Blueprint for action: steps toward a high-quality, high-value maternity care system

Financial Barriers to Expanded Birth Center Access in New Jersey: A Qualitative Thematic Analysis

INTRODUCTION

Birth centers are an underused care setting with potential to improve birth experience and satisfaction. Both hospital-based and freestanding birth centers operate with the midwifery model of care that focuses on safe, low-intervention physiologic birth experiences for healthy, low-risk pregnant people. However, financial barriers limit freestanding birth center sustainability and accessibility in New Jersey, especially for traditionally marginalized populations. This qualitative study explores the financial barriers faced by freestanding birth centers in order to expand access and choice for pregnant people in New Jersey.

METHODS

Semistructured interviews were conducted with participants from 4 sectors: (1) birth center or health system, (2) policy-adjacent philanthropy or research, (3) state departments, and (4) health insurance. Coding and analysis followed a reflexive thematic analysis process, resulting in the identification of 4 financial barriers to birth center access.

RESULTS

Facility Medicaid reimbursement rates are a primary barrier for birth centers, along with startup and operating costs and, more indirectly, low supply of midwives and low patient demand for birth center care.

DISCUSSION

New Jersey is well-positioned to enact critical policies and programs that can improve out-of-hospital birth center access, based on the findings and recommendations from this research. Other states can follow suit in pursuit of solutions to improve maternal health access and equitable birth center sustainability.

Presumptive eligibility for pregnancy Medicaid and timely prenatal care access

OBJECTIVE

To assess the association between the adoption of presumptive eligibility for pregnancy Medicaid in Kansas in 2016 and timely prenatal care access.

DATA SOURCE

2012-2019 National Center for Health Statistics natality files.

STUDY DESIGN

We used difference-in-differences to compare outcomes before (2012-2015) and after (2017-2019) presumptive eligibility in Kansas relative to seven control group states overall and stratified by maternal education. Outcomes included first-trimester prenatal care, the month of first prenatal visit, and adequate prenatal care.

DATA COLLECTION/EXTRACTION METHODS

All live births among adults aged 20 or older in Kansas, Idaho, Missouri, Nebraska, Tennessee, Utah, Wisconsin, and Wyoming.

PRINCIPAL FINDINGS

Among all births, we found no evidence that presumptive eligibility in Kansas resulted in changes in prenatal care use. Among individuals with high school education or less, presumptive eligibility was associated with a 1.92 percentage-point increase (95% CI: 0.64, 4.35) in first-trimester prenatal care, driven by earlier month of first prenatal care visit.

CONCLUSIONS

Presumptive eligibility in Medicaid non-expansion states may lead to small improvements in early prenatal care among individuals with lower education, but other interventions may be needed.

Midwife-led care and obstetrician-led care for low-risk pregnancies: A cost comparison

OBJECTIVE

Low-risk pregnant women cared for by midwives have similar birth outcomes to women cared for by physicians, although experiencing fewer medical procedures. However, limited research has assessed cost implications in the United States. Using national data, we assessed costs and resource use of midwife-led care vs obstetrician-led care for low-risk pregnancies using a decision-analytic approach.

METHODS

We developed a decision-analytic model of costs (health plan payments to clinicians) and use of medical procedures during childbirth (epidural analgesia, labor induction, cesarean birth, episiotomy) and outcomes of care (birth at preterm gestation) that may differ with midwife-led vs obstetrician-led care. Model parameters for obstetric procedures were generated using Listening to Mothers III data, a national survey of women who gave birth in US hospitals in 2011-2012 and other published estimates. Cost estimates came from published or publicly available information on health insurance claims payments.

RESULTS

The costs of childbirth for low-risk women with midwife-led care were, on average, $2262 less than births to low-risk women cared for by obstetricians. These cost differences derive from lower rates of preterm birth and episiotomy among women with midwife-led care, compared with obstetrician-led care. Across the population of US women with low-risk births each year (approximately 2.6 million), the model predicted substantially fewer preterm births (167 259 vs 219 427 for midwife-led vs obstetrician-led care) and fewer episiotomies (170 504 vs 415 686, for midwife-led vs obstetrician-led care).

CONCLUSIONS

A shift from obstetrician-led care to midwife-led care for low-risk pregnancies could be cost saving.

Severe maternal morbidity and related hospital quality measures in Maryland

OBJECTIVE

To determine hospital characteristics and quality metrics associated with severe maternal morbidity (SMM) in Maryland.

STUDY DESIGN

A population-based observational study of 364,113 statewide delivery hospitalizations during 2010-2015 linked with socio-economic community measures and hospital characteristics and quality measures. Multivariable logistic regression models with generalized estimating equations estimated SMM adjusting for individual, community, and hospital-level factors and clustering within hospitals and residence zip codes.

RESULTS

The SMM prevalence was 197 per 10,000 deliveries. Adjusted SMM risk ratios were higher for younger (<20 years), older (35+ years), non-White non-Hispanic, unmarried, multiple substance users, women with multiple gestations, and chronic medical and mental health conditions than their counterparts. Communities with greater socio-economic disadvantage and hospitals with poorer patient experience and clinical care quality had higher rates of SMM.

CONCLUSION

Addressing socio-economic disparities and improving quality of care in delivery hospitals are key to reducing the SMM burden in Maryland.

Risk-Appropriate Care to Improve Practice and Birth Outcomes

Identification and referral of women with high-risk pregnancies to hospitals better equipped and staffed to provide care for them have been important steps to improve birth outcomes. Based on recent recommendations from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine to provide regionalized maternal care for pregnant women at high risk and reduce rates of maternal morbidity and mortality, health care organizations and providers have refocused their attention to women's well-being rather than solely on the well-being of the fetus or newborn. Opportunities to improve practice and birth outcomes exist through the implementation of a more standardized and integrated system of risk-appropriate care.

