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  1. #1
    Join Date
    Sep 2012
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    Los Angeles
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    4,279

    Extremely important new paper on safety v birth setting

    As the board has been discussing some very interesting and very important topics re: birth practices and birth settings recently, I wanted to make a separate thread just for this new paper-- it's that crucial.

    The CDC (in the US, the main public health agency) has long collected very basic outcomes data based on place of birth. These data include: 1) live births versus intrapartum [in-labor] deaths; 2) 1-minute and 5-minute APGARs-- an assessment of how well a baby is breathing, how its heart is beating, and its neurological function; 3) subsequent NICU admission and NICU diagnoses, including hypoxic seizures. 'Hypoxic seizures' means those resulting from prolonged oxygen deprivation to the baby's brain, usually from cord and/or placental problems during the birth. Fetal monitors are meant to capture the worrisome trends in heartbeat that correlate with hypoxia.

    OK, enough introduction. Finally a group of researchers had enough time to cull through ALL US births-- every single one-- since 2007, and separate them into four groups: 1) Hospital birth with a physician; 2) hospital birth with a Nurse-Midwife; 3) Freestanding Birth Center birth [could be Nurse-Midwife or lay midwife]; 4) homebirth with a midwife (nearly always lay midwife, AKA CPM/LM). This is over 14 million births!!! You can't get better data than this!!! Also, only singletons were considered, and only full-term births (>37 weeks gestation).

    Two things to keep in mind:

    -- the data ONLY captures where the baby was actually BORN, not where labor started or who managed it initially. Since transfers between birth settings only go one way-- home/birth center -> hospital-- any complication that occurred at home, such a prolonged oxygen deprivation due to mismanaged labor or inability to intervene, but which was TRANSFERRED to the hospital and delivered at the hospital, counts in the "hospital" group. This ALWAYs serves to UNDERESTIMATE the inherent risk of homebirth/ birth center birth since a certain %age of their bad outcomes get counted in the hospital group.

    -- the Hospital MD group of women includes all high-risk women and all high-risk babies. The Hospital Midwife group is low-risk women only. Since a labor complication can be transferred to MD care immediately within a hospital, simply by shouting down the hall, the Hospital Midwife patient group to me represents the best, most pure outcome data for healthy, low-risk women, and shows how beautifully a two-tiered system can work. Because of the fact that all high-risk, complicated women and babies are always managed by MDs, the MD data will always look "worse" than the Hospital Midwife data.

    OK, the results:

    "Relative risk" = %age increase in your chance of developing the outcome. A RR of 2 = 200% increase, or double, your chance of developing the thing in question.

    Risk of 5 minute APGAR of ZERO [baby near-death]

    Hospital MD: 0.16% of all births; RR 1 [since hospital MDs delivered over 12 million of the babies, they were used as the reference group]
    Hospital Midwife: 0.09% of all births, RR 0.55 [only HALF the risk]

    Birth Center Midwife: 0.55%, or RR of 3.56 (356% increased risk)
    HOMEBIRTH MIDWIFE: 1.63% or RR of 10.55 (1,055% increased risk!!!)



    Even scarier: when you disaggregate the home birth data into first-time mothers versus mothers with at least one birth: the first-time mothers had an increased risk of 5-min APGAR of 0 of 14.55 (1,455% increase). 1+ previous births meant you fared slightly better, with a RR of 9.5, so only a ten-fold increase.

    Risk of neonatal hypoxic seizures from prolonged oxygen deprivation

    Birth center midwife: RR 1.88 (188% increase)
    Homebirth midwife: RR 3.80 (380% increase in severe neurological dysfunction, though not death)

    Here is the paper, though unfortunately without an institutional login or subscription you can only read the abstract:

    http://www.ajog.org/article/S0002-93...641-8/abstract

    This is raw data guys, straight from the CDC, no spin. If you suspect I'm anti-homebirth you're right, but only because I look at the data and the data tells me it kills babies unnecessarily.

    If you want a midwife-attended birth, compare the outcomes for hospital midwives (who are competent trained professionals) to homebirths midwives (who are not). Both supposedly represent the same pool of low-risk, healthy women patients, but the homebirth outcomes led to TWENTY times more dead babies than the hospital midwives.
    Blade, MD

    XY: Antoine Raphael (3.1.2012)
    XX: Cassia Viviane Noor (11.30.2013)

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