Posts Tagged ‘interventions’

It Takes a Professional Village! A Study Looks At Collaborative Interdisciplinary Maternity Care Programs on Perinatal Outcomes

September 19th, 2012 by avatar

The  Canadian Medical Association Journal, published in their September 12, 2012 issue a very interesting study examining how a team approach to maternity care might improve maternal and neonat aloutcomes.  The study, Effect of a collaborative interdisciplinary maternity care program on perinatal outcomes  is reviewed here.

The Challenge

Photo Source: http://www.flickr.com/photos/jstownsley/28337593/

The number of physicians in Canada who provide obstetric care has declined in past years for reasons that include increasing physician retirement, closure of rural hospitals, liability concerns, dissatisfaction with the lifestyle and a difficulty in accessing maternity care in a variety of settings.  While registered midwife attended births may be on the rise, midwives in Canada attend less than 10% of all births nationwide.   At the same time as the number of doctors willing or able to attend births decline, cesarean rates are on the rise,  causing pressure on the maternity care system, including longer hospital stays both intrapartum and postpartum, which brings with it the associated costs and resources needed to accommodate this increase.

The diversity of the population having babies in many provinces is increasing, presenting additional challenges in meeting the non-French/English speaking population, who are more at risk for increased obstetrical interventions and are less likely to breastfeed.

The Study

In response to these challenges, the South Community Birth Program was established to provide care from a consortium of providers, including family practice physicians, community health nurses, doulas, midwives and others, who would work together to serve the multiethnic, low income communities that may be most at risk for interventions and surgery.

The retrospective cohort study examined outcomes between two matched groups of healthy women receiving maternity care in an ethically diverse region of South Vancouver, BC, Canada that has upwards of 45% immigrant families, 18% of them arriving in Canada in the past 5 years.  One group participated in the South Community Birth Program and the other received standard care in community based practices.

The South Community Birth Program offers maternity care in a team-based shared-care model, with the family practice doctors, midwives, nurses and doulas working together .  Women could be referred to the program by the health care provider or self refer.  After a few initial standard obstetrical appointments with a family practice doctor or midwife occur to determine medical history, physical examination, genetic history, necessary labs and other prenatal testing, the women and their partners are invited to join group prenatal care, based on the Centering Pregnancy Model.  Approximately 20% of the first time mothers choose to remain in the traditional obstetric care model.  10-12  families are grouped by their expected due date, and meet for 10 scheduled sessions, facilitated by either a family physician or midwife and a community nurse.  Each session has a carefully designed curriculum that covers nutrition, exercise, labor, birth and newborn care, among other topics.  Monthly meetings to discuss individual situations and access to comprehensive electronic medical records enhanced the collaboration between the team. Trained doulas, who speak 25 different languages, also meet with the family once prenatally and provide one on one continuous labor support during labor and birth. The admitting midwife or physician remains in the hospital during the patient’s labor and attends the birth.

After a hospital stay of 24-48 hours, the family receives a home visit from a family practice physician or midwife the day after discharge. Clinic breastfeeding and postpartum support is provided by a Master’s level clinical nurse specialist who is also a board certified lactation consultant.  At six weeks, the mother is discharged back to her physician, and a weekly drop in clinic is offered through 6 months postpartum.

The outcomes of the women in the South Community Birth Program were compared to women who received standard care from their midwives or family practice physicians.  Similar cohorts were established of women carrying a single baby of like ages, parity, and geographic region, and all the mothers were considered low risk and of normal body mass index.

The primary outcome measured was the proportion of women who underwent cesarean delivery.  The secondary outcomes measured were obstetrical interventions and maternal outcomes (method of fetal assessment during labor, use of analgesia during labor, augmentation or induction of labor, length of labor, perineal tramau, blood transfusion and length of stay) and neonatal outcomes (stillbirth, death before discharge, Apgar score less than 7, preterm delivery, small or large for gestational age, length of hospital stay, readmission, admission to neonatal intensive care unit for more than 24 hours and method of feeding at discharge).


There was more incidence of diabetes and previous cesareans in the comparison group but the level of alcohol and substance use was the same in both groups.  Midwives delivered 41.9% of the babies in the birth program and 7.4% of babies in the comparison group.

