Originally appeared: November 17, 2011 at the Transforming Maternity Care Blog at transform.childbirthconnection.org/2011/11/lateptb/

More than two-thirds of preterm babies are born “late preterm,” between 34-37 weeks gestation. For many years, the epidemic of late preterm birth was largely ignored, as the typical health problems of these infants were not as severe as the challenges faced by babies born many weeks before term.

Thanks to emerging evidence and advocacy, late preterm birth is now getting recognition as the major public health problem that it is – late preterm babies do in fact face many health risks, including respiratory and feeding problems, longer and more frequent hospitalizations during infancy, and behavioral and learning problems in early childhood.

Late preterm birth is out of the shadows, but part of this public health problem is still hidden.

A new study published in the Journal of Obstetric, Gynecologic, and Neonatal Nursing looks at the emotional health outcomes of mothers of late preterm babies. Compared with mothers of full-term babies, mothers of late preterm babies had significantly more situational anxiety, depressive symptoms, post-traumatic stress disorder symptoms, and worry about their infant’s wellbeing after delivery, differences that persisted when researchers followed up with the mothers one month after giving birth. In interviews, mothers of late preterm infants described many distressing experiences, expressed concern for their own health and their infants’ health, faced many difficulties related to infant feeding and weight gain, and reported lack of timely information from care providers. They also described disruptions in their confidence in their role as mother, an experience exacerbated in women whose babies remained in the hospital after their discharge.

Depression, anxiety, and post-traumatic stress disorder are debilitating and sometimes deadly conditions for women, and the children of mothers with these conditions are at risk for poor health and social outcomes. In other words, when a baby is born a few weeks early – even when the infant health outcome is favorable – this event can still have a detrimental and persistent impact on the health and wellbeing of the family.

We need to continue to strengthen efforts to prevent prematurity. When despite these efforts babies are born preterm – even just a little preterm – this study suggests that we must work to protect the health and wellbeing not just of babies, but their mothers, too.

Originally appeared October 25, 2011 on the Transforming Maternity Care Blog at transform.childbirthconnection.org/2011/10/hbcs/

I attended the Home Birth Consensus Summit in October. The meeting was the result of several years of planning by a multi-stakeholder group of maternity care leaders. It was led by facilitators from Future Search, a theory and planning strategy designed around having the “whole system in the room” to find common ground on complex or divisive issues.

My colleagues and I at Childbirth Connection are big believers in having the whole system in the room. This was how we went about the Transforming Maternity Care Project, which yielded actionable recommendations in 11 different focal areas that make up a Blueprint for Action. Every day we see progress toward the 2020 Vision, and the Home Birth Summit was no exception. In fact, the Summit itself was a recommendation from the Blueprint.

The experience at the Summit was a reminder that, although there are many problems in our maternity care system and plenty of disagreement about how to address those problems, there is also plenty of common ground that can only be identified and acted upon when all stakeholders sit down together. When diverse stakeholders come together, we can share not just our unique perspectives on the nature of the problems at hand, but also commit to getting to work on fixing the parts of the problem over which we have influence. Rapid, achievable gains are within reach. Other improvements will take more time, but why not get started on what we can all agree on?

I was deeply moved both moved by the strong spirit of collaboration and openness each of the approximately 70 delegates brought to the common ground process, and by the nine remarkable common ground statements affirmed by the delegates. Home birth is a very small piece of our much larger maternity care system, but this diverse group’s willingness to work together on such a historically divisive issue was inspiring. My colleagues and I recognize this shift as part of a broader trend toward more meaningful multi-stakeholder collaboration, and we were honored to participate.

An extended version of this post appeared September 12, 2011 at the Transforming Maternity Care Blog at http://transform.childbirthconnection.org/2011/09/vbacquality/

According to new government statistics, 20% of the more than 4 million U.S. births each year occur to women who have previously given birth by cesarean. If evidence and national guidelines support vaginal birth after cesarean (VBAC) as a “reasonable option” for most of this population – and indeed the better option for many – it is time to be reasonable about how to make VBAC as safe, accessible, and satisfying as it can possibly be.

A QUALITY FRAMEWORK FOR VBAC

1. Help women make and carry out choices that are informed by the best quality evidence and aligned with their own values and preferences.

Rationale: Honoring people’s informed choices is the legal and ethical standard, acknowledged by all major health care bodies.

Current approach: According to the VBAC Policy Database, a voluntary monitoring project by the International Cesarean Awareness Network, half of U.S. hospitals either ban VBAC outright or have no providers willing to attend VBACs. In areas where VBACs are “offered,” women must often meet eligibility criteria that are not supported by high-quality evidence.

