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Apgar Score of Zero at Five Minutes - Page 6

post #101 of 129

By the way, I played around with the numbers on the Zero Apgar study using some figures I found in a study of CNM assisted home birth.  This study was useful to me because it showed the difference between the "actual home birth" rate of poor outcome (death in this case) and the "intend to treat" rate of poor outcome.  In that study, the intrapartum and neonatal transfer rates that would show up in the death rates were 9.4% combined, and that 9.4% accounted for 28% of the poor outcomes in the intent to treat, planned home birth population who started labor planning to birth at home.

 

If that ratio were to hold, and maybe it wouldn't but it's the best proxy I could find, the relative risk for home, midwife to hospital MD becomes 15x higher with absolute risk of 2.25 per thousand for all parities, and it's 25x higher than the hospital, midwife number with about 38 mother/baby dyads being miscategorized as hospital when they started as home birth transfers.  That is a rough guess and it may be in error, but it was the best I could identify from available evidence at my disposal.  I am not a statistician and anyone is more than welcome to correct my figures if they are in error.  

 

I can walk anyone through the numbers to show how I arrived at that number, if they would like, but I'm going to be bowing out of the thread at this point in deference to the environment of support that Mothering is trying to provide here, so contact through PM is preferable.  Thank you all for the stimulating discussion!

post #102 of 129
"While we will not restrict discussions only to those who birth at home or in a freestanding birth center, members posting to this forum should have a sincere interest in learning about or supporting the option to HB."

Thank you for realizing this. Trust me, we hear all the time about the horrors and dangers of homebirth. I worked as an EMT as well as several other fields, I've had 3 hospital and 2 home births, and I was pre-med and know all about reading scientific studies and statistics-all of which was required for my program. So in a support forum, it might not be best to jump in assuming none of us can understand the statistical methods as well as the inherent fallability in many studies.

Of course the Farm study wasn't conducted to be utterly scientific. It was factored in after they lived the life delivering babies for decades. Many of those deaths took place before we had the technology in place for preemies or life threatening birth defects. Some of those births were included when they knew the baby was stillborn and wanted a more peaceful process. It's a simple fact of biology that as much as we try to save every baby, sometimes it's not always possible. It's heartbreaking, and we should do all we can, for sure, but it would be impossible for a 0% rate.

For example, in my county the C-section rate is 38%. While some of those were surely life saving, it is fact that C-section increases the mortality rate for baby and mother. As for the Farm's 1% rate, right now in my state: "The neonatal mortality rate decreased from 5.2 in 2003 to 4.8 in 2004, the lowest ever recorded for Illinois. "

http://www.idph.state.il.us/public/press06/6.19.06InfantMort.htm

"In Illinois in 2005, the rate of perinatal mortality was 7.2 per 1,000 live births and fetal deaths."
http://www.marchofdimes.com/peristats/ViewTopic.aspx?reg=17&top=6&lev=0&slev=4&dv=mt

http://www.marchofdimes.com/peristats/ViewSubtopic.aspx?reg=17&top=6&stop=371&lev=1&slev=4&obj=1&dv=ms

So I hardly think that the Farm disqualifies as a good example of birth safety.

Another study on Apgar and outcomes in South Australia: http://hoydenabouttown.com/20100116.7157/that-homebirth-study-in-south-australia/

I would like to see the end outcome past that 5 minute score. One reason why:

"An Apgar score of 0 to 3 at 5 minutes is associated with an increased risk of cerebral palsy in full-term infants, but this increase is only from 0.3% to 1%. Scores of 4 through 6 are intermediate and are not markers of high levels of risk of later neurologic dysfunction. Such scores are affected by physiologic immaturity, medication, the presence of congenital malformations and other factors. Because Apgar scores at 1 and 5 minutes correlate poorly with either cause or outcome, the scores alone should not be considered evidence of or a consequence of substantial asphyxia. Therefore, a low 5-minute Apgar score alone does not demonstrate that later development of cerebral palsy was caused by perinatal asphyxia.

