Science & Sensibility

By Geradine Simkins, CNM, MSN, Executive Director of Midwives Alliance of North America

This week, the American Academy of Pediatrics released a policy statement on home birth. While the statement affirmed “the right of women to make a medically informed decision about delivery”, many advocates expressed concerns. The statement failed to recognize Certified Professional Midwives, the providers most likely to attend a home birth in the United States. In this response, the Midwives Alliance of North America helps families, providers, and policy makers understand the critical role CPMs play in safe, healthy birth options. – Sharon Muza, Community Manager, Science & Sensibility

High-quality out-of-hospital newborn and postpartum care is standard for midwives

 

The Midwives Alliance of North America welcomes the primary concept communicated in the American Academy of Pediatrics’ April 24, 2013, policy statement entitled “Planned Home Birth.” As should be expected, AAP reminds its practitioners that newborn infants—regardless of the setting in which they are born—deserve an equal and unbiased, high-quality standard of care. The Midwives Alliance joins with AAP in affirming the need for a collaborative and integrated maternity care system that addresses the needs of all mothers and infants, regardless of the provider type or birth setting a woman chooses.

We are disappointed, however, in AAP’s decision to align with the American Congress of Obstetrics and Gynecologists’ policy on home birth. Serving the needs of the growing number of families choosing to birth at home, Certified Professional Midwives attend the majority of intended home births in the U.S., when a skilled attendant is present, making them the primary care providers for newborns in the home setting.

Certified Professional Midwives are skilled maternity care providers

AAP’s itemized recommendations for infant and newborn care, contained in their policy statement, are standard practice for credentialed midwives. In that respect, we find much with which we agree. These standard newborn exams, screens, and preventative care practices are wholly part of a credentialed midwife’s scope of practice, and further endorsed by individual state health departments. We also note that as AAP Neonatal Resuscitation Program certificate holders (required for certification and recertification), credentialed midwives follow guidelines laid out in AAP’s recommendations, and typically surpass those standard recommendations by having at least two NRP- and CPR-trained attendants at out-of-hospital births.

In fact, the AAP’s guidelines for the care of infants intentionally born at home parallel those standards practiced by trained midwives in all birth settings. The practices listed—such as working medical equipment, emergency plans of transfer, thorough newborn exams, and so forth—are professional standards exhibited and documented by credentialed midwives, regardless of the place of birth.

The AAP policy statement, however, did not recognize or acknowledge Certified Professional Midwives (CPM), indicating that AAP may not have a thorough understanding of the training, skills, knowledge, and abilities of this country’s primary maternity care provider for infants born out of the hospital. The Certified Professional Midwife is the only national midwifery credential that requires practitioners to be trained specifically to provide prenatal, intrapartum, and postnatal care in out-of-hospital settings. CPMs are knowledgeable, expert and independent midwifery practitioners who have met the standards for certification set by the North American Registry of Midwives (NARM). NARM is accredited by the National Commission for Certifying Agencies (NCCA) to issue the professional credential of Certified Professional Midwife, which is the same agency that accredits the American Midwifery Certification Board to issue the professional credentials of Certified-Nurse Midwife, and Certified Midwife.  

Midwives are the providers of choice for out-of-hospital births, whether they occur at home or in freestanding birth centers. Offered since 1994, the CPM is currently the basis for licensure in 27 states while 11 additional states are actively seeking CPM licensure. In fact, one in nine newly certified midwives in the U.S. are Certified Professional Midwives.  

The AAP policy statement endorses birth center maternity care, which is another area in which we are in agreement. Recent numbers from the American Association of Birth Centers (AABC) indicate that a significant proportion of accredited birth centers are owned and operated by Certified Professional Midwives. A January 2013 study, The National Birth Center Study II , conducted by AABC and published in the Journal of Midwifery & Women’s Health, the official journal of the American College of Nurse-Midwives (ACNM), highlights the benefits for women who seek care at midwife-led birth centers. Findings also reinforce longstanding evidence that providers at midwife-led birth centers provide safe and effective health care for women during pregnancy, labor, birth, and the postpartum period.  

Midwives provide high-quality care that meets both national and international guidelines 

In highlighting the ethic of high-quality care for all infants across the spectrum—regardless of the site of birth—it should be noted that Certified Professional Midwives provide care intentionally similar to that of nurse-midwives and physicians. Yet we also know that CPMs are able to offer additional and valued care in terms of frequency of home visits and intense monitoring of newborns in their homes in the first weeks of life—a benefit not normally conferred to women and babies who have experienced hospital births.

This high-quality midwifery care includes routine newborn APGAR assessments, comprehensive head-to-toe physical examinations, measurements of length, head, abdomen and birth weight, monitoring vital signs including thermoregulation, assessment of respiratory sounds and patterns, assessments of cardiac sounds and peripheral pulses, assessment of gestational age and physical maturity, neuromuscular assessments, and assistance with initiation and ongoing assessment of breastfeeding. All findings are recorded in patient records and shared with mothers, per professional standards.

In addition, CPMs provide newborns with Vitamin K treatment, antibiotic eye ointment, umbilical cord care, metabolic newborn screening, glucose and bilirubin testing as indicated, and either perform Otoacoustic Emissions (OAE) hearing screens or refer to area audiologists. Midwives in a number of states are moving toward, or already offering, pulse-oximetry screening for Critical Congenital Heart Defects (CCHD) per AAP guidelines, in advance of many hospital systems. In the rare cases when newborns require consultation or referral, infants are transferred to the tertiary care system, and pediatricians where available, for active management.

