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Thoughts on "planned home births are associated with double to triple the risk of infant death... - Page 17

post #321 of 394

I wasn't talking about paternalism at all. I was talking about professionals being responsible for their outcomes. I'm a pharmacist. I do not force anybody to accept or decline any given treatment. Ultimately it's their choice if they take the medications I dispense or not; if they want an OTC product and I recommend a particular one, it's their choice whether they get that product or not. Where I am on the hook is making sure I educate them properly and dispense their prescriptions properly. I can't make the patient decide what medication is suitable for them, in what dose, and follow appropriate state and federal laws in the dispensing. That's my job. If I screw one of those things up then I am on the hook for it. I have to educate patients properly about their medication. If I fail to educate a patient in a way I should have and there are adverse consequences as a result, I am on the hook for them. It has nothing to do with paternalism. It has to do with a responsibility that I as a professional have, to execute the duties of my position correctly as I have been trained to do, and a patient does not have a corresponding responsibility because they do not have that education or training. Although they do have a responsibility to provide information for me to do my job--I can't flag a drug allergy if they don't tell me about it, for instance--but it's up to me to determine what information I need and collect it. And if someone ignores the advice of a professional, normally the professional isn't considered responsible for the outcomes. 

 

And this isn't limited to healthcare professionals. If you hire a lawyer or an accountant, they had better also take responsibility for the outcomes of whatever service they are providing you. 

 

Yet somehow, midwives are different? These midwives that both Buzzbuzz and I have encountered present themselves as not professionals, not healthcare providers, and ultimately the responsibility lies with the mom. So even if the midwife screws up, she's not on the hook. Of course a patient choosing a particular course of therapy has obligations to fulfill in order to make sure everything comes off correctly, but it's still up to the provider to choose a course of therapy that's appropriate for that patient, educate the patient about it including about what specifically they need to do for their treatment to be a success, monitor the patient to make sure it's going well and make appropriate changes if it isn't. Why are some homebirth midwives ducking this responsibility?

post #322 of 394

For those wanting more information about Oregon and the home birth deaths from 2012. This is the html version, but a pdf is available.

http://webcache.googleusercontent.com/search?q=cache:K6yHwUDTsP0J:https://public.health.oregon.gov/BirthDeathCertificates/VitalStatistics/birth/Documents/HB2380-preliminary-birth-outcomes.pdf+&cd=1&hl=en&ct=clnk&gl=us&client=firefox-a

 

This is the response from the Oregon Midwifery Council:

2012 Preliminary Data on Oregon Birth Outcomes by Planned Birth Place and Attendant

March 18, 2013

Today we received a preliminary report from the Oregon Public Health Division on 2012 birth outcomes by planned place of birth and provider type.  In 2011, the Oregon Midwifery Council worked with legislators and partners in public health to pass HB 2380 which changed the Oregon birth and death certificates so that data on planned place of birth and provider type could be more accurately captured.  The 2012 data in this preliminary report is the first data set collected since the forms were changed.

Though the report raises more questions than it answers, the initial numbers are disheartening and they substantiate our decision to prioritize accountability and quality assurance as an organization. It is hard to know whether these numbers would be accurate over time with a larger sample size, but the preliminary report gives a term perinatal mortality rate for planned out-of-hospital births of 4.0/1,000 in comparison to the in-hospital rate of 2.1/1,000 for 2012.  We are saddened by the losses that these numbers represent and take seriously our responsibility to examine these deaths for areas where our care could be improved.

The Oregon Midwifery Council actively supports the movement towards greater clarity and transparency about birth outcomes in our state.  We will use this and future data to inform us in our ongoing programs for quality improvement including chart review, continuing education, review of standards of care, and advocacy for appropriate midwifery regulation.

