Family Matters

Pediatricians Issue New Home-Birth Guidelines — and Rattle Some Midwives

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In general, doctors aren’t thrilled with the idea of home birth. And while less than 1% of U.S. babies are ushered into the world at home, the American Academy of Pediatrics (AAP) decided to collaborate on guidelines they say should govern home births, which are attended mostly by midwives.

Many of the recommendations, published in the academy’s journal, Pediatrics, are fairly straightforward: at least one person at the birth should be responsible for tending to the newborn infant; that person should also be trained in infant CPR. Medical equipment should be tested before the delivery. A phone line should be available; while you’re at it, check the weather forecast too, in case complications arise and a trip to the hospital is necessary. In case of emergency, have a plan to transfer the laboring mom to a hospital. And do all the stuff that nurses do in the hospital to brand-new babies: monitor their temperature and heart rates, keep them warm and cozy, administer vitamin K and heel-prick newborn screening tests that are sent to outside labs for processing, among other things. “No matter where a baby is born, they deserve the same standard of care,” says Dr. Kristi Watterberg, a neonatologist and professor of pediatrics at the University of New Mexico who is the lead author of the AAP’s home birth guidelines.

More controversial is the academy’s advice that pediatricians endorse only midwives who are trained and cleared by the American Midwifery Certification Board. Midwives accredited by this board typically attend deliveries at hospitals and birthing centers. That position has upset certified professional midwives, who deliver the majority of babies born at home in this country but are accredited by a different body — the North American Registry of Midwives (NARM).

“The assumption is that one type of midwife is better than the other,” says Melissa Cheyney, an associate professor of medical anthropology at Oregon State University and a practicing certified professional midwife who oversees the research division for the Midwives Alliance of North America, or MANA, which represents certified professional midwives.

(MORE: Midwives Say Birthing Centers Could Cut C-Section Rates and Save Billions)

That might be because the category of certified professional midwives has existed for just 20 years. Yet Cheyney notes that both the midwifery certification board endorsed by the AAP and the registry of midwives are accredited by the same body, the National Commission for Certifying Agencies. The AAP checklist for home birth is consistent with the standard of care upheld by the registry, says Cheyney.

Watterberg says that the AAP is simply echoing a similar recommendation from the American College of Obstetricians and Gynecologists regarding which midwives should attend home births. “It’s inappropriate for us as pediatricians to get in the middle of that,” she says. “We don’t hold ourselves out to be experts on midwifery.”

But even experts can be confused by the various categories of midwives. As I wrote in a previous story about an increase in the use of midwives in the U.S.:

… some of the obstacles to expectant moms embracing midwives may stem from the confusion around their qualifications. An obstetrician is an obstetrician, but there are three categories of midwives: certified nurse midwives (CNM) are registered nurses who’ve studied an additional two years to get a degree in midwifery. Certified midwives are a small group who undergo training but come to midwifery from a background other than nursing. Certified professional midwives follow a different track altogether and attend mostly home births.

Is one training system better than the other? The AAP guidelines cite data that show home births are slightly less safe, with an increased risk of infant death of one per 1,000 babies born. But certified professional midwives take issue with those numbers, citing other studies that show home birth is just as safe as hospital birth. And Watterberg points out that in British Columbia, where midwives routinely offer either home or hospital delivery, studies have revealed no difference in infant mortality. “Neonatal death is a rare event regardless of whether babies are born at home or in a hospital,” says Watterberg.

For now, Watterberg says that certified professional midwives should focus on defining their standards more clearly, which could help to quantify their success and complication rates. “I understand they are working very hard to do that,” she says. “It’s our best shot for the best outcomes for babies and moms.”

And that, of course, is the goal for anyone delivering babies.

MORE: Study Reports Success in Discouraging Elective Early Deliveries

27 comments
PeggyThatcher
PeggyThatcher

In Colorado, the state is required to collect information about "direct entry midwife" (DEM or CPM) practice, and the statistics are damning. 

They show that the DEMs' perinatal mortality rate (PNMR) in 2010 was 16.4 deaths per thousand births.  The usual rate for uncomplicated pregnancies should be more like 1 per 1,000, as in hospitals.   

