Archive for January, 2010

Major recommendations for childbirth education emerge from Transforming Maternity Care Symposium

January 29th, 2010 by avatar


Yesterday, a multi-stakeholder group convened by Childbirth Connection released a Blueprint for Action addressing the question:

needs to do what,
to, with, and for whom
over the next five years
to improve the quality of maternity care?

Not surprisingly, one of the answers to “who” is “childbirth educators,” and the Blueprint offered recommendations about “what” the childbirth education community should be doing.  Lamaze International participated in the planning, symposium, and workgroup efforts that produced the Blueprint for Action.  Lamaze will reflect on these and other recommendations made in the Blueprint and accompanying stakeholder workgroup reports as we plan our future as an organization and a profession.

Here are the recommendations that pertain directly to childbirth education:

Revive and broaden the reach of childbirth education through expanded models and innovative teaching modalities.

  • Investigate the current role of formal childbirth education in women’s decision making and the ways they obtain and use information about pregnancy and childbirth
  • Implement and evaluate several models of education for childbearing women:
    *Independent, community-based education that fosters taking responsibility for informed maternity care decision making
    *Peer education with “good birth ambassadors” serving as change agents in local communities
    *Alternate media for childbirth education, such as web-based formats and podcasts.
  • Seek reimbursement for childbirth education models of demonstrated effectiveness.
  • Engage National Priorities Partnership (NPP) members in piloting the various educational strategies and implementing effective ones in fulfillment of their focus on better engaging patients and families in managing their health and making decisions about their care.

The Blueprint for Action and other documents are a treasure trove of direction-setting priorities, action steps, and tools for implementation to achieve meaningful maternity care reform. Science & Sensibility will join other bloggers over the coming weeks to highlight the recommendations and resources put forth. All stake-holders, including consumers, should embrace this vision for the future of maternity care.

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Lamaze International’s Recommendations for Preventing Maternal Deaths

January 27th, 2010 by avatar


The Joint Commission Sentinel Alert #44: “Preventing Maternal Deaths” is an important document and public recognition that many of the maternal deaths in the United States are preventable. However, the alert is missing important and useful information for women and childbirth educators since the recommendations in the alert are downstream approaches or recommendations for how to save a woman from dying who may have been thrown in the river. It fails to alert our healthcare system about the need to keep women out of the river in the first place.

Let me give you some examples:

One Joint Commission recommendation is to consistently use techniques that have proven effective in the prevention of thromboembolism (blood clots) in women having surgical births. Clearly it is critical that we reduce the risks of surgery and this recommendation needs to be heeded. We need to make surgical births as safe as possible. However, if we eliminated the overuse of cesarean sections we would eliminate even more deaths and injuries. Based on publicly released data, the increase of cesarean surgical intervention is related to where a woman gives birth.

Debra Bingham, DrPH, RN, LCCE

Debra Bingham, DrPH, RN, LCCE

Indeed there is often as much as a three-fold variation in the number of surgical births performed at different hospitals even after adjusting for the woman’s age and risk factors. Reining in practice variation has been a focus of efforts to improve care in other healthcare specialties, yet wide and unwarranted practice variation remains a serious problem in maternity care.

So why are there so many more surgical births and such wide variation in rates of cesarean sections? Well one clear factor at work is variation in how women are treated in labor. For example, some hospitals keep women who present in early labor while other hospitals are more likely to offer supportive care to these women and encourage that they remain at home until active labor. Why is being in a hospital in early labor a problem? When a woman is in a hospital in early labor she is put in a bed, her movements are restricted, and she is tethered to a fetal monitor. None of these interventions has been shown by research to improve maternal or infant outcomes, and in fact they all have documented harms. In addition, it is normal and expected for early labor to start and stop for several days. However, if a woman is admitted to a hospital in early labor and her labor stops then she is likely to have an unnecessary induction of labor. Overuse of inductions lead to more cesarean sections. This becomes the beginning of a cascade of events that all too often leads to a surgical intervention.

