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Planned home birth and neonatal death: Who do we believe?

The (in)famous Wax home birth meta-analysis hit the scene over a month ago. But the buzz doesn’t seem to be dying down. In the weeks since the original pre-publication and press release, editors at The Lancet and BMJ have both weighed in, and there’s a steady stream of media attention. While all of the media have dutifully quoted midwives in leadership positions saying the meta-analysis is flawed (an assessment with which I agree), I still keep coming back to the question I asked in my earlier postdid we need a meta-analysis to establish the neonatal outcomes of planned home birth? We had, after all, a very large, methodologically rigorous study on home birth safety involving over a half million women that was published less than 2 years ago. Won’t that suffice?

I had a chance to interview two of the researchers who conducted that study when I was in Vancouver for the Normal Labour & Birth International Research Conference. Simone Buitendijk, MD, is Professor of Maternal and Child Health and Midwifery Studies at the Academic Medical Center of Amsterstam and heads up the Child Health Programme at the Netherlands Organisation for Applied Scientific Research. Ank de Jonge, the study’s lead author, is a practicing midwife with a PhD in public health who works at the Midwifery Science section within the EMGO Institute for Health and Care Research at VU University Medical Center in Amsterdam. I gained some new insights from them about their research and the Wax meta-analysis. Based on those interviews, and despite having written about the meta-analysis twice already, I thought it was time to ask anew: which is the “better” evidence for determining neonatal outcomes of planned home birth: the de Jonge cohort study or the Wax meta-analysis? Let’s have a look at some objective criteria and see how each study measures up.

Study size (home birth group):

  • Wax: 9,811
  • de Jonge: 321,307

That’s right, the Dutch neonatal mortality analysis is 33 times the size of the neonatal mortality meta-analysis. And believe it or not, this was BRAND NEW news to me that I didn’t realize until I spoke to de Jonge and Buitendijk. Although I had access to the full-text of the Wax meta-analysis and in fact looked critically at it (heck, I blogged about it!), I completely missed the fact that while the de Jonge study was “included” in the meta-analysis, it was excluded from the analysis of neonatal mortality, which was the major finding given so much attention by the media.  On the one hand, I’m pretty embarrassed to have made such a major error. On the other hand, it just underscores how misleading it can be for professionals or lay people to read headlines about a meta-analysis of “hundreds of thousands” of births finding triple the neonatal death rate.  Wax’s neonatal death data don’t come from hundreds of thousands of births at all. Not by a long shot.

Mechanism to ensure data were from planned home births:

  • Wax: mechanism varies across the included studies. In Pang et al., which contributed 63% of the home birth data and accounted for 12 of the 18 neonatal deaths in normally formed newborns, researchers relied on birth certificate data that did not differentiate between planned and unplanned home births, and assumed that any birth certificate for a baby born at home at or beyond 34 weeks, signed by a midwife, nurse, or doctor was a planned home birth, a method that has not been scientifically validated and has been widely criticized. Unplanned home births are riskier than planned home births with qualified attendants.
  • de Jonge: midwives routinely record the planned place of birth in a national perinatal database that covers 99% of births and is linked to another database of neonatal deaths by a validated method. Planned place of birth was unknown for 8.5% of the population, and the outcomes of this group were analyzed separately and reported.

Definition of neonatal death:

  • Wax: death of a live-born infant between 0 and 28 days
  • de Jonge: death of a live-born infant between 0 and 7 days (the World Health Organization definition of early neonatal death)

The appropriate definition of neonatal death has been a major bone of contention in the comments on this and other blogs that criticized the Wax meta-analysis.  Both 0-28 days (neonatal death) and 0-7 days (early neonatal death) are accepted definitions. Proponents of using early neonatal death argue that it is more sensitive to events occurring around the time of birth, such as hypoxic injury resulting from inadequate fetal monitoring or a sudden emergency like a cord prolapse or placental abruption. Indeed, some of the late (8-28 days) neonatal deaths reported in Wax resulted from sudden infant death syndrome, a condition that has nothing to do with planned place of birth. On the other hand, proponents of using 0-28 day mortality point out that some babies experiencing severe hypoxic injury in labor or birth may be kept alive for many days in a modern neonatal intensive care unit.  Their deaths should be counted as birth-related even if they don’t die as soon after birth.

Regardless of which is the more appropriate measure, I was shocked by something de Jonge and Buitendijk revealed in their interview. Wax never contacted them to ask for their 8-28 day mortality data. It is standard practice among researchers who conduct meta-analyses to contact the authors of the original papers to obtain unpublished data, clarify methodologies, or ask for data in a compatible format. One would think that if Wax was truly interested in whether planned home birth caused neonatal death up to 28 days, he would be very motivated to get his hands on the Dutch data set. And while de Jonge and Buitendijk told me that those data are not as complete as the early neonatal death data (because some pediatricians don’t reliably enter their patients’ data), they do in fact have the data up to 28 days and would have supplied it to Wax had he asked. Instead, they have done the analysis themselves and submitted it for peer review.  (Therefore, we’ll have to wait for the results.)

What were the characteristics of the population?

