Homebirth Debate

The Skeptical OB

I've moved my new blog to my own site where there is no need to register in order to comment. Everyone is welcome.

posted by Amy Tuteur, MD @ 10:50 AM

How to tell if a homebirth midwife is a quack

The Brewer diet is the flat earth theory of homebirth midwifery. It's been discredited in every possible way, but just like the flat earthers can "see" that the earth is flat, the Brewer diet supporters can "see" that it works.

If there is anything that definitively marks a homebirth midwife as a quack, it is belief in the Brewer diet.

posted by Amy Tuteur, MD @ 5:26 PM

Continuing the discussion

I've been on a temporary hiatus, but others have continued the discussion. I received e-mail requests to open a new thread for member convenience in posting. Here it is.

posted by Amy Tuteur, MD @ 7:13 AM

CDC study does NOT show bed sharing is dangerous for infants

It really irks me that the CDC has claimed that a new study on accidental infant suffocation shows that bed sharing increases the risk that an infant will suffocate. The study itself shows nothing of the kind. It merely reflects a change in the reporting criteria for infant death. You can read my rant at CDC study does NOT show bed sharing is dangerous. Feel free to comment here or there.

posted by Amy Tuteur, MD @ 9:49 AM

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

posted by Amy Tuteur, MD @ 11:01 PM

"Internet Crack for Crazy Mamaz"

A send up of MDC:

Truth be told, www.mothering.com is a festering cesspool of what can only be described as insane MAMAZ who put their children and the children of others at risk every single day because they essentially enjoy engaging in a pissing match over who can be crunchier.

Read and enjoy the full post at the author's website.

posted by Amy Tuteur, MD @ 9:58 AM

A lactivism project I can get behind

What are the folks at Facebook thinking? Why are they labeling as obscene photos of mothers nursing their children?

I strongly support the protests of Facebook's nursing mothers. I blogged about it on OpenSalon:

100,000 women demand more breasts on Facebook

posted by Amy Tuteur, MD @ 10:27 AM

"we all know natural birth is pretty much like trying to push a football through the eye of a needle"

From Orgasmic birth and other old midwives' tales written by a homebirther Avril Moore in the Australian publication The Age:

On Ina May Gaskin:

Curious to see what her contemporary take on modern birthing practices would reveal, I logged on to www.orgasmicbirth.com, only to discover a much greyer Gaskin still expounding — "it is possible to have an ecstatic birth — in fact, it is the best natural high that I know of".

... [H]aving delivered three children vaginally (two at home and one in a labour ward) and having experienced an orgasm, I can confidently report there is nothing remotely similar between them.

If ever there was a reason for women to be suspicious of natural childbirth, it is the "orgasmic" vaginal delivery and "placenta-eating" claptrap that is trotted out every time home birth is put back on the health service agenda.

On the role of men in the natural childbirth movement:

What a paradox that this "woman-centred" approach to birth, all dressed up to empower labouring mothers, remains unapologetic in its deference to men. Gaskin's book was dedicated to her husband, spiritual leader and "head honcho" of the notorious "farm", Stephen, whom she claims taught her everything she knows about midwifery, including "respect for the life force and how to move psychic energy".

A similar misguided adulation surrounded Melbourne's two sagely home-birth doctors (replete with beards and sandals) during the '70s and '80s.

Their entourage of pregnant patients, "birth helpers" and midwives became such blind devotees that they were utterly bereft when one practitioner after the other was deregistered or suspended for malpractice.

On the effect of Gaskin and her campaign for "orgasmic" birth:

This stereotype promoted by Gaskin on the Orgasmic Birth website is exactly what drives women into the arms of their scalpel-wielding obstetricians, not to mention encouraging a good dose of post-natal depression due to profound disappointment with their labour.

On the reality of birth:

But please, let's get real, and stop equating this choice with some hokey idea of "ecstasy" when we all know natural birth is pretty much like trying to push a football through the eye of a needle — imagine that, fellas, whenever you're having an orgasm.

