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Women Are Choosing Home Birth: The Infant-Maternal Health Care System in the U.S. Owes Them A Safe Option

Posted by Midwives Alliance on May 3rd, 2016

Women Are Choosing Home Birth

In the face of increasing home birth rates and declining maternal health outcomes in hospitals, society owes it to families to ensure safe birth options, regardless of the setting.

A small but growing number of families are opting out of a maternal health care system that is falling short. According to the Lancet, the U.S. is only one of eight countries in the world where the maternal death rate is increasing. In some states, such as California, rates of maternal and newborn mortality in hospitals have risen substantially – notably and alarmingly for women of color. 

Families choose home birth for many reasons. Some opt to avoid the often unnecessary interventions associated with hospital birth (including inductions, high cesarean section rates, and NICU stays). Others do not want to leave their communities or their families and have a tradition of birthing at home for personal, religious or cultural reasons. Some families cannot afford to pay the cost of a hospital or, for those who can afford to be more discriminating in their healthcare choices, feel as if their beliefs and preferences will not be honored. An integrated health care system for families that choose home birth and the midwives who serve them is the safest option.

The debate around U.S. home birth statistics as it is currently framed is only serving to confuse stakeholders in this debate. Critics of home birth cite flawed birth certificate studies and highlight relative instead of absolute risk. The State of Oregon has recently made an important leap forward by creating a birth certificate that captures the intended place of birth as well as provider type. Early data is being collected and research completed, which provides consumers and providers with the kind of data that can be used to inform practice and decision making.

The U.S maternal health care system has an obligation to support the conditions that increase safety for home births, including access to consultation, smooth transfers of care and transport to hospital when necessary. The Home Birth Summit, which brings together obstetricians, midwives, consumers, hospital administrators and others in maternal-health care, has published Guidelines for smooth transports crafted by a multidisciplinary Collaboration Task Force, as well as Transport Forms and Scripts to ease communications.

As the professional association for home birth midwives, MANA firmly supports the rights of families to birth outside of a hospital setting, with the providers who are trained in home birth specifically and within a system that supports midwives in all settings.   

The CPM, issued by the North American Registry of Midwives (NARM), is accredited by the National Commission for Certifying Agencies (NCCA), the accrediting body of the Institute for Credentialing Excellence (ICE, formerly NOCA). The mission of ICE is to promote excellence in credentialing for practitioners in all occupations and professions. The NCCA accredits many healthcare credentials, including nurse-midwives, nurse anesthetists, nurse practitioners, and critical care nurses. The CPM credential requires extensive training and the passage of exams that assure competency and focuses exclusively on the safe provision of out of hospital birth. 

Midwifery organizations and coalitions around the country are working to secure licensure for home birth midwives in all 50 states. Licensure gives families the reassurance that their provider is competent and does not have to work under the radar. Currently, misinformation, fractured interprofessional relationships (learn more here and here) and medical monopolies prevent this safe choice for mothers and babies.

Families deserve the support of a provider that meets international standards. The International Confederation of Midwives, with input from over 100 countries’ midwifery associations including those from the United States, have created standards that are increasing safety for families globally. The International Confederation of Midwives supports the “recognition that midwifery is a profession that is autonomous, separate and distinct from nursing and medicine.” and does not expect, nor recommend, that midwives be nurses first. MANA, among other midwifery organizations, is working on continuing to meet and even exceed the recommendations of the ICM. 

Families deserve the right to make choices with high quality evidence informing their decisions. A growing body of literature (including in the United States, Canada, and ) suggests that home birth is safe for women and babies when the birthing parent is healthy, the midwife is trained and medical-back-up is available should a complication arise. One of the hallmarks of home birth midwives’ care is their commitment to providing evidence based information so that clients can make truly informed decisions regarding their care during pregnancy and birth. In a system that supports the autonomy of the family, decisions can be made based on evidence, not fear.

When the maternal health system of the U.S. can have a balanced discussion on how to fully incorporate non-nurse midwives into our system, regardless of place of birth, our families will have better access to the care providers of their choice, fewer interventions including surgical birth, and better outcomes. 

