Failure to rescue
I'd like to propose a new way of thinking about preventable death at homebirth. A more accurate description might be "failure to rescue."
This phrase is used in analyzing quality of care in various aspects of medicine. It refers to the deaths that could have been prevented, either by more careful monitoring to recognize an emergency, providing appropriate care, or providing appropriate care in a timely fashion.
Not all homebirth deaths represent a failure to rescue. Some are caused by abnormalities incompatible with life. However, most homebirth deaths are caused by failure to rescue and it is easy to see how that happens. First, by the very nature of homebirth, it is impossible to provide appropriate care for an immediately life threatening emergency. Cord prolapse, massive abruption, and fetal bradycardia will result in perinatal death in the majority of cases. Simply by choosing homebirth, parents ensure that no one will be able to rescue a baby in immediate danger of death.
The lackadaisical monitoring, and the minimal knowledge base of most direct entry midwives dramatically increases the risk of failure to rescue due to failure to recognize the problem. That's why there are unanticipated homebirth deaths. The midwife has literally no idea that the baby is in serious trouble and therefore does nothing to prevent the death. A dead baby drops into her hands, a situation that is virtually inconceivable in a hospital setting.
The third type of failure to rescue, inability to provide appropriate care , is also more common at homebirth. Even if a DEM recognizes a problem, she often cannot handle it appropriately, and more importantly, she lacks the knowledge and equipment to perform the expert neonatal resuscitation that may be needed. Problems in this category include shoulder dystocia and breech with trapped head or nuchal arms. Most of these babies will simply die at home.
The key advantage of the hospital is the ability to rescue babies who need to be rescued. Parents choosing homebirth are simply betting that their baby will not need rescue. Unfortunately, if it does, the baby will most likely die as a result of failure to rescue.
Labels: neonatal mortality
An amazing fact about homebirth
Homebirth advocates often claim as a target that 10% of all births should be homebirths. Let's imagine for a moment what that would be like. That would mean that there would be approximately 400,000 homebirths per year. All the existing scientific evidence shows that homebirth has an excess rate of preventable neonatal death in the range of 1-2/1000. That does not sound like much, until you consider this:
If 10% of American babies were delivered by homebirth, homebirth deaths would vault to the 3rd or 4th leading cause of neonatal death!Food for thought.
Labels: neonatal mortality
Irish hospitals suspend waterbirths after aspiration death
According to the
Irish Independent:
Water births have been suspended in maternity hospitals and units following the death of a baby boy who was delivered in a birthing pool.
An inquest heard last week how baby Harry Eccles ... died three days after breathing in water during his birth in a pool at Cavan General Hospital in February 2006.
A spokesperson for Cavan and Drogheda maternity units said the birthing pool service was suspended for births following the incident and was now only available for pain relief.
Cork University Maternity Hospital, which also has a birthing pool, said it would not be using it for births until after the outcome of a national review on water births...
A
newspaper account of the inquest details how the drowning occurred and the findings of the pathologist:
The inquest heard that Harry's death was due to "acute near drowning" after he inhaled water from the birthing pool. A 'near drowning' means that the victim survives temporarily, whether for a matter of hours or days, but ultimately dies. The baby's brain was also starved of oxygen.
Pathologist Dr Peter Kelehan said that it is well known that babies can inhale amniotic fluid while in the womb but that this does not cause any damage to the infant.
He said the changes found in baby Harry's body would not support the theory that he had inhaled amniotic fluids and instead concluded that he had inhaled fresh water during the delivery process.
Instinctively babies should not breathe until they break the surface of the water and meet the air. Instead, they are supposed to continue to be supplied with oxygen through the umbilical cord until they breathe on their own. However, studies have shown that if they don'tget enough oxygen during birth they may gasp for air, running the risk of inhaling water...
"Then the shoulders were born. It was around 60 to 90 seconds after the head before the shoulders were born. I then assisted the baby to the surface of the water," said the midwife.
However, as the baby reached the surface it immediately became clear that something was wrong...
Harry's grandmother, Siobhan Eccles, said that after the baby's head was born, her daughter waited for the next contraction, which never came.
She said when there were no further contractions, Ms Loughran pushed on her daughter's stomach, causing her to "let out a scream".
The midwife denied that she had pushed on Ms Eccles' stomach, but said she had simply put her hands down into the pool to make sure the baby didn't drop to the bottom.
It sounds as though the delivery of the shoulders was slightly delayed, giving the baby plenty of time to inhale a large amount of freshwater. The baby inhaled so much freshwater that when it was absorbed by the lungs, it lowered the concentration of electrolytes in the baby's bloodstream to a level leading to death.
The legal case was further complicated by the fact that the
parents were told that the baby died of a genetic disorder and did not learn about the pathologist's finding of drowning until they attended the inquest.
Barrister for the Eccles family, Sara Antoniotti yesterday told the Coroner that the Eccles family were completely unaware of the pathologist's findings that little Harry died as result of drowning, when many of the people who assisted in his birth were giving evidence, (including midwife, Elisabeth Loughran) at an adjourned inquest on May 8.
As a result the family did not ask the questions that they would have asked had they been aware of the pathologist's findings and wanted an opportunity to ask those questions, the court heard.
"The Eccles family knew nothing about a proposed drowning in a birthing pool - his mother Gina had thought he died as a result of a genetic disorder.
"You can imagine the horror and shock for the family when they discovered this," said Ms Antoniotti.
"This is a most unusual case.
"It's very traumatic for the family and needs to be investigated further.
"It's not only to allay the fears of the family, but the fears of the general public," she said.
It seems that the hospital was aware of its culpability and hoped to hide it by telling the parents that the baby died from an unpreventable genetic disorder.
