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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 , , , , ,

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 , , , , , , ,

Practice Variation in Cesarean Rates: Not Due to Maternal Complications

November 13th, 2014 by avatar

By Pam Vireday

Pam Vireday, an occasional contributor to Science & Sensibility reviews the recent study by Katy Kozhimannil, PhD and colleagues that examined the differences in cesarean rates between over a thousand hospitals in the USA.  Consumers of maternity care quite possibly do not realize what a significant impact their choice of facility (and provider) may have on their birth outcome.  Can you think of hospitals in your own community serving similar populations of pregnant families that have drastically different cesarean rates.  Have you considered why that might be?  Do you think that the families you work with have explored this too?  Do they even have access to this information?  Read Pam’s discussion of this recent study below.  – Sharon Muza, Community Manager, Science & Sensibility.

© Patti Ramos Photography

© Patti Ramos Photography

There’s a new study out that discusses the variation in cesarean rates between hospitals in the United States. “Maternal clinical diagnoses and hospital variation in the risk of cesarean delivery: Analyses of a national US hospital discharge database” was released late last month and has received a lot of press and discussion ever since.

Practice variation is a serious problem in obstetrics (Arcia 2013). Women are often far more at risk for a cesarean in certain hospitals than in others, even when the hospitals serve the same geographical area and population (Arnold, January 2013 and August 2012).

Of course, care providers protest that some hospitals have higher cesarean rates because they serve higher-risk patients. This is a valid point, but it still doesn’t explain the wide variation in rates between many hospitals (Clark 2007).

For example, in a press release about the new study, the mother’s risk status and diagnoses did not explain the variation in cesarean rates between hospitals:

“We found that the variability in hospital cesarean rates was not driven by differences in maternal diagnoses or pregnancy complexity,” said [lead study author] Kozhimannil. “This means there was significantly higher variation in hospital rates than would be expected based on women’s health conditions. On average, the likelihood of cesarean delivery for an individual woman varied between 19 and 48 percent across hospitals.”

Other key points highlighted included:

  • Among lower risk women, likelihood of cesarean delivery varied between 8 and 32 percent across hospitals.
  • Among higher risk women, likelihood of cesarean delivery varied between 56 and 92 percent across hospitals.
  • Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics.

This shows that practice variation in cesarean rates is real, substantive, and not just a reflection of the mother’s risk level. 

Perhaps now we can stop playing the mother blame-game when we talk about cesarean rates? (Declerq 2006, Oganowski 2011)

This study is not the first to show that the culture of a hospital, its policies, and its routine practices all help determine how likely a woman is to “need” a cesarean in that hospital.

For example, Cáceres 2013 found that even after adjusting for socio-demographic and clinical factors and including only NTSV (Nulliparous, Term, Singleton, Vertex) pregnancies, the cesarean rate varied significantly between Massachusetts hospitals, “suggesting the importance of hospital practices and culture in determining a hospital’s cesarean rate.”

In addition, a 2014 consensus statement from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine notes, “Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed.”

Preventing cesareans when possible is important because while cesareans can be life-saving at times, they present more risk for maternal infection, bleeding and blood clots, and more neonatal breathing problems (Liu 2007, Visser 2014).

Notably, a large case-control study in U.K. maternity units found that delivery by cesarean was a strong risk factor for severe sepsis (Acosta 2014). Other research has found a high rate of maternal complications (Pallasmaa 2010) and poorer neonatal outcomes (Kolås 2006) associated with cesareans.

In addition, a cesarean’s potential negative effect on future pregnancies is important (Silver 2012). One American study found that the rate of an abnormal placental attachment increased in conjunction with the rise in cesarean delivery rate (Wu 2005), while a Canadian study found that a prior cesarean was associated with an increased risk for adverse neonatal outcomes in subsequent pregnancies (Abenhaim and Benjamin 2011).

Bottom line, it matters where and with whom a woman gives birth in order to lessen the risk for complications, both now and in the future.

But many women naively choose their care provider for pregnancy based mostly on convenience and location, not realizing that their chances of surgical birth may vary greatly depending on which hospital and caregiver they use (Arnold 2014, Arnold January 9 2013).

