Karen Hays CNM, ARNP, DNP, Melissa Denmark LM, CPM, MA, Audrey Levine LM, CPM-Retired, BA, Roberta Haynes de Regt MD, H. Frank Andersen MD, Karen Weiss FF/PM
First published: 26 November 2022 https://doi.org/10.1111/jmwh.13441
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Abstract
In Washington state, planned community births are attended by direct entry licensed midwives (LMs) and certified nurse-midwives (CNMs). The most recently published vital statistics data from 2018 reported that 3.6% of the 84,648 births in Washington occurred at home or in freestanding birthing centers. Approximately 16.2% of planned home birth and birth center clients experience intrapartum or early postpartum transfer to the hospital, while 1.8% of their newborns do. The safety of and satisfaction with these types of referrals depends on multisystem processes performed by a variety of health care professionals. Smooth Transitions is a quality improvement (QI) initiative in Washington state that was developed to enhance interprofessional collaboration between community-based midwives, emergency medical services (EMS), and hospital personnel to improve the quality of hospital transfers from planned community settings. Key interventions to date have included (1) information sharing to dispel misconceptions and provide context regarding community births and midwives; (2) co-creation of transfer guidelines; (3) regularly held interprofessional meetings to review transfers and build relationships; and (4) ongoing review of qualitative feedback that captures the perspectives of all involved. Responses on questionnaires and audits indicate that Smooth Transitions has had a positive impact on provider, staff, and patient experiences with hospital transfers. Future endeavors will include strengthening quantitative data collection processes to measure safety indicators, expanding relationships with EMS, and building a case review process that is legally protected. By engaging representatives of all stakeholder groups and addressing community-to-hospital transfers as a multisystems issue, replication of the Smooth Transitions QI Program nationally could promote increased community midwifery integration by enhancing the referral experience for both patients and caregivers.
INTRODUCTION
Each year, approximately 70,000 families in the United States give birth at home or in a freestanding birth center. National data from 2020 identified 45,646 home and 21,884 birth center births (1.3% and 0.6% of all US births, respectively).1 The motivations of people who plan to give birth at home or in a birthing center are complex and based on the unique benefits of those environments.2-4 In addition, motivations may include beliefs that many hospital personnel are unsupportive of normal physiologic birth processes, employ excessive interventions, and disallow patient preferences.2-4 More recently, closure of rural hospitals and fear of coronavirus disease 2019 (COVID-19) exposure along with restrictive hospital rules have also influenced birth setting choices.5 According to the Centers for Disease Control and Prevention1 community births increased nationally by 20% from 2019 to 2020, and the rate continues to rise. Clients who identified as Black, Native American, and Hispanic demonstrated the largest increases.1, 5
Planned community-based births in Washington state occur at approximately double the rates seen nationally. The most recently published data from 2018 indicated that of the 84,648 births that year, 3089 occurred at home or in freestanding birth centers (2.1% and 1.5% of all births, respectively).6 Some clients require hospital transfer from a community setting after labor has begun.2-6 In Washington, an estimated 16.2% of planned birth center and home birth clients, plus 1.8% of community-born neonates, experience intrapartum or early postpartum (within 6 hours) transfer to a hospital.7
QUICK POINTS
✦In Washington state, an estimated 16.2% of birth center and planned home birth clients, and 1.8% of their newborns, require intrapartum or early postpartum/neonatal transfer to the hospital.
✦Both patient and clinician experiences are adversely affected when hospital transfers from community settings encounter challenges that impede efficiency, empathy, and collegiality.
✦The Smooth Transitions Quality Improvement Program in Washington state is designed to enhance cooperative professional relationships between community midwives, emergency medical services (EMS), and hospital personnel and could be replicated by perinatal care stakeholders in other jurisdictions.
✦Future directions for Smooth Transitions include expansion of relationships with EMS, improvement of data collection and analysis, facilitation of protected case reviews, and cultivation of consumer participation in quality improvement activities.
