Norsigian and Rooks on Evidence-Based Labor and Delivery
By Rachel Walden — June 25, 2009
In November 2008, The American Journal of Obstetrics & Gynecology published a review, Evidence-based labor and delivery management, that looked at the quality of the evidence used to support labor and birth practices. In response to the review, nurse-midwife and epidemiologist Judith Rooks and OBOS Executive Director Judy Norsigian wrote a letter to the editor that was published in the May 22, 2009 issue of AJOG.
In it, Norsigian and Rooks note that while the review “makes an important contribution to the care of healthy women having normal labors,” it is problematic because “Berghella’s ‘D’ grade (‘fair evidence that harms outweigh benefits’) for home-like births in hospitals was skewed by their decision not to review the evidence on many frequently used obstetric interventions, some of which (eg, induction) can cause harm when they are overused.”
If you have access to AJOG, the authors have responded to “agree that midwife-led models of care for labor and delivery should be encouraged, based on the recent Cochrane metaanalysis” and that they “support future randomized trials to compare” the options of home vs. hospital births.
Go Judy and Judith! Thank you!
2nd what Jill–Unnecesarean said here because I found this extremely important no matter what. This isn’t just for this, but etc in my eyes as well.
Rooks and Norsigian hooray! How we need you! That AJOG article raises my hackles. It’s really such disengenuous stuff, that self-congratulation in the last paragrpah of the article. Without any specifics, they attribute their clinical improvements to monumental decreases in maternal and infant mortality “in the last century.” Most of those improvements came from very basic things like the invention of antibiotics, general improvements in public health and nutrition, and the biggest factor–women gaining control of their fertility, having two babies instead of ten, and being able to take advantage of optimal timing of those babies as well. It didn’t come from the medicalization of labor. I hope somehow that the work of Rooks and Norsigian will help OBs get real. In 1945, the US was 6th in maternal mortality, in 1960 or so we were about 12th and now the WHO rates us as 47 of 141 developed countries. Infant mortality has been marginally better, but that’s just because we can keep these little 700 gr babies alive past the neonatal period, so we saw a tiny improvement in 2008. The obstetric profession didn’t even start doing PRCTs on routine obstetric procedures until the ’70s, and as a doula in many a labor room, I see either ignorance of best-evidence protocols or wilfull disregard of caveats that even ACOG publishes, like the words in their own book “Planning Your Pregnancy and Birth” 3rd edition, in 2000, on pages 176-177 ” A large, or even a very large baby is not a medical indication for induction”. How many women will quote those words back to them when warned that their babies were getting too big and they’d better be induced? Is it a woman’s responsibility to have to study the literature to get best-evidence care? Similarly, the lack efficacy of EFM is well known…six or so definitive studies were done back in the late ’90s, and were reassessed in the Lancet in ’96, but every woman still has EFM for every labor, and are never told that intermittant listening is just as good, or better, in that it doesn’t raise the c-section rate. That’s the pesky little attribute of continuous monitoring. Imagine a laboring woman telling her L&D nurse or her OB about the ACOG technical bulletin #207 of July 1995, and getting intermittant monitoring without a fight! The last sentence of the AJOG article says: “Obstetricians are now blessed with lots of data and should make best use of it.” That’s waaaay too lukewarm an invitation to improve practice. Where is the inditement of routine interventions that work best for the convenience of the OB and the hospital, and where is the clarion call to heed the evidence of harm that’s been available for some interventions, like episiotomy, for twenty years? We all know of the travesties large and small. I know of an OB who breaks waters upon admission of her patients, each and every one, no matter where in their labor these women are. When I asked her why she does this, she answered “How will I know if there’s meconium?” Grrrr.