C-Sections Rise Again, 2020 Vision is Shared

Yesterday, I learned that the preliminary 2009 data for births in Florida was released. As a state, our c-section rates have increased to 38.9%. Here in Sarasota, this number has risen to a very dangerous 42.3%, up 2.1% from 2008. As I outlined in April in the 20/2020 vision, had this 2.1% increase instead been a decrease, we as a community would be on the path to healthier birth. Sadly, we still are not on that path.

WHY NOT? And what on EARTH are we going to do about it?

As if in answer to my question, I received an invitation tonight to join a webinar from Childbirth Connection, my preferred mecca of comprehensive maternity care research. The subject is the group's recently released action plan entitled Transforming Maternity Care: 2020 Vision for a High Quality, High Value Maternity Care System. This amazing group of researchers, medical professionals, maternity care practitioners, obstetricians, midwives, professors, healthcare administrators, doulas and childbirth educators has created a blueprint for action that will help consumers, care providers and facilities to step on the path toward healthier birth in this country.

At the core of the Transforming Maternity Care project are six aims applied to maternity care:

Woman-centered means that care respects the values, culture, choices, and preferences of the woman, and her family, as relevant, within the context of promoting optimal health outcomes. It means that all childbearing women are treated with kindness, respect, dignity, and cultural sensitivity, throughout their maternity care experiences.

• Pregnancy and birth are unique for each woman. Women and families hold different views about childbearing based on their knowledge, experiences, belief systems, culture, and social and family backgrounds. These differences are understood and respected, and care is adapted and organized to meet the individualized needs of women and families.

• To promote positive maternity care experiences, care teams engage in high-quality relationships with women and their families, based on mutual respect and trust.

• Caregivers and settings have a powerful effect on childbearing women. Attention is given to the power of language, communication, and care practices to create a climate of confidence and enhance outcomes of care, as well as women's childbearing experiences.

Safe means that care is reliable, appropriate, and provided in systems that foster coordination, a culture of safety, and teamwork to produce the best outcomes for women and babies and minimize the risk of harm. Maternity care processes impact outcomes for both mothers and babies; safe care considers and balances the risks and benefits to both recipients, taking into account the health status of each.

Effective means that the care is based on sound evidence applied properly to the circumstances of the individual pregnant woman and her baby to achieve desired outcomes. Effective care minimizes overuse, underuse, and misuse of care practices and services and emphasizes care coordination to prevent duplication, omission, fragmentation, and error.

Timely means that care delivery is structured so that all care is delivered at the time that it is needed. In maternity care, this means that the timing of the onset and course of all stages of labor and the birth of the baby are determined by maternal–fetal physiology whenever possible, and not by time pressures exerted externally without clear medical indication. In the context of informed consent/refusal in maternity care, timely means that whenever possible discussions and information to facilitate women's decision making around the time of birth are available well in advance of the onset of labor and again as relevant during labor. Finally, unnecessary wait times do not compromise safety, system efficiency, cost effectiveness, and satisfaction with maternity care.

Efficient means that the maternity care system delivers the best possible health outcomes and benefits with the most appropriate, conservative use of resources and technology. Overuse and misuse of treatments and medical interventions are avoided because they waste resources and can result in preventable iatrogenic complications. Similarly, efficient maternity care captures the unrealized benefits from effective underutilized measures.

Equitable means that all women and families have access to and receive the same high-quality, high-value care. Any variation in maternity care practice is based solely on the health needs and values of each woman and her fetus/newborn, and not on other extrinsic, nonmedical factors. Furthermore, an equitable maternity care system addresses disparities in the baseline health status of women related to class, race, ethnicity, and language to ensure optimal maternity care outcomes and experiences for every woman and her children.

In addition, Childbirth Connection has outlined very specific goals for each stage of pregnancy and birth. These goals drive the blueprint for action.

Care During Pregnancy: Summary of Goals

1. Each woman is engaged as a partner in her own care and education during pregnancy; she receives affirmation and practical support for her role as the natural leader of her care team to the extent that she so desires, and is encouraged to provide input to shape her own care.

2. Each woman's preferences are known, respected, and matched with individually tailored care that meets her needs and reflects her choices during pregnancy, delivered by a care team whose composition is also customized based on her needs and preferences.