When the state legalized DEM-assisted birth back in the 1990s, the Department of Regulatory Agencies, in their sunrise review, predicted the DEN-assisted home birth PNMR would be LESS than 1 per 1,000.  But the death rate has been climbinb since then, and the question is at what point will legislators put a stop to this needless loss of life and suffering? 

http://homebirthdeathstatistics.blogspot.com/

GeradineSimkins
GeradineSimkins

For those of you looking for evidence-based information on the outcomes of homebirth, the Midwives Alliance of North America has created an online version of Home Birth: An Annotated Guide to the Literature, http://mana.org/DOR/research-resources/

This document, compiled by Saraswathi Vedam, RM, FACNM, MSN,SciD(hc), Associate ProfessorDivision of Midwifery, University of British Columbia, Canada, was intended for policy makers and clinicians, but can provide anyone an indepth look at the growing body of research that shows that planned homebirth is safe for women and infants, resulting in lower intervention rates for women choosing this birth setting compared with hospital birth. Home Birth: An Annotated Guide to the Literature assesses the study design and level of evidence of each piece of research, highlighting those research studies that are well designed and use the best evidence and those studies that have flaws that may give a disingenuous picture or provide misleading conclusions.  

Consumers, health care professionals, and policy makers should also watch for a peer-reviewed article being published this year that reviews the data in the MANA stats database, which is the largest dataset on homebirth and birth center births in the United States. This article will look at all perinatal outcomes, including mortality and morbidity, and will support the growing body of research that shows that planned homebirth is a safe option for women, infants and families. 

Geradine Simkins, CNM, MSN, Executive Director, Midwives Alliance, executivedirector@mana.org

JenniferDelaney
JenniferDelaney

CPM's and lay midwives should stop saying one thing and doing another. They say they only take on low-risk clients for homebirth, but many of their clients are in fact high-risk, with previous c-sections, twins and diabetic mothers birthing at home. I'd like to see some explanations from Cheyney about that.

MnaMna
MnaMna

Please stop using Melissa Cheyney as a source for home birth articles.  She is purely motivated by profit and notoriety, and she advocates for conflict between CPMs and every other class of provider to sell her books. 

ATuteur
ATuteur

There's no question that American homebirth midwives (like Cheyney) are a second, inferior class of midwife with less education and training than midwives in the Netherlands, the UK, Canada, Australia and ALL other first world countries. All other industrialized countries required a college level degree in midwifery. The standards for CPMs were recently "tightened" to require a high school diploma.

Melissa Cheyney, in her role as Director of Research for the Midwives Alliance of North America, has refused to release the death rates of the 27,000 in her organization. She has released the C-section rate, the intervention rate and the transfer rate, but NOT the death rate. It doesn't take a rocket scientist to realize that MANA's own death rates are terrible.

Several weeks ago, the State of Oregon released the 2012 homebirth statistics. They show that PLANNED homebirth, with a LICENSED Oregon homebirth midwife has a death rate 800% higher than term hospital birth. The data were analyzed and presented by Judith Rooks, a midwife and epidemiologist who regretfully concluded that homebirth with an Oregon licensed midwife is unsafe.

Melissa Cheyney and MANA know that homebirth dramatically increases the risk of perinatal death. They just hope American women don't find out.

DaleKaplan
DaleKaplan

Bonnie please consider writing an informative article to promote doulas,

Thank you,

Dale Kaplan

COOLA DOULA

410-608-7009

Maryland

ATuteur
ATuteur

There's no question that American homebirth midwives (like Cheyney) are a second, inferior class of midwife with less education and training than midwives in the Netherlands, the UK, Canada, Australia and ALL other first world countries. All other industrialized countries required a college level degree in midwifery. The standards for CPMs were recently "tightened" to require a high school diploma. 

Melissa Cheyney, in her role as Director of Research for the Midwives Alliance of North America, has refused to release the death rates of the 27,000 in her organization. She has released the C-section rate, the intervention rate and the transfer rate, but NOT the death rate. It doesn't take a rocket scientist to realize that MANA's own death rates are terrible. 

Several weeks ago, the State of Oregon released the 2012 homebirth statistics. They show that PLANNED homebirth, with a LICENSED Oregon homebirth midwife has a death rate 800% higher than term hospital birth. The data were analyzed and presented by Judith Rooks, a midwife and epidemiologist who regretfully concluded that homebirth with an Oregon licensed midwife is unsafe. Melissa Cheyney and MANA know that homebirth dramatically increases the risk of perinatal death. They just hope American women don't find out.