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Angela Simpson
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| 07/07/2008 2:01 PM |
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| I actually do do that, but I'm thinking that it might be my browser playing tricks on me. I use a Mac, and typically use Safari when I'm on the forum. I'll try in firefox next time, I think. |
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Henci Goer
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| 07/07/2008 2:21 PM |
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Try that. I think the Forum software doesn't play as nicely with Macs as with Windows-based machines.
-- Henci |
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maria (guest)
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| 07/07/2008 2:59 PM |
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Nope, it doesn't! I use Firefox now and it is fine.
maria.
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maria (guest)
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| 07/07/2008 10:56 PM |
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I would really like an independant party to look at this. I mean, it would be nice if this could ne hased out once and for all.
maria.
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tienchinho (guest)
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| 07/08/2008 3:13 AM |
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I am a general surgeon in California currently working as mother. I had
my now five year old by cesarean for breech and asystole with an attempted
external version with my obstetrician friend. I had my now three year old
in water at home with a midwife with my obstetrician friend as my
backup.
I think studies can be interpreted in different ways. I
was merely pointing out the data. The reason you were not sure which
side I was one is because I am not on the home birth or the hospital
birth side. I am on the mother’s side.
Some events that happen
during labor and birth are not resolved immediately after birth.
Sometimes babies survive for weeks or months on life support only to
die later. Researchers have different time periods (infant, neonatal,
intrapartum, perinatal mortalities) because they are trying to answer
different questions, and sometimes they disagree on which time period
to use. Sometimes there is no right answer.
Prenatal care and
its effectiveness or ineffectiveness have been studied. Studies are
inconsistent in part because the purpose of prenatal care is not
consistent. Is the goal a lower maternal/ neonatal mortality rate? Or
breastfeeding success? Or avoiding repeat cesarean sections? See the
Cochrane database at:
http://www.ncbi.nlm.nih.gov/pubmed/17636711?ordinalpos=9&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
Although
you may not perceive any difference in monitoring between a home and a
hospital, those who feel they “do it better” have very strong beliefs
about how intrapartum and neonatal mortality is affected by location of
birth and birth attendant. For some, being ten minutes from the hospital is too far. For others, an hour is close enough.
As far as a general consensus, I don’t know of one.
Perhaps obstetricians believe that the advantage of a hospital birth is
that they are there, along with all the equipment and personnel with
which they are comfortable. In fact, most people have some element of
this. If you plan a home birth, is your backup plan to go to the most
rural hospital without a neonatal intensive care unit? Or is it to go
to the hospital with a perinatologist on call 24/ 7? Are you more likely to take the words of
an obstetrician or a mother more seriously? Is
not having a continuous fetal monitor only ok if you have a Doppler? Or
is a fetoscope enough? All of us participate in the idea that doctors
know more than us and that technology and science make things safer.
Some less than others. Robbie Davis-Floyd says it best in her book
Birth as an American Rite of Passage with her discussion of our
societal values of paternalism and technocracy.
http://www.amazon.com/Birth-as-American-Rite-Passage/dp/0520229320/ref=sr_1_3?ie=UTF8&s=books&qid=1215502269&sr=1-3
Tienchin
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Angela Simpson
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| 07/08/2008 6:10 AM |
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WOW doesn't get more "independent party" than that, I feel! Thank you so much for your well written response. What a breath of fresh air compared to the beligerence that's been delegated before this point. And I agree wholeheartedly that its the mother's decision and that decision should be supported by all, particularly legislation. Its a shame that there are too many variables in the studies to make them truly reliable. But see, I don't believe that Mother Nature ever intended birth to be a scientific study with the hopes that women will trust their bodies and intuitions to guide them to the right decisions. Just my opinion though 
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Eema (guest)
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| 07/08/2008 1:54 PM |
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I think Dr. Amy's blog postings and online commentary lack elegance, rhetorical style, maturity, kindness, and even really much logic. I think she belittles her readers openly and all women in more subtle but repetitive ways. I am grateful she is no longer practicing medicine.
But Ms. Goer, your responses to her weaken your case. She should be allowed to flog herself on an unlimited basis and you should let her. Limiting her expression only makes you look defensive. |
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Jenn (guest)
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| 07/08/2008 2:21 PM |
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I agree with Eema completely.
I think that the biggest weakness we have to date in any comparison data of "out of hospital birth with a CPM" compared to "in hospital birth with a Dr or CNM" is a lack of a good comparison that starts at the beginning of prenatal care between the two groups.
