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April is Cesarean Awareness Month – Resources and a Test Your Knowledge Quiz

April 10th, 2014 by avatar

fb profile cam 2014April is Cesarean Awareness Month, an event meant to direct the American public’s attention to the United States’ high cesarean rate. 32.8% of all birthing women gave birth by cesarean in 2012. A cesarean delivery can be a life-saving procedure when used appropriately, but it takes one’s breath away when you consider that one third of all women birthing underwent major abdominal surgery in order to birth their babies.

Professionals that work with women during the childbearing year can be a great resource for women, pointing them to evidence based information, support groups and organizations that offer non-biased information to help women lower their risk of cesarean surgery, receive support after a cesarean and work towards a trial of labor after a cesarean (TOLAC) and achieve a vaginal birth after a cesarean (VBAC) for subsequent births if appropriate.

Here are my top suggestions for websites and resources every birth professional should have on their short list to share with students and clients when it comes to cesarean awareness.

1. International Cesarean Awareness Network – an international organization with almost 200 volunteer led chapters, (most in the USA) offering peer to peer support for cesarean recovery and VBAC information by way of a website, e-newsletters, webinars, online forums, Facebook groups and monthly meetings in the community.

2. VBACFacts.com – Led by birth advocate Jen Kamel, this website is big on research and helps consumers and professionals alike understand the evidence and risks and benefits of both repeat cesareans and vaginal birth after cesarean, including vaginal birth after multiple cesareans.

3. Lamaze International’s “Push for Your Baby” – is a great resource for families to learn about the Six Healthy Care Practices, what evidence based care looks like and how to work with your health care provider to advocate for a safe and healthy birth. Also Lamaze has an wonderful infographic that can be shared online or printed.

4. Spinning Babies – Midwife Gail Tully really knows her stuff when it comes to helping babies navigate the pelvis during labor and birth. Many cesareans are conducted for “failure to progress” or “cephalopelvic disproportion” when really it is a case of a malpositioned baby who needed to be in a different position. This website is a wealth of information on what women can do to help their babies into the ideal position to be born, prenatally and during labor. It includes valuable information about helping a breech baby turn vertex. This is important, because finding a health care provider who will support vaginal breech birth is like finding a needle in a haystack.

© Patti Ramos Photography

© Patti Ramos Photography

5. Childbirth Connection – This website is a virtual goldmine of evidence based information about cesareans and VBACs including a valuable guide “What Every Pregnant Woman Needs to Know about Cesareans.” There are questions to ask a care provider and includes information on informed consent and informed refusal.

6. Cesareanrates.com is a great website run by Jill Arnold for those who love the numbers. Find out the cesarean rates of hospitals in your area. All the states are represented and families can use the information when searching out a provider and choosing a facility. Jill’s resource page on this site is full of useful information as well.

7. Safe Prevention of the Primary Cesarean –  The American Congress of Obstetricians and Gynecologists along with the Society for Maternal Fetal Medicine recently published a groundbreaking document aimed at reducing the first cesarean. While fairly heavy reading, there is so much good information in this committee opinion that I believe every birth professional should at least take a peek. You may be pleasantly surprised.

Test your knowledge of the facts around cesareans and VBACs with this informative quiz:

As a birth professional, you can be a great resource for all your clients, helping them to prevent their first cesarean, providing support if they do birth by cesarean and assisting them on the journey to VBAC by pointing them to these valuable resources. You can make every day “Cesarean Awareness Day” for the families you work with, doing your part to help the pendulum to swing in the other direction, resulting in a reduction in our national cesarean rates and improving outcomes for mothers and babies. What are your favorite resources on the topic of cesareans and VBACs? Share with us in the comments section.
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Assessing Birth Settings to Improve Value and Optimize Outcomes in U.S. Maternity Care

March 12th, 2013 by avatar

by Wendy Gordon, CPM, LM, MPH, MANA Division of Research, Assistant Professor, Bastyr University Dept of Midwifery

Today, occasional contributor, midwife and researcher Wendy Gordon, LM, CPM, MPH, Midwives Alliance Division of Research, shares some insights into some of the fascinating discussions that took place at last week’s Institute of Medicine’s workshop focusing on birth place settings.  From all reports from the many people in attendance, this workshop will hopefully help move the research and discussion on the topic of birth place settings forward and create opportunities for more families to chose to birth where they feel most comfortable and safe. – Sharon Muza, Community Manager, Science & Sensibility

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Hannah Russell-Davis nurses her newborn son
©photo by Michael Davis http://getprivatepractice.com

Last week marked an historic opportunity for maternity care providers to regroup and become inspired to move our professions forward together in all birth settings.  The two-day event, hosted by the prestigious Institute of Medicine (IOM) and sponsored by the W.K. Kellogg Foundation, focused on “Research Issues in the Assessment of Birth Settings” and brought together the greatest minds in research and practice in all three birth settings: home, birth center and hospital.  Issues of tremendous importance to consumers, providers and researchers in the birth community were discussed in a collegial and inspiring manner… marred only by one presentation that stirred a bit of controversy.

Historic Workshop Can Positively Impact Future Research 

Similar to the first IOM conference on this topic over 30 years ago, the intent of last week’s gathering was to discuss the research regarding the effect of place of birth on maternal and infant outcomes. Invited speakers included researchers, public health professionals, midwives, nurses, pediatricians and obstetricians.  In structured mini-sessions, panelists shared their expertise on the following topics:

  • the historical and current picture of who is giving birth in the different settings;
  • definitions of “low-risk” versus “high-risk”;
  •  what the best research says about safety in various settings; 
  • education, regulation and management of different types of providers;
  •  methods of collection and use of data regarding maternity care and birth in various settings; 
  •  cost and value differences between settings and reimbursement issues; and 
  • the rich and varied perspectives of providers in the three childbirth settings.

Members of the audience were just as impressive as the panelists themselves when, at the end of each panel, the microphone was opened and significant content was added through their questions and comments.  

