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Thank You Midwives! join Lamaze in Celebrating National Midwifery Week!

October 7th, 2014 by avatar

midwifery week poster 2014Please join Lamaze International and Science & Sensibility as we celebrate National Midwifery Week.  Midwives can and should play an integral part of healthy and safe birth practices here in the United States and around the world. Maternal infant health organizations and consumers alike are now aware that we have reached a tipping point.  Our cesarean rate is too high, the availability of VBAC supportive providers is dismal, the rate of inductions, particularly before 39 weeks is cause for concern, labor augmentations are commonplace and infant mortality – particularly amongst babies of color, in our country puts the United States ranking at an embarrassing 56 amongst all the other countries.

The midwifery model of care offers women and babies care by qualified, skilled health care providers who are experts at normal physiologic birth and meeting the needs of healthy, low risk, pregnant women.  The midwifery model of care respects the shared decision making process between the mother and her health care provider, the importance of the mother’s emotional health as well as her physical health and recognizes pregnancy and birth as part of a woman’s normal lifecycle, rather than an illness or pathological condition.  There is respect for the normal physiological process of birth, and the recognition that when things deviate from normal, collaboration and referral to obstetricians and other specialists is appropriate.  When midwives have the opportunity to care for more healthy low risk women, the United States might start to see some of the dismal statistics reverse, and women and babies will benefit from the new trend.

The American College of Nurse Midwives has created a consumer website, Our Moment of Truth, where women can learn more about midwifery, increase awareness and understanding of the different care options available, make informed choices about the type of care they would like to receive and even find a midwife in their area.  There is also a brochure available – “Normal Healthy Childbirth for Women and Families: What You Need to Know” to download in English and Spanish and share with your students and clients. This document and the ACNM program “Our Moment of Truth” was supported and endorsed by Lamaze International along with many other maternal infant health organizations.

The ACNM has a very nice “Essential Facts about Midwives” info sheet that contains some great statistics and information about Certified Nurse Midwives and Certified Midwives.  Midwives can catch babies in hospitals, birth centers and at home and Medicaid reimbursement is mandated for CNMS/CMs in all 50 states.  In 2012, CNMs/CMs attended over 300,000 births in the U.S.  When you add in Certified Professional Midwives/Licensed Midwives who also attend births at birth centers and homes, the number of midwife attended births goes up even further.

ACNM has created a fun video highlighting midwives and the care they provide.  I have also collected of a few of my favorite videos about midwives that you might enjoy viewing and sharing.

Mother of Many from emma lazenby on Vimeo.

What are you doing to celebrate and honor midwives this week?  Do you talk about the midwifery model of care in your childbirth classes and with your doula clients?  What resources do you like using to help your students understand the scope of practice and benefits of working with midwives?  Share with others in our comments below.

Babies, Childbirth Education, Healthy Birth Practices, Home Birth, Midwifery, Newborns , , , , , , ,

Thank You Midwives! Celebrate International Day of the Midwife Today!

May 5th, 2014 by avatar

2014 day of midwife_600pxMay 5th has been recognized as the International Day of the Midwife since 1992. The International Confederation of Midwives (ICM) supports, represents and works to strengthen professional associations of midwives throughout the world.  The purpose of this day is to “celebrate midwifery and to bring awareness of the importance of midwives’ work to as many people as possible.” There are currently 108 Midwives Associations, representing 95 countries across every continent. ICM is organized into four regions: Africa, the Americas, Asia Pacific and Europe. Together these associations represent more than 300,000 midwives globally.

Midwives play a crucial role in maternal and infant health.  This year’s theme is “Midwives: changing the world one family at a time.” There are many key messages that highlight how midwives around the world are helping mothers, babies, families and communities.  Some of these global messages, backed up by research and investigation include:

  • In midwife-led care, women experience less preterm births, less assisted deliveries and greater satisfaction with care.
  • Midwives change the world by caring for mothers and babies. By caring for them, midwives help ensure that women are healthy, thus contributing to a strong community and economy. When babies survive, they start growing into healthy children and adults.
  • If every childbearing woman received care with a well- educated, adequately resourced midwife, most of maternal and newborn deaths could be prevented.
  •  Investments in midwifery education as well as regulation, provision of infrastructure and information will improve access to midwifery care
  •  Midwifery services are economic and cost effective.
  •  Investment in midwives means commitment to a healthy and wealthy nation.