The authors of the 2005 BMJ study have suggested that care with a CPM may reduce the rate of prematurity, and since complications associated with prematurity are a major cause of neonatal death in the US, that could significantly affect the comparison. Dr. Amy asserts that there is no proof that care with a CPM reduces prematurity...and she is correct.
Further, I believe that the demographic choosing homebirth is more likely to include women attempting VBAC and grand-multiparas than the hospital birth population, which introduces risk. Dr. Amy asserts that the hospital group would contain some levels of risk not seen in the homebirth group such as Gestational Diabetes and pre-eclampsia; however these women do often start in CPM care (and sometimes do remain, depending on the severity of symptoms) and so I think it is unwise to discount those risk factors in the "planned homebirth" population.
I wish there were a good way to do a study that matched women planning homebirth and planning hospital birth but eligible for homebirth at the start of prenatal care and follow them through birth to see outcomes. Even better would be to follow them through to their second birth, since one of the claims of homebirth advocates is that birthing at home reduces the risk of primary cesarean--which if true, would reduce the risk to future pregnancies. Such a trial would be extremely difficult and expensive though, and likely could only be done as a retrospective study. |
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Henci Goer
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| 07/08/2008 2:28 PM |
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Posted By n/a on 07/07/2008 10:39 PM
"I posted that there had been enough information and resource links on the issue of the MANA 2000 home birth neonatal mortality statistics for people to make their own evaluations."
You're joking, right?
YOU decided that there is "enough" information and resource links. What do you think is going to happen if there are more? Do you expect people to fall down dead from information overload?
There is absolutely no legitimate reason to limit the presentation of relevant information. The ONLY reason to limit the presentation of relevant information is to prevent people from finding out the truth.
I have no need to continue this discussion. I think I have made my point and hammered it home repeatedly. I only dropped in because you wrote about me personally and you lied. I honestly cannot believe that you were so careless. It is so easy to find out the truth about me and my credentials, but you never even bothered. Your contempt for the truth about something so obvious and easily checked should be a warning to others about your contempt for the truth about obstetrics.
You were warned. You have flagrantly and repeatedly violated the Terms of Use for this Forum which forbid posting material that is, among other characteristics "defamatory," "abusive," or "harassing." You will be blocked from further posts on this site.
-- Henci |
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Jenn (guest)
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| 07/08/2008 2:32 PM |
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Posted By Dr. Amy on 06/28/2008 3:18 PM
Actually, both claims are both true.
Goer's quote from the WHO is out of date. The WHO said in April 2006:
Home-like settings for childbirth are associated with reduced likelihood of medical intervention. ... However, the evidence shows an increased risk of perinatal mortality, the reasons of which are not fully established.
Dr. Amy's quote is indeed from WHO, and certainly does not make Henci's "out of date," simply older. I'll also point out that the quote Dr. Amy uses specifically refers to "home-like" settings. The study upon which they base this conclusion looked soley at birth center births. Who is to say that birthing in a birth center doesn't increase the risk of perinatal mortality over homebirth? We really don't know.
Posted By Dr. Amy
As far as the NICE report is concerned, Goer didn't even answer the question. She was asked if NICE reports a higher rate of neonatal mortality at homebirth, and they do. From the same report that Goer quoted:
... intrapartum-related perinatal mortality (IPPM) for booked home births, regardless of their eventual place of birth, is the same as, or higher than for birth booked in obstetric units.
So the NICE report says that the perinatal mortality is the same as, or higher, than birth in a hospital. I certainly think that people should be aware of this...but the statement isn't exactly rock solid. Did they state "the same as" first because that was the statement they had more confidence in, or was "higher" stated last so that it would stick in the reader's mind? I don't know.
Goer tried to sidestep the direct question that she was asked about DEM qualifications. American DEMs have less education and training than ANY midwives in the industrialized world. There's no denying it and she didn't deny it. The education required by NARM is certainly less than other midwives. However, there are many individual midwives who have credentials far exceeding those required by NARM. I think it is worth-while to push for more stringent requirements.
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Angela Simpson
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| 07/08/2008 2:34 PM |
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| Henci, Thank you. I agree completely that Amy needed to be moderated, particularly considering her disrespectful tone toward not just you, but advocates of home birth in general. You simply deleted the posts that included repeated information or blatant attacks on you. This forum, and you as its moderator, reflect Lamaze's values and you simply did what you needed to. I applaud you for your restraint, because I probably would have been a bit less tactful in my responses. haha Seriously, though, I'm happy to see her gone, for good. She did nothing to promote a polite and balanced debate, which is something that I actually enjoy.
