MANA Committee Reports
from the June 2005 MANA News

Division of Research

Peggy Garland, Administrative Section Director
Newton, Massachusetts

The MANA Division of Research (DOR) has been very busy. We are on target with our first year goals.

With recommendations and input from many DOR members, the DOR Advisory Panel is now in place. (See sidebar.) The Advisory Panel members are there to be contacted by the DOR when we have questions and may benefit from their expertise; they are not involved in our decision-making.

Two interesting developments came from the formation of this group. When two ACNM Division of Research members were asked to serve on the Panel, it became apparent that there was mutual interest in pursing a collaborative relationship to support research efforts. The MANA Board and the Board of the ACNM have approved exploration of this connection. Nothing has been worked out in detail, but we are pleased that both organizations see a clear benefit in this collaboration.

The Centers for Disease Control (CDC-main U.S. Public Health Agency) suggested two advisors, Kitty MacFarlane, CNM, and Brian McCarthy, MD, of the World Health Organization (WHO) Collaborating Center in the Division of Reproductive Health. Their expertise is in helping midwives and other health care professionals and communities around the world with maternal-child health data collection. Because of their connection, the CDC provided funds to bring the Deep Review team to Atlanta to meet with them for the purpose of technical advice regarding data collection.

We dubbed this process the "Deep Review," because we will be looking at not just the form that the MANA Stats Project has been using successfully for many years but the underlying purpose of our system, the protocols or research rules under which we are collecting data, and especially to what use we wish to put the data in the future. Bruce Ackerman is chairing the effort. The goal is to update our data collection to address additional research ideas that we have developed beyond the CPM2000 study.

These ideas have been pulled together in our "Research Agenda" (See article later in issue.) The facilitation of the drafting of this document was done by Sarah Huntington. We envision this document as an evolving one, a statement of what our concerns are, what the questions are for which we seek answers through data collection and research. We welcome input from all MANA members, but especially hope that anyone who finds this process interesting will actually join the DOR!

The database web development is nearly complete. When it is done and all the components have been completed according to the contract, the fine tuning agreed upon in the Deep Review will begin. The decisions about accepting the recommendations of the Deep Review team will be made at the DOR meeting the day after MANA 2005 in Boulder. If you are a member of the DOR or would like to be, please arrange to stay an extra day for this important meeting.

The DOR will sponsor two workshops at MANA 2005. Check your conference flyer for further information. In addition, a traveling workshop teaching midwives to use the new web-entry system is being planned by Bruce and Ida Darragh.

Once the Deep Review is completed, we will need to seek funding to implement any changes we decide upon. After we feel we have a good plan for modifications, we will turn our attention to a thorny but vitally important issue-deciding by what process we will allow researchers to access our accumulated data. There needs to be a process for members of our own community to propose research on the database and be afforded access, as well as a careful and rigorous process to screen outsiders who request use of all or parts of the data.

Another goal accomplished since the last newsletter is the finalization of the process by which state associations can request an account to view the aggregate statistics for their midwife members. Any state wishing this sort of information can request an account by meeting and voting, by whatever process they usually make major decisions, to request a state account and assuring that it is the will of the membership to let the statistics be included. No midwife or client would be identifiable, because all the state association could see would be the totals in the various categories. Once this has been discussed and decided, the group needs to confirm their process to the Division and request an account. Two agreements will need to be signed. Please click here to send us an email if you are interested. This is available to provinces also. Two states-Missouri and Washington-are in the process of obtaining these accounts.

We wish to announce that the MANA Board has named Saraswathi Vedam as the new Director of the DOR Research and Publication Section. Saras has been an active homebirth midwife for two decades and provides homebirth/continuity clinical experience to CNM students in her role as faculty at the Yale midwifery program. She has published several times on homebirth, including an extensive critique of the Pang study in the journal Birth.

Don't forget that the membership of the DOR is open, and anyone can join by simply writing me at here, describing a little bit about yourself and why you are interested. We can also use more energy and thoughtful input!

