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Updated “Birth By The Numbers” – A Valuable Tool for Childbirth Educators and Others

October 2nd, 2014 by avatar

birth by numbers header

One of the highlights of my attendance at the joint Lamaze International/DONA International Confluence in Kansas City, MO last month was the opportunity to hear Eugene Declercq, PhD, present a plenary session entitled “What Listening to Mothers Can Tell Us about the Future Challenges in US Maternity Care.”  Dr. Declercq is a professor of Maternal and Infant Health at Boston University School of Public Health. It is always a true pleasure to listen to Dr Declercq, not only for his delightful Boston accent, but also for the creative and impactful way that he shares data and facts about the state of maternity care, primarily in the United States.

declercq-headshotThis presentation was no exception and Dr. Declercq helped conference attendees to tease apart the information gleaned from the most recent Listening to Mothers III study, and look at this information  in relationship to data from the two previous Listening to Mothers studies.

Dr. Declercq reminded those of us in the audience that the most recent update of “Birth by the Numbers” was just made available on the Birth by the Numbers website.  I am a huge fan of the previous versions of this short film, that highlighted statistics on how the United States is doing on several key maternal and infant indicators in relation to other nations around the world.  The information continues to be both eye opening and sobering at the same time.  I encourage you to view the most recent edition included here.

I have seen Teri Shilling, the director of Passion for Birth, one of the Lamaze Accredited Childbirth Educator Programs, use the Birth by the Numbers video in a very clever way when training both doulas and childbirth educators.  This learning activity could also be adapted to use in your childbirth class.  Teri provides a worksheet with many of the important statistics that Dr. Declercq shares in his video, listed out.  The learner must watch the video and assign the correct definition to each relevant number listed.  It helps the viewer to really capture the significance of the different numbers, when they are closely listening for each one and then the video can be debriefed as a group.

Dr. Declercq’s website has tons of useful information that you can take into the classroom.  I subscribe to/follow the blog on his website and look forward to new articles when they come out.   Dr. Declercq also generously shares PowerPoint slides on both the “Birth by the Numbers” presentation as well as “Cesarean Birth Trends” that educators can freely use in their own classroom.

Should you be interested in maps and details on the cesarean birth trends for several other countries, including Australia, Brazil and Germany, that information is provided along with a state by state breakdown.

You can also find the updated Birth by the Numbers video on the Lamaze websites for professionals and for parents.

If you have not seen them, I also really enjoy Dr. Declercq’s  videos “The Truth about C-Sections” and “Debunking the Myth: Home Births are Dangerous” published in cooperation with Mothers Naturally

One last fun fact – did you know that Dr. Gene Declercq is a Lamaze Certified Childbirth Educator!   Thanks Dr. Declercq for all you do to get solid data to all of us in fun and informative ways.  I appreciate it.

A challenge for you! How might you use the information in the updated video and on the Birth by the Numbers website in your childbirth class, with doula clients or with the patients you care for?  Do you have any teaching ideas that you would like to share with Science & Sensibility readers?  I would love to hear your creative ideas and I know others would too.  Sharing teaching tips helps all of us become better educators.

 

 

2014 Confluence, Cesarean Birth, Childbirth Education, Films about Childbirth, Lamaze International, Maternal Mortality, Maternal Mortality Rate, Maternal Quality Improvement, New Research, Research , , , ,

CDC & ACOG Convene Meeting on Maternal Mortality & Maternal Safety in Chicago

May 23rd, 2014 by avatar
creative commons licensed (BY-NC-SA) flickr photo by Insight Imaging: John A Ryan Photography: http://flickr.com/photos/insightimaging/3709268648

creative commons licensed (BY-NC-SA) flickr photo by Insight Imaging: John A Ryan Photography: http://flickr.com/photos/insightimaging/3709268648

Earlier this week, I shared information on the Safety Action Series kickoff that all were invited to participate in, by the National Partnership for Maternal Safety – focused on reducing the maternal mortality ratio and morbidity ratio for mothers birthing in the U.S.  This partnership is part of the Council on Patient Safety in Women’s Health Care.  Last month Christine Morton, PhD and Robin Weiss, MPH attended a meeting as board members of Lamaze International.  Christine shares meeting notes and topics that were discussed and what maternity professionals, including childbirth educators,  can do to help. – Sharon Muza, Science & Sensibility Community Manager.

Disclosure:  Christine is a member of the Patient/Family Support Workgroup of the National Partnership for Maternal Safety, and a current board member of Lamaze International. 

