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“Choosing Wisely” in maternity care: ACOG and AAFP urge women to question elective deliveries.

February 21st, 2013 by avatar

 

http://flic.kr/p/4v3Zeh

Last April, the ABIM Foundation, with Consumer Reports and other partners, drew national attention to overuse of ineffective and harmful practices across the health care system with their Choosing Wisely campaign. As part of the campaign, professional medical societies identified practices within their own specialties that patients should avoid or question carefully. Today, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP) have joined the campaigndrawing national attention to the overuse and misuse of induction of labor. ACOG and AAFP are telling women and their maternity care providers:

Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age.

Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable. 

(“Favorable” means the cervix is already thinned out and beginning to dilate, and the baby is settling into the pelvis. Another word for this is “ripe,” and doctors and midwives use a tool called the Bishop Score to give an objective measurement of ripeness. Although ACOG and AAFP do not define “favorable,” studies show cesarean risk is elevated with a Bishop Score of 8 or lower in a woman having her first birth and 6 or lower in women who have already given birth vaginally.)  

Much work has already been done to spread the first message. Although ACOG has long advised against early elective deliveries, a confluence of quality improvement programs and public awareness campaigns have made it increasingly difficult for providers to perform non-medically indicated inductions or c-sections before 39 weeks.

But as the public and the health care community have accepted the “39 weeks” directive, concern about unintended consequences has grown. Christine Morton, a researcher at the California Maternal Quality Care Collaborative and regular contributor to Science & Sensibilitysums up concerns shared by many, including Childbirth Connection:

It is possible that this measure may sensitize stakeholders to the wrong issue: timing of birth rather than the fact that it is generally best when labor begins on its own.  Additionally, is it possible that 39 weeks could become the new “ideal” gestational age, because it will be assumed that 39 completed weeks is the best time to be born?

The second Choosing Wisely statement aims to mitigate these unintended consequences. Inducing with an unripe cervix significantly increases the chance of a c-section and its many associated harms. Women considering induction for a non-medical reason deserve to know about these excess risks, and should question whether it is worth any non-medical benefits of elective delivery they perceive or expect. Lamaze International has spoken to the importance of letting labor begin on its own, as it is the first topic in the Six Healthy Birth Practices.

But will the new message lead women and care providers to think that delivery is indicated once a woman’s cervix is ripe? Through the Choosing Wisely campaign ACOG and AAFP have made powerful statements acknowledging that scheduled delivery is unwise if the baby or the woman might not be ready for birth. Although gestational age and the Bishop score are tools to estimate readiness for birth, the best indicator of readiness is still the spontaneous onset of labor at term, the culmination of an intricate interplay of hormonal signals between the fetus and the woman. Anytime we intervene with the timing of birth we have to weigh the potential benefits and harms of overriding that process in the context of the fully informed preferences and values of women.

This summer, our collaboration with the Informed Medical Decisions Foundation will culminate in the release of our first three Smart Decision Guides. These evidence-based, interactive decision support tools will help women learn the possible benefits and harms of scheduled delivery versus waiting for labor to start on its own and to weigh these based on what is most important to them. These tools help women choose wisely – to identify when an option is not appropriate or safe for them, and to thoughtfully weigh options when there are both pros and cons to consider.

Interested in learning more about shared decision making in maternity care? Sign up for a free webinar on March 13 sponsored by the Informed Medical Decisions Foundation to hear more about what clinicians, consumers, employers, and others thinking about the importance of maternity care shared decision making.

 

ACOG, Childbirth Education, Evidence Based Medicine, Guest Posts, Healthcare Reform, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternal Quality Improvement, Medical Interventions, Practice Guidelines, Pre-term Birth, Webinars , , , , , , , , , ,

Consider the Source: An Interview with Cara Osborne, SD, MSN, CNM, co-author of The National Birth Center Study II

January 31st, 2013 by avatar

http://flic.kr/p/v7Wse

The Journal of Midwifery and Women’s Health has just published the results of the National Birth Center Study II. As the name suggests, this is the second time researchers have undertaken a multi-site study of U.S. birth centers to understand the process and outcomes of care in these settings. The first appeared in the New England Journal of Medicine in 1989, and concluded that “birth centers offer a safe and acceptable alternative to hospital confinement for selected pregnant women, particularly those who have previously had children, and that such care leads to relatively few cesarean sections.”

