Disruptive Innovation in Childbirth Care
Reposted from the September 16, 2015 edition of Disruptive Women in Health Care
In considering what to write for Disruptive Women in Health Care, I couldn’t stop thinking about the idea of disruption juxtaposed with the experience of birth and the US maternity care system.
In the context of maternity care, the concept of “disruption” hints at intriguingly different possible meanings: the consequences of a newborn entering a family, disruption during the childbirth process, or the urgent need for disruptive innovation in maternity care.
Birth itself is an absolute disruption of the status quo. Birth can be tumultuous, even when it is a joyous occasion. It is a turning point, beyond which things are never the same for those who give birth and those who incorporate a newborn into their lives, not to mention for the baby who is born.
Disruption of the process of birth is a different type of disruption. Few things are as important to a positive birth experience as feeling safe, private, and calm – in other words, being free from intrusion and interference. As we have come to better understand hormonally driven childbearing processes, we have learned that the time around birth is highly sensitive for mother and baby. Practices that protect physiologic childbearing from disturbance may have longstanding and significant benefits.
A recent, comprehensive synthesis of the medical literature authored by Sarah Buckley in collaboration with Childbirth Connection investigated the impact of common maternity care practices and interventions on the physiologic processes that occur during birth. The report, Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care, found substantial and consistent evidence that protecting the innate, hormonal physiology of mothers and babies – eliminating or avoiding unnecessary and non-beneficial disruptions – has significant benefits in childbirth and beyond.[i]
Undisturbed childbirth fosters safe and effective labor and birth, maternal behaviors, maternal-newborn attachment, and breastfeeding. In contrast, medical procedures that have come to be used routinely during childbirth, such as unnecessary restrictions of movement, the use of synthetic oxytocin to begin or hasten labor, epidural pain relief, continuous electronic fetal monitoring, restrictions on food and drink, and cesarean birth, interfere with these processes and diminish their benefits.
According to the Buckley report, women and babies fare better when disruptions of physiologic labor and birth are limited to situations where evidence suggests the benefits will outweigh the potential for harm. Interventions are used to the best effect when:
- The benefits of a particular intervention are rigorously verified for the specific circumstances at hand
- Routine practices are limited to those with proven benefits to healthy mothers and babies
- Interventions are not used for the convenience of women or maternity care providers, facilities, or systems
- Non-invasive measures are used first, moving towards more consequential interventions as needed.[ii]
A third way to consider disruption in the context of labor and birth is to imagine the potential for “disruptive innovation” in the current maternity care system. Disruptive innovation can be understood as new ideas or services that upset an older, established order that is complicated and expensive, by creating solutions that are simpler, more affordable, and more accessible.
Perhaps no area of healthcare is more in need of disruptive innovation than maternity care. Several factors suggest that maternity care reform should be at the forefront of healthcare improvement initiatives:
- Nearly 1 in 4 hospital discharges is for maternal or infant care related to childbirth.
- The US spends more on childbirth-related hospital charges than any other type of hospital care[iii] – hospital bills totaled $120 billion in 2012, for maternal and newborn care. [iv]
- The US spends more on childbirth related care than any other country,[v] but…
- Maternal and infant outcomes lag far behind those of other wealthy nations. WHO data shows 36 nations with lower rates of infant mortality and 62 with lower maternal mortality ratios than the US. [vi]
One factor behind these troubling statistics is that the routine use of medical interventions and restrictions in labor and birth has skyrocketed, even in low-risk pregnancies. Too many practices in childbirth care have become commonplace despite a lack of evidence supporting their routine use: unnecessary restrictions of movement, the use of synthetic oxytocin to begin or hasten labor, epidural pain relief, restrictions on food and drink, cesarean birth, and continuous electronic fetal monitoring in the absence of a medical indication.
These practices contribute to soaring costs, lackluster outcomes, and too often a resigned expectation among families that childbirth will be characterized by disruption, confusion, and frustration rather than calm, confidence, and satisfaction.
Maternity care practices should be considered low-hanging fruit for policy- and decision-makers who are seeking to advance the triple aim of healthcare improvement. Numerous opportunities exist to eliminate non-beneficial costly procedures and practices that will improve health outcomes, enhance the experience of care and involvement in care decisions, and reduce wasteful expenditures.
So, how do we best disrupt the maternity care system as it exists now and create solutions that are simpler, more affordable, and more accessible? Existing models of care provide some answers. The midwifery model of care and support by trained doulas are two strategies that have a demonstrated track record of improving maternity care outcomes, enhancing women’s experience of and engagement in care, and reducing spending on unnecessary medical procedures and complications.
