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2 Maternal and Newborn Care in the United States
Pages 45-84

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From page 45...
... State policies and regulations can affect a woman's birth experience as well, through laws as to which providers can practice, their scope of practice, and the legal s ­ tatus of birth settings. This chapter provides a detailed look at the practices, resources, and services available in different birth settings; statistics and trends in birth settings; the education, training, credentialing, and practice of maternity care providers, as well as other clinicians and other members of the care team; and how policy and financing impact choices about birth experience.
From page 46...
... Table 2-1 summarizes information on all three birth settings -- home, birth center, and hospital -- including the birth attendants that may be present and the services, supports, resources, and tools available to woman and newborns. This section provides further d ­ etail on these variations.
From page 47...
... The statement is intended to improve maternal care, in part by facilitating admission or transfer of women with high-risk pregnancies to the perinatal centers, which have the appropriate resources and providers 1  he statement was endorsed by the American Association of Birth Centers; the American T ­ College of Nurse-Midwives; the Association of Women's Health, Obstetric and Neonatal Nurses; the Commission for the Accreditation of Birth Centers; and the Society for Obstetric ­ Anesthesia and Perinatology. The statement was supported by the American Academy ­ of ­ amily Physicians.
From page 48...
... births (85% of these were planned) Attendant Physician: 0.7% CNM/CM: 29.4% Other midwife: 50.7% Other: 19.1% Prenatal care Attendant provides 9–12 prenatal visits in the office or at home; variable based on practice Birth Attendant provides 1-to-1 continuous management of labor in the woman's home; a second attendant or birth assistant attends the birth along with the primary attendant Fetal assessment Fetal assessment usually occurs via intermittent auscultation Availability of interventions Licensed midwives carry oxygen, neonatal and adult resuscitation equipment, suturing equipment, and medications for preventing or managing postpartum hemorrhage; attendant may offer deep tubs for pain relief in labor Transfers In some situations, the mother is transferred to the hospital; the midwife may or may not be able to continue to provide care, depending on whether agreements are in place between the midwife and the hospital Trainees A midwife trainee may be in attendance under supervision Post-birth care Attendant generally stays 4–6 hours after the birth based on individual clinical situation NOTE: CM = certified midwife; CNM = certified nurse midwife.
From page 49...
... births Physician: 2.7% Physician: 90.6% CNM/CM: 56.6% CNM/CM: 8.7% Other midwife: 36.7% Other midwife: 0.1% Other: 3.9% Other: 0.5% Pregnant woman attends 9–12 prenatal Pregnant woman attends 9–12 prenatal visits at visits at the birth center or an affiliated an outpatient clinic or provider office; generally, outpatient clinic that provider has privileges to attend birth at the hospital or an arrangement for another provider to do so Attendant provides 1-to-1 continuous Majority of hands-on care is usually provided management of labor in the birth by a labor and delivery nurse; birth attendant center; a second attendant or birth may be midwife (CM or CNM) , family medicine assistant attends the birth along with physician, obstetrician, or maternal–fetal the primary attendant medicine specialist Fetal assessment usually occurs via Fetal assessment usually occurs via continuous intermittent auscultation; however, electronic fetal monitoring; however, some some birth centers may use periodic hospitals offer periodic electronic fetal electronic fetal monitoring monitoring or intermittent auscultation Birth centers supply oxygen, neonatal In addition to medications and operative and adult resuscitation equipment, interventions to prevent and manage postpartum suturing equipment, and medications hemorrhage, interventions and procedures that for preventing or managing postpartum may be offered in the hospital setting that are hemorrhage; birth centers generally generally not offered at home or in birth centers have deep tubs for pain relief in labor, include medications to ripen the cervix (Cervidil and some also offer nitrous oxide or Misoprostol)
From page 50...
... . Just as women birthing at home or in birth centers may need to be transferred to a hospital for more intensive care, women birthing at lower-level hospitals may need to be transferred to a higher-level hospital with the appropriate resources.
From page 51...
