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World Health Organization: Provide Cesareans for Women in Need, Don’t Focus on Specific Rate

April 21st, 2015 by avatar
© Patti Ramos Photography

© Patti Ramos Photography

As we have mentioned earlier this month, when Jen Kamel discussed placenta accreta as a downstream risk factor of the increasing cesarean rate, April is Cesarean Awareness Month and the World Health Organization (WHO) has come out with a new statement (WHO Statement on Caesarean Section Rates) that discourages identifying a “cesarean target rate” but rather encourages the use of cesarean surgery worldwide only when appropriate to protect the health of mother and baby. The goal should be that every cesarean performed is done out of true medical necessity and the decision to do so should be based on individual circumstances evaluated at the time for each mother/baby dyad.

Since 1985,  it has been stated that a safe and appropriate cesarean target rate was between 10-15%.  It was believed that if the cesarean rate exceeded that target rate, the mortality and morbidity for both mothers and babies would rise as a result of potentially unnecessary surgeries being performed.  Everyone recognizes that a cesarean birth can save the life of a mother and/or a baby.  But it needs to be acknowledged that there are no benefits to mothers and babies when a cesarean is done when it is not required.  WHO has decided to revisit the decades old suggested target rate as the number of cesarean surgeries being performed are increasing all around the world.  In the USA, in 2013, 1,284,339 cesarean surgeries were performed.  32.7% of all babies born in the USA that year were delivered by surgery.

There are both short term and long term risks to mothers, babies and future pregnancies every time a cesarean is performed.  These risks are even more elevated in areas where women have limited access to appropriate obstetrical care.

The WHO strived to identify an ideal cesarean rate for each country or population as well as a worldwide country level analysis.  The cesarean rate at the population level is determined by two items – 1) the level of access to cesareans and 2) the use of the intervention, both appropriate and inappropriately. Governments and agencies can use this information to allocate funding and resources.  Cesareans are costly to perform and doing more than necessary puts undue financial hardship on resources that may already be stretched too thin in many places around the world.

After conducting a systematic review – the team tasked with determining the population based cesarean rate determined that indeed, when cesareans are performed up to a rate of approximately 10-15%, maternal, neonatal and infant mortality and morbidity is reduced.  When the cesarean rate starts to increase above this level, mortality rates are not improved. When socioeconomic factors were included in the analysis, the relationship between lower mortality rates and an increasing cesarean rate disappeared.  In locations where cesarean rates were below 10%, as the rate increased, there was a decrease in mortality in both mothers and babies.  When the rate was between 10-30%, they did not see a continued decrease in mother or newborn mortality rates. The team also acknowledged that once the cesarean rate increased to 30% or above, the link between newborn and maternal mortality becomes difficult to assess.

In countries that struggle with resources, staffing and access to care, the common complications of surgery, such as infection, make cesarean surgery even more complicated and even dangerous for those women who give birth this way.

The team also struggled with analyzing the morbidity rate due to the lack of available data.  They did acknowledge that while the social and psychological impact of cesarean sections were not analyzed, potential impacts could be found in the maternal–infant relationship, women’s psychological health, women’s ability to successfully initiate breastfeeding and pediatric outcomes.  More research is needed.

WHO Cesarean Rate Conclusions

© WHO

 

The WHO team also felt it is important to establish, recognize and apply a universal classification system for cesareans that can be applied at the hospital level and allow comparisons to take place between different facilities and the unique populations that they serve. Once established, rates and systems could be compared between geographic regions, countries, different facilities and on a global level and the data analyzed effectively to help identify where change can be effective at reducing poor outcomes.

robson high res 2

© WHO – click image for full size version

After reviewing the different classification systems currently available, they determined that universal use of the Robson classification would best meet the needs of both international and local analysis.  The Robson classification system is named after Dr. Michael Robson, who in 2001 developed this system to classify women based on their obstetric characteristics for the purpose of research analysis.  This allows for comparisons to be made regarding cesarean section rates with few confounding factors.  Every woman will be clearly classified into one of the ten known groups when admitted for delivery. The WHO team states that the Robson classification system “is simple, robust, reproducible, clinically relevant, and prospective.”

The WHO team believes that using the Robson classification will aid in data analysis on many levels and the information obtained from these analyses be public information.  This information can be used to help facilities to optimize the use of cesarean section in the specific groups that will benefit from intervention.  It will also help determine the effectiveness of different strategies that are currently being used to reduce this intervention when not necessary.

Cesarean sections can be a life-saving tool under certain circumstances.  When cesareans are performed when not medically necessary, there are both long term and short term risks to both mothers and babies, including increased mortality and morbidity and risks to future pregnancies.  This becomes especially significant in areas of low resources and scare obstetric care.  Better data is needed to help reduce the cesarean rate in locations where it is unnecessarily high and to be able to direct resources where they are needed and can improve outcomes.  The World Health Organization hopes that this data becomes available so that more accurate research can be conducted and the reduction in mortality and morbidity for mothers and babies can be reduced.

Are you sharing with your classes, clients and families the importance of having a cesarean only when medically necessary?  While April may be Cesarean Awareness Month, we need to be diligent all year long to prevent cesareans that are not needed.

