1

Introduction1

More than 30 years ago, the Institute of Medicine (IOM) and the National Research Council (NRC) convened a committee to determine methodologies and research needed to evaluate childbirth settings in the United States. The committee members reported their findings and recommendations in a consensus report, Research Issues in the Assessment of Birth Settings (IOM and NRC, 1982). On March 6 and 7, 2013, in Washington, DC, the IOM convened a workshop to review updates to the 1982 report. The workshop presentations and discussions were intended to highlight research findings that advance our understanding of the effects of maternal care services in different birth settings on labor, clinical and other birth procedures, and birth outcomes. These settings include conventional hospital labor and delivery wards, birth centers, and home births. An additional objective was to identify datasets and relevant research literature that may inform a future ad hoc consensus study to address these concerns. The audience included health care providers, researchers, government officials, and other experts from midwifery, nursing, obstetric medicine, neonatal medicine, general practice medicine, public health, social science, and related fields, as well as consumer representatives. These participants represent the types of stakeholders that can be informed by this summary.

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1The planning committee’s role was limited to planning the workshop, and the workshop summary has been prepared by the workshop rapporteur as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the IOM or the NRC, and they should not be construed as reflecting any group consensus.



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1 Introduction1 M ore than 30 years ago, the Institute of Medicine (IOM) and the National Research Council (NRC) convened a committee to de- termine methodologies and research needed to evaluate childbirth settings in the United States. The committee members reported their findings and recommendations in a consensus report, Research Issues in the Assess- ment of Birth Settings (IOM and NRC, 1982). On March 6 and 7, 2013, in Washington, DC, the IOM convened a workshop to review updates to the 1982 report. The workshop presentations and discussions were intended to highlight research findings that advance our understanding of the effects of maternal care services in different birth settings on labor, clinical and other birth procedures, and birth outcomes. These settings include conventional hospital labor and delivery wards, birth centers, and home births. An ad- ditional objective was to identify datasets and relevant research literature that may inform a future ad hoc consensus study to address these concerns. The audience included health care providers, researchers, government of- ficials, and other experts from midwifery, nursing, obstetric medicine, neo- natal medicine, general practice medicine, public health, social science, and related fields, as well as consumer representatives. These participants represent the types of stakeholders that can be informed by this summary. 1  he planning committee’s role was limited to planning the workshop, and the workshop T summary has been prepared by the workshop rapporteur as a factual summary of what oc- curred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the IOM or the NRC, and they should not be construed as reflecting any group consensus. 1

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2 RESEARCH ISSUES IN THE ASSESSMENT OF BIRTH SETTINGS The information presented in this workshop summary reflects only what was spoken or visually presented (on slides) during the workshop. Although this workshop summary covers much ground, it should not be construed as a comprehensive review of the subject matter, nor should any of the information, opinions, or conclusions expressed in this workshop summary be construed as reflecting consensus on the part of the IOM, the NRC, the Board on Children, Youth, and Families, the workshop planning committee, or any other group. The purpose of the workshop was to engage in a dialogue about birth setting assessment and to identify and discuss relevant data and research, not to reach consensus on any issue or make recommendations. All of the opinions, interpretations, and suggestions for future research summarized in this document reflect the expressions of individual workshop participants. Not only has a considerable amount of time passed since the 1982 assessment, but the issues themselves have evolved. The demographic and health trends of childbirth in the United States have changed; for example, while maternal mortality rates decreased over much of the 20th century, they have increased in recent years. Birth setting trends have changed, including a growing but still very small percentage of women choosing to deliver at home. More and different types of data are available now than were available in 1982; for example, the U.S. birth certificate was revised in 1989 to distinguish between home and birthing center births. Additionally, researchers are asking different questions than they did three decades ago, such as questions about how physical features of the birthing environment can impact health outcomes by affecting the stress response system. As Patrick Simpson, M.P.H., of the W.K. Kellogg Foundation, Battle Creek, Michigan, expressed in his welcoming remarks, a better understand- ing of how birth settings and the care services offered in those settings impact maternal and birth outcomes can enhance the opportunity for vul- nerable children to be born healthy. He raised several questions that he said need to be revisited in the context of research done since the 1982 report. What factors impact a woman’s birth experience? What factors determine whether the birth setting is a stress-free environment? What is “safe”? Are hospital settings safer than freestanding birthing centers? What are the roles of physicians, nurse-midwives, doula, and other health care professionals? A better understanding of the science of birth settings will help to not only improve maternal and birth outcomes, but also build a future research agenda and allow research sponsors, like the W.K. Kellogg Foundation, to make more informed funding decisions. In her introductory remarks, Isadora Hare, M.S.W., Maternal and Child Health Bureau (MCHB), Health Resources and Services Administra- tion, echoed Simpson’s sentiment about the role of a strong evidence base in improving the safety and quality of care and the health of both mothers

