MBC Optimal Outcomes PP 10.10.13.Pptx

10/9/13

MATERNITY CARE IN THE U.S.

FREE STANDING BIRTH CENTERS

OPTIMAL OUTCOMES

CHILDBIRTH IS THE TOP REASON FOR BIRTH IN AMERICA HOSPITALIZATION ACROSS ALL AGES

Percentage of total hospitalizations by reason for men and women of ALL ages • There are nearly 4 million births Health, United States 2009 CDC/NCHS http://www.cdc.gov/nchs/data/hus/hus09.pdf each year in the U.S. 12 . 99 % of births take place in hospitals (86% 10 attended by physicians) 8 . 0.3% in birth centers (86% attended by CNM) 6 • 85% of women who give birth in 4 the hospital are considered low 2 0 risk. Childbirth Heart Injury 3.6% 11% Disease 5%

HOSPITAL BIRTH DATA CESAREAN RATES CONTINUE TO INCREASE, 2009 WHILE VBAC RATES DECREASE.

• Childbirth is the leading cause of hospitalization in the United States . mothers and newborns accounting for 23% of all hospital discharges • 6 out 10 of the most common hospital procedures were related to maternity care • Cesarean birth was the most common inpatient surgical procedure • Pregnancy, birth, and newborn care total : $97.4 billion in hospital charges . making it the single largest contributor as a health condition to the national hospital bill

Wier, LM, Andrews RM. The National Hospital Bill: The Most Expensive Conditions by Payer, 2008 . HCUP Statistical Brief #107. Rockville, MD : Agency for Healthcare Research and Quality; 2011.

1 10/9/13

ROUTINE HOSPITAL INTERVENTIONS ROUTINE INTERVENTIONS

87% Have continuous • “when normal, healthy pregnant women give birth in electronic fetal monitoring hospitals, their care often gets swept up into this same medical way of doing things. The philosophy is often "What if 92% give birth 80% receive lying on their intravenous something bad happens?" instead of "What is happening right backs fluids now?" • Standard protocols, meant to prepare for problems that may never arise, can disrupt normal labor for healthy pregnant 76% are 47% have labor artificially women. restricted to accelerated with bed medications • There is strong evidence that routine use of these practices, when carried out without medical indications, has few benefits and many potential harms for healthy mothers and 60% of women 43% of first-time giving birth in moms have labor babies hospitals are not artificially induced allowed to eat or drink, In addition Declercq ER, Sakala C, Corry MP, et al. Listening to mothers II: Report of the second national U.S. Survey of women's childbearing experiences. The Journal of Perinatal Goer H, Romano AM. Optimal care in childbirth: The case for a physiologic approach. Seattle, Washington: Classic Day Education. 2007;16:9-14. Available at: http://www.childbirthconnection.org/pdfs/LTMII_report.pdf. Laughon SK, Zhang J, Grewal J, et al. Induction of labor in a contemporary obstetric cohort. American Journal of Obstetrics and Gynecology. 2012;206:486 e481-489. Publishing; 2012. Available at: http://www.optimalcareinchildbirth.com/. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22520652.

BIRTH CENTER PHILOSOPHY

• Pregnancy and childbirth are healthy, normal life events for most women and babies. In birth centers, midwives and staff hold to the "wellness" model of birth, which means that they provide continuous, supportive care and interventions are used only when medically necessary.

Goer H, Romano AM. Optimal care in childbirth: The case for a physiologic approach. Seattle, Washington: Classic Day Publishing; 2012. Available at: http://www.optimalcareinchildbirth.com/. Minnesota Birth Center

ENTRY AND HALLWAY TWO BIRTH ROOMS

2 10/9/13

EXAM ROOM DINNING ROOM AND KITCHEN

CONVENIENT LOCATION MINNESOTA BIRTH CENTER STAFF

• All care is provided by CNMs and RNs • CNM: Certified Nurse Midwives are Advanced Practice Nurse Practitioners and have extensive, post-graduate training in both nursing and midwifery • CNMs offer obstetric and gynecological services similar to Obstetricians, but with different methodologies and results. • CNMs Care offer care from puberty to menopause including: Well-women exams, GYN, STI, Family Planning, and Hormone therapy

