Click for next page ( 11


The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 10
1 Basic Concepts and Descriptive Data Recognizing a need for research on alternative birth settings, the Office for Maternal and Child Health (OMCB) provided a grant in Sep- tember 1980 to the National Academy of Sciences (NAS), through its Institute of Medicine and Commission on Life SCiences, to undertake a study of methodological approaches for such research. The OMCB sup- ports projects on alternative birth settings but generally lacks data on which to make judgments about the strengths and liaitations of various child-delivery facilities. The absence of adequate evaluation data has fueled a growing controversy among the various advocates of particular birth settings regarding a whole range of outco.e measures, such as safety, cost, and quality of the childbirth experience. The controversy, OMCB concluded, will abate only with the development of a sound body of data about various aspects of current birth practices, including birthplace. The methodological difficulties in conducting such research, however, are great--thus the request to NAS for guidance on how best to design research directed at increasing the available information on alternative birth settings. The presumption is that good research methods should lead to scientific findings that provide the basis for informed, rational decision-aaking about various options for childbirth. In approaching its task the study comaittee focused on three seta of isaueaa (1) the provision of background information along with a range of research designs and approaches appropriate to the study of various aspects of childbirth practices' (2) the use of risk assessment and screening criteria and how this affects the choice of a study popu- lation, and (3) valid outcome measures--including medical, psychologi- cal, and social variables--and ways to study them. These three sets of issues are examined in Chapters 2-4 and are supplemented by papers in Appendixes A-F. The committee did not address econo.ic issues directly, because they were considered to be outside its range of expertise. How- ever, recognizing that coat issues will be an important part of any choice of appropriate maternity care by prospective parents, the comait- tee commissioned the paper that appears in Appendix B. The committee recognized that the experiences of such countries as Britain and Holland are relevant sources of information about various birth settings and decided that a critical review of this literature would make a valuable contribution. As a first step the comaittee 10

OCR for page 10
11 reviewed the history of maternity practices in the United States and studied the range of birth settings currently in use, both the physical sites and the typical maternity care providers and practices. Data on trends in childbirth settings were reviewed. The committee recognized that there are many value judgments surrounding childbirth and that questions and arguments will probably continue regardless of new infor- mation. This chapter gives an overview of the background and defini- tions of the birth setting. BIS'l'ORY OF MATERNITY CARE IN THE UNITED STATES During the nineteenth century in the United States, obstetrics had not yet developed as a medical specialty, and the training of birth atten- dants was •ager. Moat deliveries took place at heme and were attended by granny (or lay) •idwivea whose knowledge and experience varied widely. In 1900 fewer than 5 percent of all American babies were born in a hospital. Midwives with little training attended approximately 50 percent of home birthsr other births were attended by neither physician nor midwife. COntroversies surrounding the quality of midwife services helped to bring public and professional attention to the problema associated with inadequate childbirth practices. In one study, midwives in New York City in 1906 were found to be •hopelessly dirty, ignorant, and incompetent• (Edgar, 1911). Laws were passed requiring formal training, licensing, and supervision of •idwivea, and in 1931 a formal education program for nurse midwives was established in the United States (Lubic, 1980). 1 At that time, also, training of physicians in birth practices was considered poor, and obstetrics was viewed as the weakest of medical specialties (Flexner, 1910r Williams, 1912).1 Increased attention to medical intervention in childbirth encouraged the training of more obstetricians and the delivery of more babies in hospitals. Now the role of physicians baa eclipsed that of midwives as birth attendants. By 1979 physicians were attending 97.4 percent of u.s. births, primarily in hospitals (Devitt, 1977r National Center for Health Statistics, 198lb), while certified nurse •idwivea (CNMs) and lay midwives attended only 1.6 percent of all births, about 80 percent of the• in hospitals. Maternity care during the twentieth century baa gone through four 1 Since 1931 a graduate training program baa existed in the united States for training nurse midwives who are then certified by the profession. Lay midwives today often must receive training before they can be licensed by a state. 1 Numeroua articles document the history of obstetric care and the controversy over the variability of childbirth settings in the United States and Europe (Baldock, 198lr DeLee, 1920r Devitt, 1977, 1979a,br Edgar, 19llr Huntington, 1913r Irving, 1937r Kosmak, 1938r Marlette, 1925r Moran, 1915r Williams, 1912r Ziegler, 1922).

OCR for page 10
12 periods of shifting emphasis. At first, concern was focused on the relatively high rates of maternal mortality and on the need to make labor and delivery safer for the mother. Hospitals were opened in rural areas, physicians expanded obstetrical training and researchJ and many developments in other fields, such as the discovery of antibiotics, benefited maternity care. As a result, the incidence of infection and the complications of bleeding and toxemia were drastically reduced, and maternal mortality rates fell (see Figure 1 and Table 1). A second phase in maternity care emphasized the relief of pain dur- ing birth. Efforts were made to allay maternal anxiety about the labor and delivery process. Advances in analgesia, anesthesia, and psychopro- phylaxis were applied to childbirth. Only later was it recognized that same types of anesthesia could adversely affect both mother and infant (Speert, 1980). For many years the reduction in maternal mortality was not ace~ panied by comparable improvements in neonatal or infant survival rates (Table 1). Recognition of this discrepancy led to the third, or peri- natal, phase of care that has characterized obstetrics for the past 15 years. Technological advances in methods of maternal, fetal, and neo- natal surveillance, together with changes in clinical practice, have significantly improved the likelihood that the outcome of pregnancy will be a healthy infant (Chase, 1972J Committee on Perinatal Health, 1976J Lee et al., 1980J Paneth, 1982J world Health Organization, 1970J and Williams and Chen, 1982). In recent years there has been a resurgence of interest in and emphasis on the effects of psychological factors on the short- and long-term health of aother and baby. 'l'his fourth phase of change in obstetrical practice has attempted to provide psychological satisfac- tion with safe physical outcomes of pregnancy (Ryan, 1981J Stone, 1979). Because a normal pregnancy does not strictly fit the medical .odel of disease, doubts have arisen about the necessity for conventional hospi- tal care, and interest has developed in alternative forms of care that are believed to provide psychological benefits. RANGE OF AND TRENDS IN BIRTH SETTING A wide range of birth settings is available in the United States today. Tbe birth setting is defined by the particular combination of providers of aaternity services, the delivery site, the type of equi~nt, the range of services, and the recipients of care. Birth settings vary because of the philosophies and practices of those who control the childbirth environment. 'l'he within-category variation in childbirth practices, providers, and clientele may be as great as or greater than differences between sites. Childbirth practices will continue to evolve, and settings will continue to change, adding to the difficulty of research. In the sections that follow, five principal types of physical sites for childbirth are described, and some summary comments are aade about their perceived advantages and disadvantages. Because of the issues raised above, these examples should be viewed as

