Archive for November, 2011

Late Preterm Birth: A Maternal Health Problem, Too

November 30th, 2011 by avatar

[Editor’s note:  Amy Romano recently shared the following thoughts on Childbirth Connection’s Transforming Maternity Care site.  Those of you who missed reading Amy’s review of a recent study pertaining to the maternal emotional outcomes associated with preterm birth will surely benefit from reading her post here.]


More than two-thirds of preterm babies are born “late preterm,” between 34-37 weeks gestation. For many years, the epidemic of late preterm birth was largely ignored, as the typical health problems of these infants were not as severe as the challenges faced by babies born many weeks before term.

Thanks to emerging evidence and advocacy, late preterm birth is now getting recognition as the major public health problem that it is – late preterm babies do in fact face many health risks, including respiratory and feeding problems, longer and more frequent hospitalizations during infancy, and behavioral and learning problems in early childhood.

Late preterm birth is out of the shadows, but part of this public health problem is still hidden.

A new study published in JOGNN looks at the emotional health outcomes of mothers of late preterm babies. Compared with mothers of full-term babies, mothers of late preterm babies had significantly more situational anxiety, depressive symptoms, post-traumatic stress disorder symptoms, and worry about their infant’s wellbeing after delivery, differences that persisted when researchers followed up with the mothers one month after giving birth. In interviews, mothers of late preterm infants described many distressing experiences, expressed concern for their own health and their infants’ health, faced many difficulties related to infant feeding and weight gain, and reported lack of timely information from care providers. They also described disruptions in their confidence in their role as mother, an experience exacerbated in women whose babies remained in the hospital after their discharge.

Depression, anxiety, and post-traumatic stress disorder are debilitating and sometimes deadly conditions for women, and the children of mothers with these conditions are at risk for poor health and social outcomes. In other words, when a baby is born a few weeks early – even when the infant health outcome is favorable – this event can still have a detrimental and persistent impact on the health and wellbeing of the family.

We need to continue to strengthen efforts to prevent prematurity. When despite these efforts babies are born preterm – even just a little preterm – this study suggests that we must work to protect the health and wellbeing not just of babies, but their mothers, too.



Posted by Amy Romano, MSN, CNM

New Research, Pre-term Birth, Research , , , , , ,

Birth Outcomes by Birth Location: The Latest Study

November 29th, 2011 by avatar

The much-anticipated Planned Place of Birth study out of the UK emerged last week in the British Medical Journal.  As I complete a Biostatistics course for my Master’s of Public Health ~ Maternal & Child Health program, I have to admit:  this study, including the wealth of data contained herein, is a smorgasbord for statisticians.  But for those who may not feel naturally inclined toward margins of errors and confidence intervals, interpreting the results of such a study might feel more like a nightmare. While the blogosphere has been philosophically abuzz about this new segment of data looking at the safety of childbirth practices by location, I would like to take a look at this study from a statistics perspective.  In the coming days, we will have another review of this study submitted by evidence-based maternity care expert, medical writer, and speaker Henci Goer.

The study by the Birthplace in England Collaborative Group, Perinatal and Maternal Outcomes by Planned Place of Birth for Healthy Women in Low Risk Pregnancies, is a prospective cohort study conducted through the National Perinatal epidemiology Unit at the University of Oxford.  You may recall that a prospective cohort study is an observational, forward-looking study that follows one or several groups of subjects over a specified period of time.  No assigned interventions or treatments took place as would be typical in a clinical trial. The overall objective of this study was


to compare perinatal outcomes, maternal outcomes, and interventions in labour by planned place of birth at the start of care in labour for women with low risk pregnancies.”


The study authors explain that this study was conducted in response to several others in recent years that aimed to examine the risks and benefits associated with childbirth, relative to location, but failed to assign study groups based on planned rather than eventual place of birth. The ultimate goal of the current study, then, was to


compare intrapartum and early neonatal mortality and specific neonatal morbidities for births planned at home…”


…in the locales detailed below.  To me, this study feels a bit similar to a case-control study as odds ratios are used extensively in the data to determine the likelihood of certain events occurring during the observed births in relation to the birth location.  (Odds ratios are commonly computed for the data of case-controlled studies.)