Let’s move to the hemorrhage recommendations as another example. Hemorrhage remains a leading cause of death and severe morbidity despite more efforts over recent years to control blood loss at birth. Why haven’t these efforts succeeded? One reason is that as the cesarean rate rises, more pregnant women have uterine scars. The uterine scar increases a woman’s risk for abnormal placenta implantation when they get pregnant again. These abnormal placenta implantations are called percretas, accretas and previas. When a woman has placenta accreta or percreta this can lead to internal organ damage and permanent damage to her uterus because the placenta literally grows into the uterine muscle or even into her bowel and bladder and cannot detach from these organs after the baby is born. This abnormal implantation leads to hemorrhage and also often necessitates the removal of her uterus to save her life. Abnormal placenta implantations used to be very rare emergencies; they are becoming common now due to the overuse of cesarean sections. This is a trend that is frightening to me because based on the current rates of cesarean sections the number of women affected will only increase. Things are going to get much worse.

Lamaze International has issued our own “Sentinel Alert” on how to prevent maternal deaths. Lamaze’s recommendations are called the Six Healthy Birth Practices. Following these key practices will prevent women from being thrown in the river and needing to be rescued.

The critical behaviors that Lamaze recommends to improve health and safety are to let labor start on it’s own, encourage freedom of movementoffer labor support rather than labor management, avoid all routine interventions not supported by evidence, avoid interfering with a woman’s freedom to push in an upright position or any position of her choice, and keep the baby with the mother after birth.

Hospitals can help achieve the Joint Commission goal of reducing preventable maternal deaths while also making progress toward Joint Commission core measures by training staff in these practices. Lamaze International offers an Evidence-Based Nursing Care Workshop to do just that. Registration is currently open for our March workshop in Hollywood, Florida.

Debra Bingham, DrPH, RH, LCCE is President-Elect for Lamaze International, Executive Director of the California Maternal Quality Care Collaborative (CMQCC), a member of the California Pregnancy-Associated Maternal Mortality Review Committee and a lead researcher for determining how to prevent maternal deaths.

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Why Transparency in Maternity Care Matters

January 26th, 2010 by avatar

I’m going to be on Momotics Blog Talk Radio tomorrow evening at 10pm EST discussing the issue of transparency in maternity care with Danielle from Momotics. You can listen here.  For the occasion, I thought I would dig up this fact sheet I wrote for Lamaze a couple of years ago when we first got involved in advocacy on this issue.  I’ve learned a lot since then and have thought for a while that this fact sheet needs to be revised and updated. I’d love thoughts from readers, especially those involved in ongoing efforts to collect and publicize facility data for The Birth Survey. What would you change? What messages need to be more clear? What else do I need to include? Feedback, please!

Why Transparency in Maternity Care Matters: A Fact Sheet for Birth Advocates

What is Transparency?

A pregnant woman asks her care provider, “What is your episiotomy rate?” Her doctor responds, “I only do them when it is necessary.” On her tour of the hospital maternity center, another woman asks about the hospital’s cesarean rate and is told, “We take care of many high risk patients, so you can’t compare our cesarean section rate with the hospital across town.”

What are the consequences when women can’t objectively evaluate the quality of their maternity care options? How do we help women make sense of intervention rates? How can women make fair comparisons?

Transparency means providing health care consumers with the information they need – and the means to interpret it – in order to evaluate the quality of care provided by individual providers and institutions. Transparency is the missing ingredient to truly informed choice.

Are Intervention Rates Important Quality Measures?

A growing body of research shows that among the most important factors influencing a woman’s risk of obstetric interventions, especially cesarean surgery and episiotomy, are where and with whom she gives birth. A recent study of over 41,000 low-risk women having their first babies in 20 California hospitals found cesarean rates for this population ranging from 11% – 30%. Statistical analysis revealed that obstetric practices – not clinical or demographic factors – accounted for over half of the variation across hospitals (1). Two studies conducted in Washington State found that the individual physician was an independent risk factor for cesarean section in both induced and spontaneous labors (2, 3). Several studies have shown that episiotomy is more common in private obstetric practices versus public or university-affiliated practices (4-6). Rates varied from 6% to 60%, but at least one university hospital maintains an episiotomy rate of 1% (7).

Excess use of obstetric interventions, in turn, increases the likelihood that the woman or her baby will be injured, experience complications such as infection, suffer pain, or have negative birth experiences (8). So, in short, a woman who goes to a provider or hospital with a high cesarean section rate is more likely to end up with cesarean surgery – and to suffer its potential consequences. If she goes to a provider with a high episiotomy rate, she is more likely to have an episiotomy – and to suffer its potential consequences. And so on… However, in most states, maternity care providers and facilities are not required by law to publicly report intervention rates or other outcome indicators, nor to help the public interpret data that are available.

