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Midwifery in cny 2 11 11-10 Document Transcript

  • 1. Options for WomenMidwives as Maternity and Gyn Providers in CNY 1
  • 2. The presentersKathleen D. McMahon LM (CNM) MSN NPMidwife Perinatal Center , NYS Board of Midwifery MemberKate T. Finn LM (CM)MSMMidwife at Woman’s Way Health Care, Ithaca, NYA Community-Based, Pre Level I providerNYS Association of Licensed Midwives Board MemberHave no relevant personal or financialrelationship with a commercial interest. 2007 ACCME STANDARDS FOR COMMERCIAL SUPPORTS 2
  • 3. Objectives:! !1.Discuss Models of Care that use midwifery for healthy women during pregnancy and well woman care. 2. Discuss research findings that support safe and healthy outcomes in physiologic labor and birth. 3. Facilitate the collaboration of a health care team for providing comprehensive safe maternity care for women in !!! ! Central New York . 3MODELS OF CARE INTERNATIONALLY TO LOCALLYEVALUATING RESEARCH R/T SAFE MATERNITY CAREWHAT DOES A SAFE, COMPREHENSIVE MATERNITY CARE TEAM LOOK LIKE
  • 4. Philosophy Normalcy of the Birthing Process Empowerment Autonomy Do No Harm Responsibility 4As foundation for todays presentation, I am going to begin by addressing the philosophical cornerstones ofmaternity careRespect the Normalacy of the Birthing ProcessChildbearing women and newborns are primarily healthyFor most women, Birth is a normal, natural, and healthy process and can safely take place in hospitals, birth centers,and homes.The midwifery model of care, which supports and protects the normal birth process, is the most appropriate for themajority of women during pregnancy and birth.Care should be empowering:A womanʼs confidence and ability to give birth and to care for her baby are enhanced or diminished by every person/environment in which she gives birth.Childbearing is a milestone, profoundly affect women, babies, fathers, and families,Care should be autonomousEvery woman should have the opportunity to:have options for pregnancy, birth, providers and practicesBirth should be a positive experienceWomen should Birth in an nurturing, secure environmentWe should Do No HarmAll care should be evidence based.Finally,provider is responsible for the quality of care she or he provides.Individuals are ultimately responsible for making informed choices
  • 5. Normal Birth Wold Health Organization Definition Labor, spontaneous in onset between 37-42 weeks. Low risk at the start of labor, The infant is born spontaneously Postpartum, mother and infant are in good condition. 5The World Health Organization defines of Normal BIrth.WHO define normal birth as:spontaneous in onset, low-risk at the start of labourand remaining so throughout labour and delivery.The infant is born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy. After birth mother and infant are in good condition.
  • 6. Pearls of Evidence-Based Care Eat and drink in labor Honor the “lull phase” of No routine IV fluids second stage; eliminated IA, not continuous EFM, coached pushing for low risk No routine episiotomies or Upright and mobile aggressive vaginal/ perineal stretching Continuous 1-1 support, nursing, family member, Delay cord clamping doula Skin-to-skin contact and Don’t routinely AROM breastfeeding 6This is what care in normal birth looks like
  • 7. Midwifery Culture of Safety •Care should be based on scientific principles •Interdisciplinary team communication is a fundamental aspect of care •Active involvement of women and their families contributes to safe practice •Participation in quality management programs increases safety 7Midwives- have an important role, in the culture of safety., with influences that reach deep into the health care system.The goal is safe practice .The IOM & JCAHO have noted common errors that place patients at risk for adverse events.ACNM the professional organization of midwives have developed 4 PRINCIPLES of Best care practice• Care should be based on scientific knowledge about best practice. .• Interdisciplinary team communication is a fundamental aspect of care.Communication errors account for the majority of preventable adverse outcomes in perinatal care. We need to establish A formalmechanism for transfer of care between providers. SBARR•Active involvement of women and their families in care contributes to safe practice,It is important to include mothers and their families as informed and active team participants quality management programs increases safety. Shoulder dystocia drills , NOELLE DRILLS
  • 8. Mother Friendly Childbirth Excessive use of interventions is in itself harmful because it imposes risks with no evidence of benefit (Gore, H 2007) 8US spends more money per capita on maternity and newborn care than any other country,YET WE LAG BEHIND most industrialized countries in perinatal M&M,Midwives attend majority of births in industrialized countries with the best perinatal outcomesread slideThe Agency for Healthcare Research and Quality AHRQ stated in a 2007 report “Cesarean delivery has been aoverused procedure. As such lower rates represent better quality. VBAC has been demonstrated as as a potentiallyunderused procedure, as such higher rates represent quality”.US Maternal MORTALITY RATE HAS INCREASED;FROM 1996 -2008 Maternal mortality has risen from 8 to 17/100,000 live birthsWE UNDERUSE MANY INTERVENTIONS THAT PROMOTE NORMAL BIRTH ( as noted previously)WE OVERUSE MANY INTERVENTIONS THAT DO NOT PROMOTE NORMAL BIRTH.labor induction! ! ! ! ASK AUDIENCE TO NAME SOMEcont EFMAROMEpiduralEpisCesarean deliveryNEXT SLIDE(in a ”Quality of Care in Hospitals” 3/12/2007 Guide to Inpatient Quality indicators)
  • 9. Evidenced Based and Public Policy support for midwifery care. 1991WHO- UNICEF Baby Friendly Hospital Initiative 1996 Coalition for Improving Maternity Services CIMS 1997 WHO Care in Normal Birth WHO Care in Nl Birth 2002 , 2006 Listening to Mothers MCA- Childbirth Connection 2008 Evidence-Based Maternity Care: What it is and What it can Achieve - Milbank 2009 Transforming Maternity Care: Vision and Blue Print for a High-Quality, High- Value Maternity Care System -- Childbirth Connection 9•The Statement by Henci Goer is supported as follows:•Over the last twenty years Multidiciplinary input has resulted in several landmark, evidence based, public policy documents.•(BFHI) is a global program (WHO) and (UNICEF) to encourage and recognize hospitals and birthing centers thatoffer an optimal level of care for newborns•(CIMS) Coalition for improving maternity services involves individuals and national organizations developed:•Mother-Friendly Childbirth Initiative (MFCI)• WHO ---CARE IN NL BIRTH• In 1997, WHO, looked at the evidence then based its recommendations on practices related to normal birth into fourcategories:A." Practices which are useful and should be encouragedB." Practices which are harmful or ineffective and should be eliminatedC." Practices for which insufficient evidence exists to support .......and those practices will need additional !! research to safely adopt/D." Practices which are frequently used inappropriately.LTM I & II - This was the first time on a large scale we asked what mothers about their experience. a HARRIS POLLn=1500 Main finding:Technology-Intensive Childbirth is the Norm for Great Majority of Primarily Healthy WomenMILBANK foundation Published a report titled “Evidence Based Maternity Care: What it is and What it can Achieve”was a systemic review of maternity carehighlighted the fact that much if the care that pregnant women get has no basis inthe evidence. " The report highlighted THE UNDERUSE OF MANY beneficial practicesMIDWIVES, PNV, SMOKING CESSATION EFFORTS, EXTERNAL VERSION TO TURN BREECHES, CONTINUOUS LABOR SUPPORT, NON PHARMAMETHODS OF PAIN RELIEF., DELAYED, AND SPONT PUSHING......NEXT SLIDEMilbank report
  • 10. T Steps of the Mother-Friendly Childbirth Initiative en For Mother-Friendly Hospitals, Birth Centers and Home Birth Services 1. Support and access to care provider 2. Information about its practices and procedures, interventions,outcomes. 3. Culturally competent care 4. Freedom to walk, move position, and discourages lithotomy . 5. Established policies and procedures for CCR with other maternity services, 6. Does not routinely employ practices and procedures that are unsupported by scientific evidence; Routine interventions are limited 7. Non-drug methods of pain relief, does not promote the use of analgesic or anesthetic drugs 8. Encourages all mothers and families, including those with sick or premature newborns or infants with congenital problems, to touch, hold, breastfeed, and care for their babies to the extent compatible with their conditions. 9. Discourages non-religious circumcision of the newborn. 10. WHO-UNICEF “T Steps of the Baby-Friendly Hospital Initiative” to promote en successful breastfeeding 10WHAT WOULD AND IMPROVED SYSTEM LOOK LIKEJust highlight slideThis is a model of comprehensive maternity care, putting mom and baby first.This is in your handouts-Take a look at this and see how you can incorporate some of these initiatives into your practice
  • 11. Transforming Maternity Care “2020 Vision for A High-Quality, High-Value Maternity Care System” "Blueprint for Action" Transforming Maternity care 11Transforming Maternity Caresymposium by the Childbirth Connection150 leaders “stakeholders”, care providers,educators, policy makers...... from across the US with the goal to improve thequality of Maternity careDeveloped the Blueprint for action SPECIFIC STEPS ON HOW TO improve the quality of maternity care over the next five years.
