 And with great honor, introduce our speaker today for our presentation. Julia Van Ulfenfer is a professor emerita and is the founder of the Nurse Midwifery Education Program in the School of Nursing at Shenandoah University in Winchester, Virginia, where she was a program director for 20 years. She received her bachelor's degrees in special education from Virginia Commonwealth University and in nursing from University of Virginia. She completed her master's degree in nurse midwifery at Georgetown University and her PhD from George Mason University. Her dissertation was titled, The Caring Relationship Between Midwife and Woman During Childbirth. During her 14 years as a midwife caring for women at home, she also started an in-hospital not-for-profit perthing center. Pretty great. Over the years, she was appointed by three of Virginia's governors to serve on committees were focused on increasing access to maternity care for those living in Virginia's rural areas while serving as program director at Shenandoah University. She taught her students to use the Optimality Index US to recognize and implement evidence-based practices based in evidence to promote optimal outcomes that would facilitate physiological childbearing. She later published a study that assessed the feasibility of using this instrument for education and training as well as maintaining its original function as a performance measurement tool. Using the Optimality Index US to teach midwifery students to recognize and implement evidence-based practices that promote optimal outcomes and perinatal health. So with that, again, it's my honor to introduce Juliana in her presentation. So hi, I assume you can hear me now, right? Cindy, are you able to hear me? Yes, I'm making you presenters, just kidding. Okay, and then I'm going to click for the slides to go or you are? Yep, that will be you. That will be me and I just use my computer as normal to do that. Yeah, good to go. Good, good, good. Okay, well, hello, everyone. I'm very honored to be here and always excited to talk about one of my favorite topics, this research tool, which is the Optimality Index. And I'm not going to introduce myself any further, but I will tell you that what I really want to do is weave a story of how a research tool can be altered or not altered, but enhanced really to be a teaching tool. So my goal is that all of us, all perinatal providers together can create the safety and the energy and the possibilities for women to experience optimal physiologic job-bearing. Okay, let me go here. All right, quickly the outline for this talk, I'm just going to acknowledge a few people on some foundational publications and introduce the Optimality Index, which is a performance measurement tool that can measure the way we care through our touch, which is our clinical practice and our measurement and our teaching. And I'm going to relate Optimality to physiologic child-bearing. And then I'm going to narrow down and go into a problem statement. And I'm going to show how the enhanced scoring system of the Optimality Index transformed it into a teaching tool. I'm going to introduce the scoring system and the Optimality Profile that goes along with it. And then we're going to do a case study together using that enhanced scoring system and we're going to create the Optimality Profile together. Just a little bit of acknowledgement here. I can't go through any talk without giving special thanks to Doctors Murphy and Fullerton, who were the creators of the original Optimality Index US. They and the Optimality Index Working Group really did make this tool possible in our country. But then a very, another special acknowledgement and thanks and gratitude is to Dr. Therese Weehers, who is the person who started with the Optimality Index back in 1996 because of her frustration that the quality of nitwit pre-care was not being adequately studied when we use rare adverse outcomes like maternal mortality and infant mortality and things like that. What we really needed to do was we needed to study the way midwives care and she coined the term maximum outcome with minimum intervention as the nature of perinatal optimality. And then some midwives in the Netherlands continue to update the OINL and in 2015 and then validated it in 2018. And so I'll be using the OI US just because I'm from the US and it was culturally appropriate to do that. Okay, here are some of those wonderful, wonderful foundational documents that really created the Optimality Index. And I sort of like to look at this like the Optimality Index, NL, US, Turkey and UK. There's a four of them are sort of nestled on these long standing visions that childbearing people, women had had and also their midwives had. And so I sort of always like to talk about this, the background. And so in 2010, childbirth connections, I'm sure that there's some people here that have made themselves familiar with childbirth connections. They wrote a 2020 vision for high quality women's maternity care and really talked about it being woman-centered and safe and effective and timely and efficient and equitable. And then in 2018, the National Partnership for Women and Families followed and updated that vision and also added strategies to promote and provide and protect physiologic childbearing across all sectors of the healthcare system. So I actually use their strategy too, which was calling for advancing