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REFERENCE COPY
fOR LIBRARY. USE ONLY
"'RESEARCH ISSUES
IN THE ASSESSMENT OF
BIRTH SETIINGS
Re/X)rt of a Study
by the Committee on Assessing
Alternative Birth Settings
:> ~NSTITUTE OF MEDICINE
Dirision of Health Sciences Policy
I Nl-y;
AND
y NATIONAL RESEARCH COUNCIL
Commission on Life Sciences
NATIONAl ACADEMY PRES7'
Washington, D.C. 1982 0 '
NAS-NAE
DEC 2 71982
LIBRARY
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NOTICE1 The project that is the subject of this report was approved
by the Governing Board of the National Research Council, whose . .~r•
are drawn fro. the councils of the National Academy of SCiences, the
National Academy of Engineering, and the Institute of Medicine. The
me~r• of the ca..ittee responsible for the report were choaen for
their special ca.petences and with regard for appropriate balance.
This report has been reviewed by a groupDther than the authors
according to procedures approved by a Report Review eo..ittee con-
sisting of members of the National Academy of SCiences, the National
Academy of Engineering and the Institute of Medicine.
The National Research Council was established by the National Acad..y
of SCiences in 1916 to associate the broad co.aunity of science and
technology with the Academy's purposes of furthering knowledge and of
advising the federal gover~nt. The Council operates in accordance
with general policies deter•ined by the Academy under the authority of
its congressional charter of 1863, which establishes the Academy as a
private, nonprofit, self-governing . .mbership corporation. The Council
has beco.e the principal operating agency of both the National Acad.-y
of Sciences and the National Academy of Engineering in the conduct of
their services to the gover~nt, the public, and the scientific and
engineering conmunities. It is a~inistered jointly by both Acade•ies
and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy
of Sciences to enlist distinguished -..hers of the appropriate pro-
fessions in the ex..ination of policy .. ttera pertaining to the health
of the public. In this, the Institute acts under both the Academy's
1863 congressional charter responsibility to be an adviser to the
federal govera.ent and its own initiative in identiyfing issues of
•edical care, research, and education.
This study was supported by Maternal and Child Health (Social Security
Act, Title V) Grant MC-R-110449 awarded by the Office for Maternal and
Child Health (OMCH), Bureau of Co..unity Health Services (BCRS), Health
Services Ad•inistration (HSA), Public Health Service (PHS), Depart.ent
of Health and Human Services (DHHS). (As of Septe~r 1, 1982, the
agency was rena.ad Division of Maternal and Child Health, Bureau of
Health Care Delivery and Assistance, Health Resources and Services
Administration.)
Library of Congress Cataloging in Publication Data
eo..ittee on Assessing Alternative Birth Settings (U.S.)
Research issues in the assess. .nt of birth settings.
1. Childbirth--United States. 2. Childbirth at
ha.e--United States--Evaluation. 3. Hospitals, Gyneco-
logic and obstetric--United States--Evaluation.
4. Maternal health services--United States--Evaluation.
I. Title.
~~RG960.C53 1983. 618.4 82-22481
ISBN 0-309-03337-3 L..c..
'\IN
<
S'Publication 1~82-04
~Q
Available from
; NATIONAL ACADEMY PRESS
2101 Constitution Avenue, N.W.
Washington, D.C. 20418
Printed in the United States of America
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Committee on Assessing Alternative Birth Settings
v -?
-
LBAB LONBRSTBIN (Chairman), Dean and Vice-President, Jefferson Medical
· College, Philadelphia
GBOBGB A. LITTLE, Professor and Chairman, Departaent of Maternal and
Child Health, Dartmouth Medical School, Hanover, New Bampshire
IRWIN R. MERKATZ, Professor and Chairman, Departaent of Obstetrics and
Gynecology, Albert Einstein College of Medicine, Bronx, New York
KENNETH R. NISWANDER, Professor and Chairman, Departaent of Obstetrics
and Gynecology, University of California at Davis School of Medicine
NIGEL PANE'l'B, Assistant Professor of Public Health (Epidaiology) and
Pediatrics, ColUJibia University, New York
CHARLES A. ROBDB, Professor and Chairman, Departaent of Biostatistics,
'l'he Johns Hopkins University School of Hygiene and Public Health,
BaltiJM)re
LILLIAN RUNNERS'l'ROM (Retired), Professor and Bead, Departaent of
Maternal and Child Nursing, University of Illinois College of
Nursing, Chicago
BEATRICE J. SELWYN, Assistant Professor of Epidaiology, University of
Texas School of Public Health, Houston
MAIUORIE P. WILSON, Senior Associate Dean, Ul)iversity of Maryland
School of Medicine, Baltimore
CAMILLE B. WORTMAN, Associate Professor of Psychology, Institute of
Social Research, University of Michigan, Ann Arbor
MARVIN ZELEN, Chairman, Departaent of Biostatistics, Harvard University
School of Public Health, Boston
iii
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Institute of Medicine
INSTITUTE OP MEDICINE STUDY STAPP
ENRIQUETA c. BOND, Director, Divisions of Health Sciences Policy and
Health Promotion and Disease Prevention
