Science & Sensibility

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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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.

 

Sharon Muza Evidence Based Medicine, Guest Posts, Home Birth, informed Consent, Maternal Mortality, Maternal Mortality Rate, Maternity Care, Medical Interventions, Midwifery, New Research, Research ACOG, ACOG and homebirth, Chervenak, Evidence Based Medicine, guest posts, Home Birth, homebirth, homebirth debate, midwives, Midwives Alliance, research, Wendy Gordon

Today’s post is a fascinating interview that took place between Rebecca Dekker, PhD, RN, APRN of Evidence Based Birth and Kyoung Suk Lee, PhD, MPH, RN, APRN. Rebecca asked Dr. Lee to provide a reiew of the Wax Home Birth Meta-Analysis, as an “unbiased outsider”, but highly skilled researcher.  Dr. Lee’s comments and critique are fascinating and provided me with many further thoughts.  Please enjoy Rebecca’s interview and share your comments. – SM

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Shortly after starting my website, www.evidencebasedbirth.com, I had several people ask me if I could write an article about the research evidence on home birth. However, I was hesitant to do so for several reasons. Mainly, I was worried that I could not look at the evidence in an objective manner. My husband and I had recently chosen a home birth for our second child. I was worried that it would be difficult to objectively examine the research evidence on home birth, given my personal experience. The blogosphere is full of people who are strongly pro-home birth or anti-home birth, and their evaluations of the evidence are usually written through the lens of their own biases. I didn’t want to add to the plethora of biased articles already out there.

Then I had a sudden burst of inspiration. What if I asked one of my colleagues—who has no biases about childbirth—to review the home birth literature for me? In particular, I wanted to find someone who could review the Wax home birth meta-analysis (Wax, Lucas et al. 2010) and give me a fair assessment of its scientific value.

I chose the Wax meta-analysis for this review because in 2011, the American Congress of Obstetricians and Gynecologists emphasized the results of the Wax study in its official statement on home birth. Their statement said: “Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth.”(ACOG, 2011)

It did not take me long to figure out who I would ask to review the Wax study. Dr. Kyoung Suk Lee is considered by her colleagues to be a rising star in the field of cardiovascular research. She recently graduated with a PhD in Nursing, and she just accepted a job at a research university. People who work with Dr. Lee say that she is extremely intelligent, hard-working, and a future leader in her field. Dr. Lee’s expertise has been recognized with research awards from the Heart Failure Society of America, the Society for Heart-Brain Medicine, and the Cleveland Clinic Heart-Brain Institute, among others. She has published her work in nursing and cardiology journals. Furthermore, I knew that Dr. Lee did not have any biases about childbirth, home birth, or hospital birth. I asked Dr. Lee if she would be willing to review the Wax meta-analysis for me, and she kindly agreed.

What follows is my interview of her about the study and its results (RD in bold, KSL unbolded).

Do you have any biases or conflicts of interest related to home or hospital birth?

I do not have any biases related to home or hospital birth.

Could you summarize the methods and results of the Wax study?

The purpose of this meta-analysis was to compare maternal and neonatal outcomes between planned home-and hospital-births.

Using an electronic database search and bibliography search, the authors retrieved 237 articles and included 12 articles in their meta-analyses. Of 12 articles included, 3 were conducted after 2000 while 9 were conducted before 2000. Of 12 articles, 2 were conducted in the US (one was a retrospective design) while 10 were conducted outside US.

Women in the planned home birth group had better maternal outcomes than women in the planned hospital group. They had fewer interventions such as epidurals and episiotomies, and lower morbidity (infection, 3^rd or 4^th degree lacerations, hemorrhages, and retained placenta). There were no differences in cord prolapse between the two groups.

For neonatal outcomes, babies born to women in the planned home birth group were less likely to experience prematurity and low birth weight. However, babies born to women in the planned home birth group were more likely to experience neonatal death compared to women in hospital birth.

What is the difference between neonatal and perinatal mortality? What does this have to do with the results?