  • Wax – no requirements for home birth eligibility were defined for inclusion in the meta-analysis. Individual studies included in the meta-analysis varied in their mechanisms for determining eligibility. As noted above, the largest study that contributed the majority of neonatal deaths relied on birth certificates. Women with any of 18 medical conditions documented on the baby’s birth certificate were excluded. Neither the study authors nor Wax and colleagues comment on whether this is a reliable method for defining “low-risk”. (As someone who routinely completed birth certificates when I was practicing, my guess is that it isn’t.)
  • de Jonge – National guidelines (“Obstetric Indication List“) define who is eligible for primary midwifery care and home birth. These conservative guidelines ensure that the population of women having planned home births are healthy and at very low risk of complications.

The Dutch study has been criticized because it is, well, Dutch – midwifery and home birth in the Netherlands are highly regulated and integrated into the system, and there are clear eligibility guidelines. The same isn’t true of the United States, so we can’t generalize the results here or elsewhere where home birth is marginalized (e.g., Australia). What the Dutch study gives us, though, is a clear model to emulate in order to make sure home birth is as safe as it can be – regulate midwifery, provide continuity of care for women who need to be referred, and make sure only low-risk women are having home births. Instead of acknowledging this and moving forward to optimize safety, Wax and colleagues chose to mash together data from five different countries and four different decades with no attention paid to which women were and were not eligible and spit out an authoritative answer to the question, “Is home birth safe?” “Is home birth safe?” is a bogus question to which there is no answer. Context, training, system integration, and perhaps above all else the characteristics of the population matter. Any study worth its salt will describe these factors in as robust detail as is feasible. Combining and meta-analyzing data from dissimilar contexts may make sense in other areas of health care, but when context is everything, what’s there to gain?

A note about comments: please keep it civil and on point. I’m OK with debate, discussion, and disagreement. Name-calling, personal attacks, and other degrading commentary will be deleted or edited.

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  1. August 22nd, 2010 at 18:04 | #1

    Midhusband>> As for the Oregon issue, the experience from around the country is that the vast majority of complaints against licensed midwives arise from healthcare providers in the hospital who are hostile to home birth after an intrapartum transport.

    And why do you think that is? It usually because the transport happened way too late and put the woman and fetus are far more risk than the OB felt was justified. Some of this comes from differing expectations of what is appropriate, but a lot of it comes from completely screwed up transfers.

    In my career, I would say that at least 25% of hospital transfers were associated with some sort of negligent practice on the part of the midwife. I don’t take it personally, as they have a different training than I, but it does make for some bad feelings. Some OBs do take it personally, and try to fight back.

    Here’s just a few examples

    1) Midwife transfers patient postpartum, saying she is bleeding postpartum and she can’t stop it. She has been massaging the uterus and it stops for a bit but it keeps coming after that. The patient is in hypovolemic shock and is pouring blood from her vagina. Exam shows she has a massive sulcus tear up to her cervix with an arterial bleeder. Pt requires many units of blood and general anesthesia to repair the tear, which was completely missed by the midwife.

    2) Midwife sends a patient in in her husband’s car, saying she has been 8 cm for 12 hours. On exam the baby is frank breech. Midwife didn’t come with the family, and told the husband it was because “she was just going to stay at the house and clean up.”

    3) Midwife brings in patient with huge posterior laceration saying she can’t fix it. Exam shows that she has sewn the vagina nearly shut and still has not encircled the bleeders. Entire ‘repair’ is removed and fixed. Midwife watched the repair, and based on comments clearly had no idea what the anatomy was that needed to be repaired. The ‘repair’ she tried to do also was with the completely wrong type of suture.

    4) Midwife transfers a patient who has been complete for 6 hours without descent. By leopold’s the baby is huge and the patient’s blood sugar is 180. Midwife and patient insist that she she is not diabetic because a fingerstick blood sugar early in the pregnancy was normal (rather than a far more sensitive glucose challenge test). Midwife actively influences the mother to not accept an insulin drip to control her sugars prior to delivery, says it will hurt the baby. Baby eventually delivered by cesarean, 11.5#.

    5) Midwife transfers a mother with a stuck breech with head entrapment. Baby has an agonal rhythm and cannot be resucitated postpartum. Infant dead in labor room.

    Ask any OB and they can give you more examples.

    I try not to bring these up because there are midwives that do a good job and make appropriate transfers. But many don’t, and many don’t accept what they do not know. They transfer too late, and sometimes don’t even come with the patient to give a proper report. By doing this they undermine any good feelings between midwivery and obstetrics, and turn some OBs into absolute midwife haters. If CPM are ever going to get real acceptance, this kind of shit needs to stop, or the people who do it need to be pushed out of practice.

  2. August 22nd, 2010 at 20:50 | #2

    Great Day in the Morning, Nicholas !!!

    I sense some frustration here…

    First of all, as long we are telling stories, let’s talk about gross negligence for a minute. Check this out…

    http://fayobserver.com/Articles/2010/03/31/987295

    I must confess that I have never heard of a midwife inducing a non-gravid woman and then sectioning them only to find out the uterus is without the products of conception (because there never were any). To be fair, this spectacular event also illustrates the systemic problems with maternity care these days in addition to real issues of human performance with physicians.

    I can produce hundreds of women who will describe significant deficiencies in the practice of obstetrics. Does that mean obstetricians are incompetent as a profession given that 80% will be sued for malpractice during their career? Of course not.

    This does bring up an important aspect of the dynamics here. The hospitalists only see the transports and while most of them are not urgent, some of them are. I tend to agree that there are different thresholds for escalation of intervention (which is why there is a dramatic difference in C/S rate), and that is why the studies are useful in counting outcomes.