Labels: neonatal mortality, water birth
World Health Organization says homebirth increases perinatal mortality
The recent discussion of Marsden Wagner and his pronouncements on midwifery and homebirth made me wonder whether Wagner's positions are merely personal opinions or whether they represent the official position of the World Health Organization. Evidently, Marsden Wagner's claims are his opinions and nothing more. The World Health Organization specifically states that homebirth increases the risk of perinatal death. The relevant document is
here:
Home-like settings for childbirth are associated with reduced likelihood of medical intervention. The evidence shows that the number of spontaneous vaginal births is higher, breastfeeding initiation more common and maternal satisfaction better in home-like institutional birth settings compared to conventional institutional settings. However, the evidence shows an increased risk of perinatal mortality, the reasons of which are not fully established. Thus, there is an increased need for monitoring early signs of complications in these home-like settings. (my emphasis)
In addition, the WHO would find direct entry midwifery practice to be woefully inadequate. The WHO has published guidelines on
antenatal care. The following tests and procedures (among others) are recommended for routine antenatal care on the basic of the scientific evidence:
• screening for pre-eclampsia with a comprehensive strategy including an individual risk assessment at first visit, accurate blood pressure measurement, urine test for proteinuria and education on recognition of advanced pre-eclampsia symptoms;
• anti-D given during 72 hours postpartum to Rh-negative women who have had a Rh-positive baby;
• Down’s syndrome screening;
• screening and treatment of asymptomatic bacteriuria during pregnancy;
• screening of hepatitis B infection for all pregnant women and delivery of hepatitis B vaccine and immunoglobulin to babies of infected mothers;
• screening for HIV in early pregnancy, a short course of antiretroviral drugs, and caesarean
section for infected mothers at 38 weeks, to reduce vertical transmission;
• screening for rubella antibody in pregnant women and postpartum vaccination for those with negative antigen;
• screening and treatment of syphilis;
• routine ultrasound early in pregnancy (before 24 weeks);
• external cephalic version at term (36 weeks) by skilled professionals, for women who have an uncomplicated singleton breech pregnancy;
Indeed, the World Health Organization profoundly disagrees with a fundamental admonition of homebirth advocacy to "trust birth". The WHO does not find birth to be trustworthy at all. In addition
the WHO specifically recommends screening tests, routine ultrasound, Rhogam, intensive screening for pre-eclampsia and external version for breech.The bottom line is that the WHO agrees that homebirth increases the risk of perinatal death, does not advocate "trusting" birth, strongly supports routine screening, including routine ultrasound, and believes that vaginal breech delivery should be avoided by attempted version. In other words, American direct entry midwifery principles and practice violate the recommendations of the World Health Organization.
Labels: neonatal mortality
New national statistics: homebirth increases neonatal death
I have been waiting for these statistics.
In 2003 the US standard birth certificate form was revised to include place of birth and attendant at birth. In both the 2003 and
2004 Linked Birth Infant Death Statistics, mention was made of this data, but it was not included in the reports. Now the CDC has made the entire
dataset available for review and the statistics for homebirth are quite remarkable.
Homebirth increases the risk of neonatal death to double or triple the neonatal death rate at hospital birth.
As this chart shows, the neonatal mortality rate for DEM assisted homebirth is almost double the neonatal mortality rate for hospital birth with an MD. This is all the more remarkable when you consider that the hospital group contains women of all risk levels, with all possible pregnancy complications, and all pre-existing medical conditions. An even better comparison would be with the neonatal mortality rates for CNM assisted hospital birth. The risk profile of CNM hospital patients is slightly higher than that of DEM patients, but CNMs do not care for high risk patients. Compared to CNM assisted hospital birth, DEM assisted homebirth has TRIPLE the neonatal mortality rate.
No wonder MANA is suppressing their safety statistics. They almost certainly show that homebirth with a DEM has triple the neonatal mortality rate of hospital birth for comparable risk women in the same year.
What is also notable is that the results are consistent with all existing scientific studies, including the Johnson and Daviss study. Johnson and Daviss actually showed that homebirth with a CPM has a neonatal mortality rate almost triple that of hospital birth for low risk women. The latest statistics are the most recent and most reliable confirmation of that fact.
There really is no question about it now. Homebirth with a DEM dramatically increases the risk of neonatal death.
Labels: neonatal mortality
Two more homebirth deaths reported on MDC
The steady pace of preventable deaths at homebirth continues on MDC. Two additional homebirth deaths were reported on MDC in the past week or so. Both were intrapartum deaths. One was 6 months ago, and the other occurred a few days ago and was the result of an abnormal cord insertion.
In both cases, mention was made of grief being compounded by blame from family members for risking the babies' lives.
At this rate, sadly, MDC should start a "tribe" for women whose babies have died a preventable death at homebirth. There have been 7 homebirth or UC deaths that have been described on MDC since January. There have also been at least 2 cases of profound anoxic brain damage. This is ahead of the steady pace of homebirth deaths reported on MDC, approximately 1 every other month, in the previous 2 years.
It's no wonder that MANA (the Midwives Alliance of North America) refuses to release their statistics on homebirth safety. If MDC is any indication, the perinatal mortality rates at homebirth are extraordinarily high.
Labels: homebirth death, neonatal mortality
New study showing high homebirth death rate is poorly done
I often complain about the fact that there is a lot of poorly done research in medical journals. That's why it is important to read the study, to determine if the conclusions are justified by the data. Here is a new study that purports to show that homebirth has a rate of intrapartum death that is high and rising. It is certainly possible that this is the case, but the study is based on so many unproven assumptions as to be essentially worthless.
The study is
An estimation of intrapartum-related perinatal mortality rates for booked home births in England and Wales between 1994 and 2003 by Mori et al. in the April issue of the British Journal of Obstetrics and Gynecology. According to the authors:
Results: The overall IPPM rate for England and Wales improved between 1994and 2003. However, data to obtain a precise estimate of IPPM rate for booked home birth were not available. The average IPPM rate for all births in the study period was 0.79 per 1000 births (95% CI 0.77–0.81), and the estimated IPPM rate for booked home births was 1.28 or 0.74 per 1000 births, depending on the method of calculation (range 0.49–1.47). The IPPM rates for the completed home birth group appeared to be lower throughout the study period compared with the unintended home birth groups. Those women who had booked for a home birth, but later needed to transfer their care for a hospital birth, appeared to have the highest risk of IPPM in the study period.