A Call to Revisit the Prenatal Period as a Focus for Action Within the Reproductive and Perinatal Care Continuum

Objectives The broad maternal and child health community has witnessed increased attention to the entire continuum of reproductive and perinatal health concerns over the past few years. However, both recent discouraging trends in prenatal care access and utilization and a renewed understanding of prenatal care as a critical anchor of the reproductive/perinatal health continuum for women who do get pregnant demand a new effort to focus on the prenatal period as a gateway for maternal and infant health. Methods This commentary: describes the Medicaid expansions and the momentum for universal access to prenatal care of the 1980-1990s; examines the pivot away from this goal and its aftermath; provides a rationale for why renewed attention to prenatal care and the prenatal period is essential; and, explores the potential focus of an updated prenatal care agenda. Conclusion We conclude that increasing women's access to high quality prenatal care will require substantial effort at the clinical, community, policy, and system levels. Only when attention is paid to all phases of the reproductive/perinatal health continuum with an emphasis on continuity between all periods, and on the social determinants that affect health and well-being, will our nation be able to ensure the health of all women across the life course (whether or not they ever become mothers), while simultaneously fulfilling our nation's promise that all children-no matter their income or race/ethnicity-will have the opportunity to be born well.

Hospital variation in cost of childbirth and contributing factors: a cross-sectional study

OBJECTIVE

To examine hospital variation in cost of childbirth hospitalisations and identify factors that contribute to the variation.

DESIGN

Cross-sectional analysis of linked birth certificate and hospital discharge data.

SETTING

Two hundred and twenty hospitals in California delivering ≥ 100 births per year.

POPULATION

A total of 405 908 nulliparous term singleton vertex births during 2010-2012.

METHODS

Cost of childbirth hospitalisations was compared across hospitals after accounting for differences in patient clinical risk factors. Relative contributions of patient sociodemographic, obstetric intervention, birth attendant and institutional characteristics to variation in cost were assessed by further adjusting for these factors in hierarchical generalised linear models.

MAIN OUTCOME MEASURES

Cost of childbirth hospitalisation.

RESULTS

Median risk-standardised cost of childbirth was $7149 among the hospitals (10^th -90th percentile range: $4760-$10,644). Maternal sociodemographic characteristics and type of birth attendant did not explain hospital variation in cost. Adjustment for obstetric interventions overall reduced within-hospital variance by 15.8% (P < 0.001), while adjusting for caesarean delivery alone reduced within-hospital variance by 14.4% (P < 0.001). However, obstetric interventions did not explain between-hospital variation in cost. In contrast, adjustment for institutional characteristics reduced between-hospital variance by 30.3% (P = 0.002). Hospital type of ownership, teaching/urban-rural status, neonatal care capacity and geographic region were most impactful. Risk-standardised cost was positively correlated with risk-standardised rate of severe newborn morbidities (correlation coefficient 0.22, P = 0.001), but not associated with risk-standardised rate of severe maternal morbidities.

CONCLUSIONS

Cost of childbirth hospitalisations varied widely among hospitals in California. Institutional characteristics significantly contributed to this variation. Higher-cost hospitals did not have better outcomes, suggesting potential opportunities to enhance value in care.

TWEETABLE ABSTRACT

Hospitals vary in cost of childbirth. Institutional characteristics significantly contribute to the variation.

Outcomes of childbearing Medicaid beneficiaries engaged in care at Strong Start birth center sites between 2012 and 2014

BACKGROUND

Variations in care for pregnant women have been reported to affect pregnancy outcomes.

METHODS

This study examined data for all 3136 Medicaid beneficiaries enrolled at American Association of Birth Centers (AABC) Center for Medicare and Medicaid Innovation Strong Start sites who gave birth between 2012 and 2014. Using the AABC Perinatal Data Registry, descriptive statistics were used to evaluate socio-behavioral and medical risks, and core perinatal quality outcomes. Next, the 2082 patients coded as low medical risk on admission in labor were analyzed for effective care and preference sensitive care variations. Finally, using binary logistic regression, the associations between selected care processes and cesarean delivery were explored.

RESULTS

Medicaid beneficiaries enrolled at AABC sites had diverse socio-behavioral and medical risk profiles and exceeded quality benchmarks for induction, episiotomy, cesarean, and breastfeeding. Among medically low-risk women, the model demonstrated effective care variations including 82% attendance at prenatal education classes, 99% receiving midwifery-led prenatal care, and 84% with midwifery- attended birth. Patient preferences were adhered to with 83% of women achieving birth at their preferred site of birth, and 95% of women using their preferred infant feeding method. Elective hospitalization in labor was associated with a 4-times greater risk of cesarean birth among medically low-risk childbearing Medicaid beneficiaries.

CONCLUSIONS

The birth center model demonstrates the capability to achieve the triple aims of improved population health, patient experience, and value.

Obstetric Provider Trainees in Georgia: Characteristics and Attitudes About Practice in Obstetric Provider Shortage Areas

Objectives In Georgia, 52 % of the primary care service areas outside metropolitan Atlanta have a deficit of obstetric providers. This study was designed to identify factors associated with the likelihood of Georgia's obstetric trainees (obstetrics and gynecology (OB/GYN) residents and certified nurse midwifery (CNM) students) to practice in areas of Georgia that lack obstetric providers and services, i.e. rural Georgia. Methods Pilot-tested electronic and paper surveys were distributed to all of Georgia's OB/GYN residents (N = 95) and CNM students (N = 28). Mixed-methods survey questions assessed characteristics, attitudes, and incentives that might be associated with trainee desire to practice in areas of Georgia that lack obstetric providers and services. Surveys also gathered information about concerns that may prevent trainees from practicing in shortage areas. Univariate and bivariate analyses were performed, and qualitative themes were abstracted from open-ended questions. Results The survey response rate was 87.8 % (108/123). Overall, 24.4 % (19/78) of residents and 53.6 % (15/28) of CNM students expressed interest in practicing in rural Georgia, and both residents and CNM students were more likely to desire to practice in rural Georgia with the offer of any of six financial incentives (P < 0.001). Qualitative themes highlighted trainees' strong concerns about Georgia's political environment as it relates to reproductive healthcare. Conclusions Increasing state-level, rurally-focused financial incentive programs and emphasizing the role of CNMs may alleviate obstetric provider shortages in Georgia.

