New study showing homebirth increases risk of nenonatal death. Thoughts? - Page 3

[Turquesa]

Originally Posted by bailefeliz

If we all believe in safety of home birth, and safety of US OoH birth practice, there should be no hesitation to establish mandatory data collection of all OoH managed pregnancies and births. That is simply putting the same expectation of accountability and transparency on Ooh birth as exists in hospital birth.

Really? When I tried to call both of my local hospitals and ask for their cesarean rates, both got extremely evasive and gave me the run-around. By stark contrast, I asked my CPM about rates of transfer, episiotomies, cesarean deliveries, etc., and got a detailed list of up-to-date stats.

The CDC and state health departments collect the same data from both entities, and virtually all of that comes from the application for birth certificates that are submitted to state departments of health. While the 2000 certificate applications are more detailed, many states are still using the 1989 applications, which don't call for a lot of information about births or interventions.

Right now, The Coalition for Improving Maternity Services is trying to gather aggregate, facility-wide data of intervention rates in hospitals for all 50 states. And believe me, there is tremendous resistance from doctors and hospitals.

Another case in point? Hospitals in New York are required by the Maternity Information Act to produce such data and make it available to all women. Some years ago, they were caught red-handed not complying with their legal obligation.

Finally, here is another piece worth reading on the problem.

Do you have any evidence to support the notion that midwives are opaque in their practices and hospitals are transparent? I guess I'm not seeing it...

[bicyclingbethany]

[QUOTE=Turquesa;15586574]Really? When I tried to call both of my local hospitals and ask for their cesarean rates, both got extremely evasive and gave me the run-around. By stark contrast, I asked my CPM about rates of transfer, episiotomies, cesarean deliveries, etc., and got a detailed list of up-to-date stats.


I hear this from many women. Honestly, I don't know of any large business I could just call up and demand statistics for. Most of these numbers, such as the rate of cesarean deliveries can be found on state government websites.

I mean, if I'm some medical assistant hired to answer phones and direct calls, would I know the episiotomy rate of the hospital? No way. I would pass on the call to someone who may know this off-hand, who might then continue to pass it on. Not many folks would know these stats, and we all know how difficult it can be trying to obtain specific information from ANY bureaucratic-type enterprise. This isn't perfect, but it's not shocking or necessarily "evasive".

[bailefeliz]

Originally Posted by Turquesa

Really? When I tried to call both of my local hospitals and ask for their cesarean rates, both got extremely evasive and gave me the run-around.

I just posted on the other thread related to this...I am not so good at this discussion forum business.

I agree turquesa, that there must be transparency with hospital care. As I posted on the other thread:
In my State, institution specific method of delivery (c/s rates) are published quarterly in Vital Statistics. My institution totals following rates monthly: c/s (differentiating primary from repeat), successful VBAC, water birth, epidural use, assisted delivery, etc. True, one may not get the numbers from the unit secretary, but can get rates by asking for the nurse manager. This transparency is common in my region, as evidenced by chart below:

http://oregonianextra.com/olive-spec...omparison.html

Mortality information by type of provider is also available through vital stats, but erroneous in that not everyone can sign death certificates, and OoH transports (most sentinel events) are then folded into hospital numbers. Currently, outcomes related to OoH birth management are completely unknown--and from these threads, it is clear it is a national issue.

In my opinion, we need data.

[bailefeliz]

Oops--here is a link that will work (i hope):

http://oregonianextra.com/olive-spec...omparison.html

[MammaB21]

[/QUOTE]I mean, if I'm some medical assistant hired to answer phones and direct calls, would I know the episiotomy rate of the hospital? No way. I would pass on the call to someone who may know this off-hand, who might then continue to pass it on. Not many folks would know these stats, and we all know how difficult it can be trying to obtain specific information from ANY bureaucratic-type enterprise. This isn't perfect, but it's not shocking or necessarily "evasive".[/QUOTE]

I have to disagree with this. The information should be readily available. Maybe one simple transfer to the billing and coding department or records department and anyone there should be able to do a quite search to get those stats. Being unwilling to look for the information is different from honestly not having it available. Hospitals need to be making it easy for their staff (and public) to get this information. And I would expect to be able to call any large business and ask for stats or information. I would expect to be warmly guided to the information I was seeking in order to better make a consumer decision. Hospitals aren't exempt from customer/client care.