OCR for page 10
13 100 \ \ \ \ \ \ - - - Intent Mon.lity ~te \ P., 1,000 Live Birth1 80 . \ ;. \ - Neonetal Mo!UIIty Rete IW 1,000 Llw Blrth1 i ·;_ \ · - - - Meternel Mo!UIIty Rete IW 10,000 Llw Blnhl i .. \ ·. \ ! : . . ' \.. ' ' ! ...\... ··'' ·... ~ ··' · ' \ •·.\ eo ''·•.,; ··. " \ \ \ ~ \ \ \ ~ \ 40 ~ \ ... \ ·... \ ... \ . \ ' ........ --- ............... '' 20 ' ',, ', ,, 1920 1930 1940 1950 1980 1970 1980 YEAR PIGURB 1 Neonatal, Infant, and Maternal Mortality Rates, 1915-1980.

OCR for page 10
TABLE 1 Neonatal, Infant, and Maternal Mortality Rates by Race, 1915-1980 Neonatal Mortality Rate Infant Mortality Rate Maternal Mortality Rate per 1,000 Live Births per 1,000 Live Births Per 10,000 Live Births Black and - Black and Black and Year Total White Other Total White Other Total White Other 1980 8.4 N/A N/A 12.5 N/A N/A 0.7 N/A N/A 1975 11.6 10.4 16.8 16.1 14.2 24.2 1.3 0.9 2.9 1970 15.1 13.8 21.4 20.0 17.8 30.9 2.2 1.4 5.6 1965 17.7 16.1 25.4 24.7 21.5 40.3 3.2 2.1 8.4 1960 1955 1950 18.7 19.1 20.5 17.2 17.7 19.4 26.9 27.2 27.5 26.0 26.4 29.2 22.9 23.6 26.8 43.2 42.8 44.5 3.7 4.7 8.3 2.6 3.3 6.1 9.8 13.0 22.2 .. .... 1945 24.3 23.3 32.0 38.3 35.6 57.0 20.7 17.2 45.5 1940 28.8 27.2 39.7 47.0 43.2 73.8 37.6 32.0 77.4 1935 32.4 31.0 42.7 55.7 51.9 83.2 58.2 53.1 94.6 1930 35.7 34.2 47.4 64.6 60.1 99.9 67.3 60.9 117.4 1925 37.8 36.8 49.5 71.7 68.3 110.8 64.7 60.3 116.2 1920 41.5 40.4 55.0 85.8 82.1 131.7 79.9 76.0 128.1 1915 44.4 N/A N/A 99.9 98.6 181.2 60.8 60.1 105.6 NOTE: Figures for 1980 are estimatesr N/A indicates information not available for that year or category. SOURCES: National Center for Health Statistics, 198lar u.s. Department of Commerce, Bureau of the Census, 1975, 1980.

OCR for page 10
15 illustrative rather than definitive and are included only to give some feeling for differences. Home Deliveries Rome births take place in circumstances ranging from no attendant other than family members to an organized home birth service attended by licensed professionals. The circumstances of the delivery are as varied as the home environment. Several reports of existing home birth services cite both the advantages and disadvantages of home births (Adamson, 19811 Adamson and Gare, 19801 Burnett et al., 19801 Cameron et al., 19791 Eischen and Nelson, 198la Mehl et al., 19771 Stillwell, 1979) (see Appendix A). The advantages include psychological benefits of giving birth in familiar surroundings and supported by family and friends, and lower costs. Standards for the delivery of care in the home have been established by the American College of Nurse Midwives (1980), but many still consider home births unsafe. The lesser ability of home birth attendants to deal with complications and the relative lack of emergency backup are considered •ajor disadvantages. Freestanding Birth Centers Freestanding birth centers are facilities separate from hospitals that provide maternity care to those expecting normal childbirths (Bennetts and Lubic, 19821 Lubic, 19801 Lubic and Ernst, 1978). The facilities are customarily managed by nurse midwives and are typically equipped to provide prenatal, peripartua, and neonatal care. Following delivery, families stay in the center for 12 to 24 hours and receive follow-up care in their homes, often by public health nurses. Participating attendants may including obstetricians, certified nurse •idwives, nurse •idwife assistants, pediatricians, public health nurses, ancillary and support personnel, and families theaselves. Freestanding birth centers must meet local health and safety codes and usually have agree•ents with a laboratory, an ambulance service, and a backup hospital for use as needed by their patients. Many families feel that there are advantages to deliveries in places other than hospitals (Adamson and Gare, 19801 Bennetts and Lubic, 19821 Eischen and Nelson, 19811 Pragmatics, Inc., 19781 Stillwell, 1979). The advantages of birth in a freestanding center include a recognized standard of care by professional providers, an environment seen as both medically safe and psychologically secure, and a coat less than that in hospitals. Disadvantages include physical separation from e•ergency personnel and hospital facilities. Hospital-Based Birth Centers The hospital-based birth center, an integral part of a hospital's obstetrical service, is designed to provide low-risk obstetrical