  • 12. Crossing the Quality Chasm, Institute of Medicine 2001 Six national aims for improvement: safety Safe - supports physiology, minimal interventions/risks effectiveness Effective- Evidence based patient-centeredness Woman and Family Centered timeliness Timely efficiency Efficient Equitable 12How can we define maternity care quality?2001 IOM, published a landmark study Crossing the Quality Chasm defines quality of health careas “the degree to which health services for individuals and populations increase the likelihood ofdesired health outcomes and are consistent with current professional knowledge.”IOM developed six aims and these have been adapt by the TMCSafe care minimizes the risk of error and harm • supports the physiology of childbirth • minimizes use of interventions with established risks • Effective evidence is available to demonstrate that care achieves expected benefits. • Overuse (providing unneeded care) • Underuse (not providing beneficial care) is minimized. • Woman-and family-centered • Pregnancy and birth and birth are unique for each woman • Caregivers and settings can create a climate of safety or doubt • Timely care is delivered when needed. • Wait times compromising safety and efficiency are avoided.( transports) • Efficient Best outcomes using most appropriate resources/technology • Equitable women and families of all racial, ethnic, and economic groups have access to the same high quality high value care
  • 13. The higher the proportion of births assisted by midwives, the lower the cesarean rate. 13NYS has the 9th highest C/S rate in the US 33.7 %SIZE Dosenʼt MatterThe size and level of the 10 hospitals with the lowest C/S rates were almost identical to the 10 hospitals with the highest C/SRate Hospitals with fewer beds did not have fewer C/S INTERESTINGLY, THEY FOUND THAT The higher the proportion of births assisted by midwives, the lower the cesarean rate. In their conclusions they note that “Choosing a midwife will likely decrease the chance of an unnecessary C/S “
  • 14. ONONDAGA COUNTY 142007 for Syr HospitalsAuburn Memorial Hospitaln=253 CD16.60% PCD 9.91% VBAC 9.52% CNM 20.16%MA67.98% CNM 33.01%
  • 15. Midwife-led care confers benefits for pregnant women and their babies and is recommended. 15 THE COCHRANE REVIEWcompared models of midwifery- led, medical-led care and shared care, identified 11 trials, involving 12,276 women.In many parts of the world, midwives are the primary providers of care for childbearing women. The studies of midwifery care looked at midwives providing care antenatally, during labour and postnatally andcompared this with models of medical-led care and shared care.Midwife-led care was associated with several benefits for mothers and babies including a higher rate of SVB , and hadno identified adverse effects.he main benefits were a reduction in the use of regional analgesia, with fewerepisiotomies or instrumental births.
  • 16. After a decade of Commissioning,collecting, clarifying and disseminating best evidence about maternity care practices we came to understand that evidence alone is not enough to change practices. Rima Jolle Facts do not change feelings, and feelings are what influence behavior. The accuracy and clarity with which we absorb information has little impact on us; it is how we feel about information that determines whether we wi# use it. Vera Keane 1967 16READ First paragraphWE have the evidence now we need to commitIf evidence based medicine was enough to change practices, the are about 2000-3000 high quality systematic reviews onwhich to base practice.VERA KEANE Past President of the ACNM-
  • 17. 17CNM/CMʼs attended 316,811 Births in 2007The number of CNM/CM births has risen every yearCNM/CMʼs account for more than 90% of all midwife attended births.
  • 18. The art and science of midwifery are characterized by these hallmarks 18Midwifery is very well positioned to play an important role in our health care system.These are the hallmarks of midwifery.
  • 19. The art and science of midwifery are characterized by these hallmarks Pregnancy, birth, and menopause are normal physiologic and developmental processes 18Midwifery is very well positioned to play an important role in our health care system.These are the hallmarks of midwifery.
  • 20. The art and science of midwifery are characterized by these hallmarks Pregnancy, birth, and menopause are normal physiologic and developmental processes Nonintervention in the absence of complications 18Midwifery is very well positioned to play an important role in our health care system.These are the hallmarks of midwifery.
  • 21. Midwifery Hallmarks 19
  • 22. Midwifery HallmarksEmpowerment of womenas partners in healthcare, through informedchoice and shareddecision making 19
  • 23. Midwifery HallmarksEmpowerment of womenas partners in healthcare, through informedchoice and shareddecision makingFamily centered andculturally sensitive care 19
  • 24. Midwifery Hallmarks 20
  • 25. Midwifery HallmarksContinuity of care 20
  • 26. Midwifery HallmarksContinuity of carePrimary Care of women 20
  • 27. Midwifery HallmarksContinuity of carePrimary Care of womenIncorporation of scientific evidence into clinicalpractice 20
  • 28. Midwifery HallmarksContinuity of carePrimary Care of womenIncorporation of scientific evidence into clinicalpracticeCollaboration with other members of the healthcare team 20
  • 29. International Midwifery International Definition of a Midwife Adopted by the International Confederation of Midwives Council Meeting 19th July, 2005 Australia. • Graduate of a midwifery educational program, duly recognized in the country in which it is located, with qualifications to be registered and/or legally licensed to practice midwifery. •Recognized as a responsible and accountable profesional who works in partnership with women http://www.internationalmidwives.org/Default.aspx hyperlink 21The definition of midwifery is international.Key points are:Education and qualification for practiceLicensed by jurisdiction
  • 30. International Midwifery • Pregnancy, labour,birth, postpartum and newborn care is conducted on the midwife’s own responsibility • Care includes promotion of normal birth, the detection of complications in mother and child, the accessing of medical care and the carrying out of emergency measures. • A midwife may practice in any setting including the home, community, hospitals, clinics or health units. 22Midwifery is a partnership with womenWhile midwifery practice is independant, it occurs in multiple settings with access to a multidicipiinary team.NEXTStatement reflects the ICMʼs belief in the importance of the value of low tech approach and the midwives concern about rising rates of unnecessary intervention.In the circumstance where the midwife detects complications in the woman or child, the document recommends the ʻaccessing of medical care or otherappropriate assistance” recognizes that the mother and or baby may be in need of attention from a specialist in a multitude of disciplines, obstetrics, psychology,medicine, social, physiotherapy, nutrition, legal.....
