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7 Framework for Improving Birth Outcomes Across Birth Settings
Pages 259-302

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From page 259...
... This model recognizes that three elements -- access to care, quality of care, and informed choice and risk assessment among care options -- contribute to the ultimate goal of positive outcomes in maternity care, and that the maternity care team, the systems and settings in which those personnel care for pregnant people and newborns, and collaboration and integration among providers and systems influence the presence and expression of those elements. It also shows that structural inequities and biases; social determinants of health; and the structure, policies, and financing of the health system itself influence quality, access, choice, and risk across birth settings.
From page 260...
... After first reviewing our framework for maternal and newborn care, we discuss opportunities for improving quality and outcomes in hospital births, the setting where the vast majority of pregnant people give birth in the United States. Next, we consider opportunities for improving quality and outcomes in home and birth center births, focusing on improving coordination, collaboration, integration, and regulation of these settings within the health care system.
From page 261...
... This means that in the United States, home, birth center, and hospital birth settings each offer risks and benefits to the childbearing woman and the newborn. While no setting is risk free, these risks may be modifiable within each setting and across settings (Conclusion 6-1)
From page 262...
... Respectful Treatment In order to facilitate equitable access to maternity care services, the maternity care system must provide respectful treatment to all women in its care. The objective of respectful maternity care is to support pregnant and birthing women and remove barriers to receiving health care services before, during, and after birth.
From page 263...
... hospital settings today. As discussed in Chapter 6, Finding 6-3: In the United States, low-risk women choosing home or birth center birth compared with women choosing hospital birth have lower rates of intervention, including cesarean birth, operative vaginal delivery, induction of labor, augmentation of labor, and episiotomy, and lower rates of intervention-related maternal morbidity, such as infection, postpartum hemorrhage, and genital tract tearing.
From page 264...
... and the California Peri M natal Quality Care Collaborative and headquartered at Stanford University, now includes more than 40 partner organizations and 200 participating hospitals. Since its inception in 2006, the CMQCC has developed a number of evidence-based quality improvement (QI)
From page 265...
... To promote improvement across settings and better outcomes for all women and infants, it is essential for all birth settings to participate in sentinel event reporting and root-cause analyses as part of PQC efforts. Moreover, 13 states either do not yet have a PQC or their status in this regard is unknown (see Figure 7-1)
From page 266...
... For instance, researchers in several studies evaluated nursing care during labor as part of an overall approach to decreasing cesarean birth. One study showed that labor care
From page 267...
... CONCLUSION 7-1: Quality improvement initiatives -- such as the ­ lliance on Innovation in Maternal Health and the National Network A ­ of Perinatal Quality Collaboratives -- and adoption of national stan dards and guidelines -- such as the Maternal Levels of Care of the American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine; the American Academy of Pediatrics' Neo natal Levels of Care; and guidelines for care in hospital settings devel oped by the Association of Women's Health, Obstetric, and Neonatal Nurses, the Society for Obstetric Anesthesia and Perinatology, and the American College of Nurse-Midwives -- have been shown to improve outcomes for pregnant people and newborns in hospital settings. QI initiatives may also lead to cost savings.
From page 268...
... BOX 7-1 Performance Measures A more comprehensive set of nationally endorsed maternal and newborn performance measures would provide timely feedback to the entities being mea sured about their own and peer performance, and to purchasers, payers, and policy makers. Public reporting using well-publicized, evidence-based, and user friendly online interfaces would also enable childbearing women to make informed choices among health plans, maternity care providers, and birth settings.
From page 269...
... • Care coordination in maternity care • Use of shared decision making in maternity care • Use of health information technology to engage, inform, and support childbearing women • Measures of key concepts at the clinician/group and health plan ­evels, in l cluding those aligned with priority currently endorsed facility-level measures • Measures of peripartum nursing care of women and newborns • Facility engagement in maternal and newborn quality improvement activities To promote optimal integration, safety, and accountability, consideration is needed of facility-level measures that apply to birth centers as well as hospitals, and clinician-level measures that apply to all midwives with nationally recognized credentials, whenever feasible and appropriate. To promote equity, measures would need to be stratified to make it possible to determine whether care differs by the race and ethnicity, ability, knowledge, and language of childbearing women, whenever appropriate.
From page 270...
... This includes such maternity care services as planned vaginal birth after cesarean, external cephalic version, vaginal breech birth, and planned vaginal twin birth. Further, some women face challenges in finding hospitals that support intermittent auscultation, nonpharmacologic measures for labor comfort and progress, freedom to drink fluids and eat solids, freedom of movement in labor, and freedom of choice of birth positions, as well as the related essential care option of the choice between midwifery- or medical-led care (National Partnership for Women & Families, 2018)
From page 271...
... Moreover, there is evidence to suggest that socially and financially disadvantaged women may thrive in midwifery models of care across all birth settings. (Raisler and Kennedy, 2005; Huynh, 2014; Hill et al., 2018; Hardeman et al., 2019)
From page 272...