Why this is inadequate: Both planned VBAC and planned repeat cesarean section are reasonable choices with important potential benefits and harms but the trade-offs are very different. The current approach, intended to reduce the already low likelihood of avoidable perinatal death or injury and associated liability, has resulted in significant collateral damage: most notably an increased risk of maternal mortality and a growing prevalence of life-threatening complications for both mothers and babies in future pregnancies. The Agency for Healthcare Research and Quality (AHRQ) team that conducted the 2010 systematic review on VBAC versus routine repeat cesarean referred to the VBAC access issues as “chilling,” an assessment with which we at Childbirth Connection agree.

Another approach: We urgently need evidence-based, field-tested shared decision making tools to communicate the research evidence and help women clarify their preferences and values. Although decision support tools can help a woman select the best choice for her, system barriers including payment incentives, liability concerns, and clinician education must be addressed simultaneously to ensure that she can carry out her choice. Assessing the potential for shared decision making tools and processes to reduce liability should be a research priority.

2. Maximize the proportion of women planning VBAC who experience uncomplicated vaginal births

Rationale: Morbidity in VBAC labors is highly concentrated in the women who have unplanned cesareans in labor. Having a VBAC also reduces risks in subsequent pregnancies and virtually ensures that future births will be vaginal, while having a repeat cesarean sharply increases risks in subsequent pregnancies and virtually ensures that future births will be surgical. Repeat cesarean costs payers significantly more than VBAC and has significant downstream economic costs because of these effects in subsequent pregnancies.

Current approach: Several researchers have attempted to create prediction tools to select the women most likely to give birth vaginally, and some clinicians and hospitals have imposed strict eligibility criteria for planned VBAC. Significantly less attention has been given to care processes that may enhance a woman’s likelihood of having a safe vaginal birth.

Why this is inadequate: Calculating the likelihood of vaginal birth can support informed choice. However, the AHRQ systematic review concluded that none of the available prediction tools adequately selected women for successful trial of labor. Moreover, some groups with lower likelihoods of vaginal birth, such as women with high BMI or multiple prior cesareans, also face higher-than-average likelihood of harm if they end up with a cesarean.

Another approach: The AHRQ researchers emphasized the need to incorporate “non-medical factors,” like provider and facility characteristics, in prediction tools to enhance their usefulness, as these appear to more strongly affect VBAC likelihood than factors intrinsic to the woman. In addition, research is urgently needed to identify labor care strategies to promote safe vaginal birth in women with prior cesareans, in particular the potential contribution of midwives and doulas. A randomized controlled trial examining the impact of doula care on VBAC labors is currently underway in Canada.

3. Provide the best possible response to obstetric emergencies including uterine rupture

Rationale: Uterine rupture occurs in about 4.7 per 1000 VBAC labors and is an obstetric emergency requiring prompt delivery. Although the outcome is usually favorable for both infants and mothers, morbidity and mortality may be minimized if the team is prepared, communicates well, and responds quickly and in a coordinated fashion.

Current approach: The small chance of a sudden emergency with high risk of serious fetal and maternal harm resulted in ACOG’s recommendation that a surgical team should be “immediately available” for VBAC labors. Although in 2010 ACOG tempered this recommendation somewhat, the response to the possibility of uterine rupture continues to favor requiring women to consent to cesareans in order to access maternity care.

Why this is approach is inadequate: The AHRQ researchers identified several other obstetric emergencies that occur with similar frequency as uterine rupture and result in similar likelihoods of serious harm but for which the obstetric community does not deem 24/7 cesarean capability to be necessary.  For these obstetric emergencies, rather than forbidding labor, hospitals have begun focusing on proven patient safety strategies like enhancing teamwork, implementing checklists, and conducting drills and simulations.

Another approach: The emerging concept of “high reliability obstetrics” provides a framework for preventing adverse events and managing them in a consistent fashion when they occur despite prevention efforts. This requires a multi-disciplinary commitment to preparedness, teamwork, communication, and documentation. Various safety courses teach teamwork and management of emergencies in obstetrics. A systematic review of multi-disciplinary simulation training found that such programs improved knowledge, skills, and team performance in obstetric emergencies and were associated with improved neonatal outcome.

BRINGING BACK VBAC

If VBAC is a reasonable option for most women, we need a reasonable approach to ensuring quality and safety in VBAC. Like maternity care generally, transforming VBAC care will take multi-stakeholder commitment to system reform. With so much inertia in the system, consumers and advocates must maintain a strong voice to push for positive change. Childbirth Connection’s recently updated VBAC or Repeat C-section Topic and the latest data on cesarean and VBAC trends are two resources to help women and their advocates. Our Action Center provides more ideas for engaging in maternity care transformation.

