Childbirth Connection’s Listening to Mothers Initiative just released the Listening to Mothers III (LTMIII) results late last week.  For the third time in the past 11 years, this organization has gone out and queried women on a variety of topics related to pregnancy, birth, postpartum and breastfeeding.  They have questioned thousands of women to accurately assess how the actual experiences hold up against what we know to be best practice and evidence based maternity care. I have relied on the past two survey results frequently during my professional career in maternal health and am thrilled to have the new survey results now available.

I thought it would be interesting to run some of the LTMIII results through the filter of Lamaze International’s Healthy Birth Practices.  The Healthy Birth Practices were most recently updated by Lamaze in 2009, and consist of six simple, evidence based practices that greatly contribute to keeping birth safe and healthy for mothers and babies. Each easy to remember practice has its own short video that parents can watch that talks about that specific care practice and safe alternatives.  Additionally, each Healthy Birth Practice has an accompanying Practice Paper with all the citations for the peer-reviewed, gold standard research that supports that particular practice.

Some useful links and information upfront

Listening to Mothers I

Listening to Mothers II

New!  Listening to Mothers III

Survey Questionnaire 

Major Study Findings

Interesting facts before we get started

While the LTMIII survey only looked at 2400 women,  please be aware that one percentage point change in results would represent approximately 40,000 mother/baby pairs, based on a US birth rate of around 4 million births a year.

35% of women had not intended to be pregnant at the time of this pregnancy, including 5% who stated that they had never intended to become pregnant at all.

52% of those planning to get pregnant did have a preconception meeting with a health care provider, (which could be viewed as a wonderful time to determine if this health care provider might be a good match for their maternity care needs.)

85% of women based their maternity care provider on insurance requirements or restrictions.

78% of women worked with an obstetrician (this has dropped over the course of the three studies.)

9% of women worked with a family practice doctor

8% of women worked with a midwife who practiced in a hospital, as one of the requirements of the study was that the mother was having a hospital birth.

The average length of time spent actually in a prenatal appointment, with health care provider or their nurse was 32 minutes.  (OB: 31 min, Family Practice/MW 35 min.) I was pleasantly surprised that it was this long, I expected less.

Over the course of the three studies, the cesarean rate of study participants went up, (24% to 31%), the VBAC rate went down and labor augmentation was cut in half from 53% to 26%.  More women used nitrous oxide for pain relief during their labor in the most recent study (6%, up from 2% in the first study)

30% of the women chose not to ask a question that they wanted answered at least once during their prenatal appointments.

Overall, women were unable to make choices in line with the Healthy Birth Practices, and did not know that deviating from these practices was not evidence based and resulted in increased interventions.

Let’s see how things stack up

Healthy Birth Practice 1: Let Labor Begin on Its Own

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Research shows that in the absence of medical issues, mothers, babies and labors do best when labor starts spontaneously on its own. The final few weeks of pregnancy are vital for the putting the “finishing touches” on baby and helping to make the transition to life on the outside as smooth as possible.

41% of all women surveyed attempted a medical (involved a care provider) induction and of those induced, 74% were successful, (the woman went into labor) for an overall medically induced labor rate of 31%

Reasons why women were induced

• 44% were full term
• 19% wanted to get the pregnancy over
• 11% wanted to control the timing of birth
• 16% were induced for a large baby (note: the average weight of these babies induced for suspected macrosomia was 7 lbs 15 ounces.)
• 18% were induced for being “overdue” (note: the average gestational age of those babies induced for being overdue was 39.9 weeks)
• 18% were induced for a maternal health problem

Interestingly, 26% of women had their due date changed toward the end of their pregnancy; 66% of those were given an earlier due date and 34% were given a later one.

68% of women had a late third trimester ultrasound to estimate fetal weight

Healthy Birth Practice 2: Walk, Move Around and Change Positions in Labor

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Women with the ability to move and change positions are able to use this movement to help cope with the pain of labor.  Access to water in the form of a shower or tub can be a valuable coping technique.  Having access to intermittent fetal monitoring or telemetry movements can facilitate movement and promote labor progress for many women.

Only 43% of women walked around after being admitted to the hospital in labor

40% of women used position changes and movement for non-pharmacological pain relief

Healthy Birth Practice 3: Bring a Loved One, Friend or Doula for Continuous Support

Many women will thrive in labor if surrounded by a caring, supportive birth team.  Adding a skilled birth doula to the team has been shown in many studies to improve the outcome of birth and reduce interventions and cesareans.  While more and more birthing women are aware of a doula, many are still not having one in attendance at their birth.

