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Practice Variation in Cesarean Rates: Not Due to Maternal Complications

November 13th, 2014 by avatar

By Pam Vireday

Pam Vireday, an occasional contributor to Science & Sensibility reviews the recent study by Katy Kozhimannil, PhD and colleagues that examined the differences in cesarean rates between over a thousand hospitals in the USA.  Consumers of maternity care quite possibly do not realize what a significant impact their choice of facility (and provider) may have on their birth outcome.  Can you think of hospitals in your own community serving similar populations of pregnant families that have drastically different cesarean rates.  Have you considered why that might be?  Do you think that the families you work with have explored this too?  Do they even have access to this information?  Read Pam’s discussion of this recent study below.  - Sharon Muza, Community Manager, Science & Sensibility.

© Patti Ramos Photography

© Patti Ramos Photography

There’s a new study out that discusses the variation in cesarean rates between hospitals in the United States. “Maternal clinical diagnoses and hospital variation in the risk of cesarean delivery: Analyses of a national US hospital discharge database“ was released late last month and has received a lot of press and discussion ever since.

Practice variation is a serious problem in obstetrics (Arcia 2013). Women are often far more at risk for a cesarean in certain hospitals than in others, even when the hospitals serve the same geographical area and population (Arnold, January 2013 and August 2012).

Of course, care providers protest that some hospitals have higher cesarean rates because they serve higher-risk patients. This is a valid point, but it still doesn’t explain the wide variation in rates between many hospitals (Clark 2007).

For example, in a press release about the new study, the mother’s risk status and diagnoses did not explain the variation in cesarean rates between hospitals:

“We found that the variability in hospital cesarean rates was not driven by differences in maternal diagnoses or pregnancy complexity,” said [lead study author] Kozhimannil. “This means there was significantly higher variation in hospital rates than would be expected based on women’s health conditions. On average, the likelihood of cesarean delivery for an individual woman varied between 19 and 48 percent across hospitals.”

Other key points highlighted included:

  • Among lower risk women, likelihood of cesarean delivery varied between 8 and 32 percent across hospitals.
  • Among higher risk women, likelihood of cesarean delivery varied between 56 and 92 percent across hospitals.
  • Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics.

This shows that practice variation in cesarean rates is real, substantive, and not just a reflection of the mother’s risk level. 

Perhaps now we can stop playing the mother blame-game when we talk about cesarean rates? (Declerq 2006, Oganowski 2011)

This study is not the first to show that the culture of a hospital, its policies, and its routine practices all help determine how likely a woman is to “need” a cesarean in that hospital.

For example, Cáceres 2013 found that even after adjusting for socio-demographic and clinical factors and including only NTSV (Nulliparous, Term, Singleton, Vertex) pregnancies, the cesarean rate varied significantly between Massachusetts hospitals, “suggesting the importance of hospital practices and culture in determining a hospital’s cesarean rate.”

In addition, a 2014 consensus statement from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine notes, “Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed.”

Preventing cesareans when possible is important because while cesareans can be life-saving at times, they present more risk for maternal infection, bleeding and blood clots, and more neonatal breathing problems (Liu 2007, Visser 2014).

Notably, a large case-control study in U.K. maternity units found that delivery by cesarean was a strong risk factor for severe sepsis (Acosta 2014). Other research has found a high rate of maternal complications (Pallasmaa 2010) and poorer neonatal outcomes (Kolås 2006) associated with cesareans.

In addition, a cesarean’s potential negative effect on future pregnancies is important (Silver 2012). One American study found that the rate of an abnormal placental attachment increased in conjunction with the rise in cesarean delivery rate (Wu 2005), while a Canadian study found that a prior cesarean was associated with an increased risk for adverse neonatal outcomes in subsequent pregnancies (Abenhaim and Benjamin 2011).

Bottom line, it matters where and with whom a woman gives birth in order to lessen the risk for complications, both now and in the future.

But many women naively choose their care provider for pregnancy based mostly on convenience and location, not realizing that their chances of surgical birth may vary greatly depending on which hospital and caregiver they use (Arnold 2014, Arnold January 9 2013).

Childbirth Connection, a leading consumer education site, points out:

Research suggests that the same woman might have a c-section at one hospital but a vaginal birth if she gave birth at another, just because of the different policies and practices of those hospitals. One of the most effective ways to lower your chance of having a c-section is to have your baby in a setting with a low c-section rate.

Yet it is not always easy to find out the cesarean rates of local hospitals in some areas. For example, the health departments of Missouri, South Carolina, and Washington D.C. do not make hospital-level cesarean rates available to consumers.

Hospitals remain largely unaccountable for high cesarean rates, although we are beginning to see marginal progress in some places towards more accountability (Gentry 2014 and Dekker 2014). In the meantime, however, thousands of women are undergoing cesareans, many of which might be preventable with changes in clinical practices (Boyle 2013).

And even when a cesarean is truly necessary, there can be large discrepancies in complications afterwards between hospitals (Alonso-Zaldivar 2014). It’s not just about how many cesareans are done, but also about which hospitals have the best outcomes when a cesarean is done. Without more information, how is a woman to know which hospital to choose?

Bottom line, more transparency and accountability are needed. As the lead author of the study states:

Women deserve evidence-based, consistent, high-quality maternity care, regardless of the hospital where they give birth…and these results indicate that we have a long way to go toward reaching this goal in the U.S.

*To search for hospital-level cesarean rates in your area, see www.cesareanrates.com or the 2014 Consumer Reports article (subscription required) rating hospitals in 22 states.

Do you ever encourage your students and clients to look at the cesarean rates (and rates of other interventions which may lead to cesareans) of the hospitals they are considering birthing in.  Please share your experience in our comments section. – SM

References

Abenhaim, H. A., & Benjamin, A. (2011). Effect of prior cesarean delivery on neonatal outcomes. Journal of perinatal medicine39(3), 241-244. PMID: 21426242

Acosta, C. D., Kurinczuk, J. J., Lucas, D. N., Tuffnell, D. J., Sellers, S., & Knight, M. (2014). Severe Maternal Sepsis in the UK, 2011–2012: A National Case-Control Study. PLoS medicine11(7), e1001672. PMID: 25003759

Alonso-Zaldivar, R (2014, August 27). Study: Wide hospital quality gap on maternity care. Retrieved from http://www.fosters.com/apps/pbcs.dll/article?AID=/20140827/GJLIFESTYLES/140809539/0/SEARCH.

