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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