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Meet the Midwives Alliance Division of Research (DOR)

Posted by Midwives Alliance on March 8th, 2016

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Meet the Midwives Alliance Division of Research

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

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

Meet the Coordinating Council

Chair of the Midwives Alliance Division of Research

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

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

Director of Data Collection

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

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

Director of Data Quality

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

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

Director of Research Education

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

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

Director of Database Development

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

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

 
Senior Advisor for the MANA Division of Research

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

Saraswathi Vedam is the senior advisor to the project.

 

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

Posted by Midwives Alliance on March 8th, 2016

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

Nov 9, 2011 Meeting with MANA and ACNM

 

 

 

 

 

 

 

 

Nov 9, 2011 Meeting with MANA and ACNM

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

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

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

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

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

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

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

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

 

 

 

 

 

 

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

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

 

 

 

 

 

 

 

 

 

 

 

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

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

Sherry DeVries

Shafia Monroe, President & Founder, ICTC

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

 

 

Shafia Monroe, President & Founder, ICTC

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

Congratulations

Colleen Donovan-Batson

Sherry Devries

Midwives Alliance Board of Directors

* ICTC February E-News

Read more about US MERA.

 

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

Posted by Midwives Alliance on February 17th, 2016

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

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

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

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

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

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

Figure 1: Evidence-informed practice

 

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

Best available research evidence

+

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. 

Waterbirth Safe For Babies, Finds New Research

Posted by Midwives Alliance on February 2nd, 2016

Largest Study on Waterbirth Finds No Harm to Babies

New Position Statement Compiles Waterbirth Research for Families, Providers

Many families consider waterbirth, but the 2014 American Congress of Obstetricians and Gynecologists/American Academy of Pediatrics (ACOG/AAP) guidelines recommend against this practice. Fortunately, new information and tools that can inform birthing people’s decision-making process were released in the past week. First, the largest research study in the US on waterbirth was published in the Journal of Midwifery and Women’s Health. Last week, a new position paper compiling the findings of this and other waterbirth research, Midwives Alliance and Citizens for Midwifery Position Statement on Water Immersion During Labor and Birth, was released by Citizens for Midwifery and Midwives Alliance, with the goal of informing families, health care providers, and policy makers. Jeanette McCulloch of BirthSwell interviewed the article researchers Marit L. Bovbjerg PhD, Melissa Cheyney PhD, CPM, LDM and Courtney Everson MA, PhD and position paper authors Nasima Pfaffl MA, Jill Breen CPM, CLC and Justine Clegg MS, LM, CPM, to help inform childbirth educators and others on how to interpret the findings and the position paper for their clients. 

Jeanette McCulloch: What were the key findings of the research?

Marit Bovbjerg PhD: We found that being born underwater did not confer any excess risk to the baby. Babies born underwater were no more likely than those not born in water to have a low five-minute Apgar score, or require hospitalization or neonatal intensive care (NICU) admission. We also found no evidence that waterbirth is associated with neonatal death; on the contrary, in our sample of 6,534 babies born in water, there were no cases of death that could be attributed to being born in water. This indicates that, for low-risk mothers whose labors proceed normally, water immersion is generally a safe pain management option.

For the pregnant parent, we found that waterbirth was not associated with infection or hospitalization. Surprisingly, though, we found that mothers in the waterbirth group were slightly (11%) more likely to experience perineal tearing.  This finding is contrary to numerous previously-published studies, most of which reported a lower rate of tearing in mothers choosing waterbirth. The question of trauma (tearing), then, is still unresolved, and any future studies on waterbirth should make this outcome a focus.

However, even if the small, but increased risk of tearing that we reported is replicated in other studies, many individuals may still choose to labor and birth in water for the labor pain relief described in numerous other studies. For those who want to avoid epidurals and other drugs, spending a portion of active labor in a pool or tub may facilitate an unmedicated physiologic birth with all the benefits we know that confers for both mother and baby (ACNM, MANA, and NACPM, 2012; Buckley, 2014)1  Each childbearing family should weigh the potential benefits (reduction of labor pain) and the potential risks (possible increased risk of tearing), and decide based on their own values and preferences. The main upside of our research is that clients can explore these issues without worrying about whether or not waterbirth will negatively affect their babies. It won’t.

JMc: This research was based on home and birth center births from the MANA Stats dataset.   Are the outcomes applicable to the hospital setting?

Melissa Cheyney PhD, CPM, LDM: As Marit just highlighted, our findings suggest that waterbirth is a reasonably safe option for use in low-risk, low-intervention births, especially when the risks associated with other forms of pharmacologic pain management, like epidural and spinal anesthesia, are considered. Because hospitals that do allow waterbirths generally only provide this option to low-risk women, we believe these results could be applied in other settings. We know that there are several hospitals here in Oregon, for example, that have active waterbirth programs and are currently tracking their outcomes. Their preliminary impressions are that babies born in water are at no greater risk, and that water immersion as a pain management strategy helps to decrease rates of epidural use.  

