by Carolyn Keefe, MLS, BirthNet, Albany, NY
As birth activists have developed an understanding of the role of evidence-based care, and have become more aware of the importance of educating the public and legislators, we've come to understand the importance of having references available to support our statements about birth and midwifery.
We must at the same time, however, ensure that the statistics and references we use are accurate and can be examined by others. Only by using recognized and accessible sources can we develop and maintain our credibility. The evidence is in our favor, but no one will believe us if they can't examine it for themselves.
I've recently become concerned about this, as I've researched the cost of maternity care relative to other types of healthcare. Most of us have seen or heard the statement that "maternity care constitutes 20% of all health care costs." I wanted to see what that relationship has been historically, so I began to research this statistic. Susan gave me the original reference she had been given for this number, and I went to work tracking down the source used for it. I learned that the original source did not say anything of the sort and, in fact, didn't even address the issue of this relationship.
I later found the Healthcare Cost and Utilization Project (HCUP) at the Agency for Healthcare Research and Quality (AHRQ), an agency of the federal Department of Health and Human Services (HHS). Using HCUPNet, I discovered that, for hospital expenses at least, maternity care constitutes about 4 or 5% of healthcare costs. Although we are still talking about $28 billion dollars in costs and "Pregnancy, Childbirth & The Puerperium" is the fifth or sixth largest category, cardiac care is four times higher and around 20% of costs.
Furthermore, while the 4-5% figure is based on hospitalizations, non-maternity health care probably takes up an even larger chunk of health care costs than maternity care. Maternity care, while including some procedures, prescription drugs, provider time, and technology, may use far fewer resources than care for the elderly, for instance, or for those with cardiac illness, cancer, or diabetes. Also, maternity care rarely involves home health care (unfortunately) or transfers to skilled nursing facilities (thankfully). I haven't fully embraced that 4-5% number and plan to do more research, but I think it's pretty clear that the 20% figure is unlikely to be accurate.
Unfortunately, this 20% figure has been circulating and may cost us credibility with legislators or reporters who decide to track it down. We can still make the argument that the costs are too high, that there are too many surgical procedures related to birth, and that these issues affect large numbers of women, without overreaching based on questionable, if truly well-meaning sources.
During my training as a librarian, I was taught how to evaluate information and recognize authoritative sources – authoritative as in author, not necessarily authority. In other words, it's always important to know where the information is coming from and whether or not the source is reliable (or indeed the best source). This is even truer in the age of the Internet. Evaluating sources involves four basic criteria:
- Author – Can you determine who the author is? Can you determine her or his background and level of expertise on this topic? Does he or she seem objective?
- Publisher/Sponsor – Do you know who the publisher is? Is the publisher familiar and credible?
- Currency – How dated is the information? Is there a more current source?
- References – What references is the author using? Can you access them? Do you trust them? Would they be better (or primary) sources for the information you're seeking?
I also learned in library school that the US government is the largest collector and publisher of information and statistics in the world. Of course, you always have to “read the fine print” to understand what data was actually collected and how, in order to interpret the results. However, while no source of information is flawless or totally comprehensive, several things make using government information desirable.
First, it is free and easily accessible via the Internet. Second, it is a widely respected, relatively impartial source of information; so all parties can be on the same page. Finally, it's fairly consistent historically and geographically -- so the data can be compared using these criteria as well (though you may need to track down paper copies in depository libraries if you want to go back before 1994). As I said, it's not perfect or complete, but it's often a great place to start. Also, if you need help tracking down information, the authors of these publications are often happy to help.
Another good source of information can be associations or organizations, like Save the Children or the World Health Organization. Here we need to be careful however, because, as we know, some organizations and associations have distinct biases, which can make their information suspect. Professional organizations, for example, are best at providing information about the practitioners of their professions, but may not be as reliable as sources for information about which their members have a financial stake.
We've learned to mistrust ACOG largely because our experience has shown that some of their information is inaccurate and self-serving. Unfortunately, they are still the authority for most people in this country. To counter that situation, we must be even more scrupulous about ensuring that we know what we're talking about and can back it up.
Some Good Sources for Research and Information:
Agency for Healthcare Research and Quality
Includes information about the Healthcare Cost and Utilization Project, Evidence-based Practice, and Quality of Care
National Center for Health Statistics
Primary Publications – Final Birth Data, Final Death Data, National Hospital Discharge Survey, Mortality and Morbidity Weekly Report, Vital Statistics Reports, and various other studies.
National Library of Medicine
Source for citations of journal articles and other medical research. Includes some abstracts and includes links to some journals.
Save the Children
Publishes the annual State of the World's Mothers report, which has good maternal mortality rate info, among other data.
World Health Organization
Research tools include the Library Database and Statistical Information Service
My alma mater's library also happens to have a great web page on this topic (as I'm sure many other libraries do). Click here to get more information or do an online tutorial.
Reprinted from Citizens for Midwifery News, Fall 2002. Permission to reprint with attribution.