The Leapfrog Group Releases 2017 U.S. Maternity Care Report Card - Results Indicate Needs Improvement

Maternity Care Report Card.pngOn February 28, 2017, The Leapfrog Group released their 2017 Maternity Care Report to the public.  This report was eye-opening to both significant improvements that have been made in some areas of maternity care and a clear signal that other benchmarks still have a long way to go.  The Leapfrog Group is a nonprofit national watchdog group whose mission is to improve the safety, quality and affordability of health care by a) supporting informed health care decisions by those who use and pay for health care; and b) promoting high-value health care through incentives and rewards.  The Leapfrog Group was a participant at Lamaze International's 2015 Childbirth Education Roundtable Discussion.

The 2017 Maternity Care Report examines the performance of hospitals based in the United States in three areas of maternity care that have been determined to be key components in improving outcomes in maternal and infant health. The report is derived from the 2016 Leapfrog Hospital Survey.  49% of all hospitals in the U.S. voluntarily participated in the Leapfrog Hospital Survey. The three components of performance measured are:

  1. NTSV (Nulliparous, Term, Singleton, Vertex) cesarean section rates.
  2. Early elective deliveries (Scheduled cesarean sections or medical inductions performed prior to 39 completed weeks gestation without medical necessity).
  3. Episiotomies.

The Successes - Episiotomies and Early Elective Deliveries

One of the great successes revealed in the 2017 Maternity Care Report is in the area of early elective deliveries.  In 2010, the rate of deliveries by planned cesarean or medical induction without medical necessity that occurred prior to 39 weeks was 17%.  In 2016, this rate had dropped to 1.9%.  This is a significant decrease in six years.  There has been a coordinated effort by many professional stakeholders (ACOG, ACNM, AWHONN) to share the message about the importance of reducing early elective births.  Clearly, the message is effectively out there and great positive change has been made in reducing this unnecessary intervention.  Leapfrog's target rate for early elective deliveries is 5.0% or lower.

Episiotomies also declined from previous rates but have still not yet met The Leapfrog Group's target rate of 5%.  In 2016, the episiotomy rate of the participating hospitals was 9.6%.  This is a drop from 13.0% in 2012 but has still not met the established target rate.  More education and outreach still need to be done to meet the appropriate benchmark for this intervention that has long been recognized as often harmful and unnecessary.

Needs Improvement - NTSV Cesarean Rates

Screenshot 2017-03-02 11.07.26.pngUnfortunately, the NTSV cesarean section rate continues to reflect how much work still needs to be done to reduce this number down to a level deemed acceptable to experts in the field.  The average rate of NTSV cesareans was 25.8% in 2016.  This number indicates that there has been very little improvement and only a very small decrease from the 2015 rate which was 26.4%.  2015 was when Leapfrog first began reporting this data.

When Leapfrog examined this NTSV cesarean delivery rate more closely, it revealed that there is a significant variation across the country.  The eastern and southern states continue to show higher rates of NTSV cesarean deliveries compared to western states.  Louisiana had the highest rate at 32.1% and New Mexico the lowest with a rate of 17.1%.  Leapfrog has established a target rate of 23.0% for this benchmark which aligns with the Healthy People 2020 goals.  

Expectant families with a low-risk pregnancy need to understand that they can reduce their odds of receiving an unnecessary cesarean section by choosing their hospital and caregiver wisely.  Both The Leapfrog Group and Consumer Reports have published guides to hospital NTSV cesarean rates, a recognized important predictor of what families can expect.

What determines which hospital will have a "good" (low) NTSV cesarean delivery rate is still not widely understood.  There are not clear determinates - such as rural vs urban, high-risk facilities versus community hospitals or other factors that easily predict which hospital will have lower rates.  What is understood is that rates can vary widely within a geographic location, by facility, and by provider.  Parents must be savvy consumers when choosing both a facility to give birth in and a health care provider to take care of them.

