Abstract
The cesarean section rate has soared to a record high of 26.1 % in the United States in 2002 and is the method of delivery for more than one out of every four women (Hamilton, Martin, & Sutton, 2003). Despite advances in surgical techniques, cesarean sections are not risk-free procedures, and yet, are being used more and more frequently for questionable indications. Various factors have contributed to the higher cesarean section rate. Among these factors, are the increasing incidence of labor inductions, the latest trend of "elective" cesarean sections, rapidly increasing professional liability insurance costs, the perception of protection against lawsuits for poor birth outcomes, recent research questioning vaginal birth after cesarean section (VBAC) outcomes, and the lack of universally accepted indications for primary cesarean sections. Increased risks of bleeding, infection, trauma to pelvic organs, post operative complications, and potential risks for future pregnancies are among the risks for the mother. Neonates are exposed to an increased risk of respiratory distress and the potential of delivery prior to full maturity. Midwives are an underused strategy in the nation's efforts to reduce the cesarean section rate to 15%, the goal of the US Department of Health and Human Services (Healthy People 2010). Midwives have demonstrated a lower cesarean section rate (8.8%) when compared to obstetricians (13.6%) and family practice physicians (15.1%) (Rosenblatt, Dobie, Hart, Schneeweiss, Bould, Rain, Benedetti, et al.,1997). Currently, midwives are presiding over approximately 10% of the nation's vaginal births (American College of Nurse-Midwives [ACNM], 2002). Hallmarks of midwifery care include recognition of pregnancy and birth as normal processes and advocacy of non-intervention in the absence of complications. This philosophically driven model of care, with respect for the natural processes of birth, and intervention only when necessary, may indeed account for midwives' lower cesarean section rate. Review of the literature revealed that midwives use less interventions and have lower cesarean section rates but the processes midwives use to achieve lower cesarean birth rates are not clearly understood. A quantitative comparative research study will examine factors influencing the differences in the primary cesarean section rates in selected care strategies of midwife compared to physician practices.
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Chapter 1: Statement & Significance of the Problem
Introduction to the problem
A cesarean section is delivery of a fetus through a surgical incision in the abdominal wall, known as a laparotomy, and an incision through the uterine wall, known as a hysterotomy (Cunningham, Gant, Leveno, Gilstrap & Wenstrom, 2001). This operation is intended to be used as a life-saving procedure for the mother and/or her baby. However, a number of factors, such as, the increasing labor induction rate, the option for women to choose an elective cesarean section, and the decreasing option of VBAC for women have led to its overuse in recent years. The cesarean section rate is rising despite national goals to decrease their occurrence to 15% (Healthy People 2010). The United States has recorded the highest cesarean section rate ever, accounting for 26.1% of all deliveries in 2002 (Hamilton, Martin, and Sutton, 2002). According to Hamilton et al. (2002), the rising cesarean section rate can be correlated to the dramatic decrease in vaginal births after previous cesarean deliveries. Vaginal births after cesarean section (VBACs) fell 23% from 2001 to 2002 to a low of 12.7% of all deliveries (Hamilton, et al). The primary cesarean section rate increased 7%, from 2001 to 2002, accounting for 18% of all cesarean section deliveries (Hamilton, et al.) In 2002, there were 4,019,280 births in the United States. With cesarean sections reaching a record high of 26.1%, over one million women and their infants were delivered by cesarean section (Hamilton, et al.,2002).
Phenomenon of interest
Despite national goals the reduce cesarean births, the rate continues to climb with each passing year. Many factors may be responsible for the steadily increasing rate. One area of debate is whether the increased rate of labor inductions directly affects the cesarean section rate. Another recent phenomenon is the option of elective primary cesarean section. Reasons offered for elective primary cesarean section range from convenience of choosing the date of delivery, to fear of labor, to maintaining pelvic floor integrity (Starr, 2003). Malpractice insurance for care providers must also be considered. According to Greve (2000), specialty areas, such as obstetrics, have seen triple-digit increases in their malpractice premiums which may force health care providers to alter the way they practice. Careproviders may opt to deliver care that involves the perception of the least amount of risk, which turns the focus to risk management, not patient safety (Greve). The current practice recommendations regarding indications for primary cesarean section delivery needs to be explored. Universally accepted criteria to indicate cesarean delivery, in general, are lacking. Reasons for cesarean section delivery vary according to author and research study (see table 1). An obvious answer to reduce the increasing rate of cesarean sections would be to decrease the amount of primary cesarean sections performed (ACNM, 2002). The phenomenon of interest for this study is the primary cesarean delivery rate. Of specific interest, is the impact that midwives may have on the overall cesarean section birth rate. Midwives are an untapped resource that may help to reduce the nation's cesarean section rate.
Table 1: Indications for cesarean section according to various authors.
Gregory, Korst, Gorbein &, Platt, 2002 | Gabbe, 2002 | DiGiuseppe, 2001 |
malpresentation | nonreassuring fetal heart rate | breech presentation |
antepartum bleed | cephalopelvic disproportion | seizures during labor |
herpes | failure to progress | hydrocephalus |
severe hypertension | placental abruption | face or transverse presentation |
uterine scar | placental previa | placenta previa |
multiple gestation | conjoined twins | cord prolapse |
macrosomia |  | abruptio placenta |
unengaged fetal head | | |
maternal soft tissue disorder | | |
hypertension (other) | | |
preterm gestation | | |
fetal congenital anomaly | | |
In the year 2000, midwives attended 297,902 deliveries in the United States. At almost 10%, this is a dramatic increase from 1975, when midwives attended 0.6% of all births (ACNM, 2002). While cesarean delivery is not within the scope of practice for midwifery, midwives are adept at screening for prenatal complications and labor abnormalities and arranging physician services as needed. Midwives consistently have a lower cesarean section rate when compared to their physician counterparts. Probably the most impressive study, includes a retrospective study of over 30,000 deliveries attended by midwives. The results of this study revealed an extremely low primary cesarean section rate of 1.8% along with a remarkably low neonatal intensive care admission rate of 1.5%. This study was done on low-income, Hispanic women and strongly suggests that midwives can deliver care that reduces cesarean section births without compromising maternal and fetal health (Greulich, Paine, McClain, Barger, Edwards & Paul, 1994). A nationwide study of free-standing birth centers, attended by midwives, revealed a low cesarean section rate of 4.4% along with a high patient satisfaction rate of 98.8% (Ernst, Rooks, Rosenfield, Stapleton & Weatherby, 1989). Another study found that CNMs had a cesarean section rate of 8.8%, compared to 13.6% for obstetricians and 15.1% for family physicians (Rosenblatt, Dobie, Hart, Schneeweiss, Bould, Rain, Benedetti, et al. 1997). In the same study, it was noted that CNMs used 12.2% fewer interventions while caring for their clients when compared to both the obstetricians and the family physicians, while achieving similar or better outcomes. True to the midwifery philosophy of non-intervention unless necessary, midwives not only use fewer interventions but use them when indicated to assist in achieving lower cesarean section rates when compared to their physician counterparts.
The time has come to implement a proactive plan towards decreasing the cesarean section rate. Midwives are an underutilized resource to combat the increasing cesarean section rate. According to the Public Citizen's Health Research Group in Washington, D.C., hospitals that employ the use of nurse-midwifery services have an average cesarean section rate of 13% lower than the average rate for all hospitals (Gabay & Wolfe, 1994). Public Citizen offers the following recommendations to help reduce the cesarean section rate: (1) hospitals should incorporate midwives and their philosophy of care into labor and delivery care programs; (2) insurance companies should encourage the use of midwives and free-standing birth centers by providing equal coverage for these providers and facilities; and (3) women and their partners should consider choosing a midwife for prenatal care and delivery.
