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Advocacy: Lamaze International Leaders on Capitol Hill

April 7th, 2015 by avatar

By John Richardson, Director, Government Relations, Lamaze International

I am proud of being both a member of Lamaze International and a Lamaze Certified Childbirth Educator for many reasons.  Today’s post by John Richardson, Lamaze International’s Director of Government Relations is just one reason why I am happy to pay my membership dues and be a part of the Lamaze organization.  Lamaze is actively working in both the private sector and with public/governmental leaders to help every family to have access to the resources to have a safe and healthy birth.  Today on the blog, we share about how our Board of Directors met with Congressmen and Congresswomen to share the importance of an evidence based childbirth education class being available to all families.  My certifying organization works hard for me and the families I teach every day.  – Sharon Muza, Science & Sensibility Community Manager.

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Lamaze BoD on Capitol Hill, 2015

Advocacy is a foundational element of the Lamaze International mission to advance safe and healthy pregnancy, birth and early parenting through evidence-based education and advocacy. Assisting women and their families to make informed decisions for childbearing and acting as an advocate to promote, support, and protect safe and healthy birth are two core competencies of a Lamaze Certified Childbirth Educator.

Advocacy comes in many different forms. The new Lamaze Strategic Framework specifically calls for taking advocacy efforts to the next level, focusing on government and legislative advocacy — leveraging strategic partnerships to advocate for perinatal/childbirth education coverage under the Affordable Care Act (ACA) and partnering with insurance companies, including the Centers for Medicaid and Medicare Services (CMS), to become part of the “bundled care” system. (Bundled care payment programs refer to the concept of grouping together the multiple services associated with a certain health “episode” versus the current fee for service system where each service associated with a condition is charged separately, and is one of the ACA’s many attempts to incentivize health care providers to be more cost efficient.)

BoD President Robin Elise Weiss and BOD Christine Morton

BoD President Robin Elise Weiss and BOD Christine Morton

Over the years, Lamaze has been involved in a variety of coalition and advocacy efforts related to improving access to high-quality maternity care that includes evidence based childbirth education by qualified educators and the promotion of breastfeeding within the health care industry. These efforts will continue with Lamaze taking its message directly to Capitol Hill to have a stronger voice with federal policymakers on behalf of the organization, its members, and the women and families that Lamaze serves. We want to let Congress know that Lamaze International provides gold standard childbirth education which can play an important role in promoting healthier outcomes for mother and baby and reducing healthcare costs and burdens on the healthcare system.

What does advocacy look like?

Advocacy campaigns at the federal level in the United States are typically a set of actions targeted to create support for a specific policy or proposal. The goals of an advocacy campaign may include drafting and passing a new law, drafting and passing amendments to existing laws, commenting on regulation, or influencing public perception and awareness of a particular issue.

Why is advocacy important for Lamaze?

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Board member Alice Turner

The delivery of health care is one of the most regulated industries in the United States. State and federal regulations often define whether services are covered by insurance, which practitioners are allowed to deliver services, the manner in which services are delivered, and how much individual practitioners and health care organizations are reimbursed. Naturally, there are a lot of people and organizations invested in steering and influencing these policies. There are literally thousands of issues and groups vying for policymakers’ attention. For Lamaze, it is critical to engage directly in advocacy activities so that policymakers become aware of the issues that are important to our organization and make them priorities.

There have been several recent successful advocacy initiatives to improve care for pregnant and postpartum women. For example, Lamaze has worked in collaboration with other organizations and lawmakers to improve breastfeeding services under the Affordable Care Act. As a result, there are several benefits now available to women who receive coverage through the Health Insurance Marketplaces (exchanges) and private non-grandfathered plans. Benefits such as lactation support and counseling by trained professionals are now covered without co-pay or co-insurance. Breast pumps are also covered at no charge and most employers must provide access to clean and private locations to pump for women who are hourly employees.

These victories are impressive and it is important to note that they did not occur in a vacuum. Advocates flooded the halls of Congress for years to ensure that policymakers appreciated the importance of breastfeeding. A key component of the success of these advocacy efforts was that they were based on research, focused on higher quality health outcomes, and provided fiscal benefits to the health care system and the federal government.

