Good Monday and Happy New Year. ACOG (The American College of Obstetricians and Gynecologists) has once again reiterated the newer recommendations regarding cervical cancer screening. They have stated that “ Women ages 30 to 65 at "average risk" for cervical cancer should receive co-testing with cytology and HPV testing every five years or screening with cytology every three years”. ( Cytology just means sending cells with a pap and co-testing means DNA testing for HPV, Human Papilloma Virus via the same sample.) I would like to emphasize a couple of aspects of this statement: the phrase “ average risk”, and the idea that they are talking about sending specimens to the lab.
Average risk is not precisely defined, and this is ok, since it gives clinicians room for applying clinical judgement to individual patient cases. Average risk does not certainly include those patients, who are by virtue of disease or medication, immunocompromised. It does not include those who have recently had precancerous cells in the cervix, vagina or vulva. In my opinion it does not include those who have a significant smoking habit, since smoking is tightly associated with accelerating the progress of HPV disease. I do not believe average risk includes those with alcohol or drug problems since these patients can have poor immune function and struggle with satisfying recommended follow up protocols. In my opinion, average risk also should not include those with high risk sexual habits, such as having unprotected sex or large numbers of partners. But does the media ever highlight any of these things ? I have not seen it.
These ACOG recommendations are about the recommended sampling frequency for cells on the cervix. They are not a statement about the frequency of annual exams or even pelvic exams. Those proceed on their own schedules for their own separate indications. The media has not done a good job at highlighting this important distinction. After all, a woman is more than just her cervix.
The Journal of the American Medical Association (JAMA) has received a request from a group of researchers to retract their own study from the Journal on the grounds that they have discovered that the lead researcher has falsified data about the usefulness of nitroglycerin for improving bone density. Kudos to those whistleblower researchers.
South Carolina Department of Health and Environmental Control (DHEC) will revise its regulations concerning the practices of licensed midwives, what we call lay midwives, meaning those who are not Certified Nurse Midwives. The DHEC was picketed by about 50 midwives. ACOG has said that while women deserve the right to chose where they deliver, they should be informed of the risks and benefits of the choices, including the two to threefold risk of neonatal death while delivering outside the hospital. (This data came from a study reported in the New England Journal of Medicine (NEJM) and involved a study of 80,000 pregnancies in Oregon.)
Let’s think a little more about that statistic on neonatal death. Neonatal death is defined as the baby dying in labor or in the first month after birth. Why would such a terrible thing happen in the hospital ? High risk pregnant patients come to the hospital. High risk mothers may have very early labor, ruptured membranes, or severe preeclampsia, all resulting in deliveries so early that babies are far more apt to die or have serious morbidities. This is the source of neonatal death in the hospital, not the average pregnant women who comes in for labor or induction. On the other hand, most licensed lay midwives restrict their practice to low risk patients, with none of these aforementioned problems. And yet many more of their patients end up with dead babies, despite the fact that hospital caregivers are dealing with these sometimes insurmountable obstacles. Problems which are solved by a simple medication in the IV, or the use of forceps, or even a C Section in the hospital, result in death when the same problems occur outside the hospital.
Speaking of neonatal death being two to three times more prevalent among those who birth at home, did you ever consider that this is a group average ? What happens when you unpack that group ? It turns out that first timers delivering at home have a 14 fold increase risk of first apgar score of ZERO, which is tantamount to neonatal death. And while the multiparous patients (women with multiple prior births) may do better with labor, they are much more prone to hemorrhages and other maternal complications, which are not even addressed in this statistic.
So beware of the medical reporting in the popular media. Don’t take those statistics at face value. Remember the actual human realities behind them.
Stay tuned for more breaking news from the world of Obstetrics and Gynecology next week on Medical Monday.