Moms Speak Out: On Improving Childbirth In Boston-Area Hospitals

When we opened up the “lines” for an online chat about quality and childbirth, moms dove in with comments and questions about induction, malpractice and worse results for black women as compared to whites.

We had help answering questions from:
Gene Declercq, a Boston University School of Public Health professor who has studied childbirth practices for more than 20 years.
Dr Jeff Ecker, an OB/GYN at Massachusetts General Hospital and a member of the Massachusetts Perinatal Quality Collaborative Advisory Committee.
Betsy Deitte, a mom from Needham who had her third child, a boy, in September.
And Rebecca Loveys of Watertown, who delivered her second son in August.

Livechat

First question, from Agnes…
Is there a way we can improve these measures of childbirth by focusing not just on the labor-and-delivery part, whose benchmarks mostly are set by hospital birth, but on childbearing? On a woman’s experience of her pregnancy and not just the outcome?

Dr. Jeff Ecker responds…
I think it would be difficult to do so, as they are such different experiences. A woman can have a perfectly healthy pregnancy, and have a difficult delivery. One does not necessarily affect the other experience.

I agree that it would be ideal to focus on the whole experience of pregnancy, childbirth and post-delivery care. We have, to date, focused mostly on the process of labor and delivery because that is the point at which we most reliably collect data (think: birth certificate). Increasingly we are turning to evaluate patient satisfaction. But I need to tell you that in my experience, much of satisfaction is driven by outcome.

Question from Katie…
To what extent does the fear of medical malpractice dictate a woman’s birth experience?

Gene Declercq responds…
The research on the effects of fear of malpractice on obstetrician’s behavior is somewhat mixed. In terms of whether things like malpractice premiums are directly related to, say cesarean rates, there is not much support for that link. However, in terms of perception of malpractice concerns on obstetrician attitudes it continues to have an impact since the widespread feeling exists that interventions like cesareans are more easily defensible in court.

Cara responds…
As a labor and delivery RN I know that the fear of lawsuit is a huge driving force in the care we provide. I can’t tell you how often I hear docs and midwives say “Well I really should do (insert intervention) because how would it ‘look’ if we didn’t”…..”look” being the operative word and it means when the lawyers review the chart if a lawsuit did happen.

Ecker responds…
Cara, you’re right. Those on labor and delivery spend much time (too much time) talking about lawyers and how they might spin our care. But research is split about how such concerns actually affect care and outcomes. It turns out to be difficult, for example, to demonstrate that a recent malpractice settlement drives care in any particular direction. Don’t get me wrong: I’m no fan of lawyers second guessing good care after the fact but they’re not the only things driving cesarean rates up.

Question from Sarah…
How do doctors decide when during a woman’s labor to recommend a Cesarean section? Do most doctors have their own formula or threshold for deciding when the woman is not making progress that will lead to a vaginal delivery?

Dr. Ecker responds…
There’s no one formula for determining when progress isn’t being made and cesarean delivery is best recommended. Increasingly, however, based on recent research (The Consortium for Safe Labor) doctors, midwives and patients are all learning to be more patient and if mother and baby seem to be well, allow more time to either dilate or push.

Katie responds
As far as satisfaction….I had a cesarean birth because my daughter was breech. Her birth was very satisfying because my wishes were respected. I chose the music, my support team, and got to hold her while I was being stitched up. I think a woman deserves to be respected and informed during her pregnancy and birth

Ecker responds…
Katie: Couldn’t agree more. I think your experience and comment points to why process, communication and collaboration is as important to our impression of birth as any particular procedure.

Question from Mary S…
Are there huge disparities between the care and expertise provided at community/memorial hospitals vs. big, reputable hospitals in Boston?

Ecker responds…
There are certainly differences in resources between hospitals but because labor and delivery is, in most cases, a health process, most women can appropriately deliver at community hospitals. The data (as posted nicely on WBUR site) shows that on many measures similar care and outcomes are delivered. All that said there may be certain resources that make certain deliveries best suited to certain hospitals: premature deliveries at those with appropriate nurseries: trials of labor after past cesareans to those who can provide a prompt cesarean if needed.