Women can not make informed choices about their maternity care if they do not have access to the information that is most likely to influence their outcomes. They can not decrease their exposure to injury from injudicious use of interventions without knowing where and with whom intervention rates are too high. Without transparency, our health care system gives women a false sense of choice.

Can Transparency Improve the Quality of Maternity Care?

Yes! While most of the research on transparency and public reporting relates to other areas of health care, a few studies have looked at maternity care in particular and have found that public reporting of intervention rates and outcomes, whether alone or in combination with other quality improvement programs, translates into better care (9-11). In fact, an experiment conducted in Wisconsin suggests that the quality of obstetric care improves more in response to public reporting than other medical or surgical specialties (9). This may have been because there was more “room for improvement” in maternity care – more hospitals had low scores on obstetric indicators than on cardiac or surgical indicators. In the same study, hospitals included in a public report were more likely than those that were not to undertake quality improvement efforts. These efforts appeared to be effective – maternity units that improved their quality scores were more likely than those that stayed the same or did worse to have begun quality improvement efforts shortly after the public report was released. In other words, public reporting prompted hospitals to work to improve the areas where they scored poorly, and these efforts were effective at improving the quality of care.

Apples and Oranges: How Do We Make Fair Comparisons?

The question of which indicators to measure and how these should be reported complicate efforts to ensure transparency in maternity care. This is particularly problematic when it comes to interpreting cesarean section rates. The overall cesarean section rate (number of cesareans divided by the number of all births) may not be comparable across settings because some hospitals take care of many high risk women while others take care of low-risk women. The rate of cesarean section in high risk women may be higher for good reason. The same is true at the provider level; some providers, including many midwives, specialize in the care of low-risk women while others care for a mixed-risk population or specialize in high risk pregnancies. Similarly, factors such as parity (whether the woman has previously given birth) and age may naturally affect rates of obstetric interventions as well as outcomes.

Healthy People 2010, the federal program that sets goals for various health indicators, measures the cesarean section rate in nulliparous women (those having their first babies), with term (>37 weeks), singleton (one baby), vertex (head down) pregnancies (12). This is abbreviated as the “NTSV cesarean rate” and is used as a proxy for the cesarean section rate in low-risk first time mothers. It has been shown to be highly sensitive to variations in obstetric practices (1), so quality improvement programs should therefore be effective at safely lowering the NTSV cesarean rate. It is also a good measure because, if we can safely prevent the first cesarean, we can prevent repeat cesareans, as well as poor pregnancy outcomes resulting from accumulating many cesarean scars, such as placenta previa, preterm birth, and placenta accreta. As advocates for improvements in maternity care, we should recognize the NTSV cesarean rate as an effective quality indicator, and should educate the public to ask for and know how to interpret NTSV cesarean rates.

However, perfect indicators that can be compared easily across birth settings and providers will not be available in every community. Even when they are, the total rates of cesarean section, episiotomy, and other interventions are important quality measures. In the case of cesarean surgery, many studies have shown that rates can safely be less than 15% in mixed-risk populations, including those where considerable proportions of women have medical problems or are at risk because of poverty, age, or other factors (8, 13, 14). So, while the likelihood of requiring a cesarean will vary with individual circumstances, women with care providers whose rates are 15% or less can trust the their practitioner’s judgment should they recommend a cesarean in their case.

How Can Birth Advocates Promote Transparency?

Ensuring transparency in maternity care will require a major shift from the status quo, with buy-in and participation from hospitals, care providers, insurance companies, government, and consumers. As advocates for mother-friendly maternity care, we can help influence transparency efforts in our communities. In some areas, transparency initiatives are well underway and mother-friendly birth advocates can work to help consumers access and make sense of publicly available information. In communities where there is resistance to transparency, advocates can work to influence legislative efforts, create consumer demand for transparency, or work with the media, hospital administrators, local opinion leaders, or others to promote change. By maintaining a focus on quality improvement and safety rather than penalizing providers or facilities, transparency advocates are likely to gain greater acceptance and involvement from key stakeholders.


