Ellen L. Tilden

Planned Out-of-Hospital Birth and Birth Outcomes

BACKGROUND The frequency of planned out-of-hospital birth in the United States has increased in recent years. The value of studies assessing the perinatal risks of planned out-of-hospital birth versus hospital birth has been limited by cases in which transfer to a hospital is required and a birth that was initially planned as an out-of-hospital birth is misclassified as a hospital birth. METHODS We performed a population-based, retrospective cohort study of all births that occurred in Oregon during 2012 and 2013 using data from newly revised Oregon birth certificates that allowed for the disaggregation of hospital births into the categories of planned in-hospital births and planned out-of-hospital births that took place in the hospital after a womans intrapartum transfer to the hospital. We assessed perinatal morbidity and mortality, maternal morbidity, and obstetrical procedures according to the planned birth setting (out of hospital vs. hospital). RESULTS Planned out-of-hospital birth was associated with a higher rate of perinatal death than was planned in-hospital birth (3.9 vs. 1.8 deaths per 1000 deliveries, P=0.003; odds ratio after adjustment for maternal characteristics and medical conditions, 2.43; 95% confidence interval [CI], 1.37 to 4.30; adjusted risk difference, 1.52 deaths per 1000 births; 95% CI, 0.51 to 2.54). The odds for neonatal seizure were higher and the odds for admission to a neonatal intensive care unit lower with planned out-of-hospital births than with planned in-hospital birth. Planned out-of-hospital birth was also strongly associated with unassisted vaginal delivery (93.8%, vs. 71.9% with planned in-hospital births; P<0.001) and with decreased odds for obstetrical procedures. CONCLUSIONS Perinatal mortality was higher with planned out-of-hospital birth than with planned in-hospital birth, but the absolute risk of death was low in both settings. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.).

Group prenatal care: Review of outcomes and recommendations for model implementation

&NA; The intent and delivery of prenatal care have evolved since its formal inception in the early 1900s. Group prenatal care offers an alternative care delivery model to the currently dominant prenatal care model. The group model has been associated with a number of improved perinatal outcomes including decreased preterm birth, higher birth weight, improved breast-feeding initiation and duration, decreased cesarean delivery, and greater patient satisfaction. This article outlines the tenets of CenteringPregnancy, the current dominant form of group prenatal care, reviews literature regarding perinatal outcomes related to group prenatal care, suggests future research agendas, and highlights relevant considerations when implementing this alternate model of prenatal health care delivery. Target Audience Obstetricians and gynecologists, family physicians Learning Objectives After completing this CME activity, physicians should be better able to identify the elements of the CenteringPregnancy group prenatal care model, evaluate which perinatal outcomes have been associated with CenteringPregnancy and similar group prenatal care models, and compare the benefits and risks to implementing a group prenatal care model.

Association between Hospital Birth Volume and Maternal Morbidity among Low-Risk Pregnancies in Rural, Urban, and Teaching Hospitals in the United States

Objectives This study aims to examine the relationship between hospital birth volume and multiple maternal morbidities among low-risk pregnancies in rural hospitals, urban non-teaching hospitals, and urban teaching hospitals, using a representative sample of U.S. hospitals. Study Design Using the 2011 Nationwide Inpatient Sample from 607 hospitals, we identified 508,146 obstetric deliveries meeting low-risk criteria and compared outcomes across hospital volume categories. Outcomes include postpartum hemorrhage (PPH), chorioamnionitis, endometritis, blood transfusion, severe perineal laceration, and wound infection. Results Hospital birth volume was more consistently related to PPH than to other maternal outcomes. Lowest-volume rural (< 200 births) and non-teaching (< 650 births) hospitals had 80% higher odds (adjusted odds ratio [AOR] = 1.80; 95% CI = 1.56-2.08) and 39% higher odds (AOR = 1.39; 95% CI = 1.26-1.53) of PPH respectively, than those in corresponding high-volume hospitals. However, in urban teaching hospitals, delivering in a lower-volume hospital was associated with 14% lower odds of PPH (AOR = 0.86; 95% CI = 0.80-0.93). Deliveries in rural hospitals had 31% higher odds of PPH than urban teaching hospitals (AOR = 1.31; 95% CI = 1.13-1.53). Conclusions Low birth volume was a risk factor for PPH in both rural and urban non-teaching hospitals, but not in urban teaching hospitals, where higher volume was associated with greater odds of PPH.