Not only do Certified Professional Midwives and Certified Nurse-Midwives who attend home births provide the level of care outlined by the AAP, they provide it in a personalized, woman-centered, family-centered, culturally competent, and individualized manner that is qualitatively different from the customary assembly-line postpartum care commonly experienced in U.S. hospitals.

For example, in a home birth setting, the midwife typically conducts the initial newborn exam in the presence of the mother and family, which does not disrupt the crucial process of mother-infant bonding and breastfeeding, and is focused on being instructive to the family. Midwives provide holistic care to the mother-baby dyad in concordance with World Health Organization’s Baby-Friendly best practices.

As a way of illustrating important differences in care practices, we can point to the recent Breastfeeding Report Card issued by the CDC (2012) that indicates only six percent of U.S. hospitals are offering care that aligns with the international best practices outlined by Healthy People 2020.   By contrast in a 2005 study, 95% of babies born at home under the care of Certified Professional Midwives were exclusively breastfeeding at six weeks of age (Johnson & Daviss, 2005). This is just one area where midwives are well-trained, skilled, and uniquely positioned to help families succeed.

An opportunity for collaboration and integrated care 

Physician conversations about home birth and midwife-led birth will be better informed and more useful to maternity care consumers if AAP is able to become more cognizant of important changes in the landscape of U.S. midwifery. 

The release of the AAP policy statement on care of newborns born at home is an opportunity to reinforce the need for professional and seamless collaboration with members of community health care teams. We view this statement’s release as an opportunity to align best practices for all parties who care for and support families choosing home birth.

The Midwives Alliance stands ready to work with other pediatric and maternity care providers to establish best practices in the postpartum period to not merely provide the basic level of care in the first hours, days and weeks of life for the newborn as outlined in the latest AAP statement, but to elevate that standard to include support for breastfeeding and the personal attention that can prevent infant death and improve maternal and child health.  Babies born in all settings deserve this kind of care.

About Geradine Simkins

Geradine Simkins, CNM, MSN is an activist, midwife and author. She began as a direct-entry home birth midwife in 1976 and became a nurse-midwife twenty years later. For over thirty years she has provided health care for women, infants and families in a variety of settings, including attendance at births in the home, a freestanding birth center, and hospitals. Geradine’s work with migrant farmworkers and American Indian tribes focuses on addressing health care disparities and engendering a more equitable maternity care system for all women and infants.  Geradine is currently the Executive Director of Midwives Alliance of North America, a professional organization that promotes excellence in midwifery and is dedicated to unifying and strengthening the profession, thereby increasing access to quality health care and improving outcomes for women, babies and their families. She is the editor of the recently published book entitled Into These Hands: Wisdom from Midwives, an anthology of the life stories of 25 remarkable women who have dedicated their lives and careers to the path of midwifery and social change.  More info about Geraldine Simkins can be found here.

Sharon Muza ACOG, American Academy of Pediatrics, Babies, Delayed Cord Clamping, Home Birth, informed Consent, Maternity Care, Midwifery, Transforming Maternity Care AAP, ACNM, ACOG, CNM, CPM, Geraldine Simkins, Home Birth, MANA, Midwifery Care, Midwives Alliance of North America, newborn

“Our goal is not to have every mother birth at home—our goal is to encourage parents to gather quality information, to gain exposure to a philosophy that screams trust in mothers and trust in babies, and to provide parents who do plan a homebirth to be well equipped with an understanding of how to thrive in that decision.” – Jane E. Drichta, CPM and Jodilyn Owen, CPM, authors of The Essential Homebirth Guide: For Families Planning or Considering Birthing at Home.

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The Essential Homebirth Guide: For Families Planning or Considering Birthing at Home by midwives Jane E. Drichta, CPM and Jodilyn Owen, CPM  is a new book on the birth scene, being released today both in print and as an e-book.  I had an opportunity to read an advanced copy and and will share my thoughts with Science & Sensibility readers in this review.

The Essential Homebirth Guide is a book that is long overdue and will be welcomed by consumers and healthcare providers alike. With the recent National Birth Center Study II  released last month, many women and their families may now be considering an out of hospital (OOH) birth.  Some areas of the US offer the opportunity to birth in a birth center, while other parts of the country have no birth centers available at all and homebirth is the only OOH option.  Even where birth centers are available, women in greater numbers are now considering birthing in their own homes, with midwives, for many reasons, including comfort, cost and choosing a location where they feel they have the best chance to achieve a low intervention birth.

Sitting down to read Drichta and Owen’s guide is like spending a long weekend with your very best friend.  A best friend who just happens to be a midwife.  Whether you are just starting to explore the idea of a homebirth or have already decided that homebirth is for you, you will find that all your questions get answered in an easy to understand, factual way, with all the details and inside information that only your best friend can provide.  Drichta and Owen even provide answers to the questions you hadn’t thought of yet, but would want to know if you choose to homebirth, such as the section on communicating your homebirth choices with friends and family.

The book is arranged into chapters, and then subtopics.  Each subtopic has a nice Q&A format, with all the major questions covered in easy to understand language.  Peppered amongst the topics are real life stories and musing submitted by homebirthing women and their families, as well as special “The Midwife Says:” sections that provide additional information.  The personal stories offer a peek into the thoughts and experiences of homebirthing women, and readers will feel comforted by their stories. References are included for each chapter, and there are several hearty appendices at the back for more information. Lovely black and white pictures are scattered throughout.