the use of performance measurement instruments, but I sort of advanced it as a teaching tool to encourage clinicians to perform perinatal evidence-based practices. And then helped by the NPWF and childbirth connections was Sarah Buckley, who wrote a beautiful and comprehensive trustees on the hormonal physiology of childbearing. And it should be in every midwife's hands for sure and in every perinatal provider's hands. It has given a lot of meaning to the OI and I believe that the two should go together in a wonderful required course taught by midwives to all perinatal providers, but that's just me. So anyway, in 2014, Lancet produced a series of midwifery care and called for a transition from the fragmented care that focuses on pathology to care that focuses on skilled interdisciplinary care that supports normal reproductive processes. The series recommended a quality maternal and newborn care framework, and I'm happy to say that the optimality index fits into the education, assessment and planning and promotion of physiologic childbearing components of that framework. Finally, the World Health Organization who advises us how to care for the world's health has told us that midwifery care has improved over 50 perinatal outcomes. The OI directly addresses 30 of these and it's associated with more. So to summarize, our use of the OI as a teaching document can propel the system into an action-packed setting for transition that guides all providers to change the way we care so that mothers can achieve maximal outcomes with minimal interventions. So a little bit about optimality and physiologic childbearing. I'd like to compare this to breathing, breathing which is a normal physiological event. Right now I'm breathing optimally. I have no devices that I need to breathe or medicines or anything that I need to breathe. So I'm breathing with minimal intervention and maximal outcomes, which is the way I'm breathing is maximal with minimal intervention summarizes optimal physiologic childbearing also when interventions increase, the optimality decreases and when interventions decrease, then the optimality increases. Of course, we want to talk about normal physiologic childbearing but what we're talking about here is achieving normal as optimally as we can. Minimal interventions for maximal outcomes. Now let's narrow down then to that problem statement. Clinicians are generally lead the healthcare system in implementing evidence-based care but right now we need mid-wide clinicians that can lead us towards practicing evidence-based care for physiologic childbearing because we're better equipped to adopt these real innovations into our routines while providing care. But on the part of the perinatal providers, there's a lack of knowledge about physiologic childbearing, a lack of time to learn the skills and a lack of administrative support to learn them also. And that poses a significant barrier to their adoption but midwives are in a position to lead here with performance measurement instruments in hand that teach while they measure, we can overcome those shackles of lack of time, lack of knowledge, lack of skills and lack of support. So we're on our way, okay? So what does the optimality index help us do? Well, it helps us recognize in practice, evidence-based practices for physiologic childbearing. It also helps us eliminate interventions safely and it guides reflection before, during and after care. So let's move on. I've got a lot to cover so I wanna make sure I have it all in front of you. Let's move on and immerse ourselves in the inner workings of the OI. I just had to put this slide up again because I'm really proud of that statement there, okay? Here we go. The OIUS has two indices with a total of 56 items. Index one is the perinatal background index. It has 14 items that pertain to potential risk factors or risk markers from a client's history and it is scored separately from the optimality index. And if you wanna look at it as a relationship, which I always look at that as a relationship with midwife and woman, is the perinatal background is what the woman brings into the relationship. A little bit about her so that we can look at that and see how we can help her have the most optimal outcome. Second index is the optimality index. It has 42 items that pertain to a collection of perinatal evidence-based practices and optimal outcomes in four domains. Present pregnancy, parturition, newborn condition and mother's condition. These four domains are the essence of the enhanced scoring system that will turn this into a teaching tool. There's dichotomous questions in the OIUS requiring a yes and no answer expressed as one and zero. But though the scores look the same between the two indices, they definitely have major different meanings and that's what I'm gonna talk about right now. The perinatal background index presents risk markers as I told you and a zero means that the item, one of the 14th item that's being scored has one of the risk markers. So it's a zero. A one means no, the item that's being scored doesn't, the woman does not have that risk marker. So the higher the score for the perinatal background index, the better her risk assessment is. With the optimality index items, zero means no, the items perinatal evidence-based practices were not performed or the items optimal outcome is not present. A one says yes, the items perinatal evidence-based