Archive for April, 2009

Can Consumer Survey Results from The Birth Survey Promote Evidence-Based Maternity Care?

April 29th, 2009 by avatar

At long last, The Birth Survey has given the public access to consumer ratings of maternity care providers and birth facilities. This is a major step toward increased transparency in maternity care.

I’ve been involved with The Birth Survey for a couple of years and am a vocal proponent of transparency in maternity care. I’ve studied the research on practice variation and concluded that we urgently need to publicize the rates of procedures and outcomes so that women can make informed choices and improve their likelihood of a safe and healthy birth.  The Birth Survey team is on top of this and is working hard to obtain and publicize intervention rates for all birth facilities nationwide.

But what is the evidence that consumer feedback can drive quality improvement? Many analysts have questioned the value of “doctor rating” sites, and some doctors are even vigorously opposing and censoring these sites, a move that is ludicrous and unethical. What makes us think that The Birth Survey will be more effective than some of the consumer rating sites that have apparently failed to drive meaningful change in health care?

First, The Birth Survey is firmly rooted in scientific evidence on what comprises safe and effective maternity care. The questions were formulated from The Mother-Friendly Childbirth Initiative, a model of maternity care that is supported by a large body of medical literature and promotes the rights of childbearing women. Each of Lamaze’s evidence-based Healthy Birth Practices is also represented in the survey questions. Finally, questions about the provider’s interpersonal communication skills were developed and validated by the Agency for Healthcare Research and Quality, the leading federal agency on evidence-based health care.

In addition, women who have given birth may be more motivated to share their experiences than people who have had other types of health care encounters. Many women are eager to share their birth stories, and repositories of birth stories abound on the internet, presumably more so than testimonials about a people’s pneumonia treatments or diabetes management, for example. So we cannot assume that the same limitations of other health care rating sites will apply to women who have given birth.

Finally, women’s satisfaction and the care providers’ interpersonal skills are potent quality indicators in maternity care. Unlike most other health care encounters, women presenting to prenatal appointments or to their birth settings in labor are usually not sick. The “treatment” should therefore be to support and facilitate the normal, healthy processes of labor and birth, and to intervene judiciously with the woman’s fully informed consent only when problems arise. Research on birth physiology strongly suggests that the attitude of the care provider and the qualities of the birth setting can make labor either easier or harder, and can either promote optimal health or trigger complications and overreliance on risky procedures to correct these problems.

As a research enthusiast, I’m very eager to study the effectiveness of The Birth Survey and other transparency initiatives. But whether or not The Birth Survey drives meaningful change in maternity care depends on how many women use it, so spread the word!

Research for Advocacy, Science & Sensibility ,

Building the Case for Transparency in Maternity Care: My Annotated Bibliography

April 25th, 2009 by avatar

I’ve given a talk called, “Transparency in Maternity Care: Bringing Birth Out of the Dark to Improve Quality” a number of times at conferences and as a webinar. (I will give it again as a webinar in September for Lamaze, so make sure you’re signed up to get e-News updates if you’re interested.)  The case for transparency in maternity care is compelling. Maternity care is unique among health care specialties because women have a long interval of time (9 months!) to decide where to go for their labor and birth care, so it’s reasonable to assume that publicly available quality information might help women make informed choices and drive quality improvement. (Compare that with the decision making process for someone having acute chest pain – just call 911 and go to the closest hospital!) Also, most consumers of maternity care are healthy, so unlike surgical or chronic care specialties, good outcomes are not measured in survival or duration of hospital admission (although these are of course very important), but rather how well the system protects, promotes, and optimizes the health of its beneficiaries – women and babies.

Unfortunately, we have very few studies that actually measure the effectiveness of transparency programs in maternity care. So for my talk I built my case using the evidence that supports six points that, taken together, demonstrate an urgent need for better transparency.

