Archive for the ‘Midwifery’ Category

Midwives Alliance of North America (MANA) Invites You to Research Home Birth!

October 31st, 2013 by avatar

This past weekend I attended the Midwives Alliance of North America (MANA) annual conference; Birthing Social Change in Portland, OR. The conference was attended by more than 300 midwives and their supporters. I thoroughly enjoyed the variety of general sessions and the concurrents I attended. Eugene DeClerq, (did you know he is an LCCE!) a principal investigator on the Listening to Mothers project and the genius behind the Birth by the Numbers website, was brilliant as usual in sharing all kinds of data about the state of birth in the USA. Another keynote speaker, Melissa Cheyney, PhD, CPM, LDM, Division of Research Chairperson for MANA, provided members with an update on the MANA Stats Project. The MANA Stats Project is a multi-year registry collecting data mostly about out-of-hospital births, though some Certified Nurse Midwives are using it for tracking both home and hospital births as well.

At the conference, two much-anticipated research studies were announced. You can learn more about the articles and MANA stats in a recent post at the MANA blog here. Science & Sensibility is looking forward to sharing a review and information about these studies with you here on our blog in the early part of next year, when they are released in the Jan/Feb 2014 issue of the Journal of Midwifery and Women’s Health.

The MANA Stats registry is currently collecting more than 1,000 records per month, mostly from midwives who attend out of hospital births in the United States. The first set of records – representing more than 20,000 births – is currently available to researchers. According to Melissa Cheyney, “These datasets include some of the only U.S. data that exists regarding physiologic, low-intervention labor and birth — data that are becoming more and more rare due to the increase in “routine” interventions in the hospital setting.”

As the data set grows and more records are added, the power and possibility of exploring information contained gets even more exciting. Did you know that the data is being made available to researchers interested in conducting some analysis? Could this be you? Professionals may think that they need to be affiliated with a large research institution, but that is not the case.

All researchers applying for the data are required to have what’s known as “IRB approval,” meaning an academic institution willing and able to ensure that the research design appropriately protects the subjects’ confidentiality. However, MANA has a unique program in place that allows non-academic researchers to access the data. The program connects mothers, advocates, and others interested in research with researchers that can provide support and mentorship. You can learn more about this program – called “ConnectMe” – here 

It would be wonderful if a Lamaze Certified Childbirth Educator with the skill and abilities to do some analysis joined forces with researchers through the “ConnectMe” program and this information could be published in a professional journal! The possibilities are endless. Do you think this could be you?

It was interesting and exciting to spend time with all the midwives who are working every day to to help women and babies experience safe, healthy births and are practicing the Lamaze International Six Healthy Birth Practices that we know leads to better birth outcomes.

For more information for researchers to learn more about the dataset and how to apply, click here.

Childbirth Education, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, Home Birth, Midwifery, New Research, Research, Research Opportunities , , , , , , , , ,

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 26th, 2013 by avatar

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

Midwife Wendy Gordon shares with Science & Sensibility readers why the recent home birth research using 5 minute Apgar scores does not produce reliable data that consumers can use to make a decision on where they would like to give birth.  Have you had a chance to read the study?  What were your conclusions? See if you agree with Wendy or had some different thoughts.  Share your opinion and thoughts with us in the comments section.  Thank you Wendy for providing information that can help us to assess the study and understand it better. Sharon Muza, Science & Sensibility Community Manager



© http://www.mybirth.com.au/

A recent press release by the authors of a new study raised alarming headlines in a few media outlets, suggesting that babies born at home had a 10-fold higher death rate than babies born in the hospital. I’ve written previously about reliability concerns with the use of birth certificates in this study. In this post, we’ll go more in-depth with some of its other flaws. Let’s start with the fact that the authors did not examine stillbirths.

Apgar scores and stillbirth

The new study by Grunebaum et al. (2013), in press with the American Journal of Obstetrics & Gynecology, examined birth certificate data for almost 14 million births between 2007 and 2010 looking for differences in outcomes between home and hospital births. They did not look at “stillbirths,” perinatal, intrapartum or neonatal deaths. They looked at 5-minute Apgar scores of zero, and led the readers of their press release to believe that this meant that the babies died during or shortly after labor, due entirely to their choice of birthing at home.