Silke Akerson, CPM, LDM, President Oregon Midwifery Council

post #323 of 394

I am paging through my copy of "Optimal Care in Childbirth" by Henci Goer and Amy Romano. Henci is also the author of the "Thinking Woman's Guide to Childbirth". In the chapter on "The Place of Birth: Home Birth", I found this quote explaining studies included:

 

 

" Data on the safety of planned home birth in the presence of specific risk factors is scarce, although what is available suggests disproportionate mortality occurs in planned home birth of twins, breech babies, and pre-term and port-term infants and when meconium is present in the amniotic fluid..."  (p. 516)

post #324 of 394
Quote:

Originally Posted by mothercat View Post
 

"We are saddened by the losses that these numbers represent and take seriously our responsibility to examine these deaths for areas where our care could be improved.

The Oregon Midwifery Council actively supports the movement towards greater clarity and transparency about birth outcomes in our state.  We will use this and future data to inform us in our ongoing programs for quality improvement including chart review, continuing education, review of standards of care, and advocacy for appropriate midwifery regulation.

Silke Akerson, CPM, LDM, President Oregon Midwifery Council" 

 

clap.gif

post #325 of 394

I have read a few posts from midwives in reaction to these findings and the action of OMC. There is stunned silence in some quarters, others are saying that this is the appropriate response, and the remainder are just cynical. The last group thinks that OMC's actions do not match their words and they are still looking for a way to discredit the information.

 

On a couple of lists I belong to, there are midwives saying "finally". They knew that there have been midwives who were doing more high risk births (see Henci Goer's comment further up the thread), but how to remedy the situation was not being discussed. It is a good thing IMHO that the midwives are talking about this, because then the families will become aware that although home may be a safe place to birth, it is only safe when the midwife practices safely.
 

post #326 of 394

BTW: both Michigan and Ohio ask for intended place of birth and whether the mother was transferred from that place to where the birth took place, both since 2009 or 2010. I am thinking that we may be seeing more analysis from other states about the safety of birth at home.


Edited by mothercat - 4/21/13 at 3:11pm
post #327 of 394

"We are saddened by the losses that these numbers represent and take seriously our responsibility to examine these deaths for areas where our care could be improved.

The Oregon Midwifery Council actively supports the movement towards greater clarity and transparency about birth outcomes in our state. We will use this and future data to inform us in our ongoing programs for quality improvement including chart review, continuing education, review of standards of care, and advocacy for appropriate midwifery regulation."

 

I don't believe they didn't know the numbers were bad before Ms. Rooks' disclosures.  Melissa Cheyney has held several positions with OMC (legislative liasion, for example) and is also Director of Research for MANA.  Can we really believe that no one, ever, in any meeting in Oregon ever said "How are those mortality outcomes looking for Oregon, Missy?"  And if MANA's results are different/better why are they not publicizing that fact?

post #328 of 394
The numbers havent been that "bad" before in Oregon. Before the report year it was parity or less than hospital births and the LMs. The midwives have for a very long time asked to have each type of midwife divided out on the birth certificates for maybe 20 years now and the state had never felt it was important.
post #329 of 394

Buzzbuzz, the link says that the ONC received the report they are referring to that day. As far as the rest of your post, perhaps it best to post sources for information rather than speculation. 

 

From our UA

Quote:
We value the honest and supportive exchange of ideas and opinions, and we ask that members avoid negative characterizations and generalizations about others.

 

We all know that the MANA stats are a controversy popular with, if not created by those who oppose HB. Mothercat has been kind enough to share her opinions on the subject and MANA has released a statement on the subject. Of course you and anyone else is welcome to not find that good enough but continuing to bring the subject up without links and further information seems like an attempt to cast suspicion with little substance. 

post #330 of 394
Quote:
Originally Posted by mothercat View Post
"It is hard to know whether these numbers would be accurate over time with a larger sample size, but the preliminary report gives a term perinatal mortality rate for planned out-of-hospital births of 4.0/1,000 in comparison to the in-hospital rate of 2.1/1,000 for 2012." 

Silke Akerson, CPM, LDM, President Oregon Midwifery Council

These seem like different numbers than what Rooks came up in her report, no?  Is this one of those situations where the in-hospital birth stats are including high-risk births?  

post #331 of 394
I thought rooks data hospital numbers were for ALL risk levels at term (including congenital defects).