    You seem to have passed judgement on the CPM and I am sad for that. The vast majority of CPMs are competent and maintain the standard of care, day-in and day-out, (just like you do). Just like there are incompetent physicians, there are midwives who should not be practicing, and that is why regulation is so important.

    Russ

  3. avatar
    Aly
    August 22nd, 2010 at 21:07 | #3

    “But many don’t, and many don’t accept what they do not know. They transfer too late, and sometimes don’t even come with the patient to give a proper report. By doing this they undermine any good feelings between midwivery and obstetrics, and turn some OBs into absolute midwife haters.”

    Gee, maybe it’s because they get treated like shit when they get there, get threatened, sued, and even *jailed.* I have NEVER heard of a midwife sexually assaulting a patient, getting a court order to FORCIBLY cut a woman open for cesarean section, or threatening a woman bodily harm if she does not cooperate. Does this excuse the midwifery behavior you mention? Absolutely not, particularly the dumping of patients that generally happens in states ACOG has worked to keep ooh midwifery illegal. Besides that, the other behaviors are from lack of training, not malice, as obs do. And don’t tell me Obs don’t screw up, or cause dead or brain damaged babies. Better training, more regulation, I agree. But obstetricians absolutely cannot ignore their own culpability here. There will always be women who want to homebirth for whatever reason, whether you like it or not. We need 1)better training of cpms, no doubt. 2) formal obstetrician backup in hospital. 3) careful screening of homebirthing mothers 4) informed consent.

    I do believe midwives might even be more scorned and hated than Muslims, by people who have no concept that there are moderates and extremists in EVERY group. (That’s true of obs-moderates and extremists-, but there’s no movement to eliminate them either, unless you count malpractice insurance skyrocketing!).

    Sigh.

  4. August 23rd, 2010 at 11:14 | #4

    @Midhusband

    >> You seem to have passed judgement on the CPM and I am sad for that.

    Not really, but I can see from an OB’s perspective how so many OBs can be so anti-midwifery. Even if only 1 in 50 transfers are like this, its enough to hurt relations terribly.

    I agree that regulation is necessary and there needs to be standards of education that CPMs should meet. Right now its far too fractured, and in many states completely unregulated.

  5. August 23rd, 2010 at 11:15 | #5

    >> We need 1)better training of cpms, no doubt. 2) formal obstetrician backup in hospital. 3) careful screening of homebirthing mothers 4) informed consent.

    Agreed

    >> I do believe midwives might even be more scorned and hated than Muslims

    Its interesting that you compare midwives to a religious affiliation.

  6. avatar
    Aly
    August 23rd, 2010 at 11:36 | #6

    Trying to post without links (besides one, these are all non birth/midwife websites):

    Did I mention I hate anecdotes? It’s not right to condemn all obs
    based on these stories anymore than it is to do the same against
    homebirth midwives. But as long as we’re sharing horror stories, I know you have wondered why some women are scared to death of obstetricians. The funny thing is, it’s obs who are getting sued right and left for killing babies, and lawyers claim it’s because doctors refuse to police themselves and get rid of the bad apples. Sound familiar?

    Chicago police officer versus fired and fined obstetrician:

    Refusal of cesearean, has vaginal delivery, woman loses her baby for 3
    years after hospital calls cps:

    Obstetrician disappears after ordering pitocin, baby dies:

    Two teachers die, 15 days apart, same hospital, after c-sections:

    Medical Kidnapping: Rogue Obstetricians vs. Pregnant Women:

    ob/gyn sexual assault:

    Comments from physicians:
    Physician (to a patient who was expressing discomfort over a vaginal exam): “Come on, now, you’ve had something a lot bigger than my finger in there! How’d you ever manage to get pregnant if you can’t put up with this?”

  7. avatar
    b
    August 23rd, 2010 at 13:44 | #7

    @russ

    “Greetings Anony-b,”

    Oh, no, you have me mistaken with your friend Anony-B (big B that is). That’s OK. We look so much alike that I mistook myself for her. Or maybe your other friend Anony-bennifer or your other friend Anony-bmanda, or pretty much all your friends.

    “I must point out that there is a bit of a mismatch in this contest. You are entirely anonymous, b, and free to say whatever you like with no accountability, while I am accountable for my words.”

    Not really. People can’t be accountable for their words when they can’t be assured they will be theirs. They are always subject to the selective censorship and the editing of others or misrepresentation elsewhere. And non-midwifery types don’t act like sociopaths, on-line or off-line, so you are risking anything or doing anything noble.

    If midwifery is such a great thing for women, why do they always have to resort to these dirty tactics. Why are they always trying to control the information women see? Why do they attack and silence dissent and dissenters?

