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Maternal and perinatal mortality are so low in low-risk pregnancies that they should not be the primary outcome measures for a trial, yet they are the basis of real interest and the source of polarized concerns. (Enkin et al, 2000) Tew, M and Damstra-Wijmenga SMI, Safest Birth Attendants: recent Dutch evidence. Midwifery, 1991;7: 55 –63 All Dutch births during 1986. #Obstetricians care provokes and adds to dangers in childbirth. #compares PMR Rooks, JP, et al. Outcomes of care in
birth centers: the National Birth Centre Study. N Engl J Med 1989; 321
(26): 1804 –1811 11,814 women Lower cost, higher satisfaction, comparable safety, fewer interventions, caesarian section rate half that of the compared low-risk hospital deliveries. Campbell R and MacFarlane A. Place of delivery: a review, Br J Ostet Gynaecol 1986; 93 (7): 675 – 683 Review analyzes papers examining the association between place of birth and mortality and morbidity for British births. #PMR for low risk women planning home births are very low #No evidence to support the claim that the safest policy is for all women to give birth in the hospital. #There is some evidence to support the claim that the higher morbidity among mothers and babies cared for in hospitals, and particularly by obstetricians, is due to labour management. #A majority of women who birthed both in hospital and at home, prefer home birth. (It is likely that this group selectively contains women who chose home birth because they had an unsatisfactory hospital experience) Howe KA. Home births in south-west Australia. Med J Aust 1988; 149 (6) : 296-302 165 home births 1983 – 1986; 6 midwives. 16% transferred for complications. C/S rate 1.2%; assisted vaginal delivery 4.8%; augmentation rate 3%; induction rate 0% Consistently favourable results in studies on home birth. One ‘hypothesis’? is that common obstetric interventions do not improve outcome and are hazardous. Crotty M et al. Planned homebirths in South Australia 1976 – 1987. Med J Aust 1990;153:664 –671 Review of all planned home births registered with a group of five GPs and 11 midwives. Outcomes compared with SA hospital births for 1983. Interventions: sonograms 25.3 versus 84.4%; induction 4.8 vs 21.1%; instrumental delivery 4.1 vs.15.2%; C/S 5.5 vs 18.8%; epidural 8.4 vs 26.1%; episiotomy 8.3 vs 60.3% Several potential problems with home birth care were identified: booking high risk pregnancies, the low use of sonograms, delay in transfer, low use of oxytocics in third stage and lack of autopsies when cause of death not obvious. Woodcock HC et al. Planned homebirths in Western Australia 1981 –1987: a descriptive study. Med J Aust 1990; 153: 672-678 778 births. 96.5% attended by a midwife, a doctor also present at 17.1%, 2.1% BBA 24.6% transferred. Interventions: induction 2.5% vs 26%; elective C/S 0.6% vs 7.1%; emergency C/S 3.6% vs 6.7%. PMR 10.1/1000 vs 9.7/1000 for comparison group. No perinatal death related to place of birth. No emergency transfer associated with preventable mortality. PPH 8.4% - high rate may be due to failure to give oxytocics in third stage. Duran AM. The safety of home
birth: the Farm study. Am J
Public Health 1992; 82(3): 450 – 453. A comparative study between outcome of 1707 lay midwife attended births from 1971 – 1989 with a sample of doctor-attended births for the 1980 US National Natality/National Fetal Mortality Survey. (n =14,033) Transfer rate 13.5%. No significant differences found for perinatal death, bleeding, birth injury, respiratory distress syndrome or 5 min apgar below 7. Interventions: C/S rate 1.5% vs 16.5% (but national C/S rate rose to 24%) no others mentioned. #Home birth not less safe than hospital. #“Support by the medical and legal communities for those electing, and those attending, home births should not be with-held on the grounds that this option is inherently unsafe” Treffers PE, Obstetric care in developed countries: the case of the Netherlands, in Health matters. Public health in North-South perspective, Van der Velden K et al (eds). Houten, Bohn Stafleu Van Loghum 1995. Treffers PE. Selection as the basis of obstetric care in the Netherlands. in Abraham-Van der Mark E (ed) Successful home birth and midwifery. The Dutch model. Westport, Connecticut, Bergin and Garvey 1993. Treffers PE, Eskes M, Kleiverda G, Van Alten D. Home births and minimal medical interventions. JAMA, 1990; 264:2203–2208. Van Alten D, Eskes M, Treffers PE, Midwifery in the Netherlands; the Wormerveer study: selection, mode of delivery, perinatal mortality and infant morbidity. Br. J Obstet Gynaecol 1989, 96:656-662 Waldenstrom U, Nilsson CA, Windbladh B. The Stockholm birth center trial. Maternal and infant outcome. Brit J Obstet Gynae. 1996. Waldenstrom U, Nilsson CA. Women’s satisfaction with birth center care: a randomized controlled study. Birth, 1993; 20:3-13 Weigers TA, Keirse MJNC, Berghs GAH, Vander Zee J. An approach to measuring the quality of midwifery care. J Clin Epidem 1996; 49:319-325 Enkin et al, A guide to effective care in pregnancy and childbirth, Oxford University Press, 2000. Goer, H, Obstetric myths versus research realities, A guide to the medical literature, Bergin & Garvey, 1995. Wagner M, Pursuing the Birth Machine, The search for appropriate birth technology, Ace Graphics, 1994. This book is a must. Chapter 8, addressed to “we who are fighting to realize dreams” –‘Spreading the word: action and reaction’, informs of ways to make changes in society. Appendix D, report - current maternity care and health promotion incompatible. World Health Organization, Care in normal birth: a practical guide, WHO, 1996. |
Title: Maternal and perinatal mortality are so low in low-risk pregnancies that
they should not be the primary outcome measures for a