Cesarean section delivery is not without risks or complications for women. Cesarean deliveries are potentially morbid procedures with overall infectious morbidity rates as high as 25% (Bashore, Phillips, & Brankman, 1990). In addition to the increased risk for infections with cesarean section, women are exposed to complications such as excessive blood loss and damage to pelvic organs (Starr, 2003). Future pregnancies may also be affected. There is an increased risk of uterine rupture, placenta accreta, and placenta previa associated with a previous cesarean section (Starr). Post operative complications include endomyometritis, wound infection, fascial dehiscence, urinary tract infections, bowel dysfunction, thromboembolic complications, and pelvic thrombophlebitis (Sedev, 2002). In many regions of the country, women are not allowed to VBAC and must resign to a repeat cesarean section with each successive pregnancy, exposing them to greater risks with each procedure and subsequent pregnancy. Seyb, Berka, Socol & Dooley (1999) conclude that aside from the increased delivery costs, future pregnancies are more likely to be complicated because of a primary cesarean section. A July, 2003 American College of Obstetricians and Gynecologist (ACOG) news release reported that cesarean birth significantly increased a woman's risk of a pregnancy related fatality (35.9 deaths per 100,000 deliveries with a live-birth outcome) compared to a woman who delivered vaginally (9.2 deaths per 100,000).
One of the main benefits heralded by the medical community, in support of cesarean section, is that women can maintain pelvic floor muscle integrity and decrease their risk for incontinence later in life by avoiding vaginal deliveries. Dietz & Bennet (2003) studied the effect of childbirth on pelvic organ mobility. They conclude that all forms of cesarean delivery are associated with less pelvic organ descent and therefore offers some protection over future pelvic floor disorders. Other studies yield different results. Lal (2003) studied the structural alterations in the continence mechanism following both vaginal and cesarean section deliveries and found that incontinence can occur post-cesarean section and without labor. He concluded that the current evidence does not support the routine use of elective cesarean section to prevent incontinence.
Cesarean delivery is not without risks or complications for neonates. Known risks include increased incidence of transient tachypnea, respiratory distress syndrome, hyaline membrane disease, and fetal lung immaturity related to surgical delivery prior to fetal maturity (Cunningham, Gant, Leveno, Gilstrap & Wenstrom, 2001). Respiratory complications result from a larger residual volume of lung fluid in neonates immediately after delivery. With vaginal delivery, approximately one-third of the fetal lung fluid is removed by compression of the baby's chest during passage through the birth canal. This mechanism is missing with cesarean section delivery. With larger residual lung fluid, less surfactant is secreted leaving neonates delivered by cesarean section at risk for respiratory problems (Roth-Kleiner, M., Wagner, B. P., Bachmann, D., Pfenniger, F., 2003).
Study purpose
The purpose of this study is to investigate the degree to which midwifery care can influence the primary cesarean section rate. This study will explore factors influencing the differences in the primary cesarean section rates in midwife compared to physician practices.
Type of study
A quantitative comparative research method will be used to explore the type of care given by midwives and by physicians and the impact it has on the primary cesarean section rate. A prospective comparative research design will compare clients receiving midwifery care to clients receiving physician (Ob/Gyn) care. Differences in care practices between groups in the natural setting are of primary interest. In this comparative study, four groups of nulliparous, pregnant clients will be followed for their delivery outcomes, vaginal or cesarean section, while also recording selected independent variables. Two control groups, one group of midwife clients and one group of physician clients, will be created by allowing clients to self-select a midwife or physician provider. Two more groups will be randomly assigned to either midwife or physician care. Using the design of studying self-selecting clients and randomly assigned clients will eliminate a common critique of midwife versus physician comparative studies, which suggests that midwife clients are different to begin with, leading to better outcomes.
Study question
1. What factors influence the difference in cesarean section rates between midwives and physicians?
Theoretical and operational definition of terms
Independent variables:
Induction of labor: Use of interventions to induce the onset of labor prior to the normal physiologic processes that cause the onset of labor. Interventions to induce labor would include: artificial rupture of membranes, use of Pitocin, or use of cervical ripening agents (cytotec, prostaglandin gel, prepidil, cervidil). Induction of labor is the stimulation of contractions before the spontaneous onset of labor (Cunningham, Gant, Leveno, Gilstrap & Wenstrom, 2001). Elective inductions of labor are associated with an increased risk of cesarean section delivery (Seyb, Berka, Socol & Dooley, 1999).
Augmentation of labor: Augmentation of labor is the stimulation of spontaneous contractions that are considered inadequate because of failure of progressing dilatation and/or descent (Cunningham, Gant, Leveno, Gilstrap & Wenstrom, 2001). For the purposes of this study, augmentation of labor will be limited to the use of Pitocin, cytotec or artificial rupture of membranes. The use of interventions, to include induction/augmentation of labor, is associated with a higher cesarean delivery rate (Rosenblatt, Dobie, Hart, L.G., Schneeweiss, Gould, Raine, et al., 1997).
Time subject spends out of bed: Actual time, in hours and minutes, that study subjects spend out of bed during labor, once admitted to the hospital. Midwives are more in favor of giving the women the option to remain upright instead of recumbent during the first and second stages of labor (Fullerton, Hollenbach, & Wingard (1996).
Time careproviders spend with subjects during labor: Actual time, in hours and minutes, that careproviders spend in the subjects room during labor. Midwifery care that includes one-on-one labor support is associated with a lower cesarean section rate (Butler, Abrams, Parker, Roberts, & Laros (1993).
Dependent variable:
Cesarean section rate: The number of subjects, in each study group, which deliver by cesarean section. In the United States, careproviders are encouraged to reduce their cesarean delivery rates in an effort to reach a national goal of 15% (Healthy People 2010).
Assumptions and philosophical approach
Midwifery care focuses on the normal processes of pregnancy and childbirth and is known for its non-interventionist approach. Interventions, like induction/augmentation of labor, during the intrapartum period may lead to maternal exhaustion, inability of the woman to effectively deal with stronger, more frequent contractions, and fetal distress, which could lead to a cesarean delivery. One-on-one labor support by a careprovider can facilitate the normal processes of labor and delivery by providing encouragement, support, and suggestions for coping with labor. Supportive careproviders can recommend position changes, be a role model for the patients' labor support person(s), evaluate the patients' coping mechanisms, and provide hands-on assessments of maternal and fetal status. Time spent out of bed can facilitate the labor process by using gravity to aid in dilatation and fetal descent. Position changes can offer distraction and comfort to the laboring woman and give her a sense of control over her labor and delivery. The philosophical approach for this study stems from the midwifery model of care which strives to protect the normalcy of labor and delivery and intervene only if indicated.
Limitations of the study
This proposed study will compare four groups of nulliparous, pregnant women that are cared for by a midwife or a physician (half randomly assigned and half self-selecting). Cesarean delivery rates will be compared as well as independent variables of care provided. Labor and delivery nurses will be collecting the intrapartum data. Individual variations in data collection may occur despite attempts to achieve high interrater reliability. With the prospective design of this study, careproviders may be influenced by the fact that they know they are being studied and may alter their care.
Chapter 2: Review of the Literature & Conceptual Framework.