  • 31. International Maternity Health Systems Midwives are the entry point to care for many women Low risk women are seen by primary care midwives throughout the maternity care cycle, those with risks factors are referred to the secondary system of physicians “All women need the care of a midwife, and some will also need that of a physician.” Cathy Warwick, General Secretary of the Royal College of Midwives, UK 23The systems that use midwifery care as primary care providers have the best outcomesRead #2
  • 32. Midwifery in the United States Professional Organizations: American College of Nurse Midwives- ACNM Midwives Alliance of North America - MANA Nationally certification: American Midwifery Certification Board AMCB New York State Midwifery Licensure: Graduate Degree and National Certification and for licensure. Midwives practice according to the ACNM/MANA Standards for the Practice of Midwifery 24AMCB American Midwifery Certification BoardNARM North Am Registry of MidwivesACNMMANAAs of Jan 2011, a graduate degree is required for the licensure of licensed midwife. Midwives are required to pas the AMCB licensure exam.The Standards for practice define independent midwifery care and include mechanisms for CCR
  • 33. Midwifery in the United States 25While there are multiple education roads to midwifery as there are to other professions, Historically midwives were nurses, this was the British model brought tothe US by Mary Breckenridge.Professions such as midwifery, medicine, education and industry have realized the benefits of secondary base of education and experience.As such some midwives have background in other professions prior to their midwifery education.
  • 34. Midwifery in the United States Certified Nurse-Midwife Certified Midwife A certified nurse-midwife A certified midwife (CM) is an (CNM) is an individual educated individual educated in the in the two disciplines of nursing discipline of midwifery, who and midwifery, who possesses possesses evidence of evidence of certification certification according to the according to the requirements of requirements of AMCB. AMCB. 25While there are multiple education roads to midwifery as there are to other professions, Historically midwives were nurses, this was the British model brought tothe US by Mary Breckenridge.Professions such as midwifery, medicine, education and industry have realized the benefits of secondary base of education and experience.As such some midwives have background in other professions prior to their midwifery education.
  • 35. Independent management of womens health care, focusing on pregnancy, childbirth, the postpartum period, care of the newborn and the family planning and gynecological needs of women. The CNM/CM practice within a health care system that provides for consultation, collaborative management or referral as indicated by the health status of the woman 26Consistent with the the ICM definition, Midwifery in the US is defined as :
  • 36. Midwifery in NYS New York State Midwifery Law Professional Midwifery Practice Act 1992. Article 140 Licensure for midwives State Education Department Board of Midwifery. Midwifery Modernization Act 2010 (Amends Midwifery Practice Act of 1992) 27In NYSArticle 140 defines licensure for practicemidwives practice a full scope of independent practiceThe New York State Board of Midwifery outlines rigorous educational requirements and regulations for the practiceof midwifery and is responsible to the Office of Professions for professional dicipline ( which providesaccountability to public safety)MMA 2010The new language about collaborative relationships reflects current professional standards for midwifery and servesto protect patients.by ensuring that the midwife has access to appropriate health care professionals and hospital services as neededKate will address thisNEXT SLIDE. Midwives currently practice in 15 states (AK, AZ, CT, DC, ID, IA, ME, MN, MT, NH, NM, OR, RI, WA, WY) without signed practice agreements. Like these andmany other states, New York is experiencing a shortage in its health care workforce, especially Ob-Gyns and primary care providers. According to the New York Department of Health ("NYDOH"), the North Country regions primary care physician supply decreased by 8% between 2001 and 2005 and, inthe nine-county Southern Tier region, the number of OB/GYNs declined by 28%. In addition, NYDOH statistics for 2004-2006 show that there was late or noprenatal care in almost 7% of all births in Cattaraugus County and in over 8% of all births in Queens County. Access to quality prenatal and post-partum care isessential to achieve good health outcomes, and have healthy mothers and healthy babies.Safe, quality health care can best be provided to women and their infants when policymakers develop laws and regulations that foster midwives ability to providemidwifery care within their scope of practice while encouraging consultation, collaborative management, and seamless referral and transfer of care whenindicated.
  • 37. Midwifery Modernization Act Removes requirement for a signed written practice agreement as a precondition for midwifery practice. Institutes requirement for collaborative relationships with an OB , physician practicing obstetrics or hospital and stipulates communication of this to patient 28Eliminates barrier to practice by striking the requirement that licensed midwives require written agreement to practice theprofession of midwifery.MMA ensures seamless access to care for women and their families while protecting physicians working with midwivesfrom undue exposure to liability.
  • 38. Collaborative Practice COLLABORATION - Has its roots from Collaborare - “T labor together”- o Merrimun Websters Collegiate 29How do we define Collaboration
  • 39. ACOG/ACNM Joint Statement of Practice Consultation CNM/CM seeks advice or opinion of a physician/ another member of the health care team. Collaboration CNM/CM and physician jointly manage care of a woman or newborn who has become medically, gynecologically or obstetrically complicated Referral CNM/CM directs the client to a physician or another health care professional for management of a particular problem or aspect of the clients care. 30From the ACOG ACNM joint statement:Consultation - I seeks the advice or opinion of a physician or another member of the health care teamCollaboration physician and I jointly manage the care of a woman Ob/GYN/Psych/Referral - I refer to patient to the specialist for secondary care - This may be beneficial financially for the referralsystem.
  • 40. Interaction of health care providers in a health care system Referral Collaboration Consultation Health Care System 31The Heath Care system is DynamicPrimary care providers- Midwives, Generalists, Family physicians, Dentist, Opthalomogist,All working within the health care system.Then we have have multiple secondary care providersObstetrician/Gynecologist, Maternal Fetal Medicine, Cardiologists, Orthopedic surgeon, Neurosurgeon,,Periodontist, .....Individuals may need various levels of interaction
  • 41. Interaction of health care providers in a health care system Referral Primary Care Providers Collaboration Consultation Health Care System 31The Heath Care system is DynamicPrimary care providers- Midwives, Generalists, Family physicians, Dentist, Opthalomogist,All working within the health care system.Then we have have multiple secondary care providersObstetrician/Gynecologist, Maternal Fetal Medicine, Cardiologists, Orthopedic surgeon, Neurosurgeon,,Periodontist, .....Individuals may need various levels of interaction
  • 42. Interaction of health care providers in a health care system Referral Primary Care Providers Collaboration Consultation Health Care System 31The Heath Care system is DynamicPrimary care providers- Midwives, Generalists, Family physicians, Dentist, Opthalomogist,All working within the health care system.Then we have have multiple secondary care providersObstetrician/Gynecologist, Maternal Fetal Medicine, Cardiologists, Orthopedic surgeon, Neurosurgeon,,Periodontist, .....Individuals may need various levels of interaction
  • 43. Interaction of health care providers in a health care system Referral Secondary Care Providers Primary Care Providers Collaboration Consultation Health Care System 31The Heath Care system is DynamicPrimary care providers- Midwives, Generalists, Family physicians, Dentist, Opthalomogist,All working within the health care system.Then we have have multiple secondary care providersObstetrician/Gynecologist, Maternal Fetal Medicine, Cardiologists, Orthopedic surgeon, Neurosurgeon,,Periodontist, .....Individuals may need various levels of interaction
  • 44. Interaction of health care providers in a health care system Referral Primary Care Providers Collaboration Consultation Health Care System 31The Heath Care system is DynamicPrimary care providers- Midwives, Generalists, Family physicians, Dentist, Opthalomogist,All working within the health care system.Then we have have multiple secondary care providersObstetrician/Gynecologist, Maternal Fetal Medicine, Cardiologists, Orthopedic surgeon, Neurosurgeon,,Periodontist, .....Individuals may need various levels of interaction
  • 45. The ACOG/ACNM 2011 Issue of the Year Successful Models of Collaborative Practice in Maternity Care Invitation to submit papers: ACOG and ACNM are calling for papers describing successful and sustainable models of collaborative practice involving obstetrician-gynecologists and certified nurse-midwives/ certified midwives. The impending maternity care workforce crisis necessitates focusing on best practices across the US; therefore, preference will be given to papers about successful collaborative practice and outcomes. Discussions of how physician and midwife collaborative practice models have affected maternity and women’s health care in both community and academic settings are being sought. Top papers from academic and community settings will receive a monetary award. The authors will present at the ACOG and ACNM annual clinical meetings in 2011 Guidelines for paper submission: 1. Papers must be coauthored- Fellow of the ACOG one CNM/CM Member of ACNM 32 Recently published a call for papersACOGACOG ACNM is looking for models of collaborative practiceBackground for the initiation of the collaborative practice,The practice model, including how patient care decisions are made,State, regulatory and credentialing issues that have been addressed,Practice outcomes (using data if possible) related to women, providers and health care setting,Challenges faced and solutions,Interdisciplinary education and training,Suggestions for model replication,Plans for any future initiatives.
