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Care Model Innovations – Changing The Way Maternity Care Is Provided

February 17th, 2015 by avatar
© Serena O'Dwyer

© Serena O’Dwyer

Amy Romano was the original community manager, editor and writer of Science & Sensibility back when this blog was first established by Lamaze International in 2009.  After a healthy stint in that role, Amy has since moved on to other positions and most recently can be found in the position of Vice President of Health Ecosystems at Maternity Neighborhood, a technology company providing digital tools and apps to maternity health care providers around the world.  Additionally, Amy has been focused on finishing up her MBA at the same time.  (Talk about multitasking!)

While moving on to other things, Amy has not stopped blogging and I have been enjoying her most recent series on care model innovation in maternity care in particular and healthcare in general.  The series started in October of 2014, and Amy just published the seventh post in her ten post series. The entire series is part of Amy’s school work toward receiving her MBA.  That is a great blend of combining her degree program with her work, with her passion and interest.

Amy decided to look at four care models in particular: Nurse-Family Partnership, community-based doulas, midwife-led maternity services, and CenteringPregnancy. In talking with Amy, she shared that one of the things that really struck her is that these evidence-based care models are all very much relationship-based. She is more convinced than ever that trusting relationships are the “secret sauce” of good birth outcomes.

The posts available in the series so far include:

  1. What is care model innovation?
  2. The case for care model innovation in U.S. maternity care
  3. Care models that work: Nurse-Family Partnership
  4. Care models that work: Doulas as community health workers
  5. Care models that work: Midwife-led maternity services
  6. Care models that work: Group Prenatal Care
  7. Early examples of payment innovation in maternity care

And those posts yet to come:

8.  More mature payment reform models: An overview
9.  Driving community-based care through payment reform
10. The data infrastructure required for care model transformation

Particularly helpful are the references and learning resources that Amy includes in each of her posts, where the reader can go for more information and to dig deeper into the programs and research that Amy used to substantiate her research.

Changing the maternity care model currently in place is a critical piece for helping to improve the current status of both maternal morbidity and mortality as well as neonatal morbidity and mortality in the USA, which despite our abundance of resources, still has our world ranking in these categories shamefully at the bottom of the list.

According to Amy:

We’re in the midst of a “perfect storm” right now, with implementation of health care reform and lots of forces changing healthcare to be more patient-centered and integrated with community services. If ever there was a time when midwifery care, doulas, physiologic birth practices, etc., were going to take hold, that time is now.

As I have been reading Amy’s series, I have been struck by how some of her posts have reinforced the Lamaze Six Healthy Birth Practices themes, in particular #3 – Bring a friend, loved one or doula for continuous support, and #4 – Avoid interventions that are not medically necessary.

I asked Amy to share what her thoughts on what the role of the childbirth educator was in this time of transition.  Her response:

I think childbirth educators have lots of opportunities in the new healthcare landscape, but it will require a shift in thinking for some. New payment models will reward team-based care and CBEs have an important potential role as valued members of these teams, helping to implement shared decision making, help with care navigation/coordination, and extending educational offerings to postpartum/parenting, special conditions (e.g. gestational diabetes), etc. 

Amy Romano

Amy Romano

We need innovative ideas, forward thinking, and the ability to examine what we are currently doing with a critical eye, if we are to design and implement maternity care programs that improve outcomes and utilize resources more effectively to help mothers and babies.  As Amy highlights, there are existing programs that have shown great results and deserve the opportunity to be implemented on a wider scale.

Take some time to read the seven posts and come back to the Maternity Neighborhood blog to catch the final three when they become available.  Share your thoughts about what Amy is discussing as she rolls out the entire series.  And, consider what your role will be in the changing landscape of care that women receive during their childbearing year.

Babies, Childbirth Education, Doula Care, Healthcare Reform, Healthy Birth Practices, Maternal Mortality, Maternal Quality Improvement, Maternity Care, Midwifery, New Research, Newborns, Research , , , , , , ,

ACOG & SMFM Standardize Levels of Maternal Care to Improve Maternal Morbidity & Mortality

February 5th, 2015 by avatar

obThe American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine released their second joint consensus statement on January 22nd, 2015. This consensus statement, Levels of Maternal Care is published in the February 2015 issue of Obstetrics and Gynecology (Green Journal).