When the rate of cesarean delivery was examined for both nullips and multips, the birth group women were at significantly reduced risk of cesarean delivery and were not at increased risk of assisted vaginal delivery with forceps or vacuum.

Interestingly, the birth program women who received care from an obstetrician were significantly more likely to have a cesarean than those receiving in the standard program who also received care from an obstetrician.  More women in the birth program with a prior cesarean delivery planned a vaginal birth in this pregnancy, though the proportion of successful vaginal births after cesareans dd not differ between the two groups.

The women in the community birth program experienced more intermittent auscultation vs electronic fetal monitoring and were more likely to use nitrous oxide and oxygen alone for pain relief and less likely to use epidural analgesia (Table 3).  Though indications for inductions did not differ, the birth program women were less likely to be induced.  More third degree perineal tears were observed in the birth program group but less episiotomies were performed.  Hospital stays were shorter for both mothers and newborns in the community program.

When you look at the newborns in the birth program, they were at marginally increased risk of being large for gestational age and were readmitted to the hospital in the first 28 days after birth at a higher rate, the majority of readmissions in the community and standard care group were due to jaundice. Exclusive breastfeeding in the birth program group was higher than in the standard group.


The mothers and the babies in the community birth program were offered collaborative, multidisciplinary, community based care and this resulted in a lower cesarean rate, shorter hospital stays, experienced less interventions and they left the hospital more likely to be exclusively breastfeeding. Many of the outcomes observed in this study, especially for the families participating in the South Birth Community Program are in line with Lamaze International’s Healthy Birth Practices.  There are many questions that can be raised, and some of them are are discussed by the authors.

Was it the collaborative care from an interdisciplinary team result in better outcomes?  Was there a self-selection by the women themselves for the low intervention route that resulted in the observed differences?  Are the care providers themselves who are more likely to support normal birth self-selecting to work in the community birth program? Did the fact that the geographic area of the study had been underserved by maternity providers before the study play a role in the outcomes? Did the emotional and social support provided by the prenatal and postpartum group meetings facilitate a more informed or engaged group of families?

I also wonder how childbirth educators, added to such a model program, might also offer opportunity to reduce interventions and improve outcomes  Could childbirth educators in your community partner with other maternity care providers to work collaboratively to meet the perinatal needs of expectant families?  Would bringing health care providers interested in supporting physiologic birth in to share their knowledge in YOUR classrooms help to create an environment where families felt supported by an entire skilled team of people helping them to achieve better outcomes.

Would this model be financially and logistically replicable in other underserved communities and help to alleviate some of the concerns of a reduction in obstetrical providers and increased cesareans and interventions without improved maternal and newborn outcomes? And how can you, the childbirth educator, play a role?


Azad MB, Korzyrkyj AL. Perinatal programming of asthma: the role of the gut microbiota. Clin Dev Immunol 2012 Nov. 3 [Epub ahead of print].

Canadian Association of Midwives. Annual report 2011. Montréal (QC): The Association; 2011. Available: www .canadianmidwives.org /data/document /agm %202011 %20inal .pdf

Farine D, Gagnon R; Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada. Are we facing a crisis in maternal fetal medicine in Canada? J Obstet Gynaecol Can 2008;30:598-9.

Getahun D, Oyelese Y, Hamisu M, et al. Previous cesarean delivery and risks of placenta previa and placental abruption.Obstet Gynecol 2006;107:771-8.

Giving birth in Canada: the costs. Ottawa (ON): Canadian Institute of Health Information; 2006.

Godwin M, Hodgetts G, Seguin R, et al. The Ontario Family Medicine Residents Cohort Study: factors affecting residents’ decisions to practise obstetrics. CMAJ 2002;166:179-84.

Hannah ME. Planned elective cesarean section: A reasonable choice for some women? CMAJ 2004;170:813-4.

Harris, S., Janssen, P., Saxell, L., Carty, E., MacRae, G., & Petersen, K. (2012). Effect of a collaborative interdisciplinary maternity care program on perinatal outcomes. Canadian Medical Association Journal, doi: DOI:10.1503 /cmaj.111753

Ontario Maternity Care Expert Panel. Maternity care in Ontario 2006: emerging crisis, emerging solutions: Ottawa (ON): Ontario Women’s Health Council, Ministry of Health and LongTerm Care; 2006.