One of the things that I loved best in The Essential Homebirth Guide is how the authors use every opportunity to speak to the mother, helping to develop her self-determination.  Throughout the book, they reinforce that every mother knows both her body and her baby best.  Women who read this book will feel confident that they are (or should be) equal partners in their care with their healthcare provider and are capable of asking questions, gathering information and making decisions that feel right to them.

“…A lot happens between the time of conception and diapers, and it all matters.  It will affect you.  It will change you.  It will propel you into motherhood in a profound way and can leave you with feelings of power, health, and peace, or it may leave you with feelings of anxiety, fear, and even trauma.  What kind of emotional context do you want as you become a new mother? What kind of new mother do you aim to be?  Think about these questions first, and then start building your prenatal care to lead yourself down the road that ends with you – the kind of new mother you intend to become in the kind of health you strive to have…” The Essential Homebirth Guide

Chapters on interviewing and choosing a midwife, what to expect during your prenatal care, prenatal testing options, information on the top ten pregnancy issues, preparing to birth at home, and what to expect after the birth all provide details on what normally occurs and include topics that can be discussed with your midwife along with things you can do to keep yourself healthy and low risk. In fact, this book is useful for any pregnant woman, as it will help facilitate conversations with hospital based healthcare providers, to help the woman who has chosen to birth in the hospital avoid unnecessary interventions. 

Drichta and Owen tackle some controversial subjects such as homebirth after a cesarean, home breech birth and homebirth of twins. No doubt, everyone’s comfort level is different and women (and their healthcare providers) process and understand risk in very individual ways.  These situations may not be for everyone, but the authors don’t ignore that these birth situations are occurring at home all around the country.  Information is power, mothers, when given accurate information in a respectful manner, will be able to determine what feels like the right decision for them.

I would have appreciated more information in the book on how low income families and women of color might find their way to homebirth in today’s maternity care climate, as the increase in homebirths has not been observed amongst those populations. Where I live, in the state of Washington, almost half of our births are paid for by the state, and we are fortunate that homebirth is an option for those families receiving state aid.  That is not the case for most of the rest of the country.

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I had the opportunity to ask Jane Drichta and Jodilyn Owen some questions about their book, and wanted to share my interview with Science & Sensibility readers.

SM: Why did you want to write this book, and why now? 

JO: This book has been running around in circles inside of our heads for years.  We make it a habit to check in with each other after most births, and so there are at least a decade of late night conversations here.  As we talked, we realized that we were running into the same problem; there was not one definitive source of information for homebirthing families.  We had websites and articles and handouts, but not one place where we could send parents for unbiased, evidence based information, served up with sides of common sense and love. Homebirth is becoming more and more popular, and the time just seemed to be right. 

SM:  What was the most challenging topic for you to cover in the book? How did you handle it? 

JD: The chapter on The Big Ten, which details ten common complications in pregnancy, was difficult to write.  We are used to speaking around these topics in very technical terms, and it was difficult to distill the information down to what mothers needed to know.  We were more interested in providing a model for how we approach these issues that any woman can adapt to her situation than being prescriptive about what one must absolutely do in a given situation.  When we started that chapter, it sounded like we were writing a term paper.  We completely lost the friendly, accessible tone that we were going for.  So that was a challenge.   

SM: What is the main piece of information that you hope that women will know/take away after finishing your book?

JD:  That they can do this.  That birthing at home is a viable option in 21st century America. That the desire to do this doesn’t mean you are crazy or hate the patriarchy, or that any of the other homebirthing stereotypes apply.  Women can birth at home more safely than ever before, and it is a real alternative for most women.

SM: What challenges do you see facing the potential growth of homebirths in the US?

JO:  The integration of homebirth midwives into our current health care system.  The politics around midwifery and its place in the system are myriad, and not something that we wanted to get into in the book.  However, we do support the right of women to birth in the place of their choice, with the provider of their choice, and that is sometimes difficult and can be limiting.

SM: If midwives and doctors read this book, what do you hope they take away from it?

JO: We hope they take away a few key points:  That mothers and partners should be held responsible to seek information and share decision making in their care, that a pregnant and birthing woman is in partnership with her baby and this dyad perspective should be promoted at all times with the language and behavior providers use, and that a woman is never just her numbers—she is a whole human being with a context worthy of their curiosity and respect.  

SM: How can childbirth educators use this book with their students?

JD: Simply presenting this paradigm of woman-centered, individualized, continuous care is a great way to open the door for discussions about creating intention for pregnancy and birth.   What is it that parents really mean to establish for themselves when it comes to their care and birth?  Understanding risk, breaking apart decision-making models, and tuning in to their inner-wisdom are just some of the great tools that educators can work through.

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I wanted to see what the authors had to say about childbirth classes for women considering homebirth and was delighted to find that they encourage all women to take classes and hold Lamaze International and our Healthy Birth Practices in high esteem.  ”We can’t find anything not to love here” is found in the childbirth class section under the Lamaze heading..

Overall, I really enjoyed reading this book and found it to be an easy read and full of information that I would find useful if I was still deciding where to birth or had already made up my mind to birth at home.  I could also see myself referring back to this as my birth got closer.  This book acknowledges that I am the best person to make this very personal decision about where to birth my baby. I think that healthcare providers who offer OOH birth services might want a few copies on their bookshelves to lend to potential and current clients, and childbirth educators might very well recommend this resource to parents in their classes who want to know more about what a home birth might be like.

