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Lamaze Releases Useful New Infographic: “No Food, No Drink During Labor? NO WAY!”

July 22nd, 2014 by avatar

piece Lamaze_RestrictedFoodDrinkInfographic_FINALToday, Lamaze International releases their newest infographic “No Food, No Drink During Labor? NO WAY!” This useful infographic is available on both the Lamaze International for Professionals website and the Lamaze Parents website. The most recent Listening to Mothers III survey indicated that 60% of women did not drink and 80% did not eat during labor! (DeClercq, 2013) The common practice of restricting food and drink for laboring women is outdated and not supported by evidence.  Unfortunately, most laboring women still face resistance from health care providers and facilities when they desire to eat or drink during their labor.

Lamaze International is hosting a Twitter Chat today, July 22nd, 2014 at 9 PM EST.  Professionals and parents are invited to participate in this live Twitter discussion moderated by Kathryn Konrad, MS, RNC-OB, LCCE, FACCE (@KkonradLCCE) and Robin Weiss, PhDc, MPH, CPH, CD(DONA), CLC, LCCE, Lamaze International’s President Elect. Tonight’s topic is “Restrictions in Labor” including this infographic on eating and drinking along with last month’s infographic on moving in labor (“We Like To Move It, Move It!”) Follow the hashtag #LamazeChat.  New to participating in a Twitter chat?  Check out this article for information on how to participate and get the most out of your experience.

Lamaze International’s Healthy Birth Practices, first released in 2009, discussed in great length the benefits to moving and changing position in labor in the 2nd Healthy Birth Practice: “Walk, Move Around and Change Positions Throughout Labor“ as well as the risks to restricting food and drink in the 4th Healthy Birth Practice: “Avoid Interventions That Are Not Medically Necessary.”

These useful infographics complement the Healthy Birth Practices, are easy to share on social media and can be used in the classroom as a poster to help parents to understand how to have the safest and healthiest birth possible.

Won’t you take a moment to check out this newest infographic and share with the expectant families that you work with!  Consider sharing it on your favorite social media outlet (Facebook, Twitter, Pinterest, Instagram) and making it available in your classrooms!

If you have an interesting way you are using these infographics, or would like to just share your thoughts on the infographic topics, please let us know in the comments section. I would love to hear how you use this info in your practice.

Click here to download the newest infographic “No Food, No Drink During Labor? NO WAY!”

You may access all the infographics available here!

References

Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, A. (2013). Listening to mothers III: Pregnancy and birth. New York, NY: Childbirth Connection.

Childbirth Education, Evidence Based Medicine, Healthy Birth Practices, informed Consent, Lamaze International, Maternity Care, Medical Interventions, Push for Your Baby , , , , ,

Non-Drug Pain Coping Strategies Improve Outcomes

July 17th, 2014 by avatar

 Today, contributor Henci Goer reviews a recently published study in the journal Birth, that compared the outcomes of births in women who received non pharmacological pain management techniques with women who received the “usual care” treatment.  The researchers found that maternal and infant outcomes were improved.  Take a moment to read Henci’s review to get a glimpse at the results and her analysis.- Sharon Muza, Science & Sensibility Community Manager

© Patti Ramos Photography

© Patti Ramos Photography

In 2012,  the Cochrane Database published an overview of systematic reviews of forms of pain management that summarized the results of the Cochrane database’s suite of systematic reviews of randomized controlled trials (RCTs) of various pain management techniques. Reviewers reached the rather anemic conclusion that epidurals did best at relieving pain—no surprise there—but increased need for medical intervention—no surprise there either—while non-drug modalities (hypnosis, immersion in warm water, relaxation techniques, acupressure/acupuncture, hands on techniques such as massage or reflexology, and TENS) did equally well or better than their comparison groups (“standard care,” a placebo, or a different specific treatment) at relieving pain, at satisfaction with pain relief, or both, and they had no adverse effects (Jones 2012). Insofar as it went, this finding was helpful for advocating for use of non-drug strategies, but it didn’t go very far.

