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New and Sometimes Conflicting Research on Out-of-Hospital Birth

Posted by Midwives Alliance on January 7th, 2016

In the past month, two new studies have been released - one in the New England Journal of Medicine (NEJM), the other in the Canadian Medical Association Journal (CMAJ) - examining out-of-hospital birth outcomes. The CMAJ study examined 2006-09 provincial health records while the NEJM study analyzed two years of Oregon vital statistics data. What makes the NEJM study unique is that the Oregon birth certificate now allows researchers and others to track the intended place of birth, providing for more accurate categorization of the outcome of transfers.

The two studies both found that families that choose out-of-hospital birth experience fewer interventions, including labor augmentation, assisted vaginal births, cesarean births, and episiotomies.

Both studies also found that the absolute risk of adverse neonatal outcomes is small regardless of setting. However, the CMAJ study found equivalent risk between home and hospital settings, while the NEJM study found that planned out-of-hospital births were associated with an excess of less than 1 fetal death per 1000 deliveries -- a small but statistically significant difference. 

Resources:

Media coverage. MANA has compiled resources for midwives reviewing the outcomes and providing guidance for interpretation for families. 

First, here's a piece in Forbes that provides balanced coverage (note the article - like many - refers to "home birth" while the study combined birth center and home birth data together). 

MANA provided expert commentary to a number of the recent news articles, including The New York Times and The Washington Post.

Expanded coverage at Science and Sensibility. The official blog of Lamaze International has provided balanced coverage of the New England Journal of Medicine research. In this post, Henci Goer compares and contrasts this newest study with other recent home birth analyses. Missy Cheyney, Chair of the Midwives Alliance Division of Research, provides guidance for families interpreting the new research in this post.

Model transfer guidelines. The authors of the NEJM article call for increased collaboration and integration of out-of-hospital providers into the maternal health care system. The Best Practice Guidelines: Transfer from Planned Home Birth to Hospital, developed by the collaboration committee of the Home Birth Summit, are an important and practical tool to increase integration.

The guidelines were designed to facilitate the safe and mutually respectful transfer of care of a woman and her family from a planned home birth to the hospital. The model blueprint was created as the result of a unique collaboration among physicians, midwives, nurses and consumers.

To learn more or endorse the guidelines, visit here.

News From the DOR: Implementing Evidence-Informed Practice During Midwifery Care

Posted by Midwives Alliance on November 12th, 2015

We hear the terms “evidence-based practice” (EBP) or “evidence-informed practice” (EIP) used often in the healthcare world, being cited as an expected and central component of high-quality care delivery. But what do these terms really mean? There is a misconception that in EBP/EIP approaches, “research evidence” automatically equates to “what I should do in practice”. This, however, is simply not true. EBP/EIP rests in the triad intersection between the best available research with your professional expertise as the practitioner alongside the client’s individual values, needs, and context. Figure 1 (below) visually represents what we are striving for when we say EBP or EIP, in ultimate commitment to improved client care, informed choice, and shared decision-making models.

Evidence-informed Practice Triad

 

You may be thinking: okay, I definitely have expertise as a midwife, and I feel I have a good understanding of my client’s unique needs, but how do I integrate research into practice?  A great place to start is with a series of modules on the Principles of Evidence Informed Practice from the University of Minnesota. These modules are self-paced, free of charge, geared towards busy practitioners, and thus intended to be short and sweet, ranging from just a mere 15 minutes to 30 minutes of your time. The series includes: Section I - Overview of Evidence Informed Practice; Section II – Types of Research; Section III – Using Evidence in Practice; and Section IV – Understanding Research & Statistics; plus resources and guiding sheets to help you implement evidence-informed practice during client care. Advance your professional self and check out these modules.

Finally, how do you find research to integrate? There are many peer-reviewed journals and scholarly databases to help you in your search. A few core ones to consider (many of which are open access!) are:

Google Scholar

PubMed   

BioMed Central

BMC Pregnancy & Childbirth

Cochrane Reviews   

Directory of Open Access Journals

PLOS One

North American Journal of Medical Sciences

HighWire

ERIC: Institute for Educational Sciences (collection: midwifery)

Quick Tip: for those users of handheld devices, check out the free app, PubMed for Handheld (search in the app store for “PubMed4HH”). Acknowledgements to the Consortium of Evidence-informed Practice Educators.

Pre-appraised literature options:

Dynamed

EvidenceUpdates

ClinicalEvidence

UpToDate

Courtney Everson About the author

Courtney L. Everson, PhD, is the Director of Research Education for the Midwives Alliance Division of Research, a Biocultural Medical Anthropologist and the Graduate Dean at the Midwives College of Utah (MCU). Dr. Everson is also the 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 Board of Directors for the Australasian Professional Doula Regulatory Association and Doulas Supporting Teens. Her research and teaching specializations are in maternal-child health; adolescent pregnancy/parenting; psychosocial stress; social support; doula care; midwifery care; research & clinical ethics; collaborative care models; health inequities; and social justice.