Deliberate acquisition of competence in physiological breech birth: A grounded theory study

PROBLEM

Research suggests that the skill and experience of the attendant significantly affect the outcomes of vaginal breech births, yet practitioner experience levels are minimal within many contemporary maternity care systems.

BACKGROUND

Due to minimal experience and cultural resistance, few practitioners offer vaginal breech birth, and many practice guidelines and training programmes recommend delivery techniques requiring supine maternal position. Fewer practitioners have skills to support physiological breech birth, involving active maternal movement and choice of birthing position, including upright postures such as kneeling, standing, squatting, or on a birth stool. How professionals learn complex skills contrary to those taught in their local practice settings is unclear.

QUESTION

How do professionals develop competence and expertise in physiological breech birth?

METHODS

Nine midwives and five obstetricians with experience facilitating upright physiological breech births participated in semi-structured interviews. Data were analysed iteratively using constructivist grounded theory methods to develop an empirical theory of physiological breech skill acquisition.

RESULTS

Among the participants in this research, the deliberate acquisition of competence in physiological breech birth included stages of affinity with physiological birth, critical awareness, intention, identity and responsibility. Expert practitioners operating across local and national boundaries guided less experienced practitioners.

DISCUSSION

The results depict a specialist learning model which could be formalised in sympathetic training programmes, and evaluated. It may also be relevant to developing competence in other specialist/expert roles and innovative practices.

CONCLUSION

Deliberate development of local communities of practice may support professionals to acquire elusive breech skills in a sustainable way.

Preliminary evaluation of the Well-being in Pregnancy (WiP) questionnaire

BACKGROUND

The concept of well-being is multi-faceted by encompassing both positive and negative emotions and satisfaction with life. Measuring both positive and negative thoughts and emotions is highly relevant in maternity care that aims to optimise a woman's experience of pregnancy and childbirth, focussing on positive aspects of health and well-being, not just the prevention of ill health. Yet our understanding of well-being in pregnancy and childbirth is limited as research to date has focussed on negative aspects such as stress, anxiety or depression. The primary aim of this study is to describe the psychometric properties of a newly developed Well-being in Pregnancy (WiP) questionnaire.

METHODS

A cohort study of 318 women attending hospital antenatal clinics in Belfast completed a questionnaire including three general well-being measures (not pregnancy specific) and the newly developed WiP questionnaire. The psychometric properties of the questionnaire were analysed using correlations to explore the relationship between the WiP questionnaire with the generic well-being measures administered at the same time and exploratory factor analysis was conducted.

RESULTS

The overall Cronbach's alpha of the WiP was 0.73. Principal factor analysis was run on the WiP items and two factors were identified, one reflecting positive affect and satisfaction (Cronbach's alpha = 0.718) and the other concerns (Cronbach's alpha = 0.702). Both the overall WiP score and WiP sub-scale scores displayed significant correlations with the other well-being scales (r = 0.235-0.527).

CONCLUSIONS

Measuring well-being in pregnancy is an important step in understanding the potential physical, psychological and social benefits of pregnancy and in understanding how well-being can be enhanced for women and their families at this important life stage. The initial psychometric data presented for the WiP questionnaire are encouraging. Most importantly, the measure provides an opportunity for women to express positive and negative emotions and thoughts about their pregnancy thus reflecting the whole spectrum of well-being.

Electronic Medical Record Use and Maternal and Child Care and Health

OBJECTIVES

To evaluate effects of EHR adoption and use during pregnancy on maternal and child health care utilization and health among pregnant mothers and their infants.

METHODS

The study population was comprised of all Medicaid-insured pregnant women who delivered a singleton birth in Michigan between 1/1/2009 and 12/31/2012 and their infants (N = 226,558). Linked data included birth records, maternal and infant medical claims, and EHR adoption, implementation, upgrading and meaningful use data. Pre-post comparisons with a control group (difference-in-difference) took advantage of a natural experiment of EHR adoption and use among providers in Michigan. Women and infants who received care from providers who adopted and used EHR were compared with those who received care from other providers, in a quasi-experimental framework.

RESULTS

Over 34 % of all women in the analytic sample received perinatal care from providers who adopted and used EHR. Multivariate regressions indicate that women who received prenatal care mainly from a provider who adopted and used EHR were more likely to have any well-child visits (0.05, p = 0.04), and the appropriate number of well-child visits during the first year of life (0.03, p < 0.01).

CONCLUSIONS

The findings of this study are consistent with EHR adoption and use supporting improved child health care utilization. The findings have the potential to provide Medicaid and other healthcare program officials with evidence of the potential gains to be derived from EHRs for vulnerable low-income women and infants.

Perceived Benefits of Childbirth Education on Future Health-Care Decision Making

The aim of this qualitative study was to explore the perception of women regarding long-term effects of childbirth education on future health-care decision making. This qualitative study used a purposive sample of 10 women who participated in facilitated focus groups. Analysis of focus group narratives provided themes in order of prevalence: (a) self-advocacy, (b) new skills, (c) anticipatory guidance, (d) control, (e) informed consent, and (f) trust. This small exploratory study does not answer the question of whether childbirth education influences future health-care decision making, but it demonstrates that the themes and issues from participants who delivered 15-30 years ago were comparable to current findings in the literature.

The American College of Nurse-Midwives Clarity in Collaboration Project: Describing Midwifery Care in Interprofessional Collaborative Care Models

In 2014, the American College of Nurse-Midwives (ACNM) launched a project called Clarity in Collaboration to develop data definitions related to midwifery and maternity care delivery processes. These definitions are needed to ensure midwifery care delivered in collaborative care models is accurately and consistently captured in clinical documentation systems, data registries, and systems being developed as part of health care restructuring and payment reform. The Clarity in Collaboration project builds on the efforts of the Women's Health Registry Alliance (WHRA), which was recently established by the American College of Obstetricians and Gynecologists. Clarity in Collaboration mirrored the process used by ReVITALize, WHRA's first maternity data standardization project, which focused on establishing standardized clinical data definitions for obstetrics. The ACNM Clarity in Collaboration project brought together maternity and midwifery care experts to complete a year-long consensus process, including a period of public comment, resulting in development of 20 concept definitions. These definitions can be used to describe midwifery care within the context of collaborative care models. This article provides a summary of the ACNM Clarity in Collaboration process with discussion of implications for maternity data collection.