Since 1986, the American College of Obstetricians and Gynecologists (ACOG) and the Centers for Disease Control and Prevention (CDC) convened interested persons in public health, obstetrics and maternity care to discuss and share information about maternal mortality, including methodologies for pregnancy mortality surveillance at state and national levels, and opportunities to reduce preventable maternal deaths.   Recently, under leadership of Dr. Elliott Main, medical director of California Maternal Quality Care Collaborative (CMQCC), and drawing from the recent experience of California in maternal quality improvement and work by other organizations and collaboratives, the focus of the interest group has shifted from surveillance to quality improvement.  The meeting has evolved from the early years when 12-20 persons sat around tables to discuss the issue, to this year’s meeting which had over 180 persons registered.  Clearly the time has come for a coalition around improving maternity outcomes in the U.S.

The National Partnership for Maternal Safety was proposed in 2013 in New Orleans, and the goal of the April 27, 2014 meeting in Chicago was to formally launch the initiative and report on the progress of each work group. The goal of the National Partnership for Maternal Safety is for every birthing facility in the United States to have the three designated core Patient Safety Bundles (Hemorrhage; Venous Thromboembolus Prevention; and Preeclampsia) implemented within their facility within three years. The bundles will be rolled out consecutively, beginning with obstetric hemorrhage and advancing to the other areas. To support this national effort, publications are underway in peer-reviewed journals. The first article, as an editorial call to action, appears in the October 2013 issue of Obstetrics & Gynecology, the official publication of the American College of Obstetricians and Gynecologists.

Highlights from this year’s meeting included two presentations from CDC researchers William Callaghan, MD, MPH and Andreea Creanga, MD, PhD, on work being done to better identify cases of severe maternal morbidity (SMM) and drivers of racial/ethnic disparities.  One of the goals of creating a working definition of SMM is to help facilities track and review cases in order to identify systems issues and address them through quality improvement efforts.

Next, representatives from selected work groups (Hemorrhage; Venous Thromboembolus Prevention; Patient/Family Support) shared their updates.    It has become very clear from ongoing work within large hospital systems, state-based quality collaboratives and other countries such as the UK, that standardized protocols for recognition and response to preventable causes of mortality and morbidity are effective.  Unfortunately, there is no national requirement for all birthing facilities (hospitals and birth centers) to have updated policies and protocols on these preventable causes of maternal complications.

The good news is that there is a groundswell of support for a coordinated effort to realize the goals of the Initiative.  From state quality collaboratives in California, New York, Ohio and Florida to Hospital Engagement Networks, there are many hospitals already implementing some maternal quality improvement toolkits.  The Joint Commission plays a key role in helping hospitals work on patient safety issues and identified maternal mortality as a sentinel event in 2010 and is now proposing that any intrapartum (related to the birth process) maternal death or severe maternal morbidity should be reviewed.  As the nation’s largest accreditation body for hospitals, the Joint Commission is in a position to provide oversight as well as guidance to hospitals as they develop system-level reviews of these outcomes.

More states are being supported by federal and nonprofit agencies to develop and conduct maternal mortality reviews, and the role of Title V, the only federal program that focuses solely on improving the health of mothers and children, is critical.  Title V is administered by each state to support programs enhancing the well being of mothers and their children.

The last topics of the day were how to address the most common cause of maternal mortality – cardiovascular disease in pregnancy – but not as preventable as the three causes featured in the Initiative.

Suggested topics for future meetings including looking at maternal mortalities due to suicide, helping states with small populations aggregate their data, and addressing the issue of prescription (and other) drug abuse among pregnant women.  Eleni Tsigas from the Preeclampsia Foundation stressed the importance of including women’s perspectives and the emotional, social and ongoing physical sequelae of living after a severely complicated childbirth experience.

How is this information relevant for childbirth educators, doulas and other maternity professionals?  First, the rising rates of maternal mortality and morbidity are in the news.  While deaths are rare, severe complications are more common.  CBEs and doulas can reassure pregnant women in their classes that the likelihood of a severe morbidity is low, and can provide resources to share with women and help them learn which hospitals in their communities have begun the work of maternal quality improvement.  CBEs can share this information with key nursing and medical leaders at hospitals where they teach, and offer to help with the Quality Improvment (QI) efforts.

Childbirth educators and others can help ensure the focus not become too one sided – while it is important for every hospital to be ready for typical obstetric emergencies, it is also important for every hospital to be prepared to support women through normal physiologic birth by trained staff and supportive physicians. AWHONN launched its campaign, “Go the full 40” in January 2012 to help everyone remember that while we don’t want to ELECTIVELY deliver babies prior to 39 completed weeks gestation, we also want to support labor starting on its own.  And most recently, ACNM unveiled its BirthTOOLs site, which includes resources, tools and improvement stories on supporting physiologic, vaginal births.  CBEs and doulas can be strong advocates in supporting facility and maternity clinician preparedness for the ‘worst case’ and ‘best case’ scenarios in childbirth.