Fast forward two years, and we have a new, much more robust review: Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Its ingenious authors grouped trials of non-drug pain relief modalities according to mechanism of action, which increased the statistical power to determine their effects and avoided inappropriately pooling data from dissimilar studies in meta-analyses (Chaillet 2014). The three mechanisms were Gate Control Theory, which applies nonpainful stimuli to partially block pain transmission; Diffuse Noxious Inhibitory Control, which administers a painful stimulus elsewhere on the body, thereby blocking pain transmission from the uterine contraction and promoting endorphin release in the spinal cord and brain; and Central Nervous System Control, which affects perception and emotions and also releases endorphins within the brain.

Overall, 57 RCTs comparing non-drug strategies with usual care met eligibility criteria: 21 Gate Control (light massage, warm water immersion, positions/ambulation, birth ball, warm packs), 10 Diffuse Noxious Inhibitory Control (sterile water injections, acupressure, acupuncture, high intensity TENS), and 26 Central Nervous System Control (antenatal education, continuous support, attention deviation techniques, aromatherapy). Eleven of the Central Nervous System Control trials specifically added at least one other strategy to continuous support. More about the effect of that in a moment.

Now for the results…

Compared with Gate Control-based strategies, usual care was associated with increased use of epidurals (6 trials, 3369 women, odds ratio: 1.22), higher labor pain scores (3 trials, 278 women, mean difference 1 on a scoring range of 0-10), and more use of oxytocin (10 trials, 2672 women, odds ratio: 1.25). Usual care also increased likelihood of cesarean in studies of walking (3 trials, 1463 women, odds ratio: 1.64).

Compared with Diffuse Noxious Inhibitory Control strategies, usual care was associated with increased use of epidurals (6 trials, 920 women, odds ratio: 1.62), higher labor pain scores (1 trial, 142 women, mean difference 10 on a scoring range of 0-100), and decreased maternal satisfaction as measured in individual trials by feeling safe, relaxed, in control, and perception of experience.

We hit the jackpot with Central Nervous System Control strategies (probably because female labor support, which has numerous studies and strong evidence supporting it, dominate this category [19 labor support, 6 antenatal education, 1 aromatherapy]). As before, usual care is associated with more epidurals (11 trials, 11,957 women, odds ratio: 1.13), more use of oxytocin (19 trials, 14,293 women, odds ratio: 1.20), and decreased maternal satisfaction as measured in individual trials by perception of experience and anxiety. In addition, however, usual care is associated with increased likelihood of cesarean delivery (27 trials, 23,860 women, odds ratio: 1.60), instrumental delivery (21 trials, 15,591 women, odds ratio: 1.21), longer labor duration (13 trials, 4276 women, 30 min), and neonatal resuscitation (3 trials, 7069 women, odds ratio: 1.11).

© Breathtaking Photography http://flic.kr/p/3255VD

© Breathtaking Photography http://flic.kr/p/3255VD

The big winner, though, was continuous support combined with at least one other strategy. Usual care in these 11 trials was even more disadvantageous than in central nervous system trials overall with respect to cesareans (11 trials, 10,338 women): odds ratio 2.17 versus 1.6 for all central nervous system trials, and instrumental delivery (6 trials, 2281 women): odds ratio 1.78 versus 1.21 for all central nervous system trials.

The strength of the data is impressive. Altogether, Chaillet et al. report on 97 outcomes, of which 44 differences favoring non-drug strategies achieve statistical significance, meaning the difference is unlikely to be due to chance, while not one statistically significant difference favors usual care. And there’s still more: benefits of non-drug strategies are probably greater than they appear because on the one hand, “usual care” could include non-drug strategies for coping with labor pain and on the other, many institutions have policies and practices that make it difficult to cope using non-drug strategies alone, strongly encourage epidural use, or both.