Does the press release cite the source for the hospital numbers?
post #332 of 394
Quote:
Originally Posted by Buzzbuzz View Post

I thought rooks data hospital numbers were for ALL risk levels at term (including congenital defects).

Does the press release cite the source for the hospital numbers?

Rook's press statement didn't have sources from what I recall other than her statement of where she got the data (birth certs?). Here is Rook's statement: 

 

https://olis.leg.state.or.us/liz/2013R1/Downloads/CommitteeMeetingDocument/8585

 

Midwifecat posted a link to the data from the most recent link in post #322.

 

Here is the link:

 

http://webcache.googleusercontent.com/search?q=cache:K6yHwUDTsP0J:https://public.health.oregon.gov/BirthDeathCertificates/VitalStatistics/birth/Documents/HB2380-preliminary-birth-outcomes.pdf+&cd=1&hl=en&ct=clnk&gl=us&client=firefox-a

 

It has a date prepared date of 3/12/13 but not a release date. 

 

 

They are really interesting to compare side-by-side. 

post #333 of 394

Those are interesting to compare side by side.

 

Quote:
Originally Posted by mothercat View Post

"It is hard to know whether these numbers would be accurate over time with a larger sample size, but the preliminary report gives a term perinatal mortality rate for planned out-of-hospital births of 4.0/1,000 in comparison to the in-hospital rate of 2.1/1,000 for 2012.  We are saddened by the losses that these numbers represent and take seriously our responsibility to examine these deaths for areas where our care could be improved." Silke Akerson, CPM, LDM, President Oregon Midwifery Council

 

Quote:
Originally Posted by IdentityCrisisMama View Post

These seem like different numbers than what Rooks came up in her report, no?  Is this one of those situations where the in-hospital birth stats are including high-risk births?  

 

Yes, those are very different numbers that Rooks came up with in her report. She showed that planned out-of-hospital births had a rate of 4.5 deaths per thousand, while planned in-hospital births had a rate of 0.6 deaths per thousand. I'm baffled as to where the Oregon Midwifery Council is getting this "2.1/1000" perinatal mortality rate for in-hospital deaths for 2012. No, strike that: I know exactly where they're getting it, but the paper clearly states that they can't do what they're doing to get it.

 

Judith Rook's statement (found here: https://olis.leg.state.or.us/liz/2013R1/Downloads/CommitteeMeetingDocument/8585) clearly states that:

 

Quote:
"On the first row, you can see that nine babies died during or soon after labor in homes or birth centers.
 
The total mortality rate for planned out of hospital births was 4.5 per thousand, as seen in the last column of that row."

 

The nine babies included 4 who died term intrapartum deaths (during labor) and 5 who died neonatally (after birth).

 

Nine baby deaths divided by 1,995 (the number of planned out-of-hospital births) gives you 4.5 deaths per thousand.

 

Now, if you exclude the one baby who died who had congenital abnormalities, the deaths would be counted as 8 deaths, and divided by 1,995 would give you 4 deaths per thousand. (Personally, I see no reason why you would exclude that baby from the statistics, as babies with congenital abnormalities were not, as far as I can find, excluded from the hospital data.)

 

Okay, now moving onto the hospital deaths.

 

The total number of planned hospital births was 39,984. Looking at Judith Rook's statement and data, you can see that the number of neonatal deaths was 25. In the "term intrapartum death" column, it lists no deaths, but has asterisks with this statement: "There are extremely few term IP deaths in hospitals. Most fetuses in prolonged distress are delivered by cesarean section. Estimated rate of IP fetal deaths is 0.1 - 0.3 from the authoritative medical literature, based on studies in Canada and Europe. Data on all term fetal deaths cannot be substituted for IP fetal deaths." (emphasis mine)

 

So, using those numbers (25 neonatal deaths for 39,984 planned hospital births), you get 25/39,984 = 0.6 deaths per thousand.

