I'm going to follow up to this post after I pose this question/thought.
In choosing a doula would you allow the idea of the Doula having or not having her own children/giving birth be a part of your decision making processes?
If you answer yes, I ask you to also then rethink your choice in your OB. If you have chosen a man then you should also then with confidence be able to say that you should not use that OB because he himself has never given birth.
A Doula and any other provider should always be chosen based on chemistry, knowledge and experience. Does their idea of birth match yours? ALL other factors should be taken off the table.
Tuesday, September 8, 2009
Wednesday, September 2, 2009
Monday, August 24, 2009
Report: CDC Considers Promoting 'Universal Circumcision'
In an effort to reduce the spread of HIV, public health officials are considering the promotion of “universal circumcision” for all baby boys born in the United States.
The move comes after officials analyzed the results of several studies that show in African countries hit hard by HIV, men who were circumcised reduced their infection risk by half, the New York Times reported. However, those studies focused on heterosexual men who are at risk of getting HIV from infected female partners. The main issue in the U.S. is men who have sex with men.
In 2008, the CDC estimated that more than 56,000 people were newly infected with HIV in 2006 (the most recent year that data are available). Over half of those new infections occurred in gay and bisexual men.
Click here for more facts on circumcision from the CDC.
Meanwhile, critics of the recommendation said it subjects newborn boys to “medically unnecessary” surgery without their consent.
But Dr. Peter Kilmarx, chief of epidemiology for the division of HIV/AIDS prevention at the CDC, told the Times that any step that could stop the spread of HIV must be given “serious consideration.”
“We have a significant HIV epidemic in this country, and we really need to look carefully at any potential intervention that could be another tool in the toolbox we use to address the epidemic,” Kilmarx told the newspaper. “What we’ve heard from our consultants is that there would be a benefit for infants from infant circumcision, and that the benefits outweigh the risks.”
An official draft of the proposed recommendations by the CDC is due out by the end of the year. In the meantime, the CDC is hosting its National HIV Prevention Conference in Atlanta this week.
Fact:
Clinical trials in Kenya, South Africa and Uganda found that heterosexual men who were circumcised were up to 60 percent less likely to become infected with H.I.V. over the course of the trials than those who were not circumcised.
Fact:
79 percent of adult American men are already circumcised
Fact:
The American Academy of Pediatrics is revising its guidelines, stating that circumcision has health benefits even beyond H.I.V. prevention, like reducing urinary tract infections for baby boys, said Dr. Michael Brady, a consultant to the American Academy of Pediatrics.
Fact:
Circumcision is believed to protect men from infection with H.I.V. because the mucosal tissue of the foreskin is more susceptible to H.I.V. and can be an entry portal for the virus. Observational studies have found that uncircumcised men have higher rates of other sexually transmitted diseases like herpes and syphilis, and a recent study in Baltimore found that heterosexual men were less likely to have become infected with H.I.V. from infected partners if they were circumcised.
Click here to read more from the New York Times.
Click here to read more about why Jews Circumcise from a religious perspective.
The move comes after officials analyzed the results of several studies that show in African countries hit hard by HIV, men who were circumcised reduced their infection risk by half, the New York Times reported. However, those studies focused on heterosexual men who are at risk of getting HIV from infected female partners. The main issue in the U.S. is men who have sex with men.
In 2008, the CDC estimated that more than 56,000 people were newly infected with HIV in 2006 (the most recent year that data are available). Over half of those new infections occurred in gay and bisexual men.
Click here for more facts on circumcision from the CDC.
Meanwhile, critics of the recommendation said it subjects newborn boys to “medically unnecessary” surgery without their consent.
But Dr. Peter Kilmarx, chief of epidemiology for the division of HIV/AIDS prevention at the CDC, told the Times that any step that could stop the spread of HIV must be given “serious consideration.”
“We have a significant HIV epidemic in this country, and we really need to look carefully at any potential intervention that could be another tool in the toolbox we use to address the epidemic,” Kilmarx told the newspaper. “What we’ve heard from our consultants is that there would be a benefit for infants from infant circumcision, and that the benefits outweigh the risks.”
