Science & Sensibility

The Today Show, not known for their excellence in birth journalism, showed a live cesarean on air earlier this week. The birth advocacy community has weighed in on the shoddy reporting and the circumstances of the cesarean, pointing out that the stated indications (”big babies run in the family” and “she was past her due date”) do not in fact justify elective primary cesarean surgery.

When I heard that the cesarean had taken place at Beth Isreal Deaconess Medical Center in Boston, I had an “a-ha” moment: That’s the place where Paul Levy is President and CEO. And he has a blog. And his blog has been a sounding board for ideas about health care reform in general and transparency and practice variation in particular. I decided to leave a comment.

Here’s what I wrote about what I really think about the Red Sox the responsibility of hospital leadership to address problems in maternity care including the excess use of cesarean surgery.

I’m sure that the Today Show piece was just a convenient PR opportunity, but when I heard the birth occurred at BIDMC I came here to see what, if any, analysis you offered. Given your recent coverage of practice variation in endoscopies and hypertension treatment, it would seem this is a good opportunity to address practice variation in the use of cesarean surgery. Especially since just last week, a multi-stakeholder group released major recommendations for maternity care reform, which included many recommendations for reining in unwarranted practice variation.

Your hospital currently has the fourth highest cesarean rate in the state of Massachusetts (42%), 12 percentage points higher than the “normal range” (”25-30%”) reported by one of your OR staff during the Today Show piece, and nearly three times the rate recommended by the World Health Organization. True, your hospital cares for many women with high risk pregnancies, but studies that have looked at risk adjustments in cesarean rates have found that these adjustments make little to no difference in the rank order of hospital cesarean rates, and in fact many academic tertiary hospitals are able to safely maintain rates lower than those of community hospitals. The National Quality Foundation, Healthy People 2010, and, beginning in April when new perinatal measures are rolled out, the Joint Commission, all consider the rate of cesarean surgery in nulliparous women with singleton, head down babies (NTSV cesarean rate) to be a measure of hospital quality. You may have “Red Sox Nation plus 1″ but you now also have “NTSV cesarean rate plus one” – the woman who gave birth on the Today Show did not have an indication for cesarean delivery that is accepted by ACOG or any other standard-setting bodies. (Her indication was “big baby”.)

I urge you to use this opportunity to ask yourself and your staff what you could be doing better to safely lower your cesarean rate.

(BTW, Paul Batalden’s [whom Levy mentioned in a recent blog post about practice variation] daughter is a nurse-midwife (and a great one at that) so he might have some insights to share with you.)

After another commenter suggested that perhaps the circumstances of the cesarean were a private matter, I had more to say:

I agree that this isn’t an appropriate venue to share commentary about whether or not the televised c-section was appropriate. But as someone who cares deeply about maternity care safety and effectiveness, I often feel that people doing the heavy thinking about health care reform are completely oblivious to maternity care as a major area for improvement. So infrequently in health care debates do we hear about childbearing women or newborns, despite that 4.5 million women give birth each year, outcomes are poor, and hospital charges for maternity care far exceed those of other specialties. I have seen some coverage of maternity care issues on this blog, but the coverage seems to be out of proportion with how much “business” the maternity unit accounts for. That the current post about a televised birth was a lighthearted plug for the Red Sox, I have to admit, was extremely disappointing from my perspective. If we’re going to have a major surgery on live television with zillions of people watching, it seems a fine time to start talking about the procedure, under what circumstances it is safe, evidence-based indications for its use, and how to make sure every hospital is performing it to the highest standard of safety.

Just in the past week, there’s been a Joint Commission Sentinel Event Alert on maternal mortality, the major national reform recommendations I mentioned earlier, and today a front page article at the San Francisco Chronicle on the contribution of cesareans to California’s maternal mortality rate. Seems like there’s plenty of “blog fodder” other than the Red Sox angle.