When we examine a little more closely what it means to have a 5-minute Apgar score of zero, we might find that it does include some babies who died shortly after birth. We might also find a number of babies who had lethal congenital anomalies, who would not have survived no matter where they were born or who attended the birth; there may be important differences between home and hospital populations with regard to whether these anomalies were detected prenatally and whether parents changed their birth plans because of it. There may also be some babies who were successfully resuscitated after the 5-minute Apgar score was assessed. While the authors conceded in the study that their analysis could have included these births, as well as babies who died before labor even began, the terminology used in their press release is highly misleading.

A rigorous study that actually examined deaths would have excluded births with outcomes that had nothing to do with place of birth or attendant. Several well-designed studies have done just that and have found no differences in mortality rates between planned home and hospital births, and often fewer low 5-minute Apgar scores among planned home births attended by midwives (Ackermann-Liebrich et al., 1996; Olsen, 1997; Janssen et al., 2002; Hutton et al., 2009; Janssen et al., 2009). Grunebaum does not mention that their findings are actually the opposite of what several rigorous studies have already determined.

Absolute vs relative risk

I’ve also written previously about the dangers of reporting relative risks (“ten times higher!”) without acknowledging that the absolute risk of the complication is actually very, very low. Even if Grunebaum’s study had appropriately excluded outcomes that had nothing to do with place of birth, and even if their source of data was reliably accurate — no one is served by omitting the fact that 5-minute Apgar scores of zero are exceedingly rare.

Some of the raw numbers that Grunebaum reports in the study are so low — less than a dozen events within tens of thousands of births, in some cases — that it is hard to imagine how practitioners could use this information to draw any meaningful conclusions whatsoever about clinical practice.

Even with all of the flaws in this study, the rate of zero Apgars in the “home midwife” category in this study was 1.6/1000. This is a very low number. If these results were valid, it would be these absolute risks that mothers and families should be informed about, and honest discussions should be had regarding why there might be a higher risk in the home setting so that families can make the best decisions for themselves about all of the risks and benefits that come with location of birth.

Transfers not accounted for in “planned” home births

A concern that is often raised by anti-homebirth activists is that births that start out as planned home births but transfer to the hospital in labor are actually counted as hospital statistics in birth certificate data. To be fair, these births likely do have worse outcomes. Although most transfers are for non-urgent reasons such as stalled labor or desire for pain relief (Johnson & Daviss, 2005), some transfers occur because medical assistance is needed and the appropriate place to be is in the hospital.

But let’s look at the real impact of these transports. U.S. data shows that about 10% of planned home births result in transport to the hospital during labor (Johnson & Daviss, 2005). Even if Grunebaum was able to accurately capture planned home births and that number truly was 67,429, we could reasonably assume that about 10% of those babies (6743) were born in the hospital. Those babies account for less than 0.05% of the 14 million babies born in the hospital. Even if every single one of those babies had a 5-minute Apgar score of zero, Grunebaum’s rate of zero Apgars in the hospital would increase from 0.25/1000 to 0.49/1000. In reality, only a very small proportion of home birth transports actually do result in such an adverse outcome, and thus essentially have a negligible effect on hospital outcomes.

On the other hand, even a small percentage of misclassified outcomes in the home birth category have a dramatic impact. Because the number of home births in the U.S. is small, the inclusion of prenatal stillbirths, congenital anomalies and unplanned, unattended home births in the “home midwife” category is likely to have an appreciable effect on the negative outcomes examined here. Furthermore, the 10% of home birthers who transport to the hospital and have positive outcomes there are not appropriately attributed to the planned home birth group either. The truth about the safety of home birth simply cannot be determined in this way.

Reliability of birth certificates

I wrote my initial reaction to Grunebaum et al’s study last week when their press release came out. I expressed concerns about the low reliability and validity of birth certificates for drawing conclusions about rare outcomes. Grunebaum’s own data shows that over 10% of “home midwife” deliveries had no information on the birth certificate about the mother’s parity and had to be excluded from their calculations, while only 0.2-0.5% of hospital or birth center deliveries were missing parity data; this strongly suggests that something is amiss with the “home midwife” data.