Loveys responds…
Mary S.: I can only speak about my own experiences birthing in hospitals (I gave birth to my first son at Newton-Wellesley and my second son at Mt. Auburn). I was under the care of CNM’s (Certified Nurse Midwives) and hired doulas for both births. Both hospitals were great experiences, but I believe that is because I was confident in advocating for myself; I was fully armed and educated, I had a solid birth plan, a great team to support me, and I had a deep understanding of how hospitals work. I knew there would be hospital policies that I needed to understand ahead of time and prepare for. I asked a lot of questions during my pregnancy, about each hospital’s policies. For example, I knew I wanted to encapsulate my placenta for my second birth, so it was important for me to do my homework ahead of time to know the hospital’s required release forms, etc, and what my rights were.

Betsy Deitte responds…
I delivered my first two babies at one of the big hospitals downtown, and my third at a community hospital. There main reason why I delivered elsewhere was because I had moved. It would have taken me longer than I felt comfortable with traveling to the hospital when in labor. As far as care was concerned, I didn’t feel that they were much different, and was happy I delivered my third closer to home. Interestingly enough, I had complications with my third delivery, and after delivering at a community hospital I ended up needing to be transferred back downtown–to the same hospital I delivered my first two.

Question from Victoria…
To what degree should patients be concerned that these numbers reflect instances where a patient’s preferences are overridden at the hospital?

Declercq responds…
Victoria, in a national survey (Listening to Mothers — available free online) we asked mothers about their experiences with shared decision making. We found that it was na extremely complex relationship. For example, mothers who prenatally discussed matters like VBAC or cesareans because their baby might be large with their physicians were very strongly inclined to do what their physicians recommended and at the same time say it was their own (the mother’s) decision. In the case of VBACs, mothers who reported discussing it with their providers were less likely to have a VBAC than those who did not.

Guest responds…
I recognize, with Betsy, that women can have healthy pregnancy and difficult delivery. But I wish the meaning of a difficult delivery could be re-framed. Even using “healthy” as the positive label strikes me as not quite right. But I’m interested in Dr. Declercq’s work on comparative birth practices.

Katie responds…
I agree with the comment from “guest”. Labor is hard work. Especially in an environment that is unsupportive. We’ve taken instinct, nature, and supportive women out of the equation too many times.

Declercq responds…
To”guest” on comparative care: Some of the difficulties in our maternity care system (lack of continuity, gaps in care) are simply a manifestation of general problems in our health care system. Other industrialized countries have better outcomes in terms of mortality and morbidities and their outcomes are improving at a faster rate than those in the US. These systems rely more heavily on midwives and generally (though not always) rely less on interventions, but perhaps most importantly they focus on the normality of birth with obstetricians seen as high risk specialists whose role is to care for high risk cases rather than all mothers. Soem of the benefit comes from different roles for the respective providers and some from the underlying philosophy on which the system is based.

Question from Erica P…
What is your opinion on the growing gap between healthy birth outcomes of African-American women compared to Caucasian women?

Declercq responds…
Erica, the gaps between the outcomes of births in the US between whites and blacks has been persistent for decades. It’s not generally growing at the moment but it’s not decreasing either. What’s challenging is that in the terms we generally document practices, black mothers who enter the system generally receive more care, but continue to have worse outcomes. Part of it is ensuring broader access to care, but part is also looking at prenatal and intra-partum care as more than a series of tests and interventions and that’s a relationship with mothers that hasn’t characterized our systems.

Beverly Smith responds…
Finally someone has mentioned health disparities of Black mothers and other groups. My career was in public and community health with a focus on Black women’s health. One job was at Mass. DPH in a women’s health department–in mid-eighties. Childbirth was only one of the myriad disparities of Black women’s health experiences. I remember hearing when I was there that one year ALL the maternal mortality occurred among Black in Boston or statewide? I have never forgotten this. I went into public health because of my experiences in my own family of such tragedies. What about class?

