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Researchers compare pregnancy management styles of residents in obstetrics and family medicine

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).

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.

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.

Details are in "Differences in labor and delivery experience in family physician- and obstetrician-supervised teaching services," by Dr. Hueston and Ms. Rudy, in Family Medicine 27(3), pp. 182-187, 1995.

Low-dose aspirin does not increase the risk of placental detachment or infant death

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.

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).

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.

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 Obstetrics and Gynecology 85(6), pp. 1055-1058.

Childbirth PORT examines best ways to manage breech births

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.

Gifford, D.S., Morton, S.C., Fiske, M., and Kahn, K. (1995, June). "A meta-analysis of infant outcomes after breech delivery." Obstetrics & Gynecology 85(6), pp. 1047-1054.

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.

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).

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.

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." Obstetrics & Gynecology 85(6), pp. 930-936.

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.

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.

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.

Threat of malpractice suits has little effect on birth outcomes

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).

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.

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.

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 Medical Care 33(7), pp. 700-714, 1995.

Economic solutions alone will not improve the health of socially disadvantaged children

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.

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.

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 Archives of Pediatric and Adolescent Medicine 149, pp. 541-545, 1995.

One-third of families agree to donate organs, tissues, or corneas when loved ones die

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.

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.

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.

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, Annals of Internal Medicine 123(1), pp. 10-17.

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