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Exclusive Q&A with Rebecca Dekker – What Does the Evidence Say about Induction for Going Past your Due Date?

April 15th, 2015 by avatar

What does the evidence say about dueToday on Evidence Based Birth, occasional contributor Rebecca Dekker, Phd, RN, APRN, provides a comprehensive research review –  Induction for Going Past your Due Date: What does the Evidence Say?  I had an opportunity to preview the article and ask Rebecca some questions about her most recent project on due dates. I would like to share our conversation here on Science & Sensibility with all of you. Rebecca’s website has become a very useful tool for both professionals and consumers to read about current best practice.Consumers can gather information on the common issues that they maybe dealing with during their pregnancies. Professionals can find resources and information to share with students and clients.  How do you cover the topic of inductions at term for due date?  After reading today’s S&S post and Rebecca’s research post, do you think you might share additional information or change what you discuss?  Let us know in the comments section.- Sharon Muza, Community Manager, Science & Sensibility.

Note: if the Evidence Based Birth post is not up yet, try again in a bit, it should be momentarily.

Sharon Muza: Why did you decide to tackle the topic of due dates as your next research project and blog post?

Rebecca Dekker: Last year, I polled my audience as to what they would like me to write about next. They overwhelmingly said that they wanted an Evidence Based Birth article about Advanced Maternal Age (AMA), or pregnancy over the age of 35. As I started reviewing the research on AMA, it became abundantly clear to me that I had to first publish an article all about the evidence on due dates. This article on induction for due dates creates a solid foundation on which my readers can learn about induction versus waiting for spontaneous labor in pregnant women who are over the age of 35.

SM: When you started to dig into the research, were there any findings that surprised you, or that you didn’t expect?

RD: There were two topics that I really had to dig into in order to thoroughly understand.

The first is the topic on stillbirth rates. I began to understand that it’s really important to know which mathematical formula researchers used to calculate stillbirth rates by gestational age. It was interesting to read through the old research studies and letters to the editors where researchers argued about which math formulas were best. In the end, I had to draw up diagrams of the different formulas (you can see those diagrams in the article) for the formulas to make sense in my head, and once I did, the issue made perfect sense!

Before 1987 (and even after 1987, in some cases) researchers really DID use the wrong formulas, and it’s kind of funny to think that for so many years, they used the wrong math! In general, I thought the research studies on stillbirth rates by gestational age were really interesting…it raised questions for me that I couldn’t answer, like why are the stillbirth rates so different at different times and in different countries? Also, it was really clear from the research that stillbirth rates are drastically different depending on whether you are looking at samples that include or don’t include babies who are growth-restricted.

The other big breakthrough or “ah ha” moment I had was when I finally realized the true meaning of the Hannah (1992) Post-Term study. There was such a huge paradox in their findings… why did they find that the expectant management group had HIGHER Cesarean rates, when clinicians instinctively know that inductions have higher Cesarean rates compared to spontaneous labor? Since all of the meta-analyses rely heavily on the Hannah study, I knew I needed to figure this problem out.

There are a couple different theories in the literature as to why there were higher C-section rates in the expectant management group in Hannah’s study. One theory is that the induction group had Prostaglandins to ripen the cervix, while the expectant management group did not. However, in a secondary data analysis published by Hannah et al. in 1996, they found that this probably played just a minor role.

Another theory is that as women go further along in their pregnancy, physicians get more nervous about the risk of stillbirth, and so they may be quicker to recommend a Cesarean in a woman who is past 42 or 43 weeks, compared to one who is just at 41 weeks. This theory has been proposed by several different researchers in the literature, and there is probably some merit to it.

