Nursing News

Advancing Evidence-Based Care in Maternity Nursing

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By Jennifer Larson, contributor

August 20, 2010 - The United States has a long way to go when it comes to maternal care.

According to a recent report from Amnesty International, the United States spends more than any other country in the world on health care and on maternal care. Yet women here have a higher risk of dying of pregnancy-related complications than those in 40 other countries. The report, entitled Deadly Delivery: The Maternal Health Care Crisis in the USA, published in March 2010.

And pregnancy-related deaths are not the only alarming trend, say proponents of evidence-based maternal care practices; the United States lags behind many other countries on key indicators of maternal and newborn health.

The American College of Nurse-Midwives (ACNM), among other organizations, is hopeful that a piece of federal legislation recently introduced in Congress by Rep. Lucille Roybal-Allard of California will improve maternal health outcomes and promote the increased practice of evidence-based care. House Resolution 5807, or the Maximizing Optimal Maternity Services for the 21st Century Home Act of 2010 (MOMS 21), was designed to put a national spotlight on evidence-based maternity practices with the goal of achieving the best possible outcomes for mothers and their babies.

“The MOMS for the 21st Century Act makes overdue reforms to our nation’s maternity care system to better ensure that providers and mothers have the best information available when making serious maternity care decisions,” Roybal-Allard said in a statement. “The fact is we have a maternity care system in the United States that has not traditionally adhered to evidence-based practices.”

Lorrie Kline Kaplan, executive director of the ACNM, predicted, “If you really implement the measures in this legislation, you would see a reduction in maternal mortality.”

Also, she noted, there would likely be a similar reduction in newborn mortality and a decline in the costs associated with childbirth that includes more interventions.
“This is a case where more is not better,” she said.

Roybal-Allard cited the rate of scheduled inductions and elective C-sections as two examples of the most overused maternal care practices in the United States. Overuse is a significant problem in general in the United States; the National Quality Forum has stated that 30 percent of care in the United States is wasteful and that eliminating unnecessary care could drastically reduce costs and risks associated with overuse.

Roybal-Allard also noted that there are more cost-effective practices that are underused. And Kaplan agreed, pointing out that certain practices that have been proven to be aligned with good outcomes are often underused. She cited several: allowing a laboring mother to move freely about during labor, allowing the mother to receive oral sustenance and providing continuous support to the woman during the entire labor process. Those are the sorts of practices that have been shown to help women and lead to fewer unnecessary interventions, she explained.

“We need to reeducate people on the practices that have been shown to have the best results for mother and baby,” Kaplan said.

The MOMS 21 Act would also authorize a national campaign to educate women about these evidence-based practices. And it would establish a Center for Excellence on Optimal Maternity Outcomes and call for additional federally-supported research on cost-effective high quality maternal care models.

This is a good time to highlight the need for evidence-based practices, Kaplan said. Many facilities may not even realize that they’re not using them. But as they begin to collect and analyze data, they may get a better picture of which practices they are consistently using—and which they aren’t.

“That’s the first step, just measuring the right thing,” she noted. “And once you see you have a problem on any of those measures, just do the research on what you can do to help you improve.”

The ACNM will be releasing a new tool shortly, complete with a detailed checklist, to help organizations improve their quality of maternity care by increasing their use of evidence-based practices.

The nonprofit organization Childbirth Connection is also calling for the reformation of maternity care to include more evidence-based practices. In a comprehensive report released in 2008, the organization recommended the development of a standardized set of performance measures.

Childbirth Connection’s report, titled Evidence-Based Maternity Care: What It Is and What It Can Achieve, also addressed the issue of cost.  It noted that hospital costs for maternal and newborn care are more expensive than charges for any other condition, costing around $86 billion in 2006. The report suggested that the current reimbursement system be reformed to reduce payment for overused services and increase payment for underused services.

Kaplan noted that a serious reduction in costs could result from a more widespread usage of best practices that lead to fewer unnecessary C-sections. C-sections are expensive, averaging between $12,000 and $15,000 or more, whereas a birth attended by a nurse midwife in a birth center might only cost a couple of thousand dollars, she said.

Another significant component of the MOMS 21 Act is a provision to support the education of a more diverse workforce to provide maternal care, with grant and loan repayment programs, as a way to address the fact that outcomes tend to be worse among African-American women than white women. In fact, the Amnesty International report found that African-American women are four times more likely to die from pregnancy-related complications than white women, a phenomenon that has not improved over the past two decades.

The legislation will also establish an interagency coordinating committee to promote the best possible maternity care by all federal agencies involved in delivering health care services.

If the bill does not get passed during the current Congressional session, Kaplan said, supporters plan to insure that it gets reintroduced next year.

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