The Use of Data for Decision Making:
ACOG’s Committee Opinion #476
Planned Home Birth
William H. Barth, Jr., M.D.
11 July 13
Disclosures
• I am an obstetrician whose salary is supported
by attending hospital deliveries
• ACOG Fellow
• Past Chair of the ACOG Committee on
Obstetric Practice and primary author for the
“Planned Home Birth” Committee Opinion
• I am the Medical Director for a hospital based
midwifery practice in Boston (Supervisor)
Objectives
• Describe the genesis of ACOG’s Committee
Opinion on Planned Home Birth
• Describe limitations of existing data sets
• Describe features of the ideal data set from
a decision making perspective
• 2003 US Standard Certificate of Live Birth:
possible birth setting specific modifications
Outcome of planned home births
in Washington State: 1989 to 1996
Study design: Retrospective cohort study
Data source: Birth certificates
Country/State/Province: Washington State
Pang JYW, et al. Obstet Gynecol 2002;100:253-9
Outcome of planned home births compared to hospital births in
Sweden between 1992 and 2004. A population-based register study
Outcome
Planned Home
N = 897
Planned Hospital
N = 11,341
RR (95% CI)
Neonatal Death
2.2/1000
0.7/1000
3.6 (0.2 – 14.7)
Cesarean section
22 (2%)
776 (7%)
0.4 (0.2 – 0.7)
Operative vaginal
20 (2%)
1089 (10%)
0.3 (0.2 – 0.5)
Sphincter rupture
3 (0.3%)
311 (2.7%)
0.2 (0.2 – 0.7)
Study design: Retrospective cohort study
Data source: Swedish Medical Birth Register +
Country/State/Province: Sweden
Lindgren HE, et al. Acta Obstet Gynecol Scand 2008;87:751
Perinatal mortality and morbidity in a nationwide cohort of 529,688
low-risk planned home and hospital births
Study design: Retrospective cohort study
Data source: National perinatal database (3 linked files)
Country/State/Province: Netherlands
de Jonge A, et al. BJOG 2009;116:1177-84
Outcomes of planned home birth with registered midwife versus
planned hospital birth with midwife or physician
Study design: Population-based cohort study
Data source: provincial Perinatal database
registry
Province: British Columbia
Janssen PA, et al. CMAJ 2009;181:6-7.
Outcomes of planned home birth with registered midwife versus
planned hospital birth with midwife or physician
Study design: Population based cohort study
Data source: provincial Perinatal database
registry
Province: British Columbia
Janssen PA, et al. CMAJ 2009;181:6-7.
Outcomes associated with planned home and planned hospital
births in low-risk women attended by midwives in Ontario,
Canada, 2003-2006: A retrospective cohort study
Study design: Retrospective cohort study
Data source: Ministry of Health database of Midwifery Care
Country/State/Province: Ontario, Canada
Hutton EK, et al. Birth 2009;36:180-9
ACOG Process for Committee Opinion
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Subject proposed to committee (many prompts)
Primary author assigned
Professional literature search provided
Draft provided prior to Committee
Discussed by Committee (ACOG Fellows, AAP, AAFP,
ACNM, NICHD, CDC, SMFM, ACOG Staff)
Revised draft reviewed 6 months later
Sent to Clinical Document Review Panel
Sent to ACOG Executive Committee
Published in Obstetrics and Gynecology and online
ACOG Press Release
Reviewed for content, relevance and need 18-24 months
Maternal and newborn outcomes in planned home
birth vs.. planned hospital births: a meta-analysis
Wax JR, Lucas FL, Lamont M, et al. Maternal and newborn outcomes in planned
home birth vs.. planned hospital births: a metaanalysis. Am J Obstet Gynecol
2010;203:243.e1-8.
Maternal and newborn outcomes in planned home
birth vs. planned hospital births: a meta-analysis
Wax JR, Lucas FL, Lamont M, et al. Maternal and newborn outcomes in planned
home birth vs. planned hospital births: a metaanalysis. Am J Obstet Gynecol
2010;203:243.e1-8.
In the wake of a meta-analysis
“In response to the concerns that were expressed
in the letters, the American Journal of Obstetrics and
Gynecology convened an independent review panel
to (1) review the article that was published and these
letters to the editors and (2) make recommendations
to the Journal. The review panel consisted of 3
panelists who are all specialists in maternal fetal
medicine, with expertise in metaanalysis and clinical
research.”
“In all 3 cases, the results the panel found were
slightly different from the result in the manuscript,
although there was no difference in (1) the direction
of the point estimate of the pooled odds ratio or (2)
the overall “statistical significance” of the result. The
panel made the following recommendations: (1) The
Journal should publish online full summary graphs
for each outcome that was assessed in the study,
which will allow readers to assess the study findings
better, and (2) no retraction of the article is
necessary.”