Lamaze International has created and made available three infographics that can help families learn more about cesareans and VBACs.

Screenshot 2015-04-20 19.52.53

What’s the Deal with Cesareans?

Avoiding the First Cesarean

VBAC, Yes, It’s an Option! (NEW!)

You can download and print these and other Lamaze International infographics from this page here.

Share what you are doing to honor Cesarean Awareness Month in your professional practice in our comments section below.

 

 

 

Babies, Cesarean Birth, Childbirth Education, Maternal Mortality, Maternal Mortality Rate, Maternal Quality Improvement, Maternity Care, Medical Interventions, Newborns, Research, Systematic Review , , , , , ,

Too Bad We Can’t Just “Ban” Accreta – The Downstream Consequences of VBAC Bans

April 2nd, 2015 by avatar

April is Cesarean Awareness Month (CAM), and throughout the month, Science & Sensibility will be covering issues that are directly related to the number of cesareans (1,284,339 in 2013) performed every year in the United States.  To start our CAM series off, Jen Kamel, founder of VBACFacts.com, shares important information about placenta accreta.  Tomorrow, April 3rd, is the Hope for Accreta Awareness National Blood Drive, as part of the 30 Day Hope for Accreta Challenge sponsored by the Hope for Accreta nonprofit that provides consumer information and offers support to families affected by placenta accreta. – Sharon Muza, Community Manager, Science & Sensibility

cam lamaze 2015Even though the American College of Obstetricians and Gynecologists (ACOG) and the National Institutes of Health (NIH) have described vaginal birth after cesarean (VBAC) as a safe, reasonable, and appropriate option for most women, VBAC bans (hospital or practice wide mandates that requires repeat cesareans for all women with a prior cesarean) remain in force in almost half of American hospitals. It’s true that scheduled repeat cesareans almost always successfully circumvent the most publicized risk of VBAC (uterine rupture) by virtually eliminating its incidence and for this reason, many people celebrate and credit the repeat cesarean section for resulting in a good outcome for mother and baby. But what most people do not consider is that VBAC bans translate into mandatory repeat cesareans, and those surgeries expose women and babies to a condition far more life-threatening and difficult to treat than uterine rupture: placenta accreta.

Photo Credit: http://fetalsono.com/teachfiles/PlacAcc.lasso

Photo Credit: http://fetalsono.com/teachfiles/PlacAcc.lasso

Placenta accreta occurs when a placenta abnormally attaches to (accreta), in (increta), or through (percreta) the uterine wall. No one knows exactly why some women develop accreta other than there is some abnormality in the area where the fertilized egg implants (Heller, 2013). Anyone who has had a prior surgery on her uterus is at a substantially increased risk of accreta and, as it happens, cesarean section is the most common surgery in the United States (Guise, 2010). In fact, the rate of accreta has grown along with the rate of cesarean surgery: from 1 in 4,027 pregnancies in the 1970s, to 1 in 2,510 pregnancies in the 1980s, to 1 in 533 from 1982-2002 (American College of Obstetricians and Gynecologists [ACOG], 2012). That rate escalates to 1 in 323 among women with a prior uterine surgery and the risk rises at a statistically significant rate with each additional cesarean section (Silver, Landon, Rouse, & Leveno, 2006).

Up to seven percent of women with accreta will die from it (ACOG, 2012). After the baby is born, the placenta does not detach normally, causing bleeding, which can’t be stopped before the doctors are able to either surgically remove the placenta or perform an emergency cesarean hysterectomy. Babies die from accreta due to the very high rate of preterm delivery associated with accreta. In fact, 43% of accreta babies weigh less than 5.5 lbs (2,500 gm.) upon delivery (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013). Accreta is not a routine complication. Accreta is serious.

As Silver (2006) points out, the risk of accreta after two cesareans (0.57%) is greater than the risk of uterine rupture after one prior low transverse cesarean during a non-induced/augmented planned VBAC (0.4%) (Landon, Hauth, & Leveno, 2004). In other words, women are literally exchanging the risk of uterine rupture in a current pregnancy for the more serious risk of accreta in future pregnancies. This poses a striking public health issue when you combine what the CDC (2012) has reported for numbers of unintended pregnancies–49%–and the lack of access to vaginal birth after cesarean: over half a million repeat cesareans every year, resulting in higher rates of accreta.

Yet due to the nonmedical factors that inhibit access to VBAC and influence how the risks and benefits of post-cesarean birth options are communicated to the public, women are rarely informed of these risks in a transparent and straightforward way. Additionally, it can be very difficult for the woman to obtain social support when confusion and fear about giving birth after cesarean remains the norm.

Given all this, providers are ethically obligated to inform patients of the future implications of their current mode of delivery. However, it can be especially difficult for providers working within the political climate of a hospital where VBAC is banned to frankly inform their patients of this reality. How can providers clearly explain to women the risks and benefits of their options, with VBAC as a viable option, when they do not offer that option at the facility? Such a situation could even result in professional ramifications for the provider, like revocation of hospital privileges. Additionally, some providers do not offer VBAC, “not because of an explicit hospital policy against it, but because [they] were unwilling to stay in the hospital with a woman attempting [a planned VBAC]” (Barger, Dunn, Bearman, DeLain, & Gates, 2013).

