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Rapid Responses: Rapid Responses published:
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Home delivery and perinatal mortality
- D J R Hutchon (10 August 1998)
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Are Home Births justified in Australia?
- Peter John Sullivan (11 August 1998)
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Relocated home birth - a middle way between automatic CS and inappropriate domiciliary delivery
- Faith Gibson (18 August 1998)
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A view from Britain
- Anne Viccars (19 August 1998)
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How does study bias affect these perinatal mortality rates
- Sally Tracy (1 September 1998)
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Re: How does study bias affect these perinatal mortality rates
- Paul Duff (4 February 1999)
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D J R Hutchon, Consultant Obstetrician & Gynaecologist Memorial Hospital, Darlington.
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Comments: > Re Perinatal death associated with planned home birth in Australia: population based study > Hilda Bastian, Marc J N C Keirse, Paul A L Lancaster, BMJ 1998;317:384-388 > > Bastian et al have shown the importance of audit of in maternity care to highlight adverse outcomes. The quality and relevance of antenatal care is important in the outcome of pregnancy and the choice of place of delivery is > likely to dictate the type of antenatal care given. Good antenatal care should anticipate problems and activate timely transfer. Almost half of the stillbirths in their population based study were already dead before transfer > had been effected, which shows that the transfer was too late. This alone emphasises the importance of timely referral. With the concept of proportional audit of perinatal mortality, which I introduced in 1996 responsibility > for outcome is appropriately shared between the groups of carer when transfer takes place. When transfer is timely it seems unfair to attribute an unfavourable outcome to only one care facility. This encourages the timely > transfer of care when problems are anticipated and provides a fair and helpful analysi! > s of the morbidity and mortality which is associated with each form of care. > David J R Hutchon > Consultant Obstetrician, Memorial Hospital, Darlington. > Hutchon D J R A method of proportional audit of perinatal care. Br J O G 1996:103;402-4 |
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Peter John Sullivan, Consultant Obstetrician and Gynaecologist Jerudong park Medical Centre
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Dear Sir, I have been criticising the role of home- births in Queensland for the last two years, as Chairman of the Qld. State Committe of the RACOG, and have been even severely misquoted in the International Journal of Midwifery. In Queensland, a Registered Midwife can (and they do) go into "Independent Midwifery" practice after the basic 12 months training and 20 normal deliveries. Although the College of Midwives has rigid criteria, they are neither enforced nor policed. No-one mentions maternal mortality or morbidity. In a two-year period in Queensland, I recieved reports of one maternal death (a second admitted to me by the Qld. State President of the Aust. College of Midwives), and one near maternal death requiring hysterectomy and dialysis for three weeks.During the same period, I documented eight perinatal deaths(to my personal knowledge) out of a total of 400 deliveries by home- birth. I was assured that the two maternal deaths were amniotic fluid emboli, so would have been unavoidable even in Hospital, although I have no records of post-mortems to prove this. In conclusion, I do not believe that home- births are justified at present in Queensland, or most parts of Australia, due to inadequate controls, training, supervision, policing, and the immense geographical distances involved. In a trial of birthing at an Aboriginal homeland called Cherbourg, there were 4 perinatal deaths out of 80 deliveries, a figure which I regard as unacceptable. Queensland also suffers from home-birth practitioners who have no insight into their own limitations or what is termed low-risk, accepting women with twins(to deliver in the mountains, and who required helicopter evacuation), previous Caesarean Section, and Anti-D Antibodies! Until the training of domiciliary Midwives in Australia reaches the standards of the U.K. and holland, for example, and until these "Independent Midwives" are properly policed, and until we have adequate back-up for these people, then home-births are certainly unsafe in Queensland, and, probably,Australia. Yours sincerely, Peter Sullivan. |
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Faith Gibson, Independent midwife domicilairy birth services
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This article functions as an excellent *first step* in a chain of inquiry but is insufficient as the final conclusion/solution to the controversy about domiciliary services for mothers with “compounded” risk factors. It is unacceptable for research-based recommendations to simply identify and extrapolate from the obvious -- that additional risk factors yield additional mortality and morbidity -- without completing the equation and determining if the apparently “common sense” response (i.e., routine hospitalization and operative termination of pregnancy) is in fact a solution or merely the critical first step in risk-shifting from the present fetus to its mother and to both mother and fetus in future pregnancies. As a domiciliary midwife I personally believe that compounded-risk labors are best managed in the hospital as “relocated home births” (a term from the 1983 Koosterman List for domicilairy midwives in Holland). But as acknowledged, the reality in most countries is not a hospital-managed labor under the collaborative care of a midwife and physician but an “automatic” CS. It is this situation which is fueling the “all bets are off” mood among parents and midwives in regard to home-based