In many countries around the world, access to maternity care is limited by economics, social status, distance and many other factors.  Trained and qualified midwives can have a significant impact on mortality rates for mothers and babies worldwide.  For healthy, low risk women in developed countries, midwifery care is appropriate, cost effective and provides excellent outcomes for mothers and babies.

Are you or your community doing anything special to honor the midwives who work in your area?  Let us know some of the events planned.

Please join  Lamaze International, Science & Sensibility and myself in celebrating the women and men (yes, men are midwives too!) who serve as midwives to our partners, our wives, our sisters, our friends, our daughters and granddaughters all around the world.  Take a moment to thank them for their hard work and the gentle care they provide to birthing women and families.  You may want to send a customized “International Day of the Midwife” ecard to your favorite midwife, and  thank them for their contribution to healthy mothers and babies.  I am going to take a few minutes today to thank the midwives in my community for taking good care of families in my area.

Additionally, as an avid reader of books, I thought in honor of the International Day of the Midwife that I would share some of my favorite books that I have read about midwives.  I would love to hear your suggestions for future reading on this topic, as I enjoy the genre and would welcome your reading suggestions in our comments section.

Baby Catcher: Chronicles of a Modern Midwife by Peggy Vincent

Lady’s Hands, Lion’s Heart: A Midwife’s Saga - by Carol Leonard

The Birth House - by Ami McKay

The Midwife of Hope River – Patricia Harman

The Blue Cotton Gown: A Midwife’s Memoir - Patricia Harman

Arms Wide Open: A Midwife’s Journey – Patricia Harman

A Midwife’s Story  - Penny Armstrong and Sheryl Feldman

Orlean Puckett: Life of a Mountain Midwife - Karen Cecil Smith

Monique and the Mango Rains: Two Years with a Midwife in Mali - Kris Holloway

The  Midwife: A Memoir of Birth, Joy and Hard Times – Jennifer Worth

Call the Midwife: Shadows of the Workhouse – Jennifer Worth

Call the Midwife: Farewell to the East End – Jennifer Worth

A Midwife’s Tale: The Life of Martha Ballard, Based on her Diary, 1785-1812 - by Laura Thatcher Ulrich

Laboring: Stories of a New York City Hospital Midwife  by Ellen Cohen

The Midwife’s Apprentice – by Karen Cushman

Listen to Me Good: The Story of an Alabama Midwife – by Margaret Charles Smith

Babies, Home Birth, Maternal Mortality, Maternal Mortality Rate, Midwifery , , , ,

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

April 17th, 2014 by avatar

 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 , , , , , , , ,

Home Birth In a Risk Society: A Commentary by Sociologist Barbara Katz Rothman

February 4th, 2014 by avatar

By Barbara Katz Rothman, PhD

Today, I am delighted to share with you an essay on risk written by sociologist and author Barbara Katz Rothman, PhD.  There has been much discussion and debate on two papers just published in the Journal of Midwifery and Women’s Health, using the MANA Stats V2.0 data from the Midwives Alliance of North American. You can find these two papers and a research review by Judith Lothian published on January 30th on Science & Sensibility. – Sharon Muza, Community Manager, Science & Sensibility.