Levy’s commitment to openness and transparency is unique in the hospital administration world and I support it wholeheartedly. I have to admit it felt like quite a thrill to leave a cogent comment on a blog of a hospital CEO. Even when I’ve worked for hospitals I never had that kind of access.  Of course listening doesn’t necessarily translate into doing. I hope that Levy recognizes that his hospital could be doing much better in their provision of maternity care to the community, begins documenting quality improvement efforts on his blog, and welcomes the input he receives from those of us who have thought quite a bit about what high-quality, high-value maternity care looks like and how to get there.

*Jill from The Unnecessarean coined this term.

Amy Romano Uncategorized cesarean, hospitals, maternity care systems, media, practice variation, transparency

The Joint Commission Sentinel Alert #44: “Preventing Maternal Deaths” is an important document and public recognition that many of the maternal deaths in the United States are preventable. However, the alert is missing important and useful information for women and childbirth educators since the recommendations in the alert are downstream approaches or recommendations for how to save a woman from dying who may have been thrown in the river. It fails to alert our healthcare system about the need to keep women out of the river in the first place.

Let me give you some examples:

One Joint Commission recommendation is to consistently use techniques that have proven effective in the prevention of thromboembolism (blood clots) in women having surgical births. Clearly it is critical that we reduce the risks of surgery and this recommendation needs to be heeded. We need to make surgical births as safe as possible. However, if we eliminated the overuse of cesarean sections we would eliminate even more deaths and injuries. Based on publicly released data, the increase of cesarean surgical intervention is related to where a woman gives birth.

Debra Bingham, DrPH, RN, LCCE

Indeed there is often as much as a three-fold variation in the number of surgical births performed at different hospitals even after adjusting for the woman’s age and risk factors. Reining in practice variation has been a focus of efforts to improve care in other healthcare specialties, yet wide and unwarranted practice variation remains a serious problem in maternity care.

So why are there so many more surgical births and such wide variation in rates of cesarean sections? Well one clear factor at work is variation in how women are treated in labor. For example, some hospitals keep women who present in early labor while other hospitals are more likely to offer supportive care to these women and encourage that they remain at home until active labor. Why is being in a hospital in early labor a problem? When a woman is in a hospital in early labor she is put in a bed, her movements are restricted, and she is tethered to a fetal monitor. None of these interventions has been shown by research to improve maternal or infant outcomes, and in fact they all have documented harms. In addition, it is normal and expected for early labor to start and stop for several days. However, if a woman is admitted to a hospital in early labor and her labor stops then she is likely to have an unnecessary induction of labor. Overuse of inductions lead to more cesarean sections. This becomes the beginning of a cascade of events that all too often leads to a surgical intervention.

Let’s move to the hemorrhage recommendations as another example. Hemorrhage remains a leading cause of death and severe morbidity despite more efforts over recent years to control blood loss at birth. Why haven’t these efforts succeeded? One reason is that as the cesarean rate rises, more pregnant women have uterine scars. The uterine scar increases a woman’s risk for abnormal placenta implantation when they get pregnant again. These abnormal placenta implantations are called percretas, accretas and previas. When a woman has placenta accreta or percreta this can lead to internal organ damage and permanent damage to her uterus because the placenta literally grows into the uterine muscle or even into her bowel and bladder and cannot detach from these organs after the baby is born. This abnormal implantation leads to hemorrhage and also often necessitates the removal of her uterus to save her life. Abnormal placenta implantations used to be very rare emergencies; they are becoming common now due to the overuse of cesarean sections. This is a trend that is frightening to me because based on the current rates of cesarean sections the number of women affected will only increase. Things are going to get much worse.

Lamaze International has issued our own “Sentinel Alert” on how to prevent maternal deaths. Lamaze’s recommendations are called the Six Healthy Birth Practices. Following these key practices will prevent women from being thrown in the river and needing to be rescued.

The critical behaviors that Lamaze recommends to improve health and safety are to let labor start on it’s own, encourage freedom of movement, offer labor support rather than labor management, avoid all routine interventions not supported by evidence, avoid interfering with a woman’s freedom to push in an upright position or any position of her choice, and keep the baby with the mother after birth.

