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<p><strong>You Are Here:</strong> <span class="crumb_link"><a href="/" class="crumb_link">AHRQ Archive Home</a> &gt; <a href="/research/resarch.htm" class="crumb_link"><em>Research Activities</em> Archive</a> &gt; <a href="." class="crumb_link">October 1995</a>
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<td><h1><a name="h1" id="h1"></a>Family Health </h1>
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<td><div id="centerContent"><div class="headnote">
<p>This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: <a href="https://info.ahrq.gov/">https://info.ahrq.gov</a>. Let us know the nature of the problem, the Web address of what you want, and your contact information. </p>
<p>Please go to <a href="https://www.ahrq.gov/">www.ahrq.gov</a> for current information.</p></div>
<a name="head1"></a><h2>Researchers compare pregnancy management
styles of
residents in obstetrics and family medicine</h2>
<p>The training in obstetric care that family practice residents
receive at teaching hospitals can be done by family physicians or
obstetricians. But who supervises the training dramatically
affects the way these residents manage labor and delivery. For
example, women whose babies are delivered by residents supervised
by obstetricians have increased incidence of preterm labor, more
frequent use of epidural anesthesia, and higher episiotomy and
cesarean section rates than women whose residents are supervised
by family physicians. These findings stem from a study supported
by the Agency for Health Care Policy and Research (HS07012).</p><p>
William J. Hueston, M.D., of the University of Wisconsin, and
Mary Rudy, M.A., of the St. Claire Medical Center, reviewed the
medical records of 4,588 women whose labor and delivery were
managed by residents at five teaching hospitals in five different
States. They found that women on obstetric teaching services
delivered their babies earlier; 9 percent of deliveries occurred
before 36 weeks' gestation compared with only 2 percent of
deliveries on the family practice teaching services. Women on
obstetric services were almost twice as likely to have their
pregnancy complicated by preterm labor and more than twice as
likely to receive epidural anesthesia, undergo an episiotomy, or
have a cesarean section than those on family practice teaching
services.</p>
<p>The primary cesarean section rate on the obstetric teaching
services remained almost four times greater than that of the
family practice teaching services (15 percent vs. 4 percent),
even after adjusting for differences in risk status of
pregnancies. However, there were no differences in outcomes of
the babies delivered (after 35 weeks' gestation) by residents
trained by obstetricians and those trained by family physicians.
There also were no differences in the incidence of maternal
postpartum infection or hemorrhage. The researchers suggest that
family practice residency programs develop strong obstetric care
training services within family practice, rather than relying on
obstetric teaching services to provide this training for
residents.</p><p>
Details are in "Differences in labor and delivery experience in
family physician- and obstetrician-supervised teaching services,"
by Dr. Hueston and Ms. Rudy, in <em>Family Medicine</em> 27(3), pp.
182-187, 1995.</p>
<a name="head2"></a><h2>Low-dose aspirin does not increase the risk
of placental detachment or infant death</h2>
<p>Pregnant women who take low-dose aspirin (less than 200 mg per
day) do not increase their risk for premature detachment of the
placenta (abruptio placentae), which can lead to maternal shock;
nor do they heighten the risk of death for their newborn
(perinatal) infant, according to a study supported in part by the
Agency for Health Care Policy and Research (contract
282-92-0055). This is good news, because daily low-dose aspirin
can significantly reduce preeclampsia (late pregnancy toxemia
often characterized by high blood pressure), lessen fetal growth
restriction (FGR), and increase birthweight, according to some
reports.</p><p>
Researchers from the Low Birthweight Patient Outcomes Research
Team (PORT) performed a meta-analysis of 11 randomized clinical
trials (including nine double-blind studies) of low-dose aspirin
for prevention of either preeclampsia or FGR. The meta-analysis
was done because of the inconclusive and/or conflicting
information presented in the individual studies. The PORT
researchers found that the incidence of abruptio placentae in the
7,493 women randomized to aspirin treatment (1.67 percent) was
similar to that in the 7,340 women randomized to a placebo or
control group (1.43 percent).</p>
<p>In the nine double-blind trials, the women who took aspirin had a
1.71 percent prevalence of abruptio placentae compared with 1.33
percent of those who took a placebo. The incidence of perinatal
death was similar for both aspirin- and non-aspirin-treated women
in the trials. The PORT researchers concluded that use of
low-dose aspirin by pregnant women is not associated with the
subsequent occurrence of abruptio placentae or increased infant
death.</p><p>
Details are in "Low-dose aspirin: Lack of association with an
increase in abruptio placentae or perinatal mortality," by John
C. Hauth, M.D., Robert L. Goldenberg, M.D., C. Richard Parker,
Jr., Ph.D., and others, in the June 1995 issue of <em>Obstetrics
and
Gynecology</em> 85(6), pp. 1055-1058. </p>
<a name="head3"></a><h2>Childbirth PORT examines best ways to manage
breech births</h2>
<p>Two new studies by the Patient Outcomes Research Team (PORT) on
Management and Outcomes of Childbirth examine the outcomes of
breech infants managed with a trial of labor or elective cesarean
section. The Childbirth PORT, led by Emmett Keeler, Ph.D., of the
RAND Corporation, and supported by the Agency for Health Care
Policy and Research (contract 282-90-0039), examines the outcomes
of cesarean section compared with such alternatives as a trial of
labor, oxytocin (to induce or speed up labor), and normal and
assisted vaginal delivery; analyzes factors associated with the
use of specific diagnostic and treatment procedures in the course
of labor and delivery; and develops and disseminates
recommendations on childbirth management.</p><p>
<strong>Gifford, D.S., Morton, S.C., Fiske, M., and Kahn, K. (1995,
June). "A meta-analysis of infant outcomes after breech
delivery." <em>Obstetrics &amp; Gynecology</em> 85(6), pp.