Understanding Consumer Perceptions and Awareness of Hospital-Based Maternity Care Quality Measures

OBJECTIVE

To explore factors that may influence use of comparative public reports for hospital maternity care.

DATA SOURCES

Four focus groups conducted in 2013 with 41 women and preintervention survey data collected in 2014 to 2015 from 245 pregnant women in North Carolina.

STUDY DESIGN

As part of a larger randomized controlled trial, we conducted qualitative formative research to develop an intervention that will be evaluated through pre- and postintervention surveys.

DATA EXTRACTION METHODS

Analysis of focus group transcripts examined participants' perceptions of high-quality maternity care and the importance of different quality measures. Quantitative analysis included descriptive results of the preintervention survey and subgroup analyses to examine the impact of race, education, and being a first-time mom on outcomes.

PRINCIPAL FINDINGS

When describing high-quality maternity care, participants focused on interactions with providers, including respect for preferences and communication. The importance of quality measures was influenced by the extent to which they focused on babies' health, were perceived as the hospital's responsibility, and were perceived as representing "standard care." At baseline, 28 percent of survey respondents had used quality information to choose a hospital. Survey respondents were more aware of some quality measures (e.g., breastfeeding support) than others (e.g., episiotomy rates).

CONCLUSIONS

Public reporting efforts could help increase relevance of maternity care quality measures by creating measures that reflect women's concerns, clearly explaining the hospital's role in supporting quality care, and showing how available quality measures can inform decisions about childbirth.

Midwifery care and patient-provider communication in maternity decisions in the United States

To characterize reasons women chose midwives as prenatal care providers and to measure the relationship between midwifery care and patient-provider communication in the U.S.

CONTEXT

Retrospective analysis of data from a nationally-representative survey of women who gave birth in 2011-2012 to a single newborn in a U.S. hospital (n = 2,400). We used multivariate logistic regression models to characterize women who received prenatal care from a midwife, to describe the reasons for this choice, and to examine the association between midwife-led prenatal care and women's reports about communication. Preference for a female clinician and having a particular clinician assigned was associated with higher odds of midwifery care (AOR = 2.65, 95 % CI 1.70, 4.14 and AOR = 1.63, 95 % CI 1.04, 2.58). A woman with midwifery care had lower odds of reporting that she held back questions because her preference for care was different from her provider's recommendation (AOR = 0.46, 95 % CI 0.23, 0.89) or because she did not want to be perceived as difficult (AOR = 0.48, 95 % CI 0.28, 0.81). Women receiving midwifery care also had lower odds of reporting that the provider used medical words were hard for them to understand (AOR = 0.58, 95 % CI 0.37, 0.91) and not feeling encouraged to discuss all their concerns (AOR = 0.54, 95 % CI 0.34, 0.89). Women whose prenatal care was provided by midwives report better communication compared with those cared for by other types of clinicians. Systems-level interventions, such as assigning a clinician, may improve access to midwifery care and the associated improvements in patient-provider communication in maternity care.

Transforming Patient-Centered Care: Development of the Evidence Informed Decision Making through Engagement Model

BACKGROUND

In response to the passage of the Affordable Care Act in the United States, clinicians and researchers are critically evaluating methods to engage patients in implementing evidence-based care to improve health outcomes. However, most models on implementation only target clinicians or health systems as the adopters of evidence. Patients are largely ignored in these models. A new implementation model that captures the complex but important role of patients in the uptake of evidence may be a critical missing link.

DISCUSSION

Through a process of theory evaluation and development, we explore patient-centered concepts (patient activation and shared decision making) within an implementation model by mapping qualitative data from an elective induction of labor study to assess the model's ability to capture these key concepts. The process demonstrated that a new, patient-centered model for implementation is needed. In response, the Evidence Informed Decision Making through Engagement Model is presented. We conclude that, by fully integrating women into an implementation model, outcomes that are important to both the clinician and patient will improve.

CONCLUSIONS

In the interest of providing evidence-based care to women during pregnancy and childbirth, it is essential that care is patient centered. The inclusion of concepts discussed in this article has the potential to extend beyond maternity care and influence other clinical areas. Utilizing the newly developed Evidence Informed Decision Making through Engagement Model provides a framework for utilizing evidence and translating it into practice while acknowledging the important role that women have in the process.

Two practice models in one labor and delivery unit: association with cesarean delivery rates

OBJECTIVE

The objective of the study was to examine the association between labor and delivery practice model and cesarean delivery rates at a community hospital.

STUDY DESGIN

This was a retrospective cohort study of 9381 singleton live births at 1 community hospital, at which women were provided labor and delivery care under 1 of 2 distinct practice models: a traditional private practice model and a midwife-physician laborist practice model. Cesarean rates were compared by practice model, adjusting for potential sociodemographic and clinical confounders. Statistical comparisons were performed using the χ(2) test and multivariable logistical regression.

RESULTS

Compared with women managed under the midwife/laborist model, women in the private model were significantly more likely to have a cesarean delivery (31.6% vs 17.3%; P < .001; adjusted odds ratio [aOR], 2.11; 95% confidence interval [CI], 1.73-2.58). Women with nulliparous, term, singleton, vertex gestations also were more likely to have a cesarean delivery if they were cared for in the private model (29.8% vs 15.9%; P < .001; aOR, 1.86; 95% CI, 1.33-2.58) as were women who had a prior cesarean delivery (71.3% vs 41.4%; P < .001; aOR, 3.19; 95% CI, 1.74-5.88).

CONCLUSION

In this community hospital setting, a midwife-physician laborist practice model was associated with lower cesarean rates than a private practice model.