We live in what Social Scientists called a ‘Risk Society.”[i] If you simply google “risk and birth,” you get over 402 million ‘hits.’  So no question, birth is understood as  having risks, creating risks, being risky business indeed.  But not the riskiest of businesses – Google “risk and food,” and you get almost twice as many hits – over 746 million. That doesn’t feel right somehow – pregnancy and birth are always and everywhere in our world understood as risky; food not so much.  I nibble some snacks as I write, sip some tea – are you worrying for me? Wishing me luck with that?  Thinking about the odds of food poisoning? Insecticide exposure?  the long term risks of diabetes, joint pain, heart troubles, cancers that might be flowing forth from the snack choices I am making?

image: www.thinknpc.org

image: www.thinknpc.org

 

And what about those snack choices?  Do they not carry much of the same moral weight that pregnancy choices make — if I tell you it’s green tea and carrots, or if I tell you it’s a honey chai latte and multigrain crackers with organic almond butter, or if I tell you it’s a Nestle Iced Tea and Oreo cookies – do I not create different images of myself as a risk-taking or risk-sparing person, even as a more or less ‘good’ and responsible person?  These are of course the arguments that Risk-society thinkers have been addressing: the risks we perceive and the risks we take are judged, by ourselves and by others.

In birth, few choices have been as freighted with the language of risk and responsibility as that of home birth.

The irony here is that birth moved into the hospital with all of the data showing us that move increased risk; and all of the research we have now still shows us that hospitals present unique and particular risks for birth. Birth moved into the hospital long before the era of Risk – that move was done in the era of Science.  The same science that covered our kitchens in white laboratory-style paint and tiles, that replaced local baking with packaged white bread made out of mass-milled white flour, that created industrialized systems to raise cheap meat at whatever costs to health of humans or animals, that moved fruits and vegetables from fresh to canned – that same science that created the industrial diet of the turn of the century, created the industrial birth.

image: sharon muza

image: sharon muza

When I wanted a home birth almost forty years ago, I knew nothing of midwifery. I just assumed that obstetricians had the necessary knowledge and skills to deliver babies (and yes, I called it ‘deliver’) and that those skills could be used in my bedroom as well as in a ‘delivery room.’  Over the course of my scholarly work in the years following, I learned how wrong that was.  Home birth involves a set of skills, practices and competencies that people trained in hospital birth most often never have learned.  Thus the MANA data is not merely a comparison of place: What we are seeing in this data set is a study of midwifery-led care, or as Ronnie Lichtman has called it[ii], midwifery-guided birth, birth in settings where midwives and the women they are guiding have control over practice.

MANA’s data and these articles are showing us that the United States, for all of its problems, is not exceptional:  Fully autonomous, informed midwifery care provides better birth outcomes than does care under Obstetrical management.  Obstetrics and Gynecology is a surgical specialty, magnificently equipped to manage particular illnesses and crises, but neither the discipline nor the hospital settings it has developed for its practice are appropriate for normal, physiologic birth.

Research on women who choose home birth, as well as midwives who provide it, show that their concerns go beyond the risks of what is often called the ‘cascade of interventions’ that follows medical management, leading as it so often does to cesarean section.  In addition to the well-documented iatrogenic risks, they address risks of the hospital itself, what are called when looking at infections, ‘nosocomial’ risks. They were concerned with errors that are made when people are managed in what is essentially a factory-like setting: risks of overcrowding; risks of exposure to others and exposure of self.[iii]

Hospital-industrialized births demand standardized care. Consider something as mundane and yet intrusive as the vaginal exam.  Medical guidelines, the medical story, is that such exams are necessary to determine labor and its stages.  That of course is absurd.  Do you really think that an experienced midwife, someone who has attended hundreds or thousands of births cannot tell if a labor is established without a vaginal exam? What a midwife needs that exam for is to document, not to establish the labor.  Those exams are not only intimate and intrusive, but for women with histories of sexual abuse especially, can be experienced as traumatic.[iv] For all women, raised with ideas of bodily privacy, integrity and what used to be called ‘modesty,’ such exams at a moment of vulnerable transition are problematic. Done for reasons of institutional management and control, they are one more interruption and create risks of their own. Particularly in hospital settings, vaginal exams are one more occasion for the introduction of nosocomial infection.

