Tuesday, February 25, 2014

Tragic Death of Baby

Something happened on Friday that definitely deserves a lot of attention: A baby died a preventable death because the midwife did not understand the risks involved in the particular situation.

This was broadcast for everyone to see on Facebook. It started with this initial question, sent via private message to Jan Trittan, the editor of Midwifery Today, who then posted it on her page:


As you can clearly see, the midwife did not fully understand the risks of the situation ("what do we truly feel are the risks"). You can also clearly see that she has not transferred care to a physician ("we're in a state with full autonomy for midwives and no transfer of care regulations past 42 weeks").

If a pregnant woman's hired professional care giver is unaware of the risks, how does the pregnant woman know the risks? This midwife clearly doesn't want to acknowledge that this mother is in any danger at all, even saying "technology isn't perfect" as if a BPP done on two separate occasions, both indicating ZERO amniotic fluid, would be incorrect (again... this is not a matter of a BPP indicating LOW amniotic fluid, it indicated ZERO amniotic fluid BOTH times). Can we honestly believe this mother has any idea of the risks involved in her situation?

At 42 weeks 3 days, the baby died:


The baby died from meconium aspiration. How does that happen? There are factors that each individually increase the chances of meconium aspiration and sadly this mother had several factors:

Postterm
Low amniotic fluid (and in this case, even worse, she had NO amniotic fluid)
Placental insufficiency

Based on current research, an induction at 41 weeks (or shortly after) not only would have greatly increased the chances that this baby would have survived, but it also would have decreased the chances that this mother would end up with a c-section.

An immediate transfer of care at 42 weeks 1 day when it was initially known that there was no amniotic fluid would have also yielded a live baby. Or at 42 weeks 2 days. Clearly, going in at 42 weeks 3 days proved to be one day too long.

I have had a pit in my stomach since I watched this all unfold on Friday on Facebook. It almost seemed a like an awful prank. What midwife would do such a thing? What professional wouldn't understand the risks? What professional would seek advice on Facebook and ask others to share "opinions/stories" to help them make their decisions?

A petition has been started and I have already signed it, and I hope you will as well. Sign for this mother, because she was not given true informed consent and is now left with the loss of her child. Sign for this baby, because he or she was not given the best chance at life. Sign for the family of the mother/baby, who will also forever grieve this loss. Sign for this midwife, because her actions were beyond negligent and she should be held accountable. Sign for the current and future clients of this midwife, who deserve to know who they are hiring.

Please Sign This Petition

Update your Facebook and/or Twitter status with this hashtag: #notburiedtwice to raise awareness for the loss of this baby.... another preventable loss at the hands of a negligent midwife.

The thread was, of course, deleted. I took over 65 screen shots (including the two posted here) as I was participating in the discussion but did not get all of the comments. However, they were all captured. To view the full Facebook thread, it is available here: The Internet Never Forgets




Thursday, February 6, 2014

MANA Won't Respond

photo credit Rajiv Patel

There is a lot of criticism out there about the new MANA study. A lot of questions, a lot of concern over the mortality rates, a lot of people speaking up. Just a look at the MANA press release and you can see some of the concerns (and that's with comments being moderated).... it's been a hot topic on Facebook, in the comments on different press releases, childbirth-related forums, etc.

And MANA's response?

(crickets chirping)

I can't help but wonder if they are doing this on purpose to avoid having to answer any of the hard questions. Are they hoping it will all just go away? The questions will just die out and they'll never have to respond?

The press releases and articles have been very careful to dance around the mortality rates, highlighting things like a low cesarean section rate and high breastfeeding rates, and assuring women that home birth is a safe option.... the responses I've seen so far from MANA and Wendy Gordon all seem so calculated, as if they planned them in advance... questions are dodged and when people continue to press them for answers, they just stop responding.

Does MANA plan to respond to the results of this study?

An excellent point made by someone in a discussion about this study was this: "The point of a study is not to pat each other on the back and say "Well done!". The point of a study is to add to the collective pool of information, to learn from it, to allow others to build on it and if you believe in evidence based care -- to help create evidence based models of care."

I could not agree more.

Here are a few questions I have about the study...

