Science & Sensibility

In recognition of Cesarean Awareness Month, I want to share an interview with Christa Billings, the president of International Cesarean Awareness Network (ICAN).  For over 30 years, ICAN has had an international presence and through peer to peer support and many volunteer hours, has worked tirelessly to prevent unneeded cesareans, help women recover emotionally from a cesarean and advocated for VBAC as a safe and appropriate choice for many women when they plan their future births.

I have been the chapter co-leader of ICAN Seattle for several years, and have been honored to walk alongside the women who make up our chapter as they have discovered their own strength and power and learned how to seek information and evaluate evidence and research.  There are many chapter leaders just like myself, working hard in our own communities, to help women both before and after a cesarean birth. ICAN has partnered with many other maternal health organizations and maternity leaders to help improve the state of maternity care for many women.  Learn more about this organization and be sure to share this organization (and its resources) with your students, clients and patients.

Sharon Muza: Can you tell me a bit about the history of ICAN?

Christa Billings: The International Cesarean Awareness Network, Inc. (ICAN) is a nonprofit organization that was founded by Esther Booth Zorn and many other motivated women in 1982. ICAN originated as “Cesarean Prevention Movement,” later changing its name to ICAN in 1992 to reflect a more positive statement. ICAN has now grown to over 180 chapters throughout the United States and worldwide over the past 30 years. ICAN’s mission is to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery, and promoting Vaginal Birth After Cesarean (VBAC).

SM: How many chapters does ICAN have nationally and internationally?

CB: ICAN has 181 chapters, 145 in the USA, and another 36 internationally.   

SM: What does an ICAN meeting look like?

CB: A typical ICAN meeting entails women coming together with women of similar experiences for peer to peer support. Meetings are sometimes topic specific and sometimes general support. Often birth stories are shared. There is often laughter, tears and a feeling of camaraderie. The feel of a particular meeting can change based on who is there and what it being discussed. I like to remind newcomers that they should always try a second meeting as they are all different. Sometimes meetings can be VBAC heavy and other times they can be cesarean recovery heavy. It really depends on who shows up to the meeting and who is driving the discussion.

SM: Who is welcome? Mothers? Partners? Birth Professionals? Providers?

CB: Some meetings are open for women/lap babies only and other meetings welcome children, dads, husbands, partners, birth professionals and other community members who want to learn about cesareans, VBAC and recovery. Each chapter may vary on how they do things, so check in with the chapter leader if you have any questions.

SM: What are some things that ICAN does that reinforces it’s mission statement?

CB: We offer support to mothers through listening. We also help in educating them by providing evidence based research to help them make the best possible birth choices for them or to cope/understand what they have experienced. We recognize that both VBAC and cesareans carry risks. We help women understand what those risks are with both choices, where typically many providers only provide the VBAC risks.

SM: I know that ICAN periodically holds conferences; can you tell me about them? Are there continuing ed hours available from them?

CB: The ICAN conferences are a time to spend quality face to face, talking with women who support VBAC and are interested in reducing the cesarean rate. This conference isn’t just for VBAC and cesarean mothers; it’s for anyone who supports birth. There are many great speakers and public discussion on various birth topics.  We do offer continuing education hours.

SM: How did you get involved in ICAN yourself? How did you find yourself in the president’s position?

CB: I found ICAN five years ago when I first stepped foot into an ICAN meeting during Cesarean Awareness Month. I was just a mom looking for support as I planned a VBAC. I quickly found great support. My second birth ultimately ended in another cesarean, even though I attempted a VBAC. If I couldn’t have a vaginal birth I wanted to make sure others had the support and education to ensure the best advantage in planning for their births. I wanted to give back to the organization that helped shape my birth journey. I decided to join my local ICAN chapter’s board & accepted a position as the Northwest Regional Coordinator. Later in 2010, I went on to VBAC my 3rd daughter at home after 2 cesareans. After attending the 2011 ICAN conference I really felt pulled to do more. The conference was very inspiring and it touched me deeply.  It was a thrill to meet all the women I had been communicating with over the years. These mothers were no longer just a name in an email. Putting names & faces to it gave the journey to VBAC a whole new meaning to my life. In 2012 I joined the Board of Directors as Chapter Director. As we reshaped the board be a bit smaller and focused, I moved into the role of Vice President. The previous President stepped down and in October 2012 and I became the new President of ICAN. I never envisioned my life taking this path, but here I am and I’m proud to be the voice of the mothers for an organization so dear to my heart. ICAN has forever changed my life.

