Tag Archives: Midwifery

Birth centers: Safe, economical, and great places for low-risk births

2852282606_22551640c8An American woman with a low-risk pregnancy who chooses a midwifery-led birth center for her maternity care is four times less likely to have a cesarean than if she chooses a hospital birth, according to a review published today in the Journal of Midwifery & Women’s Health.

The review highlights the findings of the National Birth Center Study II (NBCSII), which followed 15,574 women who planned and were eligible for birth center births at onset of labor.

Among the NBCSII’s findings:

  • 84% of women who planned and were eligible for a birth center birth at onset of labor were successful in having one.
  • Only 6% of women intending a birth center birth ultimately required a cesarean section, compared with nearly 24% of comparably low-risk women receiving care in hospitals.
  • Emergency transfers from birth center to hospital were uncommon.
  • Fetal and newborn deaths were rare, and comparable to those in low-risk births in hospital settings.
  • There were no maternal deaths.
  • Birth center care is economical and in keeping with the fiscal goals of the Patient Protection and Affordable Care Act (aka “Obamacare”).

Some nuts and bolts of the NBCSII, FAQ-style:

What, exactly, is a “birth center”?

  • The American Association of Birth Centers defines a birth center as “a homelike facility existing within the health care system with a program of care designed in the wellness model of pregnancy and birth.” The key here is “within the health care system”—the integration between birth center and hospital is critical to the success of any birth center. When emergencies arise, a smooth transfer is vital to keeping mother and baby safe.

Who runs these birth centers?

  • The birth centers in the study were all midwifery-led. 80% were staffed by certified nurse midwives (CNMs), 14% by certified professional midwives (CPMs) or licensed midwives (LMs), and the remaining 6% by teams of CNMs,  CPMs, and LMs. (The different types of midwives in the U.S. can be a bit confusing for the layperson—the American College of Nurse-Midwives provides a handy comparison chart.)

What is a “low-risk” pregnancy? Who qualifies for a birth center birth?

  • Here are the AABC’s eligibility requirements for birth center birth: a single fetus in head-down position, with no medical or obstetrical risk factors that might interfere with normal vaginal birth or require interventions like continuous fetal monitoring or labor induction.
  • By those standards, approximately 85% of pregnancies are “low-risk.”

Why did 16% of the women who planned a birth center birth end up giving birth in hospitals anyway?

  • Of that 16%, about one-fourth were transferred to hospitals before being admitted to the birth center, due to medical issues. Of the rest, the majority were for non-emergency problems, such as prolonged labor. Only 0.9% of the birth center women required an emergency transfer during labor.

Is birth center birth really as safe as hospital birth?

  • Yes, according to the NBCSII’s findings. The rates of fetal death (4.7/10,000 women admitted to a birth center in labor) and neonatal death (4/10,000) in the study were comparable to those in other studies in the U.S. and elsewhere, including those of low-risk birth in hospitals. There were no maternal deaths.

Does birth center care really save money?

  • Yes. In this study alone, cost savings–mainly from fewer medical interventions (including cesareans)–were estimated at more than $30 million, and these 15,574 pregnancies represent less than 1% of all U.S. births. Given that expenses for hospital birth in 2008 exceeded $97 billion nationwide, the opportunity for savings in these health-care-dollar-scarce times is enormous.

A few quibbles:

  • The women in the study were mainly white (77.4%), well-educated (71.8% had at least some college education, and 51.8% were college graduates), and married (80.1%). They were also relatively slender (only 5.7% were overweight or obese, compared with more than 50% of all pregnant American women), mentally healthy (3.3% were being treated for depression or other psychiatric disease), and largely free of substance use (1.5% smokers, 0.5% users of other substances). Though the study’s findings on safety and cost-savings compare favorably with other studies of low-risk pregnancy outcomes, it isn’t clear that these findings can be extrapolated to the U.S. population as a whole.
  • Death rates are crude tools for measuring safety, particularly in low-risk pregnancies. I’d like to know more about morbidity–were the birth center babies more, less, or just as likely as hospital-born babies to suffer birth trauma, for example? I suspect they were less likely to have such complications, given the tendency of birth center staff to perform fewer interventions, but I can’t be certain from this study. Hopefully that will be addressed in a future review.
  • What about breastfeeding? Were the birth center mothers more likely to breast feed than those who gave birth in hospitals? Again, I suspect so, and hope that information on breastfeeding will appear in future reviews of NBCSII data.
  • The 79 birth centers that participated in the study represent only 32% of American birth centers. All 79 are AABC members and as such support the AABC’s Standards for Birth Centers. Other, non-member birth centers may or may not adhere to such standards, and their safety records may or may not be as good as those in this study. With new birth centers appearing at a remarkable pace (up 27% since 2010), ensuring high quality care in all birth center settings may be challenging.