I do have a question unrelated to that though. I read recently somewhere that a study was done that concluded in only 0.7/1000 attempted VBACs resulted in rupture (or maybe it was .07%?). Has anyone else read this too, and if so, where did you find it??? I'm having a hard time finding it again.
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Angela Simpson
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| 07/08/2008 2:35 PM |
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| (sidenote--I just used HTML tags to space my paragraphs. hooray it worked!!!!!!) |
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Henci Goer
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| 07/08/2008 3:00 PM |
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Posted By n/a on 07/08/2008 1:54 PM
I think Dr. Amy's blog postings and online commentary lack elegance, rhetorical style, maturity, kindness, and even really much logic. I think she belittles her readers openly and all women in more subtle but repetitive ways. I am grateful she is no longer practicing medicine.
But Ms. Goer, your responses to her weaken your case. She should be allowed to flog herself on an unlimited basis and you should let her. Limiting her expression only makes you look defensive.
We'll have to agree to disagree on that one. My position is that I am willing to give anyone an opportunity to have their fair say, including an opportunity to rebut my arguments or those of other posters, but I am not willing to allow anyone to hijack this Forum with endless rants that, as you say, lack logic, maturity, or kindness. I also think Tuteur's rudeness, bullying, and personal attacks create an unpleasant environment that may discourage others from participating in the Forum or even following along. That may be a generational thing--I am currently 60--and maybe the younger generation isn't put off, but, then, I am the moderator, so I get to decide. And, of course, in support of my action, that kind of behavior violates the Forum's terms of use.
-- Henci |
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Jenn (guest)
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| 07/08/2008 3:01 PM |
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Posted By n/a on 07/06/2008 4:44 AM
The link Amy Tuteur provided to CDC Wonder does not provide an appropriate cohort of births to compare to the MANA data.
Our original discussion was about finding an appropriate cohort from the year 2000 of planned HOSPITAL births to compare to data on planned HOME births published in the BMJ.
The CDC Linked Birth/Infant Death dataset for 2000 does not provide neonatal mortality rates based on planned HOSPITAL births.
The link http://wonder.cdc.gov/lbd.html navigates to a page that allows us to select one of three databases: Linked Birth/Infant Death Records with ICD 10 codes for 1995-1998, for 1999-2002, and for 2003-2004. It does not allow the user to select for data from 2000 alone.
Then we can separate the data out by maternal and infant characteristics. The data is not available by place of birth. The CDC Wonder link does not provide any information about hospital birth neonatal mortality rates in 2000.
You are right that you can't do the query on place of birth in 2000. You can in 2003 and 2004 though. But there is the rub...it is simply "place of birth" not "planned place of birth." 12% of women who start labor planning to birth at home end up transporting to the hospital...and likewise a certain percentage of women who plan to birth in a hospital will accidentally birth out of the hospital--happened to one of my clients with her second baby (ironically she had a lot of stress over her hospital choice because the hospital she'd used for her first baby closed its maternity ward during her second pregnancy, and she just wasn't sure she was going to like the alternate...turned out her labor went too fast for her to get to either of the hospitals). Also, there is a significantly larger number of women in the "other midwife" category than one would expect based on the 2005 BMJ study...which leads to the logical conclusion that many of those births were not attended by CPM's, but may have been attended by women with very little formal training. In my state, because of the Amish and Mennonite population, there are a lot of lay midwives who I'm told would not pass the NARM exam to get the CPM designation. This has made efforts to get legislation for licensure difficult. Amy believes of course that licensure will be the downfall of CPM's because she thinks it will expose them as being substandard care providers. I believe the opposite--that licensure will allow CPM's to be less hesitant to transfer care when it is meritted, thus increasing the safety for women and babies. |
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Henci Goer
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| 07/08/2008 3:14 PM |
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Jenn: Apologies, but I deleted the re-post of Tuteur's because it contained the same kind of objectionable and insulting language I just banned.
-- Henci |
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Brandy Baker (guest)
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| 07/08/2008 10:50 PM |
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| "I am not willing to allow anyone to hijack this Forum with endless rants that, as you say, lack logic, maturity, or kindness."
Thank you for this. I have too often seen list owners who are unwilling to delete nasty posts or ban abusive people all in the name of "free speech"; which is why I do not go on most boards. As a result of this contortion of the definition of "free speech", boards are taken over by these psychologically-challenged people. I am 34 and it puts me off. My argument always is: "if you are teaching a class, would you allow an overly-obnoxious student who seeks to dominate the class to remain unchecked in the name of free speech?"
