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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:

MANA Statistics Project Update

Posted by MANA Community Manager on January 24th, 2014

We’re incredibly excited to tell you that on January 30th, next Thursday, the much-anticipated outcomes from our MANA Stats 2004-2009 dataset will be publicly released.  

Two articles will be published in the upcoming Journal of Midwifery & Women’s Health: one describes the MANA Stats system and how it works, and the other describes the outcomes of planned home births with midwives between 2004 and 2009.  

The Midwives Alliance is proud of our Division of Research and the amazing MANA Stats system. This is the largest registry of planned home births in the U.S. and one of only two large datasets where normal physiologic birth can be studied, and we thank all of the contributor midwives who have made this possible. We also thank the members of the MANA Division of Research who created the system, continually improved it over the years, and have put quality assurance processes in place to make sure the data are sound.  And finally, we thank the researchers who shepherded these articles down the long road to publication.  We’re looking forward to the important conversations that these articles will generate!

For an in-depth look at what to expect from the articles, check out the post Understanding MANA Stats here.

Watch here for an update next Thursday, when we’ll share with you a summary of the findings, links to the research, and materials to share with women, families and others interested in learning more about home birth.

image credit: www.sweetbirths.com

Understanding Outliers In Home Birth Research

Posted by on September 17th, 2013

by Wendy Gordon, CPM, LM, MPH, member of the Coordinating Council of the MANA Division of Research

Yesterday, a press release was issued drawing new attention to the American Journal of Obstetrics and Gynecology’s not yet published research that finds that babies born at home are “roughly 10 times as likely to be stillborn and almost four times as likely to have neonatal seizures or serious neurologic dysfunction when compared to babies born in hospitals.”

First, it is vitally important to note that this study did not actually examine rates of stillbirth, but rather 5-minute Apgar scores.  The press release is completely misleading and inaccurate on this point.  We will return to this issue below.

This research stands in sharp contrast to a large and growing body of research that shows that, for low-risk women with a skilled midwife in attendance, home birth is a safe option for newborns with lower rates of interventions and complications for mothers.  In addition, it opposes the enormous amount of research regarding the usefulness of birth certificate data to draw conclusions about rare outcomes.

Haven’t we seen this guy before?

These claims - and these co-authors - are not unfamiliar to home birth scholars. The first glimpse of this study’s results was seen at the Institute of Medicine’s “Research Issues in the Assessment of Birth Settings” workshop earlier this year.

The early findings were presented at the IOM workshop by Dr. Frank Chervenak, a co-author of the study - whom you may remember from the notorious “recrudescence” article, where he argued that physicians have a professional responsibility to advise against home birth (read responses from consumers here and here and an analysis of the science behind it here.)

During Chervenak’s presentation of this data at the IOM workshop, serious concerns about the methodology were raised - none of which appear to have been addressed in this final article. So now that the full study is seeing the light of day, what are the concerns? And what does this research tell us?

What are the limitations of birth certificate data for this kind of research?

This research, which claims to be the largest study of its kind, relies on data from birth certificates (known as “vital records”).  What we know about using information drawn from birth certificates is that they are pretty good for capturing information about things like mother’s age and whether she is carrying twins. They are not very accurate when it comes to rare outcomes like very low Apgar scores, seizures, or deaths (Northam & Knapp, 2006).  Fortunately, these outcomes are extremely rare events, regardless of place of birth, but their rarity makes them quite difficult to study - especially when using a source of data that is known to be unreliable.  With rare events, even a small number of miscounted events can distort findings and produce misleading interpretations.

A second, deep concern is that birth certificates in almost half of U.S. states still do not adequately capture intendedplace of birth.  This has been a fatal flaw in the few studies that have shown adverse outcomes with home birth, and it is a fatal flaw in this study as well.  In recent well-designed studies that captured planned place of birth andused better sources of data, there were no differences in 5-minute Apgar scores between home and hospital settings (Hutton et al, 2009; Janssen et al, 2009; van der Kooy et al, 2011).

The fact that vital statistics data can’t tell us much about the safety of home birth has been well-established by birth certificate scholars and epidemiologists. At the IOM workshop, Marian MacDorman, Senior Statistician at the National Center for Health Statistics, CDC, clarified how to interpret the this type of data. In response to Chervenak’s presentation on the data in this study, she pointed out that regarding low Apgar scores, “the absolute risk is low; that’s all you can say with vital data.” She also made clear that data from birth certificates cannot be used to make comparisons between settings or providers.

What about equating low 5-minute Apgars with stillbirth?

One assumes that the press release was perhaps not carefully reviewed by the authors of the study, as they did not actually examine data about stillbirths. They analyzed the rare occurrence of 5-minute Apgar scores of zero, which may be indicative of a number of possible events which may or may not have been related to the time, location or care provider at the birth. The authors note that stillbirths may have occurred in the third trimester, may have been due to lethal congenital anomalies, and other possibilities that are captured in a 5-minute Apgar score of zero.  We cannot draw any conclusions about safety when looking at this piece of data in isolation.

We will examine this issue and other methodological concerns more in depth in a later blog post, as will many home birth scholars, undoubtedly.  However, if we are committed to providing women and their families with useful information about birth safety, our media materials need to correspond to the actual research conducted.

Concerns that birth in any given setting may pose a risk to mothers or babies need to be taken seriously and examined closely. However, when the underlying data source is flawed, it is difficult to draw meaningful conclusions from the analysis of the data.

To learn more about existing, well-designed home birth data, read here. To learn more about the MANA Stats Project, which provides researchers with a dataset of more than 24,000 planned home birth and birth center births, read here. And watch for new research based on the MANA Stats dataset 2004-2009. Two articles are in press and two more are under review in peer-reviewed journals.

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Wendy Gordon, LM, CPM, MPH is a midwife, mother and educator in the Seattle area.  She has practiced for several years in both home and birth center settings with nurse-midwives and direct-entry midwives.  She is a Coordinating Council member of the Midwives Alliance Division of Research, a board member of the Association of Midwifery Educators, and teaches at the Bastyr University Department of Midwifery.

References:

Hutton, E. K., Reitsma, E. H., & Kaufman, K. (2009). Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: A retrospective cohort study. BIRTH 36(3):180-189.

Janssen, P. A., Saxell, L., Page, L. A., Klein, M. C., Liston, R. M., & Lee, S. K. (2009). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ 181(6-7):377-383.

Northam, S., & Knapp, T. R. (2006). The reliability and validity of birth certificates. JOGNN 35(1):3-12.

van der Kooy, J., Poeran, J., de Graaf, J. P., Birnie, E., Denktas, S., Steegers, E. A. P., & Bonsel, G. J. (2011). Planned home compared with planned hospital births in the Netherlands: Intrapartum and early neonatal death in low-risk pregnancies. Obstetrics & Gynecology 118(5):1037-1046.

Photo credit: Jason Lander on Flickr

 
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