24h-payday

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

January 31st, 2013 by avatar

http://flic.kr/p/v7Wse

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

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

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

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

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

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

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

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

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

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

Cara Osborne, SD, MSN, CNM

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

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

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

Systems obstacles:

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

Business obstacles:

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

Professional obstacles: 

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

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

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

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

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

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

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

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

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

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

  1. avatar
    Becky
    January 31st, 2013 at 20:28 | #1

    You can’t compare the 6% cesarean rate to the overall national rate, though, because the 6% is only for those women who had not already been risked out of birth center care by the start of labor. That is a significantly lower risk group than the population of the United States as a whole, and moreover by choosing to use a birth center they were likely to be highly motivated to achieve a natural birth and avoid cesarean.

  2. avatar
    Emily
    February 1st, 2013 at 07:26 | #2

    I loved my two birth center births, and strongly believe that making birth centers available and convenient to the women who want this kind of birth would reduce our national c-section rate, reduce costs, and lead to better results. However, when taken on by either government beaurocrats or insurance company beaurocrats, I do worry that there will be pressure on women who qualify as low risk, etc, especially on Medicaid, to birth in a birth center rather than the hospital. And I think pressuring women to birth without pain medications (even if well intentioned) is a big problem. I hope the beaurocrats can be enlisted to make birth center birth feasible for those who want it, and that as it becomes normalized more women may want it. But there shouldn’t be pressure to birth without pain meds and beaurocratic initiatives can so easily turn into that or feel that way to subsets of women.

  3. February 1st, 2013 at 08:52 | #3

    This study is exciting news! I would love to have the cesarean rate in first-time moms and in women with prior births. The study only reports cesarean rates overall. Thanks!

  4. avatar
    Ariann
    February 1st, 2013 at 15:28 | #4

    Becky, I think we’re a pretty long way off from worrying about women being coerced into birthing in birth centers. If we look at similar models in other countries, though, it seems pretty clear that people are capable of making choices about where to birth when they have plenty of options. Of course, those places also have true socialized medicine! The other issue is that we lack the full gamut of pain drugs that are available in places where home birth and birth center birth are more common. Why don’t we have “gas and air” in the US? These things are effective, patient-controlled, and can be used even at home. We shouldn’t have to decide between no pain relief and a full epidural when there are plenty of options in between that work in out-of-hospital settings.

  5. avatar
    Liz
    February 2nd, 2013 at 07:33 | #5

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

    This message is in direct conflict with the language of the JMWH article stating that “the findings [of this study] may not be generalizable to all birth centers.”

    The takeaway for expectant parents should be much more cautious. An overwhelming majority of freestanding birth centers in the US are not CABC accredited and do not abide by AABC standards. To generalize the results of this study as applicable to “birth centers” without clarifying this very important distinction is incredibly misleading.

  6. avatar
    Jen
    February 2nd, 2013 at 19:16 | #6

    It’s already happening Liz. I’ve seen meme’s drawn up that are saying, hey, birth in a birth center! It’s safer! It’s happy! It’s great! But none of these “feel good” messages are distinguishing between an accredited birth center licensed and staffed by CNM’s and a lay midwife turning her barn into a “birth center”. Here in Michigan, you can open a “free standing birth center” and not have any licensing at all required. No insurance, no oversight, nada. THAT is not safe. There’s a huge world of difference between someone buying an old Victorian house and converting it to a “birth center” because they have a few extra bucks and call themselves a direct entry midwife (no training required!) and an accredited center that has oversight, insurance, resc. equip. and trained personnel to run it.

  7. February 4th, 2013 at 06:03 | #7

    It warms my heart to see there are champions such as Cara devoted to invoking a major climate change in the field of maternity care in North America. The science tells us it can be done safely and common sense shows us it is a more economical form of maternity care.

  8. February 7th, 2013 at 12:02 | #8

    I love this. My births were through our freestanding birthcenter, The Midwife Center for Birth and Women’s Health. Hopefully, we will see more birthcenters in our future.

  1. January 31st, 2013 at 12:33 | #1
  2. February 6th, 2013 at 06:50 | #2
  3. February 7th, 2013 at 13:40 | #3
  4. February 12th, 2013 at 07:19 | #4
  5. February 17th, 2013 at 05:29 | #5
  6. May 13th, 2013 at 17:14 | #6
  7. September 25th, 2013 at 22:47 | #7