Based on the definitions given by the authors, neonatal mortality was defined as “death of live born child within 28 days of birth.” This is a subset of an overall outcome– perinatal mortality, which was defined as “stillbirth (of at least 20 weeks or 500g) or death of live born child within 28 days of birth.”

According to the authors, there were no differences in perinatal death (the overall outcome) between planned home birth and hospital birth groups. However, homebirth was associated with 2 times higher risk for neonatal death (the subset of deaths occurring 28 days after birth) in all infants and 3 times higher risk for neonatal death in infants who did not have any congenital birth defects.

Interestingly, if you look at page 243.e3, the authors did a sensitivity analysis. In this analysis, they excluded the studies that had home births that were not attended by certified midwives or certified nurse midwives. In this analysis, they found that there were no differences in neonatal deaths between the home birth and hospital birth groups. This means that in the studies in which midwives with certification of some kind attended home births, the outcomes were the same except there was no increase in the neonatal death rate. In my opinion, we have to pay attention to results of sensitivity analyses because this allows us to see the results based on studies which were definitely known to be eligible or clearly described their methods and outcomes.

What is your opinion on the scientific rigor of this meta-analysis?

One thing that was strange to me is the odds ratios (ORs) in the tables. For example, in table 2, under morbidity, the percentages of infection between home births and hospital births were 0.7 vs. 2.6 (its OR was 0.27) while percentages of perineal laceration were 42.7 vs. 37.1 (its OR was 0.66). To a researcher, these numbers don’t make sense.

Many of the studies included were older (half of the studies were conducted more than 20 years ago) so results may not reflect the current practice at home births or hospital births.

The authors did not provide detailed information on how they evaluated the quality of studies included, although they cited a paper describing the method of study evaluation. This makes it difficult if not impossible to determine whether the studies they included were of good or poor quality.

The authors mentioned that women with high risks would prefer hospital births so that it would expect that home births have better outcomes than hospital births in some maternal and neonatal outcomes. If this was a concern, I wonder why the authors didn’t just focus on only the studies that used matching methods, in order to minimize confounding factors.

What is the difference between relative risk and absolute risk, and how does that apply to women who want to have a home birth?

Absolute risk is the probability of something occurring. They may be expressed as percentages or ratios. For example, neonatal mortality rate in the United States is 2.01 per 1,000 live births. This is .201 percent (2.01/1000 = .201/100).

Relative risk is a comparison between different risk levels, such as the neonatal mortality rate of home birth compared to the neonatal mortality rate of hospital birth. The researchers found that there was a higher relative risk in neonatal mortality at home births compared to hospital births, but the overall absolute risk for both was small.

How can women know whether the Wax study results would be applicable to their own individual situation?

Meta analysis is one way to generalize findings from different studies. However, women and clinicians should interpret these results cautiously because the studies included were very different from one another and some of the studies included may not have been of good quality. Also, it would be important to note that the overall neonatal death rate that they report reflects home births that were attended by midwives as well as those that may not have had any kind of certified midwife present.

Because this study seems to have some flaws, the conclusion is tentative. I do not know if this article has any implications for pregnant women.

What do you think is the value of asking someone with no conflicts of interest to evaluate controversial research? Does Dr. Lee’s even-handed critique make you view the results of this study any differently? How do you feel about Dr Lee’s conclusion that the study’s results are tentative, and that the Wax study might not have any implications for pregnant women? Please share your thoughts and comments with other readers.

References

(2011). “ACOG Committee Opinion No. 476: Planned home birth.” Obstetrics and gynecology 117(2 Pt 1): 425-428.

Wax, J. R., F. L. Lucas, et al. (2010). “Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis.” Am J Obstet Gynecol 203(3): 243 e241-248.

About Rebecca Dekker

Rebecca Dekker, PhD, RN, APRN, is an Assistant Professor of Nursing at a research-intensive university and author of www.evidencebasedbirth.com. Rebecca’s vision is to promote evidence-based birth practices among consumers and clinicians worldwide. She publishes summaries of birth evidence using a Question and Answer style.