But in the end, I found out exactly why the C-section rates are higher in the expectant management group in the Hannah Post Term study (and thus in every meta-analysis that has ever been done on this topic). Don’t you want to know why? I finally found the evidence in Hannah’s 1996 article called “Putting the merits of a policy of induction of labor into perspective.” The data that I was looking for were not in the original Hannah study… they were in this commentary that was published several years later.

dekker headshotThe reason that Cesarean rates were higher in the expectant management group in the Hannah study is because the women who were randomly assigned to wait for spontaneous labor, but actually ended up with inductions, had Cesarean rates that were nearly double of those among women who had spontaneous labor. Some of these inductions were medically indicated, and some of them were requested by the mother. In any case, this explains the paradox. It’s not spontaneous labor that leads to higher Cesarean rates with expectant management… the higher Cesarean rates come from women who wait for spontaneous labor but end up having inductions instead. 

So the good news is that if you choose “expectant management” at 41-42 weeks (which is a term that I really dislike, because it implies that you’re “managing” women, but I digress), your chances of a Cesarean are pretty low if you go into spontaneous labor. But if you end up being one of the women who waits and then later on chooses to have an induction, or ends up with a medically indicated induction, then your chances of a Cesarean are much higher than if you had just had an elective induction at 41 weeks.

SM: What information do you recommend that childbirth educators share to help families make informed decisions about inductions and actions to take as a due date comes and then even goes, and they are still pregnant.

RD: First of all, I think it’s important for all of us to dispel the myth of the 40 week due date. There really is no such thing as a due date. There is a range of time in which most women will go into labor on their own. About half of women will go into labor by 40 weeks and 5 days if you’re a first-time mom (or 40 weeks and 3 days if you’ve given birth before), and the other half will go into labor after that.

The other thing that it is important for childbirth educators to do is to encourage families—early in pregnancy—to talk with their health care provider about when they recommend induction, and why.

There are some health care providers who believe strongly that induction at 39, 40, 41, or 42 weeks reduces the risk of stillbirth and other poor outcomes. There are parents who have the same preference. Then there are other health care providers who believe strongly that induction for going past your due date is a bad thing, and shouldn’t be attempted unless there are clear medical reasons for the induction. And there are parents who will tend to share that same preference. Either way, parents need accurate information about the benefits and risks of waiting versus elective induction at 41-42 weeks—because both are valid options.

But it’s probably best to avoid a mismatch between parents and providers. If parents believes strongly that they want to wait for spontaneous labor, and they understand the risks, but they have a care provider who believes strongly in elective induction at 41 weeks, then they will run into problems when they reach 41 or 42 weeks and their care provider disagrees with their decision.

Clearly, there are benefits to experiencing spontaneous labor and avoiding unnecessary interventions. But at the same time there is a rise in the relative risk of stillbirth starting at about 39 weeks, depending on which study you are looking at. However, the overall risk is still low up until 42 weeks. At 42 weeks, the risk of stillbirth rises to about 1 in 1,000 in babies who are not growth-restricted. The risk may be higher in some women who have additional risk factors for stillbirth. Women who experience post-term pregnancy (past 42 weeks) are more likely to experience infections and Cesareans, and their infants are more likely to experience meconium aspiration syndrome, NICU admissions, and low Apgar scores.

SM: Would you recommend that families have conversations about how their due date is being calculated, at the first prenatal with their health care providers. What should that conversation include?

RD: I would recommend asking these questions:

  • What is the estimated date range that I might expect to give birth—not based on Naegele’s rule, but based on more current research about the average length of a pregnancy?
  • Did you use my Last Menstrual Period or an early ultrasound to determine my baby’s gestational age?
  • Has my due date been changed in my chart at any point in my pregnancy? If so, why?

SM: The concept of being “overdue” if still pregnant at the due date is firmly ingrained in our culture. What do you think needs to happen both socially and practically to change the way we think about the “due date?”

RD: We need to start telling everyone, “There is no such thing as a due date.” To help women deal with the social pressure they may experience at the end of pregnancy, I’ve created several Facebook profile photos that they can use as their Facebook profile when they get close to their traditional “due date.” To download those photos, visit www.evidendebasedbirth.com/duedates

SM: How available and widely used are first trimester ultrasounds? If first trimester ultrasounds were done as the standard of care in all pregnancies, would it result in more accurate due dates and better outcomes? Do you think there should be a shift to that method of EDD estimation?