COMPREHENSIVE PRENATAL CARE LABOR SUPPORT

• In house lab draws • CNM and RN -Courier to ANWH attend birth • In house Limited ultrasounds by CNM -NRP certified -Dating -Viability • Continuous labor -AFI support -Fetal Position -BPP • Frequent Position • In house complete changes ultrasound preformed by an ARDMS ultrasound • Hydrotherapy sonographer at 18 -20 weeks • Eat and drink • Prenatal visits • Music therapy • Acupressure/ Touch

3 10/9/13

POST PARTUM COLLABORATIVE PRACTICE

• Early Discharge Collaborating Physicians: . 4-12 hours post-partum • 24 hour home • Steve Calvin visit -Medical Director . Metabolic Screen . Newborn Hearing Screen • Associates in • 1 & 6 week post- Women Health partum visit -ANWH/ Mother Baby Center

SAFE SATISFYING BIRTH CENTER REQUIREMENTS SEAMLESS • MBC is located across from Abbott North • Attend orientation session Western and Children’s Hospitals’ Mother Baby Center for quick transfers • 18 week ultrasound (gross fetal anomalies and placenta location) • All of the CNMs have privileges at the • GDM screening Mother Baby Center for seamless transfers • Early Discharge class prior to 37 • CNMs can admit, deliver and discharge weeks patients independently • Pediatric Provider prior to 37 weeks

MATERNAL RISK FACTORS ANTEPARTUM RISK FACTORS

• Heart disease • Bleeding disorder or • Nonlethal fetal anomaly • Severe mental health • Pulmonary embolus hemolytic disease • Multiple gestation problem • Sickle cell anemia • Pre-eclampsia requiring • Current alcohol or drug • Symptomatic Magnesium Sulfate abuse congenital heart • Previous Rh • Intrauterine growth • Laboratory evidence of defects sensitization restriction sensitization in Rh negative woman • Chronic Hypertension • Cardiac diastolic • Oligohydramnios murmur, cardiac • EFW less than 2500 gm. or • Moderate to severe • Gestation greater than 42 greater than 4500 gm. renal disease systolic murmur III/VI weeks or above • Gestational diabetes • Development of any • Diabetes mellitus other severe obstetrical, • Evidence of active • Hematocrit less than 33% medical or surgical • Hyperthyroidism tuberculosis at term problem • Positive HIV • Epilepsy or seizures • Per CNM discretion

4 10/9/13

INTRAPARTUM RISK FACTORS BIRTH CENTER SAFETY

• Labor before 37 weeks • Cord prolapse gestation • Inadequate pain relief • 93% of women who entered the birth center had a • Non-vertex presentation • Suspected placental abruption spontaneous vaginal birth • Active genital herpes outbreak or uterine rupture  6% Caesarean section rate • Ruptured membranes greater • Evidence of infectious process than 24 hours without active or fever  1% Assisted Vaginal Birth labor • Development of other severe • Significant FHR decelerations or obstetrical or medical problems • 84% admitted to the birth center in labor ended up bradycardia • Postpartum hemorrhage failing giving birth at the birth center facility • Particulate meconium to respond to management • Arrest of dilatation or descent • 3rd and 4th degree laceration • 12% Intrapartum transfer rate (most non-emergent) • Failure to descend in second • Any condition requiring more  63% for Prolonged labor/ Arrest of Labor stage than 12 hours of observation • Third stage longer than 30 Post-partum  1.9% were hospital transfers for emergent reasons (50% for minutes • Per CNM discretion FHT’s) • Blood loss estimated greater than 500cc

BIRTH CENTER SAFETY (CONT.) BIRTH CENTER SAFETY (CONT.)

• No maternal deaths • One of the most important findings of this study was • 0.047% intrapartum fetal mortality rate for the that more than 9 out of 10 women (94%) who women who were admitted to the birth center in entered labor planning a birth center birth achieved labor( 0.47 stillbirths per 1,000 women) a vaginal birth. In other words, the C-section rate for • 0.04% neonatal mortality rate excluding anomalies low-risk women who chose to give birth at a birth center was only 6%—compared to the U.S. C- (0.40 newborn deaths (first 28 days) per 1,000 section rate of 27% for low-risk women. women)

• C-section rate for women in birth centers is more (The US neonatal mortality rate in 2007 was 0.75/1000 than 4 times lower than what is seen among low-risk for newborns weighing 2500 g or greater) women in the U.S.

