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“Choosing Wisely” in maternity care: ACOG and AAFP urge women to question elective deliveries.

February 21st, 2013 by avatar

 

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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 campaigndrawing 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 & Sensibilitysums 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.

 

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 , , , , , , , , , ,

Four Maternity Care Trends to Watch

September 6th, 2011 by avatar

[Editor’s note:  This post by Amy Romano is re-purposed here with permission, having  initially appeared on Childbirth Connection’s Transforming Maternity Care blog site on Monday, August 15.]

 

There’s a big gap between our current maternity care system and the high-quality, high-value system envisioned by a multi-stakeholder Transforming Maternity Care Project Team. We’re glad to see many of the recommendations put forth in the Blueprint for Action garnering broader interest and gaining momentum. Here are four we expect to play a growing role in system transformation over the coming months and years.

Women- and Family-Centered Maternity Care Homes

Just about everyone agrees that the patient-centered medical home will transform primary care. But we’ve seen little attention to how best to provide this model of prevention-oriented, personalized, coordinated care to childbearing women and newborns.  Although we’re just beginning to see implementation, the woman- and family-centered maternity care home concept seems to be gaining ground. North Carolina’s Pregnancy Medical Home program provides incentives to Medicaid providers to better coordinate health and social services for pregnant women and provide evidence-based care to reduce preterm births and cesareans. We’ve also seen interest in this concept in Minnesota, although legislative hurdles remain. We expect to see more innovation in this area, especially as the economic crisis and Medicaid expansion force payers to focus on cost containment and value.

Midwives, birth centers, and home birth

Just in the past month, an obstetric leader called for increased use of midwives to help curb the rising cesarean rate, Illinois cleared a regulatory hurdle paving the way for 10 freestanding birth centers to open across the state, and several major news sources reported on the rise in planned home births. Given the major cost advantages for out-of-hospital births, decades of evidence showing safety and benefits of midwifery care, and multiple forces aligning to produce critical workforce shortages, we expect midwives, birth centers, and home birth to gain the same interest among payers and policy makers that they’ve long had among consumers.

Shared decision making

Shared decision making is another broader health care trend that we expect to see find its due place in maternity care. Health care leaders are looking to shared decision making to make care more patient-centered, improve safety, rein in unwarranted practice variation, and reduce costs. While SDM found its roots in primary care and surgical specialties, our own collaboration with the Foundation for Informed Medical Decision Making represents the first major commitment to expanding the tools and concepts of SDM to maternity care. Look for a new maternity SDM web site and a suite of decision aids in the next year.

Quality Collaboratives

Facilities, providers, payers, and other stakeholders are joining forces to assess, track, and improve quality and safety. While quality collaboratives are not new, maturing information technology systems and new quality measures are enabling and accelerating data-driven improvement. Whether its hospital systems like Hospital Corporation of America, Geisinger, or Intermountain; state collaboratives like those in California, OhioWashington, and Oklahoma, or national collaboratives like the IHI Perinatal Improvement Community, we’re seeing major momentum from these entities in tackling safety problems and disseminating and replicating best practices.

What maternity care trends are you watching?

Maternal Quality Improvement, Midwifery, Patient Advocacy, Transforming Maternity Care , , , , , ,