CARBN M. CARNEY, Research Associate
LINDA A. DEPOGB, Administrative Secretary
KA'l'BY A. KING, Research Associate
COMMISSION ON LIFE SCIENCES STAPP
ALVIN G. LAZBN, Executive Director, Collllllission on Life Sciences
DANIEL L. WEISS, Executive Secretary, Division of Medical Sciences,
Commission on Life Sciences
CONSULTAN'l'S
GIGLIOLA BARUFPI, Assistant Professor, Department of Maternal and Child
Health, The Johns Hopkins University School of Hygiene and Public
Health, Baltimore
ANITA BBNNB'l"l'S, Manager, Field Services Section, Office of Community
Health Services, Oregon State Health Division, Portland
NANCY G. CLARKE, Research Analyst, Vital Statistics Section, Oregon
State Health Division
EUNICE K. M. ERNST, Director, Cooperative Birth center Network,
Maternity center Association
WILLIAM D. PULLBR'l'ON, Principal, Health Policy Alternatives, Inc.,
Silver Spring, Maryland
MIRIAM c. P. KELTY, Assistant Chief, Scientific Review Branch, and
Chief, Behavioral and Neurosciences Review Section, Division of
Research Grants, National Institutes of Health, Bethesda, Maryland
v
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AGENCY LIAISONS
ANN KOONTZ, Maternal Health Care Consultant, Office for Maternal and
Child Health, Bureau of Community Health Services, Health Services
Administration, Rockville, Maryland
GONTRAN LAMBERTY, Director, Maternal and Child Health Research Grants
Program, Office for Maternal and Child Health, Bureau of cam-unity
Health Services, Health Services Administration, Rockville, Maryland
DONALD McNELLIS, Obstetric Medical Officer, National Institute of Child
Health and Human Development, Bethesda, Maryland
vi
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Acknowledgments
Tbe coamittee would like to thank the many contributors to its
deliberations. We want to acknowledge particularly the many faailies
who wrote to express their interest in the study as well as the
following, who helped the coamittee in its task& B. David Banta, Nancy
G. Clarke, Vince L. Hutchins, Miriaa c. P. Kelty, and Ruth watson Lubic.
We especially wish to thank the members of the professional staff
of the Institute of Medicine and the National Research Council,
Bnriqueta c. Bond, Sarah Brown, Caren M. Carney, and Daniel L. Weiss,
for their labors on this study, and Linda A. DePugh for her untiring
secretarial support.
vii
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Contents
INTRODUCTION 1
SUMMARY AND RECOMMENDATIONS 2
Childbirth Trends and Statistics 2
The Birth Setting 3
Approaches to Research and Study Designs 4
Risk Assessment 6
Recommendations 7
1 BASIC CONCEPTS AND DESCRIPTIVE DATA 10
History of Maternity Care in the United States 11
Range of and Trends in Birth Settings 12
Maternity Care Providers and Trends in Their Use 19
Trends in Maternity Care Practices 21
Perinatal Regionalization 23
The Birth Setting Controversy 24
2 RESEARCH STRATEGIES FOR ASSESSING CHILDBIRTH SETTINGS 32
Descriptive and Observational Studies 33
Randomized Experimental Designs 34
Matched Groups 36
Surveillance Methods 37
Assessing Adverse Events 38
Cooperative Registries 40
Summary 41
3 RISK ASSESSMENT 45
Obstetric Risk Assessment 45
Limitations of Current Instruments 52
4 VARIABLES 55
Some General Objectives in Measurement 55
Standardization of Measurements 56
Relevant Examples of Prognostic Variables 56
Relevant Examples of Outcome or Dependent Variables 57
Time as a Variable 58
Variables of Place, Practice, Provider, and Recipient 58
ix
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Selection of Place Variables 58
Selection of Provider Variables 59
Selection of Practice Variables 59
Selection of Population Variables 60
Sources of Data for Study of Variables and Outcomes 62
APPENDIXES
A REVIEW OF THE SAFETY OF MATERNITY CARE IN DIFFERENT BIRTH
LOCATIONS 67
Conventional In-Hospital Maternity Care 67
Unconventional Hospital Maternity care 68
Nonhospital Maternity Care: Birth Centers 70
Nonhospital Maternity Care: Home Births 72
Conclusions 77
B RESEARCH ISSUES CONCERNING REIMBURSEMENT FOR CHILDBIRTH
SERVICES 80
Reimbursement 80
Research Possibilities 87
C FREESTANDING BIRTH CENTERS 91
A Description of the Administration and Services of Eleven
Birth Centers 91
Characteristics of Studies Exploring Freestanding Birth
Centers 92
How Routine Data Collection can Aid Medical, Sociodemographic,
and Administrative Comparisons of Birth Settings 95
D RESEARCH ON CHILDBIRTH SB'l'TINGS: THE ASSESSMENT OF
PSYCHOLOGICAL ~IABLBS 102
Rationale for Including Psychosocial Variables in Research on
Birth Settings 103
Methodologies in the Assessment of Psychological Variables 108
Measuring Psychological Variables 113
E REVIEW OF OBSTETRICAL RISK ASSESSMENT METHODS 149
Attributes of the Methods 149
Predictive Power of the Methods 155
Findings 162
Screening Criteria in Unconventional Settings 164
Discussion and Summary 165
F VITAL STATISTICS AND NONBOSPITAL BIRTHS: A MORTALITY STUDY OF
INFANTS BORN OUT OF HOSPITALS IN OREGON BE'l'WEEN 1975 AND 1979 171
Nonhospital Births in Oregon 172
Method 173
Results 174
Discussion 175
Conclusions 181
X
