Science & Sensibility

Last week, I attended the Normal Labour & Birth International Research Conference in Vancouver, British Columbia. With over 250 attendees from 23 countries, the conference set out to disseminate research about the nature of and optimal care for physiologic labor and birth, and to garner multidisciplinary perspectives on the implications for clinical practice, perinatal outcomes, education, management, collaboration, and policy.

I went as an agent of data dissemination. My job: to use social media (blogs, Twitter) to help make sure the conference proceedings didn’t just rattle around the four walls of the conference hotel, but got out to those in the field working to improve maternity care wherever we each are.

And I have some research I want to write about – really interesting, important research from every discipline you could imagine. But I left the three-day meeting thinking more about the (broken) link between evidence and practice than about any of the new, emerging evidence. I’ll get to the new research over the coming weeks, but first, a look at two stories that dominated the conference.

#1: Home birth on the defensive?

The plenary session by Dutch physician and epidemiologist, Simone Buitendijk, might have highlighted the unique model of midwife-led primary care geared toward planned home birth for low-risk women – a model that many birth advocates and researchers look to as a beacon of hope and reason. Buitendijk herself was co-author of the definitive study of planned home birth safety, a population-based study of over half a million births that found planned midwife-attended home birth as safe as planned midwife-attended hospital birth. And a Cochrane systematic review that came out around the same time as the Dutch home birth study provided definitive evidence that midwife-led care is superior to physician-led or shared models of care. So the Dutch have gotten it right, right? Time to celebrate and emulate? No, instead of a plenary about Dutch primary maternity care as a model to emulate, Buitendijk’s talk was a sobering call to action.

According to Buitendijk, in spite of this evidence (or perhaps in direct response to this evidence?) a well-coordinated media campaign in the Netherlands over the past year has emphasized the dangers of home birth, pointing to an entirely different body of evidence: comparative data showing that Dutch perinatal mortality rates are higher than those in other European countries. Although only about 30 of the 1700 Dutch perinatal deaths occurred at home, and perinatal mortality at the population level is affected far more by incidence and management of preterm birth and congenital anomalies than by the labor and birth care of low-risk women with term pregnancies, the Dutch mass media have made this a story about midwifery care and home birth. The result: the rate of home birth has dipped below 25% for the first time in Dutch history.

#2 VBAC is Back?

Eugene Declercq, who gives – hands down – the world’s most engaging and fun lectures about perinatal statistics, had the pleasure of making an 11th hour revision to his plenary talk on vaginal birth after cesarean (VBAC) thanks to ACOG, who released their new VBAC practice guidelines at 5pm the day prior. (Hat tip to yours truly for tipping him off about the new guidelines. I even got written into his plenary remarks, as the young woman with whom he had a “stimulating conversation” that led him to “stay up all night.” Har har, Gene!)

Anyway, we see in Declercq’s talk the familiar story of how VBAC rates increased briefly then plummeted in the early 2000’s as a result of new research on uterine rupture and, more precisely, an editorial by the ob-gyn editor for the New England Journal of Medicine saying that planned repeat cesarean is “unequivocally” safer than planned VBAC.

Research driving practice! That is, if the research (or overzealous interpretations of it) supports restricting practice.

Where’s the up-tick in VBAC rates when the Cochrane systematic review was published in 2004 concluding that “Planned elective repeat caesarean section and planned vaginal birth after caesarean section for women with a prior caesarean birth are both associated with benefits and harms?” The up-tick isn’t there because by then research wasn’t driving practice – ACOG guidelines calling for “immediately available” emergency obstetric care in VBAC labors were driving practice. And it wasn’t the NIH Consensus Development Conference on VBAC or the massive AHRQ systematic review underpinning the conference (i.e., evidence) that have been heralded as the beginning of the end of hospital “VBAC bans,” it’s ACOG’s (somewhat noncommittal) move away from the “immediately available” standard.

Evidence is not driving practice. Between evidence and practice there lives some kind of cocktail of power, money, activism, media, influence and serendipity (and preservatives). The relative strength of the ingredients dictates how practices evolve. Keeping with the cocktail metaphor, the VBAC plenary ended with an invitation to consumers and our advocates to shake things up – activism being the best hope for ACOG’s new guidelines to be used to drive meaningful change for the many, many childbearing women in the United States with scarred uteruses.

