Quality of US Maternity Care on Track to Improve With or Without Legislation

by Melissa Garvey, ACNM Writer and Editor

As you may have already heard from ACNM Federal Lobbyist Patrick Cooney, health reform legislation has reached a startling, disappointing halt. We are not sure what this means for the numerous provisions that would increase access to midwifery and birth centers.

In the face of this development, I’d like to take time out to raise everyone’s spirits and highlight a few exciting initiatives that are moving full steam ahead, whether or not health reform legislation passes soon. Each initiative has the same mission as many of the Senate’s proposed health reform provisions: to improve the quality of maternity care for US women.

1. The March of Dimes released a webcast edition of its Symposium on Quality Improvement to Prevent Prematurity, which ACNM cosponsored last October. Registration is free and gives you access to information from expert speakers, including ACNM President Melissa Avery and A.C.N.M. Foundation Secretary Nancy Jo Reedy.
   
   
2. This week, the Joint Commission issued an alert on preventing maternal deaths during and after pregnancy. The alert points out that maternal mortality rates in the United States are not declining, and may be on the rise. Even more disturbing is that for every mother who dies from pregnancy-related causes, 50 more mothers will become very ill due to significant problems during pregnancy, labor, and delivery. This isn’t good news, but it does promote awareness and proposes steps toward improvement. Lamaze International has taken this opportunity to issue its own set of recommendations for preventing maternal deaths.
   
   
3. Childbirth Connection has released findings from its 2009 Transforming Maternity Care Symposium. This was a major effort by numerous stakeholders in US maternity care, including ACNM, the American College of Obstetricians and Gynecologists (ACOG), and the Midwives Alliance of North America (MANA), with the purpose of transforming US maternity care into a wellness, woman-centered model. Their vision document, blueprint for action, and more are now available. I suspect midwife Amy Romano, CNM, will weigh in with more commentary at Science and Sensibility soon.
   

These are just three initiatives among many in progress toward improving the quality of US maternity care. What other initiatives and projects are you keeping an eye on or participating in?

How to Help Women and Children in Haiti

by Eileen Ehudin Beard, CNM, FNP
ACNM Senior Practice Advisor

The tragic situation in Haiti continues to send shock waves around the world. When you look at a picture of a young mother holding her newborn in the midst of chaos, you can’t be depressed about the economy or your 401K anymore. Those things don’t matter.

The knee-jerk reaction is to drop everything and hop a plane to Haiti, but, as we’ve all heard, that’s not the right thing to do in a disaster situation. Unless you prepare yourself mentally and physically you’ll be in a similar situation to the people you’re trying to help.

Many organizations are taking immediate action to help and are preparing to send teams of volunteers to Haiti when the time is right. Last week I participated in a conference call with representatives from ACNM, the Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG), and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). We agreed on the need for a particular focus on ensuring that women, infants, and children have access to the services that they need in camps and tent cities, and that they are protected from violence and sexual assault. The Cochrane Collaboration has published Evidence Aid, a Web site of up-to-date, relevant evidence to help people trying to cope with the aftermath of the disaster. Midwives for Haiti is organizing volunteer teams of health professionals to go to Haiti over the coming weeks and years that this country will need help.

If you are not trained to be a responder in a disaster, you can still help Haiti by donating money to a trusted organization. The Better Business Bureau has several resources and tips for choosing a legitimate charity. You can also view ratings of various organizations through Charity Navigator at www.charitynavigator.org. Please stay tuned to the Global Health Council for continuing updates on the situation in Haiti and a list of organizations that need your financial support.

Restricting food and drink in labor is not justified

by Amy Romano, CNM (Originally published on Science and Sensibility for Lamaze International)

Listen to this great podcast about the new Cochrane review showing that the policy of restricting food and drink in labor is not justified. It’s a nice summary of how and why the research was conducted. In addition, I particularly liked these tidbits:

1. Rather than asking “is eating and drinking in labor safe?” the reviewers turned the question around to ask “is there any justification for restricting food and drink in labor?” This is not just a nuance. How a researcher asks a question can influence both the findings and the conclusions, as I have discussed previously.

