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MANA and CfM release new Joint Position Statement on Waterbirth

Posted by Midwives Alliance on January 28th, 2016

Mother and baby in birthing tub

The MANA and CfM Joint Position Statement on Water Immersion During Labor and Birth is a position paper written for a broad audience including midwives and other birthcare professionals, consumers, doulas, childbirth educators, and policy makers. It is co-authored by the Midwives Alliance of North America and Citizens for Midwifery. A year of collaborative work has produced a great educational tool that gives concise access to the research and the wisdom of experience that documents the safety, benefits and recommendations for success. With over 80 citations, including the new study "Maternal & Newborn Outcomes Following Immersion During Waterbirth" by Bovbjerg, Cheyney and Everson, which utilized data from the MANA Statistics project, and research by waterbirth activist Barbara Harper, the position paper is a reference guide to the evidence for the safety of water immersion during labor and birth.

How does the new study using data from the MANA Statistics project help us better understand waterbirth?

The research of Bovbjerg, Cheyney and Everson helps to dispel some of the more publicized concerns about the safety of waterbirth to the baby, including drowning, cord avulsion and respiratory distress. No deaths in over 6500 water births were attributable to being born under water. There was also no additional risk of maternal infection or hemorrhage.

The MANA Stats study showed that 35% of over 18,000 home and birth center births occurred in water, demonstrating that the midwives contributing to MANA Stats have considerable experience attending and monitoring births in water. The experience level of the practitioner may be an important factor in the safety of waterbirth.

6,521 waterbirths, including 13 sets of twins, 29 breeches and 327 VBACs, were compared with 10,252 mothers who did not choose waterbirth, making this the largest comparative study on waterbirth to-date. Additionally, this is the first large waterbirth study of a US population, with its unique healthcare system and demographics.

While the ACOG/AAP Committee Opinion of April, 2014, not recommending water immersion for birth, acknowledged the limitations of the available research on waterbirth, this large US study fills that gap and gives us the best evidence to-date on the safety of birthing in water.

"Maternal & Newborn Outcomes Following Immersion During Waterbirth" by Bovbjerg et al, was published Jan. 20, 2016 in the Journal of Midwifery & Women's Health. JMWH has generously agreed to make this research article open access, so midwives, birth workers, and consumers can read it without needing to buy a subscription to the Journal.

What else can we learn from the MANA/CfM Joint Position Statement?

Evidence and experience show us that mothers choose waterbirth for several reasons. They report feeling more relaxed, in control, able to move more freely, and, notably, relief from pain. Especially considering the risks of pharmacologic pain management such as epidural and spinal anesthesia, water immersion during labor and birth may be safer for mother and baby. "In addition, because water immersion facilitates normal physiologic birth it may also be associated with other beneficial health outcomes for mother and baby, including decreased need for intervention during labor and reduced incidence of surgical/instrumental delivery." (quote from the statement)

As in all healthcare and birthcare decisions informed consent/refusal and shared decision making with your care provider is key to determining what is best for each family. The Joint Position Statement can help in these ways:

  • describes the benefits of water immersion for mother and baby,
  • suggests how these benefits may improve outcomes for families of color,
  • addresses consumer choice and shared decision making,
  • considers client values and individual needs and,
  • lists factors that promote safety and success.

The practical and professional pearls of wisdom make the Factors that Promote Safety and Success section an invaluable tool when considering and planning a waterbirth and we are pleased to be able to share them with you.

The conclusion: Many families consider water immersion during labor and birth a valuable option. Current research and experience show waterbirth to be safe for mothers and babies and may provide benefits to both. "MANA and CfM support the use of water immersion during labor and birth, and believe it should be made available to birthing families across all settings. MANA and CfM encourage all care providers to become educated about the safe use of water immersion during labor and birth, and to engage in a shared decision making process when discussing the option of water immersion with their clients." (quote from the statement)

The authors of the joint position statement are:

Jill Breen, CPM, CLC; Justine Clegg, CPM, LM, MS; Nasima Pfaffl, MA, President CfM; Amy Smith, CPM

Thanks also to the consultants on the statement: 

Barbara Harper, RN, CD, CCE; Holly Horan, MA; Jennie Joseph, LM, CPM, CEO of Commonsense Childbirth, Inc.; Indra Lusero, JD, MA; Jeanette McCulloch, IBCLC; Shafia M. Monroe, MPH, DEM, CDT, President and CEO of the International Center for Traditional Childbearing (ICTC).

About the author

Jill Breen, CPM, CLC, has been serving women, babies and families for 37 years as a homebirth midwife and natural family health consultant in central Maine. She has 6 children and 9 grandchildren, all born into the hands of midwives including her own. She has served MANA in several capacities, including as President, and is currently Communications Chair. She is a member of the Home Birth Summit Collaboration Taskforce.

Meet Nicole, MANA Director of Events

Posted by Midwives Alliance on January 20th, 2016

Nicole Marie White

Hello MANA members and friends,

I am your Director of Events, Nicole Marie White, CPM. I am from Michigan and currently working as a member of the Coalition to License Certified Professional Midwives in Michigan. We just passed the house in December!

My great great grandma was a midwife.

Her name was Fannie Bush. I didn't know about her until after I began attending births in 2001. I took the long road apprenticing with several midwives in different practices and finally I attended Maternidad La Luz for the year program. I am so glad I did. I was surprised at how much I loved the clinic setting, collaborating with other midwives and getting to provide access of care to many more people then I was accustomed to in the home birth setting. I started my studies in San Francisco, CA and was able to participate in an awesome program at St. Elizabeth's where we did labor support and child birth education for the teenage mothers who resided there. After 10 months, I gained an apprenticeship in Santa Cruz. I know both of those experiences colored my understanding of midwifery care and the impact that quality maternity care has on every mother and baby. I just finished a 2 year stint working in a bustling, adorable home birth practice in Traverse City, MI. Prior to that I had a fellowship in the city of Detroit to work towards lowering the infant mortality in the city. I also have spent time working as a midwife in Uganda and Haiti.

I’m thrilled to be on the MANA board.

"Midwives are the warriors on the front line of health care battling to ensure that women survive childbirth and babies are born safely even in the most marginalized areas." (World Health Organization) My interest in spreading the midwifery model of care is what fuels me. I truly believe midwives are the answer to much of the maternal health crisis we see here in the US and abroad. I look forward to when the CPM is recognized and licensed all over the USA.

What do I do at MANA?

I am Director of Events, so that means I am at the helm of our fabulous Annual Conference!

Conference is such a corner stone to MANA and I am honored to be part of the amazing team that makes it happen. SHINE was such a bright way to begin my MANA journey and this year in Atlanta will prove to be another fantastic time. Conference is so important and many people look forward to it every year. Time to connect, celebrate, learn, see old friends and make new ones. Midwives are such a unique group! We are all different but share a common, deep thread. I loved when Deborah Kaley accepted her MANA educator award in Albuquerque and she said all her friends are midwives, former midwives, current midwives or future midwives. It made me smile and be grateful to be in a room full of friends.

Please reach out to me if you want to be more involved, have questions or suggestions, this is your conference! As MANA is your organization this is your conference! Thank you for doing this work. I am in deep appreciation for all of you that have worked so hard to create this solid foundation.

I am currently in the airport in Paris on my way to Greece. I am headed to Greece to work with Circle of Health International ( COHI ) in the refugee camps. Please check them out for more info! And check my website if you want to get to know me better. Thank you for welcoming me into the folds of such a rich, important organization.

See you in October at MANA16 in Atlanta, Georgia!

~ Nicole

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.