RD: I think the option of having a first trimester ultrasound definitely needs to be part of the conversation between a woman and her care provider, especially because it has implications for the number of women who will be induced for “post-term.” I could not find any data on the percentage of women who have an ultrasound before 20 weeks, but in my geographic area it seems to be nearly 100%, anecdotally.

If your estimated due date is based on your LMP, you have a 10% chance of reaching the post-term period, but if it’s based on an early ultrasound, you only have a 3% chance of reaching 42 weeks.

One strange thing that I noted is that ACOG still prefers the LMP date over an early ultrasound date. They have specific guidelines in their practice bulletin about when you need to switch from the LMP date to an ultrasound date, but the default date is still the LMP. I found that rather odd, since research is very clear that ultrasound data is more accurate than the LMP, for a host of reasons!

Before I published the due dates article, I reached out to Tara Elrod, a Certified Direct Entry Midwife in Alaska, to get her expert feedback as a home birth midwife. She raised an excellent point:

“It is of significant interest to me as a licensed midwife practicing solely in the Out-of-Hospital setting that ultrasounds done in early pregnancy are more accurate than using LMP. If early ultrasound dating was achieved, it’s thought that this would ultimately equate to less women being induced for post-term pregnancy. This is significant to midwives such as myself due to the scope-of-care regulation of not providing care beyond 42 weeks. While an initial- and perhaps arguably by some ‘elective’ ultrasound-  may not be a popular choice in the midwife clientele population, a thoughtful risk versus benefit consideration should occur, as to assess the circumstance of “risking out” of care for suspected post-dates. [In my licensing state, my scope of care is limited to 37+0 weeks to 42+0 weeks, with the occasional patient reaching 42 weeks and therefore subsequently “risking out,” necessitating a transfer of care.]” ~Tara Elrod, CDM

SM: What do you think the economic cost of inductions for due dates is? The social costs? What benefits might we see if we relied on a better system for determining due dates and when to take action based on being postdates?

RD: There are economic costs to both elective inductions and waiting for labor to start on its own. The Hannah Post-Term trial investigators actually published a paper that looked at the cost effectiveness of their intervention, and they found that induction was cheaper than expectant management. This was primarily because with expectant management, there were extra costs related to fetal monitoring (non stress tests, amniotic fluid measurements, etc.) and the increased number of Cesareans in the expectant management group.

But there are many unanswered questions about the cost-effectiveness of elective induction of labor versus waiting for labor to begin (with fetal monitoring), so I’m afraid I can’t make any definitive statements or projections about the economic and social costs of elective inductions. Here is a study that may be of interest to some with further information on this topic.

I do know that in a healthy, low-risk population, birth centers in the National Birth Center Study II provided excellent care at a very low cost with women who had spontaneous births all the way up to 42 weeks. I would love to see researchers analyze maternal and neonatal outcomes in women stratified by gestational age in the Perinatal Data Registry with the American Association of Birth Centers.

 SM: I very much look forward to all your research posts and appreciate the work  and effort you put into doing them. What is on your radar for your next piece?

RD: The next piece will be Advanced Maternal Age!! After that, I will probably be polling my audience to see what they want, but I’m interested in tackling some topics related to pain control (epidurals and nitrous oxide) or maybe episiotomies.

SM: Is there anything else that you want to share about this post or other topics?

RD: No, I would just like to give a big thank you to everyone who helped in some way or another on this article!! There was a great interdisciplinary team who helped ensure that the due dates article passed scrutiny—we had an obstetrician, family physician, nurse midwife, several PhD-prepared researchers, and a certified direct entry midwife all provide expert review before the article was published. I am so thankful to all of them.

References

Hannah, M. E., C. Huh, et al. (1996). “Postterm pregnancy: putting the merits of a policy of induction of labor into perspective.” Birth 23(1): 13-19.

