An Update on Research Issues in the Assessment of Birth Settings Workshop Summary (2013) / Chapter Skim
Currently Skimming:
4 Birth Settings and Health Outcomes: State of the Science
4 Birth Settings and Health Outcomes: State of the Science
Pages 47-76
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 47... ...
(2012) Cochrane review on clinical birth settings was rooted in prevailing concerns about the technological focus on birth in hospital settings.
|
From page 48... ...
While there were no differences in perinatal outcomes for nulliparous women between midwifery units and obstetric units or for multiparous women between any settings, there were significantly more adverse outcomes among nulliparous women in births planned at home com pared with those planned in obstetric units. The researchers also reported fewer interventions among women planning births at home or in midwifery units compared to women planning births in obstetric units; and a higher per centage of nulliparous women transferred from either home or a midwifery unit to an obstetric unit, compared to multiparous women.
|
From page 49... ...
The reviewers found no randomized controlled trials of either Snoezelen rooms or freestanding birth centers. The eight studies on bedroom-like settings varied in some of their characteristics.
|
From page 50... ...
Results and Conclusions Women randomized to alternative birth settings were more likely to have no analgesia or anesthesia (based on data from six trials, N = 8,953) , spontaneous vaginal birth (based on data from eight trials, N = 11,202)
|
From page 51... ...
(2012) recommended several types of future studies: randomized controlled trials of freestanding birth centers; randomized controlled trials of alternative birth settings that are specifically designed to promote freedom of movement, feelings of calmness, and a sense of control; studies to determine optimal organizational models of birth center care; qualitative studies of impact of transfer on women, care providers, and decision-making processes regarding the need for intervention; and qualitative studies on the impact of competing philosophical, political, and administrative pressures on the operation of alternative settings.
|
From page 52... ...
. She said that many of these settings are now called family birth centers.
|
From page 53... ...
The guidelines do not use the word "allow." Rather, they state that women should be informed that the guidelines are based on a review of international evidence. The sample population included all NHS trusts providing intrapartum care at home, all freestanding midwifery units, all alongside midwifery units, and a stratified random sample of 142 obstetric units.
|
From page 54... ...
alongside midwifery units, and (d) obstetric units.
|
From page 55... ...
For multiparous low-risk women, there are no differences in adverse perinatal outcomes among settings. For nulliparous women, the risk of an adverse perinatal outcome appears to be higher among women who plan to give birth at home compared to women planning to give birth in obstetric units.
|
From page 56... ...
Among maternal outcomes, all low-risk women planning births at home or in either freestanding or alongside midwifery units experienced fewer interventions than those planning births in obstetric units. How Often Are Women Who Plan Birth in Nonobstetric Settings Transferred During Labor or Immediately After the Birth?
|
From page 57... ...
• How can the frequency of interventions be reduced for low-risk women planning birth in obstetric units? • To what extent do socially disadvantaged women have reduced access to choice of birth setting?
|
From page 58... ...
First, with respect to a goal for care around the time of birth, "All maternity caregivers have knowledge and skills necessary to enhance the innate childbearing capacities of women. Each woman is attended in labor and birth in the manner 3 his T section summarizes information presented by Carol Sakala, Ph.D., M.S.P.H., Childbirth Connection, New York, New York.
|
From page 59... ...
Effects also vary by mode of birth and infant feeding, which themselves vary by birth setting. Mothers too may experience lasting or long-term effects of intrapartum care processes which often vary by setting (Buckley, forthcoming; Ip et al., 2007; Kim et al., 2010; Silver et al., 2006)
|
From page 60... ...
hospital-based maternity care, including family physician maternity and midwifery care; smoking cessation interventions for pregnant women; external cephalic versions for breech presentation fetuses; vaginal births after Cesarean deliveries; continuous labor support; measures for comfort, pain, relief, and labor progress; nonsupine positions for giving birth; delayed cord clamping in term and preterm babies; early skin-to-skin contact; breastfeeding and interventions to support its initiation and duration; practices to foster women's satisfaction with childbirth experience; and interventions for postpartum depression. Sakala emphasized that her intention was not to assess the weight of the evidence or derive precise estimates, but to identify studies that help to clarify whether there are differences in practice patterns across the various birth settings.
|
From page 61... ...