Throughout the United States, improved collaboration between community midwives, EMS responders, and hospital personnel is a widely recognized need.8-14 The American College of Obstetricians and Gynecologists15 affirms that pregnant individuals have the right to make informed decisions about birth settings. They described 4 factors that optimize home birth outcomes: trained midwives, appropriate candidate selection, readily available consultation, and safe, timely hospital transport. However, variability in the willingness of hospital perinatal providers to consult with and receive transfers from community midwives remains problematic in the United States.8-10 In addition, effective communication and care coordination between midwives and emergency medical services (EMS) is often lacking.11
The purpose of this article is to describe the origins and ongoing efforts of the Smooth Transitions Quality Improvement Program in Washington state. Launched in 2009, the aim of this collaboration is to improve the safety of and satisfaction with hospital transfers from planned community-based births by building greater interprofessional collaboration. Representatives from Smooth Transitions participated in the creation of the following groundbreaking Home Birth Summit 2011 Consensus Statement that continues to guide Smooth Transitions’ activities:
“Collaboration within an integrated maternity care system is essential for optimal mother-baby outcomes. All women and families planning a home or birth center birth have a right to respectful, safe, and seamless consultation, referral, transport and transfer of care when necessary. When ongoing inter-professional dialogue and cooperation occur, everyone benefits.16”
ORIGINS AND BACKGROUND OF SMOOTH TRANSITIONS
Midwifery in Washington is an independent profession and relatively well-integrated into the perinatal care system.14, 17-19 Two types of midwives are licensed by the Washington State Department of Health (DOH): direct entry licensed midwives (LMs), most of whom are certified professional midwives (CPMs), and advanced registered nurse practitioner-midwives (ARNP-M), which licenses certified nurse-midwives (CNMs). As of this writing, certified midwives are not yet licensed in Washington; thus, the term midwives in this article refers solely to LMs and CNMs.
There are currently 27 freestanding midwifery-led birth centers licensed by the DOH.18 Midwifery services, including community births, are covered by most insurance options, including Medicaid. Professional liability insurance is also available. Participation in peer review, continuing education, and data collection are mandated by law. The state's largest community birth-focused professional organization for LMs and CNMs, the Midwives’ Association of Washington State (MAWS), participates alongside hospitals in a data collection quality improvement collaborative.19
Despite this favorable practice environment for midwives in Washington, in 2005 LMs and CNMs began to face increasing challenges with community birth transfers to Seattle-area hospitals. In response, the Washington DOH Perinatal Advisory Committee convened a Physician/Midwife Workgroup (MD/LM Workgroup) to address physicians’ concerns regarding their professional liability when accepting community birth referrals. The MD/LM Workgroup verified that most community-based midwives in the state carried sufficient professional liability insurance and thus would not need to “borrow” the receiving physician's coverage. Additionally, every Washington-based professional liability insurance carrier confirmed physician coverage for all incoming referrals. These clarifications had an immediate impact on improving cooperation between the midwives and physicians during hospital transfers.
Having successfully resolved these professional liability misperceptions, the MD/LM Workgroup was motivated to continue their collaboration by reviewing the MAWS risk-screening tool that listed clinical indications for transfers of care.20 The Workgroup concluded that this document should include references, undergo updates every 3 years, and be widely disseminated. To support use of the guidelines, the MD/LM Workgroup launched a Washington State Perinatal Collaborative voluntary quality improvement (QI) initiative in 2009 titled Smooth Transitions.
Four large hospitals, 2 in urban western Washington and 2 in the more rural east, were chosen as Smooth Transitions pilot sites, and a program coordinator began launching activities. A presentation for physicians, midwives, and nurses was facilitated by a midwife and obstetrician team, modeling the collaboration the program sought to promote. Content included addressing knowledge gaps about community midwives and reviewing local and national data on community-based birth to dispel misconceptions. For example, hospital personnel were informed that more than 80% of planned home and birth center births occur successfully in their intended setting and that, although high acuity situations do arise and tend to be more memorable, the majority of transfers are for nonurgent indications such as prolonged labor or request for analgesia.2, 7
From 2009 to 2017, as awareness of the Smooth Transitions program at the 4 pilot hospitals spread, an additional 8 hospitals requested to participate. However, ongoing engagement with each hospital was sporadic beyond the initial presentation. The lack of approved institutional-based transfer guidelines was problematic because as personnel changed over time, trust based upon previously established relationships was lost. In the absence of regularly scheduled meetings and sharing participants’ ongoing feedback, there was no established structure for disseminating information, learning from transfer experiences, and sustaining collaborative efforts.
