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.

At Last, Life after Medicare: MOMS for the 21st Century

by Kathryn Kravetz Carr, CNM, Chair ACNM Government Affairs Committee

At last Medicare reimbursement equity for nurse-midwives will begin in January. As I start my first year as chair of ACNM’s Government Affairs Committee, we are riding high on the glory that comes from decades of hard work. Now we are blessed with the opportunity to work on something new, at last, something new!

Maximizing Optimal Maternity Services (MOMS) for the 21st Century, known as MOMS21, stole the show this year in DC. This magnificent piece of legislation will support improved maternity outcomes, help decrease maternity care costs, and place midwives at the center of the solution. It should come as no surprise that we have one of our very own, certified nurse-midwife Deb Jessup and Legislative Assistant to Representative Lucille Roybal-Allard to thank for drafting this tour de force. MOMS21 has been introduced in the House of Representatives (H.R. 5807) and a Senate companion bill is expected to follow.

Despite higher childbirth costs in the United States than other industrialized countries, we rank far behind on perinatal outcomes, with striking disparities in communities of color. Procedure-rich hospital stays during a woman’s pregnancy and delivery in the United States render hospital maternity care as Medicaid’s most costly expense.

MOMS21 will allow us, and those who value our work, to pressure Congress to support best maternity practices and the education of a more diverse maternity care workforce. Bill provisions include the promotion of optimal maternity care, a national media campaign, expansion and dissemination of best maternity care data, and core maternity care curricula, more loan repayment and funding for minority recruitment and retention as well as establishing reimbursement for midwives who supervise medical residents, medical students, and student midwives.

Government Affairs Committee (GAC) members will be calling on all midwives and our supporters to contact their legislators and ask them to cosponsor MOMS21. As midwives, we are well positioned and well prepared to be at the forefront of maternity care solutions.

Need more details on MOMS for the 21st Century Act of 2010? Read the ACNM press release and the bill summary.

Midwife Reflects on Government Affairs Committee (GAC) Experience and Lobby Day 2010

My ACNM legislative tenure ended on a great high. The Midwifery Care Access and Reimbursement Equity Act of 2009 passed last March; as of January 1, 2011, the CNM reimbursement rate will increase from 65% to 100% of the Medicare Part B fee schedule. My other role as chair was to help organize midwives from across the country for Lobby Day.

ACNM hosts its Annual Meeting in DC once every four years so midwives can meet with their legislators in person on Capitol Hill and discuss issues vital to the sustainability and growth of midwifery. This is one of the most important personal contributions we can make to our profession. I am so proud and thankful that more than 450 midwives (from forty nine states) met with more than 300 offices that afternoon. It was quite a sight to walk up and down the streets of the Capitol and see midwives on every corner. As a Washington state midwife, I was quite proud of our strong contingency. More than 25 of us met with Senators Murray and Cantwell’s offices, and then split into individual groups and met with each US representative (or their staff) from our state.

The focus of our visit was a new bill that ACNM is championing called the MOMs 21 Act, which stands for Maximizing Optimal Maternity Services for the 21st Century. This bill will improve maternity care outcomes for mothers and babies and bend the cost curve of our maternity care expenditures in the US. It has many components, and the section we are most interested in will establish reimbursement for midwives who supervise residents, medical students, and student midwives in academic health centers.

After we met with our legislators, nearly 450 of us gathered at a nearby restaurant for a Capitol Hill reception, where we rehashed our day, celebrated equitable reimbursement under Medicare, and watched 10 legislators (or their staff) receive ACNM awards for their contributions to midwifery and women’s health. The highlight was when Senator Menendez (D-NJ) ended his speech by saying, “I love midwives!” I had tears in my eyes and felt so proud that midwives have such vital voices on Capitol Hill. I hope you can join us the next time we are in DC. Putting a face on midwifery for our legislators is essential to effect change in the laws that regulate our practice.

Heather Bradford served on ACNM’s Government Affairs Committee (GAC) since 2001, including three years as chair. She received an ACNM Public Policy Award at the Capitol Hill Reception.

How to Achieve Woman-friendly Policy One Legislator at a Time

by the ACNM Government Affairs Committee

Minnesota midwives with Senator Al Franken (D-MN)

Last month, more than 450 midwives and midwifery students traveled to the US Capitol to educate members of Congress on issues vital to the sustainability and growth of midwifery practice and to discuss our legislative agenda. Here is a peak into how midwives promoted woman-friendly policy one legislator at a time:

I ended up meeting with my representative by myself. I expected to meet with an aide, but ended up meeting with Representative McGovern (D-MA) himself! After recovering from my initial shock, I spoke with him about midwifery in Massachusetts and encouraged him to support the MOMS for the 21st Century Act. Not only was he nice to me, but he agreed to cosponsor the bill! As a student nurse-midwife, this was the perfect introduction to lobbying, and I am so glad that I participated!
~Christian M. Ornburn, SNM, ACNM Student Representative, Massachusetts

I had difficulty getting an appointment with Congressman Ruben Hinojosa (D-TX), but was able to obtain a meeting with his aide. I met with his aide in the office for 30 minutes to discuss midwifery issues and care of women in the Rio Grande Valley. As I was leaving, I ran into my representative. I introduced myself, thanked him for his vote for health care reform, and told him how pleased we were that Medicaid payment for birth centers was included in the bill that passed. He asked me to continue our discussion and join him in the congressional elevator. I mentioned that it said congressmen only, and he smiled and said, “You are with me.” We boarded a guarded train and continued to discuss women and children's health care issues. Next he took me to a waiting area and asked me to write my name and telephone numbers while he went to cast a vote. He returned in a few minutes, took me to the exit where I could catch a taxi or bus to the Lobby Day reception, and handed me his card.
~Nivia Nieves Fisch, CNM, Texas

My visit with Congressman Robert Andrews (D-NJ) could not have gone better! Though he was in the middle of voting, his health legislative aide whisked me off to the Capitol building because Mr. Andrews wanted to meet with me himself. The congressman and I spent a very pleasant 30 minutes discussing midwifery, health care reform, and the future of maternity care in the US. Before I could ask him, he volunteered to cosponsor Rep. Roybal-Allard's MOMS for the 21st Century bill.
~Robyn Carlisle, CNM, Mt. Royal, New Jersey

I first became aware of the importance of educating our legislators during graduate school. I quickly learned that unless the senator or representative had previously had some formal health care education, they couldn’t possibly be aware of the issues we providers face almost daily. What does it take for the issues to become important to them? The answer, at least in part, was demonstrated by the scores of midwives calling on our legislators during Lobby Day. I thoroughly enjoyed experiencing the momentum that our Washington midwife contingency exhibited during meetings with our senators’ assistants. I felt our voice was heard, and that felt great!
~Susan Collins, CNM, Washington

Midwives of Washington State