What are the objectives of this statement?

The objectives of the statement, Levels of Maternal Care, is fourfold:

  1. To introduce uniform designations for levels of maternal care that are complementary but distinct from levels of neonatal care and that address maternal health needs, thereby reducing maternal morbidity and mortality in the United States
  2. To develop standardized definitions and nomenclature for facilities that provide each level of maternal care
  3. To provide consistent guidelines according to level of maternal care for use in quality improvement and health promotion
  4. To foster the development and equitable geographic distribution of full-service maternal care facilities and systems that promote proactive integration of risk-appropriate antepartum, intrapartum, and postpartum services

With a system in place that defines the levels of care, it will be clear when a transfer of care is deemed necessary to a facility that is better able to provide risk appropriate care to those women who need a higher level of maternity care.  This will improve maternal outcomes and reduce maternal morbidity and mortality.

Our goal for these consensus recommendations is to create a system for maternal care that complements and supplements the current neonatal framework in order to reduce maternal morbidity and mortality across the country. – Sarah J. Kilpatrick, MD/PhD, Lead Author

The USA ranks 60th in maternal mortality worldwide (Kassebaum NJ, 2014) and while some states  have established programs for a striated system of maternity care separate from the needs of the newborn, designations of what level of maternal care center will best serve the mother is not consistent and and creates confusion with a lack of uniform terms and definitions. Data supports better outcomes for mothers when certain maternal complications are handled in a facility deemed most appropriate for that condition.

Many years ago, thanks to the efforts of the March of Dimes, a similar system of levels of neonatal care was designated for the newborn, with each level having clear definitions of the type of services they were best able to provide, how they should be staffed and when a baby was to be transferred to a higher level facility based on newborn health conditions.  This newborn level of care system improved outcomes for babies in the USA, as they were assigned to a location that could best meet their medical needs. The levels of maternal care compliment the levels of care for the neonate, but should be viewed independently from the neonatal designations.

What are the levels of maternal care?

The statement defines five levels of care – Birth Center, Level I (Basic Care), Level II (Specialty Care), Level III (Subspecialty Care) and Level IV (Regional Perinatal Health Care Centers).

For each level, there is a definition, a list of capabilities that each facility should have, the types of health care providers that are assumed to be competent to work there and examples of appropriate patients.

Each level requires meeting the capabilities of the previous level(s) plus the ability to serve even more complicated situations until you reach Level IV, suitable for the most complicated, high populations.

The risk appropriate patient deemed suitable for each level takes into account the skills and training of the midwives or doctors who staff that facility and the ability of those individuals to initiate appropriate emergency skills and response times for the patient.  As a woman becomes less and less “low risk”, she will need to have her care transferred to the appropriate level.  This transfer may occur prenatally, intrapartum or during the postpartum period.

Recognition of the out of hospital midwife and the birth center

The consensus statement recognizes the credentials of the Certified Midwife (CM), the Certified Professional Midwife (CPM) and the Licensed Midwife (LM) as appropriate health care providers, along with Certified Nurse Midwives, OBs and Family Practice doctors, for low risk women in out of hospital facilities where those individuals are legally recognized as able to practice.  The low risk woman is defined as low-risk women one with an uncomplicated singleton term pregnancy with a vertex presentation who is expected to have an uncomplicated birth.

The statement also officially recognizes the freestanding birth center as an appropriate place to give birth for low risk women, along with supporting the collaboration of birth center midwives with the health care providers at higher level maternal care facilities.

Clear capabilities and requirements

The statement also outlines the type of staffing requirements to be available for services, consultation, or emergency procedures at each type of facility.

The consensus statement acknowledges that the appropriate level of  care for the baby may not align with the appropriate level of care for the mother.  Care guidelines that have been long established and well determined for the newborn should also be followed.