Reaffirmed 2013
GPC 6th Ed 2007
GPC 7th Ed 2012
Personal Observations
• Review process is far more rigorous than
standard journal “peer review”
• Written from a US perspective
– Great regional variation in healthcare
infrastructure and access
– Cautious use of data from outside the US
• Carefully worded to minimize ambiguity and
avoid overstatement
• In the end, it remains an opinion
What Data is Available to Inform
Outcomes for Birth Setting
• Birth certificates
– 2003 US Standard Certificate of Live Birth
– State based reporting
• Registries
– Birth center study (AABC)
– MANA Stats (NARM)
• Data sets compiled for individual reports
• Payers
Features of an ideal data set…
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Ascertainment: “intended place of delivery”
Selection criteria: “appropriateness” (ante, intrapartum)
Type of attendant: education, certification and licensure
Integration of health system; transport agreements,
geography, indication for transport
Ascertainment: outcomes
– Standardized definitions (reVITALize, NCHS, etc.)
Health system IT, EMR, common review
Mandatory, audited, enforced reporting
Publically available for download and analysis
Birth Certificates
• ACOG and others have pushed for adoption of
the US Standard Certificate of Live Birth
– (36 States, DC, Puerto Rico, Northern Marianas)
– (32 States use US Standard Report of Fetal Death)
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Model legislation written in 2009
Every issue of Guidelines for Perinatal Care
Every opportunity for public comment
Cause for optimism: NAPHSIS and NCHS
agreement, possibly by 1 Jan 2014
2003 US Standard Certificate of Live Birth
Does not capture planned
home birth transferred to
hospital.
Does not distinguish CPM,
LM, DEM, or other
Non-specific, does not
necessarily capture transfer
from home.
None capture reason for
transfer.
2003 US Standard Report of Fetal Death
7.
Does not capture planned
home birth transferred to
hospital.
14.
Does not distinguish CPM,
LM, DEM, or other
Does not capture location of
intrapartum fetal death if
known
Use of Data for Decision Making
• Depends on who is making the decision: each
will have different perspective and values
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Patients
Providers
Payers
Government agencies
• We have not discussed ethics of decision
making regarding birth setting
Conclusions: Data for Decision Making
• No RCTs of sufficient size to inform birth setting
• Only imperfect case series and cohort studies
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Ascertainment of intended birth setting
Provider education, training, certification and licensure
Nonstandard selection criteria
Non-uniform definitions of outcomes – follow up
Great regional variation in health system infrastructure
• No uniform data platform to adequately
compare birth settings in the US
Recommendations
• Continue to encourage the states to adopt the
2003 US Standard Certificates of Live Birth,
Death and Fetal Death
• We need minor modifications to 2003 US
Standard Certificate of Live Birth and Report
of Fetal Death to help inform the issue of birth
setting, other issues
– Intended birth setting
– Attendant
– Other: risk stratification, care processes, more…
Supplemental Slides
Grimes and Schulz. Limitations of Epidemiology. Obstet Gynecol 2012.
Neonatal Death: All
Neonatal Death: Non-anomalous
MANA Stats
Enrollment is voluntary
Participation rates: CPM (20-30%), CNM/CM (17%)
Individual patients must consent to participate (<3% decline)
May withdraw from reporting (approx 8% incomplete)
All birth settings: home, birth center, hospital
Midwives: CPM > CNM/CM > other midwives
Data collection process 2.0, 3.0 and newer 4.0
Efforts underway to encourage/mandate reporting
Data quality assurance: automated review, “Data Doula”
Outcomes of planned home births with certified professional
midwives: large prospective study in North America
5418 Women planning home delivery with CPM in 2000
Transferred to hospital
Epidural
Episiotomy
Forceps
Vacuum
Cesarean delivery
Total non-anomalous death
Total low risk non-anomalous
12.1%
4.5%
2.1%
1.0%
0.9%
3.7%
2.0/1000
1.7/1000
Johnson KC, Daviss B-A. BMJ 2005;330:1416–9
American Association of Birth Centers (AABC)
AABC Standards for Birth Centers
Commission for the Accreditation of Birth Centers (CABC)
AABC Uniform Data Set (UDS)
41% of Birth Centers known to AABC are members
78% of AABC members participate in the online registry
79 Birth Centers in 33 states
Cesarean section 6%, maternal mortality 0, intrapartum death
0.47/1000, neonatal mortality 0.4/1000
J Midwifery Women's Health 2013 (Jan/Feb);58:3–14
Other Sources (not all inclusive)
• National perinatal data collection efforts
– University Health Consortium (UHC)
– National Perinatal Information Center (NPIC)
• States’ perinatal reporting beyond birth
certificates: CMQCC, OPQC, others
• Payer or system data sets: HCA, Kaiser,
Intermountain Healthcare, DoD, others
• Professional org: Women’s Health Registry
Alliance
Perinatal and maternal outcomes by planned place of
birth for healthy women with low risk pregnancies: the
Birthplace in England national prospective cohort study
BMJ 2011;343:d7400 doi: 10.1136/bmj.d7400 (Published 24 November 2011)