Conclusion - Receiving Evidence-Based Maternity Care

There are some things that are clear from this recent Leapfrog Group report.  Collaborated efforts amongst professional stakeholders can quickly and significantly reduce unnecessary maternity care interventions.  The early elective birth rate is proof of that.  Some practices, like episiotomies, which have long been shown to do more harm than good in most cases, still need to see improvement to meet rates that reflect evidence-based care.  And in the case of NTSV cesarean rates, many U.S. hospitals have a long way to go.  Identifying the factors that influence this rate, and then developing practices that can have an effect on reducing it are being studied, but all the nuances are still not clear.  

What is clear is that expectant families must do due diligence in choosing both a provider and a facility.  When families make the choice to receive services from hospitals and care providers who have demonstrated evidence-based practices and good outcomes, then change will come to those locations whose numbers fall short of acceptable.

Childbirth educators and other birth professionals that work with families can help educate families about this information and provide them the tools to evaluate where they feel comfortable in giving birth. Sharing The Leapfrog Group report and the Consumer Reports information is a great first step. When everyone, both professionals, and consumers, work together, we can start to see some traction on these statistics and an improvement in maternal infant health outcomes.  Lamaze International recognizes the importance of childbirth education in helping to improve outcomes.  To further this work, our organization continues to collaborate with The Leapfrog Group and other stakeholders to work as a collective community to improve outcomes for parents and newborns.

What are you doing in your classes to create savvy consumers of maternity care?  Please share in the comments below.

2 Comments
1 Like

Best-Evidence Care...How to Get It

March 9, 2017 02:45 AM by Jacqueline Levine

You say that “Collaborated efforts amongst professional stakeholders can quickly and significantly reduce unnecessary maternity care interventions.” and that is very true. In my classes, I give out hard copies of articles and abbreviated studies that show what docs say to each other about maternity practices and protocols, but they certainly don’t say these things to the birthing people we teach. It really helps open the eyes of the clients in our classes to the fact that there’s a yawning gap between best-evidence, optimal practices and the current status of care in many instances.

In the interest of creating, as you say, “savvy consumers of maternity care” here’s an example of the kind of info I give out: entitled “Training Reduces Cesarean Delivery and Neonatal Morbidity”, a multi-hospital study, presented at the 34th Annual Meeting of the Society for Maternal-Fetal Medicine ( Medscape. Feb 07, 2014), discussed substantial improvements in outcomes after just two days of an “on-site training workshop for health professionals that focused on the best clinical practices for intrapartum care”. And it’s a “collaborated” effort indeed.

So merely two days of “remedial” training made improvements in outcomes? That’s a really interesting, not to say shocking, turn of events. Quoting Medscape, here’s the essence of what the researchers did and what then happened:

“The researchers conducted a 3.5-year randomized controlled trial that involved 32 public hospitals with at least 300 deliveries each year, a cesarean rate of at least 17%, and no previous intervention aimed at reducing the cesarean rate. Sixteen hospitals received the intervention program and 16 served as control hospitals.

“A multifaceted intervention program for health professionals aimed at reducing the rate of cesarean delivery succeeded in doing just that, according to a new multihospital study. ‘Our hypothesis was that intervention at the right time would provide the chance to improve the quality of obstetrical care and reduce morbidity.’”

“This study of more than 100,000 women shows that an interventional program can not only reduce the chance of cesarean delivery, but can also reduce neonatal morbidity, noted William Grobman, MD, professor of obstetrics and gynecology-maternal fetal medicine at the Northwestern University Feinberg School of Medicine in Chicago.”

We can only wonder about the harm occurring in the hospitals before the “intervention” of that 2-day training. I’m sure that the maternity”health professionals” on staff in lots of hospitals could use some of that good interventional stuff. I still see some devastating effects of episiotomy, despite ACOG’s “new guidance” recommending against routine use of that discredited procedure (Practice Bulletin #165 replaces Practice Bulletin #71, “Episiotomy,” and Committee Opinion #647, “Limitations of Perineal Lacerations as an Obstetric Quality Measure”).