  • Intervention rates and outcomes vary widely across providers and facilities
  • Most of this variation has to do with factors unrelated to the woman’s health status
  • Excess use of interventions leads to excess injury and cost
  • Public awareness of quality indicators results in improved quality
  • Intervention rates can be lowered without compromising safety
  • Mother-friendliness is a measure of quality

Not long ago, Nasima Pfaffl from The Birth Survey asked me to post the bibliography from my talk on The Grassroots Grapevine, a site where maternity care advocates can connect and work together on maternity care improvement initiatives, including transparency. I’m posting that list again here, along with a brief note on the key findings of each article. Click on the extended post to see the bibliography. 

The Birth Survey just reached a major milestone. Consumer survey results rating health care providers and birth facilities are now available at TheBirthSurvey.com. Watch this space for more about transparency and The Birth Survey in the weeks to come.

Read more…

Research for Advocacy, Science & Sensibility ,

Repost: Do We Need a Cochrane Review to Tell Us that Women Should Move in Labor?

April 22nd, 2009 by avatar

This week, media outlets shared the news of a new Cochrane review that concludes upright positions are beneficial because they shorten labor by about one hour. The birth blogs have been buzzing about this, and the consensus is that we should feel delighted and vindicated to have the scientific evidence to prove what women and midwives have always known.

Cochrane reviews synthesize all of the research on a particular topic, and because the reviewers bring together and analyze all of the data from many studies, the study population gets very big. Big populations yield greater statistical power and often (but not always) more reliable findings.

Prior to this Cochrane review there was a large body of literature on movement in labor, including a good sized U.S. randomized controlled trial. There was even another systematic review! But this body of research never consistently supported the hypothesis that movement improved labor and birth outcomes. Now we have a Cochrane review, which is the gold standard for evidence-based practice.  So we can put the evidence-based “stamp of approval” on freedom of movement.

But, were we any less justified in endorsing freedom of movement before the Cochrane?

Read the full post and leave comments at The Giving Birth with Confidence Blog.

New Research, Science & Sensibility, Systematic Review , , ,

Why the largest study of planned home births won’t sway ACOG

April 22nd, 2009 by avatar

The internet is abuzz about a new study out of the Netherlands comparing the outcomes of planned home birth with those of planned hospital births in low-risk women. With over half a million women involved in the study, it is the largest of its kind. Its findings provide the best evidence to date that perinatal mortality (death of the baby during or soon after labor and birth) and morbidity (measured by likelihood of NICU admission) are no more common in planned home births than in comparable populations of planned hospital births.

The American College of Obstetricians and Gynecologists (ACOG) came out against home birth in 2006. They argued that unexpected complications can occur in labor and birth, so the hospital is the safest bet. Despite the existence of a good sized body of literature on home birth, ACOG emphasized the lack of evidence that home birth is safe, concluding that, by default, a policy of universal hospitalization is the optimal way to organize maternity care. ACOG’s statement reads:

Studies comparing the safety and outcome of U.S. births in the hospital with those occurring in other settings are limited and have not been scientifically rigorous. The development of well-designed research studies of sufficient size, prepared in consultation with obstetric departments and approved by institutional review boards, might clarify the comparative safety of births in different settings. Until the results of such studies are convincing, ACOG strongly opposes out-of-hospital births. (Out-of-hospital births in the United States, ACOG 2006)

OK, so now we have an enormous study with the statistical power to detect important differences in perinatal mortality. Will ACOG change their tune?

Some obstetricians may (and to be sure, there are a good number of OBs who already support home birth and home birth midwives), but ACOG as a professional body will most certainly stick to their guns. A closer look at their statement reveals their bias. ACOG pledges to oppose planned home birth unless and until there are large, well-designed studies on the safety and outcomes a) of U.S. births, b) prepared in consultation with obstetric departments, and c) approved by institutional review boards. This is a carefully constructed catch-22.

