Evidence into Action: Multidisciplinary Strategies for

Effective Maternity Care

Saraswathi Vedam, RM, MSN, FACNM, Sci D (hc)

Director, Division of Midwifery

University of British Columbia

2010

Maternal mortality

• Every year, approximately 600 000 women die of pregnancy-related causes (90% Asia and sub-Saharan Africa, 25% India)

• 3 million suffer childbirth related injury,

• 8 million infants die, 6 million in first month of life.

Maternal Mortality

More than 80% of maternal deaths worldwide are due to five direct causes:

• hemorrhage

• sepsis

• unsafe abortion

• obstructed labor

• hypertensive disease of pregnancy

FIGO Priority interventions1. Improving availability and use of essential obstetric

care for the management of complications;

2. strengthening family planning services;

3. ensuring skilled attendance at birth;

4. promoting women-friendly health services;

5. increasing district-level planning with community

participation; and

6. monitoring process with process indicators

Why Midwifery Care? Health Policy Perspective

(WHO 2000, APHA 2001, SOGC 2008, Cochrane 2009)

• Evidence based care– Improved maternal and fetal outcomes

– appropriate use of technology

– allocation of resources

– cost effectiveness

• Client satisfaction

Outcomes

• International literature has demonstrated the efficacy of midwifery practices with:– Outcomes (Cochrane 2009; Gabay et al 1997; Jackson 2003; Turnbull 1996;

Walker J 2000)– Safety of home birth ( Janssen 2009, Hutton 2009, de Jonge 2009, Johnson

and Daviss 2005; Weigers et al 1996; Olsen 1997; Ackermann and Liebrich 1996)

– Satisfaction of care provider (Hundley et al 1995) and client (Rowley et al 1995; Hundley et al 1997; Morgan et al 1998; Jannssen et al 2006; Hildingsson et al 2003)

• North American research has demonstrated safety of home birth and the desire and need for midwifery in rural environments (Kornelsen et al. 2005a; 2005b, 2008)

–

Rates of Midwifery Care

• 10-80% maternity care to all women in developed nations (Malott, JOGC,2009)

• 30% Gyn care provided by midwives

• 30-40% primary care for women and babies

• 70% care to underserved internationally

Who Chooses Midwifery?

• Socioeconomic status

• Education

• Rural vs. Urban

• Race

• Occupation

• Age and parity

• Marital status

Global Strategies for integrating midwifery

• Regulation

• Education

• Recruitment and Retention

• Association

• Collaboration

Credentials and Pathways

• CNM- Certified Nurse-Midwife

• CPM- Certified Professional Midwife

• LM- Licensed Midwife

• CM-Certified Midwife

• Registered Midwife

• Direct-Entry Midwife

• Traditional Midwife

Professional Midwifery • Antepartum, Intrapartum, Postpartum

care and support

• Primary Care of Newborn and infants– Lactation Consultation– Immediate newborn assessment

• Parenting and Public Health Education– Immunization, nutrition, growth, first aid

Regulation

• Europe, NZ, Australia, Canada, UK– Public funding for regulation, education,

and midwifery care

• Asia, Africa, Central and South America

• US - CNMs are recognized in all 50 states and the District of Columbia; CPMs in 27

Autonomy and collaboration

• Federal, state and provincial health codes:– The midwife as “an independent and interdependent

member of the health care team.” – In addition to managing and providing health care services,

it is assumed that the midwife will “use advanced knowledge and skills to identify abnormal conditions, diagnose health problems, implement treatment plans...and consult, collaborate or refer to other members of the health care team as appropriate to provide reasonable client care.”

