William H. Swartz

Outcomes, Safety, and Resource Utilization in a Collaborative Care Birth Center Program Compared With Traditional Physician-Based Perinatal Care

OBJECTIVE We compared outcomes, safety, and resource utilization in a collaborative management birth center model of perinatal care versus traditional physician-based care. METHODS We studied 2957 low-risk, low-income women: 1808 receiving collaborative care and 1149 receiving traditional care. RESULTS Major antepartum (adjusted risk difference [RD] = -0.5%; 95% confidence interval [CI] = -2.5, 1.5), intrapartum (adjusted RD = 0.8%; 95% CI = -2.4, 4.0), and neonatal (adjusted RD = -1.8%; 95% CI = -3.8, 0.1) complications were similar, as were neonatal intensive care unit admissions (adjusted RD = -1.3%; 95% CI = -3.8, 1.1). Collaborative care had a greater number of normal spontaneous vaginal deliveries (adjusted RD = 14.9%; 95% CI = 11.5, 18.3) and less use of epidural anesthesia (adjusted RD = -35.7%; 95% CI = -39.5, -31.8). CONCLUSIONS For low-risk women, both scenarios result in safe outcomes for mothers and babies. However, fewer operative deliveries and medical resources were used in collaborative care.

Pulsatile Gonadotropin-Releasing Hormone Release from the Human Mediobasal Hypothalamus in vitro: Opiate Receptor-Mediated Suppression

An in vitro perifusion system was used to investigate pulsatile gonadotropin-releasing hormone (GnRH) release from the fetal (20-23 weeks of gestation) and adult human mediobasal hypothalamus (MBH). Fetal human MBHs released GnRH in discrete pulses, with a periodicity of approximately 1 h. Adult human MBHs also released GnRH in a pulsatile manner, with a periodicity of 60-100 min. The calcium-dependent pulsatile GnRH release from fetal human MBHs was suppressed by addition of morphine (10 microM) to the perifusion medium, and this suppression was reversed by addition of the opiate receptor antagonist naloxone (10 microM). These results indicate that the human hypothalamic GnRH pulse-generating mechanism is located entirely within the MBH, and that this pulse generator can maintain intrinsically pulsatile GnRH release independent of all innervation from outside this site. Our data also demonstrate that human hypothalamic pulsatile GnRH release can be suppressed by an opiate receptor-mediated mechanism located within the MBH.

Impact of Collaborative Management and Early Admission in Labor on Method of Delivery

OBJECTIVE This study compared the effects of early admission in labor and perinatal care provider on delivery method. Higher spontaneous vaginal delivery rates for certified nurse midwives as compared with physicians have been reported in observational studies and randomized clinical trials. Certified nurse midwives, with their more expectant approach to labor management, would be expected to admit women later in labor than obstetricians. METHODS Prospective cohort study of 2,196 low-risk pregnancies, with singleton, vertex infants admitted in spontaneous labor. Independent and joint effects of perinatal care provider and cervical dilation at admission on delivery method were evaluated. Confounding was addressed using restriction and multiple regression. RESULTS Fewer (23.4%) women in collaborative care were admitted in early labor (< 4 cm cervical dilation) than women managed by obstetricians (95% CI = -27.6 to -19.2). Obstetrician care had 9% to 30% fewer spontaneous vaginal deliveries. Women admitted early in labor also had 6% to 34% fewer spontaneous vaginal deliveries. Evaluation of joint effects suggested that interaction between obstetrician provider and earlier admission increased the risk of operative delivery. CONCLUSION Later admission in labor (at 4 cm or greater cervical dilation) and management of perinatal care by certified nurse midwives in collaboration with obstetricians increased the rate of spontaneous vaginal delivery in low-risk women.