Managing the management thus becomes necessary in hospital settings: – midwives use the vaginal exam to create the story that will be most in the woman’s best interests, and occasionally in the midwives’ own best interest.  Midwives are thoughtful about when they measure because, for example, they are hesitant to start the clock too early.  In such care, what midwives are trying to minimize is not the risks of a prolonged labor, but the risks of intervening in a labor medically defined as prolonged.

It is reasonable to talk about how recent this language of ‘risk’ is in pregnancy and in birth – but the language of danger, that which we are in risk of, has long been an accepted part of birth.  Calling it “Risk” is adding the numbers – sure there are dangers, but precisely what are the odds? That there are dangers in pregnancy and in birth, and that they can be avoided or overcome, this is not news.  Dangers, disasters even, could happen in the best and healthiest of pregnancies and births.  The difference perhaps is that now there is no such thing as a healthy pregnancy and birth.  There still is an understanding of such a thing as a ‘healthy meal” and even a “healthy diet,’ but no longer, it seems to me, a healthy pregnancy – the best you can hope for is a low risk pregnancy.

It is not that midwives do not have understandings of danger and knowledge about ways to avoid danger, including the dangers of prolonged labors.  That is precisely what midwifery has been throughout time and across place: the development of a body of knowledge and skilled craftsmanship to navigate the dangers of childbirth.  All of that knowledge was discounted with medicalization.

Scientific or ‘Medical’ knowledge is accepted as real and authoritative; other knowledge is reduced to ‘intuition’ or ‘spiritual knowing,’ made all but laughable.   But when a baker adds a bit more flour because the dough is sticky, is that ‘intuition’?  Or is that knowledge based on craft, skill, deep knowledge of the hands?  When a violin-maker rejects a piece of wood in favor of one lying next to it that looks just the same to me or to you, is that ‘intuition’?  Or experience, skill and craft?  And when a leading neurosurgeon examines a dozen stroke patients who all present pretty much the same way on all of their tests and feels hopeful about some and concerned for others, is that ‘intuition’?  Or knowledge based on experience, using a range of senses and information that may not be captured in the tests?

In hospital settings, midwives do not have the authority to use their knowledge fully in the woman’s best interests.  And therein lie the risks.

And finally, it would be helpful to put these risks in contextIf safety were our real concern, if saving the lives of babies and of mothers were the driving force, then there are a number of changes we would make immediately.  We would require helmets for people in cars, something we know would save lives each week.  We would lower the speed limit in urban areas, and end driveway parking in suburbs. To suggest such things makes one look crazy – crazier than suggesting home birth.  But it most assuredly would protect children. If saving babies were our concern, we would invest in public housing, and in the food system.  These are large scale changes that would save far more people than anything that happens in those few hours of late labor to early neonatal period, the 24 or so hours of hospitalization that is now being debated.

Clearly something more or other than saving babies is at stake.

References

[i] Beck, U. (1992). Risk society: Towards a new modernity (Vol. 17). Sage.

[ii] Lichtman, R. (2013). Midwives Don’t Deliver or Catch: A Humble Vocabulary Suggestion. Journal of Midwifery & Women’s Health.

[iii] Katz Rothman, B., (2014) Risk, Pregnancy and Childbirth, Risk, Health and Society, edited by Alaszewski, Intro by Barbara Katz Rothman. Volume 16.1, forthcoming.

[iv]  Adult manifestations of childhood sexual abuse. Committee Opinion No. 498, American College of Obstetricians and Gynecologists. Obstet Gynecol 2011: 118:392-5.