This study included 64,538 women who gave birth between April 2008 and April 2010 in the UK, and were segmented (not by researchers, but previously by patient choice) into one of four categories:  homebirth, free-standing midwifery centers, “alongside” midwifery units (midwife-attended birth centers within a hospital), and in-hospital obstetrics units.  Remember:  these locations pertain to pre-labour planning and initiation of intrapartum care in terms of where the woman/couple intended to give birth.  The number of birthing women in each subgroup were as follows:


As the data was collected and assimilated, further stratification of the data took place: 1) assessing outcomes of nulliparous vs. multiparous women and 2) women who did, or did not, have a “complicating condition” at the start of care in labor.  These complicating conditions included:

prolonged rupture of membranes                hypertension
amniotic fluid meconium staining             abnormal vaginal bleeding
proteinuria                                                         abnormal fetal heart rate
non-cephalic fetal presentation

Women who underwent elective cesarean sections or unplanned homebirths, as well as those who were not considered “low risk” as defined by the National Institute for Health and Clinical Excellence (NICE) guidelines, were excluded from this study.  These exclusions can be seen as helpful or hindrance, depending upon the results one is interested in.  By deleting planned cesareans, there is some difficulty in being able to completely generalize the results of the data to the whole population where elective cesareans do, of course, take place—including their inherent ratios of primary and secondary outcomes.  However, in an effort to assess outcomes of spontaneous labor and delivery outcomes, it makes sense to exclude this data.  Excluding unplanned homebirths, on the other hand, makes perfect sense to me as most of these types of births are unattended by any sort of maternity care provider, and therefore not applicable in this study design.

Outcomes assessed were broken down into primary and secondary outcomes as follows:

Primary outcomes included*:
Intrapartum stillbirth                                   meconium aspiration syndrome
Early neonatal deaths                                    brachial plexus injury
Neonatal encephalopathy                             fractured humerus or clavicle

Secondary outcomes included*:
spontaneous vertex birth                             syntocin augmentation
ventouse delivery                                           immersion in water for pain relief
forceps delivery                                               epidural or spinal analgesia
intrapartum c-section                                   general anesthesia
3rd or 3th degree perineal tear                   no active management of third stage
blood transfusion                                             episiotomy
admission to higher level of care

*notice, outcomes such as maternal mortality, postpartum hemorrhage and postnatal mood disorders are not included here.

(To access all data tables for this study, go here.)

The summarized results from the study are as follows:
The overall “primary outcomes” incidence for the entire study population was 4.3/1000 births (95% confidence interval of 3.3/1000 – 5.5/1000)  Remember, a confidence interval tells us that we are 95% sure that the true incidence of primary outcomes in the studied population, as predicted by the study data—the “point estimates”—likely falls in the interval of 3.3-5.5/1000 births.)  The incidences for each subgroup were as follows:


And from the study, a summary of the findings, per group, are as follows:

We are also given odds ratios to go along with these figures—helping us to recognize the significance of the primary outcomes, in relation to location of birth.  In essence, an odds ratio greater than 1.0 suggests that “exposure” to a variable of interest (in this case, place of birth) is a risk factor for the outcome(s) of interest.  An odds ratio less than 1.0 suggests that exposure is protective against the outcome(s) of interest.  An odds ratio close to 1.0 suggests no significant associations between exposure and outcome.  Knowing this, let’s look at the (adjusted) odds ratios from this birth place study:

With all these numbers hovering rather close to 1.0 (with the exception of the alongside midwifery units boasting an odds ratio of less than 1.0) we can conclude that birth place may only bear a small amount of responsibility for primary outcomes—as defined in this study—in the homebirth group; negligible effect on the obstetric unit and FMU groups; and a protective effect on the AMU group.  In fact, the study authors concluded that,


Overall, there were no significant differences in the adjusted odds ratios of the primary outcomes for any of the non-obstetric unit settings compared with obstetric units.”

