Birth Settings Research Articles

Why Nurses Are Essential to Research on Birth Outcomes in the United States

In a consensus study on birth settings in the United States, the National Academy of Sciences, Engineering, and Medicine concluded that childbirth outcomes are influenced by quality of care, access to services, and choices of women within the maternity health care system. The United States has one of the highest rates of maternal mortality among the most developed nations in the world, and outcomes are marked by disparities among racial and ethnic groups of women. However, recommendations for improving birth outcomes are limited by the lack of an evidence base related to the physical and psychological safety of women during childbirth. Nurses who care for pregnant women and their infants are dedicated to ensuring that safe, high-quality care is provided during every encounter. Therefore, they are uniquely positioned to conduct the research on the fundamental elements of safety, quality, and inequities in health care that is needed to improve the maternity care system and outcomes for women and infants.

Understanding fear of childbirth among underrepresented populations in the United States.

The purpose of this study was to expand our understanding of fear of childbirth (FOC) by examining the interplay between individual, provider, identity, and culture among women historically underrepresented in FOC research to develop a deeper understanding of FOC. Purposive sampling was used to recruit 22 participants into three different focus groups, each with a unique demographic makeup. The results provide evidence that people's birth experiences and their experiences with fear surrounding childbirth are affected by many other social mechanisms, including relationships with providers, birth setting, race, class, gender, sexual orientation, and ethnicity.

Beweggründe von Frauen in den Niederlanden für die Wahl eines Hochrisiko-Geburtssettings gegen medizinischen Rat – eine qualitative Analyse

Hollander M, De Miranda E, Van Dillen J et al. Women’s motivations for choosing a high risk birth setting against medical advice in the Netherlands: a qualitative analysis. MC Pregnancy Childbirth. 2017; 17: 423. doi: 10.1186/s12884-017-1621-0

Establishing a Foundation for Optimal Feeding Outcomes in the NICU

Many infants in the NICU experience difficulties with oral feeding, which contribute to prolonged length of stay. Oral feeding is a complex task involving sensorimotor functioning of the face, mouth, and larynx, as well as coordination of sucking, swallowing, and breathing. The care provided in the NICU starting at birth sets the stage for future oral feeding. The purpose of this article is to describe strategies that will establish a positive foundation to support optimal oral feeding. Nurses can use these strategies to protect newborns from noxious stimuli and promote positive auditory, tactile, gustatory, and olfactory experiences to optimize neurodevelopment for the complex task of feeding.

Identifying the potential protein biomarkers of preterm birth in amniotic fluid

ObjectivePreterm birth severely threatens neonatal health and life. Although the detailed mechanism of preterm birth is not well understood, accurately predicting preterm birth can help people make preparations in advance, greatly reducing the subsequent health risk of neonates. Therefore, in this study, we aimed to identify potential protein biomarkers of preterm birth in amniotic fluid (AF). Materials and methodsWe first enrolled pregnant subjects and collected their AF samples when they underwent amniocentesis at the second trimester of gestation. After delivery, the collected AF samples were classified into a full-term birth (sample size n = 21) set or preterm birth (n = 36) set, followed by 2-D DIGE and MS/MS assays. ResultsBy doing so, we identified seven potential protein biomarkers of preterm birth, three of which were further validated in all samples with ELISA, including Apolipoprotein A-IV (Apoa4), Lumican (Lum) and Kininogen-1 (Kng1). As a result, all three potential biomarkers were significantly differently expressed between preterm and full-term birth AF samples. Furthermore, without prior classification, we found that these three biomarkers were positively correlated with gestation age (correlation coefficient ranging from 0.25 to 0.38) and were able to predict the occurrence of preterm birth. ConclusionIn this study, by examining amniotic fluid, we identified three biomarker proteins that may facilitate the identification of preterm birth. There three proteins were never reported to be related to preterm birth. Their pathogenesis roles in preterm birth deserve further investigations by using in vitro cell model or in vivo animal model assays.

Birth Settings in America: Outcomes, Quality, Access, and Choice: New Report from the National Academies of Sciences, Engineering, and Medicine.

Kathleen Rice Simpson is a Perinatal Clinical Nurse Specialist in St. Louis, MO, and the Editor-in-Chief of MCN. Dr. Simpson can be reached via e-mail at [email protected] The author declares no conflicts of interest.