Please consider coming back to the blog and sharing your thoughts after reading the book.  I would love to know what you think and if you would recommend this to clients and students.  If you would like to contact the authors, they can be reached through their website Essential Midwifery.

Disclosure: The authors of this book and I are all members of the professional birth community in Seattle, WA.  I have known them on a professional and personal level long before this book was even conceived.

Sharon Muza Book Reviews, Childbirth Education, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, Home Birth, Maternal Quality Improvement, Maternity Care, Midwifery book review, Childbirth Education, Essential Homebirth Guide, Healthy Birth Practices, Home Birth, homebirth, Jane E. Drichta, Jodilyn Owen, Lamaze International, Midwifery Care, midwives, Sharon Muza

by Wendy Gordon, LM, CPM, MPH, Midwives Alliance Division of Research

Today, midwife and researcher, Wendy Gordon, LM, CPM, MPH, Midwives Alliance Division of Research, takes a look at the recent article in the American Journal of Obstetrics and Gynecology that shared the authors’ view of the appropriate professional response from obstetricians when counseling and discussing home birth with patients.  Was this article based on good science?  Accurate and accepted studies? Did the authors selectively choose their sources and ignore other research that may have supported a different viewpoint?  Wendy shares information and research that invites consideration and discussion of the validity of the authors’ opinion. – Sharon Muza, Community Manager.

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Recently, an article in the American Journal of Obstetrics & Gynecology pled with obstetricians to not support planned home birth in any way, and even suggested that those who do “should be subject to peer review and justifiably incur professional liability and sanction from state medical boards” (1).  In their strongly worded opinion, the authors (the first two of whom are, curiously, members of the journal’s Advisory Board, and four of whom are also board members of the International Society of Fetus as a Patient) make their case that physicians should provide evidence-based information to women that planned home birth is not safe, that reports of patient satisfaction are overrated, that it’s actually not cost-effective, and that a pregnant woman has a moral duty to her fetus to give up her autonomy to her doctor’s judgment on this issue.  Let’s take a look at the basis for these recommendations.

Although there are many high-quality studies of home birth on which Chervenak et al. could have based their opinions, they led with the ACOG statement (2) that rests on the findings of the Wax et al. meta-analysis (3), which relied heavily on a study that included unplanned home births in its findings of neonatal mortality rates (4).  Many strong critiques of the Wax analysis have been published (5-11), including an unbiased look from someone who has no stake in the home birth debate.  The authors cited several more poor-quality studies, as well as 52 citations of commentaries, opinions and anecdotes (some even pulled from the popular media) to build their “evidence” basis. They conveniently ignored the large and growing body of literature that continues to show that planned home birth with qualified and experienced midwives holds no greater risk of perinatal mortality than birth in the hospital, and in fact results in far fewer interventions and lower risk of maternal and perinatal morbidity.

Here are some of the high-quality studies that Chervenak et al. did not cite in developing their opinion of the “professional responsibility response”:

• two systematic reviews (12-13) and a meta-analysis (14) of home and birth center safety studies that all show that there is no greater perinatal risk for planned, attended home births than for hospital births, and significantly fewer interventions;
• the only large-scale, high-quality study of Certified Professional Midwives (CPMs) in the U.S. that described intrapartum and neonatal death rates as similar to other studies of low-risk home and hospital births (15);
•  other high-quality U.S. studies that show no difference in perinatal mortality between planned home and hospital births (16-18);
• several high-quality Canadian studies confirming no difference in the rates of perinatal death between planned home and hospital birth with much lower rates of both interventions and adverse outcomes (19-21);
•  a huge Dutch study of over half a million births that shows no difference in perinatal mortality rates or NICU admissions between planned home and hospital births (22);
• another Dutch study that shows no difference in perinatal mortality and lower risk of interventions and other adverse outcomes, particularly for multips (23);
• large, high-quality U.K. studies that show no difference in perinatal mortality rates and lower risk of both interventions and adverse outcomes (24-25); and
• a German study that shows no difference in rates of perinatal mortality and lower risk of interventions and adverse outcomes (26).

The authors then go on to discount the evidence of higher satisfaction among women choosing to deliver at home, as well as the cost-effectiveness of doing so, while presenting absolutely no evidence to the contrary.  The authors reference a study in the Netherlands where the transport rate from home to hospital is over twice that in the U.S. (and where Chervenak et al. took great liberties in interpreting the results on patient satisfaction) and a U.K. study where the costs of home and hospital birth are virtually equivalent.  While consistent, this approach to selectively reviewing the evidence and generalizing the findings to the U.S. maternity care system is disingenuous and deliberately misleading to American obstetricians and their patients.  A Washington State study of Medicaid patients planning a home birth with Licensed Midwives showed a savings of nearly $3 million, including the increased cost of those who transferred care and/or site of delivery (27).  This analysis did not attempt to account for the vast cost reductions of potentially avoided interventions, including cesareans and their complications, which would make the case for the cost-effectiveness of midwifery-led care in Washington State even stronger.  It is puzzling that Chervenak et al. did not cite this study, which is recent, took place in the U.S., was conducted by unbiased health-economics consultants, and directly addresses one of their four concerns.

