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Book Review: Cut It Out: The C-Section Epidemic in America

November 7th, 2013 by avatar

By Christine Morton, PhD

What accounts for the dramatic rise in cesarean delivery in the United States over the past two decades? In her new book, Cut it Out: The C-Section Epidemic in America, sociologist Theresa Morris addresses this question by going to the source: she interviewed maternity clinicians (obstetricians, midwives and labor and delivery nurses) as well as women who had recently given birth. She examines guidelines from the major professional group of obstetricians and gynecologists. Morris goes beyond simply documenting the rise in C-sections, the health risks they pose to women and their babies, although she does that very well. To explain how we got to an epidemic of c-sections in the U.S, she applies an organizational lens, making it clear how “organizational changes constrain the decisions and behaviors of maternity providers and women.”

This way of looking at c-sections will be useful for childbirth educators, doulas and childbearing women because it goes one step farther than most research on c-sections, which demonstrate trends and possible associations between clinical causal factors, or characteristics of women. It is also different from advocacy around c-sections that largely frames the issue as one of individual agency or rights (“women must advocate and prepare for vaginal birth,” or “women have right to informed choice”). And although we have some research on how organizational structure impacts c-section rates, such as teaching hospitals and health maintenance organizations (HMOS), absent from these studies are explanations as to why this is so. Morris argues that the research on c-section epidemic is missing an “understanding that is rooted in the experience of maternity care providers and pregnant women” (p. 21).

While most childbirth educators and doulas have a good understanding of pregnant women’s experience, Morris takes the reader into the perspectives of a range of maternity clinicians, arguing that organizational policies and procedures constrain their actions. We can’t blame individual clinicians for the high c-section rate, she argues, nor can we hold them responsible for reducing it. Social constraints on individual behavior are very powerful and need to be understood if they are to be changed. As many sociologists have observed, deviance from social norms has real consequences for individuals. Imagine yourself riding in an elevator filled with people you don’t know, with your back to the doors. It’s not easy to do. Morris notes, “Maternity providers may face professional consequences for deviance—for example, being informally scolded by colleagues, formally reprimanded by a supervisor, or having a malpractice insurer deny coverage in a case of a bad outcome” (p. 22). By talking to maternity clinicians about how they see the problems, and what they do about them, Morris is able to show how obstetricians are also caught in systems not of their own making.

“Hospitals are organizations with fixed rules to guide individual behavior” (p. 22) and this applies to all individuals within organizations. Morris has provided a nuanced and rich picture of what she calls the “organizational paradox, in which the increasing rates of c-section do not protect the health of women or babies or make birth safer or good outcomes more likely,” and argues that if we look at the c-section rate as the result of how health care organizations respond to their legal, political and economic environments, we can understand, and hopefully change, the system.

I found one of the most compelling sections of her argument in her discussion of the patient safety movement and its emphasis on standardized protocols, language and peer review. Until very recently, c-section rates were not considered part of the patient safety movement in obstetrics. Morris shows that when a hospital embarks on patient safety initiatives, with the goal of malpractice claims due to a bad baby outcome, these initiatives often result in an increase, or at best, no change in c-section rates.

Morris also reviews how doctors frame risks of VBAC vs. repeat c-section in ways that foreground the statistically rare risk of uterine rupture (indeed, the more dangerous rupture vs. the more common, but still rare, occurrence of uterine dehiscence). The more common risk to women of repeat c-section is often not included. Here we see how possible risks for the baby (and to the physician in the event of a bad outcome) are prioritized over risks to women’s health. Organization pressures influence how these risks are defined and described to women, says Morris.

“Any effort to resolve the c-section epidemic requires organizational solutions” (p. 153).

The stakes are high, and unless there is concerted and coordinated effort to reduce the c-section rate through organizational and policy change, we are unlikely to see a downward trend. Morris concludes, however, by listing what individual women and maternity clinicians can do to help solve the c-section epidemic. For women, this includes learning about and advocating for evidence-based care, with the assistance of independent childbirth educators and birth doulas, and finding maternity physicians and hospitals with low rates of c-section. Maternity providers, she notes, may find it helpful to be up front with women about the risks of childbirth, and that even with best of care, sometimes things go wrong. The policy and social changes Morris recommends are quite sweeping and it’s not clear where political will for these will come, but happily, there are some efforts being made on the organizational solutions she proposes. In particular reporting of c-sections as a quality measure will be required by The Joint Commission as of January 2014 for hospitals with more than 1100 births/year. A recent publication on Preventing the first cesarean delivery summarized the evidence from a joint workshop held by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists.