Sharon Muza Babies, Childbirth Education, Evidence Based Medicine, Guest Posts, Home Birth, Metaanalyses, Midwifery, New Research, NICU, Research ACOG, ACOG and homebirth, ACOG Committee position papers, guest post, Home Birth, home birth vs. hospital birth, interviews, is home birth safe?, Kyoung Suk Lee, meta-analysis, Rebecca Dekker, research, Wax study

Today’s blog post is written by Mindy Cockeram, LCCE.  Mindy explores the “mystical” red/purple line that has been observed to provide information about cervical dilation without the need for a vaginal exam. – SM

When couples in my classes are learning techniques for coping in labor, such as the Sacral Rub (sacrum counterpressure), Double Hip Squeeze and Bladder32 accupressure points,  I always talk about the great position the partner is in for spotting the red, purple or dark line (depending on skin color) that creeps up between the laboring woman’s buttocks and how – by ‘reading’ that line – he or she may be able to assess more accurately the woman’s cervical progress than the health care providers!  This empowering thought is often met with smiles and laughter especially when I translate ‘natal cleft’ into more recognizable words like ‘butt cleavage’.  Strangely, I’ve never had anyone in class mention having heard of this ‘thermometer’ for accessing cervical dilation by sight and I find this interesting considering the number of medical professionals that come through my classes.

I first came across this body of research as an Antenatal Student Teacher with the National Childbirth Trust in London.  The article I was reading was in Practising Midwife and was a ‘look back’ at the original article (Hobbs, 1998) published in the same magazine.  The original Practising Midwife article was based on a letter referencing a small study by Byrne DL & Edmonds DK published in The Lancet in 1990.

In the 1990 letter to The Lancet, Byrne and Edmonds outlined and graphed 102 observations from eighteen midwifes on 48 laboring women. It states “The red line was seen on 91 (89%) occasions, and was completely absent in five (10.4%) women and initially absent in three (6.25%).”  The report then goes on to talk about the “significant correlation between the station of the fetal head and the red line length.”  Later the authors write: “To our knowledge, this is the first report of this red line.  We believe that it represents a clinical sign which is easy to recognize and which may offer valuable information in obstetric management.”

So how does this line work?  And why does this it appear?  Practising Midwife Magazine presented a graphic which I have attempted to recreate here.  Basically as the baby descends, a red/purplish (or perhaps brown depending on skin color) line creeps up from the anus to the top of the natal cleft in between the bottom cheeks.  When the line reaches the top of the natal cleft, 2^nd stage is probably a matter of minutes away.  A line sitting an inch below the natal cleft is probably in transition.  A line just above the anus probably signifies early labor.

Byrne DL & Edmonds DK, the authors of the original study, surmise that the cause of the line is “vasocongestion at the base of the sacrum.” Furthermore, the authors reason that “this congestion possibly occurs because of increasing intrapelvic pressure as the fetal head descends, which would account for the correlation between station of the fetal head and red line length.”  Fascinating and logical!

Interestingly, I came across a 2^nd Scottish study from 2010 published by BMC Pregnancy & Childbirth: (Shepherd A, Cheyne H, Kennedy S, McIntosh C, Styles M & Niven C) which aimed to assess the  percentage of women in which a line appeared (76%. ) The study cited only 48-56% accuracy of vaginal examinations to determine cervix diameter and fetal station.  So why aren’t clinicians using this less invasive visual measure – especially considering how much some women may dread vaginal exams in labor??  Wouldn’t the thought of using a methodology to lower infection rate after rupture of membranes has occurred enthuse Health Care Providers instead of using higher risk techniques?  Or how about using the accuracy of the line at the natal cleft to know when a women using epidural should really be coached to push?

My educated guess is that this information has not yet reached Medical Textbooks and non-standard practices can take years to become mainstream (for example. delayed cord clamping) – and then only if or when women request them or media sensation activates them.  In addition, since laboring women are only intermittently attended by Labor & Delivery staff during early and active labor and often encouraged to “stay in bed,” Health Care Providers aren’t necessarily faced with a woman’s buttocks in labor.  Also vaginal examinations are considered “accurate” so staff have no need to peek between a woman’s natal cleft.   However both these studies, paired with the roughly 50% accuracy rate of manual vaginal exams, show that there is potentially a more accurate and less invasive way ahead.

