Etude sur l'AAD (plutôt négative)

Voilà ce que je viens de lire:

"L'accouchement à domicile fait courir des risques au bébé"

Le Figaro - 5 juillet 2010

"De plus en plus à la mode ces dernières années dans les pays occidentaux, les accouchements à domicile sont peut-être plus agréables pour les femmes, mais ils peuvent être plus dangereux pour leurs bébés", relève Le Figaro. "C'est la conclusion quelque peu inquiétante d'une vaste étude internationale, qui vient d'être publiée en ligne dans l'American Journal of Obstetrics and Gynaecology". "Le taux de décès néonataux serait multiplié par trois lors d'une naissance à domicile par rapport à un accouchement en maternité", estiment le Dr Joseph Wax (Maine Medical Center, Portland) et ses collègues, "qui ont analysé l'ensemble des données disponibles à ce sujet en Amérique du Nord et en Europe". "Au total, leur méta-analyse a ainsi inclus près de 550 000 naissances, 342 056 qui avaient été programmées à domicile et 207 551 programmées en milieu hospitalier", précise le quotidien. Il relève que "les décès en excès à domicile seraient principalement dus à des problèmes respiratoires et un échec de la réanimation, selon les auteurs de l'étude".


Je n'ai pas les détails de l'étude, mais beuuuuuuuuuuuuh ça craint........
L'une de vous en a entendu parler??

juste ce que j'en pense : étude menée par St gynobs et ses St confrères.......

de nombreuses études ont bien démontrées le contraire. Les gynéco ferons tout pour se mettre en travers du chemin des parents qui veulent accueillir leur enfant en douceur. un AAD ne rapporte pas un centimes aux structure hospitalière, normal qu'ils soient "déçu"....

mouais ca craint, ca serait bien d'avoir des détails plutot que de dire selon gna gna...

Et qd tu regardes... pq 340000 aad et 270000 en structure?

enfin, il y a des détracteurs dans tout.

Après tout, on forme bien une secte non? (je précise que c'est ironique pour les petits esprits qui reprendraient mes ecrits (puisque cette partie est publique) )

oui j'aimerais bien la lire en entier,... et oui pourquoi ont-ils pris moins de naissance en milieu hospitalier?

Moi je voudrais savoir s'ils ont différencié les AAD des ANA.

Je vais rechercher l'étude

hum pas sur. le but de cette étude étant certainement de dissuader les futurs parents.

ouais ben rien que dans le résumé de l'article je vois des différences :

733 143 à l'hôpital
4661 en maison de naissance
et 7427 à la maison ................. on est loin des 340000 AAD

J'essaie de vous le transférer

Aloooooooooooooooooooooooors

Si je ne me trompe pas de publications :

référence : American Journal of obstetric and gynecology, "Maternal and newborn morbidity by birth facility among selected United States 2006 low-risk births ", Volume 202, Issue 2, February 2010, Pages 152.e1-152.e5

Objective

We sought to evaluate perinatal morbidity by delivery location (hospital, freestanding birth center, and home).

Study Design

Selected 2006 US birth certificate data were accessed online from the Centers for Disease Control and Prevention. Low-risk maternal and newborn outcomes were tabulated and compared by birth facility.

Results

A total of 745,690 deliveries were included, of which 733,143 (97.0%) occurred in hospital, 4661 (0.6%) at birth centers, and 7427 (0.9%) at home. Compared with hospital deliveries, home and birthing center deliveries were associated with more frequent prolonged and precipitous labors. Home births experienced more frequent 5-minute Apgar scores <7. In contrast, home and birthing center deliveries were associated with less frequent chorioamnionitis, fetal intolerance of labor, meconium staining, assisted ventilation, neonatal intensive care unit admission, and birthweight <2500 g.

Conclusion

Home births are associated with a number of less frequent adverse perinatal outcomes at the expense of more frequent abnormal labors and low 5-minute Apgar scores.


