|
|
||||
|
Volume 4, Issue 4 Compiled and Edited by Amy Romano, MSN, CNM
Updated
Cochrane Systematic Review Finds Stronger Evidence of Benefit for Early
Skin-to-skin Contact Group
Prenatal Care Reduces Preterm Birth by One-Third, Improves Breastfeeding
Success Case
Study Reveals Economic and Political Forces that Hinder Access to Midwifery
Care
Listening to Mothers II Survey
Report When Research is Flawed: Critiques
of Influential Studies Call for Abstracts: 2008 Annual
Conference Apply today for a Birth Network or Community Outreach
Grant! Email research articles you'd like to see in the next issue
to: Copyright 2007, Lamaze International, Inc.
All rights reserved. |
|
A comprehensive edition of each issue of Research Summaries for Normal Birth, including fuller discussions of research methods and results, will now appear in The Journal of Perinatal Education. Updated Cochrane Systematic Review Finds Stronger Evidence of Benefit for Early Skin-to-skin ContactSummary: In this systematic review, researchers evaluated the effects of early skin-to-skin contact (SSC) between the mothers and healthy newborns on breastfeeding, behavior, and physiologic adaptation. The review was restricted to mothers and their healthy full term (>37 weeks) or late-preterm (34-37 weeks) babies and only trials where SSC commenced within the first 24 hours were included. This Cochrane review updates a 2003 review with data from trials published since that time. Thirty trials involving 1925 mother-baby pairs were included, about twice as many as were included in the 2003 review. SSC was found to have a statistically significant effect on breastfeeding initiation, duration, and exclusivity. Infants who were held skin-to-skin were more than twice as likely to breastfeed successfully during their first feed, established effective breastfeeding sooner, were more likely to be breastfeeding at 1-4 months of age, and breastfed longer. Babies who underwent SSC were also more likely to maintain temperatures in the neutral thermal range (neither too cold nor too hot) and showed less variability in their temperatures. Infants exposed to SSC had blood glucose levels that were higher than those in the control groups by an average of nearly 11 mg/dl, which is highly clinically significant. A large difference, favoring SSC, was also found in infant crying. Late preterm babies undergoing SSC demonstrated better cardio-pulmonary and metabolic stabilization compared with similar babies placed in incubators. No statistically significant differences were found in other outcomes such as admission to the neonatal ICU or infant weight loss. The review yielded no evidence of any harm from SSC in term or healthy preterm babies. Mothers who underwent SSC displayed more affectionate behavior toward their babies, such as kissing, smiling and holding and scored better on measures of maternal attachment in the first few days after birth. Some included studies found statistically significant differences in these behaviors persisting as long as one year. The reviewers did not identify any evidence that SSC was harmful to mothers. Studies that measured women's satisfaction with their care found increased satisfaction with SSC. Significance for Normal Birth: Separation of mothers from their babies after birth does not occur in any mammals other than humans and has only occurred in humans during the last century. In order for a mammalian species to survive, newborns must learn to nurse and their mothers must learn to protect and care for them. Researchers have described a "sensitive period" in the first hour after birth where hormonal changes and innate behaviors coincide to produce optimal outcomes. They have also have identified care practices that disrupt these processes with detrimental effects. Even apparently benign practices such as weighing, bathing or swaddling babies can disrupt their innate behaviors if they occur in the first 1-2 hours after birth (1, 2). This review provides incontrovertible evidence that denying skin-to-skin contact between healthy babies and their mothers after birth is harmful. Although the Cochrane systematic review published in 2003 provided strong evidence that SSC is beneficial, in this update researchers reviewed a much larger body of research with findings related to many more clinical and psychosocial outcomes. They also gave special attention to the effects of skin-to-skin contact on babies born between 34-36 weeks of gestation, a population that unfortunately represents a growing proportion of newborns and who are at increased risk for morbidity and mortality (3). With such compelling evidence, it is unethical to continue to deny healthy babies and their mothers skin-to-skin contact after birth. The principles of beneficence (doing good) and nonmaleficence (avoiding doing harm) demand that uninterrupted time for mothers and babies after birth take priority over labor ward routines intended for staff convenience and hospital efficiency and that postpartum and newborn interventions either be delayed or, when necessary, be carried out with the baby and mother skin-to-skin. References 1. Jansson, U. M., Mustafa, T., Khan, M. A., Lindblad, B. S., & Widstrom, A. M. (1995). The effects of medically-orientated labour ward routines on prefeeding behaviour and body temperature in newborn infants. Journal of Tropical Medicine, 41(6), 360-363. 2. Righard, L., & Alade, M. O. (1990). Effect of delivery room routines on success of first breast-feed. Lancet, 336(8723), 1105-1107. 