In The Practising Midwife (Jan 2007, Vol 10 no 1, pg 27), Lesley Hobbs writes “Accurate reading would seem to the key to this practice.  I sometimes notice in myself a wish to see the line progressing more quickly than it actually does; when I do this – and check with a vaginal exam – only to find the line is right, I get annoyed with myself and wish I’d trusted my observations.”  Later she goes on to say “I can now envisage a time when I shall feel confident enough to use this as my formal measurement mechanism and abandon intrusive and superfluous vaginal exams.”

Licensed Midwife Karen Baker from Yucaipa, CA commented “The purple line is a curious thing.  It’s definitely not present on everybody but is more prominent on some than others – especially right before pushing.  It tells us when she’s in full swing if we are in a good position to spot it!”

I often urge couples to send me a picture of the so called ‘purple line’ which I promise I will use only for educational purposes but so far a picture is as elusive as the Loch Ness Monster.  So, as I say in class, ‘show me your purple line’!

Are you a midwife, doctor, nurse or doula who has observed this in a client or patient? Partners, have you seen this when your partner was in labor? Has anyone heard of it or witnessed it?  If you are a childbirth educator, do you feel this is something that you might mention in your classes?  Do you think that the families in your classes might be likely to ask for this type of assessment if they knew about it? Please comment and share your experiences.

References

Byrne DL, Edmonds DK. 1990, Clinical method for evaluating progress in first stage labour.Lancet. 1990 Jan 13;335(8681):122.

Downe S, Gyte GML, Dahlen HG, Singata M. Routine vaginal examinations for assessing progress of labour to improve outcomes for women and babies at term (Protocol). Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD010088. DOI: 10.1002/14651858.CD010088.

Hobbs 1998. Assessing cervical dilatation without Vaginal Exams. Watching the purple line. The Practising Midwife 1(11):34-5.

About Mindy Cockeram

Mindy Cockeram is a Lamaze Certified Childbirth Educator teaching for a large network of hospitals in Southern California.  She has a BA in Communications from Villanova University and qualified as an Antenatal Teacher through the United Kingdom’s National Childbirth Trust (NCT) in 2006.  A native of the Philadelphia area, she spent 20 years in London before relocating to Redlands, CA in 2010.

 

 

 

 

Sharon Muza Childbirth Education, Guest Posts, Midwifery, Research, Uncategorized cervical dilation, Childbirth Education, guest post, midwives, Mindy Cockeram, Purple Line, second stage

The  Canadian Medical Association Journal, published in their September 12, 2012 issue a very interesting study examining how a team approach to maternity care might improve maternal and neonat aloutcomes.  The study, Effect of a collaborative interdisciplinary maternity care program on perinatal outcomes  is reviewed here.

The Challenge

The number of physicians in Canada who provide obstetric care has declined in past years for reasons that include increasing physician retirement, closure of rural hospitals, liability concerns, dissatisfaction with the lifestyle and a difficulty in accessing maternity care in a variety of settings.  While registered midwife attended births may be on the rise, midwives in Canada attend less than 10% of all births nationwide.   At the same time as the number of doctors willing or able to attend births decline, cesarean rates are on the rise,  causing pressure on the maternity care system, including longer hospital stays both intrapartum and postpartum, which brings with it the associated costs and resources needed to accommodate this increase.

The diversity of the population having babies in many provinces is increasing, presenting additional challenges in meeting the non-French/English speaking population, who are more at risk for increased obstetrical interventions and are less likely to breastfeed.

The Study

In response to these challenges, the South Community Birth Program was established to provide care from a consortium of providers, including family practice physicians, community health nurses, doulas, midwives and others, who would work together to serve the multiethnic, low income communities that may be most at risk for interventions and surgery.

The retrospective cohort study examined outcomes between two matched groups of healthy women receiving maternity care in an ethically diverse region of South Vancouver, BC, Canada that has upwards of 45% immigrant families, 18% of them arriving in Canada in the past 5 years.  One group participated in the South Community Birth Program and the other received standard care in community based practices.

