Tuesday, May 23, 2006

How do we determine an acceptable level of risk?

Everyone acknowledges that some situations are high risk and some are low risk. Risk, of course, exists on a continuum.

At what point do direct entry midwives and homebirth advocates consider that the risk in a situation justifies moving a woman from low risk to high risk? Is it a specific number (the chance of a problem in this situation is x%) or is it based on rules about particular situations? Why is it that some DEMs place certain women in the low risk group (postdates, for example), while obstetricians would consider them high risk?

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"Everyone acknowledges that some situations are high risk and some are low risk. Risk, of course, exists on a continuum.

At what point do direct entry midwives and homebirth advocates consider that the risk in a situation justifies moving a woman from low risk to high risk? Is it a specific number (the chance of a problem in this situation is x%) or is it based on rules about particular situations? Why is it that some DEMs place certain women in the low risk group (postdates, for example), while obstetricians would consider them high risk?"

Probably because this is a very personal decision. The ultimate conclusion of what is "high risk" and what is "low risk" depends DRASTICALLY on how you prioritize certain conditions. If I would rather die than be an invalid, for example, the traditional medical evaluation of "risk" for a procedure might be far from my own definition of "risk".

Similarly, if you put an enormously high value on "having a natural childbirth" or "not having an intervention" then this will, logicall, also affect your risk.

I think that the population served by midwives is, by and large, one who prioritizes risk differently from the medical folks. In particular, I believe they prioritize emotions at a MUCH greater level than physicians do.

This is certainly their choice. And actually, once you change your priorities your evaluation of the risks may be perfectly rational yet different from another person who uses different priorities.

All of these procedures, and all our recommendations, are based on assumptions. Sometimes they aren't stated, but to choose an example, it's usually assumed "better alive than dead". Of course, if that's NOT true for you, then you may not fit the recommendations in that circumstance.

That is why I (for example) am an utter pain in the ass as a patient: I understand the science perfectly well, to my doctors' dismay, but I do not trust anyone else to prioritize for me. Generally my risk tolerance matches the population, but not always.

That is also why I support a woman's ability to choose home birth. If she has a different apportionment of risks and different tolerances, it may be a perfectly rational decision EVEN THOUGH the risk of neonatal mortality is slightly increased. (my only protest comes from the issue of informed choice regarding that increase in risk).

By Blogger sailorman, at 4:00 PM  

"That is also why I support a woman's ability to choose home birth. If she has a different apportionment of risks and different tolerances, it may be a perfectly rational decision EVEN THOUGH the risk of neonatal mortality is slightly increased. (my only protest comes from the issue of informed choice regarding that increase in risk)."

I had decided that I was going to bow out of this debate for awhile, but I can't help myself...

I had an epiphany earlier today. The major reason I haven't been able to agree with Dr. Amy's conclusion that hospital birth is safer than homebirth is because I disagree with the premise that neonatal mortality is the best or only indicator of safety. I would be convinced if you could show me significantly different outcomes in infant and maternal mortality AND morbidity. Another huge concern of mine, being a mother who anticipates having a large family, is the threat of c-section and the increased risk to my future children.

I have other objections to some of the premises laid out from which Dr. Amy is drawing her "facts", but her definition of safety is my primary one. Based on my criterea for safety, I believe one can reasonably say that homebirth is "safe".

Sailorman, as to your question about informed consent, I think that you will find that homebirth mothers are in general some of the most informed women you will meet. I haven't met a single one that doesn't acknowledge that there are some catastrophies that could happen at home in which it is likely that a hospital would be a better place. But, on balance, they decide that the risks of being in the hospital outweigh the risk of being at home. Most of these women have analyzed the different kinds of risks up, down and sideways and take responsibility for what those risks are. They don't simply read the statement made by many homebirth advocates that "home birth is as safe or safer than hospital birth" and then just say "Oh, ok... let's do it... this'll be way cool!" No, they analyze the risks and then decide what to do.

I appreciate that you think it is a woman's right to make the decision. Many OB's don't agree with that point of view.

By Blogger Mama Liberty, at 5:15 PM  

And a related question: what's the relative importance of possible outcomes? We agree that a live baby is of prime importance, but my feeling throughout this discussion has been that you place less importance on other facets of birth than many of the rest of us do.

Say, live baby = 1000 points. My perception is that on the Amy Tuteur scale everything else is in the small single digits. Forceps delivery and immediate resuscitation of a limp baby? If you got a live baby out of the deal, don't kvetch about it -- it's only one point. Fourth-degree tear and a couple of years of painful sex? If you wound up with a live baby, don't kvetch about it -- one point.

On my personal scale, live baby = 1000 points too. But what if I say that freedom to choose my position and location for second stage = 10 points? What if continuous care from a single trusted provider = 20 points? What if I assign 2 points to the freedom to make noise without being hassled about it?

Live baby is by far the most important outcome, and yet it's not the only outcome. Wiegers et al. attempted to address this with their perinatal outcome index, but you rejected it as a measurement strategy, preferring to focus exclusively on mortality.

By Blogger Jamie, at 5:31 PM  

Mama Liberty and Jamie:

I think you misunderstood the subject of this particular post, or, more likely, I didn't make myself clear.

I was not speaking in this instance about whether homebirth is safe or safer. I was asking how midwives decide what is low risk and what is high risk? I'm sure that things at the extremes are easy; no DEM is going to try to manage eclamptic seizures. What I am curious about is why some DEMs think that postdates (or breech, or twins) require hospital delivery and others do.