On est loiiiiiiiiiiiiiiiiiiiiiiiiiiiiiinnnnn de l'article du Figaro, j'suis pas médecin mais de mes quelques compréhension du jargon, le journaliste se fout de la poire de ses lecteurs à mon humble avis.

J'essaie de transmettre la totalité de l'article dans le post suivant

Je ne sais pas si je vais pouvoir transmettre les tableaux de résultats :

Almost 1 in 200 US women giving birth does so at home, accounting for approximately 25,000 deliveries annually.1 Two-thirds of these deliveries were attended by a physician or midwife, suggesting that home birth represented a conscious choice by the majority of these mothers. Home birth policy statements by several professional organizations are surprisingly discordant despite considering the same body of evidence, most of which comes from European studies.

The American College of Obstetricians and Gynecologists (ACOG) “strongly opposes home births,” citing a lack of scientific rigor in studies comparing the safety and outcomes of US hospital births to those occurring elsewhere.2 In support of home birth, the American College of Nurse Midwives notes that “high-quality controlled trials and descriptive studies have established that planned home births achieve excellent perinatal outcomes” while decreasing the use of potentially harmful medical interventions.3 Finally, the Association of Women's Health, Obstetric, and Neonatal Nurses “supports a woman's right to choose and have access to a full range of providers and settings for pregnancy, birth, and women's health care.”4

In the absence of professional consensus and adequate US data regarding the safety and outcomes of home birth, we sought to compare maternal and newborn morbidity by delivery location among women at low obstetric risk.

Materials and Methods

This investigation is a retrospective population-based cohort study using US 2006 birth data files at the state level, which were accessed online at the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics (http://www.cdc.gov/nchs/datawh/vitalstats/VitalStatsbirths.htm). Demographics and maternal and newborn outcomes were selected from the 2003 revision of the US Standard Certificate of Live Birth, used by 19 states and representing 49% of all US births. These states were California, Delaware, Florida, Idaho, Kansas, Kentucky, Nebraska, New Hampshire, New York (excluding New York City), North Dakota, Ohio, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Vermont, Washington, and Wyoming.

To identify a low obstetrical risk population, we excluded multiple gestations, preterm deliveries <37 weeks, smokers, women with pregestational or gestational diabetes, chronic hypertension, hypertensive disorders of pregnancy, or prior cesarean. Demographics included maternal age, race, education, and timeliness of registering for prenatal care. Maternal morbidity measures in this low-risk population included chorioamnionitis (clinical diagnosis of chorioamnionitis during labor made by delivery attendant, usually includes >1 of the following: fever, uterine tenderness and/or irritability, leukocytosis, fetal tachycardia, any maternal temperature ≥38°C [100.4°F]), fetal intolerance of labor (in utero resuscitative measures, eg, any of the following: maternal position change, oxygen administration to the mother, intravenous fluids administered to the mother, amnioinfusion, support of maternal blood pressure, and administration of uterine relaxing agents; further fetal assessment includes any of the following: scalp pH, scalp stimulation, acoustic stimulation; operative delivery is operative intervention to shorten time to delivery of the fetus, eg, forceps, vacuum, or cesarean delivery), prolonged labor (labor that progresses slowly and lasts for ≥20 hours), precipitous labor (labor that progresses rapidly and lasts for <3 hours), and meconium staining (staining of the amniotic fluid caused by passage of fetal bowel contents during labor and/or at delivery that is more than enough to cause a greenish color change of an otherwise clear fluid). Newborn morbidity included assisted ventilation (infant given manual breaths for any duration with bag and mask or bag and endotracheal tube within the first several minutes from birth, excludes oxygen only and laryngoscopy for aspiration of meconium), assisted ventilation >6 hours (infant given mechanical ventilation [breathing assistance] by any method for >6 hours, includes conventional, high-frequency, and/or continuous positive pressure), birth injury (defined as present immediately following delivery or manifesting soon after delivery, includes any bony fracture or weakness or loss of sensation but excludes fractured clavicles and transient facial nerve palsy; soft tissue hemorrhage requiring evaluation and/or treatment, includes subgaleal [progressive extravasation within the scalp] hemorrhage, giant cephalohematoma, extensive truncal, facial, and/or extremity ecchymosis accompanied by evidence of anemia and/or hypovolemia and/or hypotension; solid organ hemorrhage, includes subcapsular hematoma of the liver, fractures of the spleen, or adrenal hematoma), neonatal intensive care unit (NICU) admission (admission into a facility or unit staffed and equipped to provide continuous mechanical ventilatory support for a newborn), seizures (seizure is any involuntary repetitive, convulsive movement or behavior; serious neurologic dysfunction is severe alteration of alertness, such as obtundation, stupor, or coma, ie, hypoxic-ischemic encephalopathy, excludes lethargy or hypotonia in the absence of other neurologic findings, excludes symptoms associated with central nervous system congenital anomalies), 5-minute Apgar score <7, and birthweight <2500 g.5