In this YouTube video, author Theresa Morris shares why she wrote Cut It Out: The C-Section Epidemic in America. 

Here are several more videos in the video series, where Theresa talks about the cesarean epidemic

This book is highly recommended for all childbirth educators, doulas and other maternity care professionals who wish to help pregnant women understand how the organization in which they are giving birth will likely shape both they, and their maternity clinicians’ actions. Yet, it also holds out the promise of hopeful change, especially when it is clear that many of these efforts are underway. With states seeking ways to drive down costs and with support from national government action focusing on maternal health, more pressure from payers, women and maternity care advocates, we can look forward to reducing c-sections and turning the tide of this epidemic. Let’s discuss what we can do to bring down the c-section rate.

About Christine Morton

Christine Morton

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. Christine is also a new member of Lamaze International’s Board of Directors. For more on Christine, please see Science & Sensibility’s Contributor page.

Babies, Book Reviews, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, Maternal Quality Improvement, Maternity Care , , , , , , ,

Medicaid Coverage for Doula Care: Re-Examining the Arguments through a Reproductive Justice Lens, Part One

March 28th, 2013 by avatar

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): 527535; 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)

Pilliod, Rachel; Leslie, Jennie; Tilden, Ellen; et al. Doula care in active labor: a cost benefit analysis. Abstract presented at 33rd Annual Meeting/Pregnancy Meeting of the Society-for-Maternal-Fetal-Medicine (SMFM), San Francisco, CA, February 11-16, 2013, American Journal of Obstetrics and Gynecology, Volume: 208 (1); S348-S349.

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

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.

Cesarean Birth, Doula Care, Guest Posts, Healthy Birth Practices, Healthy Care Practices, Maternity Care, Research, Uncategorized , , , , ,

Preventing Cesarean Delivery – What is the Nurses’ Role?

January 8th, 2013 by avatar

By Christine H. Morton, PhD

 ”Experienced nurses practicing in a nurse-managed labor model have the potential to change patient outcomes.” 

Today, on Science & Sensibility, Christine Morton, PhD takes a look at a study examining the role of nurses in helping to achieve a vaginal birth for patients under their care.  No surprise from my point of view, my professional experience as a doula has demonstrated that L&D nurses play a critical role in the birth, and can really help a mother to achieve the outcome she desires.  Please enjoy Christine’s synopsis and interview with one of the study authors.- Sharon Muza, Community Manager

© 2013 Patti Ramos Photography

Readers of this blog are well aware of the 50% increase in cesarean delivery rates over the past decade, and are likely aware that the high US cesarean delivery rate is on the maternal quality and patient safety agendas for many organizations.  More attention will soon be focused on hospital rates (the Joint Commission recently expanded its performance measurement requirements such that as of January 1, 2014, all hospitals with more than 1100 annual births will be REQUIRED to report on the Perinatal Care Measure Set, which was the subject of a past blog post).  The Perinatal Care Measure Set includes a measure on the first birth cesarean among low risk women (nulliparous women who have cesareans at term, with singleton, vertex babies).  Furthermore, Centers for Medicare and Medicaid Services (CMS) is requiring that all states report rates of Elective Deliveries <39 Weeks as of 1/1/13 and it is likely that a similar requirement for the NTSV (Nulliparous Term Singleton Vertex) Cesarean measure is not far behind.

One indicator of this trend was the February 2012 symposium on preventing the first cesarean held jointly by National Institute of Child Health and Human Development (NICHD), the Society for Maternal Fetal Medicine (SMFM) and American Congress of Obstetricians and Gynecologists (ACOG.)  A comprehensive summary of the proceedings of that symposium was published in the November 2012 issue of Obstetrics and Gynecology, which is well worth reading but is available only with a subscription.  That same issue had a commentary on how to create a public agenda for reducing cesarean delivery, written by me and my California Maternal Quality Care Collaborative colleagues, which is free to all, thanks to our funder.

The attention to the detrimental health impact of our country’s cesarean rate for women and their babies is a good sign, coming as it does from powerful organizations with interests in providing care and paying for it.  Most of the focus on quality measurement reporting on cesarean delivery has been directed at hospital level (i.e., Leapfrog and The Joint Commission), though there is interest among payers and consumers for public reporting of provider-specific rates.  Virginia is one example where obstetric outcomes (cesarean, episiotomy) are publicly reported at the hospital and provider levels.  However, it is complicated to attribute outcome rates in obstetrics, which is increasingly a ‘team sport’ with multiple clinicians (physicians, midwives and nurses) involved in the care of a woman throughout her pregnancy and birth.