GROWTH OF SMOOTH TRANSITIONS
Recognizing that infrastructure and institutional support were needed, in 2018 the Smooth Transitions cochairs approached the Foundation for Health Care Quality (FHCQ), and Smooth Transitions was added to their roster of programs. The FHCQ is an independent neutral nonprofit organization that links health care providers, payers, and local and federal partners to improve health care outcomes.21 This new partnership inspired a revision of the Smooth Transitions mission and goals to address hospital transfers as a multisystem access to care issue and to broaden the definition of safety to encompass emotional, psychological, social, cultural, spiritual, and physiologic processes and outcomes.22
Affiliation with the FHCQ increased Smooth Transitions’ visibility, credibility, and involvement of additional stakeholders. The leadership team was expanded to include representation from nurse-midwifery, pediatrics, neonatology, nursing, EMS, medical education, and consumers. To preserve the integrity of the model, Smooth Transitions received a trademark in 2020. Most of the materials were uploaded for open online access.23 FHCQ connections with other health care organizations, such as the Washington State Hospital Association (WSHA), propelled the program into larger state-wide conversations. Participation in Smooth Transitions is now included in WSHA's Safe Deliveries Roadmap24 as a best practice recommendation.
Currently, 20 hospitals participate in Smooth Transitions, and 8 additional hospitals have expressed interest. Together, these hospitals represent almost 86% of the births that occur in Washington state (M. Denmark, MA, Smooth Transitions Cochair, written communication, October 16, 2022). Participating hospitals create a Perinatal Transfer Committee to develop hospital-specific intrapartum and early postpartum transfer guidelines, submit audit materials, and meet quarterly with local midwives to discuss concerns and explore opportunities for enhancing collaboration. This committee includes a designated Smooth Transitions midwife liaison who communicates conversations, activities, and new policies to midwives in the area. The liaison and a hospital clinician champion orient new community midwives and relevant hospital personnel to Smooth Transitions.
Feedback and Audits
Since 2009, Smooth Transitions has been collecting qualitative feedback to determine participants’ perceptions of the program. Individualized, voluntary online questionnaires25 are completed after transfer by community midwives, receiving clinicians, nursing staff, clients/patients, and EMS personnel. With support from an American Institutes Research grant, the Birth Place Lab at the University of British Columbia26 contributed to the development of these questionnaires, which incorporate validated tools to measure patient autonomy, respect, and decision-making.
As of July 2022, Smooth Transitions has collected 624 posttransfer questionnaires. Although not yet published, aggregate results thus far indicate several important points. Receiving physicians and CNMs (16.0% of the total responses) have remarked on the importance of accurate provider-to-provider communication and alerting the hospital about impending transfers before arrival. Both receiving providers and nurses (7.3% of the responses) appreciated when midwifery clients were prepared for anticipated interventions and acknowledged that hospital personnel are compassionate. Hospital personnel described discomfort, however, when they believed that an intrapartum transfer should have happened sooner.
Community midwives (47.4% of the responses) appreciated being treated as respected members of the clinical team. Several midwives, however, commented about delays in receiving hospital records, which are needed when the patient and newborn return to the midwife's care after hospital discharge. The referred patients (29.3% of the responses) appreciated kindness and respect and often described the transfer experience as positive despite receiving medical interventions they initially sought to avoid. Patients were dissatisfied when they were not listened to by hospital caregivers, felt rushed into making decisions, or were separated from family because of COVID-19 restrictions. To date, no EMS questionnaires have been submitted.
Aggregated, deidentified responses from all the questionnaires are shared quarterly with hospital Perinatal Transfer Committees to highlight successes and inspire conversations about improvement. Over time, it appears that the power of understanding and centering patients’ experiences, in particular, has led to more respectful interactions between the patient, midwife, and hospital personnel.
In addition to the questionnaires, Smooth Transitions annually audits participating hospitals and community midwifery practices through customized forms to assess the program's usefulness.27 Encouragingly, both midwives and hospital representatives across the state have regularly remarked that the Perinatal Transfer Committee meetings have made relationships more collegial. Feedback has also revealed that institution-specific guidelines have improved the transfer process by clarifying expectations. The Smooth Transitions team analyzes the audit information to identify persistent problems and plan future directions for the program.
Expanding the Impacts and Influence
Smooth Transitions has shared its experiences through telephone calls, professional networking discussions, and formal presentations with perinatal quality collaboratives and midwifery groups across the country. Individuals and organizations from 15 states and one US territory have requested advice about replicating Smooth Transitions. Smooth Transitions representatives have also participated in the Home Birth Summit Collaboration Task Force, which has led to 2 noteworthy resources titled Best Practice Guidelines: Transfer from Planned Home Birth to Hospital28 and Best Practice Guidelines for Interprofessional Collaboration: Community Midwives and Specialist Providers.29 Other impacts, described below, have occurred spontaneously during the past decade of Smooth Transitions’ collaborative efforts.