Arcia, A (2013, February 3). What is practice variation in obstetrics and why should I care? Retrieved from http://www.cesareanrates.com/blog/2013/2/3/what-is-practice-variation-in-obstetrics-and-why-should-i-ca.html.

Arnold, J (2012, August 22). Practice variation in New Jersey: 27 miles and 28 percentage points. Retrieved from http://www.cesareanrates.com/blog/2012/8/22/practice-variation-in-new-jersey-27-miles-and-28-percentage.html.

Arnold, J (2013, January 9). Practice variation in East Los Angeles cesarean rates. Retrieved from http://www.cesareanrates.com/blog/2013/1/9/practice-variation-in-east-los-angeles-cesarean-rates.html.

Arnold, J (2013, January 7). Practice variation in West Virginia: 60 miles and 54 percentage points. Retireved from http://www.cesareanrates.com/blog/2013/1/7/practice-variation-in-west-virginia-60-miles-and-54-percenta.html.

Arnold, J (2014, March 13). Three miles/Cinco Kilometros. Retrieved from http://www.cesareanrates.com/blog/2014/3/13/three-miles-cinco-kilometros.html.

Boyle, A., Reddy, U. M., Landy, H. J., Huang, C. C., Driggers, R. W., & Laughon, S. K. (2013). Primary cesarean delivery in the United States. Obstetrics & Gynecology122(1), 33-40. PMID: 23743454

Cáceres IA, Arcaya M, Declercq E, Belanoff CM, Janakiraman V, Dohen B, Ecker J, Smith LA, Subramanian SV (2013). Hospital differences in cesarean deliveries in Massachusetts (US) 2004-2006: the case against case-mix artifact. PLOS One, 8(3):e57817. doi: 10.1371/journal.pone.0057817. PMID:23526952

Clark SL, Belfort MA, Hankins GD, Meyers JA, Houser FM (2007). Variation in the rates of operative delivery in the United States. American journal of obstetrics and gynecology, 196(6):526.e1-526.e5.  PMID: 17547880

Caughey, A. B., Cahill, A. G., Guise, J. M., & Rouse, D. J. (2014). Safe prevention of the primary cesarean delivery. American journal of obstetrics and gynecology,210(3), 179-193. doi: 10.1016/j.ajog.2014.01.026. PMID:24565430

Declercq, E., Menacker, F., & MacDorman, M. (2006). Maternal risk profiles and the primary cesarean rate in the United States, 1991–2002. American journal of public health, 96(5), 867. PMID: 16571712

Dekker, R (2014, October 29). U.S. hospitals held accountable for C-section rates. Retrieved from http://www.birthbythenumbers.org/?p=1731

DePoint, M (2014, October 22). Maternal diagnoses doesn’t explain variation in cesarean rates across US hospitals. University of Minnesota, School of Public Health. Retrieved from http://sph.umn.edu/maternal-diagnoses-doesnt-explain-variation-cesarean-rates-across-us-hospitals/.

Gentry, C (2014, May 14). FL still C-section hotspot. Retrieved from http://health.wusf.usf.edu/post/fl-still-c-section-hotspot.

Kolås, T., Saugstad, O. D., Daltveit, A. K., Nilsen, S. T., & Øian, P. (2006). Planned cesarean versus planned vaginal delivery at term: comparison of newborn infant outcomes. American journal of obstetrics and gynecology,195(6), 1538-1543. PMID: 16846577

Kozhimannil KB, Arcaya MC, Subramanian SV (2014). Maternal clinical diagnoses and hospital variation in the risk of cesarean delivery: Analyses of a national US hospital discharge database.  PLoS medicine, 11(10):e1001745. doi: 10.1371/journal.pmed.1001745. PMID: 25333943

Liu, S., Liston, R. M., Joseph, K. S., Heaman, M., Sauve, R., & Kramer, M. S. (2007). Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. Canadian medical association journal176(4), 455-460. PMID: 17296957

Oganowski, K (2010, January 13). The C-section blame game: I’ve reached my boiling point. Retrieved from http://birthingbeautifulideas.com/?p=1245.

Pallasmaa, N., Ekblad, U., AITOKALLIO‐TALLBERG, A. N. S. A., Uotila, J., Raudaskoski, T., ULANDER, V., & Hurme, S. (2010). Cesarean delivery in Finland: maternal complications and obstetric risk factors. Acta obstetricia et gynecologica Scandinavica89(7), 896-902. PMID: 20583935

Phend, C (2013, March 5). C-Section rates vary widely between hospitals, study finds. MedPage Today. Retrieved from http://abcnews.go.com/Health/section-rates-vary-widely-hospitals-study-finds/story?id=18656847.

Silver, R. M. (2012, October). Implications of the first cesarean: perinatal and future reproductive health and subsequent cesareans, placentation issues, uterine rupture risk, morbidity, and mortality. In Seminars in perinatology (Vol. 36, No. 5, pp. 315-323). WB Saunders. PMID: 23009962

Visser GH (2014). Women are designed to deliver vaginally and not by Cesarean section: An obstetrician’s view. Neonatology, 107(1):8-13. PMID: 25301178

What every pregnant woman needs to know about Cesarean section (2012). Childbirth Connection. Retrieved from http://www.childbirthconnection.org/pdfs/cesareanbooklet.pdf.

What hospitals don’t want you to know about C-sections (2014, May). Consumer Reports. Retrieved from http://consumerreports.org/cro/2014/05/what-hospitals-do-not-want-you-to-know-about-c-sections/index.htm.

Wu, S., Kocherginsky, M., & Hibbard, J. U. (2005). Abnormal placentation: twenty-year analysis. American journal of obstetrics and gynecology192(5), 1458-1461. PMID: 15902137

A version of this post originally appeared on www.wellroundedmama.blogspot.com

About Pam Vireday

Painting by Mary Cassatt, 1844-1926. (public domain) Image from Wikimedia Commons.

Pam Vireday is a childbirth educator, writer, woman of size, and mother to four children. She has been collecting the stories of women of size and writing about childbirth research for 17 years. She writes at www.wellroundedmama.blogspot.com and www.plus-size-pregnancy.org.