A lot of ground was covered over the course of the two days, and there were several takeaways that had particular impact for the midwifery community. The home birth rate in the U.S. was predicted to continue its rise with the next release of CDC data, reaching about 31,500 births nationwide in 2010. The MANA Stats web-based system was touted by attendees as the best data collection system for home birth outcomes.  Birth certificate data was shown to still have major problems in its ability to accurately capture intended place of birth and other reliability issues, despite improvements in recent years.  A Medicaid study from Washington State demonstrated vast cost savings with midwifery care and birth at home and in birth centers.  The workshop report will have tremendous potential to impact contemporary birth policy and research agendas.

Lack of Consumer Representation and Little Discussion of Health Disparities

There was no consumer representation on workshop panels, nor was there a panel addressing disparities in maternal and infant outcomes, which seems to have been a grave oversight of the organizers.  In the 30 years since the last IOM workshop on birth settings, overall infant mortality has been reduced from 11.5/1000 to 6.7/1000, but the black-white gap has actually increased. In 1982, nearly twice as many babies born to black mothers than white mothers died before their first birthday (19.6 infant deaths per 1000 births vs 10.1/1000; National Center for Health Statistics, 1986). Recent mortality figures show that disparity to be even wider (12.67/1000 vs 5.52/1000; Mathews & MacDorman, 2012).

Hannah Russell-Davis holds her son Jack, moments after his birth at their home in Charlottesville, VA. Jack was Hannah’s third home birth.
© photo by Michael Davis http://getprivatepractice.com

With childbirth in home and birth center settings gaining momentum nationally and at the state level, research to support policy in this direction is more important than ever. The best research has shown for decades, and continues to show, that for women with low-risk pregnancies, birth that is planned to occur in the home and birth center settings with a skilled midwife is no more risky than birth in the hospital and results in far fewer interventions, lower cost and higher satisfaction (Vedam et al, 2012).  Hopefully, the breadth of this research can finally start to expand beyond proving that it is safe.

‘Recrudescence’ Revisited

Despite this body of literature, there are still some physicians who persist in torturing the data in an attempt to frame their personal opinions as “science.”  It was disappointing, although perhaps not surprising, to see Dr. Frank Chervenak use his time on the provider panel to do just that. The American Journal of Obstetrics and Gynecology recently published an article authored by Dr. Chervenak regarding the “recrudescence of homebirth” (Chervenak et al, 2013), and perhaps it was the controversy stirred by that article that prompted the conference organizers to invite him to speak on this panel. The panel members included Dr. Chervenak as a hospital-based provider, Karen Pelote, CNM with the birth center provider perspective, and Brynne Potter, CPM as a homebirth provider.  Both Pelote and Potter appeared to have taken seriously the purpose of their panel representation and showcased the data on our client-centered models of care, with photos and quotes from women regarding the care they received and their experiences in the birth center and home settings.   

In stark contrast, Chervenak used his 12 minutes (out of 10) that were to be devoted to the hospital provider perspective for, instead, a rapid-fire display of “back-of-the-envelope” bar graphs attempting to show home/hospital differences in 5-minute Apgar scores using raw data drawn from birth certificates.  Since it appears that some doctors are having a hard time getting their “research” on this topic published in peer-reviewed journals, they are presenting their data in settings that do not require peer-review, such as last year’s annual conference of the Society of Maternal-Fetal Medicine (the study still hasn’t been published) and this IOM workshop.  Meanwhile, there are several well-designed studies published in peer-reviewed journals that show that there is no difference in 5-minute Apgar scores between home and hospital settings (Hutton et al, 2009; Janssen et al, 2009; van der Kooy et al, 2011).

Apgar Distribution Hospital vs. Home © Dr. Frank Chervenak 2013

That a professional invited to contribute to a high-level workshop about research would present an un-peer-reviewed thesis based on unreliable data, lacking any statistical analysis, is… well, let’s just say “puzzling.”  Exploiting the concept of “relative risk,” Chervenak sliced and diced the data in more ways than were thought possible to suggest that babies born at home were more likely to have a low 5-minute Apgar score than babies born in the hospital.

“Home Births Should Not Happen”

Chervenak’s non-reviewed data did find a higher rate of Apgar scores of “10” in the home setting versus “9” in the hospital setting. His point? Not that, clinically speaking, there is no difference between a score of 9 vs. 10 (they’re both good). Not that babies might possibly be doing better due to normal physiologic labor and undisturbed birth and that we should explore this further. Instead, he suggested – at this historic setting – that midwives lie about Apgar scores because “no one is watching.”  After a day and a half of earnest, interprofessional collegiality, Chervenak wrapped up his extended presentation with his unabashed opinion: “Home births should not happen.”

Epidemiologists in the room were quick to step to the microphone for the open discussion part of the panel, pointing out the many flaws in Chervenak’s presentation.  Marian MacDorman, Ph.D., senior statistician and researcher for the CDC’s National Center for Health Statistics, reminded everyone that birth certificate data is notoriously unreliable for neonatal seizures and low Apgar scores; this has been shown time and again for decades and had indeed been discussed earlier in this very workshop.  More importantly, McDorman stated that data from birth certificates cannot be used to make comparisons between settings or providers.  Her point, which deserves some elaboration here, is that there is a very important distinction between “absolute risk” and “relative risk,” and different types of data are better than others depending on what you are trying to describe. 

“When we limit access to certain birth settings because of risk, are we examining the risks of the alternative?” – Brynne Potter, CPM

Absolute vs. Relative Risk

Let’s say that a person’s odds of getting struck by lightning in a heavily populated city are one in a million, and those same odds in a rural area are five in a million. These odds are called your “absolute risk” of being struck by lightning. Another way to look at this is to say that a person’s odds of being struck by lightning are five times higher in a rural area than in a densely-populated area; this is the “relative risk” of a lightning strike in one area over another.