Reid AJ, Carroll JC. Choosing to practise obstetrics. What factors influence family practice residents? Can Fam Physician 1991; 37:1859-67.

Thavagnanam S, Fleming J, Bromley A, et al. A meta-analysis of the association between cesarean section and childhood asthma. Clin Exp Allergy 2008;38:629-33.



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Midwifery Organizations Band Together in Support of Normal Physiologic Birth

July 27th, 2012 by avatar

In May of this year, three leading midwifery organizations, American College of Nurse Midwives (ACNM), Midwives Alliance of North America (MANA) and National Association of Certified Professional Midwives (NACPM) jointly released a statement titled “Supporting Healthy and Normal Physiologic Childbirth; A Consensus Statement by ACNM, MANA and NACPM,” intended for health care professionals and policymakers.  This strongly worded statement supports healthy and normal physiologic childbirth for for U.S. women. It is logical that the three main U.S. midwifery organizations coordinated in preparing this statement, as midwives are the gatekeepers of normal birth for low risk women.   The purpose of the consensus statement, which was developed by a joint task force appointed from members of the three midwifery organizations was to:

  • Provide a succinct definition of normal physiologic birth;
  • Identify measurable benchmarks to describe optimal processes and outcomes reflective of normal physiologic birth;
  • Identify factors that facilitate or disrupt normal physiologic birth based on the best available evidence;
  • Create a template for system changes through clinical practice, education, research, and health policy; and
  • Ultimately improve the health of mothers and infants, while avoiding unnecessary and costly interventions.

A normal physiologic labor and birth is one that is powered by the innate human capacity of the woman and fetus. This birth is more likely to be safe and healthy because there is no unnecessary intervention that disrupts normal physiologic processes.  Some women and/or fetuses will develop complications that warrante medical attention to assure safe and healthy outcomes.  However, supporting the normal physiologic processes of labor and birth, even in the presence of such complications, has the potential to enhance best outcomes for mother and infant.

These three organizations recognize the current state of U.S. maternity care and acknowledge how technology and interventions are being commonly used despite the lack of scientific evidence supporting routine applications. (Sakala, 2008.)  Some of the interventions cited including pitocin being used to induce or augment more than half of all pregnant women’s labors. (Declercq, Sakala, 2006.)  The cesarean rate in the United States is more than 33%. (Martin,Hamilton, Ventura 2011.) This cesarean rate is not without risks for both mothers and babies with the original cesarean birth but also recognizes the complications to subsequent pregnancies and birth.  The organizations also commented that women who have perceived their birth or the care they received as traumatic or disrespectful are more likely to develop postpartum mood disorders and potentially difficulty in establishing healthy mother-infant attachment. (Beck, 2004), (Beck, Watson, 2008), (Beck, 2006).

The consensus statement goes on to state the characteristics of normal physiologic birth;

  • is characterized by spontaneous onset and progression of labor;
  • includes biological and psychological conditions that promote effective labor;
  • results in the vaginal birth of of the infant and placenta;
  • results in physiological blood loss,
  • facilitates optimal newborn transition through skin-to-skin contact and keeping the mother and infant together during the postpartum period; and
  • supports early initiation of breastfeeding. (World Health Organization 1996).

When I was reading the above list, as outlined by the World Health Organization and cited in the consensus statement,  I was stuck by how these statements are in sync with Lamaze International’s Healthy Birth Practices.  I was also a bit discouraged that these statements, published by WHO in 1996 sometimes still seem a distant goal.

There are factors that interfere with the normal physiologic process, including many that you may be very familiar with; induction or augmentation of labor, lack of a supportive environment, time limits on labor, denial of food and drink, pain medications, episiotomies, vacuum or forceps assisted deliveries, cesareans, immediate cord clamping, separation of the new mother from her newborn and finally, a situation that may feel threatening or unsupportive to the mother.

The consensus statement recognizes the numerous short-term and long-term health implications of normal birth to the mother-baby dyad.  Allowing labor and birth to unfold without interference permits labor and birth hormones to work effectively, thereby reducing the need for the familiar “cascade of interventions.”