Hannah, M. E., W. J. Hannah, et al. (1992). “Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. The Canadian Multicenter Post-term Pregnancy Trial Group.” N Engl J Med 326(24): 1587-1592.

 

 

 

Cesarean Birth, Childbirth Education, Evidence Based Medicine, informed Consent, Maternal Quality Improvement, Maternity Care, New Research, Research , , , , ,

Book Review – Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth, Part One

March 10th, 2015 by avatar

 By Cynthia Good Mojab, MS, LMHCA, IBCLC, RLC, CATSM

transformed cover

Walker Karraa, PhD, a former contributor to Science & Sensibility, has authored a new book, Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth, that speaks to what lies on the other side for the 20 women she interviewed about their experiences with postpartum depression. Cynthia Good Mojab, MS, LMHCA, IBCLC, RLC, CATSM, who specializes in supporting people with postpartum mood and anxiety disorders and birth trauma presents a three-part series related to Dr. Karraa’s book. Today on the blog, Cynthia outlines the books content and its implications for practice. On Thursday, Cynthia shares her commentary on some of Dr. Karraa’s research and conclusions. Next week we are offered a glimpse into the person behind the book, when an interview with Dr. Karraa is shared with blog readers. Follow all three parts of this series on “Transformed by Postpartum Depression.” – Sharon Muza, Science & Sensibility Community Manager.

 In the last several decades, our awareness and understanding of postpartum depression have steadily increased. A wealth of research now exists regarding its prevalence, risk factors, prevention, symptoms, consequences, and treatment. Organizations, like Postpartum Support International and Postpartum Progress, champion the needs of families touched by postpartum depression and other perinatal mental health challenges, counter stigma, and contribute critical support and information to the safety net that all new families need and deserve. Many states in the United States have enacted legislation or developed projects related to public education, screening, and/or treatment for perinatal mental health challenges. And, at the national level in the US, the 2020 Mom Project seeks to remove institutional barriers that prevent depressed new mothers from being identified and accessing treatment.

In spite of this progress, we do not see the prevalence of postpartum depression dropping. Globally, it is as high as 82.1% when measured using self-reported questionnaires and as high as 26.3% when measured using structured clinical interviews (Norhayati, Nik Hazlina, Asrenee, & Wan Emilin, 2014). In fact, we see that depression during pregnancy and after birth routinely goes undetected and untreated (Miller et al., 2012). How is that possible? And, beyond the statistics that we have now amassed, what is it really like to experience postpartum depression, come out the other side, and make meaning from the experience?

Posttraumatic Growth after Postpartum Depression

In her new book, Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth, Walker Karraa, PhD (2014) invites readers to join her in a touching and thought provoking exploration of the potentially transformative nature of postpartum depression. Her book, which is based on the findings of her dissertation research (Karraa, 2013), brings to light both the suffering and development that women can experience on this journey. In fact, her book is one of the fruits of her own transformation through her experience of severe postpartum depression. Parents, lay supporters, and perinatal care providers who appreciate the blend of research and women’s voices found in books like Depression in New Mothers: Causes, Consequences, and Treatment Alternatives (Kendall-Tackett, 2010) and Traumatic Childbirth (Beck, Driscoll, & Watson, 2013) will also appreciate Karraa’s book. It should certainly be considered “required reading” for perinatal care providers and lay supporters.

walker karraa head shot 2015Karraa begins with a brief review of the literature, including what postpartum depression is, who develops it, and its global prevalence, risk factors, and consequences. These facts and figures help orient the reader to the general nature and scope of a veritable global mental health pandemic. They also serve to illustrate the foundation of the dominant discourse regarding postpartum depression: an allopathic worldview that frames mental illness as pathology. The following five chapters, however, contribute to an expansion of that view by illustrating how postpartum depression can be experienced as a long and painful journey culminating in positive change.

