Comparing Apples to Oranges

Imagine my surprise when reading this article about French health care, I read this quote:

Infant mortality rates are often cited as a reason socialized medicine and single-payer systems are better than what we have here. But according to Dr. Linda Halderman, a policy adviser in the California State Senate, these comparisons are bogus.

Official World Health Organization statistics show the U.S. lagging behind France in infant mortality rates — 6.7 per 1,000 live births vs. 3.8 for France. Halderman notes that in the U.S., any infant born that shows any sign of life for any length of time is considered a live birth. In France — in fact, in most of the European Union — any baby born before 26 weeks’ gestation is not considered alive and therefore doesn’t “count” in reported infant mortality rates.

This definitely makes a difference in infant mortality and neonatal mortality, n’est-ce pas? Most states have definitions of live and stillbirth which are similar to definitions used by the United Nations, namely, that if there is any sign of life (the umbilical cord still pulsing, the child taking even one breath, etc.), then the baby is considered to have been born alive. But if these extremely premature babies are just swept under the rug in most European statistics, then that is, at the least, disturbing. Sort of like counting up adult deaths but saying, “heart attacks don’t count, though.”

Since I recently learned how to do screen-shots, I’ll post the results of the CDC infant mortality rates (this is infant deaths from a live birth, as most broadly defined, up until one year of age), by gestational age for all mothers and babies  — as broad as I can make it — from 2003-2005:

GA 17-47

As you can see, it includes births from before 20 weeks of pregnancy (which no baby yet has survived, as far as I know), and combines all deaths from all gestational ages [from 17-47 weeks] into a single figure of 6.83/1000 deaths. Below is the same query, but limited to births from 28 weeks and above, including pregnancies of unknown gestation (which may also be below 28 weeks):

GA 28-42+This drops it to 3.76, a tad lower than the above-stated French infant mortality rate — although it’s not a perfect comparison, because it starts at 28 weeks, rather than at 26 weeks. [And if you exclude “unknown” gestational age, the rate drops a bit lower, to 3.64.] I wonder what the French (and other European nations’) infant mortality rate would be, if it were to include births as premature as what we count. So, it’s similar, if not identical.

This does change things in my mind. While as an absolute, we need to prevent premature births as much as possible (and I will note that the above figures do not include stillbirths; and many babies born so fragile and premature do not survive the birth process), so we can still do more and make our figures better; as a comparative measure, it’s simply inaccurate to say that the U.S. has worse infant mortality than European countries, if we include these high-mortality gestations in our figures, and they don’t. It’s apples and oranges.

Frankly, I’m a little irritated that I’ve not heard this before. I can understand impoverished countries not counting babies prior to 27 weeks, because they don’t have the technology of saving babies born so prematurely, while we do. But for France — which ought to have as much access to technology as we do — not to count babies that they could save in infant mortality rates is a little upsetting. Especially when it falsely makes us look worse by comparison.

Blossoming into an Unconventional Mom

Remember the TV show “Blossom”? [To be honest, I don’t think I ever watched a whole show, although I do remember bits and pieces of it. Shhh — don’t tell anyone! ;-)] Well, Mayim Bialik is now all grown up, has earned a doctorate, and is the mother of two young children. She’s an advocate of attachment parenting, and specifically talked about elimination communication and home-schooling in the video on that link. The interviewer said:

I have to say that I was both nervous and excited to talk to Mayim because I had heard she had a very unique parenting style. There are so many interesting/somewhat controversial things that she is doing with her family: elimination communication, bed sharing, home schooling, home birth, and choosing not to vaccinate her kids. I knew it was going to be an enlightening interview.

Very cool.

ACOG looking for home birth complications

Here’s the email I received:

Tell ACOG your birth story!

ACOG has a new database to collect anonymous data on “unsuccessful home births.” Let’s flood the database with entries on SUCCESSFUL home births!

It will take less than five minutes, but having even 25 people do it will send a loud and clear message and may force them to take it down due to bad data. At the very least we can force it into the members-only area, where far fewer OBs will bother to fill it out.

Go to http://www.acog. org/survey/ hdComplications. cfm

Below is information about the list of categories to fill out—you have to check each one except for the very last or the form won’t go through.

State

Select the month and year

Gravida (# of times you’ve been pregnant)

Para (# babies you’ve had who were born after 20 weeks)

Maternal Age

Gestational Age (number of weeks pregnant you were when your baby was born)

Problem – Please check OTHER and type in: Healthy baby born at HOME!