Correlation of the Apgar score with future neurologic outcome increases when the score remains 0 to 3 at 10, 15 and 20 minutes but still does not indicate the cause of future disability. The term asphyxia in a clinical context should be reserved to describe a combination of damaging acidemia, hypoxia and metabolic acidosis. A neonate who has had asphyxia proximate to delivery that is severe enough to result in acute neurologic injury should demonstrate all of the following(.../snip for space)

The Apgar score alone cannot establish hypoxia as the cause of cerebral palsy. A full-term infant with an Apgar score of 0 to 3 at 5 minutes whose 10-minute score improved to 4 or higher has a 99% chance of not having cerebral palsy at 7 years of age. Conversely, 75% of children with cerebral palsy had normal Apgar scores at birth.

Cerebral palsy is the only neurologic deficit clearly linked to perinatal asphyxia. Although mental retardation and epilepsy may accompany cerebral palsy, there is no evidence that they are caused by perinatal asphyxia unless cerebral palsy is also present, and even then a relationship is in doubt.- American Academy of Pediatrics policy statement, Volume 98, Number 1, July 1996"

Another study on asphyxiation: http://www.jpma.org.pk/full_article_text.php?article_id=3855

Therefore, I think just the apgar scores should be expanded in this study by including other data that has a significant outcome on cerebral palsy and mortality.
post #103 of 129

Hey, I've been following this thread.  Thanks, ladies, for the discussion.

 

I think it's good to keep in mind that when analyzing risk a person might want to decide what the likelihood is of that bad thing happening...and that in some places a person is basically guaranteed to have negative things happen in the hospital.  If you have a 99% chance of lack of respect for your ideas, lack of informed consent, bullying (even if they do it with a smile), protocol that you don't agree with and believe to be harming to either yourself or your child...but you have a X% chance of a horrible outcome at home, I feel it's not so black and white. 

 

Also, I think that this discussion seems to be all about statistics and what they mean for "the home birthing community."  That is needed to make changes, and that's great. But as far as I know, the community isn't having my baby.  Each woman has a million things to take into consideration for herself.  It seems like the attitude of this thread is OMG I can't believe anyone would have a home birth!  Have you seen the statistics!? And to me it is so weird to hear talk of supporting someone's decision as long as XYZ parameters are met.  No matter the parameters of health or location or whatever, I think that if a mom has all the information that she will make the right choice for herself.  You need to be able to see where you fit into the statistics. 

 

One thing they don't take into account for example, is the physiological response of interrupting labor to go to a hospital.  For me, that would break my concentration and I would then be so tense in a location that was not my home turf that I believe I would be setting myself up for a dysfunctional labor.  Bad surprises can happen at home (or anywhere) but known bad things would happen if I personally went to the hospital.  I would go only if the pros outweighed the cons.

 

If we come to a consensus that statistics show that home birth has way more dangers than we ever thought possible, are we going to stop supporting people who choose it?

post #104 of 129

Salr, my take on it is angled just slightly differently then the one you're talking about, and I feel it's worth explaining.

 

I support the right of women to birth at home, with or without midwives, as they, individually, see fit.  The pregnant women are the ones with rights in this situation.

 

I support the requirement that midwives honestly discuss risks with their clients.

I support legal limits on the scope of practice for midwives, so that if a home birth presents risks above a certain level, the midwife not be permitted to charge for her services as midwife.  (I would support a midwife charging for her services as a doula in this situation, either as a doula for a hospital birth or a doula under a midwife with more extensive training.  I would not support a midwife saying, basically, "home birth is really risky for you because of X, Y and Z issues that I lack the training or equipment to handle safely, but if you really want, I will bill you and attend your birth at your home, even though we have good reason to expect it to be a disaster.")

I support nationwide licensure for midwives, with uniform standards, and requirements for continuing professional education.

post #105 of 129
The reality is though, Meepycat, that this forum is intended for mothers support HB as a whole, who feel attached to the choice to HB in some way or those with a genuine interest in HB. The concept of "support" can argued but I have given some suggestions for how to host a discussion with members whose support is limited or members who no longer support HB. I ask that you respect this request as other members have done.

Feel free to PM me if you need more clarification. I will answer PMs when I get to a keyboard.
post #106 of 129
Quote:
Originally Posted by salr View Post

 

 

If we come to a consensus that statistics show that home birth has way more dangers than we ever thought possible, are we going to stop supporting people who choose it?