Conclusions: The results of this study need to be interpreted with caution due to inconsistencies occurring in the recorded data. However, the data do highlight two important features. First, they suggest that IPPM rates for home births do not appear to have improved over the study period examined, even though rates did so overall. Second, although the women who booked for home births and had their babies at home seemed to have a generally low IPPM rate, those who required their care to be transferred to hospital did not. Women who book for home births should be offered comprehensive evidence-based information about the potential benefits, risks and uncertainties associated with their choice of birthplace by the healthcare professional responsible for supporting their decision. It is of considerable concern that the data recorded nationally in England and Wales do not provide accurate information about when and why a transfer from home to hospital booking occurs and about their outcomes.
These conclusions could be true, but the paper does not show that they are true. Indeed, the paper does not show much of anything.
In reading the paper, you should keep in mind that the authors use a new statistic, intrapartum
related mortality.
IPPM rate is defined as deaths from intrapartum 'asphyxia', 'anoxia' or 'trauma', derived from the extended Wigglesworth classification 3, which is used by CEMACH. This includes stillbirths and death in the first week. The denominator was all births (live births and stillbirths).
What they appear to mean is perinatal mortality caused by intrapartum asphyxia. I have not seen this statistic used before in any other homebirth studies.
The initial comparison is straightforward: "A total of 4991 intrapartum perinatal deaths occurred in England and Wales between 1994 and 2003 among 6 314 315 births" for an IPPM rate of (0.79 per 1000 births [95% CI 0.77–0.81].In contrast, "[t]here were 125 intrapartum-related deaths among the 130 700 home births in England and Wales in this period" for an IPPM rate of 0.96 per 1000 births (95% CI 0.79–1.03).
Now comes a gigantic problem, or rather two gigantic problems. First, the homebirth group includes both planned and UNPLANNED homebirths (rather like the Pang study). Second, the homebirth group does NOT include women who planned to deliver at home but transferred to the hospital. Therefore, you cannot draw any valid conclusions from a direct comparison.
Here's where the authors get into trouble. As an
editorial accompanying the paper explains what they did:
Mori et al. attempt to compensate for this by using figures for the proportion of deaths associated with planned and unplanned home births collected since 1994 by the Confidential Enquiry into Maternal and Child Health. Furthermore, they impute from previous smaller studies in various parts of England and Wales the proportion of home births planned to be at home but transferred to hospital because problems had developed in labour (this group also has a poor outcome). This enabled the authors to make an estimate, with confidence intervals, of the likely perinatal mortality associated with an intention to give birth at home. Although this should be a selected low-risk group, their perinatal mortality between 1994 and 1997 was no lower than that of hospital births and subsequently was consistently about 80–250% higher (significantly so in 1998–99 and 2002 03).
In other words, in order to arrive at their calculated intrapartum related mortality rates, the authors estimated BOTH the denominator (the number of intended homebirths) and the numerator (the number of deaths that purportedly occured in the estimated intended homebirth group).
When the authors claim that the purported intrapartum related mortality rate in the intended homebirth group is 0.96/1000, they are really saying this:
125 deaths + estimated transfers deaths - estimated unplanned homebirth deaths
______________________________________________________________ = 0.96
130,700 births + estimated transfers - estimated unplanned homebirths
That could be true, but since four out of the six variables are only crude estimates based on past data, it is just as like to be false. It could be lower, or it could be higher; there is absolutely no way to know. Moreover, since the numerator is so small, even tiny errors in estimation will have a big impact on the result.
The only part of the paper that we can be certain is accurate is this:
It is vital that data are collected prospectively so that an accurate picture can be established of both intended and unintended home birth rates, together with a clear indication about when and why a transfer to hospital care occurred. The fact that reliable data are not currently available to inform a key health debate is a matter of great concern.
Fortunately, a study is underway to correct this deficiency. The National Perinatal Epidemiology Unit in the UK is currently collecting data for the
Birthplace Study, which is "designed to compare outcomes of births planned at home, in different types of midwifery units, and in hospital units with obstetric services." The results should be available next year.
Labels: homebirth death, neonatal mortality
Wisconsin statistics confirm high homebirth death rate
I have written repeatedly about the fact that, contrary to the claims of homebirth advocates, all the existing scientific evidence shows that homebirth has a higher rate of preventable neonatal death than hospital birth for low risk women. I have also written repeatedly about the efforts of MANA (the Midwives Alliance of North America) to withhold the safety statistics it has gathered since 2001 suggesting that their statistics also show that homebirth has a higher rate of neonatal death. Now comes hard data from Wisconsin demonstrating the homebirth with a direct entry midwife has a substantially higher rate of neonatal death than hospital birth for low risk women.
The table is derived from Wisconsin Department of Health and Family Services data on linked birth infant deaths. The table compares neonatal mortality by attendant at delivery. Neonatal mortality for homebirth attended by a DEM is consistently TRIPLE the rate of neonatal mortality for CNM attended births. Neonatal mortality at homebirth with a DEM exceeds neonatal mortality at CNM births by 2.5 deaths/1000.
These data provide hard evidence to confirm what the scientific literature has shown: homebirth increases the rate of neonatal death. There are several specific advantages to this type of data. Linked birth infant death data are the most reliable data on neonatal mortality because every death is traced back to the original birth, ensuring accuracy. The data include all types of direct entry midwives, not just CPMs. The data come from a large cohort of births. During the years 2000-2006 in Wisconsin, there were 4,471 births attended by a DEM. These data are more recent than any in the scientific literature.
In this comparison, CNM births are used as a proxy for low risk hospital births. From 2000-2006, there were 28,778 CNM attended births, of which 98.75% took place in the hospital. If the home births are excluded, the neonatal mortality rate for CNM attended deliveries falls to 1.17/1000.