Hospitals can help achieve the Joint Commission goal of reducing preventable maternal deaths while also making progress toward Joint Commission core measures by training staff in these practices. Lamaze International offers an Evidence-Based Nursing Care Workshop to do just that. Registration is currently open for our March workshop in Hollywood, Florida.

Debra Bingham, DrPH, RH, LCCE is President-Elect for Lamaze International, Executive Director of the California Maternal Quality Care Collaborative (CMQCC), a member of the California Pregnancy-Associated Maternal Mortality Review Committee and a lead researcher for determining how to prevent maternal deaths.

Debra Bingham Uncategorized cesarean, complications, hospitals, induction, interventions, Joint Commission, practice variation, safety

I’m going to be on Momotics Blog Talk Radio tomorrow evening at 10pm EST discussing the issue of transparency in maternity care with Danielle from Momotics. You can listen here.  For the occasion, I thought I would dig up this fact sheet I wrote for Lamaze a couple of years ago when we first got involved in advocacy on this issue.  I’ve learned a lot since then and have thought for a while that this fact sheet needs to be revised and updated. I’d love thoughts from readers, especially those involved in ongoing efforts to collect and publicize facility data for The Birth Survey. What would you change? What messages need to be more clear? What else do I need to include? Feedback, please!

Why Transparency in Maternity Care Matters: A Fact Sheet for Birth Advocates

What is Transparency?

A pregnant woman asks her care provider, “What is your episiotomy rate?” Her doctor responds, “I only do them when it is necessary.” On her tour of the hospital maternity center, another woman asks about the hospital’s cesarean rate and is told, “We take care of many high risk patients, so you can’t compare our cesarean section rate with the hospital across town.”

What are the consequences when women can’t objectively evaluate the quality of their maternity care options? How do we help women make sense of intervention rates? How can women make fair comparisons?

Transparency means providing health care consumers with the information they need – and the means to interpret it – in order to evaluate the quality of care provided by individual providers and institutions. Transparency is the missing ingredient to truly informed choice.

Are Intervention Rates Important Quality Measures?

A growing body of research shows that among the most important factors influencing a woman’s risk of obstetric interventions, especially cesarean surgery and episiotomy, are where and with whom she gives birth. A recent study of over 41,000 low-risk women having their first babies in 20 California hospitals found cesarean rates for this population ranging from 11% – 30%. Statistical analysis revealed that obstetric practices – not clinical or demographic factors – accounted for over half of the variation across hospitals (1). Two studies conducted in Washington State found that the individual physician was an independent risk factor for cesarean section in both induced and spontaneous labors (2, 3). Several studies have shown that episiotomy is more common in private obstetric practices versus public or university-affiliated practices (4-6). Rates varied from 6% to 60%, but at least one university hospital maintains an episiotomy rate of 1% (7).

Excess use of obstetric interventions, in turn, increases the likelihood that the woman or her baby will be injured, experience complications such as infection, suffer pain, or have negative birth experiences (8). So, in short, a woman who goes to a provider or hospital with a high cesarean section rate is more likely to end up with cesarean surgery – and to suffer its potential consequences. If she goes to a provider with a high episiotomy rate, she is more likely to have an episiotomy – and to suffer its potential consequences. And so on… However, in most states, maternity care providers and facilities are not required by law to publicly report intervention rates or other outcome indicators, nor to help the public interpret data that are available.

Women can not make informed choices about their maternity care if they do not have access to the information that is most likely to influence their outcomes. They can not decrease their exposure to injury from injudicious use of interventions without knowing where and with whom intervention rates are too high. Without transparency, our health care system gives women a false sense of choice.

Can Transparency Improve the Quality of Maternity Care?