Childbirth Connection, a leading consumer education site, points out:

Research suggests that the same woman might have a c-section at one hospital but a vaginal birth if she gave birth at another, just because of the different policies and practices of those hospitals. One of the most effective ways to lower your chance of having a c-section is to have your baby in a setting with a low c-section rate.

Yet it is not always easy to find out the cesarean rates of local hospitals in some areas. For example, the health departments of Missouri, South Carolina, and Washington D.C. do not make hospital-level cesarean rates available to consumers.

Hospitals remain largely unaccountable for high cesarean rates, although we are beginning to see marginal progress in some places towards more accountability (Gentry 2014 and Dekker 2014). In the meantime, however, thousands of women are undergoing cesareans, many of which might be preventable with changes in clinical practices (Boyle 2013).

And even when a cesarean is truly necessary, there can be large discrepancies in complications afterwards between hospitals (Alonso-Zaldivar 2014). It’s not just about how many cesareans are done, but also about which hospitals have the best outcomes when a cesarean is done. Without more information, how is a woman to know which hospital to choose?

Bottom line, more transparency and accountability are needed. As the lead author of the study states:

Women deserve evidence-based, consistent, high-quality maternity care, regardless of the hospital where they give birth…and these results indicate that we have a long way to go toward reaching this goal in the U.S.

*To search for hospital-level cesarean rates in your area, see www.cesareanrates.com or the 2014 Consumer Reports article (subscription required) rating hospitals in 22 states.

Do you ever encourage your students and clients to look at the cesarean rates (and rates of other interventions which may lead to cesareans) of the hospitals they are considering birthing in.  Please share your experience in our comments section. – SM

References

Abenhaim, H. A., & Benjamin, A. (2011). Effect of prior cesarean delivery on neonatal outcomes. Journal of perinatal medicine39(3), 241-244. PMID: 21426242

Acosta, C. D., Kurinczuk, J. J., Lucas, D. N., Tuffnell, D. J., Sellers, S., & Knight, M. (2014). Severe Maternal Sepsis in the UK, 2011–2012: A National Case-Control Study. PLoS medicine11(7), e1001672. PMID: 25003759

Alonso-Zaldivar, R (2014, August 27). Study: Wide hospital quality gap on maternity care. Retrieved from http://www.fosters.com/apps/pbcs.dll/article?AID=/20140827/GJLIFESTYLES/140809539/0/SEARCH.

Arcia, A (2013, February 3). What is practice variation in obstetrics and why should I care? Retrieved from http://www.cesareanrates.com/blog/2013/2/3/what-is-practice-variation-in-obstetrics-and-why-should-i-ca.html.

Arnold, J (2012, August 22). Practice variation in New Jersey: 27 miles and 28 percentage points. Retrieved from http://www.cesareanrates.com/blog/2012/8/22/practice-variation-in-new-jersey-27-miles-and-28-percentage.html.

Arnold, J (2013, January 9). Practice variation in East Los Angeles cesarean rates. Retrieved from http://www.cesareanrates.com/blog/2013/1/9/practice-variation-in-east-los-angeles-cesarean-rates.html.

Arnold, J (2013, January 7). Practice variation in West Virginia: 60 miles and 54 percentage points. Retireved from http://www.cesareanrates.com/blog/2013/1/7/practice-variation-in-west-virginia-60-miles-and-54-percenta.html.

Arnold, J (2014, March 13). Three miles/Cinco Kilometros. Retrieved from http://www.cesareanrates.com/blog/2014/3/13/three-miles-cinco-kilometros.html.

Boyle, A., Reddy, U. M., Landy, H. J., Huang, C. C., Driggers, R. W., & Laughon, S. K. (2013). Primary cesarean delivery in the United States. Obstetrics & Gynecology122(1), 33-40. PMID: 23743454

Cáceres IA, Arcaya M, Declercq E, Belanoff CM, Janakiraman V, Dohen B, Ecker J, Smith LA, Subramanian SV (2013). Hospital differences in cesarean deliveries in Massachusetts (US) 2004-2006: the case against case-mix artifact. PLOS One, 8(3):e57817. doi: 10.1371/journal.pone.0057817. PMID:23526952

