Transcript of "Iom birth settings_provider_perspectives_b_potter_final "
Institute of Medicine Workshop:Research Issues in the Assessment of Birth Settings Brynne Potter, CPM Provider Perspectives: Midwives and Home Birth March 7, 2013
Disclosure CEO and FounderEHR and HIT Platform for Maternity Care
Home Birth in the US❖ Polarized❖ Marginalized❖ Disruptive❖ Racialized❖ Politicized
Wax Analysis: (mis)conclusions❖ Discrepancies in sample size and inclusion criteria for neonatal and perinatal death rates❖ Causation of low morbidity/intervention in home birth erroneously linked to mortality❖ Questionable cohort for neonatal death drives widely inﬂuential ACOG published opinion “In an era of evidence-based medicine, it is incomprehensible that medical society opinion can be formulated on research that does not hold to the most basic standards of methodological rigor.” -Michal, Janssen, Vedam, Hutton, deJongePlanned Home vs Hospital Birth: A Meta-Analysis Gone Wrong; 2011 Carl A. Michal, PhD; Patricia A. Janssen, PhD; Saraswathi Vedam, SciD; Eileen K. Hutton, PhD; Ank de Jonge, PhD,
Why do women choose home birth? ❖ Safety"" " " ❖ Control of environment & process of care ❖ Privacy ❖ Cultural Congruency ❖ Comfort and Convenience" ❖ Spiritual Accommodation ❖ Self-Determination"" ❖ Low Intervention" " ❖ Family Involvement ❖ Relaxed and peaceful (Jackson 2012, Blix 2011, Symon 2010, Lindgren 2010, Hendrix 2010, Boucher 2009, Janssen 2006, Hildingsson 2010, 2003,)
Why do women choose home birth?“Comfortable setting, we can make decisionswithout pressure $om staﬀ ” — 1st baby born in hospital“I want to feel safe and comfortable. I haveconﬁdence in myself to have a natural birth. I likethe one on one attention I wi& receive using amidwife. —1st born in a birth centerI think that I wi& be able to relax in a home settingand not feel pressured by time constraints” — Expecting 1st baby
Home Birth Safety Olsen and Clausen, Cochrane 2012❖ Conclusions:❖ Only one trial (n=11) met rigorous criteria, “From an autonomy-based ethical but quality of observational studies greatly increased perspective the only justiﬁcation for practices❖ “..there is no strong evidence to favor that restrict a woman’s autonomy either planned hospital or planned home and her $eedom of choice, would be clear birth for selected, low risk pregnant women” evidence that these restrictive practices do more good than harm❖ Recommend all countries facilitate — Enkin (1995), Olsen (1998, 2012) evidence-based integration of home birth services for low-risk women Olsen, Clausen, (2012 Cochrane Collaborative Review) Planned hospital birth versus planned home birth
Best Observational Data ❖ de Jonge, et al, 2009 ❖ Janssen, 2009 ❖ 529,688 women - Netherlands (2000-2006) ❖ Prospective ﬁve-year matched cohort study - British Columbia ❖ Planned home births: 321,301 (60%) ❖ midwife-attended planned home birth (N=2802) ❖ Planned hospital births: 163, 261 (31%) ❖ physician attended hospital birth group (N=5985) ❖ No signiﬁcant diﬀerences between home and hospital for any of the main outcomes including ❖ midwife attended hospital birth group (N=5984). perinatal death ❖ Similar or reduced rates of adverse outcomes with signiﬁcantly fewer intrapartum interventionsde Jonge A, van der Goes B, Ravelli A, Amelink-Verburg M, Mol B, Nijhuis J, et al.Perinatal mortality and morbidity in a nationwide cohort of529,688 low-risk planned home and hospital births. BJOG 2009Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee Sk. Outcomes of planned home births with registered midwife versus versus plannedhospital birth with midwife or physician. CMAJ 2009
Making home birth as safe as possible❖ Access to qualiﬁed care providers with appropriate equipment❖ Appropriate risk assessment❖ Respectful communication/collaboration that maintains continuity and relationship❖ Integrated transfer of data❖ Fully implemented QI measures❖ Mechanisms to address unprofessional conduct. (Licensure)❖ Reimbursement, including Medicaid
Risk Assessment “Risk equals probability times consequence. Safety is the level of acceptable risk”❖ Home Birth is a safe choice for — Ron DuPlain, “essentially healthy women”. Private Practice-Maternity, Systems Engineer❖ What factors should inﬂuence choice of birth setting, and which factors have no bearing on that choice?❖ Perceptions of risk and safety linked to medical perspective. (Bryers, 2010)❖ Recognize impact of imposing limitation of scope in one setting on demand for services in another.