A common approach of anti-homebirth activists is to use the “relative risk” approach and ignore the absolute risk, because it’s much more dramatic and sensationalistic to suggest that the risk of something is “double!” or “triple!” that of something else, even though the absolute risk of those things are very low and may not even be statistically significantly different from each other.  Of course, any infant or maternal mortality is a tragedy.  But one of the key points raised at the IOM workshop was the idea that, in our efforts to identify “safety” with one indicator (mortality) or “truly low-risk” pregnancies by their absence of a particular factor (breech position, for example), we often fail to quantify all of the impacts of the various settings in ways that are meaningful to the women who experience the outcomes, such as the fact that in many areas, the only option for breech delivery is cesarean or the only way a VBAC can happen is at home, attended or not.  As Brynne Potter asked last week: when we limit access to certain birth settings because of risk, are we examining the risks of the alternative?

To return to the lightning analogy, it would be deeply disingenuous for a person to say that you shouldn’t move to a rural area simply because your risk of being struck by lightning is five times higher, without mentioning that at worst, that risk is five in a million. The ethics of this are further called into question when the person suggesting this is a trusted care provider, and is even worse when that person withholds all information about your option to move to a rural area — disregarding all of your other reasons for wanting to doing so — because they have decided that the risk of being hit by lightning there is too high for you.

Clarifying the Validity of Birth Certificate Data

Dr. MacDorman clarified how to interpret the data for anyone who might have been misled by Dr. Chervenak’s slides. She pointed out that regarding low Apgar scores, “the absolute risk is low; that’s all you can say with vital data.”  It doesn’t happen very often in any setting; most studies on homebirth around the world report the occurrence of low Apgar scores (<7) in the range of 1%, and very low scores (<4) are even rarer.  Studies have shown that the more rare an occurrence is, the less likely it is to be captured accurately on the birth certificate (Northam & Knapp, 2006).

Overall, the Midwives Alliance Division of Research (DOR) and other organizations working to improve maternity care are pleased with the near-consensus viewpoint by the majority of the disciplines represented at this workshop: that normal physiologic birth is best for mother and baby and should be the goal of all settings and practitioners.  We are looking forward to the future research inspired by this event.  We believe that there is potential for there to be more movement in the next 30 years than there was since the last IOM workshop on this topic 30 years ago, particularly because of the availability of high-quality datasets such as MANA Stats (primarily planned home births) and the American Association of Birth Centers’ Uniform Data Set (primarily planned birth center births).  As the stewards of the largest database on midwifery care and outcomes of normal physiologic birth in the home setting, the DOR encourages researchers to apply for the MANA Stats data to conduct this important research (application information at mana.org/DOR). 

References:

Chervenak FA, McCullough LB, Brent RL, Levene MI, Arabin B. 2013. Planned home birth: The professional responsibility response. AJOG 208(1):31-38.

Hutton EK, Reitsma AH, Kaufman K. 2009. Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: A retrospective cohort study. BIRTH 36(3):180-189.

Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee SK. 2009. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ, doi:10.1503/cmaj.081869.

Mathews, TJ & MacDorman, M. 2012. National Vital Statistics Reports: Infant mortality statistics from the 2008 period linked birth/ infant death data set. Available online at http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_05.pdf

National Center for Health Statistics. 1986. Vital Statistics of the United States, 1982, Vol II: Mortality, Part A. DHHS Pub. No. (PHS) 86-1122. Public Health Service: Washington. U.S. Government Printing Office.

Northam S, Knapp TR. 2006. The reliability and validity of birth certificates. J Obstet Gynecol Neonatal Nurs 35(1):3-12.

van der Kooy J, Poeran J, de Graaf JP, Birnie E, Denktas S, Steegers EAP, Bonsel GJ. 2011. Planned home compared with planned hospital births in the Netherlands: Intrapartum and early neonatal death in low-risk pregnancies. Obstet Gynecol 118:1037-46.

Vedam S, Schummers L, Stoll K, Fulton C. 2012. Home Birth: An Annotated Guide to the Literature.  Available online at http://mana.org/DOR/research-resources/.

About Wendy Gordon

Wendy Gordon, LM, CPM, MPH is a midwife, mother and educator in the Seattle area.  She helped to build a busy, blended homebirth practice of nurse-midwives and direct-entry midwives in Portland, Oregon for eight years before recently transitioning to Seattle.  She is a Coordinating Council member of the Midwives Alliance Division of Research, a board member of the Association of Midwifery Educators, and teaches at the Bastyr University Department of Midwifery.

 

 

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Obstetricians Claim Homebirth is Unsafe…Again. Where’s The Evidence?

November 29th, 2012 by avatar

by Wendy Gordon, LM, CPM, MPH, Midwives Alliance Division of Research

Today, midwife and researcher, Wendy Gordon, LM, CPM, MPH, Midwives Alliance Division of Research, takes a look at the recent article in the American Journal of Obstetrics and Gynecology that shared the authors’ view of the appropriate professional response from obstetricians when counseling and discussing home birth with patients.  Was this article based on good science?  Accurate and accepted studies? Did the authors selectively choose their sources and ignore other research that may have supported a different viewpoint?  Wendy shares information and research that invites consideration and discussion of the validity of the authors’ opinion. – Sharon Muza, Community Manager.

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flickr.com/photos/bogofoo/4118547231/

Recently, an article in the American Journal of Obstetrics & Gynecology pled with obstetricians to not support planned home birth in any way, and even suggested that those who do “should be subject to peer review and justifiably incur professional liability and sanction from state medical boards” (1).  In their strongly worded opinion, the authors (the first two of whom are, curiously, members of the journal’s Advisory Board, and four of whom are also board members of the International Society of Fetus as a Patient) make their case that physicians should provide evidence-based information to women that planned home birth is not safe, that reports of patient satisfaction are overrated, that it’s actually not cost-effective, and that a pregnant woman has a moral duty to her fetus to give up her autonomy to her doctor’s judgment on this issue.  Let’s take a look at the basis for these recommendations.