It is possible that training and experience level of the provider makes a difference in outcomes. In our sample (based on MANA Stats) 35 percent of births occurred under water. This means that many of the midwives who contribute data to MANA Stats are very experienced at monitoring and attending births in the water. While some hospitals do offer waterbirth programs, it is currently unclear how frequently births happen under water in these facilities. One difference between the provider populations represented in our study, who are almost all CPMs and CNM/CMs, and those who might attend waterbirths in the hospital could be variability in exposure to, and experience with, labor and delivery management in the water. 

That said, when we look at the balance of evidence from international studies, our study, and preliminary data from hospitals in the US, we believe that findings are converging around the sentiment that while waterbirth may not confer any particular safety benefit for babies, it almost certainly confers no added risk to the neonate in low-risk pregnancies. Families should be allowed to choose waterbirth from among a range of pain management options. We would like to see waterbirth offered more widely across the US in all birth settings. 

JMc: The MANA and CfM Position Statement on Water Immersion During Labor and Birth brings together peer reviewed evidence and the clinical experience of midwives who provide waterbirth. How can childbirth educators use this document to support clients considering waterbirth?         

Justine Clegg MS, LM, CPM: Because laboring and birthing in water is popular with clients, especially those choosing to birth at home and in birth centers, childbirth educators, doulas, midwives and midwifery educators need to be well versed in the issue to answer consumer questions, and provide the most current information to help families decide what is best for them. 

The Position Paper is 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. 

Jill Breen CPM, CLC: First, I think the research we cite will help to dispel some of the publicized concerns (drowning, cord avulsion, respiratory distress) about safety to the baby since no deaths in over 6500 waterbirths were attributable to being in the water.  

The position paper also makes it clear that the experience level of the practitioner may be an important factor in the safety of waterbirth. Childbirth educators can help clients identify experienced practitioners in their area or help families develop questions that they can ask to choose a site and practitioner for their planned waterbirth. 

In the position paper, Jennie Joseph LM, CPM identifies another potential outcome important to raise with some clients. Because waterbirth may reduce stress and promote physiologic birth, thereby reducing the likelihood of unnecessary procedures and disruptions of the newborn transition and parent/infant attachment, access to waterbirth may be an important tool to address disparities in outcomes for families of color.

JMc: What role should consumer choice and shared decision making play in waterbirth? 

Nasima Pfaffl MA: Just as in all birth choices, shared decision making is key. 

One of the primary tenants of the Midwives Model of Care is individualized counseling and education. For all birthing decisions, a midwife and the birthing family can explore the available evidence, the client’s needs, values and preferences, and the midwives experience, comfort level and clinical recommendations during shared decision making.

For example, let’s look at the conflicting findings across all waterbirth literature for vaginal tearing. The small increased risk of perineal trauma could be a deciding factor for some clients, but a small concern for those who place greater emphasis on the research findings that show overall high rates of satisfaction with waterbirth. The warmth, mobility, comfort, privacy and pain relieving attributes of laboring and birthing in water may be a deciding factor for others. 

For families who  want a waterbirth, I recommend when possible, choosing a practitioner with a high degree of comfort, knowledge, and experience with waterbirth. A knowledgeable practitioner will be familiar and comfortable with the differences between water and air birth (such as evaluating blood loss in water) and should be able to discuss these with their client. 

JMc: How do findings from the recently released paper on waterbirth compare to the current ACOG/AAP guidelines?

Courtney Everson MA, PhD: The ACOG/AAP guidelines (Committee Opinion No. 594), released in April 2014, were a primary impetus for this study. In those guidelines, ACOG and AAP acknowledge the safety and potential benefits (i.e., pain management) of laboring in water, but also state that the safety of birthing in water has not yet been established and, thus, waterbirth is not recommended.  

At the time the guidelines were written, many small- to medium-sized cohort studies from Europe were published suggesting that waterbirth was safe. However, the ACOG/AAP guidelines did not include this evidence, and cited instead primarily case series and case reports. Case series/reports are not studies; rather, they are a description of what happened to a few patients (laboring women/newborns, in this scenario). There is no comparison group and the results are based on a very small sample, which means that robust conclusions about the exposure (in this scenario, waterbirth) cannot be drawn. Knowing, for example, that one baby ended up in the NICU from the case group of 10 waterbirths is not helpful unless you also know how many babies went to the NICU from a similar group of non-waterbirths.  

In the guidelines, ACOG and AAP recognize the limitations of available research, stating, “Before examining available evidence concerning immersion during childbirth, it is important to recognize limitations of studies and evidence in this area” (ACOG/AAP, 2014, 1). We believe that our research has addressed these limitations, and now offers good evidence for the safety of waterbirth. 