2. Since they identified no benefits (nor harms) of restricting oral intake, the reviewers concluded that women should be able to eat and drink according to their preference.

3. It was her experience teaching antenatal classes that led one of the reviewers to study food and drink in labor. Listening to women’s concerns and anxieties made her question the justification for restricting women’s autonomy in labor.

In perusing the web to try to find an image for this post, I came across this heartbreaking picture of a woman begging for a drink in labor and being told no. (I’d post it here but it is copyrighted.) When the researchers said they found “no harms” of restricting food and drink in labor, they pointed out that no one had actually studied women’s preferences or experiences. I’m heartened to know that some of those who tout evidence based care are beginning to recognize that emotional distress is itself a harm. If there is no counterbalancing benefit, the conclusion is clear.

Attention, ACNM Members! Who Will You Choose to Lead Your Profession?

We interrupt our regularly scheduled posts to remind ACNM members that the 2010 election forum is live now through February 5. This is your chance to choose who will lead the profession of midwifery into the future. Now is the time to pose questions to the candidates. You can even read their responses to other members’ questions.

Up for election are:

• Region II representative
• Region III representative
• Treasurer
• Two members for the Nominating Committee
  

Show that midwifery matters to you by reading each candidate’s bio, and then swing by the forum to find out more. Voting begins February 10. Will you be ready to cast an informed vote for the future of midwifery?

Are consumers at the bottom of the evidence pyramid?

by Amy Romano, CNM (Originally published on Science and Sensibility for Lamaze International)

I have argued (here, here, and here) that strategies that involve increased participation by women and families in maternity care hold major potential for improving our rather dismal maternal and infant health outcomes.

A study reported in the current issue of The International Journal of Gynecology & Obstetrics highlights a major obstacle to implementing consumer-led health strategies: lack of comparative effectiveness research supporting their use.

The researchers analyzed all Cochrane Systematic Reviews addressing pregnancy, childbirth, newborns, or children up to age five. They categorized each systematic review by the level of consumer involvement versus health care system involvement the intervention required. They found that 62% of Pregnancy and Childbirth reviews, 94% of Neonatal reviews, and 71% of Children’s Health reviews addressed interventions that involved no consumer participation, such as cesarean surgical techniques, or intensive care treatments. Interventions that could be implemented within the community (such as nutritional programs) or that involved woman- or family-centered health care (e.g., labor support techniques, family-centered pediatric approaches) were far less likely to be studied. The researchers concluded:

The vast majority of research is performed on interventions that are solely in the realm of the providers. Maternal and child health research needs to be directed toward innovative interventions involving consumer participation, particularly those that can be implemented in middle- and low-income countries where the accessibility and quality of the health systems are poor.

This study highlights one of the major systemic biases we see in research. When so much of our research comes from academic medical institutions, what happens outside of those institutions – even if it has a far greater potential impact on the health and wellbeing of the institution’s beneficiaries – doesn’t get studied much. Nor do interventions that can happen within institutions (e.g. doula support in labor) but challenge the institutional hierarchy, which too often puts patients and families at the bottom.

One area in which we need far more research is perinatal education. Few studies evaluate strategies to educate, engage, and inform women. In addition, according to a review in the current issue of The Journal of Perinatal Education, even when researchers do evaluate perinatal information giving and education, they tend to evaluate approaches that accommodate medical concepts of efficiency (e.g. leaflets or DVDs) rather than meet women’s own stated needs and preferences (e.g. opportunities to discuss options in depth with their care providers or in small peer groups facilitated by knowledgeable professionals).

Pregnant women and new mothers are avid seekers of health information – online, in childbirth education classes, from health care providers, and in their communities. This natural impulse to take responsibility for their health, connect with other women, and engage in their care is currently being overwhelmed by the application of one-size-fits-all maternity care policies, including mandated cesarean surgery for women with risk factors or more subtle threats to autonomy like restricting mobility, denying access to food and drink, and excluding family members and other support people from care settings.