[alegna]

Originally Posted by bicyclingbethany

Most of these numbers, such as the rate of cesarean deliveries can be found on state government websites.

If you find them, I am in search of true c-section stats (not uncomplicated first time c-section, TOTAL) for hospitals in TX after 2004. 2004 seems to be the last time those were released. The ones from 2004 have been out for at least 3 years now, you'd think they could put out some updated ones by now.

-Angela

[bicyclingbethany]

Here are the primary c/s rates for Texas in 2007. This is not the total like you wanted, but it is more recent.
http://www.google.com/url?sa=t&sourc...fiozKVD7ZsxBCg

Also, this is a good starting point: http://www.ourbodiesourblog.org/blog...-rates-by-hosp

I agree that this info should be easier to find and more accessible. But I have NEVER dealt with any phone tree that was a simple and painless process- from my university to my internet company. Hospitals SHOULD be different, but it's silly to hold them to a standard that not even for-profit companies can attain.

Now, where can I find the total perinatal death rate for all CPMs in Texas? Where can I find all Texas CPMs' episiotomy rates? NOWHERE. Not unless I call up every single midwife in the state and ask her. I think this is what a PP was arguing- hospital transparency isn't the best, but it is better than we have for CPMs.

[liz-hippymom]

Originally Posted by bicyclingbethany

Here are the primary c/s rates for Texas in 2007. This is not the total like you wanted, but it is more recent.
http://www.google.com/url?sa=t&sourc...fiozKVD7ZsxBCg

Also, this is a good starting point: http://www.ourbodiesourblog.org/blog...-rates-by-hosp

I agree that this info should be easier to find and more accessible. But I have NEVER dealt with any phone tree that was a simple and painless process- from my university to my internet company. Hospitals SHOULD be different, but it's silly to hold them to a standard that not even for-profit companies can attain.

Now, where can I find the total perinatal death rate for all CPMs in Texas? Where can I find all Texas CPMs' episiotomy rates? NOWHERE. Not unless I call up every single midwife in the state and ask her. I think this is what a PP was arguing- hospital transparency isn't the best, but it is better than we have for CPMs.

again, well said!

[Climbergirl]

This was the exact words I got about VBAC success rates for my local hospital. I was speaking with the birth advisor whose job is to talk to women about their specific issues and the hospital services.

"I'm glad you called me. I spoke with our director of perinatal services, Terry Francis, who said that there are no true statistics for VBAC success rates. There are too many variables to be considered. It's best that your ob, whomever you select, determines that you are a good candidate for having a successful VBAC attempt."

I asked her how many woman come in planning a VBAC actually get one. Honestly, they have a ton of regulations related to a VBAC patient, so they should know the outcome of that planned VBAC. I am a Quality Engineer, so this seems incredibly odd that they aren't looking at how well they are doing. I know the medical device company I worked for had to!

I think the info needs to be better for both hospitals and midwifes. But sometimes I wonder how my birth is recorded. I almost died 5 days post-op and had complications after my c-section. Was that considered "live baby, live mama"? How do we know how many of those moms and babies were in the ICU or NICU and almost did not make it?

I wish the system was better in general.

[flitters]

Originally Posted by bicyclingbethany

Hospitals SHOULD be different, but it's silly to hold them to a standard that not even for-profit companies can attain.

I somewhat agree with what you are saying here, but wanted to clarify that not all hospitals are non-profit:

http://en.wikipedia.org/wiki/Non-profit_hospital

"In 2003, of the roughly 3,900 nonfederal, short-term, acute care general hospitals in the United States, the majority—about 62 percent—were nonprofit. The rest included government hospitals (20 percent) and for-profit hospitals (18 percent)."

