Birth Settings in America Outcomes, Quality, Access, and Choice (2020) / Chapter Skim
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5 Issues in Measuring Outcomes by Birth Settings: Data and Methods
5 Issues in Measuring Outcomes by Birth Settings: Data and Methods
Pages 145-160
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From page 145... ...
This chapter addresses that question -- an important one because such decisions will be most sound when they draw on a robust and comprehensive body of relevant information. To that end, the first section of this chapter provides an overview of the strengths and limitations of data used to study clinical outcomes with respect to birth settings, including vital statistics and birth registry data.
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From page 146... ...
Thus, linked birth certificate and hospital discharge data are not a good data source for understanding variations in birth characteristics or outcomes by birth setting. Vital Statistics Data Vital statistics data from birth certificates provide information on each of the approximately 3.9 million births occurring in the United States each year, by place of birth (birth setting)
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From page 147... ...
. Even in Oregon, the only state where M planning status and intended location are both recorded on the birth certificate, it is impossible to distinguish between birth center or planned home births and planned unassisted births (or births without a trained attendant)
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From page 148... ...
Additional limitations of birth certificate data for epidemiologic analysis have been widely discussed in the literature, and include the inability of birth certificates to provide information on clinical intentions, as well as concerns about the completeness, validity, and reliability of the reporting of specific data items (DiGuiseppe et al., 2002; Ananth, 2005; Cahill and Macones, 2006; Schoendorf and Branum, 2006; Cheyney et al., 2014a)
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From page 149... ...
birth certificates underreport or falsely report seizures, especially among home births.1 The authors conclude that "birth certificates alone should not be used to measure neonatal seizures or serious neurologic dysfunction." Multiple sources of data, such as discharge summaries and Medicaid claims data, are needed to supplement birth certificate data to obtain an accurate understanding of seizure prevalence in all three U.S. birth settings.
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From page 150... ...
; and another curated by the American Association of Birth Centers (AABC) , called the Perinatal Data Registry (PDR; formerly called the Uniform Data Set, or UDS)
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From page 151... ...
Confounding Factors In addition to the sources of bias associated with vital statistics and birth registry data, studies on birth settings are subject to potential confounding. As discussed in Chapters 3 and 4, differences exist in the demographic, cultural, social, and clinical characteristics among women who choose home or freestanding birth center births versus hospital births, and these differences have not been systematically measured (Caughey and Cheyney, 2019)
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From page 152... ...
Summary Vital statistics data are informative, but the inability to track intended place of birth or the planning status of home births in California's records limits their utility in birth settings research. And while birth registry data allow indication of intended birth setting, the reporting of these data is generally voluntary, and the data are not collected nationally or across all birth settings.
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From page 153... ...
The following is one way of categorizing study designs and sources of evidence that can be useful for addressing questions relevant to maternity care research and decision making (Institute of Medicine, 2010) : • observational studies, • qualitative research and analysis, • mixed-methods studies, • evidence synthesis methods, • experimental studies, and • quasi-experimental studies.
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From page 154... ...
A large proportion of studies on birth settings have used study designs that fall into this category.
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From page 155... ...
. Types Ethnographic studies, focus group or key informant interviews, direct observation, content or documentary analysis, case studies, logic modeling or program theory analysis, process and implementation monitoring Strengths and Qualitative research designs allow researchers to assess the experiences Weaknesses and perceptions of respondents at a much richer level than is possible with quantitative methods.
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From page 156... ...
Mixed methods allow researchers to obtain evidence after the implementation of policies or programs to measure the intended or unintended effects. Randomization and experimental controls are rarely used when studying birth settings and maternal and neonatal outcomes because it would be difficult to find women who would agree to be randomized to one or another birth setting (Hendrix et al., 2009)
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From page 157... ...
The committee chose to use both GRADE and the ResQu index because while GRADE is ubiquitous, and thus a highly accessible way of evaluating study quality, we also felt it was advisable to apply a scoring system that had been specifically designed for birth settings research, given the nature of our statement of task. Interestingly, this approach enabled us to see the impact on quality ratings when models indicating intended birth setting are weighted (ResQu Index)
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From page 158... ...
. The ResQu Index allows researchers to evaluate the strength of studies related to birth settings and accounts for items that are critical to birth settings research but less relevant to other epidemiological studies, such as use of models indicating intended birth setting.
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From page 159... ...
. An important limitation to using the GRADE approach when reviewing birth settings research is that observational studies start as low-quality evidence because they are deemed to fail to develop and apply appropriate eligibility criteria, to have flawed measurement of both exposure and outcome, to fail to adequately control confounding, and to have incomplete follow-up (Schünemann, 2013)
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From page 160... ...
Additional improvements would include designation of planned attended and planned u nassisted home births, and identification of the type of physician or midwife attending the birth. CONCLUSION 5-1: Modifications to the birth certificate that allow inquiry into birth settings based on models indicating intended birth setting, including planned attended and planned unassisted home births in the United States and intended birth attendants, and development of best practices for use of these expanded data in birth settings research are needed to better understand and assess outcomes by birth settings.
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