Empowered, informed, engaged consumers, individually or collectively, can be effective at overcoming these barriers to safe, effective care. In fact, it sometimes seems to be the only force driving meaningful change. Fifty years ago, the American Society for Psychoprophylaxis in Obstetrics (now Lamaze International) helped lead a charge to let fathers into the delivery room and challenged the harmful, demeaning childbirth routines that prevailed as standard practice. Just last month, CNN reported the happy outcome for a woman who avoided cesarean surgery she did not need or want. In advocating for her own care, she has inspired a generation of other women facing vaginal birth bans in their own communities.

Consumers are the least powerful contingent in the health care system, even though our knowledge, attitudes and actions could be the most important influence on our own health and safety. It’s time for major paradigm shifts in research, policy, and practice.

References:

Belizán, J. M., Belizán, M., Mazzoni, A., Cafferata, M. L., Wale, J., Jeffrey, C., et al. (2010). Maternal and child health research focusing on interventions that involve consumer participation. International Journal of Gynecology & Obstetrics, 108(2), 154-155.

Nolan, M. L. (2009). Education and information giving in pregnancy: A review of qualitative research, The Journal of Perinatal Education, 18(4), 21-30.

My Top Ten Legislative Wish List for 2010

by Heather Bradford, CNM, ARNP,
Chair, ACNM Government Affairs Committee

Because every woman deserves a midwife, here’s what I’ll be advocating for in the coming year:

1. Reimburse Midwives Fairly Under Medicare. I’m eagerly watching the health care reform package, which includes provisions from HR. 1101/S. 662 – the Midwifery Care Access and Reimbursement Equity Act of 2009. That’s right! After more than 20 years of work, our bill is part of both the House and Senate reform packages. This bill would allow for equitable reimbursement of certified nurse-midwife (CNM) services under the Medicare Part B fee schedule. Compared to physicians, we currently are reimbursed at just 65% for our services. Passage of health care reform will provide CNMs reimbursement equal to physicians under Medicare.
2. License Certified Midwives (CMs). Even though the CM credential is considered equivalent to the CNM credential, CMs are licensed to practice in only three states—New York, New Jersey, and Rhode Island. I want to see legislation introduced in at least 10 states that would provide full practice equity and licensure of CMs.
3. Reimburse Birth Centers Under Medicaid. HR. 2358/S. 1423 (The Medicaid Birth Center Reimbursement Act) would provide improved access to birth centers for pregnant women covered by Medicaid. It has already passed in both the House and the Senate as part of the health care reform package, and is awaiting final passage.
4. Reimburse Midwives Fairly Under Medicaid. I want to see legislation introduced in at least 10 states that would allow midwives to receive equitable reimbursement under Medicaid. Currently, only 28 states provide equitable reimbursement.
5. Recognize Midwives as Primary Care Providers. Midwives do more than care for pregnant women and babies. We specialize in women’s health throughout the reproductive life cycle. Therefore, midwives should be recognized in all state and federal legislation as primary care providers wherever the term is used.
6. Support Midwives Who Teach Students. More and more midwives are supervising students at academic health centers. However, there is no incentive for health centers to hire more, because midwives are not able to bill under Medicare for their supervisory role. Legislation needs to be introduced to address this.
7. Prevent Discrimination Against Midwives. We need a change to the Centers for Medicare and Medicaid Services (CMS) regulations to prohibit discrimination against midwives in hospital privileging.
8. Add Midwives to the VA. Midwives should provide care to female veterans covered by the Veterans Health Administration. All other advanced practice nursing groups are eligible providers, but midwives are not. The growing population of wounded women of childbearing age deserves a midwife, too.
9. Fund Nursing and Midwifery Education. I want additional funding for nursing and midwifery education within the Public Health Service Act (Title VIII) and the National Health Service Corps.
10. Protect Breastfeeding and Provide Tax Incentives for Businesses to Encourage it. As a breastfeeding mother of twins, I am ready for more legislation to be passed in this arena.
    

What would you like to see happen in 2010?

Help Reopen the Bellevue Hospital Birth Center

by Melissa Garvey, ACNM Writer and Editor

Those of you who follow ACNM on Facebook know that the Bellevue Hospital Birth Center in New York City officially closed "until further notice" on Sept 1. Bellevue was the only birth center available to Medicaid-eligible women and their families in Manhattan.