INTRINSIC PULSATILITY OF ACTH RELEASE FROM THE HUMAN PITUITARY IN VITRO

An in‐vitro perifusion system was used to investigate spontaneous ACTH release from human fetal (21–23 weeks gestation) and adult pituitaries. The pattern of ACTH release from fetal pituitaries (n= 7) exhibited a remarkable pulsatile character with a mean (± SEM) pulse interval of 11.3 ± 0.8 min. The mean pulse amplitude was 49.7 ± 6.3 pg, with a nadir to peak increment of 90.7 ± 10.4%. The mean ACTH release rate was 87.2±13.3 pg/2 min. Addition of the calcium chelator EGTA (4 nM) to the perifusion medium induced a significant (p±0.01) decrease in both ACTH release rate (from 102.0 ± 8.5 to 52.0 ± 9.9 pg/2 min) and ACTH pulse amplitude (from 57.7 ± 2.8 to 31.3 ± 4.6 pg) (n= 3). Administration of either 2 nM corticotrophin releasing factor (CRF) or 56 mM KCl induced 10‐ and 2‐fold increases in ACTH secretion, respectively (n= 2). Quarters of adult human pituitaries (n– 6) also secreted ACTH in a pulsatile fashion, with a pulse interval of 14.8±1.7 min, pulse amplitude of 86.7± 10.0 pg, nadir to peak increment of 84.5 ± 9.8%, and overall release rate of 167.2 ± 8.8 pg/2 min. These studies demonstrate that ACTH release from the isolated human pituitary in vitro is characterized by high frequency/low amplitude pulses, independent of hypothalamic stimulation. Accordingly, this spontaneous calcium‐dependent pulsatile ACTH release apparently reflects the activity of an intrinsic intrapituitary pulse‐generating mechanism.

Intrinsic pulsatility of luteinizing hormone release from the human pituitary in vitro

An in vitro perifusion system was used to investigate the spontaneous luteinizing hormone (LH) release from 10 human fetal (21–23 weeks of gestation) and 1 adult female pituitaries. The pattern of LH

Pulsatile βendorphin release from the human pituitary in vitro

An in vitro perifusion system was used to characterize spontaneous immunoreactive beta-endorphin (i beta-END) release from 10 human fetal (20-23 weeks gestation) and 2 human adult anterior pituitaries. Spontaneous i beta-END release from fetal anterior pituitaries was pulsatile, with a mean (+/- SE) pulse interval of 9.1 +/- 0.5 minutes, pulse amplitude of 120.8 +/- 46.1 pg with nadir to peak increment of 106.0 +/- 32.9%, and overall release rate of 209.7 +/- 65.0 pg/2 minutes. Blockade of calcium activity with 10 microM verapamil and 4 mM EGTA suppressed the frequency and amplitude of the spontaneous pulsatile i beta-endorphin release (n = 2). Administration of 2 nM human CRF for 20 minutes at the end of 2 perfusions induced 205 and 883% increases of i beta-END release over the preceding basal levels. Administration of 2 nM CRF for 50 minutes at the end of another perifusion led to a greater and prolonged increase (maximum 4620% relative to the immediately preceding basal level) in i beta-END release. Addition of 56 mM KCl during the last 20 minutes of this prolonged CRF stimulation further increased i beta-END release (to 7680% relative to the baseline preceding the CRF stimulation). Each of 4 quarters of adult anterior pituitaries (2 quarters each from 1 male and 1 female) also released i beta-END in a pulsatile fashion, with a pulse interval of 11.8 +/- 2.0 minutes, pulse amplitude of 7.4 +/- 0.8 ng with nadir to peak increment of 51.4 +/- 15.3%, and overall release rate of 21.7 +/- 2.9 ng/2 minutes. These studies demonstrate that i beta-END release from the isolated human anterior pituitary in vitro is characterized by high-frequency pulses, independent of hypothalamic stimulation. This spontaneous calcium-dependent pulsatile i beta-END release apparently reflects the activity of an intrapituitary pulse-generating mechanism.

HUMAN FETAL HYPOTHALAMIC GnRH NEUROSECRETION: DOPAMINERGIC REGULATION IN VITRO

An in‐vitro perifusion system was used to investigate GnRH release from fetal (21–23 weeks gestation) human hypothalami in response to dopamine (DA) and the DA receptor antagonist haloperidol. Administration of 1 μmol/l DA during five perifusions in which 1 μmol/l haloperidol was added to the medium failed to alter basal GnRH release. In contrast DA evoked a rapid and sustained 95·8 ± 20·3% increase (P > 0·01) in GnRH release during five matching perifusions with medium containing the α‐adrenergic antagonist phentolamine. While exposure to 0·01 μmol/l DA failed to alter basal GnRH release during three perifusions, 0·1 μmol/l DA elicited a 145·7 ± 65·2% increase (P > 0·05) in GnRH release in three matching perifusions, indicating a dose‐dependent effect. These studies demonstrate that DA can stimulate in‐vitro release of GnRH from the mid‐gestation fetal human hypothalamus by a DA receptor mediated mechanism.