Epidemiologists and birth certificate scholars have made their concerns about reliability and validity exceedingly clear in an enormous body of literature over the last few decades, and in fact, expressed these concerns directly to Frank Chervenak (co-author on this study) earlier this year when he presented this very data at the Institute of Medicine’s workshop on Research Issues in the Assessment of Birth Settings (IOM & NRC, 2013, p.143). The fact that these authors were clearly warned about the low quality of their data regarding both low Apgar scores — and especially seizures — but chose to push ahead with publication without addressing them, suggests other motivations.


Families deserve to have the best possible information with which to make decisions about where to have their babies. Grunebaum and co-authors miss the mark by a wide margin with the methodology and conclusions of this study.

To learn more about existing, well-designed home birth studies, read here. To learn more about the MANA Stats Project, which provides researchers with a dataset of more than 24,000 planned home birth and birth center births, read here. And watch for new research based on the MANA Stats dataset 2004-2009. Two articles are in press and two more are under review in peer-reviewed journals.


Ackermann-Liebrich, U., Voegeli, T., Gunter-Witt, K., Kunz, I., Zullig, M., Schindler, C., Maurer, M. & Zurich Study Team. (1996). Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. BMJ 313:1313-1318.

Declercq, E., MacDorman, M. F., Menacker, F., & Stotland, N. (2010). Characteristics of planned and unplanned home births in 19 states. Obstetrics & Gynecology 116(1):93-99.

Grunebaum, A., McCullough, L. B., Sapra, K. J., Brent, R. L., Levene, M. I., Arabin, B., & Chervenak, F. A. (2013). Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting. Am J Obstet Gynecol, 209:x-ex x-ex.

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

IOM (Institute of Medicine) and NRC (National Research Council). (2013). An Update on Research Issues in the Assessment of Birth Settings: Workshop Summary. Washington, DC: The National Academies Press.

Janssen, P. A., Lee, S. K., Ryan, E. M., Etches, D. J., Farquharson, D. F., Peacock, D., & Klein, M. C. (2002). Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. CMAJ 166(3):315-323.

Janssen, P. A., Saxell, L., Page, L. A., Klein, M. C., Liston, R. M., & Lee, S. K. (2009). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ 181(6-7):377-383.

Johnson, K. C. & Daviss, B. A. (2005). Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ 330:1416-

Olsen, O. (1997). Meta-analysis of the safety of home birth. BIRTH 24(1):4-13.

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.

ACOG, Childbirth Education, Guest Posts, Home Birth, Midwifery, Newborns, Research , , , , , , ,

Six Birth Blogs Every Childbirth Educator Should Be Reading

September 17th, 2013 by avatar

Today on Science & Sensibility, I wanted to share with readers some of my favorite birth related blogs, after Science & Sensibility of course! I subscribe to over 400 blogs, on a variety of topics, not just birth. I hope that someone has a larger blog list then I do, otherwise I will start to worry about how this might be an obsession.

I really enjoy reading what experts in the field of maternal and infant health have to say on their blogs and frequently find myself sharing information in my classes and with the families that I work with as well as with other professionals. I appreciate the effort, the research, the time and the energy that goes into making my favorite blogs so rich and useful for me, and so relevant to the work I do as an LCCE. 

Here are six of my favorite blogs, in no particular order:

1. Spinning Babies Blog

Midwife Gail Tully has long been well known for her website, Spinning Babies and her blog is an added bonus!  Gail frequently answers questions from readers, describes some new research she came across or shares a new technique to help babies move easier through the pelvis.  Here you can frequently find a video snippet you can use in your childbirth class, a book review or an inspiring birth story usually related to babies who chose to do things their way, as they work to be born.  

