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Letter to the Editor on Evidence-based Labor & Delivery Management

In November 2008, The American Journal  of Obstetrics & Gynecology published a review, Evidence-based labor and delivery management (.pdf), 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. The letter is reprinted below.

TO THE EDITORS: The review of Berghella et al1 makes an important contribution to the care of healthy women having normal labors, especially because of the "A" grade (good evidence of important health benefits; strong recommendation to provide these services) assigned to providing a doula or other experienced woman to support each parturient throughout labor and to using upright positions during second stage.

The 2008 Cochrane Review of "Midwife-led versus other models of care for childbearing women”2  was unfortunately published too late to be included in Berghella's review of "Midwife vs conventional care," which was assigned a "C" grade ("the balance of benefits and harms is too close to justify a general recommendation"). The more comprehensive Cochrane review, published 1 month before Berghella's, included 11 trials and concluded that "all women should be offered midwife-led models of care and women should be encouraged to ask for this option." Perhaps the American Journal of Obstetricians and Gynecology should publish an updated review on this important topic.

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. A Cochrane review of home-like births in hospitals reported a nonsignificant trend toward higher perinatal mortality from which "no firm conclusions could be drawn" and concluded that "when compared to conventional institutional settings, home-like settings for childbirth are associated with modest benefits, including reduced medical interventions and increased maternal satisfaction.”3 

Because Berghella did not review the evidence on inductions and some other overused interventions, they may not have considered how reducing harms from their overuse would be an important benefit of home-like hospital births. Instead, they focused on a statistically insignificant negative finding that could have been due to chance.

The evidence-based maternity care report issued jointly by Childbirth Connection, the Reforming States Group, and the Milbank Memorial Fund examined evidence on a wider range of labor care practices and concluded that many are overused.4  Interestingly, Berghella et all gave actual home births an "I" rating (no recommendation because ofinsufficient evidence to determine the balance of benefits and harms).

In the absence of adequate evidence, we believe that the American College of Obstetricians and Gynecologists should retract its strong opposition to home births.

Judith P. Rooks, CNM, MS, MPH
Portland, OR 97201

Judy Norsigian
Executive Director
Our Bodies Ourselves
Cambridge, MA 02140 

1.  Berghella V, Baxter JK, Chauhan SP. Evidence-based labor and delivery management. Am J Obstet GynecoI2008;199:445-54. [back to text]
2.  Hatem M, Sandall J, Devane 0, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women, Cochrane Database Syst Rev 2008:CD004667 (Review).  [back to text]
3.  Hodnett ED, Downe S, Edwards N, Walsh 0, Home-like versus conventional institutional settings for birth, Cochrane Database Syst Rev 2005:CD000012 (Review).  [back to text]
4.  Sakala C, Corry M, Evidence-based maternity care: what it is and what it can achieve. Milbank Memorial Fund. Available at: http://www.milbank.org/reports/0809MaternityCare/0809MaternityCare.html. Accessed Oct. 29, 2008.  [back to text]






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