    Do you get your blog comments deleted? (http://childbirthtruthsquad.wordpress.com/2010/07/20/can%e2%80%99t-see-the-forest-through-the-trees/)

    Do you get your blog comments held back, posted out of order and long after the discussion has moved on? (http://childbirthtruthsquad.wordpress.com/2010/08/12/keeping-baby-close-the-importance-of-high-touch-parenting-and-deleting-correct-information/)

    Do you get your quotes truncated to change their meaning? (Indiana fanny comment #12, chopping and re-imaging #10)

    Do your comments get banned towards the end so your debate partner can have the last word and orchestrate the ending she would like? (http://childbirthtruthsquad.wordpress.com/our-bodies-ourselves-our-delete-button/)

    Do you get people telling tall tales about things that you never posted on your own blog on other blogs? (http://skepticalob.blogspot.com/2010/08/breastfeeding-and-what-it-means-to-be.html in the comment, I don’t mean the post itself)

    Do you non-midwifery blogs illegally fail to safeguard information covertly collected? http://www.ftc.gov/privacy/

    Do you face tangible off-line retaliation ? (http://childbirthtruthsquad.wordpress.com/2010/08/21/midwife-on-midwife-violence/)

    “Why don’t we make it more fun and you can tell us who you are with all of your outstanding credentials.”

    What credentials do you need to state the main counter-argument to this post?

    If you look up the Mother of All Birth Studies, the subject of this post, it says nothing like what the poster or its authors claim it does when you look up the paper AND its citations. She posits we should all accept the conclusion and move along. But, the ‘data’ relied on here, the “study” that is supposed to convince us all to let midwives take over US maternity care, isn’t “data” or a “study” at all. It is a couple of midwives that used a completely invented connection between homebirth and its outcomes.

    I mean, c’mon, why doesn’t any one address this, the silence is deafening. No pat answer in the Statistics for Non-Majors book eh?

    REPEAT

    Amy Romona opined:

    “de Jonge: midwives routinely record the planned place of birth in a national perinatal database that covers 99% of births and is linked to another database of neonatal deaths by a validated method.”

    There’s no “perinatal database” RTFM. The entire thing was through statistical guessing linking Midwife to OB and then peds databases. There’s no actual data in this so-called study!! Where babies that died were intended to be born in this is no more than a guess.

    THIS IS THE CITATION OF THE METHOD FROM THE TEXT OF DEJONGE STUDY WHICH THEY CLAIM THEY USED AND VALIDATED THE DATA LINKAGE

    From the J Clin Epidemiol. 2007 Sep;60(9):883-91. Epub 2007 May 17.Probabilistic record linkage is a valid and transparent tool to combine databases without a patient identification number.Méray N, Reitsma JB, Ravelli AC, Bonsel GJ.
    Academic Medical Centrum (AMC), Department of Medical Informatics, Amsterdam, The Netherlands. (document listed by DeJonge as the method they used)

    “All four perinatal caregivers create records in one of four independent registries: the registry of midwives (LVR1 or MR), of general practitioners (LVR-h), of obstetricians (LVR2 or OR), and of pediatricians (LNR or PR), respectively, with partial records in case of transfer. Because of privacy laws of the Netherlands, no unique personal identifier (of the mother or child) is available to combine records.”

    And in case you weren’t aware, there’s no way to definitive validate anonymous databases, otherwise, ya know, they wouldn’t be anonymous. Only a small percentage matched on a small set of variables, and only a very small percent of those were unique.

    The full text is up at science direct http://www.sciencedirect.com/
    J Clin Epidemiol. 2007 Sep;60(9):883-91. Epub 2007 May 17.Probabilistic record linkage is a valid and transparent tool to combine databases without a patient identification number.Méray N, Reitsma JB, Ravelli AC, Bonsel GJ.

    Academic Medical Centrum (AMC), Department of Medical Informatics, Amsterdam, The Netherlands.

    “In absence of a large sample of validated pairs to independently estimate the awards and penalties, we used standard maximum likelihood techniques to estimate these weights from the data itself and to estimate the threshold”

    In other words, they guessed.

  8. August 23rd, 2010 at 15:14 | #8

    Nicholas Fogelson :@Midhusband
    >> You seem to have passed judgement on the CPM and I am sad for that.
    Not really, but I can see from an OB’s perspective how so many OBs can be so anti-midwifery. Even if only 1 in 50 transfers are like this, its enough to hurt relations terribly.
    I agree that regulation is necessary and there needs to be standards of education that CPMs should meet. Right now its far too fractured, and in many states completely unregulated.

    So, Nicholas, do you know why CPMs remain unregulated in about half of the US?

    That’s right!! You guessed it – the leadership of each state’s medical society exerts their considerable political leverage in the General Assembly objecting to it. They cannot separate their objections to planned attended home birth from the need to regulate the midwives.

    We just completed a substantial project at the request of the General Assembly for the stakeholders to propose a licensing methodology to regulate CPMs in our state. Just about everybody (and their lobbyist) was there. The fundamental message from the Medical Society was…

    Home birth is a bad idea and don’t do anything to make anything other than a bad idea.

    I found it remarkable. Our argumentation was compelling and the physician participants even acknowledged it, but nevertheless they ignored the request of the General Assembly and elected not to participate.

    The irony is profound.

    Russ

  9. avatar
    Augusta
    August 23rd, 2010 at 17:55 | #9

    Profound, indeed. I am always shocked by physicians who stand against midwifery presumably because it makes women babies less safe. Yet when you start talking about ways to make it safer, they do not want to participate. The argument always comes back to, “We want women to have choices and participate in their healtcare, so long as they choose hospitals and physicians.” Do they want women to be safer or not?

  10. avatar
    Augusta
    August 23rd, 2010 at 17:56 | #10

    Sorry for the typos.

  11. avatar
    Aly
    August 23rd, 2010 at 21:00 | #11

    >> I do believe midwives might even be more scorned and hated than Muslims
    DR. F:
    Its interesting that you compare midwives to a religious affiliation.

