“Except When Medically Necessary” : Making informed choices about induction of labor

by Amy Romano, CNM

This post was originally published on Science and Sensibility for Lamaze International.

It’s not hard for women to find advice and recommendations to avoid induction of labor “except when medically necessary.” But what do those words mean and who decides when an induction is medically necessary?

Lamaze’s Healthy Birth Practice Paper cites ACOG Guidelines that define medical induction of labor as necessary in the following circumstances:

• your water has broken and labor has not begun.
• your pregnancy is postterm (more than 42 weeks).
• you have high blood pressure caused by your pregnancy.
• you have health problems, such as diabetes, that could affect your baby.
• you have an infection in the uterus.
• your baby is growing too slowly.

Yet a systematic review of the highest quality research found evidence only to support the first three. Even in these three cases, differences in important health outcomes were small, study methodologies have been criticized, and some important questions remain unanswered.

For the rest of this list and other so-called “medical” reasons for induction, we simply lack scientific evidence that induction offers any clear health benefits, and for other conditions the available evidence suggests induction is more likely to harm than help.

When trade-offs are uncertain for a proposed course of treatment, that treatment is known as “preference-sensitive care.” According to the Dartmouth Atlas of Health Care, a leader in studying practice variation, “Decisions about these interventions — whether to have them or not, and which ones to have — should thus reflect patients’ personal values and preferences, and should be made only after patients have enough information to make an informed choice, in partnership with the physician.”

As the Dartmouth Atlas has demonstrated for many types of medical and surgical interventions, however, decisions are more likely to reflect local practice patterns and the preferences of individual providers than the preferences of patients themselves. While the Dartmouth Atlas does not track induction rates, a 2004 study in New York State found that risk factors (at least those documented in birth certificate records) explained just 12.6% of the four-fold variation in induction rates across hospitals.

But what of the variation in the use of interventions when clear evidence suggests is harmful? Shouldn’t rates of those interventions be stable at or near 0%? Take, for example, the rate of elective (non-medically indicated) deliveries before 39 weeks. In a landscape where clinical consensus is hard to come by, all of the major players from ACOG and ACNM to the March of Dimes, the National Quality Forum, and the Joint Commission, have gotten on the no elective deliveries before 39 weeks bandwagon. Yet this week a major hospital watchdog group, The Leapfrog Group, partnering with Childbirth Connection and the March of Dimes, released for the first time hospital rates of elective deliveries before 39 weeks and the results are all over the map (pun intended). Some hospitals are in the low single digits, rates we know are possible when quality improvement efforts are taken seriously, while others report up to half or more of all births between 37 and 39 weeks are electively delivered.

Women need individualized, evidence-based information about the likely benefits and harms when considering induction of labor in the face of complications or significant risk factors. Childbirth Connection has launched a new web resource dedicated to Induction of Labor to help fill this need. But evidence is just one piece of the puzzle. Women also need information about maternity care practice patterns in their communities, since this factor seems to affect their likelihood of induction more than any other. Leapfrog’s voluntary database of elective early delivery rates stands to drive significant quality improvement. Let’s hope it’s just the first step toward full transparency of maternity care quality.

Midwifery Care from the Client’s Perspective

by Melissa Garvey, ACNM Writer and Editor

Our friends at Science and Sensibility have an interesting post that should be generating more discussion. The post explores certified nurse-midwife Mary Ellen Doherty’s study in the Journal of Perinatal Education called “Midwifery Care: Reflections of Midwifery Clients.”

Doherty conducted her study to describe the experiences of women who chose midwives as their health care providers throughout the lifespan. She and her team interviewed 12 women who had received prenatal, birth, postnatal, well-woman gynecologic, contraceptive, and primary health care services from midwives.

Five themes emerged from the data. As a member of the ACNM communications team, I’m particularly interested in two of them: 1) decision to seek midwifery care and 2) midwives as primary health care providers throughout the lifespan.

What Makes Women Choose Midwives?

That’s the million-dollar question here at ACNM. We exist to support and promote certified nurse-midwives and certified midwives. We know midwifery patients are extremely satisfied with their care. But how do we get a woman who has never considered a midwife to realize what she’s missing?

The women in Doherty’s study said they chose a midwife because of:

• a brochure from a midwifery practice along with one from ACNM that exuded “competence, confidence, compassion, and kindness.” (Go, ACNM Communications Department!)
• the recommendation of friends who had already given birth and had a positive experience with midwifery.
• an obstetrician’s recommendation.
• an insurance company’s recommendation.
  