 

 

You rightly recommend that we should make our clients and classes aware of the quality of the care they’re getting by choosing hospital and caregiver wisely. I agree, and I use the “three legs-of-the stool” approach to give them the tools to do just that. First leg is the discussion of birthing peoples’ legal, ethical and financial rights to get nothing less than best-evidence care. Are they paying for routine care, or the very best care their docs can provide? A hard copy with those rights is theirs to take home. It’s not their job to do the research. I have that info and I must share it. But how will they be able to recognize routine care as distinct from BE care? So the second leg of the stool is the dissemination of studies and articles, also in hard copy. Guided by the Lamaze 6 Healthy Practices, I cover each of the most important parts of normal labor and birth, and all the newest ACOG directives about avoiding primary section, the new guidelines for labor progress, and lots of other things docs tell other docs, like about new EFM guidelines, and classes begin to see the vast and yawning gap between BE care and what they are being offered.

If I just “tell” classes about interventions, it’s my word against the doc’s. I give out the BE care studies and articles in actual hard copy to take away home. I highlight the important conclusions, etc, so no one has to read the whole abstract. Just the fact that clear guidelines for optimal care exist for docs to use and clients to see, is hugely empowering. Who else will give them this info if we don’t? It’s much easier to discuss and share this information on paper in your hand than reading it on a screen. If our clients and our classes have access to what docs say to each other and not to them, they can see in a doc’s own words the acknowledgment of the discordance between BE, optimal care, ACOG’s recommendations, and the way that individual OBs may practice.   The third leg of the stool is the fostering of confidence and role-play. And confidence is what our clients need most; confidence to ask questions, to insist on delayed cord clamping, for example, to ask about the inaccuracy of sonograms in the 3rd trimester, and, being aware of the evidence of the harms of routine suctioning of their newborns, be able to tell their doc not to use routine care in each circumstance. They deserve this info.

We know that our clients will be asked to make decisions about their health care during pregnancy, labor and birth, and we want them to make those decisions from a position of knowledge and confidence. If they understand their rights to BE care, are able to identify BE care, they can have the confidence to ask for, or indeed, demand it, for themselves and their babes.

 

More Best-Evidence...

March 9, 2017 03:02 AM by Jacqueline Levine

I must add this:  my new favorite little piece of info to show classes is this little nuget published in  Contemporary  OBGYN, in Sept.2016, entitled "Don't fear the patient with a birth plan". The author, Yalda Ashfar, is a Maternal-Fetal Medicine Fellow at a university in California.  I'll quote him to show you the tenor of the article, but it's surely worth a read.. He says:.

" We looked at women with birth plans and discovered that having a higher number of specific birth plan requests fulfilled correlated with greater overall satisfaction, higher chance of expectations being met, and feeling more in control.5 However, we also showed that having a high number of requests was associated with an 80% reduction in overall satisfaction with the birth experience. It is unclear if this discrepancy is due to women having higher expectations or a biased medical perspective. Perhaps there is a “paradox of choice” phenomenon in that too many choices have a proven detriment to our emotional wellbeing..."

Further along he says: " Ultimately, the purpose of a birth plan is to promote communication and not to induce friction between providers and birthing mothers. A survey-based study reported that 65% of medical personnel but only 2% of pregnant women believed that having a birth plan predicted a worse obstetric outcome.6 Obstetricians and midwives are justifiably concerned that birth plans attempt to control a process that inherently cannot be controlled or planned.For a birth plan to be effective, it should not only take into account the unpredictable course of pregnancy and the dynamic process of labor, but also ensure continuous communication among all participants involved. Communication during the birthing process should acknowledge birth plans as fluid documents that “evolve” with the unpredictable nature of labor.Today in the United States, birth plans are still the outliers, not the norm."

There seems to be some hope here, no?

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