The current study describes birth centers as a “durable model” of care because, again, outcomes were excellent. 

Here are the key findings of the National Birth Center Study II:

  • Of more than 15,000 women eligible for birth center care when labor started, 93% had spontaneous vaginal births, and 6% had cesareans.
  • 16% of women transferred during labor, and approximately 2.5% of mothers or newborns required transfer to the hospital after birth. Emergent transfer before or after birth was required for 1.9% of women in labor or for their newborns. Most women who transferred in labor had vaginal births.
  • There were no maternal deaths. The intrapartum stillbirth rate was 0.47/1000, and the neonatal mortality rate was 0.40/1000 excluding anomalies.

I had an opportunity to interview one of the study authors, Cara Osborne, SD, MSN, CNM. Dr. Osborne is an Assistant Professor at the University of Arkansas School of Nursing, a perinatal epidemiologist, and co-founder of Maternity Centers of America. I asked her what the study findings mean for women and families and what it will take to scale up the birth center model and expand access.

AR: Thanks for participating in this interview. First and foremost, what should expectant parents know about this study?

CO: The take away messages from this study for expectant parents are that birth center care is safe and minimizes the likelihood that their baby will need to be born by cesarean, and that if hospital care becomes necessary, that transfer is very unlikely (1.9%) to be an emergency.

(Rebecca Dekker, PhD, RN, APRN of Evidence Based Birth has prepared an excellent summary that appears at the American Association of Birth Centers web site with more about the study findings and their implications for women and families.)

The study is based on the AABC Uniform Data Set. What are the strengths and limitations of the UDS? 

CO: The UDS data were collected prospectively, which means women were enrolled in the study before the outcome of the pregnancy was known. This is an important strength because it means that the ultimate outcome could not bias the data that were collected during the pregnancy. Also, the UDS is used across dozens of birth centers, so it also enables us to get much more data than would be possible from a single birth center site.

Cara Osborne, SD, MSN, CNM

A primary limitation is that the UDS does not capture information that describes the family’s experience of birth center care, which makes correlating the clinical findings with experiential information impossible. Also, the UDS isn’t used by physicians practicing in hospitals, so we could not compare our findings to typical hospital-based care.

AR: The first National Birth Center Study reported outcomes of births from 1985 to 1987. Even though this study took place two decades later, the results are strikingly similar. If we’ve known for decades that birth centers are safe and effective, and they provide high quality care without costly hospital overhead, why isn’t there one in every community?

CO: You’re right, the results were very similar. For example the c-section rate in birth centers remained stable, going from 4% in the first study to 6% in the current study, while the national c-section rate during the same period has increased dramatically from 18% to 33%. We’ve known all along that greater use of birth centers could curb or reverse this trend, but there are several obstacles that have prevented a broad expansion of the model. They fall into three categories: systems obstacles, business obstacles, and professional obstacles.

Systems obstacles:

  • Hospitals have been predominant place of birth in the U.S. for so long that associated processes such as payment by commercial insurers and state Medicaid, the filing of birth certificates, and administration of state required newborn screening tests have all been developed based on hospital timelines and protocols. Therefore, changing the place of birth requires changes in all the associated systems as well, which can be difficult.

Business obstacles:

  • The skill set that it takes to be a good care provider and the skill set that it takes to start and run an efficient business have very little overlap, and it’s the rare provider that has both.
  • It takes a considerable capital investment to get a birth center up and running, and that’s not something most providers can access.
  • Equitable reimbursement for provider fees to midwives and facility fees to birth centers from commercial insurers and state Medicaid plans has not been available in most areas of the U.S., so the return on investment has been low.

Professional obstacles: 

  • Many physicians have opposed the independent practice of midwives while also refusing to enter in to collaborative practice agreements, which are required for midwives to provide intrapartum care in many states.
  • Birth center regulations in many states require that a physician be the medical director of the center, and recruiting physicians to fill this role can be difficult.
  • Hospitals have seen birth centers as competition and thus have not offered access to referral and transport.

AR: You are part of an effort to change things so that we do one day have a birth center in every community. Can you tell us about that effort, and why you think you will succeed?

