Saturday, July 01, 2006

More on intrapartum death

There seems to be some confusion about the meaning of the intrapartum death rate. Within obstetrics, the intrapartum death rate is considered to be a sensitive indicator of appropriate care. Hospitals are compared on intrapartum death rates, intrapartum death rates have been examined for deliveries at various times of the day or year to see if it reflects provider fatigue or training, and intrapartum death rates are routinely compared for breech and vertex vaginal delivery to determine if breech vaginal delivery is safe.

Therefore, intrapartum death rate is a valuable way to evaluate the safety of homebirth. I have reported previously on the very high intrapartum death rates in homebirth studies:

Murphy & Fullerton 2/1221 = 16/10,000

Johnson & Daviss 5/5418 = 9.2/10,000

Janssen 1/860 = 12/10,000

Northern Region 5/2888 = 17/10,000

I have also referenced studies that quote the hospital intrapartum death rates as in the range of 2-3 per 10,000. People have questioned the accuracy of this number. I offer two other, very large studies that place intrapartum death rates in the hospital in the same range. The Confidential Enquiry into Stillbirths and Deaths in Infancy in the UK. This was a study of 648,409 births during the year 1999 in England, Wales and Northern Ireland. From the report:
...since 1993 there was a significant downward trend in intrapartum related deaths... The 4th Annual Report (1997) found that, in 1994 to 1995, half of these cases had been associated with suboptimal care that was likely to have contributed to the outcome. A series of recommendations were made regarding training, assessment and supervision of health professionals involved in caring for women and babies in labour. Many initiatives at national and local level have occurred in response to these and it is pleasing to see a downward trend in deaths of this type. The number and rate of deaths in this category, weighing 1 kg and over, have fallen from 529 (0.77/1000 total births) in 1993 to 398 (0.62/1000 total births) in 1999.
In other words, in the year 1999, the intrapartum death rate for all babies over 2.2 pounds was 6.2/10,000. This includes premature babies and babies with congenital anomalies. The death rate for low risk babies at term is substantially lower. So the intrapartum death rate for ALL babies was lower than the intrapartum death rates found in studies of homebirth.

Stephanson et al. reported on all intrapartum deaths in Sweden from 1991-1997 in Time of Birth and Risk of Intrapartum and Early Neonatal Death (EPIDEMIOLOGY 2003;14:218 –222). They studied 694,888 births and found an intrapartum death rate of 1.2/10,000 for babies at term, including high risk pregnancies. The rate for low risk pregnancies is undoubtedly lower.

Based on the four studies I have quote, the intrapartum death rates are substantially higher for homebirth (up to 8x higher) than for hospital birth. Since intrapartum death rates are a much more sensitive indicator of the quality of care than overall perinatal mortality rates, it is quite clear that the studies done thus far suggest that homebirth is far less safe than hospital birth.


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