Posts Tagged ‘Home Birth’

Planned Home VBAC in the United States, 2004–2009: Outcomes, Maternity Care Practices, and Implications for Shared Decision Making – Interview with Study Author Melissa Cheyney, PhD, CPM, LDM

September 15th, 2015 by avatar


“Planned Home VBAC in the United States, 2004–2009: Outcomes, Maternity Care Practices, and Implications for Shared Decision Making” came out on August 26th as an e-pub ahead of print in the journal Birth: Issues in Perinatal Care. It provides a much-needed analysis of VBACs in the home setting in the United States. To help the birth professional community better communicate the findings with students, clients and others considering home birth after cesarean (HBAC), Jeanette McCulloch of BirthSwell interviewed Melissa “Missy” Cheyney, PhD, CPM, LDM, one of the paper’s authors. The abstract of the paper, lead-authored by Kim Cox, CNM, PhD and co-authored by Marit Bovbjerg PhD, MS and Lawrence M. Leeman MD, MPH, can be found in an online-only version here. Additional insights specifically for midwives can be found at the MANA blog. – Sharon Muza, Community Manager, Science & Sensibility

Jeanette McCulloch: Tell me about the new study looking at outcomes for families planning a trial of labor after cesarean (TOLAC) at home.

Melissa Cheyney: This study is significant because it is the largest study to date on outcomes for women and babies who attempt a TOLAC at home in the United States. We were able to create two subsamples from the MANA Stats 2.0 data set: 12,092 multiparous women without a prior cesarean and 1,052 women with a prior cesarean. This enabled us to compare outcomes for women who went into labor intending to deliver at home and had a previously scarred uterus with those who did not. Our goal was to provide whatever information we could (given our sample size) about the potential risks and benefits of attempting a VBAC at home.

JMc: The actual number of people who are planning TOLACs is relatively small. Why did you think this research was important?

MC: We know that as long as the primary cesarean section rate in the US remains above 20% (it’s currently 21.5%), and as long as many women continue to desire more than one baby, families will be faced with important decisions about what to do in subsequent deliveries. Because there are well-known risks to repeat cesareans as well as to a trial of labor after cesarean, we wanted to make sure that we could provide women who are considering a VBAC (and especially a VBAC outside of the hospital) with as much information as possible to support shared decision making.

JMc: What were the top findings of the study?

MC: First off, we found relatively high success rates. Overall, women with a prior cesarean had a VBAC success rate of 87%. Most of these were HBACs. While some women who who transferred to the hospital during labor went on to have a VBAC in the hospital, most had cesareans for “failure to progress.” Women who had also had a previous vaginal birth had a success rate of 90.2%, and those who had a previous VBAC had an even higher rate of success at 95.6%. These rates are among the highest reported in the literature across places of delivery and provider types.

We also found that women who had a previous cesarean were more likely to need to transfer care to the hospital in the intrapartum period than were women without a previous cesarean. So the transfer rate for women who were attempting a VBAC at home was 21.7% compared to 8.5% for multiparous women who did not have a previously scarred uterus.

We also found that, for those women who transferred, the most common reason that they transferred was a slow, non-progressive labor and not a uterine rupture or anything emergent. We also were able to calculate a combined intrapartum and neonatal mortality rate in the group that had a prior cesarean, and that was 4.75 out of 1000 compared with a rate of 1.24 out of 1000 in multiparous women without a history of cesarean. This is a highly statistically significant difference, and means that we know there is some elevated risk for women who’ve had a prior cesarean relative to a woman who’s already had a baby and who has no scarring of the uterus.

JMc: You had some interesting findings that suggest that not all TOLACs have the same outcomes. Tell us about that.

MC: We also performed some sub-group analyses where we compared women who were having a trial of labor after cesarean with other groups. We compared them to first-time mothers and to women who had a previous vaginal birth and a cesarean and were now attempting a VBAC after a cesarean. We were able to get pretty nuanced findings about relative risk within the TOLAC group.