Perhaps the implications made by the adjusted odds ratios would be a bit more powerful, if the study group sizes were more equal (see numbers and percentages of groups above).  And yet, for such an impressively large study, the distribution of the study population amongst the four groups is also rather impressive, considering the distribution of birth locale in the general population, as supplied by study authors: 92% of births in the UK occur within obstetric units and just 8% outside (2.8% at home; 3% in AMUs and <2% in FMUs).

The most striking outcome that anti-homebirth writers are citing as cause for alarm are the numbers for stillbirths, as delineated in the following table:



If you just look at the crude numbers, you will conclude that babies born at home are twice as likely to die during the birth process, compared to babies born in obstetric units.  Perhaps in some places around the world, this might be a very real estimate.  But in this study, we need to remember the difference in subgroup sizes:  there were 2,866 more births in the obstetric units group than in the homebirths group, for example.  So, if we instead look at the incidence of stillbirth between the groups, we get a different picture:


Now, I’m not going to sit here and suggest that even the difference between 0.2 and 0.3 stillbirths/1000 is insignificant…it’s certainly not to the additional three the families who experienced those outcomes.  I don’t think anyone should ever make that claim from an individual perspective.  But, if looking at the data from a statistics perspective—the perspective that informs us when we are advising expectant women/couples on place of birth…or when making our own decisions about birth locale—the incidences are still very low: out of the 16,839 homebirths, the stillbirth ratio for each group was:

Some other interesting numbers that came out in the data are as follows:

The above data suggests that the differences in outcomes between first time (nulliparous) mothers and subsequent (multiparous) mothers are more favorable for women who’ve undergone childbirth previously—regardless of birth location.  The study authors summarize these findings, in terms of policy implications, this way:

“Adverse perinatal outcomes are uncommon in all settings, while interventions during labour and birth are much less common for births planned in non-obstetric unit settings. For nulliparous women, there is some evidence that planning birth at home is associated with a higher risk of an adverse perinatal outcome.”


After reading the study and the statistics, what do you think???


~ Stay tuned for more coverage of this study ~



Posted by:  Kimmelin Hull, PA, LCCE, FACCE

New Research, News about Pregnancy, Practice Guidelines, Pregnancy Complications, Research, Uncategorized , , , , , , , , ,

Home Birth Consensus Summit: Making History and Moving Forward

November 23rd, 2011 by avatar

Last week Congresswoman Lucille Roybal-Allard spoke in the House of Representatives applauding the consensus document produced by the Home Birth Consensus Summit in Warrenton, Va. in October. The document was read into the Congressional Record.   Congresswoman Roybal-Allard noted that history had been made. It certainly has.

Two years of hard work went into the planning of the meeting. The system-wide, and very serious problems related to safety net, consultation, collaboration and referral necessary for safe home births provided the stimulus for the Consensus Summit. Dr. Saras Vedam’s energy, commitment, and relentless conviction that the time was right to bring together stakeholders and leaders with an interest in home birth, provided the momentum that kept the planning committee working, and ultimately convinced an incredibly diverse and committed group of midwives, physicians, nurses, childbirth educators, consumers, lawyers, policy makers, educators, researchers, administrators, and insurance representatives to participate in the Summit. The Summit was not a forum for reviewing, interpreting or debating the research. The Summit did not address the rightness or wrongness of home birth but accepted the reality that home birth is a choice more women are making in the U.S.  There were no papers or presentations. The goal of the Consensus Summit was to find common ground so that home birth is safe and a positive experience for mothers and babies. We had no idea where we were headed except all of us hoped that some common ground could be found.