practice was performed or the optimal outcome is present. There's other scores, seven, eight, nine, they don't tally into the final score and they make the tool look really condensed for this viewing. So I omitted them but those are basically missing items for various reasons. So I just put them down there at the bottom and when I show you the actual tool, they won't be on there just so we can see the tool better and focus on the right things at this point for this talk. So now I'm gonna talk about the actual enhanced scoring system. So the perinatal background index score and the optimality index score are two scores that make up the original scoring system. But when we go to the enhanced scoring system, what you see there is you see the perinatal background index score, you see the optimality index separated into those domains and then you see the summative optimality score. So by separating but score out and scoring each domain, we get a better picture of how this pregnancy and how the labor and delivery and the postpartum are progressing and we can step in. When we see something happening, we can quickly move into a short feedback loop and talk together about how to strategize to improve the optimality at this moment, at her moment in time. So the perinatal background index back on that just real quickly, it measures percentages of maternal and fetal risk markers and it's asking us to compare groups, aggregates, groups of midwives, groups in different regions, aggregates. And if they have, if these groups have similar perinatal background index scores, then we can compare their optimality index scores and the greatest thing there is we can look at a midwifery practice and compare their outcomes with those of a physician as long as their aggregate PBI scores are similar. This might give information on how medical practitioners and midwifery practitioners respond to the person that is coming into the relationship with them. We can also look at midwifery practices serving clients who are considered marginalized and see how we can help them facilitate greater optimal outcomes or equal optimal outcomes for their clients as those in another practice that serves clients who are not marginalized. So we have a really great direct pathway through the perinatal background index to look at how we can make some changes in providing better care for all those who need it. Okay, here's the case study. Let's start on it. So Maria is a 16 year old Panamanian woman. She's a gravita two, pair 1001. She's unmarried and she has one child who is 16 months old. Risk pregnancy is that term. There are four risk markers that have come up in this perinatal background index. One is she's not married or in a consensual relationship. She is of a marginalized population and she's an adolescent and also marginalized for that. And her inter-pregnancy interval is less than 18 months. So she has four risk markers but looking at it at a positive in a positive slant, she's got 10 that are not risk markers. So her score is 10 out of 14, which gives her a percentage of 71%. So let's see how this plays out in the actual tool. Now, as you can see, you can see why I left out the seven, eight and nine and the other questions that we had to get out of here because it's really the zero and the one that we're looking at scoring. So on the left side and left column, you can see the number of the item and then you see an E and an N and an E represents essential items, those that have to be scored in order for us to consider the tool completely scored. The non-essential items are those that we can do without but yet are part of the tool. So you see that Maria, since she's not married and she's of a marginalized population, she has those two risk markers marked down but then we go into this great road here of she doesn't smoke and she doesn't use alcohol and she doesn't use drugs and her pre-pregnancy BMI was great. And so her and her age is, you know, she's a teenager. So that has put her in a risk marker there but she doesn't have any pre-existing major chronic diseases. So she's looking real good right now. Let's go on to the next page of this. Each slide doesn't, you know, that's all a single page but I had to break it up into slides. You see the remaining questions of the parenting background index and she has this inter-pregnancy interval of less than 18 months but she doesn't have any previous pre-maturities and no previous intrauterine field deaths and no previous low birth weight and no history of serious antibardom complications. So now let's talk about the optimality profile. That's what we're gonna fill out now. We saw that she had a 71% there in that perinatal out in that perinatal background index and so that puts her entering our relationship at an average risk. Let me explain the grading scale above. It's on a 10 point grading scale that we use in the United States from the International Affairs Office of the US Department of Education and it's a 10 point intervals between the scores. So if you go down to point 50 to point 59, that's a very high risk. If you go up further up, you go the less risk there is. So the higher the score, the less risk there is. So we're talking about just the perinatal background index and we see she's coming to us at a 71% which is an average risk. Now what we want to do is we want to respond to her so that we keep her at least an average optimality. We