Midwives, family practice physicians, and other providers practicing what is often called the “midwifery model of care” achieve healthy outcomes, high rates of satisfaction with care, and a lower cost of care. Midwives are the primary maternity care providers in much of the rest of the world and in many countries that experience better health outcomes than the US.
In the US, midwives attend 8-9% of all births and around 12% of vaginal births. Midwives are independent maternity care providers – experts in low-risk healthy pregnancies who work collaboratively with physicians when complications arise. Hallmarks of the midwifery model include approaching pregnancy and birth as a healthy, normal process; the belief that interventions are best reserved for circumstances where their value is supported by evidence; providing individualized, woman-centered care; and recognizing the impact of social and emotional well-being on health. This approach decreases the likelihood of cesarean birth, preterm and low birthweight births, birth injury or trauma, and the length of hospital stays. At the same time, the midwifery model of care increases care satisfaction, prenatal education, and preparedness for birth.
Doula support is recognized as one of the most effective strategies to improve maternal and infant health. Doulas are trained to provide non-medical emotional, physical, and informational support before, during, and following birth. Continuous labor support by a trained doula fosters women’s engagement in decision-making, results in better health outcomes for women and babies, and has the potential to reduce spending on unnecessary and unwanted medical procedures.
Rigorous studies show that doula care reduces the likelihood of such consequential and costly interventions as cesarean delivery and epidural pain relief, while increasing the likelihood of a shorter labor, a spontaneous birth, higher Apgar scores for babies, and a positive childbirth experience. Other smaller studies suggest that doula support that includes prenatal and postpartum visits is associated with increased breastfeeding and decreased postpartum depression. Doula support appears to limit stress responses that can interfere with labor progress and enhance the functioning of major hormone systems. This in turn reduces the need to use interventions with established side effects and helps keep women and babies healthy.
Disruptive innovation in maternity care is not just possible, we are already seeing it in action on a small scale in hospitals, birth centers, and homes around the US. Our knowledge of approaches that are “low-tech” and “high-touch,” that are less expensive, highly effective, and have few or no side effects, illuminates an unparalleled opportunity to alter the existing paradigm on a wider scale. Our imperative in revolutionizing childbirth care is to disrupt the disruption of physiologic labor and birth.
[i] Buckley SJ. (2015). Hormonal physiology of childbearing: Evidence and implications for women, babies, and maternity care. Washington, DC: Childbirth Connection Programs, National Partnership for Women & Families. Available at http://www.childbirthconnection.org/HormonalPhysiology.
[ii] Buckley SJ. (2015). Hormonal physiology of childbearing: Evidence and implications for women, babies, and maternity care. Washington, DC: Childbirth Connection Programs, National Partnership for Women & Families. Available at http://www.childbirthconnection.org/HormonalPhysiology.
[iii] Wier LM, and Andrews RM.The National Hospital Bill: The Most Expensive Conditions by Payer, 2008. HCUP Statistical Brief #107. March 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb107.pdf
Childbirth Connection. Vaginal or cesarean birth: What is at stake for women and babies? A best evidence review.
[v] International Federation of Health Plans. (2014). 2013 Comparative Price Report: Variation in Medical and Hospital Prices by Country. Washington, DC: Author. Available at http://www.ifhp.com/1404121/.
[vi] World Health Organization. World Health Statistics 2014. Geneva, Switzerland: WHO, 2014. Available at: http://apps.who.int/iris/bitstream/10665/112738/1/9789240692671_eng.pdf
Bio: Nan Strauss, JD is the Director of Policy and Research for Choices in Childbirth. She recently authored “Doula Care in NYC: Advancing the Goals of the Affordable Care Act,” which paired research on the benefits of doula care with personal accounts from women and doulas documenting the need to expand access to doula care for all women in New York City. Previously, Nan served as the Director of Maternal Health Research and Policy at Amnesty International USA, where she worked on maternal and reproductive health and health care from a human rights perspective. She was a co-author of the groundbreaking report, Deadly Delivery: The Maternal Health Care Crisis in the USA in 2010. Her advocacy and policy work has included Congressional briefings on the U.S. maternal health crisis and work developing and strengthening federal and state legislation. Prior to joining Amnesty, Nan worked as a staff attorney at the Center for Reproductive Rights, where she litigated cases in federal court.
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