I don’t get to go to births much anymore. My midwifery practice closed in July. Our consulting doctors merged with another group and in the merger were forced to stop accepting our referrals and collaborating on VBACs. As a result of that we had to forfeit our hospital privileges. We would have continued offering only home birth services but one of our three midwives left to join another practice with 9-5 hours and we couldn’t recruit another midwife to replace her. As much satisfaction as the work brings, home birth is hard and the pay isn’t great. That’s because insurance reimbursement is a joke. It doesn’t cover things that are fundamental to our work, like home visits for mother-baby check-ups or having a skilled birth assistant present. And if we spend hours supporting a woman in labor, use our well-honed assessment skills to diagnose a complication, and facilitate a timely transfer of care so a baby can be safely delivered? We probably won’t get paid a dime if the doctor performs the delivery.

So it was really nice to come across this video last week. It’s not going to fix any of the problems I just mentioned. But it’s powerful. And important. And I just love it.

It’s about doulas – women whose profession is to support mothers in the work of birthing their children. Woman-to-woman support is such a simple way to make maternity care better, safer, and more satisfying. It’s so clear from these pictures that putting the mother at the center of our work keeps birth healthy and safe. And the statistics tell the rest of the story. Birth is healthier and safer when the mother is supported.

Am I naïve to think that if more people saw images of birth in which the woman is supported and cared for, they might start asking for this kind of care? One popular home birth video on YouTube has had over 3 million views in two years. That’s many, many times the number of people who actually had home births in North America in that time. I can only interpret this to mean that women are yearning to see birth the way it’s meant to be seen. I don’t know how long they can watch it happen on YouTube and compare that with how it happens in most real delivery rooms and tolerate the discrepancy. Could YouTube be the thing that changes birth culture?

I posed a bold question on my Facebook page the other day. (My high school friends probably tire of my birth politics). I said, “It feels like it’s been the week of egregious human rights abuses against childbearing women. Is it in the air? Or is social media just finally exposing the stuff that’s been going on forever?”  The consensus was that the internet is catching up with some of the garbage that’s been quietly happening behind hospital curtains. And that there’s plenty more to expose.

Nothing has ever changed in maternity care without women rising up and demanding change. But what’s different today is the astounding pace with which information and stories are being shared and the limitless community women can tap into. I think we may be nearing a tipping point. This could get interesting…

(For more on the evidence basis for continuous support in labor, read Lamaze’s Healthy Birth Practice.)

This year, one in three babies will be born by cesarean section. The cesarean rate in the United States has hit a historic high every year for nearly a decade, and shows no signs of abating. Research from the World Health Organization suggests that when a cesarean rate is higher than 15% in any population, cesarean surgery begins harming for women and babies than it helps. That means that each year, as many as half a million cesareans could be safely prevented in the U.S. each year.

These aren’t all unnecessary cesareans. By the time they’re performed, many if not most are necessary. But somewhere in the chain of events leading up to the cesarean there may have been a different policy, choice, or approach that could have prevented the need from arising in the first place.

There’s plenty we need to change about our system of care to lower the cesarean rate. But women themselves can make choices that optimize their chance of a safe, vaginal birth within our current system.

• Choose a care provider and birth setting carefully. If you go to a hospital with a 70% cesarean rate, you’ll probably have a cesarean.
• Do not agree to or ask for an induction of labor unless there is a valid medical reason. Carrying a big baby is not a valid medical reason. Inducing for this or another nonmedical reason may double the chance of a cesarean and doesn’t improve the baby’s safety.
• Decline continuous fetal monitoring in labor unless you have pregnancy or labor complications that require its use. Continuous monitoring doubles the chance of cesarean and listening intermittently with a Doppler is just as safe for babies.
• Have continuous labor support from a doula. Doulas increase the chance of having a vaginal birth, offer many other benefits, and have no risks. Some communities offer free or low-cost doula services. If you cannot afford to have a doula, learn ways you can get excellent support from the right friend or family member.
• Learn about other labor practices that promote healthy labor progress, such as avoiding routine interventions, walking and moving around in labor, and pushing in an upright position.
• Read more evidence-based ways to have a vaginal birth from Childbirth Connection.

Blogs, Facebook, and Twitter were bustling last week with back-to-back stories of doctors putting the kibosh on women’s right to self-determination in their birth. First, The Unnecesarean reported on a doctor who preemptively gives his own (awful) birth plan to all of his patients, and one woman’s triumphant experience firing him and hiring a midwife. Just a few days later, the internet lit up with a zillion copies of this picture of a sign in a Provo, Utah Ob-Gyn’s office:

Yes, paternalism is alive and well in obstetrics. Informed choice? Not so much.

