An alternative model of maternity care for low-risk birth: Maternal and neonatal outcomes utilizing the midwifery-based birth center model.

OBJECTIVE: To assess key birth outcomes in an alternative maternity care model, midwifery-based birth center care. DATA SOURCES: The American Association of Birth Centers Perinatal Data Registry and birth certificate files, using national data collected from 2009 to 2019. STUDY DESIGN: This observational cohort study compared key clinical birth outcomes of women at low risk for perinatal complications, comparing those who received care in the midwifery-based birth center model versus hospital-based usual care. Linear regression analysis was used to assess key clinical outcomes in the midwifery-based group as compared with hospital-based usual care. The hospital-based group was selected using nearest neighbor matching, and the primary linear regressions were weighted using propensity score weights (PSWs). The key clinical outcomes considered were cesarean delivery, low birth weight, neonatal intensive care unit admission, breastfeeding, and neonatal death. We performed sensitivity analyses using inverse probability weights and entropy balancing weights. We also assessed the remaining role of omitted variable bias using a bounding methodology. DATA COLLECTION: Women aged 16-45 with low-risk pregnancies, defined as a singleton fetus and no record of hypertension or cesarean section, were included. The sample was selected for records that overlapped in each year and state. Counties were included if there were at least 50 midwifery-based birth center births and 300 total births. After matching, the sample size of the birth center cohort was 85,842 and the hospital-based cohort was 261,439. PRINCIPAL FINDINGS: Women receiving midwifery-based birth center care experienced lower rates of cesarean section (-12.2 percentage points, p < 0.001), low birth weight (-3.2 percentage points, p < 0.001), NICU admission (-5.5 percentage points, p < 0.001), neonatal death (-0.1 percentage points, p < 0.001), and higher rates of breastfeeding (9.3 percentage points, p < 0.001). CONCLUSIONS: This analysis supports midwifery-based birth center care as a high-quality model that delivers optimal outcomes for low-risk maternal/newborn dyads.

Health outcomes and provider choice under full practice authority for certified nurse-midwives.

Full practice authority grants non-physician providers the ability to manage patient care without physician oversight or direct collaboration. In this study, we consider whether full practice authority for certified nurse-midwives (CNMs/CMs) leads to changes in health outcomes or CNM/CM use. Using U.S. birth certificate and death certificate records over 2008-2019, we show that CNM/CM full practice authority led to little change in obstetric outcomes, maternal mortality, or neonatal mortality. Instead, full practice authority increases (reported) CNM/CM-attended deliveries by one percentage point while decreasing (reported) physician-attended births. We then explore the mechanisms behind the increase in CNM/CM-attended deliveries, demonstrating that the rise in CNM/CM-attended deliveries represents higher use of existing CNM/CMs and is not fully explainable by improved reporting of CNM/CM deliveries or changes in CNM/CM labor supply.

The birth center model of care: Staffing, business characteristics, and core clinical outcomes.

OBJECTIVES: Interest in expanding access to the birth center model is growing. The purpose of this research is to describe birth center staffing models and business characteristics and explore relationships to perinatal outcomes. METHODS: This descriptive analysis includes a convenience sample of all 84 birth center sites that participated in the AABC Site Survey and AABC Perinatal Data Registry between 2012 and 2020. Selected independent variables include staffing model (CNM/CM or CPM/LM), legal entity status, birth volume/year, and hours of midwifery call/week. Perinatal outcomes include rates of induction of labor, cesarean birth, exclusive breastfeeding, birthweight in pounds, low APGAR scores, and neonatal intensive care admission. RESULTS: The birth center model of care is demonstrated to be safe and effective, across a variety of staffing and business models. Outcomes for both CNM/CM and CPM/LM models of care exceed national benchmarks for perinatal quality with low induction, cesarean, NICU admission, and high rates of breastfeeding. Within the sample of medically low-risk multiparas, variations in clinical outcomes were correlated with business characteristics of the birth center, specifically annual birth volume. Increased induction of labor and cesarean birth, with decreased success breastfeeding, were present within practices characterized as high volume (>200 births/year). The research demonstrates decreased access to the birth center model of care for Black and Hispanic populations. CONCLUSIONS FOR PRACTICE: Between 2012 and 2020, 84 birth centers across the United States engaged in 90,580 episodes of perinatal care. Continued policy development is necessary to provide risk-appropriate care for populations of healthy, medically low-risk consumers.

