An Update on Research Issues in the Assessment of Birth Settings Workshop Summary (2013) / Chapter Skim
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9 Workshop Reflections: Moving the Research Agenda Forward
9 Workshop Reflections: Moving the Research Agenda Forward
Pages 145-156
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CONSIDERATIONS WHEN EVALUATING STUDIES ON BIRTH SETTINGS1 Catherine Spong offered some suggestions to help interpret the literature that was presented over the course of the 1.5-day workshop, particularly with respect to information presented on health outcomes (as summarized in Chapter 4) , and to help plan a future birth settings research agenda.
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In particular, birth certificate data do not capture planned home births transferred to hospitals or intended place of birth for either hospital or birth center births; very large datasets are needed to detect differences in peri natal mortality; and there is no uniform data platform to adequately compare birth settings. • Henderson identified several key research needs discussed by workshop participants that could serve as a starting point for a future research agenda.
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Considerations Spong identified several overarching factors to keep in mind when evaluating the evidence from these studies on birth settings and health outcomes, indeed when evaluating the evidence from any of the research described during the workshop or when planning future research:
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, which can drive a woman's decision to have her birth in one setting versus another. • It is difficult to conduct randomized controlled trials in birth setting research; thus, few such studies have been done.
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Since 1900, the birthplace for most children born in the United States has shifted from the home to the hospital, with the rate of out-of-hospital births remaining fairly steady for decades until recently. The percentage of births outside the hospital increased rapidly from 2004 to 2010, mostly among non-Hispanic white women.
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Cultural views, women's views, and structural conditions can also affect risk perception. These challenges aside, Henderson remarked that overall absolute risk of adverse events in all birth settings is low.
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In Henderson's opinion, the field needs an evaluation of all birth settings, comparing women of equal risk across all settings. Henderson noted how workshop participants had highlighted the fact that there have been no randomized controlled trials of freestanding birth centers.
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Workforce Issues: Knowledge Gaps Gaps in knowledge include the role of education and certification in quality of care; ideal staffing models to optimize care quality (i.e., composition of collaborative teams, provider ratios) ; impact of "missed nursing care" in out-of-hospital settings; how nurse staffing affects quality, safety, and cost of hospital-based care; and the impact of technology on workforce training needs and demand.
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, workshop participants identified several limitations to the data being collected: birth certificate data do not capture planned home births transferred to hospitals, intended place of birth is not captured on the birth certificate for either hospital or birth center births, very large numbers are needed to detect differences in perinatal mortality (i.e., there have been no randomized controlled trials of sufficient size) , and there is no uniform data platform to adequately compare birth settings.
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. Future Research Needs Henderson identified several key research needs discussed by workshop participants that serve as a starting point for a future research agenda: • Randomized controlled trials to evaluate outcomes in freestand ing birth centers, outcomes in other birth settings (e.g., Snoezelen rooms, ambient rooms)
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"We are not talking about silos." She remarked that birth centers have in fact been trying to conduct randomized controlled trials, but it is difficult to randomize women among birth settings. Finally, she called for more funding to do these studies, noting that most out-of-hospital care providers do not have access to the same funds that support hospital care providers (e.g., university funds)
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More broadly, she stated that the unnecessary medicalization of birth has created fears about a natural process and that the whole culture of birth needs to be changed. Finally, she emphasized the importance of considering long-term outcomes and how what happens during the perinatal period impacts child health and learning.
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