Birth Settings in America Outcomes, Quality, Access, and Choice (2020) / Chapter Skim
Currently Skimming:
3 Epidemiology of Clinical Risks in Pregnancy and Childbirth
3 Epidemiology of Clinical Risks in Pregnancy and Childbirth
Pages 85-112
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 85... ...
It is important to note that an exact definition of a "high-risk pregnancy" is not available, because the term lacks conceptual precision in maternity care. Pregnancy is never without some risk; however, most studies use the absence of identified risk factors for poor outcomes as the comparator.
|
From page 86... ...
In addition, as more women desire and choose birth settings other than hospitals, understanding, screening, and monitoring of the medical, obstetrical, and psychosocial risk factors that affect the care needs of women are increasingly important. At the same time, unforeseen emergencies related to either the birth process or an unrecognized condition may require immediate skilled intervention on behalf of the pregnant woman, fetus, or newborn, including cesarean birth or neonatal resuscitation.
|
From page 87... ...
require more intensive care relative to women without these conditions. Demographic shifts, such as people having children later in life, and a number of growing public health challenges, such as increased opioid use, have changed the risk profile of childbearing women on a population level, increasing the proportion of people entering pregnancy with chronic conditions, including substance abuse.1 This section examines some of the medical risk factors that are present during pregnancy.
|
From page 88... ...
Type 2: • Obesity and overweight • Physically inactive • Older age • High blood pressure • History of gestational diabetes • History of polycystic ovary syndrome (PCOS) (National Institute of Diabetes and Digestive and Kidney Diseases, 2016)
|
From page 89... ...
. • cesarean birth • developing type 2 diabetes postpregnancy Increased risk of preeclampsia and Pregnant women with chronic hypertension may its negative sequelae require additional monitoring prior to delivery.
|
From page 90... ...
Obstetrical Risk Factors Breech Presentation • Preterm labor • Abnormally shaped uterus, fibroids, or too much amniotic fluid • Multifetal gestation • Placenta previa Multiple Gestation • Use of fertility drugs to induce ovulation • vitro fertilization In • Older maternal age Previous Caesarean Birth • Cesarean birth can be medically indicated or elective
|
From page 91... ...
• Vaginal birth after a previous Newborns may require monitoring based on the cesarean birth can increase risk details of the specific birth circumstance. of uterine rupture; multiple cesarean births increase risk of maternal morbidities
|
From page 92... ...
, which affects 2 percent of all hospital births, while gestational hypertension, preeclampsia, and eclampsia affect 9 percent of hospital births and chronic hypertension 2 percent (Centers for Disease Control and Prevention, 2019c)
|
From page 93... ...
. The ele ated risk of preeclampsia among women with advanced and early v maternal age and the higher rate of maternal mortality among women ages 35 and above frequently necessitate more intensive care during pregnancy and childbirth.
|
From page 94... ...
. These antepartum complications increase the risk of indicated preterm and cesarean birth, but women with higher prepregnancy BMI are also at greater risk of miscarriage, stillbirth, shoulder dystocia, and spontaneous preterm birth compared with normal-weight women (Declercq, et al., 2016; Catalano and Shankar, 2017; Schummers et al., 2015)
|
From page 95... ...
. Specifically, gestational diabetes increases the risks for preeclampsia, cesarean birth, fetal m acrosomia (fetal weight of 9 or more pounds, which can make delivery difficult)
|
From page 96... ...
, and macrosomia may necessitate cesarean birth. Substance Use Substance use during pregnancy is associated with several adverse outcomes, such as premature birth, low birthweight, neonatal abstinence disorder,8 fetal alcohol syndrome and fetal alcohol spectrum disorder, miscarriage, stillbirth, and placental abruption (Centers for Disease Control and Prevention, 2019d; Popova et al., 2017; Forray and Foster, 2016; National Institute on Drug Abuse, 2018)
|
From page 97... ...
Like medical risk factors, these obstetric factors require careful consideration during the risk-assessment process. In this section, we discuss two obstetric risk factors that need to be considered when determining appropriate birth settings for pregnant women: breech presentation and previous cesarean birth.
|
From page 98... ...