99% of mothers had at least one support person present, (most often this was a partner, then a family member or friend)

6% women used a doula

75% of mothers were aware of what a doula does and of those 75% who knew, 27% would have liked a doula supporting them at their birth.

Healthy Birth Practice 4: Avoid Interventions That are Not Medically Necessary 

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Although research shows that routine and unnecessary interference in the natural process of labor and birth is not likely to be beneficial—and may indeed be harmful—most U.S. births today are intervention-intensive.

98% of the women had at least one ultrasound during pregnancy and 70% had three or more over the course of their pregnancy

68% of women had a late third trimester ultrasound to estimate fetal weight.

83% of women had some type of pain medication

67% had an epidural or spinal, and 92% of those who did reported this to be “very helpful” or “somewhat helpful.”

62% of women surveyed had an IV during labor

51% of women had one or more vaginal exams in labor. (I was surprised at this, I would have suspected higher)

47% had bladder (Foley) catheters

31% of women had a labor augmented with pitocin

50% of birthing women had their labor either induced or augmented with pitocin

20% had their membranes ruptured artificially (AROM)  after labor began

36% of women had their labor started or augmented by AROM

1% of women requested and had a maternal request cesarean for non-medical reasons

40% of women drank fluids during their labor

21% of the women ate during labor

85% of women birthing vaginally did so without forceps or vacuum

87% of women responding had at least one of the five big interventions (attempted labor induction, epidural, pitocin augmentation, assisted delivery with vacuum or forceps or cesarean.

60% of the women had at least two of the above five interventions listed above

Healthy Birth Practice 5: Avoid Giving Birth on Your Back and Follow Your Body’s Urges to Push

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Women push most effectively when permitted to push in the positions that feel best for them.  Allowing the baby to “labor down” even after reaching full dilation until moms feel the urge to push can help women to push a baby out quicker and under their own steam.  Pushing in positions that allow the pelvis to open as much as possible and making space by getting the sacrum out of the way can help promote descent during pushing.

68% of women surveyed birthed on their backs

23% birthed in a semi-sitting position

8% gave birth in a position off their back, either side-lying, squat or hands & knees

Healthy Birth Practice 6: Keep Mother and Baby Together; Its Best for Mother, Baby and Breastfeeding

Experts now recommend that right after birth, a healthy newborn should be placed skin-to-skin on the mother’s abdomen or chest and should be dried and covered with warm blankets. Any care that needs to be done immediately after birth can be done with your baby skin-to-skin on your chest.  This early time together promotes breastfeeding, helps stabilize the newborn’s temperature and blood sugar and also offers a unique chance for high levels of natural oxytocin that promote bonding and help with immediate postpartum bleeding.

47% of mothers responding had their baby in their arms within the first hour

40% of mother-baby pairs were not skin to skin when they were first held

33% of all babies were with hospital staff the first hour

60% of mother-baby pairs roomed in together

18% of babies spent time in the NICU

25% of babies spent their days with mom and their nights in the nursery

49% of mothers who stated that they intended to exclusively breastfeed were given formula samples or offers.

29% of newborns were supplemented with water or formula during the hospital stay

Summary

After reading through the LTMIII report, I found myself discouraged by the current results.  It was clear that women were making choices and/or being informed by their care providers to choose practices that have long been known to create a cascade of interventions, do not improve outcomes for mothers or babies and are not evidence based.  For the majority of the women who responded to this survey, the Healthy Care Practices are still a pipe dream and not a reality in their hospitals and with their current providers.  I know change comes slowly, and it can take years for protocols to catch up with the evidence but frankly, after reading the summary of how things did or did not change over the course of the three studies I was still shocked.

Have you had a chance to go through the study yet?  What were your thoughts?  Anything surprise you?  Can you share a bright point that you noticed?

Join us later this week as I examine what the LTMIII survey had to say about childbirth education and how women are receiving pregnancy and birth information and from where.

