Science & Sensibility

By Geradine Simkins, CNM, MSN, Executive Director of Midwives Alliance of North America

This week, the American Academy of Pediatrics released a policy statement on home birth. While the statement affirmed “the right of women to make a medically informed decision about delivery”, many advocates expressed concerns. The statement failed to recognize Certified Professional Midwives, the providers most likely to attend a home birth in the United States. In this response, the Midwives Alliance of North America helps families, providers, and policy makers understand the critical role CPMs play in safe, healthy birth options. – Sharon Muza, Community Manager, Science & Sensibility

High-quality out-of-hospital newborn and postpartum care is standard for midwives

 

The Midwives Alliance of North America welcomes the primary concept communicated in the American Academy of Pediatrics’ April 24, 2013, policy statement entitled “Planned Home Birth.” As should be expected, AAP reminds its practitioners that newborn infants—regardless of the setting in which they are born—deserve an equal and unbiased, high-quality standard of care. The Midwives Alliance joins with AAP in affirming the need for a collaborative and integrated maternity care system that addresses the needs of all mothers and infants, regardless of the provider type or birth setting a woman chooses.

We are disappointed, however, in AAP’s decision to align with the American Congress of Obstetrics and Gynecologists’ policy on home birth. Serving the needs of the growing number of families choosing to birth at home, Certified Professional Midwives attend the majority of intended home births in the U.S., when a skilled attendant is present, making them the primary care providers for newborns in the home setting.

Certified Professional Midwives are skilled maternity care providers

AAP’s itemized recommendations for infant and newborn care, contained in their policy statement, are standard practice for credentialed midwives. In that respect, we find much with which we agree. These standard newborn exams, screens, and preventative care practices are wholly part of a credentialed midwife’s scope of practice, and further endorsed by individual state health departments. We also note that as AAP Neonatal Resuscitation Program certificate holders (required for certification and recertification), credentialed midwives follow guidelines laid out in AAP’s recommendations, and typically surpass those standard recommendations by having at least two NRP- and CPR-trained attendants at out-of-hospital births.

In fact, the AAP’s guidelines for the care of infants intentionally born at home parallel those standards practiced by trained midwives in all birth settings. The practices listed—such as working medical equipment, emergency plans of transfer, thorough newborn exams, and so forth—are professional standards exhibited and documented by credentialed midwives, regardless of the place of birth.

The AAP policy statement, however, did not recognize or acknowledge Certified Professional Midwives (CPM), indicating that AAP may not have a thorough understanding of the training, skills, knowledge, and abilities of this country’s primary maternity care provider for infants born out of the hospital. The Certified Professional Midwife is the only national midwifery credential that requires practitioners to be trained specifically to provide prenatal, intrapartum, and postnatal care in out-of-hospital settings. CPMs are knowledgeable, expert and independent midwifery practitioners who have met the standards for certification set by the North American Registry of Midwives (NARM). NARM is accredited by the National Commission for Certifying Agencies (NCCA) to issue the professional credential of Certified Professional Midwife, which is the same agency that accredits the American Midwifery Certification Board to issue the professional credentials of Certified-Nurse Midwife, and Certified Midwife.  

Midwives are the providers of choice for out-of-hospital births, whether they occur at home or in freestanding birth centers. Offered since 1994, the CPM is currently the basis for licensure in 27 states while 11 additional states are actively seeking CPM licensure. In fact, one in nine newly certified midwives in the U.S. are Certified Professional Midwives.  

The AAP policy statement endorses birth center maternity care, which is another area in which we are in agreement. Recent numbers from the American Association of Birth Centers (AABC) indicate that a significant proportion of accredited birth centers are owned and operated by Certified Professional Midwives. A January 2013 study, The National Birth Center Study II , conducted by AABC and published in the Journal of Midwifery & Women’s Health, the official journal of the American College of Nurse-Midwives (ACNM), highlights the benefits for women who seek care at midwife-led birth centers. Findings also reinforce longstanding evidence that providers at midwife-led birth centers provide safe and effective health care for women during pregnancy, labor, birth, and the postpartum period.  

Midwives provide high-quality care that meets both national and international guidelines 

In highlighting the ethic of high-quality care for all infants across the spectrum—regardless of the site of birth—it should be noted that Certified Professional Midwives provide care intentionally similar to that of nurse-midwives and physicians. Yet we also know that CPMs are able to offer additional and valued care in terms of frequency of home visits and intense monitoring of newborns in their homes in the first weeks of life—a benefit not normally conferred to women and babies who have experienced hospital births.

This high-quality midwifery care includes routine newborn APGAR assessments, comprehensive head-to-toe physical examinations, measurements of length, head, abdomen and birth weight, monitoring vital signs including thermoregulation, assessment of respiratory sounds and patterns, assessments of cardiac sounds and peripheral pulses, assessment of gestational age and physical maturity, neuromuscular assessments, and assistance with initiation and ongoing assessment of breastfeeding. All findings are recorded in patient records and shared with mothers, per professional standards.

In addition, CPMs provide newborns with Vitamin K treatment, antibiotic eye ointment, umbilical cord care, metabolic newborn screening, glucose and bilirubin testing as indicated, and either perform Otoacoustic Emissions (OAE) hearing screens or refer to area audiologists. Midwives in a number of states are moving toward, or already offering, pulse-oximetry screening for Critical Congenital Heart Defects (CCHD) per AAP guidelines, in advance of many hospital systems. In the rare cases when newborns require consultation or referral, infants are transferred to the tertiary care system, and pediatricians where available, for active management.

Not only do Certified Professional Midwives and Certified Nurse-Midwives who attend home births provide the level of care outlined by the AAP, they provide it in a personalized, woman-centered, family-centered, culturally competent, and individualized manner that is qualitatively different from the customary assembly-line postpartum care commonly experienced in U.S. hospitals.

For example, in a home birth setting, the midwife typically conducts the initial newborn exam in the presence of the mother and family, which does not disrupt the crucial process of mother-infant bonding and breastfeeding, and is focused on being instructive to the family. Midwives provide holistic care to the mother-baby dyad in concordance with World Health Organization’s Baby-Friendly best practices.

