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The Best Practice Guidelines: Transfer from Home Birth to Hospital – Collaboration Can Improve Outcomes

April 17th, 2014 by avatar

 By Lawrence Leeman, MD, MPH and Diane Holzer, LM, CPM, PA-C

© http://www.mybirth.com.au/

© http://www.mybirth.com.au/

On Tuesday, readers learned about the history and objectives of the Home Birth Consensus Summit, a collective of stakeholders, whose goal is to improve maternal infant health outcomes and increase collaboration between all those involved in serving women who are planning home births.  The interdisciplinary collaboration that occurs during the Summits brings representatives from many different perspectives to the table in order to improve the birth process for women and babies. You may want to start with the post “Finding Common Ground: The Home Birth Consensus Summit“ and then enjoy today’s post on the Home Birth Consensus Summit’s just released “The Best Practice Guidelines: Transfer from Home Birth to Hospital.”  Today’s post was written by Dr. Lawrence Leeman and Midwife Diane Holzer, two of the members on the HBCS Collaboration Task Force, a subgroup tasked with developing these transfer guidelines.  Share your thoughts on these new guidelines and your opinion on if you feel that they will improve safety and outcomes for mothers and babies. – Sharon Muza, Community Manager, Science & Sensibility

Leea Brady was a second-time mother whose first baby was born at home. One day past her due date, an ultrasound revealed high levels of amniotic fluid, which can pose a risk during delivery. Although she planned to have her baby at home, on the advice of her midwife, Leea transferred to her local hospital.

“I knew that we needed to be in the hospital in case anything went wrong,” said Brady. “I was really surprised when I arrived and the hospital staff told me they had read my birth plan, and they would do everything they could to honor our intentions for the birth. My midwife was able to stay throughout the birth, which meant a lot, because I had a trusting relationship with her. She clearly had good relationships with the hospital staff, and they worked together as a team.”

A recent descriptive study (Cheyney, 2014) reports that about ten percent of women who plan home births transfer to the hospital after the onset of labor. The reason for the overwhelming majority of transfers are the need for labor augmentation and other non-emergent issues. Brady’s transfer from a planned home birth to the hospital represents the ideal: good communication and coordination between providers in different settings, minimizing the potential for negative outcomes.

However, in some communities, lack of trust and poor communication between clinicians during the transfer have jeopardized the physical and emotional well being of the family, and been frustrating for both transferring and receiving providers. Lack of role clarity and poor communication across disciplines have been linked to preventable adverse neonatal and maternal outcomes, including death.(Guise, 2013,Cornthwaite, 2008) With optimal communication and cooperation among health care providers, though, families often report high satisfaction, despite not being in the location of their choice.

Recent national initiatives have been directed at improving interprofessional collaboration in maternity care.(Vedam, 2014) This is why a multi-disciplinary working group of leaders from obstetrics, family medicine, pediatrics, midwifery, and consumer groups came together to form a set of guidelines for transfer from home to hospital. The Best Practice Guidelines: Transfer from Planned Home Birth to Hospital are being officially launched today by the Home Birth Consensus Summit and will be highlighted at a series of upcoming presentations at conferences and health care facilities.

The authors of the guidelines, known as the Home Birth Summit Collaboration Task Force, formed as a result of their work together at the Home Birth Summits.

© http://flic.kr/p/3mcESR

© http://flic.kr/p/3mcESR

“Some hospital based providers are fearful of liability concerns, or they are unfamiliar with the credentials and the training of home birth providers,” said Dr. Timothy Fisher, MD, MS, at the Hubbard Center for Women’s Health in Keene, NH and an Adjunct Assistant Professor of Obstetrics and Gynecology, Dartmouth Medical School. “But families are going to choose home birth, for a variety of cultural and personal beliefs. These guidelines are the first of their kind to provide a template for hospitals and home birth providers to come together with clearly defined expectations.”

The guidelines provide a roadmap for maternity care organizations developing policies around the transfer from home to hospital. They are also appropriate for transfer from a free-standing birth center to hospital.

The guidelines include model practices for the midwife and the hospital staff. Some guidelines include the efficient transfer of records and information, a shared-decision making process among hospital staff and the transferring family, and ongoing involvement of the transferring midwife as appropriate.

“When the family sees that their midwife trusts and respects the doctor receiving care, that trust is transferred to the new provider,” said Dr. Ali Lewis, a member of the HBCS Collaboration Task Force. She became involved with the work of the committee in part because of her experiences with a transfer that was not handled optimally. “It is rare that transfers come in as true emergency. But when they do, if the midwife can tell the family she trusts my decisions, then I can get consent much more quickly, which results in better care and higher patient satisfaction.”

The guidelines also encourage hospital providers and staff to be sensitive to the psychosocial needs of the woman that result from the change of birth setting.

“When families enter into the hospital and feel as if things are being done to them as opposed to with them, they feel like a victim in the process,” said Diane Holzer, LM, CPM, PA-C, and the chair of the HBCS Collaboration Task Force. “When families are incorporated in the decision-making process, and feel as if their baby and their body is being respected, they leave the hospital describing a positive experience, even though it wasn’t what they had planned.”

The guidelines are open source, meaning that hospitals and practices can use or adapt any part of the guidelines. The Home Birth Summit delegates welcome endorsements of the guidelines from organizations, institutions, health care providers, and other stakeholders.

References

Cornthwaite, K., Edwards, S., & Siassakos, D. (2013). Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies. Best Practice & Research Clinical Obstetrics & Gynaecology, 27(4), 571-581.

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. (2014). Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. Journal of Midwifery & Women’s Health.

Guise, J. M., & Segel, S. (2008). Teamwork in obstetric critical care. Best Practice & Research Clinical Obstetrics & Gynaecology, 22(5), 937-951.

Vedam S, Leeman L, Cheyney M, Fisher T, Myers S, Low L, Ruhl C. Transfer from planned home birth to hospital: inter-professional collaboration leads to quality improvement . Journal of Midwifery and Women’s Health, November 2014, In Press.

About the Authors:

leeman larry headshotDr. Lawrence Leeman, MD, MPH/Medical Director, Maternal Child Health, received his degree from University of California, San Francisco in 1988 and completed residency training in Family Medicine at UNM. He practiced rural Family Medicine at the Zuni/Ramah Indian Health Service Hospital for six years. He subsequently earned a fellowship in Obstetrics. He is board certified in Family Medicine. He directs the Family Medicine Maternal and Child Health service and fellowship and co-medical director of the UNM Hospital Mother-Baby Unit. Dr. Leeman practices the family medicine with a special interest in the care of pregnant women and newborns. He is Medical Director of the Milagro Program that provides prenatal care and maternity care services to women with substance abuse problems. Dr. Leeman is a Professor in the Departments of Family & Community Medicine, and Obstetrics and Gynecology. He is currently the Managing Editor for the nationwide Advanced Life Support in Obstetrics (ALSO) program. Areas of research include rural maternity care, pelvic floor outcomes after childbirth, family planning, and vaginal birth after cesarean (VBAC). Clinic: Family Medicine Center

Diane Holzer head shotDiane Holzer, LM, CPM, PA-C, has been a practicing midwife for over 30 years with experience in both home and birth center. She was one of the founding women who passionately created an infrastructure for the integration of home birth midwifery into the system. She sat on the Certification Task Force which led to the CPM credential and also was a board member of the Midwifery Education and Accreditation council for 13 years. She served the Midwives Alliance of North America on the board for 20 years and is the chair of the International Section being the liaison to the International Confederation of Midwives. Diane is the Chair of the Collaboration Task Force of the Home Birth Summit and currently has a home birth practice and works as a Physician Assistant doing primary health care in a rural Family Practice clinic.

