Thoughts on "planned home births are associated with double to triple the risk of infant death... - Page 11

[IdentityCrisisMama]

Originally Posted by mwherbs 
 So my questions how many twin homebirths in Oregon ? Were there any losses? And were they included in Judith's research? If so how many hospital twin births were included in that same research? 

It's been a while since I fiddled with the CDC Wonder pages - I forgot how interesting that service is. 

Here's what came up for Oregon twin death (from under one hour-27 days) in hospital births: 

Census Region 4: West	22	1,428	15.41
Total	22	1,428	15.41

It wouldn't bring up homebirths due to the "suppression contraints" 

Here is the whole of the US for 2008 for hospital births: 

Census Region 1: Northeast	528	25,895	20.39
Census Region 2: Midwest	678	29,798	22.75
Census Region 3: South	1,226	51,085	24.00
Census Region 4: West	529	31,505	16.79
Total	2,962	138,283	21.42

Still even with the whole US selected it still won't give stats on out of hospital birth. 

From: http://wonder.cdc.gov/controller/datarequest/D69;jsessionid=CEA6E840FEB0EA32B70B5CAFD68B6F44

[Buzzbuzz]

But I don't think that's relevant for the point I think MWHerbs is trying to make, since that is for all twin birth regardless of maturity, right?  The Oregon numbers are for term birth only.  Also, the CDC Wonder numbers include homebirth transfers as hospital births, while the Oregon numbers are based on planned place of birth.

Could perhaps mothercat ask Ms. Rooks to clarify what she is considering "term birth" (36 weeks and after or 40 weeks and after -- for example, is she including post-dates, which increases stillbirth risk) and whether multiples are included? 

Edited to add -- If I'm running the CDC wonder site appropriately, it appears that you can't break out twin births/deaths for 2008 for Oregon by gestational age.  Maybe I'm missing something, but I can't seem to do it.

Edited by Buzzbuzz - 3/21/13 at 4:37pm

[IdentityCrisisMama]

Having fun with the Wonder pages: 

Census Region 3: South	11	8,203	Suppressed
Census Region 4: West	21	10,518	2.00
Total	47	28,231	1.66

Query Criteria:
Title:
Age of Infant at Death:	Under 1 hour, 1 - 23 hours, 1 - 6 days, 7 - 27 days
Age of Mother:	All
Birthplace:	Not in Hospital
Medical Attendant:	Certified Nurse Midwife(CNM), Other Midwife

Census Region 1: Northeast	2,703	667,598	4.05
Census Region 2: Midwest	4,006	882,234	4.54
Census Region 3: South	7,528	1,605,521	4.69
Census Region 4: West	3,723	1,049,368	3.55
Total	17,960	4,204,721	4.27

Query Criteria:
Title:
Age of Infant at Death:	Under 1 hour, 1 - 23 hours, 1 - 6 days, 7 - 27 days
Age of Mother:	All
Birthplace:	In Hospital

I am, of course, not qualified in the slightest to look into these numbers all that well but it's an interesting thing to play around with for folks that like numbers. 

[IdentityCrisisMama]

Originally Posted by Buzzbuzz 

Edited to add -- If I'm running the CDC wonder site appropriately, it appears that you can't break out twin births/deaths for 2008 for Oregon by gestational age.  Maybe I'm missing something, but I can't seem to do it.

My guess is that you can but when you start to break it down by gestational age in a small region, the numbers are too small to give any sort of accurate result. 

[mothercat]

Originally Posted by Buzzbuzz 

Could perhaps mothercat ask Ms. Rooks to clarify what she is considering "term birth" (36 weeks and after or 40 weeks and after -- for example, is she including post-dates, which increases stillbirth risk) and whether multiples are included? 

Term, by definition, is 37 to 42 weeks.

[mothercat]

Originally Posted by IdentityCrisisMama 

Having fun with the Wonder pages: 

I am, of course, not qualified in the slightest to look into these numbers all that well but it's an interesting thing to play around with for folks that like numbers. 

From what you have found, it appears that the western region has a lower newborn/infant death rate that any other area of the country. That should make the Oregon rate even more disturbing IMHO.

Edited by mothercat - 3/21/13 at 8:31pm

[Buzzbuzz]

"I am, of course, not qualified in the slightest to look into these numbers all that well but it's an interesting thing to play around with for folks that like numbers."

Yes, amazing what happens when premature birth is included basically within the hospital numbers alone (as generally even the most vehement homebirth advocate will not deliver at home before 36 weeks) and the results of all homebirth transfers are included in the hospital numbers.

[IdentityCrisisMama]

Originally Posted by mothercat 

From what you have found, it appears that the western region has a lower newborn/infant death rate that any other area of the country. That should make the Oregon rate even more disturbing IMHO.