2. Evidence Based Birth

This blog burst onto the scene in mid-2012, and has been a fantastic resource ever since.  Rebecca Dekker, PhD, RN, APRN is an assistant professor of nursing at a research university in the U.S. She teaches pathophysiology and pharmacology, but has a strong personal interest in birth, and hence the blog was created.  The mission of Evidence Based Birth is to “promote evidence-based practice during childbirth by providing research evidence directly to women and families.”  Rebecca takes a look at the big issues (failure to progress, big babies, low AFI, for example) that face women during their pregnancy and birth, and does a thorough job of evaluating all the research and explaining it in a logical, easy to understand post.  Rebecca sums up her posts with recommendations based on the evidence and gives readers the bottom line and take-away.  Additionally, there are “printables” that are concise versions of some of her blog posts that families can print out and take to appointments with their healthcare providers in order to help facilitate discussions about best practice.

3.  VBAC Facts

Jennifer Kamel has created a plethora of useful information on vaginal birth after cesarean (VBAC) facts and statistics.  She founded her blog after doing a huge amount of research on the benefits and risks of VBAC, after her first birth ended in a Cesarean and she prepared for her second.   The amount of information, statistics, research summaries and discussion found on her blog is amazing.  Jen is a “numbers gal” and does a great job of explaining risks and numbers in an easy to understand presentation.  I frequently find myself going to her blog when I want to know the risk of placental complications after a cesarean or to better understand some of the new research and policy statements from ACOG and other professional organizations.  When 1 in 3 women in the US will give birth by Cesarean, it is good to have a resource such as VBACFacts.com to go to that can help me understand and explain options to families birthing after a cesarean.

4. The Well-Rounded Mama

Pamela Vireday has written “The Well-Rounded Mama” blog since 2008 and it has been a valuable resource for women of all sizes, when they are looking for answers and facts about options for birth.  The mission of the blog is “to provide general information about pregnancy, birth, and breastfeeding, to discuss how to improve care for women of size, to raise awareness about the impact of weight stigma and discrimination on people of size, and to promote health by focusing on positive habits instead of numbers on a scale.” Pamela does an awesome job of gathering, explaining and summarizing research, particularly related to women of size, but in all honestly, extremely relevant to all birthing women.  I appreciate her plus size photo galleries of pregnant and breastfeeding women of size. If you might be a  woman who is larger than many of the models in today’s pregnancy magazines, seeing the gallery of women who look beautiful pregnant and breastfeeding, with a wide range of body shapes, can be comforting.  In addition to providing evidence based information,  Pamela answers some of the questions that plus sized mothers might have, but are hesitant to ask their healthcare provider, such as concerns about about whether fetal movement will be noticeable if they are larger sized.  A great blog, with relevant articles for all women!

5. Midwife Thinking

This blog is written by Rachel Reed, an Australian PhD midwife, who enjoys taking a look at the research and sharing her thoughts on how well the research is applied to application.  I enjoy reading her blog for that reason, and often find myself amazed that she chooses to write about the very topics that I wonder about and want to learn more on.  Rachel’s aim is to “stimulate thinking and share knowledge, evidence and views on birth and midwifery. ”  I also appreciate her “Down Under” perspective and celebrating the commonalities of birth across the many miles.  Rachel is not afraid to agree when the science backs up the “less popular” treatment and care amongst childbirth advocates, allowing the evidence to speak for itself and carefully explaining why.   Rachel does a great job of normalizing many of the topics that bog women down during labor and birth, such as the “anterior cervical lip” or “early labor and mixed messages.”  I like to share Rachel’s posts with families who are experiencing the very situation she is writing about.

6. ACOG President’s Blog

Every week, the current president of the American Congress of Obstetricians and Gynecologists (ACOG) writes a blog post on a matter of importance to women.  Not all the posts are on birth related topics, but I find it very interesting to see what Dr. Jeanne A. Conry, M.D. PhD shares with readers.  While some of her blogs are directed at her fellow physicians, many of the posts highlight information and resources directly related to women’s health, especially during the reproductive years.  I enjoy learning more about what Dr. Conry feels is important, and especially what messages and information she is directing to her colleagues. I appreciate her middle of the road approach and look forward to a new post every week.

I hope that you might consider following some of the blogs I mentioned here, if you are not already doing so.  I would also love if you shared your favorite blogs with myself and our Science & Sensibility readers.  I always have room for more good birth related blogs in my blog reader!  What blogs do you read?