  • 46. Midwifery Scope of Care Pregnancy Labor and Birth Postpartum Neonatal Care Breastfeeding Support Well Woman Care 33Although we have spent much of our time speaking of midwives and the maternity care system, midwives carefor women through the lifespan.We are actively involved in family planning, well woman , primary care, sexuality, hypertension, obesity, nutrition,exercise, prevention of disease, evaluation of testing, collaboration with specialists, referral for disease
  • 47. Practice Settings 34Most frequently midwives are involved in Births that occur in hospital.Kate will address midwifery in the non hospital setting
  • 48. Home Birth Integration into the Maternity Care System 35I am pleased to be presenting today on Home Birth and its integration into the Health CareSystem.I would like to start by examining the role of women in creating the demand for home birthservices which midwives then provide.
  • 49. Got wired? 36We are in the information age. Health care consumers have unprecedented access toinformation. Women can surf the internet and pull up original research and readcommentaries. They have online communities. They come into the maternity care processwith a vision for their care.
  • 50. Women understand they can work for births that are both safe and fulfilling. Promoting physiologic birth promotes both. 37Women are looking for birth to be both safe and fulfilling --- these are not mutually exclusiveThe idea of a satisfying birth is not just an indulgence. It effects a womenʼs sense of self worthand general health.Physiologic birth promotes sense of empowerment.Women also seek to empower other women to become central actors in their birth stories....even making movies, such as this scene from “The Business of Being Born.”
  • 51. FreeOurMidwives.org 38They become activists and organizers for insuring a full complement of birth options.
  • 52. Reasons Women Choose Home Birth •Safety,!reduced iatrogenic risk •Respect for personal choices •Minimize routine interventions •Trust known providers •Unobtrusive monitoring •Family bonding, intimacy •Follow the bodys pacing •Familiarity of surroundings •Choose positions of comfort •Ease of not traveling •Eat and drink as desired •Privacy, feeling uninhibited •Use alternative pain •Comfort management (water) •Being self reliant •Protect babys innate instincts for bonding and breastfeeding 39Women identify a variety of reasons for choosing home birth. Reasons listed in this first column are all associated withevidence of better outcomes, and the items in the second column are quality care indicators. Women know this intuitively, notneeding evidence to adopt these practices. They know intuitively, for example, that continuity of care provider is better.As one home birth mother said, "As I myself have experienced, home birth can empower a woman to be more confident andself-reliant as a mother, more in touch with her role as steward of her own and her families health and well-being, and morecapable of understanding and advocating for her own choices in the health care system." 
  • 53. Birthing Options 40This slide illustrates the Maternity care choices available to women*CS now passing the mark of 1/3 of women giving birth by surgical incision*As we learned in the Listening to Mothers Survey, Routine Care, frequently includes inductions, augmentation,continuous EFM, epidurals*Physiologic birth in hospitals, is the women-led care we have been talking about.*Birth Centers, both free standing and in hospitals. NY has two freestanding birth centers in NYC area.*Planned home birth attended by educated, certified midwives.Point to Triangle: hospital optionsPoint to Triangle: options that promote physiologic birth. Hospital Physiologic birth is the core of overlappingstyles of care.-- But unfortunately, * few women have access to birth center care, esp in rural communities-- in those locations where physiologic labor care is not available, * women who value physiologic birth thenmust choose between routine hospital care and home birth. If women intuitively understand the value ofphysiologic birth, they seek out home birth.-- * If home birth is made unavailable, then women have very restricted options. * That is when we see moreintentional unassisted home birth, something everyone can agree is not what we want to see. But indeed, whenhome birth with licensed midwives becomes unavailable then some families opt unattended birth. I see examplesof this on chat lists that I monitor, such recently:“I have a contact that is planning on an unassisted home birth, does anyone want to help?” Reply: “ I have been toa birth so I can help..”* = taps in transitional slide make dots appear and disappear.
  • 54. Birthing Options Cesarean Delivery 40This slide illustrates the Maternity care choices available to women*CS now passing the mark of 1/3 of women giving birth by surgical incision*As we learned in the Listening to Mothers Survey, Routine Care, frequently includes inductions, augmentation,continuous EFM, epidurals*Physiologic birth in hospitals, is the women-led care we have been talking about.*Birth Centers, both free standing and in hospitals. NY has two freestanding birth centers in NYC area.*Planned home birth attended by educated, certified midwives.Point to Triangle: hospital optionsPoint to Triangle: options that promote physiologic birth. Hospital Physiologic birth is the core of overlappingstyles of care.-- But unfortunately, * few women have access to birth center care, esp in rural communities-- in those locations where physiologic labor care is not available, * women who value physiologic birth thenmust choose between routine hospital care and home birth. If women intuitively understand the value ofphysiologic birth, they seek out home birth.-- * If home birth is made unavailable, then women have very restricted options. * That is when we see moreintentional unassisted home birth, something everyone can agree is not what we want to see. But indeed, whenhome birth with licensed midwives becomes unavailable then some families opt unattended birth. I see examplesof this on chat lists that I monitor, such recently:“I have a contact that is planning on an unassisted home birth, does anyone want to help?” Reply: “ I have been toa birth so I can help..”* = taps in transitional slide make dots appear and disappear.
  • 55. Birthing Options Cesarean Delivery Routine Care 40This slide illustrates the Maternity care choices available to women*CS now passing the mark of 1/3 of women giving birth by surgical incision*As we learned in the Listening to Mothers Survey, Routine Care, frequently includes inductions, augmentation,continuous EFM, epidurals*Physiologic birth in hospitals, is the women-led care we have been talking about.*Birth Centers, both free standing and in hospitals. NY has two freestanding birth centers in NYC area.*Planned home birth attended by educated, certified midwives.Point to Triangle: hospital optionsPoint to Triangle: options that promote physiologic birth. Hospital Physiologic birth is the core of overlappingstyles of care.-- But unfortunately, * few women have access to birth center care, esp in rural communities-- in those locations where physiologic labor care is not available, * women who value physiologic birth thenmust choose between routine hospital care and home birth. If women intuitively understand the value ofphysiologic birth, they seek out home birth.-- * If home birth is made unavailable, then women have very restricted options. * That is when we see moreintentional unassisted home birth, something everyone can agree is not what we want to see. But indeed, whenhome birth with licensed midwives becomes unavailable then some families opt unattended birth. I see examplesof this on chat lists that I monitor, such recently:“I have a contact that is planning on an unassisted home birth, does anyone want to help?” Reply: “ I have been toa birth so I can help..”* = taps in transitional slide make dots appear and disappear.
