Puzzling disparities found in childbirth injuries

[The Spartan]

MSNBC.com

Puzzling disparities found in childbirth injuries
Poor women less likely to be injured, but their babies are at higher risk
By Linda Carroll
msnbc.com contributor
updated 8:03 a.m. CT, Thurs., June 25, 2009
A new government study turned up some unexpected and puzzling disparities in injuries to women and babies during childbirth.

Women covered by Medicaid were less likely to be injured in childbirth than those with private insurance. Their babies, however, were more likely to experience complications, such as broken collar bones, head injuries and infections.

A similar dichotomy was revealed when the researchers compared births in urban and rural hospitals — moms did better in rural hospitals, while their babies did worse.

Overall, the news from the study was good; researchers found that childbirth complications have declined in the years between 2000 and 2006. But experts were perplexed by the disparities between the different groups of women and children.

The report, released this month by the Agency for Healthcare Research and Quality, the health services research arm of the U.S. government, doesn’t delve into the reasons for the puzzling results.

The hope is that these findings will spur other researchers to do more studies to find the underlying causes for the disparities, said the report’s senior author Roxanne Andrews, a researcher at AHRQ.

But this is the first inkling that there are some significant differences in the way doctors practice obstetrics in different types of hospitals, she said.

Overall improvements
For the new study, Andrews scrutinized data from 1,000 hospitals that are part of a national database. Included in the study were 157,000 injuries that could potentially have been prevented, Andrews said. The main injury tracked among new moms was severe tearing of the tissue between the vagina and the rectum. Generally when such a tear occurs, doctors repair it immediately. But sometimes the repairs aren’t perfect, leaving some moms at risk for serious complications such as a fistula, a condition in which the vagina and the rectum become connected.

Most of the injuries to the moms occurred during vaginal births in which instruments, such as forceps, needed be used to speed the delivery of the baby. Between 2000 and 2006, the rates of those tears dropped overall by 20 percent from 2,040 to 1,605 per 10,000 deliveries. The rate of tears when instruments were not used dropped 30 percent from 517 to 362 per 10,000 deliveries.

When researchers compared data from hospitals in rich and poor neighborhoods they found that during vaginal deliveries women from the wealthiest areas had injury rates that were 44 percent higher than those from the poorest communities.

Male infants at higher risk
The study also found that injuries were less common among black and Hispanic moms and babies than among whites. And in another unexpected association, male infants were more likely than females to sustain injuries during delivery — 15 per 10,000 newborn girls and 17 per 10,000 newborn boys.

Andrews wasn’t able to compare injuries to babies from 2000 to 2006 because hospitals changed the way that they computed those statistics in 2003. But she did determine that there were 32 injuries per 10,000 deliveries in 2006.

If the differences found by the new study turn out to be real, it’s going to take more studies to determine the causes, experts said.

You might be seeing differences in patterns of practice that are associated with the different types of hospitals, speculated Dr. Sindhu Srinivas, a specialist in high-risk pregnancy and an assistant professor of obstetrics and gynecology at the University of Pennsylvania.

One example of that could be the issue of elective cesarean section, Srinivas said. “Certain hospitals might be more likely to perform cesarean deliveries than others and this might impact the outcome. Also, different types of patients might be more likely to choose an elective cesarean.”

When C-sections aren’t as common you can end up with more cases of shoulder dystocia, a situation in which the baby’s head has passed through the mom’s vaginal opening, but then the shoulders get stuck, said Dr. Kimberly Gregory, vice chair of women’s healthcare quality and performance improvement in the department of obstetrics and gynecology at Cedars-Sinai Medical Center in Los Angeles.


Balancing the trade-off
Another factor might be differences in the way hospitals handle the trade-off between risks to the mother and her fetus during delivery, Gregory said. “There are unit ‘cultures’ that set the tone for the amount of risk doctors and hospitals will tolerate in favor of the mother or the baby,” Gregory explained. “‘Hospital culture’ is difficult to quantify, but it is very real.”

Another possible way to explain some of the findings is the prevalence of premature babies born to poor moms, said Dr. Hyagriv N. Simhan, an associate professor of obstetrics and gynecology in the division of maternal-fetal medicine at the University of Pittsburgh School of Medicine and medical director of obstetrical services at Magee-Womens Hospital.

Smaller babies are easier to deliver and far less likely to cause tears in the mom. And premature babies are more likely to be born with infections, Simhan said. Size at birth could also explain the disparity between male and female babies since boys are often born bigger, he said.

It was an odd enough result that I figured I should share with the class, as much as we talk about health care.

[JointStrikeFighter]

Its not unknown in Australia for bogan [read white trash] parents to deliberately smoke during pregnancy so the child is smaller and easier to birth.

[Cairber]

I would think another reason you would see higher rates of maternal injury in more populated areas is that you get a more "conveyor belt" type atmosphere when you have more women to treat.

[Drooling Iguana]

Could this be the the result of the poor tending to have more kids than the rich? As far as I know, first-time childbirths tend to be more problematic than subsequent births, and the smaller the family the greater the likelihood is that a given child will be his/her mother's first.

[Broomstick]

I wouldn't discount the idea that better health insurance increases compensation for intervention, leading to unnecessary procedures. I also wouldn't be surprised if fear of lawsuits from mothers of higher incomes also leads to unnecessary procedures. As any procedure carries some risk, the more you do the more likely an adverse reaction.

It could also arise from a combination of factors rather than just one.

[Adrian Laguna]

That is certainly puzzling. If it was just a quality of care issue I would expect both the mother and baby to be affected, but that's not what's happening. Maybe it's emphasis of care? Rural hospitals and lower class hospitals put more emphasis on the mother's health, while urban and upper class hospitals place more emphasis on the baby's? It would certainly be very ironic given the usual demographic spread of abortion opinions.