 

Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, Medical Interventions, New Research, Research , , , , ,

Epidural Analgesia: To Delay or Not to Delay, That Is the Question

October 23rd, 2014 by avatar

By Henci Goer

Unless you have been “off the grid” on a solitary trek, surely you have read and heard the recent flurry of discussion surrounding the just released study making the claim that the timing of when a woman receives an epidural (“early” or “late” in labor) made no difference in the rate of cesarean delivery.  Your students and clients may have been asking questions and wondering if the information is accurate.  Award winning author and occasional Science & Sensibility contributor Henci Goer reviews the 9 studies that made up the Cochrane systematic review: Early versus late initiation of epidural analgesia for labour to determine what they actually said.  Read her review here and share if you agree with all the spin in the media about this new research review. Additionally, head on over to the professional and parent Lamaze International sites to check out the new infographic on epidurals to share with your students and clients.- Sharon Muza, Science & Sensibility Manager. 

Epidural infographic oneArticles have been popping up all over the internet in recent weeks citing a new Cochrane systematic review- Early versus late initiation of epidural analgesia for labour, concluding that epidural analgesia for labor needn’t be delayed because early initiation doesn’t increase the likelihood of cesarean delivery, or, for that matter, instrumental vaginal delivery (Sng 2014). The New York Times ran this piece. Some older studies have found that early initiation appeared to increase likelihood of cesarean (Lieberman 1996; Nageotte 1997; Thorp 1991), which is plausible on theoretical grounds. Labor progress might be more vulnerable to disruption in latent than active phase. Persistent occiput posterior might be more frequent if the woman isn’t moving around, and fetal malposition greatly increases the likelihood of cesarean and instrumental delivery. Which is right? Let’s dig into the review.

The review includes 9 randomized controlled trials of “early” versus “late” initiation of epidural analgesia. Participants in all trials were limited to healthy first-time mothers at term with one head-down baby. Five trials further limited participants to women who began labor spontaneously, three mixed women being induced with women beginning labor spontaneously, and in one, all women were induced. Analgesia protocols varied, but all epidural regimens were of modern, low-dose epidurals. So far, so good.

Examining the individual trials, though, we see a major problem. You would think that the reviewers would have rejected trials that failed to divide participants into distinct groups, one having epidural initiation in early labor and the other in more advanced labor, since the point of the review is to determine whether early or late initiation makes a difference. You would think wrong. Of the nine included trials, six failed to do this.

cc photo bryanrmason http://flickr.com/photos/b-may/397189835

cc photo bryanrmason http://flickr.com/photos/b-may/397189835

The two Chestnut trials (1994a; 1994b) had the same design, differing only in that one was of women who were laboring spontaneously at trial entry and the other included women receiving oxytocin for induction or augmentation. Women were admitted to the trial if they were dilated between 3 and 5 cm. Women in the early group got their epidural immediately while women in the late group could have an epidural only if they were dilated to 5 cm or more. If late-group women were not dilated to 5 cm, they were given systemic opioids and could have a second dose of opioid one hour later. They could have an epidural when they attained 5 cm dilation or regardless of dilation, an hour after the second opioid dose. Let’s see how that worked out.

Among the 149 women in the trial that included women receiving oxytocin (Chestnut 1994b), median dilation in the early group at time of epidural initiation was 3.5 cm, meaning that half the women were dilated more and half less than this amount. The interquartile deviation was 0.5 cm, which means that values were fairly tightly clustered around the median. The authors state, however, that cervical dilation was assessed using 0.5 increments which meant that dilation of 3-4 cm was recorded as 3.5. In other words, women in the early group might have been dilated to as much as 4 cm. The median dilation in the late group was 5.0 cm, again with a 0.5 cm interquartile deviation. Some women in the late group, therefore, were not yet dilated to 5 cm when their epidural began, and, in fact, the authors report that 26 of the 75 women (35%) in the late group were given their epidural after the second dose of opioid but before attaining 5 cm dilation. The small interquartile deviation in the late group tells us that few, if any, women would have been dilated much more than 5 cm. Add in that assessing dilation isn’t exact, so women might have been a bit more or less dilated than they were thought to be, and it becomes clear that the “early” and “late” groups must have overlapped considerably. Furthermore, pretty much all of them were dilated between 3 and 5 cm when they got their epidurals, which means that few of these first-time mothers would have been in active labor, as defined by the new ACOG standards.

Overlap between early and late groups must have been even greater in Chestnut et al.’s (1994a) trial of 334 women laboring spontaneously at trial entry because median dilation in the early group was greater than in the other trial (4 cm, rather than 3.5) while median dilation in the late group was the same (5.0 cm), and interquartile deviation was even tighter in the late group (0.25 cm, rather than 0.5 cm). As before, dilation was measured in 0.5 cm increments, which presumably means that women in the early group dilated to 4-5 cm would have been recorded as “4.5,” thereby qualifying them for the “early” group even though they might have been as much as 5 cm dilated.

Based on my analysis, I would argue that there was no clinically meaningful difference in dilation between early and late groups in either trial.

A second pair of trials, one a mixed trial of spontaneous labor onset and induction and the other all induced, also had the same design in both trials (Wong 2005; Wong 2009). All women were less than 4 cm dilated at first request for pain medication. In the early group, women had an opioid injected intrathecally, i.e. the “spinal” part of a combined spinal-epidural, and an epidural catheter was set. At the second request, an epidural was initiated. In the late group, women were given a systemic opioid. At second request, they were given a second dose of systemic opioid if they hadn’t reached 4 cm dilation and an epidural if they had dilated to 4 cm or more. At third request, they were given an epidural regardless of dilation. Women who had no vaginal exam at second request and were given an epidural were “assumed,” in the authors’ words, to be dilated to at least 4 cm. What were the results?

Wong (2005) included 728 women, some beginning labor spontaneously and some induced. You may already have noticed the flaw in the trials’ design: Wong and colleagues confused the issue by considering intrathecal opioid to be equivalent to epidural anesthetic in the early group, although women didn’t actually receive anesthetic until their second request for pain medication some unknown time later. So far as I know we have no evidence that opiods, spinal or epidural, have any effect on labor progress. As to dilation at the time of epidural initiation, 63% of women in the so-called “early” group were either determined or assumed to be at 4 cm dilation or more while in the late group, some unknown proportion were less than 4 cm dilated either because they got their epidural at third pain medication request regardless of dilation or they were assumed to be at 4 or more cm dilation at second request, but weren’t assessed.

