LOCAL FRONTIERS: Raising the Bar for Services to Women, Infants and Children

Since its return to local control in 2010, Marin General Hospital (MGH) has made delivering patient-centered care a top priority. The enhancements made to its services for women, infants and children, for example, are designed not only to improve quality and safety in perinatal care, labor, delivery and pediatrics, but also to provide all Marin women and families, regardless of insurance status, with greater choice, control and satisfaction while ensuring the best possible outcomes.

In 2011, MGH and the Prima Medical Group launched an innovative new maternity program involving a partnership with local ob-gyns and certified nurse midwives (CNMs). In designing our new system, we consulted national literature and studies on how maternity systems can achieve the highest level of safety, outcomes and patient satisfaction. Two elements found to be essential to safety were having an ob-gyn in the hospital 24/7 as part of the care team during the entire labor and delivery course, and having a full operative and pediatric team available 24/7 for urgently needed operative deliveries.

To achieve high levels of patient satisfaction, we found it was essential to recognize the widely varying needs, preferences and beliefs women have about their birth experiences, and to provide them with more options during their pregnancy. For example, CNMs, who serve as the primary care providers to pregnant women in many highly developed countries, have different educational and training backgrounds and management styles than physicians. The CNM philosophy of care is more suited to the beliefs of some women. Having both physicians and CNMs available 24/7 in the hospital, working together as a team but also independently managing their own patients, allows women to choose the option that best aligns with their personal needs and beliefs.

MGH is the only hospital in Marin or San Francisco counties to provide this option for all women, regardless of insurance status. CNMs and collaborating obstetricians are available in the hospital at any time a patient arrives. Expectant mothers may choose a delivery primarily attended by a midwife or an obstetrician. (According to strict guidelines, the midwives consult, co-manage or transfer care to the obstetrician if high-risk issues develop.) The primary objective is to ensure that all patients have the chance to choose the type of labor and delivery care they want, with the safety afforded by round-the-clock support services such as anesthesia, pediatrics, perinatology and specialized nursing care.

In addition to its use of CNMs, MGH has launched several other initiatives to improve maternity and pediatric care. The hospital has one of the lowest C-section rates in the country, and one of the best VBAC rates, as well. Out of 1,349 births at the hospital last year, the total C-section rate was 23.9%--a figure that includes high-risk pregnancies. The national rate is 31.3%. Even better, NTSV (nulliparous term singleton vertex) births--which are a better gauge of controllable C-section rates because they exclude women who have a higher chance of scheduled C-section due to twins, breech or a previous C-section--are just 20.3%. In addition, the VBAC (vaginal birth after cesarean) rate at MGH for all women with prior C-sections was 29.9%, more than three times the national average.

In keeping with the World Health Organization’s Baby Friendly Hospital Initiative, MGH has adopted several new policies, including:

•  No elective deliveries prior to 39 weeks, in compliance with Joint Commission standards.
•  Delayed bathing and weighing of newborns to accommodate immediate skin-to-skin contact of non-distressed infants, which has been shown to have significant benefits both in maintaining infant body temperature and helping with the initiation of breastfeeding.
•  Consistent emphasis in the outpatient and inpatient prenatal programs of the benefits of breastfeeding. MGH has achieved an exceptional 99% breastfeeding initiation rate at discharge.

MGH has pediatric hospitalists available 24/7 and extra support when needed from UC San Francisco. In fact, UCSF and MGH pediatric specialists collaborate to establish best practices, with a multidisciplinary review of all cases to improve care, including a focus on optimal pediatric pain management. MGH participates in the California Perinatal Quality Care Collaborative and adheres to the standards set by California Children’s Services for Community Hospitals. Parents can count on having their infant, child or teen appropriately attended by a pediatric specialist.

Finally, MGH has teamed up with UCSF to provide expanded services and expertise for our neonatal and pediatric patients closer to home in the newly founded UCSF Benioff Children’s Hospital at Marin General Hospital. This collaboration includes UCSF neonatologists onsite at MGH, a prenatal diagnostic center staffed with specialists in high-risk obstetrics, and access to all the resources of a top-ranked children’s hospital. It also includes a specialty clinic nearby with experts in pediatric cardiology, gastroenterology, neurology, pulmonology, orthopedics and eating disorders.

Although only a small percentage of mothers and infants require the highest level of care, transfer to UCSF can be accomplished quickly and seamlessly through the established close collaboration of the two institutions. For preterm babies 32 weeks and above, MGH’s own Level II neonatal intensive care unit provides advanced care, including such therapies as high-flow nasal cannula for preterm infants, a therapy that is more often found in Level III NICUs.

The programs described above provide the quality assurance Marin families deserve. MGH has all the resources in place to provide both the experience patients want and the expertise they need for optimal labor, delivery and pediatric care.

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Ms. Matteo, a certified nurse midwife, directs midwifery services for the Prima Medical Group.

Email: Smatteo@primamedgroup.com