 

I think one of the most important things we can do in the natural child birth community is stop supporting choices that are extremely risky for mother and baby. We need to stop offering unconditional support to people and hold them to poor choices, not offer only hugs. If someone was taking an unnecessary risk that would almost surely lead to disaster, hell no I wouldn't support them. It would be like supporting someone who wanted to sky dive without even looking at their equiptment. We need to stop supporting every choice in the name of NCB and start serious talks about when it ISN'T prudent to have a home birth or unassisted birth.

 

So often here, I'll read about someone disregarding sound, EVIDENCE BASED advice to HB and UC and I have to wonder what the hell they are thinking? But no one calls them out, it's all hugs, support, and you can do its, without saying hey, maybe you shouldn't be home birthing. If a well rounded study came out and showed unequivocally that home birth was dangerous, I would not support it for myself or for anyone else. Just like I don't support birthing breech babies @ home, or birthing twins UC,etc. etc.

 

We also need to hold our midwives to a higher standard, and stop defending the bad ones. The bad ones lead to all the horror stories you hear about in home births, yet when they kill or injure a baby the NCB community closes ranks around them, and protects them. Why? If we want good outcomes for mother and baby we should be throwing out all of the bad midwives immediately. We should be demanding a minimum level of accreditation for our midwives, like a Bachelor's in Midwifery. I want the best for our community, I want to be sure that w are all safe, and I want us to be honest with ourselves.

 

(BTW, I am planning my 3rd HB for this fall, so I am still allowed to post my dissenting opinion?)

post #107 of 129
What I'm saying is that I believe the mom in question is the one to fully understand the risks and benefits of her choices.
PP, do you believe that a breech presentation should mean the mom chooses a c-section? Or is effectively forced into that choice? I think it would be great to advocate for hospitals providing safe vaginal birth for breech. But that is not the current state of things in many locations. I can easily imagine it being safer to have a breech birth at home than with an ill-informed or unsupportive provider in the hospital.

Also, I am not familiar with people supporting dangerous midwives. I'm familiar with people supporting midwives who I do not personally like, or who have protocols that I don't agree with.

I'm not saying we all have to support the same actions or think the same decisions are smart. But expressing blanket condemnation of things that many others on this board find ok for themselves seems weird. I know this is a discussion of broad statistics, but I think it's wiser that support be doled out on an individual basis.

What I have found most helpful on MDC has been each mom's individual story and all the information and thoughts expressed based on that. If those details don't matter to anyone else it doesn't seem like a discussion. It seems like a question/answer session with a very limited amount of right answers.

I'm pretty sure I don't have anything else to add to this thread. Except that it's obvious to me the US needs better hospitals, better ability to transfer from a home birth, and more respect for moms.
post #108 of 129
And can we throw out the bad doctors too?

I'm not sure that another year of med school will fix them though.
post #109 of 129

Quote:
Originally Posted by salr View Post

Also, I think that this discussion seems to be all about statistics and what they mean for "the home birthing community."  That is needed to make changes, and that's great. But as far as I know, the community isn't having my baby. 

Yes. And along this same idea, I have noticed that this forum tends to discuss individual choices, birth stories and etc. along with discussions of studies and etc. That's natural but it can get confusing especially if the expectation is high that we individual mothers are representing HB, which I feel I am seeing more an more suggestions of. 

Quote:
Originally Posted by StephM76 View Post

 

So often here, I'll read about someone disregarding sound, EVIDENCE BASED advice to HB and UC and I have to wonder what the hell they are thinking? But no one calls them out, it's all hugs, support, and you can do its, without saying hey, maybe you shouldn't be home birthing. 

I would LOVE if you would bookmark some of these threads for me so I can have a look because I'm not seeing what you're seeing. Are you saying you often see members being given sound, evidence based advice and individual members are disregarding it? Or that members are coming here for advice about a risky birth and our membership is not giving good advice regarding alternate choices or things to consider? 

Quote:
Originally Posted by StephM76 View Post

We need to stop supporting every choice in the name of NCB and start serious talks about when it ISN'T prudent to have a home birth or unassisted birth.

I also wonder of the way we interpret "support" is different. Obviously it is, but I wonder if that plays a role in how we interpret various forms of support within our community. For instance, I will honor a woman's instincts about where she wants to give birth - always. But, aside from being OK with an educated, experienced CPM, I am pretty conservative when it comes to HB and risk. If a mom posts here about risk, I am happy to tell her that I would not HB in various situations. I think support is a lot of things...and what looks like support to one person doesn't to another. If that makes sense.  More on this subject later... 