Fetal Outcome:  Please check: Successful delivery!

Pre-Arrival length of labor – give the overall length of your labor (you can’t leave it blank or it kicks you back)

Home Attendant – (CPMs are included as a choice!)

The final question to prevent accidental duplications is optional.

Thanks for taking a few moments to do this action.  It’s quick, easy and best of all – let’s ACOG know about all of the positive home births that happen every day!

And here’s the info from the ACOG website:

The American College of Obstetricians and Gynecologists is concerned that recent increases in elective home delivery will result in an increased complication and morbidity rate. Recent reports to the office indicate our members are being called in to handle these emergencies and in some instances have been named in legal proceedings. To attempt to determine the extent of the problem, a registry of these cases will be maintained at ACOG on a year-by-year basis.

If you have been called to attend, whether in the emergency room, operating room or labor and delivery suite, a patient who came to your hospital after an unsuccessful attempt at elective home delivery, please complete the following survey even if there was no adverse outcome. Include only current events after June 15, 2009.

So, it sounds like you’re supposed to be a doctor in order to fill this out. The problem I have with what ACOG is trying to do, is that it’s going to present an unbalanced picture. All the successful, non-complicated home births don’t even appear, which is one of the problems Melissa Cheyney discovered in her research:

Cheyney: One of the mechanisms for maintaining distrust between midwives and obstetricians is what my colleagues and I have termed “birth story telephone.” This is very similar to the childhood game of telephone where as the story spreads from one individual to another, it grows in nature and the details change substantially. As home and hospital birth stories are told and retold, and filtered through the lens of the teller, details shift to match the preconceived worldview of the teller. For example, a non-emergent transport for a slow, uncomplicated and non-progressive labor can turn into a mother laboring at home for days with poor heart tones and a uterine infection before the midwife reluctantly brings her in. By the time the story has been passed along, mother and baby who were actually never in danger were saved from a near death experience by the hospital staff.

So, if all you see as a doctor is when women come in with umbilical cord prolapse or something, then you’re going to think that every home birth has umbilical cord prolapse! That will be a false impression, but it will be true to you. So, even if this form were filled out only by doctors and only for planned home births and included no successful home births, it would still be an unbalanced picture. The only good thing about it, is that it would perhaps present a true (or true-ish) picture about what maternal and fetal/neonatal outcomes are — how many uncomplicated births there are, as opposed to complicated ones. Most studies into planned home births show that most transfers are for either pain relief or labor augmentation or some other non-emergent transfer, and would likely therefore end in an uncomplicated birth. At best, I’m hoping for these statistics to reflect that. Of course, there is built-in bias — some doctors may not realize that their patients have been having “shadow care” (planning a home birth with a midwife but also seeing an obstetrician; so their “doula” coming in with them may actually be the midwife) and may not realize that this patient that just came in was planning a home birth, not just “accidentally” came in at happening to be at 7 cm dilation without having realized she was really in labor, or whatever. Other doctors may not report the uncomplicated births but would be sure to report the complicated ones. [For instance, how many times do you tell your husband, “You know what? All the way to the store and back I didn’t see any car wrecks!” or that you saw a car broken down on the side of the road (it’s kind of a non-story, most of the times, right?) — as opposed to the one time out of thousands of trips when you did see a car wreck. And the more shocking the story, the more likely it will be told.]

[Update: apparently ACOG has changed it so now only members can post — it requires a login to even view the page. Not surprising. I don’t totally blame them, either — it was set up for obstetricians, not the general public. I almost didn’t want to blog about this as an encouragement for people to post their successful home birth stories, because, well, it did say that it was for doctors to fill out. ]

Updated again to include this link to a lawyer/doula’s tongue-in-cheek response to the ACOG website.

She did it! — What a birth story!

You’ve got to read Heather’s birth story, on The Unnecesarean. Wow.

