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The Straight Scoop On Inductions – Lamaze International Releases New Infographic

November 21st, 2013 by avatar

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The health concerns that affect preterm babies are well documented and much is known about the impact of an early birth on the long term health of children.  Some of these issues were discussed in a recent post on Science & Sensibility highlighting World Prematurity Day.  The issue of babies being born too soon was highlighted by the American College of Obstetricians and Gynecologists (ACOG) in a new committee opinion recently published in the November issue of Obstetrics and Gynecology.

In a joint committee opinion, “The Definition of Term Pregnancy” released by ACOG and the Society for Maternal Fetal Medicine, these organizations acknowledge that previously it was believed that ”the period from 3 weeks before until 2 weeks after the estimated date of delivery was considered ‘term’ with the expectation that neonatal outcomes from deliveries in this interval were uniform and good.”  More recent research has demonstrated that this is not the case.  The likelihood of neonatal problems, in particular issues related to respiratory morbidity, has a wide variability based on when during this five week “term” window baby is born.

ACOG has released four new definitions that clinicians and others can use when referring to gestational age; early term, full term, late term and postterm.

  1. Early term shall be used to describe all deliveries between 37 0/7 and 38 6/7 weeks of gestation.
  2. Term shall indicate deliveries from 39 0/7 and 40 6/7 weeks of gestation.
  3. Late term refers to all delivers rom 41 0/7 to 41 6/7 weeks of gestation.
  4. Postterm indicates all births from 42 0/7 weeks of gestation and beyond.

These new definitions should be put into practice by all those who work with birthing women, including researchers, clinicians, public health officials and organizations AND childbirth educators. We can and should be teaching and using these terms with our students.

As we move forward, we can expect to see these terms applied and research defined by the new categories, which will yield rich and useful information for those working in the field of maternal-infant health.

Lamaze International has long been focused on evidence based care during the childbearing year and continues to support childbirth educators, consumers and others by providing useful and fact based information that women and their families can use to make informed choices about their maternity care.  As part of this continued effort, Lamaze is pleased to share a new induction infographic created by the Lamaze Institute for Safe & Healthy Birth committee. This easy to read infographic is designed to highlight the facts about induction and encourage women to carefully consider all the information before choosing a non-medically indicated induction.  More than one in four women undergo an induction using medical means, and 19% of those inductions had no medical basis.

Since many women are pressured by providers or well-meaning but misguided friends and family to be induced, Lamaze encourages women to learn what are the important questions to ask during conversations with their providers and to get the facts about their own personal situation.  It is also recognized that a quality Lamaze childbirth education class can provide a good foundation for understanding safe and healthy birth practices.

Lamaze International is proud of their Six Healthy Birth Practices for safe and healthy birth, and this infographic supports the first birth practice; let labor begin on its own.  Women need to be able to gather information to discern between a medically indicated induction, which protects the baby, the mother or both from those induction that are done for a social or nonmedical reason which increases the risk of further interventions, including cesarean surgery for mothers and NICU stays for babies who were not ready to be born. This infographic can be shared with students, clients and patients.  It can be hung in classrooms and offices.  Educators can use it in creative ways during teaching sessions, when discussing the topics of inductions, informed consent and birth planning.

As the benefits of a term baby are more clearly understood, and research is revealing how critical those last days are for a baby’s final growth and development, it is perfect timing for Lamaze to share this infographic.  This tool will reduce unneeded inductions and help women learn how important it is to allow their babies to receive the full benefit of coming when the baby is ready.  There has been a huge push to stop inductions before at least 39 weeks.  March of Dimes has their “Healthy Babies are Worth the Wait” campaign. The new induction infographic provides an accessible and easy to use information sheet to help families reduce non-medical inductions. Many organizations, including Lamaze are joining together to make sure that babies are born as healthy as possible and women go into labor naturally when baby is ready.

You can find and download the full version of the Induction infographic on the Let’s Talk Induction page of Lamaze’s Push for Your Baby campaign website.  Alternately, if you are a Lamaze member, you can also download the infographic and many other useful handouts from the Teaching Handouts Professional Resource Page from Lamaze International.

Please take a moment to read over this great, new infographic and share in the comments below, both your thoughts on the finished product and how you might use this to help mothers to push for the best care. Lamaze International and its members are doing their part to help reduce the number of early term babies who arrive before they are ready.  I look forward to hearing your thoughts and your ideas for classroom use.

References

The American College of Obstetricians and Gynecologists Committee on Obstetric Practice Society for Maternal-Fetal Medicine. Committee Opinion No 579: Definition of Term Pregnancy. Obstet Gynecol 2013; 122:1139.

Declercq, E. R., & Sakala, C. (2013). Listening to mothers III: Pregnancy and childbirth.”. 