[triscuitsmom]

Originally Posted by bicyclingbethany

I'm very sad you lost your baby. ):

I agree with many folks on here- maternal care here in the US is sorely lacking in many areas. Respect for women, their choices, their bodies, etc all is in desperate need of improvement. If a woman makes a choice to birth at home no matter what, than that is her choice. But her choice affects many other people, not just her.

The CDC numbers are flawed- there are probably many births that have been recorded improperly. They do not tell us everything. I agree with this.

Because of various experiences, I have less and less faith in lay midwives. I believe there are many competent and capable midwives out there, don't get me wrong. But I believe there are many who are sadly incompetent and under-educated.

You can say the mantra of "birth is safe, birth is normal" as much as you want, but it doesn't mean nothing bad will happen. 1 out of 12 women die from pregnancy or childbirth in the developing world. This cannot be entirely blamed on poor nutrition.
Midwives have so much to offer in terms of improving maternal and infant health- better prenatals, better nutritional guidance, less interventions, more breastfeeding support- but there are too many midwives out there who genuinely do not know how to handle obstetric emergencies. Or could handle them if they do. But I am continuing to see midwives who are overly confident in the birth process and do not perform even basic care during labor because of this.

Here in Texas a baby died because the midwife wanted to deliver him, even though he was breech and she never had ANY clinical experience with this. Another baby died in utero because the midwife failed to take maternal vital signs and make an accurate judgment based on clear signs of fetal distress.

Scary, all around. I am afraid to birth anywhere, quite frankly.

For the first thing I bolded... this is true no matter what decision you're making here though. It shouldn't be the factor on which people base their decisions (unless of course they want it to, but not because someone else thinks it "should").

For the second... I don't see anyone saying that bad things don't happen or that babies don't have bad outcomes or even die... or for that matter mothers don't either. Birth is safe, most of the time it doesn't require anything that cannot be easily provided. But that isn't always true and it doesn't matter who you are, what your risk factor is, where you are birthing or who you have with you sometimes it will go wrong. That doesn't mean we shouldn't try and take steps to lower the number of times it does but what exactly that looks like won't be the same for every single situation.

[Storm Bride]

Originally Posted by bicyclingbethany

Hospitals SHOULD be different, but it's silly to hold them to a standard that not even for-profit companies can attain.

Now, where can I find the total perinatal death rate for all CPMs in Texas? Where can I find all Texas CPMs' episiotomy rates? NOWHERE. Not unless I call up every single midwife in the state and ask her. I think this is what a PP was arguing- hospital transparency isn't the best, but it is better than we have for CPMs.

I wouldn't be all that interested in the hospital rates, and I wouldn't even look rates for all the CPMs (don't think they're actually called that here) in BC. I'd be interested in the rates for the individual provider I was interviewing/seeing, and her backup, in the case of midwife (if I go into hospital in labour, I just get whoever is on duty, so I wouldn't see any point in having all the stats for everybody, unless I could kick one out).

[alegna]

Originally Posted by bicyclingbethany

Here are the primary c/s rates for Texas in 2007. This is not the total like you wanted, but it is more recent.
http://www.google.com/url?sa=t&sourc...fiozKVD7ZsxBCg

Also, this is a good starting point: http://www.ourbodiesourblog.org/blog...-rates-by-hosp

I agree that this info should be easier to find and more accessible. But I have NEVER dealt with any phone tree that was a simple and painless process- from my university to my internet company. Hospitals SHOULD be different, but it's silly to hold them to a standard that not even for-profit companies can attain.

Now, where can I find the total perinatal death rate for all CPMs in Texas? Where can I find all Texas CPMs' episiotomy rates? NOWHERE. Not unless I call up every single midwife in the state and ask her. I think this is what a PP was arguing- hospital transparency isn't the best, but it is better than we have for CPMs.

