MS Friends of Midwives on the radio

We were able to get a phone-in interview on a state-wide MS talk show, the Paul Gallo Show, on the SuperTalk MS network, with Board Member Bianca Wooden, and Mississippi Midwives Alliance member Renata Hillman, talking about midwives, midwifery, home-birth, and the bill that we hope will be introduced in the upcoming legislative session that will legally recognize the Certified Professional Midwife credential in Mississippi.

I will try to embed the player below (but I think it will only work on WordPress.org stuff, so if it doesn’t, you can click this link and play it externally):

A flawed study published in “a second-tier journal”

That was the conclusion of Dr. Nicholas Fogelson about the much-publicized recent meta-analysis on home-birth, in a comment on Science & Sensibility’s post about it. [Honestly, I didn't know that the AJOG was so poorly respected. Makes me rethink what studies I'd look at, if it was published there.] In the S&S post, Amy Romano questions whether the meta-analysis was even appropriate, in light of the huge de Jonge study of over 300,000 planned home births in the Netherlands. She writes,

Lack of statistical power could not possibly be the rationale for conducting a meta-analysis on the safety of home birth. [The de Jonge study] contributed 94% of the data on planned home birth in the meta-analysis (321,307 of 342,056 planned home births). That study found virtually identical rates of neonatal death in both the planned home and planned hospital births, with relatively narrow confidence intervals.

The blog “Birth Sense” has two posts on this study: a prologue of sorts and then a discussion of the 12 studies included in the meta-analysis. And despite Dr. Fogelson’s comment that AJOG is a “low-impact” journal, many news sources apparently didn’t get that memo, and had no problem trying to make a huge impact with the sensational headlines that “home birth is three times as deadly as hospital birth.”

I have read numerous blog posts and news articles about this study and will include links to them below, but I want to comment on some things. First, since the study isn’t going to be released for a few more months, I haven’t read it (I know it’s available by request, and I presume for a price or if you have a subscription), so I’m not sure what I can add to what those who have read it have said. In some ways, what I’ve read has raised more questions than answers. The main question is, what were the inclusion criteria? From some sources, I’ve discovered that the original study had to have been published in English (a common enough restriction — gotta make sure the doctors don’t get bogged down in any bad translations from reading foreign language studies!), and also to studies that reported outcomes of mothers and babies in both home and hospital births (apparently the reason why the Johnson & Daviss 2005 article on CPM births, published in the BMJ was not included — they didn’t have a hospital “control group”).  But I wonder, did they not have any exclusion criteria for the size? They included one study that had 5 women in each group — a total of 10 women studied! If I may say so, “Good grief, Charlie Brown!”

Additionally, they included the Pang study, which itself was flawed, in that it reported not only planned home-births (with or without a qualified attendant), but it also included unplanned home-births — this despite a title that declares that it looked at planned home births. Nor was the study limited to the “term” period, but included births as premature as 34 weeks. Since I don’t have the meta-analysis in front of me, I can’t say how heavily it influenced the conclusion, but “garbage in, garbage out” — if the data going into the study is wrong, you can’t reach the right conclusion.

In all meta-analyses I’ve read, there has always been a discussion of inclusion and exclusion factors; if there are others besides the ones I’ve mentioned above, I’d like to know — out of curiosity, if nothing else.

Some of the articles I’ve read have touched on problems researchers may have in reconciling different studies, which may all have different designs, or look at different populations, etc. Again, I don’t have the study, so I don’t know if Wax and associates looked at all the different factors and did an appropriate exclusion or analysis of differing studies. Some differences among studies that I can think of that might need some statistical calculation or exclusion of some births (which may or may not have been included in any of the cited studies), include prospective vs. retrospective study design; inclusion of term, preterm or post-term births; cross-over (women planning a home birth who transferred to the hospital, or women planning a home birth who gave birth precipitously outside of the hospital); whether babies with congenital anomalies were excluded; whether the mothers were properly matched in the groups — same general age, income, health, parity, etc.; whether twins or breech or post-term babies were included or excluded (many studies are limited by design to “singleton vertex babies from 37-42 weeks gestation”); cause of death (for example, excluding accidental deaths by smothering or car wreck would be a good idea, I’d think, if possible); whether there was a trained birth attendant; quality of the original study, and undoubtedly many other things I can’t think of.

