Making Out-of-Hospital Birth Safer Requires Systems Change

Ellen L. Tilden, PhD, CNM; Jonathan M Snowden, PhD; Aaron B Caughey, MD, PhD; Melissa J. Cheyney, PhD, CPM, LDM


May 18, 2016

Issues With Hospital Transfers

Current estimates suggest that somewhere between 8% and 16.5%[2,15] of US women intending to deliver outside of the hospital will transfer to the hospital during labor or in the immediate postpartum period. Intrapartum transfers of care have emerged as a key site of risk and also interprofessional contention.[16,17] Improving coordination during this sensitive time is essential to improving safety.[18] Specifically, timely transfer characterized by well-coordinated, interprofessional collaboration may increase safety through systems optimization.[17,19] Care in Canada, the United Kingdom, and The Netherlands includes standardized transfer criteria and protocols that are familiar to both the transferring and the receiving provider. Factors that increase respectful and effective interprofessional communication may further decrease perceived barriers to transfer among out-of-hospital providers and may improve sharing of health records essential for maximizing safety.[20] Greater uniformity and a commitment to disclosure of all relevant maternity care information during a transfer of care, again mirroring maternity care systems already functioning well, may be an important element in improving safety for families planning to deliver outside the hospital.[21]

Working Together

Emotionally charged, moralistic arguments have dominated public discussion of birth setting, creating what has been called the home/hospital divide.[17] Yet, a satisfying birth process, a healthy woman, and a healthy child are mutual goals. How can we work together to address our shared responsibility for increasing access to safe, affordable, and empowering birthing care? And how can we expand safe maternity care options for all US women?[22,23] Shifting discourses away from how women should personally define safety and toward systems-level changes that increase safety for all women across all birth settings will help to focus our efforts in positive and productive directions.

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