Clark SL, Belfort MA, Hankins GD, Meyers JA, Houser FM (2007). Variation in the rates of operative delivery in the United States. American journal of obstetrics and gynecology, 196(6):526.e1-526.e5.  PMID: 17547880

Caughey, A. B., Cahill, A. G., Guise, J. M., & Rouse, D. J. (2014). Safe prevention of the primary cesarean delivery. American journal of obstetrics and gynecology,210(3), 179-193. doi: 10.1016/j.ajog.2014.01.026. PMID:24565430

Declercq, E., Menacker, F., & MacDorman, M. (2006). Maternal risk profiles and the primary cesarean rate in the United States, 1991–2002. American journal of public health, 96(5), 867. PMID: 16571712

Dekker, R (2014, October 29). U.S. hospitals held accountable for C-section rates. Retrieved from http://www.birthbythenumbers.org/?p=1731

DePoint, M (2014, October 22). Maternal diagnoses doesn’t explain variation in cesarean rates across US hospitals. University of Minnesota, School of Public Health. Retrieved from http://sph.umn.edu/maternal-diagnoses-doesnt-explain-variation-cesarean-rates-across-us-hospitals/.

Gentry, C (2014, May 14). FL still C-section hotspot. Retrieved from http://health.wusf.usf.edu/post/fl-still-c-section-hotspot.

Kolås, T., Saugstad, O. D., Daltveit, A. K., Nilsen, S. T., & Øian, P. (2006). Planned cesarean versus planned vaginal delivery at term: comparison of newborn infant outcomes. American journal of obstetrics and gynecology,195(6), 1538-1543. PMID: 16846577

Kozhimannil KB, Arcaya MC, Subramanian SV (2014). Maternal clinical diagnoses and hospital variation in the risk of cesarean delivery: Analyses of a national US hospital discharge database.  PLoS medicine, 11(10):e1001745. doi: 10.1371/journal.pmed.1001745. PMID: 25333943

Liu, S., Liston, R. M., Joseph, K. S., Heaman, M., Sauve, R., & Kramer, M. S. (2007). Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. Canadian medical association journal176(4), 455-460. PMID: 17296957

Oganowski, K (2010, January 13). The C-section blame game: I’ve reached my boiling point. Retrieved from http://birthingbeautifulideas.com/?p=1245.

Pallasmaa, N., Ekblad, U., AITOKALLIO‐TALLBERG, A. N. S. A., Uotila, J., Raudaskoski, T., ULANDER, V., & Hurme, S. (2010). Cesarean delivery in Finland: maternal complications and obstetric risk factors. Acta obstetricia et gynecologica Scandinavica89(7), 896-902. PMID: 20583935

Phend, C (2013, March 5). C-Section rates vary widely between hospitals, study finds. MedPage Today. Retrieved from http://abcnews.go.com/Health/section-rates-vary-widely-hospitals-study-finds/story?id=18656847.

Silver, R. M. (2012, October). Implications of the first cesarean: perinatal and future reproductive health and subsequent cesareans, placentation issues, uterine rupture risk, morbidity, and mortality. In Seminars in perinatology (Vol. 36, No. 5, pp. 315-323). WB Saunders. PMID: 23009962

Visser GH (2014). Women are designed to deliver vaginally and not by Cesarean section: An obstetrician’s view. Neonatology, 107(1):8-13. PMID: 25301178

What every pregnant woman needs to know about Cesarean section (2012). Childbirth Connection. Retrieved from http://www.childbirthconnection.org/pdfs/cesareanbooklet.pdf.

What hospitals don’t want you to know about C-sections (2014, May). Consumer Reports. Retrieved from http://consumerreports.org/cro/2014/05/what-hospitals-do-not-want-you-to-know-about-c-sections/index.htm.

Wu, S., Kocherginsky, M., & Hibbard, J. U. (2005). Abnormal placentation: twenty-year analysis. American journal of obstetrics and gynecology192(5), 1458-1461. PMID: 15902137

A version of this post originally appeared on www.wellroundedmama.blogspot.com

About Pam Vireday

Painting by Mary Cassatt, 1844-1926. (public domain) Image from Wikimedia Commons.

Pam Vireday is a childbirth educator, writer, woman of size, and mother to four children. She has been collecting the stories of women of size and writing about childbirth research for 17 years. She writes at www.wellroundedmama.blogspot.com and www.plus-size-pregnancy.org.

