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Late Preterm Birth: A Maternal Health Problem, Too

November 30th, 2011 by avatar

[Editor’s note:  Amy Romano recently shared the following thoughts on Childbirth Connection’s Transforming Maternity Care site.  Those of you who missed reading Amy’s review of a recent study pertaining to the maternal emotional outcomes associated with preterm birth will surely benefit from reading her post here.]

 

More than two-thirds of preterm babies are born “late preterm,” between 34-37 weeks gestation. For many years, the epidemic of late preterm birth was largely ignored, as the typical health problems of these infants were not as severe as the challenges faced by babies born many weeks before term.

Thanks to emerging evidence and advocacy, late preterm birth is now getting recognition as the major public health problem that it is – late preterm babies do in fact face many health risks, including respiratory and feeding problems, longer and more frequent hospitalizations during infancy, and behavioral and learning problems in early childhood.

Late preterm birth is out of the shadows, but part of this public health problem is still hidden.

A new study published in JOGNN looks at the emotional health outcomes of mothers of late preterm babies. Compared with mothers of full-term babies, mothers of late preterm babies had significantly more situational anxiety, depressive symptoms, post-traumatic stress disorder symptoms, and worry about their infant’s wellbeing after delivery, differences that persisted when researchers followed up with the mothers one month after giving birth. In interviews, mothers of late preterm infants described many distressing experiences, expressed concern for their own health and their infants’ health, faced many difficulties related to infant feeding and weight gain, and reported lack of timely information from care providers. They also described disruptions in their confidence in their role as mother, an experience exacerbated in women whose babies remained in the hospital after their discharge.

Depression, anxiety, and post-traumatic stress disorder are debilitating and sometimes deadly conditions for women, and the children of mothers with these conditions are at risk for poor health and social outcomes. In other words, when a baby is born a few weeks early – even when the infant health outcome is favorable – this event can still have a detrimental and persistent impact on the health and wellbeing of the family.

We need to continue to strengthen efforts to prevent prematurity. When despite these efforts babies are born preterm – even just a little preterm – this study suggests that we must work to protect the health and wellbeing not just of babies, but their mothers, too.

 

 

Posted by Amy Romano, MSN, CNM

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Reasonable Choices for Bringing Back VBAC

September 27th, 2011 by avatar

[Editor’s note:  This article by Amy Romano was originally posted on Childbirth Connection’s Transforming Maternity Care site, September 12, 2011 and is re-purposed with permission.]

 

When I recently updated Childbirth Connection’s VBAC or Repeat C-Section Topic to reflect the findings of a government-sponsored systematic review and national consensus recommendations, I was struck by how few of the facts have changed in the years since the government’s previous VBAC evidence report. While there are more data than before, we already knew that the risks of uterine rupture in labor were about 1 in 200, that accumulating cesareans sharply increases the likelihood of life-threatening complications in future pregnancies, and that there are few situations when planned VBAC is objectively unreasonable. Although the evidence has not abated the precipitous drop in VBACs, perhaps unprecedented national consensus about the importance of prioritizing VBAC services, an increasingly savvy grassroots movement, and urgent calls from obstetric leaders will begin to move the needle.

As we shift the conversation from whether to do VBACs to how to enable more of them, focus on quality and safety in the context of VBAC is long overdue. According to new government statistics (pdf), one in five of the more than 4 million births each year in the United States occur to women who have previously given birth by cesarean. If evidence supports VBAC as a “reasonable option” for most of this population – and indeed the better option for many – it is time to be reasonable about how to make VBAC as safe, accessible, and satisfying as it can possibly be.

In the absence of nationally endorsed quality measures for VBAC, payment reform to provide better incentives to offer and achieve VBAC, and care coordination to help pregnant women navigate the health care system (all urgently needed), we turn to the broader concept of maternity care quality to offer a framework for high-quality VBAC care. We’re interested in hearing what VBAC quality improvement projects exist in your community, and are eager to feature them in our TMC Directory.

A QUALITY FRAMEWORK FOR VBAC

1. Help more women make and implement choices that are informed by the best quality evidence and aligned with their own values and preferences.

