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Intrapartum Antibiotics for GBS Positive Mothers – Still Clear as Mud

September 30th, 2014 by avatar

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

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© Wikipedia

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

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

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

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

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

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

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

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

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

What other advice can we share with women?

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

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

Reference

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

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

 

Evidence Based Medicine, Guest Posts, Medical Interventions, New Research, Research , , , , ,

“Choosing Wisely” in maternity care: ACOG and AAFP urge women to question elective deliveries.

February 21st, 2013 by avatar

 

http://flic.kr/p/4v3Zeh

Last April, the ABIM Foundation, with Consumer Reports and other partners, drew national attention to overuse of ineffective and harmful practices across the health care system with their Choosing Wisely campaign. As part of the campaign, professional medical societies identified practices within their own specialties that patients should avoid or question carefully. Today, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP) have joined the campaigndrawing national attention to the overuse and misuse of induction of labor. ACOG and AAFP are telling women and their maternity care providers:

Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age.

Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable. 

(“Favorable” means the cervix is already thinned out and beginning to dilate, and the baby is settling into the pelvis. Another word for this is “ripe,” and doctors and midwives use a tool called the Bishop Score to give an objective measurement of ripeness. Although ACOG and AAFP do not define “favorable,” studies show cesarean risk is elevated with a Bishop Score of 8 or lower in a woman having her first birth and 6 or lower in women who have already given birth vaginally.)  

Much work has already been done to spread the first message. Although ACOG has long advised against early elective deliveries, a confluence of quality improvement programs and public awareness campaigns have made it increasingly difficult for providers to perform non-medically indicated inductions or c-sections before 39 weeks.

But as the public and the health care community have accepted the “39 weeks” directive, concern about unintended consequences has grown. Christine Morton, a researcher at the California Maternal Quality Care Collaborative and regular contributor to Science & Sensibilitysums up concerns shared by many, including Childbirth Connection:

It is possible that this measure may sensitize stakeholders to the wrong issue: timing of birth rather than the fact that it is generally best when labor begins on its own.  Additionally, is it possible that 39 weeks could become the new “ideal” gestational age, because it will be assumed that 39 completed weeks is the best time to be born?

The second Choosing Wisely statement aims to mitigate these unintended consequences. Inducing with an unripe cervix significantly increases the chance of a c-section and its many associated harms. Women considering induction for a non-medical reason deserve to know about these excess risks, and should question whether it is worth any non-medical benefits of elective delivery they perceive or expect. Lamaze International has spoken to the importance of letting labor begin on its own, as it is the first topic in the Six Healthy Birth Practices.

But will the new message lead women and care providers to think that delivery is indicated once a woman’s cervix is ripe? Through the Choosing Wisely campaign ACOG and AAFP have made powerful statements acknowledging that scheduled delivery is unwise if the baby or the woman might not be ready for birth. Although gestational age and the Bishop score are tools to estimate readiness for birth, the best indicator of readiness is still the spontaneous onset of labor at term, the culmination of an intricate interplay of hormonal signals between the fetus and the woman. Anytime we intervene with the timing of birth we have to weigh the potential benefits and harms of overriding that process in the context of the fully informed preferences and values of women.

This summer, our collaboration with the Informed Medical Decisions Foundation will culminate in the release of our first three Smart Decision Guides. These evidence-based, interactive decision support tools will help women learn the possible benefits and harms of scheduled delivery versus waiting for labor to start on its own and to weigh these based on what is most important to them. These tools help women choose wisely – to identify when an option is not appropriate or safe for them, and to thoughtfully weigh options when there are both pros and cons to consider.

Interested in learning more about shared decision making in maternity care? Sign up for a free webinar on March 13 sponsored by the Informed Medical Decisions Foundation to hear more about what clinicians, consumers, employers, and others thinking about the importance of maternity care shared decision making.