As a way of illustrating important differences in care practices, we can point to the recent Breastfeeding Report Card issued by the CDC (2012) that indicates only six percent of U.S. hospitals are offering care that aligns with the international best practices outlined by Healthy People 2020.   By contrast in a 2005 study, 95% of babies born at home under the care of Certified Professional Midwives were exclusively breastfeeding at six weeks of age (Johnson & Daviss, 2005). This is just one area where midwives are well-trained, skilled, and uniquely positioned to help families succeed.

An opportunity for collaboration and integrated care 

Physician conversations about home birth and midwife-led birth will be better informed and more useful to maternity care consumers if AAP is able to become more cognizant of important changes in the landscape of U.S. midwifery. 

The release of the AAP policy statement on care of newborns born at home is an opportunity to reinforce the need for professional and seamless collaboration with members of community health care teams. We view this statement’s release as an opportunity to align best practices for all parties who care for and support families choosing home birth.

The Midwives Alliance stands ready to work with other pediatric and maternity care providers to establish best practices in the postpartum period to not merely provide the basic level of care in the first hours, days and weeks of life for the newborn as outlined in the latest AAP statement, but to elevate that standard to include support for breastfeeding and the personal attention that can prevent infant death and improve maternal and child health.  Babies born in all settings deserve this kind of care.

About Geradine Simkins

Geradine Simkins, CNM, MSN is an activist, midwife and author. She began as a direct-entry home birth midwife in 1976 and became a nurse-midwife twenty years later. For over thirty years she has provided health care for women, infants and families in a variety of settings, including attendance at births in the home, a freestanding birth center, and hospitals. Geradine’s work with migrant farmworkers and American Indian tribes focuses on addressing health care disparities and engendering a more equitable maternity care system for all women and infants.  Geradine is currently the Executive Director of Midwives Alliance of North America, a professional organization that promotes excellence in midwifery and is dedicated to unifying and strengthening the profession, thereby increasing access to quality health care and improving outcomes for women, babies and their families. She is the editor of the recently published book entitled Into These Hands: Wisdom from Midwives, an anthology of the life stories of 25 remarkable women who have dedicated their lives and careers to the path of midwifery and social change.  More info about Geraldine Simkins can be found here.

Sharon Muza ACOG, American Academy of Pediatrics, Babies, Delayed Cord Clamping, Home Birth, informed Consent, Maternity Care, Midwifery, Transforming Maternity Care AAP, ACNM, ACOG, CNM, CPM, Geraldine Simkins, Home Birth, MANA, Midwifery Care, Midwives Alliance of North America, newborn

by Wendy Gordon, CPM, LM, MPH, MANA Division of Research, Assistant Professor, Bastyr University Dept of Midwifery

Today, occasional contributor, midwife and researcher Wendy Gordon, LM, CPM, MPH, Midwives Alliance Division of Research, shares some insights into some of the fascinating discussions that took place at last week’s Institute of Medicine’s workshop focusing on birth place settings.  From all reports from the many people in attendance, this workshop will hopefully help move the research and discussion on the topic of birth place settings forward and create opportunities for more families to chose to birth where they feel most comfortable and safe. – Sharon Muza, Community Manager, Science & Sensibility

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Last week marked an historic opportunity for maternity care providers to regroup and become inspired to move our professions forward together in all birth settings.  The two-day event, hosted by the prestigious Institute of Medicine (IOM) and sponsored by the W.K. Kellogg Foundation, focused on “Research Issues in the Assessment of Birth Settings” and brought together the greatest minds in research and practice in all three birth settings: home, birth center and hospital.  Issues of tremendous importance to consumers, providers and researchers in the birth community were discussed in a collegial and inspiring manner… marred only by one presentation that stirred a bit of controversy.

Historic Workshop Can Positively Impact Future Research 

Similar to the first IOM conference on this topic over 30 years ago, the intent of last week’s gathering was to discuss the research regarding the effect of place of birth on maternal and infant outcomes. Invited speakers included researchers, public health professionals, midwives, nurses, pediatricians and obstetricians.  In structured mini-sessions, panelists shared their expertise on the following topics:

• the historical and current picture of who is giving birth in the different settings;
• definitions of “low-risk” versus “high-risk”;
•  what the best research says about safety in various settings; 
• education, regulation and management of different types of providers;
•  methods of collection and use of data regarding maternity care and birth in various settings; 
•  cost and value differences between settings and reimbursement issues; and 
• the rich and varied perspectives of providers in the three childbirth settings.

Members of the audience were just as impressive as the panelists themselves when, at the end of each panel, the microphone was opened and significant content was added through their questions and comments.  

A lot of ground was covered over the course of the two days, and there were several takeaways that had particular impact for the midwifery community. The home birth rate in the U.S. was predicted to continue its rise with the next release of CDC data, reaching about 31,500 births nationwide in 2010. The MANA Stats web-based system was touted by attendees as the best data collection system for home birth outcomes.  Birth certificate data was shown to still have major problems in its ability to accurately capture intended place of birth and other reliability issues, despite improvements in recent years.  A Medicaid study from Washington State demonstrated vast cost savings with midwifery care and birth at home and in birth centers.  The workshop report will have tremendous potential to impact contemporary birth policy and research agendas.

Lack of Consumer Representation and Little Discussion of Health Disparities

There was no consumer representation on workshop panels, nor was there a panel addressing disparities in maternal and infant outcomes, which seems to have been a grave oversight of the organizers.  In the 30 years since the last IOM workshop on birth settings, overall infant mortality has been reduced from 11.5/1000 to 6.7/1000, but the black-white gap has actually increased. In 1982, nearly twice as many babies born to black mothers than white mothers died before their first birthday (19.6 infant deaths per 1000 births vs 10.1/1000; National Center for Health Statistics, 1986). Recent mortality figures show that disparity to be even wider (12.67/1000 vs 5.52/1000; Mathews & MacDorman, 2012).

With childbirth in home and birth center settings gaining momentum nationally and at the state level, research to support policy in this direction is more important than ever. The best research has shown for decades, and continues to show, that for women with low-risk pregnancies, birth that is planned to occur in the home and birth center settings with a skilled midwife is no more risky than birth in the hospital and results in far fewer interventions, lower cost and higher satisfaction (Vedam et al, 2012).  Hopefully, the breadth of this research can finally start to expand beyond proving that it is safe.