OCR for page 10
16 patients with family-centered care in a homelike setting. The birth center conforms with the licensing regulations that apply to the hos- pital itself, but the philosophy of most centers is to provide a more relaxed setting than is present in the conventional obstetrical facility (Barton et al., 1980J Faxel and Keiffer, 1980J Nelson, 1979J Pragmatics Inc., 1978J Schmidt, 1980J Sumner, 1976). One major advantage claimed for the hospital-based birth center over the freestanding center is proximity to emergency care facilities. Some critics, however, feel that noninterventive, personalized care for a normal birth in such centers is eroded by the proximity of a high-tech- nology setting. Conventional Hospital Perinatal Units Modern conventional hospital perinatal units reflect varying degrees of integration of conventional and alternative practices. Present-day practice is moving from the traditional separate labor and delivery rooms to a single roam. Illllediately after delivery, mother and baby reaain together for a period of time. In many hospitals, mothers can opt for •roaming-in• of their babies. Hospital Maternity Units The conventional hospital aaternity unit consists of discrete labor, delivery, postpartum, and nursery areas. In addition, facilities for dealing with obstetrical co.plications are located close to these unitsa high-risk labor rooms, operative delivery rooms, intensive care nurser- ies, and special aaternal recovery rooms. Labor occurs in one room, and the patient is moved to a second room for the actual birth. '.l'be infant often is taken immediately to a nursery. Physical facilities and practices tend to separate faaily members. Advocates of births in places other than hospitals believe that the use of technology and intervention in normal births may lead to iatrogenic disease and co.plications. Trends in Delivery in Different Sites Trends in births in the various birth locations described above are difficult to determine because no reliable nationwide data about birth sites are available. Tbe National Center for Health Statistics (NCBS) has derived data on birthplaces from state birth certificates and desig- nates place of delivery as •in hospital,• •not in hospital,• or •not specified.• Table 2 shows the number and percent distribution for hos- pital and nonhospital (including not specified) births for selected years through 1979. According to these statistics, there was a steady decrease in the percentage of nonhospital births from 1960 to 1974J the percentage of nonhospital births increased minimally in 1977 and then fell again.

OCR for page 10
17 TABLE 2 Nwnber and Percent Distribution of Live Births by Place of Delivery, 1960, 1965-1979 Hospital Not in Hospital Total Live Year Births Number Percent Number Percent 1979 3,494,398 3,460,484 99.0 33,914 1.0 1978 3,333,279 3,300,659 99.0 32,620 0.9 1977 3,326,632 3,277,536 98.5 49,096 1.5 1976 3,167,788 3,123,963 98.6 43,825 1.4 1975 3,144,198 3,104,549 98.7 39,649 1.3 1974 3,159,958 3,133,797 99.2 26,161 0.8 1973 3,136,965 3,114,503 99.3 22,462 0.7 1972 3,258,411 3,233,703 99.2 24,708 0.8 1971 3,555,970 3,523,840 99.1 32,130 0.9 1970 3,731,386 3,708,142 99.4 23,244 0.6 1969 3,600,206 3,566,260 99.1 33,946 0.9 1968 3,501,564 3,449,250 98.5 52,314 1.5 1967 3,520,959 3,459,771 98.3 61,188 1.7 1966 3,606,274 3,534,608 98.0 71,664 2.0 1965 3,760,358 3,660,712 97.4 99,646 2.6 1960 4,257,850 4,114,368 96.6 143,482 3.4 NOTE: Pigures for births occurring outside hospitals include cases for which place of delivery was not specified. SOURCES: National Center for Health Statistics, 1977, 1980, 1981b, 198lc. Tbe method used by NCBS for classifying hospital and nonhospital births may obscure small shifts in nonhospital births. Por example, births in freestanding birth centers are classified by NCHS as hospital births. Yet the number of freestanding birth centers has increased from 3 in 1975 to 130 in 1982 (Lubic, 1982). Also, nonhospital births occur in such diverse locations as doctors' offices, ambulances, public places, and homes. Therefore, these data are unreliable indices for demonstrating trends in planned home births. Because of inadequacies in the NCHS data, it is difficult to esti- mate the numbers of births that take place outside hospitals. Tbe Oregon State Health Division reported that 4.4 percent of all registered births in the state in 1981 were outside hospitals (Oregon Center for Health Statistics, 1982). Using the Oregon figure as an upper limit (NCHS indicates Oregon is one of the states with a high percentage of home births) and the NCBS average figure of approximately 1 percent (conceding that this underreport& the number of nonhospital births), it can be determined that, out of 3,598,000 live births in 1980, between 35,980 and 158,422 babies were born outside of hospitals. A second estimate can be derived from data on births in hospitals during 1980 (Aaerican Hospital Association, 1980). Subtracting 3,408,482 hospital

OCR for page 10
18 births from the total of 3,598,000 live births in 1980 yields an esti- mated 189,518 nonhospital births. Data from the American Hospital Asso- ciation produce a higher estimate because of the absence of a 100 per- cent response rate, exclusion of noncommunity hospitals (i.e., federal and other public health facilities), and birth estimates based on data collected for only one-half to three-quarters of the calendar year. Some states have higher rates of nonhospital births than others (see Appendix F for information from Oregon). Unpublished data from NCHS show that 31 states had more than 100 nonhospital births delivered by physicians and midwives, and 12 states had more than 500 similarly delivered births (Table 3). Washington, North carolina, Texas, California, and Oregon are recognized by the NCBS and others as having a larger percentage of planned home births than other states (Arms, 1975J Burnett et al., 1980J Dingley, 1979r Shy et al., 1980J Stewart, National Association of Parents and Professionals for Safe Alternatives in Childbirth, personal communication, 1981). Data available from a few states may be useful for documenting trends in nonhospital births. Only 1.5 percent of all births in Oregon in 1974 took place in free- standing clinics, doctors• offices, homes, and other nonhospital ad- dresses. By 1981 the percentage had increased to 4.4 percent (Oregon Center for Health Statistics, 1982). NCBS is now undertaking a large study that may redress some of the informational deficiencies about birth location. The studies are termed •follow-back• surveys, because they trace information on one or more individuals identified on a vital record, such as a birth or death cer- tificate. They provide the opportunity to collect more detailed infor- mation than is available from vital records. Some data on such items as obstetric care, personnel, and place of birth should be available to state and local public health agencies by December 1982 and to the gen- eral public by July 1983 (Placek, 1981). The committee also reviewed related data on the users of the differ- ent birth settings, although in general the data on this issue also are inadequate. Some data, particularly for hospital births, are available for characterizing the mother by sociodemographic factors. The 1972 National Natality Survey from NCBS provides information on mother's age and education, child's race, region of residence, family income, and health insurance coverage of women during legitimate live births in the hospital in 1972. The 1980 National Natality Survey also will contain this information (Placek, 1981). Because of the large percentage of births occurring in hospitals between 1972 and 1980, demographic find- ings related to users of hospital maternity facilities are deemed repre- sentative of the u.s. childbearing population as a whole. Bennetts (1981) found that in a case comparison study using 4,790 mothers from the 1972 National Natality Survey as controls, women who went to free- standing birth centers were older (2 percent were 30 years of age or more), more highly educated (most having completed some college), and typically were white (63.1 percent) or Mexican American (33.8 percent). 1 1The percentage of Mexican Americans is so high because this study included one of the largest freestanding birth centers in the country, and that center primarily serves Mexican Americans.

