Pressure From Above

Abstract

The author of this guest editorial discusses the new perinatal standards endorsed by the National Quality Forum and goals to improve the health of all Americans announced by the National Priorities Partnership. She discusses the impact of the standards and goals on maternity care and what childbirth educators can do to help implement the standards and advance the goals.

EFFORTS TO REDUCE UNNECESSARY MATERNITY-CARE INTERVENTIONS

For many years, childbirth educators have been pressuring health-care professionals to provide low-intervention, evidence-based maternity care. In the 1970s, we read the research of Dr. Roberto Caldeyro-Barcia in prestigious U.S. medical journals. Based on his startling studies, we taught women to push for no longer than 6 seconds at a time during second-stage labor to prevent fetal distress. We encouraged women to adopt upright positions to push. We read other studies that concluded that an episiotomy was more likely to cause complications than to prevent them. We encouraged our students to ask their providers not to do one unless absolutely necessary. In the 1980s, when studies came out showing no benefit to babies and increased risk of cesarean with continuous fetal heart monitoring, we questioned why virtually all women were monitored continuously in many hospitals. As the rates of interventions with significant risk factors such as epidural analgesia, induction, and cesarean have soared in this century, we have asked why these interventions have become the “norm” rather than low-risk strategies such as continuous support, freedom of movement, and warm baths and showers.

Finally, some pressure is coming from “above” to reduce unnecessary maternity-care interventions. In October 2008, the National Quality Forum endorsed national consensus standards for perinatal care. Several of these new standards will require that hospitals create new protocols, which will reduce routine maternity-care interventions. One month later, the National Priorities Partnership announced six goals to transform America's health care. All but one of these goals affect maternity care, and two are especially relevant for childbirth educators.

WHO ARE THE NATIONAL QUALITY FORUM AND THE NATIONAL PRIORITIES PARTNERSHIP?

Founded in 1999 in response to a recommendation from the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, the National Quality Forum (NQF) is among the best-known and most respected national organizations seeking to improve American health care. The NQF membership includes major “players” from eight groups that impact and are impacted by health care: consumers; health-plan groups; health professionals; provider organizations; public and community health agencies; purchasers; quality measurement, research, and improvement organizations; and supplier/industry representatives. Its membership rolls read like a “Who's Who” in American health care. The mission of NQF is “to improve the quality of American healthcare by setting national priorities and goals for performance improvement, endorsing national consensus standards for measuring and publicly reporting on performance, and promoting the attainment of national goals through education and outreach programs” (NQF, 2008a, Mission Statement section, para. 1).

The NQF convened the National Priorities Partnership to identify the overall goals to transform (and improve) American health care. The partners are leaders from 28 organizations, including NQF, The Joint Commission, Centers for Disease Control and Prevention, Centers for Medicare and Medicaid Services, AFL-CIO, National Governors Association, National Partnership for Women & Families, and others.

The National Quality Forum's Perinatal Standards

Last fall, NQF endorsed 17 perinatal standards to measure and, thereby, improve care received by mothers and babies during the third trimester through hospital discharge. Consensus standards improve quality of care by standardizing measurement in care settings and encouraging accountability and public reporting.

Laura Riley, MD, Medical Director for Labor and Delivery at Massachusetts General Hospital in Boston, and Maureen Corry, MPH, Executive Director of Childbirth Connection, co-chaired NQF's steering committee on perinatal care. According to Dr. Riley, “Constant assessment of the care measures endorsed by NQF will allow us to address areas of weakness and reallocate resources where needed to provide babies with the best possible start to life” (NQF, 2008b, para. 7). The new perinatal standards include guidelines for

• Elective delivery prior to 39 completed weeks of gestation;

• Cesarean rate for low-risk, first-birth women;

• Exclusive breastfeeding at hospital discharge.

Because hospitals are now asked to report these outcome measures, they will want to develop protocols to improve their numbers. Childbirth educators can be instrumental in working with physicians, midwives, nurses, and administrators to design such protocols. Educating consumers will be an important part of the protocols. Every hospital has a quality improvement committee on which volunteers can sit. If you are a community educator, lobby for consumer representation on the committee and lobby to fill this role. If you can't get a place on the committee, take a committee member out for coffee to discuss the new standards.

Lamaze International members should know that Debra Bingham, Chair of the Lamaze Institute for Normal Birth and Executive Director of the California Maternal Quality Care Collaborative, was instrumental in developing and getting approved the cesarean-rate measure. Other endorsed measures of interest to childbirth educators are incidence of episiotomy and birth-trauma rate.

National Priorities Partnership

A month after NQF announced the endorsement of the perinatal standards, the National Priorities Partnership announced its report, National Priorities and Goals: Aligning Our Efforts to Transform America's Healthcare, at a press conference in Washington, DC. Two of the six goals directly impact childbirth education:

• Engage patients and families in managing their health and making decisions about their care;

• Eliminate overuse of unnecessary care while ensuring the delivery of appropriate care.

