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Why the California Toolkit: “Improving Health Care Response to Preeclampsia” Was Created

February 6th, 2014 by avatar

by Christine H. Morton, PhD

Researcher and Lamaze International Board Member Christine H. Morton, Phd shares information about a just released Toolkit on educating professionals about preeclampsia and it’s potentially very serious consequences.  Dr. Morton discusses how you can get a copy, take a webinar introducing the features and help reduce the number of women impacted by this serious pregnancy illness. – Sharon Muza, Community Manager.

Screen Shot 2014-02-05 at 10.25.11 PMWhen my academic partner and I observed childbirth classes several years ago as part of our Lamaze International-funded research (Morton 2009, Morton et al, 2007), we noted that many childbirth educators included a list of signs and symptoms to watch out for during their initial class meeting with expectant couples.  Some of these signs and symptoms were signals of early labor (mucous plug, leaking amniotic sac, contractions) while others might portend a more serious complication such as placental abruption (bright red bleeding), or preeclampsia (blurred vision, extreme swelling, headache), or worse case scenario, fetal demise (reduced to no fetal movement).  At the time, we wondered about the seeming contradiction of classes ostensibly designed to promote confidence in women’s bodies to give birth while from the outset telling women about things to watch out for, or “warning signs.”  Some instructors advised students to post the list on the fridge or on the bathroom mirror.

Now, after five years working at the California Maternal Quality Care Collaborative, and reviewing hundreds of cases of maternal death, I understand the importance of sharing information with pregnant women (and their partners) so they can understand when a symptom or condition goes beyond normal.  I understand why it is so important for women to know their own bodies, including their normal blood pressure, so they (or their partners) can be effective patient advocates if they sense something doesn’t feel right.

It’s an important balance for educators and other birth professionals to discuss the normality of physiological birth alongside the reality that about 8-12% of women will have medically complicated births. (Creanga, 2014), (Fridman, 2013) I remember hearing from partners who wanted to know what to look out for, so they could fulfill their roles as “protectors” as well as “co-creators of sacred space,” as one educator referred to them. Screen Shot 2014-02-05 at 10.25.45 PM

Preeclampsia is the second leading cause of pregnancy-related death in California, accounting for 17% of all deaths. (Druzin et al, 2014.) Preeclampsia is a severe obstetric condition characterized by high blood pressure, which left untreated, can lead to stroke, prematurity and death of women and babies.  As part of the California Pregnancy-Associated Review (CA-PAMR), an expert committee analyzed the medical records of 25 women who died of preeclampsia.  The committee identified contributing factors, and opportunities to improve care. All of the California deaths due to preeclampsia had some chance of preventability, with nearly half having a good-to-strong chance to alter the outcome.  For every woman who dies, at least 40-50 experience severe complications requiring ICU admission and another 400-500 experience moderate-to-severe complications from preeclampsia or other hypertensive disorders.   One important factor in the deaths was delayed recognition and response to signs and symptoms of severe hypertension.

Screen Shot 2014-02-05 at 10.26.04 PMThe lessons we learned from reviewing those cases were used to inform the development of the California Toolkit: Improving Health Care Response to Preeclampsia.  CMQCC and the California Department of Public Health (CDPH), Maternal, Child and Adolescent Health (MCAH) Division collaborated to develop and disseminate this toolkit using Title V MCH funds provided by CDPH-MCAH. The goal of this toolkit is to guide and support obstetrical providers, clinical staff, hospitals and healthcare organizations to develop methods within their facilities for timely recognition and organized, swift response to preeclampsia and to implement successful quality improvement programs for preeclampsia that will decrease short- and long-term preeclampsia-related morbidity in women who give birth in California. (Druzin et al 2014).

Experts from obstetrics, perinatology, midwifery, nursing, anesthesia, emergency medicine and patient advocacy relied on best evidence, expert opinion and the Toolkit includes:

  • Compendium of Best Practices: eighteen articles on multiple topics around hypertensive disorders
  • Appendices: Collection of all Care Guidelines including tables, charts and forms that are highlighted in Article Sample forms for policy and procedure
  • Slide set for Professional Education: slides that summarize the problem of and the best practices for preeclampsia to be used for local education and training

Of particular interest, the toolkit addresses the management of severe preeclampsia < 34 weeks, the importance of recognition and treatment of delayed postpartum preeclampsia/eclampsia in the emergency department and early postpartum follow-up upon discharge for women who were diagnosed with severe hypertension during childbirth.  The Preeclampsia Foundation was a partner on the Task Force, and has created educational material for pregnant women and their families, in English and Spanish.  Hospitals, clinics and childbirth educators can order these materials at no cost (shipping and handling only) from the Foundation.  There is a free webinar available on February 25th introducing the toolkit to professionals.preeclampsia

Thinking back to my childbirth education observations, I am struck that the educators never mentioned preeclampsia or defined it.  Not one suggested women should know their normal blood pressure.  The Preeclampsia Foundation commissioned a report in 2012 which reviewed the top pregnancy and childbirth advice books and found that many either failed to mention the condition or contained misleading or incorrect information about preeclampsia, HELLP or eclampsia.  With hypertensive disorders of pregnancy on the rise (as well as other maternal morbidities) (Fridman et al 2013; Creanga et al 2014) it’s important for childbirth educators and birth professionals to help women understand signs and symptoms and to know what those signs and symptoms might mean.

Even as we know most women are healthy and are highly unlikely to experience a severe complication in pregnancy and childbirth, we must also acknowledge that some women do, and by leaving them out of the classes and books, we silence their reality.  As one woman noted in a research study on experiences of severe pregnancy complications said:

There’s a lot of information out there or bad information that can make you feel like you did this to yourself. But there’s every kind of woman that has gone through some sort of thing. You don’t see red flag kind of behaviors in the population of women who get preeclampsia or a lot of the other kinds of issues that can cause childbirth injury and the bad childbirth experiences. I understand the way the books put it is that they want to reassure you that it’s not going to happen to you, but the kind of flipside of that is to say that when it does happen to you, where are you then? You know? I think they set you up for PTSD, for postpartum depression. They kind of make it seem, like, “Oh hey! You’re fine. Everything’s going to be great. It’s not going to happen to you” so what are you left when it does happen? (Lisa, in Morton et al 2103).