    Sure, there are some midwives with religious like philosophical beliefs. I’ve made clear in the past that I don’t agree with ideological commitment to either extreme. Some obstetricians have an equally tenacious ideology that pregnancy is a disease and technology is supreme. The only difference is that midwives don’t try to force their beliefs on anybody else, while obstetricians have taken a political and medical policy of forcing their “religion” on society as a whole. In addition to forcing individual women to undergo surgery with court orders. Kind of like the difference between Unitarians and fundamentalist Christians. ;-)

    My only philosophy is evidence based medicine and that benefits and risks of medications and procedures should be weighed objectively based on science and not anecdotes (on either side). That’s about medicine and health in general, not birth specifically. And that no matter how misinformed I personally think unassisted birth or elective cesareans are, women ultimately have complete control over their bodily integrity.

  12. avatar
    B
    August 24th, 2010 at 11:48 | #12

    @ Midhusband

    “Training – I think it is best to establish training requirements based upon the scope of practice and the job description as opposed to what other countries do that intentionally produce credentialed home birth midwives within the bricks and mortar university setting.”

    But the scope of practice is the same for any midwife working in a hospital or in a home – they must be able to provide high standard pre-natal care and assess risk for labour, they must be expert in low-risk physiological birth, and expert at recognizing medium and high-risk situations that need transfer to hospital, as well as providing top-notch transfer care and excellent communication and co-operation with attending ob-gyns. I hope you aren’t suggesting that the high standard university-level midwifery education, including practical training components, that midwives receive in Canada, UK, Netherlands etc. is over-kill for their scope of practice.

  13. avatar
    B
    August 24th, 2010 at 11:50 | #13

    @ Aly

    “My only philosophy is evidence based medicine and that benefits and risks of medications and procedures should be weighed objectively based on science and not anecdotes (on either side). That’s about medicine and health in general, not birth specifically. And that no matter how misinformed I personally think unassisted birth or elective cesareans are, women ultimately have complete control over their bodily integrity.”

    Well said! :)

  14. August 24th, 2010 at 18:32 | #14

    B :@ Midhusband
    “Training – I think it is best to establish training requirements based upon the scope of practice and the job description as opposed to what other countries do that intentionally produce credentialed home birth midwives within the bricks and mortar university setting.”
    But the scope of practice is the same for any midwife working in a hospital or in a home – they must be able to provide high standard pre-natal care and assess risk for labour, they must be expert in low-risk physiological birth, and expert at recognizing medium and high-risk situations that need transfer to hospital, as well as providing top-notch transfer care and excellent communication and co-operation with attending ob-gyns. I hope you aren’t suggesting that the high standard university-level midwifery education, including practical training components, that midwives receive in Canada, UK, Netherlands etc. is over-kill for their scope of practice.

    Hi B,

    The assertion that the scope of practice of the US CNM & the CPM is not the same originates from testimony given by the Director of our university based nurse-midwifery program as she argued for the adequacy of apprentice trained CPMs for their scope of work. I agree that a normal prenatal exam delivered by a CPM may be considered as identical to that delivered by a CNM, in addition to many other tasks. The point here is that the CNM has a much broader scope of practice than the care of healthy women during the childbearing year (not to belittle this aspect in any way – we think it is of prime importance).

    Of course I am not criticizing the training requirements established in the countries you site. I have no basis to criticize them nor intention to do so. I think it is terrific that the infrastructure exists there to actually produce credentialed midwives to meet the home birth demand (more or less) with that pathway as we don’t here. Producing home birth midwives is something that the architects of the training program need to be intentional about, and we don’t tend to do that in the university setting here. My argument is against the bias that says university training is the only confident training. This is not true for professions of moderate scope – particularly when they are specialized. Did you review the link to the registered apprenticeship programs I provided? I suggest embracing the notion that apprenticeship training is adequate for specialized professions of moderate scope, or don’t think about it very much the next time you get on an airplane… ;-)

    I have no objection to producing midwives of any credential. I would have no objection to requiring a Doctor of Nursing for midwives as long as we produce enough of them (but I would wonder about the motivation for doing that). When we have serious issues with access to care (and all the associated implications), we need to focus on the fundamentals of adequacy of training and then assure performance through regulation.

    Russ

  15. avatar
    B
    August 24th, 2010 at 20:25 | #15

    @ Midhusband

    I think the university is exactly the right place to teach midwifery including a long practical period for hands-on experience. University midwifery programs do not contain only academic courses and there should not be a stereotype that they are theory only programs.

    How strange that teachers from primary school to college and university-level are expected to study at university-level, but midwives who may deal with life and death situations where some medical knowledge is necessary are only expected to have high school diplomas and a certificate from a midwifery school below university-level, especially ones that teach pseudoscience like homeopathy, aromatherapy, reiki etc.

    I don’t think anyone needs a Masters degree to be a midwife, but they certainly should have a Bachelors degree with excellent academic and practical skills upon completion of the program. You’d likely find that nurses and doctors would be more cooperative working with midwives if they had at least the same education and qualification level as nurses.

    Lay midwives scare the wits out of me. I read Gloria Lemay’s site and she implied that one young woman died from post-partum hemorrhage because her baby was not with her nursing right after birth. I tried to comment how ridiculous that was but it was never published. Midwives who can spout such nonsense are a danger to birthing women. We all know that nipple stimulation triggers uterine contractions, but serious pph cannot be solved by a breastfeeding baby! Complete ignorance about medical facts.