Discussions at Washington state hospital-specific Perinatal Transfer Committee meetings have created several new opportunities for interprofessional collaboration. For example, one hospital developed a more efficient neonatal intensive care unit direct-admit procedure for neonatal transfers rather than admitting through the emergency department. Several hospitals formalized intrapartum referrals to hospital-based CNMs for nonemergencies such as prolonged labor or analgesia requests. Midwives are increasingly being invited into hospitals for training opportunities, such as neonatal resuscitation classes, alongside hospital personnel. Multiple hospitals have given community midwives read-only electronic health records access so they can obtain information about clients they transferred to the hospital. The development of more collegial relationships has given community midwifery clients greater access to a variety of services such as external cephalic versions, iron infusions, fetal surveillance, therapeutic rest, early postpartum discharge, and shared care for clients desiring labor after cesarean.
Much of the work of Smooth Transitions is designed to foster open dialogue between all program participants, which can uncover issues that need attention. For example, hospital personnel are encouraged to receive transfers with a welcoming greeting that acknowledges the change in birth plan and reassures patients of their commitment to provide safe and satisfying care. Midwives and their clients have reported that this compassionate reception has had an anxiety-reducing effect. After introducing this recommendation to Smooth Transitions hospitals, additional discussions about the transfer process among Smooth Transitions participants and leadership evolved to consider how midwives prepare clients for possible hospital transfer. Ultimately, a document was developed by the leadership team that recommended anticipatory guidance activities called Best Practices for Community Midwives re: Hospital Transfers.30
The EMS perspective is particularly important to integrate into Smooth Transitions’ work. Understanding each other's approaches to patient care and skill sets are keys to having productive conversations.11 When the EMS system is activated, crews respond with their established protocols to manage the emergency. Confusion can occur when they arrive to find a trained licensed clinical professional on site providing medical care to the patient. Therefore, to improve understanding, some midwives have introduced themselves to their local fire stations, hosted EMS personnel at their birth centers, and participated in joint training classes. These attempts at improving relationships, although well-received, are small in scale. Affecting large-scale change in Washington has been challenging, however, because of the decentralized structure of the EMS system. Nevertheless, Washington's EMS educators, aware of Smooth Transitions, reached out to collaboratively draft a 911 Protocol31 for use by community midwives to communicate with EMS dispatchers.
In January 2020, the first confirmed COVID-19 case in the United States occurred in Washington state.32 By late winter, MAWS and individual community midwives were sharing resources and offering support as the pandemic spread. Pregnant people and their newborns were considered vulnerable populations whose health care could not be suspended.33 Midwives coped with increased client caseloads as local hospitals were overwhelmed with ill patients. In addition, many families sought home birth options out of fear of the hospital environment.1, 5 This growing strain on hospitals led to creative options to serve patients, such as early discharge.33 Smooth Transitions hospitals used established relationships to expedite new agreements with community midwives, who performed early discharge home visits consisting of routine postpartum evaluations, newborn metabolic and hearing screenings, plus weight, jaundice, and feeding assessments. These hospitals also included community midwives in their early COVID-19 vaccination programs and provided testing and treatment access for midwifery clients. The pandemic experience in Washington state revealed that community and hospital-based health care providers with pre-established collaborative relationships could quickly assess and combine resources and work as an efficient team while facing unexpected perinatal challenges during a public health emergency.
FUTURE ENDEAVORS
Promoting Equity
Social and structural factors, beyond individual risk factors, contribute to health and health care inequities. Vedam et al3 recently revealed that among 107 surveyed research participants who transferred to the hospital from community birth settings, 37 (34.6%) experienced mistreatment in the hospital, compared with 28.1% of those who had planned hospital births. Widely documented evidence of disrespectful maternity care and rising rates of maternal morbidity and mortality, particularly among Black, Hispanic, and Indigenous people, have inspired critical evaluations in all care settings and have expanded the concept of safety.3, 5, 34 Increased recognition of health equity goals requires all health care providers to acknowledge and confront racial and gender biases, as well as biases against birth settings, to eliminate discrimination.