Wong (2009), a study of 806 induced women, was set up the same way but reported data somewhat differently. Early-group women were administered a spinal opioid at a median of 2 cm dilation and an interquartile range of 1.5 to 3 cm, which means that values in the middle 50% of the dataset ranged from 1.5 to 3 cm. We have no information on dilation at the time they received their epidural. The median dilation at which late-group women had their epidural initiated was 4 cm with an interquartile range of 3 to 4 cm, that is, in the middle 50% of the dataset ranged from 3 to 4 cm dilation.

As with the Chestnut trials, dilation at time of epidural initiation in the two Wong trials must have overlapped considerably between groups. And, again, few women in the late epidural group would have been in active labor. The Wong trials, however, muddy the waters even further by considering spinal opioid to be the same thing as epidural anesthetic, and while the authors were careful to use the term “neuraxial analgesia,” the Cochrane reviewers made no such distinction.

This brings us to Parameswara (2012), a trial of 120 women that included both spontaneous onset and induced labors. This trial defined the early group as women less than 2 cm dilated at time of epidural initiation and the late group as women more than 2 cm dilated. That’s all the information they provide on group allocation.

Last of the six, we have Wang (2011), a trial of 60 women in spontaneous labor. All women were given intrathecal anesthetic plus opioid. The early group was started on epidural anesthetic plus opioid 20 minutes later whereas the late group had their epidural initiated when they requested additional pain relief. No information is given on dilation at time of epidural initiation. Not only do we have no idea whether early and late groups differed from one another, women in both groups received neuraxial anesthetic at the same time.

In summary, “garbage in, garbage out.” No conclusions can be drawn about the effect of early versus late epidural administration from these six studies.

The other three studies are a different story. They achieve a reasonable separation between groups. Luxman (1998) studied 60 women with spontaneous labor onset. The early group had a mean, i.e., average, dilation of 2.3 cm with a standard deviation of + or – 0.6 cm while the late group had a mean dilation of 4.5 cm + or – 0.2 cm. Ohel (2006) studied a mixed spontaneous onset and induced group of 449 women. The mean dilation at initiation in the early group was 2.4 cm with a standard deviation of 0.7 cm, and the late group had a mean dilation of 4.6 cm with a standard deviation of 1.1 cm. Wang (2009), the behemoth of the trials, included 12,629 women who began labor spontaneously. The early epidural group had a median dilation of 1.6 cm with an interquartile range of 1.1 to 2.8 and the late group a median of 5.1 cm dilation with an interquartile range of 4.2 to 5.7. Cesarean and instrumental delivery rates were similar between early and late groups in all three trials, so had reviewers included only these three trials, they would still have arrived at the same conclusion: early epidural initiation doesn’t increase likelihood of cesarean and instrumental delivery.

We’re not done, though. Wang (2009) points us to a second, even bigger issue.

The Wang (2009) trial, as did all of the trials, limited participants to healthy first-time mothers with no factors that would predispose them to need a cesarean. The Wang trial further excluded women who didn’t begin labor spontaneously. Nevertheless, the cesarean rate in these ultra-low-risk women was an astonishing 23%. Comparing the trials side-by-side reveals wildly varying cesarean and instrumental vaginal delivery rates in what are essentially homogeneous populations.

© Henci Goer

© Henci Goer

© Henci Goer

© Henci Goer

Comparing the trials uncovers that epidural timing doesn’t matter because any effect will be swamped by the much stronger effect of practice variation.

Analysis of the trials teaches us two lessons: First, systematic reviews can’t always be taken at face value because results depend on the beliefs and biases that the reviewers bring to the table. In this case, they blinded reviewers from seeing that two-thirds of the trials they included weren’t measuring two groups of women, one in early- and one in active-phase labor. Second, practice variation can be an unacknowledged and potent confounding factor for any outcome that depends on care provider judgment.

Conclusion

So what’s our take home? Women need to know that with a judicious care provider who strives for spontaneous vaginal birth whenever possible, early epidural administration won’t increase odds of cesarean or instrumental delivery. With an injudicious one, late initiation won’t decrease them. That being said, there are other reasons to delay an epidural. Maternal fever is associated with epidural duration. Running a fever in a slowly progressing labor could tip the balance toward cesarean delivery as well as have consequences for the baby such as keeping the baby in the nursery for observation, testing for infection, or administering prophylactic IV antibiotics. Then too, a woman just might find she can do very well without one. Epidurals can have adverse effects, some of them serious. Comfort measures, cognitive strategies, and all around good emotionally and physically supportive care don’t. Hospitals, therefore, should make available and encourage use of a wide range of non-pharmacologic alternatives and refrain from routine practices that increase discomfort and hinder women from making use of them. Only then can women truly make a free choice about whether and when to have an epidural.

After reading Henci’s review and the study, what information do you feel is important for women to be aware of regarding epidural use in labor?  What will you say when asked about the study and timing of an epidural?  You may want to reference a previous Science & Sensibility article by Andrea Lythgoe, LCCE, on the use of the peanut ball to promote labor progress when a woman has an epidural. – SM 

References

Caughey, A. B., Cahill, A. G., Guise, J. M., & Rouse, D. J. (2014). Safe prevention of the primary cesarean delivery. American journal of obstetrics and gynecology210(3), 179-193.