Rationale: While much attention has been given to ACOG’s “Level C” recommendation to undertake planned VBAC “in facilities with staff immediately available to provide emergency care,” this recommendation is superseded by their “Level A” recommendation to “counsel women about VBAC and offer [trial of labor]” to appropriate VBAC candidates. In addition, “decision quality,” i.e., the extent to which choices align with a woman’s stated preferences and values and available evidence, is a marker of overall health care quality. Not to mention, honoring people’s informed choices is the legal and ethical standard, acknowledged by all major health care bodies.

Current approach: Few women have a choice at all. According to the VBAC Policy Database, a voluntary monitoring project by the International Cesarean Awareness Network, half of U.S. hospitals either ban VBAC outright or have no providers willing to attend VBACs. In our most recent national Listening to Mothers survey, more than half of women interested in a VBAC were denied the option, usually because of provider refusal or hospital policies. In areas where VBACs are “offered,” women must often meet eligibility criteria that are not supported by high-quality evidence. Informed consent processes typically solicit consent for VBAC but may not provide a special consent process for repeat cesareans, despite the fact that repeat cesareans pose different and in some cases much more serious risks than first cesareans.

Why this is inadequate: Both planned VBAC and planned repeat cesarean section are reasonable choices with important potential benefits and harms but the trade-offs are very different. The current approach, which ostensibly is intended to reduce the already low likelihood of avoidable perinatal death or injury and associated liability, has resulted in significant collateral damage: most notably an increased risk of maternal mortality and a growing prevalence of life-threatening complications for both mothers and babies in future pregnancies. We are also seeing troubling care patterns, including court-ordered repeat cesareans, women laboring in hospital parking lots so they can show up just in time to give birth and avoid the pressure for a cesarean, and a sharp increase in the number of women with prior cesareans choosing to give birth at home, sometimes with no skilled provider present at all. The Agency for Healthcare Research and Quality (AHRQ) team that conducted the 2010 systematic review on VBAC versus routine repeat cesarean referred to the VBAC access issues as “chilling,” an assessment with which we at Childbirth Connection agree.

Another approach: We urgently need evidence-based, field-tested shared decision making tools to communicate the research evidence and help women clarify their preferences and values. We have seen a commitment to this approach in Canada, the United Kingdom, and Australia, but thus far nothing in the U.S. (a situation we hope to change through our Shared Decision Making Maternity Initiative). Although decision support tools can help a woman select the best choice for her, system barriers including payment incentives, liability concerns, and clinician education must be addressed simultaneously to ensure that she can implement her choice. Assessing the potential for shared decision making tools and processes to reduce liability should be a research priority.

2. Maximize the proportion of women planning VBAC who experience uncomplicated vaginal births

Rationale: Morbidity in VBAC labors is concentrated in the subset of women who have unplanned repeat c-sections. These risks include infection, hemorrhage, blood clots and emotional distress. In addition, having a VBAC reduces risks in subsequent pregnancies and virtually ensures that future births will be vaginal, while having a repeat cesarean sharply increases risks in subsequent pregnancies and virtually ensures that future births will be surgical. Finally, repeat cesarean costs payers significantly more than VBAC and has significant downstream economic costs because of these effects in subsequent pregnancies.

Current approach: Clinicians and researchers seem to have responded by focusing on selecting the women most likely to have a vaginal birth. Several researchers have attempted to create prediction tools to select these women, and some clinicians and hospitals have imposed strict eligibility criteria for planned VBAC. Significantly less attention has been given to prenatal and intrapartum interventions and care processes that may enhance a woman’s likelihood of having a safe vaginal birth.

Why this is inadequate: Calculating the likelihood of vaginal birth can provide helpful information to women making an informed choice to plan a VBAC or repeat cesarean. However, even women with a lower-than-average likelihood of vaginal birth usually have a better than 50-50 chance. Moreover, some groups with lower likelihoods of vaginal birth, such as women with high BMI or multiple prior cesareans, also face significantly higher than average likelihood of harm if they end up with a cesarean. The AHRQ systematic review concluded that none of the available prediction tools adequately selected women for successful trial of labor.

Another approach: The AHRQ systematic review researchers emphasized the need to incorporate “non-medical factors” in prediction tools to enhance their usefulness. These factors, which include liability concerns, the nature and extent of informed decision-making, and provider and birth setting characteristics, appear to have a stronger effect on VBAC likelihood than factors intrinsic to the woman. In addition, research is urgently needed to identify labor care strategies to promote safe vaginal birth in women with prior cesareans, in particular the potential contribution of midwives and doulas. A randomized controlled trial examining the impact of doula care on VBAC labors is currently underway in Canada.