Midwives as Primary Health Care Providers

All 12 of the women in this study discovered that midwives provide services beyond prenatal, birth, and postnatal care. Just among this sample of 12 women, midwifery services included:

• Contraceptive care
• Treatment for vaginal infections
• Flu shot administration
• Throat culture
• Annual exam
• Pap smear
• Treatment referral and support for postpartum depression
• Other health care referrals and recommendations for both patient and family members
  

Because this study was a phenomenological study, small sample size is not considered a limitation. However, Doherty notes that because her study focused on a “self-selective and purposive sample,” its results are not representative of all women. The majority of women were Caucasian, highly educated, married to their child’s father, and self-identified as “middle class.” Still, there’s a lot to learn from their answers…

…and a lot to add! Here’s where you chime in. What made you decide to choose a midwife? And what health care services do you receive from your midwife?

The Truth About Omega-3s During Pregnancy

by Robin Jordan, CNM, PhD

What pregnant woman wouldn’t want to grow a smart baby, one that has every last genetically programmed fully functioning brain cell, is ahead of the preschool pack, becomes the straight-A class president, and attends an Ivy League university?

That might be a stretch. But research indicates that women who eat adequate amounts of omega-3 fatty acids—specifically DHA and EPA found in many fish and fish oils—have babies who have higher cognitive, verbal, and visual functioning than babies born to women with lower intakes of these fatty acids.

Additional benefits of consuming adequate DHA and EPA in pregnancy are higher infant birth weight and a reduction in risk of preterm birth. Research also supports a reduction in pregnancy hypertension and postpartum depression, and we’re not even getting into the gamut of health benefits for the general population! (Okay, a short list: decreased cardiovascular disease, hypertension and dementia, to name a few).

It all sounds easy, right? But it may not be that simple.

Separating Fact from Fiction

There are plenty of areas of confusion on omega-3s during pregnancy. A recent study making the news rounds does not support the findings of improved mental and visual function in offspring whose mothers consumed DHA and EPA supplements. There may be reasons for these results—or lack of. The researchers tested babies only up to 18 months old, and women’s prior patterns of DHA and EPA consumption were not taken into account. Now here’s where it gets confusing: the ratio of omega-6 to omega-3 in the diet could have played a role in study findings. Omega-3s compete for binding spots in the body with omega-6s, primarily linoleic acid (LA). LA is found in foods containing corn, soybean and safflower oils (think crackers, cakes, soda), and beef--foods that are consumed in overabundance in today’s typical diet. DHA and EPA compete with LA for receptor sites in the body. So if a woman has a diet high in LA rich foods, then the DHA and EPA she takes in might not be used by the body. When people eat less omega-6s, they can make huge increases in their body’s omega-3s!

The Mercury Conundrum

What about fish? Isn’t it full of mercury? Only certain kinds of fish like shark, mackerel, swordfish, and tilefish are high in mercury. Many others are perfectly safe to eat. Just know what they are! Dr. Joseph Hibblen, a researcher with the US Department of Public Health has stated that the benefits of eating fish during pregnancy far outweigh any risks of eating safe fish during pregnancy. Based on his analysis of other studies, he concluded that the effect of not eating enough fish in pregnancy appears to be a 5-6 IQ point difference! The general guideline of “up to” two fish meals per week is being challenged by experts as too low, that pregnant women (and the rest of us!) should be eating more.

We don’t know everything about omega-3s in pregnancy; however, we do know enough to conclude that DHA and EPA are important to pregnancy and fetal health. Who knows the difference a few IQ points can make!

Midwives and other health care professionals, read Robin’s article on the omega-3 fatty acids DHA and EPA in the November/December issue of the Journal of Midwifery & Women’s Health.

Women, get more guidance on omega-3 fatty acids during pregnancy from this free Share With Women handout.

ACNM Responds to Lancet Home Birth Editorial

by Holly Powell Kennedy, CNM, PhD, FACNM, FAAN,
President, American College of Nurse-Midwives

On the heels of a disturbing AJOG study on home birth, an editorial released today in The Lancet is fanning the flames of the home birth controversy that has been playing out in the media this summer. This morning I talked with an NPR reporter about ACNM’s take on the editorial. View her blog here, and read on for a more in-depth view of ACNM’s perspective.