Midwife / MD Collaboration

• Consult – eg. endocrine disorders, postdates, external version, dystocia, fear, comfort, culture, second stage

• Collaborate – gestational diabetes, PIH, multiple gestation, preterm labor, gyn complications

• Refer – surgical intervention – RM in supportive role for birth, resumes primary role PP

Education

• Core Competencies

• Expanded skills

• Defined scope for different roles based on competencies

• University and college programs, distance education, aboriginal

• Apprentice academics

Midwifery Model of Care

• Physical and psychosocial care• Antepartum and intrapartum testing• Time-prenatal, intrapartum, postpartum• Focus on education, self-care, partnership,

individualized care• Preventative model• Philosophy: normalcy and empowerment• Family centered care• Collaboration with health care team

Midwifery in Canada• Regulated and publicly funded

• Autonomous primary care practitioners

• Required to offer both home and hospital births

• Model of care includes the following components:– Informed choice and informed consent– Evidence-based practice– Respect for normal birth – Continuity of care – The judicious and appropriate use of medical technology

RN

RM RM

MD

RM

MDRN

Contributions to maternity care research

• Methods to enhance optimal outcomes

• Labor Pain and Progress– Maternal physiology and effects of care– Fetal physiology and effects of care

• Fetal Assessment

• Maternal Experience

• Postpartum Depression

Normal Labour & Birth: 5th International

Research Conference

The Benefits & Challenges of Preserving Physiologic Birth

 Coast Coal Harbor Hotel

Vancouver, BCJuly 20-23, 2010

2010 Conference Themes• Defining and describing normal birth • Practice • Public Information• Education• Policy

The Nature and Management of Labor PainAm J Ob Gyn, 186 (5) suppl, 2002

• Evidence-based, rigorous, peer reviewed

• Multidisciplinary steering committee: midwifery, obstetrics, pediatrics, physical therapy, neonatology, nursing, doulas, bioethics, childbirth education, consumer advocacy, epidemiology, public health, anesthesiology.

Non-pharmacologic Relief

• SR: Prospective controlled studies of five comfort measures requiring skills, policies, and/or equipment

• Continuous labor support, baths, touch and massage, maternal movement and positioning, intradermal water blocks for back pain.

• All 5 may be effective in reducing labor pain and improving other obstetric outcomes, and safe when used appropriately

Evidence Based Care:Home Birth

Saraswathi Vedam RM, MSN, FACNM, Sci D(hc)

Quieres unparto en la casa?

EresLoco?

How common is Home Birth?

• International trends:– Great Britain (30% in 1960, 2-10% & today)

– Switzerland, Denmark, Canada ,US (2-5%)

– Australia and New Zealand (2-5% and )

– Netherlands (70% in 1970, 31% in 1991, 35%)

– WHO observations (82% of all birth)

Is Home Birth Safe?

• Planned vs. unplanned

• Mortality or morbidity

• Methodological problems with research– lack of randomization– confounding factors (attendant type, transfer,etc)– small homogeneous studies– differences in definitions among countries– incomplete data (birth certificate studies)

Recent Controlled Trials

• Northern Region Perinatal Mortality Survey• National Birthday Trust Study• Ackerman-Liebrich et al.,1996• Wiegers, Keirse, et al., 1996• Meta-analyses, Olsen, 1997, 2000• Murphy and Fullerton, 1998• Janssen, 2002, 2006, 2009• Hutton 2009, de Jonge 2009

Quality of Evidence - 2009

• Janssen et al, CMAJ

• Hutton et al, Birth

• de Jonge, BJOG

de Jonge, et al, BJOG

• 529,688 women in midwifery care at labour onset (2000-2006)

• Planned home births: 321,301 (60%)

• Planned hospital births: 163, 261 (31%)

• No significant differences between home and hospital for any of the main outcomes

Hutton, et al, Birth

• 6692 women planning home births matched with 6692 planning hospital births

• Lower CS rates, and maternal and neonatal morbidity/mortality among women planning a home birth

Janssen, et al, CMAJ

• Prospective five-year long cohort study – midwife-attended PHB (2802) – physician attended hospital birth group (N=5985)

– midwife attended hospital birth group (N=5984).

