The California Maternal Quality Care Collaborative has released Toolkit to Support Vaginal Birth & Reduce Primary Cesareans. Reading it inspired “shock and awe,” “awe” of the herculean effort that has produced a meticulously documented (338 references) manual that addresses the array of factors that fuel this country’s unconscionable cesarean rate in low-risk 1st-time mothers and provides a multiplicity of strategies to remedy them, and “shock” because the Toolkit pulls back the curtain on a system that all too commonly is a Bizarro World inversion of what bests promotes safety and well-being in mothers and babies.
Starting with the “awe” side of the ledger, the Toolkit opens with “The Case for Improvement in Cesarean Birth Rates,” which lays out the numerous harms of cesarean surgery and discusses what constitutes an appropriate rate. The original goal, the Toolkit tells us, was a 15% cesarean rate overall. This was recommended by the World Health Organization in 1985 on grounds that higher rates didn’t result in better outcomes* (and was made a U.S. national objective in Healthy People 2000). In 2000 the American College of Obstetricians & Gynecologists lobbied for modifying this to a 15% rate in in low-risk nulliparous women (1st-time mothers), low-risk being defined as term (37 wks or more) pregnancy and singleton (one), vertex (head-down) baby (NTSV). This was duly adopted as the 2010 Healthy People goal but to no effect as the cesarean rate continued to march upwards. For this reason, as the Toolkit puts it: “The Healthy People 2020 NTSV target rate of 23.9% was created to reflect a more modest, attainable rate” (p. 24) (representing a 10% decrease from the 2007 rate ). Leaving aside the distinction between “attainable” and “optimal,” hospitals aren’t meeting the new goal either. Among 251 California hospitals, rates in NTSV women in 2014 ranged as high as 70%, and 60% of hospitals exceeded the 24% target. Estimating from the Toolkit’s chart, a mere 7% of hospitals meet the previous goal of 15% or less in low-risk 1st-time mothers, a rate we know from out-of-hospital studies can be achieved (Birthplace in England 2011; Johnson 2005; Rooks 1989).
The body of the Toolkit is divided into four parts. Each section lays out an evidence-based set of problems contributing to the excessive use of cesarean surgery followed by a comprehensive list of “Key Strategies” to remedy each one that is equally well-founded in the research. (The fourth part has to do with using data to drive change, which isn’t of so much interest to this blog’s readers, so we’ll focus on the other three.) The Toolkit closes with some success stories** and a set of appendices with resources to assist in planning and implementing change. Here are the parts and their subsections:
Part I: “Readiness: Improving the Culture of Care, Awareness, and Education”
- Recognizing the value of vaginal birth
- Casual acceptance of cesarean birth
- Knowledge deficit regarding the benefits of vaginal birth
- A maternity culture that under-appreciates women’s informed choices and preferences
- Payment models that conflict with high-value, high-quality maternity care
Part II: “Recognition and Prevention: Supporting Intended Vaginal Birth”
- The new normal: redesigning maternity care for low-risk women [new concepts of normal progress in labor]
- Lack of institutional support for the safe reduction of routine intervention
- Admission in latent (early) labor without a medical indication
- Inadequate labor support
- Limited choices to manage pain and improve coping during labor
- Overuse of continuous fetal monitoring in low-risk patients
- Underutilization of current treatment and prevention guidelines for potentially modifiable conditions [breech, herpes]
Part III: “Response: Management of Labor Abnormalities”
- Standardization matters
- Poor professional communication and lack of teamwork
- Lack of standard diagnostic criteria/standard responses to labor challenges and fetal heart rate abnormalities
- Failure to identify and intervene for the persistently [occiput posterior/occiput transverse] fetus
- Professional challenges in work-life balance
- Liability-driven decision making
Every section provides rock solid support for the care practices maternity care reformers have long argued should be the norm rather than the exception. To cite but a few examples,
“Changing certain hospital policies, such as instituting a freedom of movement policy, intermittent monitoring for low-risk women, or offering a full array of nonpharmacologic methods to promote comfort and coping may be necessary in order to practice high-quality maternity care in alignment with evidence-based childbirth education” (p. 29).