Question from Alisha…
I’d be curious to hear more about the issue of time pressure at many hospitals. Does it really pay for OBs to hurry things along?

Ecker responds…
Alisha, I sure can’t speak for all doctors (and midwives) but with the way labor and delivery is currently staffed with doctors and midwives dedicated to the unit for shifts of 12-24 hours, time pressure is, in my experience, increasingly a thing of the past. The days of a provider needing to hurry a delivery because she has a dinner to go to because he has patients waiting in the office are fading fast and gone already at places like mine. As I said above: we’re all learning to be patient.

Question from Agnes…
Often in these discussions, outcome (‘I just want to get the baby out safely”) is pitted against experience (“Having a good birth”). How can we avoid this perceived conflict?

Ecker responds…
Agnes: your question is a great one and points to the perils of looking at just one outcome whether it’s cesarean rate, or episiotomy or breastfeeding. We need to develop a global view. Unfortunately getting such a view is difficult: how to weigh one with another? In truth different patients with different values will weight similar outcomes differently. This all points to the importance of paients and providers having conversations to understand each others’ values and make plans and decisions concordant with such. And for those of us interested in measuring and improving quality of care: figuring how to measure and report all of this will keep us busy for many years to come.

Deitte responds…
I think that women in our society can have too many expectations in their birth experience. I think they can sometimes lose the focus on the final result and focus more on things happening exactly the way they want them to. As childbirth can be a touch unpredictable, I think it can be setting women up to believe they failed in their attempts at having the delivery they intended to. I’m not at all saying that women shouldn’t have a say in how their experience goes or that they shouldn’t think about it, I’m only saying that you have to be forgiving and willing to change in the moment as life does not always go as planned.

Question from Chris Just…
How does prenatal education fit into the discussion? Did the moms online take classes and if so, did they find the info helpful when making choices and advocating for themselves?

Deitte responds…
I think that women can prepare themselves best in the prenatal period for labor and delivery by understanding the various interventions and what are the potential outcomes. As Gene pointed out, if women are communicating with their physicians then they are likely to trust the physician’s advice more, and they will have a feeling of more control over the situation.

I am also a Nurse and have had years of experience working in a hospital. I think understanding the system, as well as the terminology really helped me feel like I was in control and getting appropriate care. Even though only one out of my three deliveries went smoothly, I am very happy with how everything worked out. I was able to advocate for myself, my providers were also very open and made me feel like we were more of a team. That was very important to me.

Kate responds…
Chris, I accessed my prenatal care through an interesting model called Centering Pregnancy, a form of group health care delivery where women are grouped by gestational stage and attend prenatal visits together. I now recommend it to every pregnant woman I know! Something about being part of a group of women all going through the experience together is empowering and certainly made me feel more equipped to advocate for what mattered most to me during my birth experience. It also offered a platform for me, and the other women in my group to spend time thinking carefully about what we valued and felt committed to during the birth process–and also to consider the things that might be somewhat out of our control. I think that the social support, and other benefits, that comes with group healthcare is something that should be evaluated in more depth. I bet some pretty interesting stuff will come up, the more we look at this model.

Alyson responds…
Just like Kate, I went through centering during my first pregnancy and it was AMAZING. Increased access to a midwife/certified NP, other women going through the same thing and the ability to hear both their questions and the answers and time spent discussing things like what slows labor down, options for natural birth, etc. Sadly, the practice I go to has discontinued this (at least for the time being) and in my 2nd pregnancy it’s really easy for me to see how women go into the whole process knowing very little about both what happens and their options.

Question from Kate…
I am curious about the use of pitocin during labor. What has driven the rising use of pitocin? What is known about the connections between the use of pitocin and the cascade of additional interventions (such as c-section) that can follow?