As far as my personal judgment of balancing morbidity and mortality for myself and my children, I was very clear with my obstetrician that I was very willing to have a C-section if necessary (or even if a problem were only suspected) and that under no circumstances would I allow forceps. As far as risk distribution was concerned, I told the obstetrician that to the extent that any potential risk developed during labor, I would rather take the risk on myself, then put it on the baby.

By Blogger Amy Tuteur, MD, at 6:23 PM  

"Sailorman, as to your question about informed consent, I think that you will find that homebirth mothers are in general some of the most informed women you will meet."

Mama liberty, I fear you may find this rude. But the truth is that the midwives here have, by and large, seemed to me to be some of the LEAST informed people I have discussed this with--to the extent that they are "informed", they are trusting problematic sources.

And I think that comes through in their statements. You may CLAIM you believe in informed consent. But I do not think, actually, that you are really giving your poatients proper information. I do not think you are giving it in an unbiased manner. In effect, I believe you are doing the exact same thing that you so often accuse the medical community of doing.

"I appreciate that you think it is a woman's right to make the decision. Many OB's don't agree with that point of view."

Oh, OBs think it's her RIGHT. They just think that most women who make the decision--especially if they only get their "advice" and "evidence" from midwives--are doing so on incorrect data. It's their job to challenge that.

Jamie:
Great! Let's get all of you to admit that home birth is less safe in terms of neonatal death, then. You are willing to admit that, right? Because that's what we've been discussing. And I notice you have not responded to many of my posts asking you to explain what (if anything) would change your mind.

If you want to claim that hospital is higher risk in terms of forceps deliveries (for example) or vacuum deliveries, you'll get no problems from us. Those things are true. Just stop lying about the neonatal death part.

By Blogger sailorman, at 6:32 PM  

"I was not speaking in this instance about whether homebirth is safe or safer."

Sorry, I was commenting on Sailorman's post, not your question. I'll comment more on your questions later.

By Blogger Mama Liberty, at 7:01 PM  

Sailorman, I am not a midwife. I am a homebirthing (formerly hospital birthing mother). I gave OBs two chances and decided to give midwives a go the third time around. I couldn't be happier and my baby couldn't be healthier! My comments are based on my observations and interactions with my peers, not from the midwife/client perspective.

It hasn't been my experience that OBs think a woman has a right to decide on a homebirth. They have consistently opposed (and won) every legislative attempt to allow midwives to practice at home in my state since 1983. They have also successfully prevented CNMs from practicing to the extent they are trained for even in the hospitals.

Danielle

By Blogger Mama Liberty, at 7:10 PM  

acceptable risk can be decided only by the client (patient), and with true informed consent.

By Anonymous Anonymous, at 7:11 PM  

Sailorman said:
Let's get all of you to admit that home birth is less safe in terms of neonatal death, then. You are willing to admit that, right?

I say:
Nope. You and Amy are sticking to that narrow definition of 'safe'. I don't agree that neonatal death is the only consideration when determining 'safe'. However, even when taking that very narrow definition... I have seen your arguements... and I don't agree. Neither to the authors of the papers you get these #s from.

By Anonymous Anonymous, at 7:22 PM  

Amy said:
I was asking how midwives decide what is low risk and what is high risk? I'm sure that things at the extremes are easy; no DEM is going to try to manage eclamptic seizures. What I am curious about is why some DEMs think that postdates (or breech, or twins) require hospital delivery and others do.


I assume you intended to say why some DEMs think postdates require hospital delivery and others don't.
I think DEMs work in partnership with their clients, so that the client has an equal say in the determination of risk.

I have never had a breech baby. But I know my midwife has delivered over 100 vaginal breech babies in her collective experience (both here and overseas)with no bad outcomes. I highly respect her knowledge in this area. I do NOT trust a young OB in a hospital who has never had any training in vaginal breech, but instead sections all breeches. Some of the older OBs (perhaps Amy included) still know how to deliver a breech. But that knowledge is fast disappearing in obstetrics today.

If I was 38 weeks today with a breech baby, I'd start looking for a provider with lots of experience and confidence in vaginal breech birth, Midwife or OB.

I think the same can be said of any of those sticky situations where you risk goes hand in hand with management.

By Anonymous Anonymous, at 7:34 PM  

Great! Let's get all of you to admit that home birth is less safe in terms of neonatal death, then. You are willing to admit that, right?

No, Sailorman, I disagree. And I'm surprised here -- I thought we agreed on J&D's neonatal mortality outcomes (1.7 (incl. congenital anomalies) < 2.4). Do you mean intrapartum plus neonatal again?

Because that's what we've been discussing. And I notice you have not responded to many of my posts asking you to explain what (if anything) would change your mind.

Have I left lots of questions from you floating unanswered? Not my intent. I know you asked me down below about what would change my mind. I'll get back to you tonight about that question. You requested an "excruciatingly clear" response, which is easier with the kids in bed.

By Blogger Jamie, at 9:15 PM  

I have a wakeful toddler here, but I am going to try to type around him. You asked me: What would convince me that homebirth was less safe than hospital birth?

I answered this question in the thread that has now dropped off the page: new research. We agree that RCTs aren't going to happen, right? It wouldn't be ethical to randomize birth site, correct? But if large well-designed studies showed a statistically significant difference (p=0.01, I'll say) in deaths for babies born at home, that would carry a lot of weight with me.

Here are the premises I'm starting from -- you may draw different conclusions if you're starting from a different spot.

1. If you have an epidemiological question, ask an epidemiologist. I have not been able to unearth any controversy about homebirth in the public health community. There are no epidemiologists here in this discussion. This is Dr. Amy's Amateur Epidemiology Hour. It's fine as far as it goes -- I've learned some things and it's been interesting if occasionally maddening -- but no one here has any epidemiological credentials.