Custom tables were generated using the online Vital Stats software (Victoria, Australia), comparing demographic characteristics and morbidity measures by delivery location (hospital, freestanding birthing center, or residence). Data were analyzed by the χ2 test with Bonferroni correction, using P < .003 as significant. Descriptive statistics included odds ratios with 95% confidence intervals and rates expressed as occurrences per 1000 births. Outcomes recorded as “not stated” were tabulated but not included in denominators for statistical analysis.

Results

There were 4,265,555 births reported in 2006, of which 2,073,368 (48.6%) used the 2003 US birth certificate and 745,690 (17.5%) met inclusion criteria. Of these births, 733,143 (97.0%) occurred in hospitals, 4661 (0.6%) in birth centers, and 7427 (0.9%) at home. Physicians delivered 678,234 infants in hospital, 620 in freestanding birthing centers, and 295 at home. Certified nurse midwives attended 51,555 in-hospital births, 2067 freestanding birthing center deliveries, and 1786 home births. Other midwives delivered 634 infants in hospital, 1865 in freestanding birthing centers, and 3521 at home. The remaining birth attendants were categorized as “not stated” or “other” (n = 4801; 0.6%). Physicians or midwives attended 5602 of 7427 (75.4%) home births, suggesting that the majority of home deliveries were planned. Subject demographics are presented in Table 1. Compared with women delivering in hospital, those delivering in freestanding birthing centers or at home were more often older, multiparous, and white, with less formal education and later registration for prenatal care. Maternal and newborn outcomes are presented in Table 2. Outcomes were missing for 0.1–1.7% of births, depending on the measure. Compared with women delivering in hospitals, those giving birth in birth centers or at home had more frequent prolonged and precipitous labors. Home births were also associated with higher rates of low 5-minute Apgar scores. In contrast, home and birthing center deliveries were associated with less chorioamnionitis, fetal intolerance of labor, meconium staining, assisted ventilation, NICU admissions, and birthweight <2500 g. There were no differences in assisted ventilation >6 hours, neonatal seizures, or birth injury rates by delivery location.
TABLE 1.

Arf oué les tableaux sont illisibles

Comment

Despite current ACOG policy, home birth remains the choice of a small proportion of US women. Therefore, we sought to further examine maternal and newborn morbidity by delivery location among selected US low-risk births. Our study demonstrates that home delivery is associated with significantly increased rates of abnormal labor progress and depressed 5-minute Apgar scores, consistent with earlier reports.[6] and [7] We chose to examine a selected low-risk population, as candidates for out-of-hospital births typically exhibit low obstetric risk.[7] and [8] It is notable that this cohort experienced significantly higher rates of an outcome, low 5-minute Apgar scores, potentially requiring neonatal resuscitation in comparison to a presumably higher-risk group of hospital deliveries. Lack of significant differences in other morbidities by delivery location could signify out-of-hospital birth practices raising certain risks compared with those of in-hospital deliveries or hospital care reducing obstetric risk in a complicated population.9

