Relay-Version: version B 2.10 5/3/83; site utzoo.UUCP Posting-Version: version B 2.10.1 6/24/83; site unc.UUCP Path: utzoo!watmath!clyde!burl!ulysses!mhuxr!mhuxn!ihnp4!houxm!mtuxo!mtunh!mtung!mtunf!ariel!vax135!timeinc!phri!pesnta!amd!amdcad!decwrl!decvax!mcnc!unc!oliver From: oliver@unc.UUCP (Bill Oliver) Newsgroups: net.med Subject: Re: Midwives / Infant Mortality (mostly the latter) Message-ID: <513@unc.UUCP> Date: Sat, 29-Jun-85 17:38:02 EDT Article-I.D.: unc.513 Posted: Sat Jun 29 17:38:02 1985 Date-Received: Wed, 3-Jul-85 08:18:35 EDT References:Reply-To: oliver@unc.UUCP (Bill Oliver) Organization: CS Dept., U. of N. Carolina at Chapel Hill Lines: 129 In article cm@unc.UUCP (Chuck Mosher) writes: Chuck here first introduces us to an interesting piece of speculative fiction........ and then : > It may also interest everyone to note that the Netherlands has one of the > lowest (if not the lowest) infant and maternal mortality rates in the > world. No, the US in not in second place, it is somewhere around 15th! > In the Netherlands almost all births take place at home, attended by midwives. > Sorry, Chuck, I was going to reply to this by mail, but then felt that I had to set the record straight about this disinformation to whomever read the original posting. This is one of the things we grumble about occasionally in the neonatal mortality and morbidity conferences here at NCMH. In fact, in 1978, the US was ranked as low as 17th. However, these are frankly spurious statistics, or rather, they are poorly presented and analyzed. The reporting and analysis of international infant/maternal mortality statistics has an interesting history, but the bottom line is that for birth weight adjusted infant and maternal mortality, THE US HAS THE LOWEST MORTALITY IN THE WORLD (1). The biggest problem somes from the statutory definitions of infant vs fetal death. In many places in Europe, there is a minimum birth weight and/or survival time that the infant must make it through before becoming an infant for inclusion in the mortality statistics. For instance, a study by Guyer, et al recently compared infant mortality in Sweden and Massachusetts(2). The crude Masachusetts death rate was 58 percent higher than Sweden, but when normalized for birth weight distribution, it was 3 percent LOWER than Sweden. Similar results have been shown to be the case in North Carolina (3). Even in the United States, there is some variation in the reporting of statistics, though it is primarily limited to fetal and not infant deaths. For instance, in 1981 all cases of fetal death had to be reported to state officials in Georgia, while only those cases over 20 weeks needed to be reported in New Hampshire. In almost all 50 states, however, a "live birth" is similarly defined (4). See the end of this discussion for the North Carolina definitions. While there are some caveats to using purely weight adjusted evaluation, in that different ethnic groups have different normal (and I use normal in both senses) term birth weights, adjusting for ethnic hetrogeneity makes US statistics even better (5,6). So, indeed, the use of midwives in the Netherlands is associated with a lower infant mortality and a higher rate of "fetal deaths" and "stillbirths" ; these "fetal deaths" and "stillbirths" are called infants in the US. The increased use of tertiary care facilities is associated with a lower mortality among low birth weight infants, though those infants have a higher rate of minor congenital anomalies (with an unchanged rate of major congenital anomalies).(7) Please folks, if you want to play at medicine-bashing, at least drop by your local medical school library for a couple of minutes first. It's not hard to find this stuff out. I have been uniformly impressed by the staffs of the university libraries I have had the opportunity to visit; they get their jollies out of helping people look this kind of stuff up. This should not be taken as a personal attack on Chuck Mosher, whose opinion (while wrong) is usually well considered. 1) Neonatal-perinatal Medicine. A.A. Fanaroff, ed. CV Moseby, pub. 1983. p. 398. 2) Guyer, B, et. al. Birth-weight standardized neonatal mortality rates and the prevention of low birth weight: How does Massachusetts compare with Sweden? New England Journal of Medicine 1982, 306:1230-1233. 3) Buescher, PA, et. al. The impact of low birth weight on North Carolina Neonatal Mortality 1976-1982. North Carolina Medical Journal 1984, 45: 437-441. 4) State Definitions and Reporting Requirements for Live Births, Fetal Deaths, and Induced Terminations of Pregnancy, 1981 Revision. US Department of Health and Human Services, DHHS Publication No. (PHS) 81-1119. 5) Wilcox, AJ and Russell, I Perinatal mortality : Standardizing for birthweight is biased. American Journal of Epidemiology 1983, 118:857-864. 6) Wilcox, AJ and Russell, I Birthwieght and perinatal mortality : II. On weight-specific mortality. International Journal of Epidemiology 1983, 12:319-325. 7) Shapiro, S, et. al. Changes in infant morbidity associated with decreases in neonatal mortality. Pediatrics 1983,72:408-415. For your information: N.C. Definitions: from reference 4 above. The numbers in parentheses below refer to sections of the code, not the previous bibliographic references. Live Birth - the complete extrusion or extraction from its mother of a product of human conception, irrespective of the duration of pregnancy, which, after such expulsion or extraction, breathes or shows any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles, whether or not the umbilical cord has been cut or the placenta is attached. (Administrative Procedure 7G, .0102 (5)) Fetal Death - death prior to the complete expulsion or extraction from its mother of a product of human conception, irrespective of the duration of pregnancy; the death is indicated by the fact that after such expulsion or extraction, the fetus does not breath or show any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. (Administrative Procedure 7G,.0102 (6)) A stillborn child shall be registered as a fetal death on a fetal death report when the child has advanced to at least the twentieth week of uterogestation. (Section 130-43, General Statutes) Coming soon..... yes, Virginia, they do teach MDs about nutrition. Bill Oliver. The above are my personal opinions and should not be taken as the opinions of the North Carolina Memorial Hospital, the Office of the Medical Examiner of the State of North Carolina, or of any other employee or office of the State of North Carolina.