The invited delegates were in positions to inform and influence a change process, and/or commit to measurable steps within their stakeholder groups. The delegates did not represent any organization but rather attended as individuals. Reading the bios of the delegates provides insight into just how influential this group is and has the potential to be.

Part of the planning involved choosing a setting that would foster collaboration and make the hard work of moving beyond disparate ideas and beliefs easier.  We were invited to set aside our own agendas, and be open to finding common ground. Careful attention was paid to the details. The setting, in rural Virginia, was perfect. The weather was glorious. Excellent food and conversation were shared together at breakfast, lunch and dinner. We got to know each other better over drinks and stories in the pub. We talked into the wee hours on the porch enjoying the cold fall weather, the stars, and the rocking chairs. The distraction of cell phones and email was amazingly minimal!

What was truly historic was not just that people with divergent opinions and beliefs met in the same space but that these remarkable people listened to each other with respect and appreciation of the challenges we all face.  It is easy to be collaborative when everyone is on the same page. But to value each other’s contribution and knowledge when you don’t see eye to eye is much more difficult.  I was humbled by everyone’s willingness to be honest, to listen, and, ultimately, to find common ground.

The reward for the hard work of the two-plus days are nine common ground statements. This is a brief version of the statements. To read the full statements go here.
•    We uphold the autonomy of all childbearing women
•    We believe that collaboration within and integrated maternity care system is essential for optimal mother-baby outcomes. All women and families planning a home or birth center birth have a right to respectful, safe, and seamless consultation, referral, transport and transfer of care when necessary. When ongoing inter-professional dialogue and cooperation occur, everyone benefits.
•    We are committed to an equitable maternity care system without disparities in access, delivery of care, or outcomes. This system provides culturally appropriate and affordable care in all settings, in a manner that is acceptable to all communities.
•    It is our goal that all health professionals who provide maternity care in home and birth center settings have a license that is based on national certification that includes defined competencies and standards for education and practice.
•    We believe that increased participation by consumers in multi-disciplinary stakeholder initiatives is essential to improving maternity care, including the development of high quality home birth services within an integrated maternity care system.
•    Effective communication and collaboration across all disciplines caring for mothers and babies are essential for optimal outcomes across all settings.
•    We are committed to improving the current medical liability system, which fails to justly serve society, families, and health care providers.
•    We envision a compulsory process for the collection of patient (individual) level data on key process and outcome measures in all birth settings.
•    We recognize and affirm the value of physiologic birth for women, babies, families and society and the value of appropriate interventions based on the best available evidence to achieve optimal outcomes for mothers and babies.

These common ground statements are just the beginning.  Those who oppose the option of home birth have been busy blogging. Those who support the value of home birth have too.  And those of us who were there are starting to work with our colleagues, including all of you, to achieve what is set out in the common ground statements. There is a tremendous amount of work to do. Lamaze Board member Betsy Armstrong and I worked on the common ground statement affirming the value of physiologic birth for women, their babies, families and society. We, with our team, are developing action items related to the statement.
Valuing physiologic birth has been the foundation for the vision and hard work of Lamaze International for over 50 years. Childbirth educators can contribute in important ways to helping women and their families value physiologic birth and develop confidence in their ability to give birth. Childbirth educators are in an important position to help women know that they have a right to autonomy in making maternity care decisions, and then to provide the knowledge and support women need as they make decisions not only about place of birth and provider but all maternity care decisions. We need to work tirelessly to make all nine common ground statements “come true.” Keep the momentum going!

Being part of this historic event leaves me wondering if there isn’t a lesson to be learned.  Much about birth is controversial, not just place of birth and provider. Issues like induction, epidural, routine interventions and cesarean surgery are important and controversial. I wonder if finding common ground in these areas would move us beyond differences in thinking and interpretation related to evidence, risk, benefit, liability and “expecting trouble”? What if one common ground statement related to epidural was insuring that women have available a full range of comfort measures to cope with labor? Would finding common ground related to all these issues provide a foundation for finding solutions that make birth safer no matter where it takes place?

