Justified skepticism about Apgar scoring in out-of-hospital birth settings

The Apgar score is used worldwide to assess the newborn infant shortly after birth. Apgar scores, including mean scores and those with high cut-off scores, have been used to support claims that planned home birth is as safe as hospital birth. The purpose of this study was to determine the distribution of 5 min Apgar scores among different birth settings and providers in the USA.We obtained data from the National Center for Health Statistics of the US Centers for Disease Control birth certificate data for 2007–2010 for all singleton, term births of infants weighing ≥2500 g (n=13,830,531). Patients were then grouped into six categories by birth setting and birth attendant: hospital-based physician, hospital-based midwife, freestanding birth center with either certified nurse midwife and/or other midwife, and home-based delivery with either certified nurse midwife or other midwife. The distribution of each Apgar score from 0 to 10 was assessed for each group.Newborns delivered by other midwives or certified nurse midwives (CNMs) in a birthing center or at home had a significantly higher likelihood of a 5 min maximum Apgar score of 10 than those delivered in a hospital [52.63% in birthing centers, odds ratio (OR) 29.19, 95% confidence interval (CI): 28.29–30.06, and 52.44% at home, OR 28.95, 95% CI: 28.40–29.50; CNMs: 16.43% in birthing centers, OR 5.16, 95% CI: 4.99–5.34, and 36.9% at home births, OR 15.29, 95% CI: 14.85–15.73].Our study shows an inexplicable bias of high 5 min Apgar scores of 10 in home or birthing center deliveries. Midwives delivering at home or in birthing centers assigned a significantly higher proportion of Apgar scores of 10 when compared to midwives or physicians delivering in the hospital. Studies that have claimed the safety of out-of-hospital deliveries by using higher mean or high cut-off 5 min Apgar scores and reviews based on these studies should be treated with skepticism by obstetricians and midwives, by pregnant women, and by policy makers. The continued use of studies using higher mean or high cut-off 5 min Apgar scores, and a bias of high Apgar score, to advocate the safety of home births is inappropriate.

Nurse training in Japan: contribution to the foundation of the Casa de Parto birthing center in Rio de Janeiro

This study was performed using a historical-social approach and aimed at discussing how the Brazilian nurse midwives trained in the Japanese birthing centers helped implement Casa de Parto in Rio de Janeiro-RJ in 2003. The primary sources of information were written and oral documentation found in collections and semi-structured interviews. The analysis happened in three steps: organization, classification and data triangulation. In order to support the analysis, concepts of habitus, field, symbolic capital and power were adopted. Results showed that the training of nurses at the Japanese birthing centers by taking a course on birth assistance was a government strategy to reconfigure the obstetrics field, which updated the habitus of these nurse midwives. Both Rio de Janeiro nurses appointed by the City to take the training course acquired better positions, which contributed to the foundation of the Casa de Parto birthing center in Rio de Janeiro.