Babies, Guest Posts, Home Birth, informed Consent, Maternal Mortality, Maternal Quality Improvement, Maternity Care, Midwifery, Newborns, Practice Guidelines, Transforming Maternity Care , , , , , , , ,

Home Birth After Hospital Birth: Women’s Choices and Reflections – A Research Review by Jessica English

April 3rd, 2014 by avatar

By Jessica English, LCCE, FACCE, CD(DONA), BDT(DONA)

Today’s research examines the factors that influenced women who chose home birth for the subsequent child, after their previous child was born in a hospital.  Lamaze Certified Childbirth Educator Jessica English, along with midwifery colleagues just published “Home Birth After Hospital Birth: Women’s Choices and Reflections” in the Journal of Midwifery and Women’s Health.  Jessica shares about the research, some of the findings and wraps up speaking about the role that childbirth educators can play in helping women to find satisfaction in their chosen birth location. Are you an LCCE and have published research?  Consider writing a review for S&S.  I would love to highlight our LCCEs.  - Sharon Muza, Science & Sensibility Community Manager.

As a childbirth educator and doula, I have been listening to women’s birth stories for many years. I’m honored that they trust me again and again with the details of their triumphs, frustrations, joys and sometimes outright trauma. When my agency, Birth Kalamazoo, organized a meeting in 2011 to discuss the midwifery model of care, I didn’t think much of it when the attendees introduced themselves and shared a few details about their births. After all, I knew most of them very well (having taught them or in some cases even attended their births), and I knew their stories.

But one of the midwives we’d invited to speak that day took special note of those stories. Ruth Zielinski, PhD, is a hospital-based nurse-midwife, university professor and researcher in my community. She noticed that a handful of the women who spoke mentioned that they had given birth to their first baby in the hospital, then chose home birth for later babies. She approached me after the meeting, curious about why the women might have chosen home birth after their hospital experiences. I shared my perceptions based on my experience listening to women. Intrigued, Ruth wondered if this was something we could research? Neither of us had ever seen academic research on the topic of women who chose home birth after a hospital experience. Soon enough, we had a four-woman research team in place: Ruth; myself; Kelly Ackerson, an academic colleague from Ruth’s department of nursing; and one of Ruth’s undergraduate students, an honors nursing student who was planning a career in midwifery.

Our first task was to identify the structure of the research process. How would we get the information we needed? We settled quickly on focus groups, and wrote a series of open-ended questions that we expected to elicit the participating women’s honest assessments of both their home and hospital experiences, as well as the reasons behind their decision to choose home birth. The next step was to recruit the participants. Through Birth Kalamazoo’s Facebook page, our e-newsletter and via local midwives, we invited women who fit our criteria to participate in a focus group. The primary requirement was that they needed to have had at least one hospital birth followed by at least one home birth within the past 10 years.

Five focus groups followed, each with four participants and two researchers (one who asked the questions and one who took field notes). The focus groups were transcribed verbatim by members of the research team. After each focus group, team members conferred to make sure that we were in agreement about the themes that were starting to emerge. After the fifth focus group, we agreed that no new themes were emerging and we had reached “saturation of the data.” Led by Ruth and her student Casey Bernhard, the research team identified five themes that summarized what the mothers had shared. A sixth focus group of women (one from each prior focus group) provided “member checking” – we shared the themes we’d identified and asked them to verify whether or not they were in keeping with what they had heard during the focus groups.

The resulting research, “Home Birth After Hospital Birth: Women’s Choices and Reflections,” is published in the current issue of the Journal of Midwifery & Women’s Health.

Some Key Findings: Women’s Choices and Reflections

To summarize, five recurring themes were identified from the women’s reflections on both their hospital and home births: choices and empowerment; intervention and interruptions; disrespect and dismissal; birth space; and connection.

Choices and empowerment. The women in our groups reported that with their hospital births they felt they did not actually have much choice in the direction of their care. Although a few women in the study had generally positive hospital experiences, most reported feelings of disempowerment and limited choices associated with their hospital birth and more meaningful choices and feelings of empowerment with their home births.

Interventions and interruptions. During their hospital births, women experienced significantly more interventions compared to their home births. Many of the women in our study perceived these interventions as unnecessary. They commented on timetables, hospital “agendas” and interruptions both during the birth and postpartum period for their hospital births.

Disrespect and dismissal. Many of the women in our study said they felt that their hospital-based providers tended to focus more on anatomical parts and the medical process of birth, rather than on them as whole people. With their home births, they reported a much more holistic model with great respect for their decisions.

Some women who wanted to continue care with both a home birth provider and a hospital-based provider (known as “dual” or “concurrent” care) were dismissed from their hospital-based practice when they revealed that they were planning a home birth.

Birth space. Universally, women reported feeling more comfortable laboring in their own homes, surrounded by only the people they chose to invite into that space. Several women mentioned the appeal of having their older children with them for the birth, or at least having that option.

Connection. When women in our study reported positive hospital births, they also spoke of their positive connections to their providers. For both home and hospital settings, women said that feeling a sense of trust and connection to their doctor or midwife was important and even helped them to feel more comfortable with the process of birth. That theme of connection extended to women’s reflections that during their home births they also generally felt more connected to their bodies, to their babies and to other family members.

Reflections and Implications for Childbirth Educators

As an experienced Lamaze Certified Childbirth Educator and doula, I wasn’t surprised by the findings of our research. The reflections of the women participating were very much in keeping with the stories I have heard for almost a decade from my students, clients and even random women (and men!) who want to share their experiences. It does help me, however, to see the themes identified so clearly. I can envision sharing this research with women who are choosing a home birth for a second, third or fourth baby after a prior hospital birth. It may be validating to them to see many of their own feelings and reflections mirrored in other women’s experiences.

When I think about limitations of this study, I think about the natural differences between first and subsequent births. First births are often longer and more complex, with second and later births often shorter and more straightforward. Could that have influenced women’s feelings of empowerment? As an educator and doula, I also have observed that, after their first baby, many women in general feel more assertive and empowered to take control of their choices for their later birth experiences, whatever the birth setting.

In fairness to the hospital environment, it’s also important to remember that our study was limited to women who felt compelled to make a change for subsequent births. Women who have had very positive, respectful, low-intervention hospital births often choose that same setting for future babies, and their voices were not represented in our focus groups.

Our research may also have been influenced by the specific birth culture in Southwest Michigan. For example, women in our area sometimes want to receive care from both a hospital-based provider and a home birth midwife, but they are typically discharged from their hospital-based practice if they reveal they are planning a home birth. I know this isn’t the case in all areas of the country, and I can’t help but wonder if it’s due in part to the lack of licensing for Certified Professional Midwives (CPMs) in our state. Fellow LCCEs and doulas in states where CPMs are licensed have shared that women in their communities may have easier access to this kind of dual care. I think this issue merits further exploration, with research comparing the home birth experiences of women in various states where CPMs are licensed, unlicensed and specifically outlawed.