One of the confounding factors that some of the articles I’ve read, is that some of the studies examined only the early neonatal period (up to 7 days), while others examined the full neonatal period (up to 28 days). Which reminds me of another factor I should have included in the paragraph above — perinatal deaths including stillbirths, and also possibly intrapartum deaths. Several of the writers have noted that the largest study, the Dutch study, was not included in the actual analysis of the most loudly trumpeted conclusion, namely, that home birth carries a 3x death risk for babies when compared to hospital birth. The largest study which had almost 95% of all of the births in all of the studies, and showed no difference for neonatal death, was excluded for the purposes of  neonatal death. It seems that it is because that study only went up to 7 days. Was there not some sort of statistical analysis that could be done to extrapolate deaths that may have occurred from days 8-28, so that this study could have been included? Or, an analysis that could have excluded deaths from 8-28 days in the other studies? As I said, I have more questions than answers. I’d love to read the study for myself (and the Birth Sense link has links to all 12 of the included studies — some of them are abstracts but some of them are the full studies, so I may start by reading those), but I wonder if any of the questions I have would be answered if I did read it.

Now for the links that I read, in addition to those I cited above (some of them include other links to other articles, as well) — obviously, most of them are going to be favorable to the “this meta-analysis is junk” viewpoint, but not all of them are:

Now for some links to other home-birth related stuff that is not about this flawed study:

  • The Unnecesarean’s blog post on a new study in this month’s issue of Obstetrics & Gynecology that says it’s important to distinguish between planned and unplanned home births [and I'm just in the mood right now, due to lack of sleep, to say cheekily, "and next, they'll tell us that water is wet, and the sun is hot!" :-)]; but seriously, it’s because many times “unplanned” home births are to women with known risk factors that may cause problems with either themselves or their babies
  • the NHS write-up of the de Jonge (Dutch) home-birth study
  • High Tech vs. Nature’s Way,” an article from Minneapolis-St. Paul
  • The College of Physicians and Surgeons of British Columbia “Resource Manual” on planned home births

Ahhh, now I can close out some tabs on my browser.

Oh, and Dr. Amy, I’m pretty sure you’ve been waiting for me to write this up since I know you read me (not to mention you probably have “home birth” on your Google Alerts, and probably regularly add other keywords to make sure you don’t miss any internet discussions), so if/when you comment, just remember that you have to stay on topic. No cut-and-paste jobs like you usually do, m’kay? Oh, and before you bluster that the studies which showed that home birth is safe only in the countries of the study (like the Netherlands and Canada), because of how their midwives are integrated into the health system, I want you to answer a question: if that is true, why don’t you try to integrate midwives into the health system in America, rather than trying to elbow them out? That would solve that problem. :-)

Kegels don’t do squat?

If there is one mantra, dogma, or axiomatic belief among women “in the know” when it comes to birth and babies, it’s that Kegels are wonderful, necessary, beneficial, etc. Now, someone is challenging that assertion. In short, the way the pelvic floor is understood is wrong, and needs to be changed. Tighter doesn’t necessarily mean better; it just means tighter, which may actually lead to a worsening of the problem. You need to read the whole article, because I’m skipping a lot (or else I’d be tempted to copy and paste most of it, but that wouldn’t be nice), but basically, squatting is what she recommends for incontinence and other things that Kegels are supposed to help.

If she just said that Kegels don’t work, I might be a tad suspicious that rather than being a lone voice of reason, she’s a lone voice for a reason [sorry, couldn't help the chiasmus there :-)], although I’ve read enough from people who say that most women don’t do them right, and doing them “wrong” is worse than not doing any at all to know that there are many people who share her opinion at least to an extent. However, it was her suggestion of doing squats rather than Kegels which resonated with me.

Squatting is natural; doing Kegels is not, really. For most of human history, women (and men too) had to do a lot of physically demanding work, including a lot of squatting — tending the fire, garden, children, etc. Even in the absence of work, squatting was a natural way to rest and relax, if a chair was not available for whatever reason. Squatting is a normal part of life except for (primarily Western) adults who view squatting as either menial or childish. It’s not really a normal part of life to try to stop and hold the Kegel muscles, is it?

So, I’ll add this to my mental list of reasons to squat more regularly. What do you think of this article?

Hope for pregnant women with heart disease

I just read this article and thought it was amazing. Often, women with pulmonary hypertension are advised not to get pregnant, and if they do get pregnant (or if they only find out that they have pulmonary hypertension while pregnant, which is unfortunately a common time for diagnosis), they are advised to undergo an abortion immediately. Why? Apparently after giving birth, the body can’t handle the fluid overload, so women frequently die. About 50-60% of women so affected die in the top health centers — with the best medicine and the best care, a greater than 50% mortality rate! Yet one doctor has a 0% mortality rate, out of 40 women. Doesn’t sound like coincidence to me!

The treatment sounds so simple, so obvious, when it’s explained: basically, since it’s the fluid overload with a term birth that overwhelms the heart and kills the woman, she is given a C-section at 35-36 weeks (less fluid build-up than at term), and then hospitalized for several days afterward while they draw fluid off with medicine and diuretics — nine liters — that’s almost two and a half gallons!

For many women with this condition, being advised to have an abortion is a horrendous decision — an unchoice. This doctor may give them hope.