We owe it to pregnant women to give them the information they need to understand the fullness of their pregnancy and childbirth experiences, whether normal or complicated.  The Preeclampsia Toolkit will hopefully help those clinicians who care for childbearing women better manage and reduce the severity of complications when they arise.  Since its release last month, the Toolkit has been downloaded over 1376 times in all 50 states states (plus District of Columbia and Puerto Rico) along with 5 countries; Australia, Canada, Wales, Mexico and Malaysia.  The response to this Toolkit has been incredible and it is clear that there is a need for practical tools that hospitals and clinicians can use to improve their response to hypertensive disorders of pregnancy. 

Do you share information about preeclampsia in your classes and with your clients?  How do you discuss it?  What are your favorite learning tools?  Let us know in the comments. – SM

References

Creanga, MD, PhD, Andreea A. ; Cynthia J. Berg, MD, MPH, Jean Y. Ko, PhD, Sherry L. Farr, PhD, Van T. Tong, MPH, F. Carol Bruce, RN, MPH, and William M. Callaghan, MD, MPH, Maternal Mortality and Morbidity in the United States: Where Are We Now? JOURNAL OF WOMEN’S HEALTH, Volume 23, Number 1, 2014, DOI: 10.1089/jwh.2013.4617

Druzin, MD Maurice; Laurence E. Shields, MD; Nancy L. Peterson, RNC, PNNP, MSN; Valerie Cape, BSBA. Preeclampsia Toolkit: Improving Health Care Response to Preeclampsia (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care) Developed under contract #11-10006 with the California Department of Public Health; Maternal, Child and Adolescent Health Division; Published by the California Maternal Quality Care Collaborative, January 2014.

Fridman, PhD, Moshe; Lisa M. Korst, MD, PhD, Jessica Chow, MPH, Elizabeth Lawton, MHS, Connie Mitchell, MD, MPH, and Kimberly D. Gregory, MD, MPH, Trends in Maternal Morbidity Before and During Pregnancy in California, Am J Public Health. Published online ahead of print December 19, 2013: e1–e9. doi:10.2105/AJPH.2013.301583)

Morton, C. H. (2009). A fine line: Ethical issues facing childbirth educators negotiating evidence, beliefs, and experience. The Journal of perinatal education, 18(1), 25.

Morton, C.H., A. Nack, and J. Banker, Traumatic Childbirth Experiences: Narratives of Women, Partners, and Health Care Providers. Unpublished manuscript. 2013.

Morton, C. H., & Hsu, C. (2007). Contemporary dilemmas in American childbirth education: Findings from a comparative ethnographic study. The Journal of perinatal education, 16(4), 25. Chicago

 

Childbirth Education, Guest Posts, Maternal Mortality, News about Pregnancy, Pre-eclampsia , , , , ,

Book Review: Cut It Out: The C-Section Epidemic in America

November 7th, 2013 by avatar

By Christine Morton, PhD

What accounts for the dramatic rise in cesarean delivery in the United States over the past two decades? In her new book, Cut it Out: The C-Section Epidemic in America, sociologist Theresa Morris addresses this question by going to the source: she interviewed maternity clinicians (obstetricians, midwives and labor and delivery nurses) as well as women who had recently given birth. She examines guidelines from the major professional group of obstetricians and gynecologists. Morris goes beyond simply documenting the rise in C-sections, the health risks they pose to women and their babies, although she does that very well. To explain how we got to an epidemic of c-sections in the U.S, she applies an organizational lens, making it clear how “organizational changes constrain the decisions and behaviors of maternity providers and women.”

This way of looking at c-sections will be useful for childbirth educators, doulas and childbearing women because it goes one step farther than most research on c-sections, which demonstrate trends and possible associations between clinical causal factors, or characteristics of women. It is also different from advocacy around c-sections that largely frames the issue as one of individual agency or rights (“women must advocate and prepare for vaginal birth,” or “women have right to informed choice”). And although we have some research on how organizational structure impacts c-section rates, such as teaching hospitals and health maintenance organizations (HMOS), absent from these studies are explanations as to why this is so. Morris argues that the research on c-section epidemic is missing an “understanding that is rooted in the experience of maternity care providers and pregnant women” (p. 21).

While most childbirth educators and doulas have a good understanding of pregnant women’s experience, Morris takes the reader into the perspectives of a range of maternity clinicians, arguing that organizational policies and procedures constrain their actions. We can’t blame individual clinicians for the high c-section rate, she argues, nor can we hold them responsible for reducing it. Social constraints on individual behavior are very powerful and need to be understood if they are to be changed. As many sociologists have observed, deviance from social norms has real consequences for individuals. Imagine yourself riding in an elevator filled with people you don’t know, with your back to the doors. It’s not easy to do. Morris notes, “Maternity providers may face professional consequences for deviance—for example, being informally scolded by colleagues, formally reprimanded by a supervisor, or having a malpractice insurer deny coverage in a case of a bad outcome” (p. 22). By talking to maternity clinicians about how they see the problems, and what they do about them, Morris is able to show how obstetricians are also caught in systems not of their own making.

“Hospitals are organizations with fixed rules to guide individual behavior” (p. 22) and this applies to all individuals within organizations. Morris has provided a nuanced and rich picture of what she calls the “organizational paradox, in which the increasing rates of c-section do not protect the health of women or babies or make birth safer or good outcomes more likely,” and argues that if we look at the c-section rate as the result of how health care organizations respond to their legal, political and economic environments, we can understand, and hopefully change, the system.

I found one of the most compelling sections of her argument in her discussion of the patient safety movement and its emphasis on standardized protocols, language and peer review. Until very recently, c-section rates were not considered part of the patient safety movement in obstetrics. Morris shows that when a hospital embarks on patient safety initiatives, with the goal of malpractice claims due to a bad baby outcome, these initiatives often result in an increase, or at best, no change in c-section rates.

Morris also reviews how doctors frame risks of VBAC vs. repeat c-section in ways that foreground the statistically rare risk of uterine rupture (indeed, the more dangerous rupture vs. the more common, but still rare, occurrence of uterine dehiscence). The more common risk to women of repeat c-section is often not included. Here we see how possible risks for the baby (and to the physician in the event of a bad outcome) are prioritized over risks to women’s health. Organization pressures influence how these risks are defined and described to women, says Morris.

“Any effort to resolve the c-section epidemic requires organizational solutions” (p. 153).