Right. Totally different numbers. I want the total section rates like they've put out in the past. They're not making them public any more.

And fwiw my understanding is that Certified Midwives in TX do NOT cut episiotomies. They are not allowed to.

-Angela

[Turquesa]

The latest data that I can find for Texas is 2004. One of you Texans should call your Department of Health and ask why similar reports are no longer being released.

[Turquesa]

Originally Posted by MammaB21

I would expect to be warmly guided to the information I was seeking in order to better make a consumer decision. Hospitals aren't exempt from customer/client care.

:

Originally Posted by bicyclingbethany

Most of these numbers, such as the rate of cesarean deliveries can be found on state government websites.

Most? Not true at all. Not even close. Here is a list of all of the states with links to their departments of health. You probably don’t have all day to visit all 50 websites, but I can guarantee you that only a handful of them provide aggregate, facility-level (i.e. by each hospital) data on intervention rates—NY and MA because their legally forced to. As Bailefeliz mentions, Oregon has cesarean rates (and some home birth data), and I know that Utah provides some data.

The closest that other states may get is to list cesarean rates by county. But even that doesn’t put enough in context.

But even in these states, rather than being buried in a government website, the data needs to be made accessible in hard-copy form to all maternity care clients of any birth setting. Period. This is required (albeit not complied with) in New York State.

Also, even though cesareans are the most serious intervention, there are more interventions that need to be listed, and it’s hit-and-miss as to which states publish data on forceps deliveries, episiotomies, etc.

Originally Posted by bailefeliz

I just posted on the other thread related to this...I am not so good at this discussion forum business.

LOL! It’s not you. I’m kind of hoping the mods merge the two threads. So we’re not clicking back and forth.

Originally Posted by bailefeliz

In my State, institution specific method of delivery (c/s rates) are published quarterly in Vital Statistics.

You are very lucky indeed. I’m surprised that your state midwifery board doesn’t collect such data. On THAT I agree that there should be more transparency. MWs in my region are voluntarily transparent, but that can’t be counted on everywhere.

Legally, it will depend on where you live, and then it will depend on who volunteers the any information. This is why I cannot support a sweeping statement about how hospitals are somehow more transparent than midwifery services.

You might check out the Coalition for Improving Maternity Services (referenced above). I know that they are trying to collect nationwide, facility-wide data on all hospitals, birthing centers, and homebirth services. I applaud the effort. Women deserve to know regardless of where they have their babies.

What happened to Liz-Hippymom’s baby is unconscionable. (Liz, if you’re reading this, I hope you report her to your State Midwifery Board if you haven’t already.)

For every story like Liz's there are other tragic stories of a hospital birth gone awry. And to bring this thread back on topic to the meta-analysis , I think that's why we're all responding based on our gut feelings and personal prejudices; most of us haven't yet read the meta-analysis, am I right?

Finally, I’ll say that Liz’s story is why as a consumer, I fight for midwifery licensure. The cause isn’t just for NCB advocates to feel all happy and chipper; rather, it ensures greater accountability for midwives who, like doctors, have their bad apples among them.

[bailefeliz]

Seems to me we need a national perinatal registry--where ALL prenatal clients are registered at their first prenatal visit with basic info (gravity, parity, prev c/s?, EDC, etc.--high risk conditions input as pregnancy progresses if/when they arise, data input after birth. I am talking every client of every OB, CPM, CNM, MFM, FP, LDM, DEM, Naturopath.

Then we could know true outcomes, including mortality/morbidity, and intervention rates related to provider type, region, etc.

Transparency would bring accountability to all aspects of maternity care.

It would ultimately save the failing American health care system----as I believe would evolve practice all around for the better----higher levels of safety, lower rates of intervention.