This is hard data confirming the increased risk of neonatal death at homebirth attended by a DEM. The real increase in risk is almost certainly greater than that depicted in the table. That's because the true CNM neonatal mortality rate for low risk women is probably lower than the data shows, and the true DEM neonatal mortality rate is almost certainly higher. The CNM neonatal mortality rate is probably lower than the rate depicted because it includes women who are not low risk, since CNMs care for all women anticipating a vaginal delivery. The DEM neonatal mortality rate is almost certainly higher because it does not include emergency transfers of the mother during labor. The attendant recorded on the birth certificate is the attendant who actually delivered the baby, not the attendant who supervised the labor, so all DEM intrapartum transfers are recorded in the MD group, not the DEM group.
So here it is: hard evidence that DEM attended homebirth has a rate of neonatal death triple that of hospital birth for low risk women.
Labels: neonatal mortality
The toll of homebirth deaths mounts
The appalling rate of homebirth death on MDC continues. There have been at least 8 neonatal deaths in the last 2 years. Since there appear to be less than 300 homebirths reported on MDC each year, that means the neonatal death rate is at least 12 per thousand, TEN TIMES HIGHER than in hospital neonatal death rates for low risk women. That does not even include late stillbirths, of which there have been several. In a small group like the MDC homebirth group, you would expect approximately one neonatal death every 2 years. Instead, there is one neonatal death every other month.
The most recent death is a late stillbirth. The mother experienced decreased fetal movment over several days and the midwife did nothing more than listen once to the baby's heartbeat (which she found only with difficulty). When the midwife next listened, several days later, in the midst of active labor, the baby was dead. As in so many of the neonatal deaths and stillbirths on MDC, there was evidence that a problem might be developing, but that evidence was dismissed because "birth is natural" and the baby "knows when to be born".
It's difficult to know whether the women on MDC who choose homebirth are representative of the majority of women who choose homebirth or are a particularly reckless group. Nonetheless, MDC should be required reading for those who think that homebirth is as safe as hospital birth. Over and over and over again otherwise healthy babies die of easily preventable causes. Based on what I have read there over the last 2 years, I suspect that in the real world (as opposed to studies carefully crafted by homebirth advocates to promote homebirth) homebirth has a perinatal death rate 10-20 times higher than hospital birth for low risk women.
This is why it is absolutely imperative for MANA (the Midwives Alliance of North America) to release their safety statistics. No matter what they show, it is unethical to withhold them. However, it would be absolutely unconscionable to withhold them specifically because they show definitively that homebirth has a neonatal death rate dramatically higher than hospital birth.
Ultimately the campaign to legalize direct entry midwives is about MONEY, pure and simple. Legalization is recognized as absolutely essential to gaining access to insurance reimbursement, and that is the goal. Homebirth is not illegal and attending a homebirth is not illegal. However, holding yourself out as a medical professional and receiving money in exchange is illegal in many states. This is not about choice, this is not about women's rights, this is only about money.
MANA continues to state that homebirth with a direct entry midwife is as safe as hospital birth. Withholding their own safety data suggests that they may know this to be a false claim. In other words, they may be letting women unknowingly risk their babies' lives just so that midwives can make more money.
Labels: neonatal mortality
Perinatal mortality: acknowledgement and denial
One of the more egregious claims of homebirth advocates is that infant mortality rates show that the US does not provide good obstetric care. Of course, infant mortality is the wrong statistic. Perinatal mortality is the correct statistic and the US has one of the lowest perinatal mortality rates in the world.
Evidently, word is getting around. Homebirth advocates are often genuinely shocked to learn the truth. They did not understand that infant mortality was the wrong statistic, and they did not understand that the US has excellent perinatal mortality rates.
Kneelingwoman, on her new blog
Close to the Root, acknowledges the truth:
... WHO is that Dr. Amy person anyway? She's more than welcome but I want to reiterate that I came here with the sole intention and objective to have a creative dialogue about how to create a maternity care system that works for everyone. I am not here to duck a verbal fist fight or a "statistics war" ... Dr. Amy, by the way, is quite correct on that score; I have long been very annoyed with the homebirth community's mangling of stats and of the semantic messing around that goes on....we are WRONG to be quoting numbers about infant mortality; that's a different animal altogether. It IS perinatal mortality that tells the tale; those are the numbers that represent outcomes for neonates and the early newborn period and, actually, the U.S. scores very high...
Most homebirth advocates simply resort to denial. On MDC, a poster asked:
I somehow got onto that Dr. Amy's site,.. she's wildly anti-homebirth and very rabid... [S]he said that infant mortality rate isn't a good indicator of how we are doing as a country because it includes deaths from birth to a year. She said we should look at perinatal mortality and US has some of the best rates in the world...
Someone responded with the data from the WHO 2006 report on perinatal mortality, which confirms my claim. Then those in denial went to work:
"Yes...if we go by this rate alone we can say we're "among the best", but look who beat us out!"
"Just wanted to put out there that not all sources of 'information' are actually sources of 'clean, honest information'. There are people who shamelessly distort real information in the pursuit of persuading others to their extreme point of view,.."
"... Stay away, ignore it, it really is just a bunch of intense negativity with no real truth involved (because once you've distorted things enough, it loses all relationship to the truth even if it was originally based upon actual facts)..."
Most homebirth advocates do not understand that a fundamental claim of homebirth advocacy is simply untrue. When confronted with the truth, most homebirth advocates simply choose to ignore it.
Labels: neonatal mortality
The dead baby card
Jill at
Keyboard Revolutionary finds it "amusing and frustrating" when people "pull out the dead baby card."
I don't find it amusing; I find that it is generally worth taking notice. What exactly is "the dead baby card, anyway?" Jill seems to think that it is telling women that their baby is at increased risk of death even though that is not the case. What Jill and most homebirth advocates don't seem to realize is that they literally have no idea about the existence or the magnitude of the increased risk of perinatal death. Not only do they not know about the increased risk; they actually parade their ignorance while congratulating themselves on being "educated".
Take Jill's comments for example:
"You're not going to do the glucose test? Your baby will die!"
Gestational diabetes DOES increase the risk of perinatal death. Untreated gestational diabetes increases the risk of perinatal death even further.