ACOG, Authoritative Knowledge, Breastfeeding, Cesarean Birth, Childbirth Education, Continuing Education, Evidence Based Medicine, Maternity Care, Midwifery, Research, Science & Sensibility , , , , , , , , , , , , , ,

The Complete Illustrated Birthing Companion: A Book Review

September 10th, 2013 by avatar

I recently had the opportunity to review a book published in January, 2013, written for birthing families. The Complete Illustrated Birthing Companion; A Step-by-Step Guide to Creating the Best Birthing Plan for a Safe, Less Painful, and Successful Delivery for You and Your Baby.  This book is authored by a diverse team of experts, Amanda French, M.D., an OB/Gyn, Susan Thomforde, CNM, Jeanne Faulkner, RN and Dana Rousmaniere, author of pregnancy and birth topics. I wanted to share my review with Science & Sensibility readers so you can consider if you want to add this book to your recommended reading list for expecting families. The book is available on Amazon for 14.29 and a Kindle version is available as well.

This book is marketed as a large 8 1/2 by 11 inch paperback with an attractive cover.  Inside is easy to read print, a pleasant amount of white space on semi-glossy paper, along with full color photographs and illustrations.  There are some beautiful photographs in there, clearly taken by talented photographers, but some of the photos seemed too unnatural, women posed in the perfect position, wearing make-up with hair just so.  The pictures are all completely modest, with the exception of just one woman in a birth tub, which surprised me in a book about birth.  In my experience, birth is a bit more “gritty” than represented by the pictures chosen for this book.  I really appreciated the diversity of images of the women and their families, women of color and their families are well represented throughout. I also appreciated the choice of language, women have partners and those partners can be men or women.

Who is this book for?

This book for is for women who are still deciding on a birth along the spectrum of options, from a home birth to a planned cesarean. It also makes sense for women who are not quite sure what type of birth they want; they can read about all the choices as they settle on what feels good to themselves and their families.  The book is written in easy to understand language, and when medical vocabulary is introduced, a definition is provided so that readers can be clearly understand what is being discussed.  The book is best used for determining what type of birth a woman is interested in having.  If the mother has already determined where and how she would like to birth,  then this book, which is in large part a comparison of the different options, would be less useful.

Jeanne Faulkner, RN

What will families find inside?

The book starts off by asking women to imagine their perfect birth, encouraging them to hold this in their minds, but to also remember that birth requires flexibility as things can change during a pregnancy or labor that will require a deviation from what a mother was planning.  A brief but accurate overview of provider types (and a good list of questions to ask providers to determine who is right for each mother) and childbirth education options are covered, and states Lamaze includes a “good, comprehensive overview of childbirth.”  The chapters are then divided into options by birth location as well as pain medication choices, and then goes on to cover induction, planned and unplanned cesarean. Natural coping techniques and pharmacological pain medication options are covered in a chapter toward the end, along with a guideline for writing a birth plan.

“Unmedicated Vaginal Birth at Home” or “Epidural, Vaginal Birth in the Hospital” are some of the chapter titles and for each section the authors take the time to explain what this option is, why it may or may not be right for any particular woman (in the case of home birth, why a woman  might risk out of this option prenatally or in labor), the pros and cons of each option and how to best prepare if this is the choice a woman has made.  Throughout the book, the authors take care to state that women should be flexible and things may change. Desiring an epidural but not having time for one is a possibility that women need to consider.  I really appreciate this gentle reminder throughout the book, as I too believe that being flexible and being able to deviate from what a woman originally planned will help as the labor unfolds.

For each type of birth, women are given suggestions to help them achieve the birth they want and are encouraged to have a variety of coping techniques lined up for dealing with labor pain if they are choosing to go unmedicated.  Realistic and useful advice is given, even when the birth is highly managed, so that the mother and her partner can have a positive experience.

Amanda French, M.D.

What families won’t find inside?

