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Assessing Birth Settings to Improve Value and Optimize Outcomes in U.S. Maternity Care

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

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

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

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

Historic Workshop Can Positively Impact Future Research 

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

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

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

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

Lack of Consumer Representation and Little Discussion of Health Disparities

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

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

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

‘Recrudescence’ Revisited

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

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

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

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

“Home Births Should Not Happen”

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

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

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

Absolute vs. Relative Risk

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

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

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

Clarifying the Validity of Birth Certificate Data

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

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

References:

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

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

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

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

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

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

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

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

About Wendy Gordon

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

 

 

Guest Posts, Healthcare Reform, Home Birth, Maternal Mortality, Maternal Mortality Rate, Maternal Quality Improvement, Maternity Care, Midwifery, Newborns, Transforming Maternity Care , , , , , , , , , , , , ,

  1. March 12th, 2013 at 05:48 | #1

    Thanks for this article. There is lots of valuable information listed to help people make informed decisions. Keep up the great work!

  2. March 12th, 2013 at 10:58 | #2

    Thank you, Wendy, for your astute analysis of the IOM workshop about research on place of birth. Your characterization of the Chevernak presentation was spot on. One wonders why the IOM steering committee for a workshop on research about place of birth would invite a speaker that has already published his opinion that research about home birth should not be supported.

    My disappointment with IOM workshop was that there was not a call for rigor in defining the research parameters for planned home birth studies into the future: that the women must be planning childbirth at home attended by certified or licensed midwives in settings that provide for legal status, adequate equipment and ready obstetrical collaboration and referral. These settings are limited in the US. At this time, unfortunately, broad US birth certificate data and even MANAstats data do not meet these inclusion criteria.

    Without this commitment to rigor in defining Planned Home Birth, future studies are “at risk” of repeating past mistakes, where “research” is developed with systematic bias and for the purpose of social control — limiting options for home birth. This critique of the studies/opinions of Pang/Wax/ACOG was largely absent at the IOM. The problems with these studies/opinions have been reviewed on this site and elsewhere and compared with other more appropriate scientific literature. While several IOM speakers allowed that these studies are “controversial,” their outcomes were repeated as mantra for describing home birth safety without acknowledgment any of the underlying problems; this is now integrated into the IOM record of proceedings. These studies purposefully confound selection of planned home birth cases when attended by licensed or certified midwives by including data from births from 34 weeks onward, by including data of births attended by nurses (not midwives), by including data of babies born on the way to the hospital and certified by the ER doctor. The Pang study reports that they could not evaluate birth weight data, because it was too sparse in the home birth group. Home birth certified and licensed midwives have baby scales for weighing babes; people do not have baby scales at unattended home births, car births, or shopping mall births. This latter group has higher risk of neonatal death. The Pang study can only be seen as a semi-veiled attempt to discredit home birth, yet it makes up 40% of the data of the later Wax “meta analysis.” The Wax study was uncharacteristically rushed to release as the featured online article 2 months before print publishing, complete with NY Times press reporting. The timing was meant to influence the signature of the governor of New York on legislation providing for independent midwifery practice, which ACOG was urging the governor to veto.

    Science is embedded in culture, and no where is that more apparent than the home birth literature. I am worried that this cultural reach into the IOM meeting will result in a report that blindly passes on manipulative studies as science. This would further erode the honest pursuit of quality evidence about risks and benefits of various places of birth. Instead, this would further the subversive political agenda of controlling the information provided to women to generate and manipulate unfounded fears regarding home birth, while glossing over the ubiquitous problems associated with normative care found in most US hospitals, a source of the current embarrassing US maternal/perinatal statistics. Lets hope this does not come to pass.

    But one thing that has changed since the original 1982 IOM report on place of birth — information is now readily available on the internet in quality sites like this, so women do not have to rely solely on the information, or misinformation, provided by their doctors. Public access to scientific inquiry and critique give women power, and that is were it belongs.

  3. avatar
    Anon
    March 12th, 2013 at 15:32 | #3

    While I don’t agree with Chervenak’s approach if it is as you have described, but what I also don’t like is the culture that seems to permiate so many midwife, home birth, birth center discussions. Home birth, birth centers are just as safe or safer and given enough time and support any ‘low risk’ mother with give birth naturally. This just isn’t true. I was a ‘low risk’ mother who trusted her midwife in a birth center environment. I thought I had the best of both worlds, no drugs, support, with a hospital staff down the corridor if things went wrong. I had no idea how many midwives don’t like OBGYN’s and won’t call even if they should. My son died in that birth room because of two things bad culture between midwives and Obgyn’s and poor judgement on the part of the midwife. Who it should be noted doctored the report after the event to cover her tracks. It didn’t work but she tried. I know I am in the minority, I know people will say oh but that hardly ever happens. But I also know it shouldn’t have happened and could have been prevented. I welcome reform to home birth and birth centers and hospitals for that matter, anything that would stop someone else going through the hell we have been through is well worth it. At the end of the day its the outcome that matters, taking that baby home safe and sound, not how many choices you had available to you.