CO: My co-founder Shannon Bedore and I formed Maternity Centers of America (MCA) in order to create a vehicle for addressing the barriers described above. As you pointed out, birth centers are a good thing and there should be more, so we built MCA to bring together professionals from a variety of backgrounds including business, real estate, construction, and health policy to look at the big picture of how maternity care works and find new ways to make birth centers a part of the healthcare system. If our efforts are successful, I believe that this broad range of perspectives will be the reason.

Credit: Center for Birth http://centerforbirth.com

As our first step, we established a demonstration site in northwest Arkansas which will allow us to try new management strategies and find ways to leverage technology while staying true to the birth center model of care. From this flagship site, we hope to develop a replicable, scalable model for the development of birth centers around the U.S. This is not a new idea, nor one that only we are working to implement. Our colleagues at New Birth Company in Kansas City and at the Minnesota Birth Center in Minneapolis are also building replicable birth center models. Each of us has a slightly different approach, and all of us need to succeed in order to or build enough scale to have measureable impact on national outcomes.

AR: The American Association of Birth Centers and the American College of Nurse-Midwives are hosting a congressional briefing next month in Washington to share the study results. Why does this study matter to policy makers?

CO: This study is of particular interest to policy makers because of both its content and its timing. Maternity care makes up the largest proportion of the national hospital bill from a single condition, and a large proportion (45%) of that is paid by government programs. A recent report from the consumer advocacy organization Childbirth Connection entitled The Cost of Having a Baby in the United States highlights the striking cost of U.S. maternity care and its inverse relationship with clinical outcomes. The report showed that almost two-thirds (59-66% depending on payer and type of birth) of the total costs of maternity care went to cover facility fees charged by hospitals. Birth centers charge facility fees too, but they are a fraction of the typical hospital fee. In addition, c-sections cost commercial payers $19,000 more than vaginal births, and they cost Medicaid programs $9,500 more than vaginal births. Multiplied by the estimated number of excess cesareans in the United States, this means about $5 billion dollars could be saved each year by improving our ability to safely get babies born vaginally.

The low value of maternity care is coming into sharper focus for policy makers at the moment due to the implementation of the Patient Protection and Affordable Care Act, which adds maternity care to the list of essential health benefits and increases the number of pregnancies that will be covered by the government through the expansion of state Medicaid programs. As policymakers attempt to realign costs and outcomes, they are looking for strategies that address the “triple aim” of healthcare championed by Don Berwick and his colleagues: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. Birth centers are a viable, evidenced-based option for meeting all three aims, which is rare, particularly in maternity care. 

Are you surprised by the results of this new study?  Will  you share this information with your clients and students?  Do you think this study will have an impact on the choices that women make about their birth location? Do you believe that more birth centers can help solve many of the problems facing birthing women and maternity care today? Share your thoughts in our comment section. I’d like to hear from you.- Sharon Muza, Community Manager.

Cesarean Birth, Evidence Based Medicine, Guest Posts, Healthcare Reform, Home Birth, Maternal Mortality, Maternal Quality Improvement, Maternity Care, Medical Interventions, New Research, Research, Uncategorized , , , , , , , ,

Maternity Care On the National Agenda – New Opportunities for Educators and Advocates

January 17th, 2013 by avatar

Today, Amy Romano, CNM, MSN, Associate Director of Programs for Childbirth Connection (and former Community Manager for this blog) follows up last Thursday’s post, Have You Made the Connection with Childbirth Connection? Three Reports You Don’t Want to Miss with her professional suggestions for educators and advocates to consider using the data and information contained in these reports and offering your students, clients and patients the consumer materials that accompany them.- Sharon Muza, Community Manager.

_________________

As we begin 2013, it is clear from my vantage point at the Transforming Maternity Care Partnership that the transformation is underway. In Childbirth Connection’s nearly century-long history, we’ve never seen so much political will from leaders, so much passion from grassroots advocates, and so much collaboration among clinicians and other stakeholders. This new landscape presents many new opportunities for educators and advocates.

