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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 interventions
1. 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?
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Socioeconomic status
Education
Rural vs. Urban
Race
Occupation
Age and parity
Marital status
Global Strategies for
integrating midwifery
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Regulation
Education
Recruitment and Retention
Association
Collaboration
Credentials and Pathways
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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
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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:
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Informed choice and informed consent
Evidence-based practice
Respect for normal birth
Continuity of care
The judicious and appropriate use of medical technology
RM
RN
RN
RM RM
MD
MD
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, BC
July 20-23, 2010
2010 Conference Themes
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Defining and describing normal birth
Practice
Public Information
Education
Policy
The Nature and Management of
Labor Pain
Am 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
Evidence Based Care:
Home Birth
Saraswathi Vedam RM, MSN, FACNM, Sci D(hc)
Quieres
un
parto
en la
casa?
Eres
Loco?
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
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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
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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
Quality of Evidence - 2009
• Janssen et al, CMAJ
• Hutton et al, Birth
• de Jonge, BJOG
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
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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
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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 patientprovider relationship
Framework for Optimal Care
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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
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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?
5/25/2017
48
General Criteria
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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
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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)
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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
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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
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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
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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”
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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
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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
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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
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Screening criteria
Basic skills necessary as attendants
Basic equipment
Continuity of care
Strong provider/patient relationship
Timely access to consultation and
referral
Homebirth Integrated
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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
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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
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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 Midwifery
University 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 Analysis
1. 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
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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
UBC Midwife
meeting the needs
rural communitie
Class of 2010
Class of 2009
Class of 2008
Haida Gwai
Squamish
Bowen Island
Maple Ridge
Mission
Comox
Hornby Island
Penticton/
Naramata
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
La Partera profesional
a Mexico
Continuity and Collaboration