Friday, July 30, 2010

ACNM Responds to Lancet Home Birth Editorial

by Holly Powell Kennedy, CNM, PhD, FACNM, FAAN,
President, American College of Nurse-Midwives

On the heels of a disturbing AJOG study on home birth, an editorial released today in The Lancet is fanning the flames of the home birth controversy that has been playing out in the media this summer. This morning I talked with an NPR reporter about ACNM’s take on the editorial. View her blog here, and read on for a more in-depth view of ACNM’s perspective.

Does ACNM disagree with the perspective articulated by The Lancet editorial regarding the AJOG study?

It's surprising that this study is getting traction, when virtually every other organization that has looked at it has pointed to flaws in the methodology of the study.

What flaws?

There are several concerns.

They included studies that did not distinguish between planned and unplanned home births. For example, if you had planned a hospital birth, but your labor progressed so quickly that you gave birth before you even made it to the hospital, then you wouldn’t have had a skilled attendant or necessary resources present.

In contrast, a planned home birth means that the woman and her health care provider have determined she is healthy, at low risk for complications, and has the necessary resources in place for a safe birth. By combining the two types of home births, the findings are limited.

Second, a meta-analysis is a way of combining the results of many studies. But in this case, there seems to be no clear reason as to which studies they included versus those they excluded. In fact, they actually did not include the best and by far largest study that's been done—which did not find a higher neonatal mortality rate.

What's good about home birth?

Keep in mind that only slightly more than one half of 1% of women in the US will have their babies at home, but the voice of the home birth movement is very strong. That's because they are the voice of women who want their maternity care provider to follow evidence-based practices to minimize intervention in childbirth. They do not believe they will receive this kind of care in a hospital and see home birth as their only way of avoiding a cesarean section.

Should we care about this home birth argument?

Yes! Healthy mothers and babies are the most important goal. However, we’ve lost sight that how a woman gives birth matters for both short- and long-term physiologic and emotional health. Research has demonstrated that how we are born is important. Mothers and babies are both better off if we support and facilitate labor and childbirth using interventions as they are needed, but avoiding them when they are not.

Labor and childbirth is an arena in which more technology is not always better. Consumer advocates and health experts have called cesarean sections one of the most over-used surgical procedures in America. One in three women in the United States will have a cesarean section – this is twice the number recommended by the World Health Organization.

What's underlying this debate?

Many women fear childbirth—thanks to images they've seen in movies, stories, and even childbirth education books that emphasize what can go wrong, rather than focusing on women’s strength and capacity to birth. A study conducted by Childbirth Connection found that almost half felt overwhelmed by their labor and birth.

The malpractice debate is also driving practice – many obstetricians will tell you that they will not be sued if they do a cesarean section, but will if they delay, even though it might not yet be indicated. Working in maternity care today is very complex and difficult.

But, what many women do not know is that labor has beneficial effects for the mother and baby. Many childbearing practices that support women’s ability to forestall a cesarean, such as avoiding elective induction of labor and continuous fetal monitoring and the ability to stay mobile and upright during labor and support are common midwifery practices, yet the majority of women in the US do not have access to midwifery care.

Why do they not have access to midwives?

Approximately 10% of women are attended by midwives during birth – 97% of those births will be in the hospital. The rest will be in birth centers or at home. They are experts in providing individualized care using evidenced-based practices to facilitate a woman’s ability to give birth. They work with the woman to help her cope with labor and pain, using a broad array of resources from hydrotherapy to epidurals – based on the woman’s desires and needs. Working with a midwife means you have the best of both worlds: the opportunity to work with a professional who is highly skilled in supporting women in labor and childbirth, but also has access to an obstetrician who can assist if complications arise.

In fact, a large study recently conducted by the Cochrane Collaboration – a highly respected organization that gathers best evidence in health care – found that midwifery-led care is associated with fewer episiotomies and more spontaneous vaginal birth, feeling in control, and initiation of breastfeeding. Women were more likely to know the midwife caring for them. These researchers concluded that most women should be offered midwife-led models of care.

Many countries have far better birth outcomes than the US. In these countries women are allowed to choose home birth, and they have skilled midwives attending them in all birth settings. This is not the case in the US. Most women do not have the option to work with a midwife, in part because the US health care system places multiple barriers to their practice. Few women are offered collaborative models that include both physicians and midwives, including seamless transition from home to hospital if needed.

What’s the Bottom Line?

As we reform US health care, all maternity care providers must partner to demand robust systems which deliver the necessary resources for high quality maternity care in all birth settings, including home, birth center, and hospital—and care by midwives.


Adele said...

Thank you for drawing attention to this.

My only concern is that people view this as a "healthcare problem", when actually it is a legislative problem. At any point the state legislators can vote that midwives can attend births without collaborative practice agreements. This is what is preventing moms/mw from working together.

Many blame the rich lobbyists, but any legislator can say no to any handout from any doctor's lobby group at any time.

Anonymous said...

I find an error in this posting. You state that the metanalysis did not include the best and largest study and link goes to the BJOG's 2009 article "Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births". However this article IS included in the metanalysis, it is article #10 in Table 1. Please check your facts before criticizing those of others.

Holly Powell Kennedy, President, American College of Nurse-Midwives said...

To clarify the comment on August 24th by “anonymous” - although the authors included the 2009 deJonge et al study for some of the analyses, they excluded their data for one of the most important outcomes – that of neonatal death, resulting in too small of a sub-group to reach statistical significance. This is likely due to how they defined neonatal mortality. If they had contacted the authors of the de Jonge study they could have clarified those definitions and then included their data. Our communication with deJonge indicates that the common practice in metaanalysis of contacting study authors for more information did not occur.