The thing that keeps sticking in my mind is knowing that all deaths for Oregon HB are registered under HB regardless of the reason for transfer/treatment at the hospital. I think a case by case determination for that would be a more accurate way to go.  

I think a big part of why this is a sticky subject for me could have to do with the role I think doctors and the hospital play in homebirth - I think they play a vital role and would be part of the continuum of care if I had my way. If I have the energy I'll post a spin-off on this topic and link here... 

[IdentityCrisisMama]

Originally Posted by Buzzbuzz 

Yes, amazing what happens when premature birth is included basically within the hospital numbers alone (as generally even the most vehement homebirth advocate will not deliver at home before 36 weeks) and the results of all homebirth transfers are included in the hospital numbers.

YES!  It gives one a lot or respect for the considerations that go into researching this kind of data and the enormous potential for error, interpretation and bias. 

[mothercat]

Originally Posted by IdentityCrisisMama 

The thing that keeps sticking in my mind is knowing that all deaths for Oregon HB are registered under HB regardless of the reason for transfer/treatment at the hospital. I think a case by case determination for that would be a more accurate way to go.  

Dr. Nigel Paneth (epidemiologist at Michigan State Univ.) did a presentation at the IOM meeting March 6 & 7. As a biostatistician he feels that birth certificates need to have more information such as what you mentioned. There should be a place on the birth certificate to identify intended place of birth as well as the place where the birth took place. He also states that there are "sentinel events" that we should NEVER see associated with the intended place of birth when it is listed as "home" or " birth center". These are:
        –Breech vaginal deliveries

        –Maternal and neonatal deaths
        –Intrapartum fetal deaths

If you are interested in seeing more of his presentation, which may answer a question or two about the difficulty in sussing out the data that would be most helpful about the safety of homebirth, this link goes to the IOM site http://www.iom.edu/Activities/Women/BirthSettings/2013-MAR-06.aspx. You need to click on the "+" sign next to "Presentation" on the right to open the list of speakers. Dr. Paneth's is down near the bottom of the list.

 This is one of his slides.

WE SHOULD BE MONITORING PLANNED OUT-OF-HOSPITAL BIRTHS
   •Use vital data to compare to hospital births in terms of:
               –Risk factors for problem births
                          •prior preterm and adverse pregnancy outcomes, maternal pregnancy complications
               –Neonatal and Maternal mortality
               –Maternal morbidity
                          •lacerations, transfusions
              –Neonatal morbidity
                          •Ventilation, transfer, Apgar scores

Edited by mothercat - 3/22/13 at 6:06am

[IdentityCrisisMama]

MSU (I went there!)  THANK YOU so very much for your wealth of knowledge you are sharing with us!  

[IdentityCrisisMama]

Originally Posted by mothercat 

If you are interested in seeing more of his presentation, which may answer a question or two about the difficulty in sussing out the data that would be most helpful about the safety of homebirth, this link goes to the IOM site http://www.iom.edu/Activities/Women/BirthSettings/2013-MAR-06.aspx. You need to click on the "+" sign next to "Presentation" on the right to open the list of speakers. Dr. Paneth's is down near the bottom of the list.

I can see the slides (which are interesting by themselves) but would love to hear the presentation. Is that possible? 

[mothercat]

I come by it honestly IdentityCrisiMama. My brother is an RN, with his doctorate in nursing.  He started out as an OR tech, became an OR RN in orthopedics, then managed OR for several naval bases before retiring and doing the same for a couple of large medical centers. At times when he was managing the naval base OR, he was also in charge of managing the L&D unit. He helped to bring CNMs to the base in Naples, Italy. Along the way he did his master's thesis on the cost-effectiveness of using CNMs in all settings (because he had a CNM for a sister and she was a good resource ).

He is a director of the organization which credentials OR nurses. His doctoral thesis was on the learning curve for new grads who became OR nurses. He realized there had to be a better way for them to learn the job. Minimum is 6 months full time on the job training with a preceptor and it still may take 2 years for the best of them to be completely proficient. With the OR nurses it is easier to track the information on knowledge, skills, and proficiency because of the setting and accountability. His complaint is that many of the older OR nurses think they are just as proficient as the RNs who are certified OR nurses and it just isn't true. There are many parallels between what he sees in the OR and the struggles occurring in midwifery.

Before I get off track, just wanted to let you know that bit of background. The point is that if midwives are so sure what they are doing is the best they could be doing, they should be more than willing to push for inclusion of the data listed above with regard to birth certificates. Having CPMs licensed makes data collection easier, but still leaves the problem of the unlicensed midwives who may have the parents register the birth because the midwife is not permitted to or is illegal. The parents won't always understand the technical questions that the midwife should be answering and thus the data will be inaccurate.