Frequently Asked Questions: Practitioner and Practice Characteristics of Certified Professional Midwives

Posted by Midwives Alliance on October 2nd, 2015

Questions about the education levels and routes to certification for Certified Professional Midwives often play a role in policy discussions about birth providers, but little current evidence has been available to inform these conversations. 

A new article in the Journal of Midwifery and Women’s Health takes a close look at data from the NARM 2011 Survey. We asked Melissa Cheyney, lead author of the article, to share with us this FAQ. This piece was developed to inform midwives, consumers, and policy makers on the outcomes.

Frequently Asked Questions: Practitioner and Practice Characteristics of Certified Professional Midwives

The demographics, education levels, routes to certification, and practice characteristics of currently practicing CPMs are assessed in a new article released September 18, 2015 in the Journal of Midwifery and Women’s Health.

The article Practitioner and Practice Characteristics of Certified Professional Midwives in the United States: Results of the 2011 North American Registry of Midwives Survey is authored by Melissa Cheyney and colleagues and uses  data collected from the 2011 North American Registry of Midwives (NARM) Survey. (Find the abstract here: Cheyney, M., Olsen, C., Bovbjerg, M., Everson, C., Darragh, I. and Potter, B. (2015), Practitioner and Practice Characteristics of Certified Professional Midwives in the United States: Results of the 2011 North American Registry of Midwives Survey. Journal of Midwifery & Women’s Health.)

What was the primary purpose of the study?

No data describing CPMs currently exist in the literature, though they attend the majority of home births in the United States. The study was designed to begin to fill this gap. Specifically, it aimed to answer three research questions: 

1) Who are CPMs in the United States, and how are they getting their educations?

2) Are there differences between CPMs practicing in regulated and unregulated states in terms of training routes or non-midwifery education levels?

3) Who are CPMs serving and how do they practice?

In addition, the project aimed to assess the degree to which US CPMs meet the ICM education standards. A concurrent, non-research goal was to provide updated information about the CPM credential, since this information does not currently appear in the peer-reviewed literature.

How about the response rate? How many currently practicing CPMs responded to the survey?

The initial invitation was sent to 1,391 CPMs, and 849 (61%) responded. Because the survey was not originally designed for research purposes, the original survey respondents were sent an email explicitly requesting consent to have their data used for research. Of the 849 initial respondents, 568 provided consent for their responses to be analyzed; 281 did not respond. The final response rate was 41%.

Is it possible to generalize to the entire population of practicing CPMs, given the response rate of 41%?

Very likely yes, because the researchers also completed something called a non-response bias analysis. This entailed calling a random 10% subsample of the initial non-respondents and asking them an abbreviated version of the survey over the phone. Because the original respondents and the non-respondent group did not differ significantly in any key characteristics or responses, the findings presented in the study very likely accurately reflect the population of currently practicing CPMs.

What did the study find regarding non-midwifery education levels for CPMs?

More than 90% of the 568 respondents attended at least some college, and 47.1% hold a bachelor’s degree or greater. Only 0.5% of respondents (n=3) did not have high school degrees or the equivalent in 2011.

How long do CPMs spend in training prior to taking on the role of primary midwife?

CPMs spent a median of 3 years in training before attending births as a primary midwife.  Sixty one percent met the International Confederation of Midwives (ICM)-recommended 3 years of training, however, 38.9% of currently practicing CPMs did not.

This is at least partially explained by the fact that “grand” CPMs (CPMs who have been practicing for 25 years or more) comprise 19% of currently-practicing CPMs. Midwives who began practicing this long ago, before certification was available, often began primary practice very early in their careers and sometimes with little or no formal training. These CPMs describe being taught by birth, other midwives, and home-birth-friendly physicians as they pieced together their training in the 1970s and 1980s, before formal training or credentialing opportunities existed. As the profession has matured and formal training routes have been developed, it is much less common today for CPMs to enter primary practice before the 3-year mark.

In addition, because of the variability in volume of births at training sites, the study also found that student midwives training in high-volume birth centers can easily attend more than 100 births per year during their 1 to 2-year internships, allowing them to acquiring their CPM prior to the internationally-recommended 3-year training period. Conversely, student midwives in low-volume home birth apprenticeships might take several years to qualify to sit for the NARM examination having attended fewer than 100 births. The authors conclude that within the current competency-based system of CPM education in the United States, length of time to primary practice may not always be the most useful way of estimating competency. Some combination of volume and years in training may be more helpful in this regard.

So what pathways to certification are CPMs actually using?