‘Recrudescence’ Revisited

Despite this body of literature, there are still some physicians who persist in torturing the data in an attempt to frame their personal opinions as “science.”  It was disappointing, although perhaps not surprising, to see Dr. Frank Chervenak use his time on the provider panel to do just that. The American Journal of Obstetrics and Gynecology recently published an article authored by Dr. Chervenak regarding the “recrudescence of homebirth” (Chervenak et al, 2013), and perhaps it was the controversy stirred by that article that prompted the conference organizers to invite him to speak on this panel. The panel members included Dr. Chervenak as a hospital-based provider, Karen Pelote, CNM with the birth center provider perspective, and Brynne Potter, CPM as a homebirth provider.  Both Pelote and Potter appeared to have taken seriously the purpose of their panel representation and showcased the data on our client-centered models of care, with photos and quotes from women regarding the care they received and their experiences in the birth center and home settings.   

In stark contrast, Chervenak used his 12 minutes (out of 10) that were to be devoted to the hospital provider perspective for, instead, a rapid-fire display of “back-of-the-envelope” bar graphs attempting to show home/hospital differences in 5-minute Apgar scores using raw data drawn from birth certificates.  Since it appears that some doctors are having a hard time getting their “research” on this topic published in peer-reviewed journals, they are presenting their data in settings that do not require peer-review, such as last year’s annual conference of the Society of Maternal-Fetal Medicine (the study still hasn’t been published) and this IOM workshop.  Meanwhile, there are several well-designed studies published in peer-reviewed journals that show that there is no difference in 5-minute Apgar scores between home and hospital settings (Hutton et al, 2009; Janssen et al, 2009; van der Kooy et al, 2011).

That a professional invited to contribute to a high-level workshop about research would present an un-peer-reviewed thesis based on unreliable data, lacking any statistical analysis, is… well, let’s just say “puzzling.”  Exploiting the concept of “relative risk,” Chervenak sliced and diced the data in more ways than were thought possible to suggest that babies born at home were more likely to have a low 5-minute Apgar score than babies born in the hospital.

“Home Births Should Not Happen”

Chervenak’s non-reviewed data did find a higher rate of Apgar scores of “10” in the home setting versus “9” in the hospital setting. His point? Not that, clinically speaking, there is no difference between a score of 9 vs. 10 (they’re both good). Not that babies might possibly be doing better due to normal physiologic labor and undisturbed birth and that we should explore this further. Instead, he suggested – at this historic setting – that midwives lie about Apgar scores because “no one is watching.”  After a day and a half of earnest, interprofessional collegiality, Chervenak wrapped up his extended presentation with his unabashed opinion: “Home births should not happen.”

Epidemiologists in the room were quick to step to the microphone for the open discussion part of the panel, pointing out the many flaws in Chervenak’s presentation.  Marian MacDorman, Ph.D., senior statistician and researcher for the CDC’s National Center for Health Statistics, reminded everyone that birth certificate data is notoriously unreliable for neonatal seizures and low Apgar scores; this has been shown time and again for decades and had indeed been discussed earlier in this very workshop.  More importantly, McDorman stated that data from birth certificates cannot be used to make comparisons between settings or providers.  Her point, which deserves some elaboration here, is that there is a very important distinction between “absolute risk” and “relative risk,” and different types of data are better than others depending on what you are trying to describe. 

“When we limit access to certain birth settings because of risk, are we examining the risks of the alternative?” – Brynne Potter, CPM

Absolute vs. Relative Risk

Let’s say that a person’s odds of getting struck by lightning in a heavily populated city are one in a million, and those same odds in a rural area are five in a million. These odds are called your “absolute risk” of being struck by lightning. Another way to look at this is to say that a person’s odds of being struck by lightning are five times higher in a rural area than in a densely-populated area; this is the “relative risk” of a lightning strike in one area over another.

A common approach of anti-homebirth activists is to use the “relative risk” approach and ignore the absolute risk, because it’s much more dramatic and sensationalistic to suggest that the risk of something is “double!” or “triple!” that of something else, even though the absolute risk of those things are very low and may not even be statistically significantly different from each other.  Of course, any infant or maternal mortality is a tragedy.  But one of the key points raised at the IOM workshop was the idea that, in our efforts to identify “safety” with one indicator (mortality) or “truly low-risk” pregnancies by their absence of a particular factor (breech position, for example), we often fail to quantify all of the impacts of the various settings in ways that are meaningful to the women who experience the outcomes, such as the fact that in many areas, the only option for breech delivery is cesarean or the only way a VBAC can happen is at home, attended or not.  As Brynne Potter asked last week: when we limit access to certain birth settings because of risk, are we examining the risks of the alternative?

To return to the lightning analogy, it would be deeply disingenuous for a person to say that you shouldn’t move to a rural area simply because your risk of being struck by lightning is five times higher, without mentioning that at worst, that risk is five in a million. The ethics of this are further called into question when the person suggesting this is a trusted care provider, and is even worse when that person withholds all information about your option to move to a rural area — disregarding all of your other reasons for wanting to doing so — because they have decided that the risk of being hit by lightning there is too high for you.

Clarifying the Validity of Birth Certificate Data

Dr. MacDorman clarified how to interpret the data for anyone who might have been misled by Dr. Chervenak’s slides. She pointed out that regarding low Apgar scores, “the absolute risk is low; that’s all you can say with vital data.”  It doesn’t happen very often in any setting; most studies on homebirth around the world report the occurrence of low Apgar scores (<7) in the range of 1%, and very low scores (<4) are even rarer.  Studies have shown that the more rare an occurrence is, the less likely it is to be captured accurately on the birth certificate (Northam & Knapp, 2006).

Overall, the Midwives Alliance Division of Research (DOR) and other organizations working to improve maternity care are pleased with the near-consensus viewpoint by the majority of the disciplines represented at this workshop: that normal physiologic birth is best for mother and baby and should be the goal of all settings and practitioners.  We are looking forward to the future research inspired by this event.  We believe that there is potential for there to be more movement in the next 30 years than there was since the last IOM workshop on this topic 30 years ago, particularly because of the availability of high-quality datasets such as MANA Stats (primarily planned home births) and the American Association of Birth Centers’ Uniform Data Set (primarily planned birth center births).  As the stewards of the largest database on midwifery care and outcomes of normal physiologic birth in the home setting, the DOR encourages researchers to apply for the MANA Stats data to conduct this important research (application information at mana.org/DOR). 