Yet, in all these domains (institutional, measurement, quality improvement), the role of nurses on cesarean delivery decisions and outcomes has been barely mentioned.  Neglecting the labor & delivery nurse’s role is unfortunately all too typical in public discourse around quality reporting, shared decision-making and improving outcomes in birth. I have become very interested in the nursing perspective as the more I learn about hospital birth, the more I realize that nurses are central to the management of labor & delivery units, and in measuring and reporting outcomes.  Thus, it was with great delight that I saw a new study, Intrapartum Nurses’ Perceived Influence on Delivery Mode Decisions and Outcomes in the January 2013 issue of JOGNN

Nurse-researchers Joyce K. Edmonds and Emily J. Jones conducted a semi-structured interview study with 13 nurses who were employed at a hospital with about 2000 births a year and overall cesarean rate of 36%.  These nurses work within a “nurse-managed labor model” which is characterized by a relatively autonomous nursing role, with intermittent communication with an off-site obstetrician.  Most nurses in the US practice within this type of model.  Nationally less than 10% of hospitals that do births are teaching hospitals, which have 24/7 access to physician consultation.  Other hospitals with 24/7 physicians on staff include HMOs like Kaiser Permanente, or those who have hospitalists.  In California, about half of all birthing facilities do not have an OB available onsite 24/7.

Shockingly few studies have looked at nurses’ role on the mode of delivery.   This is more striking when one considers the many specific nursing clinical practice responsibilities that may affect cesarean rates.  Nurses are largely responsible for assessing women during triage for admission, monitoring and assessing the health of mother/baby after hospital admission.  Nurses manage and administer oxytocin, assess and assist with labor pain, and are primary managers of second stage labor.  These practices occur within the administrative context of each hospital’s policies on admission in early labor, rates of interventions such as inductions (especially those for no medical indication), cesarean (especially those among the low risk population) and availability and rates of Vaginal Birth After Cesarean (VBAC).

Data for this study were drawn from semi-structured interviews with nurses who had a range of 10-40 years clinical experience in L&D.  Questions were specifically designed to elicit active practice and interaction with physicians (interactions with women were not addressed).  An example of a question asked of respondents, “Can you tell me about a time when you intervened to promote vaginal delivery or avoid a cesarean?”

The overarching theme in this study was how nurses described their efforts to ‘negotiate for more time’ during labor, to positively impact the likelihood of a vaginal delivery.   Negotiating for more time was defined in this study as “a form of nurse-physician interaction and an action taken to create the temporal space in which nursing interventions thought to affect delivery mode decisions operate”.    The authors found that nurses’ ability to negotiate for more time was based on their knowledge of labor and birth over their many years of experience, as well as their knowledge of individual physician practice patterns.  Furthermore, nurses’ awareness of physician and institutional-imposed time constraints was a key factor in negotiating for more time.

The important conclusion reached by the authors was that “experienced nurses practicing in a nurse-managed labor model have the potential to change patient outcomes.”  Despite the known limitations of this study – small sample of highly experienced nurses working at a single institution – I was intrigued and excited by the practice implications and the potential to develop quality improvement strategies for reducing cesarean deliveries that are specific to nurses.  So often, the labor & delivery nurses’ role is overlooked in this area and this study is an important contribution to our understanding of nurses’ influence in cesarean outcomes.   There is clearly more research and work to be done, and one of the authors, Joyce K. Edmonds, graciously responded to questions I had about the study and future directions for this research and quality improvement initiatives:

CHM: It was interesting that the range of experience represented in your study was 10-40 years – do you think your sample was more weighted toward the more experienced nurses?  Do you have any theories for why the lower end of the range was so high?  Were there nurses in that hospital with 2-3 years of experience?  Any thoughts about why they did or did not participate?

JKE:  Our sample was without doubt weighted to the experienced nurse, and we used the term experienced as a qualifier throughout the paper. This particular hospital staff was highly experienced, although, there were nurses with less than < 5 years experience. We think the sample was a self-selecting group of nurses who felt strongly about birth mode and the influence they had on birth mode decisions. Perhaps, less experienced nurses’ perspectives on birth mode were not as clearly developed as those who participated. It could also be that those who volunteered to participate were more supportive of promoting vaginal deliveries than those who did not participate. It could also be that scheduling conflicts with less experienced nurses prohibited them from participating.

