The Blogospher Responds to claims “Planned Home Births Increase Neonatal Mortality 30%”

July 11th, 2010

The birth world is reeling over recent study results stating that planned home births increase neonatal mortality by 30%. The data will be published in an article in the September issue of the Journal of the American College of Obstetricians and Gynecologists and is authored by Joseph R., Wax, MD, and colleagues at the Maine Medical Center in Portland.

The “Fright Factor” of this article cannot be ignored. Any pregnant woman who may be considering a home birth and hears the headlines on any mainstream media outlet will certainly rethink her decision, and very likely her judgment, to have a home birth. The article cites numerous studies supposedly supporting the claims that home births are unsafe and carry an increased risk of neonatal death. There in lies the rub. The articles cited in the meta-analysis don’t support the claims that a planned home birth is unsafe. Additionally, many of the articles cited are themselves unreliable and/or inconclusive about the safety of home birth.

I could go ahead and cite what I think is wrong with this study and most certainly what a disservice such an article is to the public at large. However, many of my colleagues have done a superb job  outlining the issues with this article. So in addition to the response released by CIMS in the press release that I posted previously, I am presenting several responses for mamas on bed rest to read and to contemplate.

In the end, how and where you decide to deliver your baby is your decision. I only hope that decision is an informed one. So to help with that, here are several well written responses.

Characteristics of Planned and Unplanned Home Births in 19 States

This is the title of  a study published in the July 2010 Obstetric and Gynecology, which despite already being published has generated far less media buzz than the article yet to be published and reporting that planned home births carry a 30% increased risk of neonatal mortality. In this article the authors sought to determine what caused women to choose home birth and what characterized a safe home birth. Unnecesarean Blogger Jill does a superb job analyzing this article summarizing the pertinent data. Unecesarean also questions the timing of the release of data from a soon to be published article distinctly opposing home birth and citing that home births pose a threat to the life of infants. New York and Massachusetts are currently passing legislation to expand the practice privileges of midwives and the venues in which t hey can deliver. Could the publication of “alarming data” citing harm to infants born at home potentially alter the course of legislation? It remains to be seen.

A Review of the Data

The Birth Sense Blog took a different approach, one that is my favorite approach to published information. Because the article speaking out against home births cites data from a meta-analysis of 12 other research studies, the author of the Birth Sense Blog requested and received an advance copy of the article in question. She then looked up all the studies cited and evaluated whether or not they were even appropriate studies to be included in the tmeta-analysis. This intricate analysis lead her to the conclusion that the study proclaiming that planned home births are dangerous was poorly designed, included data that was inappropriate for this type of analysis and that overall the conclusions reached by the researchers didn’t even reflect their own data.

Meta-analysis: the wrong tool (wielded improperly)

Is the conclusion Amy Romano, CNM and blog researcher for Lamaze international draws after reading the study in question. She then goes on to describe the purpose of meta-analyses and explains why meta-analysis was a poor choice for this particular study. Finally she chastises the American College of Obstetricians and Gynecologists for even deigning to publish such flawed study with such biased conclusions.

The American College of Nurse Midwives

American midwives have the most to lose with the publication of this study. Midwives have been tirelessly lobbying for rights and privileges to study their craft. Just as they are about to see legislation passed in New York and Massachusetts granting them the right to legally practice their craft, delivering babies, this article blasts on the scene with the potential to undo years of their hard work and advances they’ve made.

I realize that many laypeople may be overwhelmed at the prospect of reading medical literature. However, I want to strongly encourage any woman who is considering a planned home birth to take the time to thoroughly consider all angles of this controversy before making her decision. Regardless of her final choice, my greatest hope is that her choice is an informed one.

What impact has the declaration that planned home births increase neonatal mortality had on your impression of home birth deliveries? Pleased share your comments below.

CIMs Responds to the Publication of Study on the Safety of Homebirth

July 9th, 2010

All day I have been querying my medical friends to see if they have heard about or read what seemed to me to be an outrageous report on the dangers of home births published by The American College of  Obstetricians and Gynecologists. The article, written by Joseph R. Wax, MD, from Maine Medical Center in Portland, and colleagues, is touted as a literature review showing a three fold increase in neonatal mortality in planned home births. ACOG is staunchly opposed to home births and many see this article as an attempt to block attempts to by the Push for Midwives and others pushing for legislation to expand privileges for Midwives.

The Coalition for Improving Maternity Services has issued a press release response to this article. It is presented here in it’s entirety so women will be able to make an informed decision regarding where they may want to give birth and what biases, if any, may be held by provideres.

CIMS Responds to the Publication of an Extremely Skewed Study on the Safety of Homebirth

Raleigh, NC (July 9, 2010)-The Coalition for Improving Maternity Services (CIMS) is outraged that the publishers of the American Journal of Obstetrics and Gynecology (AJOG) accepted a poorly designed and methodologically unsound study in which authors concluded there is a 3-fold increase in neonatal mortality in planned home births compared with planned hospital birth.
 
