A new collaborative approach is designed to improve birth outcomes, decrease cesarean section procedures, and increase patient engagement.
Maternal morbidity and mortality continue to be a devastating trend in U.S. healthcare, as reported in The Washington Post last November.
Complications from C-sections such as hemorrhaging are widely considered to be a contributing factor to the country's high maternal mortality rate. The federal Centers for Disease Control and Prevention have been monitoring maternal mortality since 1986. The number of pregnancy-related deaths has risen steadily since the monitoring effort began, from 7.2 deaths per 100,000 live births in 1987 to 18.0 deaths per 100,000 live births in 2014.
In December, the federal government took a step toward addressing maternal mortality with passage of the Preventing Maternal Deaths Act.
To decrease C-sections and improve birth outcomes, Ariadne Labs, a collaborative of Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health in Boston, launched the Team Birth Project in 2018 at a handful of sites across the country to recast the hospital-based birthing process.
The Team Birth Project features two primary elements: efforts to improve communication between the mother, the family, and the clinical care team; and a pair of decision-making tools.
1. Create a labor storyboard and implement team huddles
Under the Team Birth Project model, birth plans are living documents throughout the birth process, says Margie Bridges, DNP, a perinatal clinical nurse specialist at Overlake Medical Center. The Bellevue, Washington, facility is one of the pilot sites for the initiative.
"Historically with birth plans, the patient and the family may have talked to their doctor during an office visit then brought it to labor, when it got tucked into a chart. It wasn't a living document that got changed as conditions changed," she says.
To make sure birth plans are considered during labor, the Team Birth Project calls for clinical care teams to mount a whiteboard in the birthing room that reflects the mother's preferences. At Overlake, 24 x 36-inch whiteboards are affixed to a door facing the mother.
Information on the whiteboard has crucial information such as the birth team, which includes the mother; a plan for the baby such as monitoring; a plan for the mom such as pain management; and a plan for labor progress.
The whiteboard is the "story of the labor," says Lisbeth Jordan, MD, a hospitalist and OB Hospitalist Group site director at Overlake. "It is updated regularly—what's going on with the baby, how the labor is progressing, and next steps with the provider. It's a storyboard to help the family be aware of what they want, how the baby is doing, and how the labor is going."
Birth plan huddles are held at key points during labor, Bridges says. "The huddles get the core team together when decisions are being made. Huddles are held when you would normally consult the doctor, and you include the patient."
The huddles can be held even when the physician is unable to be at the bedside, the nurse specialist says. "We get them on the phone for a conference call in the birthing room. We put the doctor on the speakerphone, and we go over the whiteboard to review changes in preferences, give status reports on the mom and the baby, and raise concerns."
Boosting communication can help avoid C-sections, Bridges says. "Sometimes, it's tricky to understand why a mom has a C-section. There are so many variables and variation. If we look very clearly at the three lanes—mom, baby, and labor progress—and have a plan, we can avoid some cesarean births."
Open communication can be pivotal in avoiding a cesarean birth, Jordan says. "There is a shared understanding of what is going on. So, the story plays out, and the provider checks in with the nurse and the family. The idea is that it is a collaborative, team effort that can reduce unnecessary C-sections because there is shared knowledge about the whole process of labor."
2. Use admission decision and C-section criteria tools
The Team Birth Project has a duo of decision-making tools to help reduce C-sections, Bridges says.
"There is an admission decision aid that helps us decide whether a patient needs to be admitted to the hospital. We know if we admit someone too early—the mother is well and the baby is fine—it starts the clock ticking and increases the rate of cesarean sections. If the patient is hospitalized, we start to intervene."
The second decision-making tool helps determine whether conditions for ordering a C-section are present, she says. "We also have an aid that we can use during the process of labor that focuses on the mom, the baby, and labor progress that tells us whether we have met the minimal criteria to even consider a C-section. It tells us whether it is safe to keep going with a vaginal birth."
While the Team Birth Project pilots are in their infancy, the early results are promising.
In February, Boston 25 News (WFXT-25) reported that South Shore Hospital in South Weymouth, Massachusetts, had achieved a 4% reduction in the facility's C-section rate through Team Birth Project implementation. South Shore was the first hospital to launch in the initiative in April 2018.
Patient experience gains are also evident, Jordan says. "The initial motivation of this initiative was to decrease C-section rates and the research outcomes are pending, but we are finding the increased communication has transformed the relationships in the entire team. Communication improves outcomes, so it may be that the most significant outcome is not decreased C-sections but a better experience for the family."
Happier families have also been noted at another pilot organization: Kirkland, Washington-based EvergreenHealth.
"We are seeing amazing things in terms of patient satisfaction—they leave the hospital feeling that they understand what happened to them. They get to write their own birth story. It's an important change in how we deliver care because we are providing care with the patient and not giving care to the patient," says Angela Chien, MD, an obstetrician-gynecologist at EvergreenHealth.
Christopher Cheney is the senior clinical care editor at HealthLeaders.
Cesarean sections are a likely contributor to the country's high maternal mortality rate.
Communication between the mother, her family, and the clinical care team is the primary component of a new approach to the birth process.
Early results from the initiative are promising, with a 4% decrease in C-sections at a pilot site in Massachusetts.