California College of Midwives
3889 Middlefield Road
Palo Alto, Ca 94303
650 / 328-8491
Medical Board of California
1426 Howe Ave
Sacramento, Ca 95814
October 19, 2003
RE: DVD & Copy of correspondence with Dr Joyce Brothers
Dear MBC Member/Staff,
Enclosed is material for the members of the Division of Licensing to consider prior to the November 7th hearing on the proposed midwifery regulations. The California College of Midwives would like to see this type of multi-media information included as a part of any in-service education for Medical Board staff members who deal with the midwifery licensing program and for the OAL judges who may be called upon to adjudicate midwifery-related cases. This would be of great benefit to all in establishing the fundamental difference between standards for obstetrical care and those for physiological management as employed by licensed midwives.
The first enclosure is a DVD that I have edited together to demonstrate the profound difference between medical management of normal labor and birth and the physiological management of normal labor and birth as practiced by family-practice physicians and midwives.
The video footage of medical care was originally broadcast on reality TV programs, primarily the TLC series called “Baby Story.” This Learning Channel program has an ACOG fellow, California obstetrician Dr Peter Weiss, as their medical consultant. I believe we can assume that the medical practices as portrayed are considered by ACOG to be the standard of care for obstetrical providers.
It is possible that the computer format used to record this DVD will not play on your commercial DVD player. This incompatibility manifests in one of two ways – the player either won’t recognize the disk at all or, more likely, will play the first half OK and then begin to skip at an increasing rate until it finally stops playing altogether. If available, try a different DVD player or your computer’s DVD drive. But if this DVD copy is unplayable on your equipment, leave a message at 650/328-8491 with your name and mailing address and I will mail you a VHS copy.
The second enclosure is a copy of my response to a syndicated column by Dr Joyce Brothers that was published in several hundred newspapers across the country. Unfortunately, Dr Brothers’ advice to the public about the relative safety of community-based midwifery care reiterated the misleading information originally published in the Pang study. The ACOG Journal published a study in August 2002, entitled “Outcomes of Planned Home Births in Washington State” by Pang et al, that was severely marred by selection and measurement bias and was ultimately misleading in the extreme. A copy of this study was submitted to the Medical Board last December by ACOG as a part of their testimony objecting to the adoption of the proposed midwifery regulations. According to ACOG, the Pang study established that hospital birth was twice as safe as home-based care. Therefore, ACOG urged the Medical Board to restrict the practice of licensed midwives to institutional settings.
The Pang study claimed to have authoritatively documented that merely planning to labor at home doubled the perinatal mortality rate, even though at least 85% of these poor outcomes occurred among babies who were actually born in the hospital (N= 269 of the 279 hospital transfers / total of 20 perinatal deaths out of 6,133 midwifery patients). However, to come up with statistics favorable to the obstetrical profession’s conventional objections, they had to design their study in three strategic ways.
In order to get sufficient numbers to provide statistical “significance,” they had to include pregnancies from 34 weeks forward. Midwives do not provide home-based birth services until after 37 completed weeks of pregnancy.
Since Washington State birth certificates do not collect data on planned place of birth, Pang et al. used a set of artificial criteria to define planned home birth that did not include the actual plan/intention as defined by the midwives or the parents. They erroneously included unplanned precipitous premature births at home. In addition, mothers who were initially assessed in labor by their midwives, were determined to have an obvious complication, and were immediately transported to the hospital were also included in the planned home birth cohort. Relative to the stated purpose of the study -- to contrast outcomes for planned home labors and births with those of planned hospitalization -- it is a fatal methodological flaw to include such flagrantly unplanned labors/births in their statistical set.
Last but not least, the authors excluded all operative deliveries from the planned hospital birth cohort. Thus they discounted all the complications associated with the 30% rate of forceps, vacuum extraction and cesarean births that is the common experience of healthy mothers cared for under obstetrical protocols.
These authors had to use extremely manipulated data to come up with this tiny fraction of difference – perinatal mortality rate of 3.3 per 1000 vs. 1.7 per 1000. (Please note that numerous studies give a perinatal mortality rate of 2 per 1000 for healthy women whether they give birth in the home, birth center or hospital.) Were the authors to have used actual numbers and the appropriate study design, physiological management by midwives in non-medical setting would have been proven to be protective of both mothers and babies, reducing the operative rate (and associated complications) from 37% to approximately 5% with a virtually identical perinatal mortality rate.
I hope you find this information helpful in your governance of the midwifery profession as it functions under the regulatory authority of the Medical Board of California.
Faith Gibson, LM, CPM
California College of Midwives
Senator Liz Figueroa
Frank Cuny, California Citizens for Health Freedom