Conclusion:

Withe the publication of this review, the well-entrenched belief that hospitals are the safest place to have a baby takes yet another beating. It’s increasingly clear that most women with low-risk pregnancies can safely give birth at midwifery-led birth centers. A personal/professional note: I’ve taken care of a number of families who’ve had their babies at the Women’s Health and Birth Center here in Santa Rosa, California, run by Rosanne Gephart, CNM. (Rosannne and I go way back). They speak glowingly of their experience at the Birth Center.

One caveat, though. Not all birth centers are alike, and it behooves expectant parents to check out things like staff credentials and birth center accreditation, and to ask pointed questions about how the center handles emergencies and hospital transfers, and how often these occur. Membership in the American Association of Birth Centers is a plus, too. Whether choosing an auto repair shop, a law firm, a pediatrician, or a birth center, it definitely pays to do your homework.

Photo credit: JER_0079

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Filed under Cesareans, Maternal-child health, Natural childbirth

“The Most Scientific Birth Is Often the Least Technological Birth”

Here’s an interesting article on the science and ethics of American childbirth, from Alice Dreger in The Atlantic. It rings very true.

My career as a pediatrician attending births has been one long tale of learning a lot of stuff and then unlearning quite a bit of it. When I started in the late 1970s we went after even mildly distressed newborns like a medical SWAT team, with laryngoscopes, oxygen masks and umbilical catheters flying, snatching our pint-sized patients from the jaws of…what, exactly? In retrospect, a lot of them would have been just fine without us. Maybe even better off. (And just to be clear, a lot of them really needed the help, too…)

Things have changed remarkably since then. More and more studies support the wisdom of a patient, mother-centered approach to childbirth, though you wouldn’t know it from current epidural, induction and cesarean rates. Some of the refusal to accept what the research clearly tells us has to do with the way new doctors are often still taught to view childbirth: as a dangerous process in need of strict control. From the article:

“Many medical students, like most American patients, confuse science and technology. They think that what it means to be a scientific doctor is to bring to bear the maximum amount of technology on any given patient. And this makes them dangerous. In fact, if you look at scientific studies of birth, you find over and over again that many technological interventions increase risk to the mother and child rather than decreasing it.”

Add in the fact that you’re frequently scared to death as a med student and find technology a comfortable/comforting suit of armor to wear, and it’s not surprising that young doctors often live in fear of normal childbirth. I know…I was there. It only takes one bad outcome to make an aggressive approach look attractive, particularly when that’s the medical culture in which you’re being educated.

Dreger’s article is all the more interesting because she’s a professor of clinical medical humanities and bioethics at Northwestern University’s Feinberg School of Medicine, and her husband is an academic internist–not exactly the stereotype (e.g., the “woman who wears long cotton skirts, braids her hair, eats only organic vegan food, does yoga, and maybe drives a VW microbus,” as Dreger puts it) associated with midwifery and low-intervention births. But when Dreger and her husband did an extensive review of the scientific childbirth literature in 2000 and found that it supported just that–a low-intervention approach–they put what they learned into practice with the birth of their own child.

There’s a place for technology in childbirth, certainly, but most pregnancies don’t need nearly as much of it as they get in the U.S. these days.

Have a read–it’s a great article.

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More on home birth risks

From the recent comments file:

While I abhor the tone taken by many comments on the blog I’m asking you to look at, this doctor has some disturbing statistics on neonatal mortality at homebirths. Could you please discuss your thoughts on this post?http://skepticalob.blogspot.com/2012/01/curious-silence-on-rising-rate-of.html
Thank you! Catherine Taylor

Catherine – thanks for your comment! I appreciate it.

Home birth neonatal mortality, by provider type

The chart (left) from the blog you referenced says more about the way home births are handled in the U.S. than it does about home birth itself. As I’ve mentioned before, the Birthplace in England study, as well safety data from Canada and Europe, show that in selected circumstances home birth can be as safe as hospital birth in terms of maternal or neonatal deaths–if home birth is integrated into the larger maternity care system, which in the U.S. it is most definitely not.

