Validation of a certified nurse-midwifery database for use in quality monitoring and outcomes research

INTRODUCTION: Certified nurse-midwives (CNMs) and certified midwives (CMs) attend 11% of US vaginal births, and CNM/CM databases include a rich source of information on the birth outcomes of women not generally available through obstetric electronic health records (oEHRs). Although CNM databases are in wide use, studies on their validity are sparse. We examined the validity of a practice-specific CNM birth database compared with an oEHR in a large tertiary-care facility. METHODS: The study population consisted of all 3133 births in a large CNM practice that were entered into a practice-specific electronic birth database from 2001 to 2008. We assessed agreement with the oEHR overall and according to individual maternal demographic characteristics; obstetric, medical, and social risk factors; labor and birth information; and newborn characteristics. We also evaluated whether there were differences in agreement according to early versus later study periods and by years of CNM clinical experience. RESULTS: Overall agreement between the CNM birth database and the oEHR was 92.4%. Agreement between the CNM birth database and the oEHR was greater than 90% for maternal age, race/ethnicity, route and type of birth, major genital tract trauma, newborn weight, and primary clinician attending the birth. Lower agreement rates for smoking, total weight gain in pregnancy, beginning of pregnancy body mass index, and anesthesia for birth were due, in part, to missing information in the oEHR. Agreement did not vary significantly by early versus late study periods or by years of CNM clinical experience. DISCUSSION: Findings indicate that a CNM/CM birth database is a valid data source for qualitymonitoring and outcomes research and may contain more complete information for some variables than the oEHR

Factors associated with genital tract trauma at spontaneous vaginal delivery

It has long been traditional for nurse-midwives (CNMs) to keep a log or database of the deliveries they attend. Because CNMs now conduct approximately 400,000 or 10% of all births in the US, these databases are a potentially rich source of research information on the birth outcomes of women cared for by CNMs. The first study assessed the validity of 3,133 deliveries in the electronic Baystate Midwifery and Women’s Health (BMWH) Delivery Database from 2001 to 2008, using the patient’s electronic medical record as the ‘gold standard’. There have been only four validation studies of nurse-midwifery delivery databases, and these have been limited by small sample sizes, sparse presentation of results and inadequate statistical methodology. Results from these analyses demonstrated excellent overall agreement and a range of agreement by individual variable; agreement among CNM clinicians, by years of CNM clinical experience, and by early versus late study periods was also excellent. Genital tract trauma is defined as episiotomy and/or genital tract lacerations and is a complication in more than 50% of all vaginal births in the US. Many factors influence the incidence of maternal genital tract trauma. The second study examined the relationship between provider type, gender and years of clinical experience and the risk of major genital tract trauma among 19,261 spontaneous vaginal births from 2001 to 2008 at Baystate Medical Center. Significantly less major genital tract trauma was associated with later time period, CNM versus physician provider type, and greater than five years of clinical experience. Provider gender did not influence risk of maternal major genital tract trauma. Finally, we evaluated the relationship between maternal back position, maternal hip flexion, and four derived maternal back and hip flexion positions, and the risk of major genital tract trauma in a cohort of 2,513 vaginal births occurring in 2008 at Baystate Medical Center. Sitting positions were associated with a statistically significant decrease in major genital tract trauma among births attended by CNMs but not physicians. No significant associations were found for hip flexion or derived maternal positions

Malaria in Pregnancy: Considerations for Health Care Providers in Nonendemic Countries

Malaria is a common infection world-wide, which carries significant risk of morbidity and mortality. Health care providers in the United States may lack experience in recognizing and treating this disease. The pathophysiology of malaria differs during pregnancy, resulting in increased risk for serious morbidity and mortality for the woman and her fetus. Screening for risk factors, especially immigration from and travel to endemic countries, is critical. Symptoms of malaria can mimic influenza-type illnesses, causing delay in diagnosis. Consultation with an infectious disease specialist and hospitalization may be required for appropriate testing and treatment. Chemoprophylaxis and counseling regarding methods to reduce risk are important components of prevention. The US Centers for Disease Control and Prevention and the World Health Organization have established protocols for treatment and are helpful resources for clinicians. A team approach to care based on the woman\u27s stage of illness and recovery, can involve midwives, physicians, specialists and others. Keywords: anemia; diagnostic tests; fetal growth retardation; malaria; placenta; pregnancy; premature birth; stillbirth

Maternal body mass index, delivery route, and induction of labor in a midwifery caseload.

The purpose of this study was to identify the association between prepregnancy body mass index (BMI), weight gain in pregnancy, and newborn birth weight on route of delivery and induction of labor in patients receiving nurse-midwifery care. This retrospe

Estimating the Financial Impact of Reducing Primary Cesareans

INTRODUCTION: Preventing a primary cesarean birth in nulliparous women with term, singleton, vertex pregnancies (NTSV) is recognized as an important strategy to reduce maternal morbidities and risks to the newborn. Multiple professional organizations are supporting approaches to safely reduce NTSV cesarean rates, including the American College of Obstetricians and Gynecologists; the Society for Maternal-Fetal Medicine; and the Association of Women\u27s Health, Obstetric and Neonatal Nurses. The American College of Nurse-Midwives (ACNM) is leading one such effort as part of its Healthy Birth Initiative: the Reducing Primary Cesareans (RPC) Learning Collaborative. The objective of this study is to estimate the cost savings of a decrease in NTSV cesareans at one hospital participating in the RPC Learning Collaborative. METHODS: All women giving birth at Baystate Medical Center from October 1, 2016, to March 31, 2017, and their newborns were identified by Medicare Severity Diagnosis Related Group (N = 1747). Total hospital costs were calculated using a resource consumption profile for each of 6 groups: women who had vaginal birth, primary cesarean, and repeat cesarean and their linked newborns. A model was developed to estimate cost differences for the first and second births and overall cost savings. RESULTS: For the NTSV birth, total costs for primary cesarean and newborn care were $5989 higher compared with vaginal birth and newborn care. For the subsequent birth, repeat cesareans and newborn care were$4250 higher compared with vaginal birth. In 2016, 69 primary cesareans were prevented, for an actual cost savings of $413,241. Projecting the prevention of 66 subsequent repeat cesareans would result in additional savings of$280,500, for a total savings of $693,741. Apgar score at 5 minutes and length of stay remained unchanged. DISCUSSION: Participation in ACNM\u27s RPC Learning Collaborative led to significant savings in hospital costs during the first year without affecting quality metrics. This cost comparison model could be replicated by other hospitals involved in cesarean reduction endeavors