In other words, we found that there is variation in risk within the TOLAC subsamples. So, just to say that VBAC is dangerous or that TOLAC at home has a high success rate doesn’t really give the full picture. You can break down this group, look at it much more closely, and get a better sense of how to talk with clients about the risks of TOLAC at home under their specific circumstances. Just as success rates vary by obstetric history, so do risks associated with VBAC. Our study is certainly the first study to do that for a large sample of planned HBACs

JMc: What advice do you give to families that may be considering HBAC in your practice?



MC: I say that it’s important to look at success rates, but that it is also important to think about the likelihood of an intrapartum transfer, distance from the hospital, and a variety of other factors that are unique to each person. I actually think that looking at the cases that did not have good outcomes can be very informative. They help us to see who might be a reasonable candidate for an HBAC and who might not be. For example, in our dataset there were five deaths overall—three during labor or in what we call the intrapartum period, one that was early neonatal (or the first 7 days of life), and one that was late neonatal (out to 28 days after birth). Those all occurred in the TOLAC group, yielding death rates of 2.85 for intrapartum, .95 for early neonatal, and .95 for late neonatal. So for the combined intrapartum and neonatal mortality rate, the total is 4.75 out of 1000.

When we look at these cases more closely, we see that two of the cases were very likely uterine ruptures, based on the heart tone patterns that the midwife was able to distinguish at home. The three other ones were deaths that were totally unrelated to the TOLAC status of the mother. One involved known risk factors related to giving birth to a twin, the second one was a surprise breech with an entrapped head, and the third one was a cord prolapse. So three of the five deaths likely had nothing to do with the fact that the mother had had a previous cesarean.

JMc: It’s surprising to see mothers with this kind of risk profile delivering at home. Can you help us understand why you think a mother, for instance, one that is attempting a twin VBAC birth at home, might choose that?

MC: In these kinds of cases, you have to ask this: if you have someone who has a cesarean for her first birth and she gets pregnant subsequently, what happens to her if she has twins in her second pregnancy? Who is going to offer her a TOLAC? What if she happens to be breech at term in the pregnancy following an unplanned and often unwanted cesarean? These women, who have a compounding of risk, have no chance, very likely, of finding a provider in the hospital who’s going to support these births. So, it might seem odd that out of only 1000 VBACs, you’d have this scenario. But it does make sense, if you think about the fact that these women might be the most likely to be excluded from a trial of labor in the hospital. This actually kind of fits with something else we found.

Regions of the US that have low rates of VBAC access in the hospital, the southeast, for example, have a higher percentage of the total births contributed to MANA Stats that are VBACs. When you look on the west coast, in states like Oregon, Washington, and California, where VBACs are more readily available in the hospital, even though there are more contributors and more data coming from the west coast, the total proportion of births that are VBACs is significantly lower in our data set. We take that to mean that when women have the option to try VBAC in the hospital, there is less pressure to attend those women at home. In a state where you have very limited access to hospital VBAC, those midwives are more commonly approached by women who are feeling forced to explore the option of a home birth for a VBAC because they can’t acquire one in their local hospital. That is both concerning and a reminder that even though we often discuss the US maternity care system as less well integrated than, say, the Netherlands, nonetheless, the various models and options for birthing care in this country do impact each other. We should all be working together to make birth safer for all women.

JMc: How do you think these findings should influence families that are considering a trial of labor after cesarean at home? What advice do you have for them?

MC: I think these findings have ramifications for everyone who’s considering a home birth, not just women who are considering a home birth after a cesarean, because one of the most interesting things that we’ve found is that that risk within our sample varies considerably by obstetric history and parity. What I mean by that is that a woman who does not have a previously scarred uterus, and she’s already had a baby vaginally, her risk is incredibly low. It is difficult to find a negative outcome in that group.

The next safest group to be delivering at home is actually women who have had a cesarean, but have also had a vaginal birth. They are less risky than first time mothers as a group. Then the highest risk, along the VBAC status and parity continuum, is a woman who has never had a vaginal birth, but has had a cesarean.

