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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.

 

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

+

Professional expertise

+

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.

Meet the New DOR Intern - Katelyn Edel

Posted by Midwives Alliance on February 16th, 2016

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Katelyn EdelMy name is Katelyn Edel, and I am the new intern for the Department of Research, where I work closely with Bruce Ackerman, Jen Brown, and Sarita Bennett. 

In addition to my new role with MANA, I am currently a first-year student at the Brown University School of Public Health, where I am focusing on rural health policy and women’s health and working towards my MPH degree. I first contacted MANA because I was looking for a data set that I could use for my upcoming thesis project. I was very committed to the idea of a thesis topic that would not only fulfill Brown’s requirements, but that would also interest and inspire me – and the two most inspiring topics I could think of were midwifery and statistics. 

I have been interested in healthcare for quite awhile, and I have a particular passion for women’s health and their well-being. The intent behind nearly all of my work is to contribute to a world in which women are supported in their reproductive choices, regardless of whether those choices are made at home, in a hospital, or in a larger societal context. I am especially invested in ensuring access, choice, and quality services for women in underserved and low-resource communities, and finding better ways to deliver care to those populations. 

I am incredibly blessed to have grown up in a family that not only supports, but also celebrates, women’s choice. My brother and some of my cousins have been born at home, all with the caring skill that only a midwife can provide. In this sense, I feel that I am really fortunate to have been exposed to midwifery throughout my life, because in school I often find myself in academic or clinical settings where the wisdom of midwifery is not supported, although I look forward to the day that this changes. 

Which, finally, brings me to my enthusiasm and interest in evidence-based practice and research. I firmly believe in the power of data, which is why I think the MANA Statistics Project is so wonderful. MANA Stats is an incredible tool for midwives, for researchers, and for the general community, because it is a vehicle that can provide truly valuable scientific insight. With the DOR, I am helping to ensure that midwives are able to use MANA Stats in an effective way – essentially, I am a “Data Doula,” and I do a lot of Support Calls, Welcome Calls, and general follow-up with the midwives that are enrolled with MANA Stats. I think it’s important to have real, honest-to-goodness phone conversations with the new enrollees, or with contributors who may feel unprepared to use the MANA Stats software, because it creates a sense of community and of support. Long-term, I will be not only continuing my work as a Data Doula but also creating a handbook and other resources for future Data Doulas, which will be important as the MANA Statistics Project continues to grow. 

I’m really very happy to have the opportunity to work with MANA Stats from both ends, as a future researcher using it for my thesis, and as a Data Doula for the midwife-contributors. So far, my work has provided me with a sense of holistic understanding about the entire research process and that has proven to be an invaluable tool. I look forward to continuing my internship throughout the year, and I am especially excited about attending the MANA Conference in Atlanta! Everyday I am inspired by all of the wonderful people that I meet at MANA, and I am honored to be a part of this community. As I continue with school (and as I start the certification process to become a doula!) I hope to be able to contribute to MANA in a myriad of ways – first as an intern, but one day as a member. 

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.

New Studies Confirm Safety of Home Birth With Midwives in the U.S.

Posted by Midwives Alliance on January 30th, 2014

by Geradine Simkins, CNM, MSN, Executive Director, Midwives Alliance of North America

In today’s peer-reviewed Journal of Midwifery & Women’s Health (JMWH), a landmark study** confirms that among low-risk women, planned home births result in low rates of interventions without an increase in adverse outcomes for mothers and babies.

This study, which examines nearly 17,000 courses of midwife-led care, is the largest analysis of planned home birth in the U.S. ever published.

The results of this study, and those of its companion article about the development of the MANA Stats registry, confirm the safety and overwhelmingly positive health benefits for low-risk mothers and babies who choose to birth at home with a midwife. At every step of the way, midwives are providing excellent care. This study enables families, providers and policymakers to have a transparent look at the risks and benefits of planned home birth as well as the health benefits of normal physiologic birth.

Of particular note is a cesarean rate of 5.2%, a remarkably low rate when compared to the U.S. national average of 31% for full-term pregnancies. When we consider the well-known health consequences of a cesarean -- not to mention the exponentially higher costs -- this study brings a fresh reminder of the benefits of midwife-led care outside of our overburdened hospital system.

Home birth mothers had much lower rates of interventions in labor. While some interventions are necessary for the safety and health of the mother or baby, many are overused, are lacking scientific evidence of benefit, and even carry their own risks. Cautious and judicious use of intervention results in healthier outcomes and easier recovery, and this is an area in which midwives excel. Women who planned a home birth had fewer episiotomies, pitocin for labor augmentation, and epidurals.