Sharon Muza Breastfeeding, Cesarean Birth, Childbirth Education, Doula Care, Epidural Analgesia, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, Lamaze International, Maternal Quality Improvement, Maternity Care, Medical Interventions, Midwifery, New Research, Newborns, News about Pregnancy, Research, Transforming Maternity Care, Uncategorized Childbirth Connection, Healthy Birth Practices, Lamaze International, Listening to Mothers III, Listening to Mothers surveys, research, Sharon Muza

By Geradine Simkins, CNM, MSN, Executive Director of Midwives Alliance of North America

This week, the American Academy of Pediatrics released a policy statement on home birth. While the statement affirmed “the right of women to make a medically informed decision about delivery”, many advocates expressed concerns. The statement failed to recognize Certified Professional Midwives, the providers most likely to attend a home birth in the United States. In this response, the Midwives Alliance of North America helps families, providers, and policy makers understand the critical role CPMs play in safe, healthy birth options. – Sharon Muza, Community Manager, Science & Sensibility

High-quality out-of-hospital newborn and postpartum care is standard for midwives

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The Midwives Alliance of North America welcomes the primary concept communicated in the American Academy of Pediatrics’ April 24, 2013, policy statement entitled “Planned Home Birth.” As should be expected, AAP reminds its practitioners that newborn infants—regardless of the setting in which they are born—deserve an equal and unbiased, high-quality standard of care. The Midwives Alliance joins with AAP in affirming the need for a collaborative and integrated maternity care system that addresses the needs of all mothers and infants, regardless of the provider type or birth setting a woman chooses.

We are disappointed, however, in AAP’s decision to align with the American Congress of Obstetrics and Gynecologists’ policy on home birth. Serving the needs of the growing number of families choosing to birth at home, Certified Professional Midwives attend the majority of intended home births in the U.S., when a skilled attendant is present, making them the primary care providers for newborns in the home setting.

Certified Professional Midwives are skilled maternity care providers

AAP’s itemized recommendations for infant and newborn care, contained in their policy statement, are standard practice for credentialed midwives. In that respect, we find much with which we agree. These standard newborn exams, screens, and preventative care practices are wholly part of a credentialed midwife’s scope of practice, and further endorsed by individual state health departments. We also note that as AAP Neonatal Resuscitation Program certificate holders (required for certification and recertification), credentialed midwives follow guidelines laid out in AAP’s recommendations, and typically surpass those standard recommendations by having at least two NRP- and CPR-trained attendants at out-of-hospital births.

In fact, the AAP’s guidelines for the care of infants intentionally born at home parallel those standards practiced by trained midwives in all birth settings. The practices listed—such as working medical equipment, emergency plans of transfer, thorough newborn exams, and so forth—are professional standards exhibited and documented by credentialed midwives, regardless of the place of birth.

The AAP policy statement, however, did not recognize or acknowledge Certified Professional Midwives (CPM), indicating that AAP may not have a thorough understanding of the training, skills, knowledge, and abilities of this country’s primary maternity care provider for infants born out of the hospital. The Certified Professional Midwife is the only national midwifery credential that requires practitioners to be trained specifically to provide prenatal, intrapartum, and postnatal care in out-of-hospital settings. CPMs are knowledgeable, expert and independent midwifery practitioners who have met the standards for certification set by the North American Registry of Midwives (NARM). NARM is accredited by the National Commission for Certifying Agencies (NCCA) to issue the professional credential of Certified Professional Midwife, which is the same agency that accredits the American Midwifery Certification Board to issue the professional credentials of Certified-Nurse Midwife, and Certified Midwife.  

Midwives are the providers of choice for out-of-hospital births, whether they occur at home or in freestanding birth centers. Offered since 1994, the CPM is currently the basis for licensure in 27 states while 11 additional states are actively seeking CPM licensure. In fact, one in nine newly certified midwives in the U.S. are Certified Professional Midwives.  

The AAP policy statement endorses birth center maternity care, which is another area in which we are in agreement. Recent numbers from the American Association of Birth Centers (AABC) indicate that a significant proportion of accredited birth centers are owned and operated by Certified Professional Midwives. A January 2013 study, The National Birth Center Study II , conducted by AABC and published in the Journal of Midwifery & Women’s Health, the official journal of the American College of Nurse-Midwives (ACNM), highlights the benefits for women who seek care at midwife-led birth centers. Findings also reinforce longstanding evidence that providers at midwife-led birth centers provide safe and effective health care for women during pregnancy, labor, birth, and the postpartum period.  

Midwives provide high-quality care that meets both national and international guidelines 

In highlighting the ethic of high-quality care for all infants across the spectrum—regardless of the site of birth—it should be noted that Certified Professional Midwives provide care intentionally similar to that of nurse-midwives and physicians. Yet we also know that CPMs are able to offer additional and valued care in terms of frequency of home visits and intense monitoring of newborns in their homes in the first weeks of life—a benefit not normally conferred to women and babies who have experienced hospital births.