SM: What challenges do we face in lowering the cesarean rate? Do you think the tide has turned?

CB: While research has consistently shown that VBAC is a reasonably safe choice for women with a prior cesarean, there is an alarming disconnect between what evidence based research shows is good for women and babies, and the way that hospitals and providers practice. Mothers need to start demanding research based care. The challenges we still face are getting care providers to work with us to improve birth outcomes by providing evidence based care and to stop practicing by provider preference, convenience, legal liability concerns and to perform cesareans only when the research clearly indicates it is needed.

I would like to think that the tide is starting to turn, but I am not ready to say it’s turned quite yet. Mothers are joining together to recognize they have a voice and choices in their maternity care and are starting to demand evidence based care. The recent statements from ACOG give us a little hope that people are opening up their eyes to see how out of control the cesarean rates are in many places.

SM: Are you optimistic with recent statements from ACOG about who should VBAC and how to handle maternal request cesareans?

CB: I’m not sure optimistic is the right word, I would say hopeful. I think it is great that ACOG is finally acknowledging that primary cesareans will affect future births and that in the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended to patients. These births are a very small percentage of the births, as often primary cesareans are not being performed based on maternal request, but rather being performed by provider preference, convenience, legal liability concerns and many other reasons. I will be optimistic when providers and hospital administration acknowledge that birth is a human right, that the consumer has the right to decide whether they accept the choices presented to her and start providing true informed consent and stop using scare tactics to influence women’s decisions. 

SM: What do you want childbirth educators to know and share with students about ICAN and cesarean awareness?

CB: That ICAN is a non-profit advocacy and support group whose mission is to improve maternal and child health by preventing unnecessary cesareans through education, providing support for cesarean recovery, and promoting vaginal birth. We offer support and information to thousands of women through our main office, local chapters, website, forums, email support groups and various social networks. We provide evidence-based information, using research that is accessible for women and their care providers.  It’s important that women understand the effects a primary cesarean can have on them and on all future births.  It would be great if childbirth educators included ICAN as a resource for the families in their classes who may end up with a cesarean.

SM:What do you want health care providers to know?

CB: We are a support network for women healing from past birth experiences and for those preparing for future births. Our vision is to reduce the cesarean rate driven by women making evidence-based and risk appropriate childbirth decisions. We are not anti-cesarean. ICAN recognizes that when a cesarean is medically necessary, it can be a lifesaving technique for both mother and baby, and worth the risks involved. While VBAC does carry risks associated with the possibility of uterine rupture, cesarean surgery carries life-threatening risks as well. The choice between VBAC and elective repeat cesareans isn’t between risk versus no risk. It’s a choice between which set of risks you want to take on. We are here to help educate mothers on all risks to help them make the best choices for their birth.

SM: If someone was interested in adding a chapter, what would the first step?

CB: If someone wanted to start a chapter in their city or town, they would need to contact the regional coordinator for their area. Their regional coordinator will walk them through the steps & requirements to open a chapter.

SM: What can people do if they want to volunteer in other ways besides being a chapter?

CB: They can contact our volunteer coordinator for more information on how they can help. Please let our volunteer coordinator know what your special skills are that you have to offer and she will match you up with the right position suited to your skills. We have many positions or tasks within ICAN that are not chapter specific. As an all volunteer organization. we are always looking for help.

SM: I want to thank you, Christa for all the information you have provided and for your time in doing this interview.  I hope that more people will share the resources that ICAN offers with the birthing families that are affected by cesarean birth.