 

What the Oregon Midwifery Council did, and what the paper told them specifically not to do, was substitute all term fetal deaths (84) and divided that by 39,984, giving = 2.1 deaths per thousand for hospital births. Can I quote the paper again: "Data on all term fetal deaths cannot be substituted for IP fetal deaths." Do I know exactly why that data cannot be substituted? No. I'm not the one with a degree in statistics. Those are the people who put the data together, and told us specifically that in order to get accurate, comparable numbers, you cannot do exactly what the Oregon Midwifery Council did.

post #334 of 394
Quote:
Originally Posted by Pillowy View Post

 Do I know exactly why that data cannot be substituted? No. I'm not the one with a degree in statistics. Those are the people who put the data together, and told us specifically that in order to get accurate, comparable numbers, you cannot do exactly what the Oregon Midwifery Council did.

I figure all term fetal deaths includes stillbirths before labor begins. Those would have to be included in both data sets, or not included at all, and they were not included in the homebirth data set. It might be interesting to compare stillbirths between the homebirth population and the hospital population, but it's not what this particular study is about. 

post #335 of 394
Quote:
Originally Posted by erigeron View Post

I figure all term fetal deaths includes stillbirths before labor begins. Those would have to be included in both data sets, or not included at all, and they were not included in the homebirth data set. It might be interesting to compare stillbirths between the homebirth population and the hospital population, but it's not what this particular study is about. 

 


That makes a lot of sense; I bet that's what it is.

post #336 of 394
Quote:
Originally Posted by Pillowy View Post

What the Oregon Midwifery Council did, and what the paper told them specifically not to do

With this statement are you still talking about the two links? I"m confused on what papers your're talking about...

 

One of the reason Rooks data looks so different is that she is only comparing DEMs. I find the whole thing to be fascinating in terms of what we look at and how we crunch data. 

 

As far as I can tell, it doesn't seem like OMC is doing much other than responding to the preliminary data provided by the Oregon Health Council. No?  What am I missing here in the desire to incriminate the ONC? 

post #337 of 394
Quote:
Originally Posted by Pillowy View Post

I'm baffled as to where the Oregon Midwifery Council is getting this "2.1/1000" perinatal mortality rate for in-hospital deaths for 2012.

They got it from here, which is the link we've been discussing. I don't quite understand the rest of your comments on what they can and cannot do with the data. 

 

BUT, that is not to say that these numbers always mean what someone says. As we can see these comparisons are very difficult to discuss, especially when you get into risk and etc. Generally it's best to compare like risk groups but that seems quite difficult to do in OR because 6/9 of the HB deaths were high-risk. 

post #338 of 394
Quote:
Originally Posted by IdentityCrisisMama View Post

Quote:

Originally Posted by Pillowy View Post

 

I'm baffled as to where the Oregon Midwifery Council is getting this "2.1/1000" perinatal mortality rate for in-hospital deaths for 2012.

 

They got it from here, which is the link we've been discussing. I don't quite understand the rest of your comments on what they can and cannot do with the data. 

 

I find it interesting that you only quoted that sentence I wrote, and not the one following it. I knew where they were they were getting the number, and I said that. What I said was:

 

Quote:

Originally Posted by Pillowy View Post

 

I'm baffled as to where the Oregon Midwifery Council is getting this "2.1/1000" perinatal mortality rate for in-hospital deaths for 2012. No, strike that: I know exactly where they're getting it, but the paper clearly states that they can't do what they're doing to get it.

 

I already said I knew where they got the rate - in fact, my whole post was an explanation of how and where they got the rate, and why it was wrong. I'm very sorry that you didn't understand "the rest of my comments on what they can and cannot do with the data," because that was the whole point of my post - to try and explain why they cannot do with the data what they did with the data. It all comes down to basic statistics, and manipulating numbers (either out of ignorance or intentionally) to make them say different things than what the data really shows.

 

Quote:
Originally Posted by IdentityCrisisMama View Post

As far as I can tell, it doesn't seem like OMC is doing much other than responding to the preliminary data provided by the Oregon Health Council. No?  What am I missing here in the desire to incriminate the ONC? 