 

ACOG, Childbirth Education, Evidence Based Medicine, Guest Posts, Healthcare Reform, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternal Quality Improvement, Medical Interventions, Practice Guidelines, Pre-term Birth, Webinars , , , , , , , , , ,

Consider the Source: An Interview with Cara Osborne, SD, MSN, CNM, co-author of The National Birth Center Study II

January 31st, 2013 by avatar

http://flic.kr/p/v7Wse

The Journal of Midwifery and Women’s Health has just published the results of the National Birth Center Study II. As the name suggests, this is the second time researchers have undertaken a multi-site study of U.S. birth centers to understand the process and outcomes of care in these settings. The first appeared in the New England Journal of Medicine in 1989, and concluded that “birth centers offer a safe and acceptable alternative to hospital confinement for selected pregnant women, particularly those who have previously had children, and that such care leads to relatively few cesarean sections.”

The current study describes birth centers as a “durable model” of care because, again, outcomes were excellent. 

Here are the key findings of the National Birth Center Study II:

  • Of more than 15,000 women eligible for birth center care when labor started, 93% had spontaneous vaginal births, and 6% had cesareans.
  • 16% of women transferred during labor, and approximately 2.5% of mothers or newborns required transfer to the hospital after birth. Emergent transfer before or after birth was required for 1.9% of women in labor or for their newborns. Most women who transferred in labor had vaginal births.
  • There were no maternal deaths. The intrapartum stillbirth rate was 0.47/1000, and the neonatal mortality rate was 0.40/1000 excluding anomalies.

I had an opportunity to interview one of the study authors, Cara Osborne, SD, MSN, CNM. Dr. Osborne is an Assistant Professor at the University of Arkansas School of Nursing, a perinatal epidemiologist, and co-founder of Maternity Centers of America. I asked her what the study findings mean for women and families and what it will take to scale up the birth center model and expand access.

AR: Thanks for participating in this interview. First and foremost, what should expectant parents know about this study?

CO: The take away messages from this study for expectant parents are that birth center care is safe and minimizes the likelihood that their baby will need to be born by cesarean, and that if hospital care becomes necessary, that transfer is very unlikely (1.9%) to be an emergency.

(Rebecca Dekker, PhD, RN, APRN of Evidence Based Birth has prepared an excellent summary that appears at the American Association of Birth Centers web site with more about the study findings and their implications for women and families.)

The study is based on the AABC Uniform Data Set. What are the strengths and limitations of the UDS? 

CO: The UDS data were collected prospectively, which means women were enrolled in the study before the outcome of the pregnancy was known. This is an important strength because it means that the ultimate outcome could not bias the data that were collected during the pregnancy. Also, the UDS is used across dozens of birth centers, so it also enables us to get much more data than would be possible from a single birth center site.

Cara Osborne, SD, MSN, CNM

A primary limitation is that the UDS does not capture information that describes the family’s experience of birth center care, which makes correlating the clinical findings with experiential information impossible. Also, the UDS isn’t used by physicians practicing in hospitals, so we could not compare our findings to typical hospital-based care.

AR: The first National Birth Center Study reported outcomes of births from 1985 to 1987. Even though this study took place two decades later, the results are strikingly similar. If we’ve known for decades that birth centers are safe and effective, and they provide high quality care without costly hospital overhead, why isn’t there one in every community?

CO: You’re right, the results were very similar. For example the c-section rate in birth centers remained stable, going from 4% in the first study to 6% in the current study, while the national c-section rate during the same period has increased dramatically from 18% to 33%. We’ve known all along that greater use of birth centers could curb or reverse this trend, but there are several obstacles that have prevented a broad expansion of the model. They fall into three categories: systems obstacles, business obstacles, and professional obstacles.

Systems obstacles:

  • Hospitals have been predominant place of birth in the U.S. for so long that associated processes such as payment by commercial insurers and state Medicaid, the filing of birth certificates, and administration of state required newborn screening tests have all been developed based on hospital timelines and protocols. Therefore, changing the place of birth requires changes in all the associated systems as well, which can be difficult.

Business obstacles:

  • The skill set that it takes to be a good care provider and the skill set that it takes to start and run an efficient business have very little overlap, and it’s the rare provider that has both.
  • It takes a considerable capital investment to get a birth center up and running, and that’s not something most providers can access.
  • Equitable reimbursement for provider fees to midwives and facility fees to birth centers from commercial insurers and state Medicaid plans has not been available in most areas of the U.S., so the return on investment has been low.