Does ACNM disagree with the perspective articulated by The Lancet editorial regarding the AJOG study?

It's surprising that this study is getting traction, when virtually every other organization that has looked at it has pointed to flaws in the methodology of the study.

What flaws?

There are several concerns.

They included studies that did not distinguish between planned and unplanned home births. For example, if you had planned a hospital birth, but your labor progressed so quickly that you gave birth before you even made it to the hospital, then you wouldn’t have had a skilled attendant or necessary resources present.

In contrast, a planned home birth means that the woman and her health care provider have determined she is healthy, at low risk for complications, and has the necessary resources in place for a safe birth. By combining the two types of home births, the findings are limited.

Second, a meta-analysis is a way of combining the results of many studies. But in this case, there seems to be no clear reason as to which studies they included versus those they excluded. In fact, they actually did not include the best and by far largest study that's been done—which did not find a higher neonatal mortality rate.

What's good about home birth?

Keep in mind that only slightly more than one half of 1% of women in the US will have their babies at home, but the voice of the home birth movement is very strong. That's because they are the voice of women who want their maternity care provider to follow evidence-based practices to minimize intervention in childbirth. They do not believe they will receive this kind of care in a hospital and see home birth as their only way of avoiding a cesarean section.

Should we care about this home birth argument?

Yes! Healthy mothers and babies are the most important goal. However, we’ve lost sight that how a woman gives birth matters for both short- and long-term physiologic and emotional health. Research has demonstrated that how we are born is important. Mothers and babies are both better off if we support and facilitate labor and childbirth using interventions as they are needed, but avoiding them when they are not.

Labor and childbirth is an arena in which more technology is not always better. Consumer advocates and health experts have called cesarean sections one of the most over-used surgical procedures in America. One in three women in the United States will have a cesarean section – this is twice the number recommended by the World Health Organization.

What's underlying this debate?

Many women fear childbirth—thanks to images they've seen in movies, stories, and even childbirth education books that emphasize what can go wrong, rather than focusing on women’s strength and capacity to birth. A study conducted by Childbirth Connection found that almost half felt overwhelmed by their labor and birth.

The malpractice debate is also driving practice – many obstetricians will tell you that they will not be sued if they do a cesarean section, but will if they delay, even though it might not yet be indicated. Working in maternity care today is very complex and difficult.

But, what many women do not know is that labor has beneficial effects for the mother and baby. Many childbearing practices that support women’s ability to forestall a cesarean, such as avoiding elective induction of labor and continuous fetal monitoring and the ability to stay mobile and upright during labor and support are common midwifery practices, yet the majority of women in the US do not have access to midwifery care.

Why do they not have access to midwives?

Approximately 10% of women are attended by midwives during birth – 97% of those births will be in the hospital. The rest will be in birth centers or at home. They are experts in providing individualized care using evidenced-based practices to facilitate a woman’s ability to give birth. They work with the woman to help her cope with labor and pain, using a broad array of resources from hydrotherapy to epidurals – based on the woman’s desires and needs. Working with a midwife means you have the best of both worlds: the opportunity to work with a professional who is highly skilled in supporting women in labor and childbirth, but also has access to an obstetrician who can assist if complications arise.

In fact, a large study recently conducted by the Cochrane Collaboration – a highly respected organization that gathers best evidence in health care – found that midwifery-led care is associated with fewer episiotomies and more spontaneous vaginal birth, feeling in control, and initiation of breastfeeding. Women were more likely to know the midwife caring for them. These researchers concluded that most women should be offered midwife-led models of care.

Many countries have far better birth outcomes than the US. In these countries women are allowed to choose home birth, and they have skilled midwives attending them in all birth settings. This is not the case in the US. Most women do not have the option to work with a midwife, in part because the US health care system places multiple barriers to their practice. Few women are offered collaborative models that include both physicians and midwives, including seamless transition from home to hospital if needed.

What’s the Bottom Line?

As we reform US health care, all maternity care providers must partner to demand robust systems which deliver the necessary resources for high quality maternity care in all birth settings, including home, birth center, and hospital—and care by midwives.