 

I have no desire to "incriminate" the Oregon Midwifery Council. I think they have good intentions. I simply want to explain that the numbers they're using - 4.0 deaths per thousand for home births vs. 2.1 deaths per thousand for hospital births - are not what the data shows.

 

Quote:
Originally Posted by IdentityCrisisMama View Post

With this statement are you still talking about the two links? I"m confused on what papers you're talking about...

 

I'm sorry, I should have been more clear in that statement. I'm talking about the data from both Judith Rook's statement (https://olis.leg.state.or.us/liz/2013R1/Downloads/CommitteeMeetingDocument/8585) and the other link we've been discussing, the Preliminary Data on Oregon Birth Outcomes (https://public.health.oregon.gov/BirthDeathCertificates/VitalStatistics/birth/Documents/HB2380-preliminary-birth-outcomes.pdf).

 

The link I was referring to there (when I said "what the paper specifically told them not to do") was Judith Rook's statement, at the bottom of the table where it says:

 

Quote:
"There are extremely few term IP deaths in hospitals. Most fetuses in prolonged distress are delivered by cesarean section. Estimated rate of IP fetal deaths is 0.1 - 0.3 from the authoritative medical literature, based on studies in Canada and Europe. Data on all term fetal deaths cannot be substituted for IP fetal deaths."

 

 

Quote:

Originally Posted by IdentityCrisisMama View Post

 

One of the reason Rooks data looks so different is that she is only comparing DEMs. I find the whole thing to be fascinating in terms of what we look at and how we crunch data. 

 

Rooks is not only comparing DEMs; she clearly splits her data into two categories. First, she shows the data that includes ALL planned out-of-hospital births. This is the data that shows the rate of 4.5 deaths per thousand (or 4.0 deaths per thousand, if you exclude the baby with congenital abnormalities). Then she shows the data on deaths that were planned out-of-hospital with DEMs. This rate was even higher - when looking just at DEMs, the rate of deaths was 5.6 per thousand (or 4.8 deaths per thousand, if you exclude the baby with congenital abnormalities).

 

So, I'm not sure where you got that she was only comparing DEMs, because she wasn't, and her data clearly explains that.

post #339 of 394
Quote:
Originally Posted by Pillowy View Post

 

I find it interesting that you only quoted that sentence I wrote, and not the one following it. I knew where they were they were getting the number, and I said that. What I said was:

 

 

I already said I knew where they got the rate - in fact, my whole post was an explanation of how and where they got the rate, and why it was wrong. I'm very sorry that you didn't understand "the rest of my comments on what they can and cannot do with the data," because that was the whole point of my post - to try and explain why they cannot do with the data what they did with the data. It all comes down to basic statistics, and manipulating numbers (either out of ignorance or intentionally) to make them say different things than what the data really shows.

 

I'm still confused. Is that data we're talking about from the OMC?  Mothercat...can you weigh in on this? What does Ms. Rooks say about this link? 

 

I'll have to go back and look at Rook's letter - I may have pulled the DEM stuff out of a hat -- seemed to mirror something from the other data set so maybe that's where I got it from. Rooks chart is very difficult for me to read/understand compared to the other link that is easier for me (a lay person) to get my head around. 

post #340 of 394

And, Pillowy, because you're a new member and we don't "know" each other well yet - I want to clarify that my tone was meant to be helpful. I dislike when people take snips of quotes and then try to fiddle with what a member says...that's not what my intentions were when I quoted you.  

 

I am just confused (and I fully own that it may well be my own confusion) about what we're talking about. 

 

I know we linked the Rooks statement and data, which was crunched by Rooks from birth cert. data. Then we saw a link to a statement from the OMC about this new set of crunched data which looks to me to be from the "Public Health Division" of the state of OR.  

 

I can't tell if you are cautioning against how the OMC used the data from the Public Health Division in their small public statement or if you think they were involved in working with the stats. 

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