Access❖ Research should address lack of access to birth services using same criteria identiﬁed by home birth opponents: 1. Safety 2. Patient Satisfaction 3. Cost 4. Ethics
Mutual Accommodation❖ How can we develop mutual respect and understanding between providers with diﬀerent approaches to care?❖ How can we optimize the expertise of providers in each setting? “Instead of a maternity system based on fear and misinformation, we need a system based on co&aboration and mutual respect.” — Melissa Cheyney, PhD, LM, CPM http://www.huﬃngtonpost.com/melissa-cheyney/post_812_b_709215.html
Intrapartum TransportDevelop standards to improve quality and safety during non-emergent and emergent transfers of care
Human Rights and Birth Choices “Is it not the opposite of autonomy to support only those choices which increase the woman’s reliance upon the physician?” — Lauren A. Plante, MD, MPH, FACOG ❖ Choice of Birth Setting ❖ Shared Decision Making ❖ Patient AutonomyPlante LA. Mommy, What Did You Do in the Industrial Revolution? Meditations on the Rising Cesarean Rate. The International Journal of Feminist Approaches to Bioethics. Spring 2009;2(1):140-147. DOI: 10.2979/FAB.2009.2.1.140
Suggestions for Comparative Eﬀectiveness Research1. Include birth setting in review of low-risk cesarean rates (Harmann 2012)2. Address race disparity for birth options. Development of community-based health workers.(Doula Care Reduces Cesarean Deliveries in Medicaid Patients. Medscape. Feb 19, 2013.)3. Patient derived data in EHR and other HIT innovations to address patient satisfaction and shared decision making.(Dhanireddy, S 2012; Leveille, S 2012, Delbanco, T 2010)4. Relocation; Impact on rural women (Kaczorowsk, J. 2000; Kornelsen, 2005, 2011; Gao, 2010; Klein,M. 2002; Thomassen, H. 2005; Grzybowski, S. 2007; Godwin,M. 2002)
Home Birth-Like❖ Woman-centered, family friendly, community based❖ Pregnancy and birth are treated as a uniﬁed process of care that includes social, emotional, physical, cultural and spiritual accommodation❖ A resolute environment for undisturbed, physiologic birth
Factors that Disturb Birth Joint Normal Physiologic Birth Statement (2012)❖ Unsupportive environment, i.e., bright lights, ❖ Opiates, regional analgesia, or general cold room, lack of privacy, multiple providers, anesthesia lack of supportive companions ❖ Episiotomy❖ Time constraints, including those driven by institutional policy and/or staffing ❖ Operative vaginal (vacuum, forceps) or abdominal (cesarean) birth❖ Separation of mother and infant ❖ Immediate cord clamping❖ Any situation in which the mother feels threatened or unsupported ❖ Induction or augmentation of labor❖ Nutritional deprivation, e.g., food & drink
Beneﬁts of physiologic labor and birth Value of Home Birth❖ Reduces likelihood of fetal compromise ❖ Increased conﬁdence and capacity to mother❖ Reduces instrumental or surgical ❖ Enhanced infant growth & development intervention. ❖ Mother-infant attachment❖ Improves physical & mental health – mother and baby ❖ Diminished incidence of chronic disease❖ Maintains delicate hormone physiology ❖ Epigenetic impact of childbirth References: Dahlen HG et al. The EPIIC hypothesis: Intrapartum effects on the neonatal epigenome and consequent health outcomes. Med Hypotheses (2013) Goer H. & Romano A. (2012) Optimal Care in Childbirth; The case for a physiologic approach, Classic Day Publishing, Seattle, WA Fahy, Fourer, Hastie. (2008) Birth Territory & Midwifery Guardianship, Elsevior Publishing, Philadelphia, PA The Hormonal Physiology of Childbearing (Buckley, Childbirth Connection; 2013-draft)
Thank You Brynne Potter, CPM Provider Perspectives:Midwives and Home Birth March 7, 2013
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