This is not a book about pregnancy, breastfeeding, postpartum care or newborn care and it doesn’t claim to be.  This is a book about birth and the choices surrounding birth.  Families who want to read about prenatal testing, or learn about breastfeeding techniques will want to have other books in their collection that cover those topics.  While this book does a nice job covering the different options, birth locations and provider choices available to them,  it does so in a very matter of fact way.  There is not a lot of “rah-rah you can do it” language or encouragement for women to stretch for a low intervention option.  On one hand, it is nice to have the facts. On the other hand, evidence shows that for normal, low risk women, the less interventions the better for both mother and baby.  I am not sure that parents will walk away with that message after reading this book.

Would I recommend this book?

While providing a nice general overview of birth choices, I felt like there were several times that the authors wrote that women should trust their care provider’s expert recommendations versus becoming more informed and discussing all options, including the right to informed refusal.

For example, in the small section on episiotomy, it reads “How do I decide whether I want an episiotomy or a tear?  The short answer is this: You don’t make that decision, your provider does…If your provider decides an episiotomy is absolutely necessary, for example, to get the baby out more quickly, then so be it.  Your provider makes that decision based on the medical situation at hand.”  No mention of informing the woman, seeking consent or alternatives to cutting, for example changing position or waiting.

One of the authors, Dr. Amanda French also states several times that she stands with ACOG’s statement on homebirth (which is that birth should occur in a hospital or birth center attached to a hospital) and does not believe that having a baby at home is safe. She does acknowledge a woman’s right to make the decision on birth location for herself.  In reading the chapter on home birth, this bias does come through.

Dana Rousmaniere

In my opinion, the book is written through the health care provider’s lens.  Doulas are promoted- but readers are warned to watch out for those doulas who may have a “strong personal agenda” and parents are encouraged to work with experienced doulas, instead of doulas-in-training or those just starting out.  Birthing women are asked to let the anesthesiologist attempt two epidural placements, (if the first one does not work due to the mother having a “challenging back” or “not being in the ideal position”) before asking for another doctor to try.  Women are told to follow the recommendations of health staff in several places in the book.  Families are told that their newborn will have antibiotic eye ointment and hepatitis B vaccines administered.

In the chapter on VBACs, women are told that a con of VBAC-ing is that ”Vaginal delivery can result in tears in the vagina, which can be repaired immediately after delivery but may result in pain for several weeks after birth.”  Isn’t this a risk of any vaginal delivery?  For the families that I work with, I try to have mothers (and their partners) view themselves as a more equal partner in the decisions that are being made during labor and birth.

In summary

Overall, this book does a fair job of representing what to expect in eight different labor and birth scenarios, who might be a good candidate for each option and how best to be prepared.  Women can read and get assistance in choosing what might be the best option for them. Information on coping techniques and even pictures of good labor positions to try are well organized for easy reference.  For a woman who is undecided about where she wants to birth, this book will help her to understand the differences and the pros and cons of each location and type of birth, along with who attends births in each location.  For women who are have more clarity on what type of birth they want, I might make a different birth book recommendation.

Have you read this book?  Can you share your thoughts and opinion in our comments section?


Book Reviews, Epidural Analgesia, Home Birth, informed Consent, Maternity Care, Medical Interventions, Midwifery, Pain Management, Vaginal Birth After Cesarean (VBAC) , , , , , , , , , , , ,

How What We Know About Midwifery Can Change Breastfeeding For All Families

August 6th, 2013 by avatar

As World Breastfeeding Week continues, the role of the midwife in promoting and facilitating breastfeeding for new mothers is examined. Midwifery clients and their babies exceed national breastfeeding rates compared to the general population and our authors today, Jill Breen, Jeanette McCulloch and Lauren Korfine take a look at some of the reasons behind this boost. – Sharon Muza, Community Manager, Science & Sensibility


By, Jill Breen, CPM, President, Midwives Alliance (MANA), Jeanette McCulloch, IBCLC, Board Member, Citizens for Midwifery and Lauren Korfine, PhD, Citizens for Midwifery

© Luna Maya Birth Center (Cris Alonso)

As we honor World Breastfeeding Week, those of us who deliver or receive midwifery care have much to celebrate. In every study we can identify, midwifery care increases the likelihood that a woman will initiate breastfeeding (Hatem, Sandall, Devane, Soltani & Gates, 2008). Even with national breastfeeding initiation rates at a recent high of 77% (Centers for Disease Control and Prevention [CDC], 2013), depending on the setting, the rates of initiation and ongoing breastfeeding for women under the care of midwives well exceed national averages.