The Use of Tranexamic Acid to Prevent Postpartum Hemorrhage

Tranexamic acid (TXA) is an antifibrinolytic pharmacologic agent with demonstrated effectiveness for reducing the incidence of death from blood loss following trauma and major surgery. In intrapartum care, TXA is being used in in conjunction with uterotonic agents to treat postpartum hemorrhage (PPH). Based on the findings of the WOMAN trial that found TXA reduced maternal death due to PPH, the World Health Organization recommends that TXA be part of the standard comprehensive PPH treatment package, and US professional organizations recognize its use as adjunctive treatment for PPH. Evidence suggests that TXA used prophylactically in the setting of cesarean birth may decrease blood loss and the incidence of PPH. There is limited evidence for prophylactic use of TXA in women of all risk categories following vaginal birth but prophylactic use in women who have an a priori risk for PPH is being investigated. This article presents a case in which a midwife identifies a woman in active labor who has significant risk factors for PPH. In consultation with the collaborating obstetrician, TXA is given early during the third stage of labor in addition to the recommended components of active management for the purpose of preventing PPH.

Providing Care for Infants Born at Home.

The American Academy of Pediatrics (AAP) believes that current data show that hospitals and accredited birth centers are the safest settings for birth in the United States. The AAP does not recommend planned home birth, which has been reported to be associated with a twofold to threefold increase in infant mortality in the United States. The AAP recognizes that women may choose to plan a home birth. This statement is intended to help pediatricians provide constructive, informed counsel to women considering home birth while retaining their role as child advocates and to summarize appropriate care for newborn infants born at home that is consistent with care provided for infants born in a medical care facility. Regardless of the circumstances of his or her birth, including location, every newborn infant deserves health care consistent with that highlighted in this statement, which is more completely described in other publications from the AAP, including Guidelines for Perinatal Care and the Textbook of Neonatal Resuscitation All health care clinicians and institutions should promote communications and understanding on the basis of professional interaction and mutual respect.

Distance to Hospital-based Intrapartum Care and Planned Home Birth in Minnesota.

Loss of hospital-based intrapartum services is associated with increases in out-of-hospital births, but less is known about associations with planned home birth. This study explores the impact of distance to hospital-based intrapartum care on planned home birth. Public-use Minnesota birth certificate data were merged with Minnesota Hospital Annual Report data (2011-2016) to test the relationship of miles from maternal residence to hospital-based intrapartum care with planned home birth in Minnesota. Logistic regression models estimated the odds of a planned home birth versus hospital birth as a function of miles to hospital-based intrapartum care. The number of hospitals offering birth services in Minnesota declined by 11% from 2011 to 2016. Moderate (>20-50 miles) and great (>50 miles) distances to nearest hospital-based intrapartum care were associated with increased odds of planned home birth compared with short distances (≤20 miles). Adjusted odds ratios were 3.31 (95% CI, 3.04-3.61) and 3.89 (95% CI, 2.37-6.37), respectively, after adjusting for maternal education, age, and race. Planned home birth was the intended birth setting in 4.3% of births among those living great distances from hospital-based intrapartum care, compared with 1.0% among those living a short distance from hospital-based intrapartum care. Better understanding of how geographical barriers affect preferred birth settings can inform efforts to reduce the impact of hospital-based intrapartum service loss on rural women and their birth outcomes.

Women's Perceptions on the Use of Video Technology in Early Labor: Being Able to See.

Delaying admission to the birth setting until active labor has commenced has known benefits. However, women and their partners often struggle to stay home in early labor. Research on telephone triage during early labor at home has illuminated significant disadvantages with this model of care, contributing to women feeling dissatisfied with the early birth experience. Research conducted with midwives on the potential benefits of using video technology suggests it might be a helpful strategy for early labor support. This study examined women's perspectives on the potential use of this technology. Focus groups and individual interviews were conducted with 23 English-speaking women who experienced spontaneous labor within the last year. The recordings were transcribed verbatim. Content analysis was used to interpret women's perceptions. The women identified potential advantages of video technology in early labor connected to the major theme of being able to see, which could enable closer human connections between the intrapartum care provider, the woman, and her partner, as well as better assessments of labor. This human connection was integral to enhancing empathy and building confidence. Concerns about using video calls during early labor at home focused on privacy issues and the need to practice beforehand. Concerns about privacy depended upon having a prior relationship with the intrapartum care provider and women being able to decide if they wanted to use the technology. One way of optimizing the experience of staying home in early labor and overall satisfaction with the birth experience may be with video technology, which could offer enhancements over traditional telephone triage.