Evidence in Action at Midwife Connection

by Melissa Garvey, ACNM Writer and Editor

We’ve been pretty silent at Midwife Connection lately, but this week we’re getting back to normal. Yolanda Landon, our communications manager, is back from maternity leave with baby Kennedy in tow (yes, ACNM has the best mother-friendly, baby-friendly work policies I’ve ever encountered!), and we’re gearing up for the ACNM 55th Annual Meeting scheduled for June 12 – 16 right here in Washington, DC. In honor of this year’s theme—Midwifery: Evidence in Action—let’s kick off the week with another post in Andrea Lythgoe's excellent “Becoming a Critical Reader” research series.

Becoming a Critical Reader: The Five Basic Questions

by Andrea Lythgoe, LCCE (Originally published on Science and Sensibility for Lamaze International)

Since it has been a while since we’ve had any articles in this series, you may want to refresh your memory by rereading the first and second installments in the “Becoming a Critical Reader” series. I promise it won’t be so long of a gap before the rest of them!

OK, having reviewed and identified your own personal biases, you are ready for the second read-through, where you can more critically read the article. We’ll spend the next few posts in this series going through the various types of articles and the things you’ll want to consider when doing this more critical reading. Some questions will be pretty universal, no matter what type of article you are reading. Others will be more specific to the various types of articles. We’ll cover those specific questions over the next few posts.

The basic questions to ask as you read:

1. What did the authors set out to do? Hopefully you’ve already figured this out in your preliminary run through. If you’re not clear on that, make that the first thing you look for. When you find it, write it down so you don’t lose sight of that aim in the remainder of your reading.

2. Did the article really do what it set out to do? Look for the “conclusions” or “results” sections to see what the authors say about a study. Sometimes what is written here will have nothing to do with their original intent. Not that this makes the conclusions invalid, because sometimes studies do make important and interesting discoveries in tangential information. Ideally, the authors should at least address the original aim of the study, even if it was to say “we did not find what we expected to find.”

NOTE: This question is NOT the same question as “Did the study show what I think it should have shown” or “Did the study look at what I wanted it to study?” Sometimes I hear people disparage a study by saying “They looked at the wrong thing! Instead of studying ‘when is the best time to do an induction?’, they should have studied whether to do them at all!” This is unfair. The study is no less valid because it addresses a different issue than you would have chosen to research. The question is “Did they do what they set out to do?”

3. Did the article use appropriate methodology? Some methods might not be a good way to study a particular question. Other methods might be a better approach. While some are fond of saying that only a double-blinded, randomized controlled trial can give you sufficient answers, it’s not always realistic or ethical to do research in this way. We’ll go more into detail on that in our next series on methodology, so don’t worry if you don’t know enough to make a good judgment on this aspect right now.

4. Did the author show undue bias or influence? Many studies will have a disclosure on the first or last page of a study that tells who paid for the study or if the researcher has any conflicts of interest. While I wouldn’t necessarily dismiss a study because of a potential conflict of interest, I certainly would be using a VERY fine-toothed comb in my perusal of the study!

5. Do the conclusions match the data? Sometimes there is a pretty obvious mismatch between the two. I once read a study where the author concluded that a vaccine for GBS would save lives. However, the aim of the article was to find out if prenatal screening for GBS would reduce the incidence of serious GBS infections. Vaccines were not mentioned anywhere in the article, except in the conclusions area. It seemed an obvious mismatch to me.

Sometimes the mismatch might be more subtle. This is why you’ll want to jot down that answer to the initial question, “What did the authors set out to do?” At this point, go back and see if both their data and conclusions answer that.

These five questions are a good place to start as you review articles. I suggest that you take some time this week to find the full text of a study and read through it, answering these questions as you go.

Becoming a Critical Reader: Bias, Bias Everywhere!

by Andrea Lythgoe, LCCE (Originally published on Science and Sensibility for Lamaze International)

Pretty much everyone would agree that there is bias in research. Most people would say that bias is inherently bad. While it absolutely can be a bad thing, it can’t be completely eliminated. So what can be done about bias in research?

There are many kinds of bias:

• Researcher bias: researcher sets out wanting to the study to prove something, and intentionally or unintentionally manipulates the study to make sure that happens
• Sponsor bias: The organization that sponsors the study either encourages researcher bias or manipulates the publication of the data. Some studies might be completely suppressed, some might have overly inflated press releases touting minimal results.
• Publication bias: Journals must be selective in what they publish due to space limitations, but I think it is fair to say that some journals may choose not to publish a study that might anger its audience.