Keep checking the home birth summit website for updates on the action plans moving forward.  Jump on the bandwagon and think about ways you can advance these common ground statements.


Saras Vedam looking at  the “mind map” created by the group to identify all the forces that impact home birth. It was part of the process that eventually led to the common ground statements.



Posted by:  Judith Lothian, RN, PhD, LCCE, FACCE


Opportunity to learn more about the NQF process of endorsing Perinatal Care and Reproductive Health quality measures

November 21st, 2011 by avatar

In our past blog posts, Kathleen Pine and I have been writing about the process by which quality measures in perinatal care are developed, endorsed and then adopted by various entities.

The last comprehensive National Quality Forum (NQF) review of Perinatal Measures was in 2008 which endorsed 17 measures, with a few additional relevant measures added during other, subsequent reviews (e.g. Healthy Term Newborn was added as part of the Pediatric Population Review Process in 2009).  As of July 8, 2011, NQF has endorsed 33 consensus standards applicable to perinatal and reproductive health in a number of previous projects.

Currently, the NQF is in the process of measure maintenance and consideration of new measures.   This current project seeks to identify and endorse measures for public reporting and quality improvement addressing reproductive health, pregnancy, childbirth and post-partum care, and newborn care. In addition, this project will include maintenance of previously NQF-endorsed standards in these topic areas.

The candidate measures will be considered for NQF endorsement as voluntary consensus standards. Agreement around the recommendations will be developed through NQF’s formal Consensus Development Process (CDP). This project will involve the active participation of representatives from across the spectrum of healthcare stakeholders and will be guided by a multiple-stakeholder Steering Committee (see below for members of this committee).

In the past month, there has been a series of 4 workgroup meetings, at which all the candidate measures have been discussed.  Agendas from those meetings, and other information about the ongoing process can be found here.

There is an upcoming 2-day steering committee meeting, which is open to NQF members and the public (in person or by phone).  Registration is free, and the link is provided below.


NQF Perinatal Care and Reproductive HealthSteering Committee Meeting 

Register Now

Start: NOV 29, 2011 (9:30am – 5:00pm EST)

End: NOV 30, 2011 (8:00am-4:00pm EST)


The Perinatal & Reproductive Healthcare Steering Committee will meet on November 29-30, 2011 at the National Quality Forum, 1030 15th Street, NW, 9th Floor, Washington DC. We respectfully request that you register so that we can adequately anticipate the number of seats and dial-in lines that will be needed. An agenda will be posted prior to the meeting.


After the steering committee meeting, the draft report is expected to be available for review and comment in January 2012. Member commenting period is 30 days. The public commenting period is 23 days (Jan 16-Feb 7, 2012).  NQF members will vote in late March 2012 with a decision announced in April and board ratification in early May 2012.


For further information, contact Reva Winkler, MD, or Suzanne Theberge, MPH, at 202-783-1300 or via email at perinatal@qualityforum.org.


Listed below are the steering committee members and links to the 33 consensus standards under review.


Perinatal and Reproductive Healthcare Endorsement Maintenance

Steering Committee Member Roster


Joanne Armstrong, MD, MPH
Aetna. Sugarland, TX


Jennifer Bailit, MD, MPH
Case Western Reserve University and MetroHealth Medical Center, Cleveland, OH


Scott Berns, MD, MPH, FAAP     
March of Dimes Foundation and Warren Alpert Medical School of Brown University, White Plains, NY


Jennifer Brandenburg, RN, MSN
Decatur Memorial Hospital, Cerro Gordo, IL


Sarah Brown, MSPH                    
National Campaign to Prevent Teen and Unplanned Pregnancy, Washington, DC


William Callaghan, MD, MPH
Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA


Charles Denk, PhD
New Jersey Department of Health, Trenton, NJ


Elizabeth Drye, MD, SM
Yale/Yale-New Haven Hospital Center for Outcomes Research and Evaluation (CORE) and Yale School of Medicine, New Haven, CT