OCR for page 10
19 TABLE 3 States with More than 500 OUt-of-Hospital Births Delivered by Physicians and Midwives, 1978 Total N\Diber of OUt- Percent Distribution Percent Distribution of-Hospital Births of Live Births by of Live Births by Delivered by Physi- Physicians Midwives State cians and Midwives (Out of HOspital) (Out of HOspital) New York 721 0.2 0.1 Pennsylvania 549 0.3 0.1 Ohio 868 0.5 o.o (49) Illinois 960 0.5 0.1 (12) North Carolina 573 0.6 0.1 Florida 789 0.2 0.5 'l'ennessee 703 0.6 0.4 Alabama 863 0.5 1.0 'l'exas 5052 0.2 1.9 Washington 951 1.0 0.6 Oregon 578 0.7 0.8 california 1978 0.5 0.1 SOURCE: National Center for Health Statistics, 1981, unpublished data. In her examination of 300 elective ho.e births in the San Francisco Bay area, Hazell (1975) found that about 90 percent of the families choosing home birth lived in single-family dwellings, were white, and the fathers were employed. Usually both members of the couple had attended some college but neither had graduated. Unfortunately, no comparison groups were studied. MA'.l'ERNITY CARE PROVIDERS AND TRENDS IN 'l'BEIR USE Physicians--primarily obstetricians, family practitioners, and general practioners---constitute by far the largest group of maternity care providers attending childbirths. In 1979 they delivered 98.1 percent of in-hospital births and 34.2 percent of nonhospital births (National Center for Health Statistics, 198lb). According to a recent Manpower Planning Study (American College of Obstetricians and G¥necologists, 1981), obstetricians attended 81 percent of u.s. births in 1977, family practitioners 6 percent, and general practitioners 12 percent. ~e training of these physicians varies from 4 years of postgraduate work for obstetricians to 3 months of training in obstetrics for family practitioners. In 1981 there were 16,000 board-certified obstetricians, 2,600 physicians eligible for certification, and 4,700 residents in obstetrical training. An additional 3,000 physicians called themselves obstetricians but had no special training beyond medical school (Ameri- can College of Obstetricians and G¥necologists, 1981). Of the 56,200 licensed general practitioners in the United States (U.s. Department of Commerce, 1980), the number practicing obstetrics is unknown. HOwever, isolated data are available. For instance, in North carolina approxi-

OCR for page 10
20 mately 50 percent of the general and family practitioners care for preg- nant women and a slightly smaller percentage do deliveries (Pearse, American College of Obstetricians and Gynecologists, personal camunica- tion, 1982). Certified nurse midwives attend about 1 percent of u.s. births (American College of Obstetricians and Gynecologists, 1981). CHMs are registered nurses who have received graduate education for 1 to 2 years in midwifery and have passed a national certifying examination set by the profession. ~ey perform deliveries in all types of birth settings, including freestanding birth centers and conventional hospital units. Approximately 2,500 CNMs have been certified since the founding of the American College of Nurse-Midwives in 1955r about 1,800 practiced mid- wifery in 1980 (American College of Nurse-Midwives, 198lr Rooks et al., 1978). Lay midwives, who usually have no formal training, attend home births almost exclusivelyr there are many practicing lay midwives in Washington, Oregon, Arizona, Texas, Tennessee, and New Hampshire (Stewart, National Association of Parents and Professionals for Safe Alternatives in Childbirth, personal communication, 1982). Lay mid- wifery practice is illegal in same states and requires licensure in others. Over the years the number of lay midwives has decreased. Nurses provide most of the intrapartum and postpartum care iri hos- pitals, and some do follow-up home visits after discharge of the mother and child from a freestanding birth center. Nurses often assist pbysi- ciana at a delivery. There were 1,059,000 registered nurses licensed to practice in the United States in 1978 (u.s. Department of oa..erce, 1980). It is not known how many are involved in maternity care. Other providers of maternity care include naturopath& and chiro- practors. ~eir numbers and training vary substantially. For example, in Oregon, in 1980, 0.6 percent of all births were attended by naturo- pathsr moat of these deliveries were nonhospital ones (Oregon Center for Health Statistics, 1981). Another 0.3 percent of the 1979-1980 births in Oregon were attended by chiropractors (Oregon Center for Health Statistics, 1981). Twenty-five states have specific legislation preventing chiropractors from providing maternity care (Duhart, American Chiropractor Association, personal c:a.unication, 1982). Trends in the birth-attendant(&) aspects of maternity care cannot be accurately determined because of discrepancies and aaissions in the available data. For example, if a birth takes place in a hospital, it is often classified as a physician-attended birth, although a midwife or medical student may have delivered the baby. Lay midwives sometiMe list themselves as •friends• on the birth certificate (see Appendix F). In some birth settings, physicians routinely sign the birth certificates of certified nurse midwives who attend the entire birth. Obstacles to complete andVor accurate reporting and to participation in research arise froa these practices as well as from the legal ambiguity of some nontraditional childbirth attendants and the lack of understanding and trust that may exist among the various maternity care providers.