In the course of conducting her qualitative research, Karraa used grounded theory to analyze the answers of 20 women to four questions (Karraa, 2013) about their experience of postpartum depression:

  • How would you describe your process of transformation through postpartum depression?
  • In what ways did you experience the process of transformation through postpartum depression?
  • What were the ways you saw yourself transforming?
  • How do you experience this transformation currently?

She uncovered five stages of transformation through postpartum depression: before, during, ending, after, and beyond. That the women described 1) feeling shocked by the nature and magnitude of their symptoms, 2) enduring physical and psychological disintegration to which care providers seemed oblivious, and 3) slowly finding a path toward recovery will strike a familiar chord for lay supporters, perinatal care providers, and individuals who have worked and/or lived with postpartum depression. What might not be familiar to all readers are the last two stages that Karraa identified: 4) an increase in self-care, self-confidence, authenticity, and compassion; improved relationships; and alteration of perception of self and purpose in the world; and 5) coming to view postpartum depression as resulting—paradoxically—in a profoundly positive transformation.

In her 7th chapter, Karraa gives the reader a thoughtful tour of her consideration of several theories that might explain her research participants’ experiences of transformation through postpartum depression. Ultimately, she recognized that the prolonged endurance of threat to their physical and psychological survival was so great that the women experienced postpartum depression as a traumatic life event and that the transformative nature of their experience of postpartum depression is, thus, an example of posttraumatic growth: “positive psychological change experienced as a result of the struggle with highly challenging life circumstances” (Tedeschi & Calhoun, 2004).

In chapter 8, Karraa shares the confirming feedback of four experts in the field of postpartum depression, including the illustrious Cheryl Tatano Beck, Jane Shakespeare-Finch, Karen Kleinman, and Jane Honikman. Then she closes with a chapter acknowledging that her work has revealed a connection that has been right under our noses waiting for us to formally notice and describe: postpartum depression is one of the adversities of life that can precipitate growth. Karraa researched, recognized, and named that connection. Naming an experience honors it. It also provides a language for new parents, lay supporters, perinatal care providers, and researchers to use as they seek to express, understand, provide support for, treat, recover from, and/or grow from the life-altering experience of postpartum depression. And, perhaps most importantly, it offers hope to those who are fighting their way back from the devastation of postpartum depression. Not only can recovery be found at the end of the darkest tunnel; transformation may await.

Care Provider Failure: A Call to Action

The power of Karraa’s book continues in its appendices, where she describes an informal survey that serves as an(other) urgent call to action for all of us: in spite of the high prevalence of postpartum depression and its negative consequences when untreated, we are collectively failing to help those who are experiencing it. Because so many women in her qualitative study reported that their care providers had failed to help them, Karraa conducted the Changing Depression Survey (n=486). When asked who was most responsible for their getting help for postpartum depression, 65.4% of her participants selected “Self,” 23.0% selected “Partner,” 16.9% selected “Family Member,” 11.7% selected “Medical Care Provider” (which includes OB/GYN, Midwife, General or Family Physician), 8.8% selected “Other (Friend),” and 6.6% selected “Therapist.” When asked who was least helpful in getting them help for postpartum depression, 43.2% of her participants selected “Medical Care Provider,” 21% reported “Family Members,” 20.6% reported “Partner,” 19.3% reported “Self,” and 6.8% reported “Therapist.”

While this is, admittedly, an informal survey, the patterns seen here match clinical experience as well as research findings that only a fraction of new mothers with postpartum depression are identified and treated (Milgrom & Gemmill, 2014). My own clients, who are new parents, frequently report finding me after seeing a series of care providers who did not formally screen or refer them for perinatal mental health challenges, did not informally ask them about how they are coping with new parenthood, and/or did not respond with sensitivity, validation, or assistance when they tried to share their struggles. A delay in diagnosis, support, and treatment can both worsen and prolong suffering for new parents struggling through postpartum depression. Karraa’s research suggests that, in some cases, it may also delay the experience of posttraumatic growth.