References:

Chervenak FA, McCullough LB, Brent RL, Levene MI, Arabin B. 2013. Planned home birth: The professional responsibility response. AJOG 208(1):31-38.

Hutton EK, Reitsma AH, Kaufman K. 2009. Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: A retrospective cohort study. BIRTH 36(3):180-189.

Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee SK. 2009. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ, doi:10.1503/cmaj.081869.

Mathews, TJ & MacDorman, M. 2012. National Vital Statistics Reports: Infant mortality statistics from the 2008 period linked birth/ infant death data set. Available online at http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_05.pdf. 

National Center for Health Statistics. 1986. Vital Statistics of the United States, 1982, Vol II: Mortality, Part A. DHHS Pub. No. (PHS) 86-1122. Public Health Service: Washington. U.S. Government Printing Office.

Northam S, Knapp TR. 2006. The reliability and validity of birth certificates. J Obstet Gynecol Neonatal Nurs 35(1):3-12.

van der Kooy J, Poeran J, de Graaf JP, Birnie E, Denktas S, Steegers EAP, Bonsel GJ. 2011. Planned home compared with planned hospital births in the Netherlands: Intrapartum and early neonatal death in low-risk pregnancies. Obstet Gynecol 118:1037-46.

Vedam S, Schummers L, Stoll K, Fulton C. 2012. Home Birth: An Annotated Guide to the Literature.  Available online at http://mana.org/DOR/research-resources/.

About Wendy Gordon

 

 

Sharon Muza Guest Posts, Healthcare Reform, Home Birth, Maternal Mortality, Maternal Mortality Rate, Maternal Quality Improvement, Maternity Care, Midwifery, Newborns, Transforming Maternity Care Apgar, birth centers, birth setting, Brynne Potter, Chervenak, Frank Chervenak, guest post, homebirth, Institute of Medicine, Karen Pelote, MANA, Marian MacDorman, midwives, Wendy Gordon

“Our goal is not to have every mother birth at home—our goal is to encourage parents to gather quality information, to gain exposure to a philosophy that screams trust in mothers and trust in babies, and to provide parents who do plan a homebirth to be well equipped with an understanding of how to thrive in that decision.” – Jane E. Drichta, CPM and Jodilyn Owen, CPM, authors of The Essential Homebirth Guide: For Families Planning or Considering Birthing at Home.

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The Essential Homebirth Guide: For Families Planning or Considering Birthing at Home by midwives Jane E. Drichta, CPM and Jodilyn Owen, CPM  is a new book on the birth scene, being released today both in print and as an e-book.  I had an opportunity to read an advanced copy and and will share my thoughts with Science & Sensibility readers in this review.

The Essential Homebirth Guide is a book that is long overdue and will be welcomed by consumers and healthcare providers alike. With the recent National Birth Center Study II  released last month, many women and their families may now be considering an out of hospital (OOH) birth.  Some areas of the US offer the opportunity to birth in a birth center, while other parts of the country have no birth centers available at all and homebirth is the only OOH option.  Even where birth centers are available, women in greater numbers are now considering birthing in their own homes, with midwives, for many reasons, including comfort, cost and choosing a location where they feel they have the best chance to achieve a low intervention birth.

Sitting down to read Drichta and Owen’s guide is like spending a long weekend with your very best friend.  A best friend who just happens to be a midwife.  Whether you are just starting to explore the idea of a homebirth or have already decided that homebirth is for you, you will find that all your questions get answered in an easy to understand, factual way, with all the details and inside information that only your best friend can provide.  Drichta and Owen even provide answers to the questions you hadn’t thought of yet, but would want to know if you choose to homebirth, such as the section on communicating your homebirth choices with friends and family.

The book is arranged into chapters, and then subtopics.  Each subtopic has a nice Q&A format, with all the major questions covered in easy to understand language.  Peppered amongst the topics are real life stories and musing submitted by homebirthing women and their families, as well as special “The Midwife Says:” sections that provide additional information.  The personal stories offer a peek into the thoughts and experiences of homebirthing women, and readers will feel comforted by their stories. References are included for each chapter, and there are several hearty appendices at the back for more information. Lovely black and white pictures are scattered throughout.

One of the things that I loved best in The Essential Homebirth Guide is how the authors use every opportunity to speak to the mother, helping to develop her self-determination.  Throughout the book, they reinforce that every mother knows both her body and her baby best.  Women who read this book will feel confident that they are (or should be) equal partners in their care with their healthcare provider and are capable of asking questions, gathering information and making decisions that feel right to them.

“…A lot happens between the time of conception and diapers, and it all matters.  It will affect you.  It will change you.  It will propel you into motherhood in a profound way and can leave you with feelings of power, health, and peace, or it may leave you with feelings of anxiety, fear, and even trauma.  What kind of emotional context do you want as you become a new mother? What kind of new mother do you aim to be?  Think about these questions first, and then start building your prenatal care to lead yourself down the road that ends with you – the kind of new mother you intend to become in the kind of health you strive to have…” The Essential Homebirth Guide

Chapters on interviewing and choosing a midwife, what to expect during your prenatal care, prenatal testing options, information on the top ten pregnancy issues, preparing to birth at home, and what to expect after the birth all provide details on what normally occurs and include topics that can be discussed with your midwife along with things you can do to keep yourself healthy and low risk. In fact, this book is useful for any pregnant woman, as it will help facilitate conversations with hospital based healthcare providers, to help the woman who has chosen to birth in the hospital avoid unnecessary interventions. 

Drichta and Owen tackle some controversial subjects such as homebirth after a cesarean, home breech birth and homebirth of twins. No doubt, everyone’s comfort level is different and women (and their healthcare providers) process and understand risk in very individual ways.  These situations may not be for everyone, but the authors don’t ignore that these birth situations are occurring at home all around the country.  Information is power, mothers, when given accurate information in a respectful manner, will be able to determine what feels like the right decision for them.

I would have appreciated more information in the book on how low income families and women of color might find their way to homebirth in today’s maternity care climate, as the increase in homebirths has not been observed amongst those populations. Where I live, in the state of Washington, almost half of our births are paid for by the state, and we are fortunate that homebirth is an option for those families receiving state aid.  That is not the case for most of the rest of the country.

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I had the opportunity to ask Jane Drichta and Jodilyn Owen some questions about their book, and wanted to share my interview with Science & Sensibility readers.