The stakes are high, and unless there is concerted and coordinated effort to reduce the c-section rate through organizational and policy change, we are unlikely to see a downward trend. Morris concludes, however, by listing what individual women and maternity clinicians can do to help solve the c-section epidemic. For women, this includes learning about and advocating for evidence-based care, with the assistance of independent childbirth educators and birth doulas, and finding maternity physicians and hospitals with low rates of c-section. Maternity providers, she notes, may find it helpful to be up front with women about the risks of childbirth, and that even with best of care, sometimes things go wrong. The policy and social changes Morris recommends are quite sweeping and it’s not clear where political will for these will come, but happily, there are some efforts being made on the organizational solutions she proposes. In particular reporting of c-sections as a quality measure will be required by The Joint Commission as of January 2014 for hospitals with more than 1100 births/year. A recent publication on Preventing the first cesarean delivery summarized the evidence from a joint workshop held by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists.

In this YouTube video, author Theresa Morris shares why she wrote Cut It Out: The C-Section Epidemic in America. 

Here are several more videos in the video series, where Theresa talks about the cesarean epidemic

This book is highly recommended for all childbirth educators, doulas and other maternity care professionals who wish to help pregnant women understand how the organization in which they are giving birth will likely shape both they, and their maternity clinicians’ actions. Yet, it also holds out the promise of hopeful change, especially when it is clear that many of these efforts are underway. With states seeking ways to drive down costs and with support from national government action focusing on maternal health, more pressure from payers, women and maternity care advocates, we can look forward to reducing c-sections and turning the tide of this epidemic. Let’s discuss what we can do to bring down the c-section rate.

About Christine Morton

Christine Morton

Christine Morton

Regular contributor Christine H. Morton, PhD, is a sociologist whose research on doulas is the topic of her forthcoming book, with Elayne Clift, Birth Ambassadors: Doulas and the Re-emergence of Woman-Supported Birth, which will be published by Praeclarus Press in Fall 2013. Christine is also a new member of Lamaze International’s Board of Directors. For more on Christine, please see Science & Sensibility’s Contributor page.

Babies, Book Reviews, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, Maternal Quality Improvement, Maternity Care , , , , , , ,

Medicaid Coverage for Doula Care: Re-Examining the Arguments through a Reproductive Justice Lens, Part Two

April 2nd, 2013 by avatar

by Christine H. Morton, PhD and Monica Basile, PhD, CPM, CD(DONA), CCE (BWI)

Last month there were great discussions after a study was published by the University of Minnesota, examining the potential cost savings to Medicaid if doulas worked with Medicaid clients, helping to reduce interventions and cesareans.  Latst week and today, regular contributor, Christine Morton and her colleague Monica Basile, take a look at that study and another from Oregon, and share thoughtful insight about topics that might still need to be addressed if costs savings were to be effectively realized in a two part blog post. Today the authors discuss concerns about reimbursement and program sustainability alongside a caution against relying too heavily on arguments that position the doula as primarily a money saver and a cesarean reducer. Find part one here. – Sharon Muza, Community Manager, Science & Sensibility

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© Patti Ramos Photography

More fundamentally, however, we argue that doula benefits cannot be captured solely through an economic model.  Neither should doulas be promoted as a primary means to reduce cesarean rates.  Both strategies (economic benefits and cesarean reduction) for promoting doulas have significant barriers, some of which are acknowledged by the Minnesota researchers, who note at the end of their paper that:

 

Recruiting a diverse population of trained doulas, however, may be difficult in the current environment. It is likely that doula work will not become more lucrative or appealing unless more people are willing to pay for these services or third-party reimbursement becomes more common.  Doulas themselves report that their work is emotionally satisfying but not financially rewarding.  Broadening the payer base will likely enhance the feasibility of a doula care business model for a wider range of women and facilitate recruitment of doulas from low-income communities, communities of color, and immigrant communities.

While acknowledging that doulas are mostly white, middle class, relatively educated women, the authors stop short of recommending, as we do, that an important step toward the goal of increasing access to doula care is the need for individual doulas and doula organizations alike to take a close look at ways in which doula culture itself is white and middle-class centered in terms of its priorities, the content of training programs, and the accessibility of doula training and certification. This is not to minimize efforts to promote diversity in the doula community that are currently underway, particularly those of the International Center for Traditional Childbearing, HealthConnectOne, and other community programs such as Everyday Miracles and Open Arms Perinatal Services.

However, greater attention needs to be paid to issues of privilege and oppression within the doula community at large.  Advocates need to consider how the prioritization of the cesarean rate as a primary research or policy issue reflects a certain level of unexamined privilege. For those facing spotty access to health care, cultural and linguistic incompetence in care settings, the detrimental effects of the prison industrial complex and the child welfare system on families, and the effects of poverty, racism, and/or homophobia in general, there are other, perhaps equally pressing concerns surrounding childbirth than over-medicalization. Certainly, unnecessary cesareans and over-medicalization are detrimental to everyone, but we need to understand how the effects of these problems play out differently for differently situated people and not limit advocacy to these issues.

The authors also propose that a below market reimbursement for services ($100-300) is a feasible business model and would be sufficient to recruit doulas from “low-income communities, communities of color and immigrant communities.”  This claim raises serious concerns on our part, two social scientists who have conducted qualitative research on doula practice and have spoken with hundreds of doulas about the economic conditions under which they work.  The assumptions embedded in the above quote assume the emotional rewards balance the economic ones, without acknowledging that even doulas who charge market rates find it challenging to make this occupation financially sustainable.  How then, can a doula program based on Medicaid funding be sustainable with such a low reimbursement rate?  Further, while hospital, volunteer, and community-based doula practices alike require loyal and committed doulas who work within them, it is not clear that any doula practice, let alone one that pays so little, can scale to meet the needs of the nearly two million women whose births are covered by Medicaid each year in the U.S. Doulas themselves, as representatives and members of the communities they serve, should be at the forefront of driving policy decisions about the work they do.

Most concerning, this claim implies that only doulas from marginalized groups would be interested in, or willing to work for, such low wages. According to Sheila Capestany, Executive Director, Open Arms Perinatal Services, a community-based doula program located in Seattle, Washington, this assumption about the doula as community health worker may lead to unanticipated consequences:

If we believe that Medicaid clients with doula support at their births will have improved outcomes (in terms of racial/ethnic disparities in cesareans and breastfeeding, etc.) that have been persistent and worsening for such a long time in the current US maternity system, then the American way is to regard these doulas as experts in supportive care in labor and reimburse them in a manner that reflects and respects that expertise and value.  Otherwise, we will potentially create a system of institutionalized racism that we are ostensibly trying to eradicate.