Review of the Literature
With more than one out of every four women delivering their babies by cesarean section, this method of delivery has reached a record high. With VBAC deliveries falling out of favor with the medical community, the primary cesarean delivery rate needs to be addressed. Having a primary cesarean section puts a woman, her baby, and future pregnancies at risk. A review of the literature was done to explore indications for primary cesarean sections; relationships between inductions of labor and cesarean delivery; mode of delivery and its impact on pelvic floor dysfunction; midwifery care and cesarean section rates; practice styles and philosophy of care issues; and interspecialty differences.
The literature review was performed via an internet search. Several search engines were used including, Medscape, Yahoo, and AOL. The following websites were also used: www.findarticles.com; www.son.utmb.edu; and www.midwife.org. These resources provided a multitude of information in the form of abstracts, full text articles, and associated websites. Key search words used were: "cesarean section", "midwife", "malpractice", newborns and cesarean section", risks and cesarean section", "elective cesarean section", "pelvic muscles" and "vaginal and cesarean." Articles that contained information on primary cesarean sections were preferred as were articles that compared outcomes of midwifery care.
Indications for primary cesarean section
One important area to explore is medical indications for primary cesarean sections. Gregory et al.(2002), used a quantitative study to investigate the reasons for primary elective cesarean sections. Elective primary cesarean section (EPC) is defined, by the researcher, as undergoing a primary cesarean section delivery without a trial of labor, regardless of whether it is for a medical or a non-medical indication. The purpose of their study was to develop a standardized methodology using readily available hospital data to identify indications for elective primary cesarean sections (EPCs). This data would be used to describe parameters in which primary elective cesarean sections may be indicated. This tool could be available to physicians to help in the decision making process when considering EPCs for their clients. The researchers hypothesized that women who underwent EPCs would represent a "high risk" group with clinical conditions that would contraindicate proceeding with a vaginal delivery.
In 1995, Gregory et al.(2002) examined all discharge deliveries, as reported by the California Office of Statewide Health Planning and Development (OSHPD). The study population consisted of a total of 463,196 discharge deliveries: 443,532 (95.75%) who labored, and 19,664 (4.25%) who underwent EPC delivery without labor. The investigators used ICD-9-CM codes as the source of their data. Up to 25 codes were recognized in this study. Excluded were patients with a history of previous cesarean delivery (code 654.2) and patients that delivered at hospitals with fewer than two hundred deliveries per year. Since no ICD-9-CM code exists for labor, and because EPC deliveries occur in the absence of labor, an algorithm based on the presence of specific ICD-9-CM codes was developed to stratify the study patients into labor and nonlabor groups. Patients who had a vaginal delivery or discharge codes representing fetal distress, labor abnormalities, cord prolapse, and breech converted to vertex were categorized as having labored. Data was entered into a recursive partitioning algorithm to develop a hierarchy of clinical conditions by which patients with multiple conditions could be sorted with respect the binary outcome of labor versus EPC without labor. A random sample representing half of the patients was used to develop the hierarchy and was subsequently validated on the remaining half of the patients. The exhaustive CHAID (Chi-Square Automatic Interaction Detector) was used and allowed up to four levels of integration among the indicators. Patient conditions in the hierarchy were listed in the order by which the greatest statistical difference was found between those who labored and those who underwent EPC without labor. Those who did not fit into any of the categories were identified as having an "unspecified" indication for delivery. The clinical investigators examined the empirically derived hierarchy for clinical consistency by comparing it to conventionally recognized obstetrical conditions for EPC, literature review, and clinical experience. The hierarchy was accepted as representative of "reasonable" indications for EPC delivery. The descriptive data was analyzed and calculated for the proportions of patients undergoing EPC delivery for each indication. Categorical variables were analyzed using chi-square analysis with Yates correction. Means were expressed [+ or - ] the standard deviation and statistical significance was defined at the p< 0.05 level. Relative risks (RR) and 95% Confidence Intervals (CI) were reported. All analyses were performed using SAS statistical software. The recursive partitions algorithm specifying the clinical hierarchy, was constructed using the Answer Tree module of SPSS.
According to Gregory et al.(2002), the study found that EPC deliveries account for approximately 4% of all births to women without a previous cesarean. Ninety three percent of EPC deliveries were able to be explained with 12 specific clinical indications ( see table 2). Noteworthy was that many of the subjects were classified with indications strongly associated with cesarean (strong RR) but delivered vaginally. The "unspecified" group accounted for 7.1% of all EPCs and may represent women who chose EPC without having a medical indication. This study suggests that there are very few absolute medical indications for EPC delivery.
One of this study's (Gregory et al., 2002) strengths is its large population size covering many different hospitals. The population size gives this study credibility as a likely representation of the general population. This study demonstrates transferability by comparing the hierarchy of clinical conditions found in their data analysis to current practice, clinical experience and literature review. Limitations may be found in the data collection phase. It was not specified who collected the data and what their credentials were. Coding errors may have been made by the original care providers or office staff that may have thrown off the results of this study. By looking simply at ICD-9-CM codes, the investigators are limited in the amount of information they have for the true reason for the EPC delivery. These codes are used for billing purposes and some diagnoses may not have codes, forcing the provider to choose a code that resembles but does not accurately reflect the clinical circumstances. Obstetric care providers could benefit from a tool to guide them in their clinical decision when faced with suggesting EPC for their clients. The fact that a high percentage of women coded as having clinical indications for EPC were not delivered by cesarean section deserves attention. This fact alone contradicts the rising cesarean section rate in this country and should have women, care providers and insurance companies demanding to know the real reasons behind the current cesarean section rate of 26.1% (Hamilton, et al., 2003).
Table 2: Indications for primary cesarean section.
Gregory, Korst, Gorbein &, Platt, 2002 |
malpresentation |
antepartum bleed |
herpes |
severe hypertension |
uterine scar |
multiple gestation |
macrosomia |
unengaged fetal head |
maternal soft tissue disorder |
hypertension (other) |
preterm gestation |
fetal congenital anomaly |
Correlation between elective labor inductions and cesarean section delivery
Along with the rising cesarean section rate, the rate of elective inductions have increased. Seyb et al.(1999) investigated the phenomenon of elective induction of labor in term, nulliparous women. The purpose of their study was to quantify the risk of cesarean delivery associated with elective induction of labor. Candidates for this cohort study were limited to nulliparous women admitted to a major urban hospital within an 8-month period. Women were classified according to the following categories: spontaneous labor, elective induction of labor, or medical induction of labor (see table 3). Spontaneous labor was defined as regular, painful uterine contractions together with either complete cervical effacement or rupture of membranes. For labor inductions, if cervical ripening was indicated, laminaria or extraamniotic saline infusion was used. Oxytocin, with or without amniotomy, was used for labor induction. All subjects were at least 37 weeks gestation, with a singleton fetus in the vertex presentation. The final study group consisted of 1561 women. Subjects were categorized at the time of admission to the hospital and later verified with the hospital database. Additional data collected on each subject included: maternal age, race, managing service, gestational age, maternal height, and body mass index. Other factors quantified during this study include cervical dilatation on admission, time in labor and delivery, timing of epidural placement, length of postpartum stay, postpartum complications, and cost analysis. Delivery data included route of delivery, indication for cesarean delivery, birth weight, Apgar scores, umbilical artery cord gases, presence of meconium, and neonatal intensive care unit (NICU) admission. Data was obtained from subjects during admission; by reviewing the prenatal records, hospital charts and hospital perinatal data base; and by reviewing information on cost analysis from the hospital finance department.