2. If you're going to rewrite a study from a respected peer-reviewed journal, you need to make a good case. I don't see a motive for researchers to try to "suppress the truth" about homebirth. As far as I can tell, there is no mighty CPM contingent putting the kibosh on anti-homebirth studies. (Attention, Dan Brown! There's a new novel waiting to be written here!) If you guys wanted to pick apart a couple of outlier studies showing unexpectedly good results for homebirth, I'd be more sympathetic to your point of view. But the question I asked Dr. Amy remains unanswered: where are the studies in which the authors agree with you about their results? (BTW, Sailorman, do you think the Pang study is ridiculous? I am going to be disappointed if you don't take it apart with a comparable level of disdain, okay?)

I have asked a number of times to see an objective source in support of the methods used here to critique a study. I'd like to see a definition of IUFD vs. IP death, which is central to Amy's critique of the Murphy & Fullerton study. A statement from the public health literature on inclusion/exclusion of congenital anomalies in comparing birth choices. Good data on intrapartum mortality in hospitals to support Amy's contention that the numbers are "vanishingly small." So far, nothing.

As far as I can tell, there have been no retractions of any of these studies in the journals that published them. Have there been accusations of dishonesty against these authors? Is there some sort of cloud hanging over their work that I'm unaware of? I'm looking at a body of research here, and if it's necessary in every case to redefine terms, redo calculations, and revise conclusions to get the studies to tell "the truth," then I am skeptical about that "truth."

3. Precision matters. Amy, you'd have more credibility in my eyes if you talked about risks and benefits of both home and hospital birth. It is lopsided and inaccurate to look exclusively at risks of homebirth and benefits of hospital birth. Like with the Janssen study, when you mentioned the women who suffered obstetric shock following a homebirth but glossed over the major maternal morbidities in the hospital group. So, yeah, I'd rather not hemorrhage to the point of shock. But -- maybe I'm being demanding here -- I'd also rather not have my uterus tear itself open or FALL OUT OF MY VAGINA, complications observed only in the hospital group.

On a related note, you guys keep talking about neonatal mortality when you seem to mean intrapartum plus neonatal mortality, or maybe antepartum plus intrapartum plus neonatal mortality. It doesn't make sense to compare the Durand mortality numbers (antepartum plus intrapartum plus neonatal) to neonatal numbers alone. And it really doesn't make sense to say they should have been some arbitrary fraction of the neonatal numbers.

The bottom line for me is that the safety of homebirth doesn't seem to be in dispute except among obstetricians, who typically don't have experience with homebirth and who seem inclined to underestimate the risk of iatrogenic complications. If Marsden Wagner comes out with a statement tomorrow that he overlooked some important problems with the data during his 15 years as director of women's and children's health for the WHO, and out-of-hospital birth isn't as safe as it appeared to be -- I assure you I'll take that very seriously. If a researcher mounts an informed critique of Peter Schlenzka's dissertation (he's the one who said, "...apparent disadvantages of the obstetric approach have such large order of magnitude, that in any clinical trial it would be considered unethical to continue with the obstetric treatment"), I'll pay close attention.

But here on this blog it seems to be you and Amy and maybe a mouse in her pocket saying that these diverse authors in diverse publications are all overlooking fatal flaws in their research and clearly they meant to conclude the opposite of what they actually concluded.

And that's why I'm not convinced.

By Blogger Jamie, at 12:09 AM  

Jamie,
I'd like to thank you for the above post. It was clearly written, and concise. I think it pretty nicely sums what it would take to change my mind.

PS
I'd also really like to see sailorman discuss the Pang study.

By Anonymous Anonymous, at 12:32 AM  

"or is it based on rules about particular situations? Why is it that some DEMs place certain women in the low risk group (postdates, for example), while obstetricians would consider them high risk?"

has to do with what we have read or experiences. how were the dates arrived at? what is the couple's birth pattern -
as I understand it risks if mapped out make a U shaped curve births at 38 weeks have a similar risk as 42 weeks it is after 42 weeks when the risk rise-- so why are docs delivering at 41 weeks or some at 40 weeks 1 day
and some how I think you believe that there is no differing opinion in the obstetric world- that all doctors who deliver babies believe that they should be born before 42 weeks. or any other risks that there are not differing opinions on those subjects-

here are some interesting bits of info to add to the mix
Pediatrics. 2003 Jun;111(6 Pt 1):1367-71.

Risk of sudden infant death syndrome and week of gestation of term birth.

Smith GC, Pell JP, Dobbie R.

Department of Obstetrics and Gynaecology, Cambridge University, Rosie Maternity
Hospital, United Kingdom. gcss2@cam.ac.uk

OBJECTIVE: We sought to determine if the risk of sudden infant death syndrome
(SIDS) varied according to week of delivery at term among elective and
nonelective births. DESIGN: Retrospective cohort study. PARTICIPANTS: All single
infants live born between 37 and 42 weeks gestation in Scotland between 1992 and
1995 documented in the Scottish Morbidity Record. OUTCOME: Death in the first
year of life where SIDS was in the principal position on the death certificate.
RESULTS: There were 202,622 eligible births and 119 deaths attributed to SIDS.
Among infants delivered electively, there was no significant association between
risk of SIDS and week of delivery. Among those delivered nonelectively, the risk
of SIDS declined significantly with each week of gestation (odds ratio .72, 95%
confidence interval .60-.86). This trend was only minimally attenuated by
adjustment for maternal age, parity, smoking and socioeconomic deprivation
category, infant sex, Apgar score, mode of delivery, and birth weight decile
(adjusted odds ratio .78, 95% confidence interval .65-.93). CONCLUSIONS: We
hypothesize that early spontaneous labor at term and SIDS may be linked because
of a common association with suboptimal intrauterine environment.