Professional obstacles: 

  • Many physicians have opposed the independent practice of midwives while also refusing to enter in to collaborative practice agreements, which are required for midwives to provide intrapartum care in many states.
  • Birth center regulations in many states require that a physician be the medical director of the center, and recruiting physicians to fill this role can be difficult.
  • Hospitals have seen birth centers as competition and thus have not offered access to referral and transport.

AR: You are part of an effort to change things so that we do one day have a birth center in every community. Can you tell us about that effort, and why you think you will succeed?

CO: My co-founder Shannon Bedore and I formed Maternity Centers of America (MCA) in order to create a vehicle for addressing the barriers described above. As you pointed out, birth centers are a good thing and there should be more, so we built MCA to bring together professionals from a variety of backgrounds including business, real estate, construction, and health policy to look at the big picture of how maternity care works and find new ways to make birth centers a part of the healthcare system. If our efforts are successful, I believe that this broad range of perspectives will be the reason.

Credit: Center for Birth http://centerforbirth.com

As our first step, we established a demonstration site in northwest Arkansas which will allow us to try new management strategies and find ways to leverage technology while staying true to the birth center model of care. From this flagship site, we hope to develop a replicable, scalable model for the development of birth centers around the U.S. This is not a new idea, nor one that only we are working to implement. Our colleagues at New Birth Company in Kansas City and at the Minnesota Birth Center in Minneapolis are also building replicable birth center models. Each of us has a slightly different approach, and all of us need to succeed in order to or build enough scale to have measureable impact on national outcomes.

AR: The American Association of Birth Centers and the American College of Nurse-Midwives are hosting a congressional briefing next month in Washington to share the study results. Why does this study matter to policy makers?

CO: This study is of particular interest to policy makers because of both its content and its timing. Maternity care makes up the largest proportion of the national hospital bill from a single condition, and a large proportion (45%) of that is paid by government programs. A recent report from the consumer advocacy organization Childbirth Connection entitled The Cost of Having a Baby in the United States highlights the striking cost of U.S. maternity care and its inverse relationship with clinical outcomes. The report showed that almost two-thirds (59-66% depending on payer and type of birth) of the total costs of maternity care went to cover facility fees charged by hospitals. Birth centers charge facility fees too, but they are a fraction of the typical hospital fee. In addition, c-sections cost commercial payers $19,000 more than vaginal births, and they cost Medicaid programs $9,500 more than vaginal births. Multiplied by the estimated number of excess cesareans in the United States, this means about $5 billion dollars could be saved each year by improving our ability to safely get babies born vaginally.

The low value of maternity care is coming into sharper focus for policy makers at the moment due to the implementation of the Patient Protection and Affordable Care Act, which adds maternity care to the list of essential health benefits and increases the number of pregnancies that will be covered by the government through the expansion of state Medicaid programs. As policymakers attempt to realign costs and outcomes, they are looking for strategies that address the “triple aim” of healthcare championed by Don Berwick and his colleagues: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. Birth centers are a viable, evidenced-based option for meeting all three aims, which is rare, particularly in maternity care. 

Are you surprised by the results of this new study?  Will  you share this information with your clients and students?  Do you think this study will have an impact on the choices that women make about their birth location? Do you believe that more birth centers can help solve many of the problems facing birthing women and maternity care today? Share your thoughts in our comment section. I’d like to hear from you.- Sharon Muza, Community Manager.

Cesarean Birth, Evidence Based Medicine, Guest Posts, Healthcare Reform, Home Birth, Maternal Mortality, Maternal Quality Improvement, Maternity Care, Medical Interventions, New Research, Research, Uncategorized , , , , , , , ,

Maternity Care On the National Agenda – New Opportunities for Educators and Advocates

January 17th, 2013 by avatar

Today, Amy Romano, CNM, MSN, Associate Director of Programs for Childbirth Connection (and former Community Manager for this blog) follows up last Thursday’s post, Have You Made the Connection with Childbirth Connection? Three Reports You Don’t Want to Miss with her professional suggestions for educators and advocates to consider using the data and information contained in these reports and offering your students, clients and patients the consumer materials that accompany them.- Sharon Muza, Community Manager.