 

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

Non-Drug Pain Coping Strategies Improve Outcomes

July 17th, 2014 by avatar

 Today, contributor Henci Goer reviews a recently published study in the journal Birth, that compared the outcomes of births in women who received non pharmacological pain management techniques with women who received the “usual care” treatment.  The researchers found that maternal and infant outcomes were improved.  Take a moment to read Henci’s review to get a glimpse at the results and her analysis.- Sharon Muza, Science & Sensibility Community Manager

© Patti Ramos Photography

© Patti Ramos Photography

In 2012,  the Cochrane Database published an overview of systematic reviews of forms of pain management that summarized the results of the Cochrane database’s suite of systematic reviews of randomized controlled trials (RCTs) of various pain management techniques. Reviewers reached the rather anemic conclusion that epidurals did best at relieving pain—no surprise there—but increased need for medical intervention—no surprise there either—while non-drug modalities (hypnosis, immersion in warm water, relaxation techniques, acupressure/acupuncture, hands on techniques such as massage or reflexology, and TENS) did equally well or better than their comparison groups (“standard care,” a placebo, or a different specific treatment) at relieving pain, at satisfaction with pain relief, or both, and they had no adverse effects (Jones 2012). Insofar as it went, this finding was helpful for advocating for use of non-drug strategies, but it didn’t go very far.

Fast forward two years, and we have a new, much more robust review: Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Its ingenious authors grouped trials of non-drug pain relief modalities according to mechanism of action, which increased the statistical power to determine their effects and avoided inappropriately pooling data from dissimilar studies in meta-analyses (Chaillet 2014). The three mechanisms were Gate Control Theory, which applies nonpainful stimuli to partially block pain transmission; Diffuse Noxious Inhibitory Control, which administers a painful stimulus elsewhere on the body, thereby blocking pain transmission from the uterine contraction and promoting endorphin release in the spinal cord and brain; and Central Nervous System Control, which affects perception and emotions and also releases endorphins within the brain.

Overall, 57 RCTs comparing non-drug strategies with usual care met eligibility criteria: 21 Gate Control (light massage, warm water immersion, positions/ambulation, birth ball, warm packs), 10 Diffuse Noxious Inhibitory Control (sterile water injections, acupressure, acupuncture, high intensity TENS), and 26 Central Nervous System Control (antenatal education, continuous support, attention deviation techniques, aromatherapy). Eleven of the Central Nervous System Control trials specifically added at least one other strategy to continuous support. More about the effect of that in a moment.

Now for the results…

Compared with Gate Control-based strategies, usual care was associated with increased use of epidurals (6 trials, 3369 women, odds ratio: 1.22), higher labor pain scores (3 trials, 278 women, mean difference 1 on a scoring range of 0-10), and more use of oxytocin (10 trials, 2672 women, odds ratio: 1.25). Usual care also increased likelihood of cesarean in studies of walking (3 trials, 1463 women, odds ratio: 1.64).

Compared with Diffuse Noxious Inhibitory Control strategies, usual care was associated with increased use of epidurals (6 trials, 920 women, odds ratio: 1.62), higher labor pain scores (1 trial, 142 women, mean difference 10 on a scoring range of 0-100), and decreased maternal satisfaction as measured in individual trials by feeling safe, relaxed, in control, and perception of experience.

We hit the jackpot with Central Nervous System Control strategies (probably because female labor support, which has numerous studies and strong evidence supporting it, dominate this category [19 labor support, 6 antenatal education, 1 aromatherapy]). As before, usual care is associated with more epidurals (11 trials, 11,957 women, odds ratio: 1.13), more use of oxytocin (19 trials, 14,293 women, odds ratio: 1.20), and decreased maternal satisfaction as measured in individual trials by perception of experience and anxiety. In addition, however, usual care is associated with increased likelihood of cesarean delivery (27 trials, 23,860 women, odds ratio: 1.60), instrumental delivery (21 trials, 15,591 women, odds ratio: 1.21), longer labor duration (13 trials, 4276 women, 30 min), and neonatal resuscitation (3 trials, 7069 women, odds ratio: 1.11).