Yes! While most of the research on transparency and public reporting relates to other areas of health care, a few studies have looked at maternity care in particular and have found that public reporting of intervention rates and outcomes, whether alone or in combination with other quality improvement programs, translates into better care (9-11). In fact, an experiment conducted in Wisconsin suggests that the quality of obstetric care improves more in response to public reporting than other medical or surgical specialties (9). This may have been because there was more “room for improvement” in maternity care – more hospitals had low scores on obstetric indicators than on cardiac or surgical indicators. In the same study, hospitals included in a public report were more likely than those that were not to undertake quality improvement efforts. These efforts appeared to be effective – maternity units that improved their quality scores were more likely than those that stayed the same or did worse to have begun quality improvement efforts shortly after the public report was released. In other words, public reporting prompted hospitals to work to improve the areas where they scored poorly, and these efforts were effective at improving the quality of care.

Apples and Oranges: How Do We Make Fair Comparisons?

The question of which indicators to measure and how these should be reported complicate efforts to ensure transparency in maternity care. This is particularly problematic when it comes to interpreting cesarean section rates. The overall cesarean section rate (number of cesareans divided by the number of all births) may not be comparable across settings because some hospitals take care of many high risk women while others take care of low-risk women. The rate of cesarean section in high risk women may be higher for good reason. The same is true at the provider level; some providers, including many midwives, specialize in the care of low-risk women while others care for a mixed-risk population or specialize in high risk pregnancies. Similarly, factors such as parity (whether the woman has previously given birth) and age may naturally affect rates of obstetric interventions as well as outcomes.

Healthy People 2010, the federal program that sets goals for various health indicators, measures the cesarean section rate in nulliparous women (those having their first babies), with term (>37 weeks), singleton (one baby), vertex (head down) pregnancies (12). This is abbreviated as the “NTSV cesarean rate” and is used as a proxy for the cesarean section rate in low-risk first time mothers. It has been shown to be highly sensitive to variations in obstetric practices (1), so quality improvement programs should therefore be effective at safely lowering the NTSV cesarean rate. It is also a good measure because, if we can safely prevent the first cesarean, we can prevent repeat cesareans, as well as poor pregnancy outcomes resulting from accumulating many cesarean scars, such as placenta previa, preterm birth, and placenta accreta. As advocates for improvements in maternity care, we should recognize the NTSV cesarean rate as an effective quality indicator, and should educate the public to ask for and know how to interpret NTSV cesarean rates.

However, perfect indicators that can be compared easily across birth settings and providers will not be available in every community. Even when they are, the total rates of cesarean section, episiotomy, and other interventions are important quality measures. In the case of cesarean surgery, many studies have shown that rates can safely be less than 15% in mixed-risk populations, including those where considerable proportions of women have medical problems or are at risk because of poverty, age, or other factors (8, 13, 14). So, while the likelihood of requiring a cesarean will vary with individual circumstances, women with care providers whose rates are 15% or less can trust the their practitioner’s judgment should they recommend a cesarean in their case.

How Can Birth Advocates Promote Transparency?

Ensuring transparency in maternity care will require a major shift from the status quo, with buy-in and participation from hospitals, care providers, insurance companies, government, and consumers. As advocates for mother-friendly maternity care, we can help influence transparency efforts in our communities. In some areas, transparency initiatives are well underway and mother-friendly birth advocates can work to help consumers access and make sense of publicly available information. In communities where there is resistance to transparency, advocates can work to influence legislative efforts, create consumer demand for transparency, or work with the media, hospital administrators, local opinion leaders, or others to promote change. By maintaining a focus on quality improvement and safety rather than penalizing providers or facilities, transparency advocates are likely to gain greater acceptance and involvement from key stakeholders.

References

1. Main, E. K., Moore, D., Farrell, B., Schimmel, L. D., Altman, R. J., Abrahams, C., et al. (2006). Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement. American Journal of Obstetrics and Gynecology, 194(6), 1644-51.

2. Luthy, D. A., Malmgren, J. A., & Zingheim, R. W. (2004). Cesarean delivery after elective induction in nulliparous women: The physician effect. American Journal of Obstetrics and Gynecology, 191(5), 1511-1515.

3. Luthy, D. A., Malmgren, J. A., Zingheim, R. W., & Leininger, C. J. (2003). Physician contribution to a cesarean delivery risk model. American Journal of Obstetrics and Gynecology, 188(6), 1579-85; discussion 1585-7.