The reviewers conclude that their findings showed that:

Nonpharmacologic approaches can contribute to reducing medical interventions, and thus represent an important part of intrapartum care, if not used routinely as the first method for pain relief…however, in some situations, nonpharmacologic approaches may become insufficient…the use of pharmacologic approaches could then be beneficial to reduce pain intensity to prevent suffering and help women cope with labor pain…birth settings and hospital policies . . . should facilitate a supportive birthing environment and should make readily available a broad spectrum of nonpharmacologic and pharmacologic pain relief approaches. (p. 133)

No one could argue with that, but a persuasive argument alone is unlikely to carry the day given the entrenched systemic barriers in many hospitals. States an anesthesiologist: “While there may be problems with high epidural usage, in the presence of our nursing shortages and economic or business considerations, having a woman in bed, attached to an intravenous line and continuous electronic fetal monitor and in receipt of an epidural may be the only realistic way to go” (quoted in Leeman 2003). The Cochrane reviewers concur, writing that using non-drug strategies is “more realistic” (p. 4) outside of the typical hospital environs.

So long as this remains the case, attempts to introduce non-drug options are likely to make little headway. As Lamaze International’s own Judith Lothian trenchantly observes:

If we put women in hospitals with restrictive policies—they’re hooked up to everything, they’re expected to be in bed—of course they’re going to go for the epidural because they’re unable to work through their pain. . . . I go wild with nurses and childbirth educators who say, . . . “[Women] just want to come in and have their epidural.” I say, “And even if they don’t . . ., they come to your hospital, and they have no choice. . . . They can’t manage their pain because you won’t let them.” (quoted in Block 2007, p. 175)

Success at integrating non-drug strategies will almost certainly depend on addressing underlying factors that maintain the status quo. Can it be done? You tell us. Does your hospital take a multifaceted approach to coping with labor pain? If so, how was it implemented and how is it sustained?

Resources

Block, Jennifer. (2007). Pushed: The Painful Truth About Childbirth and Modern Maternity Care. Cambridge, MA: Da Capo Press.

Chaillet, N., Belaid, L., Crochetiere, C., Roy, L., Gagne, G. P., Moutquin, J. M., . . . Bonapace, J. (2014). Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth, 41(2), 122-137. doi: 10.1111/birt.12103 http://www.ncbi.nlm.nih.gov/pubmed/24761801

Jones, L., Othman, M., Dowswell, T., Alfirevic, Z., Gates, S., Newburn, M., . . . Neilson, J. P. (2012). Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev, 3, CD009234. doi: 10.1002/14651858.CD009234.pub2 http://www.ncbi.nlm.nih.gov/pubmed/2241934

Leeman, L., Fontaine, P., King, V., Klein, M. C., & Ratcliffe, S. (2003). Management of labor pain: promoting patient choice. Am Fam Physician, 68(6), 1023, 1026, 1033 passim. http://www.ncbi.nlm.nih.gov/pubmed/14524393?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 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.  

Childbirth Education, Doula Care, Epidural Analgesia, Guest Posts, Maternity Care, Medical Interventions, Newborns, Research , , , , ,

The Childbirth Educator’s Role in The Cesarean Epidemic: 10 Steps You Can Take Now!

April 29th, 2014 by avatar

As Cesarean Awareness Month (April 2014) comes to a close, I wanted to share ten things that childbirth educators can do in their childbirth classes to support families to avoid unneeded cesareans, help families to have a cesarean birth that is respectful and family centered and support families who give birth by cesarean, (planned or unplanned) both during the birth, in the postpartum period and when planning future births.

1. Birth plan exercises

Have your birth planning/birth choices activity include preferences for a cesarean birth.  Allow parents the option to select items such as delayed cord clamping, skin to skin in the operating room, delaying newborn weights and measurements, and more.  While these may not be available options in all areas, encouraging discussion amongst families and their health care providers is a good place to start.  Additionally, consider role playing a cesarean section in class and discuss ways to make the procedure family friendly.  Remember to suggest ways that the partner and other support people can best support mother and baby during the surgery. Consider sharing “The natural caesarean: a woman-centred technique” video so families can explore options for a family friendly cesarean birth.

2. Access teaching resources on the Lamaze International website

Lamaze International offers some great teaching resources on cesareans for educators on their website and for families on the Lamaze International parent site.  There are two infographics that cover the topic of cesarean sections; “Avoiding the First Cesarean” and “What’s the Deal with Cesareans.”  You might consider showing the brand new infographic video to your families in class. At only 3 minutes long, it does a great interactive job of highlighting important information. In addition to using these materials in class, encourage families to explore them more thoroughly at home.