... Clinical outcomes include a cesarean birth rate of 9.5 percent, a vaginal birth after cesarean success rate of 84 percent, an episiotomy rate of 0.4 percent, an epidural rate of 6.4 percent, and an induction of labor rate of 8.7 percent. Based on existing 2019 data, approximately 600 births and 9,000 clinic visits were antici pated for the year.a aPersonal Communication, Elizabeth Cook, Director, Mercy Birthing Center.
From page 273...
... CONCLUSION 7-3: Efforts are needed to pilot and evaluate high value payment models in maternity care and identify and develop ­ ffective strategies for value-based care. e Two high-value payment models in particular provide promising approaches for fostering care transformation, curbing overuse and underuse, encouraging members of the care team to work toward shared aims, and meeting the individualized needs of women and newborns: episode payment and the maternity care home (Avery et al., 2018)
From page 274...
... The facility and professional fees for vaginal and cesarean birth were made equal. In addition, the California Maternal Quality Care Collaborative provided the facilities with data management, rapid-cycle performance feedback, and customized technical sup port to enable each to pursue approaches to cesarean reduction tailored to its local culture (Pacific Business Group on Health, 2015)
From page 275...
... . Innovative developers of episode payment models that drive toward high-value care will recognize that high-performing forms of care such as midwives, doulas, and birth centers are keys to success, including by reducing cesarean birth and increasing breastfeeding rates, improving performance on quality measures, minimizing overuse/waste and ­ nderuse/forgoing valuable u care, and fostering women's satisfaction.
From page 276...
... Similarly, they help coordinate clinical care across the episode, such as by helping the woman make care plans that include shared decision-­ aking ­ rocesses -- for m p example, carefully weighing birth options after prior cesarean or post­ artum ­ p contraception options. The care setting could be a birth center, OB/GYN practice, community health center, or health plan.
From page 277...
... and performance targets for each indicator; • program incentives, including health plan support for infrastructure development and a recognition program demonstrating that the e ­ ntity has developed capacities and meets standards of a ­ aternity m care home; • performance incentives, for example, a health plan bonus or in creased PMPM associated with performance; • dual focus both to connect women and families with community and social services as needed and to plan and coordinate clinical care across episode settings and providers; • commitment to addressing individualized needs of any woman in the practice, versus risk screening and premature, often faulty, case management segmentation, with potentially undermining "high risk" labels and exclusion of some who may need services; • support for women during the prenatal and postpartum periods, extending to 12 months after birth, reflecting the growing aware ness that women's postpartum needs and vulnerabilities are consid erable and extend beyond the traditional care trajectory of about 2 months after birth; and • integration into practice, for example, to foster communication between care navigators and maternity care providers, develop knowledge of/relationships with community and online resources, acquire and develop care coordination tools (e.g., patient portal, decision aids) , and keep records.
From page 278...
... . Thus, we focus on improved collaboration, integration, licensure, and regulation of these settings within the health care system -- each representing key levers for improving birth outcomes in home and birth center settings.
From page 279...
... . In fact, as observed in Chapter 6, Finding 6-6: Lack of B integration and coordination and unreliable collaboration across birth settings and maternity care providers are associated with poor birth outcomes for women and infants in the United States.
From page 280...
... within the Dartmouth-Hitchcock Health System in New Hampshire is one example of a hospital system collaborating with home and birth center providers. In 2010, the Northern New England Perinatal Quality Improvement Network began work to improve communication and interprofessional collaboration between community midwives and the hospital system.
From page 281...
... Further, women are able to choose birth center or home births. Women have the option of receiving care outside of the MTFs.
From page 282...
... Further enhancing collaborative practice through interprofessional education, cer tified nurse midwives in the MHS train residents in maternity care practices, including prenatal, intrapartum, and postpartum care. In summary, the MHS provides a unique model of maternity care that com bines a universal payment model, a diminished malpractice threat, safety and accountability of care, and collaborative practice.
From page 283...
... has adopted model guidelines for writing state regulations licensing birth centers.2 These regulations cover such topics as definitions, staffing, the facility, fire and building codes, and the services that can and cannot be provided. For example, no states allow cesarean births in birthing centers.
From page 284...
... The wide variation in regulation, certification, and licensing of maternity care professionals across the United States is an impediment to access across all birth settings. Much of the discussion related to the education, training, and licensure of maternity and newborn care providers in the United States has focused on the midwifery profession.
From page 285...
... CONCLUSION 7-6: The inability of all certified nurse midwives, cer tified midwives, and certified professional midwives whose education meets International Confederation of Midwives Global Standards, who have completed an accredited midwifery education program, and who are nationally certified to access licensure and practice to the full extent of their scope and areas of competence in all jurisdictions in the United States is an impediment to access across all birth settings. INFORMED CHOICE AND RISK SELECTION As discussed in Chapters 3 and 4, informed choice requires a set of real options, accurate information about the risks and benefits of those options, appropriate and ongoing medical/obstetrical risk assessment, respect for women's informed decisions, and recognition that those choices may change over the course of care.