Why not to have an ultrasound

Some things serendipitously fall into my lap. I had been thinking about writing a post like this for a while, and then today found someone who said it even better than I did (plus has done the research that I haven’t done!) — Ultrasound and Fury: One Mother’s Ordeal.

In short, her baby girl was diagnosed by three different doctors (including at least one specialist) as having club foot, so they spent the remainder of the pregnancy researching club foot, trying to come to terms with the diagnosis. At birth, the baby was perfectly normal. Other parents and babies aren’t that lucky — aborting babies who turned out to be healthy and normal, or continuing the pregnancy under a deep cloud at a diagnosis more serious than club foot.

There are some benefits of ultrasound — some parents have said that knowing their child’s diagnosis (when it was accurate) prior to birth helped them to prepare for their baby’s condition after birth, or to prepare for a stillbirth or a short life after birth. There are a few conditions that can be diagnosed prior to birth and either fixed prior to birth (extremely rare) or (occasionally) to be ready for immediate surgery or care at birth; however, the research the author cited showed that there was no significant benefit to having ultrasound done routinely, as opposed to it being done when there was reason to suspect something was wrong — such as the baby not seeming to be growing.

Of course, if you’re the parent of a child for whom ultrasound was a benefit, then it’s significant to you. However, if you’re the parent of a child who was wrongly diagnosed by ultrasound, it’s also significant to you.

This also doesn’t take into consideration that there may be harms of ultrasound even when there is no misdiagnosis. I’m convinced that most babies sense that there is something going on when an ultrasound or Doppler is aimed at them, even if it’s supposedly out of the range of hearing. Doppler was used on me during my first pregnancy to find the fetal heart-tones, and my baby ran from it every time — far too consistent for it to be a fluke. I’ve seen recent news about doctors trying to use a blast of ultrasound to render men sterile for 6 months. I’m assuming that this type of ultrasound is not exactly the same as what is used in a typical prenatal appointment — that it’s either stronger, longer, or more directly applied… but it still makes me wonder — if ultrasound can stop men from producing sperm for several months, what else can it do? Just like electricity can be used for good, powering this computer, it can also be used for bad, maiming or killing someone. I wish ultrasound were better studied, to make sure that it was only used for good, and keeping it from harming people as much as possible.

The use of ultrasound scanning during pregnancy is now so widespread it seems almost as banal as taking a patient’s blood pressure. Unlike amniocentesis, it is considered safe, noninvasive and painless for both mother and child. Formal studies indicate that 70 percent of all pregnant women get at least one scan, and the true number is probably higher, said Dr. E. O. Horger 3d, chairman of obstetrics and gynecology at the University of South Carolina School of Medicine in Columbia. If a woman does not request ultrasound, many obstetricians will recommend it, as mine did, ”just to see how things are going.” They make that suggestion even though the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians and other medical organizations advise against the routine use of ultrasound in pregnancy.

Maternal Mortality in NYC

I can scarcely get my thoughts together after reading this article:

In 2008, black women in New York City experienced 79 maternal deaths per 100,000 live births compared to 10 white maternal deaths per 100,000 live births, and a national rate of 13 maternal deaths per 100,000 live births, according to the latest data available.

I’m utterly speechless.

CBC Radio Program on Breech Birth

Rixa transcribed the radio interview of a couple of Canadian doctors who are learning how to attend breech births. Well worth a read! My favorite part is when they talk about the “new” German way of handling breech birth: put mom on her hands and knees.

Robin Guy: Well, you know what’s really exciting about this is not just that we’re starting to see vaginal breech births happen more frequently, but that we’re seeing an openness to a change in practice. It has been traditional in North America for women to have been, like it or not, placed on their backs, which actually causes some problems. It increases the likelihood of cord compression during a breech birth. Putting the mom on all fours—we’ve got early data from a group in Germany who made these videos that this [all fours position] is actually a real significant increased safety for the mother and the baby. So to see this adopted and to see the collaboration with a midwife. We don’t like it, but there is professional snobbery. There are women everywhere who are cheering for Glenn Posner, who wasn’t afraid to take advice from a midwife. We’re cheering for you Glenn; we love you!

and later,

Robin Guy: If I can add for just a second, this group in Germany who has been pioneering the hands & knees position in the hospital, they’ve been doing this for 5 years and 400 births. And they have not had to use forceps to get a baby out. Not once.

World Maternal Mortality Declining!

Now this is wonderful news!! Full article here.

From a study posted in the Lancet, a number of reasons were given for the improvement: lower pregnancy rates in some countries; higher income, which improves nutrition and access to health care; more education for women; and the increasing availability of “skilled attendants” — people with some medical training — to help women give birth. AIDS still remains a big cause of maternal death, however, with the article saying that what is needed in these areas is more drugs to fight HIV/AIDS rather than more skilled attendants.