3.  Provide current statistics

Access and share statistics about national and provincial or state cesarean rates and VBAC rates, along with local rates for facilities and providers if available.  Help your families to understand the difference between overall cesarean rates and primary cesarean rates and why facilities caring for high risk mothers or babies might have higher rates.  Make sure that you are providing the most current information available, and update your figures when new numbers are released. Encourage discussion in class with families who are considering changing birth location or providers if they feel so inclined.

4. Encourage the use of birth doulas

The addition of trained labor support has been shown to reduce common interventions and cesareans. (Hodnett, 2012)  Take some time during class to share how doulas can help support both the laboring woman and her partner and team.  Provide resources for families to locate doulas (DONA.org and DoulaMatch.net are two such lists that come to mind) and briefly share information on questions to ask a doula during an interview, so the families are prepared.

cam two ribbon5.   Share current best practice information

Be sure that the information in your classes is current, accurate and based on best practices and evidence.  Know the sources of the information you cover.  Make sure it is up to date and verifiable.  Have a short list of favorite online resources to share with families, including Lamaze International’s Giving Birth with Confidence blog- written specifically for parents.  Utilize the references that make up the Six Healthy Birth Practices, there is a citation sheet for all six of the birth practices.

6. Support the midwifery model of care

Share information in your classes about the midwifery model of care, which has been shown to be an appropriate choice for healthy, low risk women.  Let your class families know how to find a midwife by using the search functions on the American College of Nurse-Midwives website and information on finding a midwife on the Citizens for Midwifery website.

7. Have meaningful class reunions

If your childbirth class includes a reunion, create a space for all the families to share their stories, both the vaginal births and the cesarean births.  Honor the work that the families did to birth their babies and celebrate their intention and teamwork.  Highlight their shining moments and let them know that you recognize how hard they worked.  Model excellent listening skills and support all the families as they share their birth stories.

8. Provide support group information

Make sure that all families that leave your class have been given resources for a support group for women who birth by cesarean section.  Access the International Cesarean Awareness Network (ICAN) to find the nearest local ICAN chapter website or Facebook group. Or refer the families to the main ICAN Facebook page.  VBACFacts.com also has a large peer to peer support network active on Facebook as well.

9.  Share postpartum resources

Families that birth by cesarean section might find themselves needing additional support from professionals during the postpartum period.  Be sure that they have resources to find lactation consultants, mental health counselors, postpartum doulas, physical therapists and other professionals that might be useful for healing emotionally and physically from a cesarean section.  In the throes of postpartum hormones, exhaustion, sleep deprivation and physical recovery, having to hunt down appropriate professionals can be a daunting task for any new families, never mind a mother recovering from surgery with a newborn.

10.  Offer a cesarean only class

Some families know they will be needing a cesarean for maternal or infant health circumstances and are hesitant about taking the standard childbirth class, feeling like they won’t fit in.  While they may not be needing the coping skills or comfort techniques and pushing positions that you cover in the typical childbirth class, they do need information about the cesarean procedure, pain medication options, recovery, breastfeeding and newborn care/procedures and informed consent and refusal information, among other things.  Having a class designed with their needs in mind can help them to make choices that feel good to them and participate in the community building that is such an important part of childbirth classes.

Don’t underestimate the role of the childbirth educator (you!) to offer evidence based information, appropriate resources, respectful dialogue along with skills and techniques to help women to have the best birth possible, avoid a cesarean that is not needed and recover and heal  while feeling supported with options for future births.  Thank you for all you do to help women to avoid cesareans or if needed, have the best cesarean possible.

References

Hodnett, E. D., S. Gates, et al. (2012). “Continuous support for women during childbirth.” Cochrane database of systematic reviews: CD003766.