  • 56. Birthing Options Hospital Cesarean Physiologic Delivery Birth Routine Care 40This slide illustrates the Maternity care choices available to women*CS now passing the mark of 1/3 of women giving birth by surgical incision*As we learned in the Listening to Mothers Survey, Routine Care, frequently includes inductions, augmentation,continuous EFM, epidurals*Physiologic birth in hospitals, is the women-led care we have been talking about.*Birth Centers, both free standing and in hospitals. NY has two freestanding birth centers in NYC area.*Planned home birth attended by educated, certified midwives.Point to Triangle: hospital optionsPoint to Triangle: options that promote physiologic birth. Hospital Physiologic birth is the core of overlappingstyles of care.-- But unfortunately, * few women have access to birth center care, esp in rural communities-- in those locations where physiologic labor care is not available, * women who value physiologic birth thenmust choose between routine hospital care and home birth. If women intuitively understand the value ofphysiologic birth, they seek out home birth.-- * If home birth is made unavailable, then women have very restricted options. * That is when we see moreintentional unassisted home birth, something everyone can agree is not what we want to see. But indeed, whenhome birth with licensed midwives becomes unavailable then some families opt unattended birth. I see examplesof this on chat lists that I monitor, such recently:“I have a contact that is planning on an unassisted home birth, does anyone want to help?” Reply: “ I have been toa birth so I can help..”* = taps in transitional slide make dots appear and disappear.
  • 57. Birthing Options Hospital Cesarean Physiologic Delivery Birth Routine Birth Care Center 40This slide illustrates the Maternity care choices available to women*CS now passing the mark of 1/3 of women giving birth by surgical incision*As we learned in the Listening to Mothers Survey, Routine Care, frequently includes inductions, augmentation,continuous EFM, epidurals*Physiologic birth in hospitals, is the women-led care we have been talking about.*Birth Centers, both free standing and in hospitals. NY has two freestanding birth centers in NYC area.*Planned home birth attended by educated, certified midwives.Point to Triangle: hospital optionsPoint to Triangle: options that promote physiologic birth. Hospital Physiologic birth is the core of overlappingstyles of care.-- But unfortunately, * few women have access to birth center care, esp in rural communities-- in those locations where physiologic labor care is not available, * women who value physiologic birth thenmust choose between routine hospital care and home birth. If women intuitively understand the value ofphysiologic birth, they seek out home birth.-- * If home birth is made unavailable, then women have very restricted options. * That is when we see moreintentional unassisted home birth, something everyone can agree is not what we want to see. But indeed, whenhome birth with licensed midwives becomes unavailable then some families opt unattended birth. I see examplesof this on chat lists that I monitor, such recently:“I have a contact that is planning on an unassisted home birth, does anyone want to help?” Reply: “ I have been toa birth so I can help..”* = taps in transitional slide make dots appear and disappear.
  • 58. Birthing Options Hospital Cesarean Physiologic Planned Delivery Home Birth Birth Routine Birth Care Center 40This slide illustrates the Maternity care choices available to women*CS now passing the mark of 1/3 of women giving birth by surgical incision*As we learned in the Listening to Mothers Survey, Routine Care, frequently includes inductions, augmentation,continuous EFM, epidurals*Physiologic birth in hospitals, is the women-led care we have been talking about.*Birth Centers, both free standing and in hospitals. NY has two freestanding birth centers in NYC area.*Planned home birth attended by educated, certified midwives.Point to Triangle: hospital optionsPoint to Triangle: options that promote physiologic birth. Hospital Physiologic birth is the core of overlappingstyles of care.-- But unfortunately, * few women have access to birth center care, esp in rural communities-- in those locations where physiologic labor care is not available, * women who value physiologic birth thenmust choose between routine hospital care and home birth. If women intuitively understand the value ofphysiologic birth, they seek out home birth.-- * If home birth is made unavailable, then women have very restricted options. * That is when we see moreintentional unassisted home birth, something everyone can agree is not what we want to see. But indeed, whenhome birth with licensed midwives becomes unavailable then some families opt unattended birth. I see examplesof this on chat lists that I monitor, such recently:“I have a contact that is planning on an unassisted home birth, does anyone want to help?” Reply: “ I have been toa birth so I can help..”* = taps in transitional slide make dots appear and disappear.
  • 59. Birthing Options Hospital Cesarean Physiologic Planned Delivery Home Birth Birth Routine Care 40This slide illustrates the Maternity care choices available to women*CS now passing the mark of 1/3 of women giving birth by surgical incision*As we learned in the Listening to Mothers Survey, Routine Care, frequently includes inductions, augmentation,continuous EFM, epidurals*Physiologic birth in hospitals, is the women-led care we have been talking about.*Birth Centers, both free standing and in hospitals. NY has two freestanding birth centers in NYC area.*Planned home birth attended by educated, certified midwives.Point to Triangle: hospital optionsPoint to Triangle: options that promote physiologic birth. Hospital Physiologic birth is the core of overlappingstyles of care.-- But unfortunately, * few women have access to birth center care, esp in rural communities-- in those locations where physiologic labor care is not available, * women who value physiologic birth thenmust choose between routine hospital care and home birth. If women intuitively understand the value ofphysiologic birth, they seek out home birth.-- * If home birth is made unavailable, then women have very restricted options. * That is when we see moreintentional unassisted home birth, something everyone can agree is not what we want to see. But indeed, whenhome birth with licensed midwives becomes unavailable then some families opt unattended birth. I see examplesof this on chat lists that I monitor, such recently:“I have a contact that is planning on an unassisted home birth, does anyone want to help?” Reply: “ I have been toa birth so I can help..”* = taps in transitional slide make dots appear and disappear.
  • 60. Birthing Options Cesarean Planned Delivery Home Birth Routine Care 40This slide illustrates the Maternity care choices available to women*CS now passing the mark of 1/3 of women giving birth by surgical incision*As we learned in the Listening to Mothers Survey, Routine Care, frequently includes inductions, augmentation,continuous EFM, epidurals*Physiologic birth in hospitals, is the women-led care we have been talking about.*Birth Centers, both free standing and in hospitals. NY has two freestanding birth centers in NYC area.*Planned home birth attended by educated, certified midwives.Point to Triangle: hospital optionsPoint to Triangle: options that promote physiologic birth. Hospital Physiologic birth is the core of overlappingstyles of care.-- But unfortunately, * few women have access to birth center care, esp in rural communities-- in those locations where physiologic labor care is not available, * women who value physiologic birth thenmust choose between routine hospital care and home birth. If women intuitively understand the value ofphysiologic birth, they seek out home birth.-- * If home birth is made unavailable, then women have very restricted options. * That is when we see moreintentional unassisted home birth, something everyone can agree is not what we want to see. But indeed, whenhome birth with licensed midwives becomes unavailable then some families opt unattended birth. I see examplesof this on chat lists that I monitor, such recently:“I have a contact that is planning on an unassisted home birth, does anyone want to help?” Reply: “ I have been toa birth so I can help..”* = taps in transitional slide make dots appear and disappear.