  16. avatar
    Aly
    August 24th, 2010 at 21:15 | #16

    “I don’t think anyone needs a Masters degree to be a midwife, but they certainly should have a Bachelors degree with excellent academic and practical skills upon completion of the program. You’d likely find that nurses and doctors would be more cooperative working with midwives if they had at least the same education and qualification level as nurses. ”

    I agree, but don’t necessarily think it has to be a nursing degree. The CM route available in one or two states seems to be enough. A college degree, hospital training, low and high risk training, etc, are a must., as well as a strict midwifery board for oversight.

  17. avatar
    B
    August 25th, 2010 at 07:15 | #17

    I agree too, not a nursing degree, but I just meant similar standard of education.

  18. avatar
    Kathi Wilson
    August 25th, 2010 at 09:39 | #18

    As a university educated midwife in Ontario, I’d like to make a couple of comments. One is that a university midwifery program needs to be built from the ground up. One of the issues that we saw with a CM educated midwife that moved up here was that the program she went through appeared to be a condensed nursing program with midwifery crammed into the second half or so, which seemed to leave some gaps. The program here (which is responsive to external input regarding its functioning) has a core academic program with sciences (a & p, repro, pharmacology, etc) and then extensive clinical placement (over 50% of the program, with a minimum requirement for births attended in both home and hospital settings). Midwives are expected to be competent in both hospital and home settings, and competence includes extended skills like managing women with epidurals and induction/augmentation. Midwives are expected to have entry-level competence upon graduation (something that is also different from other jurisdictions), but there are restrictions in their first year of practice regarding requirements to work only with experienced midwives for mentoring purposes.

    Re: the conversations around transfer. I believe that one of the reasons that our outcome data in Ontario and BC regarding homebirth are so good is because midwives must, by regulation, function in both settings — there is no home/hospital birth midwife divide. Because we can still look after women post-transfer (and most often do) at the hospitals where we are privileged, we are less reluctant to transfer if we (or the woman) need or want to. Further to that, even if a transfer is for a more emergent reason, we are, by and large, respectfully received, and so there’s little fear of hostile reception. Because our consultants know us (and I think this is *so* important), they have far more trust in our clinical skills/knowledge and that we are not bringing in disasters to dump on their doorstep. When the impediments to good transfers are reduced or eliminated, then it’s less likely that bad ones are going to occur.

  19. avatar
    B
    August 26th, 2010 at 04:17 | #19

    @Kathi Wilson

    Thanks for explaining the system in Ontario and British Columbia Kathi. It sounds fantastic to me!

  20. August 26th, 2010 at 19:52 | #20

    @B

    I need to ask a favor of you. It is really easy and not very complex. It doesn’t cost anything and it is the right thing to do…

    Please don’t use the words “Lay Midwife”.

    There is no place for those words in professional conversation – particularly in reference to CPMs. The word “Lay” means untrained and so using it in reference to midwives who invest 3-5 years in a clinical setting learning their trade, and whose credential is accredited by the National Commission for Certifying Agencies (who also accredits the CNM credential) is not only incorrect, but is really offensive. To make the distinction between a credentialed and non-credentialed midwife, the appropriate and respectful words to use are “Traditional Midwife” when referring to the latter.

    I trust this is not a big inconvenience for you.

    Now, on to the few things we disagree on…

    B said – “I think the university is exactly the right place to teach midwifery including a long practical period for hands-on experience. University midwifery programs do not contain only academic courses and there should not be a stereotype that they are theory only programs. ”

    OK. I respect your opinion. I am not of the opinion that a university based program is a theory only program. I do believe an apprentice trained CPM is likely more capable of managing a home birth operation upon entry than a CNM, simply because she has been doing the specific job for a number of years.

    B said – “How strange that teachers from primary school to college and university-level are expected to study at university-level, but midwives who may deal with life and death situations where some medical knowledge is necessary are only expected to have high school diplomas and a certificate from a midwifery school below university-level, especially ones that teach pseudoscience like homeopathy, aromatherapy, reiki etc.”

    Well, I think I will just refer you back to the many professions in which an apprenticeship program is considered adequate, many of which have safety significance. My concern, which you kind of touched upon, is performance variability among preceptors. Recently, NARM increased requirements to be a preceptor that equates to an additional 2 years of practice after being credentialed before being qualified to serve as preceptor. In any event, requirements will continue to evolve, but, at the end of the day, it is licensure and regulation that assures performance and protects consumers.

    B said – “I don’t think anyone needs a Masters degree to be a midwife, but they certainly should have a Bachelors degree with excellent academic and practical skills upon completion of the program. You’d likely find that nurses and doctors would be more cooperative working with midwives if they had at least the same education and qualification level as nurses.”

    I agree that a graduate degree is not required to produce high quality midwives. I am not so confident that university degrees will improve the relationship between the hospital staff and the midwives as home birth CNMs also struggle in this regard. Please note that there are many CPMs who hold undergraduate degrees, graduate degrees, nursing degrees, associates degrees… in addition to the CPM credential. So, many conform to what you have described as your preference, yet it seems judgement has been passed.