The South Community Birth Program offers maternity care in a team-based shared-care model, with the family practice doctors, midwives, nurses and doulas working together .  Women could be referred to the program by the health care provider or self refer.  After a few initial standard obstetrical appointments with a family practice doctor or midwife occur to determine medical history, physical examination, genetic history, necessary labs and other prenatal testing, the women and their partners are invited to join group prenatal care, based on the Centering Pregnancy Model.  Approximately 20% of the first time mothers choose to remain in the traditional obstetric care model.  10-12  families are grouped by their expected due date, and meet for 10 scheduled sessions, facilitated by either a family physician or midwife and a community nurse.  Each session has a carefully designed curriculum that covers nutrition, exercise, labor, birth and newborn care, among other topics.  Monthly meetings to discuss individual situations and access to comprehensive electronic medical records enhanced the collaboration between the team. Trained doulas, who speak 25 different languages, also meet with the family once prenatally and provide one on one continuous labor support during labor and birth. The admitting midwife or physician remains in the hospital during the patient’s labor and attends the birth.

After a hospital stay of 24-48 hours, the family receives a home visit from a family practice physician or midwife the day after discharge. Clinic breastfeeding and postpartum support is provided by a Master’s level clinical nurse specialist who is also a board certified lactation consultant.  At six weeks, the mother is discharged back to her physician, and a weekly drop in clinic is offered through 6 months postpartum.

The outcomes of the women in the South Community Birth Program were compared to women who received standard care from their midwives or family practice physicians.  Similar cohorts were established of women carrying a single baby of like ages, parity, and geographic region, and all the mothers were considered low risk and of normal body mass index.

The primary outcome measured was the proportion of women who underwent cesarean delivery.  The secondary outcomes measured were obstetrical interventions and maternal outcomes (method of fetal assessment during labor, use of analgesia during labor, augmentation or induction of labor, length of labor, perineal tramau, blood transfusion and length of stay) and neonatal outcomes (stillbirth, death before discharge, Apgar score less than 7, preterm delivery, small or large for gestational age, length of hospital stay, readmission, admission to neonatal intensive care unit for more than 24 hours and method of feeding at discharge).

Results

There was more incidence of diabetes and previous cesareans in the comparison group but the level of alcohol and substance use was the same in both groups.  Midwives delivered 41.9% of the babies in the birth program and 7.4% of babies in the comparison group.

When the rate of cesarean delivery was examined for both nullips and multips, the birth group women were at significantly reduced risk of cesarean delivery and were not at increased risk of assisted vaginal delivery with forceps or vacuum.

Interestingly, the birth program women who received care from an obstetrician were significantly more likely to have a cesarean than those receiving in the standard program who also received care from an obstetrician.  More women in the birth program with a prior cesarean delivery planned a vaginal birth in this pregnancy, though the proportion of successful vaginal births after cesareans dd not differ between the two groups.

The women in the community birth program experienced more intermittent auscultation vs electronic fetal monitoring and were more likely to use nitrous oxide and oxygen alone for pain relief and less likely to use epidural analgesia (Table 3).  Though indications for inductions did not differ, the birth program women were less likely to be induced.  More third degree perineal tears were observed in the birth program group but less episiotomies were performed.  Hospital stays were shorter for both mothers and newborns in the community program.

When you look at the newborns in the birth program, they were at marginally increased risk of being large for gestational age and were readmitted to the hospital in the first 28 days after birth at a higher rate, the majority of readmissions in the community and standard care group were due to jaundice. Exclusive breastfeeding in the birth program group was higher than in the standard group.

Discussion

The mothers and the babies in the community birth program were offered collaborative, multidisciplinary, community based care and this resulted in a lower cesarean rate, shorter hospital stays, experienced less interventions and they left the hospital more likely to be exclusively breastfeeding. Many of the outcomes observed in this study, especially for the families participating in the South Birth Community Program are in line with Lamaze International’s Healthy Birth Practices.  There are many questions that can be raised, and some of them are are discussed by the authors.