Ms. Capestany speaks from long experience of involvement in community doula programs in the state of Washington, which had doula services covered under its Maternity Support Services (a Medicaid program) from 1992 through 2004, well before Oregon’s recent policy.

Advocates for Medicaid funded doula services can learn valuable lessons from the Washington experience.  At the start of this public payment for doula services, doulas were a new concept, the newly formed doulas of the Pacific Association for Labor Support (PALS) viewed the program as a way to obtain clients and achieve their desire to provide doula care to a high-need population. The payment (about $40 per visit as a community health worker, with up to four visits per client, including the birth) was at most, around $160.

One critical policy issue was determining whether doulas in training could use births paid by Medicaid for certification purposes.   After some discussion and debate, it was decided that as an issue of social equity, women who were poor should not be the ‘training ground’ for aspiring doulas, and the program required certification.  Early on, this was not a barrier. However, as the doula concept spread, and more childbearing people were willing to pay out of pocket for personalized labor support, it become challenging for the local organization, PALS, to find certified doulas who were willing and able to provide services for Medicaid clients.  Program managers at PALS reported that another concern was that some doulas provided a lower quality and level of services to their Medicaid clientele compared to what they offered their private paying clients, because of the differing remuneration.  One of the ironic inversions in the Washington program was that white middle class doulas were caring for low-income clients (about a third of whom were people of color).   Yet the few doulas of color who sought to provide fee-for-service doula care reported they were often not hired by prospective clients, who were primarily white, and upper to middle class professional couples.

In 2004, when Washington’s Maternity Support Services program was revised with the intent to incorporate doulas more formally as part of the care team, and to increase the reimbursement rate to $250, its application was reviewed by the federal government, which questioned the use of non-licensed providers.  In response, Washington state withdrew the doula component in order to save the remaining elements of the program.   Nearly a decade later, advocates for including doulas in Medicaid plans are proposing fees of at most, $300 per birth, with an unspecified model of doula care, and claiming this will address long standing racial/ethnic disparities in neonatal and maternal health outcomes, as well as reduce cesarean rates.  Open Arms Perinatal Services, does record lower cesarean rates among the women served by Open Arms doulas.  But importantly, Open Arms pays its community-based doulas at the low end of the market rate in Seattle, or $700, as a matter of work equity. Open Arms also has doulas who volunteer their services, who represent half their doula population.

It is crucial that policy discussions focused on improving maternity care bear in mind that high cesarean rates are primarily a problem of obstetric culture and practice. The solution to this problem, then, needs to involve reforming obstetric practices from within, and cannot rest wholly on the shoulders of doulas. The most recent Cochrane Collaboration report on doula care points out that in addition to doula support, if reductions in cesarean rates are to occur, “Changes to the content of health professionals’ education and to the core identity of professionals may also be important. Policy makers and administrators must look at system reform and rigorous attention to evidence-based use of interventions that were originally developed to diagnose or treat problems and are now used routinely during normal labours” (Hodnett, 2012).

Cesarean rates are influenced by a complex set of drivers and constraints that operate at the individual, hospital and state level.  Studies on cost-benefit analyses that do not account for the variation in state and hospital rates as well as facility-level policies and protocols affecting clinical practice have the potential to obscure, rather than clarify, the problems at hand and the role of doulas in solving them. Proposing the doula as a bandage to a gaping wound may staunch some of the blood flow but it won’t address the underlying problem, which is a massive hemorrhage.  A policy approach that neglects obstetricians, nurses and hospitals, in ongoing quality improvement efforts to reduce non-medically indicated cesareans, and instead focuses on the underpaid, least valued member of the team, the doula, may be less likely to succeed in its goals to improve maternity outcomes.

We agree that “broadening the payer base” beyond the traditional fee-for-service private doula model is an important component of increasing access to doula care, and we support the policy advocacy efforts that are needed to secure more diverse sources of funding for doula services. At the same time, we caution against relying too heavily on arguments that position the doula as primarily a money saver and a cesarean reducer. Doulas need to be recognized and compensated fairly for the valuable, multifaceted, and often, unquantifiable, contributions they make to building healthy families and communities. At the same time, doulas cannot be held entirely responsible for reforming maternity care as we know it.

Policy discussions of doula care must acknowledge this, and must carefully consider the sustainability of the reimbursement and overall structure of the programs they propose. The fact that doulas and policy advocates are turning their attention to ways in which doulas can help reduce racial disparities in birth outcomes is heartening, and much more effort is needed toward this goal. We encourage the development of a research and advocacy agenda that prioritizes work equity and social justice equally to cost savings, and we look forward to continued conversations about how to bring this into fruition.

Acknowledgements:

The authors thank Elliott K. Main, MD for his assistance in assessing the methodology of this study; Sheila Capestany, MPH, MSW for her perspectives on doula models of care and several anonymous reviewers for their critical comments.

References

Baicker, K, Kasey S. Buckles, and Amitabh Chandra. Geographic Variation In The Appropriate Use Of Cesarean Delivery: Do higher usage rates reflect medically inappropriate use of this procedure? Health Affairs 25 (2006): w355–w367; doi: 10.1377/hlthaff.25.w355

Caceres, Isabel A., Mariana Arcaya, et al., Hospital Differences in Cesarean Deliveries in Massachusetts (US) 2004–2006: The Case against Case-Mix Artifact, PLoS ONE 8(3): e57817. doi:10.1371/journal.pone.0057817

Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, 2012, Issue 10. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub4.

Kozhimannil, Katy Backes, Michael R. Law, and Beth A. Virnig. Cesarean Delivery Rates Vary Tenfold Among US Hospitals; Reducing Variation May Address Quality And Cost Issues, Health Affairs 32, NO. 3 (2013): 527535; doi: 10.1377/hlthaff.2012.1030

Main EK, Morton CH, Hopkins D, Giuliani G, Melsop K and Gould JB. 2011.  Cesarean Deliveries, Outcomes, and Opportunities for Change in California: Toward a Public Agenda for Maternity Care Safety and Quality.  Palo Alto, CA: CMQCC.  (Available at http://www.cmqcc.org/white_paper)

Pilliod, Rachel; Leslie, Jennie; Tilden, Ellen; et al. Doula care in active labor: a cost benefit analysis. Abstract presented at 33rd Annual Meeting/Pregnancy Meeting of the Society-for-Maternal-Fetal-Medicine (SMFM), San Francisco, CA, February 11-16, 2013, American Journal of Obstetrics and Gynecology, Volume: 208 (1); S348-S349.

