“Healthy mom, healthy baby” That’s all that matters, right? What does “healthy mom, healthy baby” actually entail? What about a healthy AND happy mom and baby? What does that look like?
The thing is, birth matters! How a woman feels about her birth can shape how she feels about herself and affect her mental and emotional health for years to come. Were her preferences honored? Did she get the outcome she was hoping for? If not, did she feel all care was taken to avoid that undesired outcome? Did she feel she was a part of the process and decision making versus a bystander in her own birth?
Many women today have specific ideas about what they want their birth to look like. Maybe they want to deliver in the hospital or at home? Do they want a waterbirth? They might desire to be in the hospital setting, but still only use medical intervention if absolutely indicated. Or perhaps they really prefer to be medicated and would like to have an epidural for pain management. However their plan is written, many want to avoid unnecessary intervention and an unnecessary cesarean section.
Midwifery is all about individualizing this care or tailoring care based on patients' individual concerns, their fears and anxieties, and birth plan desires, not just their medical diagnosis. We pride ourselves on positive individual experiences. We take care to ensure that birth trauma was not created and that past birth trauma was healed. In today’s googled environment, the most prominent data point on how well you are achieving that goal is individual reviews related to anecdotal experiences. Numerous five star reviews, although much appreciated and give us the boost to keep going, do not equate to a low-primary cesarean rate or a high VBAC rate. The five star review and happy mamas matter, these numbers matter at the most important, individual level. But, when it comes to evaluating our practice and ensuring we have been achieving our goals, we cannot anecdotally assess that. We cannot ignore the facts that statistics represent and what they mean to the individuals that make up those numbers. Hard objective numbers translate to healthy mamas, healthy babies and healthy families. As a practice and profession of midwifery and our greater role in the practice of obstetrics we cannot say we have good outcomes and be proud of our work, if we don’t have the objective data to back-up our claims. And a five-star review does not actually equal good outcomes.
So what numbers do matter? HealthyPeople2020, a division of the Department of Health and Human Services, primary maternal goals are related to a reduced cesarean section rate, both for low risk first time moms and moms with a history of a cesarean. Basically, as a society we need to avoid the initial cesarean and encourage more VBACs (vaginal birth after cesarean). The Joint Commission collects data from hospitals on maternal safety standards. This data ranges from elective induction, maternal hemorrhage, infection, breastfeeding and cesarean rates.
Much has been discussed lately in social media about the United States medical system failing mothers and babies. Maternal morbidity and mortality rates are shameful in the United States. According to the World Health Organization (WHO), in 2013, 28 per 100,000 women died from complications associated with childbirth. Many more than that experienced poor outcomes, unnecessary interventions, and complications. The United States ranks 65th among industrialized nations in terms of maternal death, placing our great country and all its medical advances below most developed countries and even many underdeveloped. A poor maternal outcome has devastating social and economic impact on families. So what do we do? How can we improve? We all know of the story of a doctor who always called cesarean sections just before dinner or bedtime. But we can also honestly say, that we believe that doctor justified each cesarean to him or herself as “medically necessary.” It is only once you collect the data that shows their cesarean rate is significantly higher than their colleagues that you might start to see change in practice. However, it is a rare practice that collects this data and presents it to the public.
Our mother organization, The American College of Nurse Midwifery (midwife.org) tracks benchmarking data from midwifery care all over the United States. Per their website, “The benchmarking project is vital to the future of midwifery care, quality and access in the United States as a professional self-maintenance strategy and as a method of quality assurance. Benchmarking also acts as tangible proof of the improved outcomes and lower costs of midwifery care.” This is why we keep detailed data of primary and total cesarean section rates, epidural rates, lacerations, breastfeeding, apgars, low birth weight, NICU admissions and on and on. This data then allows us to go to the obstetricians, hospital administrators, and the public to continue to prove that midwives are safe, affordable, and will be the key to improving maternal morbidity and mortality in the United States.
We do not think it is coincidental that the types of things we measure for “healthy” are also the types of outcomes that women are looking for in “happy”.
The thing is, in getting the desired outcome - the birth that matters - choosing the right provider and location matters! An expectant mother can do all the pregnancy, labor and birth preparation they want, but their single most positive predictor of birth outcome is the provider they chose and the hospital they deliver at. The problem is individual practices and providers rarely report or even track outcomes and hospitals do not always report to the general public. Providers are chosen based on likeability, a friend's recommendation, or geographic proximity. A hospital is chosen based on where that provider has privileges. A patient rarely has “proof” that the provider actually provides good care. But what we know from previous research is that a provider's outcomes are correlational to the care they provide. If a provider or practice has a cesarean section rate over the national average, every patient in that practice has a higher risk of a cesarean section regardless of risk at the beginning of pregnancy.
As practitioners of midwifery, we are doing our part. We have tracked our data since the day we opened our doors, we report that data to the public and add it to the ACNM Benchmarking project. As a patient, we urge you to ask. Ask your provider what their cesarean section rate is and if they cannot answer the question than that is more concerning than if their rate is high.
We recently reviewed our stats for the past year and were so happy to see these numbers that we know translate into happy AND healthy moms and babies. Our outcomes are significantly better than WHO goals and state and national averages. If you want a birth experience that is happy AND healthy we implore you to do your research and find a provider AND location that has statistics that support the outcome that you are looking for.
You will be hearing more from us in the coming weeks as we explore these measures individually. We will dive into the outcomes and discuss why they are important to the individual woman and our national maternal morbidity and mortality goals. Stay tuned.
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