Planned home birth accounts for less than 1% of all births in the United States. In order to construct a U.S. study the size of the new Dutch study, every single woman planning a home birth in the United States would have to be enrolled in that study for the next eight years. In addition, we would need reliable databases collecting data about perinatal death based on where a woman planned to give birth, something that the Netherlands has but the U.S. lacks. Even if these hurdles were overcome, obstetric departments and institutional review boards present another barrier. If the dominant view in our maternity care system is that home birth is unsafe, obstetric departments and IRBs would be unlikely to willingly participate in research on hundreds of thousands of babies being born at home.

ACOG will say that a study in the Netherlands does not apply to U.S.-style maternity care, a claim that is based in truth. Because conventional obstetric management holds sway in the U.S., out-of-hospital midwifery is seen as a fringe alternative and poorly integrated into our system here. Contrast that with the Netherlands, where all healthy women are cared for by midwives, and about a third of babies are born at home. Midwives are not just integrated in the system, they run the system. Home birth is certain to be less safe in a system that marginalizes women who choose to give birth at home and the professionals who attend them.

A couple of generations ago, obstetricians led a charge in the U.S. to move birth into the hospital without any a priori evidence that hospital birth was any safer. Now that home birth is all but extinct, the “lack of evidence” on planned home birth in the U.S. serves to bolster ACOG’s position. The U.S. is not fertile ground for home birth research because a professional organization looking out for the power and financial interest of its members has run home birth underground and failed to provide the complementary specialist services that ensure continuity of care and safety when complications arise.

I love this quote from a British policy-maker, shared by Eugene Declercq in his 1998 article, ‘Changing Childbirth’ in the United Kingdom: Lessons for U.S. Health Policy:

To consider it safer, or even to have a consensus view, is not the same as having evidence . . . are you not saying that you have made a policy on the basis of safety which was not justified on the statistics when they did exist, and now you say there is not any possibility of getting statistics? Is that not putting women into a trap?” (House of Commons Health Committee 1991b: 210–211).

We need more and better research on home birth. We can use data from the Netherlands to determine the safety of home birth in systems that support and integrate home birth midwifery. After all, it is the only place left with a maternity care system that lends itself to home birth safety research, and national registers to conduct that research soundly. In the U.S., we must study how we can reform our maternity care system to provide access to midwife-led care in all settings, and best practices for caring for the women who rightly and inevitably will continue to desire birth at home.

Different Methods for Different Questions, New Research , , ,

Repost: Rotating Theories of the Increasing C-section Rate: Vitamin D Edition

April 21st, 2009 by avatar

In my midwifery practice, I recently reviewed the records of a client who was transferring her care to us midway through her pregnancy. Along with the routine labs that I always encounter, I saw that her previous doctor had checked her vitamin D levels. That same day, as I waited on hold while calling Quest Diagnostics (who processes our clients’ bloodwork and other labs), I listened to an upbeat promotion of a new blood test for vitamin D deficiency. I wondered whether I had missed something in the literature about the importance of checking vitamin D in pregnant women, or whether this was another case of a new popular test with unproven usefulness but intrinsic appeal to clinicians.

Maybe a little of both? Today, I came across a study in the March issue of the Journal of Clinical Endocrinology & Metabolism. The researchers report the findings of a small study of the association between maternal blood levels of vitamin D and the risk of having cesarean surgery. They measured the vitamin D blood levels of 253 women within the first 3 days postpartum, conducted interviews about habits such as prenatal vitamin use and alcohol consumption, and gathered personal, medical, and labor and birth information from medical records. After controlling for many variables that could affect cesarean risk, the researchers reported two significant findings:

  • Women who were severely vitamin D deficient were almost 4 times more likely to have cesarean surgery.
  • The lower a woman’s vitamin D level, the higher her cesarean risk.

This is pretty compelling stuff. But how useful is this study, really? When I analyzed the study, I noticed a few problems that make me wonder if the association between vitamin D and cesarean is that straightforward after all.

Read the full post and leave comments at the Giving Birth with Confidence Blog.

New Research , , ,

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