MANA Division of Research Advisory Panel

March 2005

• Greg R. Alexander, MPH, ScD, Chair, Maternal-Child Health University of Alabama at Birmingham School of Public Health; Editor, Maternal-Child Health Journal
• Laura Mae Baldwin, MD, MPH, Researcher Department of Family Medicine University of Washington School of Medicine
• Mary Barger, CNM, MPH, DSc (cand), Assistant Professor Maternal Child Health Department Boston University School of Public Health
• Lisa Calvocoressi, PhD, Assistant Director of Research Griffin Hospital (CT); Research Affiliate, Department of Epidemiology and Public Health Yale University School of Medicine (New Haven)
• Leslie Cragin, CNM, PhD, Associate Clinical Professor Department Obstetrics, Gynecology and Reproductive Sciences University of California, San Francisco School of Medicine
• Eugene DeClercq, PhD, Professor Maternal and Child Health Boston University School of Public Health
• Christopher Glantz, MD, MPH, Associate Professor Division of Maternal-Fetal Medicine University of Rochester School of Medicine and Dentistry (NY) Editorial Board, Birth
• Patti Janssen, PhD, Assistant Professor; Department of Health Care and Epidemiology University of British Columbia
• Holly Powell Kennedy, CNM, PhD, Co-Director Nurse-Midwifery Education Program University of California, San Francisco
• Jim Leftwich, IDSA, User Interface Design; Orbit Interaction (CA)
• Kitty MacFarlane, CNM, MPH, Consultant National Center for Chronic Disease Prevention and Health Promotion Division of Reproductive Health, CDC
• Brian McCarthy, MD, MSC, Director WHO Collaborating Center for Reproductive Health Division of Reproductive Health, CDC
• Fay Menacker, DrPH, RN, Statistician* Division of Vital Statistics National Center for Health Statistics, CDC
• Patricia Aikens Murphy, CNM, DrPH, Associate Professor University of Utah School of Nursing
• Roger Rochat, MD, Associate Professor Rollins School of Public Health Emory University (Atlanta)
• Patricia Roche, MEd, JD, Assistant Professor of Health Law Department of Health Law, Bioethics and Human Rights Boston University School of Public Health
• Patricia Stephenson, ScD, Senior Social Scientist
• US Agency for International Development (USAID) Washington, DC
• Cynthia Stanton, PhD, Assistant Professor Department of Population/Family Health Sciences Bloomberg School of Public Health Johns Hopkins University (Baltimore)
• Jan Weingrad-Smith, CNM, PhD (cand), University of Connecticut Section Chair APHA MCH Section

*pending institutional approval

DOR Research Agenda

Within each of the categories (clinical, educational, health services, professional, and questions for a client survey), the research topics are prioritized based on feedback from DOR members, starting with those the members felt were most urgent or important to advancing the cause of midwifery in North America at this time. This prioritizing may influence what research is done next, but factors like funding, the interests of researchers, and practicalities of gathering additional data may mean that projects are done out of this order.

Clinical Questions

Top priority (in rough order of priority within this category)

Systematic review of direct-entry midwifery outcomes-Which elements of midwifery care affect morbidity (infant and maternal)?

Vaginal Birth After Cesarean-What have been the rates of success, morbidity and mortality among women choosing VBAC out of the hospital? As rates of VBAC have declined in hospitals, have these rates out of the hospital changed? Where are direct-entry midwives doing VBACs, and how do local regulations and local VBAC practices affect this? Can we identify women most likely to have successful VBACs (single vs. double layer suture, only one previous cesarean, previous vaginal birth, etc.)? Are changes in cesarean section rates reflective of changes in midwifery practice, hospital/physician practice, or a combination?

Questions to ask-Were one or two layers of suture used? Cm dilation at time of section? Was labor induced, augmented? If so, with what techniques and at what dilation? Indication for c-section? Indication for past cesarean(s)?

Plateaus, including 2nd stage-What are the risks? Are there plateaus that do not increase risk of morbidity or mortality?

Length of labor-When is "long" too long? Do labors greater than a certain length and/or pattern of progress show increased morbidity or mortality? Is there an ideal timing for transport in the "prolonged labor?" What do the MANA stats reveal about the timing of transports and morbidity and mortality? What are the effects/outcomes/processes of care in prolonged latent phase labor? How is "start of labor" defined?

Questions to ask-How was start of labor determined (i.e. what frequency/pattern of contractions? What dilation?)?

