Cesarean delivery rates in women cared for by certified nurse-midwives in the United States: a review

Factors influencing use of essential surgical services in North-East India: a cross-sectional study of obstetric and gynaecological surgery

INTRODUCTION

There continues to be a large gap between need and actual use of surgery in low-resource settings. While policy frequently focuses on expanding the supply of services, demand-side factors are at least as important in determining under utilisation and over utilisation. The aim of this study is to understand how these factors influence the use of selected essential obstetric and gynaecological surgical procedures in the underserved and remote setting of North-East India.

METHODS

The study combines and makes use of data from a variety of surveys and routine systems. Descriptive analysis of variations in caesarean section, hysterectomy and sterilisation and then multivariate logit analysis of demand-side and supply-side factors on access to these services is undertaken.

RESULTS

Surgical rates vary substantially both across and within North-East India, correlated with service capacity and socioeconomic status. Travel times to surgical facilities are associated with rates of caesarean section and hysterectomy but not sterilisation where services are much more deconcentrated. Travel is less important for surgery in private facilities where capacity is much more dispersed but dominated by the non-poor. The presence of non-doctor medical staff is associated with lower levels of surgical activity.

CONCLUSION

In low resource, remote settings policy interventions to improve access to services must recognise that surgical rates in low-resource settings are heavily influenced by demand-side factors. As well as boosting services, mechanisms need to mitigate demand-side barriers particularly distance and influence practice to encourage surgical intervention only where clinically indicated.

US nulliparas' perceptions of roles and of the birth experience as predictors of their delivery preferences

OBJECTIVE

to develop a model for understanding predictors of nulliparas' delivery preferences: provider type, setting, mode of delivery and the use/avoidance of pain medication.

DESIGN

a cross-sectional, descriptive, self-administered, web-based survey. The sample was composed of nulliparous women aged 18-40, living in the US and pregnant at 20 or fewer weeks' gestation (n=344). Data were analysed using structural equation modelling.

FINDINGS

women who regard their active participation as effective and essential to the childbearing process are more likely to prefer the care of a midwife, the home as the birth setting, vaginal delivery and the avoidance of pain medication compared to women who see their role as a passive one. When women perceive their provider's role to be more central to the delivery process than their own, they are likely to prefer the care of a physician and the hospital setting. If the provider's role is seen as a collaborative one, women are likelier to prefer midwifery care and planned home birth. The more painful and fearful a woman expects the delivery experience to be, the more likely she is to prefer a caesarean delivery to vaginal birth.

KEY CONCLUSIONS

women's perceptions of (a) their role in pregnancy and delivery, (b) their providers' role in assisting them and (c) the nature of the delivery experience are effective predictors of their delivery preferences.

IMPLICATIONS FOR PRACTICE

providers can help ensure that the informational resources that influence women's perceptions about delivery are factual and evidence-based.

Outcomes of high-risk women cared for by certified nurse-midwives

This study describes the incidence of specific high-risk factors of a population cared for by a group of certified nurse-midwives (CNMs) in a Mid-Atlantic, inner-city, nonprofit, hospital-based clinic. Outcomes were compared with all women who delivered in the United States in 1994. Univariate statistics, which consisted of descriptive statistics, frequencies, and percentage distribution, were used. This comparison suggests that CNMs can provide safe care to women with high-risk conditions. Outcomes for the midwifery sample were more favorable for vaginal births, vaginal deliveries after cesarean section, forceps- and vacuum-assisted deliveries, cesarean delivery, and 5-minute Apgar scores. The incidence of maternal fever and meconium stained amniotic fluid was higher. Implications and limitations of the study are discussed.

Midwifery care research: what questions are being asked? What lessons have been learned?

PURPOSE

To create and critically evaluate a research database about midwifery care that identifies topics studied, research methods, results, funding, publication data, and implications for a future midwifery research agenda.

METHODS

Systematic literature review. Studies included were 1) data-based research; 2) about midwifery care or practice; 3) in the United States; and 4) published between 1984-1998. The CINAHL and MEDLINE electronic databases were searched using a defined strategy, and relevant journals and bibliographies were searched by hand.

RESULTS

This 15-year review identified 140 studies of midwifery care published in 161 papers. A midwife was the lead author on 60%. Sixty percent were published in the Journal of Nurse-Midwifery. Six to 15 studies were published each year, and both the number of publications and funding increased over the time period. The six major areas of focus were: 1) midwifery management, 2) structure of care, 3) midwifery practice, 4) midwife-physician comparisons, 5) place of birth, and 6) care of vulnerable populations.