 

ACOG, Babies, Childbirth Education, Evidence Based Medicine, Healthy Birth Practices, informed Consent, Maternal Quality Improvement, Medical Interventions, New Research, Newborns, NICU, Practice Guidelines, Pre-term Birth, Push for Your Baby, Research , , , , , , , , , , ,

A Look Beyond the Headlines: Induction, Augmentation and Autism

August 29th, 2013 by avatar

Today on Science & Sensibility, regular contributor Deena Blumenfeld takes a look at the recent study that examined a link between induction and augmentation of labor with an autism diagnosis in those same children during their school years.  Did you have a chance to read the study?  Take a look at what Deena found. – Sharon Muza, Community Manager, Science & Sensibility

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source: momaroo.com

As the parent of an autistic child, my ears perked up when I saw my Facebook feed (and Twitter and G+ feeds…) light up with links about the latest study on Autism. This time, it wasn’t vaccines or mercury they were talking about. It was labor induction and augmentation.

On August 12, 2013, JAMA sent out a press release regarding the study entitled:  Association of Autism With Induced or Augmented Childbirth in North Carolina Birth Record (1990-1998) and Education Research (1997-2007) Databases. The media took note, and ran with it as evidenced by the following links:

As is often the case, the “big news” headlines and associated media stories attract a lot of attention, but one must look at the study to really assess what the real information has to say.  When someone only reads the short media blasts, the reader does not get the full information and bases an opinion on only the headline or sound bite. This is a type of cognitive distortion which is commonly known as jumping to conclusions. When doing so, the most common conclusion will be a negative one. 

The topic of Autism is a hot button issue. These headlines are specifically designed to garner a quick reaction from the reader. I was interested in taking a more thorough look at the study discussed, and want to share it with Science & Sensibility readers.

Gregory, et. al. acknowledge that there are both genetic predispositions and environmental factors linked to autism. They choose to look at one environmental factor, labor induction and augmentation. The team looked at 625,000 births in North Carolina. After controlling for other factors, such as congenital abnormalities, multiples, maternal education, marital status, maternal smoking, parity and mode of delivery, the group of infants was narrowed down to those who were comparable using the North Carolina Detailed Birth Record (NCDBR). These infants were followed through their school years using the North Carolina Education Research Data Center (NCERDC) containing the indicator for exceptionalities, designation autism.

After comparing the data, there does appear to be a correlation between autism and induction/augmentation. 

Approximately 1.3% and 0.4% of male and female children were diagnosed as having autism, respectively. Amon g both sexes, the percentage of induced or augmented mothers was higher among children with autism compared with non cases.

Moreover, children with autism were more likely to have a birth characterized by fetal distress or meconium.

But what correlates to what? Is the fetal distress the cause of autism, the meconium? Is it the induction? Is the fetal distress due to the induction, or for some other reason? Is the fetal distress due to pre-existing autism? Correlation is not causation.

Compared with children whose mothers were neither induced nor augmented during labor, children born to mothers who were either induced and augmented, induced only, or augmented only experienced increased odds of autism. Autism diagnosis differentially associated with induction/augmentation by sex, whereby a stronger association was observed among male children.

To our knowledge, this is the first large scale study to address the relationships among birth induction/augmentation and autism. This study also confirmed previously documented risk factors for autism such as advanced maternal age and maternal education, parity, and singleton birth (as reviewed by Gardener et al3 and Guinchat et al13).

The more risk factors mother and baby have, the higher the rates of autism in the baby. However, “We controlled for each of these variables and found that labor inductions and augmentation continued to be independently associated with ASD in offspring.”

 The authors speculate about exogenous oxytocin and its effect on the fetal brain. “Exposure to exogenous oxytocin during induction/augmentation may have a functional effect through, as yet, unidentified genetic or epigenetic factors.”

Gregory, et al. is not the first study to look at the relationship between oxytocin and autism. There are a number of studies which examine the relationships between oxytocin and vasopressin and autism in both boys and girls. The hypothesis that artificial oxytocin, administered during labor, has a negative affect on the fetus’ brain has been around for some time – this is Hollander’s theory. A 2004 review of the literature by Wahl, suggests at a molecular level (in animals) that Hollander may be on the right track, but systematic research is needed. Gregory, et al. is the beginning of that systematic research.

Is perinatal brain injury, whether through induction, augmentation, hypoxia or other issues, a cause of autism? Maybe?

We do know that there are side effects to everything we do during labor, from induction to augmentation, assisted delivery and cesarean sections. It’s not time to throw the baby out with the bathwater and give up on labor interventions. It may be a question of risk mitigation, or choosing one set of risks over another. There is no easy or straightforward answer as to whether or not we do more harm with a medical intervention than do we help. Each mother, each baby and each labor must be addressed on an individual case by case basis to determine the cost/benefit of each potential intervention. A physiologic approach to birth generally has better outcomes and avoids iatrogenic complications.