This high-quality midwifery care includes routine newborn APGAR assessments, comprehensive head-to-toe physical examinations, measurements of length, head, abdomen and birth weight, monitoring vital signs including thermoregulation, assessment of respiratory sounds and patterns, assessments of cardiac sounds and peripheral pulses, assessment of gestational age and physical maturity, neuromuscular assessments, and assistance with initiation and ongoing assessment of breastfeeding. All findings are recorded in patient records and shared with mothers, per professional standards.

In addition, CPMs provide newborns with Vitamin K treatment, antibiotic eye ointment, umbilical cord care, metabolic newborn screening, glucose and bilirubin testing as indicated, and either perform Otoacoustic Emissions (OAE) hearing screens or refer to area audiologists. Midwives in a number of states are moving toward, or already offering, pulse-oximetry screening for Critical Congenital Heart Defects (CCHD) per AAP guidelines, in advance of many hospital systems. In the rare cases when newborns require consultation or referral, infants are transferred to the tertiary care system, and pediatricians where available, for active management.

Not only do Certified Professional Midwives and Certified Nurse-Midwives who attend home births provide the level of care outlined by the AAP, they provide it in a personalized, woman-centered, family-centered, culturally competent, and individualized manner that is qualitatively different from the customary assembly-line postpartum care commonly experienced in U.S. hospitals.

For example, in a home birth setting, the midwife typically conducts the initial newborn exam in the presence of the mother and family, which does not disrupt the crucial process of mother-infant bonding and breastfeeding, and is focused on being instructive to the family. Midwives provide holistic care to the mother-baby dyad in concordance with World Health Organization’s Baby-Friendly best practices.

As a way of illustrating important differences in care practices, we can point to the recent Breastfeeding Report Card issued by the CDC (2012) that indicates only six percent of U.S. hospitals are offering care that aligns with the international best practices outlined by Healthy People 2020.   By contrast in a 2005 study, 95% of babies born at home under the care of Certified Professional Midwives were exclusively breastfeeding at six weeks of age (Johnson & Daviss, 2005). This is just one area where midwives are well-trained, skilled, and uniquely positioned to help families succeed.

An opportunity for collaboration and integrated care 

Physician conversations about home birth and midwife-led birth will be better informed and more useful to maternity care consumers if AAP is able to become more cognizant of important changes in the landscape of U.S. midwifery. 

The release of the AAP policy statement on care of newborns born at home is an opportunity to reinforce the need for professional and seamless collaboration with members of community health care teams. We view this statement’s release as an opportunity to align best practices for all parties who care for and support families choosing home birth.

The Midwives Alliance stands ready to work with other pediatric and maternity care providers to establish best practices in the postpartum period to not merely provide the basic level of care in the first hours, days and weeks of life for the newborn as outlined in the latest AAP statement, but to elevate that standard to include support for breastfeeding and the personal attention that can prevent infant death and improve maternal and child health.  Babies born in all settings deserve this kind of care.

About Geradine Simkins

Geradine Simkins, CNM, MSN is an activist, midwife and author. She began as a direct-entry home birth midwife in 1976 and became a nurse-midwife twenty years later. For over thirty years she has provided health care for women, infants and families in a variety of settings, including attendance at births in the home, a freestanding birth center, and hospitals. Geradine’s work with migrant farmworkers and American Indian tribes focuses on addressing health care disparities and engendering a more equitable maternity care system for all women and infants.  Geradine is currently the Executive Director of Midwives Alliance of North America, a professional organization that promotes excellence in midwifery and is dedicated to unifying and strengthening the profession, thereby increasing access to quality health care and improving outcomes for women, babies and their families. She is the editor of the recently published book entitled Into These Hands: Wisdom from Midwives, an anthology of the life stories of 25 remarkable women who have dedicated their lives and careers to the path of midwifery and social change.  More info about Geraldine Simkins can be found here.

Sharon Muza ACOG, American Academy of Pediatrics, Babies, Delayed Cord Clamping, Home Birth, informed Consent, Maternity Care, Midwifery, Transforming Maternity Care AAP, ACNM, ACOG, CNM, CPM, Geraldine Simkins, Home Birth, MANA, Midwifery Care, Midwives Alliance of North America, newborn

by Wendy Gordon, CPM, LM, MPH, MANA Division of Research, Assistant Professor, Bastyr University Dept of Midwifery

Today, occasional contributor, midwife and researcher Wendy Gordon, LM, CPM, MPH, Midwives Alliance Division of Research, shares some insights into some of the fascinating discussions that took place at last week’s Institute of Medicine’s workshop focusing on birth place settings.  From all reports from the many people in attendance, this workshop will hopefully help move the research and discussion on the topic of birth place settings forward and create opportunities for more families to chose to birth where they feel most comfortable and safe. – Sharon Muza, Community Manager, Science & Sensibility