Publication Types:
Multicenter Study

PMID: 12777554 [PubMed - indexed for MEDLINE]
-------------------------------------------
Am J Obstet Gynecol. 2006 Apr;194(4):992-1001.

Accuracy of obstetric diagnoses and procedures in hospital discharge data.

Yasmeen S, Romano PS, Schembri ME, Keyzer JM, Gilbert WM.

Department of Obstetrics and Gynecology, University of California, Davis, School
of Medicine, Sacramento, CA 95817, USA.

OBJECTIVE: The objective of the study was to estimate the validity of obstetric
procedures and diagnoses in California patient discharge data. STUDY DESIGN: We
randomly sampled 1611 deliveries from 52 of 267 California hospitals that
performed more than 678 eligible deliveries in 1992 to 1993. We compared
hospital-reported procedures and diagnoses against our recoding of the same
records. RESULTS: Cesarean, forceps, and vacuum delivery were accurately
reported, with sensitivities and positive predictive values exceeding 90%.
Episiotomy was underreported (70% sensitivity). Cesarean indications were
reported with at least 60% sensitivity, except uterine inertia, herpes, and long
labor. Among comorbidities, sensitivity exceeded 60% for chorioamnionitis,
diabetes, premature labor, preeclampsia, and intrauterine death. Sensitivity was
poor (less than 60%) for anemia, asthma, thyroid disorders, mental disorders,
drug abuse, genitourinary infections, obesity, fibroids, excessive fetal growth,
hypertension, premature rupture, polyhydramnios, and postdates. CONCLUSION: The
validity of hospital-reported obstetric procedures and diagnoses varies, with
moderate to high accuracy for some codes but poor accuracy for others.

PMID: 16580288 [PubMed - indexed for MEDLINE]
----------------------------------------
Obstet Gynecol. 2006 Apr;107(4):880-5.

Maternal and paternal influences on length of pregnancy.

Lie RT, Wilcox AJ, Skjoerven R.

Medical Birth Registry of Norway, Locus for Registry Based Epidemiology,
University of Bergen, Norwegian Institute of Public Health. rolv.lie@smis.uib.no

OBJECTIVE: Biological evidence suggests that both mother and fetus are involved
in triggering a normal delivery. A tendency of a child to have a gestational age
at birth similar to the father's could represent the effect of genes passed from
the father to the fetus. Similar tendencies between mother and child could
represent maternal genes passed to the fetus, as well as genes to the mother
received from the grandmother that affect a woman's capacity to carry a
pregnancy. METHODS: The Medical Birth Registry of Norway contains data on all
births in Norway from 1967 onward. We identified 77,452 pairs of boys and girls
born at term who later became parents and linked their birth data to the birth
records for their first child. RESULTS: Gestational age of the child at birth
increased on average 0.58 days for each additional week in the father's
gestational age (95% confidence interval 0.48-0.67) and 1.22 days for each
additional week in the mother's gestational age (1.21-1.32). Gestational age
was, however, 0.65 days reduced for each additional kilogram in the father's
birth weight, presumably due to more rapid growth of the fetus triggering
delivery. CONCLUSION: Initiation of delivery has a fetal component that is
heritable (passed from father and mother to child) and an additional maternal
component that is also heritable. In addition, a more rapid rate of fetal growth
appears to trigger delivery at earlier gestation. LEVEL OF EVIDENCE: II-2.

PMID: 16582127 [PubMed - indexed for MEDLINE]
----------------------------------
http://www.pubmedcentral.gov/articlerender.fcgi?tool=pubmed&pubmedid=12609943

By Anonymous Anonymous, at 2:48 AM  

I see the three papers. What are you suggesting that we should conclude from these papers?

By Blogger Amy Tuteur, MD, at 6:37 AM  

Jamie said:
1. If you have an epidemiological question, ask an epidemiologist. I have not been able to unearth any controversy about homebirth in the public health community. There are no epidemiologists here in this discussion.


OK, let me be excruciatingly clear. If I find a epidemiologist to look at the studies we have been discussing, and s/he explains the faults in the statistics, you'll change your mind? That's it?

Please let me know, before I go looking for someone to review things.

2. If you're going to rewrite a study from a respected peer-reviewed journal, you need to make a good case. I don't see a motive for researchers to try to "suppress the truth" about homebirth. ...(BTW, Sailorman, do you think the Pang study is ridiculous? I am going to be disappointed if you don't take it apart with a comparable level of disdain, okay?)

First of all, I think you may be overrwting the "peer review" process and ascribing too much weight to it.

Which one's the Pang study again? Post a link, if you have one... I'm happy to disassemble and explain the faults in any study, at least in theory.

I admit I tend to focus on the home birth studies for the moment, mostly because 1) nobody on the home birth side will do it; 2) many people on the home birth side don't seem capable of doing it; and 3) they are the ones being presented for argument.

But as you can easily see from my responses to some posts here, I apply my analysis equally to each side. When something comes up which is problematic, I'll talk about it. And I have.

This is a really strange non sequitur. I am amazed you are really bringing this up at all. We have been MUCH MUCH more willing to discuss and acknowledge any problems with hospital birth than you or your cohorts have been with home birth.


I have asked a number of times to see an objective source in support of the methods used here to critique a study.

But of course, if it supports those criticisms, you won't think it's objective.