An official draft of the proposed recommendations by the CDC is due out by the end of the year. In the meantime, the CDC is hosting its National HIV Prevention Conference in Atlanta this week.
Fact:
Clinical trials in Kenya, South Africa and Uganda found that heterosexual men who were circumcised were up to 60 percent less likely to become infected with H.I.V. over the course of the trials than those who were not circumcised.
Fact:
79 percent of adult American men are already circumcised
Fact:
The American Academy of Pediatrics is revising its guidelines, stating that circumcision has health benefits even beyond H.I.V. prevention, like reducing urinary tract infections for baby boys, said Dr. Michael Brady, a consultant to the American Academy of Pediatrics.
Fact:
Circumcision is believed to protect men from infection with H.I.V. because the mucosal tissue of the foreskin is more susceptible to H.I.V. and can be an entry portal for the virus. Observational studies have found that uncircumcised men have higher rates of other sexually transmitted diseases like herpes and syphilis, and a recent study in Baltimore found that heterosexual men were less likely to have become infected with H.I.V. from infected partners if they were circumcised.
Click here to read more from the New York Times.
Click here to read more about why Jews Circumcise from a religious perspective.
Monday, August 3, 2009
How To Pick Your Practitioner/Location For Delivery
I promised on this blog to push the envelop so I'll pull no punches on this topic.
Working in the birth community I've learned that most pregnant parents don't realize the importance of this subject until it's almost too late to do anything about it.
We as a society often spend more time researching the flat screen television we want to buy than the way we will give birth.
The history of birth in the United States is so varied over the last hundred year but most never realize this.
Every 20 years or so the "experts" decide upon a new way that is the correct way to birth. In the early part of the last century most babies were born at home. Today that information is manipulated to make homebirth sound archaic.
Homebirth's statistically have an incredibly lower c-section rate and have been shown to have no difference in infant mortality or the safety and life of the mother compared to hospital births.
But homebirth gets a bum rap. We have visions of mother's dying in childbirth or sick babies. But this could not be further from the truth.
In the begining of the last century the problem with medicine in general and with those who delivered babies was not the location but the doctors themselves. Hygiene caused a lot of infections. And today the problem is STILL the doctors themselves.
Obviously we've come very far with our understanding of germs, health, & proper cleanliness and birthing and delivering babies at home shows to statistically be safer with less c-sections.
Currently your chances of having a c-section nationally is 37.5%. The World Health Organization says that the c-section rate should not be more than 10%.
Ina May, who runs The Farm and has been a Midwife for about 38 years has a c-section rate around 2% for that entire period of time.
Women come to her location in Tennessee to experience a safe place to have an unmedicated labor and delivery. This is a great option for those who do not live close to a hospital but want a natural and unmedicated birth of their baby.
Home birth is not for everyone. There's a few main things to consider:
Your location
Your pain tolerance
Your partners support of this wish
To have a homebirth you must live in a state where this is legal. A midwife will be the practitioner to provide all your prental care and deliver your baby when the time comes.
The midwife will need to meet with you and get a full medical history to determine if you are a good candidate for homebirth. Medically, not every woman is a proper candidate. If you have high risk medical issues such as diabetes, high blood pressure or pre-eclampsia you're most likely going to be what we call "risked out".
However age is not a risk factor in home birth. Age is something you will hear from OB's as a risk factor however there is no medical evidence to support that tale.
Homebirth midwives come to your labor and delivery with everything that a hospital would need to provide in an emergency situation. Oxygen, Ambu bags, needles, syringes, pitocin, methergen, cytotec, lines for hydration etc..
It's important to note that another factor in the safety of homebirth is your location. Statistically emergencies that require some transfer of either the baby or the mother or both are very low, around 2%, however they do happen. So those who wish to achieve a homebirth should live in a city or metropolitan area.
Birthing Centers are the next best option for those who do not live close enough to have a homebirth. These locations are a place where women can come to receive care in a more natural-focused location outside the home. Again they provide all the necessities for resuscitating a baby or mother or to give medications to help stop hemmoraging and are close to a hospital in case an emergency transfer is necessary.
And then of course there are hospitals and OB's.