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As we begin 2013, it is clear from my vantage point at the Transforming Maternity Care Partnership that the transformation is underway. In Childbirth Connection’s nearly century-long history, we’ve never seen so much political will from leaders, so much passion from grassroots advocates, and so much collaboration among clinicians and other stakeholders. This new landscape presents many new opportunities for educators and advocates.

One area of maternity care that has garnered increasing attention is the overuse of cesarean section, especially in low-risk women. Last year, the multi-stakeholder Maternity Action Team at the National Priorities Partnership set goals for the U.S. health care system and identified promising strategies to reach these goals. One of the goals was to reduce the cesarean section rate in low-risk women to 15% or less. This work served as the impetus for Childbirth Connection to revisit and update our Cesarean Alert Initiative. We undertook a best evidence review to compare outcomes of cesarean delivery with those of vaginal birth. Based on the results, we also updated and redesigned our consumer booklet, What Every Pregnant Woman Needs to Know About Cesarean Section. These are powerful new tools to help educators and advocates push for safer care, support shared decision making, and inform and empower women.

Two of the biggest obstacles to change have been persistent liability concerns and the current payment system that rewards care that is fragmented and procedure-intensive. Efforts to make maternity care more evidence-based or woman-centered often run up against policies and attitudes rooted in fear of lawsuits or increasing malpractice premiums, or against the reality that clinicians can not get easily reimbursed for doing the right thing. But these barriers are shifting, 

Recently the literature has provided example after example of programs that reduced harm and saw rapid and dramatic drops in liability costs as a result. That’s right – one of the best ways to decrease liability costs is to provide safer care. Rigorous quality and safety programs are the most effective prevention strategy among the ten substantive solutions identified in Childbirth Connections new report, Maternity Care and Liability. The report pulls together the best available evidence and holds potential liability solutions up to a framework that addresses the diverse aims of a high-functioning liability system that serves childbearing women and newborns, maternity care clinicians, and payers.  

The evidence and analysis show that some of the most widely advocated reforms do not stand up to the framework, while quality improvement programs, shared decision making, and medication safety programs, among other interventions, all have potential to be win-win-win solutions for women and newborns, clinicians, and payers. If we are to find our way out of the intractable situation where liability concerns block progress, we must learn to effectively advocate for such win-win-win solutions.  Advocates and educators can better understand these solutions by accessing the 10 fact sheets and other related resources on our Maternity Care and Liability page.

Evidence also shows that improving the quality of care reduces costs to payers. As payment reforms roll out, there will be many more opportunities to realize these cost savings. To predict potential cost savings, however, it is necessary to know how much payers are currently paying for maternity care. Surprising, this information has been largely unavailable, and as a result we have had to settle for using facility charges as a proxy. This is a poor proxy because payers negotiate large discounts, and because charges data do not capture professional fees, lab and ultrasound costs, and other services. Childbirth Connection, along with our partners at Catalyst for Payment Reform and the Center for Healthcare Quality and Payment Reform, recently commissioned the most comprehensive available analysis of maternity care costs. The report, The Cost of Having a Baby in the United States shows wide variation across states, high costs for cesarean deliveries, and rapid growth in costs in the last decade. It also shows the sky-high costs uninsured women must pay – costs that can easily bankrupt a growing family. Even insured women face significant out-of-pocket costs that have increased nearly four-fold over six years. Fortunately, health care reform legislation has made out-of-pocket costs for maternity care more transparent by requiring a simple cost sample to each person choosing an individual or employer-sponsored health plan.

Educators and advocates have to be able to help women be savvy consumers of health care. That means being informed about their options and also being able to identify and work around barriers to high quality, safe, affordable care. Childbirth Connection produced this trio of reports to provide a well of data and analysis to help all stakeholders work toward a high-quality, high-value maternity care system.