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INTRODUCTION 3 and babies. She emphasized the importance of a “life-course approach” to improving maternal and child health, that is, taking into consideration the preconception and postpartum periods as well as the intrapartum pe- riod and their impacts on maternal and neonatal health. Hare said that, currently, infant mortality in the United States is 6.61 per thousand live births, placing the United States 27th among industrialized nations. She remarked on the significant disparity among rates for African American, non-Hispanic black, and non-Hispanic white women, with the rate for African American women being double what it is for non-Hispanic white women. The majority of infant deaths occur during the neonatal period. On behalf of the MCHB, Hare expressed hope that the workshop deliberations will help the MCHB in its efforts to promote the safety and quality of care being provided to mothers and babies at the time of birth. The MCHB is involved with two major efforts to reduce infant mortality and maternal mortality and morbidity. First, the bureau is collaborating with states par- ticipating in the initiative, A Collaborative Innovation Network (ACIN), which currently involves 13 southern states but is expected to expand na- tionwide by the end of 2013. Its specific goals are to reduce elective delivery before 39 weeks, expand access to interconception care through Medicaid, increase smoking cessation among pregnant women, promote safe sleep, and expand perinatal regionalization. While the ACIN initiative remains a state-level initiative. MCHB is providing management and leadership. Second, MCHB is involved with the National Maternal Health Initiative to improve women’s health across the life course and to improve the quality and safety of maternity care. The bureau is working closely with a number of public and private partners to strengthen surveillance, clinical guidelines, policies and practices in maternity care, and community-based models for improving access to prenatal and postpartum care. In closing, Hare noted what she described as a “burgeoning” research base demonstrating the advantages of breastfeeding, not only for babies but also for women, and encouraged consideration of evidence on the impact of birth setting on breastfeeding. MAJOR WORKSHOP THEMES The workshop discussion spanned a broad range of issues related to the effects of maternal care services in different birth settings on labor, clinical and other birth procedures, and birth outcomes, including historic and re- cent trends in childbirth and birth settings, assessment of risk in pregnancy, health outcomes associated with birth setting, workforce issues related to birth setting, data systems and measurement, and cost and reimbursement issues. The major themes that were raised by the participants during the workshop are highlighted in Box 1-1.

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4 RESEARCH ISSUES IN THE ASSESSMENT OF BIRTH SETTINGS BOX 1-1 Major Themes of Workshop Discussion •  hile much of the workshop discussion revolved around general differences W between hospital, birthing center, and home birth settings, several workshop participants elaborated on the variability within each setting with respect to physical environment, care, and patient experience. •  ince 1982, researchers have gathered a great deal of data and information S about birth setting trends, outcomes, and related issues. However, several participants opined that, while the lists of what has been learned are long, the list of what still needs to be learned is longer. •  any participants elaborated on the importance of vital statistic data (e.g., U.S. M birth certificate data) and the need to improve the quality of such data. While the gathering of information has improved since 1982, for example, with the distinction between home and birthing center births added to the U.S. birth certificate in 1989, the importance of accurate reporting is underappreciated. •  here was a great deal of discussion about the risks and safety of birth, with T topics ranging from varying definitions of “low risk” to varying perceptions of risks and safety (i.e., different women have different perceptions of what is safe). In addition, there were discussions about the need for greater public and provider understanding of risk, including differences between absolute and relative risk. •  here were several calls for more randomized controlled trials of health out- T comes among different types of birth settings; at the same time, the difficulty of conducting such studies (i.e., the difficulty of randomizing participants among birth settings) was recognized. •  here was much discussion about birth outcomes as related to the birth set- T ting, with several presenters observing that the birth center and home birth set- tings have been associated with fewer interventions, fewer complications, high transfer rates, and an increased risk for neonatal mortality with home births. The latter finding was deemed controversial. •  hile one of the purposes of birth setting research is to inform policy and W practice, workshop participants considered how developing and implement- ing national standards will be difficult due to state-level variation in birth and birth setting trends, provider regulation and liability, and Medicaid coverage for maternal and neonatal care. •  everal workshop participants expressed concern about choice of birth setting S and the need to better inform women about available options, and disparity in access to various birth settings and specific services. They suggested there is a need to increase access to a wider range of settings, services, and care providers and to opportunities for transfer from out-of-hospital settings to a hospital if the need should arrive. •  he lack of trust among different types of care providers was a prevailing T theme, with many participants calling for the need to improve interprofessional education, communication, and interaction.