  • 61. Birthing Options Cesarean Delivery Routine Care 40This slide illustrates the Maternity care choices available to women*CS now passing the mark of 1/3 of women giving birth by surgical incision*As we learned in the Listening to Mothers Survey, Routine Care, frequently includes inductions, augmentation,continuous EFM, epidurals*Physiologic birth in hospitals, is the women-led care we have been talking about.*Birth Centers, both free standing and in hospitals. NY has two freestanding birth centers in NYC area.*Planned home birth attended by educated, certified midwives.Point to Triangle: hospital optionsPoint to Triangle: options that promote physiologic birth. Hospital Physiologic birth is the core of overlappingstyles of care.-- But unfortunately, * few women have access to birth center care, esp in rural communities-- in those locations where physiologic labor care is not available, * women who value physiologic birth thenmust choose between routine hospital care and home birth. If women intuitively understand the value ofphysiologic birth, they seek out home birth.-- * If home birth is made unavailable, then women have very restricted options. * That is when we see moreintentional unassisted home birth, something everyone can agree is not what we want to see. But indeed, whenhome birth with licensed midwives becomes unavailable then some families opt unattended birth. I see examplesof this on chat lists that I monitor, such recently:“I have a contact that is planning on an unassisted home birth, does anyone want to help?” Reply: “ I have been toa birth so I can help..”* = taps in transitional slide make dots appear and disappear.
  • 62. Birthing Options Cesarean Delivery Routine Unattended Home Birth Care 40This slide illustrates the Maternity care choices available to women*CS now passing the mark of 1/3 of women giving birth by surgical incision*As we learned in the Listening to Mothers Survey, Routine Care, frequently includes inductions, augmentation,continuous EFM, epidurals*Physiologic birth in hospitals, is the women-led care we have been talking about.*Birth Centers, both free standing and in hospitals. NY has two freestanding birth centers in NYC area.*Planned home birth attended by educated, certified midwives.Point to Triangle: hospital optionsPoint to Triangle: options that promote physiologic birth. Hospital Physiologic birth is the core of overlappingstyles of care.-- But unfortunately, * few women have access to birth center care, esp in rural communities-- in those locations where physiologic labor care is not available, * women who value physiologic birth thenmust choose between routine hospital care and home birth. If women intuitively understand the value ofphysiologic birth, they seek out home birth.-- * If home birth is made unavailable, then women have very restricted options. * That is when we see moreintentional unassisted home birth, something everyone can agree is not what we want to see. But indeed, whenhome birth with licensed midwives becomes unavailable then some families opt unattended birth. I see examplesof this on chat lists that I monitor, such recently:“I have a contact that is planning on an unassisted home birth, does anyone want to help?” Reply: “ I have been toa birth so I can help..”* = taps in transitional slide make dots appear and disappear.
  • 63. Home Birth Care Promoting health and well-being Enhancing womens participation Screening for normalcy Providing for Consultation, Collaboration, Referral 41What constitutes Home Birth Care by NY Licensed Midwives?holistic health approach is used throughout -- with physical, emotion, social and spiritual components. Enhancing womenʼs participation -- moves care from simple education, through informed consent, to a process of shareddecision making, allowing for individualization of care and a sense of ownership, self-efficacy and control.Screening for normalcy is defined with physiologic birth as the gold standard. Defining normalcy when physiologic birthunfolds undisturbed opens great research possibilities. Home birth midwives practice within community standards for definingnormalcy.The process I have been describing is holistic primary care. When secondary level care is needed, the home birth midwifeinitiates CCR in the same manner described by Kathleen for midwives practicing in other settings, We will come back to this.
  • 64. Home Birth Care Complete prenatal, intrapartum, postpartum and neonatal care Utilization of diagnostic testing Prescriptive authority Utilization of complementary and alternative medicine resources and referrals 42Content of care is very similar -- how it looks may differ. Same schedule of prenatal care -- but Prenatal appointments are 1-2hours.Routine screening and diagnostic testing is offered and individualized.Prescriptions are available as neededCAM is used by about 1/3 of the adult population, frequently combined with use of allopathic medicine. So for this group,having a midwife provider that will use CAM/and make CAM referrals increases their care options. For example, if I have awoman experiencing significant vomiting in pregnancy, I can explain the research that acupuncture has been shown to havebenefits in reducing the nausea and vomiting of pregnancy. Clarify that the CAM options I utilize are selected to minimizeunknown effects.
  • 65. Intrapartum Care Attendance of two providers Neonatal Resuscitation and CPR certified Skilled management Safely equipment 43A primary midwife and midwife assistant are on call 24/7, both certified NRP and CPR.Midwifery skills include routine care such as monitoring the mother and fetus, protecting the mothers perineum, newbornexam, as well as managing the rare complications of birth such as shoulder dystocia, hemorrhage, resuscitations, etc.You can see the array of safety equipment available at a home birth. Where home birth midwives are licensed like NYS,midwives will bring to the home the equipment commonly found in hospital birth rooms for first-line management ofcomplications of childbirth.Lets see what a typical home birth might look like...F10 stops sound
  • 66. 44So you could see the midwife performing and intermittent auscultation assessment, chartinglabor progress, performing a newborn exam.(this film clip was very dark on big screen with room lights on... needs reworking if going tobe used. Maybe a series of pictures would be better)
  • 67. Criteria for studies of home birth Planned home birth -- intended Meets screening criteria for normalcy Care by a certified and licensed midwife Access to appropriate equipment, medical specialists and hospital care when needed 45So that describes how home birth is conducted, but what about the safety?In the modern health care scene, the appropriate defining principles for the study of home birth include the following: The women are planning a home birth and have secured necessary supplies;They receive appropriate prenatal care including risk screening and are essentially healthy and normal;They are attended at the birth by a trained birth professional, usually a midwife, who can access and bring to the home safetyequipment for managing complications of birth and who can assess the woman and her baby for normalcy and recommendand facilitate transfer to medical care in the hospital when there are significant deviations from normal."This will distinguish from emergency unplanned home birth, home births that do not have an attendant, and home birth thatare attended by providers with variable training or without access to the proper safety equipment.This is an essential distinction because neonatal morbidity and mortality are greatly increased when these criteria are not met.
  • 68. Differences of Unplanned and Planned Home Birth Declercq et al. Characteristics of Mothers Giving Birth in Planned and Unplanned Home Births and Hospital Births in 19 States Obstet Gynecol 116(1)93-99:2010 Unplanned Home birth Planned Home birth 26% No Prenatal Care 5% No prenatal care 49% in Hispanics Women, 69% in Black Women 2.2% Smokers 20% Smokers 91% Married 54% Unmarried 48% Younger than 30 63% Younger than 30 55% Education> 13 yrs. 36%Education > 13 years 52.5% Parity of 3 or more 48%Parity of 3 or more 46As this slide shows, when you have unplanned home births, you have higher risk factors associated with poorer outcomes,such as no prenatal care.ORData on whether birth was planned or unplanned was available from 19 states vital statistics records, 11,787 births at homeshowedaverage of 83% planned, but ranged from 54% to 98%.Unplanned home births- although relatively small in number- they represent high risk populations that should be in hospitals,women having preterm births, and the like.The profile of mothers with an unplanned home birth shows multiple that are well documented to result in higher risk birth, suchas No prenatal care.From the results, “Unplanned home births are also more likely to be preterm and to be attended by someone who is neither adoctor nor a midwife.”