Low-Risk Planned Out-of-Hospital Births: Characteristics and Perinatal Outcomes in Different Italian Birth Settings.

Background: The present observational study aimed to describe women and delivery characteristics and early birth outcomes according to planned out-of-hospital delivery and to compare this information with comparable planned in-hospital deliveries. Methods: 1099 healthy low-risk women who delivered out-of-hospital between 2014 to 2018, with a gestational age of 37–42 completed weeks of pregnancy, with single, vertex babies whose birth was expected to be vaginal and spontaneous were enrolled. Moreover, a case-control study was designed comparing characteristics of these births to a matched 1:5 sample. Results: living in a medium city (RR 1.81, 95% CI 1.19–2.74), being multiparous (RR 1.66, CI 1.09–2.51), having the first child at ≥35 years old (RR 1.84, CI 1.02–3.33), not working (RR 1.77, CI 1.06–2.96), not being omnivorous (RR 1.80, CI 1.08–3.00), and not smoking (RR 2.53, CI 1.06–6.07) were all related to an increased chance of delivering at home compared to in a freestanding midwifery unit. The significant factors in choosing to give birth out-of-hospital instead of in-hospital were living in a large or medium city (OR 2.20; 1.75–2.77; OR 2.41; 1.93–3.02) and having a secondary or higher level of education (OR > 2 for both parents). Within the first week of delivery, 6 of 1099 mothers and 19 of 1099 neonates were hospitalized. Conclusions: out-of-hospital births in women with low-risk pregnancies is a possible option that needs to be planned, monitored, regulated, and evaluated according to healthcare control systems in order to work, as in hospitals, for the safest and most effective care to a mother and her neonate(s).

Creating a culture of respect and interprofessional teamwork on a labor and birth unit: a multifaceted quality improvement project

ABSTRACTInterprofessional teamwork is essential to high-quality healthcare, however disrespect and incivility amongst team members is a challenge to creating and sustaining effective teams. We describe and assess the impact of a multifaceted improvement project with the primary intervention being a Compassionate Communication (CC) training on a Labor and Birth unit. Our hypothesis was this improvement project would increase staff members’ capacity for perspective-taking and self-reflection, which would in turn correlate with positive interpersonal interactions, respect and teamwork. Secondly, we hypothesized that enhanced respect and teamwork would correlate with enhanced affective commitment to the organization. Staff was surveyed midway through the project and 6 months after the CC training. A total of 74 (57%) staff completed the initial pre-training surveys and 50 (38%) staff completed post-training surveys. At 6 months post-CC training we saw changes in self-reflection and an awakening of self-awareness. There were no significant changes in perspective-taking. However, we did see changes in staffs’ perceptions of respect and teamwork. Team members’ affective commitment to the organization increased. In this Labor and Birth setting, a multifaceted improvement project with the primary intervention being CC training was beneficial in improving a culture of respect and interprofessional teamwork.

'She convinced me'- partner involvement in choosing a high risk birth setting against medical advice in the Netherlands: A qualitative analysis.

