Re: ACOG statement
From: Garry E. Siegel, M.D. (garrys@mindspring.com)
Tue Nov 28 19:57:25 2006
Barb:
Nicely done.
Maybe the numbers of bad outcomes are so small that it is exceedingly
hard to find a significant difference in outcomes.
Garry
At Tue, 28 Nov 2006, art fougner, md wrote:
>
>Barb
>
>What ... an ad rem argument? No ad hominem attack? Where's the fun in
>that?
>
>/sarc
>
>Art
>
>At Tue, 28 Nov 2006, Barbara Nicol wrote:
>>
>>Do you think that it's possible that ACOG actually reviewed the literature and thought there might be issues with OOH birth? I mean, give the people some credit - they're not stupid, and many of them are quite openminded. I think this even more after looking into it a bit (as a result of reading this thread).
>>
>>I started with the widely quoted 2005 BMJ study that is supposed to show safety of OOH birth.
>>
>>http://www.bmj.com/cgi/content/abstract/330/7505/1416
>>
>>Now, please understand that I work in a collaborative practice, in an local patient culture where the safety of OOH birth is a firmly established health belief that is difficult to question. However, also understand that I don't follow the OOH birth literature closely. I mean, why would I? Do OOH midwives follow the literature on best surgical practice at CS closely? Doubt it - it's just not what you do every day. So I hadn't really read the study closely before to see if the conclusion stated is supported by the data presented. (Also understand that I don't do OOH birth backup, but regularly - because I live where I live - see patients transfer themselves in from planned home birth who have received excellent prenatal care and are frequently arriving at a completely appropriate moment with complete records. I've also seen the occasional distrust-delay-disaster too.)
>>
>>Friends, I'm sorry, but I think this study does not support its stated conclusion about the safety of homebirth.
>>
>>It's a prospective study of the outcomes of 5000 women - a case series. There is no control group; it's just a description of outcomes. The neonatal outcome studied is "perinatal mortality rate" (which is usually the rate of fetal or neonatal death from 28 weeks to 7 days postpartum). They claim a rate of 1.7 per 1000 BUT they leave out all the antepartum stillbirths and fetal anomalies. In other words, they aren't calculating a standard PNM.
>>
>>This would be okay if there were a control group, but they don't have one.
>>
>>They then cite a lot of other studies to say that their PNM is comparable. The rather distressing thing about this is that the OOH births generally have higher PNMs than the hospital births. Because they didn't provide much information about how the PNMs were calculated in the other studies or any statistical measures around the number, it's impossible to say whether their PNM is actually the same or different. However, they do make it clear that most of the other studies did include lethal anomalies in their PNM, so their PNM is NOT comparable. They altered their calculation in a way that made it look comparable, but it ain't.
>>
>>Fine, I said, but let's look farther at some of the PNM studies they quote. Maybe OOH birth is safe. Everyone I know says so locally. It's one of those medical dogmas. (There are a LOT of midwives in San Francisco.)
>>
>>Well, Pang et al, the WA state study, says PNM doubles at home. This is widely criticized for including unplanned OOH births. However, my experience working in WA during 2002-6 says that the vast majority of OOH births were planned, easily 95+ percent, and most of the unplanned ones were fast easy multip labors where the baby was maybe a bit cold but otherwise fine. You'd have to argue for a humongous rate of perinatal death in unplanned OOH birth to make those numbers any different.
>>
>>Janssen et al is a tiny Canadian study, in an environment in North America where OOH births are supported by the local medical community. PNM increased but not reaching significance - as expected for a small study - but, fascinatingly, Apgars at 5 minutes significantly worse in the OOH setting. This blew me away! Think of all the ob interventions which have NOT been shown to increase Apgar scores - oxygen and continuous EFM to give 2 - and here's an intervention which does! Why isn't the midwifery community saying "Yes, we need to send our patients to the hospital to improve neonatal outcomes?"
>>
>>Okay, so I do see that there's a problem with the maternal outcomes. Going back to the ACOG statement, it actually acknowledges that although in a perhaps too understated way - supporting changes to improve the maternal "experience" or similar, when "maternal complication rate" might be appropriate.
>>
>>So tell me again - why is it so certain that OOH birth is equivalently safe for babies? I get that it's safe for moms, so don't tell me about that. But if it's not as safe for the newborn, then the correct position would be the exact position that ACOG is taking: it's better for the newborn to be in a hospital setting, so we have to change the hospital setting to make it work for moms.
>>
>>Getting out the asbestos underwear now...
>>
>>Barb Nicol, M.D., F.A.C.O.G.
>
>--
>art fougner, md
>"May The Wings of Liberty Never Lose a Feather." - Jack Burton
>
--
Garry E. Siegel, M.D.
Private Practice
Roswell, GA
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