4. Goode, K. T., Weiss, P. M., Koller, C., Kimmel, S., & Hess, L. W. (2006). Episiotomy rates in private vs. resident service deliveries: A comparison. The Journal of Reproductive Medicine, 51(3), 190-192.

5. Howden, N. L., Weber, A. M., & Meyn, L. A. (2004). Episiotomy use among residents and faculty compared with private practitioners. Obstetrics and Gynecology, 103(1), 114-118.

6. Robinson, J. N., Norwitz, E. R., Cohen, A. P., & Lieberman, E. (2000). Predictors of episiotomy use at first spontaneous vaginal delivery. Obstetrics and Gynecology, 96(2), 214-218.

7. Albers, L. L., Sedler, K. D., Bedrick, E. J., Teaf, D., & Peralta, P. (2005). Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: A randomized trial. Journal of Midwifery & Women’s Health, 50(5), 365-372.

8. Goer, H., Leslie, M. S., & Romano, A. (2007). The evidence basis for the 10 steps of mother-friendly care: Step 6: Does not routinely employ practices, procedures unsupported by the scientific evidence. The Journal of Perinatal Education, 16(1 Suppl), 32-64.

9. Hibbard, J. H., Stockard, J., & Tusler, M. (2005). Hospital performance reports: Impact on quality, market share, and reputation. Health Affairs, 24(4), 1150-1160.

10. Hibbard, J. H., Stockard, J., & Tusler, M. (2005). It isn’t just about choice: The potential of a public performance report to affect the public image of hospitals. Medical Care Research and Review, 62(3), 358-371.

11. Wirtschafter, D. D., Danielsen, B. H., Main, E. K., Korst, L. M., Gregory, K. D., Wertz, A., et al. (2006). Promoting antenatal steroid use for fetal maturation: Results from the California perinatal quality care collaborative. The Journal of Pediatrics, 148(5), 606-612.

12. Healthy People 2010. (2000). Objective 16-9. reduce cesarean births among low-risk (full term, singleton, vertex presentation) women. Retrieved 7/16/2007, from http://healthypeople.gov/document/html/objectives/16-09.htm

13. Haire, D. B., & Elsberry, C. C. (1991). Maternity care and outcomes in a high-risk service: The north central Bronx hospital experience. Birth, 18(1), 33-37.

14. Leeman, L., & Leeman, R. (2002). Do all hospitals need cesarean delivery capability? An outcomes study of maternity care in a rural hospital without on-site cesarean capability. The Journal of Family Practice, 51(2), 129-134.

Amy Romano Uncategorized cesarean, episiotomy, induction, interventions, practice variation, transparency

Lamaze International’s popular series, Research Summaries for Normal Birth, was discontinued in 2008 after four years of quarterly round-ups so that we could move to the blog format and launch Science & Sensibility. In order to bring all of our research resources together in one place, we are adding the Research Summaries archive to Science & Sensibility.

This week we are presenting the archive of summaries of research on induction and augmentation of labor. Don’t forget that you can find all induction and augmentation posts at Science & Sensibility (including this archive) by clicking on ”induction” or “augmentation” in the tag cloud.

The articles summarized in this archive are listed here. Please click on the extended post to read the summaries.

1. Hill MJ, McWilliams GD, Garcia-Sur D, Chen B, Munroe M, & Hoeldtke NJ (2008). The effect of membrane sweeping on prelabor rupture of membranes: a randomized controlled trial. Obstetrics and gynecology, 111 (6), 1313-9 PMID: 18515514

2. Smyth RM, Alldred SK, & Markham C (2007). Amniotomy for shortening spontaneous labour. Cochrane database of systematic reviews (Online) (4) PMID: 17943891

3. Gaudernack LC, Forbord S, & Hole E (2006). Acupuncture administered after spontaneous rupture of membranes at term significantly reduces the length of birth and use of oxytocin. A randomized controlled trial. Acta obstetricia et gynecologica Scandinavica, 85 (11), 1348-53 PMID: 17091416