Positive childbirth experiences in U.S. hospitals: a mixed methods analysis

Research on maternity care quality in the US often focuses on avoiding adverse events. Positive birth experiences receive less attention. This analysis used a mixed methods approach to identify factors associated with confidence and positive experiences during birth among a national sample of U.S. mothers. Data are from a nationally representative survey of women who delivered a singleton baby in a US hospital in 2005 (N = 1,573). We explored the relationship between confidence, positive birth experiences and socio-demographic characteristics as well as factors related to the clinical encounter and health systems, including common obstetric procedures and interventions. Self-reported confidence during birth was the outcome in quantitative analyses. We used logistic regression analysis and qualitative analysis of open-ended survey responses. Approximately 42% of mothers reported feeling confident during birth. Confidence going into labor was the strongest predictor of confidence during birth (adjusted odds ratio 12.88 for nulliparous women, 8.54 for parous women). Black and Hispanic race/ethnicity (compared to white) and having partner support were positively associated with confidence during birth for nulliparous women. Qualitative analyses revealed that positive experiences were related to previous birth experiences, communication between women and their clinicians, perceptions of shared decision-making, and communication among clinicians related to the timing and logistics of managing complications and coordinating care. For clinicians who care for women during pregnancy and childbirth, thoughtful, deliberate attention to factors promoting positive birth experiences may help create circumstances amenable to enhancing the quality of obstetric care and improving outcomes for mothers and infants.

What women want: qualitative analysis of consumer evaluations of maternity care in Queensland, Australia

BACKGROUND

Maternity care reform plans have been proposed at state and national levels in Australia, but the extent to which these respond to maternity care consumers' expressed needs is unclear. This study examines open-text survey comments to identify women's unmet needs and priorities for maternity care. It is then considered whether these needs and priorities are addressed in current reform plans.

METHODS

Women who had a live single or multiple birth in Queensland, Australia, in 2010 (n 3,635) were invited to complete a retrospective self-report survey. In addition to questions about clinical and interpersonal maternity care experiences from pregnancy to postpartum, women were asked an open-ended question "Is there anything else you'd like to tell us about having your baby?" This paper describes a detailed thematic analysis of open-ended responses from a random selection of 150 women (10% of 1,510 who responded to the question).

RESULTS

Four broad themes emerged relevant to improving women's experiences of maternity care: quality of care (interpersonal and technical); access to choices and involvement in decision-making; unmet information needs; and dissatisfaction with the care environment. Some of these topics are reflected in current reform goals, while others provide evidence of the need for further reforms.

CONCLUSIONS

The findings reinforce the importance of some existing maternity reform objectives, and describe how these might best be met. Findings affirm the importance of information provision to enable informed choices; a goal of Queensland and national reform agendas. Improvement opportunities not currently specified in reform agendas were also identified, including the quality of interpersonal relationships between women and staff, particular unmet information needs (e.g., breastfeeding), and concerns regarding the care environment (e.g., crowding and long waiting times).

Maternal clinical diagnoses and hospital variation in the risk of cesarean delivery: analyses of a National US Hospital Discharge Database

BACKGROUND

Cesarean delivery is the most common inpatient surgery in the United States, where 1.3 million cesarean sections occur annually, and rates vary widely by hospital. Identifying sources of variation in cesarean use is crucial to improving the consistency and quality of obstetric care. We used hospital discharge records to examine the extent to which variability in the likelihood of cesarean section across US hospitals was attributable to individual women's clinical diagnoses.

METHODS AND FINDINGS

Using data from the 2009 and 2010 Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project--a 20% sample of US hospitals--we analyzed data for 1,475,457 births in 1,373 hospitals. We fitted multilevel logistic regression models (patients nested in hospitals). The outcome was cesarean (versus vaginal) delivery. Covariates included diagnosis of diabetes in pregnancy, hypertension in pregnancy, hemorrhage during pregnancy or placental complications, fetal distress, and fetal disproportion or obstructed labor; maternal age, race/ethnicity, and insurance status; and hospital size and location/teaching status. The cesarean section prevalence was 22.0% (95% confidence interval 22.0% to 22.1%) among women with no prior cesareans. In unadjusted models, the between-hospital variation in the individual risk of primary cesarean section was 0.14 (95% credible interval 0.12 to 0.15). The difference in the probability of having a cesarean delivery between hospitals was 25 percentage points. Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics (0.16 [95% credible interval 0.14 to 0.18]). A limitation is that these data, while nationally representative, did not contain information on parity or gestational age.

CONCLUSIONS

Variability across hospitals in the individual risk of cesarean section is not decreased by accounting for differences in maternal diagnoses. These findings highlight the need for more comprehensive or linked data including parity and gestational age as well as examination of other factors-such as hospital policies, practices, and culture--in determining cesarean section use. Please see later in the article for the Editors' Summary.

Employment during pregnancy and obstetric intervention without medical reason: labor induction and cesarean delivery

BACKGROUND

Rising rates of labor induction and cesarean delivery, especially when used without a medical reason, have generated concern among clinicians, women, and policymakers. Whether employment status affects pregnant women's childbirth-related care is not known. We estimated the relationship between prenatal employment and obstetric procedures, distinguishing whether women reported that the induction or cesarean was performed for medical reasons.

METHODS

Using data from a nationally representative sample of women who gave birth in U.S. hospitals (n = 1,573), we used propensity score matching to reduce potential bias from nonrandom selection into employment. Outcomes were cesarean delivery and labor induction, with and without a self-reported medical reason. Exposure was prenatal employment status (full-time employment, not employed). We conducted separate analyses for unmatched and matched cohorts using multivariable regression models.

FINDINGS

There were no differences in labor induction based on employment status. In unmatched analyses, employed women had higher odds of cesarean delivery overall (adjusted odds ratio [AOR], 1.45; p = .046) and cesarean delivery without medical reason (AOR, 1.94; p = .024). Adding an interaction term between employment and college education revealed no effects on cesarean delivery without medical reason. There were no differences in cesarean delivery by employment status in the propensity score-matched analysis.

CONCLUSIONS

Full-time prenatal employment is associated with higher odds of cesarean delivery, but this association was not explained by socioeconomic status and no longer existed after accounting for sociodemographic differences by matching women employed full time with similar women not employed during pregnancy.

Rural-urban differences in obstetric care, 2002-2010, and implications for the future

BACKGROUND

Approximately 15% of the 4 million annual US births occur in rural hospitals.