This all reminds me of a third plenary talk at the Normal Birth Conference – Patti Janssen’s lecture, Transforming Research into Policy: Ingredients of Influence, in which she quotes social scientist, Martin Rein.

It also reminds me of Kay Dickerson of the Cochrane Collaboration who said, “We are only to get evidence-based healthcare in this country through consumer activism.”

More on Janssen’s plenary, and updates on the research, coming soon.

Amy Romano Uncategorized ACOG, home birth, maternity care systems, NIH Consensus Conference, Normal Labour & Birth Conference, VBAC

…is up! Go check it out at Giving Birth with Confidence. What a PHENOMENAL collection of contributions about the moments, hours, and days after birth. Each of our Blog Carnivals has vastly surpassed my own expectations. I hope you’ll agree.

Amy Romano Uncategorized breastfeeding, cesarean, childbirth education, Healthy Birth Blog Carnivals, Healthy Birth Practices, home birth, interventions, maternity care systems, newborns, no separation, postpartum, safety, skin-to-skin contact

I am impressed and surprisingly moved by this video of a NICU evacuation drill at Beth Israel Deaconess Medical Center in Boston. Drills like these are so important for patient safety.

As the hospital CEO points out in his blog, there is a “dearth of literature on NICU evacuations”. The same is almost certainly true for labor and birth, in which evacuating hospitals means telling at least some women to give birth at home. Other potential disasters, such as prolonged loss of electricity, can mean access to anesthesia and surgical care is rationed severely, or not available at all. And of course more widespread disasters such as pandemics, natural disasters, or terrorist attacks might mean that a labor and delivery unit is closed indefinitely.

In 2006, Lisa Summers wrote about representing the American College of Nurse-Midwives (ACNM) at a government meeting discussing healthcare system preparedness for pandemic flu. In an article in ACNM’s newsletter, she shared:

They are planning for three levels of care. There are pamphlets to educate the public about how to provide appropriate home care that will meet the needs of most flu victims (hydration, isolation, comfort measures); they are working with local hospitals to assess surge capacity and their ability to meet the needs of the sickest (perhaps ventilator dependent) victims; and they are designating places such as hotel ballrooms and convention centers (places with adequate bathroom and food facilities) to be used as influenza care centers for those too sick for home care but not in need of (or who cannot be accomodated in) limited hospital beds.

Summers goes on to ask, given that one-quarter of hospitalized people are childbearing women, and pregnant women and newborns may be among the most vulnerable populations to flu infection, “What plans are being made to determine the best level of care for childbearing women? Will the influenza care centers be appropriate places to give birth?” She provides two compelling reasons that midwives should be front-and-center in efforts to address these questions:

The fact that midwives are experts in normal birth – that we are comfortable and skilled at attending a birth outside of a standard delivery room and without an OR down that hall – makes us uniquely well prepared to care for childbearing women in a disaster situation…The other important skill that midwives have honed well is that of triage of childbearing women – knowing which women are likely to safely give birth without medical intervention, and which women need IVs and an OR.

She also points out that all hazards preparedness should involve educating the public about safe home birth and assessing the surge capacity of birth centers.

In addition to Summers’ article, the ACNM also offers a number of other resources on All Hazards Preparedness, including a handout for women who may be vulnerable to giving birth unexpectedly remote from a skilled provider or prepared birth setting. (Whether it’s because of a terrorist attack or the epidemic of roadside births due to the closure of community-based maternity units.) The handout notes that childbirth education classes and prenatal breastfeeding education, along with infant CPR classes, are essential to preparedness, and gives step-by-step instructions for supporting a woman to give birth at home, including how to handle the most common complications.

I’d love to know, what are the hospitals in your communities doing to prepare labor and delivery units for events such as fires, floods, and loss of electricity? Does anyone have a video of an L&D drill similar to the NICU drill from BIDMC? And how are your health departments preparing for disasters that render hospitals unsafe or inaccessible for childbearing women? How many of my readers have contacted their health departments to offer assistance for childbearing women and newborns in disasters?  (Confession: although I’ve been meaning to for ages, I haven’t!)  Do any of you teach about disaster preparedness in prenatal classes?