This call to action must be heard and effectively responded to by individuals as well as by institutions. Yes, perinatal care providers and lay supporters will benefit from reading Karraa’s book. But, reading the book is not the same as developing the skills to apply the book’s insights in practice. Her research is an invitation for organizations and credentialing institutions in the diverse fields that provide services to new families (e.g., childbirth education, doula care, midwifery, obstetrics, pediatrics, family practice medicine, lactation education, lactation consulting, counseling, social work, psychiatry, naturopathic medicine) to develop, offer, and require training related to perinatal mental health, including:

  • how to reduce stigma and increase awareness by educating expectant and new parents about perinatal mental health issues
  • why, when, and how to screen and refer
  • how to effectively provide care to new parents struggling with perinatal mental health challenges—including using approaches that incorporate an understanding of postpartum depression as potential transformation to be nurtured, not just as pathological symptoms to be eliminated.

Conclusion

Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth consistently engages the reader with the poignant and inspiring stories of 20 women, as well as with the intriguing insights of the author and four experts in the field. The moving narratives and cogent analysis effectively describe the women’s experience of postpartum depression as traumatic and the transformation of their suffering into growth. The book also invites us to transcend the dominant view of postpartum depression as pure pathology and to learn how to take effective action to keep new parents struggling with perinatal mental health challenges from falling through the cracks. I congratulate Dr. Karraa on authoring a book that makes such a meaningful contribution to our understanding of postpartum depression and, refreshingly, offers a significant focus on recovery and development. Join me here on this blog on Thursday to read my commentary regarding frameworks that might explain her findings as well as my hopes for future research.

References

Beck, C., Driscoll, J., & Watson, S. (2013). Traumatic Childbirth. New York: Routledge.

Karraa, W. (2013). Changing Depression: A Grounded Theory of the Transformational Dimension of Postpartum Depression. (Doctoral dissertation). Retrieved from ProQuest/UMI. (3607747.)

Karraa, W. (2014). Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth. Amarillo, TX: Praeclarus Press.

Kendall-Tackett, K. (2010). Depression in New Mothers: Causes, Consequences, and Treatment Alternatives. New York: Routledge.

Milgrom, J. & Gemmill, A. (2014). Screening for perinatal depression. Best Practice & Research Clinical Obstetrics & Gynaecology, 28(1), 13-23.

Miller, L., McGlynn, A., Suberlak, K., Rubin, L., Miller, M., & Pirec, V. (2012). Now What? Effects of On-Site Assessment on Treatment Entry After Perinatal Depression Screening. Journal of Women’s Health, 21(10), 1046-1052.

Norhayati, M., Nik Hazlina, N., Asrenee, A., & Wan Emilin, W. (2014). Magnitude and risk factors for postpartum symptoms: A literature review. Journal of Affective Disorders, 175C, 34-52.

Tedeschi, R. & Calhoun, L. (2004). Posttraumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry, 15(1), 1-18.

About Cynthia Good Mojab

cynthia good mojab headshot 2015Cynthia Good Mojab, MS Clinical Psychology, is a Clinical Counselor, International Board Certified Lactation Consultant, author, award-winning researcher, and internationally recognized speaker. She is the Director of LifeCircle Counseling and Consulting, LLC where she specializes in providing perinatal mental health care. Cynthia is Certified in Acute Traumatic Stress Management and is a member of the American Academy of Experts in Traumatic Stress and the National Center for Crisis Management. Her areas of focus include perinatal loss, grief, depression, anxiety, and trauma; lactational psychology; cultural competence; and social justice. She has authored, contributed to, and provided editorial review of numerous publications. Cynthia can be reached through her website.