Adoption of Consensus Guidelines for Safe Prevention of the Primary Cesarean Delivery by Freestanding Birth Centers.

INTRODUCTION: Slow or arrested progress in labor is the most frequent (64%) indication for nonemergent transfer of laboring people from freestanding birth centers to the hospital. After the 2014 publication of the Consensus Statement on Safe Prevention of Primary Cesarean Delivery (Consensus Statement), many freestanding birth centers changed their clinical practice guidelines to allow more time for active labor in the birth center prior to hospital transfer. The result of these changes has not been evaluated in birth centers. Evaluation of adoption of guidelines based on the Consensus Statement in hospitals has shown inconsistent results. METHODS: Birth centers were contacted to determine whether they changed clinical practice guidelines in response to the Consensus Statement. A before-after analysis compared outcomes for the 2 calendar years before and the 2 calendar years after adoption of new guidelines with a retrospective analysis of deidentified client-level data collected in the American Association of Birth Centers Perinatal Data Registry. RESULTS: A third of responding birth centers (11 of 33) changed their clinical practice guidelines, mostly redefining the onset of active labor as beginning at 6 cm cervical dilatation and allowing 4 hours of arrest of dilatation in active labor before transfer to the hospital. These changes were associated with fewer diagnoses of prolonged first stage of labor (13.8% vs 8.0%, P < .01) but not with fewer intrapartum transfers (14.0% vs 14.7%, P = .55) or cesarean births (5.0 vs 4.1%, P = .26.) DISCUSSION: We found no evidence that making these practice changes was associated with better outcomes. Two hours of a lack of documented cervical change in active labor is likely long enough to diagnose arrested progress in labor. Research on proportion of morbidity and mortality associated with prolonged labor could inform practice guidelines for transfers.

Progesterone and Preterm Birth: Using Empirical Research to Explore Structural Racism Within Midwifery-Led Care.

BACKGROUND: Progesterone has been the standard of practice for the prevention of preterm birth for decades. The drug received expedited Food and Drug Administration approval, prior to the robust demonstration of scientific efficacy. METHODS: Prospective research from the American Association of Birth Centers Perinatal Data Registry, 2007-2020. Two-tailed t tests, logistic regression, and propensity score matching were used. RESULTS: Midwifery-led care was underutilized by groups most at risk for preterm birth and was shown to be effective at maintaining low preterm birth rates. The model did not demonstrate reliable access to progesterone. People of color are most at risk of preterm birth, yet were least likely to receiving progesterone treatment. Progesterone was not demonstrated to be effective at decreasing preterm birth when comparing the childbearing people with a history of preterm birth who used the medication and those who did not within this sample. CONCLUSIONS: This study adds to the body of research that demonstrates midwifery-led care and low preterm birth rates. The ineffectiveness of progesterone in the prevention of preterm birth among people at risk was demonstrated.

Outcomes of Cannabis Use During Pregnancy Within the American Association of Birth Centers Perinatal Data Registry 2007-2020: Opportunities Within Midwifery-Led Care.

BACKGROUND: Healthcare providers require data on associations between perinatal cannabis use and birth outcomes. METHODS: This observational secondary analysis come from the largest perinatal data registry in the United States related to the midwifery-led birth center model care (American Association of Birth Centers Perinatal Data Registry; N = 19 286). Births are planned across all birth settings (home, birth center, hospital); care is provided by midwives and physicians. RESULTS: Population data show that both early and persistent self-reports of cannabis use were associated with higher rates of preterm birth, low-birth-weight, lower 1-minute Apgar score, gestational weight gain, and postpartum hemorrhage. Once controlled for medical and social risk factors using logistic regression, differences for childbearing people disappeared except that the persistent use group was less likely to experience "no intrapartum complications" (adjusted odds ratio [aOR] = 0.49; 95% confidence interval [CI], 0.32-0.76; P < .01), more likely to experience an indeterminate fetal heart rate in labor (aOR = 3.218; 95% CI, 2.23-4.65; P < .05), chorioamnionitis (aOR = 2.8; 95% CI, 1.58-5.0; P < .01), low-birth-weight (aOR = 1.8; 95% CI, 1.08-3.05; P < .01), and neonatal intensive care unit (NICU) admission (aOR = 2.4; 95% CI, 1.30-4.69; P < .05). CONCLUSIONS: Well-controlled data demonstrate that self-reports of persistent cannabis use through the third trimester are associated with an increased risk of low-birth-weight and NICU admission.