One area of maternity care that has garnered increasing attention is the overuse of cesarean section, especially in low-risk women. Last year, the multi-stakeholder Maternity Action Team at the National Priorities Partnership set goals for the U.S. health care system and identified promising strategies to reach these goals. One of the goals was to reduce the cesarean section rate in low-risk women to 15% or less. This work served as the impetus for Childbirth Connection to revisit and update our Cesarean Alert Initiative. We undertook a best evidence review to compare outcomes of cesarean delivery with those of vaginal birth. Based on the results, we also updated and redesigned our consumer booklet, What Every Pregnant Woman Needs to Know About Cesarean Section. These are powerful new tools to help educators and advocates push for safer care, support shared decision making, and inform and empower women.

Two of the biggest obstacles to change have been persistent liability concerns and the current payment system that rewards care that is fragmented and procedure-intensive. Efforts to make maternity care more evidence-based or woman-centered often run up against policies and attitudes rooted in fear of lawsuits or increasing malpractice premiums, or against the reality that clinicians can not get easily reimbursed for doing the right thing. But these barriers are shifting, 

Recently the literature has provided example after example of programs that reduced harm and saw rapid and dramatic drops in liability costs as a result. That’s right – one of the best ways to decrease liability costs is to provide safer care. Rigorous quality and safety programs are the most effective prevention strategy among the ten substantive solutions identified in Childbirth Connections new report, Maternity Care and Liability. The report pulls together the best available evidence and holds potential liability solutions up to a framework that addresses the diverse aims of a high-functioning liability system that serves childbearing women and newborns, maternity care clinicians, and payers.  

The evidence and analysis show that some of the most widely advocated reforms do not stand up to the framework, while quality improvement programs, shared decision making, and medication safety programs, among other interventions, all have potential to be win-win-win solutions for women and newborns, clinicians, and payers. If we are to find our way out of the intractable situation where liability concerns block progress, we must learn to effectively advocate for such win-win-win solutions.  Advocates and educators can better understand these solutions by accessing the 10 fact sheets and other related resources on our Maternity Care and Liability page.

Evidence also shows that improving the quality of care reduces costs to payers. As payment reforms roll out, there will be many more opportunities to realize these cost savings. To predict potential cost savings, however, it is necessary to know how much payers are currently paying for maternity care. Surprising, this information has been largely unavailable, and as a result we have had to settle for using facility charges as a proxy. This is a poor proxy because payers negotiate large discounts, and because charges data do not capture professional fees, lab and ultrasound costs, and other services. Childbirth Connection, along with our partners at Catalyst for Payment Reform and the Center for Healthcare Quality and Payment Reform, recently commissioned the most comprehensive available analysis of maternity care costs. The report, The Cost of Having a Baby in the United States shows wide variation across states, high costs for cesarean deliveries, and rapid growth in costs in the last decade. It also shows the sky-high costs uninsured women must pay – costs that can easily bankrupt a growing family. Even insured women face significant out-of-pocket costs that have increased nearly four-fold over six years. Fortunately, health care reform legislation has made out-of-pocket costs for maternity care more transparent by requiring a simple cost sample to each person choosing an individual or employer-sponsored health plan.

Educators and advocates have to be able to help women be savvy consumers of health care. That means being informed about their options and also being able to identify and work around barriers to high quality, safe, affordable care. Childbirth Connection produced this trio of reports to provide a well of data and analysis to help all stakeholders work toward a high-quality, high-value maternity care system.

How Childbirth Educators and Consumer Advocates Can Help

 What is the first thing that you are going to do to join this maternity care transformation? Can you share your ideas for using this information in your classroom or with clients or patients.  Can you bring others on board to help with this much needed transformation?- SM

Childbirth Education, Evidence Based Medicine, Guest Posts, Healthcare Reform, Maternal Quality Improvement, Maternity Care, Patient Advocacy, Research, Research for Advocacy, Transforming Maternity Care , , , , , , , , , ,

Hospital Charges Still All Over the Map

May 17th, 2012 by avatar

You can get from New Jersey to Maryland in less than an hour, but despite the proximity, New Jersey hospitals, on average, charge 3-4 times more than Maryland hospitals for both vaginal and cesarean births. This is just one of the notable facts gleaned from Childbirth Connection’s analyses of the latest maternity charges data. Although the data do not show whether higher charges reflect better care, researchers who look at price variation generally find no relation between prices and the quality of care, complexity of patient care needs, or costs of actually delivering care. Such unwarranted price variation amounts to billions in wasted spending across the health care system, according to a February report from Thomson Reuters that looked at various hospital procedures.