Consensus statement receives strong support

The consensus statement has been reviewed and endorsed by:

American Association of Birth Centers

American College of Nurse-Midwives

Association of Women’s Health, Obstetric and Neonatal Nurses

Commission for the Accreditation of Birth Centers

The American Academy of Pediatrics leadership, the American Society of Anesthesiologists leadership, and the Society for Obstetric Anesthesia and Perinatology leadership have reviewed the opinion and have given their support as well.

Additionally, the Midwives Alliance of North America was pleased to see this consensus statement and read how the role of out of hospital midwives was addressed.

MANA applauds ACOG’s identification of the need for birthing women to have a wide range of birthing options, from out of hospital settings for low-risk women to regional perinatal centers for families experiencing the most complicated pregnancies. As ACOG states, a wide variety of providers can meet the needs of low-risk women, including Certified Professional Midwives, Certified Nurse Midwives, Certified Midwives, and Licensed Midwives. We strongly concur with the need for collaborative relationships between midwives and obstetricians. Treesa McLean, LM, CPM, MANA Director of Public Affairs

What does this mean for the childbirth educator?

I encourage all birth professionals to read the consensus statement (it is easy to read) to understand the specifics of each level of maternal care.  As we teach classes, we can discuss with our families that there may be circumstances during their pregnancy or labor that require their care to be changed or transferred to a facility that offers the level of maternal care appropriate for their condition. Some of us already work in hospitals that are Level IV while others of us might teach elsewhere. We can help families to understand why a transfer might be necessary, and how to ask for and receive the information they need to fully understand the reason for a transfer of care and what all their options might be.  Families that are prepared, even for the events that they hoped to avoid, can feel better about how their labor and birth unfold.

Thank you ACOG and SMFM for working hard to clarify and bring about uniform standards that can be applied across the country that will improve the outcomes for mothers giving birth in the USA.

Photo source: creative commons licensed (BY-NC-SA) flickr photo by Paul Gillin

References

Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, et al. Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013 [published erratum appears in Lancet 2014;384:956]. Lancet 2014;384:980–1004. [PubMed]

Levels of maternal care. Obstetric Care Consensus No. 2. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:502–15.

American Academy of Pediatrics, Childbirth Education, Evidence Based Medicine, Maternal Mortality, Maternal Quality Improvement, Maternity Care, Medical Interventions, Midwifery, New Research, Practice Guidelines, Pregnancy Complications , , , , ,

Series: Building Your Birth Business – Free Website Content for Your Site from NIH

February 3rd, 2015 by avatar

HSS NIH

Having a blog or articles of interest on your website that are available to your students, clients and potential customers is a win-win situation for a birth professional. A win for your clientele because they are provided useful information and news important to them on the topics of pregnancy, birth and postpartum. A win for you, because providing this information creates engagement and positions you as an expert and a source of evidence based information.  Having useful content also increases traffic to your site. But writing this content takes time, requires research and can be very intimidating for some of us.

As part of our occasional series on building your birth business, I wanted to share a great service that the National Institutes of Health (NIH) Health and Human Services Division provides that can be a valuable time saver and help you to grow your business by increasing visits to your website and offering useful information to those who stop by.

NIH HSS exampleThe National Institutes of Health provides free web content that is up to date, accurate and easy to read. Even better, NIH provides a simple system that allows you to embed (place inside your website) content that you decide is important to your customer base.

Benefits of using the NIH Content Syndication Service

  • Material presented has the look and feel of your website
  • Content is updated automatically as new information or research is available, without any effort on your part
  • Time saving because you do not have to write personalized content
  • You can add your own thoughts and commentary
  • You control the topics, selecting only those you want to appear
  • You control the placement of the material on your site
  • Engagement and interaction occurs on your site, in the form of comments and dialogue
  • You can choose infographics, videos, podcasts and other multimedia offerings
  • Material is available in Spanish and in English

If you don’t find a topic you are looking for, you can request that specific information be provided for future use.

Step by step instructions are provided on the NIH website

How to Add Free Web Content from NIH to Your Website will provide everything you need to know to get started. After you register, you can browse all the topics that are offered or search for a subset of topics relevant to you and your business. You copy and paste a small snippet of code into your website and after you publish, the new material is exactly where you want it. The options are endless, you can use this material on your resource page or even drip it out slowly as part of your blog. Best of all, this material is designed for you to use in this way.  There are restrictions on using material from other sources, but this content provided by NIH is meant to be used in this way – and all the sourcing and credit appear automatically. You are also able to search for and use material from other sources in using the advanced search options.