© Breathtaking Photography http://flic.kr/p/3255VD

© Breathtaking Photography http://flic.kr/p/3255VD

The big winner, though, was continuous support combined with at least one other strategy. Usual care in these 11 trials was even more disadvantageous than in central nervous system trials overall with respect to cesareans (11 trials, 10,338 women): odds ratio 2.17 versus 1.6 for all central nervous system trials, and instrumental delivery (6 trials, 2281 women): odds ratio 1.78 versus 1.21 for all central nervous system trials.

The strength of the data is impressive. Altogether, Chaillet et al. report on 97 outcomes, of which 44 differences favoring non-drug strategies achieve statistical significance, meaning the difference is unlikely to be due to chance, while not one statistically significant difference favors usual care. And there’s still more: benefits of non-drug strategies are probably greater than they appear because on the one hand, “usual care” could include non-drug strategies for coping with labor pain and on the other, many institutions have policies and practices that make it difficult to cope using non-drug strategies alone, strongly encourage epidural use, or both.

The reviewers conclude that their findings showed that:

Nonpharmacologic approaches can contribute to reducing medical interventions, and thus represent an important part of intrapartum care, if not used routinely as the first method for pain relief…however, in some situations, nonpharmacologic approaches may become insufficient…the use of pharmacologic approaches could then be beneficial to reduce pain intensity to prevent suffering and help women cope with labor pain…birth settings and hospital policies . . . should facilitate a supportive birthing environment and should make readily available a broad spectrum of nonpharmacologic and pharmacologic pain relief approaches. (p. 133)

No one could argue with that, but a persuasive argument alone is unlikely to carry the day given the entrenched systemic barriers in many hospitals. States an anesthesiologist: “While there may be problems with high epidural usage, in the presence of our nursing shortages and economic or business considerations, having a woman in bed, attached to an intravenous line and continuous electronic fetal monitor and in receipt of an epidural may be the only realistic way to go” (quoted in Leeman 2003). The Cochrane reviewers concur, writing that using non-drug strategies is “more realistic” (p. 4) outside of the typical hospital environs.

So long as this remains the case, attempts to introduce non-drug options are likely to make little headway. As Lamaze International’s own Judith Lothian trenchantly observes:

If we put women in hospitals with restrictive policies—they’re hooked up to everything, they’re expected to be in bed—of course they’re going to go for the epidural because they’re unable to work through their pain. . . . I go wild with nurses and childbirth educators who say, . . . “[Women] just want to come in and have their epidural.” I say, “And even if they don’t . . ., they come to your hospital, and they have no choice. . . . They can’t manage their pain because you won’t let them.” (quoted in Block 2007, p. 175)

Success at integrating non-drug strategies will almost certainly depend on addressing underlying factors that maintain the status quo. Can it be done? You tell us. Does your hospital take a multifaceted approach to coping with labor pain? If so, how was it implemented and how is it sustained?

Resources

Block, Jennifer. (2007). Pushed: The Painful Truth About Childbirth and Modern Maternity Care. Cambridge, MA: Da Capo Press.

Chaillet, N., Belaid, L., Crochetiere, C., Roy, L., Gagne, G. P., Moutquin, J. M., . . . Bonapace, J. (2014). Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth, 41(2), 122-137. doi: 10.1111/birt.12103 http://www.ncbi.nlm.nih.gov/pubmed/24761801

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. doi: 10.1002/14651858.CD009234.pub2 http://www.ncbi.nlm.nih.gov/pubmed/2241934

Leeman, L., Fontaine, P., King, V., Klein, M. C., & Ratcliffe, S. (2003). Management of labor pain: promoting patient choice. Am Fam Physician, 68(6), 1023, 1026, 1033 passim. http://www.ncbi.nlm.nih.gov/pubmed/14524393?dopt=Citation

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 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.  

