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Informed Consent and Hospital Transfer: A Mother's Perspective

Posted by Midwives Alliance on March 15th, 2014

Roanna Rosewood is an author and was a keynote speaker at MANA 2013 in Portland, OR in October 2013.

Someone else told me about the incident, years after it happened. It was too late to ask questions or involve myself. Too late to find out if I was the reason why my first midwife stopped catching babies, right after my attempted HBAC turned into another cesarean. But I can't help but wonder, if I had been given the opportunity to tell the doctor that staying home for so long was my choice, would it have stopped her from berating my midwife? If I explained that my midwife had recommended transport but I was the decision-maker, would my midwife have been spared the doctor's anger and – I can only speculate – its resulting fear?

I'm not suggesting that my midwife couldn't handle a disagreement. I'm recognizing that the balance of power surrounding birth has become so skewed that belligerent obstetricians are a real threat to midwives. The same outcome that an obstetrician's insurance can write off without question could lead to criminal prosecution and crippling legal fees for a midwife. Does this unjust disturb midwives as much as it does me? Or are you so accustomed to it that you can't tell where fear of persecution ends and your work begins?

I understand that the concept of patient autonomy was so foreign to the doctor that she felt justified in gently soothing me in one room while criticizing my midwife in the other. What I don't accept is that my midwife didn't tell me about it. I hired her to advise and inform me. I trusted her to advise and inform me. That I was out of earshot when doctor let-loose, didn't invalidate her responsibility.

I recognize that my midwife's choice to bear the doctor's wrath alone was a generous and loving act, made to protect the small shreds of sanctity that remained after they tied me down and cut me open. But what she didn't understand, what every midwife who tries to shield her client from our broken maternity care system doesn't understand, is that doing so perpetuates the problem.

Until hospitals are safe and respectful places to transfer to, the attempt to isolate expectant homebirth families in affirmation-filled, "just trust birth" expectation bubbles, isn't only risky for the mothers and babies who might end up needing to transfer to the most dangerous maternity care system in the industrialized world. It is also the abandonment of every midwife who risks her livelihood and freedom to practice without legal protection.

We trust midwives to reveal what we need to know about birth. But this isn't limited to the process of bringing our babies earth-side; we also need to learn that birthing women have not yet established their right to autonomy, informed consent, or to be the decision-makers for their own newborns' care. Homebirth families must be armed with the tools necessary to win the cultural and legal war being waged against physiologic childbirth and stand with the midwives who hold the space for it. At the very least, this includes:

  1. Understanding the manner in which the family, midwife, and records will be received in the case of a hospital transfer.
  2. Awareness of the evidence (or lack of) behind routine hospital interventions and strategies for refusing unwanted ones.
  3. A welcome invitation to join other families around the world who are working to establish human rights in childbirth, by participating in the birth revolution.

Just as mothers must find the courage to face contractions in order to move through them, with midwives on our side, so too will we find the courage to face and heal our maternity care system.

Roanna Rosewood is the bestselling author of Cut, Stapled, & Mended: When One Woman Gave Birth on Her Own Terms After Cesarean, an international birth empowerment speaker, and the managing director of Human Rights in Childbirth.

Introducing MANA's New President: Marinah Valenzuela Farrell

Posted by Midwives Alliance on March 6th, 2014

MANA has begun a new era!

Introduction by Geradine Simkins, DEM, CNM, MSN is MANA's executive director. You can learn more about her here.

Three years ago when I recruited Marinah Farrell to be on the MANA board, little did I know I would be introducing her to you today as your new President. I am thrilled to say that with her Presidency MANA has begun a new era in at least two important ways. First, Marinah is the first President who is not from the "Founding Mother" generation of MANA. She stands on the shoulders of the cadre of seasoned MANA leaders who will work hand in hand with her. And second, Marinah is the first midwife of color to be president of MANA, a milestone of serious significance for MANA. Welcome to your new position, Madame President, the torch has been passed to you. Shine on!