For most women, the short-term benefits of normal physiologic birth include emerging from childbirth feeling physically and emotionally healthy and powerful as mothers…A focus on these aspects of normal physiologic birth will help to change the current discourse on childbirth as an illness state where authority resides external to the woman to one of wellness in which women and clinicians share decisions and accountability. (Kennedy, Nardini, McLeod-Waldo, 2009).

When women enter motherhood from a position of strength and confidence, babies benefit, families benefit and society benefits.  Multiple factors for the woman, the clinician and the birthing environment help to promote women birthing without intervention.  All three sides of an important triad need to share equal responsibility in meeting this goal.

The consensus statement indicates that education plays a role in helping women obtain a normal physiologic birth.  The role of the childbirth educator cannot be underestimated.  Sharing the values of Lamaze and the Lamaze Healthy Birth Practices is right in line with the midwifery statement.

ACNM, MANA and NACPM go on to encourage hospital policies to be set that support normal birth, the recognition that care practices need to be evidenced based.  Midwifery care is a “key strategy” in that direction.  Education of clinicians on care practices that promote physiologic birth and furthering research on the effects of normal birth, among other things.

This consensus statement is clear and powerful in demonstrating that our mothers and babies deserve, depend on and require the opportunity to birth without interventions and that everyone will benefit as a result, in the absence of medical complications or medical need.  I look forward to policy changes, increased accessibility of mothers to midwives and the midwifery model of care and collaboration of all health care providers, both doctors and midwives, to promote practices that result in an increase in normal physiologic birth.

Take a moment to read the entire consensus statement and let me know what you think?  A step in the right direction?  What comes next?  Do you think it is exciting that these three organizations have worked together to come out with this bold challenge to make change? What do you do in your childbirth classes or with the women you work with to promote these values represented by the consensus statement.  Would you add anything else?   I welcome your discussion in our comments section. – SM


Beck CT. Birth trauma: in the eye of the beholder. Nurs Res. 2004; 53(1):28-35.

Beck CT, Watson S. The impact of birth trauma on breastfeeding: a tale of two pathways. Nurs Res. 2008; 57(4):228-236.

Beck CT. The anniversary of birth trauma: failure to rescue. Nurs Res. 2006; 55(6): 381-390.

Beck CT.Post-traumatic stress disorder due to childbirth:the aftermath.NursRes, 2004; 53(4):216-224.

Declercq ER, Sakala C, Corry MP, et al. Listening to mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection; 2006.

Kennedy HP, Nardini K, McLeod-Waldo R, et al. Top-selling childbirth advice books: a discourse analysis. Birth. 2009;36(4):318-324.

Martin JA, Hamilton BE, Ventura SJ, et al. Births: preliminary data for 2010. Natl Vital Stat Rep. 2011; 60(2):1-25.

Sakala C, Corry MP. Evidence-based maternity care: what it is and what it can achieve. New York, NY: Milbank Memorial Fund; 2008.

World Health Organization. Care in Normal Birth: A Practical Guide. World Health Organization; 1996.

Babies, Breastfeeding, Cesarean Birth, Childbirth Education, Epidural Analgesia, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, Home Birth, Infant Attachment, informed Consent, Maternal Mental Health, Maternal Mortality, Maternal Quality Improvement, Medical Interventions, Midwifery, Newborns, Pain Management, Push for Your Baby, Transforming Maternity Care , , , , , , , , , , , , , , ,

Pregnancy and Childbirth Advice Books through the Lens of Preeclampsia

July 3rd, 2012 by avatar

Guest post by Science & Sensibility contributer Christine H. Morton, PhD

(Full disclosure:  the organization I work for, CMQCC, has been working with representatives from the Preeclampsia Foundation over the past year on the CMQCC task force developing a Preeclampsia Toolkit, and I am a big fan of their executive director, Eleni Tsigas, and frequent re-tweeter of @preeclampsia).