In addition, lower rates of chorioamnionitis, meconium staining, assisted ventilation, NICU admission, and birthweight <2500 g among out-of-hospital births likely reflect selection criteria of candidates for these delivery options. Alternatively, since most home deliveries are attended by midwives, some of these observations may reflect improved outcomes related to such practice models.10 Likewise, such practice pattern differences may explain the seemingly contradictory findings of more frequent prolonged labor but decreased rate of chorioamnionitis and fetal intolerance of labor among home births. Randomized trials of midwife-led care models are associated with fewer medical interventions, such as labor induction, electronic fetal heart rate monitoring, regional anesthesia, episiotomy, operative vaginal delivery, and cesarean delivery.10 The dataset used for our study also showed significantly less frequent labor augmentation and induction among home births (data not shown). Thus, fewer intrapartum interventions, several of which are risk factors for fever and chorioamnionitis, may contribute to the lower infection rates reported among home births. Similarly, one would expect fewer diagnoses of fetal intolerance of labor when electronic fetal heart rate monitoring is used less frequently, as in midwife-led care and home birth.[10], [11] and [12]

The demographics of the cohort varied significantly by delivery location, raising the issue of bias arising from self-selection. Such differences are not unexpected, considering that women choosing an out-of-hospital birth exhibit markedly different personality traits and expectations for their childbirth experience than mothers planning hospital deliveries.[13], [14], [15], [16], [17] and [18] We noted that women planning home births are more often multiparous, older, and white than mothers delivering in hospital, consistent with 2 earlier larger US cohort studies.[11] and [19]

Recognizing that demographic differences may have influenced our findings, such effects could be accounted for by adjusting the morbidity measures' odds ratios. However, adjustment would require patient-level data that were not available for age, education, and initiation of prenatal care. Moreover, the impact of adjustment would be questionable, considering the frequency of adverse outcomes among the home births. We suggest that clinical relevance resides in the maternal and newborn outcomes observed by delivery location, regardless of the intrinsic demographic differences among women choosing particular birth options.

We recognize several limitations of our study related to birth certificate data. Specifically, completion rates and accuracy typically result in underascertainment of prenatal and intrapartum complications. As noted earlier, completion rates for evaluated outcomes were quite high, although the accuracy of the reported data could not be assessed. This potential bias would likely underestimate risks associated with both home and hospital births in our investigation. Moreover, up to 20% of all planned home births and 25% of planned home births among nulliparous women require unplanned intrapartum transfer to hospital for delivery.[14] and [20] Thus, complications necessitating transfer or resulting from deliveries following transfer from home are attributed to hospital rather than home births, further underestimating risks associated with intended home birth. The 2003 revised birth certificate has the ability to note whether a mother was transported antepartum to the delivering hospital from another birthing facility or hospital but not from home. In addition, home deliveries can be coded as planned or unplanned. This information was unavailable in our data-set. Nonetheless, our results conservatively estimate that at least three-quarters of women delivering at home chose to do so, evidenced by a designated caregiver in attendance. The net effect of these phenomena is unclear and suggests some caution when interpreting our findings. Furthermore, we note that our data are drawn from the 49% of 2006 US births that were reported from 19 states using the 2003 revised birth certificate, rather than the entire US birth set. This approach was taken to ensure comparability of reported outcomes across subjects.1 As the reporting states are geographically diverse and still provide a large study population, we do not believe that this limitation detracts from our findings, although generalizability may be somewhat diminished.

Finally, the dataset did not consider maternal or perinatal mortality. These endpoints, while rare, arguably represent the ultimate measures of childbirth safety. Earlier investigations reported no maternal deaths among home birth cohorts too small to meaningfully address this extremely uncommon outcome.[7], [14] and [20] Importantly, 3 studies suggest higher perinatal mortality rates among planned home births compared with planned hospital births.[7], [21] and [22] Existing CDC databases, once updated, could be queried to address these critically important outcomes.

The current study offers several strengths. The large cohort of contemporary US births provides a robust evaluation of maternal and newborn outcomes that is generalizable and reflects actual practice. The large number of subjects and few missing birth certificate data permitted evaluation of infrequent but clinically significant adverse outcomes among women delivering in a variety of settings. Thus, these results serve as valuable counseling tools for women considering an out-of-hospital birth.