Sharon Muza ACOG, Cesarean Birth, Childbirth Education, Evidence Based Medicine, informed Consent, Maternity Care, Patient Advocacy Cesarean Awareness Month, Childbirth Education, Christa Billings, Evidence Based Medicine, ICAN, International Cesarean Awareness Network, Sharon Muza

Today, Rebecca Dekker, PhD, RN, APRN of Evidence Based Birth shares a quick but very effective video tutorial on how to use the Cochrane Library to find evidence based information on maternity care topics.  Free and full access to the Cochrane Library is a Lamaze International member benefit and I value the information I am able to find there.  For more information on the Cochrane Collaboration, please see my recent post  celebrating the 20th anniversary of the Cochrane and sharing a bit about the history behind it. 

What other topics would you like covered in a video tutorial?  Rebecca is looking for more suggestions for the next video tutorial!  Also,  let us know how you use the Cochrane Library and please share other favorite sources you also use to find evidence based information on birth topics you are researching.

Sharon Muza Childbirth Education, Evidence Based Medicine, Maternity Care, Research Cochrane Collaboration, Evidence Based Medicine, Lamaze International, Rebecca Dekker, video tutorial

As I wrote about in my January 3rd, 2012 post on the top 10 reasons to join Lamaze International, one of the great benefits of being a Lamaze member is complete access to the Cochrane Collaboration.  The Cochrane Collaboration is an international organization whose purpose is to make available information on the effects of healthcare interventions.  Reports in the form of Cochrane Reviews are current, accurate and made available electronically on the internet and by DVD, and updated monthly.  Systematic reviews are conducted and published on a wide variety of healthcare interventions so that people can make informed decisions. This is stored in the Cochrane Library.

Archie Cochrane, photo credit: Cardiff University. Library, Cochrane Archive, University. Hospital Llandough

The Cochrane Collaboration was founded by Archie Cochrane, who was a British medical researcher.  Mr. Cochrane is best known for his article Effectiveness and Efficiency: Random Reflections on Health Services written in 1972.  

The creation of a systematic review of randomised controlled trials (RCT’s) of care during pregnancy and childbirth is “a real milestone in the history of randomised trials and in the evaluation of care.” Professor Archibald Leman Cochrane, CBE FRCP FFCM, (1909 – 1988)

The Cochrane Collaboration is celebrating their 20th anniversary this year, 2013 and will be sharing a series of 24 short videos over the course of the anniversary year, focusing on the ideas, achievements and people that have been part of the history of this international and well-respected organization.  I am sharing the first in this series, so you can learn a bit more about how this organization came to be recognized as the gold standard in evidence-based health care.

The United States Cochrane Center has created and made available free of charge, an online tutorial, “Understanding Evidence-based Healthcare: A Foundation for Action, that can help you to learn how to best navigate and understand the resources contained in the Cochrane Library.

Lamaze International’s Healthy Birth Practice Tools is completely based on evidence based information and was created so that consumers could understand and advocate for the best care for themselves and their babies.  Lamaze recognizes the importance of educators and others having access to up to date information and therefore is pleased to offer access to the Cochrane Library as a member benefit.   To access the Cochrane Library as a Lamaze member, first login to Lamaze International’s Member Center and then follow the drop down box to the Cochrane Library. You will be redirected to the library, with full access.

I rely on and use this member benefit constantly, and appreciate it being made available to me by Lamaze.  Won’t you share in the comments section how you use the Cochrane Library?  How has it helped you?  Do you find what you need?  Do you share information and studies with your students, clients and patients?  Let us know, please.