OCR for page 10
21 '.l'RBRDS IN MATERNITY CARB PRACTICES In a 1979 report to Congress, the u.s. General Accounting Office (GAO) defined major obstetrical practices associated with high-risk preg- nancies that •ust be considered in the evaluation of particular birth settings. 'l'bese practices included medical and/or surgical induction of labor, forceps delivery, vacuua extraction, cesarean section delivery·, intrauterine fetal procedures, and the use of anesthesia in spontaneous deliveri••· Other practice• that •hould be con•idered in research on birth •etting• include the completion of childbirth and/or parenting educa- tion cla••••• nutritional intake during pregnancy, length of stay, breast feeding, and parent-infant bonding. Many of these practice•, de•pite their wide•pread use in both low- and high-ri•k settings, have received only cur.ary attention by researchers. Data on trends in the application of various maternity care prac- tice• often are difficult to obtain and usually are incomplete (see Table 4 for a preliminary compilation). Data •ources reporting •pecific practice• are the National Center for Health Statistic•, the collaborative perinatal •tudy •pon.ared by the National Institute of Neurological and oo.municative Disorders and Stroke (RINCDS), the American College of Ob•tetrician• and Gynecologi•t• (ACOG), and the CC..i••ion on Profe88ional and Bo8pital Activitie• (CPBA) (U.S. General Accounting Office, 1979). Infomation from the•• studie• shon that ce•arean •ection rate• have increased, induction rates have remained approxtaately unchanged, and forcep• delivery and u•e of anesthesia have declined. 'l'be cc:.aittee believes that the frequency of fetal monitoring i• incre..ing, although no national data are available to confir• thi•. Rate• of brea•tfeeding, after a sub•tantial decline, ••• to be increasing <••• Table 4). Maternity practice• would be expected to differ across birth ••t- ting•, e.g., freestanding birth center• are for low-ri•k mothers, and bo•pital perinatal unit• are equipped for handling complication• in both aother and child. However, adequate data to docuaent the differ- ence• are not available <••• Appendix c for practice• in freestanding birth centers). Purther.ore, there will be a great deal of variation aero•• and within •etting•, contributing to the complexity of re•earch. Two examplea--u•e of ane•thesia and breastfeeding--illu•trate differ- ence• in practice•. Pro. available •tudie•, avoiding of the use of ane•the•ia in labor appear• more com.on in nonho•pital •etting•, although hospitals appear to be u•ing 1••• ane•the•ia in labor than they once did. Table 4 has only one row providing comparative inforaation on trends in maternity care practice• aero•• birth settings. fOr freestanding birth center deliverie• •urveyed by Bennett• (1981), 56 percent of the women received no ane•th••ia during labor. Thi• figure i• higher than the percentages in the larger national •aaple• aaking up the re•t of row 5 in Table 4. However, chronologically, going fro. the top to bottom lines in the row, a trend toward le•• u•e of ane•the•ia in labor can be dbcerned. Al•o, the figures from different large studie• •eea to corre•pond (e.g., 7.8 percent and 7.0 percent nonu•e of ane•the•ia frOII CPBA and NCBS data,

OCR for page 10
TABLE 4 Trends in Maternity Care Practices: Studies, Sample Size (When Given), Years, and Percent of Sample Receiving Practice Source& Cited in u.s. General Accounting Office Study, 1979 Bennette, 198lr NINCDS 1972-79 CPBA (unpubliehed) Niavander and u.s. Senate N • 2,000 deliveries ACOG, U67r 1970 N • 262,000 NCHS, U72r Gordon, 1972r SubcOIIIIlittee in freestandinCJ Procedure 1967 N • 2,060,440 1977 N • 1,300,000 1972 N • 2,800,000 NICRD, 1981 1959-65 N • 55,908 Hearin OCR for page 10
23 respectively). Data from CPBA in 1977 indicate a jump in the nonuse of anesthesia to 18.8 percent. Women who deliver in freestanding birth centers appear to have higher rates of breastfeeding. National prevalence data on the prac- tice of breastfeeding is best estimated from the 1965 National Fer- tility Study (NCBS, 1965) and the 1973 National Survey of Family Growth (NCBS, 1973). These studies indicated a dramatic decline in breast- feeding in the United States from 72 percent of women breastfeeding their first child in 1931-1935 to 29 percent in 1971-1973. This decrease was especially marked among blacks, the poor, and less- educated women. A reversal in this trend was noted by the American Academy of Pediatrics in 1978, when it was found that 46.6 percent of women from all socioeconomic groups delivering in hospitals breastfed their infants (Martinez and Nalezineski, 1979). This finding is con- sistent with preliminary data from the 1980 NCHS National Natality Survey analysis, which indicates that 45 percent of all childbearing women in the United States used breastfeeding alone on discharge from their care providers. In contrast, in a study of 1,938 women who began labor in freestanding birth centers, Bennetts (1981) found that 79.4 percent used breastfeeding alone on discharge from the freestanding birth center. PERINATAL REGIONALIZATION In addition to reviewing different birth settings and the trends affecting them, the committee considered how different settings fit into the current organization of perinatal services and the relevance of such a system for research on this topic. In 1971 the American Medical Association House of Delegates adopted a statement that urged development and operation of centralized c~ munity or regional perinatal programs with physician, government, and public involvement. Other professional organizations, such as the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, have continued active attempts to improve peri- natal outcomes through systematic applications of knowledge and tech- nology, including development of professional standards of care. Since the original proposal for the regionalization of perinatal health care delivery, documentation of the benefit of regionalized care has appeared in the research literature. Debate continues (Sinclair, et al., 1981), but there are certain gains, such as improved survival of low birth- weight infants, that can reasonably be attributed to better perinatal health care delivery (Lee, et al., 19801 Paneth, et al., 1982). Perinatal regionalization is a systems approach that defines care in terms of a continuum for a specific geographic and demographic area. Perinatal care has been subject to some of the most structured and complete planning in the United States, with much of the country at least nominally involved in a systems approach. Three levels of care described in TOward Improving the Outcome of Pregnancy (Committee on Perinatal Health, National Foundation-March of Dimes, 1976) form the basis for most perinatal systems currently in existence. Simply stated,

OCR for page 10
24 Level I care is envisioned as occurring wherever hospital birth occurs. Care is available for uncomplicated obstetrical events, but hospitals at this level should be able to detect high-risk patients as early as possible and to provide emergency care. Level II care should be avail- able at hospitals able to provide all services of Level I plus care for most of the complicated obstetrical difficulties and for certain neo- natal illnesses. Level III care should be able to cover all types of obstetrical, fetal, and neonatal probleaa in addition to providing teaching, evaluation, and research services. Level III centers serve as referral tertiary care centers for 8,000 to 12,000 births annually. Perinatal health care planners view the levels and units within a given region and the regional systems themselves as interdependent or linked. Risk identification, movement of patients to locations with appropriate resources, and outcome are important concepts that depend upon linkage for implementation of solutions. Lowering rates of mortal- ity and morbidity has been given high priority. This effort has eapha- sized ready employment of technological advances, many of which have become available in routine hospital and office practice (Philip et al., 198lr Wallace, 1978). Although systematic regionalized perinatal care does manifest concern for interpersonal dimensions of human experi- ence, it does so in a less uniform fashion than it does for technologi- cal innovation. For example, in perinatal planning little attention has been directed to other than hospital-based births. Although most plans do not summarily exclude alternatives, they do not respond readily to the needs and desires of individual clients or their families when a nonhospital birth is proposed. Integration of services has varied widely in different regions, depending on many factors. THE BIRTH SETTING CONTROVERSY Because of the variety of birth sites, personnel, and practices, contro- versy continues over which arrangements are desirable for childbirth. At present, opinions about various alternatives tend to cluster in groups favoring •conventional• or •alternative• obstetrics. In the •conventional• practice of obstetrics, the health profes- sional is a physician who has a direct, guiding relationship with the patient and makes appropriate decisions about her care. Technological advances such as anesthesia, analgesia, and electronic fetal monitoring are typical elements of care, and the hospital is usually the preferred site of birth. Conventional obstetrics tends to emphasize such practices as: • procedures to deal with group risks such as infection • monitoring fetal and neonatal well-being • hospital atmosphere, with nearness to equipment, use of technology In the •alternative• practice of obstetrics, the health provider may be a certified nurse midwife or physician or other practitioner with a relationship to the patient that emphasizes choice on such