What not to say to someone who has experienced a pregnancy loss

So far, I have not had a miscarriage or stillbirth, so I [thankfully] don’t have any personal experience with this. But I’ve heard some doozies of what other people have said to women who have lost babies. I’m sure others can add to this list:

  • “It was meant to be.” Yeah, okay, even if so — HOW DOES THAT HELP??
  • “You can always try again.” But she can never have this baby. Or, maybe she can’t just try again. What about that?
  • “It wasn’t really a baby.” Perhaps said with an early miscarriage; perhaps said about an ectopic pregnancy; perhaps said about a baby that was lost due to genetic problems. But even if said about a “blighted ovum” pregnancy… IT STILL HURTS. The pregnancy, the baby, was very real to her, even if only in imagination and anticipation. That loss is not diminished by thinking or knowing that there was a problem with the baby, nor by there not actually being a baby. Perhaps the hurt may even be made worse by this kind of statement, if the woman begins to feel bad for feeling grief over this very real sadness that others minimize!
  • “Well, at least you’re okay.” Maybe she’s not “okay.” Maybe she’s “okay” physically, but tormented mentally and emotionally. Did you ever ask her if she is “okay” or did you just assume it?
  • “It was just a miscarriage. It happens all the time. Get over it, already!” I can’t even think of a comment after this, because I just want to punch somebody in the face, and I’m not usually given to violence.
  • “Shouldn’t you be over this by now?” A milder variation of the above statement. Everyone grieves differently. Some people need more time and space than others.
  • “At least it was early, before you really got attached to it.” Ever hear of the process of pregnancy — fertilized egg burrows into the uterine lining, part of that becomes the placenta, the rest becomes the baby, joined by the umbilical cord — by definition it is an attachment! Again, why assume that the mother was not attached to her baby? Many women plan pregnancies even months in advance, so perhaps have been “attached” to the idea of a baby for longer than some women are even pregnant, and then lose not just the baby and those few weeks and months of pregnancy, but lose all those months of anticipation and hope as well!
  • “God had a reason for this.” I will say that I agree with this statement, but not with the timing. It may help some people to hear this, but quite honestly when it was said after I lost my father in a car wreck I wanted to smack the speaker. Not because I didn’t believe it, but because it just plain hurt, and hearing this did not help.
  • “This is because you…” or “If only you hadn’t…” Even if correct, it’s probably not the right time, and you’re probably not the right person to say it. Wait until a better moment, and also think before you speak. Think first of how accurate your statement likely is (because you know one glass of wine is probably not going to cause a miscarriage), and secondly, if your statement is correct (“shooting up with cocaine was a dumb idea while pregnant”), make sure the person can hear you and also make sure that the person hasn’t already come to that conclusion on her own. Because if you tell her that she caused her miscarriage when she already knows it, you’ll be rubbing salt in her wound. Now, if you lovingly say that and keep her from future miscarriage and pain… then that may be okay, if said in the right way, at the right time, and with the right spirit.
  • Any comment about somebody you know or heard of having an abortion, or anything you read about somebody abusing a child. This also applies to women who are struggling with fertility. I still remember clearly one blog I read, when I first started reading blogs a year and a half ago, written by some L&D nurse who had to take care of some teenager having her second child (or perhaps after-care for a second abortion), when the nurse herself couldn’t get pregnant. It was all she could do to maintain a minimum of care and good attitude, because she really just wanted to throttle the girl, because this girl was throwing away that which the nurse desperately wanted and couldn’t have.

What others can you think of to add to the list?

What can you think of that would be helpful to say? The only thing I can think of is, “I’m so sorry for your loss. I’ll be praying for you.” Perhaps also, “What can I do to help?” or “Can I make supper for you tonight/tomorrow?” or “If you need to talk, I’m here.”

Reducing Infant Mortality

Unfortunately, I can’t embed the video in WordPress, so you’ll just have to click here to watch this free 15-minute video on reducing infant mortality. The thing that struck me the most was the woman with the “MD, JD” after her name that taught at UCLA, saying something about there being the midwifery model of care and the medical model of care — that women need to know that there are two models, and then saying, “But why are there two models? We should see which one works better, and then move toward that one.” Yes, indeed.

Obviously, some women will actually need the medical safety net, but why does midwifery care often get the short shrift?

What Not to Say Blog Carnival

Rebirth Nurse’s blog carnival is up — go check out all the posts! In addition to all the “what not to say to a pregnant [laboring, postpartum] woman” quotes on the posts, make sure you read the comments for more gems.

Also, the next blog carnival is…

The next carnival will be on September 6. Theme will be “first births”… so share the first birth you’ve encountered whether it be your own, one you assisted with, attended, or even just your thoughts on what you want for the first birth experience. Email your submissions to knitting-fool AT hotmail DOT com.

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