Guest Posts, Infant Attachment, Maternal Mental Health, New Research, Perinatal Mood Disorders, Postpartum Depression, Research, Trauma work, Uncategorized , , , , , , ,

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 , , , , , , ,

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

Lieberman, E., Lang, J. M., Cohen, A., D’Agostino, R., Jr., Datta, S., & Frigoletto, F. D., Jr. (1996). Association of epidural analgesia with cesarean delivery in nulliparas. Obstet Gynecol, 88(6), 993-1000. http://www.ncbi.nlm.nih.gov/pubmed/8942841

Nguyen, U. S., Rothman, K. J., Demissie, S., Jackson, D. J., Lang, J. M., & Ecker, J. L. (2010). Epidural analgesia and risks of cesarean and operative vaginal deliveries in nulliparous and multiparous women. Matern Child Health J, 14(5), 705-712. http://www.ncbi.nlm.nih.gov/pubmed/19760498?dopt=Citation

Philipsen, T., & Jensen, N. H. (1989). Epidural block or parenteral pethidine as analgesic in labour; a randomized study concerning progress in labour and instrumental deliveries. Eur J Obstet Gynecol Reprod Biol, 30(1), 27-33. http://www.ncbi.nlm.nih.gov/pubmed/2924990

Phipps, H., Hyett, J. A., Graham, K., Carseldine, W. J., Tooher, J., & de Vries, B. (2014). Is there an association between sonographically determined occipito-transverse position in the second stage of labor and operative delivery? Acta Obstet Gynecol Scand, 93(10), 1018-1024. http://www.ncbi.nlm.nih.gov/pubmed/25060716

Ponkey, S. E., Cohen, A. P., Heffner, L. J., & Lieberman, E. (2003). Persistent fetal occiput posterior position: obstetric outcomes. Obstet Gynecol, 101(5 Pt 1), 915-920. http://www.ncbi.nlm.nih.gov/pubmed/12738150?dopt=Citation

Senecal, J., Xiong, X., Fraser, W. D., & Pushing Early Or Pushing Late with Epidural study, group. (2005). Effect of fetal position on second-stage duration and labor outcome. Obstet Gynecol, 105(4), 763-772. http://www.ncbi.nlm.nih.gov/pubmed/15802403

Sizer, A. R., & Nirmal, D. M. (2000). Occipitoposterior position: associated factors and obstetric outcome in nulliparas. Obstet Gynecol, 96(5 Pt 1), 749-752. http://www.ncbi.nlm.nih.gov/pubmed/11042312?dopt=Citation

Thorp, J. A., Hu, D. H., Albin, R. M., McNitt, J., Meyer, B. A., Cohen, G. R., & Yeast, J. D. (1993). The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial. Am J Obstet Gynecol, 169(4), 851-858. http://www.ncbi.nlm.nih.gov/pubmed/8238138?dopt=Citation

Thorp, J. A., Parisi, V. M., Boylan, P. C., & Johnston, D. A. (1989). The effect of continuous epidural analgesia on cesarean section for dystocia in nulliparous women. Am J Obstet Gynecol, 161(3), 670-675. http://www.ncbi.nlm.nih.gov/pubmed/2782350

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 , , , , , , ,

“Pathway to a Healthy Birth” – Using Consumer Materials from Hormonal Physiology of Childbearing Report in Your Classes.

January 22nd, 2015 by avatar

Screen Shot 2015-01-21 at 6.01.46 PMLast week, Dr. Sarah Buckley in coordination with Childbirth Connection released a new research report, “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies and Maternity Care.”  This massive tome gathers in one place, all the current information available on the role of various hormones on pregnancy, labor, birth, breastfeeding and postpartum and provides information on what happens to the processes when interventions are introduced.  Well known childbirth educator Penny Simkin reviewed the report on Science & Sensibility on January 13th and then Michele Ondeck followed up with an exclusive Science & Sensibility interview with Sarah Buckley later in the week.

I think that everyone will acknowledge that this report is a remarkable and valuable piece of work, but at over 400 pages if you take into account all accompanying documents and with a bibliography consisting of over 1100 sources, the typical pregnant woman is hardly going to be keeping a copy on their bedside table for some light reading before drifting off to sleep.  Today on Science & Sensibility, I would like to highlight the resources and tools that Childbirth Connection has thoughtfully provided that are geared specifically for the consumer.  Childbirth educators, doulas and health care providers can access and share these materials with their students, clients and patients.