Shoulder dystocia-What are the risk factors in the out-of-hospital population? Do they differ from other populations? What are the most effective practices for managing shoulder dystocia? What does out-of-hospital birth have to teach hospital birth about management of shoulder dystocia (such as ease of maternal movement on the floor, wider bed, etc.)? What are the implications of laboring in water on shoulder dystocia rates, management, and sequelae?

Postdates-What are the risks of postdates in the out-of-hospital birth population? What are the best practices for screening appropriate candidates for out-of-hospital birth after 42 weeks gestation?

Questions to ask: How was the due date determined (LMP, U/S-at what gestation, bimanual or other exam by midwife-at what gestation, etc. )? What prenatal fetal surveillance was done? If transported, what was the indication?

Large babies and large mothers-How best to determine fetal size? Are there parameters for determining when a baby is "too big" to have the mother be a candidate for home birth? Are there greater risks at home than in a hospital setting, and who is at risk-mother or baby? Are midwives screening out women who have large babies, and is this contributing to better outcomes for moms and babies? Likewise, are midwives screening out large women, and is this affecting outcomes?

Questions to ask: How was fetal size estimated? If by centimeters from symphysis pubis to fundus, what was this measurement at last prenatal visit? If by ultrasound, at what gestation and with what estimated weight? Add estimated fetal size as a reason for transporting to hospital and cesarean section.

Postpartum hemorrhage-What are the most effective practices for controlling postpartum hemorrhage in the out-of-hospital birth setting? How do rates of postpartum hemorrhage in the out-of-hospital birth population affect maternal morbidity and mortality? How does postpartum hemorrhage incidence in the out-of-hospital birth population affect neonatal outcomes, such as breastfeeding success, hospital admission or readmission, slow or no growth?

Congenital anomalies, rates of incidence and screening in out of hospital births

Questions to ask: Was prenatal screening offered? What screening was done? If screening was refused, why was it refused?

Long-term psychosocial outcomes-Does midwifery care impact rates of child abuse/neglect? Marriage/relationship longevity? Long-term social support for mothers and children? Long-term paternal involvement, regardless of relationship with the mother?

Moderate priority (in rough order of priority within this category)

Analysis of CPM outcomes vs. other midwives-Are there differences in demographics and outcomes between home and birth center births? Are there differences based on route of training-apprenticeship, MEAC-accredited school, non-MEAC accredited school? Differences based on certification?

Pelvic floor sequelae-What practices in the out-of-hospital birth population increase/decrease risk of damage to the pelvic floor? What is the appropriate time frame for measuring pelvic floor damage/integrity?

Long-term breastfeeding-Does midwifery care improve long-term breastfeeding success? If so, what elements of care are associated with long-term success? What is "long-term?"

Questions to ask: add lactation consultant to list of providers seen postpartum

Low priority

Neonatal hypoglycemia in LGA/SGA babies-What is the best management of these babies, both for screening and nutritional intake? When should they be managed at home/in hospital?

Midwife Survey

Education of midwives questions (considered about equal priority)

These questions obviously lend themselves to co-investigation with MEAC, especially if the DOR has interest in some of the other professional questions and one (annual?) survey could address needs of both groups of researchers.

Descriptions of apprenticeship model-How do apprenticeships start? How do they work legally, financially, for clients, for midwives, for apprentices? How are apprenticeships evaluated and concluded?

Models of midwifery education-What models exist? How effective are each of the models, their strengths and weaknesses, both for producing competent midwives, and meeting the needs of students? How do students learn about these models? How well do current means of getting information to prospective students or apprentices work (i.e. magazine ads, directories, websites, MEAC information, etc.)?

Follow-up after midwifery education-How many midwives continue into practice after midwifery education? What stands in their way and what facilitates their practicing? (See JoAnne Myers-Ciecko's master's thesis for follow-up on Seattle Midwifery School graduates.) What types of education lead to the most availability of midwives?

Health services/access/insurance questions (in rough order of priority within this category)

State and provincial laws and their impact on access to care and practice-How do the laws in various states and provinces relate to the usage of midwifery care, access to it, scope of practice, insurance coverage, access to liability insurance, access to and coverage for maternity care generally?

Questions to ask: Do you have access to professional liability insurance? Do you purchase it? At what cost and with what limits? Is it possible to have managed care contracts/Medicaid reimbursement in your area? Do you accept contracts/Medicaid reimbursement? In what states/provinces do you practice?