The Preeclampsia Foundation released a new guide to pregnancy and birth books last month, a comprehensive report distilled from a review of more than 60 such books, on their accuracy, coverage and clarity of information on hypertensive complications in pregnancy.    As readers of S&S are well aware, there are numerous books geared to expectant couples, pregnant women, and male partners; by authors who claim their authority by virtue of their clinical degrees and practice, their teaching and research credentials, as well was their personal and celebrity experience.   This is the first time I’ve seen a guide to pregnancy and birth advice books from the lens of a serious disorder in pregnancy:  preeclampsia.

May was Preeclampsia Awareness Month. Hypertensive disorders of pregnancy, including elevated blood pressure, preeclampsia, eclampsia and HELLP syndrome are estimated to affect 12-22% of pregnant women and their babies each year.1 Preeclampsia is a leading cause of pregnancy-related death in the US and in the state of California, and one of the most preventable. Adverse neonatal outcomes are higher for infants born to women with pregnancies complicated by hypertension. Care guidelines have recently been developed in many countries, including the UK, Canada and Australia, with a revised practice bulletin to be released from ACOG later this year. A key focus in many of these guidelines is accurate measuring of Blood Pressure, and standardized pathways of care, depending on the clinical situation. These guidelines note that one reason for their creation is the clear evidence that the surveillance of women with suspected or confirmed preeclampsia is variable between practitioners.2,3
 Seeking to understand their experience, women turn to books, their childbirth educators and doulas to help them navigate through this new and unexpected turn into complicated pregnancy.   While many women have healthy pregnancies and births, those who are having symptoms, or have been diagnosed with preeclampsia, eclampsia or HELLP syndrome, need accurate and clear information.    Early detection, and treatment, is a proven way to lessen the severity of the disease, and mitigate its impact.  Are some pregnancy and childbirth guidebooks better than others in informing readers about these issues?

To answer this question, researchers Jennifer Carney, MA and Douglas Woelkers, MD reviewed more than 60 pregnancy and childbirth advice books and ranked them using a consistent set of criteria in five categories: Depth of Coverage, Placement of Coverage, Clarity and Accuracy of Information, Description of Symptoms, and Postpartum Concerns.  In their methods section, they note that

“Books were downgraded for out-of-date information, missing or inaccurate information and placement issues, including inaccurate or inadequate indexing.    Of the more than 60 books reviewed, none ranked above “8” in all five categories. In fact, only a handful of books scored above “8” in the category of “Postpartum Concerns,” since many books routinely state that the cure for preeclampsia and related disorders is the birth of the baby.”

Childbirth educators and doulas have strong views on the ‘best’ books to guide women through pregnancy and childbirth and might be surprised to find that even best selling books like Ina May’s Guide to Childbirth (2003) scored only a 2.6, while the much excoriated, yet highest selling advice book: What To Expect When You’re Expecting (2009) ranked last in the Preeclampsia Foundation’s TOP TEN list, with a score of 7.2.  All books reviewed are listed in the Appendix of the report.

One helpful feature of the report is a sampling of questionable claims found in pregnancy guidebooks:

“Preeclampsia never happens before the twentieth week, but your blood pressure may start to rise steadily after this. Delivery of the baby and placenta ends the problem.” From Conception, Pregnancy, and Birth by Miriam Stoppard. In rare instances preeclampsia can occur prior to 20 weeks; it can also occur up to six weeks postpartum.

The report further explains why it’s important for books on childbirth to also mention preeclampsia, eclampsia and HELLP Syndrome, since this disease can develop immediately prior to, during or after delivery.  Among the childbirth books, the reviewers found,

Only Penny Simkin’s book The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas, and All Other Labor Companions (2007) provides adequate information about preeclampsia, eclampsia, and HELLP syndrome. Although this book incorrectly uses the term pregnancy-induced hypertension (PIH) to describe preeclampsia and eclampsia, it provides a useful list of symptoms and the possible treatments, including cesarean delivery. It also presents some of the emotional issues that might arise from a diagnosis of PIH and includes some information on HELLP syndrome. It acknowledges the possibility of postpartum preeclampsia and eclampsia, something that many of the general pregnancy books omit.

The report can help childbirth educators and doulas point women to the best information about hypertensive disorders, but its authors also hope these results will guide authors in future revisions.  At the very least, up to date terminology, accurate information and complete indexing is critical in revisions. Books geared primarily to women with relatively healthy pregnancies always face the challenge of balancing reassurance, the optimality of physiological birth and the diverse range of potential complications in pregnancy.  Yet such books can point readers to resources like the Preeclampsia Foundation for up-to-date and user-friendly information and community pages.