The Lamaze Board of Directors’ “Hill Day”

cbe graphicBearing all this in mind and in conjunction with their in-person meeting in Washington, DC, members of the Lamaze Board of Directors took to Capitol Hill on March 19, 2015 to meet with their Representatives and Senators about the excellent childbirth education that Lamaze provides and its potential to reduce costs and improve outcomes. The members of the Board met with a total of 23 Congressional offices, the majority of whom sit on committees with jurisdiction over health policy.

Our advocacy efforts on Capitol Hill centered on the following core messages:

  1. Promoting greater utilization of evidence-based childbirth education is a critical element in closing quality outcomes gaps and reducing unnecessary costs. In the face of high rates of cesarean sections, early inductions, and maternal/infant mortality, there is an increasing imperative for women to be informed and in charge of their maternity care to improve birth outcomes.

Maternal or neonatal hospital stays make up the greatest proportion of hospitalizations among infants, younger adults and patients covered by private insurance and Medicaid, which is why improvements in care are a major opportunity to reduce overall healthcare spending. Increasing quality outcomes by reducing the rates of unnecessary interventions, such as early induction of labor and cesarean section, are critical to reduce healthcare spending, particularly with Medicaid.

  1. The ACA has provided an opportunity for millions of uninsured Americans to access health care coverage through the creation of the exchanges. For those that do not enroll in a plan during the “open” enrollment period, there are qualifying “life events” that trigger special enrollment periods. One of those life events is when a woman gives birth. After the birth, the mother can sign herself and her infant up for coverage.

Lamaze believes, along with many others, that pregnancy, rather than birth, should be the life event that triggers the special enrollment period. Recently, 37 Senators and 55 Representatives sent a letter to U.S. Health & Human Services Secretary Sylvia Mathews Burwell  requesting this change. It appears Secretary Burwell can make this change administratively, as it does not require an act of Congress. Lamaze will join a chorus of other organizations that are making this request directly to the Secretary. Lamaze will also emphasize the importance of ensuring that ACA and state Medicaid plans include childbirth education as a covered service under maternity care benefits.

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Hill Day meetings

While meeting and communicating with legislators and staff on Capitol Hill may seem intimidating, it is actually very easy. Legislators are elected (and re-elected) by their constituents (you) so they have an obligation to listen to their constituents (you). That is a very important dynamic to remember. They are naturally inclined to help address the issues raised by their constituents.

However, advocates should always be well-prepared, a task that proved to be almost second nature for the Lamaze Board members as they met with Congressional offices. As experts in the field and natural educators, Lamaze leadership did a fantastic job representing the views of childbirth educators and establishing a rapport with the officials and staffers they met – the most important accomplishment of any first meeting on Capitol Hill.

Check out all the pictures of our Board of Directors on the “Hill” last month here.

Getting Involved

If you want to get involved and contact or meet with Congressional offices in your state, the most important action is to convey who you are, what you do, how you do it, and why it is important. Then, continue a dialogue of how specific policies might be improved for safer, higher quality, lower cost birth outcomes. In preparation for the first Lamaze “Hill Day,” several key documents were developed, including a policy paper and supporting documents to convey Lamaze’s core message in meetings with Congressional offices. By following this link, you can access and use these documents for advocacy efforts with your state’s representatives and in your local communities with insurers, health care providers, and hospitals.

Providing Lamaze’s unique perspective on the state and national level is extremely important and we can only be successful with the help of our members and supporters. In the coming months, we will provide a webinar on how to become an effective advocate and what Lamaze is doing to have an impact on access to high-quality childbirth education. Stay tuned!  If you are already an advocate in your community, on the county or state level or even nationally, share what you are doing to help families receive good care and improve outcomes in our comments section.

About John Richardson

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© John Richardson

John Richardson joined SmithBucklin, Lamaze International’s management company, in 2001 as Director of Government Relations, Healthcare Practice Group. He guides the policy efforts of healthcare organizations whose members include healthcare administrators; allied health professionals; physicians and hospitals. His experience provides his clients with a deep understanding of policy and politics and their effects on the healthcare system.