Although there are many high-quality studies of home birth on which Chervenak et al. could have based their opinions, they led with the ACOG statement (2) that rests on the findings of the Wax et al. meta-analysis (3), which relied heavily on a study that included unplanned home births in its findings of neonatal mortality rates (4).  Many strong critiques of the Wax analysis have been published (5-11), including an unbiased look from someone who has no stake in the home birth debate.  The authors cited several more poor-quality studies, as well as 52 citations of commentaries, opinions and anecdotes (some even pulled from the popular media) to build their “evidence” basis. They conveniently ignored the large and growing body of literature that continues to show that planned home birth with qualified and experienced midwives holds no greater risk of perinatal mortality than birth in the hospital, and in fact results in far fewer interventions and lower risk of maternal and perinatal morbidity.

Here are some of the high-quality studies that Chervenak et al. did not cite in developing their opinion of the “professional responsibility response”:

  • two systematic reviews (12-13) and a meta-analysis (14) of home and birth center safety studies that all show that there is no greater perinatal risk for planned, attended home births than for hospital births, and significantly fewer interventions;
  • the only large-scale, high-quality study of Certified Professional Midwives (CPMs) in the U.S. that described intrapartum and neonatal death rates as similar to other studies of low-risk home and hospital births (15);
  •  other high-quality U.S. studies that show no difference in perinatal mortality between planned home and hospital births (16-18);
  • several high-quality Canadian studies confirming no difference in the rates of perinatal death between planned home and hospital birth with much lower rates of both interventions and adverse outcomes (19-21);
  •  a huge Dutch study of over half a million births that shows no difference in perinatal mortality rates or NICU admissions between planned home and hospital births (22);
  • another Dutch study that shows no difference in perinatal mortality and lower risk of interventions and other adverse outcomes, particularly for multips (23);
  • large, high-quality U.K. studies that show no difference in perinatal mortality rates and lower risk of both interventions and adverse outcomes (24-25); and
  • a German study that shows no difference in rates of perinatal mortality and lower risk of interventions and adverse outcomes (26).

The authors then go on to discount the evidence of higher satisfaction among women choosing to deliver at home, as well as the cost-effectiveness of doing so, while presenting absolutely no evidence to the contrary.  The authors reference a study in the Netherlands where the transport rate from home to hospital is over twice that in the U.S. (and where Chervenak et al. took great liberties in interpreting the results on patient satisfaction) and a U.K. study where the costs of home and hospital birth are virtually equivalent.  While consistent, this approach to selectively reviewing the evidence and generalizing the findings to the U.S. maternity care system is disingenuous and deliberately misleading to American obstetricians and their patients.  A Washington State study of Medicaid patients planning a home birth with Licensed Midwives showed a savings of nearly $3 million, including the increased cost of those who transferred care and/or site of delivery (27).  This analysis did not attempt to account for the vast cost reductions of potentially avoided interventions, including cesareans and their complications, which would make the case for the cost-effectiveness of midwifery-led care in Washington State even stronger.  It is puzzling that Chervenak et al. did not cite this study, which is recent, took place in the U.S., was conducted by unbiased health-economics consultants, and directly addresses one of their four concerns.

The authors’ main argument against the proven cost-effectiveness of planned home birth is that “the lifetime costs of supporting the neurologically disabled children who will result from planned home birth” have not been factored in, nor have the supposedly increased rates of death.  If one accepts the conclusions of the enormous body of literature that finds no difference in perinatal mortality rates or other adverse outcomes between planned, midwife-attended home births and hospital births, then the pursuit of this line of reasoning is a non-starter.

The U.S. continues to lag behind many other high- and low-resource countries in accepting the evidence of the vast benefits of midwifery care.  The U.K.’s National Health Service has encouraged women to plan home births with midwives for several years; the Netherlands has always acknowledged midwives as the primary care provider in the childbearing year; New Zealand’s system similarly places midwives at the forefront of maternity and newborn care; Japan has a long tradition of midwifery-led care.  Most recently, British Columbia Health Minister MacDiarmid, accepting the evidence of safety, patient satisfaction and cost-effectiveness, has announced government support for women with low-risk pregnancies to plan a home birth, including support for physicians to become appropriately trained to attend home births (28).  But the medical associations of the U.S. continue to erect barriers to the type of interprofessional collaboration that has resulted in the excellent outcomes of these other countries.  The Chervenak et al. article is clearly intended to be yet another of those barriers.

In the centerpiece of the AJOG article, Chervenak cites himself an astounding 15 times in justifying why the rights of a pregnant woman to make autonomous decisions for herself and her baby should be relegated to her doctor’s judgment of what’s right for the “fetus as a patient,” grounded firmly, of course, in the aforementioned “evidence.”  In an astonishing disregard for shared decision-making and informed choice, Chervenak et al. state that “in a professional relationship, the physician’s integrity justifiably limits the woman’s rights by limiting the scope of clinically reasonable alternatives.”  The authors’ repeated and unusual use of the word “recrudescence” when referring to home birth, which reveals their perception of the choice as a disease or disorder, and their stubborn contempt for high-quality evidence if it disproves their opinion, exposes their intent and certainly calls into question their “integrity.”

“Professional responsibility” demands that we dare to examine the evidence that does not agree with our personal beliefs.  It requires that we allow the volumes of high-quality evidence to seep into our analysis of reality and into our presentation of true informed choice to our patients.  “Professional responsibility” demands that we examine and disclose our own personal, religious or anecdotal beliefs that may bias our interpretation and presentation of the research.  And it requires that we refuse to cloak those personal beliefs as “evidence” and “integrity” and by so doing avoid an abuse of power in relationship with our patients.

References

1. Chervenak F. A., McCullough L. B., Brent R. L., Levene M. I., & Arabin B. (2012) Planned home birth: the professional responsibility response. Am J Obstet Gynecol, Nov 13. doi:10.1016/j.ajog.2012.10.002. [Epub ahead of print].