So, the range of risk goes from the lowest risk: a multiparous woman (multip); to a multip with a cesarean and a previous vaginal birth; to a nulliparous woman: and then to a woman who has never had a vaginal birth but has had a previous cesarean. Both deaths from suspected uterine rupture occurred in this later group. Each mother had had only one prior cesarean. That’s a really important thing to keep in mind, and I think that’s where our policy implications lie as well. States that want to restrict all HBACs need to be looking much more closely at the research, especially if some of this work is replicable with larger samples, because there is a nuancing of risk within subgroup. It may not make sense, for example, to allow nulliparous births at home but restrict all VBAC mothers with any prior cesarean history, regardless of the fact that they may have had a previous vaginal birth or a prior VBAC. These women who live within an appropriate distance to a hospital, have well documented placenta positions and adequate time between births may actually be lower risk than a first time mother.

JMc: What advice do you have for policy makers who might be considering HBAC regulations in their state?

MC: Over the course of my career, I’ve seen the data on home and birth center safety, patient selection, ethics, the benefits of normal physiologic birth — so multiple components of midwifery care and birth outside of the hospital — grow so quickly. I recommend setting the scope of practice for midwives in rule (sometimes called regulations or administrative laws) rather than statute. In many states, it is very difficult to get a statute changed, whereas it is often much easier to open your rules or regulations over a period of every few years, for example, to examine new research and make sure that you are writing rules/regulations that support evidence-based practice for midwives. It is an exciting time to be working on some of these questions. Data from registries like MANA Stats and the American Association of Birth Centers’ Perinatal Data Registry should enable us to engage in critical, ongoing quality assurance and quality improvement at national, state and individual practice levels. I think we need to find ways of regulating home birth that stay open, flexible and responsive to the data, to the needs of the families we serve, and to the guidance of medical ethicists who are equipped to help us sort through difficult questions related to choice, individual autonomy and relative risk.

About Melissa Cheyney and Jeanette McCulloch

Melissa Cheyney head shot 2015Melissa Cheyney, PhD CPM LDM is Associate Professor of Clinical Medical Anthropology at Oregon State University (OSU) with additional appointments in Public Health and Women’s Studies. She is also a Certified Professional Midwife in active practice, and the Chair of the Division of Research for the Midwives Alliance of North America where she directs the MANA Statistics Project. She is the author of an ethnography entitled Born at Home (2010, Wadsworth Press) along with several, peer-reviewed articles that examine the cultural beliefs and clinical outcomes associated with midwife-led birth at home. Dr. Cheyney is an award-winning teacher and was recently given Oregon State University’s prestigious Scholarship Impact Award for her work in the International Reproductive Health Laboratory and with the MANA Statistics Project. She is the mother of a daughter born at home on International Day of the Midwife in 2009.

Jeanette McCulloch head shot 2015Jeanette McCulloch, BA, IBCLC has been combining strategic communications and women’s health advocacy for more than 20 years.  Jeanette is a co-founder of BirthSwell, helping birth and breastfeeding organizations, professionals, and advocates use digital tools and social media strategy to improve infant and maternal health. She provides strategic communications consulting for state, national, and international birth and breastfeeding organizations. A board member of Citizens for Midwifery, she is passionate about consumers being actively involved in health care policy.


Babies, Cesarean Birth, Guest Posts, Home Birth, informed Consent, Maternity Care, Midwifery, New Research, Newborns, Research, Vaginal Birth After Cesarean (VBAC) , , , , , , , , , , ,

Looking Back in Time: What Women’s Bodies are Telling Us about Modern Maternity Care

June 18th, 2015 by avatar

By Christina Gebel, MPH, LCCE, Birth Doula

Christina Gebel, MPH, LCCE, Doula writes a reflective post examining current birthing conditions to see how today’s practices might be interfering with the the normal hormonal physiology and consequently impacting women’s ability to give birth.  Times have certainly changed and birth has moved from the home to the hospital.  A slow but steady increase in out of hospital births is examined and Christina asks us to consider why women are increasingly choosing to birth outside the hospital – and what do hormones have to do with it? – Sharon Muza, Science & Sensibility Community Manager

“Pregnancy is not a disease, but a beautiful office of nature.” These are the words of Victoria Woodhull, the first female candidate for President of the United States in 1872.