John lobbies Congress and government agencies at the federal level and also develops strategy for state lobbying efforts. He also has experience pursuing client objectives such as the development of practice guidelines, CPT codes, evidence based research, and technologies that promote efficiencies within healthcare administration.

Prior to joining SmithBucklin, John served as an Associate to the House Committee on Appropriations for a former member of the committee. Preceding his work of 5 years on the Hill, John acquired extensive political and grassroots experience working as a campaign aide to congressional and presidential campaigns.

A New Hampshire native, he graduated with a B.A. in Political Science from Roger Williams University in Bristol, R.I, and currently resides in Bowie, MD with his wife Kristin and sons Garrett and Holden.

 

Childbirth Education, Evidence Based Medicine, Guest Posts, Healthcare Reform, Healthy Birth Practices, Lamaze International, Lamaze News, Maternal Quality Improvement, Push for Your Baby, Research for Advocacy , , , , , ,

Care Model Innovations – Changing The Way Maternity Care Is Provided

February 17th, 2015 by avatar
© Serena O'Dwyer

© Serena O’Dwyer

Amy Romano was the original community manager, editor and writer of Science & Sensibility back when this blog was first established by Lamaze International in 2009.  After a healthy stint in that role, Amy has since moved on to other positions and most recently can be found in the position of Vice President of Health Ecosystems at Maternity Neighborhood, a technology company providing digital tools and apps to maternity health care providers around the world.  Additionally, Amy has been focused on finishing up her MBA at the same time.  (Talk about multitasking!)

While moving on to other things, Amy has not stopped blogging and I have been enjoying her most recent series on care model innovation in maternity care in particular and healthcare in general.  The series started in October of 2014, and Amy just published the seventh post in her ten post series. The entire series is part of Amy’s school work toward receiving her MBA.  That is a great blend of combining her degree program with her work, with her passion and interest.

Amy decided to look at four care models in particular: Nurse-Family Partnership, community-based doulas, midwife-led maternity services, and CenteringPregnancy. In talking with Amy, she shared that one of the things that really struck her is that these evidence-based care models are all very much relationship-based. She is more convinced than ever that trusting relationships are the “secret sauce” of good birth outcomes.

The posts available in the series so far include:

  1. What is care model innovation?
  2. The case for care model innovation in U.S. maternity care
  3. Care models that work: Nurse-Family Partnership
  4. Care models that work: Doulas as community health workers
  5. Care models that work: Midwife-led maternity services
  6. Care models that work: Group Prenatal Care
  7. Early examples of payment innovation in maternity care

And those posts yet to come:

8.  More mature payment reform models: An overview
9.  Driving community-based care through payment reform
10. The data infrastructure required for care model transformation

Particularly helpful are the references and learning resources that Amy includes in each of her posts, where the reader can go for more information and to dig deeper into the programs and research that Amy used to substantiate her research.

Changing the maternity care model currently in place is a critical piece for helping to improve the current status of both maternal morbidity and mortality as well as neonatal morbidity and mortality in the USA, which despite our abundance of resources, still has our world ranking in these categories shamefully at the bottom of the list.

According to Amy:

We’re in the midst of a “perfect storm” right now, with implementation of health care reform and lots of forces changing healthcare to be more patient-centered and integrated with community services. If ever there was a time when midwifery care, doulas, physiologic birth practices, etc., were going to take hold, that time is now.

As I have been reading Amy’s series, I have been struck by how some of her posts have reinforced the Lamaze Six Healthy Birth Practices themes, in particular #3 – Bring a friend, loved one or doula for continuous support, and #4 – Avoid interventions that are not medically necessary.

I asked Amy to share what her thoughts on what the role of the childbirth educator was in this time of transition.  Her response:

I think childbirth educators have lots of opportunities in the new healthcare landscape, but it will require a shift in thinking for some. New payment models will reward team-based care and CBEs have an important potential role as valued members of these teams, helping to implement shared decision making, help with care navigation/coordination, and extending educational offerings to postpartum/parenting, special conditions (e.g. gestational diabetes), etc. 