... Level I (Basic Care) Definition Care of low- to moderate-risk pregnancies with the ability to detect, stabilize, and initiate management of unanticipated maternal–fetal or neonatal problems that occur during the antepartum, intrapartum, or postpartum period until the patient can be transferred to a facility at which specialty maternal care is available.
From page 52...
... with level-appropriate competencies as demonstrated by nursing competency documentation. •  Physician with privileges to perform emergency cesarean readily available at all times.a Primary maternal care providers, including midwives,d family •  physicians, or OB/GYNs readily available at all times.a •  Appropriately trained and qualified RNs with level-appropriate competencies as demonstrated by nursing competency documentation readily available at all times.a •  Nursing leadership has level-appropriate formal training and experience in maternal care.
From page 53...
... . •  Onsite medical and surgical ICUs that accept pregnant women and women in postpartum period.
From page 54...
... Definition Level III facility plus onsite medical and surgical care of the most complex maternal conditions and critically ill pregnant women and fetuses throughout antepartum, intrapartum, and postpartum care. Capabilities Level III facility capabilities plus •  Onsite medical and surgical care of complex maternal conditions with the availability of critical care unit or ICU beds.
From page 55...
... Additionally, these are guidelines, and local issues will affect systems of implementation for regionalized maternal care, perinatal care, or both. aReadily available at all times: the specific person should be available 24 hours a day, 7 days a week for consultation and assistance, and able to be physically present onsite within a timeframe that incorporates maternal and fetal or neonatal risks and benefits with the provision of care.
From page 56...
... line, continuous electronic fetal monitoring, bed rest, limited oral intake during labor, cervical ripening, induction or augmentation of labor, artificial rupture of membranes, epidural analgesia, blood draws for laboratory studies, episiotomy, vacuum- or forceps-assisted birth, and cesarean birth. Rates of these procedures are highly variable across hospitals (Lundsberg et al., 2017)
From page 57...
... These units are often called "birth centers" by the hospital; however, the services they offer and the extent to which they resemble freestanding birth centers vary widely. Some, like freestanding birth centers, use the midwifery model of care, are available only to low-risk mothers, and offer only physiologic birth without medical interventions.
From page 58...
... Freestanding Birth Centers As noted above, for the purposes of this report, a birth center is defined as a freestanding health facility not attached to or inside a hospital. Birth centers are intended for low-risk women who desire less medical intervention during birth, a home-like atmosphere, and an emphasis on individually tailored care.
From page 59...
... . Midwives in birth centers provide the full scope of maternity care, from the prenatal through the intrapartum and postpartum periods out to the first 6–8 weeks following birth, as well as newborn care.
From page 60...
... cExcludes data from California, which did not report the planning status of home births. dIncludes all non-CNM/CM midwives, including certified professional midwives (CPMs)
From page 61...
... . Like birth center births, planned home D births may result in transfer to a hospital for nonemergency or emergency care.
From page 62...
... Box 2-1 provides further detail on typical home birth supplies and medications. 8 State licensure statutes typically require that two attendants be present at every birth because two people are required for neonatal resuscitation.
From page 63...
... As with most practices surrounding birth, birth and postpartum care are influenced by the licensure of the provider and insurance coverage or source of payment, which are discussed later in this chapter. Transfer to Hospital Settings Because health professionals attending birth center and home births do not offer some services during labor (e.g., epidural pain relief, induction or augmentation with medications)
From page 64...
... MATERNAL AND NEWBORN CARE TEAM Nurses, physicians, and midwives provide the majority of maternal and newborn care across birth settings. Other members of the care team who also provide care include social workers, psychologists and psychiatrists, dietitians, anesthesia professionals, lactation consultants, and physical therapists.
From page 65...
... . practice within maternity and newborn care, including low-risk neonatal nurse, maternal newborn nurse, neonatal intensive care nurse, or inpatient obstetric nurse.
From page 66...
... . Midwives Midwives specialize in the management of pregnancy, birth, and newborn care.
From page 67...