Preliminary data from a sample of more than 24,000 home and birth center births attended by midwives showed remarkable breastfeeding rates. Less than one percent of all mothers never breastfed. Eighty-five percent were exclusively breastfeeding through to the final postpartum visit, which is typically at the six week mark. A full 97% were at least partially breastfeeding at six weeks (Cheyney, 2012).

Benchmarking data that tracks breastfeeding initiation rates for families receiving care from certified midwives and certified nurse midwives showed significantly higher rates than those whose care was provided by an OB: 78.6% as compared to 51% at the time the report was compiled (American College of Nurse Midwives [ACNM], 2012).

What is it about midwifery care that helps women achieve rates of breastfeeding that meet or exceed the Healthy People 2020 objectives. And most importantly, how can we replicate these important factors in all settings, and with all types of providers?


Research tells us that prenatal breastfeeding education significantly impacts breastfeeding success, either one-on-one or in a group (de Oliveira, Camacho & Tedstone, 2001). Midwifery care typically includes a strong prenatal education component, which includes discussions of infant feeding. CenteringPregnancy®, relatively new model of midwife-led prenatal care in a group setting, including breastfeeding education, has been highly successful (ACNM, 2012) and could be replicated in many settings. In addition, one key aspect of the homebirth model – significant one-on-one time spent prenatally – ensures a woman’s breastfeeding goals and preferences are aligned with education she receives before the birth (Midwives Alliance of North America [MANA], 2012).

Providing high-quality breastfeeding education as a regular, expected part of prenatal care, (either individually or in a group) – as it is with midwifery care – could significantly increase breastfeeding success.

Birth practices

A substantial body of research illustrates that, without a doubt, birth practices can greatly impact breastfeeding success. In their second edition book on the connections between birth and breastfeeding, Linda Smith and Mary Kroeger (2009) outline a number of birth practices that impact a mother’s ability to reach her breastfeeding goals. According to Smith & Kroeger: 

 “Solid scientific evidence shows that minimizing interventions in birth and policies that preserve normalcy are associated with faster, easier births; healthier, more active and alert mothers and newborns; and mother-baby pairs physiologically optimally ready to breastfeed.” (p. 24)

A growing body of research shows that skilled midwifery care, including home and birth center birth, is as safe for babies as hospital settings and results in lower interventions for mothers in low risk births (Vedam, Schummers, Stoll & Fulton, 2012). The significance of the lower intervention rate appears to be about more than the health and wellbeing of the mother, or her birth satisfaction. A mother-baby pair with fewer birth interventions appear to be more likely to establish successful breastfeeding. This makes reducing birth interventions an essential public health goal.

Reduced interventions are possible in all settings with all providers, not just under the care of midwives. The CIMS model of mother-friendly care outlines clear steps a birthing facility can take to ensure mother-friendly (i.e., low-intervention) maternity care (Coalition for Improving Maternity Services, 1996). These steps would not only improve birth outcomes and reduce costs, but would also likely increase breastfeeding rates. 

Ongoing support

With a drop of more than 25 percentage points between breastfeeding initiation and those breastfeeding at six months in the United States (CDC, 2013), part of what families lack is ongoing breastfeeding support. Notably, the CDC Breastfeeding Report Card included two new indicators this year – rates of skin-to-skin contact after a vaginal birth and rooming in at least 23 hours of a postpartum hospital stay (CDC, 2013). These indicators were chosen specifically because of the positive impact these practices have on breastfeeding rates.