Marinah's Story

by Marinah Valenzuela Farrell

I can never think about my story without invoking the history and spirits of my ancestors. My grandfathers and grandmothers were fiercely elegant even amidst the poverty that surrounded them. I conjure memories of my grandfather's blue eagle-eyed silence as we rode his horse into the mountains of Mexico, an explorer of the wild and lover of herbal medicine. This knowledge he passed down to my mother, who passed it down to me.

My parents met in El Paso Texas, and I grew up in a place between the U.S. and Mexican borders. I grew to awareness that it was important to work for vulnerable populations because both of my parents were devoted to missionary work their entire lives. Much was given, and therefore, I have always felt much was expected. Thus, I work for many non-profit organizations here in Arizona and abroad. Everyday, I give thanks for the gift of midwifery and for the communities who invite me into their lives.

My first MANA convention (doesn't everyone have a story of their first MANA convention?!) was in Arizona. Ina May Gaskin and Marsden Wagner were there, as well as all types of midwives and birth workers and advocates. Being at MANA was a "coming home" and an all-star event of unforgettable individuals. From that time forward, I have loved MANA.

With the advent of technology, the aging of our tireless founding mentors, the explosion of maternal health organizations and the fast American pace of life, our board had to look hard at our grassroots style and wonder how in the world we would be able to keep up. We reject becoming pathologically "corporate," but also realize we need to adhere to business policies and practices in order to meet the accelerating demands of our organization. We want to remain an organization that honors all midwives, can professionally represent our members, can still be groovy and, more importantly, will be compassionately progressive.

Our learning curve became a slope. We prioritized trainings in organizational and cultural humility and how to be more supportive of gender freedoms. We created better systems of communications for the "virtual" demands of social and electronic media. We amplified our voice at International and National meetings because midwives are more supported than ever in some ways and yet more vulnerable to hostility because of it. Our Division of Research, whose Coordinating Council are pioneers each and every one, is an essential contribution we make to the midwifery profession. It facilitates us understanding what the big picture looks like in maternal and child health, and for everyone "out there" to understand the important role midwives play in that picture.

The founders of MANA packed into cars with their babies on a shoestring budget and met in hotel rooms to write bylaws and to be recognized as a profession. MANA was founded on a love of midwives and, ultimately, the families they serve, and this remains our core foundation. Looking towards the next 30 years, MANA is evolving to embrace the "new" tools of technology, social media and research. My vision is for every MANA member to have equal access to the profession and our organization because every community and every woman needs a midwife that best represents their own values and cultures. And, ultimately, MANA wishes to welcome a new generation of leaders into the movement to carry on this always hard, always beautiful, "groovy" work.

Peace, health and love to you, Marinah

To learn more about MANA's recent projects and strategic priorities, visit our new e-zine here.

Black History Month 2014 Is Ending, But Health Disparities Continue

Posted by Midwives Alliance on February 25th, 2014

Opportunities to make change year round

During the month of February, MANA has been highlighting birth workers of color and their role in improving outcomes for mothers and babies.

Although Black History Month ends this week, the impacts of health disparities in the U.S. continue year round.

MANA would like to bring attention to one national effort to create health equity: scholarships for birth workers of color.

The Birth Workers of Color Scholarship "Grand Challenge" is asking every midwifery program in the U.S. to offer one scholarship per year to women of color. As the site says:

"A midwife for every woman. That is our grand ideal. But what if you are a woman of color in America, where is your midwife from your unique culture?"

If you operate a midwifery training organization, please consider adding a scholarship today. For all of us there are many ways to get involved:

  • Raise awareness. Share the site widely and call on the organization that trained you to offer a scholarship.
  • Offer your assistance as a mentor or preceptor.
  • Offer scholarships for workshops or other trainings you provide.

This project is being spearheaded by Claudia Booker, CPM, Jennie Joseph, CPM, LM and Vicki Penwell, CPM, LM. Learn more at the Birth Workers of Color Scholarship site here.

Educate yourself and your community on maternal child health disparity in the U.S.

