April is Cesarean Awareness Month (CAM) and that presents a wonderful opportunity to share resources for cesarean prevention and recovery as well as Vaginal Birth after Cesarean (VBAC) support.

I am a co-leader of the Seattle chapter of the International Cesarean Awareness Network (ICAN) and teach classes in Seattle on both VBAC and Cesarean birth. (I call them VBAC YOUR Way and Cesarean YOUR Way)  I thought I might share my favorite resources on this topic and ask you to share with readers what you prefer to share with your students, patients and clients on this topic.

ACOG Committee Opinion on Cesarean Delivery on Maternal Request

ACOG Practice Bulletin on Vaginal Birth after Cesarean Delivery

Birthing Beautiful Ideas; VBAC Scare Tactics – Kristen Oganowski has a great series on scare tactics that women hoping to VBAC might face.  Good balance of heart and science.

Birthing Normally after A Cesarean or Two – Science & Sensibility three part interview with author and childbirth researcher Hélène Vadeboncoeur, done by Kimmelin Hull, former Science & Sensibility Community Manager

Cesareanrates.com - organized by Jill Arnold (of The Unnecessarean), provides a comprehensive breakdown of cesarean rates by state and hospital for the USA.

Childbirth Connection – Vaginal Birth or Repeat C Section: What You Need to Know

Evidence Based Birth – Rebecca Dekker is a Science & Sensibility contributor and writes a great fact based blog.  She frequently writes on the topic of cesareans.

Giving Birth With Confidence’s A Woman’s Guide to VBAC: Navigating the NIH VBAC Recommendations - Lamaze International’s parent blog hosts this wonderful resource written by Amy Romano and Kristen Oganowski

International Cesarean Awareness Network – international organization that works to prevent unneeded cesareans, promote cesarean recover and help women striving for a VBAC. Offers both online support as well as local chapter meetings.

A Natural Cesarean – A Woman Centered Technique. This video demonstrates and discusses ways that health care providers can make the cesarean more mother-baby centric, offering techniques that provide a great degree of satisfaction to the birthing woman.

NIH VBAC Consensus Statement – In 2010,  the National Institute of Health, a US government agency convened experts on VBAC and Cesareans and took testimony and heard discussions about best practice.  They summarized the results of this groundbreaking forum in this document.

The Truth about Cesareans – by Eugene Declercq.  Short 6 minute video on why the cesarean rate might be so high.

VBACFacts.com – A blog run by Jen Kamel, this website is a wealth of information and analysis on current studies and data as it relates to cesareans and VBAC birth.  Jen also runs a fabulous VBAC webinar that is available online.

The Well-Rounded Mama – blog run by occasional Science & Sensibility contributor Pamela Vireday, provides frequent information on VBACs, cesareans and large sized women, but the insight is valuable for all.

I am also aware of a free webinar, for birth professionals and providers as well as parents, “Family Centered Cesarean Birth” that you may want to consider signing up for.  Click here for more information. The webinar is presented live on Thursday, April 11th and then available after the presentation to watch as a recording.

What are your favorite go to resources to share with expectant parents?  Do you have a particular film clip that you like to show?  A book recommendation?  Do you have an effective method of presenting information on Cesareans and VBACs in your classes and with your clients and patients.  Let’s have a discussion in the comments section.  I welcome your thoughts.

Sharon Muza ACOG, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Maternal Quality Improvement, Maternity Care, Vaginal Birth After Cesarean (VBAC) CAM, Cesarean Awareness Month, cesareans, Childbirth Connection, Childbirth Education, Giving Birth With Confidence, ICAN, VBAC

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): 527–535; 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)

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

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.

Christine Morton Cesarean Birth, Doula Care, Guest Posts, Healthy Birth Practices, Healthy Care Practices, Maternity Care, Research, Uncategorized cesareans, Christine Morton PhD, doulas, Medicaid and maternity care, Monica Basile, research

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.

http://flic.kr/p/4vgkDo

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

This post is part of the forthcoming Grand Rounds Blog Carnival at e-patients.net. Contributors were asked to write a post “inspired by, supportive of, or critiquing an article in the Journal of Participatory Medicine.” I chose as my inspiration Gilles Frydman’s Patient-Driven Research: Rich Opportunities and Real Risks.

When I started this blog a year and a half ago, my primary motivation was my belief that childbearing women deserved, above nearly all else, care that was “evidence-based.”  As I prepare to hand over the reins to a new Community Manager, I want to say to my readers and to my successor: I was wrong. Evidence doesn’t hold all of the answers.

There are many reasons I have come to believe this, but there are two I want to write about today. The first is that the way research is currently funded, conducted, and disseminated, it simply doesn’t address many outcomes that women care about.  The second is that we all arrive at the point of healthcare decision making with a different constellation of factors that affect our choices. We may have different financial resources, health situations, hopes and plans for the future, tolerance to pain, tolerance to risk, prior experiences, and so on.

In other words, with the exception of practices that cause harm with no counterbalancing benefit at all or benefit with no risk of harm at all, there is no such thing as a good or bad healthcare decision. There’s only such a thing as a good or bad healthcare decision for a certain person. Evidence cannot guide practice without the other piece of the equation – the person to which the evidence is to be applied.

The more I think and write about these issues, the more I begin to wonder if there’s a better way of creating and disseminating knowledge than evidence-as-we-know-it. Underscoring this is a phenomenon that has unfolded over the past year right here on this blog.  In May 2009, Science & Sensibility contributor, Henci Goer, presented the findings of her review of the literature on cesarean surgery and a little-known complication: new onset endometriosis.  She wrote:

So why is this reasonably common serious adverse effect of cesarean surgery something you have never heard of?…Cesarean wound endometriosis would never turn up in a randomized controlled trial (RCT). Even if the problem made it onto the researchers’ radar, the trial would have to be extremely large and follow-up impractically long to detect it. Where RCTs are considered the only evidence worth having, outcomes that cannot be picked up on by RCTs functionally don’t exist.

It was kind of a technical post about the limitations of the hierarchy of evidence, using cesareans and endometriosis as the example. But an awesome thing happened. Women started finding the blog post, and sharing their own experiences with sometimes terribly debilitating endometriosis after cesarean surgery. It started with a well known cesarean activist confirming that the association between cesareans and endometriosis was “not news” to her – through her work she had met many cesarean mothers dealing with cesarean scar endometriosis. Then women who had experienced it themselves shared their insights, and asked questions, and others answered, and they got interested in eachother’s experiences and a community formed.

I highly recommend you read the original post and all of the comments, but you can also get a flavor by looking at this excerpt of the presentation I will give next week at the Digital Pharma East Conference in Philadelphia.

Amy Romano Uncategorized cesareans, endometriosis, Participatory Medicine, research