  • 69. Planned vs. Unplanned New York State Birth Certificate 47In quality studies about home birth safety, We want to avoid inclusion of accidental home births, or births planned for homewithout an attendant.But how does a researcher know which home births are planned and which are accidental, or donʼt have a qualifiedattendant? 19 states, including NY, identify this on the birth certificate.Home Delivery: Planned: Yes No 
  • 70. Attendant at Birth New York State Birth Certificate 48But it is not enough just to know if the home delivery was planned. Since there are planned unassisted home births, thequalifications of the person signing the birth certificate must also identify a qualified attendant: Name and Title in AttendantlineCertifier, if Not Attendant. This is signifies that the baby was born, exists, but the the certifier was not the attendant. Usedwhen a baby has an unattended out of hospital birth.
  • 71. Pang, et al.Outcomes of Planned Home Births in Washington State 1989-1996 Obstet Gynecol100(2)253-259:2002 Comparison birth certificates were selected in the following manner: "Because WA birth certificates do not identify which home births are planned we defined planned home births as those singleton newborns of at least 34 weeks gestation who were delivered at home and who had a midwife, nurse or physician listed as either birth attendant or certifier (if an attendant is not listed on the birth certificate, then the certifier attended the delivery)." p.253 49Lets look at one of the most commonly cited studies for Home Birth Safety, called the Pang Study.It turns out that I have the distinction of having contributed data to this study, as I attended home births in WA from 1989-1993as a licensed midwife.What can we say about the selection criteria:So they say “we defined...” home birth midwifery practice guidelines as births of at least 34 weeks. How many people herethink 34 weeks is a low risk, normal delivery?.But I am a pack rat, a very organized one, so I went back through my Midwives Association of Wa State documents and foundtheir practice guidelines from 1996, and as expected, the criteria is consult with labors before 37 weeks. It is right here,(SHOW).This demonstrates that their selection criteria for planned low risk home birth was arbitrary. There were guidelines in place inthe state MW organization, and they did not consult with any expert or practitioner of home birth.Looking further into their selection criteria...Nurse: not a primary birth attendant, childbirth is not in the scope of practice of a registered nurse.Certifier: Funny statement that if no attendant, then the certifier attended the birth. What this actually says is there are nounattended births in WA, which is an unusual finding. This is a clue that unattended home births were systematically includedin the data set, because as we have seen, an attendant always uses the attendant line, and the certifier line is only used whenthe person DID NOT attend the birth. Certifiers would be a health department nurse, or and emergency room doc who canverify that the baby was born, but was not present at the time of birth..
  • 72. ! “The proportion of physicians attending home births in this cohort was too small (7.6% of all home births) to examine pregnancy outcomes for this group alone.” p.258 “Because information on birth weight was missing more often for home than hospital births, we gave primary emphasis to the analyses that did not consider birth weight.” p. 257 Study reported limitations: "potential for misclassifying unplanned home births as planned home births..." p.256 50Extracting other qualitative data from the Pang ...Lets look more closely at Physicians: WA midwives practiced in all major cities and most small towns throughout the state...no physicians were known by these home birth midwives to be attending planned home births in Washington at the time, yetPang reports 1 out of every 13 home births was attended by a physician.  The inclusion of so many births with physicianscomes from physicians as certifiers -- again the ER doc receiving the car birth, or the FP doing a newborn check. Additionally,  Trained professionals attending home births in WA at the time were Licensed Midwives and Certified NurseMidwives. An analysis for outcomes of birth with only these providers listed who signed as Attenders was not provided by thestudy.Another clue that unattended home births were misclassified is the lack of baby weights. Baby weighing is an important ritualin home births. Midwives and family members guess weights, people take pictures, and the professional attendants recordweights on birth certificates. A lack of weights would signal unattended home births.An analysis of this qualitative data extracted from the Pang study, shows a high probability for misclassified unattended birthsto confound the planned home birth group.I am sorry that I can not report reliable quantitative data from Pang.  The study missed the opportunity to examine findings thatwould have been meaningful about the attendance of Licensed Midwives and Certified Nurse at planned home birthsDoes this study meet criteria for best evidence for developing health care policy?Apparently some members of ACOG think so, because this study figured prominently in the ACOG issuing a statementopposing home birth in 2007.
  • 73. ACOG and home birth“Although ACOG acknowledges a woman’s right tomake informed decisions regarding her delivery, ACOGdoes not support programs or individuals thatadvocate for or who provide home births” (2007) 51
  • 74. Wax et al. Maternal and newborn outcomes in planned home birth verses planned hospital births: metaanalysis AJOG 203:243. e1-8: 2010 Conclusion: “Less medical intervention during planned home birth is associated with tripling the neonatal mortality rate.” 12 Studies; “342,065 planned home births and 207,551 planned hospital births were available for analysis.” 52The Pang study got new life with the recent publication of a meta-analysis, which we call the Wax Paper.Lets start with the conclusion:That conclusion stands in opposition of the many evidence policy documents that report improved outcomes for mothers andbabies with care using less intervention. But letʼs see what the data says.We have impressive numbers, which make you think this conclusion is supported with a strong power of evidence . But inreading the paper, a different story emerges.
  • 75. Maternal Outcomes Wax Home Births Had Less Epidurals Operative Vaginal Deliver EFM Cesarean Episiotomy / Lacerations Hemorrhage Infection Retained Placenta 53No morbidity measures were greater in the home birth group.
  • 76. Neonatal Outcomes Wax Home birth had less prematurity, low birth weight, assisted ventilations Perinatal Death Rate Neonatal Death Rate Planned 225/ 330,324 0.07% 23/15,633 0.15% Home Planned 134/ 0.08% 14/3199 0.04% Hospital 173,266 OR 0.95 CI 0.76-1.18 OR 2.87 CI 1.32-6.25 Pang’s data for “home births” account for 6133/15,633 = 40% of the data on planned home birth used for the Neonatal Death Rate assessment 54Wax used different studies to measure different outcomes, and which studies used to measure each reported outcome is arenot always identified.Lets look at the Perinatal and Neonatal Death rates for infants without anomalies.Perinatal Death Rate had very strong statistical power, 330,000 home births, with no difference between planned home andhospital births.Neonatal Death Rate comes from a much smaller data set, contrary to what the abstract would have you believe, and as youcan see Pangs “dirty data” with significant misclassifications account for about 40%. I wonʼt have time to discuss the some ofthe other studies, but they have similar problems with unqualified attendants from the Australian outback, and misclassifiedbirths.
  • 77. “The analysis excluding studies that included home births attended by other than certified or certified nurse midwives had findings similar to the original study, except that the ORs for neonatal deaths... were not statistically significant.” p. 243.e3 (nonanomalous OR 3.00 CI 0.61-14.88) Studies for this sub-analysis are not identified Not included in the abstract or discussion 55Wax also made a curious statement at the end of the results section. You have to read it several times to get the meaning,because the sentence is literally a double, double negative, its a quadruple negative. Any editor should have picked this upand changed it to plainly read “ certified midwives and certified nurse midwives attending home births did not have statisticallyhigher rate of neonatal deaths, yet their care demonstrated significant benefits.Both Pang and Wax use the same strategy: They acknowledge the need to examine the outcomes for “highly trained,regulated midwives who are fully integrated into existing health care systems,” and the data about licensed or certified midwifecare at home births is available to them, but they chose to ignore it in favor of data with the confounding of unplanned homebirth, unattended home birth and birth with unregistered midwives.