Rates of perinatal mortality and hypoxic ischemic encephalopathy associated with labor after prior cesarean birth are higher than those for repeat cesarean birth without labor (National Institutes of Health Consensus Development Conference Panel, 2010)
|
From page 99... ...
An analysis of birth certificate data by Grünebaum and colleagues (2015a) found that more than 30 percent of midwife-attended planned home births that occurred between 2010 and 2012 were to women that had at least one perinatal risk factor (breech presentation, prior cesarean birth, more than 41 weeks gestation, or twin gestation)
|
From page 100... ...
were dropped before percentages were computed. aIncludes prepregnancy and gestational diabetes.
|
From page 101... ...
population, risk assessment and risk selection in birth settings are critical to decision making and choice among birth settings. It is clear that some women desire birth setting options other than hospitals, as evidenced by the increased number of women choosing home and birth center births in recent years (MacDorman and Declercq, 2019)
|
From page 102... ...
, in a qualitative study of 135 women, similarly found that women who chose hospital births did so since they perceived birthing in a hospital to be the safest choice because of its ability to minimize risks to the woman and the child (Miller and Shriver, 2012)
|
From page 103... ...
Although the survey was limited to women with hospital births, these results suggest that experienced mothers may be more open to birth center and home births than first-time mothers. First-Time Experienced Mothers (%)
|
From page 104... ...
We consider how the skills of shared decision making might facilitate provider–patient communication regarding risks, benefits, and alternatives, as well as elicit values and help women negotiate competing priorities to make the choice that best aligns with their risk profile and values. Recognizing that not all women are candidates for birth center and home birth based on medical and obstetric risks and that women in hospital settings may decline some interventions, providers will inevitably find themselves in a position in which a patient declines or refuses medically recommended care.
|
From page 105... ...
As a result, they may operate under the normative assumption that their role is to drive down perinatal mortality at all cost without recognizing that doing so may cause maternal mortality or morbidity or other neonatal morbidity to rise, or that many potentially avoidable cesareans may lead to life- hreatening conditions in future pregnancies. This is particularly the t case in settings, such as the United States, where interventions for "safe maternity" are tertiary in nature, relying on obstetric intervention and surgical "rescue" rather than preventive and safety net strategies designed to ensure that all women have an equitable prospect of entering pregnancy in good physical and mental health and with adequate support.
|
From page 106... ...
However, practitioners may not be skilled or well practiced in navigating or disclosing this uncertainty, and may be biased in their assessments of risks and benefits associated with medical therapies. Thus, for a maternity care provider, determining the optimal approach to counseling first requires determining whether the medical and obstetric risk and benefit assessment for a patient results in a clear recommendation for hospital, birth center, or home birth.
|
From page 107... ...
Women who "risk out" of or are deemed poor candidates for home or birth center care still have the right to refuse recommended care, and may do so for any number of reasons, including inability to access the type of care they desire, such as VBAC, in a hospital setting. Informed refusal also takes place within hospitals with regard to specific interventions or types of care (Declercq et al., 2007)
|
From page 108... ...
Fears of patient coercion and abandonment may lead these providers to accept patients despite or precisely because of the increased risk, particularly when a woman has either refused or been denied in-hospital vaginal birth for a given indication, such as planned VBAC, vaginal twin birth, and vaginal breech birth. In their review of a case of home birth with anticipated congenital anomalies, Jankowski and Burcher (2015, p.
|
From page 109... ...
Were decision aids available to assist in the related choices of maternity care provider and birth setting at the onset of or even prior to pregnancy, women might enter care more activated, engaged, and knowledgeable about these choices (O'Connor et al., 1999; O'Connor, 2001; Stacey et al., 2017)
|
From page 110... ...
Greater understanding of essential resources for each of the various birth settings, predictors of neonatal complications to guide decisions about level of neonatal care, predictors of maternal complications to guide decisions about level of maternal care, and predictors that should prompt maternal transport between birth settings is needed to inform continuous risk assessment and to guide decisions about which level of
|
From page 111... ...
Such consideration and assessment to match women appropriately to the setting and care they need and desire, when carried out continuously and effectively, results in risk stratification across birth settings. That is, lower-risk women predominate in home and birth center settings, while higher-risk women are generally treated in hospital settings.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.