Oddly enough, I AM objective: I'm not an OB, I don't work in the field, my wife has delivered with 2 midwives, my various family members have had successful home births. I am NOT involved in the discussion because I have anything against home birth per se. I am involved in this discussion solely because I hate people who misrepresent facts or data, especially in the science arena.

I believe precision is crucially important, and as soon as I see someone making conclusions like "both A and B are safe" = "A and B are equally safe" I jump in. I spend a lot of time argiung with creationists and a lot of anti-science folk, so it has been both interesting (and depressing) to find many of those attitudes and methods of arguments among health practitioners.

I'd like to see a definition of IUFD vs. IP death, which is central to Amy's critique of the Murphy & Fullerton study.

I am sure we can provide you with one.

A statement from the public health literature on inclusion/exclusion of congenital anomalies in comparing birth choices.

Jamie, you are missing something. Because you don't seem to understand how a good sttudy is designed, you're constantly looking to other sources for help. But you don't NEED other sources. The best decisions are made on the raw data and the theory involved, not someone else's filtering of the raw datas for your convenience.

When you start citing csources and refusing to talk about the data, it's impossible to have a conversation. After all, it's not as if you're bringing your sources here so we can talk to them--which I would be happy to do, BTW, if you want to round up a few of the researchers and bring them here to defend their work.

Good data on intrapartum mortality in hospitals to support Amy's contention that the numbers are "vanishingly small." So far, nothing.

As far as I can tell, there have been no retractions of any of these studies in the journals that published them.

This almost NEVER happens. Just FYI. The lack of a retractio ndoesn't show anything.

Have there been accusations of dishonesty against these authors? Is there some sort of cloud hanging over their work that I'm unaware of?
I am not sure.

I'm looking at a body of research here, and if it's necessary in every case to redefine terms, redo calculations, and revise conclusions to get the studies to tell "the truth," then I am skeptical about that "truth."

Really? Is it a matter of sheer numbers? This is probably an issue of training. You ALWAYS ALWAYS have to read the study, or as my teachers would say, "read the goddamn data yourself". Trust nobody.

3. Precision matters. Amy, you'd have more credibility in my eyes if you talked about risks and benefits of both home and hospital birth.

May I say something? Holy shit. If precision matters, you folks lost the argument back on Page 1. Do you seriously want to get into accusations of imprecision? Do you want to go into the hundreds of times people have cited studies they haven't read, data which didn't apply; do you want to talk about people's constant misstatements of conclusions?

Sigh.

It is lopsided and inaccurate to look exclusively at risks of homebirth and benefits of hospital birth. Like with the Janssen study, when you mentioned the women who suffered obstetric shock following a homebirth but glossed over the major maternal morbidities in the hospital group. So, yeah, I'd rather not hemorrhage to the point of shock. But -- maybe I'm being demanding here -- I'd also rather not have my uterus tear itself open or FALL OUT OF MY VAGINA, complications observed only in the hospital group.
It's not lopsided at ALL, which is something you seem ENTIRELY unable to understand.

This conversation has ALWAYS BEEN about neonatal death trates. THAT'S IT. It hasn't included morbidity, it hasn't included maternal death, it hasn't included the number of fathers who faint.

And limiting it that was is PERFECTLY OK. Why? Because we are capable of splitting things--that's how you study them! And we understand that just because something is "better" in one respect doesn't mean it's "better" in all respects. That is why we ARE precise. That is why we ARE spending all these hours crafting cafreful, accurate, statements of limited fact.

oops, gottas go work. more later.

By Blogger sailorman, at 9:38 AM  

"This conversation has ALWAYS BEEN about neonatal death trates."

By "this conversation", do you mean the whole blog? Because I've read every post and there have been many more issues raised than neonatal mortality. My understanding of Amy's position is that she believes midwives, in paricular direct entry midwives, to be wholly incompetent and that home birth is an irresponsible and uninformed decision. (Amy, please correct me if I'm wrong).

I am open to the possibility that there may be a slightly lower neonatal death rate in the hospital. But that doesn't prove or disprove the statement that homebirth advocates make that "homebirth is safe".

By Blogger Mama Liberty, at 2:47 PM  

Mama Liberty said...
By "this conversation", do you mean the whole blog? Because I've read every post and there have been many more issues raised than neonatal mortality.


In MY opinion (I don't speak for the Doc)? Yes. The issues have been raised almost entirely by midwives. Though we have--as was necessary--responded to those issues, we've really limited it to what I described.

My understanding of Amy's position is that she believes midwives, in paricular direct entry midwives, to be wholly incompetent and that home birth is an irresponsible and uninformed decision. (Amy, please correct me if I'm wrong).

I believe you are partially correct.

She (and I) believe DEMs are, generally, LESS competent than other, more highly trained, care providers. She also appears to belive, like I do, that on a general level, DEMs are below what one shoudl consider "adequate" in terms of providng care.

Our beliefs regarding home birth being uninformed stem almost entirely from the apparent failure of almost all midwives here to have read the data on which they base their beliefs, and their apparent failure to accurately summarize it for their clients.


I am open to the possibility that there may be a slightly lower neonatal death rate in the hospital. But that doesn't prove or disprove the statement that homebirth advocates make that "homebirth is safe".

No, it does not. That's why we have never said that. In fact, if you had an easy way to search my comments here, you'd see that I've probably made this point 10 times: "safe" and "as safe" (or "less safe") are NOT the same.

I would be entirely happy if the homebirth stance were "It's less safe than the hospital, but still pretty damn safe, and a good choice for many women".

I suspect Dr. Amy would agree.