3. March of Dimes. (2006). Late preterm birth: Every week matters. Retrieved August 15, 2007, from www.marchofdimes.com/files/MP_Late_Preterm_Birth-Every_Week_Matters_3-24-06.pdf. Summary: In this multi-center randomized, controlled trial, investigators evaluated the effect of the CenteringPregnancy model of group prenatal care on perinatal outcomes, including preterm birth, birth weight, psychosocial outcomes, breastfeeding success, women's satisfaction, and health care costs. Eligible women were randomized to group prenatal care (intervention group, n=653) or traditional care (control group, n=394). All women attended their first prenatal visit in the traditional one-to-one setting. For their subsequent care, women in the intervention group attended 10 prenatal sessions with approximately 7 other pregnant women due in the same month. The facilitating obstetrician or midwife had a brief one-to-one encounter with each pregnant woman in the group space to evaluate fetal and maternal wellbeing and address individual concerns. While they waited for their individual assessments, women conducted self-care activities such as weight checks and blood pressure monitoring and recorded the results in their own charts. The remainder of the 2-hour sessions was dedicated to facilitated group discussion and education based on CenteringPregnancy program materials and client self assessments. Women in the control group continued to attend prenatal visits at the clinic according to the traditional schedule or as otherwise clinically indicated. In the settings where the trial took place, traditional prenatal visits lasted about 10-15 minutes each for a total of 2 hours of prenatal care over the course of a woman's pregnancy. The group care model, on the other hand, yielded about 20 hours of prenatal care over the course of the pregnancy. After controlling for confounding factors, women assigned to group prenatal care were 33% less likely to give birth preterm (10% in the intervention group versus 14% among controls). When the investigators limited the analysis to African American women, who represented 80% of all participants, the protective effect of the group care model was even stronger - there was a 10% preterm birth rate in the intervention group compared with 16% of controls, for a 41% reduction in risk. Statistical analysis revealed that the group model was most effective at preventing late preterm births (35-37 weeks), however a significant reduction in risk of preterm birth was observed at every week of gestation from 26 weeks forward. Although there was no significant difference in the overall risk of low birth weight (defined as less than 2,500 g), the researchers demonstrated a statistically significant "dose response" effect, where increased exposure to the group care model resulted in both longer gestation and higher birth weight. Women randomized to the group care model were also more likely to initiate breastfeeding (67% versus 55%). They also scored significantly better on a pregnancy knowledge questionnaire, reported increased readiness for labor and birth, and were more satisfied with their prenatal care. There were no statistically significant differences in other clinical and psychosocial outcomes measured. Costs were similar across both models of prenatal care. Significance for Normal Birth: That CenteringPregnancy's effect on preterm birth has not been matched by any medical or technological intervention reinforces an important lesson about what is good for mothers and babies. It is not surprising that care that builds women's confidence, mitigates stress, and teaches wellness and self-care would yield psychosocial benefits. What a medicalized view of pregnancy and birth too often fails to recognize, however, is that these same elements contribute to optimal clinical outcomes as well. In pregnancy, as in birth, an approach that values medical intervention and constant technological surveillance for problems is unlikely to be effective at enhancing an essentially healthy process. In pregnancy, as in birth, building a circle of support for an expectant mother enhances her ability to care for herself and her baby and cope with unfamiliar but normal emotional and physical changes. Caring for women holistically is not just "nice" it is good medicine. Pregnancy is a normal physiologic state, though vulnerable to disruptions from chronic or acute stress, unhealthy behaviors such as smoking, and harmful conditions such as malnutrition or violence in the home. In the current prevailing model of prenatal care, visits are brief and counseling for nutrition, smoking cessation, and domestic violence concerns are often provided separately, contributing to fragmentation of care and creating unnecessary barriers to access. CenteringPregnancy, like all mother-friendly care, does not demand that the woman accommodate institutional routines and navigate complex systems but arranges care around her needs instead. This study reveals a forgotten outcome of putting the woman at the center and constructing a supportive environment around her: babies benefit, too. Admission EFM Increases the Chance of Operative Delivery in Low-Risk Women with No Evidence of Maternal or Fetal BenefitSummary:In this mini-systematic review, investigators evaluated the body of evidence related to the "admission strip," a screening test in which women undergo a brief (usually 20 minute) period of continuous electronic fetal monitoring (EFM) upon arrival at the hospital to ensure that they are eligible for subsequent intermittent auscultation (listening to the fetal heart rate at intervals during labor). The review was limited to good quality randomized controlled trials enrolling women at low obstetrical risk with term pregnancies. The investigators focused their review on the effect of the admission strip on risk of operative delivery (cesarean surgery and instrumental vaginal delivery) and on 5-minute Apgar scores. Three trials totaling 11,259 participants met inclusion criteria. Each trial compared admission EFM (followed by intermitted auscultation in women with reassuring fetal heart rate) with no admission EFM (intermittent auscultation beginning immediately upon admission). When meta-analysis was performed on the pooled data from all three trials, results showed statistically significant increases both in the likelihood of cesarean surgery and in the likelihood of instrumental vaginal delivery. Low-risk women undergoing admission EFM were 10% more likely to have an instrumental vaginal delivery and 20% more likely to have cesarean surgery than women undergoing intermittent auscultation. No statistically significant difference was found for low 5-minute Apgar scores. However, even with meta-analysis, the study may have been underpowered (not large enough) to detect a true difference in Apgar scores. Significance for Normal Birth: In hospitals, low-risk women who have intermittent auscultation in labor usually undergo 20 minutes of continuous electronic fetal monitoring on hospital admission. This "admission strip" is seen as a no-risk intervention that helps reassure hospital staff - who are often more comfortable with EFM - that the women are indeed at low risk of complications. Like continuous EFM, admission EFM became widespread before any studies showing clinical effectiveness. Also like continuous EFM, admission EFM turns out not