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.

Time Out for Good News

by Melissa Garvey, ACNM Writer and Editor

It’s a busy week at ACNM. We’re getting ready to open registration for our Annual Meeting and staying on top of a flurry of midwifery advocacy. In the midst of the activity, it’s been especially gratifying to see a hefty amount of positive press about midwives pop up in my inbox each morning. It feels great to have a chance to pause and revel in interviews well done, stories well told, and an inspiring midwifery mission making a difference in Haiti.

• Judith Rooks, CNM, MPH, FACNM, former president of ACNM, speaks up in the Portland Tribune about rising cesarean birth rates. It’s a balanced article that includes solid statistics and the midwifery perspective.
  
  
• Debbie Boucher, CNM, of Illinois is interviewed in an excellent Fit Pregnancy article titled “Home, Sweet Home.” Kudos to Fit Pregnancy for balanced coverage of home birth.
  
  
• ACNM Senior Practice Advisor, Eileen Ehudin Beard, CNM, FNP, helps women prepare for conception with straight-forward advice in the Vellejo Times-Herald, “Ready, Set Conception: 9 Steps to Prepare Your Body for Baby.”
  
  
• Nadene Brunk, CNM, explains the background and mission of Midwives for Haiti, an organization making a difference in Haiti before, during, and after the earthquake.
  

Dear Today

This afternoon, ACNM sent this letter in response to The Today Show segment “The Perils of Midwifery” (later renamed “The Perils of Home Births” online). We encourage midwives and their supporters to send their letters to TODAY@nbcuni.com and to adapt ACNM's letter for their own use to share with coworkers and clients. Thank you to the many ACNM members who have already sent letters in support of midwifery and homebirth.

The Non-perils of Midwifery

Earlier, the Today Show aired a sad, unfortunate piece called “Perils of Midwifery.” (They later updated the Web segment title to "Perils of Home Births.") Not only does it follow the heart-breaking account of a birth gone horribly wrong; it exploits the couple’s tragedy—turning it into a sensationalized story that scares women and grossly misrepresents midwifery.

The safety of midwife-attended births is well documented in a substantive and ongoing body of research. If ACNM, the professional organization for certified midwives and certified nurse-midwives, had been consulted during the development of this piece, the Today Show’s journalists would have known about these top 5 fact-based resources from the past year:

1. Evidence-Based Maternity Care: What It Is and What It Can Achieve says that midwives top the list of “underused interventions” that should be used “whenever possible and appropriate.” Several systematic reviews showing improved outcomes associated with midwifery-led care are cited.
2. A Cochrane Review concluded that “most women should be offered midwife-led models of care.”
3. A study published in the British Journal of Obstetrics and Gynaecology found that planned homebirth is as safe as hospital birth for women with low-risk pregnancies.
4. Just last week, Canadian researchers declared that “Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death…and other adverse perinatal outcomes compared with planned hospital birth....”
5. Authors of an American Journal of Obstetrics & Gynecology article say they encourage midwifery care and “support future randomized trials to compare” home vs. hospital births.
   

Women and health care professionals need to be making decisions that are informed by evidence-based medicine—not reactionary interventions and unbalanced investigative journalism. Women deserve better.

Are You In The Know?

Straight from the ACNM Communications Department, here are our top picks for happenings in midwifery for the week:

Authors of an Obstetrics & Gynecology article say they encourage midwifery care and “support future randomized trials to compare” home vs. hospital births. The statement comes in response to a letter from certified nurse-midwife Judith Rooks and Our Bodies, Ourselves Executive Director Judy Norsigian.

A midwife wrote an interesting article for Tuesday’s New York Times entitled “In a Lifeless Birth, a Midwife’s Opened Eyes.”

A fatal Metro collision happened between Washington, DC, and Silver Spring, MD—home of ACNM. Thankfully, the one ACNM staffer in the accident escaped with only a few bruises.

Saturday, June 27, is National HIV Testing Day.

Health reform is still hot, and ACNM is involved. We just posted legislation of interest to ACNM members here.

What else is going on in your world? Feel free to add to our list!

BJOG Study Finds Homebirth as Safe as Hospital Birth

A study published in the British Journal of Obstetrics and Gynaecology found that planned homebirth is as safe as hospital birth for women with low-risk pregnancies. The study examined nearly 530,000 births in the Netherlands—a country where one third of women choose to give birth at home. Researchers note the importance of both highly trained midwives who know when to transfer a woman from home to hospital as well as rapid transportation. The study is the largest of its kind and contributes to a growing body of evidence that suggests it is appropriate for women with low-risk pregnancies to choose where to give birth.