Childbirth Education, Doula Care, Epidural Analgesia, Guest Posts, Maternity Care, Medical Interventions, Newborns, Research , , , , ,

Evidence on Water Birth Safety – Exclusive Q&A with Rebecca Dekker on her New Research

July 10th, 2014 by avatar

 

Evidence Based Birth , a popular blog written by occasional Science & Sensibility contributor Rebecca Dekker, PhD, RN, APRN, has just today published a new article, “Evidence on Water Birth Safety” that looks at the current research on the safety of water birth for mothers and newborns.  Rebecca researched and wrote that article in response to the joint Opinion Statement “Immersion in Water During Labor and Delivery” released in March, 2014 by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics.  I had the opportunity to ask Rebecca some questions about her research into the evidence available on water birth, her thoughts on the Opinion Statement and her conclusions after writing her review. – Sharon Muza, Science & Sensibility Community Manager.

Sharon Muza: First off, is it waterbirth or water birth?

Rebecca Dekker: That’s actually good question! Research experts tend to use the term “waterbirth.” Google prefers “water birth.” So I used both terms in my article to satisfy everyone!

SM: Have you heard or been told of stories of existing water birth programs shutting down or being modified as a result of the recent AAP/ACOG opinion?

RD: Yes, definitely. There was a mother in my state who contacted me this spring because she was 34 weeks pregnant and her hospital decided not to offer waterbirth anymore. She had given birth to her daughter in a waterbirth at the same hospital two years earlier. With her current pregnancy, she had been planning another hospital waterbirth. She had the support of her nurse midwife, the hospital obstetricians, and hospital policy. However, immediately after the release of the ACOG/AAP opinion, the hospital CEO put an immediate stop to waterbirth. This particular mother ended up switching providers at 36 weeks to a home birth midwife. A few weeks ago, she gave birth to her second baby, at home in the water. This mother told me how disheartening it was that an administrator in an office had decided limit her birth options, even though physicians and midwives at the same hospital were supportive of her informed decision to have a waterbirth.

In another hospital in my hometown, they were gearing up to start a waterbirth program this year—it was going to be the first hospital where waterbirth would be available in our city—and it was put on hold because of the ACOG/AAP Opinion.

Then of course, there were a lot of media reports about various hospital systems that suspended their waterbirth programs. One hospital system in particular, in Minnesota, got a lot of media coverage.

SM: Did you attempt to contact ACOG/AAP with questions and if so, did they respond?

RD: Yes. As soon as I realized that the ACOG/AAP Opinion Statement had so many major scientific errors, I contacted ImprovingBirth.org and together we wrote two letters. I wrote a letter regarding the scientific problems with the Opinion Statement, and ImprovingBirth.org wrote a letter asking ACOG/AAP to suspend the statement until further review. The letters were received by the President and President-Elect of ACOG, and they were forwarded to the Practice Committee. We were told that the Practice Committee would review the contents of our letters at their meeting in mid-June, and that was the last update that we have received.

SM: What is the difference between an “Opinion Statement” and other types of policy recommendations or guidelines that these organizations release? Does it carry as much weight as practice bulletins?

RD: That’s an interesting question. At the very top of the Opinion Statement, there are two sentences that read: “This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.” But, as you will see, some hospitals do see this statement as dictating an exclusive course of treatment, and others don’t.

I have heard that “opinions” do not carry as much weight as “practice bulletins,” but it really depends on who the audience is and who is listening. In other words, some hospitals may take the Opinion Statement word-for-word and feel that they must follow it to the letter, and other hospitals may ignore it. A lot of it probably depends on the advice of their risk management lawyers.

For example, a nurse midwife at a hospital in Illinois sent me a letter that their risk-management attorneys had put together to advise them on this issue. (She had the attorney’s permission to share the letter with me). These lawyers basically said that when a committee of two highly-respected organizations says that the practice of waterbirth should be considered an experimental procedure, both health care providers and hospitals are “charged with a duty to heed that statement,” unless they find research evidence that waterbirth has benefits for the mother or fetus, and that the evidence can override the Committee’s conclusions.

On the other hand, another risk management lawyer for a large hospital system told me that of course hospitals are not under any obligation to follow an ACOG/AAP Opinion Statement. It’s simply just that—an opinion.

So as to how much weight the Opinion Statement carries—I guess it is really dependent on who is reading it!

SM: How would you suggest a well-designed research study be conducted to examine the efficacy and safety of waterbirth? Or would you say that satisfactory research already exists.

RD: First of all, I want to say that I’m really looking forward to the publication of the American Association of Birth Centers (AABC) data on nearly 4,000 waterbirths that occurred in birth centers in the U.S., to see what kind of methods they used. From what I hear, they had really fantastic outcomes.

