Post on 23-Dec-2015
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
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
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
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