How Childbirth Educators and Consumer Advocates Can Help

 What is the first thing that you are going to do to join this maternity care transformation? Can you share your ideas for using this information in your classroom or with clients or patients.  Can you bring others on board to help with this much needed transformation?- SM

Childbirth Education, Evidence Based Medicine, Guest Posts, Healthcare Reform, Maternal Quality Improvement, Maternity Care, Patient Advocacy, Research, Research for Advocacy, Transforming Maternity Care , , , , , , , , , ,

Book Review: Optimal Care in Childbirth: The Case for a Physiologic Approach Reviewed Through a Childbirth Educator’s Eyes

October 18th, 2012 by avatar

I had waited excitedly for the release of Henci Goer and Amy Romano’s new book for a long time and was delighted to receive it after it was published in May 2012. Optimal Care in Childbirth: The Case for a Physiologic Approach was a robust, updated successor to Henci’s previous book; Obstetric Myths Versus Research Realities which was a well used source on my office bookshelf.

Both authors have a long history with Lamaze International. Prior to her current position with Childbirth Connection, directing the Transforming Maternity Care Partnership, Amy launched Science & Sensibility, and provided a keen and critical eye when analyzing, reviewing and sharing research items with readers. Henci Goer has been the long time resident expert on the “Ask Henci” forum hosted by Lamaze International, providing and sharing resources on a wide variety of pregnancy and childbirth topics with consumers and professionals alike, as well as a regular contributor to this blog. Please read the full bios of Amy and Henci on their website, where you can find complete information on their work, background and other works that they have authored.

As the title clearly states, this book is about childbirth, and as such, you will not find information on pregnancy, breastfeeding or newborn topics. Nor is this the type of text that childbirth educators would hand out in class for consumers to use. This book is heavy with sources, study outcomes and insights into current obstetric practices. But, as a guide to best practice, the book becomes a great repository of information that allows consumers and professionals alike to learn and make decisions about care that can help keep birth as physiological as possible. The book focuses on what factors affect, both positively and negatively, birth, so that an optimal outcome can occur.

The authors define optimal outcomes as “the highest probability of spontaneous birth of a healthy baby to a healthy mother, who feels pleased with herself and her caregivers, ready for the challenges of motherhood, attached to her baby, and goes on to breastfeed successfully.”

The chapters are well organized, with the topic of cesareans starting things off. Cesarean rates have never been higher, and many of the topics that Goer and Romano discuss later in the book often have the unintended consequence of contributing to the skyrocketing cesarean rates in this country. I think it is an important topic and one that receives a thorough evaluation by the authors.

Each chapter starts off with “contradicting” quotes from researchers working in the field of obstetrics, and I have to say, that reading these at the beginning of each chapter was something I looked forward to, a nice added bonus and really made me pause and consider the different viewpoints and how they influence practice today. The lead in for chapter 12 on epidurals and spinals contains one of my favorites:

“There is no other circumstance in which it is considered acceptable for a person to experience untreated severe pain, amenable to safe interventions, while under a physician’s care.” ACOG 2006

“Epidural anaesthesia remains one of childbirth’s best exemplars of iatrogenesis. It is a wonderful intervention for managing labour complications, especially as an alternative to general anaesthetic for caesarean sections, but has significant side effects that constantly need weighing alongside benefits. Though its rising popularity almost grants it the status of normative practice on some [U.K.] maternity unites, it remains incompatable with physiological labour.” Walsh 2007

Each chapter begins with a wonderful perspective on each topic, sharing history and cultural practices so the reader can understand how standard protocols found in most birthing facilities have come to be, even when not backed up by research. I think it is critical to include this information, for if there is to be a shift to more evidence based care in the field of obstetrics, we need to be aware and acknowledge that some practices may have evolved for legal, cultural, social or policy reasons having nothing to do with sound research.

The authors ask and answer the very questions that I find myself asking out loud, helping the reader to understand why we continually observe care that is known to not improve outcomes. For example, when discussing electronic fetal monitoring, the question “Why does use of continuous EFM persist?” in normal low risk labors is asked (and thoroughly answered) with supporting references for further information.

Each chapter contains a brief summary of action steps that women can take to receive optimal care, along with the supporting research that backs up these steps. These lists are great talking points both for educators to integrate in their classrooms, but also for consumers to discuss with their health care providers and understand why their care might deviate from that supported by research.