By Blogger sailorman, at 3:44 PM  

Sailorman said: I would be entirely happy if the homebirth stance were "It's less safe than the hospital, but still pretty damn safe, and a good choice for many women".

I suspect Dr. Amy would agree.


but earlier ...

Amy said: However, if a homebirth midwife told you that homebirth is as safe or safer than hospital birth, she told you something that isn't true.

So I guess not.

By Anonymous MetroMidwife, at 7:34 PM  

I'm a "moderate" risk mother.
Primary c/s for single footling breech. Two homebirths later... I thankful for the Provincially funded midwifery care I received!
My level of acceptable risk was
IF I go to the hospital, I CAN be sectioned again out of fear.
WHEN I stayed home with my fully trained midwives and IF I ended up transferring, it will be for something REAL. And IF a c/s is needed, it will not be for convenience or fear.
Despite a transfer of my daughter to the hospital after her birth... *my midwives were more competantly trained than the six emt's the 911 dispatch sent out within four minutes... says something for the medical training now doesn't it?* She was treated by a neonatal neurologist who agrees that had I been in hospital, the outcome would have been disasterous. A doctor , a neo natal physician (!) agrees with homebirth. HUH?! Guess there are physicians who play nicely with midwives and learn from both "medical" communities.
Amazing isn't it?

By Anonymous Anonymous, at 11:18 AM  

Metro,

Have you even read those? They don't contradict each other.

(teaching hat on)
We are trying to be very, very, very, exact here. We are trying say EXACTLY what we mean. You should try to do the same
(teaching hat off)

Here, I'll show you:

"It's less safe than the hospital, but still pretty damn safe, and a good choice for many women".

What does this statement mean? Well, you could draw TWO and ONLY TWO conclusions from it:
1) home birth is LESS safe than the hospital; and
2) home birth is reasonably SAFE (which is a judgment call, not a testable statement).

Now for Dr. Amy:
"However, if a homebirth midwife told you that homebirth is as safe or safer than hospital birth, she told you something that isn't true."

You can draw ONE and ONLY ONE conclusion from this:

1) Home birth is less safe than hospital birth.

And guess what? The #1 conclusions AGREE!!! The #2 conclusion in my statement isn't addressed at all by Dr. Amy, though I assure you it is elsewhere in this blog. And she agrees.

Look, I try REALLY hard not to get snippy. But

-if you're not going to pay attention, and
-you're not capable of reading two sentences and accurately summarizing them, and
-you're goint to misstate our sentences,

then dammit I start to get pissed.

I spend a lot of time writing--and editing--my posts for accuracy, to make sure they say EXACTLY what I mean. Could everyone else pay the same respect?

By Blogger sailorman, at 11:24 AM  

"my midwives were more competantly trained than the six emt's the 911 dispatch sent out within four minutes... says something for the medical training now doesn't it?"

Yes, it does. It says that transfer to a hospital during a homebirth gone wrong is NOT as safe as delivering in the hospital.

"She was treated by a neonatal neurologist who agrees that had I been in hospital, the outcome would have been disasterous."

Really? I'd like to know more about that. What, specifically, was your daughter's problem? Why couldn't the homebirth midwife manage it? What did the hospital do that the midwife could not do? What specifically did the neurologist say that led you to believe that the situation would have been worse in the hospital despite the fact that the problem could ONLY be treated in the hospital?

By Blogger Amy Tuteur, MD, at 11:27 AM  

Have you even read those? They don't contradict each other.

Yes I did read them and yes, to me they contradict.

Now for Dr. Amy:
"However, if a homebirth midwife told you that homebirth is as safe or safer than hospital birth, she told you something that isn't true."

You can draw ONE and ONLY ONE conclusion from this:

1) Home birth is less safe than hospital birth.


Did you miss the part where she didn't say anything about it being a good choice for anyone? I don't believe anywhere on this blog she has said that. She remains open to the idea that women are free to risk their lives and those of their babies, but I can't recall a single place where she has said what you do.

then dammit I start to get pissed.

Wooooooo!

I spend a lot of time writing--and editing--my posts for accuracy, to make sure they say EXACTLY what I mean. Could everyone else pay the same respect?

We all take care to write what we mean, however you have no control over how the comments are interpreted.

By Anonymous MetroMidwife, at 11:53 AM  

Dr. Amy, I am the anon right after Clark Bartram in the first thirty posts on the HOME debate at neo natal doc. There was NOTHING my midwives couldn't handle... and seeing as you missed or didn't happen to interpret it properly. THE MEDICAL PERSONNEL WERE NOT TRAINED, NOR HAD THE EQUIPMENT TO DEAL WITH THE NON-EMERGENCY. She was transferred for the simple reason that we ALL felt it would be best to have someone check her over. Midwives work within the medical community here... I know it is very different in your country. Sad, but true. The ONLY thing my midwives could not have done, was order one of the blood/gas (? I'm sorry I do not have the file on me right now) tests the nnn concurred would be good to run. The nnn agreed that the delay in delivery from epidurals, positioning of mom (prefering to have them on their backs, in order to "catch" baby in the most convenient way for Dr.) and quick response from having properly trained individuals right there was the best situation. In the hospital that this person works at, a call to a nnn would have been a five to ten minute delay to get them to the room. Granted the OB's may have done everything the same, but perhaps that isn't part of the job description? Usually you pass off a baby to someone else right? With my child, she showed NO problems at all until she was out. So, there would have been a panic and a call and a wait for someone. IF I'd been within the medical system. Those lucky enough to have midwives, would have the same situation as me... only in a hospital (full rights to admit, deliver and discharge). Either way, it worked out that the medical system would have scarred me further had I stuck with them. And I wouldn't have even had my third child after the 2nd c/s...
I apologize for not making it clear, there was no "emergency". Everything was handled calmly and effeciently, my daughter is just fine.
Don't you fret... the nnn has been reading all this ... dialogue? well whatever we want to call it. So far this person is less than impressed with the examples of neo-natology the blog world is portraying.
Of course I have doubts I could make you believe this. It is enough to know that at least their are reasonable people in the medical community out there. Few and obviously far between.