Stapleton SR, Osborne C, Illuzzi J (2013). Outcomes of care in birth centers: Demonstration of a durable model. Journal of Midwifery and Women's Health. Retrieved from: http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12003/full. HealthyPeople.gov. Healthy people 2020: Maternal, infant and child health. Accessed January 21, 2013. Available at: http://healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=26.

WHERE ARE THE OPPORTUNITIES IN BIRTH CENTERS AND NEW CLINICAL THE COST OF HAVING A BABY IN THE US MODELS?

• Quality – 2013 Birth Center Study clearly Commercial Medicaid demonstrates equivalence/superiority (55%) Vaginal (45%) Vaginal • Experience – Anecdotal at present but new Delivery = Delivery = measurement tools will likely show much $18,329 $9131 higher satisfaction levels • Cost – 2013 Truven study shows that nearly Cesarean Cesarean 2/3 of costs are in facility fees for mom/baby Section = Section = $27,866 $13,590

January 2013 - commissioned by Childbirth Connection, Catalyst for Payment Reform, and the Center for Health Care Quality and Payment Reform

5 10/9/13

THE PREGNANCY CARE PIE 2013 AFFORDABLE CARE ACT 2011

• 2/3rd Goes to Facility Fees • ACA requires government funded health plans to cover services provided in a Professional Fee licensed birth center by a licensed health Facility Fee professional if the service would otherwise be covered if provided in a hospital Anst, Radio, Lab, Pharm • Medicare payment at 100% of the physician Fee schedule for certified nurse-midwives (increase from 65%)

MN statute 256B.0625.Subd. 54. MN STATUTE 256B.0625.SUBD. 54. Services provided in birth centers SERVICES PROVIDED IN BIRTH CENTERS

• MHCP covers low-risk pregnancy and delivery services provided in a licensed, free-standing birth center if the service is covered when provided in a hospital by a • Facility services provided by a birth licensed health professional. Free-standing birth centers center shall be paid at the lower of are licensed health care facilities that perform low-risk billed charges or 70% of the statewide deliveries following a low-risk pregnancy by a licensed health professional. A low-risk pregnancy is a normal, average for a facility uncomplicated pregnancy. A free-standing birth center is not a hospital or licensed as part of a hospital. All free- standing birth centers must be accredited by the • Nursery care services provided by a Commission for the Accreditation of Birth Centers birth center shall be paid the lower of (CACB). The Minnesota Department of Health (MDH) billed charges or 70% of Statewide issues licenses for free-standing birth centers. average for a facility

https://www.revisor.mn.gov/statutes/?id=256B.0625&year=2010 https://www.revisor.mn.gov/statutes/?id=256B.0625&year=2010

LEVELS OF CARE IN A BIRTH CENTER NEW DIRECTIONS CARE MODEL

• Return to normal birth • No scheduled inductions without medical indication OB Transfer • Freedom of movement during labor • Continuous labor support • Non-supine positions for birth Mother/Baby & • No routine interventions • No separation of mother and infant after birth Midwife in the • Positive media image of normal birth Hospital • True informed consent • No cesareans and induction without medical Mother/Baby & Midwife indication in the Birth Center • Nursing school education on supporting normal birth

Zwelling, E. (2008). The emergence of high-tech birthing. JOGNN, 37, 85-93.

6 10/9/13

THE POLITICS OF PREGNANCY CARE - WHY CHOOSE A BIRTH CENTER SUGGESTIONS

• Low risk motivated mothers are ideal candidates for • MDs are not your enemy (some might be their OWN birth center care. worst enemy…). Work with good ones and nurture • Pregnancy and birth are viewed as normal family relationships. events • Don’t let your enthusiasm and/or patient • Alternative to home birth expectations paint you into risky clinical corners. • Reduced use of medical interventions • Positive persistence in doing the right thing is an • Infant mortality similar to low-risk hospital births unstoppable force for good. • Birth center birth involves supporting the natural processes of pregnancy, labour and birth –while providing for intervention when necessary.