Cara Abbanato responds…
Induction and augmentation of any kind increase risk for C-section.

Declercq responds…
Kate on use of pitocin; Cara on C-sections: The rates of induction of labor in the U.S. are around one-third of all births though the rates haven’t gone up in recent years. In an analysis we did there appeared to be what’s termed a “cascade of interventions” from induction through epidural to cesarean. Lower risk first time mothers (e.g. not breech, singleton, full term, no diabetes or hypertension) who did not have an induction or epidural had a cesarean rate of around 5%; comparable mothers with an induction and epidural had a CS rate of 30%. If they had only one or the other, the rate was about 20%. There will be cases where interventions like induction and pain relief from an epidural are absolutely necessary, but the decision to have them should be made with an understanding of the tradeoffs involved.

Ecker responds…
Cara, I don’t disagree that patience — waiting in healthy pregnancies for labor to happen on it’s own — is generally best. But induction and augmentation do not always increase cesarean rates. In fact much research demonstrates that, especially in pregnancies in which there are concern for a mother’s or baby’s health, induction and augmentation decrease cesarean rates. The problem here is often one of inappropriate comparison: women who have reasons for induction or augmentation can’t simply be compared (in Cesarean rates or anything else) to those with no concerns who are appropriate to wait for spontaneous labor.

AgnesHoward responds…
Part of the problem is varied measures used to evaluate this group of interventions. At one level, we’re asking if C-sections/inductions/episiotomies have positive health outcomes, that is, end up with safer, faster-healing mothers and babies. At another level, we are looking for an experience that women judge as positive–but of course, the way they judge it, during and after the fact, is shaped by what we are primed culturally to expect. If we learn that it’s good to have no pain, we give high marks to twilight sleep or general anesthesia. If we are acculturated to think that natural is good, we will smile on fewer interventions. So while I think women’s choices should matter, having a good birth is not so much about having it go the way you want. Right? IT is not only that we are looking for safer or less costly or more efficient practices, but we want to bring new people into the world in a way that respects them and the human work their parents do in birthing.

Deitte responds…
Agnes, I couldn’t agree more!

Katie responds…
Very we’ll said Agnes!

KellyR responds
As the Huffington Post recently reported, we have (re)learned that midwifery has better outcomes (same outcomes as compared to MDs, fewer interventions, higher patient satisfaction). How can we ensure that every woman has access to midwives at every MA hospital? It will require a culture shift at many institutions for sure, but I disagree that women think the end justifies the means. That is old-school thinking in my opinion. Thank you for this discussion.

Question from Dr. Debbie…
Outside of epidural and C-section, there is usually no formal consent process for things “done” to a laboring or birthing woman. Why?

Ecker responds…
Dr. Debbie, I strongly disagree. I and my colleagues spend much time explaining to patients what we are going to do (or not do) and why. Such conversations are the essence of informed consehnt. You are correct: we may not have them sign a consent form for each decision but informed consent is much more than a piece of paper (and I’ve seen plenty of signed papers that hardly represent informed consent).

Question from Erica F…
Do you think hospitals do enough to follow up with women after they go home?

Cara Abbanato responds…
All New Hampshire and Massachusetts women get a visiting nurse after discharge included as part of maternity care covered by insurance, as far as I know. This is the time when all the emotions and questions come flooding, especially with breastfeeding. Very important!

Question from Martha B…
I’m hearing from moms who’ve had C-sections and wonder if they tried hard enough to avoid the procedure? Any guidance for these well meaning women?

Nicole responds…
During the successful campaign to save the North Shore Birth Center, a group of birth center consumers and activists met with administration from Beverly hospital. During this meeting, we were told by a high level administrator (I believe he was the Vice President for external affairs) that is he had “his (my) way, every woman who walked through those doors would have a C-section”. How, as consumers of maternity care and change makers do we combat ideas such as these from hospital administration? How do these ideas affect the way in which midwives and doctors make decisions? This quote still haunts me years later as a symbol of what is wrong in maternity care.