Cesarean Birth, Childbirth Education, Giving Birth with Confidence, Healthy Birth Practices, Lamaze International, Maternal Quality Improvement, Maternity Care, Medical Interventions, Midwifery, Practice Guidelines, Vaginal Birth After Cesarean (VBAC) , , , , , , ,

Safe Prevention of the Primary Cesarean Delivery: ACOG and SMFM Change the Game

February 19th, 2014 by avatar

I hope that readers of Science & Sensibility (and anyone working in the field of maternal infant health) are sitting down.  Be prepared to be blown away.  ACOG and SMFM have just released a joint Obstetric Care Consensus statement that has the potential to turn maternity care in the USA on its end.  I feel like this blog post title could be “ACOG and SMFM adopt Lamaze International’s Six Healthy Birth Practices.”  (Okay, that may be a little overenthusiastic!)  I could not be more pleased at the contents of this statement and cannot wait to see some of these new practice guidelines implemented.  Judith Lothian, PhD, RN, LCCE, FACCE summarizes the statement and shares highlights of this stunning announcement. – Sharon Muza, Science & Sensibility Community Manager

Today, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine issued a joint Obstetric Care Consensus statement: Safe Prevention of the Primary Cesarean Delivery. It is being published concurrently in Obstetrics and Gynecology, (the Green Journal).  The ACOG press release is here, with much more detail of the study, not behind a firewall. There is no doubt about it-  this just released statement is a game changer.

acog wordlThe alarming and sustained increase in the cesarean rate in the United States has not improved either maternal or neonatal outcomes. In fact, data suggest that there is increased maternal mortality and morbidity associated with cesarean delivery. This statement describes the myriad of complications associated with cesarean and the increased risks associated with cesarean for mother and baby. The authors suggest that potentially modifiable factors, such as patient preferences and practice variation among hospitals, systems, and health care providers are likely to contribute to the escalating cesarean rates. There is a need to prevent overuse of cesarean, particularly the primary cesarean.

Table 1 acog

source: ACOG

The most common reasons for cesarean include labor dystocia, abnormal or indeterminate fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. The authors revisited the definition of labor dystocia in light of the fact that labor progresses at a rate that is slower than what we had thought previously. They also reviewed research related to interpretation of fetal heart rate patterns, and access to nonmedical interventions during labor that may reduce cesarean rates. External cephalic version for breech presentation and a trial of labor for women with twin gestations when the first twin is in a cephalic presentation can lower the cesarean rate. The authors analyzed the research using a rubric that rated the quality of the available evidence. The result is a set of guidelines that have the potential to substantially decrease the cesarean rate.

acog logo  These guidelines change the rules of the labor management game.

These are some of the new recommended guidelines:

  • The Consortium on Safe Labor data rather than the Friedman standards should inform labor management. Slow but progressive labor in the first stage of labor should not be an indication for cesarean. With a few exceptions, prolonged latent phase (greater than 20 hours in a first time mother and greater than 14 hours in multiparous women) should not be an indication for cesarean. As long as mother and baby are doing well, cervical dilation of 6 cm should be the threshold for the active phase of labor. Active phase arrest is defined as women at or beyond 6 cm dilatation with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity, or at least 6 hours of oxytocin administration with inadequate uterine activity and no cervical change.
  • Adverse neonatal outcomes have not been associated with the duration of the second stage of labor. The absolute risks of adverse fetal and neonatal outcomes of increasing second stage duration appear to be, at worst, low and incremental. Therefore, at least 2 hours of pushing in a multiparous woman and at least 3 hours of pushing in a first time mother should be allowed. An additional hour of pushing is expected with the use of an epidural, as there is progress.  Interestingly, there is no discussion of position change during second stage, including the upright position, to facilitate rotation and descent of the baby. Also, the authors note that second stage starts at full dilatation rather than when the mother has spontaneous bearing down efforts. Research suggests it is beneficial to consider the start of second stage when spontaneous bearing down by the mother  begins. (Enkin et al, 2000; Goer & Romano, 2013). Using this definition might also decrease the incidence of cesarean.
  • Instrument delivery can reduce the need for cesarean. The authors note concern that many obstetric residents do not feel competent to do a forceps delivery.
  • Recurrent variable decelerations appear to be physiologic response to repetitive compressions of the umbilical cord and are not pathologic. There is an in depth discussion of fetal heart rate patterns and interventions other than cesarean to deal with this clinically. Amnioinfusion for variable fetal heart rate decelerations may safely reduce the rate of cesarean delivery.
  • Neither chorioamnionitis nor its duration should be an indication for cesarean.
  • Induction of labor can increase the risk of cesarean. Before 41 0/7 weeks induction should not be done unless there are maternal or fetal indications. Cervical ripening with induction can decrease the risk of cesarean. An induction should only be considered “a failure” after 24 hours of oxytocin administration and ruptured membranes.
  • Ultrasound done late in pregnancy is associated with an increase in cesareans with no evidence of neonatal benefit. Macrosomia is not an indication for cesarean.
  • Continuous labor support, including support provided by doulas, is one of the most effective ways to decrease the cesarean rate. The authors note that this resource is probably underutilized.
  • Before a vaginal breech birth is considered, women need to be informed that there is an increased risk of perinatal or neonatal mortality and morbidity and provide informed consent for the procedure.
  • Perinatal outcomes for twin gestations in which the first twin is in cephalic presentation are not improved by cesarean delivery (even if the second twin is a noncephalic presentation).