Take-away points for Childbirth Educators and Doulas:

  • Check your website and be sure to link to Preeclampsia Foundation website for unbiased, evidence-based information on this disease.  They are on Facebook too.
  • Tell your students to ask about their blood pressure at all prenatal visits and during labor.  They should know what their ‘normal’ range is, and if their BP is ever above 140 systolic or 90 diastolic, to be alert to signs and symptoms of preeclampsia, and report these changes to their care providers.
  • Many factors can affect BP readings:  BP cuff size should be appropriate, especially among women with a high BMI; the measurement should be taken while sitting, with arm at heart level; automated BP machines may underestimate the BP.
  • Remind pregnant women (and their partners) that although lots of attention will naturally be focused on the baby, they have to be alert to the new mother’s health symptoms postpartum too.  While postpartum is a whole new normal, women need to know that any significant bleeding, fever, headaches, nausea, or visual disturbances, are NOT normal, and they should follow up with their health care provider immediately.

Preeclampsia is a serious, if unlikely, complication of pregnancy.  Women diagnosed or at risk for developing hypertensive disorders of pregnancy can find accurate information for all literacy levels (and some Spanish language resources), as well as a supportive community at the Preeclampsia Foundation, a US-based 501(c)(3) not-for-profit organization whose mission is to reduce maternal and infant illness and death due to preeclampsia and other hypertensive disorders of pregnancy by providing patient support and education, raising public awareness, catalyzing research and improving health care practices.


1. American College of Obsetricians and Gynecologists. Diagnosis and management of preeclampsia and eclampsia; ACOG Practice Bulletin No. 33. Obstetrics & Gynecology. 2002;99:159-167.

2. Repke JT PM, Holzman GB, Schulkin J. Hypertension in Pregnancy and Preeclampsia: Knowledge and Clinical Practice Among Obstetrician-Gynecologists. Journal of Reproductive Medicine. 2002;47(6):472-476.

3. Caetano M OM, von Dadelszen P, Hannah ME, Logan AG, Gruslin A, Willan A, Magee LA. A Survey of Canadian Practitioners Regarding Diagnosis and Evaluation of the Hypertensive Disorders of Pregnancy. Hypertens Pregnancy. 2004;23(2):197-209.

4.  Hogan JL, et al.  Hypertens Pregnancy. Body Mass Index and Blood Pressure Measurement during Pregnancy. 2011;30(4):396-400.  PMID: 20726743

Read more about Christine H. Morton, PHD on our contributor page.





Book Reviews, Childbirth Education, Guest Posts, informed Consent, Maternity Care, Medical Interventions, Patient Advocacy, Practice Guidelines, Pre-eclampsia, Pregnancy Complications, Uncategorized , , , , , , , , , , , , , , , ,

Hospital Charges Still All Over the Map

May 17th, 2012 by avatar

You can get from New Jersey to Maryland in less than an hour, but despite the proximity, New Jersey hospitals, on average, charge 3-4 times more than Maryland hospitals for both vaginal and cesarean births. This is just one of the notable facts gleaned from Childbirth Connection’s analyses of the latest maternity charges data. Although the data do not show whether higher charges reflect better care, researchers who look at price variation generally find no relation between prices and the quality of care, complexity of patient care needs, or costs of actually delivering care. Such unwarranted price variation amounts to billions in wasted spending across the health care system, according to a February report from Thomson Reuters that looked at various hospital procedures.

New charts compiled by Childbirth Connection (PDF) show the significant price variation across states that report average labor and birth hospital charges to the Healthcare Cost and Utilization Project (HCUP). The chart set also includes average prices charged by birth centers, which fall well below charges for uncomplicated vaginal births in hospitals. State-by-state analyses (PDF) show charges increasing year-to-year, and reveal differences by mode of birth and presence or absence of complications.

What do these figures mean for improving maternity care?