SM: Why did you want to write this book, and why now? 

JO: This book has been running around in circles inside of our heads for years.  We make it a habit to check in with each other after most births, and so there are at least a decade of late night conversations here.  As we talked, we realized that we were running into the same problem; there was not one definitive source of information for homebirthing families.  We had websites and articles and handouts, but not one place where we could send parents for unbiased, evidence based information, served up with sides of common sense and love. Homebirth is becoming more and more popular, and the time just seemed to be right. 

SM:  What was the most challenging topic for you to cover in the book? How did you handle it? 

JD: The chapter on The Big Ten, which details ten common complications in pregnancy, was difficult to write.  We are used to speaking around these topics in very technical terms, and it was difficult to distill the information down to what mothers needed to know.  We were more interested in providing a model for how we approach these issues that any woman can adapt to her situation than being prescriptive about what one must absolutely do in a given situation.  When we started that chapter, it sounded like we were writing a term paper.  We completely lost the friendly, accessible tone that we were going for.  So that was a challenge.   

SM: What is the main piece of information that you hope that women will know/take away after finishing your book?

JD:  That they can do this.  That birthing at home is a viable option in 21st century America. That the desire to do this doesn’t mean you are crazy or hate the patriarchy, or that any of the other homebirthing stereotypes apply.  Women can birth at home more safely than ever before, and it is a real alternative for most women.

SM: What challenges do you see facing the potential growth of homebirths in the US?

JO:  The integration of homebirth midwives into our current health care system.  The politics around midwifery and its place in the system are myriad, and not something that we wanted to get into in the book.  However, we do support the right of women to birth in the place of their choice, with the provider of their choice, and that is sometimes difficult and can be limiting.

SM: If midwives and doctors read this book, what do you hope they take away from it?

JO: We hope they take away a few key points:  That mothers and partners should be held responsible to seek information and share decision making in their care, that a pregnant and birthing woman is in partnership with her baby and this dyad perspective should be promoted at all times with the language and behavior providers use, and that a woman is never just her numbers—she is a whole human being with a context worthy of their curiosity and respect.  

SM: How can childbirth educators use this book with their students?

JD: Simply presenting this paradigm of woman-centered, individualized, continuous care is a great way to open the door for discussions about creating intention for pregnancy and birth.   What is it that parents really mean to establish for themselves when it comes to their care and birth?  Understanding risk, breaking apart decision-making models, and tuning in to their inner-wisdom are just some of the great tools that educators can work through.

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I wanted to see what the authors had to say about childbirth classes for women considering homebirth and was delighted to find that they encourage all women to take classes and hold Lamaze International and our Healthy Birth Practices in high esteem.  ”We can’t find anything not to love here” is found in the childbirth class section under the Lamaze heading..

Overall, I really enjoyed reading this book and found it to be an easy read and full of information that I would find useful if I was still deciding where to birth or had already made up my mind to birth at home.  I could also see myself referring back to this as my birth got closer.  This book acknowledges that I am the best person to make this very personal decision about where to birth my baby. I think that healthcare providers who offer OOH birth services might want a few copies on their bookshelves to lend to potential and current clients, and childbirth educators might very well recommend this resource to parents in their classes who want to know more about what a home birth might be like.

Please consider coming back to the blog and sharing your thoughts after reading the book.  I would love to know what you think and if you would recommend this to clients and students.  If you would like to contact the authors, they can be reached through their website Essential Midwifery.

Disclosure: The authors of this book and I are all members of the professional birth community in Seattle, WA.  I have known them on a professional and personal level long before this book was even conceived.

Sharon Muza Book Reviews, Childbirth Education, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, Home Birth, Maternal Quality Improvement, Maternity Care, Midwifery book review, Childbirth Education, Essential Homebirth Guide, Healthy Birth Practices, Home Birth, homebirth, Jane E. Drichta, Jodilyn Owen, Lamaze International, Midwifery Care, midwives, Sharon Muza

The Journal of Midwifery and Women’s Health has just published the results of the National Birth Center Study II. As the name suggests, this is the second time researchers have undertaken a multi-site study of U.S. birth centers to understand the process and outcomes of care in these settings. The first appeared in the New England Journal of Medicine in 1989, and concluded that “birth centers offer a safe and acceptable alternative to hospital confinement for selected pregnant women, particularly those who have previously had children, and that such care leads to relatively few cesarean sections.”

The current study describes birth centers as a “durable model” of care because, again, outcomes were excellent. 

Here are the key findings of the National Birth Center Study II: Of more than 15,000 women eligible for birth center care when labor started, 93% had spontaneous vaginal births, and 6% had cesareans. 16% of women transferred during labor, and approximately 2.5% of mothers or newborns required transfer to the hospital after birth. Emergent transfer before or after birth was required for 1.9% of women in labor or for their newborns. Most women who transferred in labor had vaginal births. There were no maternal deaths. The intrapartum stillbirth rate was 0.47/1000, and the neonatal mortality rate was 0.40/1000 excluding anomalies.

I had an opportunity to interview one of the study authors, Cara Osborne, SD, MSN, CNM. Dr. Osborne is an Assistant Professor at the University of Arkansas School of Nursing, a perinatal epidemiologist, and co-founder of Maternity Centers of America. I asked her what the study findings mean for women and families and what it will take to scale up the birth center model and expand access.

AR: Thanks for participating in this interview. First and foremost, what should expectant parents know about this study?

CO: The take away messages from this study for expectant parents are that birth center care is safe and minimizes the likelihood that their baby will need to be born by cesarean, and that if hospital care becomes necessary, that transfer is very unlikely (1.9%) to be an emergency.

(Rebecca Dekker, PhD, RN, APRN of Evidence Based Birth has prepared an excellent summary that appears at the American Association of Birth Centers web site with more about the study findings and their implications for women and families.)

The study is based on the AABC Uniform Data Set. What are the strengths and limitations of the UDS? 

CO: The UDS data were collected prospectively, which means women were enrolled in the study before the outcome of the pregnancy was known. This is an important strength because it means that the ultimate outcome could not bias the data that were collected during the pregnancy. Also, the UDS is used across dozens of birth centers, so it also enables us to get much more data than would be possible from a single birth center site.

A primary limitation is that the UDS does not capture information that describes the family’s experience of birth center care, which makes correlating the clinical findings with experiential information impossible. Also, the UDS isn’t used by physicians practicing in hospitals, so we could not compare our findings to typical hospital-based care.