Here is a topic I have embedded on toxoplasmosis and pregnancy for you to see how it works:

Why don’t you give it a try! Place something of interest on your website  using the NIH Content Syndication Service and then share the link in our comments section! Let us see how it looks! If you allow comments on your embedded article, I will try and leave a comment!

Babies, Breastfeeding, Childbirth Education, Maternity Care, New Research, Newborns, Series: Building Your Birth Business , , ,

How to Subscribe to or Follow Science & Sensibility and Your Favorite Blogs

January 29th, 2015 by avatar

rss-feed_1About 18 months ago I wrote about the six blogs that I thought every childbirth educator and other birth professionals would benefit from reading.  It might be time for an updated list or to add a few more of my favorites to the original post.  But, before I did that, I wanted to explain how to subscribe to a blog post so you are sure not to miss any good content from those blogs or your favorites.

What does “subscribe” to a blog mean?

When you subscribe to a blog, you are asking for new posts to be “pushed” to you when they are published.  They can be delivered to you via a blog reader (more on that later) or directly into your inbox. Subscribing means information comes to you, just like a magazine you subscribe to shows up in your mailbox at home or work.  You don’t have to remember to buy it at the store or read it at the library. It should not cost anything to subscribe to a blog that is available to the public.

What does “follow” a blog mean?

Following a blog is almost the same thing as subscribing.  It seems that people use the term “follow” when they use a blog reader and subscribe when it comes by email, but really, it is the same thing.

Why should I subscribe or follow a blog?

There are many interesting, useful and informative blogs out there that publish information that is helpful to your profession or that cover topics that you enjoy learning more about.  In your internet travels, you no doubt may come across many.  You can certainly bookmark the blog urls of your favorites and check back from time to time to see if anything new has been posted.  But this is not a very efficient use of your time.  And sometimes you forget to come back and check.  Why not have the new posts delivered to you at the moment they are published.  This way you never miss a post.

Getting updates into your email inbox

Screen Shot 2015-01-28 at 9.32.14 PM

Science & Sensibility Subcription

Many blogs will have a subscription box or sign up area somewhere on the blog that requests you enter your email address and you will be signed up to receive new blog posts delivered to your inbox.  You may need to confirm your request by replying to the confirmation email sent to you or clicking on the link in that confirmation email.  Check your spam and junk folders if this confirmation email does not arrive shortly.  Sometimes it could get caught up in your spam filters.  Once you confirm your subscription request, you are good to go.  Every time your favorite blog publishes something new, you get the content delivered directly to your inbox and you can read it on any device or computer.

Using an RSS Reader

RSS stands for “Really Simple Syndication” and an RSS Reader just means that you can read all your subscriptions in one place, at one time, whenever you want. The program “feeds” you the information There are many RSS Readers to choose from, and until it went away, Google Reader was my favorite.  Currently, I use Feedly which is one of the most popular, if not the most popular RSS Reader out there and very simple to use.  Many RSS Readers are free.  I have never paid for one and I am not sure I would, as the free services work just fine for me.

Screen Shot 2015-01-28 at 10.18.19 PM

S&S sign up using Feedly

After setting up an account with the RSS Reader of your choice, you then go about telling the service what blogs you want to “follow.”  There is usually an “add new content” button.  You put the url of the blog you want to follow in that box and hit return.  Remember to use the main domain of the blog – for example http://scienceandsensibility.org if I wanted to follow this blog.  Don’t use the url from one particular post.

Sometimes, a blog will have the RSS logo, that makes it easy to subscribe or follow the blog.  You click on the symbol, indicate what Reader you are using and it adds it from there.  But in general, I tend to copy the url of the blog and enter it myself.

Once subscribed in a reader, you can sort all your “feeds” or subscriptions into categories.  The programs allow you to set up folders that can hold many subscriptions.  You might have a category for childbirth topics, and one for recipes and another for your favorite hobby.  I tend to just keep them all in one big list (I subscribe to over 400 blogs) and leave it at that.  It is your choice.