The study found that 48.5% utilized the Portfolio Evaluation Process (PEP), 36.9% graduated from a Midwifery Education and Accreditation Council (MEAC)-accredited school, 14.5% were already licensed by a state as a direct-entry midwife, and 0.7% were already a CNM or CM. However, the researchers stress that routes to certification (that is how CPMs apply to sit for the NARM examination) should not be confused with how CPMs get trained. The study found that CPMs reported a blended education pathway that commonly involved a mixture of MEAC-accredited schooling and apprenticeship in home and birth center practices, regardless of which (MEAC- or PEP-route, for example) pathway to certification the midwives used to acquire permission to sit for the NARM examination.

Debates over the CPM credential have focused on the relative merits or limitations of the two primary routes to certification: graduation from a MEAC-accredited school or successful completion of the PEP. How does this study inform that discussion?

This study found that CPM training is far more complex than this dichotomy suggests. While respondents largely cited either the PEP or MEAC route to certification, a closer look at how midwives are getting their educations showed that the vast majority of respondents combined multiple training opportunities over the course of their educations, depending on two key variables: 1) whether or not they lived in a regulated state with an accredited school and 2) whether they had sufficient funds to attend one of these schools for the entirety of their educations. Although each applicant must designate a single pathway on their NARM application, economic and legal barriers cause many to create a patchwork training trajectory that combine aspects of MEAC and PEP. As a result, the authors would argue that the "MEAC or PEP" dichotomy is a false one.

What did the study find regarding differences between CPMs living in regulated vs. unregulated states?

The regulatory status of the CPM credential in each respondent’s state was found to have an association with the certification pathway chosen by midwives. Analyses showed a significant difference (P < .001) between certification pathways chosen by midwives residing in regulated versus unregulated states. The PEP process was more likely to be used in unregulated states, while MEAC-accredited schools and the state licensed midwife pathway were more likely to be used in states where CPMs are licensed and regulated.

What about the demographic characteristics of CPMs? How diverse is the population of providers?

One-fifth (21%) of respondents identified as midwives of color. While nearly one-third (31.8%) of CPM respondents reported that 95% or more of the clients they serve are white, 5.2% serve populations that are 90% or more women of color. CPMs of color were also found to be significantly more likely to serve clients of color. Given the finding that midwives’ self-reported ethnicity/cultural group is strongly associated with the client population served, the authors identify the lack of racial, ethnic, and cultural diversity in the profession as a major concern.

Cheyney and colleagues state that while, “it is unclear from our results whether midwives of color seek clients of color or vice versa, it is clear that without more midwives of color, childbearing families of color will have limited access to culturally-matched midwifery care and particularly to home birth services. Home and birth center birth may currently be a white middle-class phenomenon in the United States not because women of color prefer hospital birth, but because they have been systematically excluded from choice in childbearing by larger structures of inequality.” 

The same economic and legal barriers that impact all CPM education may be disproportionately impacting midwifery candidates of color. These barriers, compounded with larger issues of systemic inequality, may be sufficient to bar entry to the profession for many potential midwives of color.

Melissa CheneyAbout the author

Melissa Cheyney, PhD, CPM, LDM is the Chair of the Midwives Alliance Division of Research, and an Associate Professor of Medical Anthropology and Reproductive Biology in the Department of Anthropology at Oregon State University (OSU). She received her doctorate from the University of Oregon in 2005, where her research examined the U.S. Homebirth Movement and Midwifery Models of Care. Dr. Cheyney is a Certified Professional Midwife, Director of the Reproductive Health Laboratory at OSU, and Chair of the Board of Direct-entry Midwifery for the State of Oregon. She is also the author of the recently published ethnography, Born at Home by Wadsworth Press. Her research specializations are in midwifery care, interprofessional collaboration, reproductive biology, maternal-child health, homebirth, and medical anthropology.

Hormonal Impacts of Health Disparities on Birth Outcomes

Posted by Midwives Alliance on September 24th, 2015

The Cycle of Stress and Poor Birth Outcomes

Midwives Alliance of North America, in collaboration with ICTC, ICAN, and Elephant Circle is releasing this Executive Summary of Existing Research on Racial Disparities in Birth Outcomes and Racial Discrimination as an Independent Risk Factor Affecting Maternal, Infant, and Child Health. This infographic graphically depicts key findings and offers solutions.

New Research on Planned Home VBAC in the United States: Interview with Study Author Melissa Cheyney, PhD, CPM, LDM on the Implications for Midwives

Posted by Midwives Alliance on September 15th, 2015

Topics  

“Planned Home VBAC in the United States, 2004–2009: Outcomes, Maternity Care Practices, and Implications for Shared Decision Making” came out on August 26th as an e-pub ahead of print in the journal Birth: Issues in Perinatal Care. It provides a much-needed analysis of VBACs in the home setting in the United States. 