What baffles me is how these hosptials do their tours and sell their locations to the parents. Parents are told about the amazing rooms and luxuries they provide, such as the size of the beds, the televisions, the furniture and some even go as far as to tout the room service.
All of those things are fine and dandy, however, none of them address the standard of care, your wishes or the allowance of how you want your labor to proceed. You will be seen as a person on an assembly line. Because of the volume you will be pushed into timelines, and procedures that are just nonsense to make it easier for them to finish their work for the day. In short you are forced into the cookie cutter version of birth. And I can promise you, no matter what you are told, in the end, if your body doesn't respond to their clock, you're going to end up having a c-section.
More on hospital births in a post coming soon.
Working in the birth community I've learned that most pregnant parents don't realize the importance of this subject until it's almost too late to do anything about it.
We as a society often spend more time researching the flat screen television we want to buy than the way we will give birth.
The history of birth in the United States is so varied over the last hundred year but most never realize this.
Every 20 years or so the "experts" decide upon a new way that is the correct way to birth. In the early part of the last century most babies were born at home. Today that information is manipulated to make homebirth sound archaic.
Homebirth's statistically have an incredibly lower c-section rate and have been shown to have no difference in infant mortality or the safety and life of the mother compared to hospital births.
But homebirth gets a bum rap. We have visions of mother's dying in childbirth or sick babies. But this could not be further from the truth.
In the begining of the last century the problem with medicine in general and with those who delivered babies was not the location but the doctors themselves. Hygiene caused a lot of infections. And today the problem is STILL the doctors themselves.
Obviously we've come very far with our understanding of germs, health, & proper cleanliness and birthing and delivering babies at home shows to statistically be safer with less c-sections.
Currently your chances of having a c-section nationally is 37.5%. The World Health Organization says that the c-section rate should not be more than 10%.
Ina May, who runs The Farm and has been a Midwife for about 38 years has a c-section rate around 2% for that entire period of time.
Women come to her location in Tennessee to experience a safe place to have an unmedicated labor and delivery. This is a great option for those who do not live close to a hospital but want a natural and unmedicated birth of their baby.
Home birth is not for everyone. There's a few main things to consider:
Your location
Your pain tolerance
Your partners support of this wish
To have a homebirth you must live in a state where this is legal. A midwife will be the practitioner to provide all your prental care and deliver your baby when the time comes.
The midwife will need to meet with you and get a full medical history to determine if you are a good candidate for homebirth. Medically, not every woman is a proper candidate. If you have high risk medical issues such as diabetes, high blood pressure or pre-eclampsia you're most likely going to be what we call "risked out".
However age is not a risk factor in home birth. Age is something you will hear from OB's as a risk factor however there is no medical evidence to support that tale.
Homebirth midwives come to your labor and delivery with everything that a hospital would need to provide in an emergency situation. Oxygen, Ambu bags, needles, syringes, pitocin, methergen, cytotec, lines for hydration etc..
It's important to note that another factor in the safety of homebirth is your location. Statistically emergencies that require some transfer of either the baby or the mother or both are very low, around 2%, however they do happen. So those who wish to achieve a homebirth should live in a city or metropolitan area.
Birthing Centers are the next best option for those who do not live close enough to have a homebirth. These locations are a place where women can come to receive care in a more natural-focused location outside the home. Again they provide all the necessities for resuscitating a baby or mother or to give medications to help stop hemmoraging and are close to a hospital in case an emergency transfer is necessary.
And then of course there are hospitals and OB's.
What baffles me is how these hosptials do their tours and sell their locations to the parents. Parents are told about the amazing rooms and luxuries they provide, such as the size of the beds, the televisions, the furniture and some even go as far as to tout the room service.
All of those things are fine and dandy, however, none of them address the standard of care, your wishes or the allowance of how you want your labor to proceed. You will be seen as a person on an assembly line. Because of the volume you will be pushed into timelines, and procedures that are just nonsense to make it easier for them to finish their work for the day. In short you are forced into the cookie cutter version of birth. And I can promise you, no matter what you are told, in the end, if your body doesn't respond to their clock, you're going to end up having a c-section.
More on hospital births in a post coming soon.