“In our analysis of multiple studies from countries worldwide,” stated CIMS Chair Michelle Kendell, MBA, AAHCC, “CIMS found that the authors of the study included confounding data, such as outdated and low-quality studies, low-risk and high-risk mothers, babies born preterm, babies unintentionally born at home, births attended by unqualified providers, and data from birth certificates that researchers have found to be notoriously inaccurate.”
 
Although the authors acknowledged that most of the articlesreviewed had similar outcomes of low neonatal mortality, they based their conclusion on statistics drawn from questionable and poor quality studies.
 
Furthermore, the study’s lead investigator Joseph R. Wax, MD, and his co-authors inexplicably eliminated the only high-quality study of planned homebirths in the U.S. that showed excellent health outcomes for infants and their mothers when attended by certified professional midwives.  (Johnson & Daviss BMJ 2005).
 
In a press release, the American College of Nurse-Midwives, a CIMS Organizational Member, reported, “the authors’ conclusion differs significantly from findings of many recent high-quality studies on home birth outcomes which found no significant differences in perinatal outcomes between planned home and planned hospital births.”
 
Other research conducted by the CIMS Expert Work Group found that planned home births with a qualified care provider resulted in similar, not greater, perinatal mortality rates compared with a similar low-risk population of women having hospital births, despite lower intervention rates, including electronic fetal monitoring, use of IVs, pain medication, instrumental deliveries, and cesarean sections.
 
Lamaze International, a CIMS Organizational Member, also questioned the study’s conclusion.  Amy Romano, MSN, CNM, researcher and contributor on Lamaze International’s Science & Sensibility blog, wrote, “high quality studies, conducted in low-risk women in integrated maternity care systems, find no excess risk for babies and significant benefits for mothers.” 
 
The Centers for Disease Control (CDC) reports that babies born at home are less likely to be born preterm and low birth weight compared to babies born in the hospital.
 
Mary Lawlor, CPM, president of the National Association of Certified Professional Midwives, a CIMS Organizational Member, stated the study “is far from the high-quality rigorous review that health care providers and the public expect.”
 
Also, commenting on the study, Geradine Simkins, CNM, MSN, president of the Midwives Alliance of North America, a CIMS Organizational Member, stated, “The American public, particularly women in the childbearing years and those who care for them, have a right to high quality research on childbirth. Research literature should not be used to cause undue alarm or limit a woman’s choice regarding care providers, including skilled midwives, and place of birth.”
 
The study at the heart of this debate, “Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis”, originally intended for print publication in the September 2010 issue of the American Journal of Obstetrics and Gynecology (AJOG), was published online on July 1.  Researchers and critics suspect that the early release was politically motivated to discredit midwives who attend the majority of home births in the U.S. and to discourage legislators from passing increasingly pro-midwife state legislation such as New York State’s Midwifery Modernization Act (Bill S5007a/A8117b), which passed on June 28 with overwhelming bipartisan support, providing autonomous practice for all licensed midwives working in all settings.
 
CIMS’ advisor, Dr. Michael C. Klein, a senior scientist at the Child and Family Research Institute in Vancouver and emeritus professor of family practice and pediatrics at the University of British Columbia believes this is “an unabashed attempt to have poor science cover-unsuccessfully-a political agenda.  I am very surprised that the [Journal] would publish it, let alone call it ‘Editors Choice’.”
 
According to the CDC, the number of women opting to have their babies at home has been increasing since 1990 and rose by 5% in 2005 and remained steady in 2006.  This is significant because it marked the first time in 14 years that the percentage of out-of-hospital births increased in the U.S.  In 2006 there were 4.2 million births in the U.S., of which approximately 25,000 (.59%) were home births.  About 61% of home births were attended by midwives.  Among midwife-delivered home births, one-fourth (27%) were delivered by certified nurse-midwives, and nearly three-fourths (73%) were delivered by other professional midwives.
 
“Women choose to have a home birth for many reasons,” states Nicette Jukelevics, chair of the CIMS Coalition Building Committee.  “For financial, cultural or religions concerns, lack of transportation in rural areas, or to give birth in a supportive, low-intervention, familiar environment.  Other countries like Great Britain, Ireland, Canada, and the Netherlands support women’s choice for home birth.  The unsubstantiated controversy against planned homebirth with a qualified provider has been with us for many decades.  It’s time that women in the U.S. have the same right and opportunity to give birth as they choose.”
 