  • 78. Outcomes for Certified Midwives and Certified Nurse Midwives Wax Maternal Benefits Newborn Benefits Home Births Had Less Epidurals Prematurity EFM Low Birth Weight Episiotomy / Lacerations Assisted Ventilations Infection Operative Delivery Hemorrhage Retained Placenta 56So just to review, what did the Wax meta-analysis show about home births with certified midwives and certifiednurse midwives, the type of educated midwives practicing in New York State:There were no morbidities greater in the home birth group.* There was no increase in perinatal or neonatal mortality.Also of note, the factors of hemorrhage, infection and cesarean section are main causes of maternal mortality, andrisks are reduced with home birth care.This important data, which is central to understanding the safety of home birth with properly educated attendants,was not included in the discussion or abstract.
  • 79. Outcomes for Certified Midwives and Certified Nurse Midwives Wax Maternal Benefits Newborn Benefits Home Births Had Less Epidurals Prematurity EFM Low Birth Weight Episiotomy / Lacerations Assisted Ventilations Infection No Operative Delivery increase Hemorrhage Perinatal or Neonatal Retained Placenta Mortality 56So just to review, what did the Wax meta-analysis show about home births with certified midwives and certifiednurse midwives, the type of educated midwives practicing in New York State:There were no morbidities greater in the home birth group.* There was no increase in perinatal or neonatal mortality.Also of note, the factors of hemorrhage, infection and cesarean section are main causes of maternal mortality, andrisks are reduced with home birth care.This important data, which is central to understanding the safety of home birth with properly educated attendants,was not included in the discussion or abstract.
  • 80. Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births deJonge, et al, BJOG 116:1177-1184;2009 No significant differences were found between planned home and planned hospital birth Intrapartum and Neonatal Death 0-7 Days Hospital 116/163,261 0.07% 1.0 Home 207/321,307 0.06% 1.0 CI 0.78-1.27 Unknown 22/45,120 0.05% 0.71 CI 0.45-1.12 57So where did those large numbers of home births, those 300,000 home births in the Wax metaanalysis comefrom. The answer is the Netherlands, where home birth has been a long-standing tradition, and up to 30% ofwomen birth at home with well-educated midwives.
  • 81. Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births deJonge, et al, BJOG 116:1177-1184;2009 “Planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well- trained midwives and through a good transportation and referral system.” p.1177 58There are many additional studies that look at questions about home birth practice and safety, and I would like topoint you the particularly sophisticated study from British Columbia, comparing midwives who attend both homeand hospital births.When reading home birth studies, I think you now all understand the importance of determining first whether thestudy design will eliminate confounding of higher risk births and examine only those births that are planned andattended by educated, certified and legally supported midwives with ready access to safety equipment and higherlevel medical care.
  • 82. Comparison of Home Birth to VBAC ACOG Practice Bulletin #115, 2010 Perinatal Death ERCD 0.01% TOLAC 0.13% Home Birth 0.06% deJonge “After counseling, the ultimate decision to undergo TOLAC or repeat cesarean delivery should be made by the patient in consultation with her health care provider. The potential risks and benefits.... should be discussed. Documentation of counseling and the management plan should be included in the medical record.”p.458 59When we look at procedures, such as home birth, it is sometime useful to compare the outcomes to other procedures. In thecase of VBAC, ACOG has recently reissued its guidelines to make this type of birth more available to women who would liketo choose this option, we hope. Stacking home birth risk along side VBAC risk it is easy to see that Home Birth is relativelysafer that VBAC. So we could conclude, as the VBAC document does: “After counseling the ultimate decision to plan a homebirth or a hospital birth should be made by the patient under consultation with her health care provider.”At the recent Perinatal Forum, Oct 13, the Physician speaking about TOLAC, reported “It is not an unreasonable thing to do.”The same can be said for Home Birth.
  • 83. The National Perinatal Association 2008 The National Perinatal Association (NPA) believes that planned home birth should be attended by a qualified practitioner within a system that provides a smooth and rapid transition to the hospital if necessary. Safety for all births must be evaluated through objective risk assessment, especially for non-hospital births. NPA supports and respects families’ rights to an informed choice of their birth setting. 60In contrast to ACOG’s position, this sentiment is reflected in the Position Statement ofthe National Perinatal Association.
  • 84. Importance of CCR to Home Birth Safety Midwives providing home birth services are community-based, primary care providers. Midwives obtain CCR based on the health needs of their patients according to established screening criteria. Patients with acute or urgent care needs are transferred to hospital-based providers for secondary care. Midwives make intrapartum transfers to the most appropriate hospital in the woman’s community. 61Because every quality study on home birth safety emphasizes the importance of timely access to higher level medical care,the secondary health system, it is helpful to examine what that looks like.So it is important to remember:
  • 85. Intrapartum Transfers Johnson et al, BMJ online 12% of low risk births 25% for primiparas, 6 % for multiparas 83% prior to birth 60% lack of progress, pain relief, exhaustion, malpresentation 75% not urgent 1.6% operative vaginal delivery 3.7% cesarean delivery 62Prospective data on 5418 home births collected by MANA Stats year 2000, an ongoingdataset in which I participate.CS: So you can see home birth is an important maternal health strategy for lowering CS rate.
  • 86. Legal Foundation for Home Birth to Hospital Intrapartum Transfer NYS Hospital Regulations (405.21) Women in need of medical care and services pertaining to pregnancy, delivery and the puerperal period shall be admitted to the maternity service... attended by a licensed and currently registered obstetrician, family practitioner or licensed midwife. EMTALA Emergency Medical Treatment & Active Labor Act A laboring woman is considered to have an unstable medical condition requiring assessment and stabilization (delivery). Hospitals maintain an on-call list of specialists physicians . 63In addition to the Midwifery Practice Act, which identifies midwifery practice in the homesetting, and the Midwifery Modernization Act, which establishes collaborative relationships asthe model for CCR, there are two additional legal foundations for home birth to hospitalintrapartum transfers: NYS hospital regulations and federal EMTALA regulations.
  • 87. Midwife’s Role in Hospital Transfers Midwife will develop a hospital transfer plan with each patient. Midwife will notify L & D of need for transfer, reason, brief case history, mode of transport, expected arrival time. Midwife will accompany patient to facilitate a smooth transfer of care to hospital provider, promote communication, and provide ongoing patient support. Midwife will provide a more detailed oral case presentation and pertinent prenatal and labor records,. 64
  • 88. Hospital Staff Role in Hospital Transfers Recognize midwife as a Primary Care Provider with pertinent case information, transferring to a higher level facility due to a need for secondary care resources. Admit directly to L&D, bypassing the ED. Provide respectful care and attempt to integrate the families preferences, as the situation may allow. 65Review pointsJust to remember that these patients have been educated about the informed consent processand desire to be active participants in their care plans.
  • 89. Permit midwife to accompany patient throughout procedures. Coordinate follow up care for mother and baby, with care reverting to midwife upon discharge if routine and within midwifery scope of practice. Transmit records upon patient consent. Case reviews, if conducted, would include the midwife with the primary goal of collegial dialogue and mutual feedback to build better seamless coordination across care settings. 66Home birth provides a rich opportunity for developing quality maternal and infant health carestrategies. I would like to emphasize that midwives and physicians have a long history ofworking together for the improvement of maternal and child health. Understanding thathome birth provides high-quality, high-value care requires a paradigm shift in thinking formany hospital-based providers. The best available evidence supports home birth as areasonable option, and women are seeking this form of care. It makes sense for providers totake the steps needed for building the best coordination across these care settings.Thank you.
  • 90. Thank YouKathleen Dermady McMahonNYS Licensed MidwifeKate T. FinnNYS Licensed Midwife 67
  • 91. Bibliography and references available 68