Amy Romano Uncategorized childbirth education, hospitals, maternity care systems, safety

I have felt a little bit like a slacker blogger lately, but it’s not for lack of thinking and writing about birth. I just wrapped up an article called Social Media, Power, and the Future of VBAC with Hilary Gerber from Mom’s Tinfoil Hat and Desirre Andrews from Preparing for Birth which we submitted to the 50th anniversary “Looking Back – Looking Forward” special issue of Lamaze’s Journal of Perinatal Education. I’ve also been working with Kristen Oganowski from Birthing Beautiful Ideas to coordinate the development of an NIH VBAC Statement Primer for consumers. We have a bunch of brilliant contributors on board and will be launching the primer later this month at Lamaze’s new (very cool!) social networking site for women, Giving Birth with Confidence.

Now the big looming work comes in the form of conference season. And I want you (yes YOU) to help me. I have a love-hate relationship with conferences. Mostly love. I love how much sharing, connecting, and learning happens. I love finding out what old friends and colleagues are up to and meeting the people doing the most interesting, innovative, and important work in the field. But attending (and especially speaking at) a conference is a lot of work, and often disrupts progress in my other (equally if not more important) work. Also, I hate that conferences take me away from my family.

So…I want to make the most of the opportunities these conferences offer. I want to maximize the amount of sharing, connecting, and learning we – collectively – do. And I want to leave these conferences not with tons of new projects and commitments for myself, but with tons of new opportunities for the broader maternity care community (that means YOU) to drive meaningful improvements for women, infants, and families.

Here’s some more about the conferences I’m attending, and how YOU can be part of them.

On June 7 I’ll be at Health 2.0 Goes to Washington.

Um, have I mentioned lately that I think social media is going to transform maternity care? Well I developed this delirious optimism by hanging around (online) with the Participatory Medicine crowd.  I get to actually meet most of them next week!

I first caught on to the Participatory Medicine train when I read a Grand Rounds blog carnival on the theme of “Meaningful Use” almost exactly a year ago. “Meaningful Use” is government speak for the goal of implementing electronic health records (with piles and piles of stimulus money) in a manner that actually improves care. The Participatory Medicine folks are front and center in the conversation, pushing for patient-access to be the defining characteristic of meaningful. It’s all about liberating the mounds of data that will exist in electronic health records and letting innovators, policy-makers, scientists, and – most importantly – patients themselves use that data to improve health.

I have 10 minutes to speak but a whole day to connect and learn.  Here are my questions for you to help me make the most of this opportunity:

1. What do you think are the most innovative ways women are using the internet or social media to have healthier, safer, and more satisfying childbearing experiences?
2. What are the types and sources of maternity care data that you would most like to see become available?
3. What kind of data do you think should be documented in electronic health records during pregnancy, birth, and the postpartum and newborn period? Think outside the box.
4. What do you think would be the most important benefits (and for that matter, risks or drawbacks) of having complete, unhindered, timely access to your maternity care records?
5. What ongoing or forthcoming projects in the maternity care world could use the insights or funds of outside (non-birth-enthusiast) social innovators?

The following week (June 12-16), I’ll be at the American College of Nurse-Midwives Annual Meeting.

I’m only attending ACNM for one day, but traveling with my family for my kids’ first-ever trip to the nation’s capitol.  I’m giving two educational sessions that couldn’t be more different from one another. First, I’m presenting a talk called, “How Not to Get Duped by Obstetric Research” about the importance of thinking critically about evidence, and how honing critical analysis skills can can help midwives practice and advocate for safe and effective care. The other talk is a panel discussion with Amie Newman from RH Reality Check and Mary Murry, CNM, from The Mayo Clinic “Pregnancy Week by Week Blog,” moderated by Melissa Garvey from ACNM’s own Midwife Connection Blog. We’ll be talking about why more midwives should be blogging and how they can get started.  We recorded a really lively discussion about these issues on The Feminist Breeder & Friends Radio Show on International Day of the Midwife – a preview of our ACNM panel – which you can listen to here:

My questions for YOU:

1. What do you think is the optimal role of midwives (specifically certified nurse-midwives and certified-midwives) in blogging and other social media?
2. How can we protect the privacy and dignity of the women and families we serve (and for that matter, the people we work with) when midwives share about our work in social media spaces?
3. What obstetric routines or beliefs would you most like to hear me critically analyze?  I promise to make at least a blog post or two out of my How Not to Get Duped talk. (Actually, what I’ll also do is write parts of the talk from my prior blog posts, so if you have any favorite posts from the archives that you think would make good case studies, please suggest them!)
4. What are the best DC outings to do with a 3 and an almost-6 year old?