Was it the collaborative care from an interdisciplinary team result in better outcomes?  Was there a self-selection by the women themselves for the low intervention route that resulted in the observed differences?  Are the care providers themselves who are more likely to support normal birth self-selecting to work in the community birth program? Did the fact that the geographic area of the study had been underserved by maternity providers before the study play a role in the outcomes? Did the emotional and social support provided by the prenatal and postpartum group meetings facilitate a more informed or engaged group of families?

I also wonder how childbirth educators, added to such a model program, might also offer opportunity to reduce interventions and improve outcomes  Could childbirth educators in your community partner with other maternity care providers to work collaboratively to meet the perinatal needs of expectant families?  Would bringing health care providers interested in supporting physiologic birth in to share their knowledge in YOUR classrooms help to create an environment where families felt supported by an entire skilled team of people helping them to achieve better outcomes.

Would this model be financially and logistically replicable in other underserved communities and help to alleviate some of the concerns of a reduction in obstetrical providers and increased cesareans and interventions without improved maternal and newborn outcomes? And how can you, the childbirth educator, play a role?

References

Azad MB, Korzyrkyj AL. Perinatal programming of asthma: the role of the gut microbiota. Clin Dev Immunol 2012 Nov. 3 [Epub ahead of print].

Canadian Association of Midwives. Annual report 2011. Montréal (QC): The Association; 2011. Available: www .canadianmidwives.org /data/document /agm %202011 %20inal .pdf

Farine D, Gagnon R; Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada. Are we facing a crisis in maternal fetal medicine in Canada? J Obstet Gynaecol Can 2008;30:598-9.

Getahun D, Oyelese Y, Hamisu M, et al. Previous cesarean delivery and risks of placenta previa and placental abruption.Obstet Gynecol 2006;107:771-8.

Giving birth in Canada: the costs. Ottawa (ON): Canadian Institute of Health Information; 2006.

Godwin M, Hodgetts G, Seguin R, et al. The Ontario Family Medicine Residents Cohort Study: factors affecting residents’ decisions to practise obstetrics. CMAJ 2002;166:179-84.

Hannah ME. Planned elective cesarean section: A reasonable choice for some women? CMAJ 2004;170:813-4.

Harris, S., Janssen, P., Saxell, L., Carty, E., MacRae, G., & Petersen, K. (2012). Effect of a collaborative interdisciplinary maternity care program on perinatal outcomes. Canadian Medical Association Journal, doi: DOI:10.1503 /cmaj.111753

Ontario Maternity Care Expert Panel. Maternity care in Ontario 2006: emerging crisis, emerging solutions: Ottawa (ON): Ontario Women’s Health Council, Ministry of Health and LongTerm Care; 2006.

Reid AJ, Carroll JC. Choosing to practise obstetrics. What factors influence family practice residents? Can Fam Physician 1991; 37:1859-67.

 

Sharon Muza Babies, Breastfeeding, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Fetal Monitoring, Healthy Birth Practices, Healthy Care Practices, Maternity Care, Medical Interventions, Midwifery, New Research, Research, Uncategorized breastfeeding, Canada, cesarean, Childbirth Education, epidurals, Healthy Birth Practices, hospitals, induction, interventions, maternity care quality, maternity care systems, MD, midwives, newborns, Sharon Muza, South Community Birth Program

As summer draws to a close, each day becoming a little bit shorter and the nights just a little bit cooler, many of us are remembering recent fun summer events, vacations, and relaxing times with families and friends.  Labor Day is looming next weekend, offering a long weekend for many of us and a last taste of summer for a while.  I always feel that the Labor Day holiday weekend is the closing bookend of summer, as my family’s attention and energy turn to school, sports and all that fall brings. As I say good bye to the “lazy” days of summer, reading a good book on the deck with a cold drink, I thought our “family” here on Science & Sensibility could participate in a Virtual Book Club, and maybe enjoy some of the long weekend by digging into a captivating new novel about midwives and birth by exploring Patricia Harman’s just released book, “The Midwife of Hope River.”