Table 3 : Indications for Medical and Elective Inductions of Labor according to Seyb et al. (1999)
| Indications for Medical Induction of Labor | Indications for Elective Induction of Labor (cited by the admitting physician) |
| Gestational age >/= 41 weeks | Elective (term, favorable cervix or "impending" postdates) |
| Premature rupture of membranes (PROM) | "Suspect" preeclampsia ( BP < 140/90 and/or < 1+ proteinuria) |
| Fetal growth restriction (Ultrasound estimated < 10%tile) | "Suspect" fetal growth restriction (no ultrasound documentation) |
| Preeclampsia (BP >140/90 and proteinuria > 1+) | "Suspect" macrosomia (no ultrasound verification) |
| Chronic hypertension | Decreased amniotic fluid (but amniotic fluid index > 5) |
| Nonreassuring fetal surveillance | Other (hx of multiple pregnancy losses, idiopathic polyhydramnios, remote hx of genital herpes, paraplegia, gastroenteritis, family hx preeclampsia, successful external cephalic version, hx cholelithiasis, infertility with donor oocyte) |
| Macrosomia (Ultrasound estimated > 4000 gms) | |
| Diabetes mellitus | |
| Other (Cholestasis of pregnancy, maternal thrombocytopenia, recurrent nephrolithiasis) | |
Yankou, Petersen, Oakley & Mayes (1993) designed a study that would explore the philosophy of care for CNMs and physicians. The purpose of this study was to describe and compare the beliefs and care philosophies of CNMs and ob/gyns in the area of antepartum and intrapartum care of low-risk women. The subjects consisted of seven CNMs and ten obstetricians. The work environment for both groups were comparable as both groups delivered their clients at the same hospital, shared clinical facilities and held offices along the same corridor. The practice relationship between the two groups is collaborative in nature; referrals and consultations occur in both directions. Official statements from the American College of Nurse-Midwives (ACNM) and the America College of Obstetricians and Gynecologists (ACOG) were examined for similarities and differences in standards. Study questions were compiled from areas of similarity from both organizational standards. A four and one-half page survey was created and consisted of demographic information, questions about scheduled time for client appointments, and practice philosophies. To help ensure content validity, the self-report questionnaire was developed by clinical experts well versed in the national organizational statements for both ACOG and ACNM. The chief of each practice was a co-principle investigator. This study was part of a larger study to compare the processes of care and outcomes for women cared for by CNMs and obstetricians.
Analyses of this study (Yankou et al. 1993) was done using the median test. The median test was used because the data was ordinal and there were significant differences in the variances in the two subject groups. Problems with outliers and the small sample size also made the median test a more conservative test. The Bonferroni procedure was used to select an appropriate alpha level to assess significance to be able to achieve an overall level of significance of .05 for the family of tests. For this study, a value of .0008 is considered statistically significant. Results of the study showed that CNMs schedule an average of 49.3 minutes for the first prenatal visit and 29.3 minute for return obstetric (OB) visits compared to physicians; 29.8 minutes for a first prenatal visit and 14.6 minutes for return OB visits (P=.0004 for both comparisons). The subjects were asked to rate the importance of types of care in four distinct areas. In the first area, providers were asked to rate the importance of inquiring about 6 areas in the client's life that would be important to safe, effective prenatal care and rate the importance of five elements of prenatal care management. Although CNMs rated five of the information areas higher, for example: whether the pregnancy was planned, the differences were not statistically significant. In the philosophy of managing prenatal care nutrition, screening was rated higher in the CNM group and ultrasound use and alpha-fetoprotein screening was rated higher in the physician group. Again, these differences were not statistically significant. In the second area, providers were asked to rate the importance of providing prenatal information on 15 topics. CNMs rated these topics as more important than physicians but the differences were not significant. In the third area, providers were asked to rate the importance of client teaching of medical, non-medical, and psychosocial aspects of care. CNMs rated higher, all areas as important ranging from 76.4% of respondents to 96.4 %, while physicians rated the importance of teaching in different areas 25% of respondents to 65%. The fourth area asked providers to rate the importance of intrapartum care philosophies. CMNs responded that ambulation in labor and choice of birth positions were of great importance while physicians rated the use of Pitocin and intravenous fluids as having importance. Once again, the differences were not statistically significant.
The study by Yankou et al. (1993) failed to show statistical significant differences between CNM and physician care practices, influenced by their professional philosophies. However, this is probably due to the very small sample size. Expected differences in the philosophy of care to low risk women were noted in all areas and may become statistically significant with a larger sample size. As part of the research method, the researchers used official statements on philosophy of care from the ACNM and ACOG but failed to ask the individual respondents what model of care they used for practice. A strong part of the design of this study was similar practice areas regarding hospital of delivery, shared clinical site and the close proximity of the practices. A study done on a larger sample size may validate some of the basic philosophy of care practices midwives use that may have an impact on the cesarean section rate.
Interspecialty differences
Rosenblatt et al. (1997) examined interspecialty differences in the obstetric care of low-risk women. The purpose of the study was to test the hypothesis that core differences exist in resource management styles for care provided to similar groups of women by certified nurse-midwives, family physicians, and obstetricians. The researchers hypothesized that obstetricians would display the most interventive practice styles and CNMs the least interventive, with family physicians falling somewhere in the middle. A random, stratified sample of low-risk obstetrician, family physician, and certified nurse-midwife patients were abstracted during a one year period in an urban area. A total of 156 providers contacted, 54 obstetricians, 59 family physicians, and 43 certified nurse-midwives, agreed to participate. From each provider, 11 eligible charts were randomly selected for the total of 1322 patients after some charts were omitted for incomplete records. The unit of analysis in this study was provider behavior. Chi-square and F-test statistics were used and ttest was used to adjust for multiple comparisons. Statistical significance was set at P< .01.
Results of the study (Rosenblatt et al. 1997) showed that during the prenatal period, obstetricians saw their clients slightly less than the other two providers and did less screening tests. Most notable was that obstetricians performed more amniocentesis (6.8% compared to 1.4% for family physicians and 2.2% for CNMs) for reasons charted as genetic diagnosis and fetal lung maturity. CNMs ordered more nonstress tests than the other two care providers but also had more postdate pregnancies. The majority of differences were noted in the intrapartum period. CNMs showed statistical differences in that they were less likely to induce or augment their clients, use continuous fetal monitoring, use epidural anesthesia, or perform episiotomies. The practices styles between family physicians and obstetricians were fairly similar except in the area of epidural use, a statistical difference was noted in the less frequent use of epidurals in the family physician group. The cesarean section rates for the respective groups were CNMs 8.8%, obstetricians 13.6%, and family physicians15.1%. Important to note is that when they compared cesarean delivery rates in the nulliparous clients, it was higher for all specialties: CNMs 11.7%, obstetricians 23.0%, and family physicians 26.4%. When comparing costs, obstetricians used 12.2 % more resources for their clients than CNMs, with family physicians falling in the middle. This can be interpreted as CNMs use less interventions for their clients.
Although patients were randomly selected for this study (Rosenblatt et al. 1997), the patients did select their careproviders on their own which may enter some bias into this study as to the type of interventions the clients' desired. A strength of this study was the large number of providers, representing the three groups that were studied. However, only 11 patient charts were used for each provider which may not provide enough information for a particular provider. The findings of this study may point to a core difference between the three different specialties. One may deduce that the type of training and philosophy of training may dictate how a particular care provider will practice. An important finding of this study is that CNMs use fewer interventions for their clients and ultimately end up with a lower cesarean section rate. These two factors seem to go together and cannot be ignored. The use of midwifery care may be one of the solutions to the problem of the rising rate of cesarean sections.