References 

Cochrane AL. Effectiveness and Efficiency. Random Reflections on Health Services. London: Nuffield Provincial Hospitals Trust, 1972. (Reprinted in 1989 in association with the BMJ, Reprinted in 1999 for Nuffield Trust by the Royal Society of Medicine Press, London (ISBN 1-85315-394-X)

Sharon Muza Childbirth Education, Continuing Education, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, informed Consent, Lamaze International, Maternal Quality Improvement, Maternity Care, Medical Interventions, New Research, Practice Guidelines, Research, Systematic Review Childbirth Education, Cochrane Collaboration, Evidence Based Medicine, Healthy Birth Practices, interventions, Lamaze International, maternity care systems, research, Sharon Muza, Systematic Review

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

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

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flickr.com/photos/bogofoo/4118547231/

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

By Rebecca L. Dekker, PhD, RN, APRN

Today’s post on the Evidence for Induction for Low Amniotic Fluid in a Healthy Pregnancy is a guest post by blogger Rebecca Dekker, owner of  the fairly new blog in the birth world, Evidence Based Birth that has been  very well received and enjoyed by many.  Look for an interview with Rebecca in an upcoming post where we will learn how this Assistant Professor of Nursing who teaches pathopharmacology and studies depression in patients with heart failure ended up writing the Evidence Based Birth blog appreciated by birth professionals.  I look forward to future posts and collaboration with Rebecca and thank her for her contribution today.- SM

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This question came from one of my readers:

“Low fluid seems to be the new “big baby” for pushing for induction. What does the research say about low fluid at or near term? From what I’ve been able to see in research summaries at least, there appears to be no improved outcome for babies, but I’d love to see the research really hashed out. I’m also curious about causes of low fluid (theorized or known), risks of low fluid, and perhaps as important if not more so, measurements of low fluid.”

This is a great question and I felt like it was a perfect topic for my first article for Science and Sensibility. Standard of practice in the U.S. is to induce labor at term if a mother has low amniotic fluid in an otherwise healthy pregnancy. In fact, 95% of physicians who practice maternal-fetal medicine feel that isolated oligohydramnios—low amniotic fluid in an otherwise healthy pregnancy—is an indication for labor induction at 40 weeks (Schwartz, Sweeting et al. 2009).

But what is the evidence for this standard birth practice? Let’s take a look at the evidence together.

First of all, what is oligohydramnios?

Oligohydramnios means low fluid inside the amniotic sac.

(oligo = little, hydr = water, amnios = membrane around the fetus, or amniotic sac).

Not sure how to pronounce oligohydramnios? Click here.

It is standard of care in the U.S. to induce women with isolated oligohydramnios at term.
Image Source drewesque 

What is amniotic fluid, and what does it do?

During pregnancy, the baby is surrounded by a liquid called amniotic fluid. Amniotic fluid helps protect the baby from trauma to the mother’s abdomen. Amniotic fluid cushions the umbilical cord, protects the baby from infection, and provides fluid, space, nutrients, and hormones to help the baby grow (Brace 1997).

During the second half of pregnancy, amniotic fluid is made up of the baby’s urine and lung secretions. This liquid originally came from the mother, and then flowed through the placenta, to the baby, and out through the baby’s bladder and lungs (Brace 1997).

This same amniotic fluid is then swallowed by the baby and re-absorbed by the lining of the placenta. Because the mother’s fluid levels are the original source of amniotic fluid, changes in the mother’s fluid status can result in changes in the amount of amniotic fluid. Amniotic fluid levels increase until the mother reaches about 34-36 weeks, and then levels gradually decline until birth (Brace 1997).

What can cause low amniotic fluid at term?

Both mother and baby factors can contribute to low amniotic fluid at term.

Mother factors:

• If the mother is dehydrated, this may lower the amniotic fluid levels. (Patrelli, Gizzo et al. 2012)
• Women are more likely to be diagnosed with low amniotic fluid levels during the summer, possibly because of dehydration. (Feldman, Friger et al. 2009)
• If a woman with low amniotic fluid levels at term drinks at least 2.5 Liters of fluid per day, she increases the likelihood that her amniotic fluid levels will be back up to normal by the time of delivery. (Patrelli, Gizzo et al. 2012)
• If the mother rests on her left side before or during the fluid measurement, this can increase amniotic fluid levels. (Ulker, Temur et al. 2012)
• If the mother’s water has broken (membranes ruptured), this will lead to a decrease in amniotic fluid. (Brace 1997)
• If the mother’s placenta is not acting sufficiently anymore, this may lead to a decrease in amniotic fluid. When this happens, it may be because the mother has a serious condition such as pre-eclampsia or intrauterine growth restriction. (Beloosesky and Ross 2012)

