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AHRQ--Agency for Healthcare Research and Quality: Advancing Excellence in Health Care

Topic Suggestion Description

View Topic Suggestion Disposition (PDF) 130 kB

Date submitted: August 09, 2009

Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.
For childbearing women, including those on Medicaid, will independent, woman-centered 'boutique' birthing centers on the midwifery model, with provider-consistent prenatal, birth, lying-in, and early pediatric care, provide outcomes better than, or as good as, conventional hospital obstetrics, at lower cost and with fewer legal liability issues?
Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)
If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:
Prenatal care: quality of support and teaching: obstetric vs woman-centered model.

Childbirth education & preparation: obstetric model vs woman-centered model.

One-to-one support vs. variable provider interaction during pregnancy, labor, birth, and lying-in.

Rates of usage ultrasound, induction, amniotomy, intrapartum analgesia & augmentation, instrument delivery, surgical birth,and preterm birth: OB model vs. woman-centered model.

OUTCOMES: Maternal morbidity and mortality; patient evaluations; and LONG-TERM pediatric outcomes including brain disorders (ADD/ADHD; autism spectrum); maternal and familial satisfaction with birth experience.

Rates of sustained breast-feeding (OB model vs woman-centered model)

Also: cost-effectiveness (Medicare reimbursement) and incidence of litigation.

And maybe in the long run: Long-term health consequences of empowering patients in shared decision-making and shared risk around health care issues.
What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)
Childbearing women and their children to age 6.

Patient-selected (not provider-selected) population: no denying care for VBAC, hypertension, diabetes, twins, breeches, age over 40, etc if woman is well-managed, well-informed, and chooses out-of-hospital option.
Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)
This might work as a regional study (New England); Vermont is the only New England state without an independent birthing center. Part of the evaluation might be to build one from the ground up to model a sustainable, woman-centered, highest- qualtiy childbirth experience.
Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)
Empowering women to give birth with minimal intervention (long-term familial-social-health consequences).

Lowest intervention rates and best maternal outcomes postpartum

Best pediatric outcomes postpartum

Enhanced breast-feeding abilities in mothers & babes

Best birth experience for women and families.
Describe any health-related risks, side effects, or harms that you are concerned about.
Ongoing obstruction and loss of woman-centered approach to pregnancy and childbirth.

Accelerated loss of personal and manual skills required to provide best woman-centered care in childbirth.

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?
Which priority area(s) and population(s) does this topic apply to? (check all that apply)
EHC Priority Conditions (updated in 2008)
  • Pregnancy, including preterm birth
AHRQ Priority Populations
  • Low income groups
  • Minority groups
  • Women
  • Children
  • Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care
Federal Health Care Program
  • Medicare
  • State Children's Health Insurance Program (SCHIP)


Describe why this topic is important.
ACOG, acting as an unrestricted monopoly, has continually restricted women's choices in childbirth so that the only model left is doctor-centered obstetric birth, or (increasingly threatened) birth at home. The choice of where to give birth is increasingly given to OBs, not to women or their chosen provders. Meanwhile, the hospital remains a risky, unhealthy, and expensive environment for childbirth.

A woman-centered, community-based model, where birthing women and their choice of providers can be accommodated, with all facilities on site to avoid the need to transport, and where prenatal and early pediatric care are available, might be a reasonable step toward small, local, sustainable, environmentally-friendly, patient-driven health care systems.
What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)
Since the decline of woman-centered health clinics in the 1970's, and the rise of 'active management' in OB, childbirth costs have skyrocketed; malpractice rates for OBs are astronomical(with good reason); and the newest research shows that all our popular OB interventions from induction to surgial birth are contributing to our poor ranking in maternal & fetal health outcomes.

The 'birthing centers' that do exist still require women to be transported to a hospital for surgical intervention. In the woman-centered model, we would bring the surgeon to the woman, not the woman to the surgeon. Transporting a woman in labor should be actively avoided. Everything should be on site.

And, as 'green', sustainable, local, decentralized practices are becoming more economically attractive & feasible, it would be good to synthesize a patient-centered clinical approach with an eco-friendly facility design; and see if this would indeed attract more underserved patients (many of whom, put off by the perceived, and often, real, hostility of high-tech, busy, mainstream academic OB departments, receive the poorest care and support, and the most interventions). It would be good to start, de novo, to design a facility with these problems in mind, and see if long-term good outcomes are a sustainable goal.

The only option in this immediate catchment area is a tertiary-care hospial with a 25%+ c/s rate; 60% augmnted briths; no integrated labor-delivery-recovery facility; and connected with a teaching hospital, which needs patients for practice & advertises "a high rate of surgical cases" on its residency web site.

And I am growing weary of women (doctors, even) stopping me in the supermarket with yet another horror tale about mainstream OB: "You should hear what they did to my sister/daughter/niece."
Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)
If yes, please explain:
1) State and JHACO reglations about surgical facilities, and who may be licensed to use them. There is no reason why motivated and skilled midwives cannot do their own cesareans, eventually. This model would certainly do the most to improve maternity care worldwide. Anticipating big controversy in approach.

2)ACOG-affiliated hospitals arguing against state Certificate of Need (local hospital has actively blocked attempts for independent birth centers here in VT). Policy decision or anti-trust case?

3) Redefining liability/ shared risk has to be a part of any sustainable healthcare discussion. Anticipate community-based discussions to define patient's needs on this point.

4) Final area of controversy is re-educating populaton --providers and clients -- that childbirth is a natural process, and as such, may encompass a variety of outcomes, including death - no matter what facilities are available. (Malcolm Gladwell wrote that it takes about a 20% shift in thinking to bring about social change. We had this during the natural childbirth movement of the '60s & '70s; but the OB push for to more billable procedures curtailed that movement.)We have to bring reality back to the table here. Most babies actually come out OK.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?
If we find out that the model is sustainable (better outcomes, lower cost) we can keep improving it & include an integrated cooperative teaching center.
Describe the timeframe in which an answer to your question is needed.
1 yr to look at other New England birth-center outcomes vs hospital OB outcomes(first part of question answered)

1 yr for site acquisition, community outreach, certificate of need

1 yr for building, staffing, publicity, opening

Ongoing data-collection once the center is open.
Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.
A birthing woman is at once at the strongest and the most vulnerable position in her life. We want to enable every woman who walks in the door to have the most powerful and exquisite birth experience imaginable, and to hold that power for as long as she can. "Yes I Can" is an important take-home message for any major life passage, and the best way to bgin a life of parenting.

Nominator Information

Other Information About You: (optional)
Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)
  • Patient/Consumer
  • Physician
  • Other
Are you making a suggestion as an individual or on behalf of an organization?