From page 286...
... Mechanisms for monitoring adherence to best-practice guidelines for risk assessment and associated birth outcomes by provider type and settings is needed to improve birth outcomes and inform policy.
From page 287...
... ACCESS Ability to Pay As discussed in Chapter 4, Finding 4-4: Access to all types of birth settings and providers is limited because of the lack of universal coverage for all women, for all types of providers, and at levels that cover the cost of care. Currently, only a limited number of insurance providers offer coverage for care in home or birth center settings.
From page 288...
... . In addition to the requirements for risk selection, the Oregon Health Plan delineates situations in which an out-of-hospital midwife is required to consult with a hospital-based maternity care provider (Oregon Health Authority, 2015)
From page 289...
... Therefore, the committee did not reach consensus as to whether national expansion of Medicaid and Medicare for home births would be efficacious or cost-effective, but rather points to the need for additional research, demonstration, and evaluation of these state-level models. An additional model for increasing access to birth settings for low-risk women and improving outcomes is to cover care provided by communitybased doulas.
From page 290...
... could analyze levels of payment for maternity and newborn care across birth settings to ensure that payment is adequate to support access to maternity care options nationwide. Just as Congress relies on the payment expertise of the Medicare Payment Advisory Commission (MedPAC)
From page 291...
... These centers were established to fulfill a need for services that might not be offered absent some public subsidies. HRSA could establish demonstration model birth centers and hospital services in underserved rural and urban areas and evaluate their impact on birth outcomes and access to care.
From page 292...
... CONCLUSION 7-11: Research is needed to study and develop sus tainable models for safe, effective, and adequately resourced maternity care in underserved rural and urban areas, including establishment of sustainably financed demonstration model birth centers and hospital services. Such research could explore options for using a variety of ma ternity care professionals -- including nurse practitioners, certified nurse midwives, certified professional midwives, certified midwives, public health nurses, home visiting nurses, and community health workers -- in underserved communities to increase access to maternal and newborn care, including prenatal and postpartum care.
From page 293...
... The results from the propensity score analysis showed that women who re ceived prenatal care at the FHBC were less likely to have a cesarean section, an instrumental birth, and a preterm birth and were more likely to have a vaginal birth after cesarean section compared with those who received usual care. The rates of low birthweight and a 5-minute Apgar score of less than 7 were not significantly different between women receiving FHBC care and usual care.
From page 294...
... . In addition, access to choice in birth settings is limited by the availability and distribution of the maternity care workforce.
From page 295...
... . The most significant challenges to expanding the certified nurse midwife, certified midwife, and certified professional midwife workforce are the current limited number of accredited schools or midwifery programs and the limited availability of preceptors.
From page 296...
... for maternity care providers so that maternity care could be provided in areas with shortages of these professionals. NHSC awards scholarships and loan repayment to primary care providers in eligible disciplines, including physicians, nurse practitioners, physician assistants, and certified nurse midwives, who commit to providing services for at least 2 years in sites with shortages of health professionals.8 HRSA could also expand the Maternity Provider Shortage designation to include freestanding birth centers located in shortage areas as NHSC loan repayment sites.
From page 297...
... , the CDC, and HRSA could increase opportunities for interprofessional education, collaboration, and research across all birth settings. Interprofessional education and collaboration can be fostered through shared learning and teaching that impart understanding and respect for the roles and competencies of the various team members and provide opportunities for trainees to work with and learn about the roles and expertise of other members of the care team, including community health workers, doulas, lactation personnel, childbirth educators, and diabetes educators.
From page 298...
... . Nurse midwifery students are also incorporated in the outpatient clinical environment to work with the VUSOM certified nurse mid wives (CNMs)
From page 299...
... . Additional future research efforts are needed in the following areas: • Understanding the impact of home and birth center births on dis parities in outcomes by race and ethnicity, as well as socioeconomic status.
From page 300...
... • Developing, peer reviewing, and publishing a consensus core set of outcomes for studying birth settings, aligned with the Core Out comes in Women's and Newborns' Health Initiative. • Developing and carrying out a biannual survey of childbearing women on childbearing experiences and maternity care, including questions specific to access to services, respectful care, utility of information, willingness to listen, patient engagement, and safety.
From page 301...
... Growth of the midwifery profession can help address workforce shortages and women's care preferences in a timely, cost-effective manner. While the committee acknowledges that change will not occur instantaneously, there is an urgent need for all stakeholders -- pregnant people, policy makers, payers, health care systems, professional organizations, and providers -- to come together to improve maternity care in the United States and build a high-functioning, integrated, regulated, and collaborative maternity care system, a system that fosters respect for all woman, ­ newborns, and families, regardless of their circumstances or birth or health choices.


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