About the authors

 

Monica Basile

Monica Basile has been an active birth doula, childbirth educator, and midwifery advocate for 17 years, and holds a PhD in Gender, Women’s and Sexuality Studies. Her 2012 doctoral dissertation, Reproductive Justice and Childbirth Reform: Doulas as Agents of Social Change, is an examination of emerging trends in doula care through the lens of intersectional feminist theory and the reproductive justice movement.

 

Christine Morton

Christine Morton

Regular contributor Christine H. Morton, PhD, is a sociologist whose research on doulas is the topic of her forthcoming book, with Elayne Clift, Birth Ambassadors: Doulas and the Re-emergence of Woman-Supported Birth, which will be published by Praeclarus Press in Fall 2013. For more on Christine, please see Science & Sensibility’s Contributor page.

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Medicaid Coverage for Doula Care: Re-Examining the Arguments through a Reproductive Justice Lens, Part One

March 28th, 2013 by avatar

by Christine H. Morton, PhD and Monica Basile, PhD, CPM, CD(DONA), CCE (BWI)

Last month there were great discussions after a study was published by the University of Minnesota, examining the potential cost savings to Medicaid if doulas worked with Medicaid clients, helping to reduce interventions and cesareans.  Today and next Tuesday, regular contributor, Christine Morton and her colleague Monica Basile, take a look at that study and another from Oregon, and share thoughtful insight about topics that might still need to be addressed if costs savings were to be effectively realized in a two part blog post. – Sharon Muza, Community Manager, Science & Sensibility

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http://flic.kr/p/5eqPFL

How can doula supported births help reduce the cesarean rate and realize cost savings within Medicaid-funded births? Two studies published last month offer the opportunity to address this complex question.

We support the goal of increasing access to doula supported care to childbearing people of diverse racial/ethnic and class backgrounds, and we are pleased that discussions are taking place about how doulas may be able to help reduce racial disparities in maternal and infant health. We recognize that work toward these goals requires policy advocacy, which depends heavily on economic arguments for the benefits of doula care.

However, by limiting the discussion of benefits to the economic impacts of reduced cesareans, advocacy for Medicaid funding of doula supported births—without specifying the doula model of care and without according true value to the doula’s impact—may have unintended consequences for individual doulas, and the organizations that represent them.  One such consequence may be that the resulting system will continue to perpetuate a model of economic marginality and potential exploitation for the doulas who serve a low income population of childbearing people.

The AJPH study by Katy Kozhimannil and colleagues in Minnesota received a lot of media attention when it appeared last month, even live coverage in the Huffington Post.  This study compared 1,079 selected Medicaid doula patients in Minnesota to Medicaid patients nationwide for their total cesarean rates.  They found that doula clients of a community program in Minnesota had a rate of 22.3% while national Medicaid had 31.5%.  The authors reported three scenarios, all assuming that if states reduced cesarean rates, by offering doula services, there would be varying levels of cost savings, depending on the cesarean rate achieved, and by reimbursing doulas between $100-300 per birth.

In our view, the Minnesota study design raises several methodological questions, which are applicable to this study and to future research on doula-attended births. We outline those questions here, as well as raise several more substantive concerns about the implications of the study’s stated conclusions.

  1. Why did the researchers not compare Minnesota Medicaid doula clients to Minnesota Medicaid women who gave birth?  Minnesota has a much lower rate of total cesarean that the US as a whole (27.4% during this time period), and this would have been a better matched comparison.  A better comparison would be doula attended births vs. non-doula attended births at the same facility.  It is not clear from the study whether the doula program whose data was utilized served women at one or multiple hospitals in Minneapolis. 
  2. Why did the researchers not limit their investigation to primary cesareans?  Doulas typically support women in labor rather than women undergoing repeat cesareans.  The total cesarean rate includes repeat cesarean so it will be much higher than the primary cesarean rate, which is more applicable to doula clients.  Including total cesarean rates means that the researchers are comparing a limited universe (doula support of women in labor) to all births (thus including repeat and primary cesarean).   The data source for this study, (Nationwide Inpatient Sample), however, does not have this information.
  3. Cesarean rates are very dependent on the parity distribution of the birthing population, so first time mothers need to be compared to first time mothers and multiparous women to multiparous women. This information is not available in the data source used by the researchers, but in future studies of this type, it is critical to verify that the proportion of each is the same in the intervention and control populations.
  4. States are implementing a number of payment reform models to reduce cesareans among women covered by Medicaid, with limited success.  In part, that is because cesareans are influenced by a number of factors, with payment incentives only one.  (Many of these issues are covered in the CMQCC white paper on improvement opportunities to reduce cesareans, which argues that a multi-pronged strategy is necessary). 
  5. Because hospital rates of cesarean have been shown to have high geographic variation in a number of studies (Baicker 2006; Main et al 2011; Caceres 2013; Kozhimannil 2013), it may be more feasible to have comparison groups of hospitals with similar primary cesarean rates.  Until we understand what accounts for variation in cesarean rates between institutions (unit culture; facility policies and protocols), it may be premature to assess the independent effect of labor support by a trained doula.

While doula support is associated with fewer cesareans across the board (Hodnett 2012), the methodological issues described above are likely to over estimate the benefits of doula-attended births in terms of reducing the cesarean rate for Medicaid covered births.  This, in turn, raises questions about the purported cost savings.  In the Minnesota study, the cost breakpoint is no more than $300 dollars for the doula per birth.  In most cities, doulas charge well above this amount for fee-for service care.