Tuesday, July 14, 2009
Ask Ina May On July 27
http://ask.attachme ntparenting. org/2009/ 07...kin- on-july-27/
About Ina May Gaskin
Ina May Gaskin, MA, CPM, is founder and director of the Farm Midwifery Center, located near Summertown, Tennessee. Founded in 1971, by 1996, the Farm Midwifery Center had handled more than 2200 births, with remarkably good outcomes. Ms. Gaskin herself has attended more than 1200 births. She is author of Spiritual Midwifery and Ina May's Guide to Childbirth. For twenty-two years she published Birth Gazette, a quarterly covering health care, childbirth and midwifery issues. She has lectured all over the world at midwifery conferences and at medical schools, both to students and to faculty. She was President of Midwives' Alliance of North America from 1996 to 2002. In 1997, she received the ASPO/Lamaze Irwin Chabon Award and the Tennessee Perinatal Association Recognition Award. In 2003 she was chosen as Visiting Fellow of Morse College, Yale University.
Listen In: `"Special Delivery": The Gift of Loving Your Best Birth (and Making Peace with Plan B)' with Ina May Gaskin on July 27
Join us as we talk with Ina May Gaskin on API Live!
Register now and listen in as API Co-Founder and co-author of Attached at the Heart Barbara Nicholson and former NBC anchor Lu Hanessian discuss natural birthing with Ina May Gaskin. They will delve into:
* Knowing your body and your rights;
* How to have your baby with no regrets;
* What you won't hear in your birthing classes;
* Why we get stuck in the perfect portrait of birth and how it's not our true goal;
* Why things don't always turn out the way we wanted them to (and that's OK too);
* and MORE!
Submit your questions for Ina May to API Live (apilive@attachmentp arenting. org) in advance and we will try to address them during the call.
You can support API's mission and take advantage of the knowledge and experience Ask API Live's special guest by signing up today. Every dollar of your sign up fee goes toward education, support and outreach for parents in need. And don't worry about last minute conflicts–everyone who signs up will receive a link to download the MP3 the week after the event.
SIGN UP NOW!
After purchase, you will get an email with the dial-in details for this exciting edition of API Live. Within a few days of the call, you will get an email with the link to download the MP3.
API Members always attend at a special rate of only $9.
About Ina May Gaskin
Ina May Gaskin, MA, CPM, is founder and director of the Farm Midwifery Center, located near Summertown, Tennessee. Founded in 1971, by 1996, the Farm Midwifery Center had handled more than 2200 births, with remarkably good outcomes. Ms. Gaskin herself has attended more than 1200 births. She is author of Spiritual Midwifery and Ina May's Guide to Childbirth. For twenty-two years she published Birth Gazette, a quarterly covering health care, childbirth and midwifery issues. She has lectured all over the world at midwifery conferences and at medical schools, both to students and to faculty. She was President of Midwives' Alliance of North America from 1996 to 2002. In 1997, she received the ASPO/Lamaze Irwin Chabon Award and the Tennessee Perinatal Association Recognition Award. In 2003 she was chosen as Visiting Fellow of Morse College, Yale University.
Listen In: `"Special Delivery": The Gift of Loving Your Best Birth (and Making Peace with Plan B)' with Ina May Gaskin on July 27
Join us as we talk with Ina May Gaskin on API Live!
Register now and listen in as API Co-Founder and co-author of Attached at the Heart Barbara Nicholson and former NBC anchor Lu Hanessian discuss natural birthing with Ina May Gaskin. They will delve into:
* Knowing your body and your rights;
* How to have your baby with no regrets;
* What you won't hear in your birthing classes;
* Why we get stuck in the perfect portrait of birth and how it's not our true goal;
* Why things don't always turn out the way we wanted them to (and that's OK too);
* and MORE!
Submit your questions for Ina May to API Live (apilive@attachmentp arenting. org) in advance and we will try to address them during the call.
You can support API's mission and take advantage of the knowledge and experience Ask API Live's special guest by signing up today. Every dollar of your sign up fee goes toward education, support and outreach for parents in need. And don't worry about last minute conflicts–everyone who signs up will receive a link to download the MP3 the week after the event.
SIGN UP NOW!