2. American College of Obstetricians and Gynecologists. (2011). Committee Opinion no. 476. Committee on Obstetric Practice. Planned home birth. Obstet Gynecol, 117(2, part 1), 425-8.

3. Wax J. R., Lucas F. L., Lamont M., Pinette M. G., Cartin A., & Blackstone J. (2010).  Maternal and newborn outcomes in planned home birth vs. planned hospital births: a metaanalysis. Am J Obstet Gynecol, 203(3):243.e1–243.e8. doi:10.1016/j.ajog.2010.05.028

4. Pang J. W., Heffelfinger J. D., Huang G. J., Benedetti T. J., & Weiss N. S. (2002). Outcomes of planned home births in Washington state: 1989-1996. Obstet Gynecol, 100(2):253-9. http://dx.doi.org/10.1016/S0029-7844(02)02074-4

5. Carl M. A., Janssen P. A., Vedam S., Hutton E. K., & de Jonge A. (2011). Planned home vs hospital birth: A meta-analysis gone wrong. Medscape Ob/Gyn & Wom Health. Retrieved from http://www2.cfpc.ca/local/user/files/%7B1E683014-14EB-489F-99CE-B5A2185A6FC5%7D/Medscape%20%20Wax%20Critique%20-%20Michal,%20Janssen,%20Vedam,%20Hutton,%20de%20Jonge.pdf

6. Gyte G., Newburn M., & Macfarlane A. (2010). Critique of a meta-analysis by Wax and colleagues which has claimed that there is a three-times greater risk of neonatal death among babies without congenital anomalies planned to be born at home. National Childbirth Trust. Retrieved from http://www.scribd.com/doc/34065092/Critique-of-a-metaanalysis-by-Wax

7. Keirse M. J. (2010). Home birth: Gone away, gone astray, and here to stay. Birth, 37(4):341-46.

8. Hayden E. C. (2011). Home birth study investigated. Nature [Epub]. doi:10.1038/news.2011.162.

9. American College of Nurse Midwives. (2010). ACNM expresses concerns regarding recent AJOG publication on home birth. [Epub]. Retrieved from http://www.midwife.org/documents/ACNMstatementonAJOG2010.pdf.

10. Romano A. (2010). Meta-analysis: the wrong tool (wielded improperly). Retrieved from http://www.scienceandsensibility.org/?p=1349.

11. Dekker R. & Lee K. S. (2012). The Wax home birth meta-analysis: an outsider’s critique. Retrieved from http://www.scienceandsensibility.org/?p=5628.

12. Olsen O. & Clausen J. A. (2012). Planned hospital birth versus planned home birth. Cochrane Database of Systematic Reviews, Issue 9. Art. No.: CD000352. doi: 10.1002/14651858.CD000352.pub2.

13. Leslie M. S. & Romano A. (2007). Appendix: Birth can safely take place at home and in birthing centers. J Perinat Educ, 16(Suppl 1):81S-88S. doi:10.1624/105812407X173236

14. Olsen O. (1997). Meta-analysis of the safety of home birth. Birth, 24(1):4-13; discussion 14-6.

15. Johnson K. C. & Daviss B-A. (2005). Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ, 330:1416. doi: http://dx.doi.org/10.1136/bmj.330.7505.1416

16. Cawthon L. (1996). Planned home births: outcomes among Medicaid women in Washington State. Olympia,WA: Washington Department of Social and Health Services. Retrieved from http://www.dshs.wa.gov/pdf/ms/rda/research/7/93.pdf.

17. Murphy P. A. & Fullerton J. (1998). Outcomes of intended home births in nurse-midwifery practice: a prospective descriptive study. Obstet Gynecol, 92(3):461-70.

18. Anderson R. E. & Murphy P.A. (1995). Outcomes of 11,788 planned home births attended by certified nurse-midwives: A retrospective descriptive study. J Nurse Midwifery, 40(6):483-92.

19. Janssen P. A., Saxell L., Page L. A., Klein M. C., Liston R. M. & Lee S.K. (2009). Outcomes of planned home births with registered midwife versus planned hospital birth with midwife or physician. CMAJ, 181(6):377-83.

20. Hutton E. K., Reitsma A.H. & Kaufman K. (2009). Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: A retrospective cohort study. Birth, 36(3):180-89.

21. Janssen P. A., Lee S. K., Ryan E. M., Etches D. J., Farquharson D. F., Peacock D. & Klein M. C. (2002). Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. CMAJ, 166(3):315-23.

22. de Jonge A., van der Goes B. Y., Ravelli A. C., Amelink-Verburg M. P., Mol B. W., Nijhuis J. G., Bennebroek Gravenhorst J. & Buitendijk S. E. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG, 116(9):1177-84. DOI: 10.1111/j.1471-0528.2009.02175.x.

23. Wiegers T. A., Keirse M. J., van der Zee J. & Berghs G. A. (1996). Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands. BMJ, 313(7068):1309-13

24. Chamberlain G., Wraight A. & Crowley P. (eds.). (1997). Home births – The report of the 1994 confidential enquiry by the National Birthday Trust Fund. Cranforth, UK: Parthenon Publishing.

25. Northern Region Perinatal Mortality Survey Coordinating Group. (1996). Collaborative survey of perinatal loss in planned and unplanned home births. BMJ, 313(7068):1306-09. doi: http://dx.doi.org/10.1136/bmj.313.7068.1306.

26. Ackermann-Liebrich U., Voegeli T., Gunter-Witt K., Kunz I., Zullig M., Schindler C., Maurer M. & Zurich Study Team. (1996). Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. BMJ, 313(7068):1313-18. doi: http://dx.doi.org/10.1136/bmj.313.7068.1313.

27. Health Management Associates. (2007). Midwifery licensure and discipline program in Washington State: economic costs and benefits. Retrieved from http://www.washingtonmidwives.org/documents/Midwifery_Cost_Study_10-31-07.pdf.

