Informed Decision Making
Q: This has been on my mind for quite some time. When a provider (midwife or family practice MD, in particular) claims to have a C-section rate of 1% what does that mean, really? When it is a provider who does not perform C-sections (not an OB), at what point to they still claim that patient as theirs and include that surgical birth in their statistics? And at what point is the patient considered transferred out of their care, and into the OB's care?
I suspect that this is a key issue when asking a provider's statistics. I also have trouble trusting that providers who claim such a low C-section rate are actually talking about 1% of all patients under their care during pregnancy. Several providers in my area claim this, but I personally know moms who ended up with a surgical birth (often after an induction for dates, not a medical emergency)--either a coincidence or they are skewing their numbers. Anyone have any thoughts on this??
A: You make an excellent point. It is important to clarify exactly what practitioners mean when they tell you their cesarean rate. For care providers who do not perform cesareans (all midwives and most family docs), their cesarean rate conventionally means the rate in women still eligible for that practitioner's care at the onset of labor. So a woman who goes into preterm labor would not be eligible for an out-of-hospital midwife's care. And for a home birth midwife who did not have hospital privileges, the woman would have transferred out of her care if she was admitted to the hospital for induction--I specified hospital admission for induction because home birth midwives may use various induction techniques that don't involve hospital admission. But for midwives and family docs with hospital privileges, the woman having labor induced would usually still be cared for by her midwife or family doc, that is, unless the reason for induction was a medical complication outside of their scope of practice.
Q: Any thoughts you can share on the study "Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: prospective cohort study"?
A: Here is the link to the actual study, it can be downloaded for free online, and draw your attention to a couple of rapid responses critiquing it and the investigators' response to their critiques. Scroll down the rapid responses to "Too early to question effectiveness of Dutch maternity care system" posted by De Jonge et al. and "Home or hospital delivery, who will sing the blues?" by Pop and Wijnen then go back to the investigators' response "Re: Too early to question effectiveness of Dutch maternity care system." If you haven't read the study already or the rapid response dialog, that may be enough for you to make up your own mind. Here, too, to help you with your critical thinking process are links to Science and Sensibility blogs on "Questions to ask about original research" and "Questions to ask about quantitative research." Let me add, too, that it might be wise to keep in mind that there is a movement in the Netherlands, just as there is here in the U.S., to discredit the safety of independent midwifery care and home birth and to convince the public and regulatory agencies that births should only take place in hospitals under the supervision of obstetricians. It may not be coincidental that the authors are all ob-gyns and pediatricians, with the exception of one secondary care midwife, and that the study follows on a large study establishing the safety of home birth in the Netherlands published the previous year. (FYI: De Jonge, one of the rapid response writers, was lead author on the home birth study.)
Q: As I have observed and participated in the debate of the safety of homebirth, I have seen several fundamentals:
- The Industrial Medical Complex’s point of view is that there will be an excess of intrapartum fatalities with homebirth. In fact, it is [some individuals] mission in life to try and illustrate that the hospital (intrapartum+neonatal) mortality rate is lower than Johnson and Davis established in their fine study of home birth.
- The rate of excess interventions is considered as residing in the category of inconvenience unless there is a fatality to be counted.
- [Homebirth advocates] tend to argue that the (excess) interventions in hospitals degrade safety when safety is viewed beyond counting dead babies and dead moms.
So, the engineer in me says we need a common currency to roll up all of the (technical) issues related to the safety of the birth setting (or the birth model). It seems to me we need a Composite Safety Index (CSI). This is a thing I have not seen. I have not thought this through entirely, but I think this metric might have the following attributes:
- There is a single numerical value representing the safety of the setting.
- Every defect associated with an intervention is identified.
- The rate of interventions is reasonably established.
- There is a reasonable transfer function that relates the defects associated with hospital birth to an intrapartum fatality. In other words, a single maternal mortality per 1000 births might have a score of 2 while a neonatal fatality might have a score of 1 (lower is better). Now…an inadvertent hysterectomy due to a C/S may score equal to an intrapartum fatality (i.e. a lost opportunity dead baby). Similarly, excess miscarriages due to excess C/S count equally as an intrapartum fatality. A long term, but not fatal injury (e.g. skeletal damage associated with forceps), would carry a lower score (perhaps 0.5 or 0.1). Moderate issues (i.e. pneumonia acquired in the hospital that is adequately addressed) carry a low score (perhaps 0.01 to 0.1).
- Inconvenience carries no penalty.
- So, this safety index could be a summation of the following form:
CSI = ?? (Cij*Ri*Dij)
i = Intervention or event
j = Defects (e.g. intrapartum fatality, miscarriage due to C/S, etc…)
Cij = Defect Score (e.g. 2 for maternal mortality, 1 for intrapartum mortality, etc…)
Ri = Intervention Rate (e.g. 5% C/S rate for home birth and 30% for hospital)
Dij = Probability of a Defect per intervention
For every intervention (i) there could be a number of defects (j). While I’m sure that the Defect Score would be meat for lots of argument and it would be a lot of work to survey the studies to estimate the probability of a defect, it seems to me this could be helpful in setting policy.
Has such a thing been attempted?
A: As it turns out, what you have proposed is an example of "great minds thinking alike." The American College of Nurse-Midwives has developed the Optimality Tool, a method for measuring the quality of maternity care systems. An optimal birth is one in which the best outcomes have been achieved with the least use of medical intervention. It has a yes/no scoring system for labor events and outcomes that incorporates obstetric history and current health so that apples can be compared with apples. All items are based in the research evidence. For more information, go to Optimality Index. My boss at Lamaze, a nurse midwife herself, envisions a day when women will compare their Optimality scores the way they sometimes compare Apgar scores today.
The questions and answers offered in this section are from evidence-based information, and archived from the Lamaze Ask Henci forum that was available through 2014. For medical advice, please see your care provider.