As I analyze our results with my childbirth educator hat on, I keep mulling the impact of feelings of safety and comfort on oxytocin. When women feel safe, nurtured, supported and comfortable, we know that the hormones of labor work more efficiently. Did the women in our study have more straightforward births at home in part because the environment allows their bodies to work optimally? I have given talks to labor and delivery nurses on ways they can boost oxytocin in the hospital environment, and as a doula trainer I also address this issue with new doulas. For many women, the home birth setting is inherently designed to maximize oxytocin.

The connection theme that arose in our study is also closely tied to oxytocin. In attending hospital births as a doula, I try to facilitate moments of connection between a woman and her care providers. Penny Simkin’s landmark research on women’s lasting birth memories also points to the importance of such relationships. (Simkin, 1991) Connection comes very naturally between a doula and her client, and often between a home birth midwife and a laboring woman as well. Those connections can be more difficult in a busy hospital environment where a woman is working with a nurse she has likely never met, and often with a provider who is one of many in a busy practice, and who may have several other patients in labor. Can we make more space within our medical system for nurture, if not for the emotional benefits then for the biological effect on the chemical balance in women’s bodies?

In addition to the connection challenges, the themes identified in our research also point to other weaknesses inherent in the medical model of birth. As an educator, I’m already thinking about how I can use these findings to help prepare families for more positive hospital-based experiences. How can they navigate the system to help prevent some of the pitfalls many of these women experienced during their hospital births? I believe so strongly that meaningful change in our system begins with families who speak up for what they need and want for their births. Childbirth educators are on the front lines to help educate families about what a positive, healthy birth experience can look like, and to prepare our students to advocate within the system they’ve chosen to support them.

As leaders in our birth communities, educators can also directly work for change by talking with nurses, midwives and physicians about what women are looking for in their births. Respectfully discussing both the points of dissatisfaction and satisfaction mentioned in this study can help reinforce positive behaviors and change those that may be detrimental to women and to birth. Many of the things women say they want for their births are strongly supported by quality scientific evidence. Take kangaroo care as an example. Ten years ago, a woman in our community might have said in this focus group that she wanted a home birth in part because her hospital providers refused to allow uninterrupted skin-to-skin contact for a few hours after the birth. Today, we have a hospital in our community that is a national leader in kangaroo care for all families and another that is trying to reach that benchmark.

Change is slow, but childbirth educators can help make it happen! Better birth is not just an issue of physical health and emotional well being, it is also financially beneficial to hospitals to flex to provide the compassionate, evidence-based care that will keep families within their system, coming back for subsequent births.

However, the intention of our research was not to dissuade women from home birth. For those who continue to choose that setting for later babies, it may be helpful for educators, doulas, midwives, physicians and others within the maternity care system to understand the factors that motivate them to make that informed choice for their families.

Would you share this research with your childbirth education students and expecting families?  How would you use it?  Do you think that the conclusions are valid?  Do you see things differently? Discuss with us in the comments section. – SM

References

Bernhard, C., Zielinski, R., Ackerson, K. and English, J. (2014), Home Birth After Hospital Birth: Women’s Choices and Reflections. Journal of Midwifery & Women’s Health. doi: 10.1111/jmwh.12113

Simkin, P. (1991). Just Another Day in a Woman’s Life? Women’s Long‐Term Perceptions of Their First Birth Experience. Part I. Birth, 18(4), 203-210.

About Jessica English

jessica english-bw head shotJessica English, LCCE, FACCE, CD(DONA), BDT(DONA) is a Lamaze Certified Childbirth Educator, birth doula and DONA-approved birth doula trainer. She is the owner of Birth Kalamazoo, which offers birth and postpartum doula services, natural childbirth and breastfeeding classes, birth photography, in-home lactation consulting and renewal groups for mothers. She is currently producing a short film about birth, due out in the fall.

Childbirth Education, Guest Posts, Home Birth, Maternity Care, Midwifery, New Research, Research, Transforming Maternity Care , , , , , ,

Why Pediatricians Fear Waterbirth – Barbara Harper Reviews the Research on Waterbirth Safety

March 27th, 2014 by avatar

By Barbara Harper, RN, CLD, CCE, DEM, CKC, CCCE

On March 20th, 2014, the American Academy of Pediatrics Committee on Fetus and Newborn and the American College of Obstetricians and Gynecologists Committee on Obstetric Practice released a joint clinical report entitled Immersion in Water During Labor and Delivery in the journal Pediatrics.  While not substantially different than previous statements released by the AAP, quite a stir was created.  Today, Barbara Harper, RN, CLD, CCE, DEM, CKC, CCCE, of Waterbirth International provides a research summary that supports waterbirth as a safe and reasonable option for mothers and babies.  Barbara Harper has been researching and teaching about safe waterbirth protocols for several decades and is considered an expert on the practice.  I am glad Barbara was able to share her knowledge with Science & Sensibility readers all the way from China, where she just finished another waterbirth workshop for Chinese hospital programs. – Sharon Muza, Community Manager, Science & Sensibility

In a candle lit room in Santa Barbara, California, in October of 1984, my second baby came swimming out of me in a homemade tub at the foot of my bed.  As soon as he was on my chest, I turned to my midwife and exclaimed, “We have got to tell women how easy this is!”

Earlier that month I sat in my obstetrician’s office with my husband discussing our plans, which had changed from an unmedicated hospital birth to a home waterbirth.  The OB shook with anger and accused me of potential child abuse, stating that if I did anything so selfish, stupid and reprehensible he would have no choice but to report me to the Department of Child Welfare.  I never stepped foot in his office again, but I did call his office and share the news of my successful home waterbirth.

Before setting up my homemade 300 gallon tub, I had researched through medical libraries for any published data on waterbirth, but could not find a single article, until a librarian called me and said she was mailing an article that came in from a French medical journal.  The only problem was that it was quite old. It had been published in 1803!  The next article would not come out until 1983, the very year that I was searching.[i]

The objections to waterbirth have always come from pediatricians, some with vehement opinions similar to those expressed by my former obstetrician.  The current opinion of the American Academy of Pediatrics Committee on Fetus and Newborn is nothing new.  It was issued in 2005, restated in November 2012 and it is showing up again now.  There are many obstetricians and pediatricians who are perplexed and angered over the issuing of this statement.  Especially, doctors like Duncan Neilson of the Legacy Health Systems in Portland, Oregon. [ii]  Dr. Neilson is chair of the Perinatology Department and VP of both Women’s Services and Surgical Services at the Legacy Emanuel Hospital in downtown Portland.

In 2006, Dr. Neilson did an independent review of all the literature on waterbirth, including in obstetric, nursing, midwifery and pediatric journals. He concluded, “there is no credible evidence that waterbirth is a potential harm for either mothers or babies.” He reported that the majority of the waterbirth studies have been done and published in Europe with large numbers in retrospective analyses.[iii], [iv], [v], [vi] What has been published in the US is largely anecdotal and has involved very small numbers of case reports from home birth or birth center transfers into NICU. [vii], [viii], [ix] Dr. Neilson even pointed out that Jerold Lucy, M.D., the editor of the American Journal of Pediatrics put the following commentary in a sidebar in a 2002 issue of this respected research journal, “I’ve always considered underwater birth a bad joke, useless and a fad, which was so idiotic that it would go away. It hasn’t! It should!” [x]

The publication of such prejudicial statements makes it difficult for pediatricians to look at the European research without skepticism. Dr. Neilson concluded that American doctors were not getting the complete picture.  After this comprehensive review of waterbirth literature, Dr. Neilson believed that waterbirth is a safe birth option that provides other positive obstetric outcomes. He helped set up a Legacy research committee and the parameters for waterbirth selection were created, using current recommended selection criteria followed by other Portland hospitals offering waterbirth.