Here in America we have a patchwork of state laws that in many cases increase the risk of home birth for mother and child. We also lack the kind of nationally recognized licensure and regulation of home birth midwives that most other western countries have, which can lead to women being cared for by poorly qualified, “underground”  birth attendants and to the kind of tragic outomes that the chart highlights.

The first step in addressing these issues can be found in the Home Birth Consensus Summit’s Common Ground Statements:

“It is our goal that all health professionals who provide maternity care in home and birth center settings have a license that is based on national certification that includes defined competencies and standards for education and practice.

We believe that guidelines should:

  • allow for independent practice
  • facilitate communication between providers and across care settings
  • encourage professional responsibility and accountability, and
  • include mechanisms for risk assessment.”

With few exceptions the regulatory, institutional, and medical systems in the U.S. don’t support home birth. Yet women are increasingly seeking home births, and no matter what the blogging doctor Catherine cited might fervently prefer, they can’t be forced to do otherwise. Speaking as a physician, unless you’re part of the effort to make home birth a safer alternative for those women who want one (and their babies), you’re part of the reason for those bad statistics.

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New CDC report on U.S. home birth

Heading out the door to my office, but wanted to post this for perusing…

Home births are on the rise in the U.S., according to a new report from the Centers for Disease Control and Prevention. Home births accounted for 0.72% of all U.S. births (29,650 births in all) in 2009. The rise is disproportionately among non-Hispanic white women 35 and older (a 36% increase from 2004-2009).

There’s interesting data galore: about 67% of the births were attended by midwives (mostly) or physicians (less often), while 33% of the home births were attended by “others”–which could be anyone from a relative to a paramedic. It’s the latter category that tends to include unplanned home births (eg, babies born in toilets to very surprised mothers, etc.) and most of the “disaster stories” that plague home birth’s reputation. Reporting is getting better now, less “lump-em-all-together,” which should give a more accurate picture of the risks of well-planned, well-attended home birth in the U.S.

I’ll have more to say on this report later today and tomorrow.

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Home birth’s crazy-quilt legal status: Part 2

Laws, laws, and more laws...

If you were to spend a leisurely vacation driving the length of the Atlantic coast from Florida to Maine in search of a good place to have a home birth, you would encounter:

  • 3 states in which home birth attendees must be licensed Certified Professional Midwives* (CPMs)–(New Jersey, Virginia and South Carolina)
  • 2 states that allow Certified Midwives** to attend home births, but only those who have taken a specific test from the American Midwifery Certification Board (New York, Rhode Island)
  • 1 state which allows midwives to get a license if they pass a different exam than the one given in New York and Rhode Island.  (Florida)
  • 1 state which allows CPMs, but not CMs, to practice with a state-issued certificate (New Hampshire)
  • 1 state which allows CPMs, but not CMs, to practice with a state-issued permit (Delaware)
  • 2 states in which “direct-entry” midwives are flatly prohibited (North Carolina, Maryland)

…and 4 states inhabiting a kind of legal alternate-universe:

  • 2 states in which direct-entry midwives are legal “by judicial interpretation or statutory inference” (Maine, Massachussetts). “Inferred legality”! What a concept!
  • A Zen-like state (Connecticut) in which home birth attendance is neither legal nor illegal.
  • And the grand prize winner (Georgia), where home birth attendance by direct-entry midwives is legal…but you can’t get a license!

(Source: Midwives Alliance of North America.)

The crazy-quilt pattern of home birth regulations around the country (the rest of the states are as scrambled as the Atlantic coast) and the varying education and training requirements for the different classes of home birth midwives are major stumbling blocks to integrating home birth into the larger maternity care community. The Consensus Agreements that came out of the Home Birth Consensus Conference in Airlie, Virginia, this past October reflect this.

Take Statement 4:

“It is our goal that all health professionals who provide maternity care in home and birth center settings have a license that is based on national certification that includes defined competencies and standards for education and practice.

We believe that guidelines should:

  • allow for independent practice
  • facilitate communication between providers and across care settings
  • encourage professional responsibility and accountability, and
  • include mechanisms for risk assessment ”

A national certification process for all midwives (similar to the process that already exists for physicians), acceptable to all the organizations involved in maternity care in the U.S., would go a long way toward resolving home birth’s legal limbo.

Ah, but there’s the rub in the factionalized world in which we live. Getting organizations with long histories of animosity to give up a bit of control in order to advance the greater good may strike some as a tilting-at-windmills exercise. But the Home Birth Consensus Summit, where representatives from major medical, midwifery, hospital, and insurance organizations reached agreement on some thorny issues, showed that it’s possible to move ahead.