3. Provide the best possible response to obstetric emergencies including uterine rupture

Rationale: Uterine rupture occurs in about 4.7 per 1000 VBAC labors and is an obstetric emergency requiring prompt delivery. Although the outcome of uterine rupture is usually favorable for both infants and mothers, morbidity and mortality may be minimized if the team is prepared, communicates well, and responds quickly and in a coordinated fashion.

Current approach: The small chance of a sudden emergency with high risk of serious fetal and maternal harm resulted in ACOG’s recommendation that surgical and anesthesia staff should be “immediately available” for VBAC labors. Although in 2010 ACOG clarified that women should be able to make an informed choice for a VBAC despite this recommendation, or be referred to another facility, the response to the possibility of uterine rupture continues to favor simply prohibiting women from planning VBACs.

Why this is approach is inadequate: The singular focus on availability of a surgical team has created a situation where women in communities without these resources must consent to unwanted and potentially unneeded cesareans in order to access any maternity care at all. It also assumes that availability of surgical resources automatically translates into an optimal outcome, but unprepared or ineffective care teams may not be able to avert preventable poor outcomes despite being “available.” The AHRQ review researchers identified several other obstetric emergencies that occur with similar frequency as uterine rupture and result in similar likelihoods of serious harm but for which the obstetric community does not deem 24/7 cesarean capability to be necessary.  For these obstetric emergencies, rather than forbidding labor, hospitals have begun focusing on proven patient safety strategies like enhancing teamwork, implementing checklists, and conducting drills and simulations.

Another approach: As noted above, obstetric emergencies requiring prompt cesarean delivery can happen in any labor and in any birth setting. The emerging concept of “high reliability obstetrics” provides a framework for preventing adverse events and managing them in a consistent fashion when they occur despite prevention efforts. This requires a multi-disciplinary commitment to preparedness, teamwork, communication, and documentation. Various safety courses teach teamwork and management of emergencies in obstetrics. A systematic review of multi-disciplinary simulation training found that such programs improved knowledge, practical skills, communication, and team performance in acute obstetric situations and were associated with improved neonatal outcome.

BRINGING BACK VBAC

If VBAC is a reasonable option for most women, we need a reasonable approach to ensuring quality and safety in VBAC. Like maternity care generally, transforming VBAC care will take multi-stakeholder commitment to system reform. With so much inertia in the system, consumers and advocates must maintain a strong voice to push for positive change. Our newly updated VBAC or Repeat C-section Topic and the latest data on cesarean and VBAC trends are two resources to help women and their advocates. Our Action Center provides more ideas for engaging in maternity care transformation.

 

Posted by:  Amy Romano, CNM

 

Cesarean Birth, Research, Transforming Maternity Care, Vaginal Birth After Cesarean (VBAC) , , , ,

Four Maternity Care Trends to Watch

September 6th, 2011 by avatar

[Editor’s note:  This post by Amy Romano is re-purposed here with permission, having  initially appeared on Childbirth Connection’s Transforming Maternity Care blog site on Monday, August 15.]

 

There’s a big gap between our current maternity care system and the high-quality, high-value system envisioned by a multi-stakeholder Transforming Maternity Care Project Team. We’re glad to see many of the recommendations put forth in the Blueprint for Action garnering broader interest and gaining momentum. Here are four we expect to play a growing role in system transformation over the coming months and years.

Women- and Family-Centered Maternity Care Homes

Just about everyone agrees that the patient-centered medical home will transform primary care. But we’ve seen little attention to how best to provide this model of prevention-oriented, personalized, coordinated care to childbearing women and newborns.  Although we’re just beginning to see implementation, the woman- and family-centered maternity care home concept seems to be gaining ground. North Carolina’s Pregnancy Medical Home program provides incentives to Medicaid providers to better coordinate health and social services for pregnant women and provide evidence-based care to reduce preterm births and cesareans. We’ve also seen interest in this concept in Minnesota, although legislative hurdles remain. We expect to see more innovation in this area, especially as the economic crisis and Medicaid expansion force payers to focus on cost containment and value.