Lajja_gauri ancient birth art

© “Lajja gauri

The world in which pregnant women find themselves today looks a lot different than the time of Woodhull’s campaign run. For instance, hospitals didn’t become the mainstream setting for labor and delivery until the 1930s and 40s. While modern medicine has undoubtedly helped millions of women who may have otherwise died in childbirth, mothers and birth advocates across the nation are beginning to ask if we are paying a price for today’s standard maternity care. With increasing protocols and interventions, pregnancy is viewed less like the office of nature Woodhull spoke of and more like a pathological condition.

The Hormonal Physiology of Childbearing, a recent report by Sarah Buckley, systematically reviews existing research about the impact that common maternity practices may have on innate hormonal physiology in women and fetuses/newborns. The report finds strong evidence to suggest that our maternity care interventions may disturb these processes, reduce their benefits, or even create new challenges. To find out more, read an interview that Science & Sensibility did with Dr. Buckley when her groundbreaking report was released.

Let’s examine something as simple as the environment that a woman gives birth in. In prehistoric times, laboring women faced immediate threats and dangers. They possessed the typical mammalian “fight-or-flight” reaction to these stressors. The hormones epinephrine and norepinephrine caused blood to be diverted away from the baby and uterus to the heart, lungs, and muscles of the mother so that she could flee. This elevation in stress hormones also stalled labor, to give the mother more time to escape. Essentially, she told her body ‘this place is not safe,’ and her body responded appropriately by stopping the labor to protect the mother and her child during a very vulnerable time.

Today, mothers are not fleeing wild animals but rather giving birth in hospitals, the setting for nearly 99% of today’s births, where this innate response may cause their labor to stall. The sometimes frenetic environment or numerous brief encounters with unfamiliar faces may trigger a sense of unease and, consequently, the fight-or-flight response, stalling the mother’s labor. Prolonged labor in a hospital invariably leads to concern and a need to intervene, often by the administration of Pitocin, synthetic oxytocin, to facilitate regular contractions. Arrested labor could lead to further interventions up to and including a cesarean section. The fight-or-flight response may be further reinforced by these interventions, as they potentially come one after the other, in what is often referred to as the “cascade of interventions.”

This is just one example of how a woman’s body’s natural physiology can go from purposeful to working against the labor, the mother and the baby. Epinephrine and norepinephrine are both necessary in labor and delivery. In fact, at appropriate levels, these hormones support vital processes protecting the infant from hypoxia and facilitating neonatal transitions such as optimal breathing, temperature, and glucose regulation, all markers for a healthy infant at birth.

Recent data show that mothers themselves may already think what the Hormonal Physiology of Childbearing report suggests. The series of Listening to Mothers (LtM) studies, a nationally-representative survey of childbearing women, shows a shift in mothers’ attitudes towards normal physiologic birth: In 2012, 58% of mothers agreed somewhat or strongly that giving birth is a process that should not be interfered with unless medically necessary, up from 45% in 2000. According to 2013 national birth data, out-of-hospital (home and birth center) births have increased 55% since 2004, but the overall percentage is still only 1.35% of all births nationwide. While low, this shows that a small core of mothers are voting with their feet and choosing to give birth out of the hospital. Though their choice may seem extreme, they’re not alone. In the LtM data, which only surveys women who have given birth in a US hospital, 29% of mothers said they would definitely want or would consider giving birth at home for a future birth, and 64% said the same of a birth center. All this raises the question: What’s happening in a hospital that is leading mothers to consider other settings for their next birth?

One answer to upholding women’s preferences, autonomy, and the value of normal physiologic birth is a mother’s involvement in shared decision making with her provider, along with increasing access to models of care that support innate physiologic childbearing, like midwives in birth centers. Increasing access to these options may present a challenge, as demand seems to outweigh availability.

Leslie Ludka (MSN, CNM) has been the Director of the Cambridge Health Alliance Birth Center (Cambridge, Mass.) as well as the Director of Midwifery since 2008. Like other birth centers, the center has seen a steady increase in demand each year, with patients coming from all over New England. Ludka sees many barriers to having more birth centers available including finances (the reimbursement for birth not being comparable to an in-hospital birth), “vacuums in institutional comprehension” of the advantages of the birth center model for low-risk women, and the rigorous process to be nationally certified by the Commission for the Accreditation of Birth Centers (CABC), requiring “a great commitment and a lot of support by all involved.” In order to overcome these barriers, Ludka suggests marketing the safety of birth centers to the general public, sharing outcome statistics for women and infants cared for in birth centers, and educating insurers and providers about the overall benefits and financial savings of midwifery and the birth center model. With supportive policy and better understanding on the part of insurers, the public, and healthcare institutions, models like the birth center could become more plentiful, more easily meeting the demand.