The authors’ main argument against the proven cost-effectiveness of planned home birth is that “the lifetime costs of supporting the neurologically disabled children who will result from planned home birth” have not been factored in, nor have the supposedly increased rates of death.  If one accepts the conclusions of the enormous body of literature that finds no difference in perinatal mortality rates or other adverse outcomes between planned, midwife-attended home births and hospital births, then the pursuit of this line of reasoning is a non-starter.

The U.S. continues to lag behind many other high- and low-resource countries in accepting the evidence of the vast benefits of midwifery care.  The U.K.’s National Health Service has encouraged women to plan home births with midwives for several years; the Netherlands has always acknowledged midwives as the primary care provider in the childbearing year; New Zealand’s system similarly places midwives at the forefront of maternity and newborn care; Japan has a long tradition of midwifery-led care.  Most recently, British Columbia Health Minister MacDiarmid, accepting the evidence of safety, patient satisfaction and cost-effectiveness, has announced government support for women with low-risk pregnancies to plan a home birth, including support for physicians to become appropriately trained to attend home births (28).  But the medical associations of the U.S. continue to erect barriers to the type of interprofessional collaboration that has resulted in the excellent outcomes of these other countries.  The Chervenak et al. article is clearly intended to be yet another of those barriers.

In the centerpiece of the AJOG article, Chervenak cites himself an astounding 15 times in justifying why the rights of a pregnant woman to make autonomous decisions for herself and her baby should be relegated to her doctor’s judgment of what’s right for the “fetus as a patient,” grounded firmly, of course, in the aforementioned “evidence.”  In an astonishing disregard for shared decision-making and informed choice, Chervenak et al. state that “in a professional relationship, the physician’s integrity justifiably limits the woman’s rights by limiting the scope of clinically reasonable alternatives.”  The authors’ repeated and unusual use of the word “recrudescence” when referring to home birth, which reveals their perception of the choice as a disease or disorder, and their stubborn contempt for high-quality evidence if it disproves their opinion, exposes their intent and certainly calls into question their “integrity.”

“Professional responsibility” demands that we dare to examine the evidence that does not agree with our personal beliefs.  It requires that we allow the volumes of high-quality evidence to seep into our analysis of reality and into our presentation of true informed choice to our patients.  “Professional responsibility” demands that we examine and disclose our own personal, religious or anecdotal beliefs that may bias our interpretation and presentation of the research.  And it requires that we refuse to cloak those personal beliefs as “evidence” and “integrity” and by so doing avoid an abuse of power in relationship with our patients.

References

1. Chervenak F. A., McCullough L. B., Brent R. L., Levene M. I., & Arabin B. (2012) Planned home birth: the professional responsibility response. Am J Obstet Gynecol, Nov 13. doi:10.1016/j.ajog.2012.10.002. [Epub ahead of print].

2. American College of Obstetricians and Gynecologists. (2011). Committee Opinion no. 476. Committee on Obstetric Practice. Planned home birth. Obstet Gynecol, 117(2, part 1), 425-8.

3. Wax J. R., Lucas F. L., Lamont M., Pinette M. G., Cartin A., & Blackstone J. (2010).  Maternal and newborn outcomes in planned home birth vs. planned hospital births: a metaanalysis. Am J Obstet Gynecol, 203(3):243.e1–243.e8. doi:10.1016/j.ajog.2010.05.028

4. Pang J. W., Heffelfinger J. D., Huang G. J., Benedetti T. J., & Weiss N. S. (2002). Outcomes of planned home births in Washington state: 1989-1996. Obstet Gynecol, 100(2):253-9. http://dx.doi.org/10.1016/S0029-7844(02)02074-4

5. Carl M. A., Janssen P. A., Vedam S., Hutton E. K., & de Jonge A. (2011). Planned home vs hospital birth: A meta-analysis gone wrong. Medscape Ob/Gyn & Wom Health. Retrieved from http://www2.cfpc.ca/local/user/files/%7B1E683014-14EB-489F-99CE-B5A2185A6FC5%7D/Medscape%20%20Wax%20Critique%20-%20Michal,%20Janssen,%20Vedam,%20Hutton,%20de%20Jonge.pdf

6. Gyte G., Newburn M., & Macfarlane A. (2010). Critique of a meta-analysis by Wax and colleagues which has claimed that there is a three-times greater risk of neonatal death among babies without congenital anomalies planned to be born at home. National Childbirth Trust. Retrieved from http://www.scribd.com/doc/34065092/Critique-of-a-metaanalysis-by-Wax

7. Keirse M. J. (2010). Home birth: Gone away, gone astray, and here to stay. Birth, 37(4):341-46.

8. Hayden E. C. (2011). Home birth study investigated. Nature [Epub]. doi:10.1038/news.2011.162.

9. American College of Nurse Midwives. (2010). ACNM expresses concerns regarding recent AJOG publication on home birth. [Epub]. Retrieved from http://www.midwife.org/documents/ACNMstatementonAJOG2010.pdf.

10. Romano A. (2010). Meta-analysis: the wrong tool (wielded improperly). Retrieved from http://www.scienceandsensibility.org/?p=1349.

11. Dekker R. & Lee K. S. (2012). The Wax home birth meta-analysis: an outsider’s critique. Retrieved from http://www.scienceandsensibility.org/?p=5628.

