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The Use of Data for Decision Making: ACOG’s Committee Opinion #476
Planned Home Birth
William H. Barth, Jr., M.D.
11 July 13
Disclosures
• I am an obstetrician whose salary is supported by attending hospital deliveries
• ACOG Fellow
• Past Chair of the ACOG Committee on Obstetric Practice and primary author for the “Planned Home Birth” Committee Opinion
• I am the Medical Director for a hospital based midwifery practice in Boston (Supervisor)
Objectives• Describe the genesis of ACOG’s
Committee Opinion on Planned Home Birth
• Describe limitations of existing data sets
• Describe features of the ideal data set from a decision making perspective
• 2003 US Standard Certificate of Live Birth: possible birth setting specific modifications
Outcome of planned home births in Washington State: 1989 to 1996
Pang JYW, et al. Obstet Gynecol 2002;100:253-9
Study design: Retrospective cohort studyData source: Birth certificatesCountry/State/Province: Washington State
Outcome of planned home births compared to hospital births in Sweden between 1992 and 2004. A population-based register study
Outcome Planned HomeN = 897
Planned HospitalN = 11,341
RR (95% CI)
Neonatal Death 2.2/1000 0.7/1000 3.6 (0.2 – 14.7)
Cesarean section 22 (2%) 776 (7%) 0.4 (0.2 – 0.7)
Operative vaginal 20 (2%) 1089 (10%) 0.3 (0.2 – 0.5)
Sphincter rupture 3 (0.3%) 311 (2.7%) 0.2 (0.2 – 0.7)
Lindgren HE, et al. Acta Obstet Gynecol Scand 2008;87:751
Study design: Retrospective cohort studyData source: Swedish Medical Birth Register +Country/State/Province: Sweden
de Jonge A, et al. BJOG 2009;116:1177-84
Study design: Retrospective cohort studyData source: National perinatal database (3 linked files) Country/State/Province: Netherlands
Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births
Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician
Janssen PA, et al. CMAJ 2009;181:6-7.
Study design: Population-based cohort studyData source: provincial Perinatal database registryProvince: British Columbia
Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician
Study design: Population based cohort studyData source: provincial Perinatal database registryProvince: British Columbia
Janssen PA, et al. CMAJ 2009;181:6-7.
Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario,
Canada, 2003-2006: A retrospective cohort study
Hutton EK, et al. Birth 2009;36:180-9
Study design: Retrospective cohort studyData source: Ministry of Health database of Midwifery CareCountry/State/Province: Ontario, Canada
ACOG Process for Committee Opinion
• Subject proposed to committee (many prompts)• Primary author assigned• Professional literature search provided• Draft provided prior to Committee• Discussed by Committee (ACOG Fellows, AAP, AAFP,
ACNM, NICHD, CDC, SMFM, ACOG Staff)• Revised draft reviewed 6 months later• Sent to Clinical Document Review Panel• Sent to ACOG Executive Committee• Published in Obstetrics and Gynecology and online• ACOG Press Release• Reviewed for content, relevance and need 18-24 months
Maternal and newborn outcomes in planned home birth vs.. planned hospital births: a meta-analysis
Wax JR, Lucas FL, Lamont M, et al. Maternal and newborn outcomes in planned home birth vs.. planned hospital births: a metaanalysis. Am J Obstet Gynecol 2010;203:243.e1-8.
Maternal and newborn outcomes in planned home birth vs. planned hospital births: a meta-analysis
Wax JR, Lucas FL, Lamont M, et al. Maternal and newborn outcomes in planned home birth vs. planned hospital births: a metaanalysis. Am J Obstet Gynecol 2010;203:243.e1-8.
“In response to the concerns that were expressedin the letters, the American Journal of Obstetrics andGynecology convened an independent review panel to (1) review the article that was published and these letters to the editors and (2) make recommendations to the Journal. The review panel consisted of 3 panelists who are all specialists in maternal fetal medicine, with expertise in metaanalysis and clinical research.”
“In all 3 cases, the results the panel found were slightly different from the result in the manuscript,although there was no difference in (1) the direction of the point estimate of the pooled odds ratio or (2) the overall “statistical significance” of the result. The panel made the following recommendations: (1) The Journal should publish online full summary graphs for each outcome that was assessed in the study, which will allow readers to assess the study findings better, and (2) no retraction of the article is necessary.”
