Angela Anderson Of Intermountain Health On Doctors and Hospital Leaders on How to Improve the Birthing Experience
An Interview With Lucinda Koza
Offer more patient-centered choices in the safety net of the hospital setting.
As a part of this series, I had the pleasure of interviewing Dr. Angela Anderson.
Dr. Angela Anderson is a Certified Nurse-Midwife with Intermountain Nurse-Midwives and has been in clinical practice since 1996. She serves as the Women’s Health Advanced Practice Provider Director for the Intermountain Health Canyon’s Region and the Utah Women and Newborns Quality Collaborative Board Chair. Angela is adjunct faculty at the University of Utah and actively engaged in precepting midwifery, nursing and medical students. She has participated on state and national workgroups with a focus on prevention of maternal morbidity and mortality for the past two decades. She is a strong advocate for supporting patient autonomy and the midwifery model of care.
Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” better. Can you tell us a bit about you and your backstory?
I am a Certified Nurse-Midwife (CNM) in practice for almost 29 years. I practice clinically in Utah at Intermountain Health. I attend births at Intermountain Medical Center and LDS Hospital in the Salt Lake City area. I am also the Advanced Practice Director for Certified Nurse-Midwives for Intermountain Health’s Canyon’s Region which includes most of Utah and some of Idaho. We have more than 50 employed CNMs in Utah and Idaho and more than 40 employed CNMs in Colorado and Montana and our midwifery team continues to grow! Intermountain has 20 hospitals with labor and delivery units in Utah with an additional 9 labor and delivery hospitals in other states including Colorado, Idaho and Montana.
In addition to my day job, I am the board chair of our state perinatal quality collaborative, the Utah Women and Newborn’s Quality Collaborative (UWNQC). UWNQC’s mission is to improve outcomes for women and babies in our state. I am also a member of the State of Utah’s Perinatal Mortality Review committee. I have participated on national committees focusing on maternal morbidity and mortality as well. I am Perinatal Mental Health- Certified and have a special interest in that area.
I came to midwifery organically; I grew up on a sheep farm in Ohio and fell in love with birth as a child. During the lambing season, I would sleep in the barn so I wouldn’t miss any lambs being born. I always knew I wanted to be involved with birth. I came to midwifery when I was pregnant with my first child and was pre-med in college. There was a program that provided lower cost midwifery care to university students. In getting my own prenatal care, I realized that the midwifery model resonated more with me than did the traditional obstetric model.
Before we go further, I do want to acknowledge that not all people who give birth or choose to parent identify as women or mothers, but for our conversation today, I will use these terms interchangeably and I mean no disrespect.
From your perspective, what are some of the most significant challenges in the birthing experience today? What aspects do you believe need immediate improvement?
There are disparities in access to quality maternity care, with significant differences based on race, socioeconomic status, and geographic location. High costs and a mismatch between the care women expect and what they receive contribute to poor outcomes, especially for marginalized communities. The U.S. has one of the highest maternal mortality rates among developed countries. The highest rates of maternal morbidity and mortality are experienced by Black women, Native American women and women in rural areas.
Up to 20% of women experience perinatal mood and anxiety disorders. These conditions significantly impact the well-being of women, their families and communities. Unfortunately, a majority go unidentified and untreated.
Lastly, the 2023 total Cesarean birth rate in our country was at an all-time high at 32.4%, with the primary Cesarean rate at about 23%. It has risen steadily since the 1970’s without a concurrent improvement in outcomes for babies. There are disparities in regard to Cesarean rates as well, with some hospitals, healthcare systems and geographic areas having much higher Cesarean rates than others. In Utah we are fortunate to have lower Cesarean rates than most of the rest of the country. At Intermountain, our 2023 rates for total and primary Cesareans in Utah and Idaho were 25% and 15.7% respectively. And while I could easily do a separate interview on each of these individual challenges, the truth is that they are all intertwined.
Improving access to quality care is the most pressing need, in my mind, and would address many of these challenges. Integrating midwives more widely into our US healthcare system is one approach to improving access that would lead to better patient satisfaction and outcomes.
How do you approach creating a more patient-centered birthing experience at your hospital? Can you share a specific example?