When the Bough Breaks free viewings extended for 2014.

To honor Black History Month in 2013 MANA created the opportunity for members, friends, and the community at large to have free access to When The Bough Breaks, a groundbreaking documentary that explores why black babies in the U.S. are more than twice as likely to die, be born too soon, or too small.

MANA has extended this opportunity for 2014. To learn more, email today.

Presenting and Honoring: Fatima Muhammad, MPH, of Phoenix, AZ

Posted by Midwives Alliance on February 24th, 2014

Celebrating Black History Month

Fatima Muhammad, MPH, is the Director of the new Tanner Community Development Corporation’s Birthing Project, based in Phoenix, Arizona. The mission of the TCDC Birthing Project is: "To empower our families with quality education, skills, and support that promote conscious conception, positive birth experiences and outcomes, resulting in healthy and nurturing parenting practices." Fatima began her journey in Maternal and Child Health as a doula in Tucson, AZ. A few months later she was offered a position at the Phoenix Birthing Project. While there, she worked to decrease high infant mortality rates in the African American community through training Arizona’s first group of Community based doulas, facilitating parenting classes and providing psychosocial support to African American pregnant and parenting families.

In addition to being the Director of TCDC's Birthing Project, Fatima continues her maternal and child health work as a midwifery student. "Becoming a midwife allows me the opportunity to provide quality healthcare services to our families. I believe getting back to our traditional birth practices is key to empowering, preserving and strengthening our community. I plan on practicing the best possible midwifery on all levels; mentally, physically, spiritually and skillfully, resulting in optimal birth outcomes," said Fatima. "My biggest challenges in this work thus far have been funding and finishing my midwifery license. These are no longer obstacles. I realize we are the ones we have been waiting for and no one can serve our community better than we can to improve our state of health."

When asked who her heroes are, Fatima responded, "My 'shero' is my mother. She knew how to make a way out of no way. Her love was so nurturing that it surpassed all of our hardships. My mother always reminded me that I could be or do anything! She taught me about strength, my power, and to value the gifts the Creator has given me as well to help others through the use of my gifts."

For more information on how to assist the TCDC Birthing Project please visit, or call 602.253.6904.

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

Posted by Midwives Alliance on January 30th, 2014

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

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

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

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

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

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

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

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

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

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

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

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

HUMANizing Birth

Posted by Midwives Alliance on January 16th, 2014

Tell a man that he could possibly have a heart attack when making love. Then tell him that it would be safer for him to come to the hospital and make love while being monitored by a physician. Do you think a doctor coming in to take his blood pressure and monitor his heart every 10 minutes would affect his performance?

This is the question Saraswathi Vedam asks when giving an analogy about women and their birth choices.

In many cases, women birth in an unfamiliar environment and are separated from their loved ones during labor. In an unfamiliar place with unfamiliar people, women are expected to perform at their very best and deliver on someone else’s time.

Even zoo animals do not have to experience such a thing.

But why do so many mothers?

Watch more of Vedam and her talk on HUMANizing Birth here:

Speaker bio:

Saraswathi Vedam, RM, FACNM, MSN, Sci D (h.c.) is Associate Professor of Midwifery at University of British Columbia. She serves as Senior Advisor to the MANA Division of Research, ACNM representative the MANA-ACNM Liaison Council, and Interim Executive Board Member, Canadian Association of Midwifery Educators.

She is also a co-author of two upcoming research articles on the largest dataset on planned home births in the United States. To learn more about the research, click here.

Blog post author bio:

Iola Kostrzewski is a volunteer online community manager for Midwives Alliance of North America. She is a doula and Midwifery student starting in September. She is mom of two boys and creator of Breastfeeding in Color. Her passions in birth pertain to birthing and breastfeeding outcomes within the African American community.

Accepting Abstracts to Speak at MANA 2014!

Posted by Midwives Alliance on January 13th, 2014


We are pleased to announce the theme for the MANA 2014 Conference October 23-26 in St Louis is:

"The Spirit of Midwifery."

