![Page 1: Discussant M. Kathryn Menard, MD MPH Professor and Vice Chair for Obstetrics](https://reader035.vdocuments.site/reader035/viewer/2022062807/5681517b550346895dbfb518/html5/thumbnails/1.jpg)
Institute of Medicine Institute of Medicine Research Issues in the Assessment Research Issues in the Assessment of Birth Settings:of Birth Settings:Assessment of Risk in PregnancyAssessment of Risk in Pregnancy
Institute of Medicine Institute of Medicine Research Issues in the Assessment Research Issues in the Assessment of Birth Settings:of Birth Settings:Assessment of Risk in PregnancyAssessment of Risk in Pregnancy
Discussant
M. Kathryn Menard, MD MPHProfessor and Vice Chair for Obstetrics
Director, Maternal-Fetal Medicine
University of NC School of Medicine
Discussant
M. Kathryn Menard, MD MPHProfessor and Vice Chair for Obstetrics
Director, Maternal-Fetal Medicine
University of NC School of Medicine
![Page 2: Discussant M. Kathryn Menard, MD MPH Professor and Vice Chair for Obstetrics](https://reader035.vdocuments.site/reader035/viewer/2022062807/5681517b550346895dbfb518/html5/thumbnails/2.jpg)
DisclosuresDisclosuresDisclosuresDisclosures
No Financial Disclosures
My vantage point• Mother of three
• MFM specialist and educator
• Work environment» Perinatal regional center with 3,700 deliveries
» Freestanding birth center in town
» 24/7 CNM practice within our department
No Financial Disclosures
My vantage point• Mother of three
• MFM specialist and educator
• Work environment» Perinatal regional center with 3,700 deliveries
» Freestanding birth center in town
» 24/7 CNM practice within our department
![Page 3: Discussant M. Kathryn Menard, MD MPH Professor and Vice Chair for Obstetrics](https://reader035.vdocuments.site/reader035/viewer/2022062807/5681517b550346895dbfb518/html5/thumbnails/3.jpg)
Why assess risk?Why assess risk?Why assess risk?Why assess risk?
• An attempt to predict those most likely to experience adverse health events» Focus resources for timely and effective care and prevention
» Avoid overuse of technology and intervention
• Decrease amenable mortality (and morbidity) by improving health system performance
Amenable mortality = a measure of deaths due to complications of conditions that might be avoided by timely effective care and prevention
• An attempt to predict those most likely to experience adverse health events» Focus resources for timely and effective care and prevention
» Avoid overuse of technology and intervention
• Decrease amenable mortality (and morbidity) by improving health system performance
Amenable mortality = a measure of deaths due to complications of conditions that might be avoided by timely effective care and prevention
![Page 4: Discussant M. Kathryn Menard, MD MPH Professor and Vice Chair for Obstetrics](https://reader035.vdocuments.site/reader035/viewer/2022062807/5681517b550346895dbfb518/html5/thumbnails/4.jpg)
Risk Appropriate Perinatal CareRisk Appropriate Perinatal CareRisk Appropriate Perinatal CareRisk Appropriate Perinatal Care
Preconception/Interconception
Antepartum
Intrapartum
Neonatal
Preconception/Interconception
Antepartum
Intrapartum
Neonatal
![Page 5: Discussant M. Kathryn Menard, MD MPH Professor and Vice Chair for Obstetrics](https://reader035.vdocuments.site/reader035/viewer/2022062807/5681517b550346895dbfb518/html5/thumbnails/5.jpg)
Risk Appropriate Perinatal CareRisk Appropriate Perinatal CareRisk Appropriate Perinatal CareRisk Appropriate Perinatal Care
• 1970 Reports from Canada showed the neonatal mortality was significantly lower in obstetrics facilities with NICUs
• Emphasized importance of an integrated system that would promote delivery of care to mothers and infants based on level of acuity
• 1976 TIOP I: a model system for regionalized perinatal care, including definitions of Levels of Perinatal Care
• Advances in technology, combined with regionalized system led to improvement in neonatal survival rates