to produce anticipated benefits while increasing harms in the form of increased use of operative delivery. Laboring women are vulnerable to changes in their environment. Labor often slows down when women arrive at the hospital while they become comfortable with their new surroundings. Their emotional response and thus their ability to cope with the demands of labor may also be affected. Unnecessary admission procedures, especially those that restrict movement, can significantly affect how labor unfolds. They can also shift caregiver attention away from the emotional and physical needs of the woman. Admission EFM sets the tone for a high-tech hospital experience and may be the first step on the well-documented cascade of interventions. Summary: This qualitative case study analysis illuminates the forces behind the underutilization of midwives in the U.S. maternity care system and the process of their professional marginalization. The researcher identified two prominent midwifery services that had good outcomes and were connected with prestigious and influential institutions. One was a university-affiliated hospital practice that had provided uninterrupted midwifery service to the community for nearly five decades. The other was a birth center in continuous operation for nearly 30 years and hospital-owned for the final seven. Both practices were threatened with closure in 2003. In the case of the university-affiliated practice, the midwives ultimately maintained their ability to practice but the hospital imposed restricted clinical practice guidelines resulting in an 84% decrease in the number of midwife-attended births and a number of midwives leaving the service. The birth center practice closed abruptly in a decision handed down by the hospital without the involvement of the center's Board of Directors. In order to understand the circumstances behind the closures, the researcher conducted 52 in-depth interviews with midwives, nurses, service administrators, childbirth educators, policymakers, and physicians and reviewed archival data such as email correspondence, policy statements and memos. In both cases, the publicly articulated reason for the attempted or actual closure of the midwifery services appeared to be reasonable. In the university-affiliated practice, the hospital claimed that too many of the women in the neighborhoods served by the hospital were high-risk and midwifery care was therefore unsafe. In the case of the birth center, the hospital reported that the decision to close was prompted by a 400% increase in malpractice insurance premiums. In neither case did the hospital provide any documentation or other evidence to support these rationales for closure. Interviews and analysis of archival data revealed that the midwifery services represented competition to the hospital, local physicians, or both. The case of the university-affiliated midwifery practice was particularly overt: the hospital had recently paid a multi-million dollar fine for double-billing the Medicaid program for births attended by midwives - once for the midwife and again for the consulting physician. When this fraudulent practice was discovered and the hospital was censured, midwives became a source of competition rather than income. In the case of the birth center, five-fold growth in the number of birth center births over the time the hospital had ownership may have appeared to be siphoning business away from the hospital's labor and delivery unit. Despite these potentially powerful economic and political motives for closing the midwifery services, the public were led to believe that the decisions were driven by rational concerns about safety and liability. The author concluded, "In the cases studied, institutions successfully altered maternity care and diminished midwifery services without accountability for their actions. In fact, the elimination of midwives seemed to be a rational decision when framed in the context of patient safety and the rising cost of medical malpractice" (p. 9). The author explored aspects of the U.S. health care system that facilitate professional marginalization of midwives. The most problematic is the way the U.S. medical education system is funded. Hospitals essentially get paid twice for care provided by medical residents because they can bill directly for the care and also receive large subsidies from the federal Medicare program in exchange for providing residency opportunities. The more residents a hospital employs, the more federal money they get, so there is a government-imposed disincentive for hospitals to employ midwives. Furthermore, in many states midwives must have formal practice agreements with physicians in order to obtain licenses, liability insurance, reimbursement, or hospital privileges. This requirement makes midwives dependent on their competition in order to gain access to employment. Finally, midwives' reliance on low-tech care practices result in lower utilization of medical devices and services that may be separately billable. Significance for Normal Birth: Advocates for improvements in maternity care are often at a loss to explain why childbearing women cannot access care providers who support normal birth. Normal, physiologic birth, it would seem, must be less costly than technology-intensive birth. Solving this paradox requires an understanding of the political and economic forces that foster dependency on high-cost obstetrics to the detriment of women and babies. While this study is small and focused on two specific examples of midwifery service closures, it provides important insight into the systemic forces that hinder women's access to midwifery care despite a large body of evidence that midwives provide equal or better care than physicians with lower reliance on costly technical interventions. The study documents how our market-based health care system safeguards the interests of the medical profession which can often be at odds with those of women, babies, and society. Radical, systemic reforms are needed if the United States hopes to achieve a high-functioning maternity care system, characterized by effective, high-quality care, universal access, and cost containment. Evidence from countries with excellent maternity care outcomes suggest that eliminating barriers to midwifery care must be a priority. Birth advocates can begin by calling for accountability and transparency from hospitals and maternity care providers. |
|
|