Most importantly, their babies were born healthy and safe. Ninety-seven percent of babies were carried to full-term, they weighed an average of eight pounds at birth, and nearly 98% were being breastfed at the six-week postpartum visit with their midwife. Only 1% of babies required transfer to the hospital after birth, most for non-urgent conditions. Babies born to low-risk mothers had no higher risk of death in labor or the first few weeks of life than those in comparable studies of similarly low-risk pregnancies. 

Importantly, this study also sheds light on factors that may increase risk. These findings are consistent with other research on pregnancy complications, but the numbers of these pregnancies were low in the MANA Stats dataset, making it impossible to make clear recommendations. This article from Citizens for Midwifery contains important information to share with families who are contemplating their birth options and weighing their individual risks and benefits.

This study is critically important at a time when many deeply-flawed and misleading studies about home birth have been receiving media attention. Previous studies have relied on birth certificate data, which only capture the final place of birth (regardless of where a woman intended to give birth). The MANA Stats dataset is based on the gold standard -- the medical record. As a result, this study provides a much-needed look at the outcomes of women who intended to give birth at home (regardless of whether they ultimately transferred to hospital care). The MANA Stats data reflects not only the outcomes of mothers and babies who birthed at home, but also includes those who transferred to the hospital during a planned home birth, resolving a common concern about home birth data.

This study adds to the large and growing body of research that has found that planned home birth with a midwife is not only safe for babies and mothers with low-risk pregnancies, but results in health and cost benefits that reach far beyond one pregnancy. We invite you to share this news in your communities, and join the conversation on our Facebook page, Twitter, and Pinterest

We are grateful to the ongoing support of the Foundation for the Advancement of Midwifery, which has been a major funder of the MANA Statistics Project.

** Note added 12:33 EST when the issue was published:

MANA Statistics Project Update

Posted by MANA Community Manager on January 24th, 2014

We’re incredibly excited to tell you that on January 30th, next Thursday, the much-anticipated outcomes from our MANA Stats 2004-2009 dataset will be publicly released.  

Two articles will be published in the upcoming Journal of Midwifery & Women’s Health: one describes the MANA Stats system and how it works, and the other describes the outcomes of planned home births with midwives between 2004 and 2009.  

The Midwives Alliance is proud of our Division of Research and the amazing MANA Stats system. This is the largest registry of planned home births in the U.S. and one of only two large datasets where normal physiologic birth can be studied, and we thank all of the contributor midwives who have made this possible. We also thank the members of the MANA Division of Research who created the system, continually improved it over the years, and have put quality assurance processes in place to make sure the data are sound.  And finally, we thank the researchers who shepherded these articles down the long road to publication.  We’re looking forward to the important conversations that these articles will generate!

For an in-depth look at what to expect from the articles, check out the post Understanding MANA Stats here.

Watch here for an update next Thursday, when we’ll share with you a summary of the findings, links to the research, and materials to share with women, families and others interested in learning more about home birth.

image credit: www.sweetbirths.com

Understanding Outliers In Home Birth Research

Posted by on September 17th, 2013

by Wendy Gordon, CPM, LM, MPH, member of the Coordinating Council of the MANA Division of Research

Yesterday, a press release was issued drawing new attention to the American Journal of Obstetrics and Gynecology’s not yet published research that finds that babies born at home are “roughly 10 times as likely to be stillborn and almost four times as likely to have neonatal seizures or serious neurologic dysfunction when compared to babies born in hospitals.”

First, it is vitally important to note that this study did not actually examine rates of stillbirth, but rather 5-minute Apgar scores.  The press release is completely misleading and inaccurate on this point.  We will return to this issue below.

This research stands in sharp contrast to a large and growing body of research that shows that, for low-risk women with a skilled midwife in attendance, home birth is a safe option for newborns with lower rates of interventions and complications for mothers.  In addition, it opposes the enormous amount of research regarding the usefulness of birth certificate data to draw conclusions about rare outcomes.

Haven’t we seen this guy before?

These claims - and these co-authors - are not unfamiliar to home birth scholars. The first glimpse of this study’s results was seen at the Institute of Medicine’s “Research Issues in the Assessment of Birth Settings” workshop earlier this year.