28. Dedyna K. (2012, Nov 3). B.C. minister among first to support home births. Times Colonist. Retrieved from http://www.canada.com/minister+among+first+support+home+births/7494815/story.html.

About Wendy Gordon

Wendy Gordon, LM, CPM, MPH is a midwife, mother and educator in the Seattle area.  She helped to build a busy, blended homebirth practice of nurse-midwives and direct-entry midwives in Portland, Oregon for eight years before recently transitioning to Seattle.  She is a Coordinating Council member of the Midwives Alliance Division of Research, a board member of the Association of Midwifery Educators, and teaches at the Bastyr University Department of Midwifery.

 

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Understanding and Eliminating Disparities in Maternal Health Outcomes, Part II

September 13th, 2012 by avatar

Today’s post is the second one on disparities in maternal health care by regular Science & Sensibility contributor, Christine Morton, PhD, who is a medical sociologist and has researched and written about disparities in maternal health for many years.  Today, Christine takes a look at why women of color in the United States are facing a widening gap in maternal health outcomes and what some of the underlying factors might be.  This is part two of a two part series that looks at the research and examines what might need to change. – SM

Are public health and obstetric perspectives providing us with the best paradigms for understanding and eliminating racial-ethnic disparities in maternal health outcomes?   In my last post, I reviewed a typical public health study, which looked at maternal mortality by race, ethnicity and nativity, based on U.S. death certificate data from 50 states and two cities:  NYC and Washington, DC.1

Photo Image Creative Commons Linda Dias, Photos

Documenting outcomes, while important, is only part of the answer to understand why racial-ethnic disparities exist, persist, and widen.  Even more, we can’t begin to eliminate disparities until we have a better understanding of how different groups of women experience the birth process.  By process, I mean the local context in which women experience pregnancy and give birth, the pattern of interventions and decision-making, the attitudes and behaviors of healthcare clinicians and childbearing women.  One of the best methodologies for examining local contexts of birth is ethnography, in the tradition of such classics as anthropologist Brigitte Jordan’s Birth in Four Cultures: A Cross-Cultural nvestigation of Childbirth in Yucatan, Holland, Sweden and the United States (1978) and sociologist Nancy Stoller Shaw’s Forced Labor: Maternity Care in the United States (1974.)   Only recently are social scientists turning their ethnographic lenses to current U.S. hospital childbirth settings, and I will highlight some of these projects in future posts.

Eugene Declercq, Mary Barger, and Judith Weiss2 review the evidence for disparities among five major interventions in childbirth: induction, electronic fetal monitoring, epidurals, episiotomy, and cesarean section.   They use data from multiple sources, “reflecting the fragmented nature of data systems related to the birth process.”  The birth certificate in many states has an extended worksheet, but the quality and accuracy of many elements on the birth certificate is a serious issue.  The best way to look at administrative data on pregnancy and childbirth is to have a LINKED data set that matches Birth Certificate data with Hospital Discharge Data, thus allowing for risk stratification by age, parity, etc.

DATA SOURCES ON PREGNANCY and CHILDBIRTH

Data Source Agency What it provides Used in this paper
Birth certificate National Center for Health Statistics (NCHS) Overall national trends and disparities by race/ethnicity Yes
Hospital discharge data (ICD-9/10 codes) National Hospital Discharge Survey Episiotomy use Yes
Massachusetts natality data MA Dept of Public Health Includes method of payment Yes
Listening to Mothers II Survey Childbirth Connection National retrospective survey of 1573 women who gave birth in 2005 (weighted for representativeness) Yes
Pregnancy Risk Assessment and Monitoring System (PRAMS) Centers for Disease Control and Prevention Population based survey of postpartum women conducted annually in 39 states No –only one question related to birth: “When was your baby born?”

Induction

Declercq and colleagues state that “rates of labor induction have more than doubled over the last 15 years in the United States,” and they review the geographic variability observed in this procedure – between states, within states, and among different types of hospitals.   The authors speculate that the rapid increase in induction rates, especially “elective inductions under 41 weeks gestation may have contributed to the shift in the gestational age distribution of births, with 39 weeks now being the most common gestational age.”

Rates of induction by race/ethnicity vary by data source.   National birth certificate data from 2005 show that “Regardless of parity, rates were highest among white non-Hispanic women, lowest among Hispanic women, with black non-Hispanic women falling in between.  First time mothers in each group have higher rates than multiparous mothers.”

Listening to Mothers II (LTMII) asks women whether they attempted to induce labor, whether their labor was medically induced and whether it was successful (i.e., no cesarean).  LTMII reported a higher overall rate of induction than the national birth certificate data (34% vs. 22%), in part because LTMII asks about a greater variety of methods, and because national birth certificate data only report those inductions that result in labor.  While techniques used to induce labor did not differ by race/ethnicity, LTMII found that Hispanic women who had given birth before had highest rates of attempted and successful induction (43% and 38%, respectively) compared to White women (39% and 33%) and Black women (29% and 22%) who had given birth before.  Regardless of parity, White women were more likely than Black or Hispanic women to try to self-induce (25% vs. 17% vs. 18%).

The authors also look at evidence for induction at 41+ vs. 42+ weeks gestation, but the data presented from LTMII and birth certificates does not include gestational age at induction.  This data element is on the birth certificate but is highly subject to error and missing values.

Cesarean Delivery

We know that cesarean rates have rapidly increased in the U.S. and that this rate has occurred among all racial/ethnic groups.  However, in this figure, Declercq and colleagues show that Black women had lower cesarean rates than White women until 1994, when they surpassed all groups, reaching 33.1% in 2006, compared to White women (31.3%), and Hispanic women (29.7%).  One reason for this is that Black women never experienced the decline in cesarean births the other groups did due to the rise in vaginal birth after prior cesarean (VBAC).