___________________________

Hannah Russell-Davis nurses her newborn son
©photo by Michael Davis http://getprivatepractice.com

Last week marked an historic opportunity for maternity care providers to regroup and become inspired to move our professions forward together in all birth settings.  The two-day event, hosted by the prestigious Institute of Medicine (IOM) and sponsored by the W.K. Kellogg Foundation, focused on “Research Issues in the Assessment of Birth Settings” and brought together the greatest minds in research and practice in all three birth settings: home, birth center and hospital.  Issues of tremendous importance to consumers, providers and researchers in the birth community were discussed in a collegial and inspiring manner… marred only by one presentation that stirred a bit of controversy.

Historic Workshop Can Positively Impact Future Research 

Similar to the first IOM conference on this topic over 30 years ago, the intent of last week’s gathering was to discuss the research regarding the effect of place of birth on maternal and infant outcomes. Invited speakers included researchers, public health professionals, midwives, nurses, pediatricians and obstetricians.  In structured mini-sessions, panelists shared their expertise on the following topics:

• the historical and current picture of who is giving birth in the different settings;
• definitions of “low-risk” versus “high-risk”;
•  what the best research says about safety in various settings; 
• education, regulation and management of different types of providers;
•  methods of collection and use of data regarding maternity care and birth in various settings; 
•  cost and value differences between settings and reimbursement issues; and 
• the rich and varied perspectives of providers in the three childbirth settings.

Members of the audience were just as impressive as the panelists themselves when, at the end of each panel, the microphone was opened and significant content was added through their questions and comments.  

A lot of ground was covered over the course of the two days, and there were several takeaways that had particular impact for the midwifery community. The home birth rate in the U.S. was predicted to continue its rise with the next release of CDC data, reaching about 31,500 births nationwide in 2010. The MANA Stats web-based system was touted by attendees as the best data collection system for home birth outcomes.  Birth certificate data was shown to still have major problems in its ability to accurately capture intended place of birth and other reliability issues, despite improvements in recent years.  A Medicaid study from Washington State demonstrated vast cost savings with midwifery care and birth at home and in birth centers.  The workshop report will have tremendous potential to impact contemporary birth policy and research agendas.

Lack of Consumer Representation and Little Discussion of Health Disparities

There was no consumer representation on workshop panels, nor was there a panel addressing disparities in maternal and infant outcomes, which seems to have been a grave oversight of the organizers.  In the 30 years since the last IOM workshop on birth settings, overall infant mortality has been reduced from 11.5/1000 to 6.7/1000, but the black-white gap has actually increased. In 1982, nearly twice as many babies born to black mothers than white mothers died before their first birthday (19.6 infant deaths per 1000 births vs 10.1/1000; National Center for Health Statistics, 1986). Recent mortality figures show that disparity to be even wider (12.67/1000 vs 5.52/1000; Mathews & MacDorman, 2012).

Hannah Russell-Davis holds her son Jack, moments after his birth at their home in Charlottesville, VA. Jack was Hannah’s third home birth.
© photo by Michael Davis http://getprivatepractice.com

With childbirth in home and birth center settings gaining momentum nationally and at the state level, research to support policy in this direction is more important than ever. The best research has shown for decades, and continues to show, that for women with low-risk pregnancies, birth that is planned to occur in the home and birth center settings with a skilled midwife is no more risky than birth in the hospital and results in far fewer interventions, lower cost and higher satisfaction (Vedam et al, 2012).  Hopefully, the breadth of this research can finally start to expand beyond proving that it is safe.

‘Recrudescence’ Revisited

Despite this body of literature, there are still some physicians who persist in torturing the data in an attempt to frame their personal opinions as “science.”  It was disappointing, although perhaps not surprising, to see Dr. Frank Chervenak use his time on the provider panel to do just that. The American Journal of Obstetrics and Gynecology recently published an article authored by Dr. Chervenak regarding the “recrudescence of homebirth” (Chervenak et al, 2013), and perhaps it was the controversy stirred by that article that prompted the conference organizers to invite him to speak on this panel. The panel members included Dr. Chervenak as a hospital-based provider, Karen Pelote, CNM with the birth center provider perspective, and Brynne Potter, CPM as a homebirth provider.  Both Pelote and Potter appeared to have taken seriously the purpose of their panel representation and showcased the data on our client-centered models of care, with photos and quotes from women regarding the care they received and their experiences in the birth center and home settings.   