About Barbara Katz Rothman

image: Barbara Katz Rothman

image: Barbara Katz Rothman

Barbara Katz Rothman, PhD, is Professor of Sociology, Public Health, Disability Studies and Women’s Studies at the City University of New York, and on the faculty of the Masters in Health and Society at the Charite in Berlin, the University of Plymouth in the UK, and the International Midwifery Preparation Program at Ryerson University in Toronto Canada. Her books include In Labor: Women and Power in the Birthplace, The Tentative Pregnancy: How Amniocentesis Changes the Experience of Motherhood, Recreating Motherhood, The Book of Life: A Personal and Ethical Guide to Race, Normality and the Human Gene Study,  Weaving A Family: Untangling Race and Adoption and Laboring On: Birth in Transition in the United States.  Dr. Katz Rothman is the proud recipient of an award for “Midwifing the Movement” from the Midwives Alliance of North America.

Cesarean Birth, Childbirth Education, Do No Harm, Evidence Based Medicine, Guest Posts, Home Birth, informed Consent, Maternal Quality Improvement, Maternity Care, Midwifery, New Research , , , , , , , , , ,

Research Review: Outcomes of Care for 16,924 Planned Home Births in the United States

January 30th, 2014 by avatar

Today’s post on Science & Sensibility coincides with the release of a long awaited study looking at the home birth data collected by the Midwives Alliance of North America MANAStats project, 2004-2009.  Judith Lothian, PhD, RN, LCCE, FACCE reviews the research that examines outcomes of almost 17,000 planned home births in the United States.  To date, this is the largest dataset of planned home births available. Dr. Lothian takes a look at what the research found and helps S&S readers to understand the key points of the published paper.  - Sharon Muza, Community Manager, Science & Sensibility.

The American College of Nursing today announced the publication in the Journal of Midwifery and

http://www.flickr.com/photos/wickenden/

http://www.flickr.com/photos/wickenden/

Women’s Health of important new US research on the outcomes of home birth: Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009“. This research is important for two reasons: it adds to the increasing body of research that supports the safety of home birth for healthy women in the US, and it demonstrates the value and importance of the National Data Registry for Midwife-Led Birth, the Midwives Alliance of North America (MANA) Statistics Project 2.0 dataset(2). This is the first publication of home birth outcomes research in the US since 2005, nearly a decade. Just as importantly, it is the first major research study published using the MANA dataset.

Studying planned home birth presents unusual challenges. A randomized control trial is not possible because women are not willing to consent to randomization to home or hospital. Unlike other countries, data in the US are collected state by state and most birth certificates (the most common, although often unreliable, way to collect birth data) do not collect information about planned home birth. As a result, unlike in countries like the Netherlands, population based research is not possible. There is a need in the US for a system for universal maternity care data collection.  In response to this need, and the need for high quality data on midwifery outcomes, MANA in 2004 began the momentous work of developing a national data registry for midwife-led birth. The result is the National Data Registry for Midwife-Led Births, the Midwives Alliance of North America (MANA) Statistics Project 2.0 dataset.  A companion article in the same issue of the Journal of Midwifery and Women’s Health is available to read more about the development and validations of the National Registry for Midwife-Led Births.

About the study

For this study, data were collected from 2004-2009 using the MANA Stats 2.0 Web-based tool. Midwifery participation was voluntary. Data were contributed by 432 different midwives: 20 to 30 percent of all active Certified Professional Midwives (CPMs) and a much lower percentage of active Certified Nurse Midwives (CNMs) contributed to the dataset. Other types of midwives who also participated included Licensed Midwives (LMs), Licensed Direct Entry Midwives (LDMs), Certified Midwives (CMs), and a small percentage of unlicensed direct entry midwives. The midwives obtained written informed consent from the women at the onset of care to contribute data, including outcomes, to the registry. It’s important to note that women were entered into the registry by the midwives at the onset of care before outcomes were available. More than 95% of the women cared for by the midwives who participated in the registry provided consent. The sample for the study included all women who intended to give birth at home at the time they went into labor. The final sample of women was 16,924.

http://www.flickr.com/photos/eyeliam/

http://www.flickr.com/photos/eyeliam/

The women were mostly white, married, and college educated. Almost 2/3 of the woman paid for midwifery services out of pocket. The sample came largely from the Western United States.  Almost 78% of the women had previous babies (8% having had a previous cesarean) and a just over 22% were expecting their first babies. Some, but very few, of the women in the sample had complications or co-morbidities (for example, 1.3 % breech, 0.4% multiple gestation, 1.4% pregnancy induced hypertension, 0.8% gestational diabetes).