Amy Romano

Amy Romano

We need innovative ideas, forward thinking, and the ability to examine what we are currently doing with a critical eye, if we are to design and implement maternity care programs that improve outcomes and utilize resources more effectively to help mothers and babies.  As Amy highlights, there are existing programs that have shown great results and deserve the opportunity to be implemented on a wider scale.

Take some time to read the seven posts and come back to the Maternity Neighborhood blog to catch the final three when they become available.  Share your thoughts about what Amy is discussing as she rolls out the entire series.  And, consider what your role will be in the changing landscape of care that women receive during their childbearing year.

Babies, Childbirth Education, Doula Care, Healthcare Reform, Healthy Birth Practices, Maternal Mortality, Maternal Quality Improvement, Maternity Care, Midwifery, New Research, Newborns, Research , , , , , , ,

Finding Common Ground: The Home Birth Consensus Summit

April 15th, 2014 by avatar
© HBCS

© HBCS

While home birth has a proven safety record in countries outside the U.S., some attribute that to the fact that, in other countries, home birth takes place in the context of an integrated health care system. It is critical that all of the stakeholders in the maternal health care system are working together to ensure safe birth options in the U.S. as well.

The Home Birth Consensus Summit (HBCS) is a unique collaboration of all of the stakeholders currently involved in home birth in the United States. First held in 2011, the Home Birth Consensus Summit offers physicians, midwives, consumers, administrators and policy makers; (a varied group of representatives who do not often share common ground,) a chance to take a 360 degree look at the current maternal health care system and tease out the areas of conflict and common ground in order to increase safety in all birth settings.

Today on Science & Sensibility, our readers learn about the Home Birth Consensus Summit; its participants, purpose and process. Thursday, we will have the opportunity to review one of the groundbreaking products from the past two summits, when the HBCS releases the “Best Practice Guidelines: Transfer from Home Birth to Hospital” for consideration and adoption by maternal health organizations. Learn more about the HBCS from Summit Delegate Jeanette McCulloch as she interviews Saraswathi Vedam, RM FACNM MSN Sci D(hc), Home Birth Consensus Summit convener and chair. – Sharon Muza, Community Manager, Science & Sensibility

Jeanette McCulloch: What was the motivation behind launching the Home Birth Consensus Summit?

Saraswathi Vedam: Women want – and deserve – respectful, high quality maternity care regardless of their planned place of birth. Women and their families are not served by the interprofessional conflict and confusion that occurs in many regions in the US around place of birth.

While there may be points of disagreement, I know from numerous conversations with consumers, midwives, physicians, administrators, and policy makers that there are many more areas in maternity care where we all share a common set of principles and goals. Everyone is committed to working towards improved quality and safety for women and infants.

In 2011, a very intentionally selected group of stakeholders came together for the first Summit at the Airlie Center, in Warrenton, VA. These individuals represented all key leaders of the maternity care team, researchers, policy makers, payors, consumers, and consumer advocates. They came to the Summit with a wide variety of perspectives – including those for and against planned home birth. At the Summit, these delegates engaged in a unique process designed to help those with opposing viewpoints untangle complex issues. This process, called Future Search, guided the group through a complete exploration of every aspect of the maternal health care system. There were frank, challenging, and productive conversations, often among stakeholders who rarely, if ever, had been at the same table before. Once we were able to discover common ground, we were able to create a realistic and achievable strategic action plan together.

JM: Tell us about what common ground the Home Birth Consensus Summit has found so far.

SV:  As the delegates discussed their shared responsibilities and vision for providing the best possible care, we realized that the vision applied to all birth settings. The nine common ground statements describe a maternity care environment that respects the woman’s autonomy, ensuring she has safe access to qualified providers in all settings, and that the whole team that may care for her are well prepared with the clinical skills and knowledge that best applies to her specific situation. This will require attention to equity, cross-professional education, and research that includes the woman in defining the elements of “safety” and accurately describes the effects of birth place, or different models of care, on outcomes. The delegates shared a goal of increasing knowledge and access to physiologic birth, access to professional education and systems for quality monitoring for all types of midwives, from all communities; and reduction in barriers like cost and liability. Coming to this place of understanding and agreement, though, was only the beginning. Each of those action statements had to be turned into a concrete action plan that all of the stakeholders collaborated on developing.

