Tag Archives: MPH

My pretend grant application

I am taking a grant writing class. I want to collate outcome statistics for the birth center where I trained in Miami. Here is the background research section of my assignment so far. This will be pretty long, so if you’re into that kind of stuff, enjoy. I am not going to spend any time fiddling with the formatting. Sorry, it looked great in Word. It is hell to read in this format. I am hoping to use this for a real grant application, and hopefully get a research fellowship.

Maternal morbidity and mortality, especially that of women of color and/or low socioeconomic status, is a problem in the United States. Despite skyrocketing rates of medical interventions in labor and delivery, including the majority of labors being artificially induced or augmented1, infant mortality in the United States is ranked 25th among industrialized nations. The maternal mortality rate in the United States has not fallen since 1982, nor have disparities of maternal mortality between African American mothers and white mothers. The national maternal mortality rate for African American mothers is three to four times the rate of white mothers2, and this discrepancy is reflected in the maternal mortality rates in Miami-Dade county. In fact, in some recent years, the maternal mortality rate for non whites in Miami-Dade county has been more than ten times that of whites, reaching about 50 per 100,000 twice in the past decade.3
Other indicators of maternal and infant health have been outlined by the Healthy People 2010 as maternal and infant child health objectives, spearheaded by the U.S. Department of Health and Human Services. Along with maternal and infant mortality rates, the report recommends reductions in cesarean section rates, which have topped 30% nationally. 4 This increase has occurred without a corresponding decrease in Neonatal Intensive Care Unit (NICU) admissions.5 without reductions in low birth weight and preterm deliveries, and increases in early prenatal care and initiation and continuation of breastfeeding. All of the maternal and infant health outcomes under surveillance in the report are stratified according to race, and all show similar disparities between African Americans and whites.6 These disparities are all either identical or magnified in Miami-Dade County.7
Forty two years ago, Scottish epidemiologist Archie Cochrane awarded a “wooden spoon” to obstetrics in his book Effectiveness and Efficiency: Random Reflections on Health Services, a dubious honor awarded by use of treatments without scientific justification. His criticism inspired the development of the Cochrane Pregnancy and Childbirth Database, an online database evaluating evidence-based medical practice. Unfortunately, even with this source of data for justifying interventions, it seems that many standard practices prevalent in typical hospital care are not indicated for nor supportive of a healthy, normal birth. Jennifer Block laments in her 2007 book, Pushed: The Painful Truth About Childbirth and Modern Maternity Care:

A common theme emerges in the history of obstetric care: procedures and devices developed for the treatment of abnormality rather quickly become routine practice in the name of prevention, and then simply in the name of speeding up and ordering an unpredictable, at times tedious, process. 8

If our goal is to improve maternal and child outcomes, using evidence based care is our best chance at results. Although the Cochrane database is a valuable tool for evaluating randomized studies of single treatments, birth does not occur in a vacuum. If actual institutions are achieving better outcomes, there are lessons to be learned from retrospective studies of successful protocols and practices. This is especially true of patient sample groups with disadvantaged and ethically diverse patients.9
The model of midwifery care has been examined as an alternative to the prevalent paradigm of labor and birth in hospitals. Midwives are twice as likely to care for minority clients.10 Several studies have indicated that births attended my midwives have improved outcomes for low risk patients, even disadvanted patients.11 In fact, not only was midwifery attended births and maternal outcomes among the medically underserved researched in Miami-Dade county, but specific practices, distinct from typical hosptial practices in the United States, were described in the study protocol Study subjects were match controlled to patients at a typical tertiary care center at an adjoining hospital. Patients delivering at the birth center did not have access to regional or general anesthesia, so they were not administered epidurals. No induction or augmentation of labor were performed. Women were encouraged to drink and eat lightly, and were encouraged to move around and change positions during labor. This was made easier by the practice of intermittent auscultation. In the tertiary hospital, as it is in virtually every hospital in the United States, control matched mothers were tethered to a constant external fetal monitor.12 Despite significantly fewer interventions, outcomes were the same between the two groups of low risk, predominantly African American women.
Analysis of protocols and practices in successful institutions can help lead reform in birthing practices, and can avoid the expense and possible negative outcomes of unecessary interventions. Use of metanalysis of controlled studies of individual practices can be field tested in actual real world settings. For example, the Cochrane database review of continuous external fetal monitoring (EFM), more specifically called Continuous cardiotocography (CTG), concludes:

“While specific abnormalities of the fetal heart rate pattern on CTG are proposed as being associated with an increased risk of cerebral palsy (Nelson 1996), the specificity of CTG for prediction of cerebral palsy is low with a reported false positive rate as high as 99.8%, even in the presence of multiple late decelerations or decreased variability (Nelson 1996).

Concerns have been raised about the efficacy and safety of routine use of continuous CTG in labour (Thacker 1995). The apparent contradiction between the widespread use of continuous CTG and recommendations to limit its routine use (RCOG 2001a), indicates that a reassessment of this practice is warranted.”13

Comparisons of continuous monitoring and intermittent auscultation, which involves regular monitoring of fetal heart tones with a handheld Doppler device, have mixed results. The Cochrane review reports a higher risk of neonatal seizure with intermittent auscultation, but no increased risk of NICU admission, cerebral palsy, low Apgar score (a rating of neonatal well being), or perinatal death. EFM was linked to higher risk of cesarean section and operative vaginal delivery, especially in low risk women.The comparison review concludes:

There is a reasonable consensus of opinion that continuous electronic fetal monitoring
should be reserved for women whose fetuses are at high or increased risk of cerebral palsy, neonatal encephalopathy or perinatal death.

The article continues to say that for every neonatal seizure attributable to intermittant monitoring, doctors would be performing eleven cesarean sections.14 Yet, EFM continues to be required in the vast majority of hospital births. It is less common in freestanding birth centers.
Similar conclusions are drawn about the type of birth procedures found in the majority of hospitals in general, termed “active management”. Active management includes induction and augmentation of labor, EFM, and early amniotomy (breaking of the amniotic sac to increase contractions). The Cochrane report on active management warns that a low threashold for early intervention is “not without its risks”, and suggests the frequency of these complications should be better quantified.15 These interventions are specifically outlawed in freestanding birth centers in Florida.16
Other common interventions with dubious efficacy in Cochrane reviews are significantly less common in birth centers than in hospitals. Epidural anesthesia has been linked to longer labor, use of oxytocin, malposition of the fetal head, increased risk of fetal distress, cesarean section, instrumental vaginal delivery, need for neonatal resucitation, maternal hypotension and maternal and neonatal fever.17 Having mothers spend the majority of the first stage of labor in a supine position, practically mandated by the use of EFM and epidurals, has also been linked to potential adverseevents. Lying on her back can compromise maternal blood flow, cardiac function, and the blood supply to the uterus. Studies showed that contractions slowed and weakened when the woman is lying down, and resulted in negative fetal acid-base outcomes.18 Freedom of movement and alternative delivery positions have been shown to decrease episiotomy (an operative incision in the vaginal linked to severe tears), perineal tears, and operative vaginal birth, but increases maternal blood loss.19 Induction of labor is warned to increase maternal and fetal distress, increased cesarean section, and may lead to uterine rupture.20 Restriction of food and fluids, which are replaced with intravenous (IV) therapy for the entirety of labor and birth in almost all hosptial births is more than just restrictive and inconvenient for women. The Cochrane review of this practice questions any medical justification for its widepread application. IV therapy is associated with hypoglycemia in the newborn, immobilization of the mother, fluid overload, maternal stress, and does not provide required nutrients for labor and delivery.21
Some practices that are frequently found in midwifery based care, but not in typical hosptial care, are also reviewed in the Cochrane database. Continuous support of a woman in labor, usually provided by a trained birth attendant called a doula, has been shown to have numerous benefits, including women who were more satisfied with their birth experience, reduced cesarean section rate, increased spontaneous vaginal birth, slightly shorter duration of labor, less use of analgesia or anesthesia, and reduced maternal fear and stress, without any plausible risks. The report concludes that continuous labor support “should be the norm, rather than the exception.” Costs of private doula services maybe a barrier to access for lower income women. Some hospitals have started to fund doula services.22
Although the reviews in the Cochrane database emphasize the need for randomized controlled trials of single interventions, pregnancy, labor and birth continue in real communites without randomization. Successful care with improved maternal outcomes and reduced intervention can be a guide for effective care for similar populations, or a guide for protocols for intervention studies in nearby hospitals. It is not one intervention, but the general atmosphere of drastically over treating labor and birth that seems to be the problem. As one review warns, “any effect on caesarean section rates from a policy of active management is as a result of the combination of interventions rather than the individual interventions.” Midwives and freestanding birth centers do not have an exclusive claim on expectant management of labor and birth. Even with use of continuous support during labor, the reviewers recommendations indicate that:

