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THE NEED FOR EVIDENCED-BASED MATERNITY CARE

Maternity care accounts for a very large expenditure in the US Healthcare System, which can include overuse of procedures, drugs, and medical tests. How can all of these be corrected to increase quality? Welcome to the Clinician's Roundtable on ReachMD, The Channel for Medical Professionals. I am Bruce Japsen, the healthcare reporter for the Chicago Tribune and with me today is Ms. Carol Sakala, Director of Programs for the Childbirth Connection. Childbirth Connection is the National Not-For-Profit Organization founded in 1918 as Maternity Center Association. At the Childbirth Connection, the group promotes safe, effective, and satisfying evidence-based maternity care and is the voice for the needs of interest of childbearing families. Ms. Sakala has worked with Childbirth Connection to plan its long-term national program to promote safer, effective maternity care, and has been Director of Programs since the program began. She is the former Pew Health Policy Fellow and has an adjunct faculty appointment at the Department of Maternal and Child Health at Boston University School of Public Health. Ms. Carol Sakala joins us from her offices in New York.

BRUCE JAPSEN:

Welcome to ReachMD, The Channel for Medical Professionals.

MS. CAROL SAKALA:

Thank you.

BRUCE JAPSEN:

Carol, we often hear in stories I write and lot of health professionals out there listening more and more about evidence-based medicine, but evidence-based maternity care is really not something I have heard about and it's really not something people know about. So, if you will, please tell us about this and whether this is indeed a new phenomenon and what the medical professionals and consumers should know about this?

MS. CAROL SAKALA:

In fact, the evidence-based movement started in our field in the 1970s in childbirth and growing body of colleagues started to collect and assess the weight of the best available research in our field, and in 1989, they published Nature Reports that have been since kept up-to-date and expanded and inspired other people to develop compendia of systematic review. This actually led to the formation of the Cochrane Collaboration, which many of your listeners might be familiar with. So, let's just say it's a best kept secret that in pregnancy and childbirth, we have an unprecedented body of systematic review. Many unknown questions remain, no doubt about it, but there is much that is ready to apply now, and when we took a look 10 years after those major reports were published in 1999, we found virtually no evidence that we were benefiting from the results, and so we started our program at that point in time to promote evidence-based maternity care and more recently we had a chance to work with the Milbank Memorial Fund and the Reforming States Group, a group of health policy makers from across the United States from all 50 states and also several other countries to look out what we have learned and to take a bead of the evidence-based movement in general and in our field and to develop this new report.

BRUCE JAPSEN:

And so how was this going out there in the healthcare community and may be who would be pursuing this and if may be you could give an example of how this would work? I know a lot of our listeners might not be familiar with evidence-based care, but essentially it's you want to give care based on some evidence out there and show that it works and it's not something that would lead to overuse and misuse if it will. Could you give us an example of where it is being implemented and perhaps where it should be?

MS. CAROL SAKALA:

I think we make the assumption that the care that's being provided is very much up-to-date and in line with the best research, and in fact, it's very easy to think of what my colleagues are doing, what I have learnt in my medical school, what seems to work in my experience, and there is a rigorous need, I think a need for a new type of professional education that constantly demands show me the evidence, is this really so, because when we take a look, we see major gaps between evidence and practice and many of your listeners may know about the Crossing The Quality Chasm, a major report from the Institute of Medicine around the turn of the century, which labeled it as a chasm, the gap between what we are doing and what we should be doing. So, it's not only in pregnancy and childbirth and I think it's a challenge across all healthcare fields right now. I think there is no field that's really doing what we should be doing.

BRUCE JAPSEN:

Could you give us an example or perhaps some doctors and consumers out there listening of where this needs to be addressed? Perhaps an example in the care setting of where we found, perhaps something that's gone awry, or something that's overused or underused and perhaps where their improvements could be made?

MS. CAROL SAKALA:

Well, one of the important success stories in our field is episiotomy because for almost a century that was believed to be a procedure that would improve the outcomes for babies, improve the outcomes for mothers, and in fact what we found is liberal or routine use of episiotomy creates harm and offers none of the benefits that have been perceived, and this is one procedure that has in fact decreased in recent years and now it's down to about 25% of vaginal birth. Another example that I think people don’t know about is amniotomy, rupturing the membrane after labor that is believed to hasten labor and lead to better outcomes all the way around and in fact when the best evidence was recently looked at in the new Cochrane review, they found out there were concerns about adverse effects and it was not doing what it was believed to do.