The Coalition for Improving Maternity Services (CIMS) is a coalition of individuals and national organizations with concern for the care and wellbeing of mothers, babies, and families. Our mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs. This evidence-based mother-, baby-, and family-friendly model focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis, and treatment programs.  Media Inquiries: Denna Suko (919) 863-9482, dsuko@motherfriendly.org

Walking Gets Mama into Shape After Bed Rest

July 5th, 2010

I was really excited to see several new mamas out walking with their babies in the sunshine this morning. Walking is an excellent way for mama to lose the pre-pregnancy weight and spend time with her baby. Additionally it is an exceptional way for a former mama on bed rest to regain her lower body muscle strength,endurance and her pre-pregnancy physique.

After as little as two weeks of inactivity, a mama on bed rest can lose substantial muscle strength and endurance. Judith Maloni, Ph.d, notes in her publication, Astronauts and Pregnancy Bed Rest: What NASA is teaching us about inactivity,

 “Many mamas who deliver after being on prescribed bed rest report that they have difficulty standing up, get dizzy when they first stand up and they have hip and leg pain.”

Many Mamas are unable to support themselves while standing, let alone themselves and their babies immediately post partum! The longer that a mama had been on prescribed bed rest, the longer-and perhaps harder-it is for her to regain her pre-pregnancy strength, endurance and her pre-pregnancy physique.

Most obstetricians advise new mamas not to engage in vigorous physical activity before 6 weeks post partum. While this is sage advice as it applies to engaging is structured aerobic activity, heavy lifting or strenuous activity, it does not apply to walking. In fact, new mamas should take a short walks daily-beginning almost immediately. At first, this may simply be walking down to the nursery to see their newborns. Once they are home, it may be walking around the house, around the yard or around the block. The sooner mama can begin re-engaging her muscles and reactivating the dormant connections between her brain and her limbs, the sooner she can begin the reconditioning process.But let’s not get ahead of ourselves here. I want to keep this post purely on walking and the early post partum mama.
 
So there I was, walking my 9 laps around the park in my husband’s home town (a mile=3 loops around the park path and I walk 3 miles), watching the mamas walking with their baby strollers and several important tips came to mind that insprired this post.

  • Start with a good pair of athletic shoes. It is very likely that you will need to buy a new pair of athletic shoes after you have your baby. Your feet probably swelled or spread to accommodate the added weight of your pregnancy. For some women, myself included, their feet are now a full size larger (or more) as a result of their pregnancies. Even if you are able to wear the same gym shoes you wore while pregnant, you’ll probably notice that they have stretched and/or worn in such a way that they no longer provide adequate support to your feet now. For example, I “waddled” when I was pregnant and to be able to support my weight, I walked on the outside of my feet. Once I delivered and my weight shifted back to a more even, central distribution, my old shoes actually caused pain in my calves when I wore them to walk. If you can afford to do so, get new athletic shoes.
  • Wear a good supportive bra. It’s summertime and while tank tops are appealing, be sure to wear a good, supportive bra when you walk. “But walking is low impact,” you may be thinking. True enough, but if you are nursing, you may have noticed that your breasts are not only heavier but also more sensitive than normal. The mere feeling of cloth against your nipples or extra movement of the breast tissue may be very uncomfortable right now. Make sure to wear a bra that keeps you cool and “wicks” moisture away from your breast as well as one that helps minimize movement.
  • Wear an abdominal support if necessary.I had cesarean sections with each of my children and my belly was very tender post partum-especially after the birth of my son, my second c-section. I wore a support garment after both pregnancies to help relieve pressure on my belly. There are several good one on the market and Special Addition Maternity and Nursing Boutique has several great support garments-I bought mine there and you can order online and get sizing support during normal business hours. 
  • Get a good walking stroller. If you can, get a stroller that is designed for walking. These strollers will have larger wheels and the wheels often pivot so that they are easy to turn and maneuver. Today I saw a Graco stroller that had handles that were similar to those that competitive bikes have so that mama can either grip them with her hands or rest her forearms on them. Additionally, many strollers allow you to adjust the handles so that your arms rest comfortably at your sides, not too high and not too low. Very ergonomic!!InStep, BabyTrend and other jogging strollers are great brands to start with. Also, check sporting goods stores as they often stock jogging strollers.
  • Once you have the right equipment, you need to walk with the correct posture. Be sure to stand up straight behind the stroller, not hunched over the handles. New mamas often have rounded shoulders from the weight of their pregnancies, nursing and constantly bending forward to care for their babies. Likewise, mama should not be bent at the waist with arms extended in front of her pushing the stroller as if she is hoisting a huge bolder up a hill like Sisyphus. This stance will lead to arm, shoulder, neck and back pain. It’s important that new mamas stand up straight behind the strollers as they walk to minimize pain or injury. 

Once mama has these few essential pieces of equipment and posture pointers, she is ready to begin an initial walking program and the journey back to her “pre-pregnancy” self. Our next blog post will address some specific training techniques mamas can use to enhance their walking program.

Still on bed rest yet want to maintain muscle strength and tone? Order Bedrest Fitness, the first DVD fitness program modified specifically for mamas on bed rest.

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