Upon Dr. Neilson’s recommendations, the entire Legacy system has adopted waterbirth. The most recent hospital to begin waterbirth was Good Samaritan in Portland, which conducted their first waterbirth in February of 2014.

Women seeking waterbirth and undisturbed birth have usually considered the consequences of interference with the birth process on the development, neurology and epigenetics of the baby.  The goal of the pediatrician and the goal of mothers who choose undisturbed birth is really exactly the same.  The use of warm water immersion aids and assists the mother in feeling calm, relaxed, nurtured, protected, and in control, with the ability to easily move as her body and her baby dictate.  From the mother’s perspective, using water becomes the best way to enhance the natural process without any evidence of increased risk.  A joint statement of the Royal College of Obstetricians, the Royal College of Midwives and the National Childbirth Trust in 2006 agreed.  They sat down together to explore what would increase the normalcy of birth without increasing risk and the very first agreement was that access to water for labor and birth would accomplish that task.[xi]

Framework for Maternity Services Protocol

The UK National Health Service and the National Childbirth Trusts formed a Framework for Maternity Services that includes the following statements:

  • Women have a choice of methods of pain relief during labour, including non pharmacological options.
  • All staff must have up-to-date skills and knowledge to support women who choose to labour without pharmacological intervention, including the use of birthing pools.
  • Wherever possible women should be allowed access to a birthing pool in all facilities, with staff competent in facilitating waterbirths.

There is a concerted effort to educate midwives and physicians in all hospitals in the UK on the proper uses of birthing pools and safe waterbirth practices. [xii]

The baby benefits equally from an unmedicated mother who labors in water and has a full complement of natural brain oxytocin, endorphins and catecholamines flowing through her blood supply. The mother’s relaxed state aids his physiologic imperative to be born.  The descent and birth of the baby is easier when the mother can move into any upright position where she can control her own perineum, ease the baby out and allow the baby to express its primitive reflexes without anyone actually touching the baby’s head.  The birth process is restored to its essential mammalian nature.

The true belief in the safety of waterbirth is a complete understanding of the mechanisms which prevent the baby from initiating respirations while it is still submerged in the water as the head is born and then after the full body has been expelled.  When Paul Johnson, M.D., of Oxford University, explained these mechanisms at the First World Congress on Waterbirth at Wimbledon Hall, in 1995, there was a collective nod of understanding from more than 1100 participants.  With this information, more waterbirth practices were established all over the UK and Europe.  Dr. Johnson went on to publish his explanations in the British Medical Journal in 1996.[xiii]

Johnson’s 1996 review of respiratory physiology suggests that, in a non-stressed fetus, it is unlikely that breathing will commence in the short time that the baby’s head is underwater. Johnson sees no reason to prevent this option being offered to women.

A Cochrane Review[xiv] of women laboring in water or having a waterbirth gives no evidence of increased adverse affects to the fetus, neonate, or woman.

American Academy of Pediatrics’ Misleading Committee Commentary

Despite this review, the 2005 American Academy of Pediatrics committee on Fetus and Newborn commentary raised concerns regarding the safety of hospital waterbirth. The committee commentary was not a study itself, but rather an opinion generated upon the review of research.

A review of the commentary and the sources cited, revealed irregularities. The commentary often paraphrased text from the references, redacted crucial words and sentences from the texts, and sometimes re-interpreted the authors’ conclusions.  Anecdotal case studies were referenced without being part of an empirical study.

Example:

Committee text: “All mothers used water immersion during labor, but only a limited and unspecified number of births occurred under water.” 2 infants required positive pressure support, but little additional data were provided.

From cited reference: 100 births occurred under water. Only 2 infants out of 100 needed suction of the upper respiratory tract and a short period of manual ventilatory support. [xv]

Committee text: “Alderdice et al performed a retrospective survey of 4494 underwater deliveries by midwives in England and Wales. They reported 12 stillbirths or neonatal deaths”

From cited reference: “Twelve babies who died after their mothers laboured or gave birth in water, or both, in 1992 and 1993 were reported. None of these cases was reported to be directly related to labour or birth in water.”[xvi]

Committee text: “In a subsequent survey of 4032 underwater births in England and Wales, the perinatal mortality rate was 1.2 per 1000 live births (95% confidence interval: 0.4–2.9) and the rate of admission to a special care nursery was 8.4 per 1000 live births (95% CI: 5.8–11.8) The author of this survey suggested that these rates may be higher than expected for a term, low-risk, vaginally delivered population.”

From cited reference: “4032 deliveries (0.6% of all deliveries) in England and Wales occurred in water. Perinatal mortality was 1.2/1000 (95% confidence interval 0.4 to 2.9) live births; 8.4/1000 (THEY LEFT OUT THE 2ND CI 5.8 to 11.8) live births were admitted for special care. No deaths were directly attributable to delivery in water….”

The reference also provides that the UK perinatal mortality and special care admission rates for conventional birth ranged from 0.8 to 4.6/1000 for perinatal mortality, and 9.2 to 64/1000 for special care admission—significantly higher than those utilizing waterbirth.

Nowhere in the cited reference can the statement be found that “these rates may be higher than expected for a term, low-risk, vaginally delivered population.” In fact, the study results reflect no effect on fetal outcomes and certainly not an increase in fetal mortality and special-care admissions.[xvii]

Finally, the committee commentary acknowledges the findings of the Geissbühler study[xviii]:

“A prospective observational study compared underwater birth with births using Maia-birthing stools and beds. Although underwater birth was associated with a decreased need for episiotomies and pain medication as well as higher APGAR scores and less cord blood acidosis in newborns, the birthing method was determined by maternal preference, and potential confounding variables were not analyzed.”

The committee does not elaborate on which confounding variables they feel are of concern. It appears this supportive study was automatically discredited without a reason.

While the American Academy of Pediatrics is committed to patient safety and evidence-based medicine, this commentary’s conclusions that hospital waterbirths are of greater risk than other hospital birth options for low risk and carefully screened patients are completely unfounded.

Waterbirth Studies

In 1998, I copied all the medical journal articles about waterbirth that had been published to date and sent the labeled and categorized studies to the Practice Committee of ACOG.  In the cover letter accompanying the rather weighty binders, I asked the Committee if they would review the literature and issue an opinion about actual birth in water.  The letter that arrived a few months later from Stanley Zinberg, MD, then head of the Practice Committee, stated, “until there are randomized controlled trials of large numbers of women undergoing birth in water, published in peer reviewed journals in the US, the committee is not able to issue an opinion.”

Randomized studies of waterbirth are difficult to design and implement for one major reason: women want to choose their own method of delivery and should be able to change their mind at any point of labor. Because of this, it is difficult to design a randomized controlled study without crossover between control and study group. A 2005 randomized trial which was set up in a Shanghai, China hospital was abandoned because the hospital director realized after only 45 births that the study was unethical.  The original goal was to study 500 births, but the results of those first 45 were so good they abandoned the research project, yet continued their commitment to offering waterbirth to any woman who wanted one.  The latest communication from the Changning Hospital in Shanghai indicates that they have facilitated well over 5000 waterbirths since then.