• Initial emphasis on both maternal and neonatal care
• 1970 Reports from Canada showed the neonatal mortality was significantly lower in obstetrics facilities with NICUs
• Emphasized importance of an integrated system that would promote delivery of care to mothers and infants based on level of acuity
• 1976 TIOP I: a model system for regionalized perinatal care, including definitions of Levels of Perinatal Care
• Advances in technology, combined with regionalized system led to improvement in neonatal survival rates
• Initial emphasis on both maternal and neonatal care
![Page 6: Discussant M. Kathryn Menard, MD MPH Professor and Vice Chair for Obstetrics](https://reader035.vdocuments.site/reader035/viewer/2022062807/5681517b550346895dbfb518/html5/thumbnails/6.jpg)
What we know: Neonatal What we know: Neonatal What we know: Neonatal What we know: Neonatal
• Delivery of the smallest babies in subspecialty hospitals saves lives» Infants <1500 g born at Level I or II hospital had an increase
odds of death (38% vs. 23%)• Adjusted OR, 1.62 (95% CI, 1.44-1.83)
» Infants <32 weeks gestation born at Level I or II hospital had an increase odds of death (15% vs. 17%)
• Adjusted OR, 1.55 (95% CI, 1.21-1.98)
Lasswell et al. JAMA Vol 304, September 2010
• Delivery of the smallest babies in subspecialty hospitals saves lives» Infants <1500 g born at Level I or II hospital had an increase
odds of death (38% vs. 23%)• Adjusted OR, 1.62 (95% CI, 1.44-1.83)
» Infants <32 weeks gestation born at Level I or II hospital had an increase odds of death (15% vs. 17%)
• Adjusted OR, 1.55 (95% CI, 1.21-1.98)
Lasswell et al. JAMA Vol 304, September 2010
![Page 7: Discussant M. Kathryn Menard, MD MPH Professor and Vice Chair for Obstetrics](https://reader035.vdocuments.site/reader035/viewer/2022062807/5681517b550346895dbfb518/html5/thumbnails/7.jpg)
Fast Forward 2012Fast Forward 2012Fast Forward 2012Fast Forward 2012
• American Academy of Pediatrics Policy Statement Levels of Neonatal Care*» No reference to maternal care
• Guidelines for Perinatal Care, 7th Edition• Value based health care
» Increase quality; Decrease cost
• Patient centered care• Greater recognition of a woman’s right to choose
*Pediatrics Vol 130, September 2012
• American Academy of Pediatrics Policy Statement Levels of Neonatal Care*» No reference to maternal care
• Guidelines for Perinatal Care, 7th Edition• Value based health care
» Increase quality; Decrease cost
• Patient centered care• Greater recognition of a woman’s right to choose
*Pediatrics Vol 130, September 2012
![Page 8: Discussant M. Kathryn Menard, MD MPH Professor and Vice Chair for Obstetrics](https://reader035.vdocuments.site/reader035/viewer/2022062807/5681517b550346895dbfb518/html5/thumbnails/8.jpg)
What we know: Neonatal What we know: Neonatal What we know: Neonatal What we know: Neonatal
• Delivery of term babies» Planned home birth
• Less medical intervention with 2-3X neonatal mortality*
» Free standing birth centers ?» Alternative setting (co-located midwifery units)**
• Ten RCTs, 11,795 women• More SVD (RR=1.03); more breast feeding at 6-8 weeks (RR=1.04), more
positive views of care (RR=1.96); No difference in maternal or neonatal outcomes
» Hospital environment• Delivery volume (high volume, lower rate of asphyxia)***• Care model ?
*Wax et al. Amer J Obstet Gynecol Vol 203. September 2010
**Hodnett et al. Cochrane review 2012
***Snowden et al. Amer J Obstet Gynecol Vol 207 December 2012
• Delivery of term babies» Planned home birth
• Less medical intervention with 2-3X neonatal mortality*
» Free standing birth centers ?» Alternative setting (co-located midwifery units)**
• Ten RCTs, 11,795 women• More SVD (RR=1.03); more breast feeding at 6-8 weeks (RR=1.04), more
positive views of care (RR=1.96); No difference in maternal or neonatal outcomes
» Hospital environment• Delivery volume (high volume, lower rate of asphyxia)***• Care model ?