1. Main, E. K., Moore, D., Farrell, B., Schimmel, L. D., Altman, R. J., Abrahams, C., et al. (2006). Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement. American Journal of Obstetrics and Gynecology, 194(6), 1644-51.

2. Luthy, D. A., Malmgren, J. A., & Zingheim, R. W. (2004). Cesarean delivery after elective induction in nulliparous women: The physician effect. American Journal of Obstetrics and Gynecology, 191(5), 1511-1515.

3. Luthy, D. A., Malmgren, J. A., Zingheim, R. W., & Leininger, C. J. (2003). Physician contribution to a cesarean delivery risk model. American Journal of Obstetrics and Gynecology, 188(6), 1579-85; discussion 1585-7.

4. Goode, K. T., Weiss, P. M., Koller, C., Kimmel, S., & Hess, L. W. (2006). Episiotomy rates in private vs. resident service deliveries: A comparison. The Journal of Reproductive Medicine, 51(3), 190-192.

5. Howden, N. L., Weber, A. M., & Meyn, L. A. (2004). Episiotomy use among residents and faculty compared with private practitioners. Obstetrics and Gynecology, 103(1), 114-118.

6. Robinson, J. N., Norwitz, E. R., Cohen, A. P., & Lieberman, E. (2000). Predictors of episiotomy use at first spontaneous vaginal delivery. Obstetrics and Gynecology, 96(2), 214-218.

7. Albers, L. L., Sedler, K. D., Bedrick, E. J., Teaf, D., & Peralta, P. (2005). Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: A randomized trial. Journal of Midwifery & Women’s Health, 50(5), 365-372.

8. Goer, H., Leslie, M. S., & Romano, A. (2007). The evidence basis for the 10 steps of mother-friendly care: Step 6: Does not routinely employ practices, procedures unsupported by the scientific evidence. The Journal of Perinatal Education, 16(1 Suppl), 32-64.

9. Hibbard, J. H., Stockard, J., & Tusler, M. (2005). Hospital performance reports: Impact on quality, market share, and reputation. Health Affairs, 24(4), 1150-1160.

10. Hibbard, J. H., Stockard, J., & Tusler, M. (2005). It isn’t just about choice: The potential of a public performance report to affect the public image of hospitals. Medical Care Research and Review, 62(3), 358-371.

11. Wirtschafter, D. D., Danielsen, B. H., Main, E. K., Korst, L. M., Gregory, K. D., Wertz, A., et al. (2006). Promoting antenatal steroid use for fetal maturation: Results from the California perinatal quality care collaborative. The Journal of Pediatrics, 148(5), 606-612.

12. Healthy People 2010. (2000). Objective 16-9. reduce cesarean births among low-risk (full term, singleton, vertex presentation) women. Retrieved 7/16/2007, from http://healthypeople.gov/document/html/objectives/16-09.htm

13. Haire, D. B., & Elsberry, C. C. (1991). Maternity care and outcomes in a high-risk service: The north central Bronx hospital experience. Birth, 18(1), 33-37.

14. Leeman, L., & Leeman, R. (2002). Do all hospitals need cesarean delivery capability? An outcomes study of maternity care in a rural hospital without on-site cesarean capability. The Journal of Family Practice, 51(2), 129-134.

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You Bet Your Life (and your baby’s life too?)

January 24th, 2010 by avatar

[This is Science & Sensibility’s very first giveaway!  Instructions for how to enter are below.]

Through my involvement in the Society for Participatory Medicine, I’ve gotten to know and respect some pretty amazing patient advocates. Trisha Torrey (@TrishaTorrey on Twitter)  is one of these. After being misdiagnosed with a rare type of terminal cancer and coming close to risking her life to accept treatment she did not need, she discovered that many of her long-held assumptions about our health care system were dead wrong. She also realized that if she could make the mistakes she made, others could too.  She made a mid-life career change to become a patient advocate and now helps others become informed, engaged, and empowered through her About.com Patient Empowerment Blog, her patient advocate search site AdvoConnection, her popular series of columns and podcasts, and elsewhere around the web.

She has also written a book, and it’s excellent.