Randomized controlled trials may be few, however, many retrospective and prospective case-controlled studies have been performed, primarily in European countries with a long history of waterbirth. In reviewing published studies, a comparison of the safety of waterbirth to conventional births among low-risk patients can be made. The evidence reveals the option of waterbirth is safe and, looking at certain parameters, has superior outcomes.

European Research

Highlights of the literature:

  • APGAR scores were found to be unaffected by water birth.[xix] One study found a decrease in 1-minute APGAR scores exclusively in a subgroup of women who were in water after membranes were ruptured longer than 24 hours.[xx]
  • A consensus of researchers found that waterbirth had either no effect or reduced cesarean section and operative delivery rates.[xxi]
  • No studies have found an effect on rates of maternal or fetal infection.[xxii]
  • Statistically, waterbirth leads to increased relaxation and maternal satisfaction, decreased perineal trauma, decreased pain and use of pharmaceuticals, and decreased labor time.[xxiii]

Cochrane Collaboration Findings

A Cochrane Collaboration review of waterbirth in three randomized controlled studies (RCTs) show no research that demonstrates adverse effects to the fetus or neonate.[xxiv] Other studies that were not RCTs were included in the conclusion:

“There is no evidence of increased adverse affects to the fetus or neonate or woman from laboring in water or waterbirth. However, the studies are variable and considerable heterogeneity was detected for some outcomes. Further research is needed.”

Conclusion

Waterbirth is an option for birth all over the world. World-renowned hospitals, as well as small hospitals and birthing centers, offer waterbirth as an option to low risk patients. Though some members of the American Academy of Pediatrics and American College of Obstetricians and Gynecologists feel otherwise, the Cochrane Review and many other studies find no data that supports safety concerns over waterbirth.

Women increasingly are seeking settings for birth and providers that honor their ability to birth without intervention. Waterbirth increases their chances of attaining the goal of a calm intervention free birth.

Physicians and midwives are skilled providers who are being trained in waterbirth techniques, safety concerns, the ability to handle complications and infection control procedures.

Carefully managed, waterbirth is both an attractive and low-risk birth option that can provide healthy patients with non-pharmacological options in hospital facilities while not compromising their safety.

In contrast to Dr. Lucy’s statement, waterbirth is not a fad and it is not going away, especially when it is mandated as an available option for all women in the UK and practiced worldwide in over ninety countries. The first hospital that began a waterbirth practice in 1991, Monadnock Community Hospital in Peterborough, New Hampshire, is still offering this service to low risk women 23 years later.  They have been joined since then by just under 10% of all US hospitals including large teaching universities and the majority of all free standing birth centers.  Hospitals have invested in equipment, staff training and are collating data to present to the medical community.  Dr. Duncan Neilson in Portland, Oregon is working on a summary of the data on over 800 waterbirths at only one hospital in the Legacy Health System.

I have dedicated my entire life to changing the way we welcome babies into the world since that October night in 1984, when I told my midwife that we have to tell women about the wonders of waterbirth. Since that night, I have traversed the planet to 55 countries and helped hundreds of hospitals start waterbirth practices.  Birth in water is safe, economical, effective and is here to stay, despite the AAP’s recent statement.

References


[i] Odent, M.,1983. The Lancet, December 24/31, p 1476

[ii] Medical Plaza Bldg. 300 N. Graham St., Suite 100 Portland, OR 97227, (503) 413-3622 dneilson@lhs.org

[iii] Alderdice, F., R., Mary, Marchant, S., Ashiurst, H., Hughes, P., Gerridge, G., and Garcia, J. (April 1995). Labour and birth in water in England and Wales. British Journal of Medicine, 310: 837.

[iv] Geissbuehler, V., Stein, S., & Eberhard, J. (2004). Waterbirths compared with landbirths: An observational study of nine years. Journal of Perinatal Medicine, 32, 308-314

[v] Gilbert, Ruth E., Tookey, Pat A. (1999) Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. British Medical Journal ;319:483-487 (21 August)

[vi] Zanetti-Dallenback, R., Lapaire, O., Maertens, A., Frei, F., Holzgreve, W., & Hoslit, I. (2006). Waterbirth:, more than a trendy alternative: A prospective, observational study. Archives of Gynecology and Obstetrics, 274, 355-365

[vii] Bowden, K., Kessler, D., Pinette, M., Wilson, D Underwater Birth: Missing the Evidence or Missing the Point? Pediatrics, Oct 2003; 112: 972 – 973.

[viii] Nguyen S, Kuschel C, Reele R, Spooner C. Water birth—a near –drowning experience. Pediatrics. 2002; 110:411-413

[ix] Schroeter, K., (2004). Waterbirths: A naked emperor (commentary) American Journal of Pediatrics, 114 (3) Sept, 855-858

[x] Neilson, Duncan  Presentation at the Gentle Birth World Congress, Portland, Oregon, Setpember 27, 2007

[xi] RCOG/The Royal College of Midwives (2006) Joint Statement no 1: Immersion in Water During Labour and Birth. London: RCOG

[xii] Johnson P (1996) Birth under water – to breathe or not to breathe. British Journal of Obstetrics and Gynaecology 103(3): 202-8

[xiii] ibid

[xiv] Cluett, E.R., Burns, E. Water in Labor and Birth(review) Cochrane Database of Systematic Reviews 2012, Issue 2 Art. No.: CD000111.DOI: 10:1002/14651858.CD000111.pub3

[xv] Odent, M.,1983. The Lancet, December 24/31, p 1476

[xvi] Alderdice, F. et.al.1995. British Journal of Midwifery 3(7), 375-382

[xvii] ibid

[xviii] Geissbühler V, Eberhard J, 2000

[xix] Aird, et al, 1997; Cammu, et al, 1994; Eriksson, et al, 1996; Lenstrup et al, 1987; Ohlsson et al, 2001, Otigbah et al, 2000; Rush, et al, 1996, Waldenstrom & Nilsson, 1992.

[xx] Waldenstrom & Nillson, 1992

[xxi] Aird, Luckas, Buckett, & Bousfield, 1997; Cammu et al, 1994; Cluett, Pickering, Getliffe, & St. George, 2004; Eckert, Turnbull, & MacLennon, 2001; Lenstrup, et al, 1987, Ohlsson, et al, 2001, Rush, et al, 1996)

[xxii] Cammu, Clasen, Wettere, & Derde, 1994; Eriksson, Lafors, Mattson, & Fall, 1996; Eldering, 2005; Lenstrup, Schantz, Feder, Rosene, & Hertel, 1987; Geissbuhler & Eberhard, 2000; Rush, et al, 1996; Schorn, McAllister, & Blanco, 1993, Thöni A, Mussner K, Ploner F, 2010; Waldenstrom & Nilsson, 1992.