A cost-benefit analysis by Oregon Health & Science University researchers for the Oregon State Legislature was presented at the Society for Maternal Fetal Medicine in February 2013, which found that doula care in labor provides a cost benefit to payers only when doula costs are below $159.73 per case.  In that study, data sources are not entirely clear, but do seem to come from the OHSU facility where a hospital-based doula program is in place.  In that program, doulas are on call on weekends only and come to assist in a labor when requested by the woman during her prenatal care or when she arrives at the hospital.  A case-control study claiming the benefits of this doula model at OHSU was published as an abstract, and although it claims “women receiving doula care were statistically less likely to have an epidural during labor (p = 0.03), have an episiotomy (p = .03), or cesarean delivery (p = .006) and on average, doula attended women had a shorter hospital stay compared to the control group (p = .002),” nowhere does it show what the actual rates were.  This is important, because, they are likely to be relatively low overall, given that OSHU is a teaching hospital, with midwives and family practice physicians providing maternity care.

There are several types of doula models; not all have the same components.  The community-based doula model, as exemplified by the HealthConnectOne approach has a solid evidence base. This model employs doulas who are trusted community members, and provides extensive prenatal and postpartum support in addition to continuous labor support.  Doulas work collaboratively with community organizations, have extensive training in experiential learning and cultural sensitivity, and are paid a wage commensurate with their value and expertise, serving an important workforce development and grassroots empowerment function. Some so-called community doula programs do not incorporate all these components.

Hospital-based programs usually assign or utilize an on-call doula, who has not met the mother in advance and is not likely to follow up postpartum.  Some advocates of Medicaid doula programs utilize the community health worker (CHW) model, which seems to mirror the community-based doula (CBD) model but with important differences.  The American Public Health Association has defined CHWs as “frontline public health workers who are trusted members of and/or have an unusually close understanding of the community they serve.”  Yet, despite their widespread utilization in public health over the past several years, the conditions of their training, job opportunities, and even job description are idiosyncratic, and highly varied, and this “lack of CHW identity and standards of practice has led employers to contribute to the confusion about who CHWs are and what they do.” While the CHW and CBD models offer important job opportunities to members of under-resourced communities, their wages are often on the low side, with full time work paying $35,000 to $42,000 annually.  According to a health careers website, “CHWs often are hired to support a specific health initiative, which may depend on short-term funding sources. As a result, CHWs may have to move from job to job to obtain steady income.  This short-term categorical funding of health services is a challenge to the stability and sustainability of the CHW practice.”

In cost-benefit or cost effectiveness studies, it is critical to clearly specify the doula model of care on which the economic model is based.  It seems the doula model in the Minnesota study incorporates extensive pre and post partum contact and that there is an attempt to match doulas and clients in terms of race/ethnicity and language, but this is not always possible.   The study does not indicate what the doulas in the Minnesota program were paid, however, and that information was unavailable on their website.

Before we move to the topic of reimbursement, we want to note that the type of doula model is critical for assessing the benefits of doula-attended births.  The research clearly shows different outcomes for doulas who are affiliated with hospitals compared to those who work independently (Hodnett, 2012).  If a cost benefit model shows little gain in terms of outcomes, or yields a price point in the low hundreds of dollars, it may be that findings are affected by the assumptions embedded in the calculations.

More fundamentally, however, we argue that doula benefits cannot be captured solely through an economic model.  Neither should doulas be promoted as a primary means to reduce cesarean rates.  Both strategies (economic benefits and cesarean reduction) for promoting doulas have significant barrier.  In part two of this topic, running on Tuesday, April 2nd,  we discuss our concerns about reimbursement and program sustainability alongside a caution against relying too heavily on arguments that position the doula as primarily a money saver and cesarean reducer.

References

Baicker, K, Kasey S. Buckles, and Amitabh Chandra. Geographic Variation In The Appropriate Use Of Cesarean Delivery: Do higher usage rates reflect medically inappropriate use of this procedure? Health Affairs 25 (2006): w355–w367; doi: 10.1377/hlthaff.25.w355

Caceres, Isabel A., Mariana Arcaya, et al., Hospital Differences in Cesarean Deliveries in Massachusetts (US) 2004–2006: The Case against Case-Mix Artifact, PLoS ONE 8(3): e57817. doi:10.1371/journal.pone.0057817

Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, 2012, Issue 10. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub4.

Kozhimannil, Katy Backes, Michael R. Law, and Beth A. Virnig. Cesarean Delivery Rates Vary Tenfold Among US Hospitals; Reducing Variation May Address Quality And Cost Issues, Health Affairs 32, NO. 3 (2013): 527535; doi: 10.1377/hlthaff.2012.1030

Main EK, Morton CH, Hopkins D, Giuliani G, Melsop K and Gould JB. 2011.  Cesarean Deliveries, Outcomes, and Opportunities for Change in California: Toward a Public Agenda for Maternity Care Safety and Quality.  Palo Alto, CA: CMQCC.  (Available at http://www.cmqcc.org/white_paper)

Pilliod, Rachel; Leslie, Jennie; Tilden, Ellen; et al. Doula care in active labor: a cost benefit analysis. Abstract presented at 33rd Annual Meeting/Pregnancy Meeting of the Society-for-Maternal-Fetal-Medicine (SMFM), San Francisco, CA, February 11-16, 2013, American Journal of Obstetrics and Gynecology, Volume: 208 (1); S348-S349.

About the authors

 

Monica Basile

Monica Basile has been an active birth doula, childbirth educator, and midwifery advocate for 17 years, and holds a PhD in Gender, Women’s and Sexuality Studies. Her 2012 doctoral dissertation, Reproductive Justice and Childbirth Reform: Doulas as Agents of Social Change, is an examination of emerging trends in doula care through the lens of intersectional feminist theory and the reproductive justice movement.

 

Christine Morton

Christine Morton

Regular contributor Christine H. Morton, PhD, is a sociologist whose research on doulas is the topic of her forthcoming book, with Elayne Clift, Birth Ambassadors: Doulas and the Re-emergence of Woman-Supported Birth, which will be published by Praeclarus Press in Fall 2013. For more on Christine, please see Science & Sensibility’s Contributor page.

Cesarean Birth, Doula Care, Guest Posts, Healthy Birth Practices, Healthy Care Practices, Maternity Care, Research, Uncategorized , , , , ,

Preventing Cesarean Delivery – What is the Nurses’ Role?

January 8th, 2013 by avatar

By Christine H. Morton, PhD

 ”Experienced nurses practicing in a nurse-managed labor model have the potential to change patient outcomes.” 