Smooth Transitions’ questionnaires capture patient demographics and qualitative information about patients’ experiences of care, including mistreatment and abuse, which is deidentified and shared regularly at Perinatal Transfer Committee meetings. This information then informs each hospital's efforts to change policies and practices that fail to adequately serve a diverse clientele.35 To bring the patients into this process, Smooth Transitions is now exploring a partnership with the Point of Care Foundation to implement experience-based co-design, which organizes feedback on health care experiences from patients, combined with clinician engagement, to develop specific improvement strategies.36 Through both video interviews and patient involvement in the development and implementation of QI activities, hospital personnel and community midwives will hear directly from patients about their transfer of care experiences and their recommendations for improvement. The Point of Care Foundation has documented the impact of such interventions on the attitudes and behaviors of health care personnel.
Community Birth Data Collection
Comprehensive, validated, and reliable quantitative data collection is an essential responsibility for Smooth Transitions to track morbidity, mortality, and near-miss indicators for the transferred parents and their newborns. In Washington, several approved midwife data repositories exist, but each collects slightly different data and the repositories do not communicate with each other. This has made it difficult to determine an accurate number of, indications for, and outcomes of hospital transfers. MAWS participated in the initial phases of the Obstetrical Care Outcomes Assessment Program, during which data from community births were collected alongside those from hospitals.21 Currently, a Community Birth Data Registry within this program is being developed to serve as a repository for all home and birth center data in the state, ensuring that process and outcomes data from every transfer of care can be captured. This information will contribute to the development of a state-approved patient decision aid to give consumers accurate information for making choices about which birth setting best aligns with their values, needs, and expectations.
Protected Case Reviews
Hospitals have nondiscoverable internal QI processes for case reviews, but community midwives, most of whom do not have hospital privileges, have not been able to participate. Smooth Transitions has developed 2 different processes for confidential case reviews that will soon be activated, made possible by Washington's Coordinated Quality Improvement Program. State-approved protected reviews will enable community midwives, EMS personnel, and hospital providers to engage in more open discussions within the context of Smooth Transitions Perinatal Transfer Committee meetings, without these conversations being discoverable in the event of litigation. In addition, in consultation with the Northern New England Perinatal Quality Improvement Network Confidentiality Review and Improvement Board, Smooth Transitions is creating an external, neutral, third-party review process that will allow for impartial, multidisciplinary reviews of transfer cases with adverse outcomes.37
Partnering With EMS
Partnership with local and regional EMS agencies is vital for consistent practices when an urgent perinatal patient transfer to the hospital occurs. Understanding professional roles and capabilities, developing guidelines and communication strategies, and building trusting relationships prior to an urgent event are the current objectives. Smooth Transitions has reached out to multidisciplinary team-training and simulation experts at Pronto International38 to create an intrapartum transfer curriculum for EMS personnel and community midwives in Washington, with implementation planned for 2023.
Engaging OB hospitalists as champions
Smooth Transitions has established a relationship with the OB Hospitalist Group to introduce the program to the physicians who are most likely to receive transfers from community midwives and might therefore invest in pursuing productive relationships. Hospitalists also support CNMs who receive referrals from the community when midwife-to-midwife transfer protocols are in place. If hospitalists serve as clinician champions for Smooth Transitions QI efforts, buy-in will be enhanced and may help Smooth Transitions attain sustainability. Planned outreach activities in 2023 will include presentations at hospitals in Washington and other states where OB Hospitalist Group members practice, and also at a national hospitalist conference.
CONCLUSION
Smooth Transitions is an example of a successful midwifery-led collaborative QI program designed to enhance the patient and caregiver experience by improving the process of hospital transfers from planned community-based births. Multiple stakeholders in Washington state are taking steps to promote respectful and efficient transfers and are working collaboratively to improve and grow the program. Data collection on the program's impacts is improving and ongoing, with a goal of publishing these results. By addressing community-to-hospital transfers as a multisystem issue, replication of the Smooth Transitions QI Program across the nation could promote increased community midwifery integration, thus enhancing the transfer experience for all involved.
ACKNOWLEDGMENTS
Smooth Transitions Founders and Original Members of the MD/LM Workgroup: Robert Palmer, MD; Audrey Levine, LM, CPM-ret; Suzy Myers, MPH, CPM-ret; JoAnne Myers-Ciecko, MPH; M. Alician Lewis, MD; Dale Reisner, MD; Jane Dimer, MD; Polly Taylor, CNM, MPH.
CONFLICT OF INTEREST
Karen Hays is a Master Trainer with Pronto International. Karen Weiss is an Assistant Chief, Medical Services Officer and EMS Response, Curriculum Development & Training Delivery for Lacey Fire District 3. Audrey Levine is a Co-Chair on the Smooth Transitions Leadership Team, Foundation for Health Care Quality.
The other authors have no conflicts of interest to disclose.
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