"You're not going to be induced if you go past 40 weeks? Your baby will die!"
The perinatal death rate DOES increase every day beyond 40 weeks. We have set an abitrary cut off at 42 weeks when the death rate has essentially doubled, but it has been rising steadily every day of the previous 2 weeks and continues rising every day thereafter.
"You're having a homebirth? Your baby will die!"...
Homebirth DOES increase the risk of preventable neonatal death. All the scientific evidence to date shows that it increases the risk of preventable neonatal death approximately 1-2/1000 ABOVE the hospital neonatal death rate.
"You're not getting him his vaxes? Your baby will die!"
Rejecting vaccination DOES increase the risk of death from vaccine preventable illnesses.
Of course Jill, like most homebirth advocates who lack an understanding of even basic statistics, makes the typical homebirth advocacy mistake. She assumes that when doctors inform people that something increases the risk of death, that means the risk of death is 100%; and if the risk of death is 100% and the baby doesn't die, then the doctor was wrong. However, increasing the risk of death means just that: it is increased over what it was before. It might be double, triple or 10 times higher. It does not mean that the risk is 100% or even 10%. When the risk is increased, that does NOT mean that a baby is guaranteed to die. That does NOT mean that if the baby doesn't die the doctor was wrong. It simply means that if you group together all the people in the higher risk group, their babies have an increased risk of dying compared those in the low risk group.
It's like carseats. If you drive to the store and don't put your baby in a car seat, it does not mean that your baby will die. And if you baby doesn't die on the way to the store, that does NOT mean that the benefits of carseats have been exaggerated. The mortality rate of a baby not strapped into a carseat is not 100%; it is simply higher than the mortality rate of a baby who is strapped into a carseat.
Jill goes on to illustrate an irony of homebirth advocacy.
Really, now, what mother in her right mind WANTS her baby to die? Look at all the fun stuff we have to abstain from just to ensure that we cook a healthy baby!
We can't smoke, drink, or take drugs. We can't eat undercooked meat, certain kinds of fish, or soft cheeses. We can't dye our hair. We can't ride rollercoasters or mechanical bulls. We can't take a dip in a hot tub. We can't drink coffee or soda. We can't put artificial sweeteners in our tea. We can't take ibuprofen, or any legitimate pain reliever for that matter, since Tylenol is the only option, and Tylenol really sucks. We can't take most cold medicines if we get stuffy. In a nutshell, we can't do a whole lot of stuff that we'd normally enjoy, all for the sake of our unborn baby.
Those risks are actually LESS than the risks that homebirth advocates dismiss as playing the "dead" baby card.
What's the neonatal mortality rate of hair dying? It's zero. How about riding roller coasters, drinking coffee or drinking soda? Zero. What about artificial sweetners? Zero again.
Personally, I find it "amusing and frustrating" that women who obsess about theoretical risks of drinking coffee and soda during pregnancy casually dismiss REAL risks of increased rates of perinatal death as playing the "dead baby card."
Labels: homebirth death, neonatal mortality
Homebirth death of a breech baby
Yet another homebirth death has occured. From
Midwife Is Suspended After Death of Baby During Difficult Home Birth:
A baby died during a breach birth after a midwife over-estimated her ability to deal with the difficult home labour, an inquiry has heard.Nurse Julie Duthie tried to deliver the child on her own at the mother's home two miles from the Royal Devon & Exeter Hospital.
She was forced to call for help but two back-up midwives and an ambulance crew took 20 minutes to arrive, it was claimed at the Nursing and Midwifery Council hearing in London yesterday...
Duthie also failed to follow a supervision plan drawn up by her superiors, and failed to tell them the baby was more than 4kg after scans in August, it is claimed. A breach birth carries more risk if the baby is large.
Mr Hafejee said: "There was insufficient preparation for delivery and resuscitation. Crucial information about the baby's weight was withheld and not communicated to a supervisor who was in a position to offer assistance."
Duthie told the NMC panel she had tried to arrange a vaginal birth at the hospital but it had refused because it was not the safe option...
On the day the mother went into labour, Duthie was called at about 10.30pm and arrived to find the baby was in breach as expected. But as it emerged feet first, the arms became stuck near the head.
Duthie told the hearing: "There was no sign of the arms coming down, no sign of elbows appearing, the arms were extended upwards. I tried to turn it but I couldn't."
She said she tried several movement techniques to get the arms down but the baby became stuck...
It sounds like the complication was nuchal arms, where the arms become locked behind the baby's head. This is probably the most dreaded complication of vaginal breech delivery.
The hospital had refused vaginal delivery of this patient because doctors believed it was not a safe option. The midwife and the patient decided to go ahead anyway, further increasing the danger. It is important to understand that this same complication could have occured in the hospital and had equally tragic results. That's why the doctors recommended C-section, in order to avoid precisely this outcome.
Labels: homebirth death, neonatal mortality
Midwives' skills criticized after baby dies
Do you notice a tragically recurring theme here?
From today's
Belfast Telegraph:
A coroner has criticised the skills of midwives who he said could have saved the life of a newborn baby boy if they had acted earlier...
Paul was born in Antrim Area Hospital "in poor condition" with the umbilical cord wrapped three times around his neck. Attempts to resuscitate him were unsuccessful.
He was transferred to the Neonatal Unit, but died four days later from Ischaemic brain injury...
The inquest revealed that during labour the midwives failed to spot a drop in the baby's heart rate through the cardiotocograph (CTG)...
Mr Leckey said: "If fetal heart traces had been interpreted correctly and medical assistance sought promptly, opportunities existed for the earlier delivery of the baby... Earlier intervention would have improved the chances of survival."
Within the past month there have been newspaper reports of 4 preventable perinatal deaths. The deaths differ in location, attendant, and in precipitating cause, but they are united by the same themes: all four involved failure to recognize or manage complications in a timely fashion; all four could have been averted with a C-section; in all 4 cases, had a C-section been done early and resulted in a healthy baby, the C-section would have appeared in retrospect to have been "unnecessary". In other words, had the attendants practiced "defensive medicine", those babies would have had a much higher chance of survival.