After purchase, you will get an email with the dial-in details for this exciting edition of API Live. Within a few days of the call, you will get an email with the link to download the MP3.
API Members always attend at a special rate of only $9.
SOGC (Candadian OB's) Use Evidence-Based Medicine To Determine that Breech Is Not A Direct Route To C-Sections
http://www.scienceandsensibility.org/?p=239
Flip Flop: How we (or at least Canada) went to routine cesarean for breech and back again in the era of evidence-based medicine
June 18th, 2009 by Amy Romano
The media is reporting that the Society of Obstetricians and Gynaecologists of Canada (SOGC) no longer recommends routine cesarean when the baby is presenting breech at term. The new clinical practice guideline entitled "Vaginal Delivery of Breech Presentation" concludes that "vaginal delivery is reasonable in selected women with a term singleton breech fetus."
Automatic cesarean for breech has been the international standard of care since the results of the Term Breech Trial (TBT), a multicenter, randomized controlled trial of over 2,000 women that was designed to "give the option of vaginal breech delivery its best, and perhaps last, chance to be proven a reasonable method of delivery." That chance appeared to be dashed with the release of the trial's findings, which seemed to suggest that vaginal breech birth posed unacceptable risks to the baby. The results included:
combined stillbirth and neonatal mortality rate excluding lethal congenital abnormalities: 0.3% in the planned c-section group vs. 1.25% in the planned vaginal group
combined perinatal mortality and serious neonatal morbidity: 1.6% in the planned c-section group vs. 5.0% in the planned vaginal group
no differences in maternal mortality or morbidity between groups
There has not been another randomized controlled trial of term breech birth since the TBT. So in the absence of any new "Level 1 evidence," what explains SOGC's new endorsement of vaginal breech birth and their commitment to retrain their obstetric and midwifery workforce to ensure the option remains a safe one? The journey to routine cesarean and back provides an important lesson in the nuances of evidence-based medicine. Let's take a look at how the evidence has unfolded.
First, over the months and years following the trial's publication, a flurry of responses poured in from clinicians and researchers around the world, pointing to flaws and irregularities in the trial, suggesting that labor care in some of the trial hospitals was not optimal, and claiming a failure of adequate peer review by The Lancet, the journal that had fast-tracked it to publication. (These problems are summarized in Henci Goer's critique, When Research is Flawed: Planned Vaginal Birth versus Elective Cesarean for Breech Birth.) Cracks in the evidence were already appearing.
Then, after two years, the TBT research team tracked down the trial participants and reported long-term health outcomes. This new data revealed that almost all of the babies with severe morbidity after birth in both trial groups survived without any long-term neurological compromise, and differences in combined mortality and morbidity between the cesarean and vaginal groups had disappeared. The new SOGC Guidelines note:
With the limitations in the TBT, women had a 97% chance of having a neurologically normal two-year old, regardless of planned mode of birth. Those randomized to a trial of labour had a 6% absolute lower chance (or 30% relative risk reduction) of having a two-year-old child with unspecified medical problems, suggesting some lasting benefit of labour to the newborn immune system.
Meanwhile, several large non-randomized studies were released, consistently reporting excellent outcomes of planned vaginal breech birth. The largest, a prospective cohort study four times the size of the TBT, compared outcomes of planned vaginal birth versus elective cesarean for breech in 174 French and Belgian hospitals. There was no difference in perinatal mortality (0.08% vs. 0.15%) or serious neonatal morbidity (1.6% vs. 1.45%) between planned vaginal and planned cesarean birth. While not randomized, this robust and well designed study provided strong evidence that the risks of vaginal breech birth can be minimized in modern obstetrical units that adhere to rigorous practice standards for care in breech labor and birth.
The growing body of research set the stage for a new policy, but SOGC's change of heart was clearly also influenced by a vocal and persistent group of consumers and clinicians who pushed back against routine cesarean for breech. A few brave doctors and midwives saw the TBT results not as a dictum about whether breech vaginal birth is safe, but as an invitation to study how it could be made safer. They also recognized the ethical problems inherent in coercing women to accept the risks of surgery in exchange for little if any benefit to their infants, and lamented the hoops women must jump through to obtain a safe vaginal breech birth in the post-TBT era.