The BirthPlace collaborative practice model: results from the San Diego Birth Center Study

Objective: The search for quality, cost-effective health care programs in the United States is now a major focus in the era of health care reform. New programs need to be evaluated as alternatives are developed in the health care system. The BirthPlace program provides comprehensive perinatal services with certified nurse-midwives and obstetricians working together in an integrated collaborative practice serving a primarily low-income population. Low-risk women are delivered by nurse-midwives in a freestanding birth center (The BirthPlace), which is one component of a larger integrated health network. All others are delivered by team obstetricians at the affiliated tertiary hospital. Wellness, preventive measures, early intervention, and family involvement are emphasized. The San Diego Birth Center Study is a 4-year research project funded by the U.S. Federal Agency for Health Care Policy and Research (#R01-HS07161) to evaluate this program. The National Birth Center Study (NEJM, 1989; 321(26): 1801-11) described the advantages and safety of freestanding birth centers. However, a prospective cohort study with a concurrent comparison group of comparable risk had not been conducted on a collaborative practice-freestanding birth center model to address questions of safety, cost, and patient satisfaction.Methods: The specific aims of this study are to compare this collaborative practice model to the traditional model of perinatal health care (physician providers and hospital delivery). A prospective cohort study comparing these two health care models was conducted with a final expected sample size of approximately 2,000 birth center and 1,350 traditional care subjects. Women were recruited from both the birth center and traditional care programs (private physicians offices and hospital based clinics) at the beginning of prenatal care and followed through the end of the perinatal period. Prenatal, intrapartum, postpartum and infant morbidity and mortality are being compared along with cost-effectiveness and acceptance of the model by patients. Data collection occurred primarily through medical record abstraction with the addition of two patient questionnaires. Comparability of the cohorts was established by using a validated methodology to determine medical/perinatal risk and birth center eligibility, which included assessment by two CNMs and an independent blind review by a perinatologist. The cost analysis uses a resource-utilization approach and new methodologies such as activity-based-costing to compare costs from both the perspective of the payor and the health care provider. Patient satisfaction was measured using a self-administered patient questionnaire.Results: Current preliminary results from approximately 38% of the final expected study sample are available. Crude and adjusted analysis have been conducted. Overall, the preliminary results suggest similar morbidity and mortality in the two groups. Fetal deaths are 0.75% in the index and 0.64% in the comparison group, with early neonatal deaths at 0.26% and 0.23%, respectively. The traditional care group showed adjusted rate differences of 5.83% more major maternal intrapartum complications and 9% more NICU admissions. While the birth center group showed adjusted rate differences of 5.5% more low birth weight and 0.95% more preterm birth. For other outcomes, the birth center group showed an adjusted rate difference of 22.34% more exclusive breastfeeding at discharge. Also, there was less utilization of cesarean section and assisted delivery in the birth center group as compared to the traditional care group. The adjusted rate difference for normal spontaneous vaginal deliveries in nulliparas was 10.23% more in the birth center group, with similar results in multiparas with and without history of cesarean (28.88% and 7.84%, respectively). Preliminary results also show that the average total cost for pregnancy-related services paid by California Medicaid was

PULSATILE GNRH-STIMULATED LH RELEASE FROM THE HUMAN FETAL PITUITARY IN VITRO : SEX-ASSOCIATED DIFFERENCES

4,550 for the birth center and

Prophylaxis of Minor Febrile and Major Infectious Morbidity following Hysterectomy

5,535 for the traditional care group. Final results based on the full study sample (full data available February 1998) details of payor costs such as provider, facility, NICU, and ancillary along with costs from the health care system perspective and patient satisfaction results will be presented.Conclusion: Current results suggest similar morbidity and mortality between the birth center program and traditional care groups, with less resource utilization translating to lower costs in the collaborative practice model. Results suggest that collaborative practice using a freestanding birth center as an adjunct to an integrated perinatal health care system may provide a quality, lower-cost alternative for the provision of perinatal services.