Our findings also suggest areas for future research. Specifically, apparently improved outcomes associated with home and birthing center deliveries deserve attention and should not simply be attributed to expectations for a preselected cohort of low-risk women. Rather, demonstrated benefits of midwifery-led care models, which typically characterize out-of-hospital births, should be critically evaluated and potentially incorporated into hospital-based best-practice obstetrical care.[10] and [23] Likewise, interventions potentially increasing morbidity among hospital births may warrant more selective use. Not unlike vaginal birth after cesarean or cesarean delivery on maternal request, choosing home birth likely represents balancing risks of uncommon but potentially serious complications with improved alternative outcomes framed by women's expectations for childbirth.[24] and [25] This study and suggested future investigations are useful in identifying and quantifying the relative advantages and risks of hospital vs out-of-hospital childbirth.

un tit résumé pour les nuls en anglais?

Là c'est pas l'anglais qui me pose problème, c'est un jargon médical que je ne maîtrise pas du coup je me vois mal traduire au risque de faire des contre sens.

moi aussi, comprend pas tout , voir meme presque rien

A moi, sans connaître le sujet AAD plus que ça, ces études me semblent absurdes et orientées par les gygys et autres personnels médicaux qui gagnent des sous à faire des accouchements en milieu hospitalier.

Non mais franchement, la mortalité du bébé et / ou de la maman en hôpital ça n'existe pas peut être ? Quand ils sont overbookés, que y'a genre 5 ou 6 accouchements en même temps (plus peut être) et qu'on voit les SF genre toutes les 30/45 min, si souci il y a (parce que du coup elles répondent pas forcément aux appels) t'as pas le temps d'y passer 10 fois ? Bah si.

AAD en France = une sage femme munie des mêmes connaissances concernant un accouchement, du matériel nécessaire à la surveillance de la maman et du bébé (en plus du fait qu'elle est là QUE pour toi, et qu'elle a moins de chances de rater un éventuel souci).

Un peu d'objectivité ça fait pas de mal.
Je diabolise pas l'hôpital, si souci il y a, repéré "normalement", effectivement, la prise en charge peut être directe, efficace. L'AAD, tu prends ce risque qu'il y ait potentiellement un imprévu, et qu'il faille "tenir le coup" jusqu'à l'hôpital le plus proche.
Mais tu prends aussi le risque d'accoucher sans souci (comme, quand même, la plupart des mamans...) dans le calme, la sérénité de ton foyer, dans des conditions d'hygiène, de surveillance, très très correctes (ça ne peut pas être comparé aux accouchements des femmes dans les pays "du tiers-monde" -je déteste ce mot là- ou l'hygiène et les connaissances médicales ne sont absolument pas les mêmes).




Chawa', ou la maman qui commence à faire cheminer l'idée d'un AAD après une césa' pour son prochain.. Vous m'aviez repérée hein ?

je comprend pas l'anglais

Je me plongerai dans l'article, merci de l'avoir copié, Louve. Je ne suis pas sûre de tout comprendre non plus...

Par contre, je me méfierais du "résultat" du Figaro, ce n'est pas la première fois que je vois un "résumé" d'une étude dans un journal et quand je vais voir l'étude en question, les résultats sont tous différents de ce qui est rapporté dans le journal. Donc j'essayerais plutôt de comprendre un minimum cette étude (mais j'ai pas le temps de tout lire maintenant).

je trouve le ton de l'article du figaro très patriarcal : femme tu veux du bien être et de l'humain dans ton accouchement mais ton enfant risque d'en mourir !
Mauvaise mère !
Je comprends rien à l'anglais mais on dirait qu'au figaro aussi ils en font une interprétation libre.

faudrait ptet faire un mot au figaro?

Ben pour ça faudrait bien comprendre l'article en lui même.

ça me rappelle l'article paru dans le canard enchainé sur les probiotiques et l'obésité ça

Bonjour,

Quel article du figaro en effet!

