Building the Case for Transparency in Maternity Care: My Annotated Bibliography
I’ve given a talk called, “Transparency in Maternity Care: Bringing Birth Out of the Dark to Improve Quality” a number of times at conferences and as a webinar. (I will give it again as a webinar in September for Lamaze, so make sure you’re signed up to get e-News updates if you’re interested.) The case for transparency in maternity care is compelling. Maternity care is unique among health care specialties because women have a long interval of time (9 months!) to decide where to go for their labor and birth care, so it’s reasonable to assume that publicly available quality information might help women make informed choices and drive quality improvement. (Compare that with the decision making process for someone having acute chest pain – just call 911 and go to the closest hospital!) Also, most consumers of maternity care are healthy, so unlike surgical or chronic care specialties, good outcomes are not measured in survival or duration of hospital admission (although these are of course very important), but rather how well the system protects, promotes, and optimizes the health of its beneficiaries – women and babies.
Unfortunately, we have very few studies that actually measure the effectiveness of transparency programs in maternity care. So for my talk I built my case using the evidence that supports six points that, taken together, demonstrate an urgent need for better transparency.
- Intervention rates and outcomes vary widely across providers and facilities
- Most of this variation has to do with factors unrelated to the woman’s health status
- Excess use of interventions leads to excess injury and cost
- Public awareness of quality indicators results in improved quality
- Intervention rates can be lowered without compromising safety
- Mother-friendliness is a measure of quality
Not long ago, Nasima Pfaffl from The Birth Survey asked me to post the bibliography from my talk on The Grassroots Grapevine, a site where maternity care advocates can connect and work together on maternity care improvement initiatives, including transparency. I’m posting that list again here, along with a brief note on the key findings of each article. Click on the extended post to see the bibliography.
The Birth Survey just reached a major milestone. Consumer survey results rating health care providers and birth facilities are now available at TheBirthSurvey.com. Watch this space for more about transparency and The Birth Survey in the weeks to come.
Bibliography from Transparency in Maternity Care: Bringing Birth Out of the Dark to Improve Quality
Albers, L. L., Sedler, K. D., Bedrick, E. J., Teaf, D., & Peralta, P. (2005). Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: A randomized trial. Journal of Midwifery & Women’s Health, 50(5), 365-372.
*** This study reports that the university hospital where the study took place has a 1% episiotomy rate across all providers. The hospital adheres to best practice in the management of second stage.
Allcock, C., Griffiths, A., & Penketh, R. (2008). The effects of the attending obstetrician’s anxiety trait and the corresponding obstetric intervention rates. Journal of Obstetrics and Gynaecology, 28(4), 390-393.
*** Doctors with more anxious personalities were more likely to perform unplanned c-sections in labor.
Baicker, K., Buckles, K. S., & Chandra, A. (2006). Geographic variation in the appropriate use of cesarean delivery. Health Affairs, 25(5), w355-67. doi:10.1377/hlthaff.25.w355
***Large study that showed that over 40% of the variation in c-section risk remained unexplained after controlling for medical/obstetrical factors, socioeconomic factors, malpractice environment, etc.
Clark, S. L., Xu, W., Porter, T. F., & Love, D. (1998). Institutional influences on the primary cesarean section rate in utah, 1992 to 1995. American Journal of Obstetrics and Gynecology, 179(4), 841-845.
***Hospitals that have NICUs and take care of high-risk women actually tend to have lower, not higher, c-section rates than community hospitals.
Griffiths, A. N., Avasarala, S., & Wiener, J. J. (2005). A prospective observational study of emergency caesarean section rates and the effect of the labour ward experience. Journal of Obstetrics and Gynaecology, 25(7), 666-668.
*** The individual physician is an independent risk factor for “emergency” c-section.
Glantz, J. C., & Guzick, D. S. (2004). Can differences in labor induction rates be explained by case mix? The Journal of Reproductive Medicine, 49(3), 175-181.
*** The answer is no, factors unrelated to the health of women/fetusus account for most of the variation. The study was conducted in upstate New York.