don't want her to go below. So now our performance, we're measuring our performance. This is a performance measurement tool. So we are going to be doing that right now. We're gonna measure how did we respond to her entering the relationship with us? So we're gonna go now into the optimality index and the first domain is present pregnancy and we see that Maria's first visit was at 28 weeks gestation. That is a non-optimal item. Now we're talking about optimality, not risk but optimal and it's a non-optimal item because her perinatal care wasn't initiated in the first trimester or up to 14 weeks but she's got six optimal items in this present pregnancy. So her score then is six out of seven and her percentage is 86. So let's move and see how it looks like on the score sheet and indeed look at that column with the ones. She's looking very good. Her pregnancy is doing quite well. The only thing is that her prenatal care initiation was not in the first trimester and that's always up for grabs. Lots of controversy about that and it is a non-essential item. Okay, here we go. Here's her score. Present pregnancy in the optimality index domain, she's 86%. She's got high at high optimality. That is wonderful. We're entering parturition with a high optimality for her pregnancy. So that should give us a lot of ideas of how we can respond to her during this time to increase the optimality of her parturition. The parturition, let's go on to that then. The parturition is the longest domain. It's the largest. It has 24 items in it and it is probably the most significant particularly in Maria's history here. She arrived at the hospital with an elderly woman who returned home as she was admitted to the hospital at 3 a.m. with contractions that were about 10 minutes apart. She said they felt like menstrual cramps and amniotomy was performed at 4 a.m. Electronic fetal monitoring was initiated. Her initial vaginal exam at 4.30 was five centimeters dilated, 60% of base and a minus one station. Potosin was started at 5 a.m. An epidural was started at 5.30 a.m. and after laboring in a supine position, Maria was 10 centimeters dilated at 1 p.m. And after two hours of pushing, as coached by an obstetric nurse, she delivered a baby boy at 3.15 p.m. over an apesiodomy that extended to a third degree. The baby was taken to the nursery and then returned to Maria later in the afternoon. So look at those non-optimal items. I'd like to say to you to make, to understand that these are our actions. These are how we performed here. So we broke her bag of waters, augmented her labor, started an epidural, did electronic fetal monitoring. She labored in a supine position. She had no support person that wasn't a member of the staff and she pushed according to the direction of the obstetric nurse and she had an apesiodomy that extended and no immediate skin-to-skin contact and the time between her first digital exam was less and birth was less than 24 hours. Okay, let's see how this looks on the optimality index score. Now for me, when I see this, and I'm sure you'll see this too, is look at the dispersal of the scores on the right two columns. It looks like there's just as many non-optimal there as there are optimal. So yes, but of course we know about the non-optimal ones but her amniotic fluid was clear. That's great. She didn't have any oral or injectable IM or IB medications in the first or second stage of labor. That's great. And she also, her baby didn't have any abnormalities that altered the management of her labor. That's good also. Moving on. She didn't have the presence of a support person during labor other than the care provider. Interesting thing there. That is also controversial and we can talk about that at the end if you'd like. She was directed in her pushing. So that's also not optimal. But what was optimal is that her delivery occurred in a place originally intended at the onset of labor. So she wasn't transferred to any higher risk center. She had a non-supine position but what was optimal is the presentation of the baby was subbalic. And she also didn't have an instrumental vaginal delivery and she didn't have a cesarean section. She did have an epithetomy. It did extend. So it was a difficult perineal situation there. She didn't have any other medication than oxytocin or local anesthetic for perineal repair but she didn't have skin-to-skin contact. But look at that. She didn't have hemorrhage. She didn't have a placental retention. She didn't have an extra blood loss and she didn't have any serious intrapartum complications. That's pretty optimal for her. And so to me, that just shows how strong a human body can be after receiving a lot of non-optimal interventions. Let's go to our optimality profile and look at this. Well, she got 12 out of 24 optimal and that grades her at a very low optimality. So here we can look at this. We could look at it while we're doing it. There's things that we could do to change that. Maybe we can discuss that afterwards. But also when we're doing monthly chart reviews with practices, when we're comparing our practices with other practices, with other regions, everything, we can look at this and go, okay, how did this happen that this average risk went to a very low optimality? And if you'll note back on the, and I'm gonna go backwards on these slides for just a second, is that everything here that she gave to our relationship