*Wax et al. Amer J Obstet Gynecol Vol 203. September 2010
**Hodnett et al. Cochrane review 2012
***Snowden et al. Amer J Obstet Gynecol Vol 207 December 2012
![Page 9: Discussant M. Kathryn Menard, MD MPH Professor and Vice Chair for Obstetrics](https://reader035.vdocuments.site/reader035/viewer/2022062807/5681517b550346895dbfb518/html5/thumbnails/9.jpg)
What we know: MaternalWhat we know: MaternalWhat we know: MaternalWhat we know: Maternal
• Maternal mortality is am uncommon event
• Maternal severe morbidity is not measured in a consistent manner
• Factors that predict need for higher level of care are not well defined
• Maternal mortality is am uncommon event
• Maternal severe morbidity is not measured in a consistent manner
• Factors that predict need for higher level of care are not well defined
![Page 10: Discussant M. Kathryn Menard, MD MPH Professor and Vice Chair for Obstetrics](https://reader035.vdocuments.site/reader035/viewer/2022062807/5681517b550346895dbfb518/html5/thumbnails/10.jpg)
““Low obstetric risk”Low obstetric risk”““Low obstetric risk”Low obstetric risk”
• COSMOS randomized controlled trial, Australia » Singleton
» Uncomplicated obstetric history (no stillbirth, neonatal death, consecutive miscarriages, fetal death, preterm birth<32 weeks, isoimmunization, gestational diabetes)
» No current pregnancy complications (fetal anomaly)
» No precluding medical conditions (cardiac disease, htn, diabetes, epilepsy, severe asthma, substance use, significant psychiatric disorder, BMI>35 or <17.
» No prior cesarean
» McLachlan et al BJOG 2012» Assessed effects of primary CNM continuity versus usual care within a tertiary care setting
• COSMOS randomized controlled trial, Australia » Singleton
» Uncomplicated obstetric history (no stillbirth, neonatal death, consecutive miscarriages, fetal death, preterm birth<32 weeks, isoimmunization, gestational diabetes)
» No current pregnancy complications (fetal anomaly)
» No precluding medical conditions (cardiac disease, htn, diabetes, epilepsy, severe asthma, substance use, significant psychiatric disorder, BMI>35 or <17.
» No prior cesarean
» McLachlan et al BJOG 2012» Assessed effects of primary CNM continuity versus usual care within a tertiary care setting
![Page 11: Discussant M. Kathryn Menard, MD MPH Professor and Vice Chair for Obstetrics](https://reader035.vdocuments.site/reader035/viewer/2022062807/5681517b550346895dbfb518/html5/thumbnails/11.jpg)
““Low obstetric risk”Low obstetric risk”““Low obstetric risk”Low obstetric risk”
• RCT of simulated home delivery in hospital (midwife led care) versus usual care, UK» Nullip and multiparous women
» No prior cesarean
» No maternal illness such as diabetes, epilepsy and renal disease
» No prior stillbirth, neonatal death or SGA
» Singleton
» No Rhesus antobodies or elevated MSAFPx2
» MacVicar el al BJOB, 1993» 45% transferred to specialist care, 22% during labor or PP
• RCT of simulated home delivery in hospital (midwife led care) versus usual care, UK» Nullip and multiparous women
» No prior cesarean
» No maternal illness such as diabetes, epilepsy and renal disease
» No prior stillbirth, neonatal death or SGA
» Singleton
» No Rhesus antobodies or elevated MSAFPx2
» MacVicar el al BJOB, 1993» 45% transferred to specialist care, 22% during labor or PP
![Page 12: Discussant M. Kathryn Menard, MD MPH Professor and Vice Chair for Obstetrics](https://reader035.vdocuments.site/reader035/viewer/2022062807/5681517b550346895dbfb518/html5/thumbnails/12.jpg)
““Low obstetric risk”Low obstetric risk”““Low obstetric risk”Low obstetric risk”
• RCT of three levels on in hospital units. Norway» Healthy, low-risk women without ay disease known to
influence pregnancy
» Singleton
» Cephalic
» BMI<32
» Smokes < 10 cigarettes/day
» No prior operation on the uterus
» 36 1/7 to 41 6/7 weeks gestation
» Bernitz et al BJOG 2011
• RCT of three levels on in hospital units. Norway» Healthy, low-risk women without ay disease known to
influence pregnancy
» Singleton
» Cephalic
» BMI<32
» Smokes < 10 cigarettes/day
» No prior operation on the uterus
» 36 1/7 to 41 6/7 weeks gestation
» Bernitz et al BJOG 2011