Personal Observations• Review process is far more rigorous than
standard journal “peer review”• Written from a US perspective
– Great regional variation in healthcare infrastructure and access
– Cautious use of data from outside the US
• Carefully worded to minimize ambiguity and avoid overstatement
• In the end, it remains an opinion
What Data is Available to Inform Outcomes for Birth Setting
• Birth certificates– 2003 US Standard Certificate of Live Birth– State based reporting
• Registries– Birth center study (AABC)– MANA Stats (NARM)
• Data sets compiled for individual reports• Payers
Features of an ideal data set…
• Ascertainment: “intended place of delivery”
• Selection criteria: “appropriateness” (ante, intrapartum)
• Type of attendant: education, certification and licensure
• Integration of health system; transport agreements, geography, indication for transport
• Ascertainment: outcomes
– Standardized definitions (reVITALize, NCHS, etc.)
• Health system IT, EMR, common review
• Mandatory, audited, enforced reporting
• Publically available for download and analysis
Birth Certificates• ACOG and others have pushed for adoption of the US
Standard Certificate of Live Birth– (36 States, DC, Puerto Rico, Northern Marianas)– (32 States use US Standard Report of Fetal Death)
• Model legislation written in 2009• Every issue of Guidelines for Perinatal Care• Every opportunity for public comment• Cause for optimism: NAPHSIS and NCHS agreement,
possibly by 1 Jan 2014
2003 US Standard Certificate of Live Birth
Does not capture planned home birth transferred to hospital.
Does not distinguish CPM, LM, DEM, or other
Non-specific, does not necessarily capture transfer from home.
None capture reason for transfer.
2003 US Standard Report of Fetal Death
Does not capture planned home birth transferred to hospital.
Does not distinguish CPM, LM, DEM, or other
Does not capture location of intrapartum fetal death if known
7.
14.
Use of Data for Decision Making
• Depends on who is making the decision: each will have different perspective and values– Patients– Providers– Payers– Government agencies
• We have not discussed ethics of decision making regarding birth setting
Conclusions: Data for Decision Making
• No RCTs of sufficient size to inform birth setting• Only imperfect case series and cohort studies
– Ascertainment of intended birth setting– Provider education, training, certification and licensure– Nonstandard selection criteria– Non-uniform definitions of outcomes – follow up– Great regional variation in health system infrastructure
• No uniform data platform to adequately compare birth settings in the US
Recommendations• Continue to encourage the states to adopt the 2003 US Standard
Certificates of Live Birth, Death and Fetal Death
• We need minor modifications to 2003 US Standard Certificate of Live Birth and Report of Fetal Death to help inform the issue of birth setting, other issues– Intended birth setting
– Attendant
– Other: risk stratification, care processes, more…
MANA Stats
Enrollment is voluntaryParticipation rates: CPM (20-30%), CNM/CM (17%)Individual patients must consent to participate (<3% decline)May withdraw from reporting (approx 8% incomplete)All birth settings: home, birth center, hospitalMidwives: CPM > CNM/CM > other midwivesData collection process 2.0, 3.0 and newer 4.0Efforts underway to encourage/mandate reportingData quality assurance: automated review, “Data Doula”
Outcomes of planned home births with certified professional midwives: large prospective study in North America
Johnson KC, Daviss B-A. BMJ 2005;330:1416–9
5418 Women planning home delivery with CPM in 2000
Transferred to hospital 12.1%Epidural 4.5%Episiotomy 2.1%Forceps 1.0%Vacuum 0.9%Cesarean delivery 3.7%
Total non-anomalous death 2.0/1000Total low risk non-anomalous 1.7/1000
J Midwifery Women's Health 2013 (Jan/Feb);58:3–14
American Association of Birth Centers (AABC)AABC Standards for Birth CentersCommission for the Accreditation of Birth Centers (CABC)AABC Uniform Data Set (UDS)41% of Birth Centers known to AABC are members78% of AABC members participate in the online registry79 Birth Centers in 33 states
Cesarean section 6%, maternal mortality 0, intrapartum death 0.47/1000, neonatal mortality 0.4/1000
Other Sources (not all inclusive)
• National perinatal data collection efforts– University Health Consortium (UHC)– National Perinatal Information Center (NPIC)
• States’ perinatal reporting beyond birth certificates: CMQCC, OPQC, others
• Payer or system data sets: HCA, Kaiser, Intermountain Healthcare, DoD, others
• Professional org: Women’s Health Registry Alliance