CHNET-WORKS! recent Fireside Chats series webinar, Caesarean Section After the Hospital: Public Health Perspectives on the CARE Strategy, focused on long term outcome targets to decrease the use of medical intervention in low risk births and increase positive health outcomes related to breastfeeding, mental health, infant attachment, and parenting confidence. The webinar was presented in partnership with Ontario Public Health Association (OPHA), Markham Stouffville Hospital Corporation and the Canadian Institute of Health Research (CIHR/IRSC).

Presenters:

Esther Shoemaker PhD(c), University of Ottawa, is a medical Sociologist and PhD candidate in Population Health at the University of Ottawa and trainee in the Health Services and Policy Research diploma program. Her research focuses on maternal health and family-centered care.

Carol Cameron RM, Assistant Clinical Professor, McMaster University, has practiced midwifery since 1989.  She served as president of the Association of Ontario Midwives from 1996-1997, representing Ontario midwifery during the time that the profession began to expand with the introduction of the first graduates of the Ontario Midwifery Education Programme.

In collaboration with members of the Markham Stouffville Hospital Task Force, Ms. Cameron developed the components of the CARE strategy.

Deanna Stirling BScN, RN, PHN, Ontario Public Health Association (OPHA), is a Public Health Nurse at the Middlesex-London Health Unit and Supporting Normal Birth Task Group Lead for the Reproductive Health Workgroup of the OPHA. Her work focuses on prenatal health advocacy, education and curriculum development.

Jeanell Vanbesien BScN, RN, PHN, Ontario Public Health Association (OPHA), is a Public Health Nurse for Halton Region Public Health Department and a member of the Normal Birth Task Group for the Reproductive Health Workgroup of the OPHA. Her passion is guiding prenatal families and new parents to trust their intuition through prenatal education, social media, and community programs.

The Ontario Public Health Association Reproductive Health Work Group (RHWG) addresses health issues from preconception to the early postpartum period and is committed to supporting, promoting and protecting normal birth.

The goal of the RHWG is to develop and implement a comprehensive birth strategy that supports normal physiological birth across Ontario, with pregnant persons and their partners identifying their birth experience as the best birth for them. Their long term outcome targets are to decrease the use of medical intervention in low risk births and increase positive health outcomes related to breastfeeding, mental health, infant attachment, and parenting confidence across Ontario by December 2019.

In the webinar, the presenters quote: “In the past quarter century, maternity care has undergone significant changes; today the use of technology in birth has become the norm, which is noticeable in the rise in medical interventions in low-risk births” from the joint Policy Statement on Normal Childbirth (2008) reviewed and approved by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada (SOGC), the Association of Women’s Health, Obstetric and Neonatal Nurses of Canada (AWHONN Canada), the Canadian Association of Midwives (CAM), the College of Family Physicians of Canada (CFPC), and the Society of Rural Physicians of Canada (SRPC).

From the Policy Statement on Normal Childbirth:

• Birthing is a natural process
• Health care professionals should be committed to protecting, promoting, and supporting normal childbirth
• There should be a valid reason (evidence-based practice) to intervene in the natural process
• It is important to restore confidence in the normal birth process

The presenters stress the importance of physiological birth:

• Release of endogenous oxytocin and beneficial catecholamines in response to stress. These hormones promote effective labor patterns and the following protective physiologic responses:
• Enhanced endorphin levels,
• Facilitation of cardio-respiratory transition and thermoregulation of the newborn,
• Successful lactation, and
• Enhanced bonding behavior between the mother and infant (ACNM, MANA and NACPM 2012)

Four major hormonal systems are active during labour: Oxytocin; Endorphins; Epiniphrine and norepinephrine; prolactin. They quote research that shows that these hormonal systems are adversely impacted by “induction, the use of painkillers and epidurals, caesarean surgery, and separation of mother and baby after birth.”

The CARE Strategy (Caesarean Section Reduction) involves three major components:

1. Patient Education
   1. Public Education Campaign to increase patient awareness of the CS reduction initiative through posters located in the maternity care unit. CS, VBAC and induction rates are posted monthly.
   2. Prenatal class content is reviewed annually to ensure content is evidence-based and supports normal birth.
   3. Patient education booklet (provided to all women at 16-20 weeks gestation) is reviewed annually, is evidence-based and 
supports normal birth.
   4. Options for Birth after Caesarean information session counsels women with a previous CS in a group setting about their 
options for birth. A presentation on the evidence and a patient decision aid is used to guide discussion.
2. Care Provider Strategy:
   1. Audit and Feedback
   2.  The chief of obstetrics updates HCPs on the start of the initiative, baseline rates and targets.
   3. Every month, HCPs are provided with the unit’s overall and each HCP’s CS, VBAC and inductions rates (blinded for the 
first three months, then un-blinded among peers).
   4. Supportive Care in Labour
   5. HCPs receive education on benefits of supportive care.
   6. HCPs are encouraged to use auscultation instead of electronic fetal monitoring.
   7. Women receive 1:1 nursing care at least 80% of the time during active labour.
3. Childbirth Unit Strategy
   1. Supportive Care in Labour
      1. A desk and chair is placed in every labour and delivery room to encourage nurses to remain close to labouring women while doing chart work.
      2. HPs are given a nurse call system to be able to locate peers while they are in a patient’s room.
   2. Unit Policies:
      1. The Canadian Joint Statement on Normal Birth is adopted as a principle guideline to define and support normal birth.
      2. Labour induction policies are changed to ensure that post-date inductions only happen starting at 41 weeks gestation. 
All induction requests are reviewed by the on-call physician and facilitating nurse prior to booking the patient.
      3. Admission policy changed to ensure only women >4 cm dilated with regular contractions are fully admitted.