And it’s also really exciting that anyone can join the AABC research registry, whether you practice in a hospital, birth center, or at home. The more people who join the registry, the bigger the data set will be for future research and analysis. Visit the AABC PDR website to find out more.

I think it’s pretty clear that a randomized trial would be difficult to do, because we would need at least 2,000 women in the overall sample in order to tell differences in rare outcomes. So instead we need well-designed observational studies.

My dream study on waterbirth would be this: A large, prospective, multi-center registry that follows women who are interested in waterbirth and compares three groups: 1) women who have a waterbirth, 2) women who want a waterbirth and are eligible for a waterbirth but the tub is not available—so they had a conventional land birth, 3) women who labored in water but got out of the tub for the birth. The researchers would measure an extensive list of both maternal and fetal outcomes.

It would also be interesting to do an additional analysis to compare women from group 2 who had an epidural with women from group 1 who had a waterbirth. To my knowledge, only one study has specifically compared women who had waterbirths with women who had epidurals. Since these are two very different forms of pain relief, it would be nice to have a side-by-side comparison to help inform mothers’ decision making.

SM: What was the most surprising finding to you in researching your article on the evidence on water birth safety?

RD: I guess I was most surprised by how poorly the ACOG/AAP literature review was done in their Opinion Statement. During my initial read of it, I instantly recognized multiple scientific problems.

A glance at the references they cited was so surprising to me—when discussing the fetal risks of waterbirth, they referenced a laboratory study of pregnant rats that were randomized to exercise swimming in cold or warm water! There weren’t even any rat waterbirths! It was both hilarious and sad, at the same time! And it’s not like you have to read the entire rat article to figure out that they were talking about pregnant rats—it was right there in their list of references, in the title of the article, “Effect of water temperature on exercise-induced maternal hyperthermia on fetal development in rats.”

These kind of mistakes were very surprising, and incredibly disappointing. I expect a lot higher standards from such important professional organizations. These organizations have a huge influence on the care of women in the U.S., and even around the world, as other countries look to their recommendations for guidance. The fact that they were making a sweeping statement about the availability of a pain relief option during labor, based on an ill-researched and substandard literature review—was very surprising indeed.

SM: What was the most interesting fact you discovered during your research?

RD: With all this talk from ACOG and the AAP about how there are “no maternal benefits,” I was fascinated as I dug into the research to almost immediately find that waterbirth has a strong negative effect on the use of episiotomy during childbirth.

Every single study on this topic has shown that waterbirth drastically reduces and in some cases completely eliminates the use of episiotomy. Many women are eager to avoid episiotomies, and to have intact perineums, and waterbirth is associated with both lower episiotomy rates and higher intact perineum rates. That is a substantial maternal benefit. It’s kind of sad to see leading professional organizations not even give the slightest nod to waterbirth’s ability to keep women’s perineums intact.

In fact, I’m puzzled as to why keeping women’s perineums intact and uncut is not perceived as a benefit by anyone other than the women themselves. And here is the heart of declaring waterbirth as “not having enough benefits” to justify its use: Who decides the benefits? Who decides what a benefit is, if not the person benefitting? Who should be weighing the potential harms and the potential benefits of waterbirth, and making an informed decision about their options? Should it be the mother? Or should it be the obstetrician?

SM: What can families do if they want waterbirth to be an option in their local hospital or birth center and it has been taken away or not even ever been offered before?

RD: That’s a hard question. It’s a big problem.

Basically what it boils down to is this—there are a lot of restraining forces that keep waterbirth from being a pain relief option for many women. But there are also some positive driving forces. According to change theory, if you want to see a behavior change at the healthcare organization level, it is a matter of decreasing the restraining forces, while increasing the driving forces. Debunking the ACOG/AAP Opinion Statement is an important piece of decreasing restraining forces. On the other side, increasing consumer pressure can help drive positive change.

SM: Do you think that consumers will be responding with their health dollars in changing providers and facilities in order to have a waterbirth?

RD: I think that if a hospital offered waterbirth as an option to low-risk women, that this could be a huge marketing tool and would put that hospital at an advantage in their community, especially if the other hospitals did not offer waterbirth.