Your allowing Tuteur to post at all is generous. If she thinks that you are so wrong, let her post on her own blog |
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Brandy Baker (guest)
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| 07/08/2008 11:02 PM |
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| Oh and for the record, I found this site through Tuteur's blog, which I found through her posts on our alternative weekly and I did not read for very long at all (I saw more than enough after 30 seconds). So you may be getting more people to your site through her linking to you, which, if that is true, is peachy, IMHO. |
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maria (guest)
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| 07/09/2008 11:09 AM |
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Ok, I posted this to a prof. in statistics and here is his response:
The study I am looking at is this study:
http://www.bmj.com/cgi/content/full/330/7505/1416
The following explanation was given by Johnson and Daviss about their study:
http://understandingbirthbetter.com/section.php?ID=31&Lang=En&Nav=Section
Some people say they have used the wrong comparison groups and that the correct comparison would prove that homebirth has triple the neonatality rate of hospital birth.
***
OK, here’s my take on it…
When I read the executive summary of the BMJ, I was struck by it’s modest claims in the results. By modest, I mean that it essentially reported the percentages of differing outcomes within it’s own data set. It was the conclusion, however, that struck me: it claims that their study group was similar to a group not in the study, namely, low risk hospital births in the US.
That seems to be the basis of the criticism. The comparison group has one obvious difference that masks for lots of other potential discrepancies: it was retrospective data. The authors of the study actually point this out in the study, however, so, to me, it isn’t fair to fault them for making the comparison. Perhaps they could have added a footnote to the conclusion in the exec summary, but that’s a bit picky. The disclaimer is clear in the discussion section:
“Regardless of methodology, residual confounding of comparisons between home and hospital births will always be a possibility. Women choosing home birth (or who would be willing to be randomised to birth site in a randomised trial) may differ for unmeasured variables from women choosing hospital birth….”
Consistent with this disclaimer, the biggest factor (in my opinion) is the demographics of their study group. This is visible in Table 1, which shows the characteristics of the mothers in the two groups:
- More women above the age of 25
- Likelihood of having already given birth is much higher
- Typical education levels are higher
- 95% had partners—which I would wager is significantly larger than the comparison group, whose rate is reported as N/A
Their study group is a self-selecting subpopulation of women—they are different from other women in ways that move them to choose a birth method that is out of the “main stream.” This fact alone (supported by the items I just listed) suggests to me that they were better prepared for birth, and more aware of risks and of ways to handle them.
They did attempt to sort the data from the Nat. Center for Health Stats into “low risk” mothers, in order to make a better comparison. Assuming that sorting method valid, they arrive at the result that their group is, essentially, equivalent to the in hospital “low risk” group. Not shocking, given the kind of mom in their population.
I hope this is helpful.
***
Now my question is, what numbers did Amy Tuteur use to come to her comparison of homebirth being triple the risk of hospital birth. Where can I find these numbers and how are they a better comparison?
I think in the end, on one hand, eventhough this study has lots of merrit, the homebirth advocates should maybe not take it as a decisive study about the safety of homebirth, as they tend to do now, saying 'see!'
However, I do not think Amy's claims are grounded either so I would like to present to this prof. the numbers Amy is talking about and see what he comes up with.
Henci, would you please refer me to where I can find the numbers Amy is talking about? My apologies if they are posted here before!
Thanks!
maria.
ps: I asked two other people knowledgeable in statistics to look at this and I am waiting for their responses as well.
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ernst (guest)
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| 07/09/2008 11:27 AM |
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Silly question, perhaps: but how can you think Amy is wrong (or right) if you don't understand the study yet?
You've got the process backwards: you have come to a conclusion and now you look for evidence to support it. But it's supposed to work the other way; you are supposed to understand the subject ad the evidence before you come to a conclusion on it.
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maria (guest)
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| 07/09/2008 12:17 PM |
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I am trying to understand it. I thought I understood it, but I am looking at it again, trying to be open to the study's possible flaws and its implications. There seems to be two ways of looking at this study depending on where you stand in the debate.
I don't understand your question. I am not looking for evidence. I am looking to understand how Amy comes to her conclusion and others come to theirs. This is why I posted my question to some people knowledgeable about statistics and not involved in birth like I am (or Henci or Amy for that matter). Just curious what they thought is all and I thought others may be interested as well.
I personally do not care either way how accurate this study is. I birth unassisted.
I hope this answers your question.
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