Joyce Edmonds

CHM: I think the fluid nature of ‘time’ and the constraints on physician time bear further exploration.  In this regard, it would have been helpful have analyses of accounts where nurses felt they were ‘unsuccessful’ in buying more time for labor.  The counter-factual example can sometimes shed light on the dynamics – what didn’t work in this case? Do you have any unsuccessful stories in your data and/or did you analyze those?   It seemed as though all the nurses in your study DID negotiate for time, or at least provided you with accounts of when they did.  Were there any nurses who did NOT have a story to share about negotiating for more time?

JKE: All the nurses did talk about negotiating for time, which is the reason it emerged as the overarching theme.  Nurses did talk about not being able to negotiate for more time when cesareans were scheduled because the course of labor management was already established. They also seemed to have less influence when inductions were scheduled because again the labor management plan was established prior to their involvement in the care. I’d have to look back at the interviews with an eye toward specific counter-factual examples.

CHM: I also found it fascinating to read the quote that begins, “It almost feels like you’re working against the machine.” I was curious to know more about the justifications for that taboo of not being able to talk or confront the physician with the ‘agenda.’   In my interviews with OB nurses, I also came across this and think it is an important factor to explore further.  I imagine that nurses with less clinical experience are even less able to identify or recognize this ‘agenda’ and that comes with its own set of practice and policy issues for nursing training.  

JKE: I think the nurse physician relationship shapes the day-to-day work environment of the nurse. It is a long-term relationship relative to the nurse-patient relationship. It is likely that talking about or confronting a particular physician about the potential of an agenda could negatively disrupt the work environment, which is significantly related to nurses’ job satisfaction. Nurses want to be seen as team players and discussing the potential of physician ‘hidden agendas’ is like being a whistle blower. In addition to not wanting to disrupt the power balance, they may not want to invite scrutiny into their own practice patterns.

CHM: I was struck in particular by the account on page 5 of your paper that ends with the quote, “There are certainly situations where the baby needs to come out via C-section, but it is not as many as we do by any stretch.”  What situations?  What factors influence those decisions?  Where do nurses feel they lost power to bargain /buy more time?  

JKE: In this quote, the nurse is referring to medically indicated versus potentially unnecessary cesareans. I believe when nurses speak about cesareans they are not only focused on unplanned, intrapartum cesareans but also scheduled cesareans or scheduled inductions, which can result in a cesarean. It was clear from the interviews that nurses felt less invested in the decision-making process when women came in for scheduled cesareans or planned inductions. Nurses also spoke of how women are set up for failure during pregnancy—by way of unfavorable media messages, lack of unbiased childbirth education, and lack of risk reduction information from prenatal care providers.

CHM: I was intrigued that in this study you did not appear to ask about nurses’ views toward physiological birth (vaginal) and cesarean, or other indicators of their philosophy of birth.  The comment from the nurses who viewed themselves as a ‘dying breed’ begin to capture some sense of that – whether it is experience, knowledge, or philosophy of birth that unites them against this perceived different group of newer nurses.

JKE:  Great question, although it assumes that nurses’ personal philosophy of birth impacts their practice, which it likely does according to Reagan et al. In an attempt to keep the data focused on our main aim we did not ask nurses directly about their personal philosophy of birth. I believe the nurses in the study were united in their knowledge of childbirth–without the now pervasive assessment and intervention technology–knowledge borne out of experience.

CHM: How do you plan to follow up with this research and what are your future projects?    

JKE: Locally, we want to continue the discussion about the influence of nursing care and knowledge on cesarean rates that started with our interviews. Due to the sensitive nature of the topic and hospital policies, we have not had much success with direct follow-up where the study was conducted. However, we are very interested in presenting and discussing the results with other interested audiences. With regard to future projects, we are currently initiating a study to document the degree of nursing influence on cesarean rates at the level of the individual nurse, at an academic medical center and at a community hospital, building on the sentinel, yet dated, work of Radin et. al.  If the results are significant, we foresee the development of a quality improvement strategy directed at providing individual nurses routine (e.g., bi-monthly or quarterly) feedback on standard measures, such as risk adjusted primary cesarean section rates, cervical dilation at cesarean, and cesarean indication, based on the cohort of women in their care. Clearly, although not without great effort, such a strategy would need to be interdisciplinary and have adequate IT infrastructure and support. I also think nurses, as part of a team, should be involved in giving feedback about physician practice patterns in accordance with obstetric standards.