Women’s bodies are sending subtle messages that our current healthcare system is, at times, not serving their needs. It’s time to respond to these messages, beginning by viewing childbirth foundationally as a life event and not first as pathology, and adapting our models of care to speak to this viewpoint. If we fail to do so, we run the risk of creating excess risk for women and newborns.

It’s been 143 years since Woodhull ran for president. We’ve made progress in getting much closer to seeing our first woman president, but with childbirth, perhaps our progress now starts with looking back in time.

About Christina Gebel

© Christina Gebel

© Christina Gebel

Christina Gebel holds a Master of Public Health in Maternal and Child Health from the Boston University School of Public Health. She is a birth doula and Certified Lamaze Childbirth Educator as well as a freelance writer, editor, and photographer. She currently resides in Boston working in public health research. You can follow her on Twitter: @ChristinaGebel and contact her through her website duallovedoula.com

Childbirth Education, Guest Posts, Home Birth, Maternity Care, Medical Interventions, Midwifery , , , ,

Henci Goer – Fact Checking the New York Times Home Birth Debate

February 26th, 2015 by avatar
home birth

© HoboMama

An article in The New York Times Opinion Pages – Room for Debate was released on February 24th, 2015.  As customary in this style of article, the NYT asks a variety of experts to provide essays on the topic at hand, in this case, the safety of home birth. Henci Goer, author and international speaker on maternity care, and an occasional contributor to our blog, takes a look at the facts on home birth and evaluates how they line up with some of the essay statements. Read Henci’s analysis below.  – Sharon Muza, Science & Sensibility Community Manager

As one would predict, three of the four obstetricians participating in the NY Times debate “Is Home Birth Ever a Safe Choice?“assert that home birth is unacceptably risky. Equally predictably, the evidentiary support for their position is less than compelling.

John Jennings, MD president of the American Congress of Obstetricians & Gynecologists, in his response- “Emergency Care Can Be Too Urgently Needed,” cites a 2010 meta-analysis by Wax and colleagues that has been thoroughly debunked. Here is but one of the many commentaries, Meta-Analysis: The Wrong Tool Wielded Improperly, pointing out its weaknesses. In a nutshell, the meta-analysis includes studies in its newborn mortality calculation that were not confined to low-risk women having planned home births with a qualified home birth attendant while omitting a well-conducted Dutch home birth study that dwarfed the others in size and reported equivalent newborn death rates in low-risk women beginning labor at home and similar women laboring in the hospital (de Jonge 2009).

The other naysayers, Grunebaum and Chervenak, in their response – “Home Birth Is Not Safe“, source their support to an earlier NY Times blog post that, in turn, cites a study conducted by the two commentators (and others) (Grunebaum 2014). Their study uses U.S. birth certificate data from 2006 to 2009 to compare newborn mortality (day 1 to day 28) rates at home births attended by a midwife, regardless of qualifications, with births attended by a hospital-based midwife, who almost certainly would be a certified nurse midwife (CNM) in babies free of congenital anomalies, weighing 2500 g or more, and who had reached 37 weeks gestation. The newborn mortality rate with home birth midwives was 126 per 10,000 versus 32 per 10,000 among the hospital midwives, nearly a 4-fold difference. However, as an American College of Nurse-Midwives commentary on the abstract for the Society for Maternal-Fetal Medicine presentation that preceded the study’s publication observed, vital statistics data aren’t reliably accurate, don’t permit confident determination of intended place of birth, and don’t follow transfers of care during labor.

