personally know a few who speak and understand the science of obstetrics as well as any physician I know.
You’re right that a part of the group that seeks out of hospital delivery may represent a greater risk than other parts. Its a tough thing to work out. There are also biases in the way outcomes are recorded, which was the point that Dr Grimes was making in the editorial we discussed this month.
It would be great if there were a definitive study, but there never will be. The populations are too heterogeneous, and the population we are most concerned about are very unlikely to record outcomes in an accurate and unbiased way. As Dr Grimes notes, such data collections strategies can result in poor data even when the data is produced at major research institutions.
I think the best thing to take from all of this is that even if there is a 3x relative risk of perinatal death in out of hospital births, the overall rate is extremely low. The choice of place of birth, while probably statistically linked to perinatal death, has a very small attributable risk associated with it. In these situations, other considerations may be more influential in the final decision.
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One other point…. you mentioned your group is made up of CNMs all of who have at least a Masters degree. Sounds like you have a really interesting and challenging practice. Dr F, I was surprised that the last podcast didn’t discuss the issue of midwife training in the European home birth data. My understanding is the European data looks at home birth with trained, educated midwives who have at least the equivalent of a bachelor’s degree. It seems if we are drawing conclusions from those studies we can only apply them to home deliveries attended by CNMs here in the US and not all of US midwives since their training is not anywhere near the same. However one interprets the studies you discussed it seems to me the conclusions only apply to home births in the European with a trained midwife and can not be generalized to home birth in general.
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