For more info about National Partnership for Maternal Safety or the CDC/ACOG Maternal Mortality Interest Group, please contact:  Jeanne Mahoney, jmahoney@acog.org

Past and future webinars about the initiative are available to the public here: http://www.safehealthcareforeverywoman.org/safety-action-series.html

Archived presentations from past CDC/ACOG maternal mortality interest group meetings

2014:  http://bit.ly/1sXkaGw

2012: http://bit.ly/1pfay9S

 

Childbirth Education, Guest Posts, Lamaze International, Maternal Mortality, Maternal Mortality Rate, Maternal Quality Improvement, Pregnancy Complications, Uncategorized , , , , ,

Thank You Midwives! Celebrate International Day of the Midwife Today!

May 5th, 2014 by avatar

2014 day of midwife_600pxMay 5th has been recognized as the International Day of the Midwife since 1992. The International Confederation of Midwives (ICM) supports, represents and works to strengthen professional associations of midwives throughout the world.  The purpose of this day is to “celebrate midwifery and to bring awareness of the importance of midwives’ work to as many people as possible.” There are currently 108 Midwives Associations, representing 95 countries across every continent. ICM is organized into four regions: Africa, the Americas, Asia Pacific and Europe. Together these associations represent more than 300,000 midwives globally.

Midwives play a crucial role in maternal and infant health.  This year’s theme is “Midwives: changing the world one family at a time.” There are many key messages that highlight how midwives around the world are helping mothers, babies, families and communities.  Some of these global messages, backed up by research and investigation include:

  • In midwife-led care, women experience less preterm births, less assisted deliveries and greater satisfaction with care.
  • Midwives change the world by caring for mothers and babies. By caring for them, midwives help ensure that women are healthy, thus contributing to a strong community and economy. When babies survive, they start growing into healthy children and adults.
  • If every childbearing woman received care with a well- educated, adequately resourced midwife, most of maternal and newborn deaths could be prevented.
  •  Investments in midwifery education as well as regulation, provision of infrastructure and information will improve access to midwifery care
  •  Midwifery services are economic and cost effective.
  •  Investment in midwives means commitment to a healthy and wealthy nation.

In many countries around the world, access to maternity care is limited by economics, social status, distance and many other factors.  Trained and qualified midwives can have a significant impact on mortality rates for mothers and babies worldwide.  For healthy, low risk women in developed countries, midwifery care is appropriate, cost effective and provides excellent outcomes for mothers and babies.

Are you or your community doing anything special to honor the midwives who work in your area?  Let us know some of the events planned.

Please join  Lamaze International, Science & Sensibility and myself in celebrating the women and men (yes, men are midwives too!) who serve as midwives to our partners, our wives, our sisters, our friends, our daughters and granddaughters all around the world.  Take a moment to thank them for their hard work and the gentle care they provide to birthing women and families.  You may want to send a customized “International Day of the Midwife” ecard to your favorite midwife, and  thank them for their contribution to healthy mothers and babies.  I am going to take a few minutes today to thank the midwives in my community for taking good care of families in my area.

Additionally, as an avid reader of books, I thought in honor of the International Day of the Midwife that I would share some of my favorite books that I have read about midwives.  I would love to hear your suggestions for future reading on this topic, as I enjoy the genre and would welcome your reading suggestions in our comments section.

Baby Catcher: Chronicles of a Modern Midwife by Peggy Vincent

Lady’s Hands, Lion’s Heart: A Midwife’s Saga - by Carol Leonard

The Birth House - by Ami McKay

The Midwife of Hope River – Patricia Harman

The Blue Cotton Gown: A Midwife’s Memoir - Patricia Harman

Arms Wide Open: A Midwife’s Journey – Patricia Harman

A Midwife’s Story  - Penny Armstrong and Sheryl Feldman

Orlean Puckett: Life of a Mountain Midwife - Karen Cecil Smith

Monique and the Mango Rains: Two Years with a Midwife in Mali - Kris Holloway

The  Midwife: A Memoir of Birth, Joy and Hard Times – Jennifer Worth

Call the Midwife: Shadows of the Workhouse – Jennifer Worth

Call the Midwife: Farewell to the East End – Jennifer Worth

A Midwife’s Tale: The Life of Martha Ballard, Based on her Diary, 1785-1812 - by Laura Thatcher Ulrich

Laboring: Stories of a New York City Hospital Midwife  by Ellen Cohen

The Midwife’s Apprentice – by Karen Cushman

Listen to Me Good: The Story of an Alabama Midwife – by Margaret Charles Smith

Babies, Home Birth, Maternal Mortality, Maternal Mortality Rate, Midwifery , , , ,

April is Cesarean Awareness Month – Resources and a Test Your Knowledge Quiz

April 10th, 2014 by avatar

fb profile cam 2014April is Cesarean Awareness Month, an event meant to direct the American public’s attention to the United States’ high cesarean rate. 32.8% of all birthing women gave birth by cesarean in 2012. A cesarean delivery can be a life-saving procedure when used appropriately, but it takes one’s breath away when you consider that one third of all women birthing underwent major abdominal surgery in order to birth their babies.