I couldn't have said it better myself.

posted by Amy Tuteur, MD @ 5:50 PM

MacDorman studies further undermined by new data

Homebirth and "natural" childbirth advocates like to claim that Cesarean section increases the risk of neonatal death almost 3 fold, based on the findings of Marian MacDorman and colleagues. What they do not realize is that MacDorman herself has already revised this claim drastically downwards, and that even then, the conclusions are false.

In September 2006, MacDorman et al. published (and heavily publicized with interviews to the lay press) a paper that purported to show that Cesarean section increases the risk of neonatal death almost 3 fold. MacDorman et al. compared outcomes of C-sections with "no indicated risk" (a blank space on the risk section of the birth certificate) with outcomes from vaginal deliveries with "no indicated risk" and found that the neonatal death rate was higher in the C-section group. However, MacDorman neglected to mention that it is well known that the risk section of the birth certificate is often left blank even when there are serious risk factors and complications. Indeed, in 50% or more of serious risk factors (heart disease, kidney disease, etc.) the space is left blank. So their assumption that "no indicated risk" means no risk is completely unjustified.

In the follow up paper Neonatal Mortality for Primary Cesarean and Vaginal Births to Low-Risk Women: Application of an "Intention-to-Treat" Model, MacDorman et al. use the same dataset, known to be flawed and incomplete, but applied a better form of analysis. Using this new, more accurate statistical analysis, MacDorman et al. went back and reviewed their incomplete, flawed dataset.

...In the most conservative model, the adjusted odds ratio for neonatal mortality was 1.6 (95% CI 1.35–2.11) for cesareans with no labor complications or procedures, compared with planned vaginal deliveries. Conclusions: The finding that cesarean deliveries with no labor complications or procedures remained at a 69 percent higher risk of neonatal mortality than planned vaginal deliveries is important, given the rapid increase in the number of primary cesarean deliveries without a reported medical indication.

MacDorman et al. adjusted their claim downward by a substantially amount. Instead of their original claim that C-section increases the risk of neonatal death by 200%, they now find that C-section increases the rate of neonatal death by only 69%. Yet even then, they failed to acknowledge the most significant flaw in the paper. MacDorman and colleagues assumed that a birth certificate that listed no risk factors for C-section indicated that there really were no risk factors. A large body of data on the accuracy of birth certificates had long ago shown that more than 50% of cases of major risk factors were never listed on the birth certificate and that, therefore, their assumption was completely unjustified.

In the January issue of Obstetrics and Gynecology there is a new paper that adds to the mountain of evidence demonstrating that it is impossible to determine C-section risk factors merely by looking at birth certificates. According to Cesarean Delivery Among Women With Low-Risk Pregnancies: A Comparison of Birth Certificates and Hospital Discharge Data:

Among 40,932 women with primary cesarean deliveries and no risk indicated on the birth certificate, 35,761 (87.4%) had a risk identified in the hospital discharge data. The overall agreement between data sources on the presence of any risk indicator was low (κ=0.18). Among primary cesarean deliveries, the percentage without indicated risk was 58.3% when using birth certificate data alone and 3.9% when using hospital discharge data in combination with the birth certificate.

CONCLUSION: Using birth certificate information alone overestimated the proportion of women who had no-indicated-risk cesarean deliveries in Georgia. Evidence of many indications for cesarean delivery can be found only in the hospital discharge data. The construct of no indicated risk as determined from birth certificates should be interpreted with caution, and the use of linked data should be considered whenever possible.

In other words, virtually all women who had primary C-sections but had no risk factors on the birth certificate, actually did have risk factors. In the case of the MacDorman study, the authors reported that there were 469 deaths out of 271,179 births to women who had primary C-sections and no risks documented on the birth certificate. Yet if 87% of the birth certificates were inaccurate, that means that over 235,000 were wrongly placed in this category, thoroughly invalidating the results of the study.

The bottom line is that there is no evidence that C-section increases the risk of neonatal death in this study or in any other study to date.

posted by Amy Tuteur, MD @ 7:41 PM

Happy Holidays

Wishing everyone happy holidays!

posted by Amy Tuteur, MD @ 4:47 PM