smfm logo

These guidelines offer great promise in lowering the cesarean rate and making labor and birth safer for mothers and babies. They also suggest an emerging respect for and understanding of women’s ability to give birth and a more hands off approach to the management of labor. Women will be allowed to have longer labors. Obstetricians will need to be patient as nature guides the process of birth. Hospitals will have to plan for longer stays in labor and delivery. And women will need to have more confidence in their ability to give birth. Childbirth educators can play a key role here. The prize will be safer birth and healthier mothers and babies.

The authors rightly note that changing local cultures and obstetricians’ attitudes about labor management will be challenging. They also note that tort reform will be necessary if practice is to change. It’s interesting to consider whether standards of practice based on best evidence (as these guidelines are) rather than on fear of malpractice might make tort reform more likely.

The American Academy of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine are to be applauded for their careful research and willingness to make recommendations for labor management based on best evidence. These guidelines provide direction for health care providers and women and will make a difference in not just the cesarean rate but women’s experiences. The game has changed. It is a most welcome change.

What are your first impressions after learning of the elements of this new ACOG/SMFM statement?  What impact do you think these changes will have on the care that women receive during labor and birth?  Are you considering what barriers to change might exist in the hospitals you serve?  How will you share this new information with the families that you work with? As a side note, I found it interesting that this Consensus statement did not suggest using midwives for normal, low risk women.  Research has consistently shown that midwives working with low risk populations can reduce the cesarean rate. – SM

Further press information -

Lamaze International Statement – New Consensus Statement Important Step to Reduce Unnecessary Cesareans

Group Calls for Safe Reduction In Cesareans

ACOG Press Release

References

Enkin, M.,  Keirse, M., Neilson, J., Crowther, C., et al (2000). A Guide to Effective Care in Pregnancy and Childbirth. New York: Oxford Press.

Goer, H. &  Romano, A. (2013). Optimal Care in Childbirth: The Case for a Physiologic Approach.  Seattle: Classic Day Publishing (Chapter 13).

Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists. Obstet. Gynecol. 2014; 123: 693-711.

About Judith Lothian

@ Judith Lothian

@ Judith Lothian

Judith Lothian, PhD, RN, LCCE, FACCE is a nurse and childbirth educator. She is an Associate Professor at the College of Nursing, Seton Hall University and the current Chairperson of the Lamaze Certification Council Governing Body. Judith is also the Associate Editor of the Journal of Perinatal Education and writes a regular column for the journal. Judith is the co-author of The Official Lamaze Guide: Giving Birth with Confidence. Her research focus is planned home birth and her most recent publication is Being Safe: Making the Decision to Have a Planned Home Birth in the US published in the Journal of Clinical Ethics (Fall 2013).