© HBCS

© HBCS

JM: What is happening with the common ground statements now?

SV: Multi-disciplinary work groups have formed around each common ground statement. In 2013, the work groups came together for the second summit, again at the Airlie Center, to discuss progress made so far and tackle challenges.

Coming to this place of understanding and agreement, though, was only the beginning. The common ground statements are also encouraging a dialogue outside of our action groups that we could have never predicted. For example, the statements were read into the congressional record by Congresswoman Roybal-Allard, who said that the publication of the Home Birth Consensus document was “of critical importance to all current and future childbearing families in this country.” In the following year, several of the Summit delegates were invited panelists and presenters at an Institute of Medicine Workshop on Research Issues in the Assessment of Birth Settings.

JM: What are some of the top outcomes of the work groups?

SV: One exciting outcome – a set of Best Practice Guidelines to provide optimal care for mothers and families transferring from home to hospital – will be released by the Home Birth Consensus Summit later this week. This project represents what the Summits are all about: bringing together stakeholders to look at every facet of an issue, and work together on concrete initiatives to improve outcomes. These guidelines are based on the best available research on effective interprofessional collaboration. Delegates who are leading midwives, physicians, nurses, policy makers and consumers from across the U.S. formed the Collaboration Task Force. They met regularly over eight months on weekends and after hours to research and carefully design a concrete evidence-based tool to improve quality and safety for women and increase respectful communication among providers. Easing the friction that can sometimes occur when families arrive at the hospital can not only increase safety for families, but also build trust and collaboration between providers.

© HBCS

© HBCS

Another group is collaborating to develop a Best Practice Regulation and Licensure Toolkit – a resource for state policy makers that will provide a best practice model of midwifery regulation to be used as a template to enact or improve licensure in a particular state.

Another important outcome is a study of midwives and mothers of color to better understand social and health care inequities that lead to higher incidence of prematurity and low birth weight.

JM: What comes next for the Summit?

SV: The action groups are continuing their work on initiatives in each of the common ground areas. At Summit III, scheduled for Fall 2014 in Seattle, WA, each action work group will share the products of their collaborations, and address some remaining priorities. These include research and data collection, ethics, and access to equitable care during pregnancy. We plan to expand the participants to include more leaders from policy and practice to disseminate the documents and engage more in this exciting work.

I have been working towards ensuring equitable birth options for women and their families for nearly 30 years. My goal for the Summits is to increase the probability that my four daughters – and everyone’s daughters, wives, and sisters – will experience high quality, respectful maternity care.

What are your thoughts on the Home Birth Consensus Summits and this collaborative model?  How do you see this further maternal infant health and safety.  What would you like to see discussed by the stakeholders at Summit III in Seattle this fall?  Let us know in the comments and join us on Thursday to learn more about the details of the soon to be released “Best Practice Guidelines: Transfer from Home Birth to Hospital.”

Bios:

© Saraswathi Vedam

© Saraswathi Vedam

Saraswathi Vedam, RM FACNM MSN Sci D(hc), is the convener and chair of the Home Birth Consensus Summit. She has been active in setting national and international policy on home birth and midwifery education and regulation, providing expert consultations in Mexico, Hungary, Chile, China, Canada, and the United States. She serves as Senior Advisor to the MANA Division of Research, Chair of the ACNM Transfer Task Force, and Executive Board Member, Canadian Association of Midwifery Educators. Over the past 28 years she has cared for families in all birth settings. Professor Vedam’s scholarly work includes critical appraisal of the literature on planned home birth, and development of the first US registry of home birth perinatal data. Contact Saraswathi Vedam.