4. Kramer MS, Rouleau J, Baskett TF, Joseph KS, & Maternal Health Study Group of the Canadian Perinatal Surveillance System (2006). Amniotic-fluid embolism and medical induction of labour: a retrospective, population-based cohort study. Lancet, 368 (9545), 1444-8 PMID: 17055946

5. Main EK, Moore D, Farrell B, Schimmel LD, Altman RJ, Abrahams C, Bliss MC, Polivy L, & Sterling J (2006). Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement. American journal of obstetrics and gynecology, 194 (6) PMID: 16643812

6. Fok WY, Chan LY, Tsui MH, Leung TN, Lau TK, & Chung TK (2006). When to induce labor for post-term? A study of induction at 41 weeks versus 42 weeks. European journal of obstetrics, gynecology, and reproductive biology, 125 (2), 206-10 PMID: 16139416

7. Allen VM, O’Connell CM, Farrell SA, & Baskett TF (2005). Economic implications of method of delivery. American journal of obstetrics and gynecology, 193 (1), 192-7 PMID: 16021078

8. Luthy DA, Malmgren JA, & Zingheim RW (2004). Cesarean delivery after elective induction in nulliparous women: the physician effect. American journal of obstetrics and gynecology, 191 (5), 1511-5 PMID: 15547518

9. Ngwenya S, & Lindow SW (2004). 24 hour rhythm in the timing of pre-labour spontaneous rupture of membranes at term. European journal of obstetrics, gynecology, and reproductive biology, 112 (2), 151-3 PMID: 14746949

10. Magann EF, Doherty DA, Field K, Chauhan SP, Muffley PE, & Morrison JC (2004). Biophysical profile with amniotic fluid volume assessments. Obstetrics and gynecology, 104 (1), 5-10 PMID: 15228994

11. Daniel-Spiegel E, Weiner Z, Ben-Shlomo I, & Shalev E (2004). For how long should oxytocin be continued during induction of labour? BJOG : an international journal of obstetrics and gynaecology, 111 (4), 331-4 PMID: 15008768

Read more…

Amy Romano Uncategorized augmentation, From the Research Summaries Archives, induction, labor progress, practice variation, safety

In preparing the Home Birth chapter for the forthcoming second edition of Obstetric Myths versus Research Realities, I have literally just finished reading the entire body of literature on planned home birth. Just last week, I said to my co-author, Henci Goer, “frankly, I’m pretty underwhelmed by the quality of most of the studies.” (Though, don’t get me wrong, I still believe that the preponderance of the evidence strongly favors the choice of planned home birth.) But for the second time this year, an exemplary study on planned home birth has been released. Together with the Dutch study released in April, the current study ushers in a new era of home birth evidence that addresses many of the methodological limitations of previous home birth research. Seriously, folks, these two studies raise the bar.

Researchers in Canada analyzed the outcomes of all women who were intending to give birth at home at the onset of labor in British Columbia between 2001-2004 (n=2899 women). Data were obtained from the provincial database that collects information on all births and is cross-referenced with the national vital statistics (birth/death certificates) database. The researchers compared outcomes in the planned home birth group with those of two groups of women who met eligibility requirements for home birth but planned to give birth in hospitals instead. One of the two comparison cohorts had planned hospital births with midwives (n=4752); the other with physicians (n=5331).

Consistent with many other studies comparing planned home with planned hospital birth, the results showed comparable perinatal mortality rates, less serious morbidity for both women and infants, and lower use of obstetric technology in planned home births. Here are the results, as presented in the study’s abstract:

The rate of perinatal death per 1000 births was 0.35 (95% confidence interval [CI] 0.00–1.03) in the group of planned home births; the rate in the group of planned hospital births was 0.57 (95% CI 0.00–1.43) among women attended by a midwife and 0.64 (95% CI 0.00–1.56) among those attended by a physician. Women in the planned home-birth group were significantly less likely than those who planned a midwife-attended hospital birth to have obstetric interventions (e.g., electronic fetal monitoring, relative risk [RR] 0.32, 95% CI 0.29–0.36; assisted vaginal delivery, RR 0.41, 95% 0.33–0.52) or adverse maternal outcomes (e.g., third- or fourth-degree perineal tear, RR 0.41, 95% CI 0.28–0.59; postpartum hemorrhage, RR 0.62, 95% CI 0.49–0.77). The findings were similar in the comparison with physician-assisted hospital births. Newborns in the home-birth group were less likely than those in the midwife-attended hospital-birth group to require resuscitation at birth (RR 0.23, 95% CI 0.14–0.37) or oxygen therapy beyond 24 hours (RR 0.37, 95% CI 0.24–0.59). The findings were similar in the comparison with newborns in the physician-assisted hospital births; in addition, newborns in the home-birth group were less likely to have meconium aspiration (RR 0.45, 95% CI 0.21–0.93) and more likely to be admitted to hospital or readmitted if born in hospital (RR 1.39, 95% CI 1.09–1.85).

What makes this study stand out from most  of the rest:

1. Planned home births occurred in a context with relatively rigid guidelines for eligibility (see the full-text of the article to view the guidelines). These guidelines, determined by the Ministry of Health, were applied to women planning hospital births in order to construct the comparison cohorts. This increases the likelihood that, medically at least, the populations were similar. In addition, participants in the home birth group were matched with participants in the physician-attended hospital birth for the following parameters: year of birth, parity, single parent (yes or no), maternal age, and the hospital where the midwife conducting the index home birth had hospital privileges.

2. The authors made the cohorts more similar with statistical analysis – first, controlling for confounding variables and second, testing and retesting their data with different assumptions and exclusions. (Referred to as “sensitivity analysis,” this is a mechanism used by researchers to make sure their findings hold up under various circumstances and are unlikely therefore to be biased.)

3. The researchers isolated the effect of the birth setting itself by comparing midwife-attended home birth with midwife-attended hospital birth. In fact, the same group of midwives cared for women in both settings, so differences are likely to be related to the setting and its protocols and technological accoutrements (or lack thereof) rather than differences in the providers who actually provide the care.

4. According to the study authors, midwives in British Columbia are required to offer medically eligible women a choice of planned home or hospital birth. While women still must self-select to one choice or another, this certainly mitigates some bias. Self-selection bias refers to the possibility that individuals who, in this case, select different birth settings or providers, may be different in ways that are not measured but that nonetheless affect the likelihood of important outcomes. For example, women who choose home birth may have better nutrition, stronger family support systems, or a more positive outlook on labor and birth. But these differences may be less pronounced when the group selecting home birth showed up at the same prenatal clinic as all of the rest of the women and were (perhaps enthusiastically) presented the option of birthing at home. Contrast this with the population of women in parts of the United States who must actively seek out home birth, pay out of pocket, and be told that no physician will willingly consult if medical problems arise so they must settle for the emergency room, whether or not the transfer to the hospital is urgent. (The vast majority of transfers from home to hospital are not.) Only the most dedicated are likely to choose such an option.

5. Although the study was retrospective (meaning data were collected after the fact), data were obtained from province-wide databases to which care providers are obligated to enter data on each and every birth. In addition, these databases have been tested for the reliability of the data (to detect the possibility that certain outcomes are systematically underreported or overreported). Reliability was above 97% for all outcomes. Fewer than 1 in 10,000 records were missing. *

The only thing I did not see in the report that I would have liked to is a detailed description of the circumstances of each fetal or newborn death. These descriptions often provide clues as to whether small differences in perinatal mortality could have been attributed to the planned place of birth and whether and how they might have been averted.

No study of home birth will be perfect, but large perinatal databases and systems that integrate rather than marginalize home-birth midwifery have helped to achieve the “scientific rigor” that the American College of Obstetricians and Gynecologists has called for. And the results are looking very good indeed.

* denotes edited text. Click “read more” to view the original version. Read more…

Amy Romano Lamaze news, Uncategorized, new research, practice guidelines, sensibility, systematic review cesarean, home birth, interventions, midwives, practice variation