Science & Sensibility

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

Research by our UBC affiliated Child and Family Research Institute has revealed that the increase in Caesarean section rates across Canada may be largely due to the attitudes and beliefs of the obstetricians and other providers towards birth technology and Caesarean sections. 81 per cent of obstetricians 40 years or younger were women versus 40 per cent over 40 years of age. The attitudes and beliefs vary by age of practitioner. In contrast to their older counterparts, younger obstetricians were significantly more likely to favour a hospital based medically managed birth and the routine use of epidural analgesia in normal births. They were less likely to support vaginal birth after Caesarean section or to appreciate the importance of mothers’ role in their own birth. They also appeared to be more “fearful” of the consequences of vaginal birth, particularly in relation to urinary incontinence and sexual problems and more likely to select Caesarean section for their own births. Older obstetricians, the majority of which are male, were more supportive of a woman-centered model of care, more positive about birth plans, and were more likely to see vaginal birth as more empowering to the mother than Caesarean section. (1) The finding that younger obstetricians, who are mostly women, appeared to have less appreciation of the role of a woman in her own birth than older usually male obstetricians is counterintuitive and requires further study. These attitudes appear related to experiences in training rather than to gender, as younger male obstetricians have attitudes similar to their female counterparts. Without addressing the educational system, attitudes will be difficult to change.

Another study by our group (2) found that clients of midwives, were more supportive of women’s roles in their own deliveries and less likely to support the use of technology, compared to physicians’ patients. It should be noted that regardless of the type of care provider, many women reported inadequate knowledge of common procedures. Women’s lack of knowledge about procedures such as epidural analgesia, Caesarean section and episiotomy, raise concerns about prenatal education and prenatal care. Attendance at prenatal education classes is decreasing in all regions of Canada and most pregnant women indicated they use health care providers, books and the internet as their main sources of prenatal information. (2) When combined with evidence on the nature of obstetrical power and control, and research showing that many providers are not evidence-based in their views, (3) this suggests that even a woman with strong values and beliefs could find it challenging to assert her choices in the professionally controlled process of birth. Women, especially first time mothers, who do not have evidence-based knowledge, are likely to be particularly sensitive to negative attitudes toward birth procedures and processes, from providers and other sources.

A third study from our group found that family doctors who do not provide intrapartum care have more negative attitudes toward birth and are less evidence-based about what is going on in the delivery suite. (4) Since this group provides more than 50% of the antenatal care in Canada, efforts to keep them up to date need to be implemented, lest they transmit their negative attitudes to women before transfer for birth care to other providers.

Finally as Caesarean section rates are steeply rising, with BC having the highest rates in Canada, and for the first time, maternal mortality and morbidity rates are increasing in the US and Canada due to overuse of Caesarean sections, (2)it is time for the public to realize that Caesarean section, while life-saving when needed, is not as safe a vaginal birth (5-7), and it is not just another way to have a baby.

And lest you think that this is a Canadian problem, the educational and training systems for medical students and obstetrical and family practice residents is the same both sides of the border. Educational, rather than health care models, trumps evidence. We are teaching directly and indirectly that childbirth is just an opportunity for things to go wrong. Medical students, obstetrical and family practice residents rarely see normal birth, and they are not exposed to midwives in hospital or at home births. It is going to take a revolution driven by women to change this, as practitioners are not going to change very soon. To the barricades!

Posted by:  Michael Klein, MD

[Editor's note:  As an example of the debate Dr. Klein introduces here, proposing that Caesarean birth is "not just another way to have a baby," check out this article in today's edition of The Sun, questioning whether or not Caesarean birth is "normal."]

References

1.         Klein M, Liston R, Fraser W, Baradaran N, Hearps S, Tomkinson J, et al. The attitudes of the new generation of Canadian obstetricians: how do they differ from their predecessors. Birth. 2011.

2.         Klein M, Kaczorowsk J, Hearps S, Tomkinson J, Baradaran N, Hall W, et al. Birth technology and maternal roles in birth: knowledge and attitudes of Canadian women approaching childbirth for the first time. JOGC. 2011(June):598-608.

3.         Klein M, Kaczorowski J, Hall W, Fraser W, Liston R, Eftekhary S, et al. The Attitudes of Canadian Maternity Care Practitioners Towards Labour and Birth: Many Differences But Important Similarities. Journal of Obstetrics & Gynaecology Canada: JOGC. 2009;31(9 ):827-40.

4.         Klein M, Kaczorowski J, Tomkinson J, Hearps S, Baradaran N, Brant R. Family physicians who provide intrapartum care and those that do not: very different ways of viewing childbirth. Can Fam Phys. 2011 57(4):e139-e47.

5.         SOGC. Joint Policy Statement on Normal Childbirth. JOGC. 2008;221(December):1163-5.

6.         SOGC. C-sections on demand—: SOGC’s position. [Press Release].  Society of Obstetricians and GynecologistsMar 10, 2004.

7.         Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS, et al. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. Cmaj. 2007 February 13, 2007;176(4):455-60.

Michael Klein MD Medical Interventions, New Research, Uncategorized attitudes about birth of Canadian obstetricians, beliefs about childbirth, caesarean section, cesarean section, labor & birth medical interventions, Michael Klein MD