In stark contrast, Chervenak used his 12 minutes (out of 10) that were to be devoted to the hospital provider perspective for, instead, a rapid-fire display of “back-of-the-envelope” bar graphs attempting to show home/hospital differences in 5-minute Apgar scores using raw data drawn from birth certificates.  Since it appears that some doctors are having a hard time getting their “research” on this topic published in peer-reviewed journals, they are presenting their data in settings that do not require peer-review, such as last year’s annual conference of the Society of Maternal-Fetal Medicine (the study still hasn’t been published) and this IOM workshop.  Meanwhile, there are several well-designed studies published in peer-reviewed journals that show that there is no difference in 5-minute Apgar scores between home and hospital settings (Hutton et al, 2009; Janssen et al, 2009; van der Kooy et al, 2011).

Apgar Distribution Hospital vs. Home © Dr. Frank Chervenak 2013

That a professional invited to contribute to a high-level workshop about research would present an un-peer-reviewed thesis based on unreliable data, lacking any statistical analysis, is… well, let’s just say “puzzling.”  Exploiting the concept of “relative risk,” Chervenak sliced and diced the data in more ways than were thought possible to suggest that babies born at home were more likely to have a low 5-minute Apgar score than babies born in the hospital.

“Home Births Should Not Happen”

Chervenak’s non-reviewed data did find a higher rate of Apgar scores of “10” in the home setting versus “9” in the hospital setting. His point? Not that, clinically speaking, there is no difference between a score of 9 vs. 10 (they’re both good). Not that babies might possibly be doing better due to normal physiologic labor and undisturbed birth and that we should explore this further. Instead, he suggested – at this historic setting – that midwives lie about Apgar scores because “no one is watching.”  After a day and a half of earnest, interprofessional collegiality, Chervenak wrapped up his extended presentation with his unabashed opinion: “Home births should not happen.”

Epidemiologists in the room were quick to step to the microphone for the open discussion part of the panel, pointing out the many flaws in Chervenak’s presentation.  Marian MacDorman, Ph.D., senior statistician and researcher for the CDC’s National Center for Health Statistics, reminded everyone that birth certificate data is notoriously unreliable for neonatal seizures and low Apgar scores; this has been shown time and again for decades and had indeed been discussed earlier in this very workshop.  More importantly, McDorman stated that data from birth certificates cannot be used to make comparisons between settings or providers.  Her point, which deserves some elaboration here, is that there is a very important distinction between “absolute risk” and “relative risk,” and different types of data are better than others depending on what you are trying to describe. 

Absolute vs. Relative Risk

Let’s say that a person’s odds of getting struck by lightning in a heavily populated city are one in a million, and those same odds in a rural area are five in a million. These odds are called your “absolute risk” of being struck by lightning. Another way to look at this is to say that a person’s odds of being struck by lightning are five times higher in a rural area than in a densely-populated area; this is the “relative risk” of a lightning strike in one area over another.

A common approach of anti-homebirth activists is to use the “relative risk” approach and ignore the absolute risk, because it’s much more dramatic and sensationalistic to suggest that the risk of something is “double!” or “triple!” that of something else, even though the absolute risk of those things are very low and may not even be statistically significantly different from each other.  Of course, any infant or maternal mortality is a tragedy.  But one of the key points raised at the IOM workshop was the idea that, in our efforts to identify “safety” with one indicator (mortality) or “truly low-risk” pregnancies by their absence of a particular factor (breech position, for example), we often fail to quantify all of the impacts of the various settings in ways that are meaningful to the women who experience the outcomes, such as the fact that in many areas, the only option for breech delivery is cesarean or the only way a VBAC can happen is at home, attended or not.  As Brynne Potter asked last week: when we limit access to certain birth settings because of risk, are we examining the risks of the alternative?

To return to the lightning analogy, it would be deeply disingenuous for a person to say that you shouldn’t move to a rural area simply because your risk of being struck by lightning is five times higher, without mentioning that at worst, that risk is five in a million. The ethics of this are further called into question when the person suggesting this is a trusted care provider, and is even worse when that person withholds all information about your option to move to a rural area — disregarding all of your other reasons for wanting to doing so — because they have decided that the risk of being hit by lightning there is too high for you.

Clarifying the Validity of Birth Certificate Data

Dr. MacDorman clarified how to interpret the data for anyone who might have been misled by Dr. Chervenak’s slides. She pointed out that regarding low Apgar scores, “the absolute risk is low; that’s all you can say with vital data.”  It doesn’t happen very often in any setting; most studies on homebirth around the world report the occurrence of low Apgar scores (<7) in the range of 1%, and very low scores (<4) are even rarer.  Studies have shown that the more rare an occurrence is, the less likely it is to be captured accurately on the birth certificate (Northam & Knapp, 2006).