Cost‐Effectiveness Analysis of Latent versus Active Labor Hospital Admission for Medically Low‐Risk, Term Women

OBJECTIVE To assess the outcomes and costs of hospital admission during the latent versus active phase of labor. Latent labor hospital admission has been consistently associated with elevated maternal risk for increased interventions, including epidural anesthesia and cesarean delivery, longer hospital stay, and higher utilization of hospital resources. METHODS A cost-effectiveness model was built to simulate a theoretic cohort of 3.2 million term, medically low-risk women either being admitted in latent labor (< 4 cm dilation) or delaying admission until active labor (≥ 4 cm dilation). Outcomes included epidural use, mode of delivery, stillbirth, maternal death, and costs of care. All probability, cost, and utility estimates were derived from the literature, and total quality-adjusted life years were calculated. Sensitivity analyses and a Monte Carlo simulation were used to investigate the robustness of model assumptions. RESULTS Delaying admission until active labor would result in 672,000 fewer epidurals, 67,232 fewer cesarean deliveries, and 9.6 fewer maternal deaths in our theoretic cohort as compared to admission during latent labor. Additionally, delaying admission results in a cost savings of

The Effect of Childbirth Self-Efficacy on Perinatal Outcomes

694 million annually in the United States. Sensitivity analyses indicated the model was robust within a wide range of probabilities and costs. Monte Carlo simulation found that delayed admission was the optimal strategy in 76.79 percent of trials. CONCLUSION Delaying admission until active labor is a dominant strategy, resulting in both better outcomes and lower costs. Issues related to clinical translation of these findings are explored.

The Influence of Group Versus Individual Prenatal Care on Phase of Labor at Hospital Admission

OBJECTIVE To synthesize and critique the quantitative literature on measuring childbirth self-efficacy and the effect of childbirth self-efficacy on perinatal outcomes. DATA SOURCES Eligible studies were identified through searches of MEDLINE, CINAHL, Scopus, and Google Scholar databases. STUDY SELECTION Published research articles that used a tool explicitly intended to measure childbirth self-efficacy and that examined outcomes within the perinatal period were included. All articles were in English and were published in peer-reviewed journals. DATA EXTRACTION First author, country, year of publication, reference and definition of childbirth self-efficacy, measurement of childbirth self-efficacy, sample recruitment and retention, sample characteristics, study design, interventions (with experimental and quasiexperimental studies), and perinatal outcomes were extracted and summarized. DATA SYNTHESIS Of 619 publications, 23 studies published between 1983 and 2015 met inclusion criteria and were critiqued and synthesized in this review. CONCLUSION There is overall consistency in how childbirth self-efficacy is defined and measured among studies, which facilitates comparison and synthesis. Our findings suggest that increased childbirth self-efficacy is associated with a wide variety of improved perinatal outcomes. Moreover, there is evidence that childbirth self-efficacy is a psychosocial factor that can be modified through various efficacy-enhancing interventions. Future researchers will be able to build knowledge in this area through (a) use of experimental and quasiexperimental design, (b) recruitment and retention of more diverse samples, (c) explicit reporting of definitions of terms (e.g., high risk), (d) investigation of interventions that increase childbirth self-efficacy during pregnancy, and (e) investigation about how childbirth self-efficacy-enhancing interventions might lead to decreased active labor pain and suffering. Exploratory research should continue to examine the potential association between higher prenatal childbirth self-efficacy and improved early parenting outcomes.

Vaginal birth after cesarean: neonatal outcomes and United States birth setting

INTRODUCTION Group prenatal care, an alternate model of prenatal care delivery, has been associated with various improved perinatal outcomes in comparison to standard, individual prenatal care. One important maternity care process measure that has not been explored among women who receive group prenatal care versus standard prenatal care is the phase of labor (latent vs active) at hospital admission. METHODS A retrospective case-control study was conducted comparing 150 women who selected group prenatal care with certified nurse-midwives (CNMs) versus 225 women who chose standard prenatal care with CNMs. Analyses performed included descriptive statistics to compare groups and multivariate regression to evaluate the contribution of key covariates potentially influencing outcomes. Propensity scores were calculated and included in regression models. RESULTS Women within this sample who received group prenatal care were more likely to be in active labor (≥ 4 cm of cervical dilatation) at hospital admission (odds ratio [OR], 1.73; 95% confidence interval [CI], 1.03-2.99; P = .049) and were admitted to the hospital with significantly greater cervical dilatation (mean [standard deviation, SD] 5.7 [2.5] cm vs. 5.1 [2.3] cm, P = .005) compared with women who received standard prenatal care, controlling for potential confounding variables and propensity for group versus individual care selection. DISCUSSION Group prenatal care may be an effective and safe intervention for decreasing latent labor hospital admission among low-risk women. Neither group prenatal care nor active labor hospital admission was associated with increased morbidity.