1047-1054.</strong></p>
<p>Use of cesarean section to deliver breech babies increased from
15 percent in 1970 to 84 percent in 1989 in efforts to avoid the
risks that had been associated with vaginal breech deliveries.
However, the debate continues about the appropriate management of
full-term breech births, and recently, the routine cesarean
delivery of these infants has been questioned.</p><p>
The researchers performed a meta-analysis of nine studies on
maternal and infant outcomes after breech deliveries. They found
a significantly higher risk of fetal injury or death in term
breech infants whose mothers were allowed a trial of labor
instead of elective cesarean delivery. In either case, the risk
for any infant injury or death was not large (1.23 percent after
a trial of labor vs. 0.09 percent following elective
cesarean).</p>
<p>As a result of these findings, the PORT researchers caution
against the institution of policies requiring a trial of vaginal
breech delivery for eligible mother-infant pairs. Instead, they
recommend that maternal risk of cesarean delivery be considered
along with the potential for increased risk of fetal problems
with vaginal delivery.</p><p>
<strong>Gifford, D.S., Keeler, E., and Kahn, K.L. (1995, June).
"Reductions in cost and cesarean rate by routine use of external
cephalic version: A decision analysis." <em>Obstetrics &amp;
Gynecology</em> 85(6), pp. 930-936.</strong></p>
<p>The practice of external cephalic version of the breech infant
(turning the baby's head toward the mother's pelvis by
manipulation through the mother's abdominal wall) fell out of
favor in the 1950s and 1960s. At that time, mothers were put
under general anesthesia for the procedure, and several reports
suggested high rates of fetal death and maternal complications
after attempted version. However, the development of safer
techniques has led to renewed interest in this procedure for
full-term breech births in Europe and the United States,
according to the Childbirth PORT researchers. In a recent study,
they conclude that routine use of external cephalic version can
result in more vaginal deliveries and lower costs than strategies
that allow vaginal delivery but do not include an attempted
cephalic version.</p><p>
PORT investigators reviewed the literature, including four
randomized trials of version, and used decision-analysis
techniques to calculate the predicted delivery outcomes and
costs associated with various delivery options for full-term
breech infants. They estimate that applying external cephalic
version to term breech pregnancies and delivering unsuccessful
versions by scheduled cesarean resulted in a 32 percent cesarean
rate, at a cost of $8,276 per case. In contrast, a strategy not
using external version, but allowing a trial of labor for those
mothers who met eligibility criteria, resulted in a 63 percent
cesarean rate, at a cost of $8,755 per case. Routinely
scheduling a cesarean when a breech was identified at term
resulted in an 89 percent cesarean rate, at a cost of $9,544 per
case.</p>
<p>As a result, the PORT researchers recommend routine use of
external cephalic version for term breech pregnancies in the
absence of contraindications to labor or version (for example,
placenta previa or amniotic fluid abnormalities). Even though
breech deliveries are less than 5 percent of births, routine use
of external cephalic version could lead to more than a 1 percent
reduction in the U.S. cesarean rate.</p>
<a name="head4"></a><h2>Threat of malpractice suits has little effect
on birth outcomes</h2>
<p>Numerous medical malpractice suits have been filed against
obstetricians for birth-related injuries. However, the threat of
a medical malpractice suit (as measured by claim frequency) does
not affect the outcomes of babies delivered by these physicians,
according to a study supported in part by the Agency for Health
Care Policy and Research (HS06499).</p><p>
Led by Frank A. Sloan, Ph.D., of Duke University, the research
team examined data from two sources: records of births and fetal
and infant deaths from 1987 Florida vital statistics data and the
results of a telephone survey of obstetric care provided to 963
women in Florida in 1992 who had delivered babies 5 years
earlier. The researchers conducted telephone interviews
concerning 66 fetal and 143 infant deaths and 53 births resulting
in permanent impairments, some of which were clearly unrelated to
poor obstetrical care.</p>
<p>Dr. Sloan and his colleagues measured the threat of medical
malpractice litigation and found no systematic improvement in
birth outcomes when obstetricians faced a high threat of
litigation compared with instances in which they faced a lesser
threat. Only in the case of fetal deaths was there any evidence
that increased claim frequency improved birth outcomes, and this
association was only obtained from one of the data sets. Several
other factors accounted for poor birth outcomes, such as urinary
tract infections during pregnancy, more than one birth by a
mother in a year, previous spontaneous abortions and stillbirths,
a previous very low birthweight infant or infant death, as well
as Medicaid coverage or lack of insurance.</p><p>
For more information, see "Effects of the threat of medical
malpractice litigation and other factors on birth outcomes," by
Dr. Sloan, Kathryn Whetten-Goldstein, Ph.D., Penny B. Githens,
M.A., and Stephen S. Entman, M.D., in <em>Medical Care</em> 33(7),
pp.