AR: The first National Birth Center Study reported outcomes of births from 1985 to 1987. Even though this study took place two decades later, the results are strikingly similar. If we’ve known for decades that birth centers are safe and effective, and they provide high quality care without costly hospital overhead, why isn’t there one in every community?

CO: You’re right, the results were very similar. For example the c-section rate in birth centers remained stable, going from 4% in the first study to 6% in the current study, while the national c-section rate during the same period has increased dramatically from 18% to 33%. We’ve known all along that greater use of birth centers could curb or reverse this trend, but there are several obstacles that have prevented a broad expansion of the model. They fall into three categories: systems obstacles, business obstacles, and professional obstacles.

Systems obstacles:

• Hospitals have been predominant place of birth in the U.S. for so long that associated processes such as payment by commercial insurers and state Medicaid, the filing of birth certificates, and administration of state required newborn screening tests have all been developed based on hospital timelines and protocols. Therefore, changing the place of birth requires changes in all the associated systems as well, which can be difficult.

Business obstacles:

• The skill set that it takes to be a good care provider and the skill set that it takes to start and run an efficient business have very little overlap, and it’s the rare provider that has both.
• It takes a considerable capital investment to get a birth center up and running, and that’s not something most providers can access.
• Equitable reimbursement for provider fees to midwives and facility fees to birth centers from commercial insurers and state Medicaid plans has not been available in most areas of the U.S., so the return on investment has been low.

Professional obstacles: 

• Many physicians have opposed the independent practice of midwives while also refusing to enter in to collaborative practice agreements, which are required for midwives to provide intrapartum care in many states.
• Birth center regulations in many states require that a physician be the medical director of the center, and recruiting physicians to fill this role can be difficult.
• Hospitals have seen birth centers as competition and thus have not offered access to referral and transport.

AR: You are part of an effort to change things so that we do one day have a birth center in every community. Can you tell us about that effort, and why you think you will succeed?

CO: My co-founder Shannon Bedore and I formed Maternity Centers of America (MCA) in order to create a vehicle for addressing the barriers described above. As you pointed out, birth centers are a good thing and there should be more, so we built MCA to bring together professionals from a variety of backgrounds including business, real estate, construction, and health policy to look at the big picture of how maternity care works and find new ways to make birth centers a part of the healthcare system. If our efforts are successful, I believe that this broad range of perspectives will be the reason.

As our first step, we established a demonstration site in northwest Arkansas which will allow us to try new management strategies and find ways to leverage technology while staying true to the birth center model of care. From this flagship site, we hope to develop a replicable, scalable model for the development of birth centers around the U.S. This is not a new idea, nor one that only we are working to implement. Our colleagues at New Birth Company in Kansas City and at the Minnesota Birth Center in Minneapolis are also building replicable birth center models. Each of us has a slightly different approach, and all of us need to succeed in order to or build enough scale to have measureable impact on national outcomes.

AR: The American Association of Birth Centers and the American College of Nurse-Midwives are hosting a congressional briefing next month in Washington to share the study results. Why does this study matter to policy makers?

CO: This study is of particular interest to policy makers because of both its content and its timing. Maternity care makes up the largest proportion of the national hospital bill from a single condition, and a large proportion (45%) of that is paid by government programs. A recent report from the consumer advocacy organization Childbirth Connection entitled The Cost of Having a Baby in the United States highlights the striking cost of U.S. maternity care and its inverse relationship with clinical outcomes. The report showed that almost two-thirds (59-66% depending on payer and type of birth) of the total costs of maternity care went to cover facility fees charged by hospitals. Birth centers charge facility fees too, but they are a fraction of the typical hospital fee. In addition, c-sections cost commercial payers $19,000 more than vaginal births, and they cost Medicaid programs $9,500 more than vaginal births. Multiplied by the estimated number of excess cesareans in the United States, this means about $5 billion dollars could be saved each year by improving our ability to safely get babies born vaginally.

The low value of maternity care is coming into sharper focus for policy makers at the moment due to the implementation of the Patient Protection and Affordable Care Act, which adds maternity care to the list of essential health benefits and increases the number of pregnancies that will be covered by the government through the expansion of state Medicaid programs. As policymakers attempt to realign costs and outcomes, they are looking for strategies that address the “triple aim” of healthcare championed by Don Berwick and his colleagues: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. Birth centers are a viable, evidenced-based option for meeting all three aims, which is rare, particularly in maternity care. 

Are you surprised by the results of this new study?  Will  you share this information with your clients and students?  Do you think this study will have an impact on the choices that women make about their birth location? Do you believe that more birth centers can help solve many of the problems facing birthing women and maternity care today? Share your thoughts in our comment section. I’d like to hear from you.- Sharon Muza, Community Manager.

Amy Romano Cesarean Birth, Evidence Based Medicine, Guest Posts, Healthcare Reform, Home Birth, Maternal Mortality, Maternal Quality Improvement, Maternity Care, Medical Interventions, New Research, Research, Uncategorized American Association of Birth Centers, Amy Romano, Birth Center, Cara Osborne, cesarean, guest post, Journal of Midwifery and Women's Health, Maternity Centers of America, National Birth Center Study II

by Wendy Gordon, LM, CPM, MPH, Midwives Alliance Division of Research

Today, midwife and researcher, Wendy Gordon, LM, CPM, MPH, Midwives Alliance Division of Research, takes a look at the recent article in the American Journal of Obstetrics and Gynecology that shared the authors’ view of the appropriate professional response from obstetricians when counseling and discussing home birth with patients.  Was this article based on good science?  Accurate and accepted studies? Did the authors selectively choose their sources and ignore other research that may have supported a different viewpoint?  Wendy shares information and research that invites consideration and discussion of the validity of the authors’ opinion. – Sharon Muza, Community Manager.

___________________

Recently, an article in the American Journal of Obstetrics & Gynecology pled with obstetricians to not support planned home birth in any way, and even suggested that those who do “should be subject to peer review and justifiably incur professional liability and sanction from state medical boards” (1).  In their strongly worded opinion, the authors (the first two of whom are, curiously, members of the journal’s Advisory Board, and four of whom are also board members of the International Society of Fetus as a Patient) make their case that physicians should provide evidence-based information to women that planned home birth is not safe, that reports of patient satisfaction are overrated, that it’s actually not cost-effective, and that a pregnant woman has a moral duty to her fetus to give up her autonomy to her doctor’s judgment on this issue.  Let’s take a look at the basis for these recommendations.