There is also the problem of the midwife being truthful in what she enters on the birth certificate. If mom was GBS positive, and the baby became ill due to inadequate treatment, what is to stop the midwife from entering that mom was unknown or GBS negative? That information is for demographic purposes and doesn't show up on the certified copy of the birth certificate that the parents get. There needs to be better data on the birth certificate and there needs to be follow up and investigation of the adverse outcomes so we have a clearer picture of what is wrong and what needs to be changed.
 

[mothercat]

I am not sure on that. You could always ask the people listed as contacts if that is possible. I know the 2 days of meetings were live streamed so I'm sure there was video made and archived.

[IdentityCrisisMama]

Originally Posted by mothercat 

Having CPMs licensed makes data collection easier, but still leaves the problem of the unlicensed midwives who may have the parents register the birth because the midwife is not permitted to or is illegal. The parents won't always understand the technical questions that the midwife should be answering and thus the data will be inaccurate.

I am in Maryland and I believe this is the case in my state. I think there may even sometimes be some confusion about whether the mother should say she had at MW that she did not want to name or if she is supposed to say that she birthed unattended. I just looked at my MD born DC's birth cert. and it's blank for attendant name and title - no space to say place of birth. 

[IdentityCrisisMama]

Originally Posted by mothercat 

 He helped to bring CNMs to the base in Naples, Italy.

I'll bet we could play 6 degrees of separation...  

[mothercat]

Originally Posted by IdentityCrisisMama 

I am in Maryland and I believe this is the case in my state. I think there may even sometimes be some confusion about whether the mother should say she had at MW that she did not want to name or if she is supposed to say that she birthed unattended. I just looked at my MD born DC's birth cert. and it's blank for attendant name and title - no space to say place of birth. 

I know when we registered the birth for for youngest DS, my only home birth, that DH was listed as the informant and birth attendant was blank because the midwife was an illegal CPM. That birth is probably tabulated with the unattended, but it wasn't.

[marjavernice]

Prior to having my two babies i was very pro home birth but now i dont think i would be a srong advocate at all. I had two fairly complicated labours and births despite having great pregnancies and being young, fit and healthy. My second labor was particularly traumatic - my daughter was 11lb 8 oz and got very stuck  (shoulder dystocia)  - i am pretty small at 5ft 5 and 55kg so she was quite a big bubba for me! My doctor and midwives called a code and had to act very quickly to ensure a safe deliver and they really did need all the help they could get. Ever was pretty blue when she came out and had to go on oxygen straight away and i lost quite a bit of blood. I just think that the outcome could have been very bad had we not been in the hospital and even though these situations are probably rare, it did happen to me and im so glad i had the medical help available. I was seriously considering a homebirth for my second baby as i was a strong believer that my body would know what to do the second time around (i would have liked one with my first too but cost was a factor and i was also a little wary, being my first baby). My first labour/birth was very slow and complicated with threatened c section but despite this i really thought that my second labour would be easy and straight forward and there would be no reason that i couldnt have her at home. I was just lucky that home births are pretty expensive in country WA and we are currently building and couldnt really justify the cost when there is a great hospital just 10 mins down the road. I had been doing the hypnobirthing readings and visualisations for the second time round and was really in the zone and positive that my body was prefect for giving birth and that my baby would be the perfect size for me etc etc and i did think that i would probably have a decent size baby as my first was 8lb 10oz but i would never have guesses she would be 11lb 8!! Now i kind of just think that even though the chances are very small of something going wrong, that unlucky person could be you and why risk it. I had wonderful midwives and overall a pretty good hospital experience. I think you just need to be very confident and clear without being uncomprimising if having a hospital birth. I personally wouldnt attempt a homebirth if i have any more babies and even though i hate to admit it, i dont think i would suggest it to anyone over a hospital birth, solely based on my own experience

[erigeron]

Originally Posted by mothercat 

I know when we registered the birth for for youngest DS, my only home birth, that DH was listed as the informant and birth attendant was blank because the midwife was an illegal CPM. That birth is probably tabulated with the unattended, but it wasn't.

We interviewed with CPMs before deciding to have a hospital birth and they told us that we would be registering as unattended in this manner. We are in Ohio. 

[krst234]

My births were attended by licensed midwives but recorded as unattended. Being licensed is separate from being allowed to complete birth certificates. So some births attended by licensed midwives are mis-categorized as "unattended" or as the mother as the attendant. (Explanation: There are limited opportunities for midwives to become birth certificate filers - once or twice a year - and often a good drive away. Licensing occurs year-round. Wouldn't it be handy to have licensed providers granted the authority to file birth certificates when they get a license?)

Conversely, one does not need to have a license to file birth certificates, so some births are attended by lay midwives (mostly in the Amish communities) and filed as attended by the birth certificate filer usually designated as "other" midwife.

Just trying to illustrate some of the many problems with gathering data from birth certificates.