Martha B responds…
Wow Nicole – I hope that’s old-school! When was this conversation?

Nicole responds…
I wish I could say it was, Martha. This was in December of 2008.

Question from Martha B…
Does anyone know about hospital induction rate policies?

Ecker responds…
Martha, thanks for asking about induction rate policies. Most hospitals have policies banning “elective” inductions below 39 weeks and many ban elective inductions altogether. But in focusing in banning elective inductions we need to be mindful that inductions are often indicating and important for the healthy outcome of mother and/or baby. Imagine a women at 37 weeks of pregnancy with high blood pressure and other dysfunction of vital organs characteristic of pre-eclampsis (aka: toxemia) and a too small baby. Induction in that case can prevent a mother’s seizure (ecclampsia) or worse and, potentially, save a stillbirth. So it’s complicated thing: not all inductions are good, not all inductions are bad. Ideally many hospitals (like mine at MGH) have policies to sort the good from the bad.

A question to everyone on the chat…
If you could add one quality measure to the five WBUR has posted so far, what would it be?

Guest responds…
Would modify the breastfeeding question outcome to breastfeeding at 3 months.

Another Guest responds…
Health of baby and Mom postpartum!

MarthaBebinger responds…
Thanks guest – how would you define “health” for mom and baby?

Guest responds…
It’s hard for me to define “health” but my personal #1 concern is that my baby is well cared for, and healthy, and I guess #2 is that I am able to care for him after he is born. Also I think “health” of the mother pertains to long-term, and whether or not she is able to have the option for VBAC in the future.

Martha responds…
Thanks Guest – great goals. Your comments reminds me though how hard it is to define and then measure quality in childbirth and so many other aspects of health care.

Deitte responds…
I’d like to see the ICU admission rates for the baby post delivery.

Ecker responds…
Betsy, I agree that looking at ICU admissions are important and we look carefully at all of ours. But rates may not be they best way to look. Appropriately, many are sent to a place like mine (MGH) because their babies are likely to need an ICU (maybe they are at risk for being born early or have a recognized birth defect). So it’s really unexpected ICU admissions at term —babies who unexpectedly very sick—-we should probably best focus on.

KellyR responds…
Percent of midwife births at each hospital – that is the determining factor in the outcomes – higher percent midwife attended births, lower interventions (c/s, etc), lower midwife-attended birth rates, higher interventions. Every hospital should aim for at least a 20% midwife attended birth rate.

Declercq responds…
I’m supportive of greater midwife involvement, but it depends how the midwives are used. Our research has suggested it’s as much about a midwifery approach to birth — i.e. an emphasis on the normality of birth — as it is about the numbers of midwives. More midwife attended births can be a plus, but unless it’s accompanied by a philosophy that supports midwifery care, as opposed to some settings where midwives are used essentially as nurses with very limited scope of practice, it won’t really make a difference.

KellyR responds…
I was implying full-scope midwifery care. Where there are midwives, there is much more likely a midwifery model of care that honors women, families and the normalcy of pregnancy and birth. Collaborative midwifery and obstetrical care is working in many MA hospitals. It is absent in many also.

Loveys responds…
Availability of doulas – I hired one for both my births, because I wanted that 24/7 support before, during and after birth. I often texted my doula at midnight and she’d text back with an immediate, comforting reply. She helped me feel so supported, especially with breastfeeding concerns – even a month after I gave birth I was asking her questions and receiving amazing encouragement. I would recommend to any woman who wants this type of continuous support to look into hiring a Doula.

Ecker responds…
For those inclined to have such support, doulas can be wonderful and have been shown in studies to reduce Cesarean rates. Happily and accordingly, many doctors, midwives and hospitals welcome them.

Thanks very much to our panelists and everyone who joined the chat. Please feel free to add any final thoughts in the comment section below, and be sure to check the data we’ve gathered in our interactive map, and the stories in our series on Comparing Childbirth at Hospitals in Massachusetts.

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