Overall, the Midwives Alliance Division of Research (DOR) and other organizations working to improve maternity care are pleased with the near-consensus viewpoint by the majority of the disciplines represented at this workshop: that normal physiologic birth is best for mother and baby and should be the goal of all settings and practitioners.  We are looking forward to the future research inspired by this event.  We believe that there is potential for there to be more movement in the next 30 years than there was since the last IOM workshop on this topic 30 years ago, particularly because of the availability of high-quality datasets such as MANA Stats (primarily planned home births) and the American Association of Birth Centers’ Uniform Data Set (primarily planned birth center births).  As the stewards of the largest database on midwifery care and outcomes of normal physiologic birth in the home setting, the DOR encourages researchers to apply for the MANA Stats data to conduct this important research (application information at mana.org/DOR). 

References:

Chervenak FA, McCullough LB, Brent RL, Levene MI, Arabin B. 2013. Planned home birth: The professional responsibility response. AJOG 208(1):31-38.

Hutton EK, Reitsma AH, Kaufman K. 2009. Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: A retrospective cohort study. BIRTH 36(3):180-189.

Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee SK. 2009. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ, doi:10.1503/cmaj.081869.

Mathews, TJ & MacDorman, M. 2012. National Vital Statistics Reports: Infant mortality statistics from the 2008 period linked birth/ infant death data set. Available online at http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_05.pdf. 

National Center for Health Statistics. 1986. Vital Statistics of the United States, 1982, Vol II: Mortality, Part A. DHHS Pub. No. (PHS) 86-1122. Public Health Service: Washington. U.S. Government Printing Office.

Northam S, Knapp TR. 2006. The reliability and validity of birth certificates. J Obstet Gynecol Neonatal Nurs 35(1):3-12.

van der Kooy J, Poeran J, de Graaf JP, Birnie E, Denktas S, Steegers EAP, Bonsel GJ. 2011. Planned home compared with planned hospital births in the Netherlands: Intrapartum and early neonatal death in low-risk pregnancies. Obstet Gynecol 118:1037-46.

Vedam S, Schummers L, Stoll K, Fulton C. 2012. Home Birth: An Annotated Guide to the Literature.  Available online at http://mana.org/DOR/research-resources/.

About Wendy Gordon

Sharon Muza Guest Posts, Healthcare Reform, Home Birth, Maternal Mortality, Maternal Mortality Rate, Maternal Quality Improvement, Maternity Care, Midwifery, Newborns, Transforming Maternity Care Apgar, birth centers, birth setting, Brynne Potter, Chervenak, Frank Chervenak, guest post, homebirth, Institute of Medicine, Karen Pelote, MANA, Marian MacDorman, midwives, Wendy Gordon

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.

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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.

 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

Amy Romano Childbirth Education, Evidence Based Medicine, Guest Posts, Healthcare Reform, Maternal Quality Improvement, Maternity Care, Patient Advocacy, Research, Research for Advocacy, Transforming Maternity Care Amy Romano, cesarean, cesarean section, Childbirth Connection, Childbirth Education, guest post, interventions, maternity care quality, maternity care systems, research, Transforming Maternity Care

The past few weeks have been big ones for 95 year old, New York based Childbirth Connection.  Since I started working in the birth world, I have always appreciated the information and publications from Childbirth Connection, not only to advance my own professional knowledge, but as a reliable, evidence based resource for my clients and students as well as the doula and CBE trainees that I work with.  Today on Science & Sensibility, I would like to share the three new Childbirth Connection reports that you may find useful.

1. Vaginal or Cesarean Birth: What Is at Stake for Women and Babies?

Maternity care stakeholders (consumers, health care professionals, insurers, state Medicaid agencies and others) are increasingly concerned about the immediate, short-term and long-term impact that the country’s high cesarean delivery rate is having on mothers and children.  A Maternity Action Team was convened by a collaboration of national organizations. The purpose of this team was to address unsafe or inappropriate maternity care.  The team’s overall goal of reducing the cesarean rate in low-risk women to 15% or less.