So, from Gregory, et al. we so know that there is an increased risk of autism, especially in boys with the use of labor induction and augmentation. Many pieces of the puzzle are still missing, however. It is still too early to determine if this is correlation or causation. 

“Our results are not sufficient to suggest altering the standard of care regarding induction or augmentation; our results do suggest that additional research is warranted.”

In other words, it’s far too soon to change how we treat women when it comes to induction and augmentation. We need to go deeper, and study further the effects of artificial oxytocin on the fetal brain.

As an educator, and as a mother to a child on the spectrum, I will address this in my classes in the same manner I always have. I give parents the best evidence-based information, tell them to use their BRAINS questions and let them go with what their hearts, and their heads, tell them is best for mother and baby. As of now, the evidence isn’t strong enough to point the finger at induction and augmentation. It is, in my opinion, strong enough to encourage our parents to ask more questions with regards to the effects of induction and augmentation on their babies.

Have you discussed this research with your students?  Have any questions been raised?  Do you discuss these research findings when you discuss benefits and risks to labor induction and augmentation? Please share your thoughts in the comments section of our blog. – SM

References:

Carter CS. Sex differences in oxytocin and vasopressin: implications for autism spectrum disorders? Behav Brain Res. 2007;176(1):

Gregory SG, et al “Association of autism with induced or augmented childbirth in North Carolina birth record (1990-1998) and education research (1997-2007) databases JAMA Pediatr 2013; DOI: 10.1001/jamapediatrics.2013.2904.

Wahl RU, “Could oxytocin administration during labor contribute to autism and related behavioral disorders?–A look at the literature.” Med Hypothesis, Initiative for Molecular Studies in Autism (IMSA) 2004.

Gardener H, Spiegelman D, Buka SL. Prenatal risk factors for autism: comprehensive meta-analysis. Br J Psychiatry. 2009;195(1):7-14.

Gardener H, Spiegelman D, Buka SL. Perinataland neonatal risk factors for autism: a comprehensive meta-analysis. Pediatrics. 2011;128(2):344-355.

Gregory SG, Connelly JJ, Towers AJ, et al. Genomic and epigenetic evidence for oxytocin receptor deficiency in autism. BMC Med. 2009;7:62.

 

Babies, Childbirth Education, Guest Posts, Medical Interventions, New Research, Research, Uncategorized , , , , ,

A Game of Telephone and Misinterpreting Information

March 19th, 2013 by avatar

© http://flic.kr/p/bS581K

Regular contributor Deena Blumenfeld shares her recent experience with a “research” article that washed over social media outlets and was shared and discussed by many birth professionals.  Deena explains how she fell in step with others and ended up being lead down the wrong path.  Have you every made this mistake too?  Please share your thoughts in our comment section.- Sharon Muza, Science & Sensibility Community Manager.

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Gathering information from social media can be like playing a giant game of “telephone” with a million of your closest friends.

This is often how it goes:

  • Someone reads an article. They post to Facebook (or other venue) a link and a comment.
  • We read this person’s comment and add our own comment.
  • Then we go back and skim the article, and comment again.
  • Next we post a link to the article, with our own comments and opinions regarding the article.
  • The next reader takes our opinion as gospel, only reads the headline of the article and then shares our opinion on their page, neglecting to link the article with their comment.
  • So now we have a rumor about an opinion and after 345 more postings, no one knows where the original source was of what anyone is talking about anymore.  But, whatever it is, it sounds AWFUL and we are indignant about it.

Does this sound familiar to you? Have you ever taken a rumor, opinion or comment about an article or study to be gospel truth, without fully reading and researching the information on your own… and then go on to repeat that rumor or opinion? 

I’ll sheepishly raise my hand here…

Not too long ago, there was an article on medpagetoday.com entitled New Form of Misoprostol Speeds Up Labor.” Now, without reading the article, doesn’t it seem that we now have a form of misoprostol being used for augmentation? 

This is the misinterpretation that was flying around Facebook, Twitter and other social media sites for days after the article was published on February 18, 2013. The outrage, fear and condemnation of anyone who thought it might possibly be a good idea to use misoprostol for augmentation was overwhelming. I read, and participated in, many discussions regarding the dangers of this drug; uterine rupture, mothers who have died, babies who have died, the Safe Motherhood Quilt Project, and so on. 

But yet we all missed it, me included.  That misleading headline leads us to believe that this was misoprostol for augmentation of labor; when in reality, it is an article about a new form of misoprostol, designed in the appropriate dosage, to induce labor.  This ‘little oops’ caused a big stir for not much. 

So, let’s look at what the article really talks about and what we should know.