But today I want to focus on READER bias:

Your first job in the critical reading of an article is to check your bias. We are all human, and so we all have bias. Sometimes it is hard to see your own biases. Take a look at the pictures below. In the first picture, we can tell that there is something there, but it is difficult to see. In this case, the letters are lined up with our angle of vision.

In this second picture, the letters are running the opposite way as our line of vision, and as you can see, suddenly that bias is crystal clear!

The same is true with our reading of the research. The biases that we have act as a filter that alters our reactions to the research. If we already have our minds made up that induction of labor = bad, then any research on labor induction is going to be seen through that filter. Any research that seems to place induction in a favorable light will be seen has highly suspicious. Any minor flaws will be exaggerated. Any research showing bad outcomes from inductions will likely get a “free pass” and flaws may be overlooked.

Murray Enkin, author of “A Guide to Effective Care in Pregnancy and Childbirth”, said this:

Perhaps the most important bias of all resides in the (potential) reader, who determines how (or if) the results will be read and interpreted.

I would agree with him. I have, over the years, seen the best and worst of research used to back up various points, ignoring the quality (of lack of it!) as long as it agrees with them. This is a normal human tendency, and one that is at the heart of many discussions about the available research.

But the good news is that reader bias isn’t impossible to overcome.

The solutions? Awareness of bias and a change of perspective! As you read, consider how this research might be read and understood by someone with a completely different perspective. When you read a study that really resonates as a great study with you, play “devil’s advocate” and pick it apart. Be merciless in looking for flaws, weaknesses and the other types of bias listed above. The same is true of seeing an article you disagree with. Look for strengths and solid evidence. Have an open mind to other possibilities. Sometimes when doing this, you’ll be able to see some aspects you would never have noticed otherwise.

So, here’s an exercise for you. Take a few minutes, and write down what your biases are when it comes to research. Which kinds of research, which methods, which topics do you particularly feel drawn to? Which ones seem silly or useless? For inspiration, you may want to read a personal commentary article written by Murray Enkin (2008) where he goes through his own personal biases. The things he feels a bias for or against may not be the same for you. I know I have a disagreement with one of his stated preferences. But taking the time to carefully think through your own personal biases, to clearly acknowledge the filters through which you view the research, can only help you as you try to step back and make a critical analysis of the research.

Reference: Enkin, M. W. (2008) Biases in evaluating research: Are they all bad? Birth: Issues in Perinatal Care. 35(1). 31-32.

Restricting food and drink in labor is not justified

by Amy Romano, CNM (Originally published on Science and Sensibility for Lamaze International)

Listen to this great podcast about the new Cochrane review showing that the policy of restricting food and drink in labor is not justified. It’s a nice summary of how and why the research was conducted. In addition, I particularly liked these tidbits:

1. Rather than asking “is eating and drinking in labor safe?” the reviewers turned the question around to ask “is there any justification for restricting food and drink in labor?” This is not just a nuance. How a researcher asks a question can influence both the findings and the conclusions, as I have discussed previously.

2. Since they identified no benefits (nor harms) of restricting oral intake, the reviewers concluded that women should be able to eat and drink according to their preference.

3. It was her experience teaching antenatal classes that led one of the reviewers to study food and drink in labor. Listening to women’s concerns and anxieties made her question the justification for restricting women’s autonomy in labor.

In perusing the web to try to find an image for this post, I came across this heartbreaking picture of a woman begging for a drink in labor and being told no. (I’d post it here but it is copyrighted.) When the researchers said they found “no harms” of restricting food and drink in labor, they pointed out that no one had actually studied women’s preferences or experiences. I’m heartened to know that some of those who tout evidence based care are beginning to recognize that emotional distress is itself a harm. If there is no counterbalancing benefit, the conclusion is clear.

Are consumers at the bottom of the evidence pyramid?

by Amy Romano, CNM (Originally published on Science and Sensibility for Lamaze International)

I have argued (here, here, and here) that strategies that involve increased participation by women and families in maternity care hold major potential for improving our rather dismal maternal and infant health outcomes.

A study reported in the current issue of The International Journal of Gynecology & Obstetrics highlights a major obstacle to implementing consumer-led health strategies: lack of comparative effectiveness research supporting their use.