Our sample of 6,521 women (6,534 neonates), with a comparison group of 10,252 women (10,290 neonates) who did not choose waterbirth, makes this the largest study on waterbirth to-date. Additionally, this is the first large waterbirth study in a US population, which is important because of the acknowledged uniqueness of both the US healthcare system and the US population. 

With this publication, there is now a study in a US population examining neonatal and maternal outcomes for more than 6500 waterbirths. Contrary to conclusions drawn in the ACOG/AAP guidelines, findings from this study demonstrate that waterbirth confers no additional risk for babies. Future position statements and clinical guidelines should reflect the balance of evidence on waterbirth to-date, which suggests that birth in the water is a safe and viable option for low-risk pregnancies and, accordingly, should be offered as an option to childbearing families. 


1ACNM, MANA, NACPM. (2012). Supporting healthy and normal physiologic childbirth: A consensus statement by the American College of Nurse-Midwives, Midwives Alliance of North America, and the National Association of Certified Professional Midwives. Journal of Midwifery & Women’s Health, 57(5), 529–532. http://doi.org/10.1111/j.1542-2011.2012.00218.x

Buckley, S. (2015). Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity. Washington, D.C.: Childbirth Connection Programs, National Partnership for Women & Families.

Photo credit: Megan Hannon Photography courtesy Izabella de Barbaro


About the authors

Marit BovbjergMarit 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.

Jill Breen

Jill Breen CPM, CLC has been serving women, babies and families for 37 years as a homebirth midwife and natural family health consultant. A MANA member since 1984, Jill has served on the Board of Directors in several positions including President, as well as on several working committees, and currently is Communications Chair. She is a founding member of Midwives of Maine, a statewide, inclusive association of midwives since 1981. Jill is a Home Birth Summit delegate active on the Collaboration Task Force. She was an appointee to the Maine Governor’s Advisory Committee on Rulemaking regarding certified midwives and was a member of the Maine CDC Inter-professional Work Group addressing flow of care across birth settings. The Maine Best Practice Recommendations for Handoff Communication During Transport from a Home or Freestanding Birth Center to a Hospital Setting was approved by the Commissioner of Health and Human Services in November, 2014. Jill writes, speaks, and mentors including as a guest lecturer at University of Maine. She is the mother of 6 children, all born at home, and has 9 grandchildren, all born into the hands of midwives, including her own.

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.

Justine CleggJustine Clegg MS, LM, CPM is a Florida Licensed Midwife, Licensed Mental Health Counselor, and Certified Lactation Counselor with over 35 years experience in maternal-child healthcare, homebirth and education. She lives in Miami, FL and Asheville, NC with husband Jim Brinkman. She is currently AME Board secretary, and most recently Academic Director for Commonsense Childbirth School of Midwifery in FL. As Midwives Association of Florida “founding mother” (1979) Justine helped write and pass Florida’s midwifery licensing law, start the South Florida School of Midwifery, and was Administrative Director in the 1980s. She established a 3 year midwifery degree program at Miami Dade Community College, served as Midwifery Chair and Professor 1993-2008, and earned an Endowed Chair (2003). As Council of Licensed Midwifery Chair from 1993-2001, she helped write Florida’s midwifery practice rules. She is on Miami-Dade County Fetal and Infant Mortality Review’s team since 1997, and FIMR Chair, 2004-2008. A former Board member of MEAC and NACPM, she helped create NARM’s certification program in the 1990s. As Midwives Association of Florida CEU coordinator, she helps host MAF’s state conferences every two years. As a member of the North Carolina Midwives Alliance, Justine was MANA Region 3 conference CEU coordinator August 2011 in Cary, NC, and supports the initiative to legalize CPMs in North Carolina. She is the Midwives Alliance Documents Chair. Her 3 children and 6 grandchildren make her a “granny midwife.”

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.

Jeanette McCullochJeanette 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.

Nasime Pfaffl

Nasima Pfaffl MA is a medical sociologist with a focus on social movements and women’s health. She is a second generation home birth mom. She is the current president of Citizens for Midwifery and has served on the board since 2006. She worked for the Midwifery Education Accreditation Council as their Accreditation Coordinator. She served on the MAMA Campaign steering committee, on the Birth Network National Board, the Coalition for Improving Maternity Services Leadership Team (Board), and as the Grassroots Advocates Committee Co-Chair and Survey Team Lead for The Birth Survey. Nasima focuses on coalition building and utilizing capacity building technologies and tools to make midwifery advocacy organizations stronger, more effective and able to create the change needed in our broken maternity care system. She lives in Florida with her son, daughters and husband. Nasima can be reached by email.

 

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.

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