The conclusion of each chapter has what the authors call a “mini-review” and neatly summarizes the important topic statements and provides (and references) outcomes of studies so that the reader can evaluate for himself or herself the validity of the research. Though these sections are called reviews, I found them to be a very helpful component of the book, when looking for solid sources.

At the end of each chapter, all of the sources referenced in that chapter are listed.

Henci Goer

I was very appreciative throughout the book, for the definitions that the authors provided when discussing a topic. It is important (and helpful) to know how terms are defined, so that the reader can best understand the discussion. For example, in one of the cesarean chapters, one can find a list of “rate” terms, so when “primaparous cesarean rate” is discussed, this term has already been explained.

Several places throughout the book, in various callout boxes, Goer and Romano discussed the selective language that health care providers use when talking about childbirth and presenting information to families. I found these small detours fascinating, as I am very interested in the language that HCPs use to discuss risk, procedures and events with their patients.

The last chapters of the book take a look at choice of birth location, what the ideal maternity care system might include and includes information on maternal mental health. The appendices speak to common “less than optimal” situations, such as the OP fetus in labor, meconium staining and other circumstances that frequently cause concern and labor interventions. Again, the authors include information on optimal care in these cases that can help.

It is clear from some of the phrasing, chapter titles and choice of words in some of the discussions, that the authors have a bias towards a childbirth process that unfolds in a natural and physiological manner. This language, while potentially off-putting to those who firmly believe in the medical model, is effective in causing the reader to consider standard practices that make no logical “sense”, and certainly, references are provided for further research should the reader wish to investigate further.

I must say that I very much enjoyed this book, and I will find it very useful in my doula and Lamaze childbirth education practice. It is the type of book that one thumbs through frequently, when asked a question by a student or client, or when helping a client to prepare to speak to their health care provider about best practices and birth preferences. I think that any birth professional would do well to have this book on their shelf and be able to refer to it when necessary. This book represents a significant amount of research and I find great comfort in knowing that all the resources and references supporting the statements made in the book are available for me to source myself.

Amy Romano

I look forward to the release of the e-book version of this title, expected this fall, for the Kindle, iPad and other tablets, so that I could have easy access from wherever I am. I would be delighted if the references and sources could be routinely updated as new research is released and published, so that I can use this guide for many years to come, confident that it reflects the newest and most valid research. I know that is a formidable task, but I would gladly pay a small subscription fee to have an updated version as often as necessary.

This book is available for purchase from both Amazon.com and the Optimal Care in Childbirth website. The book is on the expensive side, costing approximately $50.00, but very well may become the go-to source for evidenced based research on your office shelf, so worth the investment. If you choose to purchase from the book’s site, there are bulk and wholesale discounts available.  For purchases made from the book’s website, the authors are providing a 15% discount for our Science & Sensibility blog readers and conference attendees. Enter code UXJXI52F at checkout to receive the discount.

I hope that you are planning to attend the upcoming Lamaze International Innovative Learning Forum next week, where both Amy Romano and Henci Goer have been invited to speak. You will have an opportunity to meet these authors, ask them questions, purchase this book and hear their powerful presentations. As a General Session Speaker, Amy’s session will be available as part of the “Virtual Conference” option for those unable to attend the conference in person.

Have you read Optimal Care in Childbirth?  Are you using it already in your practice?  Please share your thoughts and comments in our comment section here on the blog.  I look forward to hearing your views. – SM

References

ACOG committee opinion. No. 339: Analgesia and cesarean delivery rates. Obstet Gynecol 206;107(6):1487-8.

Walsh D. Evidenced Based Care for Normal Labor and Birth. London: Routledge; 2007.

Book Reviews, Cesarean Birth, Childbirth Education, Epidural Analgesia, Fetal Monitoring, Healthcare Reform, informed Consent, Lamaze 2012 Annual Conference, Maternal Mental Health, Medical Interventions, New Research, Pain Management, Practice Guidelines, Research, Systematic Review, Transforming Maternity Care , , , , , , , , ,