Baby factors:

• If the baby has a problem with the urinary tract or kidneys, this may decrease the flow of urine. (Brace 1997)
• In the 14 days before the start of spontaneous labor, the baby’s urine output starts to decrease. (Stigter, Mulder et al. 2011)
• As the baby gets closer to term, the baby swallows more amniotic fluid, thus leading to a decline in fluid levels. (Brace 1997)
• If the baby is post-term (after 42 weeks), he or she begins to swallow significantly more fluid, contributing to a decline in amniotic fluid. (Brace 1997)
• If the baby has a birth defect, he or she may swallow significantly more fluid, leading to low amniotic fluid levels. (Beloosesky and Ross 2012)

What is the best way to measure amniotic fluid levels?

The gold-standard method is to inject the amniotic sac with dye and then take samples of the amniotic fluid to check the dilution. However, this method is very invasive. So the most commonly used methods instead are 2 ultrasound techniques:  the amniotic fluid index (AFI) and the single deepest pocket (Gilbert 2012).

To calculate the AFI, the technician divides the uterus into 4 areas. The largest fluid pocket in each area is measured, and then these 4 numbers are added make up the AFI. An AFI value of 5 cm or less is considered oligohydramnios. With the single deepest pocket method, the technician looks for the largest pocket of amniotic fluid in the uterus. If the largest pocket is less than 2 cm by 1 cm, then that is considered a diagnosis of oligohydramnios (Nabhan and Abdelmoula 2009).

It is important to understand that amniotic fluid levels exist on a continuum and that there is no agreement among researchers about the cut-off value that predicts poor outcomes—the AFI level of 5 was arbitrarily chosen to define oligohydramnios (Nabhan and Abdelmoula 2009). Furthermore, a large body of research has shown that both AFI and single deepest pocket are poor predictors of true amniotic fluid volume. For example, the AFI catches only 10% of all cases of true oligohydramnios (10% sensitivity)(Gilbert 2012).

There are several factors that make it difficult to get an accurate ultrasound measurement. As fluid levels decrease, ultrasound results become less accurate. Inexperience on the part of the technician can reduce the accuracy of the test results, as well as the amount of pressure that the technician puts on the ultrasound probe. The position of the baby can also affect the accuracy of the results. (Nabhan and Abdelmoula 2009; Gilbert 2012).

So which is the best way to measure amniotic fluid?

In a Cochrane review, researchers combined the results from 5 randomized controlled trials with more than 3,200 women. In these studies, women were randomized to either the AFI method or the single deepest pocket method. Researchers found that when the AFI is used to measure amniotic fluid, women were 2.4 times more likely to be diagnosed with oligohydramnios, 1.9 times more likely to be induced, and 1.5 times more likely to have a Cesarean for fetal distress without any corresponding improvement in infant outcomes. The researchers concluded that the single deepest pocket measurement has fewer risks and should be the preferred way to measure amniotic fluid (Nabhan and Abdelmoula 2009).

What is the clinical significance of low amniotic fluid when a mother reaches 37 or more weeks?

In 2009, 91% of physicians believed that isolated oligohydramnios, or low amniotic fluid in an otherwise healthy pregnancy at term, was a risk factor for poor outcomes (Schwartz, Sweeting et al. 2009).