The report created by Childbirth Connection focuses on the adverse consequences of cesarean birth on both women and children.  Included in the report is also information on potential adverse outcomes of labor and vaginal delivery.  The following questions are answered:

• What physical effects may occur in women more frequently with
• cesarean delivery?
• What physical effects may occur in babies more frequently with cesarean delivery?
• What role may cesarean delivery play in the development of childhood chronic disease?
• What complications are unique to cesarean delivery?
• What complications are unique to vaginal birth?
• What are potential psychosocial consequences of cesareans?
• What are potential effects of cesareans on women in future
• pregnancies and births?
• What are potential effects of a scarred uterus on future babies?
• Does cesarean delivery protect against sexual, bowel, urinary, or
• pelvic floor dysfunction?
• Does cesarean delivery protect against injuries to babies?

The results of the evidence reviewed allowed the following conclusion to be reached the authors:

The findings of this report overwhelmingly support striving for vaginal birth in general and spontaneous vaginal birth in particular in the absence of a compelling reason to do otherwise. To improve both the quality and value of maternity care in the United States and promote the optimal health of women and infants, clinicians, policy makers, and other stakeholders should prioritize identifying and promulgating practices that promote safe, spontaneous vaginal birth and reduce the use of cesarean delivery.

2. The Cost of Having a Baby in the United States

Childbirth Connection in collaboration with Catalyst for Payment Reform and the Center for Healthcare Quality and Payment Reform recently released a report on the financial impact our current maternity care system has on both private payers and government funded care.  Maureen Corry, Childbirth Connection Executive Director shared that if the US were able to reduce the cesarean rate down to 15%, (from the current 33%), national spending on maternity care would go down by $5 billion dollars.

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There are facilities and providers who are effective at providing quality care and excellent outcomes while also demonstrating fiscal responsibility.  Yet other teams have costs that are drastically higher with outcomes that leave a lot of room for improvement.  What is the difference?  The report also noted that there were large variations in costs based on different geographic regions in the US.  Does the opportunity for practicing evidence based maternity medicine (resulting in a lower cesarean rate) provide the path for a reduction in maternity costs?  We learn in this report that “high-quality, high-value care” is an attainable goal and one that will benefit mothers and babies everywhere in our country.

3. Maternity Care and Liability: Pressing Problems, Substantive Solutions

If everyone is in agreement that the cesarean rate in the United States is too high, and that health care costs, including maternity care costs are skyrocketing, without an improvement in outcomes, then the next stop has to be examining the risks that health care providers and facilities assume and are held liable for when a less than optimum outcome occurs for mother or baby.  In the newest Childbirth Connection report released this week, Childbirth Connection takes a look at 25 different possible liability reforms and runs each scenario through the same filter, to find out which ones;

• promote safe, high-quality maternity care that is consistent with best evidence and minimizes avoidable harm
• minimize maternity professionals’ liability-associated fear and unhappiness
• avoid incentives for defensive maternity practice
• foster access to high-value liability insurance policies for all maternity caregivers without restriction or surcharge for care supported by best evidence
• implement effective measures to address immediate concerns when women and newborns sustain injury, and provide rapid, fair, efficient compensation
• assist families with responsibility for costly care of infants or women with long-term disabilities in a timely manner and with minimal legal expense
• minimize the costs associated with the liability system

Additionally, along with this fascinating report, is a set of 10 printable fact sheets that can be shared with health care administrators,  consumers and health care providers to facilitate understanding and discussion on the topic of liability reform.

Childbirth Connection Executive Director Recognized

Finally, I would like to share that Maureen P. Corry, MPH, the executive director of Childbirth Connection was recently named by Forbes Magazine as one of the “13 To Watch in 2013: The Unsung Heroes Changing Health Care Forever.”  Maureen is recognized as ”a strong policy advocate, but also a thoughtful and purposeful researcher who brings all sides together in very constructive ways, which is why many of the issues she has raised over the years are now on the top of the policy agenda in Washington.”

The reports that Childbirth Connection has recently released clearly show that this organization, under the leadership of Maureen, is making significant and timely contributions to improving pregnancy and birth outcomes for mother and babies.  I am grateful for this organization, and would like to congratulate Maureen on behalf of myself, this blog and Lamaze International for a job well done!

Next week, Amy Romano, former Science & Sensibility community manager, and current Associate Director of Programs for Childbirth Connection will share how educators and advocates can use these reports in their classroom and with their clients and patients.  Have you taken the time to read any of the reports listed here today?  Are you already using them?  Please share your thoughts in our comments section.

Sharon Muza Awards, Babies, Cesarean Birth, Evidence Based Medicine, Healthcare Reform, Maternal Quality Improvement, Maternity Care, Transforming Maternity Care Catalyst for Payment Reform, Center for Healthcare Quality and Payment Reform, cesareans, Childbirth Connection, liability, maternity care systems, maternity costs, Maureen Corry, Transforming Maternity Care