Labor, birth, and newborn care are the most common and costly hospital conditions for both Medicaid programs and private insurers. The data in Childbirth Connection’s Charges Charts reveal four potential strategies for reining in costs:

  1. increase the proportion of vaginal births – Hospital charges for cesareans are about 66% higher than hospital charges for vaginal births (a difference of $5,900- $8,400 depending on complications).
  2. provide safer care – Complications increase charges by about 35% (a difference of $2,800 – $5,400 depending on mode of birth). Some complications are preventable with hospital safety initiatives.
  3. remove barriers to out-of-hospital birth for low-risk women interested in these options – Birth center charges are $6,600 less than charges for uncomplicated vaginal births in hospitals.
  4. reduce charges for births in facilities and states where charges exceed average – Policy makers can work to increase price transparency and align payment with quality.

We can improve the quality and value of maternity care by identifying innovations that safely and fairly achieve these goals and reduce unintended consequences.

Resources from Childbirth Connection

State-by-state Charges Charts

Multi-state Charges Comparisons (PDF)

Quick Facts About Hospital Labor & Birth Charges

Thank you, Amy Romano, for this fascinating guest post on the economic side of birth.  Childbirth is the most common reason for hospital admission in the United States (AHRQ, 2002).  Simple changes that will improve the experience of the families, save significant money and reduce unnecessary interventions, Lamaze’s Healthy Birth Practice #4. have been needed for a long time. Midwifery care for low risk women is one step in that direction. There are many other things that can happen to achieve the goal of healthy mothers, healthy babies while reducing costs. What do you think are some steps that can be taken to reduce the spiraling and often unnecessary medical costs of having a baby?  What should hospitals and health care providers be doing to get these costs under control?  How can consumers play a part in that?  Please share your ideas here, or programs that you are aware of that are working on this very issue!

Sharon Muza



Agency for Healthcare Research and Quality, (2005). Hospitalization in the United States, 2002 (AHRQ Publication No. 05-0056). Retrieved from website: http://archive.ahrq.gov/data/hcup/factbk6/


Guest Posts, Healthy Birth Practices, Maternal Quality Improvement, Medical Interventions, Midwifery, Uncategorized , , , , , , ,

Caring for Survivors of Sexual Abuse Throughout the Childbearing Journey

April 25th, 2012 by avatar

A guest post by Deborah Issokson, Psy.D.

Childbearing is a vulnerable process.

Regardless of our profession within the childbirth world, we are working to facilitate an experience that has a positive emotional outcome accompanied by a healthy psychological adjustment to motherhood. It is incumbent upon us to understand and be sensitive to all the ways in which childbearing can be both triggering and potentially healing for women with abuse histories.

It is crucial to remember that not all survivors will have the same experience of pregnancy, birth, postpartum and breastfeeding. And we cannot assume that all women experiencing difficulties with aspects of childbearing such as pelvic exams, touch, immodesty, language, and pain are abuse survivors.

For an abuse survivor, abuse memories may be triggered by the physical changes, social and psychological tasks, medical procedures, and rituals of childbearing.

For some, abuse memories and emotions will be familiar, expected; others may experience these memories as regressive in their healing. For still others, the memories and emotions will be unexpected and intrusive, signaling the first time they are coming forth.

Preserving the Mental Health of Sexual Abuse Survivors

From a mental health perspective, the task with an acknowledged sexual abuse survivor during childbearing is threefold: help her maintain her current level of functioning, help her contain the memories, and facilitate further healing using childbearing as a vehicle for growth.

If the woman is unaware of her abuse history, we may be in the position of suspecting it or listening to her share her own inklings based on the feelings, concerns, fears and distress that she is experiencing and we are observing.

However, the Pandora’s box of sexual abuse memories must be opened delicately. Ideally, pregnancy is a time of containment as a woman grows a baby inside her body, preparing psychologically and spiritually for motherhood. And while birth is a time of opening and transforming, it is also a time when we want to limit extraneous, stressful stimuli so that a woman can immerse in her transformation to motherhood.

Strategies for Childbirth Professionals

So what do we do, in our respective roles, to meet these goals, implement these tasks and stay mindful of pacing, timing and professional limitations and boundaries?