Je suis en train de regarder. L'article dont il est question n'est pas celui dont tu parles Louve. Il est "in press" et s'intitule de la sorte:

Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis
In Press, Corrected Proof, Available online 2 July 2010
Joseph R. Wax, F. Lee Lucas, Maryanne Lamont, Michael G. Pinette, Angelina Cartin, Jacquelyn Blackstone

J'essaie de le télécharger mais il y a une erreur avec le fichier, j'arrive à télécharger les autres, mais forcément pas celui là!!!

J'ai pu voir le résumé (je ne peux plus) et j'ai vu qu'il y avait en effet un facteur 3 dans les morts, mais il y a une différence entre périnatal et néonatal (?!!!) L'un des 2 serait significatif (facteur 3) et pour l'autre il n'y aurait pas de différence.

Je ne trouve pas le résumé dans pubmed (trop tot probablement)

Forcément sans l'article c'est plus compliqué.

Je n'ai pas trop le temps mais j'essaierai de regarder davantage, si quelqu'un trouve l'article.

Micha

Ha prout prout prouuuuuuteuuuuh

Merci Micha pour la correction

Je ne le trouve pas non plus sur science direct, ni résumé ni PDF.

Du coup j'en viens à me poser la question de comment le journaliste a eu accès à cette référence alors qu'elle n'est même pas publiée

En fait elle est quand même déjà "in press" mais c'est vrai que je ne sais pas comment ils peuvent être informés si rapidement. Ils ont dû leur envoyer un message.
Tellement croustillant comme information.
cela dit je ne comprend pas la nuance entre perinatal et néonatal. Quelqu'un sait?

La nuance est là :

"D'après l'OMS la période périnatale démarre le 154e jour de la gestation et se termine le 7e jour après la naissance.

Ceci ne doit pas être confondu avec la période néonatale correspondant aux premiers jours de la vie juste après lesquels le nouveau-né devient un nourrisson et ceci jusqu'à la fin de la deuxième année."

alors ça serait intéressant de savoir si c'est le périnatal ou le néonatal qui est augmenté d'un facteur 3 (quand même bizarre).
J'ai rééssayé plusieurs fois mais le fichier ne veut décidément plus s'afficher.

michaychama a écrit:

alors ça serait intéressant de savoir si c'est le périnatal ou le néonatal qui est augmenté d'un facteur 3 (quand même bizarre).
J'ai rééssayé plusieurs fois mais le fichier ne veut décidément plus s'afficher.

ben oui parce que ça veut dire dans ce cas que le périnatal englobe les accouchements prématurés, or c'est très clair qu'en cas de prématurité, la morbidité à domicile est plus élevée qu'en structure où on a tt ce qu'il faut pour la réanimation et les premiers soins du prématuré...

Des réactions sur doctissimo sur le sujet.
http://bebe.doctissimo.fr/blog/10667-L-accouchement-a-la-maison-une-nouvelle-etude.html

Et voilà le résumé:

Maternal and newborn outcomes in planned home
birth vs planned hospital births: a metaanalysis


/> Objective
We sought to systematically review the
medical literature on the maternal and newborn safety of
planned home vs planned hospital birth.

Study
design
We included English-language peer-reviewed
publications from developed Western nations reporting maternal
and newborn outcomes by planned delivery location. Outcomes'
summary odds ratios with 95% confidence intervals were
calculated.

Results
Planned home births
were associated with fewer maternal interventions including
epidural analgesia, electronic fetal heart rate monitoring,
episiotomy, and operative delivery. These women were less
likely to experience lacerations, hemorrhage, and infections.
Neonatal outcomes of planned home births revealed less
frequent prematurity, low birthweight, and assisted newborn
ventilation. Although planned home and hospital births
exhibited similar perinatal mortality rates, planned home
births were associated with significantly elevated neonatal
mortality rates.

Conclusion
Less medical
intervention during planned home birth is associated with a
tripling of the neonatal mortality rate.