Archives for posts with tag: Cochrane Collaboration

In February, the New York Times ran six short pieces on home birth in its “Room for Debate” online feature.  I am going to discuss each of the pieces in posts over the next few days.

One of the featured pieces is titled “Home Birth is Not Safe,” written by two doctors who have made a number of anti-home-birth contributions to the medical literature.  Their NYT bio line says,

Amos Grunebaum is the director of obstetrics and Frank Chervenak is the obstetrician and gynecologist-in-chief at New York-Presbyterian Hospital, Weill Medical College of Cornell University.

Their work brings up a number of interesting issues to consider about home birth safety, but they also appear to conduct their research with an anti-home-birth agenda–Chervenak has written articles stating that it is unethical for MDs to participate in home births in any way and that it is the professional responsibility of all health workers to forcefully persuade women to birth in hospitals.  All birth data in the United States has limits, but Grunebaum and Chervenak’s use of vital records data to draw sweeping conclusions about home birth outcomes has been broadly criticized (e.g. here, here, and here).

Grunebaum and Chervenak say,

[i]n our research we have found that in the United States at least 30 percent of home births are not low-risk and that two thirds of home births are delivered by midwives who are not properly credentialed.

While I have argued that a woman has the right to birth wherever she chooses, regardless of risk, one might ask why a woman at high risk would choose to give birth at home when she has a hospital as an alternative.  Some women may be compelled to do so for religious reasons (and may not have full control of their choices), but it is also true that some well-educated, well-informed women also make the choice to have high-risk births at home.

Grunebaum and Chervenak acknowledge some of the problems with hospital-based obstetrical care that drive women to seek out home births even when their medical profiles indicate that they may need the kinds of medical interventions that are only available in a hospital-based setting.  They particularly note high numbers of “unnecessary C-sections” and lack of “compassionate care” in hospital births.

They propose as a solution that “the profession [of obstetrics] should strive for home-like hospital births.”

We know from his bio that Chervenak is in charge of the obstetrics unit at NY Presbyterian-Weill Cornell Medical College (NYP-WC).  If women are to shun home birth in favor of hospital birth, a good hospital environment must already be in place.  Let’s take a look at what he and his colleagues are doing to reduce unnecessary C-sections, provide compassionate care, and strive for home-like settings.

New York state now requires hospitals to report certain data, including C-section rates.  NYP-WC’s is 31.6%, a smidge below the national average, but hardly indicative of a culture that is eschewing unnecessary C-sections.  For the last year reported, there were only 38 VBACS at NYP-WC.

NYP-WC’s episiotomy rate is a whopping 25.7%.  Episiotomy is rarely necessary, and this rate is far, far above the home birth rate of under 2%.  According to a 2005 JAMA review by Katherine Hartmann and her colleagues, a national episiotomy rate of less than 15% should be “immediately within reach”–10 years later, NYP-WC is not on board, even though the national rate was already close to 15% by 2010.  Nearby Bellevue Hospital has a rate around 2%.   Compassionate care should not include cutting gashes in women’s vaginas for no reason.

Planned home births are generally attended by midwives.  Both certified professional midwives (who cannot attend hospital births) and certified nurse midwives (who most commonly work in hospitals) subscribe to “The Midwives Model of Care.”  The American College of Nurse Midwives summarizes this philosophy of care on its website–some notable components include:

  • Complete and accurate information to make informed health care decisions
  • Self-determination and active participation in health care decisions
  • Acknowledg[ing] a person’s life experiences and knowledge
  • […] therapeutic use of human presence and skillful communication
  • Watchful waiting and non-intervention in normal processes
  • Appropriate use of interventions and technology for current or potential health problems

Grunebaum and Chervenak brag that “we have a midwife teach our residents at NewYork-Presbyterian.”  However, they do not employ midwives to attend births.  Zero births at NYP-WC are attended by a midwife.  In addition, because they are a teaching hospital, NYP-WC has many births attended by residents whom the woman may not even know.  No one invites complete strangers into their home to attend their births.  Most women who have home births are seeking the Midwives Model of Care, but though Grunebaum and Chervenak acknowledge that CNMs can safely attend hospital births, they choose not to offer this option.

The hospital’s maternity unit has a “Patient and Visitor Guide: During Your Stay” that lays out standard processes and procedures on the unit, gives prospective patients an overview of what to expect, and lays out hospital and maternity unit policies.

The guide begins by saying that the hospital offers “Family Centered Care,” though what this means is not explained other than to say that rooming-in with the baby is encouraged.