In the U.S., 91% of maternal-fetal physicians believe that isolated oligohydramnios at term is a risk factor for poor outcomes, and 95% will recommend labor induction.
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However, this belief is not accurate. In early studies on amniotic fluid and outcomes, researchers included babies with congenital defects , women with pre-eclampsia or intrauterine growth restriction (IUGR), and women who were post-term (past 42 weeks) in their samples. These women and babies are more likely to have low amniotic fluid, and they are also much more likely to have poor outcomes. So although early researchers found that babies born to women with low amniotic fluid had higher perinatal mortality rates (Chamberlain, Manning et al. 1984), higher Cesarean rates for fetal distress, and lower Apgar scores (Chauhan, Sanderson et al. 1999), the poor outcomes were due to the complications—not the low amniotic fluid (Gilbert 2012).

So, if a woman has TRUE ISOLATED oligohydramnios at term, meaning low amniotic fluid in a healthy pregnancy with a healthy baby at term (between 37 and 42 weeks), what are the risks?

There is no evidence that isolated oligohydramnios at term is a risk factor for poor outcomes. However, induction for isolated oligohydramnios leads to higher Cesarean rates. In a systematic literature review, I found 5 studies from the last 10 years. I will discuss the 3 highest quality studies here. For results from all 5, you can see my findings summarized in this Google document table here.

1. Locatelli et al. (2003) studied 3,049 healthy pregnant women who were between 40 and 41.6 weeks pregnant. The purpose of this study was to find out if low amniotic fluid (defined as AFI ≤ 5) led to poor outcomes. Eleven percent of women had low amniotic fluid, and these women had higher induction rates (83% vs. 25%), higher Cesarean rates (15% vs. 11%), and higher Cesarean rates for non-reassuring fetal heart rates (8% vs. 4%). Babies born to women with low amniotic fluid were more likely to have birth weights beneath the 10^th percentile (13% vs. 6%). There were no differences between groups with meconium staining, meconium aspiration, umbilical artery pH <7, or Apgar scores. There was only one stillbirth (in the normal fluid group) for a true knot in the umbilical cord.

After controlling for the fact that some women were induced and some women were having their first baby, the researchers found no association between Cesarean for non-reassuring heart rate and amniotic fluid. This means that the inductions were probably responsible for the higher Cesarean rates in the low amniotic fluid group. However, when the researchers controlled for gestational age, they found that the association between low birth weight and low amniotic fluid remained significant. This means that women with low amniotic fluid were 2 times more likely to have a baby that is born beneath the 10^th percentile. These babies may have had undiagnosed fetal growth restriction (IUGR), which is a separate risk factor for poor outcomes.

1. Manzaneres et al. (2006) compared outcomes from 206 healthy pregnant women who were induced for isolated oligohydramnios at term and 206 healthy pregnant women with normal amniotic fluid levels who went into spontaneous labor.  The women in both groups delivered between 37 and 42 weeks. The researchers found that the low amniotic fluid group was more likely to require forceps or vacuum delivery (26% vs. 17%), Cesarean delivery (16% vs. 6%), and have non-reassuring fetal status during labor (8% vs. 2%). The non-reassuring fetal status may have been due to the induction medications, but this explanation was not proposed by the authors. There were no differences between groups with birth weight, Apgar scores, meconium staining, neonatal admissions, or umbilical cord pH. In summary, the authors found that inducing labor for isolated oligohydramnios at term increased Cesarean and operative vaginal delivery rates without any improvement in newborn outcomes.

1. There was one small pilot study done in which researchers randomized women with isolated oligohydramnios at term to induction or watchful waiting. The researchers randomly assigned 54 women who were 41 weeks pregnant to either induction or watchful waiting. There were no differences between groups in any outcomes, including birth weight, Cesarean delivery, Apgar scores, or neonatal admission. This study was limited by its small sample size and the fact that it only included women who were 41 weeks pregnant (Ek, Andersson et al. 2005).

So what is the evidence for induction because of low amniotic fluid (without any other complications) at term?

There is no evidence that inducing labor for isolated oligohydramnios at term has any beneficial impact on mother or infant outcomes. Based on the lack of evidence, any recommendation for induction for isolated oligohydramnios at term would be a weak recommendation based on clinical opinion alone.