Place of Birth Preferences and Relationship to Maternal and Newborn Outcomes Within the American Association of Birth Centers Perinatal Data Registry, 2007-2020.

PURPOSE: The purpose of this study was to describe sociodemographic variations in client preference for birthplace and relationships to perinatal health outcomes. METHODS: Descriptive data analysis (raw number, percentages, and means) showed that preference for birthplace varied across racial and ethnic categories as well as sociodemographic categories including educational status, body mass index, payer status, marital status, and gravidity. A subsample of medically low-risk childbearing people, qualified for birth center admission in labor, was analyzed to assess variations in maternal and newborn outcomes by site of first admission in labor. RESULTS: While overall clinical outcomes exceeded national benchmarks across all places of admission in the sample, disparities were noted including higher cesarean birth rates among Black and Hispanic people. This variation was larger within the population of people who preferred to be admitted to the hospital in labor in the absence of medical indication. CONCLUSION: This study supports that the birth center model provides safe delivery care across the intersections of US sociodemographics. Findings from this study highlight the importance of increased access and choice in place of birth for improving health equity, including decreasing cesarean birth and increasing breastfeeding initiation.

Overuse, underuse, and misuse: Improving effective primary care at a Federally Qualified Health Center.

BACKGROUND: U.S. healthcare costs have increased exponentially to almost $4 trillion. Despite increased costs, patient outcomes remain suboptimal. It is imperative that primary care providers are intentional with testing and medical technology to improve effective care. LOCAL PROBLEM: Preintervention chart audits showed average overspending of $79.41 per provider per day. Despite overspending, outcomes are not optimal. Only 48% of persons with hypertension and 38% of persons with diabetes at Orange Blossom Family Health (OBFH) are controlled. The aim of this 8-week quality improvement (QI) project was to decrease lab spending by 20% for adult primary care patients at OBFH. METHODS: A rapid cycle QI initiative of four Plan-Do-Study-Act cycles, 2 weeks each, was completed to implement four interventions concurrently. The data was assessed every 2 weeks with iterative tests of change as indicated. INTERVENTIONS: The primary care quality metrics chart audit and preclinical care coordination tools were developed, and the My Life, My Healthcare tool and medical assistant (MA)-provider huddles were initiated with the focus on effective patient care. RESULTS: A savings of $3406.43 on overordering of labs by one provider in 8 weeks was identified. The average provider compliance to national guidelines was found to be 54.1%. There was a 19.3% increase in referrals. MA-provider huddles were balanced for this initiative. CONCLUSIONS: The initiative addressed effective care through awareness of resource allocation, patient engagement, and team communication. Continued application of these core interventions will ensure consistent and quality healthcare.

The American College of Nurse-Midwives' Benchmarking Project: A Demonstration of Professional Preservation and Improvement.

Maternal and newborn outcomes in the United States are suboptimal. Care provided by certified nurse-midwives and certified midwives is associated with improved health outcomes for mothers and newborns. Benchmarking is a process of continuous quality assurance providing opportunities for internal and external improvement. Continuous quality improvement is a professional standard and expectation for the profession of midwifery. The American College of Nurse-Midwives Benchmarking Project is an example of a long-standing, midwifery-led quality improvement program. The project demonstrates a program for midwifery practices to display and compare their midwifery processes and outcomes of care. Quality metrics in the project reflect national quality measures in maternal child health while intentionally showcasing the contributions of midwives. The origins of the project and the outcomes for data submitted for 2019 are described and compared with national rates. The American College of Nurse-Midwives Benchmarking Project provides participating midwifery practices with information for continuous improvement and documents the high quality of care provided by a sample of midwifery practices.

Breastfeeding as a Quality Measure: Demonstrating Levers of the National Quality Strategy.