1. Why didn't the authors provide any numbers for comparison for the studies they reference? Here is what I am referring to in the study: "The intrapartum fetal death rate among women planning a home birth in our sample was 1.3 per 1000 (95% CI, 0.75-1.84). This observed rate and CI are statistically congruent with rates reported by Johnson and Daviss[4] and Kennare et al[30] but are higher than the intrapartum death rates reported by de Jonge et al,[10] Hutton et al,[12] and Stapleton et al.[14] " Readers are expected to wade through a bunch of different studies, searching for the information because the authors couldn't supply it. Why?

2. Why didn't they compare numbers to hospitals in the USA? The information is available on the CDC Wonder Database (I pulled them here). I cannot imagine a reasonable/acceptable response to be anything along the lines of "we don't know how reliable that data is" when the Wonder Database information is linked between birth and death certificates -- especially when they are asking people to trust information from their study where the data was self-reported. There is clearly literature and studies available regarding intrapartum mortality rates as well. Why didn't they include any of this information?

3. Here is what it says in the Discussion about higher risk pregnancies: "However, the safety of home birth for higher-risk pregnancies, particularly with regard to breech presentation (5 fetal/neonatal deaths in 222 breech presentations), TOLAC (5 out of 1052), multiple gestation (one out of 120), and maternal pregnancy-induced comorbidities (GDM: 2 out of 131; preeclampsia: one out of 28) requires closer examination because the small number of events in any one subgroup limited the effective sample size to the point that multivariable analyses to explore these associations further were not possible. It is unclear whether the increased mortality associated with higher-risk women who plan home births is causally linked to birth setting or is simply consistent with the expected increase in rates of adverse outcomes associated with these complications." It's a very open-ended way to leave that. A VBAC mortality rate of 4.75/1000, twin mortality rate of 8.33/1000, a breech presentation mortality rate of 22.67/1000. These numbers might just be "consistent with the expected increase in rates of adverse outcomes associated with these complications"? The safety of home birth for higher risk requires further examination. What are the steps they are going to take to look into this and further examine it? What do they recommend in the meantime to high risk pregnant women in that are planning a home birth?

What questions and concerns do YOU have about the study? What would you like the authors and/or MANA to answer?




Tuesday, February 4, 2014

MANA Study: Comparing Mortality Rates


For a more in-depth look at the MANA numbers, click here to read my series.

****

I wanted to get a closer comparison for looking at the rates between the hospital group and the MANA study.

The neonatal mortality rate for the USA as a whole is 4.0/1000. However, this is for any live birth, regardless of gestational age, regardless of risk, regardless of lethal anomalies. So it includes extreme prematurity, high risk moms, etc etc... every complication you can think of. This is clearly not the appropriate number to use for full term babies.

So I used the CDC Wonder Database (http://wonder.cdc.gov/). My search was based on the following criteria to match the MANA study as close as possible:

White women
Singles and twins
37 weeks and above
Birth weight of 2500 grams or more
Live birth through 27 days (the neonatal period)
Years 2004-2009
It includes everything else… all ages, all education levels, all marital statuses, etc

Here are the rates based on that criteria:

Years 2004-2006










Years 2007-2009







Average those numbers and here are our rates:

Hospital MD neonatal mortality rate = 0.62/1000
Hospital CNM neonatal mortality rate = 0.38/1000

(CNMs will care for mostly low risk, which is why their numbers are lower. The MD group is low risk and high risk. These numbers include lethal anomalies.)

Now to compare…

MANA STUDY:
Intrapartum mortality rate = 1.30/1000
Intrapartum mortality rate for low risk only = 0.85/1000
Neonatal mortality rate (excluding lethal anomalies) = 0.77/1000

HOSPITALS:
Intrapartum mortality rate = 0.1/1000-0.3/1000
Neonatal mortality rate for low risk (including lethal anomalies) = 0.38/1000
Neonatal mortality rate for low risk and high risk (including lethal anomalies) = 0.62/1000

TOTAL MORTALITY RATES (intrapartum plus neonatal):
MANA study = 2.07/1000 (excluding lethal anomalies)
MANA study for low risk = 1.62/1000 (excluding lethal anomalies)
Hospital rate for low risk = 0.48/1000 to 0.68/1000 (including lethal anomalies)
Hospital rate for low risk and high risk = 0.72/1000 to 0.92/1000 (including lethal anomalies)