OBJECTIVE

To (1) measure differences in obstetric care in rural and urban hospitals, and to (2) examine whether trends over time differ by rural-urban hospital location.

RESEARCH DESIGN AND SUBJECTS

This was a retrospective analysis of hospital discharge records for all births in the 2002-2010 Nationwide Inpatient Sample, which constitutes 20% sample of US hospitals (N = 7,188,972 births: 6,316,743 in urban hospitals, 837,772 in rural hospitals).

MEASURES

Rates of low-risk cesarean (full-term, singleton, vertex pregnancies; no prior cesarean), vaginal birth after cesarean (VBAC), nonindicated cesarean, and nonindicated labor induction were estimated.

RESULTS

In 2010, low-risk cesarean rates in rural and urban hospitals were 15.5% and 16.1%, respectively, and nonindicated cesarean rates were 16.9% and 17.8%, respectively. VBAC rates were 5.0% in rural and 10.0% in urban hospitals in 2010. Between 2002 and 2010, rates of low-risk cesarean and nonindicated cesarean increased, and VBAC rates decreased in both rural and urban hospitals. Nonindicated labor induction was less frequent in rural versus urban hospitals in 2002 [adjusted odds ratio = 0.79 (0.78-0.81)], but increased more rapidly in rural hospitals from 2002 to 2010 [adjusted odds ratio = 1.05 (1.05-1.06)]. In 2010, 16.5% of rural births were induced without indication (12.0% of urban births).

CONCLUSIONS

From 2002 to 2010, cesarean rates rose and VBAC rates fell in both rural and urban hospitals. Nonindicated labor induction rates rose disproportionately faster in rural versus urban settings. Tailored clinical and policy tools are required to address differences between rural and urban hospitals.

Birth volume and the quality of obstetric care in rural hospitals

BACKGROUND

Childbirth is the most common reason for hospitalization in the United States. Assessing obstetric care quality is critically important for patients, clinicians, and hospitals in rural areas.

METHODS

The study used hospital discharge data from the Statewide Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, for 9 states (Colorado, Iowa, Kentucky, New York, North Carolina, Oregon, Vermont, Washington, and Wisconsin) to identify all births in rural hospitals with 10 or more births/year in 2002 (N = 94,356) and 2010 (N = 103,880). Multivariate logistic regression was used to assess the relationship between hospital annual birth volume, measured as low (10-110), medium (111-240), medium-high (241-460) or high (>460), and 3 measures of obstetric care quality (low-risk cesarean rates for term, vertex, and singleton pregnancies with no prior cesarean; nonindicated cesarean; and nonindicated induction) and 2 patient safety measures (episiotomy and perineal laceration).

RESULTS

The odds of low-risk and nonindicated cesarean were lower in medium-high and high-volume rural hospitals compared with low-volume hospitals after controlling for maternal demographic and clinical factors. In low-volume hospitals, odds of labor induction without medical indication were higher than in medium-volume hospitals, but not significantly different from medium-high or high-volume hospitals. Odds of episiotomy were greater in medium-high or high-volume hospitals than in low-volume hospitals. The likelihood of perineal laceration did not differ significantly by birth volume.

CONCLUSIONS

Obstetric quality and safety outcomes vary significantly across rural hospitals by birth volume. Better performance is not consistently associated with either lower or higher volume facilities.

In a maternity shared-care environment, what do we know about the paper hand-held and electronic health record: a systematic literature review

BACKGROUND

The paper hand-held record (PHR) has been widely used as a tool to facilitate communication between health care providers and a pregnant woman. Since its inception in the 1950s, it has been described as a successful initiative, evolving to meet the needs of communities and their providers. Increasingly, the electronic health record (EHR) has dominated the healthcare arena and the maternity general practice shared-care arrangement seems to have adopted this initiative. A systematic review was conducted to determine perspectives of the PHR and the EHR with regards to data completeness; experiences of users and integration of care between women and health care providers.

METHOD

A literature search was conducted that included papers from 1985 to 2012. Studies were chosen if they fulfilled the inclusion criteria, reporting on: data completeness; experiences of users and integration of care between women and health care providers. Papers were extracted by one reviewer in consultation with two reviewers with expertise in maternity e-health and independently assessed for quality.

RESULTS

A total of 43 papers were identified for the review, from an initial 6,816 potentially relevant publications. No papers were found that reported on data completeness in a maternity PHR or a maternity EHR, in a shared-care setting. Women described the PHR as important to their antenatal care and had a generally positive perception of using an EHR. Hospital clinicians reported generally positive experiences using a PHR, while both positive and negative impressions were found using an EHR. The few papers describing the use of the PHR and EHR by community clinicians were also divergent and inconclusive with regards to their experiences. In a general practice shared-care model, the PHR is a valuable tool for integration between the woman and the health care provider. While the EHR is an ideal initiative in the maternity setting, facilitating referrals and communication, there are issues of fragmentation and continued paper use.

CONCLUSIONS

There was a surprising gap in knowledge surrounding data completeness on maternity PHRs or EHRs. There is also a paucity of available impressions from community clinicians using both forms of the records.

Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues

Cesarean delivery is the most commonly performed surgical procedure in the United States, and cesarean rates are increasing. Working with 2009 data from 593 US hospitals nationwide, we found that cesarean rates varied tenfold across hospitals, from 7.1 percent to 69.9 percent. Even for women with lower-risk pregnancies, in which more limited variation might be expected, cesarean rates varied fifteenfold, from 2.4 percent to 36.5 percent. Thus, vast differences in practice patterns are likely to be driving the costly overuse of cesarean delivery in many US hospitals. Because Medicaid pays for nearly half of US births, government efforts to decrease variation are warranted. We focus on four promising directions for reducing these variations, including better coordinating maternity care, collecting and measuring more data, tying Medicaid payment to quality improvement, and enhancing patient-centered decision making through public reporting.

Trends in maternal morbidity before and during pregnancy in California

OBJECTIVES

We examined trends in maternal comorbidities in California.