The consequences to the parents are devastating, but the consequences to the attendants are quite serious as well. In all four cases the attendants have been the focus of public investigations, public censure, and potential loss of license. I can assure you that none of them can use the high C-section rate as a defense in administrative hearings, disciplinary hearings or a court of law. I can assure you that none of the parents are comforted to know that they won't have to worry about VBAC (one woman actually had a C-section AND lost her baby). Newspaper accounts have indicated that none of the parents have taken the position that "sometimes babies die".
So I ask critics of the high C-section rate:
Which are the unnecessary C-sections?
If you can't even tell me which ones are unnecessary after the fact, how on earth are we supposed to know which ones are unnecessary before the fact?
How "trustworthy" was birth in these circumstances?
Where is the tolerance for the type II errors that are inevitable when you don't practice defensive medicine?
Which message is the public sending: "A few perinatal deaths are acceptable as the consequence of lowering the C-section rate." OR "Any perinatal death that might have been prevented with a C-section is totally unacceptable and will result in public investigation and public censure."?
Which parents accepted the death of their child with fatalism?
Labels: midwifery, neonatal mortality
Midwives announce plan to ignore coroner's recommendations
According to the
Gazette:
Quebec's midwives are planning no changes in the short term to the way they deliver babies, despite a coroner's report that calls for an overhaul of their practice.
Coroner Paul Dionne recommended the Quebec Order of Midwives significantly improve the training of midwifery to respond better to high-risk births after what he described as the "preventable" death of a baby boy in Montreal last year...
Dominique Porret, president of the Quebec Order of Midwives, insisted yesterday there is no need to follow the coroner's recommendations because they are already in place...
"It's not that we haven't responded to the recommendations," she added, after being grilled by reporters at a news conference on what the Order intends to do in light of the report.
"Nothing will change, in the sense that we are already doing our very best to ensure the safety of mothers, babies and their families..."
Last year, midwives delivered 1,453 babies, and no complaints were lodged with the Order. Porret said there were a few stillbirths - comparable to the rate in hospitals - but could not give a number.
I can't imagine why the midwives' organization would hold a press conference to insist that they are not going to implement the recommendations. It makes them look defensive and is very insensitive to the parents who lost their child. Interestingly, the president of the Quebec Order of Midwives could not or would not reveal the number of deaths that have occured under midwifery care. It is completely inappropriate to withhold that information.
Labels: midwifery, neonatal mortality
Coroner: homebirth midwives' inaction led to baby's death
This story from
CTV.ca illustrates all too clearly why a baby can easily die at a homebirth. The midwives refused to call for assistance during a bradycardia, and (not surprisingly) when they attempted to intubate the lifeless infant, they put the tube in the wrong place. Almost certainly, they had no prior experience with a real infant intubation.
According to the coroner:
The coroner reports that the labour, attended by two midwives, seemed to progress normally until the mother's water was broken. The midwives noticed the presence of meconium in the amniotic fluid -- a life-threatening development.
Rather than calling for emergency help immediately, the midwives continued the birth.
When they later noticed that they had lost the baby's heart rate, they again failed to call for help, nor did they perform an episiotomy to hasten the delivery.
When the baby finally emerged, it was limp, grey and had no heart rate. Only then did the midwives call an ambulance -- a full 12 minutes after they noticed the lack of heartbeat.
While waiting the 10 minutes for help to arrive, they attempted to intubate the baby to suction out the meconium from the baby's lungs. When paramedics arrived, they found that the intubation had been done improperly and the child was declared dead shortly after.
[The coroner] determined in his investigation that the baby likely died less than 15 minutes before its birth. He contends the midwives were competent and knew what was happening, but failed to see the need for help.
Under Quebec law the baby should have been transported to hospital. In fact, the [baby's] home was minutes from Montreal's Maisonneuve Rosemont hospital.
This was a classic set up for a homebirth death. The midwives' elected to do a high risk birth at home. They did not call for backup when they diagnosed fetal distress. It was irrelevant that they were close to the hospital. And, of course, they were incapable of performing a correct neonatal resucitation. This was yet another preventable neonatal death at homebirth.
Labels: homebirth death, midwifery, neonatal mortality
Low perinatal mortality correlates with a high C-section rate
Homebirth advocates like to claim that there is no justification for high C-section rates. In particular, they often make two points. The first is the claim that country X has a low neonatal mortality rate AND a low C-section rate. The second is the claim that the World Health Organization recommends a C-section rate of only 15%. So I thought it would be interesting to see what the C-section rates are in countries with low neonatal mortality.
Suprisingly, there has been very little research. I did find a very recent paper in the journal Birth,
Cesarean Section Rates and Maternal and Neonatal Mortality in Low-, Medium-, and High-Income Countries: An Ecological Study, claiming to show that there is no relationship between C-section rates and mortality rates in middle and high income countries. Yet that conclusion is belied by the data. Although there is no linear relationship between C-section rates and mortality rates, the data show that virtually every country with low neonatal and maternal mortality rates have high C-section rates. Moreover, most countries with low neonatal and maternal mortality rates have C-section rates ABOVE the 15% level recommended by the World Health Organization. In fact, based on the data, one would have to conclude that there is evidence to suggest that a 15% C-section rate is not high enough.
One of the first things I do when I read a paper is to look for the raw data so I can see if the conclusions are actually justified. I become concerned when the raw data is buried, so you can imagine that my suspicions were aroused by the fact that the raw data is not even published within the paper. It is available only as a separate supplement.
The authors of the paper concluded:
No association between cesarean
section rates and maternal or neonatal mortality was shown in medium- and high-income countries. Thus, it becomes relevant for future good-quality research to assess the effect of the high figures of cesarean section rates on maternal and neonatal morbidity. For low-income countries, and on confirmation by further research, making cesarean section available for high-risk pregnancies could contribute to improve maternal and neonatal outcomes, whereas a system of care with cesarean section rates below 10 percent would be unlikely to cover their needs.
Does the data justify this conclusion? I don't think so.