By Anonymous Anonymous, at 1:33 PM  

Okay, Sailorman, let me try to respond to your comment back to me. Let me know if I leave out anything important, because that's not my intent.

A couple of little things first: I didn't bring up morbidity to take the focus off mortality. Amy brought up morbidities when she first mentioned the Janssen study, but she only mentioned the outcomes for which homebirth compared unfavorably. That's why I was grousing about precision. If we're going to talk about mortality, let's talk about mortality (and let's specify, please, which combo of antepartum, intrapartum, and neonatal we're talking about when). If we're going to talk about the bigger picture, that's great by me. But let's talk about risks and benefits of both home and hospital, not risks of one and benefits of the other.

The Pang study was not just about hospital birth; it's a study of homebirth vs. hospital birth that was discussed quite a bit at Neonatal Doc's. It's linked in the sidebar here, and if you're interested in others' critiques of it I have links to Faith Gibson's and Henci Goer's in the post on my blog called "Risks and Outcomes." I am looking forward to your thoughts on it. (Hey, who else is reading this thread? Let's start a pool to predict how many times Sailorman says "Kee-rist" in his critique of the Pang study. I'll pick two.)

And now the meatier questions you raise: I guess in reading the studies I'm mindful of what I don't know about assessing birth outcomes. I know that I can ask better questions about the professional literature in my own field now than I could as a grad student or as a less experienced practitioner. It seems unlikely to me that I, as a newcomer to the research on birth choices, could rewrite the conclusions of a body of studies. A couple of bad ones? Sure. All of the studies that describe homebirth as a safe option for low-risk women? Not so fast.

Before you jump in to distinguish btw "safe" and "as safe as," I hear what you're saying on that point. But it would be pretty poor public health decision-making to say "safe except for the extra dead babies part." If you turn up statements from public health associations opposed to homebirth, I will be most intrigued. I haven't been able to do so.

Oh, you mentioned retractions -- I know full retractions are unusual. But in my professional journals, corrections are not uncommon, and neither are letters arguing about methods and definitions. The only real argument I've seen in the literature on homebirth is the back-and-forth I linked to...um...several threads ago. Did you see it? In the BMJ? There was a doctor who wrote in to say hospitals were safer than home and the unanimous response, from writers in different fields, was "Don't be a rockhead." (Pardon the paraphrase.)

If Murphy and Fullerton misclassified IP deaths as IUFDs and understated the mortality rate as a result, that's important. Why hasn't anyone complained about it? Where's the correction?

Why is our computer making such wretched noises when it is only a year old? Can anyone tell me that? I think I should finish this in haste but just let me know if I've left bases uncovered.

Bottom line: I find the apparent consensus on homebirth compelling. A single epidemiologist saying, "No, it's not a good idea" would not cause me to say, "Okay, I'll never do it again," but I would give his opinion a lot of weight. FWIW, I ran the question by the one guy I know who's an MD, MPH and he referred me to Johnson & Daviss and the Cochrane reviewers. (He did also ask if ACOG had a statement. He's a pediatric researcher, with no real interest in birthplace choices as long as babies get vitamin K.)

Anyway, a shift in the epidemiology/public health POV is what I'd need to see to call homebirth less safe than hospital birth.

By Blogger Jamie, at 12:16 AM  

"But it would be pretty poor public health decision-making to say "safe except for the extra dead babies part."

I think this mistake may be underlying the root of our disagreement. It can be very good public health policy to promote home birth, even if it is less safe than hospital birth.

Public health policy looks for overall improvement. And as you may have heard many places, "perfection is the enemy of the good."

Say you're a public health official, and you look at home birth. You realize that right now, the population you're concerned about is getting almost no prenatal care, is delivering in some nonsterile locations wihout any good professional help, and has extremely high infant mortality.

You need to tell them what they "should" do. Now, perhaps you've read the studies, and you think hospital birth is slightly safer--let's pretend for a moment that it is safer by 1 death in 1,000 births. That's significant, but not hugely so (for example, the black/white difference in the US is around 5/1000).

The "compliance" problem. If you tell everyone "go to the hospital" you don't think your compliance rate will be high. Perhaps there are few hospitals, and your population can't get there easily. Perhaps your local hospitals are overfilled. Perhaps the member of your popoulation distrust doctors. Perhaps (and this is a VERY BIG factor) they simply can't afford it. And if they don't cmoply wih your recommendations, they'll stick with the current, unsafe, method they are using now.

If you think that your population WILL comply if you advise home birth, but will NOT comply if you use hospital birth, it's clear as day that you should be advising home births.

The "only so much money" problem. Money is crucial. Remember that you're thinking about the OVERALL health of your popoulation. So if they're poor, you might well rather advise them to go to a home birth (and "lose" 1/1000 deaths) but if that saves them enough money to feed the infants properly, or it means they can afford to buy prenatal vitamins, you're better off in the long run even if home birth itself is less safe

That's why the public health argument isn't really the best way to go here. They are taking a VERY broad look at health and infant mortality.