It is for this reason that some argue that VBAC bans create a conflict of interest among providers (ACOG, 2011; Charles, 2012). On one hand, they are bound by ethical obligations to the patient’s well-being, respect for patient autonomy, and support of an informed decision-making process. But these obligations are threatened by financial and professional ties to the hospital.

ACOG stresses throughout their guidelines and committee opinions that informed consent and patient autonomy are paramount (ACOG, 2011). They share how obstetrics should be moving from a paternalistic system to a more collaborative model (ACOG, 2013). They acknowledge that women should be allowed to accept increased levels of risk (ACOG, 2010). They assert how there is no “right” or “wrong” answer, only what is right or wrong for a specific woman (ACOG, 2010). And they are clear that restrictive VBAC policies cannot be used to force women to have a repeat cesarean or to deny a woman care during active labor (ACOG, 2010).

Yet, with 48% of women interested in the option of VBAC, 46% of them cannot find a provider or facility to attend their VBAC (Declercq, Sakala, Corry, Applebaum, & Herrlick, 2013). Only 10% of U.S. women have a vaginal birth after cesarean, as opposed to another cesarean (National Center for Health Statistics, 2013). Barriers to VBAC remain firm.

Those barriers often include one-sided counseling to women of the risk of uterine rupture in a VBAC. Rarely are they told of the complication rates of accreta, which are higher across several measures. This is true when we look at maternal mortality (7% vs. 0%) (ACOG, 2012; Guise, et al., 2010), blood transfusion (54% vs. 12%) (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013; Barger, et al., 2012), cesarean hysterectomy (20-70% vs. 6%) (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013; Barger, et al., 2012), and maternal ventilation (14% vs. 3%) (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013; Barger, et al., 2012). Further, 5.8% of accreta babies will die within the first week of life (Eshkoli, Weintraub, Sergienko, & Sheiner, 2013) in comparison to 2.8 – 6.2% of uterine rupture babies (Guise, et al., 2010).

Accreta results in higher rates of mortality and morbidity because it requires a complex response which most hospitals are not equipped to provide. A 2012 study advises, “Treatment of placenta accreta is best accomplished in centers that have the expertise to handle the management, which involves multiple disciplines, including blood bank, interventional radiology, anesthesia, and surgical expertise, gynecologic oncology, urology, or obstetric subspecialty expertise” (Heller, 2013).

It ís worth noting that uterine rupture does not require this level of response in order to generate a good outcome. As Aaron Caughey, OB-GYN and Chairman of the Department of Obstetrics and Gynecology at Oregon Health & Science University in Portland explains, “From an obstetrician standpoint, there are no particular special skills to managing a VBAC. Even in an emergency situation, we all have the surgical skills to deal with it” (Reddy, 2014).

Because some hospitals are not equipped to manage an accreta, some women who are diagnosed prenatally find themselves traveling hundreds of miles away from their family in order to deliver with accreta specialists.

At 19 weeks pregnant, Dawn was diagnosed with percreta, the most severe form of accreta where the placenta goes through the uterine wall and attaches to other structures in the abdominal cavity. She had nine prior pregnancies. Dawn was among the 93% of women who were never informed of the risks of accreta when she was pregnant after her first, second, or third cesarean (Kamel, 2014). All she heard were the dangers of VBAC. Thus, she had three cesareans.

Mother after cesarean hysterectomy in ICU. © Dawn Johnson-Baranski

When she got pregnant again, she heard the word accreta for the first time upon her diagnosis as is the case in 59% of women diagnosed with accreta (Kamel, 2014). Dawn ultimately traveled from her home in rural Virginia to Houston, Texas, at 27 weeks pregnant, to the Fox-Texas Children’s Pavilion for Women, an accreta specialty center. Due to complications related to her precreta, her son was delivered by cesarean hysterectomy at 33 weeks. Her son spent 19 days in the NICU before they could return back home to Virginia (personal communication, March 30, 2014).

It’s because accreta is so dangerous, complex to treat, and unknown to the general public, that professionals and researchers are sounding the alarm about the risk exchange that happens when repeat cesarean is chosen (or forced) over VBAC. As Dr. Elliot Main, Medical Director of the California Maternal Quality Care Collaborative, cautions, “In California, we are seeing a lot of hysterectomies, accretas, and significant blood loss due to multiple prior cesareans. Probably the biggest risk of the first cesarean is the repeat cesarean” (Main, 2013). (The state of California has a 9% VBAC rate, just a point below the national rate) (State of California Office of Statewide Health Planning and Development, 2013). A 2009 study from the Netherlands advises, “Ultimately, the best prevention [of uterine rupture] is primary prevention, i.e. reducing the primary caesarean delivery rate. The obstetrician who decides to perform a caesarean has a joint responsibility for the late consequences of that decision, including uterine rupture” (Zwart, et al., 2009). And a 2012 study warns, “Because cesarean delivery now accounts for about one-third of all deliveries in the United States, rates of abnormal placentation and subsequent hysterectomy will likely continue to rise” (Bateman, Mhyre, Callaghan, & Kuklina, 2012). By reducing the primary cesarean rate and increasing access to VBAC, we could also reduce the incidence of accreta, cesarean hysterectomy, and hemorrhage.