At Intermountain Health, we conducted focus groups with women and families to hear what options they wanted during birth. In response to the themes identified from these conversations, we have a number of patient-centered options that are available at some of our hospitals. Expansion of these programs to more hospitals is underway. They include Simply Birth, waterbirth, nitrous oxide for pain relief in labor, Family Friendly Cesarean Birth and group prenatal care.
Simply Birth is a program that is offered at a number of our hospitals for women who are looking for an unmedicated birth experience. Simply Birth has a childbirth education piece that is designed to help women prepare for unmedicated birth. The Simply Birth program ensures that the room, environment and care team are prepared to support unmedicated birth.
What steps can healthcare professionals and hospitals take to ensure that the emotional and mental well-being of mothers is prioritized during and after childbirth?
It is crucial that women are screened for Perinatal Mood and Anxiety Disorders (PMAD) throughout the prenatal and postpartum periods. In addition, women who experience these conditions must be connected with resources and support. Intermountain has a number of programs in place to provide care for behavioral health conditions, including Mental Health Integration where behavioral health providers are present in clinics, Behavioral Health Collaborative Care which we have in my own practice, where we combine the expertise of a licensed clinical social worker to provide therapy and psychiatry oversight in a program aimed at helping women get better. We also have Behavioral Health Connect Care which is a telehealth service and Behavioral Health Access Centers where women in crisis can go for onsite care on a walk-in basis. UWNQC has an online Maternal Mental Health Toolkit full of resources for women, families and providers.
Are there any innovative practices, technologies, or policies that you believe can significantly enhance the safety and comfort of the birthing process?
Midwifery is an ancient profession but still the idea of bedside labor support can be seen as innovative by some. Providing bedside labor support has been shown to increase patient satisfaction with their labor experience and reduce the Cesarean rate. Providing doula services is another avenue for providing bedside labor support.
Let’s move on to the heart of the discussion. Can you please share “5 Things That We Can Do to Improve the Birthing Experience for Mothers”?
1 . Optimize health before pregnancy whenever possible. Ask women if they are planning a pregnancy in the next year or two when they are seen for annual exams, pap smears and other medical visits. If they answer yes, be sure they are taking a prenatal vitamin, discuss healthy lifestyle choices and avoidance of practices that could be detrimental to pregnancy. Adjust or change medications that might not be safe in pregnancy. Work to get chronic conditions under control like hypertension or diabetes to make pregnancy safer for both women and babies.
At Intermountain, we have a great program, the PrePPARE clinic which stands for pregnancy, preparation, prevention and risk evaluation and is run by our maternal fetal medicine team. It aims to help women who have high risk medical conditions understand their specific risks and to help them optimize their health prior to pregnancy.
2 . Listen to women. Ask women about their preferences, concerns and fears about birth and really listen. Understand what is important to them as individuals. In the Listening to Mothers surveys which began in the early 2000’s and continue today, women who felt listened to and respected by their healthcare providers reported better overall experiences. We encourage women to come to their prenatal visits with a list of things that they want to talk about, in addition to the things we want to teach them.
3 . Treat women with respect. Respectful maternity care (RMC) is a fundamental human right that emphasizes the dignity, autonomy, and preferences of birthing individuals. RMC stresses that privacy is maintained, care is equitable, and women are protected from harm or mistreatment. Shared decision making between patients and providers includes informed choice and consent prior to any procedure. Another of the RMC tenets is offering continuous emotional and physical support during labor and birth. Research in this area indicates that continuous labor support also reduces the Cesarean rate. Our Intermountain midwifery group practices have a commitment to bedside labor support. We work closely with the nurses on our labor and delivery units to provide this type of support to women and their families. My own group, Intermountain Nurse-Midwives, has maintained a primary Cesarean rate of under 10% for the past 20 years. We are very proud of our outcomes.
4 . Provide trauma informed care. Trauma-informed care (TIC) is an approach to healthcare that recognizes and responds to the impact of trauma on individuals. It focuses on promoting safety, transparency and empowering the individual. And while this goes hand in hand with RMC, it includes acknowledging the impact of past traumatic experiences. Screening for Adverse Childhood Experiences (ACEs) during prenatal care can help identify those who have experienced trauma as children as well. TIC may also help prevent or mitigate perinatal trauma. It is estimated that a third of U.S. women perceive events during their birth or postpartum period as traumatic. Even with good outcomes it is possible for a woman to experience birth as a traumatic event. UWNQC has a birth trauma resource page which can be very helpful for individuals, families and providers.