 

About the Author

Marinah FarrellMarinah Valenzuela Farrell, LM, CPM Politics and traditional medicine are what led Marinah to midwifery, and she has a firm commitment to both political activism and birth work. Marinah has worked in waterbirth centers and medical facilities for international NGOs, in free­standing birth centers in the U.S., and is the owner of a long standing homebirth practice in Phoenix, Arizona. In addition, Marinah is known for her grassroots activism at the community level. Marinah is currently a founding board member and the Director of Maternal Health for Phoenix Allies for Community Health (PACH) a community, not federally, funded free clinic in downtown Phoenix, and the President of the Midwives Alliance of North America (MANA). Marinah is focused on the issue of lack of access to midwives and the profession of midwifery in communities where health disparities are overwhelming, trainings in cultural safety and is active in numerous grassroots political collaboratives. Marinah continues to work with traditional midwives outside of the U.S and bridges professional midwifery with community traditions.

Validating MANA Stats 4.0: The Largest Available Dataset on Physiologic Birth in the US

Posted by Midwives Alliance on May 2nd, 2016

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Validating MANA Stats 4.0

More than 50,000 cases of midwifery-led care will now be available to researchers thanks to the validation of the MANA stats 4.0 dataset. This key achievement makes MANA Stats by far the largest available dataset on physiologic birth and midwife-led care in the United States. Of particular interest to researchers is that MANA stats is based on medical records, which are considered to be the "gold standard" of health care research.

"Validity" is a statistical term that means, essentially, that the data are accurate. In this case, it means that the MANA Division of Research (DOR) selected a random sample of 10% of the records in 4.0, and checked them against the original medical records. We now know which variables in the 4.0 dataset are extremely accurate (cesarean, for instance, is almost always entered correctly), and which variables are slightly less accurate (labor duration has a little more "wiggle room" in it).DOR members are currently analyzing the validation findings, and plan to submit a validation paper for publication in the near future. These steps are time-consuming, but critical, because they ensure that the data can be used by academic researchers in studies for publication.

The 4.0 validation process began in 2012 and was made possible thanks to the efforts of:

  • Midwives whose practices were sampled for the 4.0 validation study for their extensive cooperation with this process
  • Research assistants - Gina Gerboth, Susanna Snyder, and Sudy Storm, who were responsible for checking the existing MANA Stats data against the medical records for sampled births
  • Project Manager - Holly Horan, who generally organized and kept the project on track
  • Funders - the Foundation for the Advancement of Midwifery, who provided much needed funding to support the validation
  • MANA DOR members - Melissa Cheyney, Bruce Ackerman, Marit Bovbjerg, Jennifer Brown, Courtney Everson, Ellen Harris-Braun, and Saraswathi Vedam

MANA Stats datasets include some of the only U.S. data that exists regarding physiologic, low-intervention labor and birth -- data that are becoming more and more rare due to the ubiquitous use of "routine" interventions in the hospital setting. The MANA Stats datasets are a source of information on outcomes of midwifery care, normal lengths of pregnancy and labor, non-pharmacological approaches to pain management, mother-led birth positions, hydrotherapy in labor, and more.

The MANA Stats datasets have been provided to every researcher who has applied to date. These investigators engage research projects designed to explore midwifery care and normal, physiologic birth processes. Learn more about published studies using MANA Stats data and approved projects here.

Next up for validation: the MANA stats 3.0 dataset. The 3.0 data form had the largest number of variables available, which led to a uniquely rich - but more challenging to process - dataset. This effort is being led by Saraswathi Vedam and Kathrin Stoll at the University of British Columbia.

About the authors

Missy Cheney

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

Marit Bovbjerg

Marit Bovbjerg PhD, MS is a reproductive and health services epidemiologist at Oregon State University. Dr. Bovbjerg's research focuses on maternity care in the US, with a sideline into physical activity during pregnancy/postpartum. In her non-work time, she likes to knit, grow vegetables, cook, and play outside (hiking, running, biking, etc.) She does not like to sit still and in fact avoids doing so whenever possible. Marit and her husband are attempting to turn three exuberant children into responsible adults, a task at which they might, on a good day, be slowly succeeding (though likely through no fault of their own). They live in an untidy but cheerfully-painted house in rural Oregon, and enjoy vacationing in places with abundant outdoor activities but few people.

