Friday, October 03, 2008

Homebirth is like smoking cigarettes

Homebirth is like smoking cigarettes. In both cases, the people that do it evince a curious contempt for preventive measures, a bizarre fatalism about the bad things that might happen, and an outsize faith in the ability of doctors to save people from their own mistakes.

There isn't a smoker around who doesn't know that smoking causes cancer, yet people smoke anyway. Some people continue to smoke long after they want to quit, because they are addicted to nicotine. Yet many others like to pretend that bad things won't happen to them. They tend toward a fatalism that predicts that bad things are going to happen anyway; might as well enjoy life's simple pleasures. Of course, in the back of their minds they're counting on the fact that if they do develop cancer, they will receive extremely high tech, highly expensive care that will prolong their life and perhaps even cure their cancer.

As for homebirth advocates, yesterday's post about a predictable shoulder dystocia at a homebirth illustrates the bizarre contempt and fatalism of homebirth advocates. The patient had had an unpredicted severe shoulder dystocia at her previous birth. The odds were high that she would have another, and therefore she was strongly advised to give birth in a hospital where an team of medical professionals, including an expert in neonatal resuscitation, would be available to render all possible insistence. The patient and her midwife (oops, I mean "support person") viewed any and all attempts at preparing for shoulder dystocia with utter contempt. They ignored the advice to deliver in a hospital because they reasoned, correctly, that the doctors would do everything they could to prevent a fractured arm, neurologic injury and anoxic brain damage, and that would likely mean interfering with the patient's birth "experience."

The fatalism of the patient and her midwife (oops, I mean "support person"} is truly astounding. It's not that they didn't believe that another shoulder dystocia could happen. They simply didn't care. Bad stuff happens; why do anything to prevent it? Of course, in the midst of the emergency, they did call for medical assistance. The same people who are sure that medical help won't be needed, and equally sure that it will fix everything when they've guessed wrong.

What the patient and her midwife didn't understand, because neither knows very much about childbirth, is that successfully delivering a baby during a shoulder dystocia depends to a large extent on the experience and training of the person delivering the baby. Coincidentally, this month's journal Obstetrics and Gynecology, has a paper on the impact of training on preventing injury during shoulder dystocia. According to the abstract of the article Observations From 450 Shoulder Dystocia Simulations:
Poor neonatal outcomes after shoulder dystocia have been associated with inappropriate management. Until there are significant developments in the prediction and subsequent prevention of shoulder dystocia, improving shoulder dystocia management through practical training may be the most effective method of reducing the associated morbidity and mortality. Four hundred fifty simulated shoulder dystocia scenarios, managed by 95 midwives and 45 doctors from six U.K. hospitals during the course of 1 year, were video recorded during a study of obstetric emergency training. Analysis of recorded data revealed that, before training, 57% were unable to deliver the baby, almost two thirds failed to call for pediatric support, and 1 in 27 used fundal pressure. Recurring difficulties in management were observed: poor communication, inability to gain internal access, confusion over internal maneuvers, and the application of excessive traction. Significant improvements in management were observed after training and persisted up to 1 year after training. The lessons learned from this study can inform and improve future training and management...
The simulations were performed on a specially designed mannequin that was set to release the baby if the appropriate obstetric maneuvers were performed. In addition, the mannequin could measure the force applied to the baby during attempts to deliver it. The authors found:
Pretraining data revealed that 80 of 140 (57%) were unable to
deliver the fetus ... Before training, 75 of the 113 participants (66%) applied a force above 100N (22.5 lbs), and 12 (11%) applied more than 200N (45.0 lbs). However, after training there was a significant improvement in the proportion of participants who successfully achieved the simulated delivery, from 60 of 140 (42.9%) pretraining to 110 of 132 (83.3%) posttraining; the majority retained the ability to achieve delivery up to 1 year after training, with 80 of 95 (84%) able to deliver at 6 months and 75 of 82 (85%) at 12 months.
These findings are consistent with the results from studies of neonatal deaths due to shoulder dystocia:
The 5th Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) in England and Wales found grade three suboptimal care ... in 66% of neonatal deaths after shoulder dystocia ... The 2003 National Health Service for England and Wales Litigation Authority Report on 264 claims for obstetric brachial plexus injury in England judged 46% (72/158) of the reviewed cases to involve substandard care. The most common criticism is related to failure to carry out standard shoulder dystocia resolution maneuvers. Furthermore, a study conducted in two English hospitals reported that 70 of the 166 (42%) midwives and junior obstetricians surveyed did not feel confident in the management of shoulder dystocia.
In addition:
The CESDI report into fatal cases of shoulder dystocia found a pediatrician was present at the time of delivery of the body in only 55% of cases and recommends that a pediatrician should be called as soon as shoulder dystocia is identified...
We know for a fact that in the case of shoulder dystocia, experience is key to successfully delivering the baby without injury or anoxic brain damage. Deliberately ignoring that reality in order to preserve a particular birth "experience" is like deliberately smoking cigarettes: irresponsible at best, and criminally negligent at worst.

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