Today, on Science & Sensibility, Christine Morton, PhD takes a look at a study examining the role of nurses in helping to achieve a vaginal birth for patients under their care.  No surprise from my point of view, my professional experience as a doula has demonstrated that L&D nurses play a critical role in the birth, and can really help a mother to achieve the outcome she desires.  Please enjoy Christine’s synopsis and interview with one of the study authors.- Sharon Muza, Community Manager

© 2013 Patti Ramos Photography

Readers of this blog are well aware of the 50% increase in cesarean delivery rates over the past decade, and are likely aware that the high US cesarean delivery rate is on the maternal quality and patient safety agendas for many organizations.  More attention will soon be focused on hospital rates (the Joint Commission recently expanded its performance measurement requirements such that as of January 1, 2014, all hospitals with more than 1100 annual births will be REQUIRED to report on the Perinatal Care Measure Set, which was the subject of a past blog post).  The Perinatal Care Measure Set includes a measure on the first birth cesarean among low risk women (nulliparous women who have cesareans at term, with singleton, vertex babies).  Furthermore, Centers for Medicare and Medicaid Services (CMS) is requiring that all states report rates of Elective Deliveries <39 Weeks as of 1/1/13 and it is likely that a similar requirement for the NTSV (Nulliparous Term Singleton Vertex) Cesarean measure is not far behind.

One indicator of this trend was the February 2012 symposium on preventing the first cesarean held jointly by National Institute of Child Health and Human Development (NICHD), the Society for Maternal Fetal Medicine (SMFM) and American Congress of Obstetricians and Gynecologists (ACOG.)  A comprehensive summary of the proceedings of that symposium was published in the November 2012 issue of Obstetrics and Gynecology, which is well worth reading but is available only with a subscription.  That same issue had a commentary on how to create a public agenda for reducing cesarean delivery, written by me and my California Maternal Quality Care Collaborative colleagues, which is free to all, thanks to our funder.

The attention to the detrimental health impact of our country’s cesarean rate for women and their babies is a good sign, coming as it does from powerful organizations with interests in providing care and paying for it.  Most of the focus on quality measurement reporting on cesarean delivery has been directed at hospital level (i.e., Leapfrog and The Joint Commission), though there is interest among payers and consumers for public reporting of provider-specific rates.  Virginia is one example where obstetric outcomes (cesarean, episiotomy) are publicly reported at the hospital and provider levels.  However, it is complicated to attribute outcome rates in obstetrics, which is increasingly a ‘team sport’ with multiple clinicians (physicians, midwives and nurses) involved in the care of a woman throughout her pregnancy and birth.

Yet, in all these domains (institutional, measurement, quality improvement), the role of nurses on cesarean delivery decisions and outcomes has been barely mentioned.  Neglecting the labor & delivery nurse’s role is unfortunately all too typical in public discourse around quality reporting, shared decision-making and improving outcomes in birth. I have become very interested in the nursing perspective as the more I learn about hospital birth, the more I realize that nurses are central to the management of labor & delivery units, and in measuring and reporting outcomes.  Thus, it was with great delight that I saw a new study, Intrapartum Nurses’ Perceived Influence on Delivery Mode Decisions and Outcomes in the January 2013 issue of JOGNN

Nurse-researchers Joyce K. Edmonds and Emily J. Jones conducted a semi-structured interview study with 13 nurses who were employed at a hospital with about 2000 births a year and overall cesarean rate of 36%.  These nurses work within a “nurse-managed labor model” which is characterized by a relatively autonomous nursing role, with intermittent communication with an off-site obstetrician.  Most nurses in the US practice within this type of model.  Nationally less than 10% of hospitals that do births are teaching hospitals, which have 24/7 access to physician consultation.  Other hospitals with 24/7 physicians on staff include HMOs like Kaiser Permanente, or those who have hospitalists.  In California, about half of all birthing facilities do not have an OB available onsite 24/7.

Shockingly few studies have looked at nurses’ role on the mode of delivery.   This is more striking when one considers the many specific nursing clinical practice responsibilities that may affect cesarean rates.  Nurses are largely responsible for assessing women during triage for admission, monitoring and assessing the health of mother/baby after hospital admission.  Nurses manage and administer oxytocin, assess and assist with labor pain, and are primary managers of second stage labor.  These practices occur within the administrative context of each hospital’s policies on admission in early labor, rates of interventions such as inductions (especially those for no medical indication), cesarean (especially those among the low risk population) and availability and rates of Vaginal Birth After Cesarean (VBAC).

Data for this study were drawn from semi-structured interviews with nurses who had a range of 10-40 years clinical experience in L&D.  Questions were specifically designed to elicit active practice and interaction with physicians (interactions with women were not addressed).  An example of a question asked of respondents, “Can you tell me about a time when you intervened to promote vaginal delivery or avoid a cesarean?”

The overarching theme in this study was how nurses described their efforts to ‘negotiate for more time’ during labor, to positively impact the likelihood of a vaginal delivery.   Negotiating for more time was defined in this study as “a form of nurse-physician interaction and an action taken to create the temporal space in which nursing interventions thought to affect delivery mode decisions operate”.    The authors found that nurses’ ability to negotiate for more time was based on their knowledge of labor and birth over their many years of experience, as well as their knowledge of individual physician practice patterns.  Furthermore, nurses’ awareness of physician and institutional-imposed time constraints was a key factor in negotiating for more time.

The important conclusion reached by the authors was that “experienced nurses practicing in a nurse-managed labor model have the potential to change patient outcomes.”  Despite the known limitations of this study – small sample of highly experienced nurses working at a single institution – I was intrigued and excited by the practice implications and the potential to develop quality improvement strategies for reducing cesarean deliveries that are specific to nurses.  So often, the labor & delivery nurses’ role is overlooked in this area and this study is an important contribution to our understanding of nurses’ influence in cesarean outcomes.   There is clearly more research and work to be done, and one of the authors, Joyce K. Edmonds, graciously responded to questions I had about the study and future directions for this research and quality improvement initiatives:

CHM: It was interesting that the range of experience represented in your study was 10-40 years – do you think your sample was more weighted toward the more experienced nurses?  Do you have any theories for why the lower end of the range was so high?  Were there nurses in that hospital with 2-3 years of experience?  Any thoughts about why they did or did not participate?