Midwives, birth centers, and home birth

Just in the past month, an obstetric leader called for increased use of midwives to help curb the rising cesarean rate, Illinois cleared a regulatory hurdle paving the way for 10 freestanding birth centers to open across the state, and several major news sources reported on the rise in planned home births. Given the major cost advantages for out-of-hospital births, decades of evidence showing safety and benefits of midwifery care, and multiple forces aligning to produce critical workforce shortages, we expect midwives, birth centers, and home birth to gain the same interest among payers and policy makers that they’ve long had among consumers.

Shared decision making

Shared decision making is another broader health care trend that we expect to see find its due place in maternity care. Health care leaders are looking to shared decision making to make care more patient-centered, improve safety, rein in unwarranted practice variation, and reduce costs. While SDM found its roots in primary care and surgical specialties, our own collaboration with the Foundation for Informed Medical Decision Making represents the first major commitment to expanding the tools and concepts of SDM to maternity care. Look for a new maternity SDM web site and a suite of decision aids in the next year.

Quality Collaboratives

Facilities, providers, payers, and other stakeholders are joining forces to assess, track, and improve quality and safety. While quality collaboratives are not new, maturing information technology systems and new quality measures are enabling and accelerating data-driven improvement. Whether its hospital systems like Hospital Corporation of America, Geisinger, or Intermountain; state collaboratives like those in California, OhioWashington, and Oklahoma, or national collaboratives like the IHI Perinatal Improvement Community, we’re seeing major momentum from these entities in tackling safety problems and disseminating and replicating best practices.

What maternity care trends are you watching?

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Focus On: Childbirth Connection

May 5th, 2011 by avatar

Nearly a Century of Innovation

Childbirth Connection is a national not-for-profit organization founded in 1918 as Maternity Center Association (MCA) to reduce maternal and infant mortality in New York City. By fostering access to high-quality prenatal, childbirth and postpartum care and education that met the needs of underserved women, MCA achieved significant measured success. This focus on effective ways to improve the quality of maternity care and address best interests of women, babies, and families has continued throughout the organization’s history.

Improving Maternity Care in the 21st Century

In the decades that followed, MCA provided leadership inaugurating and strengthening many core elements of the maternity care system and related health policy, including: maternity nursing, childbirth and parenting education, nurse-midwifery education and credentialing, out-of-hospital birth centers, program evaluation, collaborative practice, and public education.

As the 20th century came to a close, MCA assessed contemporary maternity services and the wealth of best available evidence on care for pregnancy and childbirth. We found that many important lessons from the best research were not being translated into routine maternity care practice. To address this evidence-practice gap, MCA inaugurated in 2000 a long-term national program to promote evidence-based maternity care through three strategies: research, education and advocacy.

Since that time, the organization has commissioned and conducted many systematic and narrative reviews to clarify best evidence regarding safety and effectiveness of important maternity practices, conducted three pioneering national surveys of women’s childbearing experiences, carried out national media outreach campaigns to educate women and the general public about safe and effective maternity care, developed and updated an award-winning website with evidence-based resources for women and health professionals, engaged consumers in providing feedback to improve reviews of research, informed health professionals about safe and effective maternity care through leading professional journals, and raised awareness among elected officials and policymakers about the need to improve maternity care.

In 2006, MCA became Childbirth Connection to better reflect its contemporary focus and expanded its mission statement to improve the quality of maternity care through research, education, advocacy, and policy. Through its Maternity Quality Matters Initiative, Childbirth Connection focuses on policy as a core strategy to foster a maternity care system that delivers care of the highest quality and value to achieve optimal health outcomes and experiences for mothers and babies.

Childbirth Connection is taking advantage of the country’s current unprecedented focus on health care quality improvement by engaging leaders from across the health care system to ensure that maternity care is provided in ways that are safe, effective, woman-centered, timely, efficient, and equitable. In collaboration with the Reforming States Group and the Milbank Memorial Fund, Childbirth Connection issued a major report, Evidence-Based Maternity Care: What It Is and What It Can Achieve (2008). The report assesses the present maternity care system and identifies barriers and opportunities for improvement. Through Childbirth Connection’s landmark policy symposium, Transforming Maternity Care: A High Value Proposition, its 2020 Vision for a High Quality, High Value Maternity Care System, and Blueprint for Action, the organization works to improve the structure, process and outcomes of maternity care in the 21st century. Childbirth Connection believes that deliberative, collaborative multi-stakeholder efforts to improve the quality, value and experience of care for women, babies, families, and other stakeholders are the way to get there. We know that maternity quality matters.