700-714, 1995.</p>
<a name="head5"></a><h2>Economic solutions alone will not improve the
health of socially disadvantaged children</h2>
<p>Economic remedies are only part of the answer for improving the
health of socially disadvantaged children, according to Peter A.
Margolis, M.D., Ph.D., and his colleagues at the University of
North Carolina at Chapel Hill. Personal roadblocks range from
lack of knowledge about health care and language problems to
inability to obtain child care, transportation, or time off work
to keep doctor's appointments. In addition, long waiting times,
limited clinic hours, difficulties with making appointments, and
lack of 24-hour availability of physicians may be strong
deterrents to the appropriate use of health care services by
families. Organizational barriers like these have been associated
with poor health outcomes, such as low immunization rates, among
children younger than 2 years, note the researchers.</p><p>
They encourage physicians to provide care for poor children,
including preventive care and patient education, and to learn
more about community resources and social services available to
families and how families can access such services. The
researchers also recommend implementing specific interventions
such as Medicaid-billing assistance, intensive outreach efforts,
and integration of community-based and clinical health services.
Physicians are in a unique position as advocates of children to
identify specific personal and structural barriers to care and to
devise strategies to overcome these barriers, concludes Dr.
Margolis.</p>
<p>This project was supported in part by the Agency for Health Care
Policy and Research (HS07106). More details are in "The rest of
the access-to-care puzzle: Addressing structural and personal
barriers to health care for socially disadvantaged children," by
Dr. Margolis, Timothy Carey, M.D., M.P.H., Carole M. Lannon,
M.D., M.P.H., and others, in the <em>Archives of Pediatric and
Adolescent Medicine</em> 149, pp. 541-545, 1995.</p>
<a name="head6"></a><h2>One-third of families agree to donate organs,
tissues, or corneas when loved ones die</h2>
<p>As of January 31, 1995, 37,873 patients in the United States were
awaiting solid-organ transplants. According to national polls, at
least 75 percent of Americans claimed they would be willing to
donate an organ after death. This led to the assumption that
health care professionals simply weren't asking families of
donor-eligible patients to donate organs, prompting nearly all
States and the District of Columbia to require hospitals to
request these donations. Later, the policy became a requirement
nationally as a condition of Medicare reimbursement. A recent
study reveals, however, that it is family reluctance to donate,
not physician reluctance to ask, that is limiting organ
availability.</p><p>
The study found that health care professionals asked for
donations from 73 percent of all families of donor-eligible
patients. In the case of organ-eligible patients, 86 percent of
families were asked to donate, compared with less than 70 percent
of families of tissue-and cornea-eligible patients. When asked,
however, only one-third of families agreed to donate organs,
tissues, or corneas of dead loved ones. Families of younger
patients were more likely to donate than those of older patients.
The patient's sex, race, insurance status, type of hospital
service, or location of death were not associated with the
family's willingness to donate organs.</p>
<p>This study clearly shows that the policy of mandatory request has
not led to the increase in organ procurement that was anticipated
with the passage of required request laws, notes Laura A.
Siminoff, Ph.D., of the University of Pittsburgh's Center for
Medical Ethics. Dr. Siminoff and her colleagues reviewed patient
deaths and studied 841 donor-eligible cases at 23 acute-care
general hospitals in two metropolitan areas. Of all the patients
deemed eligible to donate, 18.6 percent were older than 59 years,
and almost 98 percent had died in an intensive care unit. Results
showed only 46.5 percent of these families agreed to donate
organs, 34.5 percent agreed to donate tissues, and 23.5 percent
agreed to donate corneas. Some argue that the United States
should adopt policies similar to Belgium, Austria, and France,
where it is assumed that all adults wish to donate their organs
unless they have specifically stated otherwise. In France,
however, presumed consent has not resulted in higher donor
rates.</p><p>
This research was supported by the Agency for Health Care Policy
and Research (HS06579). More details are in "Public policy
governing organ and tissue procurement in the United States," by
Dr. Siminoff, Robert M. Arnold, M.D., Arthur L. Caplan, Ph.D.,
and others, in the July 1, 1995, <em>Annals of Internal
Medicine</em> 123(1), pp. 10-17.
</p>
<p class="size2"><a href=".">Return to Contents</a><br />
<a href="dept2.htm">Proceed to Next Section</a></p>
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<p> The information on this page is archived and provided for reference purposes only.</p></div>
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