  • We can encourage a woman to review coping strategies she has previously employed.
  • We can encourage her to seek support from a therapist, partner, friends, a support network.
  • We can help her stay grounded by contextualizing her physical changes and discomforts, reviewing the real and appropriate changes happening in her body, reflecting on her health and resilience and helping her pace herself as she adjusts to the changes.
  • We can be instrumental in helping a woman explore her choices for place of birth, care providers, and birth intentions. Her choice of provider and the manner in which she makes her choices may be affected by her abuse history and by the gender of her abuser. She may choose a provider and a place of birth that could facilitate a healing experience for her. On the other hand, she may unconsciously recreate the dynamics she experienced with her abuser.

Women wonder about sharing their abuse story with everyone who cares for them, be it the medical provider, the educator, the doula or the breastfeeding counselor. While it isn’t necessary to tell the entire story, it can be helpful for certain providers to have a general sense of the history in order to be sensitized to the woman’s issues as they pertain to prenatal care, labor and delivery, postpartum care and breastfeeding assistance.

If a woman is working with a group practice or being taught by a revolving set of educators, she may not want to repeat her story for each provider. Rather, we can encourage her to share with one provider with whom she feels most comfortable, asking that a brief note be put in her chart to inform the others. We can also suggest she write a brief statement herself, highlighting what she most wants her providers to know about her story, her vulnerabilities and her coping strategies.

Emotional dynamics of birth and transition to parenting
For an abuse survivor, normal fears, anxieties and concerns about birth can take on additional psychic charge due to the physical and sexual nature of birth.

On one end of the continuum is the experience of giving birth as healing; on the other end is the feeling that birthing is tantamount to a recurrence of sexual abuse. In between are shades of gray.

Most births have healthy, uncomplicated physical outcomes; the emotional outcome is not so predictable. There is no telling how a woman will experience her birth and how she will make meaning of it. As a witness to her birth, we may perceive it as wonderful, empowering and successful, while the woman may have a completely different emotional experience and perception.

Furthermore, the emotional outcome is an unfolding process for the postpartum woman. The new mother spends part of her postpartum year reviewing and dissecting her birthing experience. It is not unusual for the survivor of abuse, years later, to have a new perspective on her experience. Sometimes it is a more healing perspective.

For an abuse survivor, the postpartum period can be a time of consolidation of past healing efforts as she enters a phase of parenting and protecting a new human being.

For other women, parenting can be the catalyst for new memories and flashbacks, new conflicts with extended family, and even regression in the healing process. Survivors of abuse are at high risk for experiencing postpartum depressive and anxiety disorders. These mental health issues require attention and treatment as soon as possible as they have a detrimental impact not only on the woman, but also on her baby and her entire family.

Empower by Giving Space to the Individual Woman
As providers of care, we are often witness to great courage, strength and healing as survivors of sexual abuse journey toward parenthood.

Empower your client to shape this childbearing experience for herself. Ideally, your work together can culminate in a positive emotional experience of pregnancy and birth, a healthy connection between mother and baby, and a sense of self-efficacy as a mother.


Issokson, Deborah. 2004. Chapter 11, Effects of Childhood Abuse on Childbearing and Perinatal Health in Health Consequences of Abuse in the Family: A Clinical Guide for Evidence-Based Practice, K. Kendall- Tackett, editor. Washington D.C.: American Psychological Association.

Kendall-Tackett, K. 1998. Breastfeeding and the sexual abuse survivor. Journal of Human Lactation, 14(2), 125-130.

Simkin, Penny and Phyllis Klaus. 2004. When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women. Washington: Classic Day Publishing.

Sperlich, Mickey and Julia Seng. 2008. Survivor Moms: Women’s Stories of Birthing, Mothering and Healing after Sexual Abuse. Oregon: Motherbaby Press.

Deborah Issokson, Psy.D, is a licensed psychologist in Massachusetts specializing in Perinatal Mental Health. She is a contributor to several editions of Our Bodies, Ourselves. She was a faculty member of the Boston University School of Public Health, lecturing on Maternal and Child Health (now closed). She  can be reached at info@reproheart.com. Visit her website at www.reproheart.com.

Childbirth Education, Depression, Evidence Based Medicine, Guest Posts, Healthy Care Practices, informed Consent, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, Research, Survivors of Sexual Abuse , , , , , , , , ,

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