To help the birth-professional community better communicate the findings with students, clients and others considering home birth after cesarean (HBAC), Jeanette McCulloch of BirthSwell interviewed Missy Cheyney, PhD, CPM, LDM, one of the paper’s authors. The abstract of the paper, lead-authored by Kim Cox, PhD, CNM, and co-authored by Marit Bovbjerg, PhD, MS, and Lawrence M. Leeman, MD, MPH, can be found in an online-only version here

The first part of the interview is currently available in a guest blog at Science and Sensibility. In that post, which you can read here, Missy shares the findings and her recommendations for parents and policy makers. Missy shares advice specific to midwives, based on the study’s findings, here at the MANA blog. Read on to learn more.  

Jeanette: So, what advice do you have for midwives working with a family who is considering an HBAC?

Missy: I think it is important to look very closely at the mortality and uterine rupture findings presented in the paper [the study found five deaths overall in the TOLAC sample, with three deemed unrelated to the mother having had a previous cesarean]. If we look at the two instances of confirmed uterine rupture (confirmed upon cesarean section), neither of those babies died. The midwives attending these mothers were monitoring very closely during labor and caught, early on, that something was going awry, as in decreased heart tone variability and a non-progressive labor pattern. They transferred, there was a repeat cesarean, and mother and baby were discharged in excellent condition three days after their births. In the other two cases of presumed uterine rupture (no cesarean, so no confirmation), trouble was not detected until very, very late in the process, there was no time to transfer, and both babies were born at home, but could not be resuscitated. Both of those babies died. 

The MANA Stats 2.0 form had a question that asked midwives how frequently they monitored. The midwives who said their client was attempting a TOLAC did not, in many cases, also indicate on the form that they listened more frequently. Now, part of that is because the question was not asked in an ideal way, but I will say that an overall trend in our mortality case-review process is examining the degree to which some midwives are listening and whether we are listening sufficiently. I said this last year in my presentation at the MANA 2014 conference: you have got to really be on heart tones, especially if the mother has any risk factors, including a longer than average labor or a clear plateau. What we have learned from the mortality case review - which is what we did here, we case-reviewed every one of these deaths - is that midwives who were listening very diligently (so through contractions and then for 30 seconds afterwards with increasing frequency as labor intensifies), can catch early signs of decreasing variability and respond appropriately.

The other thing that's significant is that in the cases with fatal ruptures, those mothers had plateaued, so their first or second stages were stalled for a prolonged period of time, and this can be a problem. It fits with what we know from the larger body of the literature that if you have a mother that is contracting adequately and her cervix is not changing or the baby is not moving down, the strength of those contractions will cause something to open, something to move. We're hoping it will be the cervix, but if the cervix is not opening, we need to be concerned that it might be the scar. I would advise midwives attending any woman who's attempting an HBAC to be aware that a plateau itself can be a risk factor; to listen more frequently; and to have a tighter protocol around transfer. And that means acknowledging that women attempting a TOLAC are higher risk than a multiparous woman without a previously scarred uterus. I'm not saying that they are so high risk that we can never consider them for home birth. In fact, I think that some women desiring a TOLAC are excellent candidates for HBAC. But I would say, we've got to listen more carefully and engage in very individualized, shared decision-making related to the location of the placenta, length of time to the hospital, our relationships with hospital providers in our communities once we arrive, length of time between pregnancies, etc.

I think that the vast majority of midwives attending HBACs in the United States are doing these things. Yet a study like this gives us all the invaluable opportunity to stop, turn the lens inward, and think critically about how we can make our practices as safe as possible. We all know that there is no joy, no empowerment as we typically hope for our clients in an HBAC, when there is also a loss.

Jeanette: And do you recommend any additional prenatal screening?

Missy: I do. It was concerning to us (the authors) that nearly 25 percent of women in the TOLAC group did not receive an ultrasound for placental location and diagnosis of accreta prior to attempting a TOLAC at home. Given that the rate of abnormal placentation is rising, an obstetrical ultrasound should be standard of care for any woman with a prior cesarean. Also, less than 40% of the women in the TOLAC group had GDM testing. Some of this may be reflective of the difficulty in some states of acquiring lab tests and ultrasounds, and this needs to be addressed immediately. Women are going to continue to want to attempt VBACs, and HBACs more specifically. They need access to adequate prenatal screening. If we are caring for someone who already has the known risk factor of a previously scarred uterus, we want to make sure that we have normal placentation, and we want to know that she doesn't have any other comorbidities because there can be a compounding of risk, like we see in the twin VBAC case [presented in the study]. 

This study makes me think about how important it is that all maternity care providers work together to make birth as safe and empowering for families as possible, wherever we practice, and whether or not we ourselves would ever consider having or attending a home birth after cesarean.

To read the complete interview, visit our guest post at Science and Sensibility.

About the authors

 

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.

 

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