Following multiple uterine rupture lawsuits in the 1990s, some hospitals crafted their restrictive VBAC policies around litigation fears. However, the concern over lawsuits resulting from “VBAC gone wrong” may soon be overshadowed by the worry of being sued when women or babies die from accreta, after failing to adequately respond to this dangerous condition and/or denying access to VBAC (Associated Press, 2013; Children to sue hospital over death of mother, n.d.). This will certainly become the case as the public becomes more aware of the connection between VBAC bans, cesareans, and accreta.

It could also become a public relations nightmare as Americans begin to realize that litigation fears–not patient safety, drive hospital policy. This becomes more likely as more women are diagnosed with accreta.

As mothers are the ones who carry the risk of either uterine rupture or accreta, shouldn’t they be the ones deciding which set of risks are tolerable to them? As ACOG (2010) says, “the ultimate decision to undergo [planned VBAC] or a repeat cesarean delivery should be made by the patient in consultation with her health care provider” –  not by hospital administrators, malpractice insurance companies, or providers who simply don’t want to deal with VBAC.

As Dr. Howard Minkoff (2010) shared at the 2010 NIH VBAC Conference, “We should be starting with a sense of what’s the best interest of the mother. Unfortunately, the decision here is not always who are better equipped, it’s more like who are willing. There are a lot of hospitals that are quite capable of providing VBACs but exercise an option not to do it particularly if there’s someone nearby that will take that on for them.”

Hospitals around the country, and particularly those that are located in areas where VBAC bans mean that all women have repeat cesareans, are seeing and will continue to see increasing numbers of accreta. They have no choice but to manage it – which can be especially problematic for smaller facilities in rural areas that don’t offer the sophisticated response accreta requires.

But motivation remains the driving factor in hospital VBAC policy even in rural hospitals. Take the five small community hospitals in New Mexico that serve the Navajo Nation. As Dr. Jean Howe (2010), their Chief Clinical Consultant for Obstetrics, shared at the 2010 NIH Conference, these rural facilities collectively deliver 3,000 babies each year and maintain a 15% cesarean rate and a 38% VBAC rate. Numbers like that just don’t happen. They are the result of motivated administrators, providers, and patients who want VBAC to be an option at their facility.

The bottom line is, VBAC bans simply delay risk. The sooner hospital administrators and the American public realize this, the sooner we can mobilize–reducing future risks of accreta by making VBAC a viable option in more hospitals. It is one thing for a woman to knowingly plan a repeat cesarean understanding this risk. That is her choice as both VBAC and repeat cesarean come with risk. However, it is unconscionable when a woman is not presented with her options and she develops accreta in a subsequent pregnancy.

As the American public becomes more aware of the serious risks associated with repeat cesarean, will more providers and facilities be sued as a result of accreta-related complications and death? Will it have to come to fear of litigation, again, in order for hospitals to throw aside their current VBAC bans, listen to what the NIH, ACOG, and the medical research has to say; to create an environment that is supportive of VBAC, respect a mother’s right to make her own medical decisions, and prepare accreta-response protocols?

Women are entitled to understand what that first cesarean means in terms of their future birth options and their long term health. Consumers and providers should work with hospital administration to reverse VBAC bans, review current VBAC policies to insure they are aligned with national guidelines and evidence, and improve response times for obstetrical emergencies through team training and drills (Cornthwaite, Edwards, & Siassakos, 2013). Providers should have frank conversations with patients about the immediate and long-term risks and benefits of their options within the context of intended family size, acknowledging that sometimes the stork delivers when you’re not expecting it. This is about administrators, providers, professionals, and consumers working together for better processes and healthier outcomes. Let’s get to work.

References

American College of Obstetricians and Gynecologists. (2010, August). Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics & Gynecology, 116(2), 450-463. Retrieved from http://dhmh.maryland.gov/midwives/Documents/ACOG%20VBAC.pdf

American College of Obstetricians and Gynecologists. (2011). Code of Professional Ethics. Retrieved May 16, 2013, from ACOG: http://www.acog.org/About_ACOG/~/media/Departments/National%20Officer%20Nominations%20Process/ACOGcode.pdf

American College of Obstetricians and Gynecologists. (2012, July). ACOG Committee Opinion No. 529: Placenta accreta. Obstetrics & Gynecology, 201-11. Retrieved from http://www.acog.org/Resources%20And%20Publications/Committee%20Opinions/Committee%20on%20Obstetric%20Practice/Placenta%20Accreta.aspx

American College of Obstetricians and Gynecologists. (2013). Elective surgery and patient choice. Committee Opinion No. 578. Obstetrics & Gynecology, 122, 1134-8. Retrieved from http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Ethics/Elective_Surgery_and_Patient_Choice

Associated Press. (2013, Nov 25). $15 million awarded in Illinois childbirth death lawsuit. Retrieved from Insurance Journal: http://www.insurancejournal.com/news/midwest/2013/11/25/312169.htm