METHODS

We conducted a retrospective cohort study of 1,551,017 California births using state-linked vital statistics and hospital discharge cohort data for 1999, 2002, and 2005. We used International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify the following conditions, some of which were preexisting: maternal hypertension, diabetes, asthma, thyroid disorders, obesity, mental health conditions, substance abuse, and tobacco use. We estimated prevalence rates with hierarchical logistic regression models, adjusting for demographic shifts, and also examined racial/ethnic disparities.

RESULTS

The prevalence of these comorbidities increased over time for hospital admissions associated with childbirth, suggesting that pregnant women are getting sicker. Racial/ethnic disparities were also significant. In 2005, maternal hypertension affected more than 10% of all births to non-Hispanic Black mothers; maternal diabetes affected nearly 10% of births to Asian/Pacific Islander mothers (10% and 43% increases, respectively, since 1999). Chronic hypertension, diabetes, obesity, mental health conditions, and tobacco use among Native American women showed the largest increases.

CONCLUSIONS

The prevalence of maternal comorbidities before and during pregnancy has risen substantially in California and demonstrates racial/ethnic disparity independent of demographic shifts.

Outcomes of the Evidence-Based Pitocin Administration Checklist at a Tertiary-Level Hospital

Pitocin, a synthetic form of the hormone oxytocin, is a high-alert medication that heightens patient harm when used incorrectly. This investigation examined the outcomes of an evidence-based Pitocin administration checklist used for labor augmentation at a tertiary-level hospital. Data came from patient records. Using the Perinatal Trigger Tool, N = 372 clinical records (n = 194 prior to and n = 178 following checklist implementation) were reviewed. Checklist implementation resulted in statistically significant reductions in the duration of hospitalization (1.72 vs. 2.02 days, p = .0005), presence of meconium (23.7% vs. 6.7%, p < .001), maternal fevers (7.2% vs. 2.3%, p = .030), and episiotomies (8.8% vs. 1.7%, p = .002), and clinically important reduction in APGAR scores < 7 at 5 min (3.6%-0.6%, p = .069) and instrumented deliveries (11.9%-8.4%, p = .307). A universal Pitocin checklist implementation can improve birth outcomes and costs of care.

Social Media, Power, and the Future of VBAC

The Internet has been called a disruptive technology because it has shifted power and altered the economics of doing business, whether that business is selling books or providing health care. Social media have accelerated the pace of disruption by enabling interactive information sharing and blurring the lines between the "producers" and "consumers" of knowledge, goods, and services. In the wake of the National Institutes of Health Consensus Development Conference on Vaginal Birth After Cesarean (VBAC) and major national recommendations for maternity care reform, activated, engaged consumers face an unprecedented opportunity to drive meaningful changes in VBAC access and safety. This article examines the role of social networks in informing women about VBAC, producing low-cost, accessible decision aids, and enabling multi-stakeholder collaborations toward workable solutions that remove barriers women face in accessing VBAC.

Continuing education module transforming maternity care: implementing the blueprint for action

In January 2010, Women's Health Issues published two direction-setting reports from the Transforming Maternity Care (TMC) Project: "2020 Vision for a High-Quality, High-Value Maternity Care System" and "Blueprint for Action: Steps Toward a High-Quality, High-Value Maternity Care System." This guest editorial summarizes highlights of the implementation phase of what is now known as the TMC Partnership. Major progress has been made in elevating maternity care quality to a national policy priority, increasing the availability and use of maternity care performance measures, and developing shared decision making tools for childbearing women.

Reevaluating the relationship between prenatal employment and birth outcomes: a policy-relevant application of propensity score matching

BACKGROUND

Prior research shows an association between prenatal employment characteristics and adverse birth outcomes, but suffers methodological challenges in disentangling women's employment choices from birth outcomes, and little U.S.-based prior research compares outcomes for employed women with those not employed. This study assessed the effect of prenatal employment status on birth outcomes.

METHODS

With data from the Listening to Mothers II survey, conducted among a nationally representative sample of women who delivered a singleton baby in a U.S. hospital in 2005 (n = 1,573), we used propensity score matching to reduce potential selection bias. Primary outcomes were low birth weight (<2,500 g) and preterm birth (gestational age <37 weeks). Exposure was prenatal employment status (full time, part time, not employed). We conducted separate outcomes analyses for each matched cohort using multivariable regression models.

FINDINGS

Comparing full-time employees with women who were not employed, full-time employment was not causally associated with preterm birth (adjusted odds ratio [AOR], 1.37; p = .47) or low birth weight (AOR, 0.73; p = .41). Results were similar comparing full- and part-time workers. Consistent with prior research, Black women, regardless of employment status, had increased odds of low birth weight compared with White women (AOR, 5.07; p = .002).

CONCLUSIONS

Prenatal employment does not independently contribute to preterm births or low birth weight after accounting for characteristics of women with different employment statuses. Efforts to improve birth outcomes should focus on the characteristics of pregnant women (employed or not) that render them vulnerable.

Doula care, birth outcomes, and costs among Medicaid beneficiaries

OBJECTIVES

We compared childbirth-related outcomes for Medicaid recipients who received prenatal education and childbirth support from trained doulas with outcomes from a national sample of similar women and estimated potential cost savings.

METHODS

We calculated descriptive statistics for Medicaid-funded births nationally (from the 2009 Nationwide Inpatient Sample; n = 279,008) and births supported by doula care (n = 1079) in Minneapolis, Minnesota, in 2010 to 2012; used multivariate regression to estimate impacts of doula care; and modeled potential cost savings associated with reductions in cesarean delivery for doula-supported births.

RESULTS

The cesarean rate was 22.3% among doula-supported births and 31.5% among Medicaid beneficiaries nationally. The corresponding preterm birth rates were 6.1% and 7.3%, respectively. After control for clinical and sociodemographic factors, odds of cesarean delivery were 40.9% lower for doula-supported births (adjusted odds ratio = 0.59; P < .001). Potential cost savings to Medicaid programs associated with such cesarean rate reductions are substantial but depend on states' reimbursement rates, birth volume, and current cesarean rates.

CONCLUSIONS

State Medicaid programs should consider offering coverage for birth doulas to realize potential cost savings associated with reduced cesarean rates.