This story is still unfolding. We do not yet know if the change in guidelines will translate to a meaningful change in practice, or for that matter, whether we will see a similar guideline revision south-of-the-border. But I am heartened to see that we are moving forward from a rigid hierarchy of evidence, where randomized controlled trials - methodologically sound or otherwise - represent absolute truth and trump consumers' rights to informed consent and refusal. In this new era of health care quality improvement, views on the intersection of evidence-based practice and consumer preference are evolving. The story of the Term Breech Trial and its aftermath reminds us that even when the landmark clinical trial is done, there is still room for more and better research and grassroots advocacy to hone our understanding of optimal practice in maternity care and ensure access to options that are safe and satisfying.
Click on the extended post for a bibliography.
Goffinet, F., Carayol, M., Foidart, J. M., Alexander, S., Uzan, S., Subtil, D., et al. (2006). Is planned vaginal delivery for breech presentation at term still an option? results of an observational prospective survey in france and belgium. American Journal of Obstetrics and Gynecology, 194(4), 1002-1011.
Hannah, M. E., Hannah, W. J., Hewson, S. A., Hodnett, E. D., Saigal, S., & Willan, A. R. (2000). Planned caesarean section versus planned vaginal birth for breech presentation at term: A randomised multicentre trial. term breech trial collaborative group. Lancet, 356(9239), 1375-1383.
Hodnett, E. D., Hannah, M. E., Hewson, S., Whyte, H., Amankwah, K., Cheng, M., et al. (2005). Mothers' views of their childbirth experiences 2 years after planned caesarean versus planned vaginal birth for breech presentation at term, in the international randomized term breech trial. Journal of Obstetrics and Gynaecology Canada, 27(3), 224-231.
Kotaska, A. (2004). Inappropriate use of randomised trials to evaluate complex phenomena: Case study of vaginal breech delivery. BMJ (Clinical Research Ed.), 329(7473), 1039-1042.
Whyte, H., Hannah, M. E., Saigal, S., Hannah, W. J., Hewson, S., Amankwah, K., et al. (2004). Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: The international randomized term breech trial. American Journal of Obstetrics and Gynecology, 191(3), 864-871.
Flip Flop: How we (or at least Canada) went to routine cesarean for breech and back again in the era of evidence-based medicine
June 18th, 2009 by Amy Romano
The media is reporting that the Society of Obstetricians and Gynaecologists of Canada (SOGC) no longer recommends routine cesarean when the baby is presenting breech at term. The new clinical practice guideline entitled "Vaginal Delivery of Breech Presentation" concludes that "vaginal delivery is reasonable in selected women with a term singleton breech fetus."
Automatic cesarean for breech has been the international standard of care since the results of the Term Breech Trial (TBT), a multicenter, randomized controlled trial of over 2,000 women that was designed to "give the option of vaginal breech delivery its best, and perhaps last, chance to be proven a reasonable method of delivery." That chance appeared to be dashed with the release of the trial's findings, which seemed to suggest that vaginal breech birth posed unacceptable risks to the baby. The results included:
combined stillbirth and neonatal mortality rate excluding lethal congenital abnormalities: 0.3% in the planned c-section group vs. 1.25% in the planned vaginal group
combined perinatal mortality and serious neonatal morbidity: 1.6% in the planned c-section group vs. 5.0% in the planned vaginal group
no differences in maternal mortality or morbidity between groups
There has not been another randomized controlled trial of term breech birth since the TBT. So in the absence of any new "Level 1 evidence," what explains SOGC's new endorsement of vaginal breech birth and their commitment to retrain their obstetric and midwifery workforce to ensure the option remains a safe one? The journey to routine cesarean and back provides an important lesson in the nuances of evidence-based medicine. Let's take a look at how the evidence has unfolded.
First, over the months and years following the trial's publication, a flurry of responses poured in from clinicians and researchers around the world, pointing to flaws and irregularities in the trial, suggesting that labor care in some of the trial hospitals was not optimal, and claiming a failure of adequate peer review by The Lancet, the journal that had fast-tracked it to publication. (These problems are summarized in Henci Goer's critique, When Research is Flawed: Planned Vaginal Birth versus Elective Cesarean for Breech Birth.) Cracks in the evidence were already appearing.