... Most CNMs and CMs work in hospitals, although they also work in birthing centers and attend home births. CPMs provide care only in birth centers and at home births, as they have not been granted hospital privileges in most areas (Cheyney et al., 2015)
From page 68...
... Minimum Registered nurse (RN) Master's degree High school diploma required + master's degree or equivalent; some education earn a certificate or an associate's, bachelor's, or master's degree Required Training offered during educational program, Training offered during training primarily in the hospital setting educational program, or through at least 2 years of apprenticeship, primarily in birth centers or home settings Exams National Council American Midwifery North American Licensure Examination Certification Board Registry of Midwives (NCLEX-RN)
From page 69...
... . CNMs work in a wide variety of settings, includ­ng hospitals and birth centers; 94 percent of CNM-attended births i in the United States occur in a hospital (Martin et al., 2019)
From page 70...
... . CPMs attend the majority of home births (MacDorman and Declercq, 2016)
From page 71...
... .10 Physicians Physicians providing maternal and newborn care evaluate, diagnose, manage, and treat patients; order and evaluate diagnostic tests; prescribe medications; and attend births. After graduating from a 4-year college, all physicians must attend an accredited medical school and receive a doctor of medicine (MD)
From page 72...
... The proportion of family physicians who offer maternity care has declined in recent years, and many provide only prenatal and postpartum care, with fewer attending vaginal births and even fewer offering cesarean birth (Rayburn et al., 2014)
From page 73...
... . Other Members of the Care Team While nurses, physicians, and midwives provide the majority of care for women during pregnancy, birth, and the postpartum period, others, such as doulas and community health workers, can also play a critical role in ensuring that the needs of pregnant people and babies are met.
From page 74...
... In the postpartum setting, the doula may assist the new mother with breastfeeding and newborn care, and may also help with light housekeeping and cooking duties at home. Doulas care for women in every birth setting -- home, birth center, and hospital.
From page 75...
... By contrast, in a state where policies restrict these choices -- for example, by not offering licensure or coverage for settings other than the hospital, or through reduced scope of practice for providers and limited Medicaid options -- giving birth at home or in a birth center will likely remain the domain of women who can afford to pay out of pocket. Financing Women pay for maternity care in several ways: private insurance (either employer sponsored or individually purchased)
From page 76...
... births, whereas such costs were negligible for individuals with Medicaid coverage. A major finding from this analysis is that about 4 of 5 dollars paid on behalf of the woman and newborn across the full episode of care went to intrapartum care, while only 1 in 5 dollars went to prenatal and postpartum/newborn care.
From page 77...
... does not cover home births because it "considers planned deliveries at home and associated services not medically appropriate." Aetna notes, however, that it will consider coverage when mandated by state law. A few states, including New Hampshire, New York, New Mexico, and Vermont, do require private insurers to cover home births (Rathke, 2011)
From page 78...
... The federal government mandates certain groups that must be eligible for Medicaid, including pregnant women whose income level is at or below 133 percent of the federal poverty level (FPL) (Kaiser Family Foundation, 2017)
From page 79...
... . In addition, some states have implemented presumptive eligibility, in which pregnant women may receive immediate care while their eligibility for M ­ edicaid is being determined (Kaiser Family Foundation, 2017)
From page 80...
... A 2018 survey found that 21 states allowed Medicaid coverage for home births, out of 41 states that responded (Kaiser Family Foundation, 2017)
From page 81...
... . Self-Financing  Only about 4 percent of all births are self-paid, although women who use birth centers or home birth are more likely to self-pay.
From page 82...
... Hospitals, home births, and birth centers offer different resources, services, and care options. For example, hospitals offer more intensive interventions, such as induction and augmentation of labor, epidural pain relief, and cesarean birth, whereas birth centers and home births do not offer similar interventions and instead put more emphasis on supporting physiologic birth.
From page 83...
... Other state policies may restrict the types of providers who are licensed, the types of birth settings that are legal, and the scope of practice for different providers. In addition to these factors, pregnant people's birth experiences may be shaped by social determinants and medical risk profile.


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