• Similar or reduced rates of adverse outcomes with significantly fewer intrapartum interventions

Mortality and Morbidity• Perinatal mortality

– comparable home birth populations - 1-2/1000– U.S. Birth Centers - 1.3/1000– Uncomplicated hospital births - 1-2/1000

• Maternal and fetal outcomes– less medical interventions (induction,augmentation,

episiotomy, operative vaginal birth, and cesarean)– better Apgar scores, less severe lacerations– findings supported by clinical trials of elements of

care

Transfers from home to hospital

• 10-20% antepartum referrals for obstetric reasons (IUGR, previa, PIH, twins, preterm)

• 5-8% intrapartum referrals • 1% postpartum maternal referrals• 1% neonatal referrals• urgent transfer 1/1000• 30 minute rule

Reasons for IP Transfer

• failure to progress (65-75%)• desire for pharmaceutical pain relief• prolonged rupture of membranes• meconium staining• nonvertex presentation• Abnormal FHR by IA• bleeding• hypertension

Reasons for PP transfer• Maternal

– laceration repair– Retained placenta– postpartum hemorrhage

• Neonatal– inability to establish normal respirations– congenital anomalies

– low birth weight– low Apgar– birth trauma– sepsis

Conclusions• “Safe in selected women, and with adequate

infrastructure and support” Springer and VanWeel, BMJ, 1996

• Goal should be “maximal [maternal/fetal] outcome with minimal intervention” Weigers, Keirse, et al, BMJ 1996

• Good outcomes and successful home births strongly associated with strong patient-provider relationship

Framework for Optimal Care

• Screening criteria

• Basic skills necessary as attendants

• Basic equipment

• Continuity of care

• Strong infrastructure support

• Access to medical consultation and referral

Framework for Optimal Care

• Screening criteria

• Basic skills necessary as attendants

• Basic equipment

• Continuity of care

• Strong provider/patient relationship

• Timely access to consultation and referral

The Midwife’s Lens:

Does this mother or baby have some condition that would benefit from the additional equipment or personnel that the hospital has to offer?

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General Criteria

– good general health and a healthy pregnancy– shared responsibility for care– adequate social support network– birth without pharmacologic analgesia or

anesthesia– preparation of participants and the birthing

environment – open and clear communication with the midwife– transport plan

Medical Consultation

• Rh incompatibility with a rise in titer• Malnutrition, poor weight gain• Drug or alcohol addiction • Multiple pregnancy• Polyhydramnios or oligohydramnios• Insulin dependent diabetes• Maternal history of small-for-dates babies• Intrauterine growth retardation• Significant maternal anemia at term

Medical Consultations (2 of 2)

• History of severe postpartum hemorrhage• Pre-eclampsia• Placenta previa• Prematurity• Abnormal presentation • Primary herpes infection in labor• Positive serology for syphilis• Positive surface antigen for Hepatitis B• Positive HIV• Unexplained antepartum bleeding (especially after first

trimester)

Labor and Delivery Complications Requiring Hospitalization

• Fetal heart rate persistently over 160 or under 100• Abnormal intrapartum bleeding• Prolonged labor with no evidence of progress• Cord prolapse• Elevated maternal temperature with ruptured membranes• Severe or persistent postpartum hemorrhage• Retained placenta• Newborn health status unstable• Discretion of attendant

Framework for Optimal Care

• Screening criteria

• Basic skills necessary as attendants

• Basic equipment

• Continuity of care

• Strong provider/patient relationship

• Timely access to consultation and referral

Basic Skills for Attendants

• Ability to monitor maternal and fetal condition, and assess and treat common ob conditions, with low tech methods

• Ability to screen for complications requiring hospitalization and initiate referral

• Ability to manage complications if delivery is imminent or condition prohibits transfer

• Neonatal resuscitation• Specialized competencies for rural and remote

Framework for Optimal Care

• Screening criteria

• Basic skills necessary as attendants

• Basic equipment

• Continuity of care

• Strong provider/patient relationship

• Timely access to consultation and referral

Essentials for the “Birth Bag”

• Sterile tray (delivery instruments, gloves, etc)• Doppler, fetascope, BP cuff, stethoscope• Resuscitation equipment (O2, suction, ambu)• Medications (pitocin, methergine, antibiotics)• Suturing supplies• IV supplies• Scales, blood collection tubes, catheters,….