Chestnut, D. H., McGrath, J. M., Vincent, R. D., Jr., Penning, D. H., Choi, W. W., Bates, J. N., & McFarlane, C. (1994a). Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are in spontaneous labor? Anesthesiology, 80(6), 1201-1208. http://www.ncbi.nlm.nih.gov/pubmed/8010466?dopt=Citation

Chestnut, D. H., Vincent, R. D., Jr., McGrath, J. M., Choi, W. W., & Bates, J. N. (1994b). Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are receiving intravenous oxytocin? Anesthesiology, 80(6), 1193-1200. http://www.ncbi.nlm.nih.gov/pubmed/8010465?dopt=Citation

Lieberman, E., Lang, J. M., Cohen, A., D’Agostino, R., Jr., Datta, S., & Frigoletto, F. D., Jr. (1996). Association of epidural analgesia with cesarean delivery in nulliparas. Obstet Gynecol, 88(6), 993-1000. http://www.ncbi.nlm.nih.gov/pubmed/8942841

Luxman, D., Wolman, I., Groutz, A., Cohen, J. R., Lottan, M., Pauzner, D., & David, M. P. (1998). The effect of early epidural block administration on the progression and outcome of labor. Int J Obstet Anesth, 7(3), 161-164. http://www.ncbi.nlm.nih.gov/pubmed/15321209?dopt=Citation

Nageotte, M. P., Larson, D., Rumney, P. J., Sidhu, M., & Hollenbach, K. (1997). Epidural analgesia compared with combined spinal-epidural analgesia during labor in nulliparous women. N Engl J Med, 337(24), 1715-1719. http://www.ncbi.nlm.nih.gov/pubmed/9392696?dopt=Citation

Ohel, G., Gonen, R., Vaida, S., Barak, S., & Gaitini, L. (2006). Early versus late initiation of epidural analgesia in labor: does it increase the risk of cesarean section? A randomized trial. Am J Obstet Gynecol, 194(3), 600-605. http://www.ncbi.nlm.nih.gov/pubmed/16522386?dopt=Citation

Parameswara, G., Kshama, K., Murthy, H. K., Jalaja, K., Venkat, S. (2012). Early epidural labour analgesia: Does it increase the chances of operative delivery? British Journal of Anaesthesia 108(Suppl 2):ii213–ii214. Note: This is an abstract only so all data from it come from the Cochrane review.

Sng, B. L., Leong, W. L., Zeng, Y., Siddiqui, F. J., Assam, P. N., Lim, Y., . . . Sia, A. T. (2014). Early versus late initiation of epidural analgesia for labour. Cochrane Database Syst Rev, 10, CD007238. doi: 10.1002/14651858.CD007238.pub2 http://www.ncbi.nlm.nih.gov/pubmed/25300169

Thorp, J. A., Eckert, L. O., Ang, M. S., Johnston, D. A., Peaceman, A. M., & Parisi, V. M. (1991). Epidural analgesia and cesarean section for dystocia: risk factors in nulliparas. Am J Perinatol, 8(6), 402-410. http://www.ncbi.nlm.nih.gov/pubmed/1814306?dopt=Citation

Wang, F., Shen, X., Guo, X., Peng, Y., & Gu, X. (2009). Epidural analgesia in the latent phase of labor and the risk of cesarean delivery: a five-year randomized controlled trial. Anesthesiology, 111(4), 871-880. http://www.ncbi.nlm.nih.gov/pubmed/19741492?dopt=Citation

Wang, L. Z., Chang, X. Y., Hu, X. X., Tang, B. L., & Xia, F. (2011). The effect on maternal temperature of delaying initiation of the epidural component of combined spinal-epidural analgesia for labor: a pilot study. Int J Obstet Anesth, 20(4), 312-317. http://www.ncbi.nlm.nih.gov/pubmed/21840705

Wong, C. A., McCarthy, R. J., Sullivan, J. T., Scavone, B. M., Gerber, S. E., & Yaghmour, E. A. (2009). Early compared with late neuraxial analgesia in nulliparous labor induction: a randomized controlled trial. Obstet Gynecol, 113(5), 1066-1074. http://www.ncbi.nlm.nih.gov/pubmed/19384122?dopt=Citation

Wong, C. A., Scavone, B. M., Peaceman, A. M., McCarthy, R. J., Sullivan, J. T., Diaz, N. T., . . . Grouper, S. (2005). The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. N Engl J Med, 352(7), 655-665. http://www.ncbi.nlm.nih.gov/pubmed/15716559?dopt=Citation

About Henci Goer

Henci Goer

Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach She is the winner of the American College of Nurse-Midwives “Best Book of the Year” award. An independent scholar, she is an acknowledged expert on evidence-based maternity care.  

Cesarean Birth, Childbirth Education, Epidural Analgesia, Guest Posts, informed Consent, Medical Interventions, New Research, Systematic Review , , , , , , ,

Updated “Birth By The Numbers” – A Valuable Tool for Childbirth Educators and Others

October 2nd, 2014 by avatar

birth by numbers header

One of the highlights of my attendance at the joint Lamaze International/DONA International Confluence in Kansas City, MO last month was the opportunity to hear Eugene Declercq, PhD, present a plenary session entitled “What Listening to Mothers Can Tell Us about the Future Challenges in US Maternity Care.”  Dr. Declercq is a professor of Maternal and Infant Health at Boston University School of Public Health. It is always a true pleasure to listen to Dr Declercq, not only for his delightful Boston accent, but also for the creative and impactful way that he shares data and facts about the state of maternity care, primarily in the United States.

declercq-headshotThis presentation was no exception and Dr. Declercq helped conference attendees to tease apart the information gleaned from the most recent Listening to Mothers III study, and look at this information  in relationship to data from the two previous Listening to Mothers studies.

Dr. Declercq reminded those of us in the audience that the most recent update of “Birth by the Numbers” was just made available on the Birth by the Numbers website.  I am a huge fan of the previous versions of this short film, that highlighted statistics on how the United States is doing on several key maternal and infant indicators in relation to other nations around the world.  The information continues to be both eye opening and sobering at the same time.  I encourage you to view the most recent edition included here.

I have seen Teri Shilling, the director of Passion for Birth, one of the Lamaze Accredited Childbirth Educator Programs, use the Birth by the Numbers video in a very clever way when training both doulas and childbirth educators.  This learning activity could also be adapted to use in your childbirth class.  Teri provides a worksheet with many of the important statistics that Dr. Declercq shares in his video, listed out.  The learner must watch the video and assign the correct definition to each relevant number listed.  It helps the viewer to really capture the significance of the different numbers, when they are closely listening for each one and then the video can be debriefed as a group.

Dr. Declercq’s website has tons of useful information that you can take into the classroom.  I subscribe to/follow the blog on his website and look forward to new articles when they come out.   Dr. Declercq also generously shares PowerPoint slides on both the “Birth by the Numbers” presentation as well as “Cesarean Birth Trends” that educators can freely use in their own classroom.

Should you be interested in maps and details on the cesarean birth trends for several other countries, including Australia, Brazil and Germany, that information is provided along with a state by state breakdown.