The early findings were presented at the IOM workshop by Dr. Frank Chervenak, a co-author of the study - whom you may remember from the notorious “recrudescence” article, where he argued that physicians have a professional responsibility to advise against home birth (read responses from consumers here and here and an analysis of the science behind it here.)

During Chervenak’s presentation of this data at the IOM workshop, serious concerns about the methodology were raised - none of which appear to have been addressed in this final article. So now that the full study is seeing the light of day, what are the concerns? And what does this research tell us?

What are the limitations of birth certificate data for this kind of research?

This research, which claims to be the largest study of its kind, relies on data from birth certificates (known as “vital records”).  What we know about using information drawn from birth certificates is that they are pretty good for capturing information about things like mother’s age and whether she is carrying twins. They are not very accurate when it comes to rare outcomes like very low Apgar scores, seizures, or deaths (Northam & Knapp, 2006).  Fortunately, these outcomes are extremely rare events, regardless of place of birth, but their rarity makes them quite difficult to study - especially when using a source of data that is known to be unreliable.  With rare events, even a small number of miscounted events can distort findings and produce misleading interpretations.

A second, deep concern is that birth certificates in almost half of U.S. states still do not adequately capture intendedplace of birth.  This has been a fatal flaw in the few studies that have shown adverse outcomes with home birth, and it is a fatal flaw in this study as well.  In recent well-designed studies that captured planned place of birth andused better sources of data, there were no differences in 5-minute Apgar scores between home and hospital settings (Hutton et al, 2009; Janssen et al, 2009; van der Kooy et al, 2011).

The fact that vital statistics data can’t tell us much about the safety of home birth has been well-established by birth certificate scholars and epidemiologists. At the IOM workshop, Marian MacDorman, Senior Statistician at the National Center for Health Statistics, CDC, clarified how to interpret the this type of data. In response to Chervenak’s presentation on the data in this study, she pointed out that regarding low Apgar scores, “the absolute risk is low; that’s all you can say with vital data.” She also made clear that data from birth certificates cannot be used to make comparisons between settings or providers.

What about equating low 5-minute Apgars with stillbirth?

One assumes that the press release was perhaps not carefully reviewed by the authors of the study, as they did not actually examine data about stillbirths. They analyzed the rare occurrence of 5-minute Apgar scores of zero, which may be indicative of a number of possible events which may or may not have been related to the time, location or care provider at the birth. The authors note that stillbirths may have occurred in the third trimester, may have been due to lethal congenital anomalies, and other possibilities that are captured in a 5-minute Apgar score of zero.  We cannot draw any conclusions about safety when looking at this piece of data in isolation.

We will examine this issue and other methodological concerns more in depth in a later blog post, as will many home birth scholars, undoubtedly.  However, if we are committed to providing women and their families with useful information about birth safety, our media materials need to correspond to the actual research conducted.

Concerns that birth in any given setting may pose a risk to mothers or babies need to be taken seriously and examined closely. However, when the underlying data source is flawed, it is difficult to draw meaningful conclusions from the analysis of the data.

To learn more about existing, well-designed home birth data, read here. To learn more about the MANA Stats Project, which provides researchers with a dataset of more than 24,000 planned home birth and birth center births, read here. And watch for new research based on the MANA Stats dataset 2004-2009. Two articles are in press and two more are under review in peer-reviewed journals.

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Wendy Gordon, LM, CPM, MPH is a midwife, mother and educator in the Seattle area.  She has practiced for several years in both home and birth center settings with nurse-midwives and direct-entry midwives.  She is a Coordinating Council member of the Midwives Alliance Division of Research, a board member of the Association of Midwifery Educators, and teaches at the Bastyr University Department of Midwifery.

References:

Hutton, E. K., Reitsma, E. H., & Kaufman, K. (2009). Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: A retrospective cohort study. BIRTH 36(3):180-189.

Janssen, P. A., Saxell, L., Page, L. A., Klein, M. C., Liston, R. M., & Lee, S. K. (2009). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ 181(6-7):377-383.

Northam, S., & Knapp, T. R. (2006). The reliability and validity of birth certificates. JOGNN 35(1):3-12.

van der Kooy, J., Poeran, J., de Graaf, J. P., Birnie, E., Denktas, S., Steegers, E. A. P., & Bonsel, G. J. (2011). Planned home compared with planned hospital births in the Netherlands: Intrapartum and early neonatal death in low-risk pregnancies. Obstetrics & Gynecology 118(5):1037-1046.

Photo credit: Jason Lander on Flickr

 
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