  4. avatar
    Wendy Gordon, LM, CPM, MPH
    March 13th, 2013 at 10:40 | #4

    Anon, I’m so sorry to hear about the loss of your son. The death of a baby is a horrible tragedy in any setting. While I don’t know all of the circumstances of your loss, poor interprofessional relationships are a major element wrapped up within the topic of transfer of care. A greater culture of respect between midwives and doctors is essential in allowing for those transfers to occur seamlessly, whether they are across town or down the hall. With the singular exception of Dr. Chervenak’s presentation, the IOM workshop was a shining example of interprofessional respect and collaboration towards healthier mothers and babies in all birth settings.

  5. avatar
    Liz
    March 14th, 2013 at 06:14 | #5

    anon – I am so sorry for your loss. Thank you for sharing your story. The stories of loss at OOH births need to be honored and shared.

    My deepest wish is that midwifery as a profession will someday respond to stories like yours not by passing the buck, but by taking responsibility for the culture and attitudes that lead to increased infant mortality. That a midwife leader would say: We take the issue of safety at out of hospital births very seriously – and we work hard to assure that all certified midwives appropriately risk screen during pregnancy and labor, and that all certified midwives are highly-trained and skilled in emergency medical techniques, and that all certified midwives have relationships with medical professionals and hospitals which assure rapid and appropriate transfer of clients from the OOH to the hospital setting.

    To echo Kate FInn – a previous poster:
    “that the women must be planning childbirth at home attended by certified or licensed midwives in settings that provide for legal status, adequate equipment and ready obstetrical collaboration and referral.”

    These are the circumstances that have the shown the safest outcomes for mothers and babies. And I agree with Finn’s follow-up statement:

    ” These settings are limited in the US. ”

    I live in a state where midwives are licensed and legal. But the relationships with medical back up are deplorable. It is wrong to assert that midwifery is safe and neglect to inform clients of the inherent problems of OOH birth that jeopardize the health and safety of themselves or their babies. These problems with OOH midwifery should be a part of ‘informed consent.’

    It was probably only after anon lost her baby in an OOH birth that she fully understood all the factors that came into play. That her midwives were reluctant to consult with doctors, that risk factors went unrecognized or unheeded. That these factors made her birthing situation more dangerous – all the while she’d believed she was making a ‘safe’ choice for herself and her family. Because that is what she’d been told – “OOH birth with a midwife is as safe, if not safer, than hospital birth”

    Before I get discounted for being a ‘troll’ I’d like to say that I have a license to practice midwifery in my state, I’ve assisted numerous CPMs at OOH births, and I’ve personally seen these situations where risk factors were minimized or ignored, labors went on too long, the clients were not made aware of the risks taken with their lives. I left OOH midwifery because my conscience could not stand by and witness needless risks being taken with people’s lives.

    I entered midwifery to work with low-risk women experiencing normal pregnancies and deliveries wishing to have a birth in an OOH setting. This is not what is happening in American midwifery. Risks are being taken in the name of ‘informed consent’ – research is being touted of proof of safety – yet the conditions by which OOH birth is most safe are not the conditions under which all women are giving birthing with midwives OOH.

    I will fight to have these voices heard – of anon, and other loss moms – their voices are so vitally important to the future of midwifery.

    I agree that PART of the problem is the poor relationship between midwives and physicians – there is a lot of work to do in that arena. But another part is the culture of midwifery that accepts increased risks in the OOH setting, that does not assure exemplary training of professional midwives, and that minimizes the seriousness of preventable deaths.

    Anon, again, I’m sorry. I don’t want you to think no one is listening to you. Some of us are listening. And we’re trying to make a change.

  6. avatar
    Lauren Korfine
    March 14th, 2013 at 11:25 | #6

    As someone who has worked with women who have experienced losses (in varying birth settings), I agree with Liz that their stories need to be heard and the tragedy of their experiences honored with exquisite care. What these families do not need is to become pawns in anyone’s political mission. It concerns me greatly, for example, to see Anon’s story get used as a springboard for a diatribe against out of hospital birth, when from her description, her son was born in a birth center that was located in a hospital. The very least we can do to honor someone’s story is to read it carefully.

  7. avatar
    Michelle Palmer
    April 3rd, 2013 at 14:34 | #7

    As a midwife who has worked both at home and in hospital in the US and abroad I implore all of us to be mindful of our judgments. I see short falls and triumphs in our communications in all settings and in my experience most of us are doing the best we can with what we know in the moment. We do better as we know better. Both settings are guilty of hiding what is perceived as failures. Bad outcomes happen sometimes due to our human error, be it our zeal to intervene with the best intention or to let what we perceive to be the physiologic process with best intention, sometimes the outcome is beyond our control. Listening to the women we care for and rising above our fear, our egos, and the politics of the moment is our constant challenge/opportunity.

  1. March 21st, 2013 at 07:32 | #1