“Published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula…” (p. 40)
(c) California Maternal Quality Care Collaborative, reprinted with permission
“Induction of labor before 41+0 weeks should be reserved for women with a maternal or fetal medical indication” (p. 62)
“Amniotomy prior to 5 cm eliminates the cushion of the fore waters which allow for fetal repositioning, and may result in more non-reassuring FHR patterns” (p. 64).
“Physical and psychological support measures are critical for the woman who is fatigued and doubts her ability to give birth vaginally. If the fetus demonstrates health, a sip of liquid with some glucose (e.g. juice, Gatorade) or a light carbohydrate snack might give her a burst of energy to continue to run the ‘final lap.’” (p. 64) [Advice for caring for women with a persistent occiput posterior or occiput transverse baby.]
“[H]ospitals must design systems of care that safely and efficiently allow for the seamless transfer of care from the out-of-hospital environment to the hospital environment. This will require ‘effective interdisciplinary teamwork and integration across facility and community settings.’ An integrated system of care embraces the understanding that some women will choose to birth safely in an out-of-hospital environment and that a minority of these women will require transport and transfer to medical care within the hospital. Interprofessional dialogue between out-of-hospital and inhospital providers should remain respectful and cooperative. The safety of mothers and babies, and the future of a fully integrated system, will be at risk if women and out-of-hospital providers perceive they will be received with judgment and disrespect for timely, necessary, and medically-sound transfers of care” (p. 66).
“Implement policies that support the physiologic onset of active labor, reduce stress and anxiety for the woman and family, and improve coping and pain management” (p. 42)
“Modify standing admission orders to reflect the use of intermittent auscultation or [electronic fetal monitoring] as the default mode of monitoring for women who do not meet exclusion criteria” (p. 42)
“As long as incremental descent is being made, and fetal and maternal statuses permit, allow for longer durations of the second stage (e.g. at least 4 hours for nulliparous women and at least 3 hours for multiparous women)” (p. 56)
Midwifery care has been identified as an underused maternity service, with the potential to curb costs, improve overall outcomes, and reduce rates of cesarean (p. 56)
Turning to the other side of the ledger, as the list of contributory factors has already made clear, the Toolkit lays bare the shocking degree to which typical management fails to provide safe, effective care to pregnant women and their babies in the teeth of abundant, long-established evidence. Expanding on this theme, here are the Toolkit’s astonishingly frank descriptions of some of the problems, all of which are backed by research evidence:
“[D]ecisions about pregnancy and birth are often made by providers rather than by women. Institutional practices and caregiver workflows, even as far as timing of birth, may take precedence over women’s informed choices” (p. 26).
“Unfortunately, hospital philosophies and policies are not always congruent with evidence-based childbirth education. This disconnect often makes the information disseminated through formal classes irrelevant once the woman enters the birthing facility. Hospital providers and nurses may find themselves in a conflicted position where the patient believes a certain type of care will or should be given (e.g. less routine intervention) and feels confused as to why, for example, they are not allowed to walk, must have continuous monitoring, or are encouraged to use pitocin” (p. 29).
“Despite the fact that most women are at low-risk for complications, the vast majority of women who deliver in hospitals are faced with liberal use of common obstetric interventions and procedures. These include routine use of pitocin, continuous fetal monitoring, and induction of labor. This suggests that many providers may not fully appreciate their role in the prevention of iatrogenesis [doctor-caused harm] through more judicious use of interventions” (p. 39).
“[T]here are many barriers to nurses providing adequate labor support to patients. These include burdensome and time-consuming nursing documentation and other time constraints, a deficiency in knowledge of hands-on labor support techniques, and a hospital unit culture that does not value labor support as a primary responsibility of the nurse” (p. 40).
