An Update on Research Issues in the Assessment of Birth Settings Workshop Summary (2013) / Chapter Skim
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3 Assessment of Risk in Pregnancy
3 Assessment of Risk in Pregnancy
Pages 25-46
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From page 25... ...
The shift from home to hospital births that occurred during the 1940s, coupled with the use of antibiotics and transfusions in the 1950s, drove further d eclines, bringing maternal mortality down to about 7 per 100,000 by 1982 1 his T section summarizes information presented by Kimberly Gregory, M.D., M.P.H., Cedars-Sinai, Los Angeles, California.
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. However, more recently, based on data from the Maternal, Child and Adolescent Health Division of the California Department of Public Health, there is very clear evidence that the maternal mortality rate is increasing (see Figure 3-2)
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FIGURE 3-1 (A) Maternal mortality rate per 100,000 live births by year, United States, 1900-1997.
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She searched using several combinations of terms: "low risk" and "pregnancy"; "risk assessment" and "pregnancy"; "levels of care" and "pregnancy"; and all of those same terms crossed with "midwives," "family practice," "birth centers," and "home births." Later, she updated her search to include maternal transfers. Gregory also considered discussions of low risk in consensus statements issued by representative
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From page 29... ...
Because no such tools exist, and given that home and birth center births are supposed to be low risk, Gregory examined criteria used to identify candidates for home and birth center births as a means of identifying "low risk." According to criteria posted on the Open Door Midwifery website,3 in order to be a candidate for home birth, exam and laboratory tests must be within normal limits and show no evidence of chronic hypertension, epilepsy or seizure disorder, HIV infection, severe psychiatric disease, persistent anemia, diabetes, heart disease, kidney disease, endocrine disease, multiple gestation, or substance abuse. According to the American Public Health Association (APHA)
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From page 30... ...
They reported a trend toward lower preterm birth, less antepartum hemorrhage, and lower perinatal mortality with midwife and general practice care; significant decreases in pregnancy-induced hypertension (PIH) and eclampsia with midwife and general practice care; a significant increase in failure to diagnose malpresentation with midwife and general practice care; and a similar or higher satisfaction with midwife and general practice care.
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From page 31... ...
The researchers concluded that fetal and neonatal mortality rates among the birth center births were consistent with those of low-risk births reported elsewhere in other settings, including hospital births. In her search for additional information to help guide the identification of obstetric low risk, Gregory identified Baskett and O'Connell (2009)
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From page 32... ...
Low risk can also be defined regionally or locally within the context of collaborative care. Rates of neonatal and maternal adverse events are low if events are triaged appropriately with skilled clinicians.
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Thus, birth is depicted in the media as a full-blown crisis, with vanishingly few planned home births depicted at all. In television and the movies, the only births occurring outside hospitals are precipitous ones; often, no one is in charge, and the birth resembles nothing so much as an unmitigated disaster.
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It is this fourth phenomenon, that some social actors have greater authority than others to define risk that leads to what anthropologist Brigitte Jordan calls "authoritative knowledge" (Jordan, 1997; Jordan and DavisFloyd, 1992)
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Indeed, in Armstrong's opinion, most women trust modern medical care to ensure safe births. Yet, studies show that many women who birth in hospitals end up very dissatisfied with their birth experiences (Declercq et al., 2002, 2006)
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In addition to feelings about control and safety, trust appears to be another determinant of home birth choice. Women who choose home births often report that they trust their body's ability to birth and that they have a deep level of trust with their care provider.
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Focusing resources on those who need them most and avoiding unnecessary interventions can lead to better care, better health, and lower cost. When thinking about risk-appropriate perinatal care, it is important 5 his T section summarizes information presented by M
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described a model system for regionalized perinatal care that included definitions for varying levels of perinatal care based on both neonatal and maternal characteristics (March of Dimes, Committee on Perinatal Health, 1976)
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(2010) metaanalysis, which reported that planned home birth delivery of term babies is associated with less medical intervention but a two- to threefold increase in neonatal mortality.
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Research Needed to Describe "Risk" In addition to developing uniform definitions of risk factors, several other research steps need to be taken in order to advance our understanding of risk. Menard called for a greater understanding of essential resources for each of the various birth settings, predictors of neonatal complications to guide decisions about level of neonatal care (i.e., predictors beyond the context of birth weight, which is how most current neonatal care criteria are based)
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From page 41... ...
Topics addressed included international birth setting trends and risk guidelines; perception of risk among women entering pregnancy and how it varies depending on age, culture, and other factors; the large proportion of non-Hispanic black women who deliver unplanned out-of-hospital births; the increasing rate of home births in the United States; how economic factors drive birth setting decisions; the need for infrastructure in states without birth center regulations; and the challenge of transfer (legal and professional mistrust issues)
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From page 42... ...
"I want the record to show," he said, "that [in the Netherlands] it is considered a privilege to have a hospital birth." Elizabeth Armstrong agreed that, yes, more women in the Netherlands are seeking hospital births, but she warned that the reasons for the trends are complex and that the trend does not necessarily mean that women feel unsafe in home birth settings.
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From page 43... ...
. Marian MacDorman clarified that the incidence of home births in general is much lower for non-Hispanic black women, perhaps because fewer non-Hispanic black women have access to care providers that allow that option, and that the proportion of unplanned home births is high but the absolute numbers are low.
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From page 44... ...
She remarked that studies have shown that the cost of a home birth is about one-third the cost of a hospital birth, but in fact home births cost women much more than hospital births if they are not covered by insurance. The Need for Infrastructure in States with Birth Center Regulations In response to remarks made by Nigel Paneth about a birth center in Michigan closing after a breech delivery, an audience member commented on the fact that Michigan is one of the few states without licensure for freestanding birth centers.
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From page 45... ...
Two other participants echoed concerns about liability and the important role that state legislation plays in either restricting or promoting collaboration during transfer. For example, malpractice carriers telling physicians that they cannot provide midwifery backup significantly restricts collaboration.
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