Patricia Harman is a certified nurse midwife who lives in Morgantown, West Virginia where she works with her OB/Gyn husband, Tom Harman to provide woman centered care at all stages of a woman’s life as well as prenatal care to women in the early stages of pregnancy.  The Harmans stopped catching babies in 2003, and Patricia decided that she would use some of her “free” time to do some writing.  Her first book, The Blue Cotton Gown: A Midwife’s Memoir, shared the stories of her midwifery patients, who came from all walks of life, to sit in her office, offering their intimate stories of challenge, laced with her own personal struggles with her health, the task of running a business and the stress it placed on relationships with those she loves.

In Patricia’s second non-fiction work, Arms Wide Open: A Midwife’s Journey, the prequel to her first book, readers are offered insight into the journey that Patricia Harman took to become a midwife. We read about her first exposure to helping women birth their babies, her exploration into living a life more in line with nature, community and supporting causes in line with her philosophy and her heart during a turbulent period of time in America’s history. Patricia shares how she, along with other women, stretched their wings and stood up for what they believed in, even if it veered from the mainstream culture and norms of the time.

I am delighted to announce that Patricia Harman is releasing her first fiction book, The Midwife of Hope River, A Novel of an American Midwife today, August 28th, and I have selected it as the very first book in the Science & Sensibility Virtual Book Club.  I invite all of you to join me in reading this new novel and participate in the events I have planned for our virtual book club in the beginning of October.

The Midwife of Hope River follows along with Patience Murphy, a midwife practicing during the Great Depression, serving the women of Appalachia, establishing trust and relationships with the mothers who struggle with poverty, challenges and hardship on a daily basis.  Midwife Patience’s own intimate secrets and the presence of the Klu Klux Klan add even more intrigue and suspense, as care is provided to the most fragile and deserving of women as they persevere to birth their babies under circumstances that stretch the midwife and risk the lives of all involved.

I hope that you will join me in reading Patricia Harman’s The Midwife of Hope River, and participating in the events I have planned for the beginning of October.  That timeframe will allow everyone time to read it over the next 5-6 weeks.  Here are some of the things you can look forward to in Science & Sensibility’s first Virtual Book Club;

• An interview with the author, Patricia Harman, to learn more about how she came to write this novel, how she did the historical research needed to capture the personalities and events she created  and and the message she felt that needed to be shared with all of the readers.
• An engaging discussion between Science & Sensibility readers, myself and book author, Patricia about your thoughts on the book, the challenges faced by the main character, Patience Murphy and the birth climate for the women of Appalachia during the Depression.  I have no doubt that all of us will be impacted by what we read and will appreciate a venue in which to share our thoughts and the emotions that arise from this passionate story.
• When you participate in our Virtual Book Club by leaving a comment on the Book Club Discussion blog post in early October, your name will be entered in the random drawing to receive an autographed copy of the book personally inscribed to you.

I have always enjoyed reading memoirs and fictional books about birth, some of my favorites have been The Birth House, Monique and the Mango Rains, Midwives, Catching Babies and The Red Tent  and I am looking forward to adding The Midwife of Hope River to the list.  I know that any discussion with the readers of this blog will be interesting, and I look forward to hearing your thoughts and impressions of the book and sharing that discussion with the author.

Won’t you join me in celebrating good bye to summer, hello fall and maybe starting off the Labor Day weekend with this book, jotting down your notes along the way for sharing when I review the book and we share in our discussion with Patricia Harman.

You can find the book at your local library, Amazon, major book retailer or favorite independent bookseller. Grab yourself a copy, settle down with your favorite tea or coffee and start right in.  In the meantime, let me know in our comments section, what your favorite novels or memoirs about birth have been to date, and why.  Then look forward to our vibrant discussion about this newest novel on midwives, mothers and birth, along with an interview with the author. Join in that discussion and you may be chosen to receive your very own autographed copy.  Happy reading!

Sharon Muza Home Birth, Maternity Care, Midwifery, Newborns, Science & Sensibility Virtual Book Club maternity care systems, Midwifery Care, midwives, newborns, Patricia Harman, Sharon Muza, The Midwife of Hope River, Virtual Book Club