Courtney Everson

Courtney L. Everson PhD is a Medical Anthropologist and the Dean of Graduate Studies at the Midwives College of Utah, Salt Lake City, UT. Dr. Everson is also the Director of Research Education for the Midwives Alliance of North America (MANA) Division of Research (DOR); Co-founder and Vice President of the Oregon Doula Association (ODA); a Research Working Group (RWG) member of the Academic Collaborative for Integrative Health (ACIH); an Accreditation Review Committee (ARC) member for the Midwifery Education Accreditation Council (MEAC); and serves on the Boards of Directors for the Australasian Professional Doula Regulatory Association (APDRA), the Oregon Doula Connection, the Association of Midwifery Educators (AME), and the Academic Collaborative for Integrative Health (ACIH). Dr. Everson's research and teaching specializations include: maternal-child health; human childbirth; adolescent pregnancy and parenting; psychosocial stress; social support; doula care; midwifery care; research and clinical ethics; evidence-informed practice; collaborative care models; mixed methodologies; health inequities; cultural competency/humility; social justice; and underserved populations. She actively publishes in academic forums, and is an invited, avid speaker at local, national and international venues.

 

Meet the Midwives Alliance Division of Research (DOR)

Posted by Midwives Alliance on March 8th, 2016

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Meet the Midwives Alliance Division of Research

The Midwives Alliance Division of Research (DOR) is a volunteer group comprised of clinicians, academics, research and policy experts, and database developers. Together they work to increase knowledge about midwifery care and help midwives become more fluent in conducting research, critically appraising the available data, and incorporating the best available research findings into their practice. 

The DOR is guided by an Advisory Panel and Coordinating Council. The DOR is currently working on a series of projects designed to increase the capacity for, and dissemination of, rigorous research and innovation in maternal-infant health and midwifery care. These projects include the Maternity Care Data Alliance (MCDA), annual benchmarking, expansion of dissemination capacity, public information about the MANA Stats datasets, and educating midwives about research. 

Meet the Coordinating Council

Chair of the Midwives Alliance Division of Research

Melissa CheneyMelissa Cheyney PhD CPM LDM HBM is Associate Professor of Clinical Medical Anthropology at Oregon State University (OSU) with additional appointments in Public Health and Women Gender and Sexuality Studies. She is also a Certified Professional Midwife in active practice, and the Chair of the Division of Research for the Midwives Alliance of North America. She is the author of an ethnography entitled Born at Home (2010, Wadsworth Press) along with several peer-reviewed articles that examine the cultural beliefs and clinical outcomes associated with midwife-led birth at home. Dr. Cheyney is an award-winning teacher and in 2014 was given Oregon State University’s prestigious Scholarship Impact Award for her work in the International Reproductive Health Laboratory and with the MANA Statistics Project. She is the mother of a daughter born at home on International Day of the Midwife in 2009.

Dr. Cheyney is responsible for overseeing DOR projects including the MANA Stats Projects. Her major responsibilities fall into three categories: 1) Facilitation of projects and management of DOR and Coordinating Council activities; 2) Provision of research expertise and recommendations for DOR activities and projects; and 3) Liaison between the DOR Coordinating Council and other midwifery research entities and experts (for example, the ACNM benchmarking project, the Home Birth Summit Research Committee, the MCDA), as well as liaison between the DOR Coordinating Council and the MANA membership at-large via MANA conference presentations and other communications. 

Director of Data Collection

Bruce AckermanBruce Ackerman HBD works on design and improvement of the web data collection system, supports users of this system, and participates in DOR coordination. His interest in birth comes through his marriage to a midwife and long-time involvement with the Midwives Alliance, and the births of his two children at home, and also through a lifelong interest in the ways that our future and our relationship with technology are envisioned. He has worked in laboratory instrumentation, on medical devices, and on renewable energy planning and research.