This theme speaks to MANA Conferences as a place where midwives of all types and backgrounds can gather and be nourished and enriched. We hope it resonates for you too and that you will consider submitting a proposal to present a talk, workshop, or poster at MANA 2014. This is an excellent way to share your expertise and knowledge with the midwifery community.

The deadline for submission is February 10, 2014. We are seeking pre-conference workshops (full and half day), breakout sessions, plenary talks, and poster presentations. You may submit your presentation for consideration in more than one category.

The initial abstract form is streamlined and efficient. If your presentation has been selected, you will be notified by early March, and you will then have approximately 4 weeks to complete the more in-depth form necessary for MANA to apply for CEUs from MEAC and ACNM. For details and to submit your proposal, click here.

Thank you!

The MANA 2014 Programming Committee

Understanding MANA Stats: a Q & A with Missy Cheyney

Posted by Midwives Alliance on October 24th, 2013

Melissa Cheyney, PhD, CPM, LDM, will again be presenting at the Midwives Alliance of North America convention this year, providing membership with an update on the MANA Stats Project. This year at the convention, she will also be announcing the upcoming release of two research articles that examine outcomes from MANA Stats 2004-2009. I sat down to talk with Missy about her presentation at MANA, her hopes for MANA Stats in the future, and how this critical research project can be a tool for expectant parents. Missy 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). Learn more about her here. You can learn more about MANAstats here.

Jeanette: So first of all, tell me the basics. What is MANA Stats?

Missy: The MANA Statistics Project (known as MANA Stats) is a web-based data collection tool that has been gathering data about maternity care and birth outcomes since 2004. There have been three main data collection form versions since the project’s inception: the 2.0, 3.0 and 4.0 versions. Overall, more than 60,000 courses of care now comprise the MANA Stats data registry, with more than a 1,000 new records submitted monthly. The majority of records are for planned home births.

Midwives' participation in the MANA Stats registry is voluntary, except in Oregon and Vermont. Midwives log clients into the system early in care before the outcome of care is known. The system then prompts midwives to complete records for all clients who are logged. Once the data is entered, they go through a rigorous review process to make sure the data are as accurate and reliable as possible.

J: And what’s the news about your upcoming research articles?

M: I’m excited to report that a group of researchers and I have two papers on the MANA Stats 2.0 dataset coming out in the Jan/Feb 2014 issue of the Journal of Midwifery and Women’s Health.

J: Before we talk more about the upcoming articles, let’s discuss the basics of the work of the Division of Research. What are the goals of MANA Stats?

M: MANA Stats is designed to serve three purposes.

The first is that it provides contributing midwives with a tool to track outcomes for her or his own practice. The MANA Stats system auto-calculates midwives’ practice outcomes instantly so they can keep close track of their own outcomes. Ideally, as a midwife sits down with a prospective client who’s asking questions, he or she can provide up-to-the-minute information about transport rates, neonatal mortality rates, or whatever data are relevant to the questions the client is asking. This is an important part of shared decision making.

Second, once the sample size is large enough to allow for analysis, researchers on the MANA Division of Research calculate outcomes that midwives can use to compare to their own practice statistics. These larger analyses are communicated to contributors at the annual MANA meetings and via direct contributor communications. They allow midwives to perform quality assurance and quality improvement in their own practices.

The third thing we do is to maintain datasets for researchers. We export our data from the online format it is collected in and respond to requests for data access. Although fewer researchers have requested data than we initially anticipated, all requests to date have been granted. We welcome all data access applications for research projects that have IRB approval from the primary investigator’s home institution and that have research questions that can be addressed with our dataset. Researchers can ask innumerable questions related to place of birth, normal physiologic birth, midwife-led birth, and many other interesting research questions.

J: At the MANA convention you provide midwives with benchmarking statistics based on the MANA Stats data set. Why is this important? Can’t midwives just look at vital statistics (birth certificate) data for their states?

