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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 interventions 1. 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 MD RN 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, BC July 20-23, 2010 2010 Conference Themes Defining and describing normal birth Practice Public Information Education Policy The Nature and Management of Labor Pain Am 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 un parto en la casa? Eres Loco? 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 Midwifes Lens: Does this mother or baby have some condition that would benefit from the additional equipment or personnel that the hospital has to offer? *48 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 Midwifery University of British Columbia Provider Attitudes Providers attitudes influence womens 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 Analysis 1.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 pred