You can also find the updated Birth by the Numbers video on the Lamaze websites for professionals and for parents.

If you have not seen them, I also really enjoy Dr. Declercq’s  videos “The Truth about C-Sections” and “Debunking the Myth: Home Births are Dangerous” published in cooperation with Mothers Naturally

One last fun fact – did you know that Dr. Gene Declercq is a Lamaze Certified Childbirth Educator!   Thanks Dr. Declercq for all you do to get solid data to all of us in fun and informative ways.  I appreciate it.

A challenge for you! How might you use the information in the updated video and on the Birth by the Numbers website in your childbirth class, with doula clients or with the patients you care for?  Do you have any teaching ideas that you would like to share with Science & Sensibility readers?  I would love to hear your creative ideas and I know others would too.  Sharing teaching tips helps all of us become better educators.

 

 

2014 Confluence, Cesarean Birth, Childbirth Education, Films about Childbirth, Lamaze International, Maternal Mortality, Maternal Mortality Rate, Maternal Quality Improvement, New Research, Research , , , ,

Intrapartum Antibiotics for GBS Positive Mothers – Still Clear as Mud

September 30th, 2014 by avatar

 In July, 2009, former blog community manager Amy Romano wrote about the Cochrane systematic review of intrapartum antibiotics for mothers with GBS colonization.  The researchers recently went back and did another review of for new literature and updated their research.  Melissa Garvey of the American College of Nurse-Midwives updated the original article with recent information from the June 2014 review and I wanted to share that with you now.- Sharon Muza, Community Manager, Science & Sensibility.

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© Wikipedia

But sometimes Cochrane reviews leave us with more questions than answers.

Last June, the Cochrane Library released a systematic review evaluating the effectiveness of intrapartum antibiotics for known maternal group B streptococcal (GBS) colonization. And it’s a hot mess.

The 4 included trials that compared IV antibiotics with no treatment in labor collectively had only 852 participants, which we automatically know is far too small to find statistically significant differences in a condition that affects 1 in 2000 newborns, and results in death or long-term complications even less frequently. But small sample sizes were the least of the problems here. The reviewers noted several other problems with the trials:

  • In one study, researchers tracked their findings and halted the trial as soon as a significant difference was found (favoring treatment with antibiotics). This is a blatant form of bias – it is like flipping a penny until you get heads 5% more often than you got tails. If you keep flipping long enough (or stop flipping soon enough) you’ll be able to find that 5% difference simply by chance.
  • In the same study, researchers changed to a different statistical test that allowed them to achieve statistical significance with their data, when the originally planned (and more appropriate) test would have produced a nonsignificant finding.
  • None of the studies used placebos, so women, care providers, and hospital staff knew which women received antibiotics and which did not. This may have altered treatment of the women or the babies, possibly in ways that would make no antibiotics appear safer (for instance, avoiding or delaying membrane rupture in a woman who is GBS+ but not getting antibiotics).
  • One study excluded women who developed fevers in labor. GBS colonization can cause maternal fever and newborn sepsis, so excluding these cases makes no sense.
  • Some women included in the studies were likely GBS negative because methods used to determine GBS status were inadequate.
  • Outcomes were poorly defined.
  • Data on a substantial proportion of women and babies were missing.
  • Groups were mysteriously differently sized.
  • Need I go on?

The Cochrane reviewers, in my opinion, did a respectable job with what they had, but what they had was garbage and as the saying goes, “Garbage in, garbage out.” You can’t make reliable conclusions out of a bunch of bad research, even if you’re a Cochrane reviewer.

So what were the findings? Three trials, which were more than 20 years old, compared ampicillin or penicillin to no treatment and found no clear differences in newborn deaths although the occurrence of early GBS infection in the newborn was reduced with antibiotics.

More, better research is needed, but the Cochrane reviewers are not optimistic:

Ideally the effectiveness of IAP to reduce neonatal GBS infections should be studied in adequately sized double-blind controlled trials. The opportunity to conduct such trials has likely been lost, as practice guidelines (albeit without good evidence) have been introduced in many jurisdictions.

In the meantime, women should be aware that other evidence, albeit not from randomized controlled trials, suggests that antibiotic treatment reduces deaths from early onset GBS disease in newborns. According to the Centers for Disease Control and Prevention, a steady decline in GBS disease has been seen in individual institutions, in the whole US population, and in other countries as antibiotic use has risen. But these population-level data cannot tell us whether antibiotics or some other factor caused the decline.

What other advice can we share with women?

  1. Be aware that antibiotics are not harmless. Severe allergic reactions are possible, and antibiotic use in labor can result in thrush (candida infection) which causes painful breastfeeding and sometimes early weaning. We do not know other possible harmful effects because they have never been studied adequately or at all.
  2. No study confirms the effect of labor practices on GBS infection in newborns, but here we can use our common sense. Care providers should avoid or minimize sweeping/stripping membranes before labor, breaking the bag of waters, vaginal exams, and other internal procedures, especially those that break the baby’s skin and can be a route for infection. These include internal fetal scalp electrodes for fetal heart rate monitoring and fetal blood sampling.
  3. Keep mothers and babies skin-to-skin after birth. This exposes the baby to beneficial bacteria on the mother’s skin, facilitates early breastfeeding, and lowers the likelihood that the baby will exhibit signs or symptoms that mimic infection, such as low temperature or low blood sugar, which could cause the need for blood tests or spinal taps to rule out infection.

If you would like additional information about GBS treatment, check out Science & Sensibility’s interview with Rebecca Dekker of EvidenceBasedBirth.com and Rebecca’s article “Group B Strep in Pregnancy: Evidence for Antibiotics and Alternatives.”

Reference

Ohlsson A, Shah VS. Intrapartum antibiotics for known maternal Group B streptococcal colonization. Cochrane Database of Systematic Reviews 2014, Issue 6. Art. No.: CD007467. DOI: 10.1002/14651858.CD007467.pub4

Thank  you to Melissa Garvey of ACNM for her reworking of the original article.