M: Midwives cannot go to Vital Records to ask how they’re doing because Vital Records – except in a few states – does not evaluate outcomes based on intended place of birth. When you are looking at your own outcomes and asking, “how am I doing?” you want to make sure you are comparing apples to apples. We want to compare our outcomes to all women who went into labor intending to deliver at home (or in a birth center), regardless of where they actually delivered.

If you were to look at national statistics—which includes high-risk women who give birth in the hospital—it would not be appropriate, for example, to compare your c-section rate to Vital Records data on c-section rates. We would expect there to be a higher c-section rate in the hospital because, presumably, more higher-risk women are giving birth in the hospital.

Without MANA Stats or the American Association of Birth Centers’ Perinatal Data Registry, it is difficult to find an appropriate benchmark. How would midwives know if their transfer rates were approximately what other midwives are getting? Or whether it is uncommonly high or low, if there isn’t a benchmark by which to compare it?

That’s the goal of these convention presentations: to provide contributing midwives with those benchmarks. We’ve been providing them to membership in some form annually since 2007. Our ability to provide them, however, is tied to sample size. We have been able to talk about demographics for years and even c-section rate because something like a c-section is not a rare event as it occurs in around 6% of cases. It has only been quite recently that we have had enough data to evaluate rare events like deaths with any degree of reliability. In the upcoming article on the 2.0 dataset, even waiting until we reached a sample of size of close to 17,000, there is still much that we could not evaluate because the power of our tests was too low. We need to keep collecting data, and we need all midwives to participate.

J: And why doesn’t MANA make those benchmarking numbers open to the public?

M: It has always been our goal to publish them in a peer reviewed journal, to provide the public with the highest level of accountability.

J: Explain why the peer review process is so important to you and to MANA.

M: I think it is very important that research papers that come from the MANA Stats Project’s datasets go through the process of rigorous peer review required for publication in an academic journal.

The debate around homebirth is very polarized in our country. Many of us hold very deep convictions about it. I am a midwife who attends homebirth. Like most midwives, I feel homebirth is an excellent option for low risk women who hope to avoid unnecessary interventions and to support the processes of physiologic birth. Physicians who only receive our transfers and so only witness the times when mothers need interventions only available in the hospital, like epidural or pitocin augmentation, may feel very differently. How do we remove these biases from our research? The answer is that we cannot completely. What we can do is allow our work to be reviewed critically by others before it goes to press. Our reviewers may see things we have missed or see alternative interpretations of our data.

In a peer-reviewed publication process, outside researchers, who don’t know who you are, look at your work. They look very closely at your methods, and they critically evaluate the tests you have run and the interpretations you have made. They hold you to a very high standard. This can serve as an important corrective to researcher bias.

In the absence of rigorous peer-review, really you can say anything that you want to.  And with a controversial topic like home birth, we want that added measure of protection to have as many eyes as possible on it. We want to make sure that we haven’t made any mistakes, that we’ve been really transparent in how we’ve calculated our numbers, and that it meets the standard of rigorous peer-review for an academic journal.

Otherwise there’s nothing to keep anyone from making claims to safety just by going on the Internet and saying "it is safe; here are our rates." We want that level of scrutiny on our work and peer review is the way to achieve that.

J: We see the CDC release their numbers each year, and we see some states release their numbers each year. Why doesn’t MANA release their data every year?

M: A CDC-style report every year that takes MANA stats and reports on safety has been a vision of mine for some time. We would love to do that, and I received a grant from FAM to study the feasibility of doing just that.

To have meaningful data on rare events like infant death, we need to increase the sample size by increasing the number of participating midwives. Only about one percent of people in the U.S. choose a home birth. In addition, not every midwife in the U.S. uses MANA Stats to track their data, although participation has grown each year. It has taken six years to get a large enough sample size to allow for this first set of publications. It takes time for a project like MANA Stats to build a sufficient sample size to have credibility with a peer reviewed journal.

The good news is that our contributor base is expanding, and the number of homebirth and birth center births are on the rise in the U.S. We now have more than 400 participating midwives. In 2012, we collected data on around 10,000 courses of care. I will be presenting some preliminary findings from this dataset at the convention, and it will be one of the next articles that I work on.