DISCUSSION

Although retrospective descriptive studies still predominate, more prospective studies, randomized controlled trials, multi-site studies, and quasi-experimental designs are being conducted. Qualitative methods are helping to measure nontraditional outcomes. A research agenda should be established based on discussion and debate within the profession. Midwife investigators need to build research teams and collaborate with other disciplines. Key areas for future research include alternative therapies, breastfeeding, cost-effectiveness, cultural studies, gynecology, health policy, menopause, postpartum care, substance abuse interventions, and the woman's experience of birth and midwifery care.

Factors predicting cesarean delivery for American Indian women in New Mexico

BACKGROUND

American Indian women have one of the lowest cesarean delivery rates among all ethnic groups evaluated in the United States. Our objective was to identify risk factors for cesarean delivery among American Indian women in New Mexico.

METHODS

Live birth certificate data (1994) from the New Mexico Bureau of Vital Records and Health statistics were used to compare American Indian women who had a cesarean delivery with those who had a vaginal delivery. We examined demographic, prenatal, and intrapartum factors to determine risk factors for cesarean delivery.

RESULTS

In 1994 American Indian women in New Mexico had a cesarean delivery rate of 12 percent. Risk factors for cesarean delivery included age equal to or over 35 years (OR = 1.8, 1.3-2.5) and nulliparity (OR = 1.9, 1.5-2.5). Obstetric risk factors included prematurity (OR = 2.3, 1.5-3.6), low birthweight (OR = 2.6, 1.7-4.2), diabetes (OR = 1.7, 1.1-2.5), pregnancy-induced hypertension (OR = 2.6, 1.8-3.8), and labor and delivery complications (OR = 9.5, 7.5-12.1). Age less than 20 years was negatively associated with cesarean delivery (OR = 0.5, 0.3-0.7).

CONCLUSION

American Indian women have risk factors for cesarean delivery that are similar to those reported in other populations. Future prospective research evaluating intrapartum management may help identify reasons for the low cesarean birth rate.

College students' knowledge and attitudes about cesarean birth

BACKGROUND

Numerous clinicians and researchers have expressed concern about the necessity and potential adverse consequences of many cesarean births in the United States. The purpose of this study was to explore college students' attitudes and beliefs about cesarean section.

METHODS

One hundred two college students (66% women) completed a 20-item questionnaire that asked if they viewed cesarean delivery as a potentially negative experience, as a normal or acceptable method of childbirth, and as medically necessary, and asked about their beliefs concerning risk and prevention of cesarean birth.

RESULTS

The number of "undecided" responses in the study was striking (7.8% to 69.6% across the 20 items). In general, women and men responded similarly, although women were significantly more likely than men to say they would be profoundly disappointed if their babies had to be delivered by cesarean section. Despite expressing cynicism about the cesarean birth rate (40% agreed that many unnecessary cesarean births occurred) and not viewing the procedure as a normal way of giving birth (47%), most respondents (over 70%) disagreed that giving birth by cesarean would be a negative experience or would make a woman feel like a failure.

CONCLUSION

A high level of uncertainty exists about certain aspects of cesarean birth among young women and men, highlighting the need for information for prospective parents. Most college students did not view the cesarean birth experience as either potentially negative or normal. Future research should explore coverage of cesarean birth in childbirth education classes and the roles physicians, nurses, and midwives play in preparing expectant parents for the possibility of cesarean delivery.

A randomized, controlled trial of nurse-midwifery care

BACKGROUND

In 1990 a pilot nurse-midwifery program was implemented in a tertiary care hospital in a major western Canadian city. a randomized, controlled trial was conducted to determine if, when maternal and newborn patient outcomes were compared, the midwifery program was as effective as traditional, low-risk health care available in the city.

METHODS

All low-risk women who requested and qualified for nurse-midwifery care were randomly assigned to an experimental or control group.

RESULTS

One hundred one women received care from nurse-midwives and 93 received standard care from either an obstetrician or family physician. The rate of cesarean delivery in the nurse-midwife group was 4 percent compared with 15.1 percent in the physician group. The episiotomy rate, excluding cesarean deliveries, for the nurse-midwife group was 15.5 percent compared with 32.9 percent in the physician group. The rates of epidural anesthesia for pain relief in labor were 12.9 percent and 23.7 percent, respectively. Statistically significant differences were found ultrasound examinations, amniotomy, intravenous drug administration during labor, dietary supplements, length of hospital stay, and admission of infants to the neonatal intensive care unit.

CONCLUSIONS

The results clearly support the effectiveness of the pilot nurse-midwifery program and suggest that more extensive participation of midwives in the Canadian health care system is an appropriate use of health care dollars.