Andrea Gelzer, MD, MS, FACP
The AmeriHealth Mercy Family of Companies, Philadelphia, PA


Rebekah Gee, MD, MPH, MS       
Louisiana State University (LSU) and Louisiana Department of Health and Hospitals, New Orleans, LA


Craig Gilliam, BSMT, MT (ASCP), CIC
Arkansas Children’s Hospital, Little Rock, AR


Kimberly D. Gregory, MD, MPH  
Cedars-Sinai Medical Center and University of California Los Angeles, Los Angeles, CA


William A. Grobman, MD, MBA  
Northwestern Memorial Hospital, Chicago, IL


Mambarath Jaleel, MD                 
University of Texas Southwestern Medical Center, and Parkland Memorial Hospital, Dallas, TX


Barbara Kelly, MD                        
AF Williams Family Medicine Center, Denver, CO


Teri Kiehn, MS, RNC
Intermountain Healthcare, Salt Lake City, UT


Nancy K. Lowe, CNM                   
University of Colorado College of Nursing, Aurora, CO


Jochen Profit, MD, MPH
Texas Children’s Hospital, Houston, Texas


Laura Riley, MD
Massachusetts General Hospital, Boston, MA


Carol Sakala, PhD, MSPH            
Childbirth Connection, New York, NY


Kathleen Rice Simpson, PhD, RNC, FAAN          
St John’s Mercy Medical Center and Saint Louis University, St. Louis, MO


Sharon Sutherland, MD               
Cleveland Clinic, Cleveland, OH


Robert K. Watson, MD, MMM, CPE           
Andrews Women’s Hospital, Baylor All Saints Medical Center, Dallas, TX


Janet Young, MD                          
Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA




Perinatal and Reproductive Healthcare Endorsement Maintenance Measures Submitted




Posted by:  Christine Morton, PhD and Kathleen Pine, UCI

Conference Schedule, Maternal Quality Improvement , , , , , ,

Preliminary Data is Out: U.S. Sees Drop in C-Section Rate for the First Time in More Than a Decade

November 17th, 2011 by avatar

The news is off the press and circulating the blogosphere:  According to the preliminary 2010 data released by the Centers for Disease Control and Prevention, the U.S. cesarean section rate has actually dropped compared to the finalized 2009 data.  In fact, most of the maternity-related rates have dropped:


 Critics of this change in the c-section rate will argue that a 0.1% drop is hardly anything to get excited about.  But just as a ball tossed into the air with an initial upward momentum, there must be a slight pause in motion before a new direction of momentum can occur.  Perhaps, then, we are at the apex of the c-section rate trajectory, with a change in direction inevitably to follow.  That, I think, is nothing to scoff at.

Many will speculate on the cause of this changed momentum; others will grapple to claim responsibility.  Still, more may claim to “have no idea” why this drop has occurred.  Media sources may cite the overall drop in fertility rate, or teen pregnancy rates as responsible. Clinicians can claim the decreased cesarean rate is due to practice changes.  Normal birth advocates and childbirth educators can claim the change comes from efforts to teach the public about various birthing options—and the dangers of over-using an approach to childbirth that is ideally used more judiciously.  But what of consumers? I hope to see in the coming days, as this piece of news circulates, that the stalled momentum of our nation’s increasing cesarean rates is related, at least in some part, to consumer voice.  Is it possible that, amidst all other influences, the c-section rate dropped (slightly) due to consumer demand for more normal birthing options?  What do you think?


*Our sister blog, Giving Birth With Confidence, posted an excellent piece today about premature birth, in observance of World Prematurity Day—including a great overview of issues pertaining to prematurity which you might find useful for referring your clients/patients to.



Posted by:  Kimmelin Hull, PA, LCCE, FACCE

Cesarean Birth, Pre-term Birth, Uncategorized , , , , , , ,

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