Only 54% of babies born in the US are skin-to-skin in the first hour after a vaginal birth, although up from 41% in 2007 (CDC, 2013). This is in sharp contrast to what the overwhelming majority of mothers experience in the care of midwives. As described in the Midwives Alliance position paper on homebirth;

“Nursing the newborn in the first hours is undisturbed in the homebirth setting. Motherbaby closeness, motivation, encouragement, and knowledgeable guidance contribute to high success rates of breast-feeding for home birth families.” (MANA, 2012)

Typical breastfeeding support provided by a midwife extends well past the first 24 hours of life. Although we are unaware of research that supports this, anecdotal evidence suggests that the continuity a midwife provides in the first six weeks plays a large role. For example, one midwife describes her approach: “After birth we wait for self attachment, encourage skin to skin. But when a woman has trouble, I always start my conversation with, ‘What is it you want? What is your goal in breastfeeding?’” says Treesa Mclean, LM, CPM, a midwife based in California. “Then we make 24 hour plans. My role is listening to the mom, making a plan they like and meeting them where they are.” Midwifery care often extends past the typical 3 day and 6 week visit, with additional follow-up when needed to ensure breastfeeding is well-established. 

These practices – support in the early days through basic practices like skin-to-skin contact, maintaining proximity between a newborn and nursing parent, and providing a continuity of breastfeeding support – are all enjoyed by families who employ the care of a midwife. However, there is nothing in the midwifery model of care that is unique to these practices. Any provider – from home birth providers to hospital based OBs – can employ all or nearly all of these strategies, except in unique circumstances. We hope that all providers can learn from and replicate the practices of midwifery, with the goal of ensuring improved breastfeeding outcomes for all families.


American College of Nurse-Midwives [ACNM]. (2012). Midwifery: Evidence-Based Practice. A Summary of Research on Midwifery Practice in the United States. Retrieved from  http://www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000002128/Midwifery%20Evidence-based%20Practice%20Issue%20Brief%20FINALMAY%202012.pdf

Centers for Disease Control and Prevention [CDC]. (2013). Breastfeeding Report Card: United States/ 2013. Retrieved from http://www.cdc.gov/breastfeeding/pdf/2013BreastfeedingReportCard.pdf.

Cheyney, M. (2012). “Research updates.” Conference presentation at the 2012 Annual Conference of the the Midwives Alliance of North America.

Coalition for Improving Maternity Services. (1996). “Mother-Friendly Childbirth Initiative.” Retrieved from http://www.motherfriendly.org/MFCI

de Oliveira, M. I. C., Camacho, L. A. B., & Tedstone, A. E. (2001). Extending breastfeeding duration through primary care: A systematic review of prenatal and postnatal interventions. J Human Lact17(4):326-343.

Hatem, M., Sandall, J., Devane, D., Soltani, H., & Gates, S. (2008). Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, 2008(4). doi:10.1002/14651858.CD004667.pub2.

Midwives Alliance of North America [MANA]. (2012). Homebirth Position Paper. Retrieved from http://mana.org/sites/default/files/MANAHomebirthPositionPaper.pdf

Smith, L. J., & Kroeger, M. (2009). Impact of Birthing Practices on Breastfeeding, 2nd ed. Sudbury, MA: Jones and Bartlett Publishers.

Vedam, S., Schummers, L., Stoll, K., & Fulton, C. (2012). Home birth: An annotated guide to the literature. Retrieved from http://mana.org/research/homebirth-safety

About the Authors

© Jill Breen

Jill Breen, CPM, has been a homebirth midwife for over 35 years. She is the mother of 6 homeborn children and has 7 grandchildren, all born into the hands of midwives, including her own! She is the president of the Midwives Alliance of North America (www.mana.org).




© Lauren Korfine

Lauren Korfine, PhD is a mother of three, and she works as a doula, community educator, and consumer advocate. Prior to having children, she was a lecturer in psychology and women’s studies. She is a founding member of BirthNet of the Finger Lakes, a consumer advocacy and education organization. Lauren analyzes research and writes for Citizens for Midwifery. She received her degrees from Cornell and Harvard Universities, but her education from her three children. She lives with her family in Ithaca, New York.

© Jeanette McCulloch

Jeanette McCulloch, IBCLC, is the co-founder of BirthSwell and a true believer in the power of communications to create change. She is a board member at Citizens for Midwifery and the mother of two children, born with the love and support of midwives.

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