Lastly but Oh-So-Not-Leastly, I’ll be attending the Normal Labour and Birth 5th International Research Conference in July.

I’m not speaking at this conference. I’m going for the sole purpose of blogging it! I wrote a proposal to the conference organizers suggesting that they let me attend and help disseminate the proceedings. They agreed!  I think this is a huge opportunity to learn from the people doing the research about how to optimize the health and safety of healthy women and their babies around the time of birth. We’ll also hear from leaders who are creating and maintaining integrated, midwife-led primary maternity care systems, the gold standard for achieving “woman-centered, safe, effective, timely, efficient, and equitable” care.

What happened when bloggers and other connected consumers attended the NIH Consensus Development Conference on VBAC was astounding and continues to deliver. Since that experience, I’m addicted to putting scientific findings in the hands of engaged, connected consumers, because, as Kay Dickerson from the Cochrane Collaboration says, “We’ll only get evidence-based healthcare in this country through consumer activism.” Today activists have more access than ever before to information and are getting increasingly social media savvy. There’s no telling what we can do if we put our innovative, passionate minds to it and work collaboratively.

So here’s what I want to know from YOU:

1. Whose research are you most interested in hearing about? (Look over the Normal Labour and Birth agenda to see who will be presenting about what.)
2. Would you rather have a little bit of information/analysis about more of the presentations or more in-depth analysis of fewer presentations?
3. Are there any researchers you would like me to conduct a “Consider the Source” Interview with?

Finally, any readers who are planning to attend any of these conferences – I invite you to submit a guest post. I’d love to share multiple perspectives (not to mention the tremendous work of blogging all of these meetings!) Just email me at amyromano [at] Lamaze [dot] org.

Amy Romano Uncategorized ACNM, announcements, cesarean, childbirth education, Healthy Birth Practices, hospitals, interventions, maternity care systems, media, midwives, NIH Consensus Conference, Normal Labour & Birth Conference, Participatory Medicine, Personal Health Records, safety

The Institute for Healthcare Improvement (IHI), the leading nonprofit organization working to accelerate change in healthcare, has been in the news this month because its CEO, Donald Berwick, was recently nominated to head up the Centers for Medicare and Medicaid Services. (For those not familiar with Berwick, read his phenomenal article, “What ‘Patient-Centered’ Should Mean: Confessions of an Extremist“). Berwick himself and IHI’s Managing Director, Sue Gullo, RN, were key players in the recent Transforming Maternity Care Project coordinated by Childbirth Connection. Now, the IHI is rolling out programs to help hospitals and health care systems implement some of the work put forth in the project’s Blueprint for Action. These initiatives also coincide with the new Joint Commission perinatal core measures which hospitals may implement as of this month. Here’s what is on offer so far:

• Earlier this month, IHI recorded Momentum for Maternity of the Safest Kind, a podcast with the Transforming Maternity Care leadership about trends in health care for pregnant women, new mothers, and newborns and the work needed to reliably provide safe and effective care, reduce disparities, and rein in costs.
• On Tuesday, May 4 from 3-4 PM ET, Sue Gullo will host a public call to discuss the IHI’s work on improving safety in second-stage labor. The call can be accessed through the IHI Webex System (Click on Improving Perinatal Care Collaborative Info Call) or via land line at 866-469-3239 (enter the session ID 354 952 217*. More information can be found on IHI’s Improving Perinatal Care page.
• A series of seven web-based sessions for hospital staff involved in quality improvement efforts will focus on the safe use of oxytocin for induction, starting with avoiding all elective deliveries before 39 weeks. The series begins May 14.

To keep up with other IHI offerings, you can follow them on Facebook or Twitter

Amy Romano Uncategorized announcements, hospitals, induction, interventions, maternity care systems, safety, second stage