As it happens, we have a study that is accurate and allows us to do both those things. The Midwives Alliance of North America study reports on almost 17,000 planned home births taking place between 2004 and 2009 (Cheyney 2014b), and therefore overlapping Grunebaum and Chervenak’s analysis, in which all but 1000 births (6%) were attended by certified or licensed home birth midwives. According to the MANA stats, the newborn death rate in women who had never had a cesarean and who were carrying one, head-down baby, free of lethal congenital anomalies was 53 per 10,000, NOT 126 per 10,000. This is less than half the rate in the Grunebaum and Chervenak analysis. (As a side note, let me forestall a critique of the MANA study, which is that midwives simply don’t submit births with bad outcomes to the MANA database. In point of fact, midwives register women in the database in pregnancy [Cheyney 2014a], before, obviously, labor outcome could be known. Once enrolled, data are logged throughout pregnancy, labor and birth, and the postpartum, so once in the system, women can’t fall off the radar screen.)

We’re not done. Grunebaum and Chervenak’s analysis suffers from another glaring flaw as well. Using hospital based midwives as the comparison group would seem to make sense at first glance, but unlike the MANA stats, which recorded outcomes regardless of where women ultimately gave birth or who attended them, hospital-based midwives would transfer care to an obstetrician when complications arose. This would remove labors at higher risk of newborn death from their statistics because the obstetrician would be listed on the birth certificate as the attendant, not the midwife. For this reason, the hospital midwife rate of 32 per 10,000 is almost certainly artificially low. So Grunebaum and Chervenak’s difference of 94 per 10,000 has become 21 per 10,000 at most and probably much less than that, a difference that I’d be willing to bet isn’t statistically significant, meaning unlikely to be due to chance. On the other hand, studies consistently find that, even attended by midwives, several more low-risk women per 100 will end up with cesarean surgery—more if they’re first-time mothers—then compared with women planning home births (Romano, 2012).

Hopefully, I’ve helped to provide a defense for those who may find themselves under attack as a result of the NY Times article. I’m not sanguine, though. As can be seen by Jennings, Grunebaum, and Chervenak, people against home birth often fall into the category of “My mind is made up; don’t confuse me with the facts.”

photo source: creative commons licensed (BY-NC-SA) flickr photo by HoboMama: http://flickr.com/photos/44068064@N04/8586579077


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. J Midwifery Womens Health, 59(1), 8-16. doi: 10.1111/jmwh.12165 http://www.ncbi.nlm.nih.gov/pubmed/24479670

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. (2014b). Outcomes of care for 16,924 planned home births in the United States: the midwives alliance of north america statistics project, 2004 to 2009. J Midwifery Womens Health, 59(1), 17-27. doi: 10.1111/jmwh.12172 http://www.ncbi.nlm.nih.gov/pubmed/24479690

de Jonge, A., van der Goes, B. Y., Ravelli, A. C., Amelink-Verburg, M. P., Mol, B. W., Nijhuis, J. G., . . . 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), 1177-1184. http://www.ncbi.nlm.nih.gov/pubmed?term=1177%5Bpage%5D+AND+2009%5Bpdat%5D+AND+de+jonge%5Bauthor%5D&cmd=detailssearch

Grunebaum, A., McCullough, L. B., Sapra, K. J., Brent, R. L., Levene, M. I., Arabin, B., & Chervenak, F. A. (2014). Early and total neonatal mortality in relation to birth setting in the United States, 2006-2009. Am J Obstet Gynecol, 211(4), 390 e391-397. doi: 10.1016/j.ajog.2014.03.047 http://www.ajog.org/article/S0002-9378(14)00275-0/abstract

Romano, A. (2012). The place of birth: home births. In Goer H. & Romano A. (Eds.), Optimal Care in Childbirth: The Case for a Physiologic Approach. Seattle, WA: Classic Day Publishing.

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.e241-e248. http://www.ajog.org/article/S0002-9378%2810%2900671-X/abstract

About Henci Goer

Henci Goer

Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach She is the winner of the American College of Nurse-Midwives “Best Book of the Year” award. An independent scholar, she is an acknowledged expert on evidence-based maternity care.  



Babies, Evidence Based Medicine, Guest Posts, Home Birth, Maternal Quality Improvement, Maternity Care, Midwifery , , , , ,

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 , , , , , , ,

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/

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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.


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 , , , , , , , ,

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