In summary, this is what I found about low amniotic fluid in an uncomplicated pregnancy at term (37-42 weeks):

• Ultrasound measurement is a poor predictor of actual amniotic fluid volume
• The single deepest pocket method of measurement has fewer risks than the AFI
• Poor outcomes seen with low amniotic fluid are usually due to underlying complications such as pre-eclampsia, birth defects, or fetal growth restriction
• The main risk of low amniotic fluid at term in a healthy pregnancy is induction (and Cesarean delivery as a result of the induction) and potentially the risk of lower birth weight
• Current evidence does not support induction for isolated oligohydramnios at term

Are women in your local areas being induced for isolated oligohydramnios at term? Are consumers and clinicians aware of this evidence? What is the standard of practice for evaluating amniotic fluid in your local facilities, AFI or Single Deepest Pocket? How do you discuss this in your classes and with your patients, clients and students?

References

1. Beloosesky, R. and M. G. Ross. (2012). “Oligohydramnios.”   Retrieved 8/20/12, 2012, from www.UpToDate.com
2. Brace, R. A. (1997). “Physiology of amniotic fluid volume regulation.” Clin Obstet Gynecol 40(2): 280-289.
3. Chamberlain, P. F., F. A. Manning, et al. (1984). “Ultrasound evaluation of amniotic fluid volume. I. The relationship of marginal and decreased amniotic fluid volumes to perinatal outcome.” Am J Obstet Gynecol 150(3): 245-249.
4. Chauhan, S. P., M. Sanderson, et al. (1999). “Perinatal outcome and amniotic fluid index in the antepartum and intrapartum periods: A meta-analysis.” Am J Obstet Gynecol 181(6): 1473-1478.
5. Ek, S., A. Andersson, et al. (2005). “Oligohydramnios in uncomplicated pregnancies beyond 40 completed weeks. A prospective, randomised, pilot study on maternal and neonatal outcomes.” Fetal Diagn Ther 20(3): 182-185.
6. Feldman, I., M. Friger, et al. (2009). “Is oligohydramnios more common during the summer season?” Arch Gynecol Obstet 280(1): 3-6.
7. Gilbert, W. M. (2012). Amniotic Fluid Disorders. Obstetrics: Normal and Problem Pregnancies. S. G. Gabbe. Philadelphia, PA, Elsevier. 6.
8. Locatelli, A., P. Vergani, et al. (2004). “Perinatal outcome associated with oligohydramnios in uncomplicated term pregnancies.” Arch Gynecol Obstet 269(2): 130-133.
9. Nabhan, A. F. and Y. A. Abdelmoula (2009). “Amniotic fluid index versus single deepest vertical pocket: a meta-analysis of randomized controlled trials.” International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 104(3): 184-188.
10. Patrelli, T. S., S. Gizzo, et al. (2012). “Maternal hydration therapy improves the quantity of amniotic fluid and the pregnancy outcome in third-trimester isolated oligohydramnios: a controlled randomized institutional trial.” J Ultrasound Med 31(2): 239-244.
11. Schwartz, N., R. Sweeting, et al. (2009). “Practice patterns in the management of isolated oligohydramnios: a survey of perinatologists.” J Matern Fetal Neonatal Med 22(4): 357-361.
12. Stigter, R. H., E. J. Mulder, et al. (2011). “Fetal urine production in late pregnancy.” ISRN Obstet Gynecol 2011: 345431.
13. Ulker, K., I. Temur, et al. (2012). “Effects of maternal left lateral position and rest on amniotic fluid index: a prospective clinical study.” J Reprod Med 57(5-6): 270-276.

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. You can contact Rebecca via email here.

Sharon Muza Evidence Based Medicine, Fetal Monitoring, Guest Posts, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternity Care, Medical Interventions, Systematic Review, Uncategorized AFI, Evidence Based Birth, Evidence Based Medicine, Fetal Monitoring, guest post, Healthy Birth Practices, induction, Oligohydramnios, prenatal ultrasound, Rebecca Dekker