In health care today, the concept of “informed consent” is transforming into the concept of “informed decision making.” The distinction is important. It is no longer enough to present the consumer (or patient) with the risks and benefits of a particular treatment. Instead, the health-care provider should provide the consumer with information about the risks and benefits of all possible treatments for his or her condition. Despite what some providers believe, research indicates that, when presented with a full array of possible treatments, consumers most often choose the least interventive treatment. Imagine that, at the same time an anesthesiologist tells a laboring woman about the risks and benefits of epidural analgesia, he also tells her that she could relax in a warm tub for pain relief.

Childbirth educators can play a vital role in addressing this National Priorities Partnership goal by presenting full information about all options in childbirth classes. Educators must work with hospital providers, nurses, and administrators to make sure that all options are available in all birth settings. Are tubs and showers available? Is intermittent monitoring available so that women can walk and easily change positions? Are doulas welcomed as important members of the maternity-care team? Childbirth educators play a key role in identifying options and educating both health-care professionals and consumers about these options.

BOX. What Can the Childbirth Educator Do?

1. Be informed!

   1. Read about the National Priorities and Goals report and download a copy at www.nationalprioritiespartnership.org/AboutNPP.aspx (under “Useful Information”)

   2. Read about the National Quality Forum's endorsed perinatal standards at www.qualityforum.org/news/releases/102708-endorsed-measures-pc.asp

   3. Read Evidence-Based Maternity Care: What It Is and What It Can Achieve (the Milbank Report), available on the Childbirth Connection Web site (www.childbirthconnection.org)

2. Be involved!

   1. Volunteer to serve on the Quality Improvement Committee at your local hospital

   2. Make copies of the National Priorities and Goals report and of the National Quality Forum's endorsed perinatal standards for key influencers at your local hospital

   3. Join or start a local Birth Network to raise community awareness

3. Be bold!

   1. Structure your childbirth classes around Lamaze International's Six Healthy Birth Practices, available at the Lamaze Web site (www.lamaze.org)

   2. Provide plenty of time in class for thoughtful discussions about all options in maternity care today

   3. Provide plenty of audiovisual images and stories of safe, healthy, low-intervention normal birth

When discussing the goal of eliminating overuse, the National Priorities Partnership specifically identified reducing unnecessary maternity-care interventions, targeting unnecessary cesarean sections. As the cesarean rate soars in this country and a few physicians even propose cesareans for all women, it is a welcome sign that leaders from the most influential and prestigious health-care organizations recognize that there are too many unnecessary cesarean surgeries. Acknowledging that there is a problem is the first step to addressing that problem. Childbirth educators are well familiar with strategies to reduce the risk of cesarean surgery. Again, childbirth educators can work with providers, nurses, and administrators to develop protocols that include strategies such as encouraging women not to go to the hospital until labor is well established and not to ask for or agree to induction unless there is a medical indication.

All but one of the other national goals also can be applied to maternity care:

• Improve the health of the population;

• Improve the safety and reliability of America's health-care system;

• Ensure patients receive well-coordinated care within and across all health-care organizations, settings, and levels of care;

• Guarantee appropriate and compassionate care for patients with life-limiting illnesses.

Increasing the number of low-intervention births will decrease complications to both babies and mothers and will “improve the health of the population.” Mothers who experience low-intervention vaginal births are able to return to a healthy lifestyle, including exercise, more quickly. These mothers are more likely to breastfeed successfully for a longer duration, improving the immediate and future health of both themselves and their babies. Babies who begin labor spontaneously at full-term are less likely to have breathing problems and admission to the neonatal intensive care unit. Induction of labor and scheduled cesarean surgery has contributed to the increase in the percentage of late-preterm babies born in this country. Research has documented that these babies are at risk for complications and learning problems, even into school age.

The goal to “ improve the safety and reliability of America's health-care system” clearly relates to maternity care. Certainly, it is safer for both mothers and babies to experience low-intervention, physiological births that have fewer risks of complications. This is especially true when you consider the safety of a normal vaginal birth as compared to cesarean surgery, both for the first birth and for future births.

The last National Priorities Partnership goal that applies to maternity care is to “ensure patients receive well-coordinated care within and across all health-care organizations, settings, and levels of care.” This is especially relevant when considering home births and birth center births. Both the American College of Obstetricians and Gynecologists and the American Medical Association have taken strong stands against home birth. This “disapproval” sometimes translates into hostility toward the laboring woman who has to be transferred from a planned home birth to the local hospital. Her chosen care provider, usually a midwife, is often not allowed to stay with her or to participate in her care. In the Netherlands, where approximately 30% of women still give birth at home, the home birth midwife is welcomed into the hospital when transfer becomes necessary and continues to play an important role in the care of the laboring woman. (Note: The Netherlands has a far lower rate of both infant and maternal mortality than does the United States.) The health care of women and babies in the United States would be improved if we were to develop such collaborative models. In addition, there are many countries in the world that provide health-care visits to women and babies in the home during the postpartum period. Such visits decrease the incidence of repeat hospitalizations for complications in both mothers and babies and have the potential to increase breastfeeding success and duration.

EXCITING FUTURE FOR MATERNITY CARE

It is an exciting and challenging time to be a childbirth educator. The time has come for childbirth educators to step forward and work with other health-care professionals to advance the objectives outlined in National Priorities and Goals. Lamaze International's commitment to low-intervention, safe, and healthy childbirth and promotion of the Six Healthy Birth Practices are important strategies to help improve America's health care.