The purpose of this study is to explore the National Quality Strategy (NQS) levers (measurement and feedback, public reporting, learning and technical assistance, and certification) on state and national breastfeeding performance. The research evaluates the NQS levers of measurement and feedback and public reporting using secondary data analysis of publicly reported data from the National Immunization Survey and the Centers for Disease Control and Prevention Breastfeeding Report Cards between 2008 and 2018, the latest years available. Linear regression explores the association between the prevalence of state-level Baby-Friendly hospitals and state-level breastfeeding rates. Subsequent analyses use event study to test whether state-level Baby-Friendly hospital adoption is associated with higher breastfeeding rates. A 10% increase in Baby-Friendly hospitals at the state level is associated with increased population breastfeeding rates by nearly 5% and a decrease in early formula use (before 2 days of life) by 2% to 9%. Breastfeeding increased by 2% to 5% in the first 2 years following state-level Baby-Friendly initiatives, with subsequent increases up to 10% in the next 4 years. The National Quality Strategy levers of measurement and public reporting combined with certification and learning and technical assistance are associated with increases in exclusive breastfeeding, a national quality metric.

Birth Outcomes of Women with Obesity Enrolled for Care at Freestanding Birth Centers in the United States.

INTRODUCTION: Current US guidelines for the care of women with obesity generalize obesity-related risks to all women regardless of overall health status and assume that birth will occur in hospitals. Perinatal outcomes for women with obesity in US freestanding birth centers need documentation. METHODS: Pregnancies recorded in the American Association of Birth Centers Perinatal Data Registry were analyzed (n = 4,455) to form 2 groups of primiparous women (n = 964; 1:1 matching of women with normal body mass indices [BMIs] and women with obese BMIs [>30]), using propensity score matching to address the imbalance of potential confounders. Groups were compared on a range of outcomes. Differences between groups were evaluated using χ2 test for categorical variables and Student's t test for continuous variables. Paired t test and McNemar's test evaluated the differences among the matched pairs. RESULTS: The majority of women with obese BMIs experienced uncomplicated perinatal courses and vaginal births. There were no significant differences in antenatal complications, proportion of prolonged pregnancy, prolonged first and second stage labor, rupture of membranes longer than 24 hours, postpartum hemorrhage, or newborn outcomes between women with obese BMIs and normal BMIs. Among all women with intrapartum referrals or transfers (25.3%), the primary indications were prolonged first stage or second stage (55.4%), inadequate pain relief (14.8%), client choice or psychological issue (7.0%), and meconium (5.3%). Primiparous women with obesity who started labor at a birth center had a 30.7% transfer rate and an 11.1% cesarean birth rate. DISCUSSION: Women with obese BMIs without medical comorbidity can receive safe and effective midwifery care at freestanding birth centers while anticipating a low risk for cesarean birth. The risks of potential, obesity-related perinatal complications should be discussed with women when choosing place of birth; however, pregnancy complicated by obesity must be viewed holistically, not simply through the lens of obesity.

Improving the Experience of Care: Results of the American Association of Birth Centers Strong Start Client Experience of Care Registry Pilot Program, 2015-2016.

In 2018, the Center for Medicare and Medicaid Innovation in the United States (US) released report demonstrating birth centers as the appropriate level of care for most Medicaid beneficiaries. A pilot project conducted at 34 American Association of Birth Centers (AABC) Strong Start sites included 553 beneficiaries between 2015 and 2016 to explore client perceptions of high impact components of care. Participants used the AABC client experience of care registry to report knowledge, values, and experiences of care. Data were linked to more than 300 process and outcome measures within the AABC Perinatal Data Registry™. Descriptive statistics, t tests, χ analysis, and analysis of variance were conducted. Participants demonstrated high engagement with care and trust in pregnancy, birth, and parenting. Beneficiaries achieved their preference for vaginal birth (89.9%) and breastfeeding at discharge through 6 weeks postpartum (91.7% and 87.6%). Beneficiaries reported having time for questions, felt listened to, spoken to in a way they understood, being involved in decision making, and treated with respect. There were no variations in experience of care, cesarean birth, or breastfeeding by race. Medicaid beneficiaries receiving prenatal care at AABC Strong Start sites demonstrated high levels of desired engagement and reported receiving respectful, accessible care and high-quality outcomes. More investment and research using client-reported data registries are warranted as the US works to improve the experience of perinatal care nationwide.

Providing effective asthma care at a pediatric patient-centered medical home.