The researchers analyzed all Cochrane Systematic Reviews addressing pregnancy, childbirth, newborns, or children up to age five. They categorized each systematic review by the level of consumer involvement versus health care system involvement the intervention required. They found that 62% of Pregnancy and Childbirth reviews, 94% of Neonatal reviews, and 71% of Children’s Health reviews addressed interventions that involved no consumer participation, such as cesarean surgical techniques, or intensive care treatments. Interventions that could be implemented within the community (such as nutritional programs) or that involved woman- or family-centered health care (e.g., labor support techniques, family-centered pediatric approaches) were far less likely to be studied. The researchers concluded:

The vast majority of research is performed on interventions that are solely in the realm of the providers. Maternal and child health research needs to be directed toward innovative interventions involving consumer participation, particularly those that can be implemented in middle- and low-income countries where the accessibility and quality of the health systems are poor.

This study highlights one of the major systemic biases we see in research. When so much of our research comes from academic medical institutions, what happens outside of those institutions – even if it has a far greater potential impact on the health and wellbeing of the institution’s beneficiaries – doesn’t get studied much. Nor do interventions that can happen within institutions (e.g. doula support in labor) but challenge the institutional hierarchy, which too often puts patients and families at the bottom.

One area in which we need far more research is perinatal education. Few studies evaluate strategies to educate, engage, and inform women. In addition, according to a review in the current issue of The Journal of Perinatal Education, even when researchers do evaluate perinatal information giving and education, they tend to evaluate approaches that accommodate medical concepts of efficiency (e.g. leaflets or DVDs) rather than meet women’s own stated needs and preferences (e.g. opportunities to discuss options in depth with their care providers or in small peer groups facilitated by knowledgeable professionals).

Pregnant women and new mothers are avid seekers of health information – online, in childbirth education classes, from health care providers, and in their communities. This natural impulse to take responsibility for their health, connect with other women, and engage in their care is currently being overwhelmed by the application of one-size-fits-all maternity care policies, including mandated cesarean surgery for women with risk factors or more subtle threats to autonomy like restricting mobility, denying access to food and drink, and excluding family members and other support people from care settings.

Empowered, informed, engaged consumers, individually or collectively, can be effective at overcoming these barriers to safe, effective care. In fact, it sometimes seems to be the only force driving meaningful change. Fifty years ago, the American Society for Psychoprophylaxis in Obstetrics (now Lamaze International) helped lead a charge to let fathers into the delivery room and challenged the harmful, demeaning childbirth routines that prevailed as standard practice. Just last month, CNN reported the happy outcome for a woman who avoided cesarean surgery she did not need or want. In advocating for her own care, she has inspired a generation of other women facing vaginal birth bans in their own communities.

Consumers are the least powerful contingent in the health care system, even though our knowledge, attitudes and actions could be the most important influence on our own health and safety. It’s time for major paradigm shifts in research, policy, and practice.

References:

Belizán, J. M., Belizán, M., Mazzoni, A., Cafferata, M. L., Wale, J., Jeffrey, C., et al. (2010). Maternal and child health research focusing on interventions that involve consumer participation. International Journal of Gynecology & Obstetrics, 108(2), 154-155.

Nolan, M. L. (2009). Education and information giving in pregnancy: A review of qualitative research, The Journal of Perinatal Education, 18(4), 21-30.

The “Patient Push” for Early Birth: A Dangerous Concept or Valid Point?

by Melissa Garvey, ACNM Writer and Editor

Last summer, ACOG officially revised its recommendations on elective labor induction, raising the “safe” gestational age to induce from 37 to 39 weeks. Now a study in the December 2009 issue of Obstetrics & Gynecology examines women’s perceptions of the definition of full term and the safety of birth at various gestational ages. Long study short, nearly half of the 650 women surveyed believe it is safe to give birth at 37 weeks, and almost all believe it is safe to give birth before 39 weeks. (Note: All women were insured and had recently given birth.)

While there are numerous discussion-worthy topics nestled in the article, one in particular piques my interest as an informed consumer. Remember ACNM President Melissa Avery’s post about the startling rise in rates of preterm birth in the US? The number-one reason is labor induction. With that in mind, check out this statement from the Discussion section of the article:

Misinformation about the safety of early deliveries, especially those that are perceived to be “only a little early,” combined with the desire for the pregnancy to be over, likely contributes to a patient “push” for early delivery.

The authors say that recent educational efforts aimed toward providers have been promising in reducing the rate of elective preterm or early term birth, but the role of the patient has not yet been studied. So, my question is should we start looking at women’s role in elective induction or does this sound eerily similar to blaming women for the rise in cesarean section rates?