Giving birth with epidural analgesia: the experience of first-time mothers

The purpose of our qualitative descriptive study was to describe the birth experiences of women using epidural analgesia for pain management. We interviewed nine primiparas who experienced vaginal births. Five themes emerged: (a) coping with pain, (b) finding epidural administration uneventful, (c) feeling relief having an epidural, (d) experiencing joy, and (e) having unsettled feelings of ambivalence. Although epidural analgesia was found to be effective for pain relief and may contribute to some women's satisfaction with the birth experience, it does not guarantee a quality birth experience. In order to support and promote childbearing women's decision making, we recommend improved education on the variety of available pain management options, including their risks and benefits. Fostering a sense of caring, connection, and control in women is a key factor to ensure positive birth experiences, regardless of pain management method.

Recent trends in clinicians providing care to pregnant women in the United States

INTRODUCTION

Health care needs of pregnant women are met by a variety of clinicians in a changing policy and practice environment. This study documents recent trends in types of clinicians providing care to pregnant women in the United States.

METHODS

We used a repeat cross-sectional design and data from the Integrated Health Interview Series (2000-2009), a nationally representative data set, for respondents who reported being pregnant at the time of the survey (N = 3204). Using longitudinal logistic regression models, we analyzed changes over time in pregnant women's reported use of care from 1) obstetrician-gynecologists; 2) midwives, nurse practitioners (NPs), or physician assistants (PAs); or 3) both an obstetrician-gynecologist and a midwife, NP, or PA.

RESULTS

The percentage of pregnant women who reported seeing an obstetrician-gynecologist (87%) remained steady from 2000 through 2009. After controlling for demographic and clinical variables, the percentage who reported receiving care from a midwife, NP, or PA increased 4% annually (yearly adjusted odds ratio [AOR] 1.04; P < .001), indicating a cumulative increase of 48% over the decade. The percentage of pregnant women who received care from both an obstetrician-gynecologist and a midwife, NP, or PA also increased (AOR 1.027; P < .001), for a cumulative increase of 30%.

DISCUSSION

The increasing role of midwives, NPs, and PAs in the provision of maternity care suggests changes in the perinatal workforce and practice models that may promote collaborative care and quality improvement. However, better data collection is required to gather detailed information on specific provider types, these trends, and their implications.

Expanding access to midwifery care: using one practice's success to create community change

Starting in 1991, Marin's County Certified Nurse-Midwife-Physician Collaborative Practice has proven to be a successful model of care for underinsured women. Functioning within the same hospital as traditional physician-led practices, the practice displayed excellent clinical outcomes and gained respect within the community. Twenty years later, the Marin obstetric community decided to restructure its programs to incorporate the care of underinsured and privately insured women into one system. The goal was to design a system that would be patient-centered, financially and professionally sustainable, and accessible to all women and would provide evidence-based care with excellent outcomes. The community agreed, based on its own experience and on current literature, that continuing and expanding the midwife-led model of care was a way to achieve these goals. Here we describe the history, practice, and outcomes of Marin's county practice and the factors that contributed to extending the availability of midwifery care to privately insured women.

A window of opportunity: the Louisiana Birth Outcomes Initiative

Louisiana ranks forty-ninth nationally in birth outcomes indicators such as infant mortality and in the percentage of low birth weight and very low birth weight babies. This article describes the formation of the Birth Outcomes Initiative, a statewide targeted investment to reduce poor birth outcomes. It describes how the initiative is a result of the convergence of the triad of well-defined problems, a credible array of potential solutions, and favorable political process. It then describes the Birth Outcomes Initiative in Louisiana, a targeted program to improve health indicators for reproductive-aged women and reduce the incidence of prematurity, low birth weight, and infant mortality.

Safe and healthy birth: the importance of data

In this column, the author reprises recent selections from the Lamaze International research blog, Science & Sensibility. Each selection discusses the mismatch between data commonly collected at the time of birth and the data needed to measure optimal care for physiologic birth. Selections include the importance of documenting duration of skin-to-skin contact after birth, the role of qualitative research in improving care in the second stage of labor, and pitfalls of meta-analyzing data on the safety of planned home birth.

Postpartum depression and help-seeking behaviors in immigrant Hispanic women

OBJECTIVES

To describe perceptions of immigrant Hispanic women experiencing symptoms of postpartum depression (PPD) and to identify barriers to seeking mental health services.

DESIGN

Qualitative descriptive.

SETTING

Community health clinic.

PARTICIPANTS

Twenty immigrant Hispanic women scoring positive for symptoms of PPD receiving health care at a community health clinic who declined mental health services participated in audiotaped interviews held in their homes.

METHODS

Following Institutional Review Board approval and informed consent, interviews were conducted with study participants. Transcribed data were analyzed as appropriate for qualitative inquiry.

RESULTS

Some of the women did not recognize and/or denied their symptoms attributing their sadness to financial concerns, family relationships, and/or work stressors. Study participants articulately described their symptoms and identified personal barriers including beliefs about emotional health, the perceived stigma of mental illness, hesitancy to seek treatment for symptoms of PPD, and cultural beliefs about motherhood and the role of women. Social barriers included inadequate social support, immigration status, and limited English proficiency. Health care delivery barriers included financial and time constraints and lack of child care and transportation.

CONCLUSION

Limited social networks and barriers to health care should be addressed to foster positive outcomes. Mental health services should be embedded with primary health care or obstetric care clinics to facilitate access. Personal and professional support can make a significant contribution to the reduction of symptoms of PPD.

Steps toward innovative childbirth education: selected strategies from the blueprint for action

To mark the 50th anniversary of Lamaze International, Childbirth Connection celebrates landmark accomplishments in education for childbearing women and families, and takes stock of the changing educational needs and preferences of current childbearing families in looking toward the future. Childbirth Connection's multi-year, multi-stakeholder Transforming Maternity Care initiative resulted in two landmark reports: 2020 Vision for a High-Quality, High-Value Maternity Care System and Blueprint for Action: Steps Toward a High-Quality, High-Value Maternity Care System. Selected recommendations of greatest relevance to the field of childbirth education are discussed, and the new Transforming Maternity Care Partnership is introduced.