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.
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Tuesday, July 14, 2009
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
Tuesday, July 7, 2009
Outcomes of planned home births with certified professional midwives: large prospective study in North America
See full paper/study here.
Highlights from this study below.
Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.
We focused on the 5418 women who intended to deliver at home at the start of labour. Table 1 compares them with all women who gave birth to singleton, vertex babies of at least 37 weeks or more gestation in the United States in 2000 according to 13 personal and behavioural variables associated with perinatal risk. Women who started birth at home were on average older, of a lower socioeconomic status and higher educational achievement, and less likely to be African-American or Hispanic than women having full gestation, vertex, singleton hospital births in the United States in 2000.
Individual rates of medical intervention for home births were consistently less than half those in hospital, whether compared with a relatively low risk group (singleton, vertex, 37 weeks or more gestation) that will have a small percentage of higher risk births or the general population having hospital births (table 3). Compared with the relatively low risk hospital group, intended home births were associated with lower rates of electronic fetal monitoring (9.6% versus 84.3%), episiotomy (2.1% versus 33.0%), caesarean section (3.7% versus 19.0%), and vacuum extraction (0.6% versus 5.5%). The caesarean rate for intended home births was 8.3% among primiparous women and 1.6% among multiparous women.
Our study has several strengths. Internationally it is one of the few, and the largest, prospective studies of home birth, allowing for relatively stable estimates of risk from intrapartum and neonatal mortality. We accurately identified births planned at home at the start of labour and included independent verification of birth outcomes for a sample of 534 planned home births. We obtained data from almost 400 midwives from across the continent.
As with the prospective US national birth centre study19 and the prospective US home birth study,23 the main study limitation was the inability to develop a workable design from which to collect a national prospective low risk group of hospital births to compare morbidity and mortality directly. Forms for vital statistics do not reliably collect the information on medical risk factors required to create a retrospective hospital birth group of precisely comparable low risk,38-40 and hospital discharge summary records for all births are not nationally accessible for sampling and have some limitations, being primarily administrative records.
One exception, and an important adjunct to our study, was Schlenzka's study in California.22 In this PhD thesis, Schlenzka was able to establish a large defined retrospective cohort of planned home and hospital births with similar low risk profiles, because birth and death certificates in California include intended place of birth and these had been linked to hospital discharge abstracts for 1989-90 for a caesarean section study. When the author compared 3385 planned home births with 806 402 low risk hospital births, he consistently found a non-significantly lower perinatal mortality in the home birth group. The results were consistent regardless of liberal or more restrictive criteria to define low risk, and whether or not the analysis involved simple standardisation of rates or extensive adjustment for all potential risk variables collected.22
Highlights from this study below.
Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.
We focused on the 5418 women who intended to deliver at home at the start of labour. Table 1 compares them with all women who gave birth to singleton, vertex babies of at least 37 weeks or more gestation in the United States in 2000 according to 13 personal and behavioural variables associated with perinatal risk. Women who started birth at home were on average older, of a lower socioeconomic status and higher educational achievement, and less likely to be African-American or Hispanic than women having full gestation, vertex, singleton hospital births in the United States in 2000.
Individual rates of medical intervention for home births were consistently less than half those in hospital, whether compared with a relatively low risk group (singleton, vertex, 37 weeks or more gestation) that will have a small percentage of higher risk births or the general population having hospital births (table 3). Compared with the relatively low risk hospital group, intended home births were associated with lower rates of electronic fetal monitoring (9.6% versus 84.3%), episiotomy (2.1% versus 33.0%), caesarean section (3.7% versus 19.0%), and vacuum extraction (0.6% versus 5.5%). The caesarean rate for intended home births was 8.3% among primiparous women and 1.6% among multiparous women.
Our study has several strengths. Internationally it is one of the few, and the largest, prospective studies of home birth, allowing for relatively stable estimates of risk from intrapartum and neonatal mortality. We accurately identified births planned at home at the start of labour and included independent verification of birth outcomes for a sample of 534 planned home births. We obtained data from almost 400 midwives from across the continent.
As with the prospective US national birth centre study19 and the prospective US home birth study,23 the main study limitation was the inability to develop a workable design from which to collect a national prospective low risk group of hospital births to compare morbidity and mortality directly. Forms for vital statistics do not reliably collect the information on medical risk factors required to create a retrospective hospital birth group of precisely comparable low risk,38-40 and hospital discharge summary records for all births are not nationally accessible for sampling and have some limitations, being primarily administrative records.
One exception, and an important adjunct to our study, was Schlenzka's study in California.22 In this PhD thesis, Schlenzka was able to establish a large defined retrospective cohort of planned home and hospital births with similar low risk profiles, because birth and death certificates in California include intended place of birth and these had been linked to hospital discharge abstracts for 1989-90 for a caesarean section study. When the author compared 3385 planned home births with 806 402 low risk hospital births, he consistently found a non-significantly lower perinatal mortality in the home birth group. The results were consistent regardless of liberal or more restrictive criteria to define low risk, and whether or not the analysis involved simple standardisation of rates or extensive adjustment for all potential risk variables collected.22
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