Bruce’s role on the DOR is to coordinate among multiple disciplines, including researchers, software developers, funders, the MANA Board, and the midwives who contribute data, for the long-term planning and detailed maintenance of the MANA Stats system.

Director of Data Quality

Marit BovbjergMarit Bovbjerg PhD MS HBM is a reproductive and health services epidemiologist in the College of Public Health and Human Sciences at Oregon State University. Her research focuses on maternity care in the U.S., with a particular focus on midwifery care, homebirth, and other potential interventions that might improve outcomes for low-risk women by de-medicalizing childbearing. Marit also studies physical activity during pregnancy/postpartum, breastfeeding, the economics of various healthcare choices, and has recently become interested in methods for quantifying and analyzing variability in longitudinal data. She has 3 children--two intelligent, engaging, beautiful daughters (who came with her husband), and a son, born at home while his sisters slept, who is entirely too smart and energetic for his own good.

Dr. Bovbjerg is the DOR’s Director of Data Quality. Her roles include: serving as the main liaison with external researchers wishing to use MANA Stats data, developing and maintaining the research datasets and accompanying documentation, consulting with the Data Collection team as necessary (e.g., when we are contemplating a slight alteration to question wording or determining what to do with an unusual case), and  since math with greek letters makes her really happy — she is the primary person responsible for data analysis for internal DOR projects. 

Director of Research Education

Courtney EversonCourtney L. Everson PhD is a Medical Anthropologist and the Dean of Graduate Studies at the Midwives College of Utah, Salt Lake City, UT. Dr. Everson is also co-founder and Vice President of the Oregon Doula Association (ODA); an Accreditation Review Committee (ARC) member for the Midwifery Education Accreditation Council (MEAC); and serves on the Boards of Directors for the Australasian Professional Doula Regulatory Association (APDRA), the Oregon Doula Connection, the Association of Midwifery Educators (AME), and the Academic Collaborative for Integrative Health (ACIH). Dr. Everson's research and teaching foci include: psychosocial stress, social support, midwifery care, doula care, physiologic birth, and health inequities. She actively publishes in academic forums, is an avid guest speaker, and has won multiple awards for her teaching, research, and service.

Dr. Everson’s role on the DOR is Director of Research Education. Dr. Everson leads efforts to increase research education among aspiring and currently practicing midwives. She also contributes to many DOR and Coordinating Council (CC) initiatives and research projects. In her role of advancing research education, Dr. Everson works with midwifery schools and midwifery education professional organizations to integrate research literacy skills into educational routes (both initial training and ongoing continuing education). She also collaborates with external stakeholders to ensure that best practices and resources in research fluency for practitioners can be incorporated into both midwifery education/training and client care, with the goal of advancing evidence-informed practice frameworks. Dr. Everson also serves on the Research Review Committee (RRC) of the DOR CC and coordinates the Connect Me! Mentorship program.

Director of Database Development

Ellen Harris-BraunEllen Harris-Braun CPM HBM is half of Harris-Braun Enterprises, an experienced Web-development team that wrote the software for the MANA Statistics web site. Ellen is also a midwife, certified doula, and childbirth teacher involved with birth since 1999 and with MANA since 2002.

Ellen Harris-Braun’s role on the DOR is focused primarily on the creation and maintenance of the software that operates the beautiful MANA Stats web site.

 
Senior Advisor for the MANA Division of Research

Saraswathi VedamSaraswathi Vedam RM FACNM MSN Sci D (h.c.) HBM is Associate Professor at the Division of Midwifery in the Faculty of Medicine, University of British Columbia, and founder of the UBC Midwifery Faculty Practice, Birth & Beyond. Over the last 30 years, she has cared for families in the USA, the Netherlands, India, and Canada in a variety of private and public health care settings. She serves on the Interim Executive Board, Canadian Association of Midwifery Educators, and is the Founding Chair of the historic multi-disciplinary Home Birth Consensus Summits. Professor Vedam has also enjoyed teaching midwifery, medical, and nursing students in universities across North America.

Saraswathi Vedam is the senior advisor to the project.