Are you an L&D nurse?  Can you comment on your experiences and how you feel your actions can influence the mode of birth.  If you are a doula, what has been your observation.  Doctor or midwife?  How do you view the role of the L&D nurse?  I look forward to a robust discussion. – SM

References

Edmonds, J. K. and Jones, E. J. (2013), Intrapartum Nurses’ Perceived Influence on Delivery Mode Decisions and Outcomes. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 42: 3–11. doi: 10.1111/j.1552-6909.2012.01422.x

Main, E.K., Morton, C.H, Hopkins, D., Giuliani, G.,  Melsop, K., and Gould, J.B (2012), Creating a Public Agenda for Maternity Safety and Quality in Cesarean Delivery, Obstetrics and Gynecology, November 2012; 120 (5):1194-1198.

Radin TG, Harmon JS, Hanson DA. Nurses’ Care During labor: Its Effect on the Cesarean Birth Rate of Healthy, Nulliparous Women. Birth. 1993;20(1):14-21.

Regan M, Liaschenko J. In the Mind of the Beholder Hypothesized Effect of Intrapartum Nurses’ Cognitive Frames of Childbirth Cesarean Section Rates. Qualitative Health Research. 2007;17(5):612-624.

Spong, C. Y. MD; Berghella, V. MD; Wenstrom, K. D. MD; Mercer, B. M. MD; Saade, G. R. MD (2012), Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop, Obstetrics & Gynecology, Volume 120(5), November 2012, p 1181–1193

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Understanding and Eliminating Disparities in Maternal Health Outcomes, Part II

September 13th, 2012 by avatar

Today’s post is the second one on disparities in maternal health care by regular Science & Sensibility contributor, Christine Morton, PhD, who is a medical sociologist and has researched and written about disparities in maternal health for many years.  Today, Christine takes a look at why women of color in the United States are facing a widening gap in maternal health outcomes and what some of the underlying factors might be.  This is part two of a two part series that looks at the research and examines what might need to change. – SM

Are public health and obstetric perspectives providing us with the best paradigms for understanding and eliminating racial-ethnic disparities in maternal health outcomes?   In my last post, I reviewed a typical public health study, which looked at maternal mortality by race, ethnicity and nativity, based on U.S. death certificate data from 50 states and two cities:  NYC and Washington, DC.1

Photo Image Creative Commons Linda Dias, Photos

Documenting outcomes, while important, is only part of the answer to understand why racial-ethnic disparities exist, persist, and widen.  Even more, we can’t begin to eliminate disparities until we have a better understanding of how different groups of women experience the birth process.  By process, I mean the local context in which women experience pregnancy and give birth, the pattern of interventions and decision-making, the attitudes and behaviors of healthcare clinicians and childbearing women.  One of the best methodologies for examining local contexts of birth is ethnography, in the tradition of such classics as anthropologist Brigitte Jordan’s Birth in Four Cultures: A Cross-Cultural nvestigation of Childbirth in Yucatan, Holland, Sweden and the United States (1978) and sociologist Nancy Stoller Shaw’s Forced Labor: Maternity Care in the United States (1974.)   Only recently are social scientists turning their ethnographic lenses to current U.S. hospital childbirth settings, and I will highlight some of these projects in future posts.

Eugene Declercq, Mary Barger, and Judith Weiss2 review the evidence for disparities among five major interventions in childbirth: induction, electronic fetal monitoring, epidurals, episiotomy, and cesarean section.   They use data from multiple sources, “reflecting the fragmented nature of data systems related to the birth process.”  The birth certificate in many states has an extended worksheet, but the quality and accuracy of many elements on the birth certificate is a serious issue.  The best way to look at administrative data on pregnancy and childbirth is to have a LINKED data set that matches Birth Certificate data with Hospital Discharge Data, thus allowing for risk stratification by age, parity, etc.

DATA SOURCES ON PREGNANCY and CHILDBIRTH

Data Source Agency What it provides Used in this paper
Birth certificate National Center for Health Statistics (NCHS) Overall national trends and disparities by race/ethnicity Yes
Hospital discharge data (ICD-9/10 codes) National Hospital Discharge Survey Episiotomy use Yes
Massachusetts natality data MA Dept of Public Health Includes method of payment Yes
Listening to Mothers II Survey Childbirth Connection National retrospective survey of 1573 women who gave birth in 2005 (weighted for representativeness) Yes
Pregnancy Risk Assessment and Monitoring System (PRAMS) Centers for Disease Control and Prevention Population based survey of postpartum women conducted annually in 39 states No –only one question related to birth: “When was your baby born?”

Induction

Declercq and colleagues state that “rates of labor induction have more than doubled over the last 15 years in the United States,” and they review the geographic variability observed in this procedure – between states, within states, and among different types of hospitals.   The authors speculate that the rapid increase in induction rates, especially “elective inductions under 41 weeks gestation may have contributed to the shift in the gestational age distribution of births, with 39 weeks now being the most common gestational age.”