Barger, M. K., Dunn, T. J., Bearman, S., DeLain, M., & Gates, E. (2013). A survey of access to trial of labor in California hospitals in 2012. BMC Pregnancy and Childbirth. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636061/pdf/1471-2393-13-83.pdf

Barger, M. K., Nannini, A., Weiss, J., Declercq, E. R., Stubblefield, P., Werler, M., & Ringer, S. (2012, November). Severe maternal and perinatal outcomes from uterine rupture among women at term with a trial of labor. Journal of Perinatology, 32, 837-843. Retrieved from http://www.nature.com/jp/journal/v32/n11/full/jp20122a.html

Bateman, M. T., Mhyre, J. M., Callaghan, W. M., & Kuklina, E. V. (2012). Peripartum hysterectomy in the United States: nationwide 14 year experience. American Journal of Obstetrics & Gynecology, 206(63), e1-8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21982025

Charles, S. (2012, Jul-Aug). The Ethics of Vaginal Birth After Cesarean. The Hastings Center Report, 42(4), 24-27. Retrieved from Medscape: http://onlinelibrary.wiley.com/doi/10.1002/hast.52/abstract

Cornthwaite, K., Edwards, S., & Siassakos, D. (2013). Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies. Best Practice & Research Clinical Obstetrics and Gynaecology, 27, 571-581. Retrieved from http://www.bestpracticeobgyn.com/article/S1521-6934(13)00051-5/abstract

Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Herrlick, A. (2013). Listening to Mothers III: Pregnancy and Birth. New York: Childbirth Connection. Retrieved from http://www.childbirthconnection.org/article.asp?ck=10450

Eshkoli, T., Weintraub, A., Sergienko, R., & Sheiner, E. (2013). Placenta accreta: risk factors, perinatal outcomes, and consequences for subsequent births. American Journal of Obstetrics & Gynecology, 208, 219.e1-7. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23313722

Guise, J.-M., Eden, K., Emeis, C., Denman, M., Marshall, N., Fu, R., . . . McDonagh, M. (2010). Vaginal Birth After Cesarean: New Insights. Rockville (MD): Agency for Healthcare Research and Quality (US). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK44571/

Hale, B. (n.d.). Children to sue hospital over death of mother. Retrieved from Daily Mail: http://www.dailymail.co.uk/health/article-129801/Children-sue-hospital-death-mother.html

Heller, D. S. (2013). Placenta accreta and percreta. Surgical Pathology, 6, 181-197. Retrieved from http://www.surgpath.theclinics.com/article/S1875-9181(12)00183-3/abstract

Howe, J. (2010). National Institutes of Health VBAC Conference, Day 2, #04: Public Comments. 14:45-17:08. Retrieved from Vimeo: http://vimeo.com/10898005

Kamel, J. (2014, Dec 14). Online poll of 227 women with prior cesareans.

Landon, M. B., Hauth, J. C., & Leveno, K. J. (2004). Maternal and Perinatal Outcomes Associated with a Trial of Labor after Prior Cesarean Delivery. The New England Journal of Medicine, 351, 2581-2589. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMoa040405

Main, E. (2013). HQI Regional Quality Leader Network December Meeting. San Diego.

Minkoff, H. (2010). National Institutes of Health VBAC Conference, Day 2, #04: Public Comments. 11:16. Retrieved from Vimeo: http://vimeo.com/10898005

National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. (2012, Apr 4). Unintended Pregnancy Prevention. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/index.htm

National Center for Health Statistics. (2013). User Guide to the 2012 Natality Public Use File. Hyattsville, Maryland: National Center for Health Statistics. Retrieved from ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/DVS/natality/UserGuide2012.pdf

Reddy, S. (2014, Dec 8). A type of childbirth some women will fight for. Retrieved from Wall Street Journal: http://www.wsj.com/articles/a-type-of-childbirth-some-women-will-fight-for-1418081344

Silver, R. M., Landon, M. B., Rouse, D. J., & Leveno, K. J. (2006). Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries. Obstetrics & Gynecology, 107(6), pp. 1226-1232. Retrieved from http://journals.lww.com/greenjournal/fulltext/2006/06000/maternal_morbidity_associated_with_multiple_repeat.4.aspx

State of California Office of Statewide Health Planning and Development. (2013, December 17). Utilization Rates for Selected Medical Procedures in California Hospitals, 2012. Retrieved from http://www.oshpd.ca.gov/HID/Products/PatDischargeData/ResearchReports/Hospipqualind/vol-util_indicatorsrpt/

Zwart, J. J., Richters, J. M., Ory, F., de Vries, J., Bloemenkamp, K., & van Roosmalen, J. (2009, July). Uterine rupture in the Netherlands: a nationwide population-based cohort study. BJOG: An International Journal of Obstetrics and Gynaecology, 116(8), pp. 1069-1080. Retrieved January 15, 2012, from http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2009.02136.x/full

About Jen Kamel

Jen kamel head shot 2015Jen Kamel is a consumer advocate and a leading national speaker on the medical facts and political, historical climate surrounding vaginal birth after cesarean.  She is the founder of VBACFacts.com and has brought her workshop “The Truth about VBAC: Politics, History and Stats” to over 900 people around the country, giving accurate, current information about post-cesarean birth options directly to families, practitioners, and professionals.

Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, Maternal Mortality, Maternal Quality Improvement, Pregnancy Complications, Vaginal Birth After Cesarean (VBAC) , , , , , , ,

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 , , , , , , ,

ACOG & SMFM Standardize Levels of Maternal Care to Improve Maternal Morbidity & Mortality

February 5th, 2015 by avatar

obThe American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine released their second joint consensus statement on January 22nd, 2015. This consensus statement, Levels of Maternal Care is published in the February 2015 issue of Obstetrics and Gynecology (Green Journal).

What are the objectives of this statement?

The objectives of the statement, Levels of Maternal Care, is fourfold:

  1. To introduce uniform designations for levels of maternal care that are complementary but distinct from levels of neonatal care and that address maternal health needs, thereby reducing maternal morbidity and mortality in the United States
  2. To develop standardized definitions and nomenclature for facilities that provide each level of maternal care
  3. To provide consistent guidelines according to level of maternal care for use in quality improvement and health promotion
  4. To foster the development and equitable geographic distribution of full-service maternal care facilities and systems that promote proactive integration of risk-appropriate antepartum, intrapartum, and postpartum services

With a system in place that defines the levels of care, it will be clear when a transfer of care is deemed necessary to a facility that is better able to provide risk appropriate care to those women who need a higher level of maternity care.  This will improve maternal outcomes and reduce maternal morbidity and mortality.

Our goal for these consensus recommendations is to create a system for maternal care that complements and supplements the current neonatal framework in order to reduce maternal morbidity and mortality across the country. – Sarah J. Kilpatrick, MD/PhD, Lead Author

The USA ranks 60th in maternal mortality worldwide (Kassebaum NJ, 2014) and while some states  have established programs for a striated system of maternity care separate from the needs of the newborn, designations of what level of maternal care center will best serve the mother is not consistent and and creates confusion with a lack of uniform terms and definitions. Data supports better outcomes for mothers when certain maternal complications are handled in a facility deemed most appropriate for that condition.

Many years ago, thanks to the efforts of the March of Dimes, a similar system of levels of neonatal care was designated for the newborn, with each level having clear definitions of the type of services they were best able to provide, how they should be staffed and when a baby was to be transferred to a higher level facility based on newborn health conditions.  This newborn level of care system improved outcomes for babies in the USA, as they were assigned to a location that could best meet their medical needs. The levels of maternal care compliment the levels of care for the neonate, but should be viewed independently from the neonatal designations.

What are the levels of maternal care?

The statement defines five levels of care – Birth Center, Level I (Basic Care), Level II (Specialty Care), Level III (Subspecialty Care) and Level IV (Regional Perinatal Health Care Centers).

For each level, there is a definition, a list of capabilities that each facility should have, the types of health care providers that are assumed to be competent to work there and examples of appropriate patients.

Each level requires meeting the capabilities of the previous level(s) plus the ability to serve even more complicated situations until you reach Level IV, suitable for the most complicated, high populations.

The risk appropriate patient deemed suitable for each level takes into account the skills and training of the midwives or doctors who staff that facility and the ability of those individuals to initiate appropriate emergency skills and response times for the patient.  As a woman becomes less and less “low risk”, she will need to have her care transferred to the appropriate level.  This transfer may occur prenatally, intrapartum or during the postpartum period.

Recognition of the out of hospital midwife and the birth center

The consensus statement recognizes the credentials of the Certified Midwife (CM), the Certified Professional Midwife (CPM) and the Licensed Midwife (LM) as appropriate health care providers, along with Certified Nurse Midwives, OBs and Family Practice doctors, for low risk women in out of hospital facilities where those individuals are legally recognized as able to practice.  The low risk woman is defined as low-risk women one with an uncomplicated singleton term pregnancy with a vertex presentation who is expected to have an uncomplicated birth.

The statement also officially recognizes the freestanding birth center as an appropriate place to give birth for low risk women, along with supporting the collaboration of birth center midwives with the health care providers at higher level maternal care facilities.

Clear capabilities and requirements

The statement also outlines the type of staffing requirements to be available for services, consultation, or emergency procedures at each type of facility.

The consensus statement acknowledges that the appropriate level of  care for the baby may not align with the appropriate level of care for the mother.  Care guidelines that have been long established and well determined for the newborn should also be followed.

Consensus statement receives strong support

The consensus statement has been reviewed and endorsed by:

American Association of Birth Centers

American College of Nurse-Midwives

Association of Women’s Health, Obstetric and Neonatal Nurses

Commission for the Accreditation of Birth Centers

The American Academy of Pediatrics leadership, the American Society of Anesthesiologists leadership, and the Society for Obstetric Anesthesia and Perinatology leadership have reviewed the opinion and have given their support as well.

Additionally, the Midwives Alliance of North America was pleased to see this consensus statement and read how the role of out of hospital midwives was addressed.