Home births in high risk pregnancies and unassisted childbirth seem to be increasing in the Netherlands. There is a lack of qualitative data on women's partners' involvement in these choices in the Dutch maternity care system, where integrated midwifery care and home birth are regular options in low risk pregnancies. The majority of available literature focuses on the women's motivations, while the partner's influence on these decisions is much less well understood. We aimed to examine partners' involvement in the decision to birth outside the system, in order to provide medical professionals with insight and recommendations regarding their interactions with these partners in the outpatient clinic. An exploratory qualitative research design with a constructivist approach and a grounded theory method were used. In-depth interviews were performed with twenty-one partners on their involvement in the decision to go against medical advice in choosing a high risk childbirth setting. Open, axial and selective coding of the interview data was done in order to generate themes. Four main themes were found: 1) Talking it through, 2) A shared vision, 3) Defending our views, and 4) Doing it together. One overarching theme emerged that covered all other themes: 'She convinced me'. These data show that the idea to choose a high risk birth setting almost invariably originated with the women, who did most of the research online, filtered the information and convinced the partners of the merit of their plans. Once the partners were convinced, they took a very active and supportive role in defending the plan to the outside world, as well as in preparing for the birth. Maternity care providers can use these findings in cases where there is a discrepancy between the wishes of the woman and the advice of the professional, so they can attempt to involve partners actively during consultations in pregnancy. That will ensure that partners also receive information on all options, risks and benefits of possible birth choices, and that they are truly in support of a final plan.

Neonatal mortality in the United States is related to location of birth (hospital versus home) rather than the type of birth attendant

Planned home births have leveled off in the United States in recent years after a significant rise starting in the mid-2000s. Planned home births in the United States are associated with increased patient-risk profiles. Multiple studies concluded that, compared with hospital births, absolute and relative risks of perinatal mortality and morbidity in US planned home births are significantly increased. To explore the safety of birth in the United States by comparing the neonatal mortality outcomes of 2 locations, hospital birth and home birth, by 4 types of attendants: hospital midwife; certified nurse-midwife at home; direct-entry ("other") midwife at home; and attendant at home not identified, using the most recent US Centers for Disease Control and Prevention natality data on neonatal mortality for planned home births in the United States. Outcomes are presented as absolute risks (neonatal mortality per 10,000 live births) and as relative risks of neonatal mortality (hospital-certified nurse-midwife odds ratio, 1) overall, and for recognized risk factors. We used the most current US Centers for Disease and Prevention Control Linked Birth and Infant Death Records for 2010-2017 to assess neonatal mortality (neonatal death days 0-27 after birth) for single, term (37+ weeks), normal-weight ( >2499 g) infants for planned home births and hospital births by birth attendants: hospital-certified nurse-midwives, home-certified nurse-midwives, home other midwives (eg, lay or direct-entry midwives), and other home birth attendant not identified. The neonatal mortality for US hospital midwife-attended births was 3.27 per 10,000 live births, 13.66 per 10,000 live births for all planned home births, and 27.98 per 10,000 live births for unintended/unplanned home births. Planned home births attended by direct-entry midwives and by certified nurse-midwives had a significantly elevated absolute and relative neonatal mortality risk compared with certified nurse-midwife-attended hospital births (hospital-certified nurse-midwife: 3.27/10,000 live births odds ratio, 1; home birth direct-entry midwives: neonatal mortality 12.44/10,000 live births, odds ratio, 3.81, 95% confidence interval, 3.12-4.65, P<.0001; home birth-certified nurse-midwife: neonatal mortality 9.48/10,000 live births, odds ratio, 2.90, 95% confidence interval, 2.90; P<.0001). These differences increased further when patients were stratified for recognized risk factors. The safety of birth in the United States varies by location and attendant. Compared with US hospital births attended by a certified nurse-midwife, planned US home births for all types of attendants are a less safe setting of birth, especially when recognized risk factors are taken into account. The type of midwife attending US planned home birth appears to have no differential effect on decreasing the absolute and relative risk of neonatal mortality of planned home birth, because the difference in outcomes of US planned home births attended by direct-entry midwives or by certified nurse-midwives is not statistically significant.

Interprofessional Communication and Collaboration During Emergent Birth Center Transfers: A Quality Improvement Project.