 

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Evidence on Water Birth Safety – Exclusive Q&A with Rebecca Dekker on her New Research

July 10th, 2014 by avatar

 

Evidence Based Birth , a popular blog written by occasional Science & Sensibility contributor Rebecca Dekker, PhD, RN, APRN, has just today published a new article, “Evidence on Water Birth Safety“ that looks at the current research on the safety of water birth for mothers and newborns.  Rebecca researched and wrote that article in response to the joint Opinion Statement “Immersion in Water During Labor and Delivery” released in March, 2014 by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics.  I had the opportunity to ask Rebecca some questions about her research into the evidence available on water birth, her thoughts on the Opinion Statement and her conclusions after writing her review. – Sharon Muza, Science & Sensibility Community Manager.

Sharon Muza: First off, is it waterbirth or water birth?

Rebecca Dekker: That’s actually good question! Research experts tend to use the term “waterbirth.” Google prefers “water birth.” So I used both terms in my article to satisfy everyone!

SM: Have you heard or been told of stories of existing water birth programs shutting down or being modified as a result of the recent AAP/ACOG opinion?

RD: Yes, definitely. There was a mother in my state who contacted me this spring because she was 34 weeks pregnant and her hospital decided not to offer waterbirth anymore. She had given birth to her daughter in a waterbirth at the same hospital two years earlier. With her current pregnancy, she had been planning another hospital waterbirth. She had the support of her nurse midwife, the hospital obstetricians, and hospital policy. However, immediately after the release of the ACOG/AAP opinion, the hospital CEO put an immediate stop to waterbirth. This particular mother ended up switching providers at 36 weeks to a home birth midwife. A few weeks ago, she gave birth to her second baby, at home in the water. This mother told me how disheartening it was that an administrator in an office had decided limit her birth options, even though physicians and midwives at the same hospital were supportive of her informed decision to have a waterbirth.

In another hospital in my hometown, they were gearing up to start a waterbirth program this year—it was going to be the first hospital where waterbirth would be available in our city—and it was put on hold because of the ACOG/AAP Opinion.

Then of course, there were a lot of media reports about various hospital systems that suspended their waterbirth programs. One hospital system in particular, in Minnesota, got a lot of media coverage.

SM: Did you attempt to contact ACOG/AAP with questions and if so, did they respond?

RD: Yes. As soon as I realized that the ACOG/AAP Opinion Statement had so many major scientific errors, I contacted ImprovingBirth.org and together we wrote two letters. I wrote a letter regarding the scientific problems with the Opinion Statement, and ImprovingBirth.org wrote a letter asking ACOG/AAP to suspend the statement until further review. The letters were received by the President and President-Elect of ACOG, and they were forwarded to the Practice Committee. We were told that the Practice Committee would review the contents of our letters at their meeting in mid-June, and that was the last update that we have received.

SM: What is the difference between an “Opinion Statement” and other types of policy recommendations or guidelines that these organizations release? Does it carry as much weight as practice bulletins?

RD: That’s an interesting question. At the very top of the Opinion Statement, there are two sentences that read: “This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.” But, as you will see, some hospitals do see this statement as dictating an exclusive course of treatment, and others don’t.

I have heard that “opinions” do not carry as much weight as “practice bulletins,” but it really depends on who the audience is and who is listening. In other words, some hospitals may take the Opinion Statement word-for-word and feel that they must follow it to the letter, and other hospitals may ignore it. A lot of it probably depends on the advice of their risk management lawyers.

For example, a nurse midwife at a hospital in Illinois sent me a letter that their risk-management attorneys had put together to advise them on this issue. (She had the attorney’s permission to share the letter with me). These lawyers basically said that when a committee of two highly-respected organizations says that the practice of waterbirth should be considered an experimental procedure, both health care providers and hospitals are “charged with a duty to heed that statement,” unless they find research evidence that waterbirth has benefits for the mother or fetus, and that the evidence can override the Committee’s conclusions.

On the other hand, another risk management lawyer for a large hospital system told me that of course hospitals are not under any obligation to follow an ACOG/AAP Opinion Statement. It’s simply just that—an opinion.

So as to how much weight the Opinion Statement carries—I guess it is really dependent on who is reading it!

SM: How would you suggest a well-designed research study be conducted to examine the efficacy and safety of waterbirth? Or would you say that satisfactory research already exists.

RD: First of all, I want to say that I’m really looking forward to the publication of the American Association of Birth Centers (AABC) data on nearly 4,000 waterbirths that occurred in birth centers in the U.S., to see what kind of methods they used. From what I hear, they had really fantastic outcomes.

And it’s also really exciting that anyone can join the AABC research registry, whether you practice in a hospital, birth center, or at home. The more people who join the registry, the bigger the data set will be for future research and analysis. Visit the AABC PDR website to find out more.

I think it’s pretty clear that a randomized trial would be difficult to do, because we would need at least 2,000 women in the overall sample in order to tell differences in rare outcomes. So instead we need well-designed observational studies.

My dream study on waterbirth would be this: A large, prospective, multi-center registry that follows women who are interested in waterbirth and compares three groups: 1) women who have a waterbirth, 2) women who want a waterbirth and are eligible for a waterbirth but the tub is not available—so they had a conventional land birth, 3) women who labored in water but got out of the tub for the birth. The researchers would measure an extensive list of both maternal and fetal outcomes.

It would also be interesting to do an additional analysis to compare women from group 2 who had an epidural with women from group 1 who had a waterbirth. To my knowledge, only one study has specifically compared women who had waterbirths with women who had epidurals. Since these are two very different forms of pain relief, it would be nice to have a side-by-side comparison to help inform mothers’ decision making.

SM: What was the most surprising finding to you in researching your article on the evidence on water birth safety?

RD: I guess I was most surprised by how poorly the ACOG/AAP literature review was done in their Opinion Statement. During my initial read of it, I instantly recognized multiple scientific problems.

A glance at the references they cited was so surprising to me—when discussing the fetal risks of waterbirth, they referenced a laboratory study of pregnant rats that were randomized to exercise swimming in cold or warm water! There weren’t even any rat waterbirths! It was both hilarious and sad, at the same time! And it’s not like you have to read the entire rat article to figure out that they were talking about pregnant rats—it was right there in their list of references, in the title of the article, “Effect of water temperature on exercise-induced maternal hyperthermia on fetal development in rats.”