BACKGROUND: A recent assessment of the national annual burden of the cost of asthma among school-aged children was nearly $6 million. In a Midwestern county, the incidence of childhood asthma was 15.8%, which was above both state and national levels. LOCAL PROBLEM: Effective asthma care was not being provided at a rural, pediatric patient-centered medical home due to a lack of standardization. This quality improvement (QI) initiative aimed to increase the mean effective asthma care score to 78% for patients with asthma over the course of 90 days. METHODS: This right care initiative was implemented using a rapid-cycle Plan-Do-Study-Act methodology. Tests of change in the areas of team engagement, patient engagement, and two process measures were analyzed through chart audits and run charts over four cycles. Likert scale surveys were used to analyze qualitative data. INTERVENTIONS: Interventions included developing the Asthma Patient Identification Tool, implementing an asthma education protocol with teach-back, creating standardized smart phrases for effective documentation, and initiating asthma care huddles. RESULTS: The delivery of effective asthma care increased to 84%. The number of patients receiving the asthma education protocol increased to 65%, with 80% of the patients participating in effective teach-back sessions. The mean effective documentation score increased to 92%. CONCLUSIONS: A standardized approach to asthma care grounded in evidence-based guidelines positively affected the delivery of care. Nurse practitioners are effective team leaders for clinical QI initiatives.

Outcomes of childbearing Medicaid beneficiaries engaged in care at Strong Start birth center sites between 2012 and 2014.

BACKGROUND: Variations in care for pregnant women have been reported to affect pregnancy outcomes. METHODS: This study examined data for all 3136 Medicaid beneficiaries enrolled at American Association of Birth Centers (AABC) Center for Medicare and Medicaid Innovation Strong Start sites who gave birth between 2012 and 2014. Using the AABC Perinatal Data Registry, descriptive statistics were used to evaluate socio-behavioral and medical risks, and core perinatal quality outcomes. Next, the 2082 patients coded as low medical risk on admission in labor were analyzed for effective care and preference sensitive care variations. Finally, using binary logistic regression, the associations between selected care processes and cesarean delivery were explored. RESULTS: Medicaid beneficiaries enrolled at AABC sites had diverse socio-behavioral and medical risk profiles and exceeded quality benchmarks for induction, episiotomy, cesarean, and breastfeeding. Among medically low-risk women, the model demonstrated effective care variations including 82% attendance at prenatal education classes, 99% receiving midwifery-led prenatal care, and 84% with midwifery- attended birth. Patient preferences were adhered to with 83% of women achieving birth at their preferred site of birth, and 95% of women using their preferred infant feeding method. Elective hospitalization in labor was associated with a 4-times greater risk of cesarean birth among medically low-risk childbearing Medicaid beneficiaries. CONCLUSIONS: The birth center model demonstrates the capability to achieve the triple aims of improved population health, patient experience, and value.

Unwarranted Variation in Utilization of Cesarean Birth Among Low-Risk Childbearing Women.

INTRODUCTION: Unwarranted variations in care are defined as differences in utilization of health care resources that cannot be explained by patient risk factors, standards of evidence-based medicine, or patient preferences. Also known as nonmedical determinants of variation, differences in health care utilization across the United States have been well documented in the literature during the past 40 years. The purpose of the literature review is to summarize the state of the science related to the nonmedical determinants of variation in cesarean birth among low-risk childbearing women, defined within national quality standards as nulliparous women with term, singleton pregnancies in the vertex presentation. METHODS: A literature search was performed using the electronic databases PubMed, CINAHL, Ovid MEDLINE, Google Scholar, Cochrane Database of Systematic Reviews, and ProQuest Dissertation Database. Articles published in English, with full text available, including birth in the United States after 1995, are included in the analysis. Nine studies met criteria for inclusion. Forty-four states are represented within the data, with Arizona, California, Massachusetts, New Jersey, and New York being the subject of more than one of the publications analyzed. RESULTS: This literature review includes more than one million births, in at least 44 states between 1996 through 2009, revealing significant unwarranted variation in cesarean birth. Nonmedical determinants of variation, such as access to resources, hospital characteristics, payer source, and provider practice styles, are identified as independent predictors of increased cesarean utilization in more than half of the studies reviewed. In all studies reviewed, women of low medical risk demonstrate susceptibility to unwarranted variation in the use of cesarean birth. DISCUSSION: Continued emphasis on the specific needs of low-risk childbearing women is necessary to decrease unwarranted variation in the use of cesarean birth in the United States. Specific attention to the costs of unwarranted variation in cesarean birth is imperative.