was healthy. Clear amniotic fluid, no medications, no abnormalities. Those are all coming from her. And also the delivery occurred in the place she originally intended and she didn't hemorrhage. And so the things that were non-optimal there came from the provider. Okay, let's look at this baby. Okay, the baby boy weighed 2,270 grams. She weighed over five pounds and she decided not to breastfeed two non-optimal items, low birth weight and not breastfeeding and the optimality, the optimal items over six. So her score is six over eight. So the baby got a 75% and if we look at it here, we can just see by our eyes that most of the baby's outcomes were optimal. It was a term baby and a half-carb score that wasn't low and no transfer to a high risk neonatal care setting, no congenital anomalies, no birth trauma, let's go on. And even though there's no breastfeeding, which was non-optimal, the baby, there was no perinatal death. So let's go back to that optimality profile. Baby is average optimality. Isn't that interesting? She comes to us with an average risk and the baby has an average optimality. So those two were definitely in sync with each other. Okay, the condition of the mother, let's go to that one. And that was hard. She developed a fever and she was treated with antibiotics and she developed that fever, her infection with her sutures. So there's only one optimal item here and that is that she didn't die. The score is one out of three optimal items and the question is how come there's only three but three are very highly weighted items. Her percentage is 33%. Let's look at those in the score sheet. So the first one is a fever, but it's a fever that's due to cystitis, things like and sutures and endometritis and hematomas and local infections and mastitis. So there's a lot of causes for that fever and also prescription meds for conditions that were newly identified. So that's a large issue also and maternal mortality as you know is major, but she got a low score. She had one that didn't happen to her out of the three and so she came out with a very low optimality. So if we look at this, we've got an optimality index score with low optimality and coming from a woman who came to us in the relationship with an average risk. Right, I'm just giving you a time check. Okay. And what is it, sorry. You have about 13 minutes left in the session. Oh, great, good. Okay. So by measuring together, so we're doing our clinical practice together, we measure together and we teach together. And by measuring together, we can use the optimality index to adjust our strategies to prevent interventions that are not judicious. And we can also detect the optimality of our practices and we can assess achievements that we may have wanted to make if a practice has a low rate of breastfeeding, for example, in their aggregate group, they can do things like say, well, what can we do to raise that basic, that optimal outcome? So what can we do to raise that happening? And so the practice itself looks at the optimality indexes. This is what we'd like to achieve. It looks like we sort of have this low score in this area. Let's see what we can do to improve it. And it also helps us investigate practices that may facilitate or ameliorate systemic racism, discrimination, and geographic isolation. Okay, well, here we are using the OI together as a guide for clinical practice. Together, we do touch. And now I'm gonna talk about you and I. You know, we just witnessed, we just did a birth. We need rest. You're in a midwifery group practice though and the group uses the OI embedded in the woman's clinical plans for her daily care and her monthly plans for her group reflection. Because you're touching, measuring, and teaching together, you can be assured that your partners will continue to use the OI for performance measurement, guiding clinical practice, and teaching each other, women, students, and colleagues while you rest happily. And I know for my many years as a being a midwife, I like to rest happily. So here, what we're looking at is we're looking at what is scoring a system enhancement, how it can help us. Well, we're always learning physiologic child bearing skills, particularly if there's students with us, or if we're modeling, or if there's other healthcare providers with us. It helps us do that. It helps us assess the perinatal background index. Like how should we care when somebody has a perinatal background of a certain number? And it helps us adjust practices in real time and detect items that contributed to the optimality score or took away from it and assess where we can make changes ourselves. And it can highlight recurring patterns of care. How come this particular pattern of care is always happening? Whatever, whether it's optimal or not, what are we doing to make it recurring? And then we can focus on specific evidence-based practices that we would like to prioritize for integration in whatever setting we're in. To Viana, excuse me, I'm just gonna pause here for a second for this, and I apologize for interrupting, but I do wanna make sure that we allow time for questions from the people attending. So if anybody would like to raise a hand or put a question in the chat box, that would be fantastic. Absolutely. These slides will be available to continue to see the slides. And if we don't get any questions, we can certainly try to roll through a couple more. How to go