Professionals that work with women during the childbearing year can be a great resource for women, pointing them to evidence based information, support groups and organizations that offer non-biased information to help women lower their risk of cesarean surgery, receive support after a cesarean and work towards a trial of labor after a cesarean (TOLAC) and achieve a vaginal birth after a cesarean (VBAC) for subsequent births if appropriate.

Here are my top suggestions for websites and resources every birth professional should have on their short list to share with students and clients when it comes to cesarean awareness.

1. International Cesarean Awareness Network – an international organization with almost 200 volunteer led chapters, (most in the USA) offering peer to peer support for cesarean recovery and VBAC information by way of a website, e-newsletters, webinars, online forums, Facebook groups and monthly meetings in the community.

2. VBACFacts.com – Led by birth advocate Jen Kamel, this website is big on research and helps consumers and professionals alike understand the evidence and risks and benefits of both repeat cesareans and vaginal birth after cesarean, including vaginal birth after multiple cesareans.

3. Lamaze International’s “Push for Your Baby” – is a great resource for families to learn about the Six Healthy Care Practices, what evidence based care looks like and how to work with your health care provider to advocate for a safe and healthy birth. Also Lamaze has an wonderful infographic that can be shared online or printed.

4. Spinning Babies – Midwife Gail Tully really knows her stuff when it comes to helping babies navigate the pelvis during labor and birth. Many cesareans are conducted for “failure to progress” or “cephalopelvic disproportion” when really it is a case of a malpositioned baby who needed to be in a different position. This website is a wealth of information on what women can do to help their babies into the ideal position to be born, prenatally and during labor. It includes valuable information about helping a breech baby turn vertex. This is important, because finding a health care provider who will support vaginal breech birth is like finding a needle in a haystack.

© Patti Ramos Photography

© Patti Ramos Photography

5. Childbirth Connection – This website is a virtual goldmine of evidence based information about cesareans and VBACs including a valuable guide “What Every Pregnant Woman Needs to Know about Cesareans.” There are questions to ask a care provider and includes information on informed consent and informed refusal.

6. Cesareanrates.com is a great website run by Jill Arnold for those who love the numbers. Find out the cesarean rates of hospitals in your area. All the states are represented and families can use the information when searching out a provider and choosing a facility. Jill’s resource page on this site is full of useful information as well.

7. Safe Prevention of the Primary Cesarean –  The American Congress of Obstetricians and Gynecologists along with the Society for Maternal Fetal Medicine recently published a groundbreaking document aimed at reducing the first cesarean. While fairly heavy reading, there is so much good information in this committee opinion that I believe every birth professional should at least take a peek. You may be pleasantly surprised.

Test your knowledge of the facts around cesareans and VBACs with this informative quiz:

As a birth professional, you can be a great resource for all your clients, helping them to prevent their first cesarean, providing support if they do birth by cesarean and assisting them on the journey to VBAC by pointing them to these valuable resources. You can make every day “Cesarean Awareness Day” for the families you work with, doing your part to help the pendulum to swing in the other direction, resulting in a reduction in our national cesarean rates and improving outcomes for mothers and babies. What are your favorite resources on the topic of cesareans and VBACs? Share with us in the comments section.
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  1. Patti Ramos
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Assessing Birth Settings to Improve Value and Optimize Outcomes in U.S. Maternity Care

March 12th, 2013 by avatar

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

___________________________

 

Hannah Russell-Davis nurses her newborn son
©photo by Michael Davis http://getprivatepractice.com

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).

Hannah Russell-Davis holds her son Jack, moments after his birth at their home in Charlottesville, VA. Jack was Hannah’s third home birth.
© photo by Michael Davis http://getprivatepractice.com

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).

Apgar Distribution Hospital vs. Home © Dr. Frank Chervenak 2013

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

Wendy Gordon, LM, CPM, MPH is a midwife, mother and educator in the Seattle area.  She helped to build a busy, blended homebirth practice of nurse-midwives and direct-entry midwives in Portland, Oregon for eight years before recently transitioning to Seattle.  She is a Coordinating Council member of the Midwives Alliance Division of Research, a board member of the Association of Midwifery Educators, and teaches at the Bastyr University Department of Midwifery.

 

 

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