MANA applauds ACOG’s identification of the need for birthing women to have a wide range of birthing options, from out of hospital settings for low-risk women to regional perinatal centers for families experiencing the most complicated pregnancies. As ACOG states, a wide variety of providers can meet the needs of low-risk women, including Certified Professional Midwives, Certified Nurse Midwives, Certified Midwives, and Licensed Midwives. We strongly concur with the need for collaborative relationships between midwives and obstetricians. Treesa McLean, LM, CPM, MANA Director of Public Affairs

What does this mean for the childbirth educator?

I encourage all birth professionals to read the consensus statement (it is easy to read) to understand the specifics of each level of maternal care.  As we teach classes, we can discuss with our families that there may be circumstances during their pregnancy or labor that require their care to be changed or transferred to a facility that offers the level of maternal care appropriate for their condition. Some of us already work in hospitals that are Level IV while others of us might teach elsewhere. We can help families to understand why a transfer might be necessary, and how to ask for and receive the information they need to fully understand the reason for a transfer of care and what all their options might be.  Families that are prepared, even for the events that they hoped to avoid, can feel better about how their labor and birth unfold.

Thank you ACOG and SMFM for working hard to clarify and bring about uniform standards that can be applied across the country that will improve the outcomes for mothers giving birth in the USA.

Photo source: creative commons licensed (BY-NC-SA) flickr photo by Paul Gillin

References

Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, et al. Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013 [published erratum appears in Lancet 2014;384:956]. Lancet 2014;384:980–1004. [PubMed]

Levels of maternal care. Obstetric Care Consensus No. 2. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:502–15.

American Academy of Pediatrics, Childbirth Education, Evidence Based Medicine, Maternal Mortality, Maternal Quality Improvement, Maternity Care, Medical Interventions, Midwifery, New Research, Practice Guidelines, Pregnancy Complications , , , , ,

Ebola, Fearbola, and the Childbirth Educator

November 6th, 2014 by avatar

By Rebecca Dekker, PhD, RN, APRN

ebola infographic cc cdcMany news outlets and social media venues have been disseminating information on the Ebola virus and the impact on populations both in West Africa as well as the potential impact on developed nations, including the USA.  The expectant families that you work with may have shared concerns for themselves, their children and their unborn baby with you?  How have you responded?  Did you feel like you had the information that you needed to provide them with facts to calm their concerns?  Occaisonal contributor Rebecca Dekker of EvidenceBasedBirth.com takes a look at the facts about the Ebola virus and shares resources and information applicable to pregnant and breastfeeding families that you can share. – Sharon Muza, Community Manager, Science & Sensibility

What’s the childbirth educator got to fear about Ebola? How do you address your students and clients’ fears?

Well, if you live in the U.S. or in any other country other than Africa—right now, there’s really not much to actually fear. That is, if you’re only worried about yourself and your own community.

The truth is, here in the U.S., there are so many more things that are more likely to kill you than Ebola—other infectious diseases such as influenza, motor vehicle accidents, smoking, secondhand smoke exposure, cardiovascular disease, cancer, even radon—an odorless, colorless gas that exists in many of our homes in the Southeast and can cause lung cancer—you name it, and it’s probably more likely to harm you than Ebola.

So why all the fear here in the U.S.? 

Ebola is a rare but deadly disease, and it has been ravaging West Africa. In developed countries, we feel fear because cases of the disease have finally reached our own shores, when in fact we should have paid attention much sooner to what is happening to our brothers and sisters in Liberia, Guinea, and Sierra Leone.

Does all this fear of Ebola do any good?

Personally, I believe that the fact that so much attention has been drawn to Ebola in developed countries may be a good thing. Fear here means that our governments have finally begun to put energy and resources into stopping the epidemic in Africa– not necessarily for humanitarian reasons– but to prevent the spread of this disease to us.

The Ebola epidemic that has affected parts of West Africa has been a fast-moving event that is only just now showing signs of slowing down. Researchers have conclusive evidence that this is the largest, most severe and most complex Ebola epidemic that we have witnessed since Ebola was first discovered nearly 40 years ago. The number of cases and deaths in this epidemic is many times larger than all past Ebola outbreaks combined.

Before the current epidemic, the Ebola virus had mostly been contained to small outbreaks in rural communities. This time, all of the capital cities in in Liberia, Guinea, and Sierra Leone have experienced large outbreaks.

For the first time, Ebola has entered communities like West Point, in Monrovia, Liberia. According to the World Health Organization, “West Point is West Africa’s largest and most notorious slum: more than 70,000 people crowded together on a peninsula, with no running water, sanitation or garbage collection. The number of Ebola deaths in that slum will likely never be known, as bodies have simply been thrown into the two nearby rivers.”

Ebola has been especially hard-hitting on health care workers. Health workers on the front lines are often exposed to very infectious bodily fluids—blood, vomit, and diarrhea. The fact that health care workers can be at high risk for catching and dying from Ebola was first discovered during the very first Ebola outbreaks that took place in Zaire and Sudan in 1978. Fortunately, researchers have found that proper use and training with personal protective equipment can drastically lower health care workers’ chances of catching the virus. It’s probable that the cases we saw in the U.S. among nurses were due to improper training, inadequate protection equipment, or both.