Hueston & Rudy (1993) explored the management styles of nurse-midwives and family physicians. The purpose of this study was to determine if differences in management styles existed between midwives and family physicians and how they affect patient outcomes. The study population were patients from a co-practice of family physicians and midwives. The purpose of this co-practice originated to offer perinatal services to an indigent population in northeast Kentucky. In the practice, patients see both midwives and family physicians. When patients present to the hospital in labor, they are cared for by a midwife or a physician depending on who is on call. Patients were randomly selected via a retrospective chart audit of patients that received care during a period of one year. To ensure randomization, charts were selected based on computer-generated random numbers that corresponded to the order in which patients gave birth in a particular month. A total of 800 patients were used for the study; 400 in the midwife group and 450 in the physician group, which represented 84% of all patients that delivered within the study period. The type of careprovider that presided over intrapartum care determined which group the patient was to be assigned. Data collected from the charts included demographics, medical and obstetrical history, labor and delivery results, and identity of careprovider during labor and delivery.
Data analysis in this study (Hueston & Rudy, 1993) was performed using two-tailed Student's ttest for normally distributed data and the Kruska-Wallis Htest for data not normally distributed. A two tailed chi-square was used for categorical variables, with Fisher's exact test for expected cells less than 5. A bivariate analysis was performed separately for primiparous and multiparous clients to allow for the strong effect of parity of labor, delivery, and outcomes. Stepwise logistic regression was performed with Epistat software to adjust for computer identified variables. Independent variables identified were provider specialty, parity, and the total number of preexisting risks. The dependent variable was route of delivery, vaginal or cesarean section. Results of the study found some differences between the two specialties. During management of labor, multiparous patients under physician care were twice as likely to be augmented with oxytocin (P=.02). Primiparous clients managed by midwives were more likely to undergo amniotomy (p=.01). Other areas like labor induction rates, prostaglandin use and all types of labor anesthesia were similar between the two providers. There were some notable differences in the area of management of delivery. Episiotomies were used less frequently by midwives (P=.02) and the rate of third and fourth degree lacerations was less for midwife clients (P=.007). Most notably was that family physician clients had a higher cesarean delivery rate when compared to the midwife clients (P=.05). Reasons for cesarean delivery were recorded as dystocia or failure to progress. Patients in the physician group that underwent cesarean delivery did so at a lower cervical dilation than the midwife clients.
This study (Hueston & Rudy, 1993) introduced a unique practice of family physicians and midwives to compare. Patient preference for a certain type of provider was eliminated by using the provider on call for management of the intrapartum period. The researches of this study had the foresight to realize that some patients would start the intrapartum period with one provider but be delivered by a different provider if the labor overlapped the time frame that the providers were on call. Patients that were managed by two different types of careproviders were excluded from this study to avoid the potential for invalid data collection. Although the patient sample size was adequate, the number of providers was small which may limit the transferability of the results of this study to the larger population. By studying a practice composed of midwives and family practice physicians, the management styles of the different careproviders during the prenatal period should have been analyzed. While the differences in management styles during the prenatal period may be more difficult to pinpoint in an integrated midwife/physician practice, they should be explored. The results showed a decreased rate of cesarean deliveries in midwife clients but do not offer the reasons for the lower rate. It was noted that family physician clients underwent cesarean delivery at a lower cervical dilatation and reasons for that mode of delivery were frequently cited as dystocia and failure to progress. This may suggest that midwives were simply more patient and allowed their clients to labor longer. More study is needed to explore the true reasons for the decreased rate of cesarean deliveries in midwife clients.
Jackson, Lang, Swartz, Ganiats, Fullerton, Ecker, et al (2003) desired to use a large prospective cohort study to explore outcomes of birth center deliveries. They wished to avoid problems of previous studies on this subject which were related to the perception that women who choose a birth center delivery are healthier and seek low-intervention care. The purpose of this study was to compare outcomes, safety, and resource utilization in a collaborative management birth center model of perinatal care versus traditional physician-based care. Meticulous attention was paid to the perinatal risk of all the women in the study to ensure that both groups were low-risk. The study population were low-income, low-risk women who presented for prenatal care and delivery at several study sites. Two study programs were compared: collaborative management/birth center care and traditional care. The subjects included 2957 women: 1808 received collaborative care and 1149 received traditional care. In the collaborative care model, obstetricians and CNMs comprised the same practice. During the antepartum period, 30% of the subjects saw only CNMs, 65% were collaboratively managed, 5% were exclusively managed by a physician. Low-risk women in this group were given the option of delivering at the freestanding birth center managed or co-managed by CNMs. The birth center provided a home-like atmosphere and promoted non-intervention. Intermittent auscultation was used along with encouraging ambulation, emotional support, warm baths, and narcotic analgesics as needed. Epidural analgesia was not available. Traditional care was performed at two hospital-based prenatal care clinics and 7 private physician practices. Subjects in this group were managed by obstetricians or obstetric residents. The hospital where these women would deliver had 24-hour anesthesia services, used continuous fetal monitoring and intravenous fluids routinely, and had neonatal intensive care units. Collaborative care subjects were assessed at the first prenatal visit to determine birth center eligibility. Traditional care subjects were also assessed to determine if they would meet the criteria of a birth center delivery for comparison. Data was collected on maternal, perinatal, and neonatal mortality and morbidity; antepartum, intrapartum, and postpartum risk factors and complications; sociodemographics; use of resources and procedures; and neonatal outcomes such as birthweight, gestational age, and Apgar scores.
For this study (Jackson et al. 2003), three categories of outcomes were studied: maternal, neonatal, and behavioral. The researches recognized that there would be a low occurrence of major perinatal complications in the low-risk group and assigned aggregate variables for serious morbidity. All potential risks or complications were evaluated for potential to contribute to serious morbidity or mortality and comparability of information across study groups. The researchers used the general linear modeling with SAS GENMOD (SAS Institute, Inc. Cary, NC) with binomial distribution and identity link function, to produce adjusted risk differences and Wald estimates of 95% confidence intervals.
The researchers (Jackson et al. 2003) found that the use of resources and interventions varied between the two groups. Subjects in the traditional care model received more interventions like oxytocin induction and augmentation, episiotomies, and epidural use. Women in the collaborative care model had access to less technical interventions like ambulation, tub or shower use, and oral fluids. The cesarean section rate was 10.7% in the collaborative care model and 19.1% in the traditional model. Women in the traditional group were more likely to receive an episiotomy (37.8%) compared to women in the collaborative group (13.1%). Fetal heart rate abnormalities were reported in 10.5% of the collaborative subjects and 19.4% of the traditional subjects. Neonatal outcomes were similar in both groups but the newborns in the traditional model received sepsis workups (with and without treatment) more frequently. The researchers concluded that low-risk women in both models received safe care for mothers and babies. The collaborative model was able to deliver safe outcomes with less interventions and resources.
Once again, care delivered by midwives, with less intervention, results in a lower cesarean section rate. Not only were they able to demonstrate safe, effective care but a lower use of resources, thus, less cost. This study relied on data abstraction from medical records which could potentially provide inadequate or missing data. One of the main differences noted in this study was the type of fetal monitoring: continuous versus intermittent. There have been previous studies that suggest continuous fetal monitoring does not improve fetal outcomes in most laboring women. That suggestion was true in this study. Perhaps the use of continuous fetal monitoring led to the increased numbers of cesarean sections on women in the traditional group.