The reader can show you unread blogs only (i.e., when there is new content) or all the content.  Kind of like your inbox can show you unread messages or all the messages.  There are other options to toggle on and off, depending on the RSS Reader you are working with.  I tend to keep it simple and just have a central list of any new posts from all the blogs I follow as the new ones are released.

Reading on a phone or tablet device

I like to skim my subscriptions or feeds once a day.  I tend to do this at the end of the day, in the evening, on my iPad.  I enjoy reading the blogs on my tablet, easy to move around and navigate on and easy on the eyes.  I use an application called Newsify which is geared for iPods, iPhones and iPads. If you have an another type of device, you will want to find an app that works well on yours.  Reading my feeds on my device lets me easily save those I want to keep for reference, and also makes it easy to share with others via email or social media.  I can also choose to read offline if I wish.  Sometimes I save up a big bunch of unread blog posts to devour on a long airplane flight, when I don’t have internet access.

Conclusion

There is a lot of great content coming out all the time that can help you stay on top of news and information professionally as well as for your personal enjoyment. Subscribing to blogs and getting information delivered to your inbox or your RSS Reader is an easy way to have the content come to you, and be ready and waiting when you want to read it.  Consider subscribing to your favorite blogs and see how easy it is.  Why not try it now with this blog, Science & Sensibility, so you never miss another post!  Let us know how it goes, if this whole process is new to you.

Additional resources

How to Subscribe to RSS Feeds

RSS- What is RSS

 

 

Childbirth Education, Lamaze International, New Research, Science & Sensibility , , , , ,

Epidurals: Do They or Don’t They Increase Cesareans?

January 27th, 2015 by avatar

By Henci Goer

In October, Author Henci Goer wrote an article for Science & Sensibility, Epidural Anesthesia: To Delay or Not To Delay – That is the Question – examining the impact of the timing of an epidural on labor and birth.  Today Henci looks at some new research, Epidural analgesia in labour and risk of caesarean delivery which seeks to determine whether receiving an epidural at all impacts the likelihood of a cesarean delivery.  Lamaze International has a great infographic on epidurals that you also may find very helpful. – Sharon Muza, Community Manager, Science & Sensibility.

© J. Wasikowski, provided by Birthtastic

© J. Wasikowski, provided by Birthtastic

Let’s start with a bit of background for those of you who didn’t personally live through the early controversy over whether epidurals increased the cesarean rate. As epidurals began to achieve popularity in the late 1970s and 1980s, one researcher sounded the alarm when he and his group published a study of 714 first-time mothers showing that even after excluding women with big babies and women whose labor pattern was abnormal prior to having an epidural, epidurals remained a potent factor in cesarean rates for delayed progress (Thorp 1989). Everyone pooh-poohed his finding on grounds that observational studies can’t truly determine whether epidurals lead to more cesareans or women experiencing more prolonged, painful labors, and therefore at higher risk for cesarean, were more likely to want epidurals. The “chicken versus egg” question, they argued, couldn’t be resolved without a randomized controlled trial (RCT), and it wasn’t likely that women would agree to be assigned by chance to have an epidural or not. In point of fact, that same year saw publication of a small Danish RCT (107 women, 104 of them first-time mothers) (Philipsen 1989). It reported that having an epidural nearly tripled the cesarean rate (16% vs. 6%) for “cephalopelvic disproportion” despite no clinical evidence of CPD being a requirement for inclusion. The investigators ignored this, however, concluding only that instrumental vaginal delivery rates were similar, and epidurals provided better pain relief. In any case, the anesthetic dose was much higher than was already becoming the norm, so it could be reasonably argued that the trial’s findings wouldn’t apply to modern-day practice.