 

What I think and observe on this forum through my own bias are some very active threads on HB safety. Some challenges on the CPM issue. Lots of discussion on regulation. I just don't see some of the accusations I've seen on this thread (not from you but from others) or on skeptic sites that we are this group of women that want to keep our heads in the sand and encourage risky homebirth and don't address issues within HB. 

 

But, Steph, you are MOST welcome to post. The point of the guidelines is not to limit dissent or disagreement within the community but to be sure that we create a safe for exactly that - and for all things HB. 

post #110 of 129

It comes back to standards for education and risk criteria.
 


Edited by mothercat - 7/12/13 at 3:12pm
post #111 of 129

ICM --

 

I am very concerned about the posting regime you are describing here.  I can easily see a situation where "positive" homebirth scientific evidence can be posted to this board but only discussed in approving terms, while "negative" homebirth scientific evidence must be posted to the main board where it can be debated in full (both positive and negative).

 

I find that troubling, because scientific evidence cannot, in a meaningful way, be discussed, debated and analyzed in a "support only" format.

 

If the people running this board have a true interest in being a legitimate information source, I believe that all discussions of the scientific evidence pro and con re: homebirth safety should be required to be posted outside the support only board.

 

ETA:  What I am suggesting is the creation of a homebirth safety discussion forum.  All discussions of what to feed the midwife, what gifts to get her, what fishy pool to buy, etc. can remain here and discussions of the safety issues can be moved to a separate forum.


Edited by Buzzbuzz - 7/12/13 at 6:43am
post #112 of 129
We will be happy to discuss moderation and guideline issues. Please post a thread in "Questions and suggestions" or PM me. I will also raise your concern with admins later today.
post #113 of 129
I do want to reiterate that these guidelines do not prohibit a broad discission of HB safety. to the contrary, they are intrnded in part to create a space for the HB commuinty to discuss these very issues. Please do not assume or imply that HB mothers will not have these conversations without those with extremely limited or withdrawn support for homebirth.
post #114 of 129
I guess I'm feeling unsure about the guidelines here because I think this has been a great, and respectful, discussion, and I value the critical viewpoints expressed here. I don't want to hear the judgements of anti hb flamers, not at all, but respectful discussion by women who have intimate experience with the decision to birth OOH is exactly what I want to read. No matter which way they're leaning at this time. The extremists on either side are no help.
post #115 of 129

"Please do not assume or imply that HB mothers will not have these conversations without those with extremely limited or withdrawn support for homebirth."

 

I'm sorry, I'm not seeing these discussions currently happening anywhere on the internet with a strict litmus test for the participants.   In my experience with other homebirth sites, these studies don't get posted and they don't get discussed.  Let's not forget how daunting it can be to be a questioner in and amongst a group of believers.

post #116 of 129

Quote:
Originally Posted by Buzzbuzz View Post
 
 Let's not forget how daunting it can be to be a questioner in and amongst a group of believers.

To me, this is an ironic statement to make in light of this discussion. Most families planning a HB know this QUITE well. To me, this is precisely  why this forum should be a safe place to post with like-minded members. 

 

Although the decision has been made to limit this forum to members who support or are interested in learning about HB, I have said that members who don't may still participate on a case by case basis so long as they post with respect for the choice to HB. To me, that includes letting members know that your support for their choices is limited. That seems like a reasonable request. If you don't support some choice or another or have not experience with this or that, I think it is helpful for the member to know that as they factor your opinion. 

 

PLEASE, members, if there is a thread that is not answered (like Steph's question about risk), or a thread with responses that you don't agree with, post to that thread!  I went through the last two pages of threads (back to March, I think) and I am not seeing the accusations I've read on this thread. But, even so, this is a discussion board and there is no excuse for complaining about how a thread goes if you haven't even bothered to participate. /rant. 

 

Jenny, I TOTALLY agree that this has been a respectful discussion. I'm sorry if the discussion of the guidelines has taken over the thread. I am attempting to make new and regular members aware of the new guidelines and this thread happened to be a good place to start. We do have a procedure for discussing moderation, which is to PM the moderator or post to Questions and Suggestions. Future questions about moderation and the newly posted guidelines should be voiced through one of these two channels to avoid derailing threads.  