© Jeanette McCulloch

© Jeanette McCulloch

Jeanette McCulloch, IBCLC, is the co-founder of BirthSwell an organization improving infant and maternal health by changing the way we talk about birth and breastfeeding. She has been using strategic communications and messaging to change policy, spread new ideas, and build thriving businesses for more than 20 years. Jeanette is honored to be working with local, national, and international birth and breastfeeding organizations (including the Home Birth Consensus Summit) and advocates ensuring that women have access to high-quality care and information.

Babies, Healthcare Reform, Home Birth, Legal Issues, Maternal Quality Improvement, Maternity Care, Newborns, Practice Guidelines, Uncategorized , , , , ,

April is Cesarean Awareness Month – Resources and a Test Your Knowledge Quiz

April 10th, 2014 by avatar

fb profile cam 2014April is Cesarean Awareness Month, an event meant to direct the American public’s attention to the United States’ high cesarean rate. 32.8% of all birthing women gave birth by cesarean in 2012. A cesarean delivery can be a life-saving procedure when used appropriately, but it takes one’s breath away when you consider that one third of all women birthing underwent major abdominal surgery in order to birth their babies.

Professionals that work with women during the childbearing year can be a great resource for women, pointing them to evidence based information, support groups and organizations that offer non-biased information to help women lower their risk of cesarean surgery, receive support after a cesarean and work towards a trial of labor after a cesarean (TOLAC) and achieve a vaginal birth after a cesarean (VBAC) for subsequent births if appropriate.

Here are my top suggestions for websites and resources every birth professional should have on their short list to share with students and clients when it comes to cesarean awareness.

1. International Cesarean Awareness Network – an international organization with almost 200 volunteer led chapters, (most in the USA) offering peer to peer support for cesarean recovery and VBAC information by way of a website, e-newsletters, webinars, online forums, Facebook groups and monthly meetings in the community.

2. VBACFacts.com – Led by birth advocate Jen Kamel, this website is big on research and helps consumers and professionals alike understand the evidence and risks and benefits of both repeat cesareans and vaginal birth after cesarean, including vaginal birth after multiple cesareans.

3. Lamaze International’s “Push for Your Baby” – is a great resource for families to learn about the Six Healthy Care Practices, what evidence based care looks like and how to work with your health care provider to advocate for a safe and healthy birth. Also Lamaze has an wonderful infographic that can be shared online or printed.

4. Spinning Babies – Midwife Gail Tully really knows her stuff when it comes to helping babies navigate the pelvis during labor and birth. Many cesareans are conducted for “failure to progress” or “cephalopelvic disproportion” when really it is a case of a malpositioned baby who needed to be in a different position. This website is a wealth of information on what women can do to help their babies into the ideal position to be born, prenatally and during labor. It includes valuable information about helping a breech baby turn vertex. This is important, because finding a health care provider who will support vaginal breech birth is like finding a needle in a haystack.

© Patti Ramos Photography

© Patti Ramos Photography

5. Childbirth Connection – This website is a virtual goldmine of evidence based information about cesareans and VBACs including a valuable guide “What Every Pregnant Woman Needs to Know about Cesareans.” There are questions to ask a care provider and includes information on informed consent and informed refusal.

6. Cesareanrates.com is a great website run by Jill Arnold for those who love the numbers. Find out the cesarean rates of hospitals in your area. All the states are represented and families can use the information when searching out a provider and choosing a facility. Jill’s resource page on this site is full of useful information as well.

7. Safe Prevention of the Primary Cesarean –  The American Congress of Obstetricians and Gynecologists along with the Society for Maternal Fetal Medicine recently published a groundbreaking document aimed at reducing the first cesarean. While fairly heavy reading, there is so much good information in this committee opinion that I believe every birth professional should at least take a peek. You may be pleasantly surprised.

