New study opens door for integrating maternal care system


The out-of-hospital birth setting in Oregon was associated with a higher risk of perinatal death, while the in-hospital birth setting was associated with a higher risk for cesarean delivery and other obstetric interventions, according a new study.

The study, published in the New England Journal of Medicine by researchers at Oregon Health & Science University, continues the national dialogue about the care, setting and health care systems that can provide more women with a safe, healthy birth that meets their birthing preferences.

"Our findings show that Oregon women are very likely to have a safe delivery in any setting. While those who deliver at home or in birth centers are much more likely to have a normal, vaginal delivery, there is also a small but statistically significant increase in risk for adverse baby outcomes," said Dr Jonathan Snowden, an epidemiologist and assistant professor in the department of obstetrics and gynecology in the OHSU School of Medicine and lead author of the study.

The study, which looked at outcomes for mothers and babies based on birth setting, was conducted using data collected from Oregon birth certificates in 2012 and 2013 on what a mother's intended birth setting was when she went into labor.

The study compared two groups of 'low-risk' pregnancies, meaning the babies were head down, close to their due date, and not twins or triplets. One group was planning hospital birth, the other out-of-hospital birth.

"While the overall risk for perinatal death was low in all settings, the stakes can be high," said Dr Aaron Caughey, professor and chair in the OHSU department of obstetrics and gynecology, associate dean for women's health research and policy in the OHSU School of Medicine, and paper co-author.

"As health care providers, we need to make sure women know what the trade-offs are so they can make an informed choice that reflects their birth preferences."

The paper also addresses the overuse of C-sections in US hospitals, a topic on which Dr Caughey and the research team are nationally known experts.

"There is now consensus in the medical and midwifery communities that the US C-section rate is too high, and the desire to avoid a C-section may shape women's choices when seeking out-of-hospital birth," said Dr Ellen Tilden, assistant professor at OHSU school of nursing and study co-author.

"It's really important that we strive to make birth safer in any setting, both through decreasing fetal and neonatal morbidity and mortality out of the hospital but also through supporting safe vaginal birth in hospitals."

The authors agree that working to integrate the maternal health care system would be a good first step. Specifically, they recommend focusing on: looking to countries with better integrated maternity care systems, like the Netherlands, where midwives are the lead care providers for healthy women; developing formal guidelines for which women are appropriate candidates for out-of-hospital birth; improving communication and collaboration between in- and out-of-hospital providers; and creating an agreed upon transfer system where patients can easily be transferred to a hospital when needed.

Oregon, New England Journal of Medicine, Oregon Health & Science University, Childbirth, Dr Jonathan Snowden, US