Since then, there has been a collective effort to reopen the birth center’s doors. In December, a public petition and a letter signed by ACNM and other supporting organizations was presented to Bellevue Hospital’s Community Advisory Board (CAB)—the body charged with representing the voice of the public to the hospital administration. The hope is that the CAB will officially support the letter and become a significant ally in the effort to reopen.

On Wednesday, January 27, the CAB will vote on becoming a joint signatory of the letter. At that public meeting, Dr. Keefe, the new head of obstetrics and gynecology, will address the board in support of the birth center reopening. After the meeting, supporters will present the public petition and organizational letter to Linda Curtis, executive director of Bellevue Hospital. Anyone interested in supporting the cause is encouraged to participate in the public meeting on Wednesday, January 27, 6 p.m., at Bellevue Hospital, C/D Building, 8th Floor Medical Library.

The “Patient Push” for Early Birth: A Dangerous Concept or Valid Point?

by Melissa Garvey, ACNM Writer and Editor

Last summer, ACOG officially revised its recommendations on elective labor induction, raising the “safe” gestational age to induce from 37 to 39 weeks. Now a study in the December 2009 issue of Obstetrics & Gynecology examines women’s perceptions of the definition of full term and the safety of birth at various gestational ages. Long study short, nearly half of the 650 women surveyed believe it is safe to give birth at 37 weeks, and almost all believe it is safe to give birth before 39 weeks. (Note: All women were insured and had recently given birth.)

While there are numerous discussion-worthy topics nestled in the article, one in particular piques my interest as an informed consumer. Remember ACNM President Melissa Avery’s post about the startling rise in rates of preterm birth in the US? The number-one reason is labor induction. With that in mind, check out this statement from the Discussion section of the article:

Misinformation about the safety of early deliveries, especially those that are perceived to be “only a little early,” combined with the desire for the pregnancy to be over, likely contributes to a patient “push” for early delivery.

The authors say that recent educational efforts aimed toward providers have been promising in reducing the rate of elective preterm or early term birth, but the role of the patient has not yet been studied. So, my question is should we start looking at women’s role in elective induction or does this sound eerily similar to blaming women for the rise in cesarean section rates?

Bonus Discussion
To fully appreciate the survey results, it’s worth looking at the actual questions that researchers asked women:

1. “At what gestational age do you believe the baby is considered full term?” (Possible responses ranged from 34 to 40 weeks.)
2. “What is the earliest point in the pregnancy that it is safe to deliver the baby, should there be no other medical complications requiring early delivery?” (Again, possible responses ranged from 34 to 40 weeks.)
   

These questions measure the women’s knowledge base, but not where they’re getting that knowledge. Perhaps they’re getting it from the media, the Internet, or their care provider? It’s also worth noting, as the authors point out, these questions do not control for women’s varying interpretations of “full term” and “safe,” nor do they distinguish between spontaneous preterm labor and elective labor induction.

What’s on Your Blog Roll This Year?

by Melissa Garvey, ACNM Writer and Editor

As we kick off another year of advocating for midwifery, what blogs will you visit (between Midwife Connection posts, of course) to stay informed and inspired? Here are a few of my recommendations. Make a comment to add yours to the list.

Science & Sensibility: Hosted by Lamaze International, this blog discusses research related to pregnancy and birth. Right now, an interesting discussion is brewing about what data should be considered at the upcoming NIH Consensus Development Conference on VBAC.

RH Reality Check: In addition to regular posts on contraception, maternal health, and more, this blog features reader diaries. This is a wonderful site to start a conversation about the issues that matter to you.

Our Bodies, Our Blog: Count on lively coverage of the latest women’s health news at this blog hosted by Our Bodies Ourselves. Check out their recent post on Depo Provera and bone loss.

Birth Sense: This self-described “midwife next door” shares her stories, offers ideas, and supports her readers with common-sense wisdom to help them improve their childbirth experience. In her latest posts, she shares her most memorable births.