What follows is a snapshot of some of the most important findings of the study. The authors go into great detail presenting and discussing the findings and then comparing their findings to previous published studies of planned home birth. I encourage you to read the full article.

Study results

Almost 94% of the women had spontaneous vaginal births. There was a 5.2% cesarean rate and an 87% VBAC rate. Only 4.5% of the sample required oxytocin augmentation and/or epidural. Ninety two percent of the births were full term, 2.5% were pre-term and 5.1% were post-term. Less than 1% of the babies were low birth weight. There was an intrapartum transfer rate of 10.9%. Women giving birth for the first time were three times more likely to transfer during labor, most often for failure to progress. Postpartum transfers were 1.7% for women who gave birth at home. The most common reason (over 70%) was for complications related to hemorrhage and/or retained placenta. Neonatal transfer was 1.0% with the most common reason being respiratory distress or low Apgar.

In this sample, the rate of postpartum hemorrhage (defined as over 500cc in a vaginal birth and 1000 cc in a cesarean) was 15.4%, higher than previous research has reported. That said, the transfers for excessive bleeding were low. Active management of third stage is infrequent in this sample. The authors posit that without intravenous oxytocin administration, the 500cc benchmark for diagnosing hemorrhage may not be appropriate in this physiologic birth population.

The intrapartum neonatal death rate was 1.3 per 1000, consistent with rates reported in some studies, but higher than the rates reported in others. While the rate is still relatively low, it might, the authors suggest, be partially explained by a sample that included women who are at higher risk for adverse outcomes (multiple gestations, breech presentations, VBAC, gestational diabetes or pre-eclampsia). When these women were removed from the sample, the intrapartum death rate drops to 0.85 per 1000, a rate that is statistically congruent with rates reported in most studies, with the exception of large population studies in the Netherlands that report somewhat lower rates.(deJonge et al, 2009). The authors also note that the lack of an integrated system and possible delays in transfer may contribute to the small but somewhat higher rate of intrapartum neonatal death in the sample.

There was one maternal death in the study, as a result of a blood clot in the heart at three days postpartum after an uncomplicated pregnancy, labor, birth and postpartum.

Discussion

As in any research there are limitations. This is not a population based study. Not all midwives in the US contributed data to the registry. The births took place mostly in the Western United States. The women were largely white, college educated and married. Nonetheless, the findings make a major contribution to the literature on planned home birth supporting the findings of previous research conducted both in the US and in Canada, the Netherlands, and the United Kingdom (Johnson & Daviss, 2005; Janssen et al 2009; Hutton et al, 2009; Janssen et al, 2002; deJonge et al, 2009; Birthplace in England, 2011).

In spite of the meticulous development and validation of the dataset and the acknowledged limitations of the data, I suspect the usual naysayers will question the validity and the usefulness of the dataset. I suspect those opposed to planned home birth will exaggerate the implications of findings related, for example, to maternal bleeding in spite of the fact that almost no mothers required transfer or intervention, and point out the higher intrapartum neonatal mortality numbers than other studies have reported without discussing the fact that the increase is largely accounted for by infants of women at higher risk for adverse outcomes (pre-eclampsia, gestational diabetes, multiple gestation, VBAC,  breech). It is difficult for anyone to dismiss the importance of the overall excellent outcomes for both mothers and babies.

The excellent outcomes in this study, (with care provided mostly by CPMs & LMs, in a country that does not have integrated systems of care including seamless transfer and collaboration between providers, and with a sample that included women who are usually considered at higher risk for planned home birth {breech, VBAC, multiple gestations, pre-eclampsia, gestational diabetes}), should make us pause. Could it be that even for women with some risk factors, planned home birth could be as safe as hospital birth?  What would the outcomes be if we had an integrated system of care?