Rates of induction by race/ethnicity vary by data source.   National birth certificate data from 2005 show that “Regardless of parity, rates were highest among white non-Hispanic women, lowest among Hispanic women, with black non-Hispanic women falling in between.  First time mothers in each group have higher rates than multiparous mothers.”

Listening to Mothers II (LTMII) asks women whether they attempted to induce labor, whether their labor was medically induced and whether it was successful (i.e., no cesarean).  LTMII reported a higher overall rate of induction than the national birth certificate data (34% vs. 22%), in part because LTMII asks about a greater variety of methods, and because national birth certificate data only report those inductions that result in labor.  While techniques used to induce labor did not differ by race/ethnicity, LTMII found that Hispanic women who had given birth before had highest rates of attempted and successful induction (43% and 38%, respectively) compared to White women (39% and 33%) and Black women (29% and 22%) who had given birth before.  Regardless of parity, White women were more likely than Black or Hispanic women to try to self-induce (25% vs. 17% vs. 18%).

The authors also look at evidence for induction at 41+ vs. 42+ weeks gestation, but the data presented from LTMII and birth certificates does not include gestational age at induction.  This data element is on the birth certificate but is highly subject to error and missing values.

Cesarean Delivery

We know that cesarean rates have rapidly increased in the U.S. and that this rate has occurred among all racial/ethnic groups.  However, in this figure, Declercq and colleagues show that Black women had lower cesarean rates than White women until 1994, when they surpassed all groups, reaching 33.1% in 2006, compared to White women (31.3%), and Hispanic women (29.7%).  One reason for this is that Black women never experienced the decline in cesarean births the other groups did due to the rise in vaginal birth after prior cesarean (VBAC).

Black women have higher rates of cesarean at nearly every age group, and this is true among the three time periods examined (1991, 1996, 2005) and among every level of education.  Because the national data has limited variables to measure social status, Declercq and colleagues looked at Massachusetts data by payer.  Again, regardless of whether they had private or public insurance, Black women had higher rates of cesarean than White or Hispanic women.

Conclusion

Declercq and colleagues have made a valuable contribution to the public health literature by pointing out the gaps in public health surveys and summarizing what is known about its evidence base, current practice and associated health disparities. They conclude:

Three clear findings emerge:

(1) while there has been considerable research on each of these interventions, actual practice is not consistently related to its associated evidence base;

(2) randomized trials have not examined the relationship of these interventions and disparities in outcomes; and

(3) in all cases but fetal monitoring, which is virtually universally applied, there are differences in the application of the interventions to mothers from different race/ethnicity groups. However, there is also no clear pattern that would suggest that one group is more likely than any other to receive evidenced-base care.

Discussion

So back to the opening question – Are public health and obstetric perspectives providing us with the best paradigms for understanding and eliminating racial-ethnic disparities in maternal health outcomes?   In light of the variation among common childbirth procedures (interventions) like induction and cesarean, and with research showing that African American women are more likely to have cesareans,3-5 yet are less likely that White women to agree that the “birth process should not be interfered with unless medically necessary,” how do we understand what is happening in clinics and labor units across the country?

Clinicians are beginning to realize that quantitative data is only the first step toward changing behaviors, and acknowledge that health care culture drives much of this practice variation.6 Yet most clinician researchers are untrained in the methods best suited to discovering how to maximize quality improvement efforts—ethnography and qualitative research. Donald M Berwick (Institute for Healthcare Improvement) has argued for a wider embrace of methodologies beyond the “gold standard” randomized control trial, to assist quality improvement efforts in health care. In particular, he informs his clinical colleagues that approaches such as “ethnography, anthropology, and other qualitative methods … are not compromises in learning how to improve; they are superior.”2

Clinicians, public health researchers (and maternity care advocates) have long relied on population data to make the case that evidence-based care can improve maternal and infant health outcomes. Yet every childbirth educator and doula knows the value of the story – which includes the mechanisms (how things work in practice) and context (local conditions, including actions and meaning, that influence the outcomes of interest).  Systematically combining good epidemiological data with compelling accounts of the childbirth experience by all participants is the next research frontier we must cross in our quest to improve the quality of care and outcomes for all women and their babies.

References

1. Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Race, ethnicity, and nativity differentials in pregnancy-related mortality in the United States: 1993-2006. Obstetrics and gynecology. Aug 2012;120(2 Pt 1):261-268.