They proceed to say that the woman’s care team may involve “your attending obstetrician, who is often your personal obstetrician or the doctor who admitted you, …[and] other medical or surgical specialists, as well as fellows or residents…[and] a pediatrician.”  But that’s just the doctors!  They say that the nursing staff is “constantly present” and indicate that there will be many nurses involved in care.  Other people involved in the hospital birth experience are care coordinators, unit clerks, physician assistants, lactation consultants, social workers, dieticians, nutrition assistants, housekeepers, patient escorts, and volunteers.  There is also a Rapid Response Team for emergencies.

I don’t know about you, but I’m not sure that many people could fit in my house.

The Labor and Delivery Unit is described as “comfortable, family-friendly, [and] private with soothing natural light.”  The birthing rooms are

spacious and light-filled birthing rooms [that] combine comfort with leading-edge technology. All suites are private and equipped with a special multi-positioned birthing bed, as well as state-of-the-art equipment for monitoring and delivering your baby. Your progress will be monitored regularly throughout labor, and your nurses will help you explore which comfort measures work best for you.

My home has a queen sized bed.  The most leading-edge technology in it is my iPhone.

Then we move on to pain management, and the real trouble starts.  Many women choose home birth because they want to be able to access a wide variety of non-pharmacological pain management strategies.  In my research, a frequent complaint from women who were not interested in epidurals was the pressure from hospital staff to have an epidural.  Here is what the guide says about pain management (emphasis mine):

The intensity of discomfort during labor and delivery varies from person to person. Some women may manage well with relaxation and breathing techniques. However, most women choose some type of pain relief. The majority of women receive analgesia (relief from pain without losing consciousness) from an anesthesiologist….The most effective methods for relief of labor pain are regional anesthetics in which medications are placed near the nerves that carry the painful impulses from the uterus and cervix, lessening pain and facilitating your participation in your delivery. Our anesthesiologists commonly use an epidural, spinal, or combined spinal-epidural to minimize pain.

Nothing is mentioned other than relaxation, breathing, and calling the anesthesiologist.  However, in home settings (and even at other hospitals) many women choose “pain relief” from any number of options that do not require an anesthesiologist, such as walking, changing position frequently, sitting on a birth ball, taking a warm shower, or submerging in warm water.  They may also get pain relief assistance from massage or from non-drug-based interventions such as acupuncture.  This is not a complete list.  It should be noted that all of these other options could be made available at home–the only one that could not is the anesthesiologist.  No mention is made of the risks of anesthesia nor of what can be done in the event that the epidural or spinal doesn’t work.  Choosing pain relief does NOT have to mean choosing an epidural–unless you are at this hospital, where according to the state more than 85% of women have epidurals (and that doesn’t include spinals and other medical methods).

Many of NYP-WC’s policies and standard procedures would preclude use of most pain relief options anyway.  Here’s what happens once a women is admitted to her birthing room:

your nurse will assess your blood pressure, pulse, and temperature, and place you on a fetal monitor. The nurse will monitor you throughout your labor and help you explore which comfort measures work best for you. An intravenous line may be placed to give you medication and fluids. You may also receive ice chips to help quench your thirst. Do not eat any food without your physician’s permission.

Not only are these policies not home-like, they aren’t even evidence based:

  • According to the Cochrane Reviews, continuous electronic fetal monitoring (EFM) in low-risk births increases a woman’s risk of an unnecessary C-section. Because the risks-benefits ratios of EFM and intermittent auscultation, in which a health care provider listens to the fetal heart rate with a Doppler or fetoscope at regular intervals, are similar, Cochrane recommends that women be given information and then choose for themselves.
  • IV fluids can also lead to complications, such as too much fluid in the mother or newborn.  In addition, having an IV in place is conducive to starting a cascade of interventions, as having the IV in place makes it easier to begin a Pitocin drip.
  • The Cochrane Review on eating and drinking in labor concludes, “Since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labour for women at low risk of complications.”

cascade of interventions

(see original here)

Only two people can be with the woman in labor.  Last I checked, I was allowed to have whoever the heck I want in my house.

The hospital does not allow videorecording of the birth.  At home, you could live stream your birth if you were so inclined.

Rooming in is offered but not required.  Obviously at home, there is no nursery staffed by nurses.  In addition, rooming in is the standard for Baby Friendly Hospitals, as non-medically necessary separations can negatively impact breastfeeding.

One of the things many women appreciate most about their home births is the freedom to move around and to birth in any position they choose.  An acquaintance of mine who had an accidental home birth said that although she hadn’t planned it, she liked the experience, especially because “no one made me get on the little table.”  Another acquaintance said that as she was birthing, her OB asked that she get on her back for each contraction because, the OB said, “that’s the way I prefer to deliver.” Still another friend said that although there was a squat bar available in her birthing room, her OB refused to let her use it and threatened to leave if she would not lie on her back.