Not incidentally, that's also why Dr. Amy and I don't dislike home birth in general. It is far, far, cheaper. And it is far, far, safer than many alternatives. In fact, if you consider the monetary costs of a normal hospital birth, it's quite possible that home birth for all low risk infants is perferable to hospital births. Sure, you may lose a few infants at birth. But if you're saving a clean $1000 per head and you spend that elsewhere on public health, you may come out ahead.

Anyway, that's long--but homefully a good explanation of why the views of places like the WHO are NOT determanative on the very limited question which we have been discussing.

SO perhaps my question is moot.

I think I could probably find some epidemilogist and ask them to look at a couple of studies. If they were a statistics hound they would be able to discuss the issues. (Of course, analyzing the fine details of studies isn't really what they DO, but they could probbaly manage)

But now it seems like you want to change the goalposts, to use a common term from the ID debates. From what I uderstand you need either an epidemilogist to tell you home birth is a bad option, or you need a wholesale swing in the current public health field.

Do you understand how that's not really the same thing we've been talking about? At ALL?

By Blogger sailorman, at 10:17 AM  

Twice now in this particular reply thread Sailorman has taken the liberty of speaking for Amy in his statements that home birth might be a good choice for some families. Is her lack of personal reply to the contrary to be interpreted as acknowledgement that home birth might be a good choice for some families?

And here's to hoping Sailorman has taken his anti-snippy pill this morning :)

By Anonymous MetroMidwife, at 1:47 PM  

Why yes, I did have three (!) cups of coffee. And I'm not feeling snippy at all. Hmm, wonder if that's related...

Metro, search the comments.

I will stop speaking for Dr. Amy--it's rude (sorry, Doc!)--but I believe that you will be able to find the answer on your own.

By Blogger sailorman, at 2:48 PM  

As you probably figured out by now, I am not shy. If I thought that Sailorman was misrepresenting me, I wouldn't hesitate to point that out.

Homebirth is a perfectly reasonable option for some women as long as they have accurate information about the risks as well as the benefits. That's why I strongly object to homebirth advocates saying that homebirth is as safe or safer than hospital birth. The additional risk is small, but it is real and it is important that women know that so they can take it into account.

By Blogger Amy Tuteur, MD, at 3:09 PM  

"That's why I strongly object to homebirth advocates saying that homebirth is as safe or safer than hospital birth."

Based on the full body of scientific literature and an agreement of what the term "safe" means, homebirth advocates can absolutely make this statement. They cannot say it has been proven that "home birth has lower rates of neonatal mortality". (I personally don't think that has been proven either way.) The term safety must take into account the *long term* physical and emotional health of the baby and the mother. This is not simply a "fall back position", I want a living, breathing, healthy baby for more than 28 days! And I'd prefer to not be hacked up in the process.

By Blogger Mama Liberty, at 4:28 PM  

Mama Liberty:

"Based on the full body of scientific literature and an agreement of what the term "safe" means, homebirth advocates can absolutely make this statement."

No, they cannot. They can say that homebirth is safe. It is not truthful to say it is as safe or safer than hospital birth. It is not ethical to imply that homebirth is as safe or safer than hospital birth because for most people, the risk of their baby dying is the most important criterion.

There is no doubt that the research is being misused. Almost every major homebirth advocacy website has a page about how to answer people who question whether the choice of homebirth is safe. None of those pages mention that every homebirth study has an excess of preventable neonatal deaths. That omission is inexcusable.

By Blogger Amy Tuteur, MD, at 4:43 PM  

Sailorman, I've been thinking a lot about your last comment. First let me touch on the "moving the goalposts" issue -- there are two layers of debate here, IMO. We have to talk about what the individual studies actually say, and we have to talk about what we should conclude from them. The conversation about whether Mark Durand's statistical weighting adequately compensated for the differences btw Farm women and NNS women, and whether Johnson & Daviss should have included congenital anomaly deaths -- that's a separate conversation from whether I should suggest to women in my community that they consider homebirth. So my intent was not to say, "Nyah nyah, you're wrong anyway," but to point out that the second question is not the same as the first.

That said, I disagree with your summary of the public health POV. I find it unlikely, first of all, that public health policymakers would be unconcerned about dead babies. The APHA statement encourages increased access to out-of-hospital birth services. Suppose 5% of American women wound up choosing homebirth ten years from now, and suppose your 1/1000 figure for an increase in perinatal death rates is correct, and suppose the 3,360,858 figure from J&D for full-term vertex singleton births in 2000 is more or less consistent with future birthrates -- that's an additional 168 babies dying every year.

I don't see that as a good public health strategy.

An additional consideration: public health policymakers don't have the freedom to exclude morbidity from their considerations. You and Amy seem to be saying that home-born babies are more vulnerable to intrapartum hypoxia. Some of those babies will die, but some will also be resuscitated and survive with some level of impairment. And those costs are HUGE. There are not only the initial hospitalization costs, but there's the federal mandate for states to provide special services to those kids from birth to age 21. Then there's the consideration of their level of functioning as adults, which is a whole 'nother kettle of fish.

If homebirth really results in more dead and impaired babies, it doesn't make sense for the APHA to support it.

I'm also puzzled by the demographics implied in your last comment. Who exactly are the women who will opt for no prenatal care vs. homebirth midwifery care? You've said before that homebirthers are mostly middle-class educated white women. Some women will opt for unattended childbirth if they can't have a homebirth, but most of us will go, with some reluctance, to the hospital.

The older of my two home-born sons is celebrating his fourth birthday today (a couple of days early, but the grandparents could come today). I need to take his cake out of the oven. :-)

By Blogger Jamie, at 12:28 PM