Interestingly, Ebola actually isn’t as contagious as many other infectious diseases. Measles is an airborne disease, and it is highly contagious. Someone with measles can walk through a room, and another person can walk through that same room two hours later and catch the same measles infection. For every one person who has measles and lives among an unvaccinated population, they will—on average—infect 18 more people.

© CDC

© CDC

In contrast, one person with Ebola infects two other people on average, usually people who have had close, prolonged contact with that person. And the research we have on humans so far shows that Ebola is not airborne—although there have been a few primate studies that suggested otherwise (but some researchers think that maybe the monkeys were spitting on each other!)

One reason Ebola has spread so widely in West Africa – in spite of the fact that this virus is relatively hard to catch compared to other infectious diseases—is that the countries affected are extremely poor. Many people lack running water and soap in their homes.

This means that in West Africa, if one family member comes down with Ebola, there’s a good chance that others in the home will become infected, especially if patients bleed and vomit profusely. Families without modern toilets and washing machines have trouble cleaning up after patients who lose control of their bowels and produce huge amounts of diarrhea. Even burying the dead can spread Ebola in these countries, because common burial rites involve washing the dead and preparing the bodies. However, news organizations are reporting that communities have begun adhering to recommendations to refrain from traditional burial practices that expose more people to the disease.

So, it makes sense that we would fear for our fellow humans in West Africa. They are experiencing what can only be described as a humanitarian crisis. What’s even more concerning is that the virus has—at least for now—crippled an already weak health care infrastructure. This has created what the World Health Organization calls, “an emergency within an emergency.” A great example of this is that pregnant women and infants cannot receive emergency care while resources are drained by the Ebola virus epidemic.

So why are some people panicking about Ebola in the U.S., where the chances of an infection are completely remote? How do we make sense of this?

Well, when it comes to understanding how people perceive risk, and why some people are panicking about Ebola in the U.S., it may be helpful to understand some basic scientific principles behind how people perceive risk.

First of all, risk is subjective. And emotions and our mood change how we interpret risk. So facts matter less when emotions take over.

Also, many people also have an inherent lack of trust in scientists and the government– both here in the U.S. and in West Africa. People often believe their own senses and own experiences more than what scientists say. Many people don’t really understand the scientific process, and have doubts about what they hear. They confuse the research evidence on Ebola with the legal system, and they think there is lots of room for reasonable doubt about whether or not Ebola is airborne, for example.

Also, it’s really important to understand that people perceive a higher risk from rare events with really severe outcomes than they do for common outcomes with less severe or delayed outcomes.

[Does this sound familiar? Just take that sentence above and think about the concept of VBAC and repeat Cesarean. Obstetricians perceive a higher risk from rare events with really severe outcomes—such as uterine rupture—than they do for common outcomes with less severe or delayed outcomes—such as serious maternal infections after a planned repeat Cesarean, or placental abnormalities in future pregnancies].

People also tend to worry more over things that we can’t control. We can control our driving, and getting a flu vaccine, and our diet, and cigarette smoking. But we can’t control Ebola, so that scares us more.

So when we bring fear and emotion into the mix, people’s risk perceptions can end up looking like they do for some people in the U.S. right now– paranoia about Ebola.

It is unfortunate that we have overblown fears of contracting Ebola in the U.S., but if we could redirect our thoughts and channel our efforts into containing the outbreak in West Africa, this is where we will make the biggest difference.

So, in summary:

  • Ebola is a rare but deadly viral infection
  • We are currently witnessing the largest Ebola outbreak in history.
  • The chances of any one of us contracting the virus in the U.S. are extremely remote
  • Fear of Ebola will hopefully trigger people in developed countries to reach out to our fellow humans in West Africa and help them fight the virus

Items of interest related to childbirth and breastfeeding

How can we help?

If you’re worried about Ebola, don’t panic but do put your concern into action. Many health and relief organizations in West Africa are in need of resources, and you can help. This blog article has a comprehensive list of charities working in West Africa right now.

Have your clients and students asked you about Ebola?  Have they expressed concern for themselves or their baby?  Have families discussed the fear of entering the hospital to birth, due to their perceived risk of the hospital as being a potential source of exposure to the Ebola virus?  Hopefully after reading this blog post by Rebecca, you can help provide the facts.  You can also direct them to the Evidence Based Birth online class “Ebola, Fearbola: Separating Facts from Paranoia” and the About.com article “Five Things Pregnant Women Need to Know about Ebola” written by Robin E. Weiss. The Centers for Disease Control and Prevention also provides a wealth of information that you can access and share with the families you work with. – SM

About Rebecca Dekker

Rebecca Dekker

Rebecca Dekker

Rebecca Dekker, PhD, RN, APRN, is the founder of Evidence Based Birth and teaches pathophysiology at a research university. She has taught continuing education classes on HIV and recently developed an in-depth class on the pathophysiology and epidemiology of Ebola (2 nursing contact hours). To learn about how Ebola is transmitted, prevented, diagnosed, and treated, check out Rebecca’s class on “Ebola or Fearbola? Separating Facts from Paranoia,” here.

Childbirth Education, Continuing Education, Evidence Based Medicine, Guest Posts, Maternal Mortality, Maternity Care, Newborns, Research , , , ,