In You Bet Your Life! The 10 Mistakes Every Patient Makes, Trisha takes a critical look at our health care system and points out the incorrect assumptions and other mistakes we make that ultimately compromise our safety and wellbeing. More importantly, she builds the reader’s confidence and gives clear instructions for how to fix or avoid each mistake. The book is organized intelligently into chapters for each “mistake”,  followed in turn by chapters on how to “fix the mistake.”  It is peppered with true stories (of both the tragic and triumphant variety) as well as tools such as checklists and recommended resources.

With a title like this book has, it is easy to assume that Trisha blames patients for things that go wrong. But quite the opposite is true. Trisha sees that no one has more at stake in healthcare than the consumer herself, and although the system erects barriers, an informed and engaged consumer can overcome them. Our biggest mistake is assuming that our healthcare system should function as it is intended, which is sadly far from the case.

Here are Trisha Torrey’s 10 Mistakes:

You Bet Your LifeMistake 1: Thinking the Healthcare System is Focused on Helping Patients

Mistake 2: Thinking Doctors Put Patients’ Needs First

Mistake 3: Not Confirming Your Diagnosis

Mistake 4: Thinking You’ve Been Told About All Your Treatment Options

Mistake 5: Thinking You’re Safe In the Hands of the Healthcare System

Mistake 6: Not Understanding the Influence of Your Medical Records on Your Health and Your Wallet

Mistake 7: Spending Time in the Hospital Unless It’s Absolutely Necessary

Mistake 8: Using the Internet to Find Health Information Without a Compass

Mistake 9: Thinking Medical Research Is Searching for Cures

Mistake 10: Letting the Media Influence Your Decisions Without Reading Between the Lines

When I saw this list I wrote to Trisha, only a little bit jokingly, that she could copy and paste this list into another book about pregnancy and birth and call it, You Bet Your Life, and Your Baby’s Life, Too! Well, it turns out that plans for a follow-up book about pregnancy and birth are in the works!  So, dear readers, here’s where you come in.  Trisha Torrey has graciously offered to send a free copy of her book to one of you. To be eligible to win, please leave a comment on this post with one of the following:

1. An anecdote (or link to a story posted elsewhere on the web) that demonstrates how one of the “10 mistakes” can play out – or be overcome – in maternity care, or

2. A maternity care mistake that belongs on the list but isn’t.

Please do not share an unpublished anecdote unless it is about your own experience or you have removed all personal details that might enable someone to learn the identity of the woman and/or baby involved. Published anecdotes are fair game. If in doubt, I will delete the comment and the entry will be voided.

Additional Rules: You can leave multiple comments for multiple entries. A winner will be chosen randomly from all entries. The book can be sent to U.S. addresses only. The deadline is 11:59pm EST Wednesday, February 3. Use a valid email address when you register your comment so we can contact you if you are the winner. (Your email address will be kept private but will be visible to me as blog administrator.) Comment contributors may be contacted as well for permission to feature anecdotes in a forthcoming pregnancy and birth edition in the series.

For full disclosure: I received a free review copy of You Bet Your Life! The 10 Mistakes Every Patient Makes. I also may be involved in the forthcoming pregnancy and birth edition of the You Bet Your Life series.

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Restricting food and drink in labor is not justified

January 20th, 2010 by avatar

Listen to this great podcast about the new Cochrane review showing that the policy of restricting food and drink in labor is not justified. It’s a nice summary of how and why the research was conducted.  In addition, I particularly liked these tidbits:

1. Rather than asking “is eating and drinking in labor safe?” the reviewers turned the question around to ask “is there any justification for restricting food and drink in labor?”  This is not just a nuance. How a researcher asks a question can influence both the findings and the conclusions, as I have discussed previously.

2. Since they identified no benefits (nor harms) of restricting oral intake, the reviewers concluded that women should be able to eat and drink according to their preference.

3. It was her experience teaching antenatal classes that led one of the reviewers to study food and drink in labor. Listening to women’s concerns and anxieties made her question the justification for restricting women’s autonomy in labor.

In perusing the web to try to find an image for this post, I came across this heartbreaking picture of a woman begging for a drink in labor and being told no. (I’d post it here but it is copyrighted.) When the researchers said they found “no harms” of restricting food and drink in labor, they pointed out that no one had actually studied women’s preferences or experiences. I’m heartened to know that some of those who tout evidence based care are beginning to recognize that emotional distress is itself a harm. If there is no counterbalancing benefit, the conclusion is clear.

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