 

Midwives Alliance Announces the International Center for Traditional Childbearing (ICTC) joining US MERA

Posted by Midwives Alliance on March 8th, 2016

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Midwives Alliance is very happy to announce the International Center for Traditional Childbearing (ICTC) will be joining the United States Midwifery Education Regulation & Association (US MERA) coalition of midwifery organizations.

Nov 9, 2011 Meeting with MANA and ACNM

 

 

 

 

 

 

 

 

Nov 9, 2011 Meeting with MANA and ACNM

MANA has long advocated for the participation of ICTC as an essential voice at the table. Since the groundbreaking meeting in 2011 with the American College of Nurse Midwives (ACNM) at the MANA conference in Niagara Falls, Ontario, to discuss the future of midwifery in the U.S., through the inception and development of US MERA, and into the winter of 2016, MANA has urged representation from ICTC. We believe strongly in their mission “to increase the number of Black midwives, doulas, and healers, to empower families, in order to eliminate infant and maternal mortality.” 

Marinah Farrell, Colleen Donovan-Batson, Sarita Bennett and Geradine Simpkins US MERA meeting, 2014

Our past Executive Director and President Geradine Simkins repeatedly stood up for inclusion of ICTC from the first organizational meeting of US MERA. 

Subsequent Presidents Jill Breen, Marinah Farrell and the MANA board were in full support and remained steadfast throughout, always speaking clearly for acceptance of ICTC as a full association member of the coalition.

More recently, current MANA President Marinah Farrell expressed a conscientious objection to the long and challenging process of ICTC's application

Marinah Farrell, Colleen Donovan-Batson, Sarita Bennett and Geradine Simpkins, US MERA meeting, 2014

and relinquished her steering committee position in an act of solidarity, while acknowledging the importance of MANA continuing on at an organizational level.

Oct 22, 2014  ICTC President Shafia Monroe advocating for ICTC membership on US MERA

 

 

 

 

 

 

ICTC President Shafia Monroe advocating for ICTC membership on US MERA, Oct 22, 2014

MANA Board Member Colleen Donovan-Batson and ICTC President Shafia Monroe

 

 

 

 

 

 

 

 

 

 

 

MANA Board Member Colleen Donovan-Batson and ICTC President Shafia Monroe

Sherry DeVriesSherry Devries graciously filled-in with me on the MERA Steering Committee as we continued to fight for the principles of equity and inclusion, and the importance of addressing disparities at every level. MANA is grateful to Sherry for her encouragement and support during difficult consensus discussions, as well as to the entire MANA board of directors for recognizing the importance of staying at the table on behalf of our membership. 

Sherry DeVries

Shafia Monroe, President & Founder, ICTC

Most importantly, it was through the hard work and determination of President and Founder Shafia Monroe and the ICTC board and membership that this has come to pass. “In 2015, ICTC represented Black midwives and doulas in the national debate of increasing the number of midwives and doulas of color, diversifying the midwifery and doula workforce and improving infant and maternal health in the African American community. And we continued to petition for autonomous membership with the US MERA Coalition.”*

 

 

Shafia Monroe, President & Founder, ICTC

MANA looks forward to welcoming and working with the ICTC representatives to the MERA leadership meeting in April 2016. 

Congratulations

Colleen Donovan-Batson

Sherry Devries

Midwives Alliance Board of Directors

* ICTC February E-News

Read more about US MERA.

 

Integrating Data from the New Waterbirth Study into Care: An Evidence-informed Practice Framework

Posted by Midwives Alliance on February 17th, 2016

A new study on the safety of waterbirth was released in the Journal of Midwifery & Women’s Health on January 20, 2016, authored by MANA Division of Research Coordinator Council members, Drs. Marit Bovbjerg, Melissa Cheyney, and Courtney Everson. This study used data from the MANA Stats project (2004 to 2009) and reported on neonatal and maternal outcomes for 6,534 babies born underwater in home and birth center settings.