OCR for page 10
25 matters as the birth environment and location. Technological advances are considered important when warranted, but they may be viewed with skepticism or avoided. Homes, birth rooms in hospitals, and free- standing birth centers are locations associated with alternative set- tings. Most alternative locations depend upon hospital back-up systems when an emergency arises. Practices more likely to be associated with alternative settings include: • homelike atmosphere for birth • individual choice of activity for the laboring mother, e.g., walking, eating, etc. • family participation and control in the birth process The •alternative• movement has already caused a reexamination of conventional obstetrical practice and some resulting changes. Both factions place high value on such basic issues as the safety of the mother and child, good prenatal care, childbirth education to increase a laboring woman's comfort and decrease her use of anesthesia and analgesia, encouragement of breastfeeding, and education about infant care. Unfortunately, the absence of adequate data on a whole range of issues associated with birth settings makes it unlikely that the con- troversy will ease in the immediate future or that parents can make informed choices about the setting best for them. 1be committee commissioned a review to assess the literature on the safety of nonhospital birth settings (Appendix A). The review makes it apparent that the literature is insufficient for a conclusive determi- nation of whether safe, appropriate care can be provided in unconven- tional settings. Risks are neither clearly identified nor quantified. There are no good comparative studiesr the number of subjects studied is small and the studies are poorly controlled. In fact, there is little, if any, objective evidence about the advantages or disadvan- tages of any birth setting (Adamson, 1981), or whether low-risk preg- nancies managed in unconventional settings have outcomes that are worse, the same, or better than outcomes in traditional hospital practices. As Adamson and Gare (1980) have stated, the •1ack of data has been a major factor preventing effective and reasoned dialogue among health professionals and lay people, especially those holding widely divergent views.• In scientific and lay discussions on aspects of childbirth settings, clear distinctions have not always been made among the various maternity care practices, personnel, and places. Evidence of beneficial or detri- mental effects of one compared with another can be statistically unreli- able or anecdotal. In addition, assertions based on unreliable research have made their way into discussions and policy statements with seem- ingly little follow-up evaluation. The controversy over various types of maternal and child care, the lack of available data, the interest among recipients of care in alter- native settings, the declining fertility rates (Pigure 2 and Table 5), and the competition among providers for this •market• indicate that

OCR for page 10
26 300 70 z w 60 2 50 i ~ ~ ~ ~ w ~ w % ~ ~ ~ m 10 9 8 7 6 5 4 PIGURB 2 Age-specific birth rates: United States, 1955-78. 3~----~--_.----L----L--~ 1955 1960 1965 1970 1975 1980 SOURCBa National Center for Health Statistics, in press. YEAR research into the safety, efficacy, psychosocial value, and costs of the various alternatives is urgently needed. Such research would assist prospective parents to choose the most suitable birth setting and also would provide policymakers with information for making decisions about allocation of resources for maternity care. The committee recognizes the difficulties of doing good research in this area. Issues of psychological health and satisfaction will be hard to quantify in persuasive ways. Furtheraore, the large number of birth setting combinations of providers, locations, and practices add to the difficulties of generalizing any results to other settings. The con- founding influence of the regional perinatal system, in which patients are transferred from one setting to another, means investigators will have to keep track of clients across settings. They will have to deter-

OCR for page 10
27 TABLE 5 Live Births, Crude Birth Rates, and Births per 1,000 Women by Age of Mother, According to Race: United States, Selected Years 1950-1978 (data are based on the national vital registration system) Live Births per 1,000 wc.en by Age of Mother Crude Race and Live Birth- 10-14 lS-19 2G-24 2S-29 3G-34 35-39 4G-44 45-49 Year Births Rate! Years Years Years Year• Years Years Years Years 'l'otal 1950 3,632,000 24.1 1.0 81.6 196.6 166.1 103.7 S2.9 lS.l 1.2 19SS 4,097,000 2S.O 0.9 90.3 241.6 190.2 116.0 S8.6 16.1 1.0 1960 4,2S7,8SO 23.7 o.8 89.1 258.1 197.4 112.7 S6.2 15.S 0.9 196S 3,760,3S8 19.4 o.8 70.S 195.3 161.6 94.4 46.7 12.8 o.8 1970 3,731,386 18.4 1.2 68.3 167.8 US.l 73.3 31.7 8.1 o.s 197S 3,144,198 14.8 1.3 S6.3 114.7 110.3 53.1 19.4 4.6 0.3 1977 3,326,632 15.4 1.2 S3.7 115.2 114.2 57.S 19.2 4.2 0.2 1978 3,333,279 1S.3 1.2 S2.4 112.3 112.0 S9.1 18.9 3.9 0.2 1979 3,473,000 15.8 n/a n/a n/a n/a n/a n/a n/a n/a 1980 3,S98,000 16.2 n/a n/a n/a n/a n/a n/a n/a n/a White 1950 3,108,000 23.0 0.4 70.0 190.4 16S.l 102.6 Sl.4 u.s 1.0 19S5 3,485.000 23.8 0.3 79.1 23S.8 186.6 114.0 56.7 15.4 0.9 1960 3,600,744 22.7 0.4 79.4 2S2.8 194.9 109.6 54.0 14.7 o.8 196S 3,123,860 18.3 0.3 60.6 189.0 158.4 91.6 44.0 12.0 0.7 1970 3,091,264 17.4 o.s S7.4 163.4 145.9 71.9 30.0 7.5 0.4 197S 2,5Sl,996 13.8 0.6 46.8 109.7 110.0 S2.1 18.1 4.1 0.2 1977 2,691,070 14.4 0.6 44.6 109.8 113.8 S6.3 17.8 3.8 0.2 1978 2,681,116 14.2 0.6 43.6 106.3 111.1 57.9 17., 3.5 0.2 1979 n/a 1980 n/a All Other 1950 S24,000 33.3 S.l 163.S 242.6 173.8 112.6 64.3 21.2 2.6 1955 613,000 34.5 4.8 167.2 281.6 218.2 132.6 74.9 22.0 2.1 1960 657,106 32.1 4.0 1S8.2 294.2 214.6 135.6 74.2 22.0 1.7 196S 636,498 27.6 4.0 138.4 239.2 183.5 113.0 62.7 19.3 1.5 1970 640,122 2S.l 4.8 133.4 196.8 140.1 82.S 42.2 12.6 0.9 197S S92,202 21.2 4.7 108.6 143.S 112.1' S9.7 27.6 7.6 o.s 1977 63S,S62 21.9 4.3 102.4 145.7 116.5 64.8 27.5 6.9 0.5 1978 6S2,163 22.1 4 ..1 99.1 145.7 117.3 66.7 27.0 6.5 0.4 1979 n/a 1980 n/a Black& 1960 602,264 31.9 4.3 156.1 295.4 218.6 137.1 73.9 21.9 1.1 1965 S81,126 27.S 4.3 144.6 243.1 180.4 111.3 61.9 18.7 1.4 1970 S72,362 2S.3 5.2 147.7 202.7 136.3 79.6 41.9 12.5 1.0 197S S11.581 20.9 S.l 113.8 145.1 10S.4 54.1 25.4 7.5 0.5 1977 S44,221 21.7 4.7 107.3 147.7 111.1 58.8 25.1 6.6 0.5 1978 S51,540 21.6 4.4 103.7 147.S 110.6 S9.6 24.0 6.0 0.4 1979 n/a 1980 n/a Data are based on births adjusted for underregistration for 1950 and 1955 and on IIIO'fB I registered births for all other years. Fi9ures for 1960, 1965, and 1970 are based on a SO percent sa.ple of births, for 197S-1978, they are based on 100 percent of births in ..lected states and on a SO percent sa.ple of births in all other states. Beg innift9 in 1970, births to nonresidents of the United States are excluded. !Live births per 1,000 population. IIOURCBt Rational Center for Health Statistics, 198la.

