The Maternal Quality Landscape–Part Three, Segment Five: How do we measure AND achieve it?

[Editor’s Note:  In this final segment of Christine Morton and Kathleen Pine’s series on the Maternal Quality Care landscape in the United States, the post authors look at where the <39 weeks elective deliveries bans have been effective, and where such attempts may have some unintended outcomes.  Finally, Morton and Pine offer a feasible list of actions childbirth educators and doulas can take in their own communities.  To read this entire series from the beginning, go here.]


Unintended consequences

We would like to now draw your attention to some of the unintended consequences of quality measurement.

 There has been strong support for this initiative among many stakeholders, including ACOG, the March of Dimes, and several National Quality organizations, such as NQF, TJC and Leapfrog.  Many states or major hospital systems have convened collaboratives, such as Ohio and Intermountain HealthCare in Utah, and several more are in the works, such as North Carolina, Oregon, Oklahoma and Illinois.  State Medicaid programs are expressing interest, especially in payment reforms and commercial insurance companies have launched initiatives, such as Anthem Blue Cross Patient Safety First initiative in California.  This type of support from a wide range of stakeholders is impressive, and positive.  Yet, some stakeholders promoting the <39 weeks measure assumed its adoption would lead to a significant reduction in the overall cesarean section rate.   Unfortunately, this assumption is largely unwarranted since only about 4-10% of all births are elective deliveries between 37 and 39 weeks, and most of these are scheduled repeat cesareans.

 Another unintended consequence is that this measure may affect the way elective inductions are scheduled.  At the micro-level, it is possible that schedulers may simply schedule inductions so as to not negatively impact the hospital’s statistics (for example, by scheduling inductions automatically for 39 weeks and 1 day gestation).  However, this brings up a big-picture question: If we focus on 39 weeks, what are we doing to prevent elective inductions at any gestational age, which may arguably be the bigger issue?  It is possible that this measure may sensitize stakeholders to the wrong issue: timing of birth rather than the fact that it is generally best when labor begins on its own.  Additionally, is it possible that 39 weeks could become the new “ideal” gestational age, because it will be assumed that 39 completed weeks is the best time to be born?  While the measure does not state that 39 weeks is ideal for all inductions, providers and the general public may not understand that selecting 39 weeks as an upper limit is not an endorsement of this age as the ideal age to be born.



The last unintended consequence we discuss has to do with how the public message is conveyed via the media, such as the recent NPR story with the title, “Doctors to Pregnant Women: Wait at Least 39 Weeks.”  Some reports, like the one in the Portland Tribune, cover the issue in a balanced way, and note that there are pressures/drivers from both women and physicians in early term deliveries.  Yet, others, with headlines like “More hospitals banning elective C-sections” convey the message that women have been the driving force behind this trend in early deliveries and hospitals/providers are finally drawing the line in the sand.   Data from Listening to Mothers II doesn’t support such claims, but while it’s true some women seek early elective deliveries there are also physicians who recommend or ‘lead women’ to that decision.   After all, women can’t schedule a cesarean or an induction – only hospital staff can, upon orders from a provider.   The result of this framing is that public comments on such stories often take women to task for being selfish and unthinking, unfit mothers. There are a few who provide the other side, however, citing providers as drivers, and hospitals as willing partners, of the increase in early deliveries.


What can childbirth educators and doulas do?