JKE:  Our sample was without doubt weighted to the experienced nurse, and we used the term experienced as a qualifier throughout the paper. This particular hospital staff was highly experienced, although, there were nurses with less than < 5 years experience. We think the sample was a self-selecting group of nurses who felt strongly about birth mode and the influence they had on birth mode decisions. Perhaps, less experienced nurses’ perspectives on birth mode were not as clearly developed as those who participated. It could also be that those who volunteered to participate were more supportive of promoting vaginal deliveries than those who did not participate. It could also be that scheduling conflicts with less experienced nurses prohibited them from participating.

Joyce Edmonds

CHM: I think the fluid nature of ‘time’ and the constraints on physician time bear further exploration.  In this regard, it would have been helpful have analyses of accounts where nurses felt they were ‘unsuccessful’ in buying more time for labor.  The counter-factual example can sometimes shed light on the dynamics – what didn’t work in this case? Do you have any unsuccessful stories in your data and/or did you analyze those?   It seemed as though all the nurses in your study DID negotiate for time, or at least provided you with accounts of when they did.  Were there any nurses who did NOT have a story to share about negotiating for more time?

JKE: All the nurses did talk about negotiating for time, which is the reason it emerged as the overarching theme.  Nurses did talk about not being able to negotiate for more time when cesareans were scheduled because the course of labor management was already established. They also seemed to have less influence when inductions were scheduled because again the labor management plan was established prior to their involvement in the care. I’d have to look back at the interviews with an eye toward specific counter-factual examples.

CHM: I also found it fascinating to read the quote that begins, “It almost feels like you’re working against the machine.” I was curious to know more about the justifications for that taboo of not being able to talk or confront the physician with the ‘agenda.’   In my interviews with OB nurses, I also came across this and think it is an important factor to explore further.  I imagine that nurses with less clinical experience are even less able to identify or recognize this ‘agenda’ and that comes with its own set of practice and policy issues for nursing training.  

JKE: I think the nurse physician relationship shapes the day-to-day work environment of the nurse. It is a long-term relationship relative to the nurse-patient relationship. It is likely that talking about or confronting a particular physician about the potential of an agenda could negatively disrupt the work environment, which is significantly related to nurses’ job satisfaction. Nurses want to be seen as team players and discussing the potential of physician ‘hidden agendas’ is like being a whistle blower. In addition to not wanting to disrupt the power balance, they may not want to invite scrutiny into their own practice patterns.

CHM: I was struck in particular by the account on page 5 of your paper that ends with the quote, “There are certainly situations where the baby needs to come out via C-section, but it is not as many as we do by any stretch.”  What situations?  What factors influence those decisions?  Where do nurses feel they lost power to bargain /buy more time?  

JKE: In this quote, the nurse is referring to medically indicated versus potentially unnecessary cesareans. I believe when nurses speak about cesareans they are not only focused on unplanned, intrapartum cesareans but also scheduled cesareans or scheduled inductions, which can result in a cesarean. It was clear from the interviews that nurses felt less invested in the decision-making process when women came in for scheduled cesareans or planned inductions. Nurses also spoke of how women are set up for failure during pregnancy—by way of unfavorable media messages, lack of unbiased childbirth education, and lack of risk reduction information from prenatal care providers.

CHM: I was intrigued that in this study you did not appear to ask about nurses’ views toward physiological birth (vaginal) and cesarean, or other indicators of their philosophy of birth.  The comment from the nurses who viewed themselves as a ‘dying breed’ begin to capture some sense of that – whether it is experience, knowledge, or philosophy of birth that unites them against this perceived different group of newer nurses.

JKE:  Great question, although it assumes that nurses’ personal philosophy of birth impacts their practice, which it likely does according to Reagan et al. In an attempt to keep the data focused on our main aim we did not ask nurses directly about their personal philosophy of birth. I believe the nurses in the study were united in their knowledge of childbirth–without the now pervasive assessment and intervention technology–knowledge borne out of experience.

CHM: How do you plan to follow up with this research and what are your future projects?    

JKE: Locally, we want to continue the discussion about the influence of nursing care and knowledge on cesarean rates that started with our interviews. Due to the sensitive nature of the topic and hospital policies, we have not had much success with direct follow-up where the study was conducted. However, we are very interested in presenting and discussing the results with other interested audiences. With regard to future projects, we are currently initiating a study to document the degree of nursing influence on cesarean rates at the level of the individual nurse, at an academic medical center and at a community hospital, building on the sentinel, yet dated, work of Radin et. al.  If the results are significant, we foresee the development of a quality improvement strategy directed at providing individual nurses routine (e.g., bi-monthly or quarterly) feedback on standard measures, such as risk adjusted primary cesarean section rates, cervical dilation at cesarean, and cesarean indication, based on the cohort of women in their care. Clearly, although not without great effort, such a strategy would need to be interdisciplinary and have adequate IT infrastructure and support. I also think nurses, as part of a team, should be involved in giving feedback about physician practice patterns in accordance with obstetric standards.

Are you an L&D nurse?  Can you comment on your experiences and how you feel your actions can influence the mode of birth.  If you are a doula, what has been your observation.  Doctor or midwife?  How do you view the role of the L&D nurse?  I look forward to a robust discussion. – SM

References

Edmonds, J. K. and Jones, E. J. (2013), Intrapartum Nurses’ Perceived Influence on Delivery Mode Decisions and Outcomes. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 42: 3–11. doi: 10.1111/j.1552-6909.2012.01422.x

Main, E.K., Morton, C.H, Hopkins, D., Giuliani, G.,  Melsop, K., and Gould, J.B (2012), Creating a Public Agenda for Maternity Safety and Quality in Cesarean Delivery, Obstetrics and Gynecology, November 2012; 120 (5):1194-1198.

Radin TG, Harmon JS, Hanson DA. Nurses’ Care During labor: Its Effect on the Cesarean Birth Rate of Healthy, Nulliparous Women. Birth. 1993;20(1):14-21.

Regan M, Liaschenko J. In the Mind of the Beholder Hypothesized Effect of Intrapartum Nurses’ Cognitive Frames of Childbirth Cesarean Section Rates. Qualitative Health Research. 2007;17(5):612-624.

Spong, C. Y. MD; Berghella, V. MD; Wenstrom, K. D. MD; Mercer, B. M. MD; Saade, G. R. MD (2012), Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop, Obstetrics & Gynecology, Volume 120(5), November 2012, p 1181–1193

ACOG, Cesarean Birth, Fetal Monitoring, Guest Posts, Maternal Quality Improvement, Maternity Care, Research, Transforming Maternity Care , , , , , , , , , , ,