 

ETA: I have read PMs from the two members who wanted to share their opinions and gotten some feedback from mods. Starting a new HB skeptic board is not an option but if members would like to have a discussion like that, we can see about hosting it in the general birth forum. Moving this thread for the reasons suggested is not something we do. The guidelines are clearly stated so I assume the OP meant to host the discussion with those in favor of HB.  When a thread is hosted in a forum where you don't identify the traditional thing to do is post a spin-off. I will watch for the boards becoming an "echo-chamber". All members are welcome to help watch for this and PM me with examples (or past examples, which I still have not seen). HB members are encouraged to make this forum what they want it to be by active participation. To repeat, this is not intended to be a dissent, disagreement, question-free zone but a place for HB members to do just that. To paraphrase one of my PM's from a member I have grown to respect a great deal, "Members are more likely to hear advice from this board if they know it is coming from members who have a fundamental respect for their choices."

 

Mothercat, thanks for your edit. 

 

Let's get back to the topic of the APGAR study.

post #117 of 129

I sent the study to a MW and this was her reply (I think she made some really good points):

 

 

Quote:
 I just quickly reviewed this data, and right out of the gate, the data is collected from Birth Certificate data which is notoriously inaccurate.  I believe that an Apgar score of 0 can be the result of a catastrophic hemorrhage, or placental abruption, or serious neurological insult, etc.  Personally, I have never seen one in over 1700 births, although we have dealt with placental abruptions, hemorrhages, numerous shoulder dystocias (the longest was 9 minutes and require full resuscitation, but still had a one minute Apgar of 2).  One thing that perplexes me, is that the birth Certificate Applications here in Florida changed in 2003 to only include a 5 minute Apgar score, so how would they get data on a one minute Apgar from us.  The Health Department advised me when they changed the form that this was a newly instituted national form, so I assume that everyone is under the same regulations as far as reporting a 5 minute Apgar score, but not a 1 minute one.
    Interesting and thanks for sending it along.  I will try to spend some more time digesting it.
post #118 of 129
Quote:
One thing that perplexes me, is that the birth Certificate Applications here in Florida changed in 2003 to only include a 5 minute Apgar score, so how would they get data on a one minute Apgar from us.  The Health Department advised me when they changed the form that this was a newly instituted national form, so I assume that everyone is under the same regulations as far as reporting a 5 minute Apgar score, but not a 1 minute one.

 

I didn't get a chance to read through the study yet. Did they look at 1 minute scores? The study and results were based on the 5 minute scores.

post #119 of 129

SillyMommy, I had the same impression as fruitfulmomma, that the study looked only at five minute scores, but I do not have the full text.  That also means I don't know what forms or years the data was drawn from, either what state (some states may have chosen to keep more comprehensive reporting forms then the national form), or what other data was used. 

 

The big point I would make is that, if 5 minute Apgar of 0 occurs in <2 homebirths per thousand, it is completely possible that your midwife has gotten through 1700 births without seeing any.  Based on the numbers, if your midwife was completely average, you'd expect her to have seen about 3 cases of this particular outcome, and not seeing three might mean that she's been lucky or might mean she's been careful to appropriately risk out patients.  IIRC, Florida has very strict standards for the legal practice of midwifery, so home birth midwives in FL may risk patients out more then home birth midwives in other states.

 

I will say that her reference to a 9 minute SD alarms the heck out of me - the reason SD is a problem is that the position of the baby at that point results in oxygen deprivation, and 6 minutes is generally the limit at which we see irreversible brain damage.  I would want to know what the long-term looked like for that baby.

 

I have been reminded, however, that I have not had a home birth, and do not plan a home birth, and that I should be clear about this when posting in the home birthing forum.  I support the right of every women to birth in the location of her choice, and I feel very strongly that information about comparative risk should be made available to all mothers, regardless of the context in which they choose to deliver.

post #120 of 129

It's already been said, but bears repeating, that HB is NOT restricted to low risk mothers in the U.S. (and Oz, and I am sure other first world countries as well). That particular fiction leads to HB looking scarier than it is. But of course not many HB proponents want to shout from the rooftops, "oy, lots of moms are proceeding with homebirths despite high risk pregnancies and having bad outcomes, thus skewing the statistics!"

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