Goode, K. T., Weiss, P. M., Koller, C., Kimmel, S., & Hess, L. W. (2006). Episiotomy rates in private vs. resident service deliveries: A comparison. The Journal of Reproductive Medicine, 51(3), 190-192.
*** Women with private practice physicians were much more likely to have episotomies than women with OB residents.
Hibbard, J. H., Stockard, J., & Tusler, M. (2003). Does publicizing hospital performance stimulate quality improvement efforts? Health Affairs, 22(2), 84-94.
***This and the other two Hibbard articles (see below) report on the findings of the only large experiment of transparency in maternity care. Among the findings: Hospitals included in a public reporting program were more likely to undertake quality improvement efforts; These efforts were effective at improving quality; The effects were pronounced with maternity care (compared with hip/knee surgery, cardiac care); and the public paid attention to the report, used or planned to use the information, and recalled high and low performers correctly.
Hibbard, J. H., Stockard, J., & Tusler, M. (2005). Hospital performance reports: Impact on quality, market share, and reputation. Health Affairs, 24(4), 1150-1160.
***See above
Hibbard, J. H., Stockard, J., & Tusler, M. (2005). It isn’t just about choice: The potential of a public performance report to affect the public image of hospitals. Medical Care Research and Review, 62(3), 358-371.
***See above
Howden, N. L., Weber, A. M., & Meyn, L. A. (2004). Episiotomy use among residents and faculty compared with private practitioners. Obstetrics and Gynecology, 103(1), 114-118.
*** Women with private practice physicians were much more likely to have episotomies than women with OB residents.
Keeler, E. B., Park, R. E., Bell, R. M., Gifford, D. S., & Keesey, J. (1997). Adjusting cesarean delivery rates for case mix. Health Services Research, 32(4), 511-528.
***Adjusting for risk factors explained only 37% of the variation across hospitals in c-section rates. Adjustments did not significantly change the rank-order of hospitals with respect to other hospitals.
Luthy, D. A., Malmgren, J. A., & Zingheim, R. W. (2004). Cesarean delivery after elective induction in nulliparous women: The physician effect. American Journal of Obstetrics and Gynecology, 191(5), 1511-1515.
*** Concludes that the individual physician is an independent risk factor for c-section in induced labors.
Luthy, D. A., Malmgren, J. A., Zingheim, R. W., & Leininger, C. J. (2003). Physician contribution to a cesarean delivery risk model. American Journal of Obstetrics and Gynecology, 188(6), 1579-85.
*** Concludes that the individual physician is an independent risk factor for c-section in spontaneous labors.
Main, E. K., Moore, D., Farrell, B., Schimmel, L. D., Altman, R. J., Abrahams, C., et al. (2006). Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement. American Journal of Obstetrics and Gynecology, 194(6), 1644-51.
*** This is the large California study that shows that early labor admission and induction accounted for 60% of the variation across hospitals in c-sections in low-risk nulliparous women
Robinson, J. N., Norwitz, E. R., Cohen, A. P., & Lieberman, E. (2000). Predictors of episiotomy use at first spontaneous vaginal delivery. Obstetrics and Gynecology, 96(2), 214-218.
***Provider is an independent risk factor for episiotomy
Smith, D. P., Rogers, G., Dreyfus, A., Glasser, J., Rabson, B. G., & Derbyshire, L. (2000), Balancing accountability and improvement: A case study from Massachusetts, The Journal on Quality Improvement, 26(5), 299-312.
***Reports findings from a satisfaction survey of MA hospitals. More hospitals were “outliers” (i.e., performed either very well or very poorly) for maternity care than for cardiac or surgical care. In other words, there is a lot of variation in consumer satisfaction across maternity care settings.
Villar, J., Valladares, E., Wojdyla, D., Zavaleta, N., Carroli, G., Velazco, A., et al. (2006). Caesarean delivery rates and pregnancy outcomes: The 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet, 367(9525), 1819-1829.
***This is the large WHO study that shows that higher c-section rates correlate with higher maternal mortality, maternal morbidity, NICU admission, and perinatal mortality.