2. Declercq E, Barger M, Weiss J. Contemporary Childbirth in the United States: Interventions and Disparities. In: Handler A, eds. Reducing Racial/Ethnic Disparities in Reproductive and Perinatal Outcomes: The Evidence from Population-Based Interventions: Springer Science+Business Media; 2011:401-427. Accessed online: http://www.springer.com/public+health/book/978-1-4419-1498-9

3. Braveman P, Egerter S, Edmonston F, Verdon M. Racial/ethnic differences in the likelihood of cesarean delivery, California. Am J Public Health. May 1995;85(5):625-630.

4. Getahun D, Strickland D, Lawrence JM, Fassett MJ, Koebnick C, Jacobsen SJ. Racial and ethnic disparities in the trends in primary cesarean delivery based on indications. American Journal of Obstetrics and Gynecology. Oct 2009;201(4):422 e421-427.

5. Roth LM, Henley M. Unequal Motherhood: Racial-Ethnic and Socioeconomic Disparities in Cesarean Sections in the United States. Social Problems. 2012;59(2):207-227.

6. Main E, Morton C, Hopkins D, Giuliani G, Melsop K, Gould J. Cesarean Deliveries, Outcomes, and Opportunities for Change in California:  Toward a Public Agenda for Maternity Care Safety and Quality. Palo Alto, CA: California Maternal Quality Care Collaborative;2011.  Available online: http://www.cmqcc.org/white_paper

 

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The Importance of Understanding and Eliminating Disparities in Maternal Health Outcomes

September 7th, 2012 by avatar

Today’s post is by regular Science & Sensibility contributor, Christine Morton, PhD, who is a medical sociologist and has researched and written about disparities in maternal health for many years.  Today, Christine takes a look at why women of color in the United States are facing a widening gap in maternal mortality and what some of the underlying factors might be.  This is part one of a two part series that looks at the research and examines what might need to change. – SM

Maternal mortality is associated with the widest and most persistent disparity (inequality) in all of public health.  African American women have a three to four-fold greater chance of dying as a result of pregnancy than women in any other racial-ethnic group.1  The gap between maternal mortality in African American women and women of other racial-ethnic groups is greater today than it was in the 1940s.2

Photo image creative commons Seattle Municipal Archives

Yet despite multiple studies over the past several years demonstrating this widening gap, experts today commonly state that reasons for this disparity are “not fully understood,” and “limited data exist” to explain why they continue to occur.  What is clear, however, is that disparities in maternal deaths are likely to increase, as the proportion of childbearing women who self-identify as members of a racial or ethnic minority group (i.e., non-white) increases in the next decades.  Indeed, whether to call these women ‘minority’ is in question: In May 2012, the Census Bureau reported for the first time that non-Hispanic whites now account for a minority of births in the U.S.

Debates over maternal quality cannot ignore these trends.  Are public health and obstetric perspectives providing us with the best paradigms for understanding and reversing disparities in maternal health outcomes?

Let’s consider this by examining two recent publications looking at the issue from slightly different perspectives.  In the first, Andreea A. Creanga, MD, PhD and her colleagues from the CDC Division of Reproductive Health examined data from 52 reporting areas (50 states, New York City and Washington, DC).3    This Pregnancy Mortality Surveillance System consists of de-identified copies of death certificates for all deaths occurring during or within one year of pregnancy (regardless of cause of death) as well as matching birth or fetal death certificates if available.


Figure 1: Definitions of Death in Relation to Pregnancy (4)
The Pregnancy Mortality Surveillance System used by the CDC requires that a pregnancy-related death satisfy both temporal and casual criteria. A pregnancy-related death is defined as the death of a woman during or within 1 year of pregnancy that was caused by a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy. In contrast, the World Health Organization defines maternal mortality as ‘‘the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.’’

The CDC paper compares women of different races, ethnicities and nativity (US or foreign-born) from 1993-2006.  They found that for all women, “the pregnancy-related mortality ratio (PRMR) increased significantly (P<.001) from 11.1 to 15.7 deaths per 100,000 live births from 1993-2006, respectively” (p. 263).   Striking differences are found in the overall rate, and the researchers explore the relative effects of age and nativity among racial/ethnic groups.  Using US-born white women as the reference group, the study found that those women NOT in this group comprised 62% of the deaths but only accounted for 41% of the live births during this period.

% of deaths

% of live births

US-born White Women (reference)

38%

59%

Not US-born White (everyone else)

62%

41%

When the PRMR rates are broken down further, the study found that when compared to US-born white women, only foreign-born white women had a significantly lower risk of dying from pregnancy-related causes (after adjusting for age differences).  The table below shows the risk of dying from pregnancy complications among other groups of women compared to US-born white women.

