Evidence into Action: Multidisciplinary Strategies for Effective Maternity Care

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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

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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.

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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

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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

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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

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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)

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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

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Who Chooses Midwifery?

• Socioeconomic status
• Education
• Rural vs. Urban
• Race
• Occupation
• Age and parity
• Marital status

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Global Strategies for integrating midwifery

• Regulation
• Education
• Recruitment and Retention
• Association
• Collaboration

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Credentials and Pathways

• CNM- Certified Nurse-Midwife
• CPM- Certified Professional Midwife
• LM- Licensed Midwife
• CM-Certified Midwife
• Registered Midwife
• Direct-Entry Midwife
• Traditional Midwife

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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

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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

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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.

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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

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Education

• Core Competencies
• Expanded skills
• Defined scope for different roles based on
  competencies
• University and college programs, distance
  education, aboriginal
• Apprentice academics

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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

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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

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RM
RN
MD
RN
MD
RM
RM
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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

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Normal Labour Birth 5th International
Research Conference

• The Benefits Challenges of Preserving
  Physiologic Birth
•  

Coast Coal Harbor Hotel Vancouver, BC July 20-23,
2010
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2010 Conference Themes

• Defining and describing normal birth
• Practice
• Public Information
• Education
• Policy

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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.

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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

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Evidence Based CareHome Birth

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

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Quieres unparto en la casa?
Eres Loco?
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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)

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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)

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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

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Quality of Evidence - 2009

• Janssen et al, CMAJ
• Hutton et al, Birth
• de Jonge, BJOG

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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

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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

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Janssen, et al, CMAJ

• Prospective five-year long cohort study
• midwife-attended PHB (2802)
• physician attended hospital birth group (N5985)
• midwife attended hospital birth group (N5984).
• Similar or reduced rates of adverse outcomes with
  significantly fewer intrapartum interventions

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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

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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

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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

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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

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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

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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

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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

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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?

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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

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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

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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)

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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

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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

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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

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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

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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,.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Methods - Data Analysis

• Descriptive statistics (e.g. socio-demographic
  factors, educational and professional experience)
• Bi-variate analysis (t-test and correlational
  analysis) to examine associations between
  background and external barrier variables and
  attitudes
• Linear regression modeling (with 27 variables
  that emerged at plt 0.05 in bi-variate analysis)
  to determine which factors are predictors of
  attitude.

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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

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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

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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

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UBC Midwifery
meeting the needs of rural communities
Haida Gwai
Squamish
Bowen Island
Maple Ridge
Penticton/Naramata
Comox
Mission
Hornby Island
Duncan
Pender
Langley
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Womens 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

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La Partera profesional a Mexico

• Continuity and Collaboration