The Midwifery Model of Care MHPA Conference

November 2015

The Specialty of Midwives: Normal Physiologic Birth

What is Normal Physiologic Birth?

Source: Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by ACNM, MANA and NACPM. Available on-line at: http://www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000002179/Physioloigical%20Birth%20Consensus%20Statement-%20FINAL%20May%2018%202012%20FINAL.pdf

Spontaneous onset and progression of

labor

Biological and psychological conditions that promote

effective labor

Vaginal birth of the infant and placenta

Results in physiologic blood loss

Skin-to-skin contact between mother and

infant post partum

Supports early initiation of breastfeeding

Disruptions of Normal Physiologic Birth

Source: Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by ACNM, MANA and NACPM. Available on-line at: http://www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000002179/Physioloigical%20Birth%20Consensus%20Statement-%20FINAL%20May%2018%202012%20FINAL.pdf

Induction or augmentation

of labor

An unsupportive environment (bright

lights, cold room, lack of privacy, multiple providers, lack of

supportive companions)

Time constraints, including those driven by institutional policy

and/or staffing

Nutritional deprivation,

e.g., food and drink

Opiates, regional analgesia, or general

anesthesia

Episiotomy Operative vaginal

(vacuum, forceps) or abdominal (cesarean)

birth

Immediate cord clamping

Separation of mother and infant

Any situation in which the mother

feels threatened or unsupported

Practices that Support Normal Physiologic Birth

Source: Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by ACNM, MANA and NACPM. Available on-line at: http://www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000002179/Physioloigical%20Birth%20Consensus%20Statement-%20FINAL%20May%2018%202012%20FINAL.pdf

Access to midwifery care

Time for shared decision making, freedom from

coercion

No inductions or augmentations without

an evidence-based indication

Encouragement of food and drink during labor as the

woman desires

Freedom of movement in labor and choice of birth

position

Intermittent auscultation of heart tones unless

electronic monitoring is indicated

Providers skilled in non-pharmacologic methods of

coping with pain

Care that supports woman’s comfort, dignity,

and privacy

Respect for woman’s

cultural needs

Midwifery Outcomes: Cesarean Sections

Data from Risk Adjusted Comparative Studies in the US: % of Cesarean Births

0%

5%

10%

15%

20%

25%

30%

Study1 -

1992

Study2 -

1993

Study3 -

1993

Study4 -

1994

Study4 -

1994*

Study4 -

1994*

Study5 -

1995

Study6 -

1997

Study7 -

2002

Study7 -

2002*

Study8 -

2003

Study9 -

2006*

Study9 -

2006

Study10 -

2013

Study11 -

2015

0.40

%

12.3

0%

4.00

%

12.8

8%

18.0

7%

6.67

%

19.3

0%

13.6

0%

25.8

0%

13.7

0%

19.1

0%

15.6

0%

34.0

0%

16.6

0%

7.93

%

2.14

%

9.75

%

2.00

%

8.51

% 12

.73%

1.93

%

13.0

0%

8.80

%

15.9

0%

8.40

%

10.7

0%

5.60

%

13.0

0%

12.4

0%

2.44

%

Physician Attended Births Midwife Attended Births

Sources and methods listed in “Notes” view. * Study 4 included overall cesarean rates, as well as C/S for primiparas and multiparas cesarean. * Study 7 included overall cesarean rate and primary cesarean rate. * Study 9 included overall cesarean rate and primary cesarean rate.

Among studies reporting study population and incidence figures, there were 2,435 cesareans among 19,241 births attended by physicians (12.66%) and 304 of 3,746 births attended by Midwives (8.12%).

Among the 234 midwifery practices reporting on 97,158 births in ACNM’s 2013 benchmarking data, the median rate of cesarean birth was 11.8%

Savings From the Midwifery Model – Cesarean Sections

Hypothetical Group of 1,000 Women Number of Women

Giving Birth via Cesarean Section

Payments for All 1,000 Births if All Covered by

Medicaid

Payments for All 1,000 Births if All Covered by

Commercial

CNM/CM Attended Women 85 $9,837,106 $19,797,863

Physician Attended Women 147 $10,122,014 $20,407,230

Reduced Cesareans/Savings

from Midwifery Model

62 $284,908 $609,367

Description of methodology in “Notes” view.

Complications Associated with Cesarean Short-term harms to mother that are

more likely with a C/S Greater likelihood of events

impacting future fertility Babies more likely to

have:

• Maternal death • Emergency hysterectomy • Blood clots and stroke • Surgical injury • Longer hospitalization and more

likely re-hospitalization • Poor birth experience • Less early contact with babies • Intense and prolonged postpartum

pain • Poor overall mental health and self-

esteem • Poor overall functioning

• Involuntary infertility • Reduced fertility due to

decreased desire to have more children

• C/S scar ectopic pregnancy • Placenta previa • Placenta accretia • Placental abruption • Uterine rupture • Hemorrhage • Low birth weight • Preterm birth • Stillbirth • Maternal death

• Respiratory problems

• Surgical injuries • Failure to establish

breastfeeding • Asthma in

childhood and adulthood

Complications cost money too!