I downloaded the data and analyzed it a number of different ways. First, I wanted to know the C-section rates for countries with low neonatal and maternal mortality rates. I considered a low neonatal mortality rate to be less than 10/1000 and a low maternal mortality rate to be less than 20/100,000. The authors had looked at 119 countries. Of those countries, only 30 countries met the criteria for low neonatal and maternal mortality. Second, I wanted to see if the countries with low neonatal and maternal mortality complied with the WHO recommendation. Only 10 had C-section rates of 15% or less AND low neonatal and maternal mortality. In other words, of the 30 countries with low neonatal and maternal mortality, fully two thirds had C-sections above the WHO recommendation. The WHO has acknowledged that the 15% recommendation is arbitrary and not based on any data. It seems that the recommended rate is too low.
The bottom line is that low neonatal and maternal mortality rates appear to require C-section rates in the range of 20% or more. Keep in mind that none of these statistics has been adjusted to reflect the risk status of the population. It appears, however, that countries that have low neonatal and maternal mortality AND low C-section rates are countries with homogenous (generally very white) populations that place them at lower risk for complications, neonatal and maternal mortality.
addendum: As I have said before, perinatal mortality is a more sensitive indicator of obstetric care than neonatal mortality because many countries remove certain neonatal deaths by counting them stillbirths even though the babies are born alive. Replacing neonatal mortality with perinatal mortality results in 4 additional countries failing to meet the standard for low perinatal mortality (less than 10/1000). Therefore, there are only 26 countries with low perinatal and maternal mortality. Of these, only 8 have C-section rates of 15% or less. In other words, of the countries with the best perinatal and maternal mortality rates, 70% exceed the WHO recommendations of a 15% C-section rate. Interesting, the country with lowest C-section rate (Croatia) has the highest perinatal mortality, and the country with the highest C-section rate (Italy) has the lowest perinatal mortality.
Here are the C-section rates (1998-2001) for countries with low perinatal and maternal mortality:
Croatia 11.9
Slove 12.6
Czech Republic 12.9
Netherlands 13.6
Norway 13.6
Sweden 14.4
Denmark 15
Israel 15
Finland 15.7
Belgium 15.9
Poland 16.1
France 16.1
Iceland 16.7
United Kingdom 17.0
Ireland 18.6
Austria 18.8
Canada 19.1
Spain 19.6
New Zealand 20.1
Germany 20.8
Hungary 21.1
Australia 21.7
United States 24.4
Portugal 27.5
Italy 31.1
Labels: neonatal mortality
Starting from the wrong place
One of the fundamental problems with homebirth advocacy is that homebirth advocates start from the wrong place. Like many Americans, they have little knowledge of history and little knowledge of life outside the first world. They erroneously assume that what they see is the way things are everywhere and the way things have always been. Hence, they assume that childbirth in nature is inherently safe and that is the wrong place to start. The fact is that childbirth in nature is inherently dangerous and anyone who does not know that, does not know much about birth. Since homebirth advocates start from the wrong place, it is not surprising that they draw the wrong conclusions about what they see.
In order to understand where we are, it is critical to understand where we have been. As I often point out, in the last 100 years, modern obstetrics has dropped the neonatal mortality rate 90% and the maternal mortality rate 99%. This is one of the greatest public health achievements of all time. This success is primarily due to the application of technology, large amounts of it. As I have reviewed in the past, it is NOT the result of improved sanitation, hand washing or improved public water supplies.
The primary causes of neonatal mortality 100 years ago were congenital anomalies and prematurity. The primary causes of neonatal mortality now are still congenital anomalies and prematurity. The difference is that technology has allowed us to save almost 90% of babies who would have routinely died in the past. That technology includes more C-sections, fetal monitoring, pediatric surgery, neonatalogy and other highly technological innovations.
The primary causes of maternal mortality 100 years ago were eclampsia, hemorrhage, obstructed labor, and infection. With the exception of obstructed labor, they are still among the primary causes of maternal death. The difference is that technology has allowed us to save 99% of the women who would have died in the past. That technology includes improved anesthesia, more C-sections, induction and early delivery for pre-eclampsia, medication to prevent eclamptic seizures, blood transfusions, antibiotics and other highly technological innovations.
Starting from the assumption that childbirth is inherently safe is absurd. Any attempt to understand, criticize or reform modern obstetrics must start from a basic fact: Each year modern obstetrics saves approximately 240,000 babies and 40,000 women who would NATURALLY die. When contemplating ways to improve the experience of birth, we must start by acknowledging that each year 240,000 babies and 40,000 women will otherwise die unless we bring the technology of modern obstetrics to bear, AND that we still aim to prevent the approximately 22,000 neonatal deaths and almost 400 maternal deaths that do occur each year despite our best efforts.
Childbirth did not "naturally" become as safe as it is now, and it did not magically become as safe as it is now. It became safe and remains safe only because of the diligent efforts of obstetricians, nurse-midwives, nurses, neonatologists and other professionals and the continuing application of large amounts of technology. Now that we have achieved this extraordinary feat, we have the luxury of turning out attention to the "experience" of childbirth, but ONLY while continuing to repeat this achievement each and every year.
Labels: maternal mortality, neonatal mortality
MANA is unethical in withholding its statistics
As we have seen repeatedly, the amount of data on homebirth is sparse, and most of the studies are poorly done and biased. Even so, the existing scientific evidence shows that homebirth has an excess rate of preventable neonatal death. There is not enough evidence to draw any conclusions regarding maternal mortality.
There is, however, a repository of statistical information that dwarfs all the existing scientific information, even when it is added all together. That repository is the MANA (Midwives' Alliance of North America) collection of statistics for all registered midwives from 2001-2006 and continuing up through the present. The database probably contains somewhere in the range of 30,000 deliveries, perhaps more. We know that the data is available because MANA is offering it to pre-approved individuals who sign confidentiality agreements preventing them from sharing the data with anyone else.