Then, after two years, the TBT research team tracked down the trial participants and reported long-term health outcomes. This new data revealed that almost all of the babies with severe morbidity after birth in both trial groups survived without any long-term neurological compromise, and differences in combined mortality and morbidity between the cesarean and vaginal groups had disappeared. The new SOGC Guidelines note:
With the limitations in the TBT, women had a 97% chance of having a neurologically normal two-year old, regardless of planned mode of birth. Those randomized to a trial of labour had a 6% absolute lower chance (or 30% relative risk reduction) of having a two-year-old child with unspecified medical problems, suggesting some lasting benefit of labour to the newborn immune system.
Meanwhile, several large non-randomized studies were released, consistently reporting excellent outcomes of planned vaginal breech birth. The largest, a prospective cohort study four times the size of the TBT, compared outcomes of planned vaginal birth versus elective cesarean for breech in 174 French and Belgian hospitals. There was no difference in perinatal mortality (0.08% vs. 0.15%) or serious neonatal morbidity (1.6% vs. 1.45%) between planned vaginal and planned cesarean birth. While not randomized, this robust and well designed study provided strong evidence that the risks of vaginal breech birth can be minimized in modern obstetrical units that adhere to rigorous practice standards for care in breech labor and birth.
The growing body of research set the stage for a new policy, but SOGC's change of heart was clearly also influenced by a vocal and persistent group of consumers and clinicians who pushed back against routine cesarean for breech. A few brave doctors and midwives saw the TBT results not as a dictum about whether breech vaginal birth is safe, but as an invitation to study how it could be made safer. They also recognized the ethical problems inherent in coercing women to accept the risks of surgery in exchange for little if any benefit to their infants, and lamented the hoops women must jump through to obtain a safe vaginal breech birth in the post-TBT era.
This story is still unfolding. We do not yet know if the change in guidelines will translate to a meaningful change in practice, or for that matter, whether we will see a similar guideline revision south-of-the-border. But I am heartened to see that we are moving forward from a rigid hierarchy of evidence, where randomized controlled trials - methodologically sound or otherwise - represent absolute truth and trump consumers' rights to informed consent and refusal. In this new era of health care quality improvement, views on the intersection of evidence-based practice and consumer preference are evolving. The story of the Term Breech Trial and its aftermath reminds us that even when the landmark clinical trial is done, there is still room for more and better research and grassroots advocacy to hone our understanding of optimal practice in maternity care and ensure access to options that are safe and satisfying.
Click on the extended post for a bibliography.
Goffinet, F., Carayol, M., Foidart, J. M., Alexander, S., Uzan, S., Subtil, D., et al. (2006). Is planned vaginal delivery for breech presentation at term still an option? results of an observational prospective survey in france and belgium. American Journal of Obstetrics and Gynecology, 194(4), 1002-1011.
Hannah, M. E., Hannah, W. J., Hewson, S. A., Hodnett, E. D., Saigal, S., & Willan, A. R. (2000). Planned caesarean section versus planned vaginal birth for breech presentation at term: A randomised multicentre trial. term breech trial collaborative group. Lancet, 356(9239), 1375-1383.
Hodnett, E. D., Hannah, M. E., Hewson, S., Whyte, H., Amankwah, K., Cheng, M., et al. (2005). Mothers' views of their childbirth experiences 2 years after planned caesarean versus planned vaginal birth for breech presentation at term, in the international randomized term breech trial. Journal of Obstetrics and Gynaecology Canada, 27(3), 224-231.
Kotaska, A. (2004). Inappropriate use of randomised trials to evaluate complex phenomena: Case study of vaginal breech delivery. BMJ (Clinical Research Ed.), 329(7473), 1039-1042.
Whyte, H., Hannah, M. E., Saigal, S., Hannah, W. J., Hewson, S., Amankwah, K., et al. (2004). Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: The international randomized term breech trial. American Journal of Obstetrics and Gynecology, 191(3), 864-871.
Friday, July 10, 2009
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