Using an evidence-informed practice (EIP) framework, this blog will help you understand the potential care implications of this research.                                                         

~Haven’t had a chance to read the study yet? Read it here first and then come back to this blog for additional guidance!~

What is evidence-informed practice (EIP)? Also referred to as “evidence-based practice,”  “evidence-based care” or “evidence-based medicine,” an EIP framework is the intersection between the best available research, your professional expertise as the practitioner, and the client’s individual values, needs, and context. 

Figure 1 (below) visually depicts EIP. EIP helps improve client care, and supports informed choice and shared decision-making models. (For more information on the EIP framework and resources, see: News From the DOR: Implementing Evidence-Informed Practice During Midwifery Care, November 2015 Blog by C. Everson)

What is Evidence-Informed or Evidence-Based Practice (EIP/EBP)?

Figure 1: Evidence-informed practice

 

Let’s look at the outcomes of the new waterbirth study through the EIP lens:

Best available research evidence

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Professional expertise

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Client values and individual needs

 

Best Available Research Evidence

Let’s start with highlights from the research:

The study included data from 18,343 women who had home or birth center births; 6,521 (35%) of these women had waterbirths. The researchers found no evidence of harm to babies who were born underwater. Whether looking at 5-minute Apgar score, neonatal transfer to the hospital, any hospitalization in the first 6 weeks, NICU admission in the first 6 weeks, or neonatal death, the results were clear: babies born underwater fared as well as those babies whose mothers did not choose a waterbirth.

While the study confirmed that mothers who had a waterbirth were not at increased risk of postpartum transfer (for a maternal indication), hospitalization in the first 6 weeks, or perineal/uterine infection, the study did suggest that mothers who choose waterbirth have a slightly increased risk of experiencing perineal trauma.  

This study is the largest ever published, and the first study to be published in a US population. It provides solid evidence that waterbirth can be a safe and viable option for many lower-risk pregnant women, though midwives and other health care professionals should, as with all childbearing decisions, discuss potential risks and benefits with families and engage in shared decision making. 

One final important point from the research: there were actually THREE groups. Waterbirth, non-waterbirth, and intended-waterbirth. This latter group consisted of those women who had planned a waterbirth, but then did not have one. Women and neonates in this intended waterbirth group had the worst outcomes of the three groups in this study—more on them later. For now, what you need to know is the main conclusion from the study: waterbirth is not associated with ANY adverse outcome for the baby, but it might be associated with an increased risk of tearing for the mother.

Professional Expertise

Now, let’s consider the data from a clinical perspective:

This study demonstrates what midwives already know: waterbirth is safe for babies. The take home message: nothing in this study suggests that midwives need to change current practice to increase safety for neonates during waterbirth. 

However, we want to apply our clinical expertise to dig deeper into the adverse finding of increased perineal trauma for some women. The data cannot tell us the full story because there are not enough variables to create a discernible pattern—or in other words, while the research suggests that there is an increase in perineal trauma among women who gave birth in the water, there was no pattern in terms of where or how bad the trauma was. What we can do, however, is consider this question from a clinical perspective. Possible contributing factors include: How long was the woman in the water? Were “hands on” or “hands off” techniques used for perineal support and protection? Could the birth position (hands and knees, squatting, etc.) be a factor? Your experience as a midwife allows thoughtful reflection on why an increase may have occurred, and this forms the professional expertise area of an EIP approach. 

You may also be questioning why outcomes were worse for the intended-waterbirth group, compared to the waterbirth and non-waterbirth groups. From your clinical experience, you may have come to this logical conclusion: if complications arose during labor, the midwife may have requested that the client get out of the tub in order to facilitate closer monitoring. This may mean that midwives are engaging in appropriate screening to ensure that clients remain good candidates for a waterbirth (of course, some women also just choose to get out of the tub on their own accord). 

On the flip side, you may have noticed that the best outcomes were among the waterbirth group. Does that mean that waterbirth is actually beneficial? Not necessarily. What we have to remember is that “best” and “worst” is relative to the other groups involved. In other words, the outcomes of babies born under water were better compared to those babies not born under water. Why would the outcomes for waterbirth babies be better, comparatively? One explanation is that the lowest risk women stayed in the water, just like the higher risk women may have been asked to get out of the water. What this means is that the location of birth (waterbirth, intended-waterbirth, non-waterbirth) may be serving as a proxy for the risk level of the mother. In research, we call this “selection bias.” Recognizing this bias helps us to understand why even though it may look like waterbirth is beneficial (because those babies have the best outcomes), the improved outcomes are likely a reflection of who stayed in the water and who did not. 