Specifically, there was no difference in positive pressure ventilation, NICU admission, major complication composite measures, preterm birth or low birthweight, intrapartum maternal febrile morbidity, or maternal and newborn readmissions. Outcomes that favored birth centers included fetal heart abnormalities (11 percent in birth centers, compared to 19 percent in hospitals)
|
From page 62... ...
With respect to newborn morbidity outcomes, two favored planned home births: prematurity (1 percent in a home setting, compared to 5 percent in hospitals) and low birthweight (1 percent in a home setting, compared to 2 percent in hospitals)
|
From page 63... ...
, where the odds ratio for that study's "normal birth" measure was 4.47 for the births planned at home compared to births planned in obstetric units. For a recent summary of these and other studies on home versus hospital birth, see Goer and Romano (2012)
|
From page 64... ...
3. Care around the time of birth in birth centers and home births appears to be more closely aligned with needs of lower-risk child bearing families, but our broader health care system needs to bet ter integrate and support these settings, and to hold all settings accountable.
|
From page 65... ...
The parasympathetic nervous system also plays a role. Basically, when stressed, or when someone perceives stress, the brain's hormonal stress response turns on and releases corticotropin-releasing hormone from the hypothalamus, adrenocorticotropic hormone from the pituitary gland, and glucocorticoids from the adrenals.
|
From page 66... ...
and adrenergic stress responses, activate the parasympathetic relaxation response, activate brain opioid pathways and dopamine reward pathways, and enhance the immune response. These studies have used a variety of measures, including brain imaging (positron emission tomography, functional magnetic resonance imaging)
|
From page 67... ...
. For example, the Clarian Health Partners Methodist Hospital in Indianapolis, Indiana, merged critical care and step-down units5 in an effort to reduce complications associated with transfer of critical care patients from critical care units to step-down units; the Pebble Project reported that the merging of the units resulted in 90 percent fewer patient transfers, fewer medical errors, and greater satisfaction (Voelker, 2001)
|
From page 68... ...
Both outcome measures were sensitive enough to detect physiological changes associated with working in an old versus new office space. Heart-rate variability, which provides an indication of the balance between the parasympathetic relaxation and sympathetic stress responses, was higher in workers in the new office space.
|
From page 69... ...
Third, most of the existing structures are conflicting, not cooperative, with limited options for birth centers, great isolation of home birth providers, and highly variable credentialing among care providers. Finally, and arguably most challenging, it is often difficult or impossible to randomize study participants.
|
From page 70... ...
Reflections on Sandall's Presentation The Birthplace in England study (Brocklehurst et al., 2011) that Sandall summarized in her presentation was focused on four settings: home births, freestanding midwifery units, alongside midwifery units, and hospital-based obstetric units.
|
From page 71... ...
Common Themes A common theme among the four presentations, in Watterberg's opinion, was that alternative birth settings are associated with fewer interventions and high transfer rates and that home deliveries are associated with an increased neonatal risk. Regarding the last trend, several studies suggest that home birth is associated with increased neonatal mortality.
|
From page 72... ...
? In a relatively small study of home births in British Columbia, Canada, where a unified system is in place, with registered midwives mandated to offer home or hospital care depending on very specific safety criteria, home births were associated with fewer interventions and no increase in baby morbidity or mortality (perinatal death was 0.35 per 1,000 in planned home births with midwives, compared to 0.57 per 1,000 in hospital births with midwives and 0.64 per 1,000 in hospital births with medical doctors)
|
From page 73... ...
study on home births in Washington State was flawed in several ways, most importantly by the lack of a subgroup analysis of home births attended by licensed midwives or certified nurse midwives. The attendee asked, "Why are we still talking about this study?
|
From page 74... ...
. She clarified that the observed increased rate of adverse outcomes among planned home births reported in the Birthplace in England Collaborative Group study (Brocklehurst et al., 2011)
|
From page 75... ...
midwife education and training: certified nurse midwives (CNMs) , certified professional midwives (CPMs)
|
From page 76... ...
76 RESEARCH ISSUES IN THE ASSESSMENT OF BIRTH SETTINGS the certification. Once certified, the CPM can apply for state licensure in 27 states where it is recognized.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.