OCR for page 10
28 mine bow to handle births in which labor is conducted in a nontradi- tional setting andVor is managed by someone other than a physician until a complication occurs, after which the .other is transferred to a hos- pital and the delivery is cmapleted by a physician. It will be very difficult to auater a powerful, well-controlled study to deteraine con- clusively if one birth setting is incr...ntally more or leas safe than another. Nevertheless, the cOIIIIIlittee believes research can illuainate some of the issues and provide inforaation to aake better decisions about aaternal and child care. RBI'BRBNCBS Adamson, G. D. 1981. Health outcomes of home and hospital births. Paper presented at the University of california at San Francisco Series on Continuing Education in the Health Sciences, i'be Birth Process a Progress and Problema, May 2, 1981. AdaJIBon, G. D., and D. J. Gare. 1980. a.:.e or hospital births? Journal of the American Medical Association 243al732-1736. Aaerican College of Nurse-Midwives. 1981. 1980 Annual Report. washington, D.C.a American College of Nurse-Midwives. Aaerican College of Obstetricians and Gynecologists. 1981. Manpower Planning Study. Washington, D.C.a American COllege of Obstetricians and Gynecologists. American Hospital Association. 1980. Hospital Statistics, 1980 Edition. Cbicagoa Aaerican Hospital Association. Arms, s. 1975. Illllaculate Deception. Boatona Boughton Mifflin. Baldock, D. 1981. One of the oldest professions. Nursing Mirror 153140-42. Barton, J. J., s. Rovner, K. Pula, and P. A. Read. 1980. Alternative birthing centera Experience in a teaching obstetric service. American Journal of Obstetrics and Gynecology 137a377-384. Bennetts, A. B. 1981. Out-of-hospital childbearing centers in the United Stateaa A descriptive study of the demographic and aedical- obatetric characteristics of women beginning labor therein• 1972-1979. Ph.D. thesis. University of ~xaa Health Science Center at Houston. Bennetts, A. B., and R. w. Lubic. 1982. The free-standing birth centre. Lancet la378-380. Burnett, c., J. Jones, J. Rooks, c. Cben, c. Tyler, and c. A. Miller. 1980. Home delivery and neonatal mortality in North carolina. Journal of Aaerican Medical Association 244a2741-2745. cameron, J., B. s. Cbaae, and s. O'Neal. 1979. a.:.e birth in Salt Lake county, Utah. American Journal of Public Health 69a716-717. Chase, B. c. 1972. i'be position of the United States in international comparisons of health status. American Journal of Public Health 621581-589. Colllllittee on Perinatal Health. 1976. "l'oward iaproving the outcome of pregnancy. White Plains, New Yorka National Foundation-March of DiMs.

OCR for page 10
29 DeLee, J. B. 1920. i'he prophylactic forceps operation. Transactions of the American Gynecological Society 45166-83. Devitt, N. 1977. i'he transition from home to hospital birth in the United States, 1930-1960. Birth and the Family Journal 4147-58. Devitt, N. 1979a. i'he statistical case for elimination of the midwife1 Pact versus prejudice, 1890-1935 (Part 1). women and Health 4181-96. Devitt, N. 1979b. i'he statistical case for elimination of the midwife1 Pact versus prejudice, 1890-1935 (Part 2). Nomen and Health 4:169-186. Dingley, E. 1979. Birthplace and attendanta1 Oregon's alternative experience. Women and Health 41239-253. Edgar, J. c. 1911. i'he remedy for the midwife problem. American Journal of Obstetrics and Gynecology 631882. Biachen, M., and M. Nelson. 1981. A case study of the perceived risk associated with hame and hospital birth. Paper presented at the annual meeting of the American Association of Geographers, LOa Angeles, calif., April 1981. Paxel, A. M. B., and M. J. Kieffer. 1980. i'he birthing roam concept at Phoenix Memorial Hospital. Journal of Obateric/Gynecology Neonatal Nursing 91151. Plexner, A. 1910. Medical education in the United States and canada1 A report to the carnegie FOundation for the Advancement of Teaching 41117. Hazell, L. D. 1975. A study of 300 elective home births. Birth and the Family Journal 2:11-15. Huntington, J. L. 1913. i'he midwife in Massachusetts: Her anomalous position. Boston Medical and Surgical Journal 1681419. Irving, P. c. 1937. Maternal mortality at the Boston Lying-In Hospital in 1933, 1934, and 1935. New England Journal of Medicine 2171 693-695. Koamak, G. w. 1938. i'he favorable and unfavorable results from the practice of modern obstetric trends and procedures. Mississippi Doctor 16:1-11. Lee, K. s., N. Paneth, L. Gartner, M. A. Perlman, and c. Gruss. 1980. Neonatal mortality1 An analysis of recent improveaent in the United States. American Journal of Public Health 70115-21. Lubic, R. w. 1980. Evaluation of an out-of-hospital maternity center for low-risk patients • .!!l. Health Policy and Nursing Practice, Linda B. Aiken, ed. New York1 McGraw-Bill. Lubic, R. w., and B. K. M. Ernst. 1978. The childbearing center1 Alternative to conventional care. Nursing Outlook 261754-760. Martinez, G. A., and J. P. Nalezineaki. 1979. The recent trend in breast-feeding. Pediatrics 641686-692. Marlette, G. c. 1925. Discussion • .!!l. B. R. Bardin, The midwife problem, Southern Medical Journal 181347. Mehl, L., c. B. Peterson, M. Whitt, and w. A. Hawes. 1977. Outcomes of elective home birtha1 A aeries of 1,146 cases. Journal of Reproductive Medicine 191281-290. Moran, J. P. 1915. i'he endowaent of .otherhood. Journal of the American Medical Association 641126.