[xxiii] Mackey,2001; Benfield et al, 2001

[xxiv] Cluett, E.R., Burns, E. 2012

About Barbara Harper

© Barbara Harper

© Barbara Harper

Barbara Harper, RN, CLD, CCE, DEM, CKC, CCCE,  loves babies and has been a childbirth reform activist since her first day at nursing school over 42 years ago. She is an internationally recognized expert on waterbirth, a published author and she founded Waterbirth International in 1988, with one goal in mind – to insure that waterbirth is an available option for all women. During the past four decades, Barbara has worked as a pediatric nurse, a childbirth educator, home birth midwife, midwifery and doula instructor and has used her vast experience to develop unique seminars which she teaches within hospitals, nursing schools, midwifery and medical schools and community groups worldwide. She was recognized in 2002 by Lamaze International for her contributions in promoting normal birth on an international level. Her best selling book and DVD, ‘Gentle Birth Choices’ book has been translated into 9 languages so far. Her next book ‘Birth, Bath & Beyond: A Practical Guide for Parents and Providers,’ will be ready for publication at the end of 2014. Barbara has dedicated her life to changing the way we welcome babies into the world. She considers her greatest achievement, though, her three adult children, two of whom were born at home in water. She lives in Boca Raton, Florida, where she is active in her Jewish community as a volunteer and as a local midwifery and doula mentor and teacher. Barbara can be reached through her website, Waterbirth International.

ACOG, American Academy of Pediatrics, Babies, Evidence Based Medicine, Guest Posts, Home Birth, informed Consent, Midwifery, New Research, Newborns, Research, Second Stage, Uncategorized , , , , , , , ,

Home Birth In a Risk Society: A Commentary by Sociologist Barbara Katz Rothman

February 4th, 2014 by avatar

By Barbara Katz Rothman, PhD

Today, I am delighted to share with you an essay on risk written by sociologist and author Barbara Katz Rothman, PhD.  There has been much discussion and debate on two papers just published in the Journal of Midwifery and Women’s Health, using the MANA Stats V2.0 data from the Midwives Alliance of North American. You can find these two papers and a research review by Judith Lothian published on January 30th on Science & Sensibility. – Sharon Muza, Community Manager, Science & Sensibility.

We live in what Social Scientists called a ‘Risk Society.”[i] If you simply google “risk and birth,” you get over 402 million ‘hits.’  So no question, birth is understood as  having risks, creating risks, being risky business indeed.  But not the riskiest of businesses – Google “risk and food,” and you get almost twice as many hits – over 746 million. That doesn’t feel right somehow – pregnancy and birth are always and everywhere in our world understood as risky; food not so much.  I nibble some snacks as I write, sip some tea – are you worrying for me? Wishing me luck with that?  Thinking about the odds of food poisoning? Insecticide exposure?  the long term risks of diabetes, joint pain, heart troubles, cancers that might be flowing forth from the snack choices I am making?

image: www.thinknpc.org

image: www.thinknpc.org

 

And what about those snack choices?  Do they not carry much of the same moral weight that pregnancy choices make — if I tell you it’s green tea and carrots, or if I tell you it’s a honey chai latte and multigrain crackers with organic almond butter, or if I tell you it’s a Nestle Iced Tea and Oreo cookies – do I not create different images of myself as a risk-taking or risk-sparing person, even as a more or less ‘good’ and responsible person?  These are of course the arguments that Risk-society thinkers have been addressing: the risks we perceive and the risks we take are judged, by ourselves and by others.

In birth, few choices have been as freighted with the language of risk and responsibility as that of home birth.

The irony here is that birth moved into the hospital with all of the data showing us that move increased risk; and all of the research we have now still shows us that hospitals present unique and particular risks for birth. Birth moved into the hospital long before the era of Risk – that move was done in the era of Science.  The same science that covered our kitchens in white laboratory-style paint and tiles, that replaced local baking with packaged white bread made out of mass-milled white flour, that created industrialized systems to raise cheap meat at whatever costs to health of humans or animals, that moved fruits and vegetables from fresh to canned – that same science that created the industrial diet of the turn of the century, created the industrial birth.

image: sharon muza

image: sharon muza

When I wanted a home birth almost forty years ago, I knew nothing of midwifery. I just assumed that obstetricians had the necessary knowledge and skills to deliver babies (and yes, I called it ‘deliver’) and that those skills could be used in my bedroom as well as in a ‘delivery room.’  Over the course of my scholarly work in the years following, I learned how wrong that was.  Home birth involves a set of skills, practices and competencies that people trained in hospital birth most often never have learned.  Thus the MANA data is not merely a comparison of place: What we are seeing in this data set is a study of midwifery-led care, or as Ronnie Lichtman has called it[ii], midwifery-guided birth, birth in settings where midwives and the women they are guiding have control over practice.

MANA’s data and these articles are showing us that the United States, for all of its problems, is not exceptional:  Fully autonomous, informed midwifery care provides better birth outcomes than does care under Obstetrical management.  Obstetrics and Gynecology is a surgical specialty, magnificently equipped to manage particular illnesses and crises, but neither the discipline nor the hospital settings it has developed for its practice are appropriate for normal, physiologic birth.

Research on women who choose home birth, as well as midwives who provide it, show that their concerns go beyond the risks of what is often called the ‘cascade of interventions’ that follows medical management, leading as it so often does to cesarean section.  In addition to the well-documented iatrogenic risks, they address risks of the hospital itself, what are called when looking at infections, ‘nosocomial’ risks. They were concerned with errors that are made when people are managed in what is essentially a factory-like setting: risks of overcrowding; risks of exposure to others and exposure of self.[iii]

Hospital-industrialized births demand standardized care. Consider something as mundane and yet intrusive as the vaginal exam.  Medical guidelines, the medical story, is that such exams are necessary to determine labor and its stages.  That of course is absurd.  Do you really think that an experienced midwife, someone who has attended hundreds or thousands of births cannot tell if a labor is established without a vaginal exam? What a midwife needs that exam for is to document, not to establish the labor.  Those exams are not only intimate and intrusive, but for women with histories of sexual abuse especially, can be experienced as traumatic.[iv] For all women, raised with ideas of bodily privacy, integrity and what used to be called ‘modesty,’ such exams at a moment of vulnerable transition are problematic. Done for reasons of institutional management and control, they are one more interruption and create risks of their own. Particularly in hospital settings, vaginal exams are one more occasion for the introduction of nosocomial infection.

Managing the management thus becomes necessary in hospital settings: – midwives use the vaginal exam to create the story that will be most in the woman’s best interests, and occasionally in the midwives’ own best interest.  Midwives are thoughtful about when they measure because, for example, they are hesitant to start the clock too early.  In such care, what midwives are trying to minimize is not the risks of a prolonged labor, but the risks of intervening in a labor medically defined as prolonged.

It is reasonable to talk about how recent this language of ‘risk’ is in pregnancy and in birth – but the language of danger, that which we are in risk of, has long been an accepted part of birth.  Calling it “Risk” is adding the numbers – sure there are dangers, but precisely what are the odds? That there are dangers in pregnancy and in birth, and that they can be avoided or overcome, this is not news.  Dangers, disasters even, could happen in the best and healthiest of pregnancies and births.  The difference perhaps is that now there is no such thing as a healthy pregnancy and birth.  There still is an understanding of such a thing as a ‘healthy meal” and even a “healthy diet,’ but no longer, it seems to me, a healthy pregnancy – the best you can hope for is a low risk pregnancy.