The devil (probably a whole army of them) will be in the details. I’ll keep reporting on progress, or lack thereof, in future posts.

* * * *

* “A Certified Professional Midwife (CPM) is a knowledgeable, skilled and professional independent midwifery practitioner who has met the standards for certification set by the North American Registry of Midwives (NARM) and is qualified to provide the midwifery model of care. The CPM is the only international credential that requires knowledge about and experience in out-of-hospital settings.”

** “A Certified Midwife (CM) is an individual educated in the discipline of midwifery, who possesses evidence of certification according to the requirements of the American College of Nurse-Midwives.”

(Source: Midwives Alliance of North America)

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Home birth’s crazy-quilt legal status: Part 1

What a difference a few miles makes...

Okay, so I was a wee bit wrong about North Carolina. (Thanks to Russ Fawcett, Deb O’Connell, and Ida Darragh for their clarifying comments.)

Home birth is technically legal in the Tar Heel State. I say “technically,” because by state law the people who would be attending most of the home births in North Carolina—direct-entry midwives*—are legally barred from doing so. This sounds like a bit of a legal end-run, kind of like saying acupuncture is a legal activity… as long as nobody with needles is allowed in the room.

According to the Charlotte Observer report, home birth attendance in North Carolina is limited to registered nurses operating under the direct supervision of a physician. Due at least in part to that requirement for physician supervision, only about a half dozen of the 300 certified nurse midwives in North Carolina attend home births. So, yes, home births are legal, but if you’re looking for a qualified home birth midwife, in most of the state you’re on your own.

My legal fuzziness about the situation in North Carolina is understandable (at least to me). The laws governing home birth in the U.S. vary dramatically from state to state and are often quite byzantine.

Nowhere is this more obvious than in Charlotte. I’ve never been there, but from the look of things on the map, if you were to walk to the south side of town and take a long leap you’d land in South Carolina—where home births and the midwives who attend them are completely legal, and midwives are even paid by Medicaid for their services.

But just meander up and down the Atlantic coast a bit and things change, and change again. More on that in my next post.

* * * * *

* “A Direct-Entry Midwife is an independent practitioner educated in the discipline of midwifery through self-study, apprenticeship, a midwifery school, or a college- or university-based program distinct from the discipline of nursing. A direct-entry midwife is trained to provide the Midwives Model of Care to healthy women and newborns throughout the childbearing cycle primarily in out-of-hospital settings.” (Source: Midwives Alliance of North America.)

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Illegal home birth and bad outcomes: A self-fulfilling prophecy?

Kind of like home birth. Sort of.

Thinking a bit more about the North Carolina tragedy

The bad outcomes that happen in states where home birth is illegal (or poorly supported) strike me as classic self-fulfilling prophecies… kind of  like the outcome of the U.S.’s 50+ year economic embargo of Cuba. That may sound like a stretch (sorry, I just love analogies), but bear with me.

When Castro took over Cuba and embraced communism in the early 1960s, U.S. officials predicted that the Castro government would soon fail, as socialism/communism was an infinitely inferior economic system compared to capitalism. And, lo and behold, here in 2011 Cuba is one of the poorest nations in the western hemisphere. So the prediction of economic failure was accurate from the start…right?

Well, not entirely. The U.S.-versus-Cuba struggle has never been been a fair, level-playing-field test of economic philosophies. The U.S. government made sure of that in 1960 when it imposed a total economic embargo on Cuba. A classic self-fulfilling prophecy ensued: barred from trading with the world’s largest consumer nation (us), Cuba’s economy predictably floundered.

Back to North Carolina and home birth. In a state where home birth is illegal or poorly supported, bad things will inevitably happen as a result of poor communication and collaboration in times of emergency. And when those bad things happen, critics will inevitably point to home birth itself as the problem, rather than the many hurdles to success thrown in its path. This in turn leads to calls for ever-more draconian laws and restrictions, which in turn leads to potentially more bad outcomes. (Actually, that sounds like a combination of a self-fulfilling prophecy and a vicious circle…)

Home birth can only thrive in a system in which it is integrated with the larger OB community, so that all providers are well-educated and trained, and emergency care–especially transfer from home to hospital–is quick and seamless. Anything less simply invites more tragedy.

So judging home birth per se to be unsafe based on outcomes arising from a system stacked against it is a bit like our history with Cuba: when you work really hard to make something fail, it likely will.

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