OCR for page 10
30 National Center for Health Statistics. 1979. Advance report, final natality statistics, 1977. Vital Statistics Report 27(11):16. National Center for Health Statistics. 1980. Advance report, final natality statistics, 1978. Monthly Vital Statistics Report Supplement 29(1):. National Center for Health Statistics. 198la. Annual summary of births, deaths, marriages, and divorces: United States, 1980. Monthly Vital Statistics Report 29(13): National Center for Health Statistics. 198lb. Monthly Vital Statistics Report 30(6, Supplement 2):16. National Center for Health Statistics. 1965. National Fertility survey. Hyattsville, Md.: National Center for Health Statistics. National Center for Health Statistics. 1972. National Natality Survey. Hyattsville, Md.: National Center for Health Statistics. National Center for Health Statistics. 1973. National survey of Family Growth. HYattsville, Md.: National Center for Health Statistics. National Center for Health Statistics. 198lc. Vital Statistics of the United States, 1976: Volume I: Natality. HYattsville, Md.: National Center for Health Statistics. Nelson, L. P. 1979. Results of the first 124 deliveries in the birth room at Roosevelt hospital in New York City. Birth and the Family Journal 6a97-102. Oregon Center for Health Statistics. 1981. Oregon Vital Statistics, 1980. Portland, Oreg.: Departaent of Ruman Resources. Oregon Center for Health Statistics. 1982. Oregon Vital Statistics County Data, 1981. Portland, Oreg.: Departaent of Bwaan Resources • Paneth, N. 1982. Infant mortality re-examined. Journal of the American Medical Association 247:1027-1028. Paneth, N., J. L. Kiely, s. Wallenstein, M. Marcus, J. Pakter, and M. Susser. 1982. Newborn intensive care and neonatal .ortality in low-birth-weight infants: A population study. New England Journal of Medicine 307:149-155. Philip, A. G. S., G. A. Little, D. R. Polivy, and J. P. Lucey. 1981. Neonatal mortality risk for the eighties: The tmportance of birth weigh~gestational age groups. Pediatrics 68:122-130. Placek, P. J. 1981. July 1981 Progress Report on the 1980 National Natality Survey and 1980 National Petal Mortality Survey. Hyattsville, Md.: National Center for Health Statistics. Pragmatics, Inc. 1978. Alternatives in Obstetrics Services for Indiana. Indianapolis: Pragmatics, Inc. Ryan, G. 1981. Caring: The key to our future. Obstetrics-Gynecology 58:639-641. Rooks, J., s. Fischman, E. Kaplan, P. Lescynski, G. Morgan, and J. Witek. 1978. Nurse-Midwifery in the United States: 1976-1977. Washington, D.C.: American College of Nurse-Midwives. Schmidt, J. 1980. The first year at Stanford University birthing roam. Birth and the Family Journal 7:169-174. Shy, K. K., P. Prost, and J. Ullom. 1980. Out-of-hospital delivery in Washington State, 1975-1977. American Journal of Obstetrics and Gynecology 137:547-552.

OCR for page 10
31 Sinclair, J. c., G. W.!Orrance, M. B. Bc¥le, s. P. Horwood, s. Saigal, and D. L. Sackett. 1981. Evaluation of neonatal-intensive-care progrua. New England Journal of Medicine 305a489-494. Speert, B. 1980. Obstetrics and Gynecology in Aaerica: A History. Washington, D.C.a American College of Obstetricians and Gynecologists. Stewart, D. 1981. The Pive Standards for Safe Childbearing. Marble Bill, Mont.: National Association of Parents and Professionals for Safe Alternatives in Childbirth. Stillwell, J. A. 1979. Relative costs of hospital and home confinement. British Medical Journal 2:257-259. Stone, M. Presidential Address. 1979. Washington, D.C.: American College of Obstetricians and Gynecologists. Sumner, P. E. 1976. Six years experience of prepared childbirth in a home-like labor-delivery room. Birth and the Pamily Journal 3a79-82. u.s. Department of Commerce, Bureau of the Census. 1980. Statistical Abstract of the United States, 1980. Washington, D.C.: Bureau of the Census. u.s. General Accounting Office. 1979. A Review of Research Literature and Federal Involvement Relating to Selected Obstetric Practices. Publication BRD-79-85A. Washington, D.C.: u.s. General Accounting Office. Wallace, B. M. 1978. Status of infant and perinatal morbidity and mortalitya A review of the literature. Public Health Reports 93a386-393. Williams, J. w. 1912. Medical education and the midwife problem in the United States. Journal of the American Medical Association 58:1-7. Williams, R. L., and P. M. Chen. 1982. Identifying the sources of the recent decline in perinatal mortality rates in California. New England Journal of Medicine 306:207-214. WOrld Health Organization. 1970. Prevention of Perinatal Mortality and Morbiditya Report of a WHO Expert CoiiiDittee. world Health Organization Technical Report Series, Number 457. Geneva: WOrld Health ~ganization. Ziegler, c. E. 1922. Bow can we beat solve the midwifery problem? ~rican Journal of Public Health 12:405-413.