I don't know what the data shows, but I'd be willing to bet a lot of money that it shows a significant excess rate of preventable neonatal death, perhaps even higher than 1-2/1000. I wouldn't be suprised, either, if it included maternal deaths. Why do I think the data shows that homebirth is not safe? The issue of licensing of DEMs is being discussed in several states. If the MANA data demonstrated the safety of homebirth, they would release it publically themselves. The fact that they refuse to release it except to pre-approved individuals, and the fact that they require a legal document preventing disclosure suggests that the data will be very harmful to MANA's interests.
MANA does not seem to realize that it has an ethical obligation beyond serving its members and their professional and economic interests. It has an ethical obligation to patients. If MANA is in possession of a large database that demonstrates that homebirth is not safe, and I believe they are, it is unethical for them to withhold that information and to take legal steps to insure that the public does not learn that information.
MANA should release the information immediately, both in print and on the web. Any state agencies contemplating DEM licensure should insist on a release of the information as a prerequisite for even considering the licensure issue.
There is simply no ethical justification for withholding the safety information in the MANA database.
Labels: midwifery, neonatal mortality
Birth asphyxia
A new paper on birth asphyxia in the developing world provides insight into the inherent dangers of childbirth.
Reducing one million child deaths from birth asphyxia – a survey of health systems gaps and priorities was published in Health Research Policy and Systems in May of this year. Birth asphyxia is defined as: "the full-term baby who is not breathing and in poor condition at birth with an assumed association to acute intrapartum events."
The magnitude of the problem is huge:
Birth asphyxia is the fifth largest cause of under-five child deaths (8.5%), after pneumonia, diarrhoea, neonatal infections and complications of preterm birth. Birth asphyxia accounts for an estimated 0.92 million neonatal deaths annually and is associated with another 1.1 million intrapartum stillbirths, as well as an unknown burden of long-term neurological disability and impairment... [B]irth asphyxia plus intrapartum stillbirths constitute the number-one cause of child and late fetal deaths.
In nature, therefore, birth asphyxia represents a major cause of child deaths. As a cause of perinatal mortality, it is exceeded only by prematurity. The claim by "natural" childbirth advocates, the birth is inherently safe, is belied by the fact that death from birth asphyxia is quite common.
Labels: neonatal mortality
The Farm Study: a classic case of deception
I never tire of pointing out that there are no studies that show homebirth to be as safe as hospital birth. There are, however, studies that CLAIM to show that homebirth is as safe as hospital birth. None of them do because they rely on the deliberate use of the WRONG group for comparison. By deliberately choosing the wrong group (always a group with higher neonatal or perinatal mortality than the right group) the authors can make homebirth look safer than it really is.
My favorite example is the BMJ 2005 study by Johnson and Daviss which compared neonatal death at homebirth in 2000 to a bunch of out of date papers instead of comparing it to hospital birth in 2000. The correct comparison shows that homebirth has a neonatal mortality rate 3-4 times higher than hospital birth for low risk women.
The Farm study (Durand, 1992) is even worse. The Farm study compares homebirth to the 1980 US National Natality-National Fetal Mortality Survey and concludes that homebirth is safer. However, the documentation for the NN-NFMS reveals that it is a deliberately non-representative sample of births in 1980 and was never meant to be used as a measure of neonatal mortality. Durand calculated a perinatal mortality rate for homebirth at the Farm was 10/1000 and compared it to the perinatal mortality rate for the NN-NFMS of 13/1000. However, the neonatal mortality rate at the Farm was 8.2/1000 and the neonatal mortality rate for the entire US in 1980 was 8.5/1000. It was only 7.6/1000 for white women and was substantially lower for low risk white women at term, probably in the range of 3.8/1000 or less. So, rather than showing that homebirth is as safe as hospital birth, the Farm study showed the the neonatal mortality rate at homebirth is more than double that in the hospital.
What is the 1980 US National Natality-National Fetal Mortality Survey and does it give us accurate information about neonatal death rates? The 1980 US National Natality-National Fetal Mortality Survey comes with copious data about the methodology of the NN-NFMS and this data leaves absolutely no doubt that the NN-NFMS does NOT yield neonatal mortality rates for hospital birth in 1980. Let's look at some important reasons why:
The NN-NFMS was not designed to yield mortality data for 1980. It had an entirely different purpose. The NN-NFMS was designed to obtain health data that was not on the original birth certificate in order to analyze that data. So, for example, the NN-NFMS asked about the use of ultrasound during pregnancy, which does not appear on the birth certificate. The investigators also collected data that did appear on the birth certificate in order to determine the accuracy of the NN-NFMS data.
No other scientific paper uses the mortality data on the NN-NFMS. (This is not suprising, since, as explained above, the mortality data is not accurate).
The NN-NFMS deliberately oversampled high risk births. This fact is acknowledged within the Durand paper, but it is not explained. It means that the sample used in the NN-NFMS has a higher risk level than the population in general, and is much higher risk than any lower risk group. As expected, the neonatal mortality rate in the NN-NFMS sample is HIGHER than the overall neonatal mortality rate for the entire country in 1980.
The NN-NFMS is known to be a tiny (0.3% of births) NON-REPRESENTATIVE fraction of the deliveries in 1980. That is deliberate on the part of the authors, but it means that under no circumstances can the NN-NFMS mortality data be substituted for the 1980 birth certificate data.
In summary, Durand compared death at homebirth at the Farm with neonatal death rates from a tiny, non-representative fraction of deliveries in 1980 instead of comparing the Farm to know mortality rates from hospital birth in 1980. The correct comparison shows that homebirth at the Farm had a neonatal death rate more than twice as high as hospital birth for low risk white women. Once again, the only way to make homebirth look good is to use deception.
You can find out much more about the NN-NFMS by reading these publications:
Response Characteristics 1980 National Natality and Fetal Mortality SurveysComparability of Reporting Between the Birth Certificate and the 1980 National Natality SurveyFor more information about neonatal mortality rates in 1980:
Infant, neonatal, and postneonatal mortality rates by race and sex: United States, 1940, 1950, 1960, 1970, and 1975-2000Labels: neonatal mortality