Utilizing Datasets to Advance Perinatal Research

BACKGROUND: Women who seek vaginal birth after cesarean delivery may find limited in‐hospital options. Increasing numbers of women in the United States are delivering by vaginal birth after cesarean delivery out‐of‐hospital. Little is known about neonatal outcomes among those who deliver by vaginal birth after cesarean delivery in‐ vs out‐of‐hospital. OBJECTIVE: The purpose of this study was to compare neonatal outcomes between women who deliver via vaginal birth after cesarean delivery in‐hospital vs out‐of‐hospital (home and freestanding birth center). STUDY DESIGN: We conducted a retrospective cohort study using 2007–2010 linked United States birth and death records to compare singleton, term, vertex, nonanomolous, and liveborn neonates who delivered by vaginal birth after cesarean delivery in‐ or out‐of‐hospital. Descriptive statistics and multivariate regression analyses were conducted to estimate unadjusted, absolute, and relative birth‐setting risk differences. Analyses were stratified by parity and history of vaginal birth. Sensitivity analyses that involved 3 transfer status scenarios were conducted. RESULTS: Of women in the United States with a history of cesarean delivery (n=1,138,813), only a small proportion delivered by vaginal birth after cesarean delivery with the subsequent pregnancy (n=109,970; 9.65%). The proportion of home vaginal birth after cesarean delivery births increased from 1.78–2.45%. A pattern of increased neonatal morbidity was noted in unadjusted analysis (neonatal seizures, Apgar score <7 or <4, neonatal seizures), with higher morbidity noted in the out‐of‐hospital setting (neonatal seizures, 23 [0.02%] vs 6 [0.19%; P<.001]; Apgar score <7, 2859 [2.68%] vs 139 [4.42%; P<.001; Apgar score <4, 431 [0.4%] vs 23 [0.73; P=.01]). A similar, but nonsignificant, pattern of increased risk was observed for neonatal death and ventilator support among those neonates who were born in the out‐of‐hospital setting. Multivariate regression estimated that neonates who were born in an out‐of‐hospital setting had higher odds of poor outcomes (neonatal seizures [adjusted odds ratio, 8.53; 95% confidence interval, 2.87–25.4); Apgar score <7 [adjusted odds ratio, 1.62; 95% confidence interval, 1.35–1.96]; Apgar score <4 [adjusted odds ratio, 1.77; 95% confidence interval, 1.12–2.79]). Although the odds of neonatal death (adjusted odds ratio, 2.1; 95% confidence interval, 0.73–6.05; P=.18) and ventilator support (adjusted odds ratio, 1.36; 95% confidence interval, 0.75–2.46) appeared to be increased in out‐of‐hospital settings, findings did not reach statistical significance. Women birthing their second child by vaginal birth after cesarean delivery in out‐of‐hospital settings had higher odds of neonatal morbidity and death compared with women of higher parity. Women who had not birthed vaginally prior to out‐of‐hospital vaginal birth after cesarean delivery had higher odds of neonatal morbidity and mortality compared with women who had birthed vaginally prior to out‐of‐hospital vaginal birth after cesarean delivery. Sensitivity analyses generated distributions of plausible alternative estimates by outcome. CONCLUSION: Fewer than 1 in 10 women in the United States with a previous cesarean delivery delivered by vaginal birth after cesarean delivery in any setting, and increasing proportions of these women delivered in an out‐of‐hospital setting. Adverse outcomes were more frequent for neonates who were born in an out‐of‐hospital setting, with risk concentrated among women birthing their second child and women without a history of vaginal birth. This information urgently signals the need to increase availability of in‐hospital vaginal birth after cesarean delivery and suggests that there may be benefit associated with increasing options that support physiologic birth and may prevent primary cesarean delivery safely. Results may inform evidence‐based recommendations for birthplace among women who seek vaginal birth after cesarean delivery.

Authorship grids: Practical tools to facilitate collaboration and ethical publication

Many organizations collect and make available perinatal data for research and quality improvement initiatives. Analysis of existing data and use of retrospective study design has many advantages for perinatal researchers. These advantages include large samples, inclusion of women from diverse groups, data reflective of actual clinical processes and outcomes, and decreased risk of direct maternal and fetal harm. We review 11 publicly available datasets relevant to perinatal research and quality improvement, detail the availability of interactive websites, and discuss strategies to locate additional datasets. While analysis of existing data has limitations, it may provide statistical power to study rare perinatal outcomes, support research applicable to diverse populations, and facilitate timely and ethical well-woman research immediately relevant to clinical care.

Formulating and Answering High-Impact Causal Questions in Physiologic Childbirth Science: Concepts and Assumptions

Publication of new findings and approaches in peer-reviewed journals is fundamental to advancing science. As interprofessional, team-based scientific publication becomes more common, authors need tools to guide collaboration and ethical authorship. We present three forms of authorship grids that are based on national and international author recommendations, including guidelines from the International Committee of Medical Journal Editors, the Committee on Publication Ethics, National Institutes of Health data sharing policies, common reporting guidelines, and Good Clinical Practice standards from the International Conference on Harmonization. The author grids are tailored to quantitative research, qualitative research, and literature synthesis. These customizable grids can be used while planning and executing projects to define each authors role, responsibilities, and contributions as well as to guide conversations among authors and help avoid misconduct and disputes. The grids also can be submitted to journal editors and published to provide public attribution of author contributions.