These kind of mistakes were very surprising, and incredibly disappointing. I expect a lot higher standards from such important professional organizations. These organizations have a huge influence on the care of women in the U.S., and even around the world, as other countries look to their recommendations for guidance. The fact that they were making a sweeping statement about the availability of a pain relief option during labor, based on an ill-researched and substandard literature review—was very surprising indeed.

SM: What was the most interesting fact you discovered during your research?

RD: With all this talk from ACOG and the AAP about how there are “no maternal benefits,” I was fascinated as I dug into the research to almost immediately find that waterbirth has a strong negative effect on the use of episiotomy during childbirth.

Every single study on this topic has shown that waterbirth drastically reduces and in some cases completely eliminates the use of episiotomy. Many women are eager to avoid episiotomies, and to have intact perineums, and waterbirth is associated with both lower episiotomy rates and higher intact perineum rates. That is a substantial maternal benefit. It’s kind of sad to see leading professional organizations not even give the slightest nod to waterbirth’s ability to keep women’s perineums intact.

In fact, I’m puzzled as to why keeping women’s perineums intact and uncut is not perceived as a benefit by anyone other than the women themselves. And here is the heart of declaring waterbirth as “not having enough benefits” to justify its use: Who decides the benefits? Who decides what a benefit is, if not the person benefitting? Who should be weighing the potential harms and the potential benefits of waterbirth, and making an informed decision about their options? Should it be the mother? Or should it be the obstetrician?

SM: What can families do if they want waterbirth to be an option in their local hospital or birth center and it has been taken away or not even ever been offered before?

RD: That’s a hard question. It’s a big problem.

Basically what it boils down to is this—there are a lot of restraining forces that keep waterbirth from being a pain relief option for many women. But there are also some positive driving forces. According to change theory, if you want to see a behavior change at the healthcare organization level, it is a matter of decreasing the restraining forces, while increasing the driving forces. Debunking the ACOG/AAP Opinion Statement is an important piece of decreasing restraining forces. On the other side, increasing consumer pressure can help drive positive change.

SM: Do you think that consumers will be responding with their health dollars in changing providers and facilities in order to have a waterbirth?

RD: I think that if a hospital offered waterbirth as an option to low-risk women, that this could be a huge marketing tool and would put that hospital at an advantage in their community, especially if the other hospitals did not offer waterbirth.

SM: The ACOG/AAP opinion sounded very reactionary, but to what I am not sure. What do you think are the biggest concerns these organizations have and why was this topic even addressed? Weren’t things sailing along smoothly in the many facilities already offering a water birth option?

RD: I don’t know if you saw the interview with Medscape, but one of the authors of the Opinion Statement suggested that they were partially motivated to come out with this statement because of the increase in home birth, and they perceive that women are having a lot of waterbirths at home.

I also wonder if they are hoping to leverage their influence as the FDA considers regulation of birthing pools. You may remember that in 2012, the FDA temporarily prohibited birthing pools from coming into the U.S. Then the FDA held a big meeting with the different midwifery and physician organizations. At that meeting, AAP and ACOG had a united front against waterbirth. So I guess it’s no surprise for them to come out with a joint opinion statement shortly afterwards.

My sincere hope is that the FDA is able to recognize the seriously flawed methods of the literature review in this Opinion Statement, before they come out with any new regulations.

SM: How should childbirth educators be addressing the topic of waterbirth and waterbirth options in our classes in light of the recent ACOG/AAP Opinion Statement and what you have written about in your research review on the Evidence on Water Birth Safety?

RD: It’s not an easy subject. There are both pros and cons to waterbirth, and it’s important for women to discuss waterbirth with their providers so that they can make an informed decision. At the same time, there are a lot of obstetricians who cannot or will not support waterbirth because of ACOG’s position. So if a woman is really interested in waterbirth, she will need to a) find a supportive care provider, b) find a birth setting that encourages and supports waterbirth.

You can’t really have a waterbirth with an unwilling provider or unwilling facility. Well, let me take that back… you can have an “accidental” waterbirth… but unplanned waterbirths have not been included in the research studies on waterbirth, so the evidence on the safety of waterbirth does not generalize to unplanned waterbirths. Also, you have to ask yourself, is your care provider knowledgeable and capable of facilitating a waterbirth? It might not be safe to try to have an “accidental” waterbirth if your care provider and setting have no idea how to handle one. Do they follow infection control policies? Do they know how to handle a shoulder dystocia in the water?

SM: What kind of response do you think there will be from medical organizations and facilities as well as consumers about your research findings?

RD: I hope that it is positive! I would love to see some media coverage of this issue. I hope that the Evidence Based Birth® article inspires discussion among care providers and women, and among colleagues at medical organizations, about the quality of evidence in guidelines, and their role in providing quality information to help guide informed decision-making.

SM: Based on your research, you conclude that the evidence does not support universal bans on waterbirth. Is there anything you would suggest be done or changed to improve waterbirth outcomes for mothers or babies?

RD: The conclusion that I came to in my article—that waterbirth should not be “banned,” is basically what several other respected organization have already said. The American College of Nurse Midwives, the American Association of Birth Centers, the Royal College of Obstetricians and Gynaecologists, and the Royal College of Midwives have all said basically the same thing.

How can we improve waterbirth outcomes? I think continuing to be involved in clinical research studies (such as the AABC registry) is an important way to advance the science and provide evidence on which we can base practice and make more informed decisions with. Also, conducting clinical audits (tracking outcomes) in facilities that provide waterbirth would be important for quality control.

SM: Let’s look into the future. What is next on your plate to write about?

RD: I recently had a writing retreat with several amazing clinicians and researchers who flew from across the country to conduct literature reviews with me. We made an awesome team!! The topics that we have started looking at are: induction for post-dates, induction for ruptured membranes, and evidence-based care for women of advanced maternal age. I can’t decide which one we will publish first! The Evidence Based Birth readers have requested AMA next, but the induction for ruptured membranes article is probably further along than that one. We shall see!!

SM: Is there anything else you would like to share with Science & Sensibility readers on this topic?

RD: Thanks for being so patient with me! I know a lot of people were eagerly awaiting this article, and I wish it could have come out sooner, but these kinds of reviews take a lot of time. Time is my most precious commodity right now!

Has the recent Opinion Statement released by ACOG/AAP impacted birth options in your communities?  Do you discuss this with your clients, students and patients?  What has been the reaction of the families you work with? Let us know below in the comments section! – SM.

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