Notably, NOTHING is said in the guide about freedom of movement or position during labor or birth.  If a woman is tethered to a monitor and has an epidural, her movement would be curtailed even if hospital policy did not restrict her.

Finally, in the “Patient Responsibilities” section, the guide lists this “responsibility” (all emphasis mine):

Follow the treatment plan recommended by the health care team responsible for your care and the care of your baby. This group may include doctors, nurses, and allied health personnel who are carrying out the coordinated plan of care, implementing your doctor’s orders, and enforcing the applicable Hospital rules and regulations.

In your own home, you make the rules.

If Grunebaum and Chervenak want women to choose their hospital’s maternity care over a home birth, they’ve got a lot of work to do.

This may shock you, but there is no evidence that bed rest does anything to prevent preterm birth or help with any other health condition of pregnancy, including placenta previa, pre-eclampsia, preterm premature rupture of membranes (pPROM), or shortened cervix.

Really, truly.  No evidence that bed rest helps.  And this has been known for a long time.

Preventing Preterm Birth

cover33 (image from Babble)

The American Congress of Obstetricians and Gynecologists (ACOG) published the following recommendation in 2003, which was reaffirmed in 2012:

Bed rest and hydration have not been shown to be effective for the prevention of preterm birth and should not be routinely recommended.*

Got that?  Not effective.  Should not be routinely recommended.

In fact, a study of women with shortened cervix by Grobman et al showed that bed rest increased risk for preterm birth.

The Cochrane Collaboration, which sets international standards for evidence based medicine by reviewing randomized control trials (considered the “gold standard” in medical research), says of bed rest for preterm labor,

Due to the potential adverse effects that bed rest could have on women and their families, and the increased costs for the healthcare system, systematic advice of bed rest for preventing preterm birth should not be given to pregnant women.

The World Health Organization reports on the largest known randomized control trial of bed rest for preventing preterm labor:

For the purpose of comparing the effects of bed rest to no bed rest, 432 women allocated to bed rest at home were compared with a control group …422 had received no intervention. Incidence of preterm birth prior to 37 weeks was similar in both groups.

Here are the conclusions on the efficacy of bed rest from a series of articles posted on Medline:

Bed rest is used extensively to treat a wide variety of pregnancy conditions, at substantial cost but with little proof of effectiveness (Goldenberg, et al).

We should not assume any efficacy for bed rest. (Glaziou and Del Mar)

Mitigating Medical Conditions in Pregnancy

There is no evidence base for bed rest for conditions other than preterm birth risk either.  Here is what ACOG guidelines say about bed rest for hypertension/pre-eclampsia (high blood pressure in pregnancy):

There is little evidence of the efficacy of nonpharmacologic management of hypertension in pregnancy.  Whether bed rest is efficacious requires more research, including larger trials, and the risks of immobilization for long periods of time (e.g. thromboembolic events [blood clots, etc]) must also be addressed.

Update: I have a full post on preeclampsia here.

On placenta previa, for which hospital bed rest is often prescribed, Cochrane says,

[T]here are only trials of cervical cerclage (‘tying’ the cervix), and the effects of hospitalisation. The review found that cervical cerclage may reduce very premature births, although the evidence was not strong. There is little evidence of advantages or disadvantages to hospitalisation.

Regarding threatened miscarriage, and multiple gestations (e.g. twins or triplets), and preeclampsia, in addition to preterm labor, Drs. Bigelow and Stone of Mount Sinai School of Medicine in New York write,

Although the use of bed rest is pervasive, there is a paucity of data to support its use. Additionally, many well-documented adverse physical, psychological, familial, societal, and financial effects have been discussed in the literature. There have been no complications of pregnancy for which the literature consistently demonstrates a benefit to antepartum bed rest.

The evidence is unwavering.  There is no known benefit of bed rest in pregnancy.  Even if bed rest has no associated harms, if it has no benefit, why bother?  When we have two options with equal outcomes, one involving living life normally, and one involving a major life alteration that is inconvenient, expensive, and boring, why would anyone choose the latter?

But, in fact, bed rest does have harms–lots of them.  Read Part II and Part III .

*All emphasis in quotes throughout the post is mine

Update: WebMD has a new piece on bed rest for preventing preterm birth that actually provides evidence based information here.

There appears to be an ongoing effort to pit obstetricians and midwives against one another as if the two can’t both play important parts in optimizing pregnancy and birth outcomes and women’s reproductive health.