Markham Stouffville Hospital, a 2,500-4,000 birth volume hospital, has been piloting the CARE Strategy. In the period from 2008-9 to 2012-13 it demonstrated decreases in its CS rates across all measures, against the trend of Control Group hospitals and hospitals across Ontario.

A measure of Postdate Labour Induction at less than 41 weeks gestation was taken in the period Sept-Nov 2012. During that period, the proportion of women who were induced with any indication of past-dates and were less than 41 weeks gestation at delivery were:

• Markham Stouffville Hospital: 2.9% (achieving the target zone of less than 5% set by the CARE Strategy)
• Other Neonatal Level IIc hospitals: 35.9%
• Other 25000-4000 birth volume hospitals: 25.7%
• Ontario overall: 27.1%

Over 80% of parents attending the information sessions indicated that they were learning information that was new to them.

A mother who experienced successful VBAC and attended the “Birth Options After CS” session is quoted: “I was very scared to go through labour again. Lee took great care of me, kept me informed and made me feel safe. Once the delivery was over I couldn’t believe how quick I was able to move around and start caring for my baby. That is what has made me feel so much better about delivering this way. I just feel it is a safer way to deliver and I can care for my baby sooner. I will also get to go home sooner to be with my other child.”

Nine other Ontario hospitals have now expressed interest in implementing the CARE Strategy.

The presenters also discuss the public health outcomes impacted by intervention in birth:

1. Breastfeeding
   1. Inhibited milk ejection reflex (let down reflex)
   2. Interrupted skin to skin
   3. Delayed first suckling
   4. Increased risk of discontinuing breastfeeding with increasing number of interventions
2. Parenting Efficacy
3. Attachment and Bonding
   1. Disruption of hormone production in mother
   2. Birth trauma
   3. Post-traumatic stress disorder (PTSD)
4. Maternal and Infant Mental
   1. Birth interventions impact the newborn from receiving maternal hormones.
   2. A baby separated from mother at birth will continue to release steroids in the face of an unfamiliar environment.
   3. Maternal mental health impacts infant mental health.
5. Late Preterm Birth
   1. Preterm birth rate is increasing in Canada
   2. Late preterm babies have more health 
challenges than previously understood. (PCMCH,
   3. Late Pre-term Labour Clinical Guidelines, 2012)
6. Childhood Obesity (emerging research)
   1. Human Microbiome: Gut flora colonization during birth and skin to skin immediately after birth
   2. Immunology: Protection from allergies
   3. Childhood obesity after Cesarean section
   4. Endocrine Production

The presenters point out that Caesarean birth leads to shorter or absent exposure to the important normal hormonal changes during physiological birth; maternal-infant separation; and side effects of medications. The long-term benefits of supporting, promoting and protecting normal physiological birth include:

• Beneficial effects for the woman’s physical and mental health and capacity to mother
• Enhanced infant growth and development
• Potentially diminished incidence of chronic disease
• Enhanced family functioning
• Cost effective care

They quote from the SOGC Joint Policy Statement on Natural Childbirth, which recommends national practice guidelines on normal childbirth, including:

• Spontaneous onset of labour
• Freedom of movement throughout labour
• Continuous labour support
• No routine interventions
• Spontaneous pushing in the woman’s preferred position
• Use of fetal surveillance by intermittent auscultation
• Institutions offering options for pharmacologic and non-pharmacologic approaches to pain relief (such as tubs/showers, access to natural light, environmental designs/adaptations, quiet area)” (SOGC et al, 2008)

The presenters end by pointing out that Public Health can play a key advocacy role to help make systemic changes that support normal physiological birth for all women. The OPHA RHWG is currently advocating for:

• A provincial best practice for birth and dissemination strategy to Health Care Providers
• A provincial physiological birth media campaign for the general public
• Provincial access to decision aids for both HCPs and the general public

Inclusion of the importance of physiological birth and decision aids in provincial prenatal curriculum.