Black women have higher rates of cesarean at nearly every age group, and this is true among the three time periods examined (1991, 1996, 2005) and among every level of education.  Because the national data has limited variables to measure social status, Declercq and colleagues looked at Massachusetts data by payer.  Again, regardless of whether they had private or public insurance, Black women had higher rates of cesarean than White or Hispanic women.

Conclusion

Declercq and colleagues have made a valuable contribution to the public health literature by pointing out the gaps in public health surveys and summarizing what is known about its evidence base, current practice and associated health disparities. They conclude:

Three clear findings emerge:

(1) while there has been considerable research on each of these interventions, actual practice is not consistently related to its associated evidence base;

(2) randomized trials have not examined the relationship of these interventions and disparities in outcomes; and

(3) in all cases but fetal monitoring, which is virtually universally applied, there are differences in the application of the interventions to mothers from different race/ethnicity groups. However, there is also no clear pattern that would suggest that one group is more likely than any other to receive evidenced-base care.

Discussion

So back to the opening question – Are public health and obstetric perspectives providing us with the best paradigms for understanding and eliminating racial-ethnic disparities in maternal health outcomes?   In light of the variation among common childbirth procedures (interventions) like induction and cesarean, and with research showing that African American women are more likely to have cesareans,3-5 yet are less likely that White women to agree that the “birth process should not be interfered with unless medically necessary,” how do we understand what is happening in clinics and labor units across the country?

Clinicians are beginning to realize that quantitative data is only the first step toward changing behaviors, and acknowledge that health care culture drives much of this practice variation.6 Yet most clinician researchers are untrained in the methods best suited to discovering how to maximize quality improvement efforts—ethnography and qualitative research. Donald M Berwick (Institute for Healthcare Improvement) has argued for a wider embrace of methodologies beyond the “gold standard” randomized control trial, to assist quality improvement efforts in health care. In particular, he informs his clinical colleagues that approaches such as “ethnography, anthropology, and other qualitative methods … are not compromises in learning how to improve; they are superior.”2

Clinicians, public health researchers (and maternity care advocates) have long relied on population data to make the case that evidence-based care can improve maternal and infant health outcomes. Yet every childbirth educator and doula knows the value of the story – which includes the mechanisms (how things work in practice) and context (local conditions, including actions and meaning, that influence the outcomes of interest).  Systematically combining good epidemiological data with compelling accounts of the childbirth experience by all participants is the next research frontier we must cross in our quest to improve the quality of care and outcomes for all women and their babies.

References

1. Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Race, ethnicity, and nativity differentials in pregnancy-related mortality in the United States: 1993-2006. Obstetrics and gynecology. Aug 2012;120(2 Pt 1):261-268.

2. Declercq E, Barger M, Weiss J. Contemporary Childbirth in the United States: Interventions and Disparities. In: Handler A, eds. Reducing Racial/Ethnic Disparities in Reproductive and Perinatal Outcomes: The Evidence from Population-Based Interventions: Springer Science+Business Media; 2011:401-427. Accessed online: http://www.springer.com/public+health/book/978-1-4419-1498-9

3. Braveman P, Egerter S, Edmonston F, Verdon M. Racial/ethnic differences in the likelihood of cesarean delivery, California. Am J Public Health. May 1995;85(5):625-630.

4. Getahun D, Strickland D, Lawrence JM, Fassett MJ, Koebnick C, Jacobsen SJ. Racial and ethnic disparities in the trends in primary cesarean delivery based on indications. American Journal of Obstetrics and Gynecology. Oct 2009;201(4):422 e421-427.

5. Roth LM, Henley M. Unequal Motherhood: Racial-Ethnic and Socioeconomic Disparities in Cesarean Sections in the United States. Social Problems. 2012;59(2):207-227.

6. Main E, Morton C, Hopkins D, Giuliani G, Melsop K, Gould J. Cesarean Deliveries, Outcomes, and Opportunities for Change in California:  Toward a Public Agenda for Maternity Care Safety and Quality. Palo Alto, CA: California Maternal Quality Care Collaborative;2011.  Available online: http://www.cmqcc.org/white_paper

 

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The Importance of Understanding and Eliminating Disparities in Maternal Health Outcomes

September 7th, 2012 by avatar

Today’s post is by regular Science & Sensibility contributor, Christine Morton, PhD, who is a medical sociologist and has researched and written about disparities in maternal health for many years.  Today, Christine takes a look at why women of color in the United States are facing a widening gap in maternal mortality and what some of the underlying factors might be.  This is part one of a two part series that looks at the research and examines what might need to change. – SM

Maternal mortality is associated with the widest and most persistent disparity (inequality) in all of public health.  African American women have a three to four-fold greater chance of dying as a result of pregnancy than women in any other racial-ethnic group.1  The gap between maternal mortality in African American women and women of other racial-ethnic groups is greater today than it was in the 1940s.2

Photo image creative commons Seattle Municipal Archives

Yet despite multiple studies over the past several years demonstrating this widening gap, experts today commonly state that reasons for this disparity are “not fully understood,” and “limited data exist” to explain why they continue to occur.  What is clear, however, is that disparities in maternal deaths are likely to increase, as the proportion of childbearing women who self-identify as members of a racial or ethnic minority group (i.e., non-white) increases in the next decades.  Indeed, whether to call these women ‘minority’ is in question: In May 2012, the Census Bureau reported for the first time that non-Hispanic whites now account for a minority of births in the U.S.

Debates over maternal quality cannot ignore these trends.  Are public health and obstetric perspectives providing us with the best paradigms for understanding and reversing disparities in maternal health outcomes?

Let’s consider this by examining two recent publications looking at the issue from slightly different perspectives.  In the first, Andreea A. Creanga, MD, PhD and her colleagues from the CDC Division of Reproductive Health examined data from 52 reporting areas (50 states, New York City and Washington, DC).3    This Pregnancy Mortality Surveillance System consists of de-identified copies of death certificates for all deaths occurring during or within one year of pregnancy (regardless of cause of death) as well as matching birth or fetal death certificates if available.