  • Take advantage of education resources, including the March of Dimes’ “brain card” which illustrates the differences in brain development at 35 and 40 weeks of pregnancy, and can be used to help women understand the importance of waiting.
  • Share this excellent article by Kathleen Rice Simpson and colleagues on the success of an educational intervention to decrease the rate of elective labor indication among nulliparous women at a community hospital with hospital staff in your community, and implement in your own classes.
  • Make sure your local hospital maternity nursing staff is aware of AWHONN’s new education campaign: “40 Reasons to Go the Full 40 Weeks.”
  • Reach out to a local March of Dimes organization to partner with them on a public education seminar- this is an issue for the general public as much as for pregnant women.  March of Dimes chapters tend to have good relationships with hospitals and may be a new ally in your community for promoting optimal birth practices.
  • Set up Google Alerts for key words (“Elective Deliveries” “cesarean”) so that you are notified by email when new content appears online (news or blogs).  Then monitor the public comments pages and offer your perspective as a childbirth educator/doula and be sure to include information on your services or cite Lamaze as a place for people to get evidence based information.
  • Ask the perinatal nurse manager at your local hospital(s) whether the facility is going to report on TJC perinatal measure set.  If not, ask when they plan to, and who in the hospital is the decision maker.   But understand it may be a struggle for hospitals to report on this measure set, and the process might be slower than advocates would like.
  •  Reach out to non-mainstream audiences, especially among those who are not likely to attend typical childbirth classes but who may be at greater risk for elective deliveries –Latinas, African American women, younger and non-native English speaking women and those without partners.

    Posted by:  Christine Morton, PhD and Kathleen Pine (University of California, Irvine)



Maternal Quality Improvement, Maternity Care , , , , , , , , , , , , ,

  1. avatar
    Walker Karraa, MFA, MA, CD
    | #1

    The list of things we can do is very helpful. I would like to gently offer that in addition, we need to go through each step you offer and see where we might add maternal mental health. As you and everyone reading S&S knows, it is solidly proven that anxiety and depression greatly increase a woman’s chance of PTB–yet where are cbe’s and doulas on this matter?

    Lamaze itself refuses to publish a white paper or position paper on maternal mental health. Where are the articles on maternal mental health in the JPE? Conference?


    ICEA, under the incredibly vision of Nancy Lantz, is the ONLY certifying childbirth education organization with a position paper on PPMAD. They have reviewed reading list, and curriculum to include evidence based practices and research regarding PPMADs.

    Not sure what the obstacle is…MOD has even succumbed to the overwhelming evidence and added depression to their site.

    If we visit our organizations’ websites right now, where is there any resource for women and families, much less care providers, to address childbirth for the 1 in 7 women who walk into the labor room with a full-blown mood or anxiety disorder?

    This is a systemic problem and one of the symptoms of birth profession’s
    Failure to Progress.

    I respect you both so very much, I would appreciate your thoughts on this issue.Great series, and thank you Kimmelin Hull for providing good science and sensibility.

  2. | #2

    Thank you for pointing out the flaw in the 39 wk guideline, i.e., that it leaves the impression that elective delivery after 39 weeks is harmless, possibly even desirable. For one thing, at least with elective cesarean, excess incidence of respiratory morbidity is not completely eliminated by delivery after 39 weeks http://www.ncbi.nlm.nih.gov/pubmed/18077440?dopt=Citation and http://www.ncbi.nlm.nih.gov/pubmed/19274494?dopt=Citation. Even more important, studies consistently find that elective induction–which means that any harms result from inducing labor itself, not the indication for induction–doubles the odds of the labor ending in a cesarean. The use of cervical ripening agents does not change that. Cesarean surgery, of course, has negative consequences–including increased likelihood of severe morbidity and mortality–for women and babies in both the current and any future pregnancies. Even one of your recommendations, using “40 Reasons to Go the Full 40 Weeks,” misses this latter point. The *median* length of pregnancy exceeds 40 weeks by several days and possibly by as much as a week in first-time mothers http://www.ncbi.nlm.nih.gov/pubmed/2220340?dopt=Citation http://www.ncbi.nlm.nih.gov/pubmed/11425837?dopt=Citation http://www.ncbi.nlm.nih.gov/pubmed/2342739?dopt=Citation, which means that following this recommendation, with its implication that induction at 40 weeks is fine, will result in many preventable cesareans, if fewer cases of neonatal respiratory morbidity.

    Also, the Rice Simpson study not only shows that education can help reduce elective induction but the degree to which elective induction is driven by obstetricians, not women, including many cases in which the physician defined the induction as “elective,” but the woman thought she was agreeing to a medically indicated induction.

  3. | #3

    Apologies, I forgot to put in the link to Amy Romano’s S&S blog post on the Rice Simpson article: http://www.scienceandsensibility.org/?p=1507.

