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Updated MANA Community Policy

Posted by MANA Community Manager on October 4th, 2013

Dear members of the MANA community:

Thank you all for the warm welcome the blog has received. We are very grateful for your input, your feedback, and most of all, your community.

Our goal in launching the blog and all of our online communications is to create a safe space for those who want to discuss evidence-based information about midwifery (and related topics). To ensure that we can maintain that safe space, we have had in place for some time a set of community guidelines, which you can find here.

We welcome and encourage healthy dissent within our community. Our goal as an organization is to ensure high quality, empowering, women-centered maternity care as exemplified by the midwifery model of care. (To learn more about our goals, mission, and vision, read here.) Sometimes that means tough conversations, and we are ready and willing to meet those head on, with openness and transparency.

We also know that these conversations will not achieve the full participation of our community if some members feel as if their comments are subject to bullying or harassment.

To ensure the highest level of debate, we are going to modify our comment policy.

For a comment to be published, it must include your first and last name, and may be verified via e-mail. As with most comment systems, your e-mail will be required for you to leave a post. Your e-mail will not be published on the MANA site and will be kept private - we request it so that we can contact you if necessary. (If there are special circumstances in which you’d like to keep your name private, please leave a comment explaining the situation and we’ll discuss it privately. When that happens, we’ll agree on a solution and let the group know our joint thinking.)

All comments must be relevant to the post or topic. If we have already answered a question you posted, we may refer you to previous responses and/or not publish your comment. If your comment does not directly correspond with the post it will not be posted.

Please honor and recognize that MANA is a volunteer-driven organization. We do our best to moderate comments quickly, but may not always be able to publish comments as fast as we’d like.

You can view the newly updated policy here. If you have questions, comments, or thoughts about our policy, this post is the place to share them! We look forward to deepening the conversation with the MANA community.

Honoring Grand Midwife Umm Salaamah “Sondra” Abdullah-Zaimah

Posted by MANA Community Manager on October 2nd, 2013

“Every community should have their own midwife. Someone who understands their culture, who they already trust, who is a part of their community, who they’ve known since they were children.” ~ Umm Salaamah “Sondra” Abdullah-Zaimah, MN, CNM, CPM

Umm Salaamah “Sondra” Abdullah-Zaimah will be turning 70 this month and has been practicing midwifery for nearly 35 years. She will be honored this year at the upcoming MANA convention with the Sage Femme Award. MANA volunteer Nermari Broderick recently interviewed Umm Salaamah so we could all learn more about her and her work.

Umm Salaamah’s career began when she was seeking maternity care options for her daughter and goddaughter, both teenage mothers-to-be with a high distrust of the health care system.

“I found a group of midwives working with a doctor at a free clinic in the Bronx, but by the time I found them, she was five months pregnant, so they wouldn’t take her on,” said Umm Salaamah. “I had been through the emergency childbirth training that they gave police officers. Both of those babies were born at home, during a snow storm that shut everything down. Only the national guard was out in New York City.” Both mothers and babies were healthy and as Umm Salaamah describes it, “I was dumb and lucky. Blessed, really.”

Umm Salaamah was studying to become a nurse with the goal of becoming a nurse midwife when her daughter became pregnant again. This time, Umm Salaamah reached out to Ina May Gaskin and the Farm community for training. Recalling an initial training at the Farm, Umm Salaamah says, “I fell in love with how they did things at the Farm. I came home, I quit my job, I bought a van and wrote a letter and told Ina May I was on my way.”

Umm Salaamah spent two years on the Farm, and then returned home to her family in Brooklyn to work with her community. She went on to also become a certified nurse midwife and has worked with communities across the country and the world, including Georgia, Florida, Texas, Kentucky, Mississippi, Tennessee, Honduras, Ghana and many others. She has helped to launch or support a number of international projects, including a maternal health clinic in Senegal. Sharing her insights with others working internationally: “If you go in with an attitude of respect and love, you see other people - as if they are your sister, your daughter, your mother. If you don’t see the outside of a person, but you see that they love their children, want the best for their children, they want the same things you want, if you love them and respect them and are willing to share, rather than coming to tell people what to do, you have a much, much better relationship and you are in a position to learn. It has to be a sharing, compassionate, loving relationship.”

She is particularly focused on ensuring that her knowledge - and the knowledge of other elder midwives - gets shared with the next generation of midwives. “The more I can train women to recognize when they need to transport, to recognize problems, and pass those on, the more I am sharing good practices among women. There’s an African proverb that says if you teach a man, you teach an individual. If you teach a woman, you teach a nation. She is going to share with her community.”

Umm Salaamah has devoted significant time and energy to the midwifery community, including serving on the MANA board, chairing the committee that became the North American Registry of Midwives (NARM) and serving on the NARM board.

Umm Salaamah provides critical support to a number of organizations, including serving as the midwifery director for Birthing Project USA, an international organization and resource center for improving birth outcomes for women of color. She is a founding member and director of midwifery education of the International Center for Traditional Childbearing. The organization was created to promote the health of women and their families and to train Black women aspiring to become midwives.

She is also a founder of Midwives On the Move (MOM). MOM is a committed group of midwives, aspiring midwives, doulas, nurses, birth activists, consumers and volunteers working together in the U.S. and Ghana, West Africa, to exchange midwifery skills, knowledge and ideas.

Today, one of her goals is to ensure that all women have access to community-based midwifery. “I think that every community should have their own midwife, someone who understands their culture who they already trust, someone who is a part of their community, who has known them since they are children. I don’t think it is good for a people to have to take their most most vulnerable members - their pregnant women and brand new babies - off to another culture, that is not always respecting their rituals or their culture.”

One midwife is chosen each year to be the recipient of The Sage Femme award. It honors a grand midwife, past or present, who has practiced the art of midwifery over many years. One whose work, perseverance and dedication will serve as an inspiration to midwives future and present. Learn more about the Sage Femme award and MANA’S 2013 convention, Birthing Social Change.

Nermarí Faría Broderick is one of MANA’s volunteer online community managers. A mother of three (soon to be four), she is very passionate about birth and midwifery since she became pregnant with her first over seven years ago. In her day job, she does public relations. You can find her on twitter at @justNermari

[eds. note - new photo added 10/8, provided by Aima Bey]

Guest Post at Science & Sensibility on Home Birth Safety Research

Posted by MANA Community Manager on September 26th, 2013

Have you been following the debate about the recent press release by the authors of a new study, suggesting that babies born at home had a 10-fold higher death rate than babies born in the hospital?

We hope you'll check out today's Science and Sensibility post, where Wendy Gordon shares with Lamaze's readers "why the recent home birth research using 5 minute Apgar scores does not produce reliable data that consumers can use to make a decision on where they would like to give birth."

To read Wendy's earlier piece here on the MANA blog about the limitations of using birth certificate data for this kind of research, click here.

To read today's guest post, click here. We hope you'll join the discussion over at Science and Sensibility!

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