Pathway to a Healthy Birth – How to Help Your Hormones to Do Their Wonderful Work – consumer booklet

This 17 page colorful consumer booklet is written in easy to comprehend language and illustrated with attractive photographs that show a diverse collection of families.  Families are introduced to the hormones of birth and postpartum; oxytocin, beta-endorphins, catecholamines and endorphins.  Each hormone has a brief description and a short explanation about the role it plays in childbearing.

Families are told that events can interfere with the intended actions of the childbearing hormones.  Birthing women are encourage to think about how activities around them during their labor and birth may interfere with hormones and prevent the hormones from working effectively.

Women learn that hormones prepare her body for an efficient labor and birth.  The booklet addresses how women’s bodies are prepared by some hormones to handle the pain and stress that may accompany labor. They also find out that the hormones help prepare their babies for the newborn transition.  Infant attachment and maternal behaviors are also supported by the role of the hormones.

Follow Angela’s Birth Story

Families are introduced to “Angela” and read about her labor and birth story.  The story shows how the hormones allow the labor and birth to unfold in support of the normal processes and how small things can have a big impact and disrupt the process.  For example, The transition from home to hospital reduces the intensity and frequency of Angela’s contractions as a result of interference with the normal hormonal process.  The story is filled with lots of strategies to encourage and allow the hormonal effects as they are intended to occur.

It is easy to see from Angela’s story, that while labor and birth are hard and do involve pain, with the right support and environment, along with best practices that endorse physiological birth, Angela is able let her body do the work it is designed to do, and have a birth that is very satisfying to her.

“What’s Happening”

Accompanying the story is an easy to read guide that demonstrates exactly what the hormones of childbearing are doing at each particular point in Angela’s story.  Explanations of the role of each hormone as things unfold help families to understand how what happens in their own birth can affect their own birth story and outcome.

What Can You Do

The next portion of the brochure offers steps that families can take to help them identify providers and facilities that support physiologic birth.  Lists of questions to ask, tips for making a hospital room comfortable and private, interview questions for their doctor or midwife, how to pick a childbirth class, find a doula, how to determine if medical procedures are necessary and explore less interventive alternatives and more are all there in an easy to digest format. Included are valuable links in the final section that makes the booklet resource rich.  There are many web links to get more information about all the topics covered above.  This makes the booklet an ideal handout for a childbirth class, doula consultation or meet and greet with potential health care providers.

Infographic

Screen Shot 2015-01-21 at 6.03.49 PMThere is a consumer infographic that can be printed in a size suitable for hanging in a classroom or office, or provided in a smaller format that makes a great accompaniment to the above booklet.  The infographic identifies things that can keep a woman on the “pathway” to a physiological birth and what can steer her away from the pathway.  There is a lot of similarity between the points made in this infographic and the Lamaze Six Healthy Birth Practices.

One teaching idea

After discussing the role of hormones in labor and sharing the infographic as a visual aid, I can easily see how an educator can play a game with her class – making and distributing cards to class members with scenarios on them, and asking families to share if those scenarios and activities are making it easier for the mother to stay on the physiological pathway or what steers her further away and having the students identify which hormones are affected.

We have a responsibility as childbirth educators to share the important role the hormones of childbearing play in supporting healthy mothers, healthy births and healthy babies.  Using the Pathway to a Healthy Birth consumer booklet and accompanying infographic as part of your teaching materials provides a simple to understand but effective tool for conveying this information to the families you interact with.

How do you see yourself using these consumer products in your childbirth classes?  With your doula clients?  Please share your ideas for teaching, discussing and using this material and covering these topics with the families you work with.  I would love to hear your thoughts.

Babies, Breastfeeding, Childbirth Education, Healthy Birth Practices, Infant Attachment, Medical Interventions, Newborns, Research, Transforming Maternity Care , , , , , ,