Tuesday, 22 April 2014

ANALYSIS - NEW STUDY: Private Health Coverage is an Independent Risk factor for Caesarean Section

Last week, an important new study was released: "Private health care coverage and increased risk of obstetric intervention"

AIMS Ireland examines the new study and key points.

What was the study looking for?

When complications arise during pregnancy, labour, or birth interventions are often necessary to improve the health of women and/or babies. This medical need is often called clinical or medical indications. Appropriate use of intervention is necessary and important to ensure that women and their babies are safe.

In Ireland there are wide variations in rates of interventions. Rates can vary significantly across the 19 public maternity units. This suggests that practice in maternity units is not standardised and that interventions may not be used appropriately - based on medical need.

Previous studies have shown that women who choose obstetric led care and private obstetric led care have higher intervention rates than women who attend midwife led care or public obstetric led care. Discussion following these studies often focused on risk factors between the two groups - that women who opted for private obstetric led care were of higher risk groups (have more risk factors) than women who did not.

This study wanted to see if there is a difference in interventions used in Irish maternity hospitals between women who book into public maternity care (without using private health insurance) vs women who book into private maternity care (with private health insurance).

This study is significant as researchers controlled for relevant risk factors between public and private patients.

* Obstetric Led Care is hospital based care where a consultant obstetrician is the lead clinician. The policies, practice, and guidelines in the maternity unit are based on a medical care model.

What are "obstetric interventions"?

This study looked at the outcomes of 403, 642 births across Ireland - a third of which were private consultant led care - and examined the births WITH and WITHOUT the following:

* Caesarean Section

* Operative Vaginal Delivery (some times called   'assisted  delivery' - use of forceps or vacuum)

* Induction of Labour

* Episiotomy

Why is controlling for risk factors significant?

When we talk about "risk factors" this is a way of estimating the odds of a woman requiring intervention during her pregnancy, labour, or birth. Some risk factors suggest that a woman is more likely to require an induction of labour, episiotomy, emergency caesarean, or planned caesarean.

Sometimes risk factors can be conditions occurring in a pregnancy, like gestational diabetes or placenta previa. Others can be age (we hear a lot of older mothers), previous births, epidural, or if you are having multiples.

 This study isolated known risk factors for each obstetric intervention, in order to compare like with like.

The following risk factors were adjusted for each intervention group:

Induction of Labour

* Age
* heart disease
* diabetes
* placental disorders
* previous caesarean section

Planned and Emergency Caesarean Section

* age
* heart disease
* diabetes
* placental disorders
* previous caesarean section
* multiple births

(Due to recent evidence, use of epidural and induction of labour were not considered risk factors for Caesarean Section)

Assisted/operative Vaginal Births (Forceps and Vacuum)

* age
* heart disease
* diabetes
* previous caesarean section
* multiple birth
* induction of labour
* epidural


* age
* multiple birth
* assisted/operative vaginal birth (forceps or vacuum)

What did the study find?

After controlling the public and private groups for relevant risk factors, the study looked at the birth outcomes between women who chose public vs private health coverage. The study found:

* women with private health coverage were more likely to have a planned caesarean section

* women with private health coverage were more likely to have an emergency caesarean section

* in vaginal births, women with private health coverage were 40% more likely to have an episiotomy

Key Points: Quotes from the full study which AIMSI feel are of significance.

"Irrespective of obstetric risk factors, we found that women who opted for private maternity care in Ireland were significantly more likely to have an obstetric intervention than women who opted for public care."

"assessing the influence of health care coverage status in a variety of health care settings is critical given that rates of obstetric intervention are likely impacted by a country’s prevailing model of obstetric care (i.e. midwifeled, obstetrician-led or shared care models) and health care system (i.e. socialised medicine or fee-for-service).

"health care coverage status is part of a broad spectrum of non-clinical reasons, including obstetrician preference [27,28], litigation fears [29-31], maternal preference [32,33], and fewer women attempting a trial of labour after previous caesarean [34,35]. For this reason, to better understand both clinical and non-clinical dynamics, in future studies of health care coverage status and caesarean delivery, mixed-method research would be a clear advantage."

"We are unable to confirm why differences in episiotomy rates were observed in this population. Speculatively, however, uncomplicated deliveries in the public scheme are largely attended by midwives, who may be less likely to carry out an episiotomy [44]."

"residual confounding is of concern as we were not able to adjust for all maternal (e.g. parity, obesity, assisted conception, ethnicity and socio-economic status) and fetal (e.g. position, intrauterine growth restriction, macrosomia, heart rate) risks factors which may have increased risk of obstetric intervention."

"Data extracted from hospital records may underreport the true extent of covariates and outcomes of interest in this population."


In relation to increased C-section rates:

"While undoubtedly such trends are impacted by differences in obstetric profiles, our study suggests that health care coverage status is likely an independent risk factor for caesarean delivery."

Tuesday, 1 April 2014

The National Committee for the Elimination of Home Birth (NCEHB)

This National Committee has been in existence for several decades. It came into being some time in the 1960s when Ireland first bought into the medicalisation of childbirth and the only acceptable birthplace became a centralised obstetric-led maternity unit. Control over birth started to move into the domain of the obstetrician; a specialist in abnormal labours and birth. Traditionally, normal births had been attended in the community by midwives; the specialists in normal birth. Their place of work was either in local maternity homes or in the women’s home. The BBC TV series “Call the Midwife” captures the spirit of these times well

Membership of the Committee.
The Committee has had many members over time, and membership changes as and when demand arises. So for example, sometimes it would appear that the committee is only made up of HSE personnel, whereas other times it would appear that the judiciary, social services, regulatory bodies and the media are also opted into the committee as ad-hoc members.

