Science & Sensibility

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

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

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 

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

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

Childbirth Connection has just released the Listening to Mothers III study today, and will holding a press conference shortly to share the results.  I plan to listen in and read the study thoroughly to see what the mothers have to say!  Look for a complete post early next week evaluating the current state of pregnancy care, labor, birth postpartum and breastfeeding and how it stacks up to Lamaze International’s Six Healthy Birth Practices.  In the meantime, consider joining the press conference, or reading this new study.  You can also check out the previous two LTM studies to see if things have changed.

Listening to Mothers I

Listening to Mothers II

New!  Listening to Mothers III

Sharon Muza Babies, Cesarean Birth, Childbirth Education, Depression, Healthcare Reform, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternal Quality Improvement, Maternity Care, Medical Interventions, New Research, Research Childbirth Connection, Healthy Birth Practices, Healthy Care Practices, lamaze, Listening to Mothers, research, Sharon Muza

This Thursday 1-2 pm ET, you are invited to speak with national health care leaders about findings from Listening To Mothers III — the third in a series of major national studies that examines women’s maternity experiences from before birth through the postpartum period. Among many other findings, the survey reveals the overuse of risky procedures and the fact that many women feel pressured to undergo them.

Listening to Mothers III is the third in a series of landmark, national studies that poll American women about their maternity experiences. This online press conference will highlight new findings about the American maternity experience, including:

• Exposure of women and babies to the overuse of risky procedures, and underuse of beneficial practices;
• Women’s experience of pressure to undergo consequential and costly procedures;
• How informed women are about the risks of those procedures;
• Failure of the health system to provide shared decision-making processes for major decisions;
• Trends across the three national Listening to Mothers surveys.

Leading national health experts representing clinical quality improvement, employer, and consumer perspectives will discuss major findings. The in-depth report describes many experiences from before pregnancy through pregnancy, childbirth, and the postpartum period. Harris Interactive conducted the survey of 2,400 women who gave birth from July 2011 through June 2012.

What

The American Birth Experience: Results From Listening to Mothers III

Who

Leah Binder, President & CEO, The Leapfrog Group

Maureen Corry, Executive Director, Childbirth Connection

Eugene Declercq, Assistant Dean, School of Public Health, Boston University

Carol Sakala, Director of Programs, Childbirth Connection

Thomas Westover, MD, Co-Chair, New Jersey Hospital Association Perinatal Safety Collaborative, Assistant Professor, Maternal & Fetal Medicine & OB&GYN, Robert Wood Johnson Medical and Cooper Medical School

When

Thursday, May 9, 2013; 1-2:00 pm EDT

Details

Please use this link to register for this online press conference at:

If interested in an advance copy of the report, contact Kat Song 

Sharon Muza Childbirth Education, Healthcare Reform, Maternal Quality Improvement, Maternity Care, Research, Webinars Carol Sakala, Childbirth Connection, Eugene Declercq, Leah Binder, Listening to Mothers surveys, Maureen Corry, Sharon Muza, Thomas Westover, Webinar

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

 

Last April, the ABIM Foundation, with Consumer Reports and other partners, drew national attention to overuse of ineffective and harmful practices across the health care system with their Choosing Wisely campaign. As part of the campaign, professional medical societies identified practices within their own specialties that patients should avoid or question carefully. Today, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP) have joined the campaign, drawing national attention to the overuse and misuse of induction of labor. ACOG and AAFP are telling women and their maternity care providers:

• Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age.

• Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable. 

(“Favorable” means the cervix is already thinned out and beginning to dilate, and the baby is settling into the pelvis. Another word for this is “ripe,” and doctors and midwives use a tool called the Bishop Score to give an objective measurement of ripeness. Although ACOG and AAFP do not define “favorable,” studies show cesarean risk is elevated with a Bishop Score of 8 or lower in a woman having her first birth and 6 or lower in women who have already given birth vaginally.)  

Much work has already been done to spread the first message. Although ACOG has long advised against early elective deliveries, a confluence of quality improvement programs and public awareness campaigns have made it increasingly difficult for providers to perform non-medically indicated inductions or c-sections before 39 weeks.

But as the public and the health care community have accepted the “39 weeks” directive, concern about unintended consequences has grown. Christine Morton, a researcher at the California Maternal Quality Care Collaborative and regular contributor to Science & Sensibility, sums up concerns shared by many, including Childbirth Connection:

It is possible that this measure may sensitize stakeholders to the wrong issue: timing of birth rather than the fact that it is generally best when labor begins on its own.  Additionally, is it possible that 39 weeks could become the new “ideal” gestational age, because it will be assumed that 39 completed weeks is the best time to be born?

The second Choosing Wisely statement aims to mitigate these unintended consequences. Inducing with an unripe cervix significantly increases the chance of a c-section and its many associated harms. Women considering induction for a non-medical reason deserve to know about these excess risks, and should question whether it is worth any non-medical benefits of elective delivery they perceive or expect. Lamaze International has spoken to the importance of letting labor begin on its own, as it is the first topic in the Six Healthy Birth Practices.

But will the new message lead women and care providers to think that delivery is indicated once a woman’s cervix is ripe? Through the Choosing Wisely campaign ACOG and AAFP have made powerful statements acknowledging that scheduled delivery is unwise if the baby or the woman might not be ready for birth. Although gestational age and the Bishop score are tools to estimate readiness for birth, the best indicator of readiness is still the spontaneous onset of labor at term, the culmination of an intricate interplay of hormonal signals between the fetus and the woman. Anytime we intervene with the timing of birth we have to weigh the potential benefits and harms of overriding that process in the context of the fully informed preferences and values of women.

This summer, our collaboration with the Informed Medical Decisions Foundation will culminate in the release of our first three Smart Decision Guides. These evidence-based, interactive decision support tools will help women learn the possible benefits and harms of scheduled delivery versus waiting for labor to start on its own and to weigh these based on what is most important to them. These tools help women choose wisely – to identify when an option is not appropriate or safe for them, and to thoughtfully weigh options when there are both pros and cons to consider.

Interested in learning more about shared decision making in maternity care? Sign up for a free webinar on March 13 sponsored by the Informed Medical Decisions Foundation to hear more about what clinicians, consumers, employers, and others thinking about the importance of maternity care shared decision making.

 

Amy Romano ACOG, Childbirth Education, Evidence Based Medicine, Guest Posts, Healthcare Reform, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternal Quality Improvement, Medical Interventions, Practice Guidelines, Pre-term Birth, Webinars AAFP, ABIM Foundation, ACOG, Amy Romano, avoiding labor induction, Childbirth Connection, Foundation for Informed Medical Decision Making, induction, informed Consent, labor induction, Webinars