1. Research Issues in the Assessment of Birth Settings
Workshop Reflections and
Future Research Needs
The CDC's Division of Reproductive Health's (DRH) mission is to promote optimal and equitable health in women and infants through public health surveillance, research, leadership, and partnership to move science to practice.
(As was said earlier in the workshop, this is a topic that is fraught with emotion and not so much with good supportive data.)
Zsakeba Henderson, MD
Maternal & Infant Health Branch, Division of Reproductive Health
National Center for Chronic Disease Prevention and Health Promotion
Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion
Division of Reproductive Health

2. “ Learning without reflection is a waste
“ Learning without reflection is a waste. Reflection without learning is dangerous.” – Confucius
The purpose of this workshop was to highlight research findings that advance our understanding of the effects of maternal care services in different types of birth settings on maternal labor, clinical and other birth procedures, and birth outcomes. We have learned quite a bit during these two days, and now that we have come to the end, the real work begins. It would be a waste of our time to sit here and absorb all of this information without reflecting on it and learning how we can move forward. Unfortunately, many recommendations that were made back in 1982 were not all carried out, for whatever reason. However, we are now given an opportunity to take what new information we have and set a new agenda for research in this area.

3. Childbirth Trends and Statistics What have we learned?
There have been substantial increases in births to women age ≥ 30, births to Hispanic women, and women with >40 lb gestational weight gain
Cesarean births rose nearly 60% from , followed by a small decline (32.9% to 32.8%)
The preterm birth rate fell for the 5th straight year to 11.72%
There have also been substantial decreases in the low birth weight rate and the number and rate of triplet and higher order multiple births
So, what have we learned?
A lot has changed over the past 30 years since this issue was last addressed, and as our colleagues at NCHS have pointed out, chilbirth trends have changed:
Moms are older, with substantial increases in births to women age ≥ 30, births to Hispanic women, and women with weight gain during pregnancy above what is recommended.
Cesarean births rose nearly 60% from , followed by a small decline (32.9% to 32.8%)
The preterm birth rate fell for the 5th straight year to 11.72%
There have also been substantial decreases in the low birth weight rate and the number and rate of triplet and higher order multiple births
Source: CDC/NCHS, National Vital Statistics System

4. Women Giving Birth in Various Settings What have we learned?
The percentage of births outside of the hospital has increased rapidly from (1.2% in 2010), mostly due to increases among non-Hispanic white women
More out-of-hospital births occurred among older, multiparous women with lower risk profiles
In 2010, 67% of out-of-hospital births were home births, 28% birthing center
In 2010, 88% of home births were planned
Since 1900 the birthplace for most children in the U.S. has shifted from the home to the hospital. The rate of out-of-hospital births had remained pretty steady for decades until recently.
The percentage of births outside of the hospital has increased rapidly from (1.2% in 2010), mostly due to increases among non-Hispanic white women
More out-of-hospital births occurred among older, multiparous women with lower risk profiles
In 2010, 67% of out-of-hospital births were home births, 28% birthing center
In 2010, 88% of home births were planned
Source: CDC/NCHS, National Vital Statistics System

5. Birth Statistics Knowledge Gaps
Intended place of delivery
Planning status of home birth reported by only 31 states and DC (60% of US births)
States are in varying stages of implementing the 2003 revised birth certificate (required by 2014)
Reporting of transfers from alternative birth settings
Home birth patients who were transferred to a hospital may not be determined from birth certificate
Reporting of patient transfers not required in all states
Oregon has added transfer of births from home to birth certificate
Reporting of birth attendant
Categorization of “other midwife”, “other” birth attendant, level of training/certification not known
 There were several gaps in birth statistics that were addressed during the workshop, including the following:
Intended place of delivery – The planning status of home birth is currently reported by only 31 states and DC, which represents 60% of US births
Reporting of transfers from alternative birth settings to hospitals, and
Reporting of birth attendant

6. Assessment of Risk in Pregnancy What have we learned?
Complex, involves determination of what is considered “low risk”
Singleton, term, vertex, no other medical/surgical conditions, other factors?
Risk is dynamic and subject to change
Risk to the mother must be balanced with risk to the fetus
Risk perception varies between provider and patient
Cultural views, women’s views and structural conditions affect risk and risk perception
Overall absolute risk of adverse events is low

7. Assessment of Risk in Pregnancy Knowledge Gaps
Uniform definitions of outcomes
Risk assessment tools for maternal morbidity and mortality
Consistent “low-risk” criteria
Descriptors for maternal resources, levels of maternal care
Predictors of neonatal and maternal complications
Predictive triggers for elevation of care or transport
Role of providers and care system
Interprofessional working relationships
Consultation/transfer of care
Thresholds for intervention in high level care facilities

8. Birth Settings and Health Outcomes What have we learned?
Alternative birth settings associated with*:
Less intervention, fewer maternal complications, high transfer rates, no difference in perinatal death rate
Home, freestanding, and “alongside” midwifery units associated with**:
Decreased obstetrical intereventions, increased normal births, high transfer rates, increased neonatal risk for first pregnancies with home births
Other studies have shown association of home births with increased neonatal mortality
The process of care has an impact on health outcomes
The built environment has an impact on neural immune connections and on health

9. Birth Settings and Health Outcomes Knowledge Gaps
Evaluation of all birth settings, comparing women of equal risk in all settings
No trials of freestanding birth centers
Studies with conistent process and outcome measures
Assessment of pain relief
Effects of pain management on neonate
Effects on successful breastfeeding
Physiologic/biochemical measures
Studies with longer-term outcomes
Developmental origins of health and disease
Optimal process of care
Optimal process of care: What are optimum principles and practice for the process of care, and what settings best implement them. What criteria would be used to assess?

