Reducing Maternal Mortality with Obstetric Care Designations

Maternal deaths related to childbirth in the United States have been rising in the past decade. According to a 2014 report published in The Lancet, the maternal mortality rate in the U.S. is now more than double the rate in Saudi Arabia and Canada, and more than triple the rate in the United Kingdom.

To address this trend, ACOG and the Society for Maternal-Fetal Medicine (SMFM) recently issued Levels of Maternal Care, the first consensus document establishing levels of care for perinatal and postnatal women. It is the second document in the joint ACOG and SMFM Obstetric Care Consensus series.

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Our Patients Deserve Our Patience

Recent reports of rising cesarean delivery rates in the United States are a significant concern, both to the public and to those of us who are practicing obstetrics. Cesarean delivery rates vary dramatically across geographic areas of the country but also from one neighboring hospital to the next.

Certainly the variations in cesarean delivery rates are multi-factorial. It is easy to understand if a tertiary care hospital receiving high-risk pregnancies from a broad referral area would have an elevated cesarean delivery rate. However, it is disturbing to see that some hospitals with a high percentage of low-risk deliveries have higher cesarean delivery rates than the tertiary care hospitals in their referral area.

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Teaming Up with Our Nurse-Midwife Friends

Earlier this month, I had the good fortune to attend the American College of Nurse Midwives (ACNM) annual meeting in Nashville, TN. What a fabulous meeting in a great location. The meeting program was diverse and holistic, with an emphasis on the same issues ob-gyns are struggling with: improving safety in our birthing centers, improving global women’s health, and changing the delivery of care right here at home so that we see healthier moms and babies.

An ACOG delegation—including myself, Executive Vice President Dr. Hal Lawrence, Past President Dr. Richard Waldman, and President Elect Dr. John Jennings—attended the opening ceremonies and were greeted with a thunder of applause, an acknowledgment that collaboration in improving women’s health and access to care is a shared goal of our organizations. ACNM also gave ACOG a very special award: the Organizational Partner Award for aiding in the development and practice of midwifery. This award was very meaningful to us. It was recognition that ob-gyns and nurse-midwives do collaborate, share delivery services, and very much depend on one another. The changing face of health care ensures that our professions will continue to interact, innovate, and work together.

Change is tough, because often it means separation from our comfort zone and having to adopt different behaviors or different approaches. Some physician practices have quickly incorporated midwives, and others have not. According to trends in the ob-gyn workforce, we do not have enough physicians in our specialty to meet the challenges ahead. The reality as we look toward the future? It is likely that many models of collaborative practice will be adopted by more and more physicians, both out of necessity and because it just makes sense. Expanding our access to patients with physician assistants, nurse-midwives, and nurse practitioners when possible both serves our patients and allows ob-gyns an opportunity to focus on the work that specifically requires our special skill set. We will need to look closely at how we provide care, and particularly on how we collaborate on the delivery of care, over the next decade. I’m personally looking forward to sharing more information on successful strategies to provide our patients with the best coordinated care we can.

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With Delivery Times, Defer to Mother Nature

“Let nature take its course.” Over the years, I’ve found this saying particularly applies to the process of giving birth. My personal experience as an ob-gyn and reams of scientific research demonstrate that Mother Nature knows best when a child is ready to be born. The start of natural labor is the main sign, but we’re not always patient enough to wait for it.

Today, one in three babies in the US are born by cesarean—the delivery of a baby through an incision in the mother’s abdomen and uterus. The rate of labor induction is also at an all-time high. Unfortunately, many of these births occur before the pregnancy is considered “term” at 39 weeks. These upward trends have long been a source of concern in the medical community, especially considering the increased risks to a baby who may not be fully developed at delivery.

Among cesarean deliveries, an estimated 2.5% (more than 100,000 births each year) are scheduled on a designated date by the mother and her doctor. Some women cite reasons such as a lower risk of future incontinence, better sexual functioning after childbirth, and fear of pain as motivations to schedule cesareans. Inevitably, some cesareans (and labor inductions, too) are scheduled before a pregnancy is full term, increasing the risk of negative outcomes for the newborn, including respiratory problems and time spent in the neonatal intensive care unit. The fact remains that due dates are estimates, and you can never be sure that the infant will have reached optimal maturity at the time of a scheduled delivery.

Women should keep in mind that cesarean delivery is no walk in the park. While it’s a safe option, cesarean delivery is a major surgery and comes with a number of risks, such as placental complications in future pregnancies, problems with anesthesia, infection, and longer recovery times.

Certain urgent situations—such as preeclampsia, eclampsia, multiple fetuses, fetal growth restriction, and poorly controlled diabetes—may make it necessary to deliver the baby before the onset of natural labor. However, newly issued guidelines from ACOG remind women and ob-gyns that in uncomplicated pregnancies, a vaginal birth that occurs after the natural onset of labor is ideal. Additional new ACOG guidelines reaffirm that cesareans and labor inductions should only be performed when medically-necessary.