Resources for Childbirth Educators:

Posted by:  Amy Romano, CNM, MSN

 

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The Transforming Maternity Care Toolbox

April 19th, 2011 by avatar

At Childbirth Connection, one of our mantras is: A high-quality, high-value maternity care system is within reach, but none of us can do it alone. The Transforming Maternity Care “2020 Vision” and “Blueprint for Action” reports, released last year, involved intense collaborative work by all stakeholders – from delivery system leaders, providers, and consumers to health plan and purchaser leaders, liability insurers and quality experts. But these consensus documents are just the beginning. The devil is in the details, and much more work is needed to implement the Blueprint’s recommendations and continually refine quality improvement efforts.

To foster and accelerate implementation, Childbirth Connection just launched a new Transforming Maternity Care web site. Whereas ChildbirthConnection.org offers evidence-based information to women and health professionals to aid decision making, the Transforming Maternity Care site addresses system reform. We thought about four major factors that could get in the way of our collective ability to seize unprecedented opportunities to effect real change, and set out to offer solutions.

Problem: The 2020 Vision and Blueprint for Action are robust but dense and may be hard to digest at once.

Solution: This problem was easy to address. The Vision and Blueprint now each have home pages of their own, and the content is delivered in smaller chunks in both HTML and PDF. Want to know about how performance measurement fits into maternity care system improvement? Go straight to the performance measurement page. From there you have the key messages available at a glance or you can drill deeper to understand the problems in the current system and read the in-depth recommendations and action steps. You can also download the full-text of that Blueprint section (pdf). Also at your fingertips: watch a webinar, access a bibliography of studies, reports and other background materials, and search for projects in our Transforming Maternity Care Directory that address performance measurement.

Performance measurement isn’t your cup of tea? Just pick any of the 10 other focal areas (like care coordination, informed decision making, or liability reform) and drill down the same way.

Problem: Many individuals and organizations want to help fix maternity care, but stakeholders may not know where to begin.

Solution: Behold: the Action Center. No matter what kind of stakeholder you are, there’s something you can begin doing today to help improve maternity care. We’ve pulled together the most promising opportunities for consumers, health professionals, hospital and health system administrators, purchasers, and quality experts.

Problem: Energy and resources are easily wasted reinventing the wheel.

Solution: There are many examples of high-performing maternity care services and successful quality improvement efforts. But it can be difficult to translate effective models into widespread practice. What’s more: all change is local – stakeholders need tools and support to adapt innovations to their own settings and populations.

To foster, coordinate, and accelerate maternity care quality improvement, we put the tools and resources in one place and set up a way to connect individuals and organizations with common interests. The site features a directory of quality improvement projects that users can browse by Blueprint area or by quality improvement strategy. Are you improving maternity care quality where you live or work? Add your project to the directory.

Other resources include a list of quality improvement toolkits, links to obstetric and perinatal safety courses for health professionals, a directory of quality collaboratives, and a bibliography of the quality improvement literature.

One stop shopping!

Problem: Data to track and improve maternity quality are collected by many different agencies and reported on many different web sites.

Solution: We’ve created a Data Center where you can find statistical reports, interactive maps, and raw data files to help understand and improve maternity care quality. The data center is where you’ll find Childbirth Connection’s Listening to Mothers surveys, our continually-updated Facts & Figures page, and cost and payment data. We’ve also collected all provider-, facility-, and state-level maternity care data that we know is available, and provided links in one place. Last but not least, the data center includes our interactive maternity care map from Mapping Health, the winner of Childbirth Connection’s Health 2.0 Developer Challenge.

We hope these resources help and inspire you to make change. If there is a quality improvement toolkit or resource that you think should be listed on the site, please let us know. If you have any other feedback about the new site, contact me at romano@childbirthconnection.org. And don’t forget, if you are involved with a quality improvement project, there’s someone else who wants to know about it, and might even want to replicate it. Please fill out our project submission form to share your story.

Posted by:  Amy Romano, CNM

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