![Page 13: Discussant M. Kathryn Menard, MD MPH Professor and Vice Chair for Obstetrics](https://reader035.vdocuments.site/reader035/viewer/2022062807/5681517b550346895dbfb518/html5/thumbnails/13.jpg)
““Low obstetric risk”Low obstetric risk”““Low obstetric risk”Low obstetric risk”
• RCT of midwifery care versus consultant led ward, Ireland» >40 or <16 years old
» Grand multiparity >5
» Height <152cm (5 feet)
» BMI <18 or >29
» Medical history: any
» Social: Current drug misuse, Smoking>20 cigs/day
» Previous obstetric history: PTB<34 weeks, recurrent miscarriage, moderate to severe pre-eclampsia, stillbirth, cesarean, 3rd or 4th degree tear, neonatal death
» Previous gyn history: Uterine surgery, cone biopsy, cerclage, uterine anomaly, perineal reconstruction
» Begley et al BMC Pregnancy and Childbirth, 2011
• RCT of midwifery care versus consultant led ward, Ireland» >40 or <16 years old
» Grand multiparity >5
» Height <152cm (5 feet)
» BMI <18 or >29
» Medical history: any
» Social: Current drug misuse, Smoking>20 cigs/day
» Previous obstetric history: PTB<34 weeks, recurrent miscarriage, moderate to severe pre-eclampsia, stillbirth, cesarean, 3rd or 4th degree tear, neonatal death
» Previous gyn history: Uterine surgery, cone biopsy, cerclage, uterine anomaly, perineal reconstruction
» Begley et al BMC Pregnancy and Childbirth, 2011
![Page 14: Discussant M. Kathryn Menard, MD MPH Professor and Vice Chair for Obstetrics](https://reader035.vdocuments.site/reader035/viewer/2022062807/5681517b550346895dbfb518/html5/thumbnails/14.jpg)
Levels of Maternal CareLevels of Maternal CareLevels of Maternal CareLevels of Maternal Care
• Birth Center
• Level 1 (Basic)
• Level 2 (Specialty)
• Level 3 (Subspecialty)
• Level 4 (Regional Perinatal Center)
• Birth Center
• Level 1 (Basic)
• Level 2 (Specialty)
• Level 3 (Subspecialty)
• Level 4 (Regional Perinatal Center)
![Page 15: Discussant M. Kathryn Menard, MD MPH Professor and Vice Chair for Obstetrics](https://reader035.vdocuments.site/reader035/viewer/2022062807/5681517b550346895dbfb518/html5/thumbnails/15.jpg)
Research needed to describe “risk”Research needed to describe “risk”Research needed to describe “risk”Research needed to describe “risk”
• Uniform definitions» Obstetric risk factors
» Medical risk factors
» Psychosocial risk factors
• Determine essential resources for every birth setting• Determine predictors of neonatal complications to guide
Level of Neonatal Care (beyond birth weight) • Determine predictors of maternal complications to guide
criteria for recommended Level of Maternal Care• Determine predictive “triggers” that should prompt
maternal transport
• Uniform definitions» Obstetric risk factors
» Medical risk factors
» Psychosocial risk factors
• Determine essential resources for every birth setting• Determine predictors of neonatal complications to guide
Level of Neonatal Care (beyond birth weight) • Determine predictors of maternal complications to guide
criteria for recommended Level of Maternal Care• Determine predictive “triggers” that should prompt
maternal transport
![Page 16: Discussant M. Kathryn Menard, MD MPH Professor and Vice Chair for Obstetrics](https://reader035.vdocuments.site/reader035/viewer/2022062807/5681517b550346895dbfb518/html5/thumbnails/16.jpg)
Research needs to describe “risk”Research needs to describe “risk”Research needs to describe “risk”Research needs to describe “risk”
• Uniform definitions of outcomes» Maternal and neonatal morbidity
» Family perceptions/satisfaction with care
• Role of care provider and continuity of care• Role of care “system” -- interprofessional working
relationship, consultation, hand offs, transfer of care• Qualitative study of culture/threshold for intervention in
high level care facility• Qualitative study of patient’s perception of risk and
influence on birth outcome and perception of care
• Uniform definitions of outcomes» Maternal and neonatal morbidity
» Family perceptions/satisfaction with care
• Role of care provider and continuity of care• Role of care “system” -- interprofessional working
relationship, consultation, hand offs, transfer of care• Qualitative study of culture/threshold for intervention in
high level care facility• Qualitative study of patient’s perception of risk and
influence on birth outcome and perception of care