Delaying delivery until labor starts naturally may not make ob-gyns too popular with a patient who’s uncomfortable and near the end of her pregnancy, but it’s a decision that will pay dividends by giving the baby the extra time it needs to face the world.

With Routine Medical Tests and Procedures, Choose Wisely

Hal C. Lawrence III, MD, ACOG Vice President, speaking during the press briefing.

Hal C. Lawrence III, MD, ACOG Executive Vice President, speaking during the press briefing.

Open lines of communication are the basis of successful doctor-patient interactions. However, when it comes to medical tests and procedures, doctors and patients alike can easily slide into cruise control without taking the time to discuss what’s truly needed, appropriate, supported by evidence-based research, and in the best interest of the patient’s care.

With this in mind, ACOG has teamed up with the Choosing Wisely campaign—an initiative that aims to spark a conversation about commonly performed tests and exams in different areas of medicine. By taking a critical eye to routine health care practices, we can make better decisions on how to provide thorough and comprehensive care while avoiding unnecessary, redundant, or even risk-increasing procedures.

Today, at a joint press conference with 16 other partnering organizations, ACOG made the following recommendations:

1. Don’t schedule elective, non-medically indicated inductions of labor or cesarean deliveries before 39 weeks 0 days gestational age.
Delivery prior to 39 weeks 0 days has been shown to be associated with an increased risk of learning disabilities and a potential increase in morbidity and mortality. There are clear medical indications for delivery prior to 39 weeks 0 days based on maternal and/or fetal conditions. A mature fetal lung test, in the absence of appropriate clinical criteria, is not an indication for delivery.

2. Don’t schedule elective, non-medically indicated inductions of labor between 39 weeks 0 days and 41 weeks 0 days unless the cervix is deemed favorable.
Ideally, labor should start on its own initiative whenever possible. Higher cesarean delivery rates result from inductions of labor when the cervix is unfavorable. Health care practitioners should discuss the risks and benefits with their patients before considering inductions of labor without medical indications.

3. Don’t perform routine annual cervical cytology screening (Pap tests) in women 30–65 years of age.
In average–risk women, annual cervical cytology screening has been shown to offer no advantage over screening performed at 3-year intervals. However, a well-woman visit should occur annually for patients with their health care practitioner to discuss concerns and problems and to have appropriate screening with consideration of a pelvic examination.

4. Don’t treat patients who have mild dysplasia of less than two years in duration.
Mild dysplasia (Cervical Intraepithelial Neoplasia [CIN 1]) is associated with the presence of the human papillomavirus (HPV), which does not require treatment in average–risk women. Most women with CIN 1 on biopsy have a transient HPV infection that will usually clear in less than 12 months and, therefore, does not require treatment.

5. Don’t screen for ovarian cancer in asymptomatic women at average risk.
In population studies, there is only fair evidence that screening of asymptomatic women with serum CA-125 level and/or transvaginal ultrasound can detect ovarian cancer at an earlier stage than can be detected in the absence of screening. Because of the low prevalence of ovarian cancer and the invasive nature of the interventions required after a positive screening test, the potential harms of screening outweigh the potential benefits.

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Placenta Problems during Pregnancy

How much do you know about the placenta? If you’re like most people, probably not much. But for the millions of women in the US who become pregnant each year, the placenta becomes a very interesting organ.

The placenta forms during pregnancy and serves as the life support system for a growing baby. It supplies the baby with oxygen, nutrients, and hormones, removes waste products through the umbilical cord, and is vital for a healthy pregnancy and delivery. In some pregnancies, problems with the placenta occur that can endanger mother and baby.

You may have recently heard about placenta previa, a condition that threatened actress Tori Spelling’s fourth pregnancy. Roughly 1 in 200 pregnant women will experience this potentially serious complication. Blood vessels attach the placenta to the uterus. In women with placenta previa, the placenta lies low in the uterus and may partially or completely cover the cervix, blocking the baby’s exit from the uterus. Placenta previa can also cause excessive bleeding in the mother when the cervix begins to thin and open in preparation for delivery. The risk of developing placenta previa is higher in women who’ve had more than one child, a cesarean delivery, surgery on the uterus, or who are carrying twins or triplets.

Roughly 1% of women will experience placental abruption—the detachment of the placenta from the uterus before or during birth. Placental abruption deprives the baby of oxygen and can cause the mother to lose large amounts of blood. Symptoms may include vaginal bleeding and severe abdominal or back pain. Placental abruption usually occurs in the last 12 weeks of pregnancy and is more common among women who have high blood pressure, smoke, or use cocaine or amphetamines during pregnancy. Women who’ve had a previous placental abruption, have had children, are older than 35, or have sickle cell disease are at higher risk.

Placenta accreta occurs when the blood vessels that attach the placenta grow too far into the uterine wall. The condition can cause bleeding during the third trimester of pregnancy and severe, life-threatening blood loss during delivery. Previous cesarean delivery is the main risk factor for placenta accreta, and the risk increases with each cesarean a woman has had.

If you experience bleeding during pregnancy, talk to your doctor right away. It may be related to a placental problem that requires prompt treatment. Learn more about placenta problems during pregnancy.