[mwherbs]

Liz-hippymom has complained to the board and the hearing has been done- resulting in "a slap on the wrist"- i imagine they do not require peer review - which would have been a bit more helpful atleast in illuminating how other midwives would handle the situation and why and could also make recommendations like more education ...
the results/actions of the board is published on line- although the most recent actions are not there so you can see lists of results /sanctions against midwives - there is also published online lists of actions on other professions-

I have read the full text of the article and will have to re-read, probably the most compelling reply I have read was written by 2 of the authors of one of their reference articles that was information mined-
they mention things like 1/4 -4801 of the home births had no recorded attendant- so could be any type of birth from accidental to intentional UC

- I also see that the info in the Netherlands is client coded pretty much as bailefeliz recommends as a solution - and I talked with a mw I know in Oregon who volunteered her time to number crunch for the health department because they had collected a bunch of data that they never had the money to look at or publish- so she did do that for 5 years- and she looked at the published data having LDMs listed in the attendant slot in hospital - her best guess is that represents mom's provider- not who was the birth attendant as the hospitals in Oregon do no allow LDMs as attendants.

[bailefeliz]

Data (fetal death certificates, essential to assess outcome) from Oregon DHS, Vital Stats, is entirely flawed because of data input errors by the admission of the Director or DHS.

Again, currently, at least in my State, there is no data on LDM/CPM/DEM outcomes. There is a high suspicion that rates are unacceptably high for perinatal death within OoH birth management. The only way anyone currently knows of a sentinel event is if someone--hospital or family member--reports to the Board of licensure. That is less than ideal for obvious reasons. As Lix-Hippymom has so bravely and eloquently demonstrated, it is excruciating--and humiliating-- on many fronts to stand up and report in the face of such extreme loss. Complaints to the Board are also necessarily protected--so public cannot know of incidence of adverse outcomes unless a final order is issued--which can take years. Even then, in Oregon, when one does a license inquiry on a licensed midwife on an individual who HAS had a disciplinary action related to egregious management--"none" appears in the history of disciplinary action window. ????

i do not blame the midwives in my State for the current mess. The State clearly needs to step up around the charge of providing public safety related to practice of State licensed practice.

This meta analysis simply highlights the need for mandatory data collection in my mind so consumers can truly make an informed decision--now completely elusive.

[bicyclingbethany]

Angela- Just FYI, CPMS can and do cut episiotomies here in Texas. I had one!

PP whose name I don't remember- Texas has released data more recent than 2004, and I posted the link to 2007 primary c/s data in my previous post.

Well, I guess we can all agree from this- no one is crunching enough numbers and no one is being transparent enough!

[Storm Bride]

Originally Posted by bailefeliz

Seems to me we need a national perinatal registry--where ALL prenatal clients are registered at their first prenatal visit with basic info (gravity, parity, prev c/s?, EDC, etc.--high risk conditions input as pregnancy progresses if/when they arise, data input after birth. I am talking every client of every OB, CPM, CNM, MFM, FP, LDM, DEM, Naturopath.

Then we could know true outcomes, including mortality/morbidity, and intervention rates related to provider type, region, etc.

Transparency would bring accountability to all aspects of maternity care.

It would ultimately save the failing American health care system----as I believe would evolve practice all around for the better----higher levels of safety, lower rates of intervention.

That sounds a bit scary, really.

I have my records from my first four "births". None of them is accurate. Not one. I'm not just talking about the BS assessment of my motives and emotional state and all that. I'm talking about claims that I was informed about medications that I wasn't informed of, mis-statements about the weight and gender of my babies, misstatement about presentation of one of my babies, incorrect number of previous pregnancies, etc. It's not one set of records. There are errors in all of them. Punching some stuff into a database sounds good...but I'd want to see some really serious measures in place to ensure accuracy.

And, all that being said...it's still not enough, because birth isn't just about gravity, parity, previous c/s, due dates, etc.

I know how my entire history would look if it were chopped into numbers for statistical purposes, and it's wildly misleading, even without the errors in my records. There's a lot more to what's going on than the numbers.