  4. avatar
    Christine Morton
    | #4

    Thanks Kimmelin for your attention to maternal mental health issues. The challenges are many, as you point out, for individual women and their loved ones; for childbirth organizations; for clinicians and medical providers – a lot of work needs to be done! Katie and I wrote this series of posts because we wanted to learn more about the maternal quality landscape in the US and we realized we weren’t the only ones in the dark!

    The challenge if we are to think of maternal mental health as a QUALITY indicator or measure, in the technical sense, is how to accurately and feasibly measure and report it. Developers of maternal quality measures are incredibly handicapped in terms of having reliable data for tracking outcomes of interest (positive or negative). The data collected by hospitals doesn’t capture the complexity of women’s subjective experiences of birth and also misses a lot of the physiological elements due to poor data collection (via birth certificate) or due to the mismatch between ICD-9 codes or billing codes and what happens to women’s bodies and minds during a childbirth hospitalization. It’s an additional challenge to capture health outcomes which occur some days or weeks after a hospitalization – and to link those with the hospital data. Childbirth advocates who are informed about the quality measure process AS IT EXISTS are best able to intersect with the process, as have Maureen Corry and Carol Sakala at Childbirth Connection; but the extent to which we have maternal quality measures that capture experiences that are most relevant to women & their families requires retooling what data we collect and what we consider to be most critical for improving the quality of care women receive during childbirth hospitalizations.

    In describing how things are, we are not saying this is how they should be In the larger quality discussion occurring in medicine, quality measures are what payers and hospitals and physicians pay attention to. Maternity is just now gaining some attention, in part due to the worsening outcomes for mothers in terms of physical and mental health. Quality measures are the data points needed to change policy or even to have a sense of how hospitals and providers compare. Unfortunately, in Ohio and in California, state websites comparing hospital outcomes around maternity measures are in danger of being discontinued due to hospital associations not willing to participate. As poor as the current quality measures are, it would be a shame to lose the platform which allows women to compare maternity outcomes by hospital. One thing I forgot to mention is another thing that local advocates can do — keep pressure on hospitals to report outcomes of interest to your clientele – in Seattle, Great Starts surveyed birthing hospitals and published the results (http://www.parenttrust.org/index.php?page=books); I’m sure NYC and others have similar guides. I know this can be challenging and I commend all those who work to improve women’s knowledge around pregnancy and birth.

  5. avatar
    Walker Karraa, MFA, MA, CD
    | #5

    Wonderful, thank you! Great Starts is a wonderful model. As is Open Arms Perinatal Services (www.oaps.org) in Seattle. Hopefully through increased awareness through this and other media, maternity outcomes will become a comprehensive examination of reproductive wellness (ala Michael Lu’s 3.0 model).

    Great stuff, thanks.

  6. | #6

    Thank you, Christine for a thoroughly thought provoking series. And thank you Walker Karraa for bringing up an additional limitation in the current systems of assessing maternal quality. That being the (almost complete) lack of attention to maternal mental health. You rightfully point out that numerous studies convincingly show a real relationship between maternal mental health and (not only) preterm birth but other pregnancy complications.


    Christine is also correct in her comment that the data collected by hospitals is deficient in reliable measures of maternal mental health. I think that we all agree that the solution to this problem is not to discard the currently monitored quality metrics but rather to find a way to insert the subjective & narrative assessments of the mental and emotional adequacy of care into our quality of care metrics.

    I have a few suggestions: 1. Strengthen the appreciation of the current quality measures among women and their providers. (Efforts to abandon objective comparisons of quality measures will also damage efforts to include an appreciation of mental health concerns). 2. Educate all members of the health care team regarding the importance of mental health outcomes measures. 3. Create systems to transparently discuss shortcomings in dealing with mental health issues in the same way that we now (attempt) to discuss quality assurance and morbidity/mortality. 4. Agitate, educate and encourage more discussion of the topic in social media.

    I think we can turn the tide in maternal outcomes but it will take a great deal of work in areas that presently do not appear to be at the top of the list of priorities for maternal health thought leaders.
    Thanks for the great discussion.

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