  • This is an article about an abstract which was presented at a conference. It is not a peer-reviewed, published study.
  • We do not have access to the full study, since it isn’t published. So, we cannot evaluate it effectively.
  • The study compared the efficacy of this new form of misoprostol suppository to the existing dinoprostone (cervadil) suppository for induction of labor.
  • This study of 1,358 women found that the misoprostol suppository worked more quickly than the dinoprostone to get women to active labor as well as to birth.

“Along with the primary efficacy benefit of shorter time to vaginal delivery, the novel agent was also associated with faster delivery of any type, vaginal or cesarean (median 18.3 hours versus 27.3 hours with dinoprostone, P<0.001).”

“Other secondary outcome benefits were shorter time to active labor at 12.1 hours versus 18.6 hours, respectively (P<0.001), with substantially fewer women needing oxytocin prior to delivery (48% versus 74%, P<0.001).” 

Hang on a minute: “faster delivery of any type, vaginal or cesarean.” If the results of the induction end up as a cesarean, can we call it a successful induction? I’m not sure we can. I think this is a failed induction. Sure the medication worked to get labor started, but for whatever reason she ended up with a cesarean section. Faster to a cesarean section – wouldn’t it have been even faster to just schedule the cesarean section? 

“T’he primary safety outcome of cesarean delivery came out similar between groups at 26% with misoprostol and 27% with dinoprostone (P=0.65). Nor was there a difference in indication for cesarean section.”

When asked at the session why a faster vaginal delivery didn’t translate into fewer cesarean deliveries, Wing pointed to the myriad other factors that play into delivery mode. “We can flip the switch on but that doesn’t always get us the desired result,” she told the audience.” 

The article is leaning towards “faster is better” in terms of labor. We are left with more questions than answers. The answers may be found within the study itself, however, we don’t have access to the study. My questions:

But why? Why is a faster induction (or faster labor) better than a slower one?

Aren’t faster labors more painful? Aren’t contractions more challenging to cope with when they are more intense?

Do we have high rates of fetal distress with a faster labor vs. a slower one?

Who benefits from a faster birth?

The articles states that fewer women needed to be augmented with pitocin with a misoprostol induction vs. a dinoprostone induction. Is that a good thing? Bad? Neutral?

We also don’t know the researcher’s intentions. Without being able to read the study, we can only make assumptions. Do we assume the intention is a faster labor? Do we assume the intention is to make misoprostol safer for induction? Something else? Or maybe, just maybe, we don’t assume anything at all. Assumptions can be very dangerous and in most cases, they are wrong. 

How to avoid misinterpreting the data and spreading rumors:

  • Always go to the study! An article about the study is someone else’s opinion. The abstract is the Cliff’s Notes version of the study.
  • Admit when you don’t understand something and talk to someone who does.
  • Look to the citations and in the study to check for further information.
  • Use the Cochrane Library and other sources for more information.
  • Don’t make assumptions based on other people’s opinions.
  • If you don’t know for sure, don’t spread the information!
  • If you made a mistake and misinterpreted a study or article, say so. It’s better to admit you are wrong than to continue to spread inaccurate information.

My Take Away

The take away from all of this is that an article about an abstract presented at a conference leaves us with more questions than answers. We cannot accurately evaluate that which we cannot read in its entirety. Social media is a good tool, but we should be cautious about that which sounds too good (or bad!) to be true. We should take others opinions as just that – opinions, until we’ve done our own solid research. We should also be cautious about the ‘click and share’ phenomenon. Double check, do your homework and make sure the information we share is accurate. I’ll do better next time too.

For more on misoprostol for labor induction please read:

  1. Science & Sensibility: Update on Spin Doctoring Misoprostol (Cytotec): Unsafe at Any Dose
  2. Science & Sensibility: ACOG’s 2009 Induction Guidelines: Spin Doctoring Misoprostol (Cytotec)
  3. Journal of Perinatal Education: The Freedom to Birth—The Use of Cytotec to Induce Labor: A Non-Evidence-Based Intervention by Madeline Oden
  4. WHO: Misoprostol for cervical ripening and induction of labour
  5. WHO: WHO Recommendations for Induction of Labor, 2011
  6. Induced and Seduced: The Dangers of Cytotec by Ina May Gaskin
  7. Adverse Events Following Misoprostol Induction of Labor by Marsden Wagner, MD, MS

 

 

Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, Maternity Care, Medical Interventions, New Research, Research, Uncategorized , , , , , , , , ,

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

February 21st, 2013 by avatar

 

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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 , , , , , , , , , ,

It Takes a Professional Village! A Study Looks At Collaborative Interdisciplinary Maternity Care Programs on Perinatal Outcomes

September 19th, 2012 by avatar

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

Photo Source: http://www.flickr.com/photos/jstownsley/28337593/

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].

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