Cost-analysis of out-of-hospital birth-What contributes to cost of home birth, including transfers of care, and how does that compare to costs for similar populations of women choosing hospital birth? (See Anderson and Anderson, "The cost-effectiveness of home birth." Journal of Nurse-Midwifery, 1999. Vol. 44, pp. 30-35.)

Questions to ask: What do you charge for a complete course of care? Through what means are you reimbursed? What is your average reimbursement? Are you reimbursed for labor management in the event of intrapartum hospital transfer?

Transport and access to hospital care-How does access to hospital care and transport mechanisms affect usage of out of hospital birth options? How does it affect outcomes? Where are there barriers to access to hospital care, and how could these be addressed to improve public health?

Questions to ask: What barriers do you face in transport and access to care for your clients (limited ambulance service, hostile reception at the hospital, physician willingness to consult/accept transports, etc.)?

Increase visibility of direct-entry midwives (with descriptive studies in the literature)

Questions to ask: what are midwives' preparation, practice setting and models, consultation arrangements, role in hospital, time spent with clients prenatally, in labor, postpartum, gynecology.

Case studies of communities with out-of-hospital birth rates above 10% of total births-What factors do these communities have that differentiate them from other communities in which there are direct-entry midwives? How have the midwives in these areas marketed, become culturally appropriate, or filled a gap in maternity services?

Questions to ask: Where are the areas (counties?) where there are high percentages of births taking place with out of hospital midwives? This data may be available from state/provincial departments of health.

Professional Questions (in rough order of priority within this category)

Demographic description of midwives and changes over time-Who is entering direct-entry midwifery? Why are they choosing it? Who is leaving direct-entry-midwifery and why?

Causes of liability claims among midwives-What have been the types of cases for which direct-entry midwives have been sued? Which cases are most likely to end in settlement, trial, awards? What has been the magnitude of these awards, and how has that changed over time and in relationship to awards for other professions? How does the presence of liability insurance affect numbers and types of cases?

Midwives salaries/incomes-What types of pay structures are direct-entry midwives using to pay themselves, or to be paid? What are the ranges of salaries, and the costs to clients in various areas of the country? What benefits do midwives get-Worker's Compensation, health insurance, retirement funds, vacations, etc.? How do these benefits compare with others in the health care field with comparable experience and training? Does certification make a difference?

Models of practice configurations/ Practice sustainability-What work arrangements help midwives stay in practice vs. burn out and leave practice?

Questions to ask: How many weeks per year are you on call? How many weeks per year are you on vacation (without any midwifery duties)? How many midwives work in your practice?

Relationships with other health care providers-With which other health care providers do direct-entry midwives have professional relationships, and how do these relationships improve care for their clients? What areas of those relationships are most successful? What obstructs them or facilitates them? How to best cultivate and maintain such relationships?

Questions to ask: Do you meet regularly with consultant physicians? Do you consult with a single physician, or multiple physicians? Do you use family practitioners, obstetricians, perinatologists, neonatalogists, etc.? What other health care providers do you consult with regularly-naturopaths, acupuncturists, chiropractors, etc.? How would you characterize your relationships with these consultants and other care providers?

Client Survey-Demographic/Population/Cultural Questions

Reasons for choice of birth site-Who chooses to birth outside of the hospital and why? Do certain groups of women have more access to midwives or information about midwives and out of hospital birth? When do women choose to birth out of the hospital, or with midwives, and what would be effective means for increasing women's access to information at these times? What cultural influences contribute to women's choices around childbirth?

Client satisfaction and preferences-Were clients satisfied with the care they received from their midwife? Would they have preferred changes in the care? Would they have preferred another option, such as home birth if only birth center was available, or vice versa?

Demographic description of midwifery clients and changes over time-(Similar questions as reasons for choice of birth site.) Can we compare these answers from the early 2000s to similar responses in some of the 80s and 90s studies?

Education Committee

Marina Alzugaray, Chair
Summerland Key, Florida

Dear friends just as I passed the torch to our new SE representative there was another job to continue with my involvement with MANA. I am glad to serve now as the Educational chair. Soon the transition will take place, and I will be fully involved in this position.

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