Parent Supplies for Home Birth

• Sources of Heat, Light, and Water

• Foods and fluids

• Clean pads, baby supplies, etc

• Emergency plan - numbers, maps, car

• Clear surfaces, firm surfaces

• Cleaning supplies

Framework for Optimal Care

• Screening criteria

• Basic skills necessary as attendants

• Basic equipment

• Continuity of care

• Strong provider/patient relationship

• Timely access to consultation and referral

Framework for Optimal Care

• Screening criteria

• Basic skills necessary as attendants

• Basic equipment

• Continuity of care

• Strong provider/patient relationship

• Timely access to consultation and referral

Homebirth Integrated

• Midwife in attendance from active labour• Notifies Hospital on arrival and after birth• Sets up equipment• Completes regular assessments• Documents care• Contacts 2nd attendant when indicated• Cleans up after birth• Departs home 2-3 hours after birth

MD/Midwifery Relationships

• MD consultant chart review antepartum• Specific MD consultants, AP and OB

competencies• Labor and delivery summaries shared with

pediatric consultants• Joint reviews of transfers

Obstetric Consultant Role

• 24hr availability by phone or pager

• Provides consultant or collaborative care

• Willing to preserve as much of birth plan as possible

• Involves CNM (as primary OB provider) in decision making process

• Assumes primary care role as necessary

Pediatric Care of the Normal Neonate

• CNM roles and responsibilities

• Client responsibilities

• Client meeting with pediatric provider

• Lactation Consultation

• Immediate newborn assessment

• Newborn screening

• Follow-up care

MD/CNM Collaborative Care of the At-Risk Neonate

• Conditions requiring consultation and/or transfer of care

• Anticipation and preparation for unforeseen complications

• Communication with and transport to pediatric staff

• CNM roles in ongoing care

Barriers to Practice

• Lack of knowledge in hospital staff or community providers re:– home birth standards of care– planned vs unplanned home birth

• Inability to secure hospital privileges• Hostile tx of clients• Lack of neonatal trained transport personnel• Insurance

Do provider attitudes affect home birth safety and

access?

Saraswathi Vedam RM CNM MSN Sci D (h.c)Kathrin Stoll, BA, MA

Laura Schummers, BSc

Division of MidwiferyUniversity of British Columbia

Provider Attitudes• Providers’ attitudes influence women’s

choices 10,12,19-22, 30,31

• Providers may present options that are congruent with their own education, experience, and scope of practice 10,12,19,22,31

Methods- Survey Administration

• Surveys were distributed to approx 4800 U.S. midwives (members of the American College of Nurse-Midwives).

• 1,919 midwives responded to the survey

• Final sample size of 1893

Methods - Data Analysis1. Descriptive statistics (e.g. socio-demographic

factors, educational and professional experience)

2. Bi-variate analysis (t-test and correlational analysis) to examine associations between background and external barrier variables and attitudes

3. Linear regression modeling (with 27 variables that emerged at p< 0.05 in bi-variate analysis) to determine which factors are predictors of attitude.

Significant independent predictors of positive attitudes towards PHB

Demographic predictors:• Being younger

Educational predictors:• Having attended educational program with midwifery faculty

who provided PHB as part of practice• Having attended PHB in midwifery school

Practice predictors:• Midwives who performed clinical role (as opposed to an

observer or support role) at PHB• Attended PHB prior to getting degree • Having provided intrapartum care in home or freestanding

birth center • Having attended PHBs as the primary midwife for longer

External barriers that significantly predicted less favorable attitudes

• Increased time commitment• Problems with accessing MD consultation• Perception that home birth providers are

looked down upon by hospital providers• Cost of practice • Lack of confidence in skills

Meeting Health Human Resource Challenges

• Rural maternity services– Increase supply of providers– Model and support inter-professional

collaboration – Prepare graduates for rural practice

• Support evidence based maternity care– Maintain professional currency of providers– Evaluate practice and practice models– Document and evaluate methods to increase

access

Hornby Island

Squamish

Maple Ridge

Haida Gwai

Comox

Bowen Island

Mission

UBC Midwiferymeeting the needs of

rural communities

Penticton/Naramata

Class of 2010

Class of 2009

Class of 2008

Duncan

Women’s Health Care in the New Millenium

• Evidence-based medicine• Appropriate use of technology and resources• More research needed on factors beyond

mortality and morbidity – effects of birth environment on labor – influences of maternal and provider anxiety – effects of birth experience on long term physical

and psychological well-being

La Partera profesional a Mexico

Continuity and Collaboration