A couple of years ago, Time magazine published a piece called, “Doctors Versus Midwives: The Birth Wars Rage On.”  Wars?  Really? What is this, the sequel to Monsters vs. Aliens?  How can doctors and midwives be at war when every licensed, practicing midwife has to work with an obstetrician as back up for births that exceed her scope of practice?  And when many states require midwives to work under the direct supervision of a physician?  So how do these midwives practice if they are spending all of their spare time laser blasting obstetricians?  Or hiding from the obstetricians who want to laser blast them?

And even though physicians’ organizations do sometimes fight against licensure of midwives or expanding midwives’ scope of practice, many obstetricians include midwives in their own practices or work with them side by side in hospitals, birthing centers, and even at homebirths (4 to 5% of homebirths are attended by obstetricians).  Again, working together like this is hard to do for people trying to kill each other.

In a recent article in Slate, Laura Helmuth concludes,

For individual simple, low-risk births, having a home birth overseen by a highly trained midwife isn’t necessarily a clearly terrible decision. But when you take a world-historical look at childbirth, it’s not midwives and cozy home births that get credit for making maternal death such an unthinkable outcome today. One of the great victories of modern times is that childbirth doesn’t need to be natural, and neither does the maternal death rate. It’s modern medicine for the win. Doctors may have killed a lot of women in the first part of the 20th century, but they can save your life today.

Note that Helmuth does not out-and-out condemn homebirth (though she certainly doesn’t provide a ringing endorsement).  However, Helmuth, while lauding advances that have indeed made birth safer, does not note that (1) the vast majority of midwives practice exclusively in hospitals and  (2) that the Cochrane review of the most recent research indicates that pregnant women have better pregnancy outcomes when their care is provided by a midwife and recommends that most women receive their prenatal and birth care from a midwife.  The Cochrane review also points out the important role obstetricians can play in high-risk situations.  That does not mean that birthing with an obstetrician when her/his high level of expertise is superfluous is safer.

Anti-homebirth activist and blogger Amy Tuteur (a former obstetrician) responded to Helmuth’s piece with a post with the gleeful title, “Obstetricians for the Win!”  I’m not sure what they won.  I guess the good graces of Laura Helmuth?  I doubt most obstetricians know who she is.

Tuteur is convinced that the technocratic model of childbirth (rather than a model based on actual science) is the savior of womankind.  In her post on Helmuth’s piece, she says

Not surprisingly, as technology drove down rates of maternal and perinatal mortality, women flocked to hospitals to give birth. Midwifery has never really recovered.  But midwives have fought back, mainly by pretending that the massive decreases in maternal and perinatal mortality didn’t actually occur, and that childbirth was always as safe as it is today.

Tuteur does not appear to have read the original article, which notes that obstetricians killed a lot of women by promoting technology not based in science, that they sold women a bill of goods regarding their skills, and successfully pushed midwifery to the sidelines even when hospital outcomes were consistently worse than homebirth outcomes.  Women flocked to hospitals before they became places where birth was safe. In one of her many posts denigrating those who do not agree with her adherence to a technocratic model of childbirth, Tuteur makes her argument (which is repeated throughout her blog) that midwives, doulas, and others with humanistic and/or scientific approaches to childbirth are only in it for the money:

Midwives, doulas and childbirth educators can only make money from births that involve minimal or no technology… The promotion of “normal” birth is a marketing strategy, no more and no less… NCB [Natural Childbirth] advocates recognize that increasing their profits involves creating a demand for their product. They are no different from the myriad of other purveyors in the marketplace who imply that their products will lead to social success and approbation. “Buy PearlyWhite toothpaste and you will get the girl!” translates to “Have a normal birth and you will be happier, empowered and have healthier children!”

I don’t particularly like the term “normal birth” myself, as concern about women’s bodies deviating from established “norms” (e.g. the stubborn adherence to Friedman’s curve for determining “normal” labor time) is what makes contemporary obstetrics such a mess.  Most midwives actually use the term physiologic birth, and while individual midwives may detour from practice guidelines, practice guidelines for midwives do not eschew technology or interventions when there is a demonstrated need for them.  The idea that “NCB advocates” are in it for the money is laughable.  On average, the salary of a certified nurse midwife is about a quarter to a third of that of an obstetrician.  Certified Professional Midwives (CPMs) earn less, and a doula may earn as little as a minimum wage worker.  While obstetrics requires substantially more investment in training, the payback is huge.  And even obstetricians say that it is OBs who feel financially threatened by midwives, not the other way around.

The British obstetricians and midwives have practiced together for a long time, and British OBs don’t seem threatened by midwives.  Here is the Royal College of Obstetricians and Gynecologists’ response to the Cochrane review on midwifery.  Basically it says all women should have access to midwifery care but should see an obstetrician if they need to.

So who wins in this manufactured “war” between doctors and midwives?  Somehow I don’t think it’s women.

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