Now let’s include lethal anomalies in the home birth numbers to have a better comparison since we cannot completely exclude them from the hospital group… so ALL numbers below include lethal anomalies:

MANA STUDY:
Intrapartum mortality rate = 1.30/1000
Intrapartum mortality rate for low risk only = 0.85/1000
Neonatal mortality rate = 1.29/1000

HOSPITALS:
Intrapartum mortality rate = 0.1/1000-0.3/1000
Neonatal mortality rate for low risk = 0.38/1000
Neonatal mortality rate for low risk and high risk = 0.62/1000

TOTAL MORTALITY RATES (intrapartum plus neonatal):
MANA study = 2.59/1000
MANA study for low risk = 2.14/1000
Hospital rate for low risk = 0.48/1000 to 0.68/1000
Hospital rate for low risk and high risk = 0.72/1000 to 0.92/1000

This is an even closer comparison than listed above since we are now comparing apple to apples by including lethal anomalies. A low risk baby is 3 to 4.5 times more likely to die at a home birth than in the hospital. This means for every 10,000 babies born at home (to low risk mothers), 15-17 will die that would have lived had they been born in the hospital.

Part of the problem with home birth midwifery is that screening measures aren’t always taken (and in many cases, are not encouraged) to ensure a low risk woman remains low risk. If a pregnant woman planning a home birth does not take screening measures recommended to make sure she is low risk throughout her pregnancy and just assumes she is low risk (or if her known high risk pregnancy is not referred out and simply referred to as a “variation of normal”), then you are looking at comparing the low risk hospital numbers to the numbers in the MANA study that represent all women, which would mean a baby is 4-5.5 times more likely to die at home vs in hospital. This means for every 10,000 babies born at home, 19-21 will die that would have lived had they been born in the hospital.

Here are some other important rates from the study:

HIGH RISK MORTALITY RATES (intrapartum plus neonatal):
Home birth VBAC = 4.75/1000
Home birth twins = 8.33/1000
Home birth breech baby = 22.67/1000

MANA did not offer numbers for comparison in their study. Every woman has a right to this information.

****

UPDATE 03/04/2014:

(update made due to comment below)

There is an option on the CDC Wonder Database to exclude most lethal anomalies. It does not include *all* lethal anomalies, though, as certain congenital anomalies that are lethal may be labeled as something else like cardiovascular disease. So keep in mind, the hospital rates are likely even lower. 

Hospital rates, excluding most lethal anomalies:
Neonatal mortality rate for low risk = 0.25/1000
Neonatal mortality rate for low risk and high risk = 0.33/1000

Again, MANA study rate, excluding lethal anomalies:
Neonatal mortality rate = 0.77/1000

Total rates, excluding anomalies are:

TOTAL MORTALITY RATES (intrapartum plus neonatal):
MANA study = 2.07/1000
MANA study for low risk = 1.62/1000
Hospital rate for low risk = 0.35/1000 to 0.55/1000
Hospital rate for low risk and high risk = 0.43/1000 to 0.63/1000

ALL RISK:
All risk hospital birth (low plus high risk pregnant women) compared to all risk home birth (low plus high risk pregnant women) = 3 to 5 times more likely that a baby will die at home. For every 10,000 babies born at home, 14-16 babies will die that would have lived had they been born in a hospital.

LOW RISK:
Low risk hospital birth compared to low risk home birth = 3 to 5 times more likely that a baby will die at home. For every 10,000 babies born at home to low risk moms, 11-13 babies will die that would have lived had they been born in a hospital.

ALL RISK to LOW RISK:
If a woman having a home birth assumes her low risk status (instead of confirms her low risk status by taking all screening measures to ensure she is truly low risk) and/or if her high risk pregnancy is brushed off as a "variation of normal" and/or if her midwife does not recognize certain complications due to ignorance or lack of screening/monitoring during pregnancy or during labor/delivery, then we would compare low risk hospital birth to the MANA study numbers representing low AND high risk. Which means:
A baby is 4-6 times more likely to die at home. For every 10,000 babies born at home, 15-17 will die that would have lived had they been born in a hospital.

Excluding anomalies, there is still a very significant risk to babies born at home.

Screen shots of the CDC Wonder Database results:

2004-2006:

2007-2009:



For a more in-depth look at the MANA numbers, click here to read my series.


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