Bonus Discussion
To fully appreciate the survey results, it’s worth looking at the actual questions that researchers asked women:

1. “At what gestational age do you believe the baby is considered full term?” (Possible responses ranged from 34 to 40 weeks.)
2. “What is the earliest point in the pregnancy that it is safe to deliver the baby, should there be no other medical complications requiring early delivery?” (Again, possible responses ranged from 34 to 40 weeks.)
   

These questions measure the women’s knowledge base, but not where they’re getting that knowledge. Perhaps they’re getting it from the media, the Internet, or their care provider? It’s also worth noting, as the authors point out, these questions do not control for women’s varying interpretations of “full term” and “safe,” nor do they distinguish between spontaneous preterm labor and elective labor induction.

Cherrypicking stats: bad form and not helpful

by Amy Romano, CNM (Originally published on Science and Sensibility for Lamaze International)

Science & Sensibility contributor, Andrea Lythgoe, has a great post up at her own blog. In The Doula Numbers Game, Andrea shows that many of us may be overestimating – and overstating – the beneficial effects of continuous support from doulas. She argues and I agree that using outdated statistics that yield “better” results could compromise our integrity. Moreover, doing so is not necessary to advocate for greater access to doulas.

Data from the Cochrane Systematic Review show more modest effects of doula support, but they still add up to “clinically significant” benefits, greater satisfacation, and no evidence of harm. Maternal-fetal medicine researchers who evaluated the evidence for a variety of obstetric interventions in the November 2008 issue of the American Journal of Obstetrics and Gynecology called doula support “one of the most effective interventions” (p. 446) for improving outcomes. And they did so without being wowed by the inflated early statistics. (They stuck to the Cochrane.)

It can be extremely difficult to look at research objectively. It is human nature to want to cherrypick the research that furthers our cause the most. We may try to find fault with statistics we don’t like and subconsciously ignore problems or limitations of statistics we do. But improving the safety and effectiveness of maternity care requires that we critically analyze the research, which means recognizing limitations and flaws in the studies we agree with and standing behind solid research even when we don’t like the conclusions. We need not worry. Even with a critical lens, research points to a need to radically reform our system to make it more mother-friendly.

Andrea finishes each post in her Understanding Research series with a familiar plea to practice, practice, practice finding and reading research literature. One of the skills we all should practice is to read the studies that seem to contradict our beliefs or biases. Often, these studies are flawed, and spending time reading them helps us hone our ability to spot methodological problems and logical inconsistencies in other research. Other times the research is valid, and we see circumstances where technology and medicine do in fact improve outcomes. Reading these studies can also shed light on important unanswered research questions.

I highly recommend that readers take a look at Andrea’s post for an example of thoughtful critical analysis of statistics on doula support in labor. It is hard to update our long-held beliefs or alter the ways we teach and practice. But this is just what we’re asking of our “medical model” counterparts. We should lead by example.

The Real Risk of Late Prematurity

A study in the August 2009 issue of Obstetrics and Gynecology shows that late prematurity is an independent risk factor for neonatal morbidity. For those of us who aren’t women’s health experts, that means babies born between 34 and 37 weeks of pregnancy are at greater risk for health problems than babies born on or after week 37.

Midwives already know that late prematurity puts babies at risk for complications, but this retrospective study involving nearly 10,000 low-risk pregnancies singles out late prematurity as an independent risk factor. After adjusting for potential confounders, including maternal age, birth weight, and mode of delivery, researchers found a 30-fold increase in complications like respiratory problems, hypoglycemia, and hypothermia in babies who were born at 34 weeks. Researchers also observed a “gradual and consistent decrease” in risk of neonatal morbidity as gestational age increased with risks leveling off at about 39 weeks.

Study authors note that late prematurity has increased dramatically over the past two decades to about 8% of all deliveries and 75% of preterm deliveries. Interestingly, ACOG recently revised their labor induction guidelines, encouraging avoidance of induction before 39 weeks of pregnancy (the previous recommendation was 37 weeks). Do you think this study had anything to do with this?