Summary
The review of the literature shows that there have been studies on indications for primary cesarean sections and various authors report different indications. With cesarean deliveries rising at an alarming rate, it is time to develop nationally accepted standards for primary cesarean deliveries. Elective inductions of labor without medical necessity have a direct correlation to a higher risk of cesarean delivery. This is another area where definitions are grey. What careproviders consider a medical necessity for induction of labor varies from provider to provider. Pelvic floor integrity is a new buzz word in the medical community. Some providers claim vaginal by-pass deliveries via cesarean section will preserve pelvic floor function and decrease associated problems like incontinence. The review of the literature shows that it is pregnancy that tax these muscles and not the mode of delivery. The exception is an operative vaginal delivery, which has been associated with lack of pelvic floor integrity. Midwives tend to use less interventions like epidurals, episiotomies, and oxytocin. The use of epidurals and oxytocin has been associated with higher cesarean section rates. As far as philosophy of care, midwives view education in all areas of care and the woman's life, in general, as important. It was also found that midwives spend more time at office visits with their clients. This study will explore factors that influence the differences in primary cesarean section rates in midwife compared to physician practices.
Conceptual Framework
In the area of research, one must consider what is the driving force for the study. A conceptual framework is the driving force for a research study. Although it may not always be clearly stated, the researcher has been guided by a formal or informal conceptual framework. In understanding what a conceptual framework is, it is easiest to break it down into smaller components. A theory is an abstract idea representing a sequential path that shows how phenomenon are related (Polit, Beck & Hungler, 2001). A theory is the basis of research. A conceptual model is a loose schematic of how concepts come together. Conceptual models are often represented in a conceptual map which is simply a diagram of the conceptual model. Conceptual models may be shown by boxes, arrows, letters, or other symbols to show how concepts are related. The theory, conceptual model and conceptual map all build up to the conceptual framework which guides and directs the research process and helps researchers to develop relationships between what is known and what they are researching. Ultimately, the conceptual framework helps to develop the hypothesis and guide the study (Polit et al).
The conceptual framework that is the driving force of this research study is the midwifery model of care. Unlike the medical model of care, which is based on an illness model, the midwifery model of care focuses on the normalcy of pregnancy, childbearing, and families. Midwives are trained to intervene only if necessary. Midwifery care is centered around the whole woman. Midwives strive to know the woman as the person she is and explores how each woman fits into her family, environment, and world. Midwives explore expectations of their clients for pregnancy and childbirth and develop client-centered plans to help women meet their goals. Midwifery care is individualized care for each woman (Rooks, 1997).
In contrast to the medical model of care, in which training, education and skills focus on pathology and the diagnosing and treatment of disease, under the midwifery model of care, midwives use their training, education and skills to protect, support and enhance normal pregnancy and childbirth (Rooks, 1997). Under the midwifery model of care, pregnancy is viewed as a critical and vulnerable period but also as a very normal part of women's lives (Rooks, 1999). To begin with, certified nurse-midwives are educated in two disciplines: nursing and midwifery. Midwives receive extensive training in reproductive anatomy and physiology, health care of women, pharmacology, antepartum care, intrapartum care, postpartum care, and newborn care. While the emphasis is on the normalcy of pregnancy and childbirth, under the midwifery model of care, midwives are trained to identify abnormal conditions that may develop. The midwifery model of care provides for a system of collaboration, consultation, or referral with or to a physician if the need arises.
The midwifery model of care recognizes the pregnant women as an active participant in her own care. At each prenatal visit, midwives devote some time to teaching and education. A large part of midwifery care involves providing women with information and allowing them to make decisions related to their own health care. To do this, midwives provide their clients with information, options, and the overall authority to make their own choices (Rooks 1999). Under the midwifery model of care, the woman and her life are the central focus of care. Midwives strive to focus on each pregnant woman as a unique person, get to know her in the context of her family and lifestyle, and work to develop a plan of care that is client focused. The midwife is interested in each woman's expectation and experience of her pregnancy and birth. When armed with the knowledge of the woman's beliefs, desires, questions, worries, and lifestyle, the midwife and the client can work together to tailor an individualized plan of care (Rooks, 1999).
In childbirth, the midwifery model focuses on the normalcy of labor and delivery and uses intervention only if indicated. Midwives, as a whole, tend to have a higher tolerance for variation, within the range of normal, as long as the woman and her baby and tolerating labor well (Rooks, 1999). By treating labor as normal, interventions such as oxytocin augmentation, induction of labor, artificial rupture of membranes, and epidurals may be avoided helping to avoid stress to mom or baby and allowing the labor to stay normal. Midwives believe that women's bodies were designed to give birth and they try to protect, support, and avoid interfering with the normal processes (Rooks, 1999). Avoidance of interference, however, does not mean neglect. Midwifery care is known to be time intensive and relationship intensive (Rooks, 1999). Midwives often spend more time with their laboring clients, offering support, encouragement, coaching, and comfort. The physiology of labor is well understood by midwives and they encourage their clients to change positions, ambulate, eat small frequent meals, take in oral hydration, use hydrotherapy, and use exhalatory pushing during second stage. The midwifery model of care views pregnancy and childbirth as a healthy state and strives to protect the normalcy of this time in a woman's life.
Key concepts and relationships
The hallmark of the midwifery model of care focuses on viewing pregnancy and birth as normal physiologic and developmental processes. Non-intervention is advocated in the absence of complications. Normal is defined as occurring naturally or free from disorder. Non-intervention is a "hands off" approach to pregnancy and childbirth. The use of this simple, two-tiered approach can be applied to the current problem of the rising cesarean section rate. Review of the literature showed that clients that received midwifery care had a lower cesarean section rate. This research study will explore whether the use of midwifery care can help reduce the cesarean section rate. To do this a quantitative comparative study will be used to explore the type of care given by midwives and by physicians and the impact it has on the primary cesarean section rate. When compared to other care providers, midwives consistently had significantly lower cesarean delivery rates for their clients. What needs to be explored and quantified is the type of care that midwives deliver that get these results. Although the midwifery model of care is valued and fostered by most midwifery practitioners, other careproviders may apply this model of care to their practice.
Conceptual Map
MMOC-------(-)----------<P C/S
MMOC= Midwifery Model of Care
P C/S= Primary Cesarean Sections
Implementing the midwifery model of care can result in the lower rate of primary cesarean sections. By reducing the primary cesarean section rate the overall cesarean section rate may be impacted. For some, using the midwifery model of care would require a paradigm change, from viewing pregnancy as a catalyst for pathology to viewing pregnancy as a normal process.
Chapter 3: Methodology
Research Design
A quantitative comparative research method will be used to explore the type of care given by midwives and by physicians and the impact it has on the primary cesarean section rate. Research has shown that clients cared for by midwives had lower primary cesarean delivery rates (Butler,1993; Davis,1994; Ernst,1989; Hueston,1993; Jackson, 2003; & Rosenblatt,1997). A prospective comparative research design will compare clients receiving midwifery care to clients receiving physician (Ob/Gyn) care. Comparative research studies are often used when the parameters of the study does not meet the requirements for an experimental design (Polit, Beck & Hungler, 2001). One of the requirements for experimental design is the ability to manipulate the intervention or treatment. However, in this study, it is the differences in care practices between groups in the natural setting that are of primary interest. In this comparative study, four groups of nulliparous, pregnant clients will be followed for their delivery outcomes, vaginal or cesarean section, while also recording selected independent variables. Two control groups, one group of midwife clients and one group of physician clients, will be created by allowing clients to self-select a midwife or physician provider according to the current system set up at the study site. Prior to the first appointment, women choose which type of provider they desire for their care, which encompasses prenatal, antepartum and postpartum. Currently, about 60% choose an Ob/Gyn provider and 40% choose a midwife provider. Two more groups will be randomly assigned to either midwife or physician care by the researcher. Using the design of studying self-selecting clients and randomly assigned clients will eliminate a common critique of midwife versus physician comparative studies. It has been suggested that midwife clients are different to begin with, leading to better outcomes, because they are healthier, lower risk and desire less intervention. Independent variables that will be studied are induction of labor, use of Pitocin to augment labor, amount of time clients spent out of bed during labor and provider time spent with clients during labor. The cesarean section rate will be the dependent variable.