Midwifery care in the birth center setting has proven to be a safe and ideal option for some low-risk women. Although rare, perinatal complications that require emergent transfer to a higher level of care can occur in community birth settings. Optimal perinatal outcomes during emergent transfers depend on excellent interprofessional communication and collaboration. The purpose of this quality improvement project was to implement interprofessional emergent birth center transfer mock drills in order to improve communication and collaboration among birth center midwives, local paramedics, and receiving hospital staff during emergent birth center transfers. Birth center midwives and hospital staff provided education sessions on perinatal emergencies and the scope of practice for midwives for local paramedics. Paramedics' knowledge level was assessed with pretests and posttests, before and after the education sessions, respectively. An interprofessional, collaborative mock drill was then organized and included birth center, paramedic, and hospital staff. All participants received a questionnaire after the drill. Mean test scores after paramedic education sessions increased by 43.5% (n = 95, P <.001). The Likert-type scale questionnaire given to mock drill participants after drill completion revealed that 97% indicated probable support for the sustainability of future mock drills in the birth center setting (n = 10). Health care providers can help improve perinatal outcomes during emergent transfers from the community setting by having clearly outlined guidelines and procedures and communicating efficiently with interprofessional members of the health care team. Both interprofessional education sessions and collaborative mock drills are effective methods to increase knowledge of perinatal emergencies, thus improving interprofessional communication and collaboration during emergent birth center transfers.

790: Use of multiple concurrent preterm birth interventions among patients with private versus Medicaid insurance

Several interventions are recommended to reduce risk of preterm birth including vaginal progesterone (VP) for women with short transvaginal ultrasound cervical length (TVUS CL), intramuscular 17 alpha-progesterone caproate (17P) in the setting of prior preterm birth, and cerclage for short TVUS CL in the setting of prior preterm birth. Little is known regarding how often women receive concurrent interventions based on insurance status. The objective of this analysis was to characterize receipt of concurrent preterm birth prevention interventions based on Medicaid versus private insurance. A retrospective cohort study using the MarketScan database from 12/2008 to 1/2015 was performed. Marketscan is a claims-based data source that includes privately insured and Medicaid patients. We identified women with an index preterm birth who underwent a subsequent pregnancy. We then determined receipt of the following interventions: (i)17P, (ii) TVUS CL screening, (iii) cerclage, and (iv) VP based on pharmacy receipts for 17P and VP and billing codes for cerclage and TVUS CL screening. The proportion of women receiving >1 intervention was then determined. Overall, 1103 women with an index preterm birth received 17P in a subsequent pregnancy and 1455 received VP. Of women receiving 17P, 13.3% (n=147) received a cerclage, 75.6% received TVUS CL screening, and 7.8% received VP (n=86). Of women receiving vaginal progesterone, 12.0% received cerclage (n=175). Compared to patients with Medicaid receiving 17P, patients with private insurance receiving 17P were significantly more likely to receive concurrent TVUS CL screening (84.3% versus 73.2%, p< 0.01), cerclage (18.2% versus 12.0%, p=0.01), and VP (15.7% versus 5.6%, p< 0.01). Women with a prior preterm birth with private compared to Medicaid insurance were more likely to receive multiple concurrent preterm birth prevention interventions. Comparative effectiveness research evaluating benefit of concurrent interventions is needed to direct clinical care and resource utilization and optimize outcomes.

Mapping the trajectories for women and their babies from births planned at home, in a birth centre or in a hospital in New South Wales, Australia, between 2000 and 2012

BackgroundIn New South Wales (NSW) Australia, women at low risk of complications can choose from three birth settings: home, birth centre and hospital. Between 2000 and 2012, around 6.4% of pregnant women planned to give birth in a birth centre (6%) or at home (0.4%) and 93.6% of women planned to birth in a hospital. A proportion of the woman in the home and birth centre groups transferred to hospital. However, their pathways or trajectories are largely unknown.AimThe aim was to map the trajectories and interventions experienced by women and their babies from births planned at home, in a birth centre or in a hospital over a 13-year period in NSW.MethodsUsing population-based linked datasets from NSW, women at low risk of complications, with singleton pregnancies, gestation 37–41 completed weeks and spontaneous onset of labour were included. We used a decision tree framework to depict the trajectories of these women and estimate the probabilities of the following: giving birth in their planned setting; being transferred; requiring interventions and neonatal admission to higher level hospital care. The trajectories were analysed by parity.ResultsOver a 13-year period, 23% of nulliparous and 0.8% of multiparous women planning a home birth were transferred to hospital. In the birth centre group, 34% of nulliparae and 12% of multiparas were transferred to a hospital. Normal vaginal birth rates were higher in multiparous women compared to nulliparous women in all settings. Neonatal admission to SCN/NICU was highest in the planned hospital group for nulliparous women (10.1%), 7.1% for nulliparous women planning a birth centre birth and 5.1% of nulliparous women planning a homebirth. Multiparas had lower admissions to SCN/NICU for all thee settings (hospital 6.3%, BC 3.6%, home 1.6%, respectively).ConclusionsWomen who plan to give birth at home or in a birth centre have high rates of vaginal birth, even when transferred to hospital. Evidence on the trajectories of women who choose to give birth at home or in birth centres will assist the planning, costing and expansion of models of care in NSW.