ACOG, Evidence Based Medicine, Guest Posts, Healthcare Reform, Healthy Birth Practices, Maternal Quality Improvement, Medical Interventions, New Research, Practice Guidelines, Uncategorized , , , ,

Safe at Home? New Home Vs. Hospital Birth Study Reviewed by Henci Goer

November 26th, 2013 by avatar

 Regular contributor Henci Goer examines the most recent study on the safety of home birth in the United States.  When taking a closer look at the data analysis done by the authors, there are concerns not addressed in the study, that raise issues that cause the study’s conclusions to be questioned. Henci shares some other studies that do not reach the same results about the safety of home birth. Have you read this study?  If you had read this study too, did you find more questions than answers when you were done? – Sharon Muza, Community Manager, Science & Sensibility.

“Researchers have already cast much darkness on the subject, and if they continue their investigation, we shall soon know nothing at all.” – Mark Twain

flickr.com/photos/vestfamily/2591899412/

The latest contender in the long list of studies attempting to compare the safety of home and hospital birth, “Selected perinatal outcomes associated with planned home births in the United States,” was published last month (Cheng 2013). Let’s start by summarizing the study:

Using data compiled from the U.S. birth certificate, Cheng and colleagues compared outcomes between 12,039 women “planning” home births with 2,081,753 women having hospital births. All women were at term (between 37 and 43 weeks) and carrying one head-down baby. Women with prior cesarean were not excluded. After adjustment for numerous factors including number of prior births, medical conditions (hypertension, diabetes), risk factors (smoking), and social and demographic factors (race/ethnicity, age, marital status), women having home births were much less likely to have an instrumental vaginal delivery (0.1% vs. 6.2%; odds ratio 0.1), induced labor (1.4% vs. 25.7%; odds ratio 0.2), or labor augmentation (2.1% vs. 22.2%; odds ratio 0.3). They were also, however, twice as likely to have a baby with a 5-minute Apgar less than 4 (0.24% vs. 0.37%; odds ratio 1.9), three times as likely to have a baby experience neonatal seizure (0.06% vs. 0.02%; odds ratio 3.1), and more than twice as likely to have a baby with 5-minute Apgar less than 7 (2.42% vs. 1.17%; odds ratio 2.4). On the other hand, similar percentages of babies needed more than 6 hours of ventilator support, and babies born at home were much less likely to be admitted to intensive care (0.57% vs. 3.03%; odds ratio 0.2). In the discussion, the investigators note that removing the 489 women with previous cesareans who had planned home birth and women with medical or obstetric conditions did not alter that infants of women with prior births who planned home birth were more likely to have a low Apgar score. They don’t specify whether this was 5-minute Apgar less than 4 or less than 7 nor do they report the occurrence rate in this higher-risk subgroup.

There is more. To evaluate the effect of birth attendant qualifications, the investigators excluded births attended by doctors or unknown birth attendant and stratified the remaining home birth population into those attended by professional midwives and those attended by “other midwives.” (Confusingly, study authors state that Certified Professional Midwives [CPMs] were categorized as Certified Nurse-Midwives in the birth certificate data yet go on to refer solely to “CNMs” in the rest of the analysis.) In the subset attended by professional midwives, newborn outcomes were similar except that hospital-born infants were more likely to be admitted to intensive care (0.37% vs. 3.03%; odds ratio 0.1).

Cheng and colleagues conclude that while women planning home births are less likely to experience obstetric intervention, their babies are more likely to be born in poor condition. Do their data warrant that conclusion?

To begin with, the relevant question isn’t the tradeoffs between planned home birth per se and hospital birth. It is: “What are the excess risks for healthy women at low risk of urgent complications who plan home birth with qualified home birth attendants compared with similar women planning hospital birth?” This study can’t answer that question. Here’s why:

The study only includes women actually delivering at home, but you can’t make a meaningful comparison unless you have the outcomes of women transferred to hospital. “Planning” in this study meant only that birth at home wasn’t accidental, not the more usual meaning that birth may be planned at home but problems during labor may alter that plan. I discovered this when I wrote the lead author to request cesarean rates, which, oddly, to me, were not reported in the study. She responded that this was because cesareans aren’t performed at home. Puzzled by this explanation, I wrote back that neither are instrumental vaginal delivery, induction, nor labor augmentation, which were reported. She responded that birth certificate data don’t state how labor was induced or augmented but that perhaps at home births it was by rupturing membranes and that “apparently some midwives or birth attendants do perform vacuum extraction at home,” but it is rare since only 10 were reported.