This research design is expressed in the following design notation form:
Group 1 X O1 Delivery Method (self-selecting midwife clients)
Group 2 X RO2 Delivery Method (randomly assigned midwife clients)
Group 3 X O3 Delivery Method (self-selecting physician clients)
Group 4 X RO4 Delivery Method (randomly assigned physician clients)
R= randomization
O= observations
X= treatment (either physician or midwife care)
Internal and External Validity
Internal validity is the degree to which it is possible to infer that the independent variable(s), rather than uncontrolled, extraneous factors, are responsible for the observed outcome(s) on the dependent variable (Polit, Beck & Hungler, 2001). Researchers must identify threats to internal validity and take measures to control them.
Threats to internal validity in this study might include:
| Topeka, Kansas Demographics | United States Demographics |
| White 82.9% | White 75.1% |
| Black or African American 9% | Black or African American 12.3% |
| Hispanic 7.3% | Hispanic 12.5% |
| American Indian 1.2% | American Indian 0.9% |
| Asian 1% | Asian 3.6% |
References
American College of Nurse-Midwives (2002, December). CNM-attended births still on the rise! Retrieved October 8, 2003, from http://www.midwife.org/prof/display.cfm?id=79
American College of Obstetricians and Gynecologists (2003, July). ACOG news release. Retrieved October 7, 2003,from http://www.acog.org/from_home/publications/press_releases/nr07-31-03-3.cfm
Bashore, R.A., Phillips, W. A., Brankman, C. R. (1990). A comparison of the morbidity of midforceps and cesarean delivery. Am J Obset Gynecol, 162, 1428-35.
Butler, J., Abrams, B., Parker, J., Roberts, J. M., Laros, R. K. (1993). Supportive nurse-midwife care is associated with a reduced incidence of cesarean section. Am J Obstet Gynecol, 168, 1407-13.
Centers for Disease Control and Prevention (2003). Epi info 3.01. Retrieved January 12, 2004, from http://www.cdc.gov/epiinfo/about.htm
Cunningham, G. C., Gant, N., Leveno, K. J., Gilstrap III, L. C., Hauth, J. C., Wenstrom, K. D. (2001). Williams obstetrics (21st ed). New York: The McGraw-Hill Companies, Inc.
Davis, L. G., Riedmann, G. L., Sapiro, M., Minogue, J. P., Kazer, R. R. (1994). Cesarean section rates in low-risk private patients managed by certified nurse-midwives and obstetricians. Journal of Nurse-Midwifery, 29(2), 91-97.
Dietz, H. P., Bennet, M. J. (2003). The effect of childbirth on pelvic organ mobility. Obstet Gynecol, 102(2), 217-9.
DiGiuseppe, D. L. (2001). Risk adjusting cesarean delivery rates: A comparison of hospital profiles based on medical record and birth certificate data. Health Services Research. Retrieved October 7, 2003, from http://www.findarticles.com/df_0/m4149/5_36/80025041/print.jhtml
Ernst, K., Rooks, J., Rosen, D., Rosenfield, A., Stapleton, S., Weatherby, N. (1989). Outcomes of care in birth centers. (The national birth center study). New England Journal of Medicine, 321, 1804-11.
Fullerton, J. T., Hollenbach, K. A., Wingard, D. L. (1996). Practice styles: A comparison of obstetricians and nurse-midwives. Journal of Nurse-Midwifery, 41(3), 243-50.
Gabbe, S. G., Neibyl, J. R., Simpson, J. L. (2002). Obstetrics: normal and problem pregnancies. Philadelphia: Churchill Livingstone.
Gabay, M., Wolfe, M. D. (1994). Unnecessary cesarean sections: curing a national epidemic. Washington: Public Citizen.
Gregory, K. D., Korst, L. M., Gornbein, J. A., Platt, L. D. (2002, October). Using administrative data to identify indications for elective primary cesarean delivery. Health Services Research. Retrieved October 5, 2003, from http://www.findarticles.com/cf_0/m4149/5_37/95105514/print.jhtml
Greulich, B., Paine, L. L., McClain, C., Barger M. K., Edwards, N., Paul, R. (1994). Twelve years and more than 30,000 nurse-midwife-attended births: the Los Angeles County + University of Southern California women's hospital birth center experience. Journal of Nurse-Midwifery, 39(4), 185-96.
Greve, P. A. (2002). Anticipating and controlling rising malpractice insurance costs. Healthcare Financial Management. Retrieved October 7, 2003, from http://www.findarticles.com/cf_0/m3257/5_56/86064160/print.jhtml
Hamilton, B. E., Martin, J. A., Sutton, P. D. (2003, June). Births: preliminary data for 2002. Natl Vital Stat Rep, 51 (11),1-20.
Hueston, W., Rudy, M. (1993). A comparison of labor and delivery management between nurse midwives and family physicians. The Journal of Family Practice, 37(5), 449-454.
Jackson, D. J., Lang, J. M., Swartz, W. H., Ganiats, T. M., Fullerton, J., Ecker, J., Nguyen, U. (2003). Outcomes, safety, and resource utilization in a collaborative care birth center program compared with traditional physician-based perinatal care. Research and Practice, 93(6), 999-1006.
Lal, M. (2003). Prevention of urinary and anal incontinence: role of elective cesarean delivery. Curr Opin Obstet Gynecol, 15(5), 439-48.
MacLennan, A. H., Taylor, A. W., Wilson, D. H., Wilson, D. (2000). The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. British Journal of Obstetrics and Gynaecology, 107,1460-1470.
Polit, D., Beck, C., Hungler, B. (2001). Essentials of nursing research. Methods, appraisal, and utilization (5th ed.). Philadelphia: Lippincott.
Rooks, J. P. (1997). Midwifery and childbirth in america. Philadelphia: Temple University Press.
Rooks, J. P. (1999). The midwifery model of care. Journal of Midwifery & Women's Health, 44(4), 370-74.
Rosenblatt, R. A., Dobie, S. A., Hart, L.G., Schneeweiss, R., Gould, D., Raine, T. R., et al. (1997). Interspecialty differences in the obstetric care of low-risk women. American Journal of Public Health, 87(3), 344-51.
Roth-Kleiner, M., Wagner, B. P., Bachmann, D., Pfenniger, F. (2003). Respiratory distress syndrome in near-term babies after caesarean section. Swiss Med Wkly, 133, 283-288.
Sedev, H. M. (2002). Cesarean delivery. Retrieved September 30, 2003, from http://www.emedicine.com/med/topic3283.htm
Seyb, S. T., Berka, R. J., Socol, M. L., Dooley, S. L. (1999). Risk of cesarean delivery with elective induction of labor at term in nulliparous women. Obstetrics & Gynecology, 94(4), 600-607.
Starr, C. (2003). Elective cesarean section: a new dividing line for OBs. Contemporary OB/GYN. Retrieved September 30, 2003, from http://obgyn.pdr.net/be_core/MVC?mag=g&action=viewArticle&y=2003&m=06&d=02&..