[LadyTevar]

In WV there is a number of ob/gyn doctors who schedule a date for the delivery, as in we will do a induction of labour on this date (38-40week mark), and if that doesn't work we'll do a C-section.

I have seen a large number of 38-40week term mothers who have been given C-Sections after the Inductions didn't work. The larger hospitals are the main culprits.

[Mayabird]

I'm not surprised at all after reading the threads about childbirth in hospitals and all the unnecessary things that doctors do to make things worse (episiotomies! Very rarely necessary, performed routinely, and a major cause of infection and maternal deaths outside third world countries). The rates of deaths from childbirth actually increased during the early 20th century, directly linked to the increase of women going to the hospital for births. This is why if I ever have kids, I'm getting a midwife. If there are actual complications, there are still hospitals and ambulances for that reason.

[Shroom Man 777]

Err... we perform episiotomies all the time here in the Philippines. It's done, they've told me, so that the damage to the perineum won't be as bad as it would be if it was due to uncontrolled tearing from the baby coming out of the vagina. Either way, the perineums still get damaged. But I really don't like episiotomies. Or any other form of genital mutilation.

I've assisted in a forceps delivery. That was one of the few things that made me squick.

[Cairber]

I assume these doctors either consciously choose to ignore current medical research regarding episiotomies for whatever gain (money, quicker delivery, the semblance of 'doing all they can', etc) or are just completely ignorant of current medical research.

*sigh*

examples of research:

http://www.bmj.com/cgi/content/full/320 ... d=10625261

Results: Women who had episiotomies had a higher risk of faecal incontinence at three (odds ratio 5.5, 95% confidence interval 1.8 to 16.2) and six (3.7, 0.9 to 15.6) months postpartum compared with women with an intact perineum. Compared with women with a spontaneous laceration, episiotomy tripled the risk of faecal incontinence at three months (95% confidence interval 1.3 to 7.9) and six months (0.7 to 11.2) postpartum, and doubled the risk of flatus incontinence at three months (1.3 to 3.4) and six months (1.2 to 3.7) postpartum. A non-extending episiotomy (that is, second degree surgical incision) tripled the risk of faecal incontinence (1.1 to 9.0) and nearly doubled the risk of flatus incontinence (1.0 to 3.0) at three months postpartum compared with women who had a second degree spontaneous tear. The effect of episiotomy was independent of maternal age, infant birth weight, duration of second stage of labour, use of obstetric instrumentation during delivery, and complications of labour.
Conclusions: Midline episiotomy is not effective in protecting the perineum and sphincters during childbirth and may impair anal continence.

http://jama.ama-assn.org/cgi/content/full/293/17/2141

Evidence Synthesis Fair to good evidence from clinical trials suggests that immediate maternal outcomes of routine episiotomy, including severity of perineal laceration, pain, and pain medication use, are not better than those with restrictive use. Evidence is insufficient to provide guidance on choice of midline vs mediolateral episiotomy. Evidence regarding long-term sequelae is fair to poor. Incontinence and pelvic floor outcomes have not been followed up into the age range in which women are most likely to have sequelae. With this caveat, relevant studies are consistent in demonstrating no benefit from episiotomy for prevention of fecal and urinary incontinence or pelvic floor relaxation. Likewise, no evidence suggests that episiotomy reduces impaired sexual function—pain with intercourse was more common among women with episiotomy.

Conclusions Evidence does not support maternal benefits traditionally ascribed to routine episiotomy. In fact, outcomes with episiotomy can be considered worse since some proportion of women who would have had lesser injury instead had a surgical incision.

[Surlethe]

My wife has seen the idea that episiotomies are done because it's actually easier for the doctor - a straight cut is easier to stitch up than a tear. However, a tear will (presumably) heal better because it has greater surface contact than a straight cut.

It's only in the last few decades that not doing episiotomies has become commonplace; when she was talking with some older women, who'd had their children thirty years ago, they were astounded that she was planning to birth without one. One asked, "Well, how is the baby going to get out, then?"

[Broomstick]

Episotomies: something that was a good idea for a limited number of situations that wound up being applied every time, "just in case".

For unusually large babies, or unusually small mothers, yes, a surgical cut can reduce the chances of a catastrophic tear, which is no joke and can do major permanent damage not only to a woman's vagina but also her bladder and rectum. In Africa this is a major problem and there are specialized hospitals to surgically repair such damage. However, a healthy, fully adult woman with a normal sized baby probably doesn't need one, and if she did tear during delivery in a modern western nation with decent health care, or even the US, any damage would be immediately repaired.

On the other hand, doctors doing episiotomies sometimes slip - with the resulting damage being catastrophic. I've seen medical records of women who had to have extensive reconstructive surgery on their crotches and rectums, including multiple surgeries, due to doctors fucking up what should be a small cut.

So I regard episiotomies like circumcision - a procedure done MUCH more frequently than justifiable, which has only a very limited scope of valid medical indications.

[Shroom Man 777]

I guess that's very much correct. Having seen many episiotomies, I guess it makes some (not-necessarily correct) sense for the doctors to simply cut the perineum with scissors to make a clean and easy-to-stitch incision rather than have it get torn and go through all the hassle of stitching an inconvenient laceration. They may not know that there's a whole lot of difference between the two, with unforeseen consequences due to the episiotomies.

Those few times when children are born without episiotomies or lacerations are truly wonderful though.A clean and quick in-and-out, now that's what I'm talking about.

But goddamn, there was this time I was assisting the delivery of a woman who STILL couldn't bring her baby out despite getting an episiotomy. So the doctor came in and made the incision EVEN BIGGER, and stuck in these foreceps and pulled the baby out in one single bloody motion - with blood pooling out of the woman's vagina like a faucet. Goddamn.