Test your knowledge of the facts around cesareans and VBACs with this informative quiz:

As a birth professional, you can be a great resource for all your clients, helping them to prevent their first cesarean, providing support if they do birth by cesarean and assisting them on the journey to VBAC by pointing them to these valuable resources. You can make every day “Cesarean Awareness Day” for the families you work with, doing your part to help the pendulum to swing in the other direction, resulting in a reduction in our national cesarean rates and improving outcomes for mothers and babies. What are your favorite resources on the topic of cesareans and VBACs? Share with us in the comments section.
Images

  1. Patti Ramos
  2. creative commons licensed ( BY-NC ) flickr photo shared by Neal Gillis
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Safe Prevention of the Primary Cesarean Delivery: ACOG and SMFM Change the Game

February 19th, 2014 by avatar

I hope that readers of Science & Sensibility (and anyone working in the field of maternal infant health) are sitting down.  Be prepared to be blown away.  ACOG and SMFM have just released a joint Obstetric Care Consensus statement that has the potential to turn maternity care in the USA on its end.  I feel like this blog post title could be “ACOG and SMFM adopt Lamaze International’s Six Healthy Birth Practices.”  (Okay, that may be a little overenthusiastic!)  I could not be more pleased at the contents of this statement and cannot wait to see some of these new practice guidelines implemented.  Judith Lothian, PhD, RN, LCCE, FACCE summarizes the statement and shares highlights of this stunning announcement. – Sharon Muza, Science & Sensibility Community Manager

Today, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine issued a joint Obstetric Care Consensus statement: Safe Prevention of the Primary Cesarean Delivery. It is being published concurrently in Obstetrics and Gynecology, (the Green Journal).  The ACOG press release is here, with much more detail of the study, not behind a firewall. There is no doubt about it-  this just released statement is a game changer.

acog wordlThe alarming and sustained increase in the cesarean rate in the United States has not improved either maternal or neonatal outcomes. In fact, data suggest that there is increased maternal mortality and morbidity associated with cesarean delivery. This statement describes the myriad of complications associated with cesarean and the increased risks associated with cesarean for mother and baby. The authors suggest that potentially modifiable factors, such as patient preferences and practice variation among hospitals, systems, and health care providers are likely to contribute to the escalating cesarean rates. There is a need to prevent overuse of cesarean, particularly the primary cesarean.

Table 1 acog

source: ACOG

The most common reasons for cesarean include labor dystocia, abnormal or indeterminate fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. The authors revisited the definition of labor dystocia in light of the fact that labor progresses at a rate that is slower than what we had thought previously. They also reviewed research related to interpretation of fetal heart rate patterns, and access to nonmedical interventions during labor that may reduce cesarean rates. External cephalic version for breech presentation and a trial of labor for women with twin gestations when the first twin is in a cephalic presentation can lower the cesarean rate. The authors analyzed the research using a rubric that rated the quality of the available evidence. The result is a set of guidelines that have the potential to substantially decrease the cesarean rate.

acog logo  These guidelines change the rules of the labor management game.

These are some of the new recommended guidelines:

  • The Consortium on Safe Labor data rather than the Friedman standards should inform labor management. Slow but progressive labor in the first stage of labor should not be an indication for cesarean. With a few exceptions, prolonged latent phase (greater than 20 hours in a first time mother and greater than 14 hours in multiparous women) should not be an indication for cesarean. As long as mother and baby are doing well, cervical dilation of 6 cm should be the threshold for the active phase of labor. Active phase arrest is defined as women at or beyond 6 cm dilatation with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity, or at least 6 hours of oxytocin administration with inadequate uterine activity and no cervical change.
  • Adverse neonatal outcomes have not been associated with the duration of the second stage of labor. The absolute risks of adverse fetal and neonatal outcomes of increasing second stage duration appear to be, at worst, low and incremental. Therefore, at least 2 hours of pushing in a multiparous woman and at least 3 hours of pushing in a first time mother should be allowed. An additional hour of pushing is expected with the use of an epidural, as there is progress.  Interestingly, there is no discussion of position change during second stage, including the upright position, to facilitate rotation and descent of the baby. Also, the authors note that second stage starts at full dilatation rather than when the mother has spontaneous bearing down efforts. Research suggests it is beneficial to consider the start of second stage when spontaneous bearing down by the mother  begins. (Enkin et al, 2000; Goer & Romano, 2013). Using this definition might also decrease the incidence of cesarean.
  • Instrument delivery can reduce the need for cesarean. The authors note concern that many obstetric residents do not feel competent to do a forceps delivery.
  • Recurrent variable decelerations appear to be physiologic response to repetitive compressions of the umbilical cord and are not pathologic. There is an in depth discussion of fetal heart rate patterns and interventions other than cesarean to deal with this clinically. Amnioinfusion for variable fetal heart rate decelerations may safely reduce the rate of cesarean delivery.
  • Neither chorioamnionitis nor its duration should be an indication for cesarean.
  • Induction of labor can increase the risk of cesarean. Before 41 0/7 weeks induction should not be done unless there are maternal or fetal indications. Cervical ripening with induction can decrease the risk of cesarean. An induction should only be considered “a failure” after 24 hours of oxytocin administration and ruptured membranes.
  • Ultrasound done late in pregnancy is associated with an increase in cesareans with no evidence of neonatal benefit. Macrosomia is not an indication for cesarean.
  • Continuous labor support, including support provided by doulas, is one of the most effective ways to decrease the cesarean rate. The authors note that this resource is probably underutilized.
  • Before a vaginal breech birth is considered, women need to be informed that there is an increased risk of perinatal or neonatal mortality and morbidity and provide informed consent for the procedure.
  • Perinatal outcomes for twin gestations in which the first twin is in cephalic presentation are not improved by cesarean delivery (even if the second twin is a noncephalic presentation).