While selection bias may mean that waterbirth by itself does not improve outcomes, it also does not take away from the key finding: waterbirth is safe for babies. We can say this with certainty because all 6,534 neonates in the waterbirth group were, in fact, born underwater, and there was no evidence of increased risk for any outcome.

Client Values & Individual Needs

Finally, let’s integrate our clients’ values and individual needs:

Midwives provide informed consent on the risks and benefits of waterbirth using a shared decision-making framework. You counsel clients using what you know from research and your own practice, and the family then decides what route is best for them and their baby.

The new understanding of increased risk of perineal trauma will need to be discussed. Other key findings that demonstrate the safety of waterbirth should also be shared, such as: 1) there was no increased risk of mortality or morbidity for newborns; and 2) that waterbirth was not associated with maternal hospitalization in the immediate or first six weeks postpartum, or with maternal infection.

By engaging shared decision-making and EIP frameworks, you can (and should) also draw on the larger body of literature on waterbirth (see the references list in the current study to get you started) as well as professional practice guidelines, including a soon-to-be-released evidence-based waterbirth clinical bulletin drafted by a multi-stakeholder group (anticipated release: Spring 2016). Collectively, existing research combined with your expertise as a midwife allows you to engage in a detailed and comprehensive conversation with clients, where autonomy in decision-making can be exercised within an EIP framework. 

Concluding Thoughts

Excited about this research? We are too, and we owe it all to you! This research would not be possible without the many midwives who contribute data to the MANA Statistics project. The ability to even study waterbirth highlights the value of the MANA Stats project, which provides a rich dataset focused on physiologic birth practices. Without this data source, large research studies on practices like waterbirth would be difficult, given their relative infrequency in the hospital. So, midwife contributors, many thanks for taking the time to advance research on midwifery care and physiologic birth practices! And for those midwives not yet contributing, you can sign-up anytime! Learn more, here.

About the authors

Courtney Everson

Courtney L. Everson MA, PhD is a Medical Anthropologist and the Dean of Graduate Studies at the Midwives College of Utah, Salt Lake City, UT. Dr. Everson is also the Director of Research Education for the Midwives Alliance of North America (MANA) Division of Research (DOR); Co-founder and Vice President of the Oregon Doula Association (ODA); a Research Working Group (RWG) member of the Academic Collaborative for Integrative Health (ACIH); an Accreditation Review Committee (ARC) member for the Midwifery Education Accreditation Council (MEAC); and serves on the Boards of Directors for the Australasian Professional Doula Regulatory Association (APDRA), the Oregon Doula Connection, the Association of Midwifery Educators (AME), and the Academic Collaborative for Integrative Health (ACIH). Dr. Everson's research and teaching specializations include: maternal-child health; human childbirth; adolescent pregnancy and parenting; psychosocial stress; social support; doula care; midwifery care; research and clinical ethics; evidence-informed practice; collaborative care models; mixed methodologies; health inequities; cultural competency/humility; social justice; and underserved populations. She actively publishes in academic forums, and is an invited, avid speaker at local, national and international venues.

Marit Bovbjerg

Marit Bovbjerg PhD, MS is a reproductive and health services epidemiologist at Oregon State University. Dr. Bovbjerg's research focuses on maternity care in the US, with a sideline into physical activity during pregnancy/postpartum. In her non-work time, she likes to knit, grow vegetables, cook, and play outside (hiking, running, biking, etc.) She does not like to sit still and in fact avoids doing so whenever possible. Marit and her husband are attempting to turn three exuberant children into responsible adults, a task at which they might, on a good day, be slowly succeeding (though likely through no fault of their own). They live in an untidy but cheerfully-painted house in rural Oregon, and enjoy vacationing in places with abundant outdoor activities but few people.

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