Although there are many high-quality studies of home birth on which Chervenak et al. could have based their opinions, they led with the ACOG statement (2) that rests on the findings of the Wax et al. meta-analysis (3), which relied heavily on a study that included unplanned home births in its findings of neonatal mortality rates (4).  Many strong critiques of the Wax analysis have been published (5-11), including an unbiased look from someone who has no stake in the home birth debate.  The authors cited several more poor-quality studies, as well as 52 citations of commentaries, opinions and anecdotes (some even pulled from the popular media) to build their “evidence” basis. They conveniently ignored the large and growing body of literature that continues to show that planned home birth with qualified and experienced midwives holds no greater risk of perinatal mortality than birth in the hospital, and in fact results in far fewer interventions and lower risk of maternal and perinatal morbidity.

Here are some of the high-quality studies that Chervenak et al. did not cite in developing their opinion of the “professional responsibility response”:

• two systematic reviews (12-13) and a meta-analysis (14) of home and birth center safety studies that all show that there is no greater perinatal risk for planned, attended home births than for hospital births, and significantly fewer interventions;
• the only large-scale, high-quality study of Certified Professional Midwives (CPMs) in the U.S. that described intrapartum and neonatal death rates as similar to other studies of low-risk home and hospital births (15);
•  other high-quality U.S. studies that show no difference in perinatal mortality between planned home and hospital births (16-18);
• several high-quality Canadian studies confirming no difference in the rates of perinatal death between planned home and hospital birth with much lower rates of both interventions and adverse outcomes (19-21);
•  a huge Dutch study of over half a million births that shows no difference in perinatal mortality rates or NICU admissions between planned home and hospital births (22);
• another Dutch study that shows no difference in perinatal mortality and lower risk of interventions and other adverse outcomes, particularly for multips (23);
• large, high-quality U.K. studies that show no difference in perinatal mortality rates and lower risk of both interventions and adverse outcomes (24-25); and
• a German study that shows no difference in rates of perinatal mortality and lower risk of interventions and adverse outcomes (26).

The authors then go on to discount the evidence of higher satisfaction among women choosing to deliver at home, as well as the cost-effectiveness of doing so, while presenting absolutely no evidence to the contrary.  The authors reference a study in the Netherlands where the transport rate from home to hospital is over twice that in the U.S. (and where Chervenak et al. took great liberties in interpreting the results on patient satisfaction) and a U.K. study where the costs of home and hospital birth are virtually equivalent.  While consistent, this approach to selectively reviewing the evidence and generalizing the findings to the U.S. maternity care system is disingenuous and deliberately misleading to American obstetricians and their patients.  A Washington State study of Medicaid patients planning a home birth with Licensed Midwives showed a savings of nearly $3 million, including the increased cost of those who transferred care and/or site of delivery (27).  This analysis did not attempt to account for the vast cost reductions of potentially avoided interventions, including cesareans and their complications, which would make the case for the cost-effectiveness of midwifery-led care in Washington State even stronger.  It is puzzling that Chervenak et al. did not cite this study, which is recent, took place in the U.S., was conducted by unbiased health-economics consultants, and directly addresses one of their four concerns.

The authors’ main argument against the proven cost-effectiveness of planned home birth is that “the lifetime costs of supporting the neurologically disabled children who will result from planned home birth” have not been factored in, nor have the supposedly increased rates of death.  If one accepts the conclusions of the enormous body of literature that finds no difference in perinatal mortality rates or other adverse outcomes between planned, midwife-attended home births and hospital births, then the pursuit of this line of reasoning is a non-starter.

The U.S. continues to lag behind many other high- and low-resource countries in accepting the evidence of the vast benefits of midwifery care.  The U.K.’s National Health Service has encouraged women to plan home births with midwives for several years; the Netherlands has always acknowledged midwives as the primary care provider in the childbearing year; New Zealand’s system similarly places midwives at the forefront of maternity and newborn care; Japan has a long tradition of midwifery-led care.  Most recently, British Columbia Health Minister MacDiarmid, accepting the evidence of safety, patient satisfaction and cost-effectiveness, has announced government support for women with low-risk pregnancies to plan a home birth, including support for physicians to become appropriately trained to attend home births (28).  But the medical associations of the U.S. continue to erect barriers to the type of interprofessional collaboration that has resulted in the excellent outcomes of these other countries.  The Chervenak et al. article is clearly intended to be yet another of those barriers.

In the centerpiece of the AJOG article, Chervenak cites himself an astounding 15 times in justifying why the rights of a pregnant woman to make autonomous decisions for herself and her baby should be relegated to her doctor’s judgment of what’s right for the “fetus as a patient,” grounded firmly, of course, in the aforementioned “evidence.”  In an astonishing disregard for shared decision-making and informed choice, Chervenak et al. state that “in a professional relationship, the physician’s integrity justifiably limits the woman’s rights by limiting the scope of clinically reasonable alternatives.”  The authors’ repeated and unusual use of the word “recrudescence” when referring to home birth, which reveals their perception of the choice as a disease or disorder, and their stubborn contempt for high-quality evidence if it disproves their opinion, exposes their intent and certainly calls into question their “integrity.”

“Professional responsibility” demands that we dare to examine the evidence that does not agree with our personal beliefs.  It requires that we allow the volumes of high-quality evidence to seep into our analysis of reality and into our presentation of true informed choice to our patients.  “Professional responsibility” demands that we examine and disclose our own personal, religious or anecdotal beliefs that may bias our interpretation and presentation of the research.  And it requires that we refuse to cloak those personal beliefs as “evidence” and “integrity” and by so doing avoid an abuse of power in relationship with our patients.

References

1. Chervenak F. A., McCullough L. B., Brent R. L., Levene M. I., & Arabin B. (2012) Planned home birth: the professional responsibility response. Am J Obstet Gynecol, Nov 13. doi:10.1016/j.ajog.2012.10.002. [Epub ahead of print].

2. American College of Obstetricians and Gynecologists. (2011). Committee Opinion no. 476. Committee on Obstetric Practice. Planned home birth. Obstet Gynecol, 117(2, part 1), 425-8.