10. Workforce Issues What have we learned?
Supply trends are variable by profession
There are increasing numbers of midwife-attended births (in and out of hospital)
State variability of who is licensed to do what
Competent nursing staff contribute to improved patient outcomes
Collaborative teams of care improve outcomes
Supply trends are variable by profession
The share of attended births are shifting, with increasing numbers of midwife-attended births (in and out of hospital)
Competent nursing staff contribute to improved patient outcomes
Collaborative teams of care improve outcomes

11. Workforce Issues Knowledge Gaps
Role of education and certification in quality of care
Ideal staffing model to optimize care quality
Collaborative teams
Provider ratios
Impact of “missed nursing care” in out-of-hospital settings
How nurse staffing affects quality, safety, and cost of hospital-based care
Impact of technology on workforce training needs and demand
Role of education and certification in quality of care
Ideal staffing model to optimize care quality
What provider ratios are optimal for full utilization of the workforce and highest quality care
Impact of “missed nursing care” in out-of-hospital settings
How nurse staffing affects quality, safety, and cost of hospital-based care
Impact of technology on workforce training needs and demand

12. Data Systems and Measurement What have we learned?
Data sources to inform outcomes for birth settings include:
2003 US Standard Certificate of Live Birth
Linked birth certificate data sets (PDD, Medicaid)
Registries (MANA Stats, AABC)
Payers
State/Regional Perinatal Quality Collaboratives
Professional organizations
CMMI Strong Start Initiative
Measurement of outcomes in preterm birth and cost of care, along with other outcomes of interest
Data sources to inform outcomes for birth settings include:
2003 US Standard Certificate of Live Birth
Linked birth certificate data sets (PDD, Medicaid)
Registries (MANA Stats, AABC)
Payers
State Perinatal Quality Collaboratives
Professional organizations
CMMI Strong Start Initiative
nationwide public awareness effort working to improve the health of moms and babies by encouraging them to let labor bein on its own.

13. Data Systems and Measurement Knowledge Gaps
Birth Certificate does not capture planned home birth transferred to hospital
Intended place of birth is not captured for Hospital or Birthing Center births on the birth certificate
Very large numbers are needed to detect differences in perinatal mortality (No RCTs of sufficient size)
No uniform data platform to adequately compare birth settings

14. Cost, Value, and Reimbursement Issues What have we learned?
Medicaid is payer for 40% of US births
CMMI is realigning incentives to reward providers for lower cost, high quality care
Medicaid, in some states, does not cover home births
State-state variability limits the ability to create a national agenda around this issue
Washington state Medicaid expenditures for hospital-based cesarean and vaginal births were higher than birth center or home births

15. Cost, Value and Reimbursement Issues Knowledge Gaps
Not a lot of data from Medicaid MCOs
Cost-comparison data may not include all costs associated with each birth setting
National-level cost data is not available
Variability in reimbursement from state-state
Variability in linkage of Medicaid claims to vital records data

16. Where do we go from here? FUTURE RESEARCH NEEDS
There are many possible approaches to consider to research the many gaps in knowledge discussed during this workshop. I would like to focus on the topics for future research needs, as a full discussion of the possible approaches is beyond the scope of this short commentary. The list of future research needs exceeds the list of things we already know, and this list is not exhaustive, but it was my intention to capture the greatest needs, as evidenced by mention by multiple presenters.

17. Future Research Needs: Where do we go from here?
Randomized controlled trials
Freestanding birthing centers
Other birth settings (Snoezelen room, Ambient room)
Impact of interventions in the hospital setting
Other studies
Evaluation of organizational models of care in all settings
Most effective methods of transitioning care from out-of-hospital settings to the hospital
Impact of transfer on women and care providers
Determination of predictors of neonatal and maternal complications
Evaluation of potential unintended impact of intrapartum care processes
Home birth randomized trials? Challenging to implement. Every “home” is not the same.

18. Future Research Needs: Where do we go from here?
Other Studies
Cost assessment of birth settings
Cost-effectiveness analyses of birth settings
Access to care in various birth settings
Evaluation of continuity of caregiver
Evaluation of the experience of maternity care in different settings (Consumer Assessment of Healthcare Providers and Systems)
Environment and neuroendocrine immune interactions/physiologic responses

19. Other Needs: Where do we go from here?
Maintenance and support of the National Vital Statistics System
Measurement of transfer to hosptial care
Measurement and reporting of perinatal morbidity and mortality for all birth settings
Passive/Active surveillance
State-based review committees
Development of clear protocols for consultation and transfer of care
Development of risk assessment tools for maternal morbidity and mortality
Although the focus of this workshop is on research issues, the research informs policy and protocols and guidelines, so it is important to keep these issues in mind as a research agenda is developed. Some of the issues that came up during this workshop that I think are worth noting:

20. Other Needs: Where do we go from here?
Development of consistent policies for education, certification and licensing of care providers
Adress cost/reimbursement issues for care provided out-of-hospital
Increase efforts for interprofessional education, communication, and interaction
Involve patients in every step of the process

21. “Life can only be understood backwards; but it must be lived forward
“Life can only be understood backwards; but it must be lived forward.” Soren Kierkegaard
The variation within and among all of the different settings for birthing contributes to the complexity of conducting research in this area and to the difficulty of following patients across different locations for full and complete data collection

22. zhenderson@cdc.gov Can you put the CDC 24/7 logo on aThank you slide?
Can you also add a “Questions” slide before this one?
National Center for Chronic Disease Prevention and Health Promotion
Division of Reproductive Health