Women’s Nativity and Race Risk of dying from pregnancy complications
US-born White Reference
US- and foreign-born Hispanic 1.1  times higher
US- and foreign-born Asian/Pacific Islander 1.5 times higher
Foreign-born Black 3.6 times higher
US-born Black 5.2 times higher

The study also found that for “all groups of women, pregnancy-related mortality ratios increased with age and were especially high for women older than 35 years” (p. 264).   For Black women over 35, the PRMR was 99.42, compared to the PRMR for Hispanic (27.20) and White (17.60) women.

Breaking 1993-2006 into two time periods, 1993-1999 and 2000-2006, the study found that the PRMR increased for all groups except for foreign-born Asian/Pacific Islander women, but the increase was statistically significant for only US- and foreign born white women and US-born Black women (30.4%, 29.2%, and 30.4%, respectively; all P<.05).

Also explored in the study are the differences in causes of death for U.S.-born vs. foreign-born women.

The takeaway

 “Except for foreign-born white women, all other race, ethnicity, and nativity groups were at higher risk of dying from pregnancy-related causes than U.S.-born white women after adjusting for age differences” (p. 261).   The authors suggest that “integration of quality-of-care aspects into hospital-and state-based maternal death reviews may help identify race, ethnicity, and nativity-specific factors for pregnancy-related mortality,” yet the low numbers of women who die may preclude a full examination of the multiple and complex factors involved in health care provision.

Some suggestive work in this area was published by Tucker and colleagues from the CDC (2007), who examined the prevalence of five conditions considered major causes of mortality occurring during hospitalization for labor, birth and postpartum. They found that African-American women did not have a higher prevalence of these conditions (preeclampsia, eclampsia, abruption placentae, placenta previa and postpartum hemorrhage) compared to other racial/ethnic groups, but were more likely to die from them, suggesting either a possible difference in the severity of the disease or the quality of care provided during hospitalization.

What is needed is a consideration of the birth process, including interventions and the experience of decision-making, as well as the attitudes and behaviors of healthcare clinicians as well as those of childbearing women.  Thus, a welcome view into the process of birth comes from a chapter in a book by Eugene Declercq, Mary Barger, and Judith Weiss.  In their review, “Contemporary Childbirth in the United States: Interventions and Disparities,”5 the authors note that  public health paradigms have more often focused on antecedents to care (access to contraception and prenatal care) and outcomes (mostly newborn and infant health) with less attention to the processes of care or interventions during the birth itself.  While social science research has focused on the context of care systems, there has been little in-depth investigation of the processes of care delivery.   Until very recently, there have been no observational studies of U.S. labor and birth in hospital settings since the 1970s.6

As there is little systematic national data to examine patterns of birth process nor any racial-ethnic disparities within them, the authors have examined “five major interventions used in the birth process: induction, electronic fetal monitoring, epidurals, episiotomy, and cesarean section.” We will briefly summarize the existing research on evidence based approaches to promote or prevent certain maternal and/or perinatal outcomes in these areas with an understanding that such research is rarely definitive and, even when it appears to be clear, it may not have a major influence on clinician behavior. We will then examine the distribution of these interventions across different groups, most notably by race/ethnicity. Since parity is such a crucial element in determining birth related behavior, in many cases we will also distinguish the results for primiparous and multiparous mothers.”

Part 2 of this blog post will examine their results and answer the question at the beginning:  Are public health and obstetric perspectives providing us with the best paradigms for understanding and reversing disparities in maternal health outcomes?

 References 

1. Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the United States, 1998 to 2005. Obstetrics and Gynecology. Dec 2010;116(6):1302-1309.

2. California Department of Public Health. Maternal Death Rates by Race California, 1940-1968. Death Records. Sacramento, CA1968.

3. Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Race, ethnicity, and nativity differentials in pregnancy-related mortality in the United States: 1993-2006. Obstetrics and gynecology. Aug 2012;120(2 Pt 1):261-268.

4. Berg C, Daniel I, Atrash H, Zane S, Bartlett L. Strategies to reduce pregnancy-related deaths: From identification and review to action. Atlanta, GA: Centers for Disease Control and Prevention;2001.

5. Declercq E, Barger M, Weiss J. Contemporary Childbirth in the United States: Interventions and Disparities. In: Handler A, al e, eds. Reducing Racial/Ethnic Disparities in Reproductive and Perinatal Outcomes: The Evidence from Population-Based Interventions: Springer Science+Business Media; 2011:401-427.

6. Morton CH. Where Are the Ethnographies of US Hospital Birth? Anthropology News. March 2009.

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