The consensus among birth advocates about these two stories is that they may actually be good for women and babies. After all, too often women find out that their doctors treat their patients this way when it’s too late. It’s not really what we meant when we demanded more transparency in maternity care, but, hey, it’s a start.

It may come as no surprise that evidence that having a birth plan improves outcomes for mothers or babies is scarce. In fact, research seems to suggest just one consistent effect of birth plans: antagonism between women and hospital staff. Are birth plans obsolete?

Based on a rigorous review of the scientific research and recommendations from the World Health Organization, Lamaze International promotes Six Healthy Birth Practices that ease and facilitate labor, prevent complications, and protect breastfeeding and early mother-infant attachment. With a care provider and birth setting that offer these practices as the standard of care, a detailed birth plan is rarely needed. Unfortunately, fewer than 2% of women who give birth in U.S. hospitals actually experience this package of care. That leaves 98% of women at the negotiating table for a safe and healthy birth. A simple birth plan based on the Healthy Birth Practices can be a starting place for discussion. A good childbirth education class can give women the information and confidence they need to stand by these choices in the face of arbitrary hospital routines and “doctor’s orders”. If a care provider balks at this kind of birth plan in a prenatal visit, that’s a red flag and a cue to transfer care to another provider who will support your choice for a safe and healthy birth. Motivating women to change care providers or choose a new birth setting may in fact be the most powerful way a birth plan can change birth.

If you had your baby in a United States hospital in 2005:

• There’s a 1 in 3 chance you had cesarean surgery.
• There’s less than a 2% chance that you experienced a package of evidence-based care practices known to ease labor and prevent complications.
• You most likely were separated from your baby during the first hour after giving birth.
• There’s a 1 in 5 chance (1 in 4 if you are black) that you had symptoms of childbirth-related post-traumatic stress disorder (PTSD) in the months after giving birth.
• There’s a 7% chance you had to be rehospitalized before your baby was 18 months old.

These data are from a national survey called Listening to Mothers. For years, as a midwife, I’ve listened to mothers ask if there is a healthier way to give birth. Many of them ask this after they’ve already had a baby and been disappointed with or even traumatized by the experience or endured health problems stemming from the care they and their babies got around the time of birth.

Yes, you can and should expect more from your care in pregnancy and birth. And if you’re pregnant again, you can plan for a healthier, safer, and more satisfying birth. But you must actively participate in your care and find a provider who encourages this kind of participation. If passively accepting what our system routinely offers was a good idea, we’d have much better health outcomes, instead of being outranked by nearly every other industrialized nation in the world. In this week’s collection of posts, I will show that our system is not designed to protect and optimize the health of babies and mothers. (Perhaps I’ve already done that. Surely the costliest maternity care system in the world should have better stats than what we see above.) I will also show how empowered, supported women who participate in their care have the healthiest outcomes of all. I’m looking forward to it.

Pop quiz: what is the most important factor determining whether a woman has a cesarean or not? How healthy she is? How big her baby is? Whether she has pregnancy complications? These all seem like reasonable answers, but the research tells a different story.

A large body of literature suggests that where a woman gives birth is one of the strongest – or even the strongest – predictors of whether she’ll have a cesarean. Yes, you read that right. The same woman could walk into two different hospitals and walk out having had either a vaginal birth or abdominal surgery. The same is true with care providers. Some have high cesarean rates and others have low cesarean rates, and most of that difference has little to do with how many women in their care actually need cesareans to give birth safely.

A similar pattern emerges with other interventions and outcomes. Which care provider a woman goes to is actually the strongest predictor of whether she will have an episiotomy. Induction of labor, access to pain relief options, and access to vaginal birth after a previous cesarean also vary widely across providers and facilities. Different hospitals may also be more or less effective at promoting breastfeeding, more babies may end up in intensive care in one hospital than another, infections may be rampant in one hospital and well controlled in others, and the list goes on.

A woman can increase her chance of a safe birth by choosing a care provider and birth setting with excellent outcomes, but currently only a few states mandate that facilities publicly report such safety data. No state provides that information for individual care providers. A grassroots, mom-led movement is aiming to change that. The Birth Survey is working to obtain intervention rates at the facility level in every state and has already published the data for 9 states. The site also collects robust consumer feedback about every maternity care facility and licensed provider nationwide and makes this consumer data available to the public. Over 22,000 women have taken the survey since the project launched last year. (If you have given birth in the last two years, you can give your feedback.)

Currently, you can find out more about the safety, reliability, cost, and consumer satisfaction of a stroller or bassinet than the hospital or care provider you are going to rely on for a safe birth. Blindly choosing where and with whom to give birth is bad for the health of mothers and babies. Transparency is the missing ingredient to informed choice and safer birth.