Not all women planning home birth were low-risk. For one thing, women with prior cesareans were included. For another, the methods section states that the analysis adjusted for medical risk, and the discussion notes that women with prior children in the home birth group were more likely to have babies with low Apgar scores even after removing women with medical risk, which implies that some of them had medical problems.

Not all women in the home birth group had qualified home birth attendants. Outcome data on the overall population came from women recorded as being attended by MDs, DOs, “other midwife,” “others,” and “unknown/not stated” as well as by professional midwives.

Rates of neonatal seizure and 5-minute Apgar less than 4 were very low, and the study doesn’t report on perinatal death or permanent disability. As concerning as an excess in low Apgar scores and seizures may be, the real question is excess incidence of permanent harm. Even without limiting the population to low-risk women with qualified care providers, only 1 more baby per 1000 born at home experienced very low 5-minute Apgar, and only 4 more babies per 10,000 experienced neonatal seizure, and while babies born in poor condition are more likely to incur permanent neurologic damage or die, most will recover. Also, as we saw, differences in rates of these adverse outcomes disappeared with a qualified provider.

The proof of the pudding lies in studies free of these weaknesses. A study of 530,000 low-risk Dutch women found no difference in deaths during labor or newborn death rates between women planning, but not necessarily having, home birth and those planning hospital birth (de Jonge 2009). A Canadian study comparing outcomes of 2900 women eligible for home birth with women equally eligible but planning hospital birth reported worse newborn outcomes (more required resuscitation at birth or oxygen for more than 24 hrs and more birth injuries), worse maternal outcomes (more anal sphincter tears and postpartum hemorrhage), and more use of instrumental and cesarean delivery in the hospital population (Janssen 2009).

What can we take away from Cheng and colleagues analysis? First, care provider qualifications matter. Women desiring home birth should have access to professional midwifery care, which argues for making CPMs legal in all 50 states. Second, less than optimal candidates are birthing at home, and some women may be continuing labor at home who shouldn’t. Why might that be? Women may choose home birth because they want control over what happens to them, they have had a prior negative hospital experience, or they want to avoid unnecessary medical intervention (Boucher 2009), the last of which will include women denied hospital VBAC. Women may resist hospital transfer for the same reasons or because they know that at best, hospital transfer means losing the care and advice of the care provider they trust and at worst, they will be treated badly by disapproving hospital staff. If we want to reduce their numbers, hospital-based practitioners need to address the behaviors, practices, and policies that drive women away from hospital birth. This would have the added benefit of improving care for the 99% of American women who would never consider birthing at home.

References

Boucher, D., Bennett, C., McFarlin, B., & Freeze, R. (2009). Staying home to give birth: why women in the United States choose home birth. J Midwifery Womens Health, 54(2), 119-126. http://www.ncbi.nlm.nih.gov/pubmed/?term=boucher+2009+home+birth

Cheng, Y. W., Snowden, J. M., King, T. L., & Caughey, A. B. (2013). Selected perinatal outcomes associated with planned home births in the United States. Am J Obstet Gynecol, 209(4), 325 e321-328. doi: 10.1016/j.ajog.2013.06.022 http://www.ncbi.nlm.nih.gov/pubmed/23791564

de Jonge, A., van der Goes, B. Y., Ravelli, A. C., Amelink-Verburg, M. P., Mol, B. W., Nijhuis, J. G., . . . 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), 1177-1184. http://www.ncbi.nlm.nih.gov/pubmed/?term=de+jonge+2009+planned+home

Janssen, P. A., Saxell, L., Page, L. A., Klein, M. C., Liston, R. M., & Lee, S. K. (2009). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ, 181(6-7), 377-383. http://www.ncbi.nlm.nih.gov/pubmed/19720688

 

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