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INTRODUCTION 5 At the conclusion of the workshop, two presenters provided “big picture” overviews of the workshop discussion. Catherine Spong of the National Institute of Child Health and Human Development, Rockville, focused her overview on factors to consider when evaluating research on birth settings, especially research on health outcomes associated with dif- ferent birth settings. She discussed selection bias (i.e., factors that influence a woman’s decision to choose one birth setting over another), variation in outcome measures, variation in institutional policies, varying definitions of low risk, the focus on women at low obstetric risk, and other factors to consider when evaluating the evidence and its implications for policy and practice decision making. Following Spong’s presentation, Zsakeba Henderson of the Centers for Disease Control and Prevention, Atlanta, Georgia, provided an overview of key findings since 1982 and key knowledge gaps. To set the stage for developing a future research agenda, Henderson also listed what she gathered to be the most important research needs based on the information and insights presented, discussed, and debated. Her list included the need for randomized controlled trials involving all birth settings (e.g., including all of the various types of hospital settings), the need for an examination of effective methods to transfer care from out-of- hospital settings into hospital settings, a cost assessment of birth settings, an evaluation of the experience of care in different settings, and several other types of studies. Given that the purpose of birth setting research is to inform policy and practice, Henderson also identified important nonresearch, but research- related, steps to consider. They included improving the quality of birth certificate data, data on transfer to hospital care, and other types of data; developing risk-assessment tools for maternal mortality and morbidity; developing consistent policies for education, certification, and licensing of care providers; and other steps. Most importantly, and the most important take-home message of the workshop for Henderson, was the need to im- prove interprofessional education, communication, and interaction. ABOUT THIS REPORT The organization of this report parallels the organization of the work- shop. The workshop was organized into panels, with all but one panel fo- cusing on one of a range of general topics: birth and birth setting trends and statistics (Chapter 2); assessment of risk in pregnancy (Chapter 3); health outcomes associated with birth setting (Chapter 4); workforce issues related to birth setting (Chapter 5); data systems and measurement (Chapter 6); and cost, value, and reimbursement issues (Chapter 7). For each of these general topic panels, the speaker presentations were followed by a discus-

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6 RESEARCH ISSUES IN THE ASSESSMENT OF BIRTH SETTINGS sant whose task was to reflect on the information presented during that panel. Discussants highlighted key findings, identified gaps in the evidence base, contributed additional information, and offered personal observa- tions about future research needs. At the end of each general topic panel, audience members were invited to comment or ask questions; summaries of those discussions are included at the end of each chapter. An additional panel was included in the workshop agenda to allow three maternity care providers working in different birth settings to share their varying perspectives on future research needs. Chapter 8 summarizes the information and opinions presented during that panel. Complete summaries of Catherine Spong and Zsakeba Henderson’s concluding “big picture” overviews of the workshop discussion are in- cluded in Chapter 9. Appendix A contains the agenda, Appendix B presents the biographi- cal sketches of the moderators and speakers, and Appendix C identifies abbreviations and acronyms.