through them some more. Yeah, I think it's great. It would be great to hear from our attendees. Also, I feel as though it's just amazing the amount and how you pointed out that there are 50 outcomes that were improved by this quality. There are 50 outcomes that the WHO has addressed and 30 of those have been addressed by this tool. So pretty fantastic. We did have a comment in the chat. Yeah, why don't we stop now because we can stop now because this is one of my first ending points. So let's just end now. I don't have to read this aloud to anyone, except I'd like to say that we need to focus on work as learning. And we need to use quick assessments and also curriculum embedded lessons when we're doing the OI. And that's it. So are there any questions? And we can go through how we would make it if we were all in the same practice together. How would we respond to Maria's care? It's interesting. And I would ask the audience and also you, Juliana, in terms of setting, right? So this is a U.S. index. And you look at the other index, so there was Turkey and the UK. And so how much is impacted by the setting that somebody like Maria is in as well? Teaching hospital versus private would be interesting to know. Yes, well, the setting is not only impacted by the country that the optimality index comes from, but actually the facility or where this person is giving birth and what provider the person has with them. And so that is something that we look at all the time. The OINL is the one that is most updated and has the Dutch midwives has put a lot of effort behind that optimality index. And it is very similar to the OIUS. There's not a lot of differences between them, but there is always the feedback that we need to look at cultural issues that may come into play with some of the indexes. Like, let's say one is supine position, the non-supine position. So we say that they should be in a non-supine position, but culturally there's cultures that don't do that normally for birth. And I think that needs to be recognized. But what happens is that they are automatically recognized in ways that if everything else is about the same, then that non-supine position is not going to affect the outcome at all. You know, it's not gonna be heavily weighted. Whereas if you do a cesarean section, all the other items are probably gonna follow suit and heavily weight that item. And that's how the differences are shown. But there's many different ways to do non-supine positions as we all know. And so that's the beauty, I think, of an index like this is, yes, did we do the best? Did we have a maximal outcome with minimal interventions? Or no, did we not? And if no, what could we do? So I think you answered actually a question by one of the guests in the chat about how they're different in terms of the countries, but also interestingly, how did you choose and how were the items identified that were actually chosen to be the indicators? They were identified back with doctors Murray and Fullerton when they actually created the optimality index and they created it as a U.S. answer to the original, original optimality index, which was in 1996 from the Netherlands. But they are created through rigid research quality levels where there's either a difficult, there's a difficult way to get evidence that's gonna follow something up like the more the qualitative evidence, that's not gonna be as strong as the evidence that is in the system now to choose the item. Let me go back just really quickly and say that everything that is chosen has been assessed by organizations such as the World Health Organization, the Cochrane Database and all of the organizations that look at quality of research. So one of the questions is kind of in line with the setting idea, which is the model of care as a factor in the index. The model of care is definitely a factor. It is the midwifery model of care. If you look at the physiology in physiologic childbirth, that's midwifery care. We do midwifery care because we believe in the normalcy of a woman's body to be able to give birth in the first place. So the model of care is definitely an issue, but it really shouldn't be. That's sort of where I want to go is I believe that midwife is also a verb. And I believe that, yes, we are midwives and that is my identity, and but we also midwife people through transitions and I believe we as midwives, when we have evidence like this, when we can keep on coming back and saying, this is what happens when we are entering a relationship with a woman, this is what we do, then I believe that the model of care is going to be spread among different perinatal providers. So everyone should be able to practice the evidence-based practices that create the possibility, the safety and the energy and the possibility for women to have the option of having physiologic childbirth. I hope that answered the question. It was sort of a long answer, but... I think that's a beautiful conclusion to your session. I mean, those words are magic to our ears and really important to hear, but also stressing the importance of research tools becoming a teaching tool, which is where this started. So endless possibilities and exciting for those of us who are interested in changing the phase and empowering midwifery certainly. So thank you, Juliana. I know you're welcome and feel free to contact me and I'll be happy to talk about this forever and ever. So...