It is not that midwives do not have understandings of danger and knowledge about ways to avoid danger, including the dangers of prolonged labors.  That is precisely what midwifery has been throughout time and across place: the development of a body of knowledge and skilled craftsmanship to navigate the dangers of childbirth.  All of that knowledge was discounted with medicalization.

Scientific or ‘Medical’ knowledge is accepted as real and authoritative; other knowledge is reduced to ‘intuition’ or ‘spiritual knowing,’ made all but laughable.   But when a baker adds a bit more flour because the dough is sticky, is that ‘intuition’?  Or is that knowledge based on craft, skill, deep knowledge of the hands?  When a violin-maker rejects a piece of wood in favor of one lying next to it that looks just the same to me or to you, is that ‘intuition’?  Or experience, skill and craft?  And when a leading neurosurgeon examines a dozen stroke patients who all present pretty much the same way on all of their tests and feels hopeful about some and concerned for others, is that ‘intuition’?  Or knowledge based on experience, using a range of senses and information that may not be captured in the tests?

In hospital settings, midwives do not have the authority to use their knowledge fully in the woman’s best interests.  And therein lie the risks.

And finally, it would be helpful to put these risks in contextIf safety were our real concern, if saving the lives of babies and of mothers were the driving force, then there are a number of changes we would make immediately.  We would require helmets for people in cars, something we know would save lives each week.  We would lower the speed limit in urban areas, and end driveway parking in suburbs. To suggest such things makes one look crazy – crazier than suggesting home birth.  But it most assuredly would protect children. If saving babies were our concern, we would invest in public housing, and in the food system.  These are large scale changes that would save far more people than anything that happens in those few hours of late labor to early neonatal period, the 24 or so hours of hospitalization that is now being debated.

Clearly something more or other than saving babies is at stake.

References

[i] Beck, U. (1992). Risk society: Towards a new modernity (Vol. 17). Sage.

[ii] Lichtman, R. (2013). Midwives Don’t Deliver or Catch: A Humble Vocabulary Suggestion. Journal of Midwifery & Women’s Health.

[iii] Katz Rothman, B., (2014) Risk, Pregnancy and Childbirth, Risk, Health and Society, edited by Alaszewski, Intro by Barbara Katz Rothman. Volume 16.1, forthcoming.

[iv]  Adult manifestations of childhood sexual abuse. Committee Opinion No. 498, American College of Obstetricians and Gynecologists. Obstet Gynecol 2011: 118:392-5.

About Barbara Katz Rothman

image: Barbara Katz Rothman

image: Barbara Katz Rothman

Barbara Katz Rothman, PhD, is Professor of Sociology, Public Health, Disability Studies and Women’s Studies at the City University of New York, and on the faculty of the Masters in Health and Society at the Charite in Berlin, the University of Plymouth in the UK, and the International Midwifery Preparation Program at Ryerson University in Toronto Canada. Her books include In Labor: Women and Power in the Birthplace, The Tentative Pregnancy: How Amniocentesis Changes the Experience of Motherhood, Recreating Motherhood, The Book of Life: A Personal and Ethical Guide to Race, Normality and the Human Gene Study,  Weaving A Family: Untangling Race and Adoption and Laboring On: Birth in Transition in the United States.  Dr. Katz Rothman is the proud recipient of an award for “Midwifing the Movement” from the Midwives Alliance of North America.

Cesarean Birth, Childbirth Education, Do No Harm, Evidence Based Medicine, Guest Posts, Home Birth, informed Consent, Maternal Quality Improvement, Maternity Care, Midwifery, New Research , , , , , , , , , ,

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30th, 2014 by avatar

Today’s post on Science & Sensibility coincides with the release of a long awaited study looking at the home birth data collected by the Midwives Alliance of North America MANAStats project, 2004-2009.  Judith Lothian, PhD, RN, LCCE, FACCE reviews the research that examines outcomes of almost 17,000 planned home births in the United States.  To date, this is the largest dataset of planned home births available. Dr. Lothian takes a look at what the research found and helps S&S readers to understand the key points of the published paper.  - Sharon Muza, Community Manager, Science & Sensibility.

The American College of Nursing today announced the publication in the Journal of Midwifery and

http://www.flickr.com/photos/wickenden/

http://www.flickr.com/photos/wickenden/

Women’s Health of important new US research on the outcomes of home birth: Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009“. This research is important for two reasons: it adds to the increasing body of research that supports the safety of home birth for healthy women in the US, and it demonstrates the value and importance of the National Data Registry for Midwife-Led Birth, the Midwives Alliance of North America (MANA) Statistics Project 2.0 dataset(2). This is the first publication of home birth outcomes research in the US since 2005, nearly a decade. Just as importantly, it is the first major research study published using the MANA dataset.

Studying planned home birth presents unusual challenges. A randomized control trial is not possible because women are not willing to consent to randomization to home or hospital. Unlike other countries, data in the US are collected state by state and most birth certificates (the most common, although often unreliable, way to collect birth data) do not collect information about planned home birth. As a result, unlike in countries like the Netherlands, population based research is not possible. There is a need in the US for a system for universal maternity care data collection.  In response to this need, and the need for high quality data on midwifery outcomes, MANA in 2004 began the momentous work of developing a national data registry for midwife-led birth. The result is the National Data Registry for Midwife-Led Births, the Midwives Alliance of North America (MANA) Statistics Project 2.0 dataset.  A companion article in the same issue of the Journal of Midwifery and Women’s Health is available to read more about the development and validations of the National Registry for Midwife-Led Births.

About the study

For this study, data were collected from 2004-2009 using the MANA Stats 2.0 Web-based tool. Midwifery participation was voluntary. Data were contributed by 432 different midwives: 20 to 30 percent of all active Certified Professional Midwives (CPMs) and a much lower percentage of active Certified Nurse Midwives (CNMs) contributed to the dataset. Other types of midwives who also participated included Licensed Midwives (LMs), Licensed Direct Entry Midwives (LDMs), Certified Midwives (CMs), and a small percentage of unlicensed direct entry midwives. The midwives obtained written informed consent from the women at the onset of care to contribute data, including outcomes, to the registry. It’s important to note that women were entered into the registry by the midwives at the onset of care before outcomes were available. More than 95% of the women cared for by the midwives who participated in the registry provided consent. The sample for the study included all women who intended to give birth at home at the time they went into labor. The final sample of women was 16,924.

http://www.flickr.com/photos/eyeliam/

http://www.flickr.com/photos/eyeliam/

The women were mostly white, married, and college educated. Almost 2/3 of the woman paid for midwifery services out of pocket. The sample came largely from the Western United States.  Almost 78% of the women had previous babies (8% having had a previous cesarean) and a just over 22% were expecting their first babies. Some, but very few, of the women in the sample had complications or co-morbidities (for example, 1.3 % breech, 0.4% multiple gestation, 1.4% pregnancy induced hypertension, 0.8% gestational diabetes).

What follows is a snapshot of some of the most important findings of the study. The authors go into great detail presenting and discussing the findings and then comparing their findings to previous published studies of planned home birth. I encourage you to read the full article.

Study results

Almost 94% of the women had spontaneous vaginal births. There was a 5.2% cesarean rate and an 87% VBAC rate. Only 4.5% of the sample required oxytocin augmentation and/or epidural. Ninety two percent of the births were full term, 2.5% were pre-term and 5.1% were post-term. Less than 1% of the babies were low birth weight. There was an intrapartum transfer rate of 10.9%. Women giving birth for the first time were three times more likely to transfer during labor, most often for failure to progress. Postpartum transfers were 1.7% for women who gave birth at home. The most common reason (over 70%) was for complications related to hemorrhage and/or retained placenta. Neonatal transfer was 1.0% with the most common reason being respiratory distress or low Apgar.