Figure 1: Definitions of Death in Relation to Pregnancy (4)
The Pregnancy Mortality Surveillance System used by the CDC requires that a pregnancy-related death satisfy both temporal and casual criteria. A pregnancy-related death is defined as the death of a woman during or within 1 year of pregnancy that was caused by a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy. In contrast, the World Health Organization defines maternal mortality as ‘‘the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.’’

The CDC paper compares women of different races, ethnicities and nativity (US or foreign-born) from 1993-2006.  They found that for all women, “the pregnancy-related mortality ratio (PRMR) increased significantly (P<.001) from 11.1 to 15.7 deaths per 100,000 live births from 1993-2006, respectively” (p. 263).   Striking differences are found in the overall rate, and the researchers explore the relative effects of age and nativity among racial/ethnic groups.  Using US-born white women as the reference group, the study found that those women NOT in this group comprised 62% of the deaths but only accounted for 41% of the live births during this period.

% of deaths

% of live births

US-born White Women (reference)

38%

59%

Not US-born White (everyone else)

62%

41%

When the PRMR rates are broken down further, the study found that when compared to US-born white women, only foreign-born white women had a significantly lower risk of dying from pregnancy-related causes (after adjusting for age differences).  The table below shows the risk of dying from pregnancy complications among other groups of women compared to US-born white women.

Women’s Nativity and Race Risk of dying from pregnancy complications
US-born White Reference
US- and foreign-born Hispanic 1.1  times higher
US- and foreign-born Asian/Pacific Islander 1.5 times higher
Foreign-born Black 3.6 times higher
US-born Black 5.2 times higher

The study also found that for “all groups of women, pregnancy-related mortality ratios increased with age and were especially high for women older than 35 years” (p. 264).   For Black women over 35, the PRMR was 99.42, compared to the PRMR for Hispanic (27.20) and White (17.60) women.

Breaking 1993-2006 into two time periods, 1993-1999 and 2000-2006, the study found that the PRMR increased for all groups except for foreign-born Asian/Pacific Islander women, but the increase was statistically significant for only US- and foreign born white women and US-born Black women (30.4%, 29.2%, and 30.4%, respectively; all P<.05).

Also explored in the study are the differences in causes of death for U.S.-born vs. foreign-born women.

The takeaway

 “Except for foreign-born white women, all other race, ethnicity, and nativity groups were at higher risk of dying from pregnancy-related causes than U.S.-born white women after adjusting for age differences” (p. 261).   The authors suggest that “integration of quality-of-care aspects into hospital-and state-based maternal death reviews may help identify race, ethnicity, and nativity-specific factors for pregnancy-related mortality,” yet the low numbers of women who die may preclude a full examination of the multiple and complex factors involved in health care provision.

Some suggestive work in this area was published by Tucker and colleagues from the CDC (2007), who examined the prevalence of five conditions considered major causes of mortality occurring during hospitalization for labor, birth and postpartum. They found that African-American women did not have a higher prevalence of these conditions (preeclampsia, eclampsia, abruption placentae, placenta previa and postpartum hemorrhage) compared to other racial/ethnic groups, but were more likely to die from them, suggesting either a possible difference in the severity of the disease or the quality of care provided during hospitalization.

What is needed is a consideration of the birth process, including interventions and the experience of decision-making, as well as the attitudes and behaviors of healthcare clinicians as well as those of childbearing women.  Thus, a welcome view into the process of birth comes from a chapter in a book by Eugene Declercq, Mary Barger, and Judith Weiss.  In their review, “Contemporary Childbirth in the United States: Interventions and Disparities,”5 the authors note that  public health paradigms have more often focused on antecedents to care (access to contraception and prenatal care) and outcomes (mostly newborn and infant health) with less attention to the processes of care or interventions during the birth itself.  While social science research has focused on the context of care systems, there has been little in-depth investigation of the processes of care delivery.   Until very recently, there have been no observational studies of U.S. labor and birth in hospital settings since the 1970s.6

As there is little systematic national data to examine patterns of birth process nor any racial-ethnic disparities within them, the authors have examined “five major interventions used in the birth process: induction, electronic fetal monitoring, epidurals, episiotomy, and cesarean section.” We will briefly summarize the existing research on evidence based approaches to promote or prevent certain maternal and/or perinatal outcomes in these areas with an understanding that such research is rarely definitive and, even when it appears to be clear, it may not have a major influence on clinician behavior. We will then examine the distribution of these interventions across different groups, most notably by race/ethnicity. Since parity is such a crucial element in determining birth related behavior, in many cases we will also distinguish the results for primiparous and multiparous mothers.”

Part 2 of this blog post will examine their results and answer the question at the beginning:  Are public health and obstetric perspectives providing us with the best paradigms for understanding and reversing disparities in maternal health outcomes?

 References 

1. Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the United States, 1998 to 2005. Obstetrics and Gynecology. Dec 2010;116(6):1302-1309.

2. California Department of Public Health. Maternal Death Rates by Race California, 1940-1968. Death Records. Sacramento, CA1968.

3. Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Race, ethnicity, and nativity differentials in pregnancy-related mortality in the United States: 1993-2006. Obstetrics and gynecology. Aug 2012;120(2 Pt 1):261-268.

4. Berg C, Daniel I, Atrash H, Zane S, Bartlett L. Strategies to reduce pregnancy-related deaths: From identification and review to action. Atlanta, GA: Centers for Disease Control and Prevention;2001.

5. Declercq E, Barger M, Weiss J. Contemporary Childbirth in the United States: Interventions and Disparities. In: Handler A, al e, eds. Reducing Racial/Ethnic Disparities in Reproductive and Perinatal Outcomes: The Evidence from Population-Based Interventions: Springer Science+Business Media; 2011:401-427.

6. Morton CH. Where Are the Ethnographies of US Hospital Birth? Anthropology News. March 2009.

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