    B said – “@&$ (offensive language deleted) midwives scare the wits out of me. I read Gloria Lemay’s site and she implied that one young woman died from post-partum hemorrhage because her baby was not with her nursing right after birth. I tried to comment how ridiculous that was but it was never published. Midwives who can spout such nonsense are a danger to birthing women. We all know that nipple stimulation triggers uterine contractions, but serious pph cannot be solved by a breastfeeding baby! Complete ignorance about medical facts.”

    OK. I don’t judge OBs by the spectacular few, but if those concerns are paramount for you then you must be a strong advocate for regulation as the CPM is indeed the primary care provider to women who choose home birth in the US whether they are regulated or not.

    Can we produce credentialed home birth midwives better than we in the US produce them today? Sure we can. The best we can do today to manage planned home birth is to regulate CPMs irrespective of pathway. Ten years from now it may be different.

    Russ

  21. August 26th, 2010 at 19:55 | #21

    @Kathi Wilson

    Hi Kathi,

    The Ontario program sounds terrific (I travel there on occasion and I adore the people). I have a few questions for you…

    1) From the time folks first started working on developing the program, how long did it take until it was active?
    2) What did you do in the interim until the program was in place?
    3) Do you produce enough home birth midwives from the program to meet the need?
    4) Prior to the training program and licensure, what was the environment like?
    5) Can you describe how many midwives are practicing who were not trained in the program?

    Best,

    Russ

  22. avatar
    Kathi Wilson
    August 26th, 2010 at 21:58 | #22

    It was actually a very fast (relatively speaking) turnaround from the universities being granted the program to its inception. I don’t know precisely, but I’m thinking not much more than a year. The program actually began prior to legislation (it started in 1993 and midwifery was not formally enshrined in legislation and funded by the province until Jan 1 1994). All midwives who had been practicing prior to legislation had to undergo a program of evaluation and upgrading in order to become registered (there were about 60 midwives in that group). I, personally, was apprenticing at the time that the program for “grandmothering” began, but did not have the numbers needed to do that, so applied to the first university class and was accepted.

    All midwives in Ontario are “homebirth” midwives. Our regulatory college requires that all midwives attend and be competent at births both at home and in hospital — midwives cannot choose to be one or the other. We are required to submit “active practice” reports every 5 years that demonstrate minimum numbers attendance in each setting. It’s difficult to assess how many women who want homebirths are unable to access midwifery care, although in most places demand exceeds supply. We are roughly capped in the numbers of women each full-time midwives provides care to in a year — usually each midwife has 40 – 50 primary clients/year. Approximately 2% of babies in Ontario are currently born at home (overall, not just midwifery clients, and the rates within practices varies. My practice runs at about a 20% homebirth rate.

    Midwifery in Ontario was never illegal, but rather alegal. Prior to legislation in 1993, there was no legislated midwifery in Canada; however that has changed over the last decade and a half, with only a couple of remaining Atlantic provinces not having regulation (which will likely change). Although midwives never faced prison in this province, there was certainly a good deal of suspicion and hostility, but there was also a very active consumer lobbying group that arose in the early 80′s that worked alongside some sympathetic high-profile supporters to accomplish legislation. That was also spurred by a couple of coroner’s inquests in midwifery baby deaths that led to recommendations that midwifery be regulated and legislated.

    Don’t know how many precisely who are currently practicing who have not gone through the university program. Many of the original 60 have retired, but we do have a very active “bridging” program to evaluate and integrate midwives who have had formal training in other jurisdictions, which is a year-long program administered by one of the universities. There are currently about 500 midwives now practicing in Ontario, and I would hazard a guess that maybe 1/4 of them have come through the bridging program. Many of those have trained in the Middle East (many from Iran), UK and the USA (both CNMs and CPMs).

    Hope that answers your questions!

    Kathi

  23. avatar
    B
    August 28th, 2010 at 05:08 | #23

    Midhusband (Russ) said, “B said – “@&$ (offensive language deleted) midwives scare the wits out of me.”

    Lay midwife is not an expletive just because you don’t like the term. Please do not edit my comments to imply that I was using an expletive. I’d expect a professional not to play such games.

    Russ, I certainly hope that you take a look at midwifery programs worldwide, especially in other countries with successful homebirth infrastructures and outcomes and see what the gaps are between current CPM training and that midwifery training. A large gap in curricula and apprenticeship should tell you something.

  24. August 28th, 2010 at 10:03 | #24

    Well, B, we certainly have managed to push each other’s buttons, haven’t we…I do regret that. Maybe we should walk a mile in each other’s moccasins for perspective.

    I am simply arguing from a perspective similar to this recent, and outstanding, Time article.

    http://www.time.com/time/magazine/article/0,9171,2011940,00.html

    Unfortunately, the entire article is not yet available online, but the fundamental message is go license CPMs.

    If I could snap my fingers and install the Ontario program, with regulation, and sufficient quantities of midwives, I would do it in a heartbeat. If I think about what it would take to do that, I think of the following process steps…

    1) advocate until a target university is charged with designing a program and activating it (3-5 years)
    2) activate the program (1 year, but I think that is extraordinary)
    3) graduate the first class (2-4 years depending…)
    4) continue to produce midwives until the production rate offsets the attrition rate and growth in demand (2-4 years?)

    Note that we would also have to assure that the licensing statute does not require a written practice agreement with a physician – the CNMs have been trying to change that for decades.

    At this point, we can establish the new program as minimum required for entry.