3. Each woman has access to complete, accurate, up-to-date, high-quality information, decision support, and education to help ensure that she feels emotionally and psychologically prepared to make decisions during her pregnancy, and confident about her birth care options and choices well in advance of the onset of labor.

4. Education and care during pregnancy are designed and delivered to be empowering to women, emphasizing a climate of confidence.

5. Education and care during pregnancy include support for breastfeeding; most women make decisions about infant feeding well before they give birth.

6. Each pregnant woman receives personalized coaching and has access to high-quality resources for comprehensive health promotion, disease prevention, and improved nutrition and exercise for optimal wellness during her pregnancy.

7. Care during pregnancy is available when needed and can be accessed in a time and place that is convenient and accessible for each woman, as balanced with concerns for value and efficiency.

8. Care during pregnancy acknowledges the social context in which pregnancy occurs for each woman and includes opportunities for social networking and access to adequate professional and peer support during pregnancy.

Care Around the Time of Birth: Summary of Goals

1. Each woman has a comfortable, confident relationship of trust with her birth care provider(s).

2. Each woman is engaged as a partner in her own care around the time of birth; she receives affirmation and practical support for her role as the natural leader of her care team and approaches birth prepared and confident to express her preferences and make informed choices about key decisions for labor and birth.

3. Each woman can decide where to labor and give birth as appropriate based on her health status and that of her fetus/baby; she is free to make this choice without judgment and can change her mind without sanction, as an array of risk-appropriate birth setting choices is available and supported system wide.

4. Low-risk women planning hospital birth remain at home during early labor with adequate support and appropriate contact with their care team.

5. All maternity caregivers have knowledge and skills necessary to enhance the innate childbearing capacities of women. Each woman is attended in labor and birth in the manner that is most appropriate for her level of need and that of her baby and experiences only interventions that are medically indicated, supported by sound evidence of benefit, with least risk of harm compared with effective alternatives. Women and babies at high risk for complications for whom a higher level of specialized care is appropriate have specialty care available to them that adheres to the same basic values and principles.

6. Each woman is well-supported physically and emotionally throughout labor and birth; continuous labor support is built in to maternity care.

7. Each woman has access to a full-range of evidence-based, nonpharmacologic and pharmacologic strategies for pain management and relief as appropriate to each birth setting and to staff that is trained to implement them effectively.

8. Providers are trained to maintain skills and have system support to offer the fullest range of management options supported by evidence for women with special clinical circumstances.

9. Mothers and babies routinely stay together, skin to skin, receiving evidence-based care, support, and minimal disruption in the minutes and hours after birth to promote early attachment and the initiation of breastfeeding, whenever neither requires specialized care at this time.

Care After Giving Birth: Summary of Goals

1. Each woman, baby, and family receives care that effectively addresses their needs starting in the immediate postpartum period, and extending seamlessly forward across time, settings and disciplines to anticipate and respond to both continuing and new-onset mental, physical, and social needs that may develop throughout the first year of life and beyond.

2. Each woman receives strong support for breastfeeding through an array of community-based resources and the implementation of workplace supports for breastfeeding.

3. Each woman receives strong support for mother–baby attachment that includes educational offerings, experiential learning opportunities, and peer group support available through a web of services and support systems.

4. Each woman has adequate help to cope with the challenges of the period after birth, including physical changes, shifting priorities, changes in primary relationships, family planning, and issues related to sexuality, isolation, mother–baby codependence, and postpartum depression and other mood disorders. Care at this time includes opportunities to connect with people and services through innovative mechanisms and delivery models that emphasize community and social networking, and facilitate the development of longitudinal supportive relationships.

5. Each woman receives practical support at home as needed to cope with increased demands and fatigue in the period after birth and to develop confidence in her competence as a new mother. Each woman has access to social support, health care services and information, and practical advice and assistance in the period after birth. To this end, given consideration for value and efficiency, maternity care extends beyond the direct provision of health care services to routinely include postpartum services that facilitate optimal family development. This helps to ensure that each woman is valued and supported by society in her role as a new mother.

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I am looking forward to joining Childbirth Connection in this vision, and hope that you will consider joining them as well.