Source: Carol Sakala and Maureen Corry, “Evidence-Based Maternity Care: What It Is and What It Can Achieve,” Co-published by Childbirth Connection, the Reforming States Group, and the Milbank Memorial Fund, October 2008, Available at: http://www.milbank.org/uploads/documents/0809MaternityCare/0809MaternityCare.html

Midwifery Outcomes: Induction and Epidurals

Data from Risk Adjusted Comparative Studies in the US: % of Induced Labor

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Study 1 -1993

Study 2 -1994

Study 3 -1995

Study 4 -1997

Study 5 -2000

Study 6 -2003

Study 7 -2015

8.22

% 15

.00%

17.2

0%

41.8

0%

28.8

8%

14.7

0%

35.2

4%

7.75

%

8.50

%

15.1

0%

26.3

0%

14.2

0%

8.40

%

22.7

6%

Physician Attended Births Midwife Attended Births

Sources and methods listed in “Notes” view.

Among studies reporting study population and incidence figures, there were 790 inductions among 3,467 births attended by physicians (22.79%) and 316 inductions among 3,019 births attended by Midwives (10.47%).

• A 2002 study found no significant difference between the rate of induction by physicians and midwives.

• Among the 234 midwifery practices reporting on 97,158 births in ACNM’s 2013 benchmarking data, the median rate of total induction of labor was 17.1%.

Data from Risk Adjusted Comparative Studies in the US: % of Births with Epidural

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Study 1 -1993

Study 2 -1993

Study 3 -1994

Study 4 -1994

Study 5 -1997

Study 6 -2000

Study 7 -2002

Study 8 -2003

Study 9 -2006

Study 10- 2015

2.89

%

29.4

6%

53.1

2%

39.6

0%

42.1

0%

67.4

5%

62.5

0%

68.6

0%

51.2

0%

85.4

1%

2.00

%

16.4

8% 10.9

6%

14.6

0%

18.4

0%

49.7

3%

32.6

0%

29.8

0%

30.8

0%

61.7

9%

Physician Attended Births Midwife Attended Births

Sources and methods listed in “Notes” view.

Among studies reporting study population and incidence figures, there were 7,699 epidurals among 15,422 births attended by physicians (49.92%) and 1,195 epidurals among 4,604 births attended by Midwives (25.96%).

Among the 234 midwifery practices reporting on 97,158 births in ACNM’s 2013 benchmarking data, the median rate of epidural was 36.4%.

CNM/CM Attended Births The Opportunity for Savings

Pregnancy and Risk Stratification

Higher Risk

Pregnancies

Low-Moderate Risk

Pregnancies

There is no uniformly utilized definition of a high risk pregnancy.

• CDC estimates that in 2013, 83% of first time mothers were at low risk for a cesarean birth.1

• The NIH lists several high risk factors affecting 2-10% of pregnancies.2

• More than half of pregnant women in the US are overweight or obese, which increases their risk.3

It is reasonable to assume that the majority of women are low-moderate risk.

Sources in Notes View.

Percent of Births Attended by CNMs/CMs - 2013

MT

9.70%

WY 4.48%

ID 7.83%

WA 9.32%

OR 17.81%

NV 3.96% UT

8.04% CA 8.72%

AZ 6.51%

ND 6.13%

SD 6.73%

NE 5.88%

CO 12.47%

NM 24.95%

TX 3.16%

OK 4.04%

KS 4.94%

AR 0.56%

LA 2.62%

MO 3.31%

IA 7.33%

MN 10.99% WI

9.12%

IL 6.24%

IN 6.38%

KY 5.95%

TN 5.72%

MS 2.28%

AL 1.67%

GA 14.02%

FL 10.41%

SC 4.30%

NC 12.59%

VA 7.22%

WV 12.37%

OH 6.80%

MI 6.53%

NY 10.12%

PA 11.41%

MD 9.74% DE 8.77% NJ 6.90%

CT 11.01% RI 11.13%

MA 15.22%

ME 17.78% VT 20.87%

NH 18.95%

AK 26.80%

HI 8.81%

4.51% – 6.49% of births

6.50% - 8.89% of births

12.00% - 28.00% of births

Source: CDC Vital Stats, Births - Available at: http://www.cdc.gov/nchs/data_access/vitalstats/vitalstats_births.htm

8.90% - 11.99% of births

0% – 4.50% of births

DC 10.72%

• In 2013, CNMs/CMs attended 8.2% of births nationally. • The opportunity for savings through the midwifery model is substantial!