Saturday, February 6, 2010

Do midwives ignore science?

This week I was interviewed by the producer of Channel 7's Today Tonight program. The questions were about the safety of homebirth, in response to the paper published recently in the Medical Journal of Austraila, 'Planned home and hospital births in SA, 1991-2006: differences in outcomes'.

For more detail about this publication, and links, go to the MiPP blog.

This is important topic, and I am pleased to be asked to comment.

The producer quizzed me several times about safety.
How can I, a (mere) midwife, disagree with the conclusions published in a scientific journal?
Didn't I know that doctors go to university for 8 or more years?
Didn't I know that animals die out there in the wild?

I pointed out that no matter how educated they are, doctors don't practise midwifery.   Midwives do.  

I hope I answered in a useful way, and I hope the little part of the recording that ever reaches the television screen will be true and helpful. When I reflected on the questions later in the day, I wondered if the producer knows about statistics: that they can be manipulated and used to deceive. 

The paper, written by leading epidemiologists in South Australia, makes claims that perinatal death and particularly death from asphyxia are more likely to happen in the group of planned home births - those babies whose mothers planned to give birth at home - compared with those babies whose mothers planned to give birth in the hospital. I do not question their findings. 

It's the conclusions that are drawn that I question. 

Note the emphasis on 'planned' home births. These are not actual home births. Many of these deaths happened in hospital despite the interventions and monitoring carried out in the hospital.

Does anyone turn the spotlight in the same way on the outcomes for women who planned to give birth in the big private hospital in Melbourne, known in the trade as 'Caesar's Palace'?  Of course not.  That would be bad for business. 

The authors themselves have given enough information that a fair minded person using the intra-occular statistical test (it hits you between the eyes) would conclude that there is a great deal of safety in the planned homebirth model of care.  In the body of the paper, the authors state that "in the 16-year study period there were only three perinatal deaths for which one can reasonably assume that a different choice of care provider, location of birth, or timing of transfer to hospital might have made a difference to the outcome." (p79)  An amazingly significant statement.  Just think about it!

The focus that this paper, and indeed the focus our society places on 'planned' place of birth places an unrealistic, and in my opinion, undue emphasis on the planned setting for birth. Noone can predict outcomes, regardless of the model of care.

The best standard of care available for any well woman with an uncomplicated pregnancy is primary care from a known and trusted midwife, who has the skill to work in harmony with natural processes in birth, and who is able to move seamlessly from home to hospital if required. The woman is able to come into labour spontaneously, to progress without undue interruption or interference, and to make decisions about obtaining medical/hospital referral if the need arises.

The paper appears to trivialise the outcomes for women who want to give birth vaginally after a previous caesarean, stating in the Discussion that "several women accepted for home birth also had previous caesarean sections." (p79) Elsewhere in the same paper it is stated that "From 1998-2006, 56 of 635 women (8.8%) with a previous caesarean section planned a home birth, of whom 32 (57%) gave birth at home." (p77) That's a few more than "several"!
There is no evidence given of poor outcomes for these women, yet women who have had a previous caesarean birth are amongst those considered to have risk factors which some would consider require the greater fetal surveillance that is practised for births after caesarean in hospital. The State government's Policy for Planned Home Birth in South Australia, which is used in government funded homebirth programs, does not permit women who have had a previous caesarean to plan home birth:
6.4 The following conditions preclude a woman giving birth at home.
Obstetric history—previous:
�� caesarean section;" (p7)

I, and my midwifery colleagues, do not lightly discount a paper such as this one.  Our first concern is the wellbeing and safety of mother and baby.  I find that midwives and homebirth mothers/parents are very cognisant of the scientific literature. A retrospective study such as the SA one must be understood in context of its own limitations, and put next to other reliable sources of information.

In fact the SA study gives considerable evidence of the safety of home birth for those who actually give birth at home, in the care of a midwife.

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