But here’s the part I don’t quite understand: “[S]ome advocates for women’s health tried to pressure The Lancet into delaying publication of the new findings, fearing that good news would detract from the urgency of their cause, Dr. Horton said in a telephone interview.” Yeah, I understand that these people may fear that the decline in deaths will lead to increased apathy about the problem, but, as Dr. Horton said, “…my feeling is that they are misguided in their view that this would be damaging. My view is that actually these numbers help their cause, not hinder it.” In fact, I can see that if there were no change in the rates, that there could be increased apathy, because “nothing we’ve tried so far works, so why bother?” Exactly!

Yet part of me wonders if there is a darker reason for these unnamed “advocates” to delay publication. They apparently wanted the publication to be delayed until after a couple of big meetings with some powerful people (and lots of money) to put towards maternal health. Why? Maybe it’s because I’m optimistic, but I would think that this news would be a big boon to them, as they could say, “Well, now we know what works, so let’s do this and this and this.” After all, isn’t it part of evidence-based medicine to look at what studies say and go from there? This may not be purely “medicine” (higher income and better female education don’t exactly fall under those categories), but it is at least evidence-based funding so that we can get the most bang for our buck. The negative part of me thinks that these people wanted to delay it possibly because the results didn’t match what they expected, and they wanted to push alternative methods for reducing maternal mortality that have not been proven, but which might line their pockets a bit more. I don’t know how exactly all this funding stuff works, but if you have ten different people or organizations each pushing a different way of improving maternal mortality, but only five of those ways have been shown to actually work, then it is likely that the other five unproven (or perhaps disproven) methods may get their funding reduced or even eliminated. If you’re one of those five whose money is about to be cut, don’t you think you’d want to delay the news that what you’re pushing doesn’t work?

Shame on those who wanted to delay the publication of this research! It shows what works, and should be a boost in confidence — it’s exciting that we can actually say that what we’re doing is helping; now let’s redouble our efforts to keep the trend going in the right direction. And if these people had high and pure motives for their desire to delay publication… I don’t know — get a dose of sunshine, watch Pollyanna, or do something to lift your spirits and restore some positivity to your life. At the least, hire a better spin doctor so that you don’t come off looking like a first-class woman-hating jerk, trying to suppress this wonderful news.

Amazing Vernix

I just had to share this link — the “summary” would be (drum roll, please) that there are antimicrobial agents in vernix and amniotic fluid. The authors theorize that if more babies were allowed to have the vernix kept on their skin and/or rubbed in, that there would be fewer infections that sometimes can be dangerous.

“You’re not instilling a lot of confidence into me, Doc!”

Thus said Marty McFly in Back to the Future. The scene was Doc Brown simulating the lightning bolt that would send Marty in the DeLorean back to 1985… and the model car caught fire. But it works for this news as well: research doctor is accused of having falsified data in at least 21 studies (and perhaps more), as far back as 1996. It literally makes me sick to my stomach to know that stuff like this goes on. Plus, at least two of the papers had the name of another doctor on them as a co-author, though the other doctor says he had no part in writing them, and the addition of his name was a forgery. Niiiiiiice. One of the basic tenets or underpinnings of research is that the authors, researchers, scientists and doctors are all academically and intellectually honest. While they may have hidden biases (or open biases), and they are human so may make errors, the automatic assumption is that they attempt to be as honest as possible. If we can’t trust the research, then we’re back to “he said, she said” — the blind leading the blind.

To me, this undermines the whole field of science and research. It shouldn’t, but it does. Sort of like the woman that finds out her husband is cheating on her, and then thinks all men are scumbags like her husband. Not fair, but understandable. I think of Dr. Hannah who did the Term Breech Trial which more or less completely eliminated the possibility of vaginal breech birth. Other researchers have questioned the conclusion of the paper, and the validity of some of the negative outcomes that were included in the paper. The Canadian Society of Obstetricians and Gynecologists has in fact reversed its recommendations, citing the problems with the paper, and is now suggesting that doctors learn how to properly manage breech birth. It seems that a couple of other major studies Dr. Hannah did have likewise come under similar criticism — though I don’t know that they have been retracted. Though the results may be invalid, I would assume that at least she was academically honest — I believe she did actually perform the research, and the data was real — so is better than that guy. Some people will point to his getting caught as an example of “the system working,” while others (like me) will say that if the system was actually working, it shouldn’t have gone on as long as it did. I understand that it is impractical to “police” doctors to make sure fraud like this doesn’t occur, and I’m not advocating treating researchers like two-year-olds. At the least, I’m asking for a return to integrity. Like in so many other areas, if people would “just do the right thing” then there wouldn’t have to be laws and fines and oversight committees and what-not. I don’t think that’s asking too much.

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