Personal “Take Aways”

  • The MANA dataset is an extremely valuable resource for researchers. Thanks to the work of MANA, the dedicated midwives who participate in the registry, and the women who consent to having their outcomes registered, we have further evidence, this time in the US, that planned home birth reduces interventions including cesarean, and has outcomes similar or better than planned hospital births. CPMs, CMs and LDMs, who are the largest group of midwives contributing to the dataset, deserve recognition and respect. The positive outcomes reflect the excellence of care that they provide for women. With the publication of this important study, and the publication of the companion article describing the development and validation of the dataset, hopefully, many more midwives, including CNMs and those who practice in other parts of the country, will be persuaded to contribute to the registry.
  •  I encourage you to share the findings of this study with the women you teach, talk to and touch. Most women will not choose home birth but knowing that women today give birth safely at home without routine interventions or tied to machines, and subjected to the ticking clock, should give all women a boost of confidence in their ability to give birth. And, it just might encourage some women to think about having a planned home birth.
  • We might think of a childbirth education registry. We have wanted high quality data for decades to track the outcomes of childbirth education. Perhaps this is a way to collect quality data?

Conclusion

This is a landmark study of US home birth. Hats off to MANA for its ground breaking contribution in collecting and providing data that will further advance our knowledge of planned home birth and midwifery.  Hats off to the dedicated midwives who contributed their outcomes to the dataset, and to the women who were so willing to share their information with the world. And, hats off to the dedicated researchers, Melissa Cheyney, Marit Bovbjerg, Courtney Everson, Wendy Gordon, Darcy Hannibal and Saraswathi Vedam who continue to contribute in groundbreaking ways to promoting and supporting normal, physiologic birth and the health and safety of childbearing women and babies.

 References

Birthplace in England Collaborative Group. (2011). Perinatal and Maternal Outcomes by Planned Place of Birth for Healthy Women with Low Risk Pregnancies: The Birthplace in England National Prospective Cohort Study, British Medical Journal 343, d7400.

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 and Women’s Health.

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D. & Vedam, S. (2014). Development and Validation of a National Data Registry for Midwife-Led Births: The Midwives Alliance of North America Statistics Project 2.0 Dataset. Journal of Midwifery and Women’s Health.

de Jonge,  B. van der Goes,  A. Ravelli, M. Amelink-Verburg , et al.(2009). Perinatal Mortality and Morbidity in a Nationwide Cohort of 529,688 Low-risk Planned Home and Hospital Births. British Journal of Obstetrics and Gynecology 16, no. 9, 1177-84.

Hutton, E.,  Reitsma, A., 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, no. 3, 180-89.

Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee Sk. (2009). Outcomes of Planned Home Births with Registered Midwife versus Attended by Regulated Midwives versus Planned hospital Birth in British Columbia. Canadian Medical Association Journal 181, no. 6, 377-83.

Janssen, P. Lee,S.,  Rya,E,  et al. (2002). Outcomes of Planned Home Births versus Planned Hospital Births after Regulation of Midwifery in British Columbia. 166, no. 3, 315-23.

Johnson, K. & Davis, B.A. (2005). Outcomes of Planned Home Brth with Certified Professional Midwives: A Large Prospective Study in North America. British Medical Journal 330, 1416-19.

About Judith Lothian

@ Judith Lothian

@ Judith Lothian

Judith Lothian, PhD, RN, LCCE, FACCE is a nurse and childbirth educator. She is an Associate Professor at the College of Nursing, Seton Hall University and the current Chairperson of the Lamaze Certification Council Governing Body. Judith is also the Associate Editor of the Journal of Perinatal Education and writes a regular column for the journal. Judith is the co-author of The Official Lamaze Guide: Giving Birth with Confidence. Her research focus is planned home birth and her most recent publication is Being Safe: Making the Decision to Have a Planned Home Birth in the US published in the Journal of Clinical Ethics (Fall 2013 ).

 

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