Implementation Study of Innovative Maternity Care: Outcomes Related to the SDGs

Background: Improving maternal health is the 5^th Sustainable Development Goal (SDG). Although, cesarean birth can be a life-saving surgery, in many middle- and higher-income countries there is overuse. Globally, cesarean birth has increased in middle income countries like Brazil to 55%. In the U.S. 32% of births are cesareans and this has not led better maternal and newborn outcomes. On the contrary, the US has the highest maternal mortality ratio compared to other developed countries. Research shows a higher risk of cesarean when women are admitted to the hospital in early labor. The Knowledge-to-Action Framework guided an implementation study assessing the adoption of an early labor support program. This program is applicable to any setting regardless of resources. An interdisciplinary team designed a new triage protocol and an early labor lounge with evidence-based activities to promote comfort during labor. These activities included yoga, a nutrition center, walking and meditation. These early labor support activities are low cost and could be implemented in any labor setting if culturally appropriate. The program’s objective was to shift the culture of admitting low risk women too early in their labor process with the end of goal of decreasing the cesarean birth rate.

Methods: In this mixed-method study, a purposive sample of 25 hospital staff were interviewed using a qualitative descriptive approach. Interviews were recorded, transcribed and inductively coded by a two-person team. The Consolidated Framework for Implementation Research (CFIR) was then used deductively to identify constructs and domains related to barriers and facilitators of implementation. A convenience sample of 67 first time mothers completed an electronic survey after they gave birth and prior to discharge. The Birth Satisfaction Tool captured satisfaction. Additional data were collected on demographics, prenatal provider and mode of birth.

Findings: Staff interviews identified barriers and facilitators for implementation of the early labor lounge. Barriers included a lack of protocol knowledge and variation in buy-in to the program. Facilitators were empowering women during labor and the use of tools from the early labor lounge. Survey data from the women showed barriers including 33% indicating their prenatal provider did not discuss planning for labor to start spontaneously. Facilitators from the surveys found that 43% used the lounge; 100% of users stated nursing staff oriented them to the space; 93% of users indicated the lounge helped their partner coach them through early labor and 89% would recommend its use. 21% of the surveyed women delivered by cesarean, however, during this same time period the rate was 30% for this population. Initial analysis shows those surveyed had a high level of birth satisfaction.

Discussion: The early labor lounge provides laboring women a high level of support and satisfaction. Integrating the lounge into nursing practice was a success and has global implications. This concept innovates care of low risk mothers in many different settings as the cost of the materials is minimal, and nursing care is universal. Globally, women birth with a support person and a trained healthcare provide who often has a nursing background. A barrier in some institutions, would be places with policies that do not allow support people in the birthing room; however, the WHO 2013 handbook specifically supports a woman having a childbirth companion. Providing institutional structures that support poorer communities having access to evidenced based maternity care are specifically related to SDGs 1, 3, 5 and 17. There is overwhelming evidence that supportive care during labor and birth is an effective intervention to improve birth outcomes for women and their newborns. The labor lounge provides an institutional structure for this support. If a support person is present, then they can follow activities with the laboring woman and encourage hydration and nutritional intake. Understanding context of active labor admission needs further research. There were situational factors mentioned during interviews that could lead to admission including distance to the hospital and concern for inclement weather. While an interdisciplinary team designed the program, some staff had difficulty not admitting women to the birthing unit even if they were not in active labor. Furthermore, the mother’s birth plans need to be fully understood. Safety is another topic requiring further investigation because some staff raised concerns about patient safety with lounge use, yet overuse of cesarean was also recognized as a safety issue.