Denis Walsh, mommy wars, and coming together On Common Ground

Originally published on Science and Sensibility by Amy Romano, CNM, for Lamaze International

Last week, I was thrilled and humbled to be asked to contribute to the On Common Ground collection at RH Reality Check. My assignment was to write a piece from the maternity care perspective that represents common ground for people on opposing sides of the abortion debate. I was asked to help readers who cannot agree even on the basic precepts of an issue discover concerns and beliefs held in common. I hope I succeeded. But I may have stepped from one divisive debate right into another. In my article, Improving Maternity Care: A Mother and Child Reunion, I discuss how what happens in birth can affect a woman’s transition to motherhood, and even her biological bond with her baby. Sound familiar? This is a bit like what midwife and researcher Denis Walsh is reported to have said in a recent article. The article, published in the Daily Mail’s Online Edition, ignited a storm of attacks against Dr. Walsh, who is a man, for allegedly saying that epidurals can complicate maternal-infant attachment and breastfeeding. A look at the hundreds of comments on the feminist site Jezebel will give you a sense of how unpopular his remarks are.

Whether Denis Walsh said what was reported or not (there’s a good chance he didn’t), this isn’t the first time any of us have heard the claim – and even the science behind the claim – that epidurals disrupt the biological processes of maternal-infant attachment and breastfeeding. These claims are made about cesareans, too. But clearly, even the most eloquent and informed among us (for example, Denis Walsh) are unable to talk about these effects in language that resonates with the majority of women.

Is there a better way we can talk about the impact of maternity care practices on mother-infant attachment? I think so.

In my article at On Common Ground, I discuss the beneficial effects on maternal-infant attachment of two practices: continuous support in labor and skin-to-skin contact between mothers and newborns after birth. I give an example from a randomized controlled trial comparing women who had continuous support from friends or family members trained as “lay doulas” with other women who labored without such support. I also discussed the findings of a Cochrane systematic review of studies of skin-to-skin contact. In both cases, beneficial effects included easier transitions to motherhood and improved maternal-infant attachment.

These are practices we can offer women whether or not they have epidurals, and regardless of how they give birth. More importantly, they improve mother-infant attachment whether or not women have epidurals and regardless of how they give birth.

In the doula study, postpartum effects were profound. Women who had continuous support were more likely to describe their babies as “very easy” and to believe that their babies cried less often than other babies. They were more likely to pick up their babies when they cried and to report that they were able to sense their babies’ needs “very well.” Regarding their own postpartum experience, they were more likely to say that the transition to motherhood had been “very easy” and to report that they had received support from others in the previous week. Women assigned to the doula group also scored more favorably on measures of self-worth including sense of self as a woman, sense of their bodies’ physical strength, and ability to be a good mother. Do you want to know what did not differ? The rates of epidural use (85% doula group vs. 88% no doula group) and cesarean surgery (19% doula group vs. 18% no doula group).

The systematic review of skin-to-skin contact included mostly studies of vaginal births in women without epidurals, but one study included in the review looked only at women who had scheduled repeat cesareans under spinal anesthesia. This study in fact yielded some of the most impressive differences in maternal-infant attachment behaviors of all of the studies included in the review. Some of the differences in maternal attachment behaviors persisted an entire month after giving birth.

I believe that mothers and babies experience physiological and emotional benefits when the woman has an unmedicated vaginal birth. But in our culture, women are not given a fair shake to achieve unmedicated vaginal births, and are fed messages that they shouldn’t care how they give birth as long as there’s a healthy baby. Even when care is top-notch, some women will still need epidurals or cesareans. Do we really want to tell these women that they might not be able to parent effectively?

The Healthy Birth Practices that Lamaze International has been championing for years allow us to have our cake and eat it too. Taken together as a package of care, they decrease the need for cesarean surgery and pharmacologic pain management. As we have seen in the two examples here (which represent two of the six Healthy Birth Practices), they may also mitigate or even overcome the effects of epidurals and cesareans on maternal-infant attachment. How’s that for a win-win?

We need to find common ground with women when it comes to talking about birth and bonding. Focusing on outcomes, which can result from choices, circumstances, or system effects, dooms us to alienate some women and ultimately fail to reach them with information that matters. Let’s instead advocate for better, safer care in labor – The Healthy Birth Practices – and fight to make sure no woman is denied access.

Mothers of Multiples at Greater Risk for Postpartum Depression

A study in the April 2009 issue of Pediatrics found that mothers of multiples are at a 43% greater risk of having moderate/severe depressive symptoms compared to mothers of singletons. These results were found even after adjusting for demographic and household socioeconomic characteristics and maternal history of mental health problems. Researchers conclude that greater care must be taken to address postpartum depression in families with multiple births.