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These guidelines offer great promise in lowering the cesarean rate and making labor and birth safer for mothers and babies. They also suggest an emerging respect for and understanding of women’s ability to give birth and a more hands off approach to the management of labor. Women will be allowed to have longer labors. Obstetricians will need to be patient as nature guides the process of birth. Hospitals will have to plan for longer stays in labor and delivery. And women will need to have more confidence in their ability to give birth. Childbirth educators can play a key role here. The prize will be safer birth and healthier mothers and babies.

The authors rightly note that changing local cultures and obstetricians’ attitudes about labor management will be challenging. They also note that tort reform will be necessary if practice is to change. It’s interesting to consider whether standards of practice based on best evidence (as these guidelines are) rather than on fear of malpractice might make tort reform more likely.

The American Academy of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine are to be applauded for their careful research and willingness to make recommendations for labor management based on best evidence. These guidelines provide direction for health care providers and women and will make a difference in not just the cesarean rate but women’s experiences. The game has changed. It is a most welcome change.

What are your first impressions after learning of the elements of this new ACOG/SMFM statement?  What impact do you think these changes will have on the care that women receive during labor and birth?  Are you considering what barriers to change might exist in the hospitals you serve?  How will you share this new information with the families that you work with? As a side note, I found it interesting that this Consensus statement did not suggest using midwives for normal, low risk women.  Research has consistently shown that midwives working with low risk populations can reduce the cesarean rate. – SM

Further press information –

Lamaze International Statement – New Consensus Statement Important Step to Reduce Unnecessary Cesareans

Group Calls for Safe Reduction In Cesareans

ACOG Press Release

References

Enkin, M.,  Keirse, M., Neilson, J., Crowther, C., et al (2000). A Guide to Effective Care in Pregnancy and Childbirth. New York: Oxford Press.

Goer, H. &  Romano, A. (2013). Optimal Care in Childbirth: The Case for a Physiologic Approach.  Seattle: Classic Day Publishing (Chapter 13).

Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists. Obstet. Gynecol. 2014; 123: 693-711.

About Judith Lothian

@ Judith Lothian

@ Judith Lothian

Judith Lothian, PhD, RN, LCCE, FACCE is a nurse and childbirth educator. She is an Associate Professor at the College of Nursing, Seton Hall University and the current Chairperson of the Lamaze Certification Council Governing Body. Judith is also the Associate Editor of the Journal of Perinatal Education and writes a regular column for the journal. Judith is the co-author of The Official Lamaze Guide: Giving Birth with Confidence. Her research focus is planned home birth and her most recent publication is Being Safe: Making the Decision to Have a Planned Home Birth in the US published in the Journal of Clinical Ethics (Fall 2013).

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