New charts compiled by Childbirth Connection (PDF) show the significant price variation across states that report average labor and birth hospital charges to the Healthcare Cost and Utilization Project (HCUP). The chart set also includes average prices charged by birth centers, which fall well below charges for uncomplicated vaginal births in hospitals. State-by-state analyses (PDF) show charges increasing year-to-year, and reveal differences by mode of birth and presence or absence of complications.

What do these figures mean for improving maternity care?

Labor, birth, and newborn care are the most common and costly hospital conditions for both Medicaid programs and private insurers. The data in Childbirth Connection’s Charges Charts reveal four potential strategies for reining in costs:

  1. increase the proportion of vaginal births – Hospital charges for cesareans are about 66% higher than hospital charges for vaginal births (a difference of $5,900- $8,400 depending on complications).
  2. provide safer care – Complications increase charges by about 35% (a difference of $2,800 – $5,400 depending on mode of birth). Some complications are preventable with hospital safety initiatives.
  3. remove barriers to out-of-hospital birth for low-risk women interested in these options - Birth center charges are $6,600 less than charges for uncomplicated vaginal births in hospitals.
  4. reduce charges for births in facilities and states where charges exceed average - Policy makers can work to increase price transparency and align payment with quality.

We can improve the quality and value of maternity care by identifying innovations that safely and fairly achieve these goals and reduce unintended consequences.

Resources from Childbirth Connection

State-by-state Charges Charts

Multi-state Charges Comparisons (PDF)

Quick Facts About Hospital Labor & Birth Charges

Thank you, Amy Romano, for this fascinating guest post on the economic side of birth.  Childbirth is the most common reason for hospital admission in the United States (AHRQ, 2002).  Simple changes that will improve the experience of the families, save significant money and reduce unnecessary interventions, Lamaze’s Healthy Birth Practice #4. have been needed for a long time. Midwifery care for low risk women is one step in that direction. There are many other things that can happen to achieve the goal of healthy mothers, healthy babies while reducing costs. What do you think are some steps that can be taken to reduce the spiraling and often unnecessary medical costs of having a baby?  What should hospitals and health care providers be doing to get these costs under control?  How can consumers play a part in that?  Please share your ideas here, or programs that you are aware of that are working on this very issue!

Sharon Muza

 

Source

Agency for Healthcare Research and Quality, (2005). Hospitalization in the United States, 2002 (AHRQ Publication No. 05-0056). Retrieved from website: http://archive.ahrq.gov/data/hcup/factbk6/


 

Guest Posts, Healthy Birth Practices, Maternal Quality Improvement, Medical Interventions, Midwifery, Uncategorized , , , , , , ,

How to Get Good Maternity Care

December 20th, 2011 by avatar

As someone who is knowledgeable about pregnancy and birth, I often hear from far-flung friends and relatives who have questions. The questions run the gamut: “Can I take this medication?,” “Do I really need to be induced?,” “What does this test result mean?” But I hear in these questions a much more basic question: “How do I get good maternity care?”

Whether each woman can articulate it or not, all women want maternity care that is woman-centered, safe, effective, timely, efficient, and equitable. These are the domains of high-quality care.

So how can a woman get high quality maternity care? As part of our Join the Transformation Campaign, Childbirth Connection created a new resource to answer this question.

 

 

 

(You can download a PDF handout of these tips here.)

These ten tips give women the foundation they need to begin to engage as savvy consumers of high-quality care, but there’s so much more work to be done to retool our system to fully enable this kind of engagement. How can women choose their caregiver and setting wisely without transparent performance data to evaluate quality? How can women understand the evidence without access to high-quality decision support tools that are appropriate for their literacy and numeracy levels? How can women control their health records if they can’t even access them electronically?

We launched our Join the Transformation campaign to strengthen our work to address these gaps. We’re working with partners to implement key recommendations from our consensus Blueprint for Action, so in the future when women ask “How Can I Get Good Maternity Care?” the answer is clear and the resources are at their fingertips.

 

Maternity Care With a Heart from Childbirth Connection on Vimeo.

 

 

Posted by:  Amy Romano, MSN, CNM

Films about Childbirth, Films about Pregnancy, Maternal Quality Improvement, Maternity Care, Patient Advocacy, Transforming Maternity Care, Uncategorized , , , , , ,