    So, if we start today, maybe we could achieve the transition in 8-14 years depending upon success. We need to address the safety issues today by regulating CPMs which is what every state that manages midwifery care in the home setting has done. We know the training model is adequate, even if others may be evaluated as better. Evolving to a university based program should be put in the context of a Multi-Generational Program Plan.

    We should not let the perfect be the enemy of the good.

    Russ

  25. avatar
    IndianaFran
    August 29th, 2010 at 13:32 | #25

    @b
    “I mean, c’mon, why doesn’t any one address this”

    because your argument contains so many falsehoods that it is hardly worth it.

    “There’s no “perinatal database” RTFM.”

    Yes, there is:
    http://www.perinatreg.nl/home_english
    “The LVR1, LVR2 and LNR registries are linked to one combined PRN-registry.”

    You are trying to make an argument regarding the methodology by which the registries were linked. However, making the claim that the linked registry does not exist is an argument not worth having.

    “There’s no actual data in this so-called study!! ”

    Again, of course the data exists. The existence of the data does not depend on your acceptance of the way the linkage was accomplished.

    “It is a couple of midwives that used a completely invented connection between homebirth and its outcomes.”

    No, it’s not. The data linkage was performed by a different group of researchers, including epidemiologists and statisticians. One of the co-authors of the de Jonge paper was also involved with the data linkage project (ACJ Ravelli). She is an epidemiologist, not a midwife. Her contribution to the de Jonge paper was most likely related to her knowledge of the creation of the data linking methods.

    And then there are your repeated disparaging references to “they just guessed”, “invented connections”, “fabricated links”.

    A group of specialists in epidemiology, medical informatics, and public health developed a sophisticated method for linking the Dutch obstetrics, midwifery, and pediatrics registries. They published their methods and results in several papers in peer-reviewed journals of epidemiology and medical informatics.
    Their primary result and conclusions:
    “Independent validation confirmed that the procedure successfully linked the three Dutch perinatal registries despite nontrivial error rates in the linking variables.
    Probabilistic linkage techniques allowed the creation of a high-quality linked database from crude registry data. The developed procedures are generally applicable in linkage of health data with partially identifying information. They provide useful source date even if cohorts are only partly overlapping and if within the cohort, multiple entities and twins exist.”

    The linked registry has been used by other groups of researchers as the basis for a number of other peer-reviewed publications, besides the de Jonge study.

    So, on the one hand, we have the opinions of a wide range of specialist professionals, who submit their work to peer review, whose product is considered to be a high-quality database suitable for further peer-reviewed work.
    On the other hand, we have a random internet individual who disagrees with their methods and results.

    I submit that if you want to undertake a serious criticism of the combination of probabilistic and deterministic record linkage techniques used to create the Dutch Perinatal Registry, this is probably not the right forum. And I’m afraid that “in other words, they just guessed” does not constitute a serious criticism. And your approach is certainly not strengthened by the inclusion of outright falsehoods.

  26. avatar
    B
    August 29th, 2010 at 22:56 | #26

    I’m all for changes, even if they take time, as long is isn’t a case of maintaining the status quo because it is easier and pisses less CPMs off.

  27. avatar
    Tatiana
    August 30th, 2010 at 18:28 | #27
  28. avatar
    Tatiana
    August 30th, 2010 at 20:02 | #28

    That was supposed to be a trackback.

  29. avatar
    Tiny
    September 4th, 2010 at 19:50 | #29

    As long as modern obstetrics continues its assault on women through the use of practices that are based in $$ rather than in evidence-based medicine, I am thankful that we have well-trained home birth midwives available. For those women that are unlikely or unwilling to go to the hospital, I am thankful that we have the same. For those women that have precipitous labors and refuse induction, ditto…

    Life is not perfect. Planning is not perfect. While I support those that find the hospital their most comfortable place for birth, we must take care not to alienate those that find otherwise — at the risk of creating more of a problem than we solve. And certainly OBs cannot at this time claim to be problem free, what with all the absolutely unnecessary c-sections, epis, inductions, managed labors and tests that do not have reasonable research evidence to back them up.

    That said, I also support excellent training for home birth attendants — ideally a combination of coursework and hands on practice. That is what we have in the CPM credential. In my state, a vast majority of the CPMs have BA/BS degrees or higher. And most have years of observation and hands-on work before they attempt the credential process.

    Just like any medical personnel, it makes sense to shop around. I will certainly point out that it is way more likely to have an OB with serious issues still practicing, since there is no required reporting that the consumer has access to. The anecdotes of negativity can go both ways, from the woman who dies of intestinal perforation from her c/s to the postpartum hemorrhage. It would be so nice if people could step back and realise that women are people who deserve choices, not just vessels for a child. PTSD and trauma can be avoided in all settings, when care is appropriate for each individual, and guided by a combination of empathy, compassion, caring, and evidence-based medicine. Demonizing either side, or deciding that one side is somehow intrinsically of more value or has intrinsically better outcomes is childish.

  30. avatar
    A. Elliot
    February 20th, 2011 at 19:35 | #30

    How many think that the real, bottom-line reason OB’s don’t encourage midwifery for low-risk women is that they’ll lose the $$$? I think all births should be encouraged to take place at home and OB’s should be used for those who have conditions that put them at risk (including fear and lack of preparation). That’ll be the day!

Comment pages
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