“Policy makers and hospital administrators in high income countries who wish to effect clinically important reductions in inappropriately high caesarean rates should be cautioned that continuous support by nurses or midwives may not achieve this goal, in the absence of other changes to policies and routines.”

Using a combination of evidence based reivews, retrospective analysis of successful programs already serving the target population, and selective ethical randomized trials, maternity care and outcomes can improve, even in demographically high risk populations.

References

1. Declercq ER et al. Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbirthing Experiences. New York: Childbirth Connection; 2006.
2. U.S.Department of Health and Human Services. Maternal, Infant and Child Health. Healthy People 2010; With Understanding and Improving Health and Objectives for Improving Health. 2 ed. Washington, D.C.: U.S. Government Printing Office; 2008.
3. Rivera L, Leguen F. Vital and Morbidity Statistics 2003. Miami-Dade County Health Department; 2008.
4. U.S.Department of Health and Human Services. Maternal, Infant and Child Health. Healthy People 2010; With Understanding and Improving Health and Objectives for Improving Health. 2 ed. Washington, D.C.: U.S. Government Printing Office; 2008.
5. Resnik R. Can a 29% cesarean delivery rate possibly be justified? Obstet Gynecol 2006 April;107(4):752-4.
6. U.S.Department of Health and Human Services. Maternal, Infant and Child Health. Healthy People 2010; With Understanding and Improving Health and Objectives for Improving Health.
7. Riviera et al, Vital and Morbidity Statistics 2003.
8. Block J. Pushed: The Painful Truth About Childbirth and Modern Maternity Care. Cambridge: De Capo Press; 2007.
9. Raisler J, Kennedy H. Midwifery care of poor and vulnerable women, 1925-2003. J Midwifery Womens Health 2005 March;50(2):113-21.
10. Declercq ER et al. Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbirthing Experiences.
11. Raisler and Kennedy, Midwifery care of poor and vulnerable women.
12. Scupholme A, McLeod AG, Robertson EG. A birth center affiliated with the tertiary care center: comparison of outcome. Obstet Gynecol 1986 April;67(4):598-603.
13. Alfirevic Z. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews 2006 April 24;(2).
14. Devane D. Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing. Cochrane Database of Systematic Reviews 2004 September 16;(2).
15. Wei SQ. Early amniotomy and early oxytocin for delay in first stage spontaneous labor compared with routine care. Cochrane Database of Systematic Reviews 2007 June 21;(2).
16. Birth Center Licensure Act, XXIX, Florida Legislature, (2007).
17. Anim-Somuah M. Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews 2005 August 16;(2).
18. Lewis L. Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews 2002 August 26;(2).
19. Gupta JK. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews 2003 April 25;(2).
20. Singata M. Restricting oral fluid and food intake during labour. Cochrane Database of Systematic Reviews 2002 August 2;(2).
21. Hofmeyr GJ. Methods for cervical ripening and labour induction in late pregnancy: generic protocol. Cochrane Database of Systematic Reviews 2000 February 15;(2).
22. Hodnett ED. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2007 April 18;(2).
23. Brown H. Package of care for active management in labour for reducing caesarean section rates in low-risk women. Cochrane Database of Systematic Reviews 2004 April 27;(2).
24. Hodnett, Continuous support for women during childbirth.