Also, MANA does not have the organizational capacity of the CDC. MANA is a largely volunteer-driven organization, and MANA Stats has a very small budget. The CDC and the various states releasing annual data have paid staffs—some quite large—devoted to this effort. We welcome any and all funding opportunities that would allow us to engage in similar efforts to the CDC and other reporting bodies.

In my life as a researcher at Oregon State, I really cannot imagine a project as large as MANA stats running on volunteer time and such a miniscule budget. It would be a multi-million dollar endeavor in that world. I am so grateful for the committed staff on the coordinating council of the DOR who work tirelessly to support contributors, review data, export data, and analyze findings fueled only by a desire to know more about midwife-led births at home and in birth centers. All of this is done under almost constant criticism. Their work is herculean, and I am proud to be a part of it.

J: Please tell us more about the research that is on the horizon.

M: We’ve had seven researchers or sets of researchers apply to use our data set, all of whom have received access, and now some of the publications from those requests are starting to either go to press or are under review. Some are students who have used the data for a Master’s thesis but may not have the intention to publish the findings. Four articles have emerged that are either in press or under review, including the two that I mentioned, on the MANA Stats 2.0 dataset coming out in the Jan/Feb 2014 issue of the Journal of Midwifery and Women’s Health.

J: One of those two articles looks at the outcomes of the MANA Stats 2.0 dataset. What can we expect to learn?

M: This article looks at the demographics of the MANA Stats data set 2004-2009, including the intended place of birth and the type of midwife in attendance (we have mostly CPMs but also some CNMs, naturopathic midwives, doctors of osteopathy, or midwives who identify as un-credentialed or traditional midwives who utilize the data set).

It also looks at standard maternal-child health outcomes and home birth indicators, like transfer rates, i.e. intrapartum transfer, neonatal transfer, maternal postpartum transfer, and it looks at reasons for those transfers. It also examines cesarean section rates and spontaneous vaginal birth rates. It also examines intrapartum, early neonatal, and late neonatal mortality. Finally, it explores rates and type of tearing, hemorrhage, and NICU admissions.

J: How can the outcomes research inform consumers?

M: I think many consumers are asking themselves: "What are the trade-offs for the place of birth that I am choosing?" There’s no perfect place to give birth, and there’s no place to give birth that will have a mortality rate of zero.

So what a woman is actually doing is negotiating her own individual risk profile, as well as her own personal and family values as she chooses a place to give birth. An informed consumer needs access to information on all of the potential birth options: home, birth center, and hospital, as well as by provider type: CPM, CNM, OB, etc.

Women are often forced to make difficult decisions that involve trade-offs around rates of intervention, the likelihood they will be able to know who will attend them when they go into labor, cost, and access to medical back-up should a complication arise. If you are in the hospital, you may have significantly more intervention than you might at home. But then the question might be, at what cost? What's the impact of interventions when they are unnecessary? Do they increase morbidity? Those are questions you cannot ask if you do not track outcomes by intended and actual place of delivery.

Consumers today have to piece together information from studies that are often conducted outside of the U.S. So they are also making inferences about safety and benefits across different medical systems. There’s not a perfect place to get information about place of birth and provider type. But MANA Stats is bringing something to that discussion. Our sample size is getting large enough to start to look at things like rare events that will figure in for a woman trying to decide where she wants to give birth and with whom. What is her risk of having a c-section? What’s her risk of having an unnecessary c-section? What’s the risk of the baby having problems? Those are all questions a woman might want to ask, and there’s not one place that she can go to get this information right now. I think that's a problem, and I am excited to see all that has been happening in the research world over the last few years—the National Birth Center Study II, the Home Birth Consensus Summit, and the Institutes of Medicine Birth Settings Workshop. What an exciting time!

J: And what is your hope for MANA stats long term?