In this sample, the rate of postpartum hemorrhage (defined as over 500cc in a vaginal birth and 1000 cc in a cesarean) was 15.4%, higher than previous research has reported. That said, the transfers for excessive bleeding were low. Active management of third stage is infrequent in this sample. The authors posit that without intravenous oxytocin administration, the 500cc benchmark for diagnosing hemorrhage may not be appropriate in this physiologic birth population.

The intrapartum neonatal death rate was 1.3 per 1000, consistent with rates reported in some studies, but higher than the rates reported in others. While the rate is still relatively low, it might, the authors suggest, be partially explained by a sample that included women who are at higher risk for adverse outcomes (multiple gestations, breech presentations, VBAC, gestational diabetes or pre-eclampsia). When these women were removed from the sample, the intrapartum death rate drops to 0.85 per 1000, a rate that is statistically congruent with rates reported in most studies, with the exception of large population studies in the Netherlands that report somewhat lower rates.(deJonge et al, 2009). The authors also note that the lack of an integrated system and possible delays in transfer may contribute to the small but somewhat higher rate of intrapartum neonatal death in the sample.

There was one maternal death in the study, as a result of a blood clot in the heart at three days postpartum after an uncomplicated pregnancy, labor, birth and postpartum.

Discussion

As in any research there are limitations. This is not a population based study. Not all midwives in the US contributed data to the registry. The births took place mostly in the Western United States. The women were largely white, college educated and married. Nonetheless, the findings make a major contribution to the literature on planned home birth supporting the findings of previous research conducted both in the US and in Canada, the Netherlands, and the United Kingdom (Johnson & Daviss, 2005; Janssen et al 2009; Hutton et al, 2009; Janssen et al, 2002; deJonge et al, 2009; Birthplace in England, 2011).

In spite of the meticulous development and validation of the dataset and the acknowledged limitations of the data, I suspect the usual naysayers will question the validity and the usefulness of the dataset. I suspect those opposed to planned home birth will exaggerate the implications of findings related, for example, to maternal bleeding in spite of the fact that almost no mothers required transfer or intervention, and point out the higher intrapartum neonatal mortality numbers than other studies have reported without discussing the fact that the increase is largely accounted for by infants of women at higher risk for adverse outcomes (pre-eclampsia, gestational diabetes, multiple gestation, VBAC,  breech). It is difficult for anyone to dismiss the importance of the overall excellent outcomes for both mothers and babies.

The excellent outcomes in this study, (with care provided mostly by CPMs & LMs, in a country that does not have integrated systems of care including seamless transfer and collaboration between providers, and with a sample that included women who are usually considered at higher risk for planned home birth {breech, VBAC, multiple gestations, pre-eclampsia, gestational diabetes}), should make us pause. Could it be that even for women with some risk factors, planned home birth could be as safe as hospital birth?  What would the outcomes be if we had an integrated system of care?

Personal “Take Aways”

  • The MANA dataset is an extremely valuable resource for researchers. Thanks to the work of MANA, the dedicated midwives who participate in the registry, and the women who consent to having their outcomes registered, we have further evidence, this time in the US, that planned home birth reduces interventions including cesarean, and has outcomes similar or better than planned hospital births. CPMs, CMs and LDMs, who are the largest group of midwives contributing to the dataset, deserve recognition and respect. The positive outcomes reflect the excellence of care that they provide for women. With the publication of this important study, and the publication of the companion article describing the development and validation of the dataset, hopefully, many more midwives, including CNMs and those who practice in other parts of the country, will be persuaded to contribute to the registry.
  •  I encourage you to share the findings of this study with the women you teach, talk to and touch. Most women will not choose home birth but knowing that women today give birth safely at home without routine interventions or tied to machines, and subjected to the ticking clock, should give all women a boost of confidence in their ability to give birth. And, it just might encourage some women to think about having a planned home birth.
  • We might think of a childbirth education registry. We have wanted high quality data for decades to track the outcomes of childbirth education. Perhaps this is a way to collect quality data?

Conclusion

This is a landmark study of US home birth. Hats off to MANA for its ground breaking contribution in collecting and providing data that will further advance our knowledge of planned home birth and midwifery.  Hats off to the dedicated midwives who contributed their outcomes to the dataset, and to the women who were so willing to share their information with the world. And, hats off to the dedicated researchers, Melissa Cheyney, Marit Bovbjerg, Courtney Everson, Wendy Gordon, Darcy Hannibal and Saraswathi Vedam who continue to contribute in groundbreaking ways to promoting and supporting normal, physiologic birth and the health and safety of childbearing women and babies.

 References

Birthplace in England Collaborative Group. (2011). Perinatal and Maternal Outcomes by Planned Place of Birth for Healthy Women with Low Risk Pregnancies: The Birthplace in England National Prospective Cohort Study, British Medical Journal 343, d7400.

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D. & Vedam, S. (2014). Outcomes of Care for 16, 924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. Journal of Midwifery and Women’s Health.

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D. & Vedam, S. (2014). Development and Validation of a National Data Registry for Midwife-Led Births: The Midwives Alliance of North America Statistics Project 2.0 Dataset. Journal of Midwifery and Women’s Health.

de Jonge,  B. van der Goes,  A. Ravelli, M. Amelink-Verburg , et al.(2009). Perinatal Mortality and Morbidity in a Nationwide Cohort of 529,688 Low-risk Planned Home and Hospital Births. British Journal of Obstetrics and Gynecology 16, no. 9, 1177-84.

Hutton, E.,  Reitsma, A., 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, no. 3, 180-89.

Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee Sk. (2009). Outcomes of Planned Home Births with Registered Midwife versus Attended by Regulated Midwives versus Planned hospital Birth in British Columbia. Canadian Medical Association Journal 181, no. 6, 377-83.

Janssen, P. Lee,S.,  Rya,E,  et al. (2002). Outcomes of Planned Home Births versus Planned Hospital Births after Regulation of Midwifery in British Columbia. 166, no. 3, 315-23.

Johnson, K. & Davis, B.A. (2005). Outcomes of Planned Home Brth with Certified Professional Midwives: A Large Prospective Study in North America. British Medical Journal 330, 1416-19.

About Judith Lothian

@ Judith Lothian

@ Judith Lothian

Judith Lothian, PhD, RN, LCCE, FACCE is a nurse and childbirth educator. She is an Associate Professor at the College of Nursing, Seton Hall University and the current Chairperson of the Lamaze Certification Council Governing Body. Judith is also the Associate Editor of the Journal of Perinatal Education and writes a regular column for the journal. Judith is the co-author of The Official Lamaze Guide: Giving Birth with Confidence. Her research focus is planned home birth and her most recent publication is Being Safe: Making the Decision to Have a Planned Home Birth in the US published in the Journal of Clinical Ethics (Fall 2013 ).

 

Babies, Childbirth Education, Evidence Based Medicine, Guest Posts, Home Birth, Maternal Mortality, Maternity Care, Midwifery, New Research, Newborns, Research , , , , , , , , , , , ,