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Screeching to a halt

My summer vacation will end Monday morning when I return to class. I will be an M2 (jargon for a second year student in medical school), with new hard classes like pharmacology *shudder*, plus the added responsibility of being an officer in a few clubs and two MPH classes. Oh, and I am going to try out working for the notes service a few hours a week.

I have already started having nightmares.

I am doing research for a grant writing class (my MPH classes started earlier this summer). I found out that the author of many studies on midwifery care and maternal inequalities is affiliated with the University of Miami Jackson Medical Center, which is where I want to do my residency. I am excited about trying to find her. I am hoping she can come and give a talk about doing research in women’s health.

I am also thrilled to see this kind of a paragraph in an article about women’s health, especially obstetrics. I love seeing examples that feminist does NOT equal anti motherhood:

“From a feminist perspective, research on childbirth and women’s
health is a means to social change, conducted in partnership
with women and for their benefit.51 Feminists try to make
the research process cooperative and transparent by including
women’s and community groups on research advisory boards
to help formulate research questions, design studies, and
interpret their results. Sometimes women are asked directly
what they want and need from health care, and interventions
are designed on the basis of their responses, rather than on
researchers’ preconceived objectives. A feminist perspective
could add an important new dimension to research on midwifery
care of the poor by involving women as partners as
well as subjects.”

from Midwifery Care of Poor and Vulnerable Women, 1925-2003, by Raisler and Kenndey, J Midwifery Womens Health 2005;50:113–121

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More on home birth, and my class!

(Note: Many of my older posts are transferred from my old blog, and all of the links are broken. I may, one day, have time to come back and re-link the posts. Maybe. This post would be high on the list if that ever happens. Sorry!)

I love my new online public health class. It is a class about culture and health, and the class is run as a discussion board. *Squeal!!!!*

This week’s topic is reproduction in different cultures. *Double squeal!!!*

Here is a copy of my post on the class board about homebirth in the US, UK, and the Netherlands:

There is a hubbub brewing right now, since the American Medical
Association (AMA) just passed a resolution encouraging state legislation
regulating childbirth, specifically to regulate that childbirth only
takes place in a hospital or a licensed freestanding birth center.

link

The American College of Obstetrics and Gynecologists (ACOG) adopted a
similar resolution, originally also discouraging birth in freestanding
birth centers. An outpouring of negative reaction, with evidence, led
them to revise their position to admit that free standing birth centers
have a strong safety record. However, the ACOG resolution was just a
position statement. This AMA resolution recommends drawing up model
legislation to enforce the position.

The most recent study on home births in the United States shows them to
not only to be safe, but to have better outcomes than comparable low
risk deliveries in US hospitals:

link

Currently, 30% of babies are delivered at home in the Netherlands, and
they enjoy a much lower maternal mortality rate and infant mortality
rate than the US.

link

The Royal College of Obstetricians and Gynaecologists (RCOG) issued a
joint statement with The Royal College of Midwives (RCM) (they work
together in the UK! and in the Netherlands! Imagine…integrated care!)
supporting and even encouraging home birth. They also enjoy a much lower
rate of maternal and infant perinatal morbidity and mortality than the US.

link

I broke the format rules. Consider that all one paragraph! As for my
opinion, I think it is clear that I support home birth in the full
spectrum of reproductive choice and informed consent. I am afraid that
obstetrics, the field I love and plan to practice, is in a very confused
state in the United States. Interventionist practices are not based on
evidence of improved outcomes. I just spoke to an attending at the
closest Ob/Gyn residency who was appalled by the practices she saw when
she started at that well renowned research and teaching hospital. What
was the most appalling to her, and to me, is not simply that these are
medical interventions. We are all in support of life saving technology.
But, when these interventions have been shown in easily accessible peer
reviewed research to lead to negative perinatal outcomes, why have they
become standard of care in normal pregnancy instead of in the rare cases
that they are indicated?

Announcement of bias/conflict of interest: I trained as a midwife for
two years, and had both of my children with a midwife. One in a
hospital, one in a freestanding birth center. I have attended births in
hospitals, including cesareans, in birth centers and at homes. I am
training to be an Ob/Gyn, however, so you can take anything I say with
whatever flavor grain of salt you like.

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