maternity services, unwise as it may ultimately prove to be. Obviously, either response is a two edged sword and speaks for a more appropriate remedy. It was eloquently stated by an American doctor (Bruce Flamm) in the title of his article: “Once a Cesarean, Aways a Controversy” and I might add, always an increased risk. According to an advertisement in the Ob-Gyn News, a cesarean is performed is every 39 seconds in the USA. Maternal mortality attributable to CS delivery is thought to be between 1 per 1000 (Gabbe’s ob text, p. 668 ) to 31 per 100,000 (Liliford et al ) compared to 1:16,666 (ibid) for all vaginal births. When one factors in a uterine rupture rate of 1: 200 in subsequent pregnancies/TOL, then routinely performing CS for compounded risk factors such as breech, twins or macrosomia appears to be a problem rather than a solution, at least when viewed from the perspective of the childbearing woman and her family. The next phase of inquiry needs to be a correlation of hospital-managed births in term pregnancies with compounded risk factors (twins, breech, post-dates, and EFW over 4500 grams.) to determine the over-all level of perinatal AND maternal morbidity and mortality in both the original birth AND its long term sequela in subsequent pregnancies. I am a mother and grandmother whose own daughter had a CS because no one at the hospital knew how to deliver breeches and a midwife who must deal with this professionally. In that capacity, I am asking the medical profession to please help us acquire and utilize evidenced-based research on this topic so that childbearing families and midwives are not tempted to push the envelope at home when all involved would be better served by the simple remedy of a “relocated home birth” in the hospital co-managed with a midwife and a “mother-friendly” physician. Only in this way can we guarantee that mothers will have the option of a safe vaginal birth rather than being forced to choose between a mandatory CS or a possibly inappropriate home birth. faith gibson, Licensed Community Midwife, California, USA |
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Anne Viccars
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I would like to comment on the information presented.
Firstly, the introduction cites the leaflets by MIDIRS/NHS Centre for Dissemination and Reviews as not specifying any contraindication to homebirth, which may be misleading to the reader as the professional leaflet states: "For women with serious complications, the effects of which could be ameliorated by birth in hospital, birth in a consultant unit should be strongly advised". and "…. women who might be encouraged to consider home birth as an option could include those with no complications…" p 8. Furthermore, the leaflet suggests that women need to receive information about which complications they or their babies have an increased risk of developing. The woman's leaflet states that "there's no evidence that hospital births are safer for all women and all babies, as long as there are no serious complications during pregnancy" Although the research findings are of concern, the study is specific to Australia and does acknowledge some of the problems with care for pregnant women, i.e. their lack of choices within hospital often leading them to find an independent carer. It must also be recognised that to care for women in Australia, as the authors acknowledge it is not necessary to be a Registered Midwife, and there is no professional governing body such as the UKCC which oversees professional practice. The data collection methods were uncorroborated: although most of the information was collected from birth notifications, data from 576 births (8%) came from home birth support group newsletters. How accurate was this data and should it have been included? It would have been useful if the authors had identified the births from "other sources". Were the birth notifications collected by, the consumers' association: Homebirth Australia cross-checked with any government or national statistics? How accurate was the annual summary of births attended by practitioners who did not submit these forms at the time of birth? I think that these questions must be answered before these findings can be relied upon. It is clear that women who wish to have a home birth must be given the information to ensure that they can make an informed decision about whether to deliver there or go into hospital. Midwives and other health professionals in the UK must continue to put the safety of the mother and baby first so that the deaths, which occurred in Australia, are not repeated here. For example, the delivery of twins, preterm infants and breech presentations should take place in hospital. Midwives must be vigilant about identifying complications during labour and ensure that women are transferred at the earliest opportunity if problems occur. Anne Viccars Midwifery Manager MIDIRS Refs MIDIRS/The NHS Centre for Reviews and Dissemination (1997) Where will you have your baby? Bristol: MIDIRS MIDIRS/The NHS Centre for Reviews and Dissemination (1997) Place of birth. Bristol: MIDIRS |
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Sally Tracy, independent research midwife Glenbrook, Sydney, Australia