12. Olsen O. & Clausen J. A. (2012). Planned hospital birth versus planned home birth. Cochrane Database of Systematic Reviews, Issue 9. Art. No.: CD000352. doi: 10.1002/14651858.CD000352.pub2.

13. Leslie M. S. & Romano A. (2007). Appendix: Birth can safely take place at home and in birthing centers. J Perinat Educ, 16(Suppl 1):81S-88S. doi:10.1624/105812407X173236

14. Olsen O. (1997). Meta-analysis of the safety of home birth. Birth, 24(1):4-13; discussion 14-6.

15. Johnson K. C. & Daviss B-A. (2005). Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ, 330:1416. doi: http://dx.doi.org/10.1136/bmj.330.7505.1416

16. Cawthon L. (1996). Planned home births: outcomes among Medicaid women in Washington State. Olympia,WA: Washington Department of Social and Health Services. Retrieved from http://www.dshs.wa.gov/pdf/ms/rda/research/7/93.pdf.

17. Murphy P. A. & Fullerton J. (1998). Outcomes of intended home births in nurse-midwifery practice: a prospective descriptive study. Obstet Gynecol, 92(3):461-70.

18. Anderson R. E. & Murphy P.A. (1995). Outcomes of 11,788 planned home births attended by certified nurse-midwives: A retrospective descriptive study. J Nurse Midwifery, 40(6):483-92.

19. Janssen P. A., Saxell L., Page L. A., Klein M. C., Liston R. M. & Lee S.K. (2009). Outcomes of planned home births with registered midwife versus planned hospital birth with midwife or physician. CMAJ, 181(6):377-83.

20. Hutton E. K., Reitsma A.H. & Kaufman K. (2009). Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: A retrospective cohort study. Birth, 36(3):180-89.

21. Janssen P. A., Lee S. K., Ryan E. M., Etches D. J., Farquharson D. F., Peacock D. & Klein M. C. (2002). Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. CMAJ, 166(3):315-23.

22. de Jonge A., van der Goes B. Y., Ravelli A. C., Amelink-Verburg M. P., Mol B. W., Nijhuis J. G., Bennebroek Gravenhorst J. & Buitendijk S. E. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG, 116(9):1177-84. DOI: 10.1111/j.1471-0528.2009.02175.x.

23. Wiegers T. A., Keirse M. J., van der Zee J. & Berghs G. A. (1996). Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands. BMJ, 313(7068):1309-13

24. Chamberlain G., Wraight A. & Crowley P. (eds.). (1997). Home births – The report of the 1994 confidential enquiry by the National Birthday Trust Fund. Cranforth, UK: Parthenon Publishing.

25. Northern Region Perinatal Mortality Survey Coordinating Group. (1996). Collaborative survey of perinatal loss in planned and unplanned home births. BMJ, 313(7068):1306-09. doi: http://dx.doi.org/10.1136/bmj.313.7068.1306.

26. Ackermann-Liebrich U., Voegeli T., Gunter-Witt K., Kunz I., Zullig M., Schindler C., Maurer M. & Zurich Study Team. (1996). Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. BMJ, 313(7068):1313-18. doi: http://dx.doi.org/10.1136/bmj.313.7068.1313.

27. Health Management Associates. (2007). Midwifery licensure and discipline program in Washington State: economic costs and benefits. Retrieved from http://www.washingtonmidwives.org/documents/Midwifery_Cost_Study_10-31-07.pdf.

28. Dedyna K. (2012, Nov 3). B.C. minister among first to support home births. Times Colonist. Retrieved from http://www.canada.com/minister+among+first+support+home+births/7494815/story.html.

 

Sharon Muza Evidence Based Medicine, Guest Posts, Home Birth, informed Consent, Maternal Mortality, Maternal Mortality Rate, Maternity Care, Medical Interventions, Midwifery, New Research, Research ACOG, ACOG and homebirth, Chervenak, Evidence Based Medicine, guest posts, Home Birth, homebirth, homebirth debate, midwives, Midwives Alliance, research, Wendy Gordon

Today’s post is a fascinating interview that took place between Rebecca Dekker, PhD, RN, APRN of Evidence Based Birth and Kyoung Suk Lee, PhD, MPH, RN, APRN. Rebecca asked Dr. Lee to provide a reiew of the Wax Home Birth Meta-Analysis, as an “unbiased outsider”, but highly skilled researcher.  Dr. Lee’s comments and critique are fascinating and provided me with many further thoughts.  Please enjoy Rebecca’s interview and share your comments. – SM

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Shortly after starting my website, www.evidencebasedbirth.com, I had several people ask me if I could write an article about the research evidence on home birth. However, I was hesitant to do so for several reasons. Mainly, I was worried that I could not look at the evidence in an objective manner. My husband and I had recently chosen a home birth for our second child. I was worried that it would be difficult to objectively examine the research evidence on home birth, given my personal experience. The blogosphere is full of people who are strongly pro-home birth or anti-home birth, and their evaluations of the evidence are usually written through the lens of their own biases. I didn’t want to add to the plethora of biased articles already out there.

Then I had a sudden burst of inspiration. What if I asked one of my colleagues—who has no biases about childbirth—to review the home birth literature for me? In particular, I wanted to find someone who could review the Wax home birth meta-analysis (Wax, Lucas et al. 2010) and give me a fair assessment of its scientific value.

