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

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

© http://www.mybirth.com.au/

© http://www.mybirth.com.au/

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

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

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

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

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

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

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

© http://flic.kr/p/3mcESR

© http://flic.kr/p/3mcESR

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

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

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

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

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

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

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

References

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

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

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

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

About the Authors:

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

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

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

  1. avatar
    Kate T Finn, MS, Licensed Midwife (NY)
    April 17th, 2014 at 08:30 | #1

    These guidelines are intended to be used by maternity system planners, midwives, consumer advocates, maternity unit managers, chiefs of obstetrical programs, transfer coordinators and others to facilitate the development of coordinated policies in maternity hospitals and midwifery practices. All providers are aligned in placing the woman/baby’s needs first, ensuring quality communication between providers, shared decision making with the woman/family, and care provision to facilitate a smooth transition and optimal outcomes.

    As Regional Perinatal Centers have responsibility for conducting educational outreach and quality improvement with affiliated local hospitals, leaders in Regional Perinatal Centers are a logical entry point for bringing these guidelines to the attention of local hospitals. Regional Perinatal Centers frequently have a Transport Coordinator, and implementation of these guidelines may fall under that person’s job role.

    Any community with a hospital offering maternity services and midwives providing community-based care will find that these best practices guidelines apply. These guidelines provide a starting point for essential coordination of communication and services, as transfers of women/babies for specialized care from home setting to the hospital can be expected as a matter of routine.

  2. avatar
    Sarita Bennett
    April 18th, 2014 at 05:16 | #2

    I am so amazed and grateful for this awesome work. As someone who has worked both inside and outside of the hospital, I understand how important following these guidelines will be to improving the safety and experience for anyone transporting from home to hospital. Yay, Team!

  3. April 18th, 2014 at 10:57 | #3

    As a midwife providing Birth Emergency Skills Training for out of hospital practitioners, I am encouraged by this historical move toward unified OB care in the US. We have long served in a society which caused more fear for practitioners, not in the emergent care they might need to provide, but rather the transfer of care should their treatment fail. This is a huge step forward for families, their birth setting of choice and the health of mothers and babies.

  4. April 18th, 2014 at 20:53 | #4

    As a home birth and birth center Midwife, I am excited about these guidelines and look forward to seeing the implementation of more integrated, seamless transports for out-of-hospital birth clients, when transferring from home or birth center becomes necessary. I have been fortunate throughout my career to have great collaboration relationships in every community I have worked in.

    These guidelines will help providers, both inside and outside the hospital, to establish a higher level of quality transitional care for women and their babies! I applaud the work of the Home Birth Summit participants!

  5. April 21st, 2014 at 12:47 | #5

    As a perinatal CNS and nurse scientist I am always trying to investigate “Better Ways” to implement childbirth care. I am presenting with my Irish Colleague – Midwife at the International Federation of Midwifes ICM in Prague in June, 2014. We did a concurrent study of the meaning of Women’s decisions to have Home Births, in WA State and the Republic of Ireland. The ability to safely transfer to a hospital, if indicated, was an important aspect of our study. I am excited to present your new guidelines to support home births in the US.

    Thank you for your stellar job pulling this together. Implementing these guidelines in clinical practice will be your new challenge. I wish you well.
    ~Susan

  6. avatar
    Mari Patkelly
    April 22nd, 2014 at 11:40 | #6

    Many thanks to Lawrence Leeman, Diane Holzer and all those who participated in creating this important document during the recent Home Birth Summit gatherings!
    This work in creating, promoting and distributing these guidelines widely will facilitate hospital transfers which promote quality MCH care and good outcomes for those women and families who have been and will be choosing the safety of home and birth center births since time immemorial with various types of midwives who serve Women, Babies and their Families.
    This invaluable cooperation among our Family Health Care providers is essential for all – as out of hospital birth becomes more mainstreamed in the United States and our culture embraces, at last, evidence based care for all. The communication and cooperation that is blooming now, between all practitioners in all settings,is truly something to celebrate.
    And, so I – who started working with women and their families in 1966 – am proud of the progress we are making as we work to cross now, a much too deep, old and unnecessary divide – which has fractured our Maternal and Child health care system for too long…
    Blessings to all for all… forever more!

  7. avatar
    Mari Patkelly
    April 22nd, 2014 at 11:44 | #7

    Many thanks to Lawrence Leeman, Diane Holzer and all those who participated in creating this important document during the recent Home Birth Summit gatherings!
    This work in creating, promoting and distributing these guidelines widely will facilitate hospital transfers which promote quality MCH care and good outcomes for those women and families who have been and will be choosing the safety of home and birth center births since time immemorial with various types of midwives who serve Women, Babies and their Families.
    This invaluable cooperation among our Family Health Care providers is essential for all – as out of hospital birth becomes more mainstreamed in the United States and our culture embraces, at last, evidence based care for all. The communication and cooperation that is blooming now, between all practitioners in all settings, is truly something to celebrate!
    And, so I – who started working with women and their families in 1966 – am proud of the progress we are making as we work to cross a much too deep, old and unnecessary divide – which has fractured our Maternal and Child health care system for too long…
    Blessings to all for all… forever more!

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