M: My hope is that someday we will not need MANA Stats for tracking safety. My hope is that the system of national surveillance will eventually accurately take into account provider type and intended place of birth, because many of our discussions right now are around safety; those are the most fundamental questions that people are asking.

However MANA Stats will still need to collect data because, from a researcher’s perspective, safety questions aren’t the only questions one could ask. I’m really interested in the process of care. How does a particular style of care lead to different outcomes? What components of midwife-led care lead to lower rates of unnecessary interventions? How can normal physiologic birth best be supported? How does midwifery care improve outcomes for communities of color who have a higher risk of mortality under standard medical maternity care? There are still some questions about process of care that are best evaluated by a more nuanced data collection tool like MANA Stats or AABC's PDR that are designed for home and birth center settings.

I am also excited about the future of data sharing. What if ACNM, AABC, and MANA could share data between our systems or bring it all together so data could be collapsed into one large data set across provider type and across intended place of birth? That would really be ideal.

J: I know one goal is to expand the number of researchers accessing the data. How can a researcher apply?

M: Interested applicants should go to the website. Interested researchers can read through our handbook and contact me with any questions. We are also committed to ensuring that midwives and student midwives have access to the data. If someone is interested but doesn’t have access to an Institutional Review Board (IRB) for example, we can help match students and midwives without formal research experience or institutional affiliations with expert researchers through a program called Connect Me. Midwives and students midwives can serve as content experts and learn the processes of research design and analysis as they collaborate with more experienced researchers. Two student midwives have successfully used the Connect Me program to date, and they will be presenting their findings at this MANA meeting.

J: Why is Institutional Review Board (IRB) approval so important?

M: IRB or ethics boards exist at institutions to ensure the rights of human research participants are protected. Unfortunately this process had to be created to prevent future atrocities like the Tuskegee experiments or some of the experimentation on human beings done in concentration camps in Nazi Germany.

To prevent the exploitation or coercion of research participants, universities and other organizations conducting or sponsoring research require that all researchers who intend to use data collected from human subjects be familiar with national and state-level guidelines for working with human subjects data. Institutional Review Boards are also usually inter-disciplinary, and they review research proposals to make sure that if there are any places where special protection of participants needs to be in place, that that is done.

There are two reasons why this is important to us. First, we want to make sure the privacy of participants is respected and protected. For example, in MANA Stats there are such a small number of early neonatal deaths that it wouldn’t be impossible for a researcher to figure out who some of the mothers and babies are in the sample. By combining the date of birth and the location where the birth occurred, a Google search could potentially give you the name of a participant.

Our second reason is very practical: The code of federal regulations # 21 part 56 requires it, and researchers cannot submit findings for publication unless they have gone through appropriate procedures to access data. You must have IRB clearance before you analyze data for publication.

J: Any final thoughts?

M: Yes two things. First, I encourage all those engaged in the place of birth debate to remain open, curious, and critical about what the flurry of research coming out now can tell us. It is difficult to move science forward when pro- and anti- sides of a debate become entrenched. The answer to the question of where women should give birth is very likely more complicated than simply answering yes or no to whether one thinks homebirth should be an option. I don’t think every woman is a good candidate for home birth, but I am also very frustrated with its wholesale dismissal by some as an option ever. We need a more nuanced research agenda that examines questions of safety, benefit, risk, cost, and access to care for multiple subsamples of women with various risk profiles. Secondly, no matter where a woman chooses to give birth or where we as providers feel the safest choice might lie, we have a duty to work together across difference to support and care for our nation’s mothers and babies.

Jeanette McCulloch, IBCLC, has been combining communications work and women’s health advocacy for more than 20 years. She is a co-founder of BirthSwell, which is working to improve infant and maternal health—and the way we talk about birth and breastfeeding—by making social media accessible for birth and breastfeeding professionals. She is a board member of Citizens for Midwifery and is active in local, statewide, and national birth and breastfeeding advocacy projects.

Photo credit: Scott Kemp

Updated 10-29: The URL of this post was changed due to technical issues. All comments submitted with a full name and valid email address have been moved to the new, correct, URL.

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