3. Wax J. R., Lucas F. L., Lamont M., Pinette M. G., Cartin A., & Blackstone J. (2010).  Maternal and newborn outcomes in planned home birth vs. planned hospital births: a metaanalysis. Am J Obstet Gynecol, 203(3):243.e1–243.e8. doi:10.1016/j.ajog.2010.05.028

4. Pang J. W., Heffelfinger J. D., Huang G. J., Benedetti T. J., & Weiss N. S. (2002). Outcomes of planned home births in Washington state: 1989-1996. Obstet Gynecol, 100(2):253-9. http://dx.doi.org/10.1016/S0029-7844(02)02074-4

5. Carl M. A., Janssen P. A., Vedam S., Hutton E. K., & de Jonge A. (2011). Planned home vs hospital birth: A meta-analysis gone wrong. Medscape Ob/Gyn & Wom Health. Retrieved from http://www2.cfpc.ca/local/user/files/%7B1E683014-14EB-489F-99CE-B5A2185A6FC5%7D/Medscape%20%20Wax%20Critique%20-%20Michal,%20Janssen,%20Vedam,%20Hutton,%20de%20Jonge.pdf

6. Gyte G., Newburn M., & Macfarlane A. (2010). Critique of a meta-analysis by Wax and colleagues which has claimed that there is a three-times greater risk of neonatal death among babies without congenital anomalies planned to be born at home. National Childbirth Trust. Retrieved from http://www.scribd.com/doc/34065092/Critique-of-a-metaanalysis-by-Wax

7. Keirse M. J. (2010). Home birth: Gone away, gone astray, and here to stay. Birth, 37(4):341-46.

8. Hayden E. C. (2011). Home birth study investigated. Nature [Epub]. doi:10.1038/news.2011.162.

9. American College of Nurse Midwives. (2010). ACNM expresses concerns regarding recent AJOG publication on home birth. [Epub]. Retrieved from http://www.midwife.org/documents/ACNMstatementonAJOG2010.pdf.

10. Romano A. (2010). Meta-analysis: the wrong tool (wielded improperly). Retrieved from http://www.scienceandsensibility.org/?p=1349.

11. Dekker R. & Lee K. S. (2012). The Wax home birth meta-analysis: an outsider’s critique. Retrieved from http://www.scienceandsensibility.org/?p=5628.

12. Olsen O. & Clausen J. A. (2012). Planned hospital birth versus planned home birth. Cochrane Database of Systematic Reviews, Issue 9. Art. No.: CD000352. doi: 10.1002/14651858.CD000352.pub2.

13. Leslie M. S. & Romano A. (2007). Appendix: Birth can safely take place at home and in birthing centers. J Perinat Educ, 16(Suppl 1):81S-88S. doi:10.1624/105812407X173236

14. Olsen O. (1997). Meta-analysis of the safety of home birth. Birth, 24(1):4-13; discussion 14-6.

15. Johnson K. C. & Daviss B-A. (2005). Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ, 330:1416. doi: http://dx.doi.org/10.1136/bmj.330.7505.1416

16. Cawthon L. (1996). Planned home births: outcomes among Medicaid women in Washington State. Olympia,WA: Washington Department of Social and Health Services. Retrieved from http://www.dshs.wa.gov/pdf/ms/rda/research/7/93.pdf.

17. Murphy P. A. & Fullerton J. (1998). Outcomes of intended home births in nurse-midwifery practice: a prospective descriptive study. Obstet Gynecol, 92(3):461-70.

18. Anderson R. E. & Murphy P.A. (1995). Outcomes of 11,788 planned home births attended by certified nurse-midwives: A retrospective descriptive study. J Nurse Midwifery, 40(6):483-92.

19. Janssen P. A., Saxell L., Page L. A., Klein M. C., Liston R. M. & Lee S.K. (2009). Outcomes of planned home births with registered midwife versus planned hospital birth with midwife or physician. CMAJ, 181(6):377-83.

20. Hutton E. K., Reitsma A.H. & Kaufman K. (2009). Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: A retrospective cohort study. Birth, 36(3):180-89.

21. Janssen P. A., Lee S. K., Ryan E. M., Etches D. J., Farquharson D. F., Peacock D. & Klein M. C. (2002). Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. CMAJ, 166(3):315-23.

22. de Jonge A., van der Goes B. Y., Ravelli A. C., Amelink-Verburg M. P., Mol B. W., Nijhuis J. G., Bennebroek Gravenhorst J. & Buitendijk S. E. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG, 116(9):1177-84. DOI: 10.1111/j.1471-0528.2009.02175.x.

23. Wiegers T. A., Keirse M. J., van der Zee J. & Berghs G. A. (1996). Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands. BMJ, 313(7068):1309-13

24. Chamberlain G., Wraight A. & Crowley P. (eds.). (1997). Home births – The report of the 1994 confidential enquiry by the National Birthday Trust Fund. Cranforth, UK: Parthenon Publishing.

25. Northern Region Perinatal Mortality Survey Coordinating Group. (1996). Collaborative survey of perinatal loss in planned and unplanned home births. BMJ, 313(7068):1306-09. doi: http://dx.doi.org/10.1136/bmj.313.7068.1306.

26. Ackermann-Liebrich U., Voegeli T., Gunter-Witt K., Kunz I., Zullig M., Schindler C., Maurer M. & Zurich Study Team. (1996). Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. BMJ, 313(7068):1313-18. doi: http://dx.doi.org/10.1136/bmj.313.7068.1313.

27. Health Management Associates. (2007). Midwifery licensure and discipline program in Washington State: economic costs and benefits. Retrieved from http://www.washingtonmidwives.org/documents/Midwifery_Cost_Study_10-31-07.pdf.

28. Dedyna K. (2012, Nov 3). B.C. minister among first to support home births. Times Colonist. Retrieved from http://www.canada.com/minister+among+first+support+home+births/7494815/story.html.

 

Sharon Muza Evidence Based Medicine, Guest Posts, Home Birth, informed Consent, Maternal Mortality, Maternal Mortality Rate, Maternity Care, Medical Interventions, Midwifery, New Research, Research ACOG, ACOG and homebirth, Chervenak, Evidence Based Medicine, guest posts, Home Birth, homebirth, homebirth debate, midwives, Midwives Alliance, research, Wendy Gordon