Thorp, meanwhile, took up the RCT challenge. He and his colleagues carried out an epidural versus no epidural trial in 93 first-time mothers and found that epidurals did, in fact, lead to cesareans (25% vs. 2%), not vice versa (Thorp 1993). That bit of unwelcome news precipitated a stampede to perform more RCTs, and when enough of those had accumulated, to a series of systematic reviews pooling their data (meta-analysis), of which the Cochrane review, Anim-Somuah et al. (2011), is the latest. These reached the more comfortable conclusion that epidurals didn’t increase likelihood of cesarean, and pro-epiduralists breathed a collective sigh of relief and went back, if they had ever stopped, to unreservedly recommending epidurals. (This rather sweeps under the rug the other problems epidurals can cause, but that’s a topic for another day.)

Weaknesses of the “Epidural” vs. “No Epidural” Trials

Epidural

By User:Ravedave (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html)

The finding that epidurals don’t increase cesareans is puzzling because they increase likelihood of factors associated with them (Anim-Somuah 2011). For one thing, they increase use of oxytocin to augment labor, which implies they slow labor. For another, more women run fevers, and it stands to reason that a woman progressing slowly who starts running a fever is a likely candidate for cesarean. For a third, the difference in fetal malposition (occiput posterior) rates at delivery comes close to achieving statistical significance, meaning the difference is unlikely to be due to chance. Persistent OP is strongly associated with cesarean delivery (Cheng 2006; Fitzpatrick 2001; Phipps 2014; Ponkey 2003; Senecal 2005; Sizer 2000). Epidurals even increase cesareans for fetal distress by 40%, although the absolute difference didn’t amount to much (1 more per 100 women). Could a difference exist and meta-analysis of RCTs fail to detect it?

A string of well-conducted observational studies over the years have suggested that they could (Eriksen 2011; Kjaergaard 2008; Lieberman 1996; Nguyen 2010), the most recent of which is a very large, very convincing study published last fall (Bannister-Tyrrell 2014). Its authors point out, as have others before them, the weaknesses of the RCTs, weaknesses serious enough to nullify their results or make them inapplicable to typical community practice (external validity).

To begin with, in most trials, substantial percentages of women allocated to the non-epidural group ended up having epidurals, and some women allocated to the epidural group ended up not having one. Since RCTs analyze results according to group assignment (to do otherwise would negate the point of random assignment, which is to avoid bias), not what actually happened, this diminishes differences between groups. In addition, trials were mostly confined to women with no medical or obstetric complications who were treated according to strict protocols for labor management and indications for cesarean delivery. Neither is the case in most hospitals. To these I would add that many trials lumped together first-time mothers and women with prior births when reporting outcomes. First-time mothers are much more susceptible to factors that impede progress, so including women with prior vaginal births can make it appear that epidurals are less problematic for first-time mothers than they really are. In addition, three of the trials were carried out in a hospital where participants were mostly attended by midwives, and cesarean rates were much lower than is common for women attended by obstetricians.

All of this means that any null results in meta-analyses of the trials can be taken with a grain of salt, any findings of significant differences probably represent a minimal value, and first-time moms may be harder hit than appears. To cite one example, Anim-Somuah (2011) reported that 5 more women per 100 having epidurals had a malpositioned baby at delivery (18% vs. 13%) in the 4 trials reporting this outcome, a difference, as I said, that just missed achieving statistical significance. But when I confined results to the two trials in first-time mothers alone in which 10% or fewer of the women in the “no-epidural” group had an epidural, the gap widened to 9 more per 100 (11% vs. 2%).

Summary of the Bannister-Tyrrell (2014) Analysis

Bannister-Tyrrell and colleagues (2014) drew their population from a database of 210,700 Australian women with no prior cesareans who were laboring at term with a singleton, head-down baby. A strength of the database was that, unlike most, it distinguished epidurals for labor from epidurals for delivery. Using a long list of factors, investigators constructed a propensity score for how likely a woman was to have an epidural, matched women according to their score, and compared results according to whether women with the same score had or didn’t have an epidural. Matched controls were found for 52,600 women who had an epidural and were found across the full range of propensity scores. Women having epidurals were 2.5 times more likely to have a cesarean (20% vs. 8%), or put another way, 12 more women per 100 having epidurals had a cesarean (absolute excess), which amounts to 1 additional cesarean for every 8.5 women having an epidural (number needed to harm). Among first-time mothers, women having epidurals were 2.4 times more likely to have a cesarean. Study authors didn’t provide cesarean rates for this subgroup, but the raw cesarean rates overall were 18% in first-time mothers versus 2% in women with prior births, so the effect on this more vulnerable population could be dire.