Topeka Chamber of Commerce (2000). Demographics. Retrieved January 5, 2003 from http://www.topekachamber.org/ecoDevo_sub/qualityLife/demographics.htm
US Department of Health and Human Services. (2000, November). Healthy people 2010: understanding and improving health. Retrieved October 10, 2003, from http://www.healthypeople.gov/document/htlm/objectives/16-09.htm
U.S. Census Bureau (2002). Geographic area: United States. Retrieved January 5, 2003 from http://factfinder.census.gov/servlet/QTTable?ds_name=DEC_2000_SF1_U&geo_id=01000...
Yankou, D., Petersen, B. A., Oakley, D., Mayes, F. (1993). Philosophy of care: A pilot study comparing certified nurse-midwives and physicians, 38(3), 159-64.
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Appendix A:
Indications for primary cesarean section.
Gregory, Korst, Gorbein &, Platt, 2002 |
malpresentation |
antepartum bleed |
herpes |
severe hypertension |
uterine scar |
multiple gestation |
macrosomia |
unengaged fetal head |
maternal soft tissue disorder |
hypertension (other) |
preterm gestation |
fetal congenital anomaly |
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Appendix B:
Administration protocol for cervical ripening
Cytotec 25 mcg or Prostaglandin E2 gel (one applicator full) vaginally every 4 hours, maximum of four doses
discontinue if:
-SROM/AROM
-hyperstimulation of the uterus
-adequate contraction pattern demonstrated by greater than 200 Montevideo units
-fetal distress
-Bishop score greater than 5
Administration protocol for Pitocin induction/augmentation
Start Pitocin at 2 milliunits/minute and increase 2 milliunits/minute every 20 minutes until adequate labor pattern is established as demonstrated by greater than 200 Montevideo units. Maximum Pitocin rate is 20 milliunits/minute.
discontinue if:
-fetal distress
-hyperstimulation of the uterus
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Appendix C:
SUBJECT RECRUITMENT LETTER
I would like to invite you to participate in a research study that will examine the kind of care women receive in labor and delivery and whether is makes a difference in the birth outcomes. Women who are pregnant with their first baby and who are considered "low-risk" from a medical point of view, are ideal candidates for this study. In this study the researcher will compare women who receive care from a physician (Ob/Gyn) to women who receive care from a certified nurse-midwife. Birth outcomes, vaginal delivery or cesarean delivery, will be compared among the groups of women observed. Different types of care provided will be observed to see how it relates to the type of delivery outcome. Willing participants will be given an informed consent document to read and sign and will be allowed to ask questions of the researcher prior to agreeing to be a part of this study. Women who agree to participate in this study will either self-select the type of provider they want for their obstetrical care or will agree to be randomly assigned to a care provider. Participants will also give permission to the researcher and research staff to have access to their medical records both in the care providers office and at the hospital during and after their delivery. Participants will not be required to fill out questionnaires or be manipulated in anyway. Your only requirements are your willingness to participate, to possibly be randomly assigned to a care provider, and to allow access to your medical records. If you would be willing to participate in this study please sign this document and include your address and phone number so the researcher can contact you.
Thank you for you time,
Kim Keen RN, BSN, SNM
I, __________________, agree to be contacted by the researcher, Kim Keen, regarding the above research study.
Signature: ___________________________
Address: ___________________________
___________________________
Phone #: (s) ___________________________
Email address: _________________________
Please initial one of the following:
____ I prefer to select a Certified Nurse-Midwife for my careprovider.
____ I prefer to select and Obstetrician/Gynecologist for my careprovider.
____ I agree to be randomly appointed to a careprovider.
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Appendix D:
Informed Consent
PHILADELPHIA UNIVERSITY IRB No. 130
CONSENT FOR PARTICIPATION IN
PRIMARY CESAREAN SECTION RESEARCH
I ________________________, consent to participate in research entitled "Factors Influencing Differences in the Primary Cesarean Section Rates in Midwife Compared to Physician Practices." I understand that this study is being conducted by Kim Keen, RN, BSN, SNM as part of a Critical Inquiry Final Project in the Master's of Midwifery program at Philadelphia University. I acknowledge and fully understand that my participation is voluntary and I may resign from this study at any time without penalty. The purpose of this study is the explore factors influencing the differences in the primary cesarean section rate in midwife versus physician practices. By agreeing to be a part of this study I authorize the researcher, Kim Keen, and her research staff access to my medical records both at the Topeka Ob/Gyn Associates facility and at St. Francis Health Center. I understand that demographic information will be obtained from my medical records to be used in this study. In addition, I understand that data associated with my prenatal history, labor and delivery, and birth outcome will be obtained from my medical records. Personal contact will not have to be made between me and the researcher and I will not be required to fill out any forms or questionnaires.
My privacy will be protected and the information collected from my medical records will not be identifiable by name or in any other way. The results of this study will be submitted to the American Journal of Obstetrics and Gynecology for publication and will also be posted on a website that I will have access to. I understand that there are no identifiable risks related to my participation in this study. I fully understand that I have the right to withdraw from the study at any time that I deem necessary. I also understand that if I have any questions, I may contact the researcher at any time throughout the study.
I certify that I have read the above information and agree, without hesitation, to participate in this research study. I have received all necessary information to enable me to make an informed decision.
___________________________ _____________
Signature of Participant Date
___________________________
Telephone Number
___________________________
Email Address
___________________________
Witness Signature
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Appendix E:
Initial Data Collection Sheet
Age:__________
Race:(check one)
___ Caucasian (White)
___ African American (Black)
___ Hispanic
___ American Indian
___ Asian
___ Other (specify) ____________
Marital Status: (check one)
___ single (no significant other)
___ single (significant other involved)
___ married
___ divorced
___ widowed
___ estranged
Employment: (specify)_______________________
Last Menstrual Period:_________
EDC: ____________
EDC confirmed by:
___ LMP
___ Sonography
Prepregnancy Weight: ______
Height: ______
Careprovider:_________________________
Labor and Delivery Data Collection Sheet
| Gestation (wks/days) | Reason for admission: | Cervical Exam on admission: | Complications during Labor & Delivery | Total time spent in client room by careprovider | Total time client spent out of bed | Labor induced? |
| wks_____ days_____ confirmed by sono? Yes/No (circle) | ___induction ___early labor ___active labor ___ROM ___ bleeding ___other (describe) | ___dilation ___effacement ___station | ___meconium ___fetal distress ___prolapsed cord ___abruption ___maternal hypotension ___maternal hypertension ___elevated temperature ___other describe: | Hours _____ Minutes_____ | Hours ______ Minutes______ | Yes/No (circle) How? __AROM __Pitocin __Cytotec __Prostaglandin Gel ___Prepidil or Cervidil Why? (describe) |
| Labor Augmented? | If labor induced or augmented, did provider use the medication protocol? | Intravenous pain medication used during labor? | Epidural used during labor? | Method of delivery | Newborn Apgars |
| Yes/No (circle) How? ___Pitocin ___Cytotec ___AROM ___Other describe for other: | Yes/No (circle) | Yes/No (circle) | Yes/No (circle) Cervical dilatation at time of epidural? ______ | __Vaginal __C/S __Vacuum __ Forcep | ___ 1-minute ___ 5-minute ___ 10-minute |
Gregory, Korst, Gorbein &, Platt, 2002 |
malpresentation |
antepartum bleed |
herpes |
severe hypertension |
uterine scar |
multiple gestation |
macrosomia |
unengaged fetal head |
maternal soft tissue disorder |
hypertension (other) |
preterm gestation |
fetal congenital anomaly |