Some members have of course been given honorary life membership for their great and tireless devotion to Committee business. They have been outspoken on home birth within their hospital units, within the media and even sometimes as expert witnesses in the country’s Coroner’s Courts or High Courts.

Accessing the Minutes of the Committee.
In true HSE style the Minutes of NCEHB meetings are difficult to access or find and may require an FOI. Sometimes when Minutes are found they bear no real reflection of what actually happened at the meeting, with meeting events spuriously added in by key individuals to suits the Committee’s central agenda. As with all committees the real work is done is secret working groups and subcommittees that do not maintain minutes, so the best stuff is probably recorded on someone’s mobile phone!

Furthermore, since the Committee’s membership is so fluid and not officially noted anywhere it is hard to know how often they meet and who attends never mind what decisions have been reached. It is assumed that these meetings take place in the dark corners of the HSE, in Department of Health corridors and in the by-ways of the nation’s Maternity Units, not to mention golf clubs and dinner tables of the medico-media-legal triumvirate. Some Committee members do not even realise that they are members of the Committee believing themselves to actually be part of the home birth supporters club.

Key achievements of the Committee

  1. Eliminating the term independent midwife.
  2. Removing autonomy from the midwife to make clinical assessments and judgements for their client
  3. Insisting on indemnity insurance for midwives in the cynical knowledge that this was not available on the open market yet legislate that other medical professionals can attend childbirth without such indemnity
  4. Creating a set of exclusion criteria that eliminates the choice of home birth for women without even allowing them individual assessment
  5. Requiring that obstetricians who are not experts in the field of home birth decide on whether women can avail of a home birth service or not
  6. Insisting that women whose babies are not in clinical distress transfer to a hospital setting in labour where they will probably be subject to a rigorous set of interventions
  7. Ensuring that women transferring from a home birth to a hospital setting do not get to transfer with their primary care giver.
  8. Insisting on two midwives present at every birth, in the cynical knowledge that there are not enough second midwives available in certain areas to perform this role.
  9. Refusing to engage in the recruitment of more midwives in order to provide midwives for the second midwife service. This is a particularly notable achievement of the NCEHB as there is no evidence anywhere to show that having a second midwife present at the birth improves outcomes for mother or baby.
  10. Tell women who are booking into hospitals for their bloods and scans that there is no national home birth service
  11. Ensure that the wage paid directly to self employed community midwives is very low and ensuring that any unaccompanied transfer to hospital, even in the woman’s best interests incurs a reduction of up to €1000
  12. Ensuring that newly qualified midwives cannot act as second midwives in a community setting until they have had three years experience in a maternity hospital. This is a great committee achievement especially considering that there is absolutely no evidence anywhere to suggest that second midwives improve outcomes for mothers and babies at all, neither is there any evidence to suggest that experience in an obstetric dominated maternity setting prepares newly qualified midwives for work in the community. Leaked Subcommittee Minutes tell us that this particular decision was based on a number pretty much plucked out of thin air and agreed upon based on the personal experience of individuals present in the room at the time.
  13. Striking independent midwives off the register following in-camera hearings in which it would appear evidence from midwifery professors currently practising in home birth is ignored in favour of evidence from those not currently involved in home birth.
  14. Subjecting SECMs to a different set of professional practice evaluation criteria than those reserved for other maternity care professionals. The country has been shocked in the last year by so many revelations of failure in our hospital maternity services, but so far none of the individuals involved have been subjected to any disciplinary action blame or reproach. In fact do we even have a guarantee that they are not still doing the same thing? Thankfully, due to the Committee’s ever vigilant and tireless pursuit of self employed midwives they get a public lambasting at best should they merely be within a whiff of an event the Committee doesn’t like, and if they were present at such an event the FTP card pops up like a jack in the box..
  15. Ensuring that mothers who disobey the Committee’s rules are punished. What is the best way of punishing a new mother? The best possible way of torturing a new mother is to take her baby way from her. The NCEHB have been carrying out some interesting experiments in this area by suggesting to social services that mothers who insist on birthing at home are unfit or unsafe parents, who therefore need to have their newborns removed from them.
  16. Forbidding midwives to attend women who do not wish to transfer to hospital care, thereby putting the woman her baby and her family at greater risk and putting midwives in the invidious position of having to relinquish their commitment to duty of care.
  17. Refusing to acknowledge the woman’s right to choose the circumstances by which she becomes a parent. This is carried out despite a European Court of Human Rights ruling to the contrary.
  18. Creating research that is deliberately statistically biased to try and prove that home birth is dangerous. The committee is aided and abetted in this regards by journals, which the committee control, that are willing to print such poor research.
  19. Citing the 8th amendment as a justification as to why a mother should not be permitted to proceed with a home birth.
  20. Eliminating home birth as an option for women who have had previous cesarean birth. This, despite the fact that she may have had previous babies at home in Ireland. Given the country’s extremely poor VBAC rates (despite the existence of national guidelines too promote it) this means that such women are basically being forced into repeat sections even though this is not in their baby’s or their best interest and is not best practice.
Congratulation to the NCEHB, you are doing a great job. The only fly in the ointment are the women’s advocacy groups that seem to be opposing Committee business; harping on about such irrelevant issues as human rights in childbirth, the right to choose, evidenced based care and the right to bodily self autonomy. Some of these groups have even exposed the high quality research that shows home birth to be safer than hospital birth in an obstetric unit, with both mothers and babies having better outcomes and fewer interventions. Whilst the Committee are aware of such evidence, the general modus operandi (as with any other evidence that does not align itself with any accepted clinical practice in our maternity system) is to simply ignore it.