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This research has the potential to influence the practice of home birth in Australia, but there are several issues to address before the findings should be adopted. The first concerns the likelihood of bias corrupting the study findings, and the second concerns the methodology of the study. This retrospective analysis lends itself to two obvious issues of bias. The first, where the author knows what information to look for and therefore unwittingly finds only the information which fits the hypothesis; and the second, when the researcher is classifying a cause of death and the underlying pathology may not be documented or searched for, again unwittingly allowing the authors argument to be strengthened in a certain direction. A 'national consumers' association register was used to obtain the data on births for this study. There is no suggestion of 'blind' data collection, or corroboration of this data. The nature and extent of the data, what percentage of births and deaths are reported and to whom, is unknown. The number of states who supplied perinatal data sets for the years 1989-1990, and whether the non participants for the Homebirth Australia register complied with these data collections is also not known. Given the paucity of the data available one has to suspect the observed rates are not genuine due to incomplete data. Study results indicate that "50 perinatal deaths occurred in 7002 planned homebirths" and that 11 deaths were excluded for reasons not fully stated. Thereafter in the report the authors still refer to 50 deaths and it is not clear whether there were in fact 61 deaths or the minimum data available on 39. Birthweight specific data was available for the years 1985-88 (Table 4.). Why was the rate calculated for the five year period with the number of births 7002? The numerator is unstated and the denominator remains 7002 (all the births regardless of birthweight). It would seem that the mortality rate which adversely results in a higher mortality rate for homebirths was for birthweight specific perinatal deaths and these were calculated without : a) the necessary criteria at hand (birthweight specific data), b) the number of known births as the denominator. The paper does not reference the source for national figures on birthweight specific perinatal mortality rates, nor for which years the data was available. Surely gestational age and cause of death can not be ascertained with any certainty through retrospective case analysis without confirmation from a post mortem conducted by an experienced perinatal pathologist. What percentage of the intrapartum fetal deaths (% of all deaths, and of stillbirths Table 4.) might otherwise have been described as inevitable spontaneous abortions? Is it justifiable to compare perinatal mortality rates internationally? For example the baseline measurement for a fetal death in Australia is 20 weeks, the UK 24 weeks, Norway 16 weeks and New Zealand until recently was 28 weeks. The political, educational and social determinants for homebirth differ very widely between the countries compared and Australia, as do the exclusion criteria and the discrepancies in collecting study data. The authors do not give evidence to suggest a link between late neonatal deaths and homebirth. The five late neonatal deaths (Table 3.) include death from post-viral cardiomyopathy, chromosomal abnormality and SIDS. We believe the definitions of late neonatal death and Sudden Infant Death Syndrome to be mutually exclusive. The paper concludes by saying "the two largest contributors to the excess mortality were underestimation of the risks associated with post-term birth, twin pregnancy and breech presentation and a lack of response to fetal distress". To ascertain the cause of death requires more than newsletter reports and summaries. In a study where the unknowns include basic birthweight specific data for a large number of the sample there has to be a certain amount of conjecture in ascertaining not only the cause of death, but the underlying reason for the death. It is also questionable whether the authors are in a position to make estimates of severity of risk, and whether or not response to fetal distress was adequate given the paucity of data. Risks associated with twin births are possibly five times higher than in singleton births, regardless of carer, but without the knowledge of how many twin pregnancies the study observed, neither the rate of twins in the national data set, it is impossible to say whether the higher mortality rate amongst twins reflected those observed in the general population. No attempt is made to compare twin births/deaths with hospital data. There are several other issues which arise out of this research paper. Where it is reported that 13 of the 31 stillbirths were born in hospital after transfer of the mother in labour, is it possible that the mothers had been reasonably transferred at the onset of labour to deliver not at home, but in hospital? The authors say they used only data from 'planned home births' but then identified preterm births in their sample. Surely, these were not planned? Was ethical approval sought to use the newsletters and summaries collected; and similarly was consent obtained from both women and practitioners involved? The area of debate as to the relevance of meconium stained liquor as a recognisable risk factor for intrapartum asphyxia is vigorous and not conclusive at this stage. How should a paper like this inform the debate around home birth? Should researchers attempt to draw authoritative conclusions with regard to shortcomings in perinatal care, risk assessment, rates and birth asphyxia, cause and time of death in a study such as this. The method with which the study has been undertaken may in fact undermine more open and genuine attempts to inform practice and decision making in the area of maternity care in Australia. |
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Paul Duff, GP Bright, Victoria, Australia
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Sally Tracy seeks to criticise a study which was partly funded by Homebirth Australia and which sought data from the very practitioners which she seeks to defend. You can't get much more prospective than that! The fact that the authors had to get data from newsletters and Governments is more an indictment of the practitioners than a deficiency in the study. Furthermore, the decrease in the number of participants in the last two years of the study suggests, to the cycnical observer, that they may have pulled out to save further embarassment or worse still, censure. I am a GP in a four-doctor practice which has conducted some 300 deliveries, over the past 8 years, in co-operation with capable midwives in a small country hospital . We do not electively manage breech, twins or pre-term pregnancies - these are transferred to the care of the nearest obstetrician - and we have a perinatal mortality of zero. Readers may interpret these figures as they see fit. |
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