Traumatic childbirth experiences: practice-based implications for maternity care professionals from the woman's perspective.

To explore women's traumatic childbirth experiences in order to make maternity care professionals more aware of women's intrapartum care needs. A qualitative exploratory study with a constant comparison/grounded theory design was performed. Thirty-six interviews were conducted with women who had given birth in a Dutch birth setting. Three themes, playing a profound role in the occurrence of traumatic birth experiences, emerged: (i) lack of information and consent - maternity care professionals' unilateral decision making during intrapartum care, lacking informed-consent. (ii) feeling excluded - women's mal-adaptive response to the healthcare professionals's one-sided decision making, leaving women feeling distant and estranged from the childbirth event and the experience. (iii) discrepancies - inconsistency between women's expectations and the reality of labour and birth - on an intrapersonal level. Women's intrapartum care needs cohere with the concept of woman-centred care, including personalised care and reflecting humanising values. Care should include informed consent and shared decision-making. Maternity care professionals need to continuously evaluate whether the woman is consistently part of her own childbearing process. Maternity care professionals should maintain an ongoing dialogue with the woman, including women's internalised ideas of birth.

Modelling and solving resource allocation problems via a dynamic programming approach

In this paper, resource allocation problems are formulated via a set of parallel birth–death processes (BDP). This way, we can model the fact that resources can be allocated to customers at different prices, and that customers can hold them as long as they like. More specifically, a discretisation approach is applied to model resource allocation problems as a set of discrete-time BDPs, which are then integrated into one Markov decision process. The stochastic dynamics of the resulting system are also investigated. As a result, revenue management becomes a stochastic decision-making problem, where price managers can propose suitable prices to the allocation requests such that the maximum expected total revenue is obtained at the end of a predefined finite time horizon. Stochastic Dynamic Programming is employed to solve the related optimisation problem with the support of an ad-hoc Matlab-based application. Several simulations are performed to prove the effectiveness of the proposed model and the optimisation approach.

Immediate, uninterrupted skin-to-skin contact and breastfeeding after birth: A cross-sectional electronic survey

ObjectiveTo determine the incidence of immediate, uninterrupted skin-to-skin contact and breastfeeding after birth; and which factors are associated with it. DesignCross-sectional e-survey was developed and piloted prior to distribution. Sampling was purposive and included snowball sampling. Associations between maternity care practices and the primary outcome measure were examined using logistic regression. SettingAustralia. ParticipantsWomen who birthed a term baby within the previous three years, in any Australian setting (hospital, birth centre or at home), were eligible to participate. Measurements and findings1200 postpartum women met the eligibility criteria and completed the e-survey. The primary outcome, ‘pronurturance’, included: (1) immediate mother/baby holding; (2) skin-to-skin contact; (3) uninterrupted holding for at least 60 min; 4) breastfeeding in the birth setting. Of 1200 participants, 22% (n = 258) experienced pronurturance. Pronurturance was less likely following caesarean section (adjusted Odds Ratio (aOR) 0.07, 95% Confidence Interval (CI) 0.03–0.17). Pronurturance was more likely with a known midwife during labour and birth (aOR 1.89, 95% CI 1.35–2.65). Contributing to the low rate of pronurturance were lack of antenatal skin-to-skin information; babies being wrapped; women wearing clothing; and non-urgent caregiver interruptions including weighing the baby or facilitating the mother to shower. Key conclusionHealth services must strategically address the institutional processes which delay and/or interrupt skin-to-skin contact and breastfeeding in birth suite and operating theatre settings. Implications for practiceMidwives and midwifery students providing continuity of carer are best placed to provide pronurturance to mothers and babies. Caregivers should educate women about pronurturance antenatally, and actively support immediate, uninterrupted mother/baby skin-to-skin contact and breastfeeding after birth.