I chose the Wax meta-analysis for this review because in 2011, the American Congress of Obstetricians and Gynecologists emphasized the results of the Wax study in its official statement on home birth. Their statement said: “Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth.”(ACOG, 2011)

It did not take me long to figure out who I would ask to review the Wax study. Dr. Kyoung Suk Lee is considered by her colleagues to be a rising star in the field of cardiovascular research. She recently graduated with a PhD in Nursing, and she just accepted a job at a research university. People who work with Dr. Lee say that she is extremely intelligent, hard-working, and a future leader in her field. Dr. Lee’s expertise has been recognized with research awards from the Heart Failure Society of America, the Society for Heart-Brain Medicine, and the Cleveland Clinic Heart-Brain Institute, among others. She has published her work in nursing and cardiology journals. Furthermore, I knew that Dr. Lee did not have any biases about childbirth, home birth, or hospital birth. I asked Dr. Lee if she would be willing to review the Wax meta-analysis for me, and she kindly agreed.

What follows is my interview of her about the study and its results (RD in bold, KSL unbolded).

Do you have any biases or conflicts of interest related to home or hospital birth?

I do not have any biases related to home or hospital birth.

Could you summarize the methods and results of the Wax study?

The purpose of this meta-analysis was to compare maternal and neonatal outcomes between planned home-and hospital-births.

Using an electronic database search and bibliography search, the authors retrieved 237 articles and included 12 articles in their meta-analyses. Of 12 articles included, 3 were conducted after 2000 while 9 were conducted before 2000. Of 12 articles, 2 were conducted in the US (one was a retrospective design) while 10 were conducted outside US.

Women in the planned home birth group had better maternal outcomes than women in the planned hospital group. They had fewer interventions such as epidurals and episiotomies, and lower morbidity (infection, 3^rd or 4^th degree lacerations, hemorrhages, and retained placenta). There were no differences in cord prolapse between the two groups.

For neonatal outcomes, babies born to women in the planned home birth group were less likely to experience prematurity and low birth weight. However, babies born to women in the planned home birth group were more likely to experience neonatal death compared to women in hospital birth.

What is the difference between neonatal and perinatal mortality? What does this have to do with the results?

Based on the definitions given by the authors, neonatal mortality was defined as “death of live born child within 28 days of birth.” This is a subset of an overall outcome– perinatal mortality, which was defined as “stillbirth (of at least 20 weeks or 500g) or death of live born child within 28 days of birth.”

According to the authors, there were no differences in perinatal death (the overall outcome) between planned home birth and hospital birth groups. However, homebirth was associated with 2 times higher risk for neonatal death (the subset of deaths occurring 28 days after birth) in all infants and 3 times higher risk for neonatal death in infants who did not have any congenital birth defects.

Interestingly, if you look at page 243.e3, the authors did a sensitivity analysis. In this analysis, they excluded the studies that had home births that were not attended by certified midwives or certified nurse midwives. In this analysis, they found that there were no differences in neonatal deaths between the home birth and hospital birth groups. This means that in the studies in which midwives with certification of some kind attended home births, the outcomes were the same except there was no increase in the neonatal death rate. In my opinion, we have to pay attention to results of sensitivity analyses because this allows us to see the results based on studies which were definitely known to be eligible or clearly described their methods and outcomes.

What is your opinion on the scientific rigor of this meta-analysis?

One thing that was strange to me is the odds ratios (ORs) in the tables. For example, in table 2, under morbidity, the percentages of infection between home births and hospital births were 0.7 vs. 2.6 (its OR was 0.27) while percentages of perineal laceration were 42.7 vs. 37.1 (its OR was 0.66). To a researcher, these numbers don’t make sense.

Many of the studies included were older (half of the studies were conducted more than 20 years ago) so results may not reflect the current practice at home births or hospital births.

The authors did not provide detailed information on how they evaluated the quality of studies included, although they cited a paper describing the method of study evaluation. This makes it difficult if not impossible to determine whether the studies they included were of good or poor quality.

The authors mentioned that women with high risks would prefer hospital births so that it would expect that home births have better outcomes than hospital births in some maternal and neonatal outcomes. If this was a concern, I wonder why the authors didn’t just focus on only the studies that used matching methods, in order to minimize confounding factors.

What is the difference between relative risk and absolute risk, and how does that apply to women who want to have a home birth?

Absolute risk is the probability of something occurring. They may be expressed as percentages or ratios. For example, neonatal mortality rate in the United States is 2.01 per 1,000 live births. This is .201 percent (2.01/1000 = .201/100).

Relative risk is a comparison between different risk levels, such as the neonatal mortality rate of home birth compared to the neonatal mortality rate of hospital birth. The researchers found that there was a higher relative risk in neonatal mortality at home births compared to hospital births, but the overall absolute risk for both was small.

How can women know whether the Wax study results would be applicable to their own individual situation?

Meta analysis is one way to generalize findings from different studies. However, women and clinicians should interpret these results cautiously because the studies included were very different from one another and some of the studies included may not have been of good quality. Also, it would be important to note that the overall neonatal death rate that they report reflects home births that were attended by midwives as well as those that may not have had any kind of certified midwife present.

Because this study seems to have some flaws, the conclusion is tentative. I do not know if this article has any implications for pregnant women.

What do you think is the value of asking someone with no conflicts of interest to evaluate controversial research? Does Dr. Lee’s even-handed critique make you view the results of this study any differently? How do you feel about Dr Lee’s conclusion that the study’s results are tentative, and that the Wax study might not have any implications for pregnant women? Please share your thoughts and comments with other readers.