“[K]nowledge of specific non-pharmacologic coping methods is inconsistent among clinicians and is not the cultural norm in many hospital settings” (p. 44).
“Although doula care is rising in the United States, it has not been fully accepted in the hospital setting. There are still many misconceptions about doula care and often there is a stigma surrounding the ‘type’ of woman who has a doula” (p. 46).
“[G]eneral institutional acceptance of this new labor curve has been slow. Many factors may contribute to this, including that the definition of prolonged latent phase by Friedman is still widely accepted, many women are admitted to the hospital before active labor has truly begun, and many providers still adhere to a frequent cervical examination schedule of every two hours even before commencement of active labor. All of these things combined may lead to an overall culture of care that diagnoses labor dystocia far too early” (p. 52).
“Since most complications are associated with uterine activity and are dose-related, recent quality improvement efforts to reduce adverse events related to oxytocin have focused on using lower initial dosing and increasing more slowly until the lowest effective dose has been achieved. Nonetheless, wide variation in oxytocin protocols and administration persists” (p. 53).
“Whether real or perceived, the risk of and fear of litigation may present an obstacle to success for institutions or individuals attempting to curtail rates of cesarean birth” (p. 55).
Challenges in work-life balance exist for many medical professionals. . . . Providers must somehow weave an intricate balance between these demands and those of personal life and family — a balance that is often disrupted by the unpredictability of labor and birth” (p. 55). [Loose translation: wanting to get home for dinner or back to the office leads to provider-elected inductions and cesarean surgeries.]
“Other reasons providers may be more commonly inclined to suggest induction of labor include provider convenience and financial incentives” (p. 63).
The Toolkit isn’t perfect. For example, it stresses “shared decision making,” which would be a long-sight better than what’s going on now, but doesn’t acknowledge a woman’s right to refusal. The “decision talk” incorporates “the patient’s personal values and preferences” and arrives “at a decision grounded in the best evidence available,” (p. 31) which isn’t the same thing as affirming her inalienable right to say “No” regardless of what her care providers believe the evidence supports.
It also gets a few things wrong. For example, the Toolkit greenlights early epidurals based on three studies finding that they don’t increase cesareans, but those studies are flawed. Furthermore, the likelihood of epidural-related fever correlates linearly with epidural duration, and a woman progressing slowly who is running a fever is a prime candidate for a cesarean, not to mention fever’s adverse effects on the baby, including keeping the baby in the nursery for observation, which interferes with breastfeeding; diagnostic testing to rule out infection; and, in rare cases, possibly seizure (Goer 2012).
These quarrels aside, the Toolkit is an invaluable resource for pregnant women wanting to know if their care providers and chosen location for birth measure up; a powerful buttress for childbirth educators and doulas guiding families on what policies and practices promote safe, healthy, vaginal birth; and strong support for advocates for reform both inside and outside the hospital system. Kudos to CMQCC. The Toolkit to Support Vaginal Birth & Reduce Primary Cesareans has the potential to spare tens of thousands of women the consequences of cesareans they didn’t really need. It will surely keep a few women from losing their uteruses; it might even save a life. Here’s fervent hopes that it doesn’t go the way of all previous attempts to date: lots of fanfare, no effect.
*A study recently challenged that rate, concluding that 19% was the optimal total cesarean rate for countries or regions, but this is arguable.
Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011;343:d7400.
Goer H. Epidurals and combined spinal-epidurals: the “Cadillacs” of analgesia. In: Goer H, Romano A, eds. Optimal Care in Childbirth: The Case for a Physiologic Approach. Seattle, WA: Classic Day Publishing; 2012.
Johnson KC, Daviss BA. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ 2005;330(7505):1416-22.
Rooks JP, Weatherby NL, Ernst EK, et al. Outcomes of care in birth centers. The National Birth Center Study. N Engl J Med 1989;321(26):1804-11.