SM: The ACOG/AAP opinion sounded very reactionary, but to what I am not sure. What do you think are the biggest concerns these organizations have and why was this topic even addressed? Weren’t things sailing along smoothly in the many facilities already offering a water birth option?

RD: I don’t know if you saw the interview with Medscape, but one of the authors of the Opinion Statement suggested that they were partially motivated to come out with this statement because of the increase in home birth, and they perceive that women are having a lot of waterbirths at home.

I also wonder if they are hoping to leverage their influence as the FDA considers regulation of birthing pools. You may remember that in 2012, the FDA temporarily prohibited birthing pools from coming into the U.S. Then the FDA held a big meeting with the different midwifery and physician organizations. At that meeting, AAP and ACOG had a united front against waterbirth. So I guess it’s no surprise for them to come out with a joint opinion statement shortly afterwards.

My sincere hope is that the FDA is able to recognize the seriously flawed methods of the literature review in this Opinion Statement, before they come out with any new regulations.

SM: How should childbirth educators be addressing the topic of waterbirth and waterbirth options in our classes in light of the recent ACOG/AAP Opinion Statement and what you have written about in your research review on the Evidence on Water Birth Safety?

RD: It’s not an easy subject. There are both pros and cons to waterbirth, and it’s important for women to discuss waterbirth with their providers so that they can make an informed decision. At the same time, there are a lot of obstetricians who cannot or will not support waterbirth because of ACOG’s position. So if a woman is really interested in waterbirth, she will need to a) find a supportive care provider, b) find a birth setting that encourages and supports waterbirth.

You can’t really have a waterbirth with an unwilling provider or unwilling facility. Well, let me take that back… you can have an “accidental” waterbirth… but unplanned waterbirths have not been included in the research studies on waterbirth, so the evidence on the safety of waterbirth does not generalize to unplanned waterbirths. Also, you have to ask yourself, is your care provider knowledgeable and capable of facilitating a waterbirth? It might not be safe to try to have an “accidental” waterbirth if your care provider and setting have no idea how to handle one. Do they follow infection control policies? Do they know how to handle a shoulder dystocia in the water?

SM: What kind of response do you think there will be from medical organizations and facilities as well as consumers about your research findings?

RD: I hope that it is positive! I would love to see some media coverage of this issue. I hope that the Evidence Based Birth® article inspires discussion among care providers and women, and among colleagues at medical organizations, about the quality of evidence in guidelines, and their role in providing quality information to help guide informed decision-making.

SM: Based on your research, you conclude that the evidence does not support universal bans on waterbirth. Is there anything you would suggest be done or changed to improve waterbirth outcomes for mothers or babies?

RD: The conclusion that I came to in my article—that waterbirth should not be “banned,” is basically what several other respected organization have already said. The American College of Nurse Midwives, the American Association of Birth Centers, the Royal College of Obstetricians and Gynaecologists, and the Royal College of Midwives have all said basically the same thing.

How can we improve waterbirth outcomes? I think continuing to be involved in clinical research studies (such as the AABC registry) is an important way to advance the science and provide evidence on which we can base practice and make more informed decisions with. Also, conducting clinical audits (tracking outcomes) in facilities that provide waterbirth would be important for quality control.

SM: Let’s look into the future. What is next on your plate to write about?

RD: I recently had a writing retreat with several amazing clinicians and researchers who flew from across the country to conduct literature reviews with me. We made an awesome team!! The topics that we have started looking at are: induction for post-dates, induction for ruptured membranes, and evidence-based care for women of advanced maternal age. I can’t decide which one we will publish first! The Evidence Based Birth readers have requested AMA next, but the induction for ruptured membranes article is probably further along than that one. We shall see!!

SM: Is there anything else you would like to share with Science & Sensibility readers on this topic?

RD: Thanks for being so patient with me! I know a lot of people were eagerly awaiting this article, and I wish it could have come out sooner, but these kinds of reviews take a lot of time. Time is my most precious commodity right now!

Has the recent Opinion Statement released by ACOG/AAP impacted birth options in your communities?  Do you discuss this with your clients, students and patients?  What has been the reaction of the families you work with? Let us know below in the comments section! – SM.

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