References

(2011). “ACOG Committee Opinion No. 476: Planned home birth.” Obstetrics and gynecology 117(2 Pt 1): 425-428.

Wax, J. R., F. L. Lucas, et al. (2010). “Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis.” Am J Obstet Gynecol 203(3): 243 e241-248.

About Rebecca Dekker

Rebecca Dekker, PhD, RN, APRN, is an Assistant Professor of Nursing at a research-intensive university and author of www.evidencebasedbirth.com. Rebecca’s vision is to promote evidence-based birth practices among consumers and clinicians worldwide. She publishes summaries of birth evidence using a Question and Answer style.

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A new study has been making the rounds of the popular news sites.  The abstract – 65: Neonatal outcomes associated with intended place of birth: birth centers and home birth compared to hospitals  The abstract of the study is published in AJOG It was presented at the Society for Maternal-Fetal Medicine 32nd Annual Meeting.

It is strange that this abstract is getting so much attention. With only an abstract available it is impossible to judge the study’s merits. We look forward to the publication of the study. At this point we have to reserve judgment for later.  We simply don’t have the data available to determine the strength or validity of the study.  That said, it is amazing that the findings presented in the abstract are getting so much attention.

Here are some of the many articles, with varying perspectives, discussing it: 

I found this article to be neutral verging on steering families toward hospital birth:

 “Babies born at home were more than twice as likely to have an Apgar score of under 7 as children born in a hospital or at a birthing center, and also had double the chances of having a seizure….

The overall number of kids who had seizures was low — less than 1 percent at any location.

Prior research has shown that babies with lower Apgar scores are more likely to have complications after birth, such as needing breathing assistance, going to the ICU, having seizures or having developmental issues, Cheng said.”

Study Weighs Pros, Cons of Home or Hospital Birth: More seizures, lower Apgar scores found in home or hospital birth  

 

This article has a positive spin for homebirth:

 “But when a certified midwife was present, it seems babies born at home may fare as well as those born in hospitals, said study researcher Dr. Yvonne Cheng, an obstetrician and gynecologist at the University of California, San Francisco.

“It’s not just about where you deliver, but perhaps who you deliver with,” Cheng said.

Home births are known to be associated with fewer obstetric interventions — that is, women in labor at home receive fewer epidurals and less pain medication.

Women must weigh the benefits of home births against the risks to make an informed decision about where to give birth, Cheng said.”

Midwives make homebirth safer for babies  

 

 This article seems to treat the study in a neutral manner:

 “Women who have home births or plan to deliver at home have lower rates of cesarean delivery; however, their babies are more likely to have neonatal seizures and lower Apgar scores if a certified midwife is not in attendance, according to research presented here at the Society for Maternal-Fetal Medicine 32nd Annual Meeting.”

Home Births Associated With More Seizures, Lower Apgar Scores

 

This one uses bad data to back a claim:

“…recent evidence suggests that while the absolute risk of planned home births is low, such births carry a neonatal death rate at least twice as high as that of planned hospital births. Neonatal death occurred less than once in 1,000 hospital births, compared with two in 1,000 home births, said an American Journal of Obstetrics & Gynecology meta-analysis published in September 2010.”

Home births rise despite higher neonatal mortality rate: Although the vast majority of deliveries occur in hospitals, more women who want a less institutional experience are opting to give birth at home.

This AMA article is citing the Wax et al study.  Science and Sensibility has discussed the vast array of errors and misinformation in the Wax study on four separate occasions:

• When Scientific Methods Fail: New Criticisms Over the Wax et al Homebirth vs. Hospital Study 
• Becoming a Critical Reader: Questions to ask about systemic reviews and meta-analysis 
• Planned homebirth and neonatal death: Who do we believe?
• Meta-analysis: the wrong tool (wielded improperly)

Others have cited Wax et al, although not explicitly such as this one: Homebirths up Dramatically, but are they safe?

There were numerous letters written to AJOG with regards to the flaws in the study, as well.  So, to have the Wax et al study brought up again is inappropriate and poor science.  It feels to me like a scare tactic or propaganda.

Given that we don’t have all the information, I question the journalistic integrity with which the articles above are written.  It’s always a good headline – about the dangers of home birth.  It’ll get links clicked, newspapers sold and running commentary on social media sites.  However, without proper analysis of the data things are potentially misrepresented.  Once we gain access to the full study, Science and Sensibility will be able to respond appropriately.

Some questions we hope to answer:

• What data were used? How strong is the data set?
• Many home births are not reported as such, so data will be lacking.  How is this accounted for?
• Does the legal status of a homebirth midwife impact outcomes?  Especially because the author states that CNMs have better outcomes than do CPMs or DEMs. We are not aware of research that supports this.
• Is it considered homebirth if the mother was transferred from home to hospital mid-labor if her intention was to have a home birth?

For more on recent perspectives on homebirth please visit the Homebirth Consensus Summit.

Let’s get the discussion going here.  What are your thoughts on homebirth?

Deena Blumenfeld Evidence Based Medicine, Guest Posts, Home Birth, Metaanalyses, Midwifery, News about Pregnancy, Research AJOG, becoming a critical reader, causes of fetal death, CNM, Home Birth, homebirth, homebirth consensus committee, homebirth debate, infant mortality, media, midwives, newborns, News about Pregnancy, Social Media, Wax et al study on homebirth vs. hospital birth, Wax study