But there’s still more. Investigators further adjusted for confounding factors not captured in their database. These included differences in health-care settings (same state but not same city), care provider (women without epidurals are more likely to be attended by midwives), and for confounding interventions more likely with epidurals (continuous fetal monitoring). Relative risk of cesarean with an epidural remained at 2.5. Investigators then adjusted for the association between occiput posterior baby and cesarean by setting estimates of the risk ratio to exceed the strongest associations reported in the literature, and they assumed that the prevalence of severe labor pain was 3 to 4 times higher in women having epidurals. Factoring these into their statistical analysis reduced the risk ratio, but women having epidurals still were 50% more likely to have a cesarean. This means that with a baseline cesarean rate of 8% in women without an epidural, 12% of women with an epidural will have one or 4 more women per 100 or 1 more cesarean for every 25 women.

The Take-Home

At the very least we cannot assure women with confidence that epidurals don’t increase the likelihood of cesarean. For this reason and because of their numerous other drawbacks and considering that comfort measures and other strategies have been shown to be both effective for most women and free of adverse effects (Declercq 2006; Jones 2012), women may want to make epidurals Plan B rather than Plan A. That being said, whatever their choice, women can minimize their chance of cesarean—with or without an epidural—by choosing a midwife or doctor whose policies and practices promote spontaneous vaginal birth http://www.lamaze.org/HealthyBirthPractices.

References

Anim-Somuah, M., Smyth, R. M., & Jones, L. (2011). Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev(12), CD000331. doi: 10.1002/14651858.CD000331.pub3 http://www.ncbi.nlm.nih.gov/pubmed/22161362

Bannister-Tyrrell, M., Ford, J. B., Morris, J. M., & Roberts, C. L. (2014). Epidural analgesia in labour and risk of caesarean delivery. Paediatr Perinat Epidemiol, 28(5), 400-411. http://www.ncbi.nlm.nih.gov/pubmed/25040829

Cheng, Y. W., Shaffer, B. L., & Caughey, A. B. (2006). Associated factors and outcomes of persistent occiput posterior position: A retrospective cohort study from 1976 to 2001. J Matern Fetal Neonatal Med, 19(9), 563-568. http://www.ncbi.nlm.nih.gov/pubmed/16966125?dopt=Citation

Declercq, E., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection. http://childbirthconnection.org/pdfs/LTMII_report.pdf

Eriksen, L. M., Nohr, E. A., & Kjaergaard, H. (2011). Mode of delivery after epidural analgesia in a cohort of low-risk nulliparas. Birth, 38(4), 317-326. http://www.ncbi.nlm.nih.gov/pubmed/22112332

Fitzpatrick, M., McQuillan, K., & O’Herlihy, C. (2001). Influence of persistent occiput posterior position on delivery outcome. Obstet Gynecol, 98(6), 1027-1031. http://www.ncbi.nlm.nih.gov/pubmed/11755548?dopt=Citation

Jones, L., Othman, M., Dowswell, T., Alfirevic, Z., Gates, S., Newburn, M., . . . Neilson, J. P. (2012). Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev, 3, CD009234. http://www.ncbi.nlm.nih.gov/pubmed/22419342

Kjaergaard, H., Olsen, J., Ottesen, B., Nyberg, P., & Dykes, A. K. (2008). Obstetric risk indicators for labour dystocia in nulliparous women: a multi-centre cohort study. BMC Pregnancy Childbirth, 8, 45. http://www.ncbi.nlm.nih.gov/pubmed/18837972?dopt=Citation

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About Henci Goer

Henci Goer

Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach She is the winner of the American College of Nurse-Midwives “Best Book of the Year” award. An independent scholar, she is an acknowledged expert on evidence-based maternity care.  

 

Cesarean Birth, Childbirth Education, Epidural Analgesia, Guest Posts, Healthy Birth Practices, Medical Interventions, New Research, Pain Management, Research , , , , , , ,