BRUCE JAPSEN:

We talked about evidence-based care, usually doctors get a little nervous because they feel that may be an insurance company is behind this or perhaps employers, who are worried about high healthcare costs. Are there areas where the employers and the insurers are looking at this to get physicians to follow certain standards that are based on evidence and is it going well?

MS. CAROL SAKALA:

Well, I think there was a backlash after the managed care era because it was perceived to relate to cause and interfere with professional autonomy and perhaps lead to care that wasn’t in the best interests of patients. I feel that there is a lot to be gained from putting structures in place that helps all parties and especially the people, who are providing and receiving care to understand what is the best evidence and different kinds of incentives. Now, one of the big opportunities that are widely recognized is performance measurement and there is a new kind of perinatal care measures that is just being released in that area, and what we can do is develop good measures that are based on the best evidence that are shown to perform well and then collect data on those and put it out there so that consumers can make wise choices, facilities, and health professionals can use that information to improve their care, and it may not be negative and punitive, it can lead to a sense of teamwork and pride and excellent PR and building of market share. So, I think there are definitely positive sides to that and also healthcare purchaser should be able to understand, who is performing well, who they want to contract with, possibly, who they want to reward by giving extra reimbursement.

BRUCE JAPSEN:

Well, if you are just joining us or even if you are new to our channel, you are listening to The Clinician's Roundtable on ReachMD, The Channel for Medical Professionals. I am Bruce Japsen, your host. I am with the Chicago Tribune and joining me today is Ms. Carol Sakala. She is the Director of Programs for the Childbirth Connection and she joins us from their offices in New York and we are talking about evidence-based maternity care.

Our evidence-based medicine is certainly a buzzword that physicians are hearing more about and consumers will be hearing more about it because healthcare is costly and consumers want the right healthcare delivered and they want it based on some evidence and Carol you were just talking about how there is more and more of a push on a perfect world consumers could be able to make wise decisions on their maternity care. Can you give an example of where this is going on and perhaps what would a perfect scenario be, I mean, would it be a consumer going to a website and saying, "boy oh boy I want that doctor and I want that hospital." Could you give us a little background on what we should see or what would be the perfect scenario here?

MS. CAROL SAKALA:

Well, certainly in maternity care, women have 9 months to prepare and so it's different from a heart attack and going off in an ambulance all of a sudden, and in that case, we strongly encourage a whole advanced process of informed decision making. We encourage women to get access to the best available evidence and I have to say that our website, which is www.childbirthconnection.org is entirely built on providing resources for both childbearing women and health professionals to learn about the lessons from the best evidence. So, we definitely encourage taking responsibility, reading, becoming informed. There is a lot of potential around decision support tools for women, but that is they mostly need to be developed in the future, but I think there is a tremendous movement to develop a better tool in that regard and also I think it's really important to emphasize the focus on what's called transparency and disclosure and that gets back to the question of performance measurement, and increasingly, there are places where childbearing women can go to learn at least at the hospital level how one hospital that they might have assess to compared to another.

BRUCE JAPSEN:

And what are some of the things if a health professional or consumer went to your website, which is again www.childbirthconnection.org, what should they look for and what could they find that would help them?

MS. CAROL SAKALA:

Well, we emphasize greatly for childbearing women that major decisions are who you are going to be with for your care and where you can get your care. So, we have important sections on our website about choosing a caregiver and choosing a birth setting because those greatly influence what ends up happening. Another area that's very important to the childbearing women is labor pain, how they are going to get help with it, will they be comfortable, will they be afraid, and so forth and we have major sections on labor pain for childbearing women, we have sections on labor support, care from a doula or another companion, who comes in which makes a huge difference it ends up. This is an age-old practice that has recently been revived and makes a very large difference in many areas for childbearing women. On the health professional side, we have an evidence-based maternity care directory, which has about 12 pages of different kinds of things, best resources or guidelines, and best resources for making practice change and where to go to find versus on the best available evidence about different forms of care. We also have done a quarterly columns of best maternity evidence that is co-published in 2 journals in our field and those columns are all freely available going back from the beginning of 2003, so that the page called evidence column, which is just an inventory of new systematic reviews and features some reviews and important resources, a look at some of the material that's available on our website.

BRUCE JAPSEN:

Well, with that I would like to thank Ms. Carol Sakala who has been our guest. She is the Director of Programs for the Childbirth Connection, an organization that is helping promote and get healthcare providers and the healthcare system in line with the evidence-based maternity care and I would like to thank her for joining us today.

My name is Bruce Japsen. I am with the Chicago Tribune. I have been your host and you have been listening to The Clinician's Roundtable on ReachMD, The Channel for Medical Professionals, and I would like to thank you today for listening.

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