5 . Offer more patient-centered choices in the safety net of the hospital setting.
Referring back to the focus groups that Intermountain conducted, we know that women and families are looking for more patient-centered choices in the hospital setting. In addition to Simply Birth, another service that was often asked about was waterbirth. While waterbirth is widely offered in other countries, we have been slower to adopt this option in hospitals in the U.S. It does tend to be more prevalent in the out-of-hospital birth setting in our country. Prior to implementing waterbirth as a regular service at Intermountain, our practice conducted an Institutional Review Board approved study. When we were able to demonstrate good outcomes and patient satisfaction, we were able to take the next step of moving beyond the study to offer waterbirth as a regular service in one hospital, with more to come.
How do you ensure that there is effective communication between healthcare teams and expectant mothers to reduce anxiety and build trust during labor and delivery?
When a woman comes into labor and delivery we write her preferences on a whiteboard in the room. In addition, if she has prepared a birth plan with her preferences, we make sure that everyone on the team reads it. We discuss her preferences with her. Our Intermountain teams give bedside report. When shifts or providers change, we have that conversation at the woman’s bedside so that the woman and her family can speak up to add any information they think is important or correct any misinformation they perceive. I think these practices help to build trust and reduce anxiety.
Do you think that there are ways in which hospitals or healthcare systems might unintentionally contribute to negative experiences for mothers, and how can they be addressed?
There is sometimes a delicate balance to maintain between patient preferences and hospital policies. For example, in our hospitals it is the policy that women choosing to attempt a VBAC, vaginal birth after Cesarean, have continuous electronic fetal monitoring in active labor. That policy exists to promote safety and help identify a uterine rupture if it occurs. If a woman’s preference is intermittent monitoring throughout her labor, then we must have a conversation about the rationale for the policy and in this case, the medical intervention and engage in shared decision making. Sometimes our patients make choices that we as medical professionals wouldn’t make for them but if we give women and families the information they need to make those choices, the choices are theirs to make.
Balancing the medical needs of childbirth with the personal wishes of expectant mothers can be complex. How do you navigate this balance, and what advice do you have for other healthcare providers facing similar challenges?
Shared decision making is key. Providers may worry about their own liability if women are making choices that they feel are not medically sound or safe. Shared decision making in the hospital setting is a collaborative process where healthcare providers and patients work together to make healthcare decisions. This approach ensures that medical decisions align with the patient’s values, preferences, and individual circumstances. Often, a common understanding can be reached. Documentation of the discussion of risks, benefits and the ultimate patient decision in the medical record can help providers to feel safe in these circumstances.
Wonderful. We are nearly done. Is there a person in the world, or in the US, with whom you would like to have a private breakfast or lunch, and why? He or she might just see this, especially if we tag them.
I would love to talk to Melinda French Gates about her philanthropic work.
If you could start a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂
I’ll take a quick step out of the birth environment here but stay in the realms of Women’s Health and midwifery. We know that group prenatal care improves outcomes for women and babies. I would like to see a movement for group menopausal care. Perimenopause and menopause can be a challenging time for women emotionally, physically and mentally. I think the group care format would be an excellent way to promote health and well-being for this group of women too.
How can our readers follow your work online?
Thank you so much for joining us. This was very inspirational.
About the Interviewer: Nancy Landrum, MA, Relationship Coach, has authored eight books, including “How to Stay Married and Love it” and “Stepping Twogether: Building a Strong Stepfamily”. Nancy has been coaching couples and stepfamilies with transformative communication skills for over thirty years. Nancy is an engaging interviewer and powerful speaker. Nancy has contributed to The Washington Post, Huffington Post, Authority, Medium, Yahoo, MSN, Psych Central, Thrive, Woman’s Day magazine, and more. Nancy is the Founder of the only one of its kind online relationship solution, www.MillionaireMarriageClub.com. Nancy coaches couples across the globe in person and via Zoom. Nancy’s passion is to guide couples and families to happy lasting marriages where children thrive and lovers love for life.
Angela Anderson Of Intermountain Health On Doctors and Hospital Leaders on How to Improve the… was originally published in Authority Magazine on Medium, where people are continuing the conversation by highlighting and responding to this story.