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 like.author.displayName like.author.displayName 2 Like

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

ATuteur
ATuteur

Vedam's document is deeply disingenous and thoroughly misleading.

Let’s start with the title. Reading it, you might think that the guide provides an overview of scientific citations and original scientific research on home birth. You’d be wrong.

Sure, there are some scientific studies in there, but out of 66 total “citations,” fully 25, more than 1/3, are not scientific studies at all, 1 was never published and 1 was published in a non-peer reviewed publication.

Well, that’s not too bad, is it? Vedam has compiled and annotated a list of 39 studies that “support” homebirth and its safety.

Not exactly.

Of the 39 actual scientific citations:

1 was publicly retracted

17 do not address the issue of homebirth safety.

Okay, so in an effort to support homebirth, Vedam has compiled and annotated 21 contemporary scientific studies that address the issue of homebirth safety. And they show that homebirth is safe, right?

Not exactly.

Of the 21 scientific studies:

2 are underpowered

4 compared homebirth to a hospital group containing high risk women

That leaves 15 studies of which:

12 showed that homebirth had an INCREASED risk of perinatal or neonatal death

3 showed homebirth may be as safe as hospital birth under very strict conditions

That’s right. Out of 66 separate citations in Vedam’s Guide, only 3 show that homebirth is as safe as hospital birth, 2 from Canada and 1 from the Netherlands. The results from the Dutch study are called into question by the fact that it compared homebirth with a midwife to hospital birth with a midwife. A more recent study showed that low risk birth (home or hospital) with a Dutch midwife has a HIGHER perinatal mortality rate than high risk delivery with a Dutch obstetrician.

As far as MANA's claim that it will publishe it's data is concerned, it has already publicly released the C-section rates, the interventions rates, and the transfer rates of homebirths attended by its members. For years it has refused to release the death rates claiming repeatedly that they will be published "this year" or "next year." It not longer matters. They are now thoroughly out of date and have been superceded by statistics from the State of Colorado and the State of Oregon, all of which demonstrate that PLANNED homebirth with a LICENSED homebirth midwife has a death rate 4-9X higher than hospital birth.

ATuteur
ATuteur

@GeradineSimkinsVedam's document is deeply disingenuous and fundamentally misleading.

Let’s start with the title. Reading it, you might think that the guide provides an overview of scientific citations and original scientific research on home birth. You’d be wrong.

Sure, there are some scientific studies in there, but out of 66 total “citations,” fully 25, more than 1/3, are not scientific studies at all, 1 was never published and 1 was published in a non-peer reviewed publication.

Well, that’s not too bad, is it? Vedam has compiled and annotated a list of 39 studies that “support” homebirth and its safety.

Not exactly.

Of the 39 actual scientific citations:
1 was publicly retracted
17 do not address the issue of homebirth safety.

Okay, so in an effort to support homebirth, Vedam has compiled and annotated 21 contemporary scientific studies that address the issue of homebirth safety. And they show that homebirth is safe, right?

Not exactly.

Of the 21 scientific studies:
2 are underpowered
4 compared homebirth to a hospital group containing high risk women

That leaves 15 studies of which:
12 showed that homebirth had an INCREASED risk of perinatal or neonatal death
3 showed homebirth may be as safe as hospital birth under very strict conditions

That’s right. Out of 66 separate citations in Vedam’s Guide, only 3 show that homebirth is as safe as hospital birth, 2 from Canada and 1 from the Netherlands. The results from the Dutch study are called into question by the fact that it compared homebirth with a midwife to hospital birth with a midwife. A more recent study showed that low risk birth (home or hospital) with a Dutch midwife has a HIGHER perinatal mortality rate than high risk delivery with a Dutch obstetrician.

The document contains no evidence that American homebirth with a CPM is safe.

Vedam’s deeply disingenous Guide illustrate how professional homebirth advocates use the forms and language of science to mislead their supporters.

JenniferDelaney
JenniferDelaney like.author.displayName like.author.displayName 2 Like

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 like.author.displayName like.author.displayName 2 Like

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 like.author.displayName 1 Like

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.

mjg
mjg

@ATuteur 

Please check your grammar before you start making comments on medical professions.  i.e.  "The data were analyzed..."

ATuteur
ATuteur like.author.displayName like.author.displayName like.author.displayName like.author.displayName 4 Like

@mjgFrom dictionary.com:

Data  is a plural of datum,  which is originally a Latin noun meaning “something given.” Today, data  is used in English both as a plural noun meaning “facts or pieces of information” ...  It is almost always treated as a plural in scientific and academic writing.

annoyed
annoyed

@mjg You really need to look up how to correctly use the word "data" before you keep digging this hole.

ATuteur
ATuteur like.author.displayName like.author.displayName 2 Like

It's hilarious indeed; you still don't understand.. The correct sentence is "the data WERE analyzed" because the word "data" is plural. The singular form is datum.

mjg
mjg

HILARIOUS!  I wasn't even taking about the word data!  The correct sentence is, "the data WAS analyzed."  (not were)

TaraDukaczewicz
TaraDukaczewicz like.author.displayName 1 Like

@mjg If all else fails, and you have no logical way to refute someone's argument, find a grammatical error to nitpick about.  Good job.

mjg
mjg

I am not here to refute ANY argument.  I would just appreciate if someone is going to post their opinion, they should at LEAST know the correct grammar.

DaleKaplan
DaleKaplan

Bonnie please consider writing an informative article to promote doulas,

Thank you,

Dale Kaplan

COOLA DOULA

410-608-7009

Maryland

ATuteur
ATuteur like.author.displayName 1 Like

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.

aliberaldoseofskepticism
aliberaldoseofskepticism

Oh, you again, Dr Amy? How is it on sciencebasedmedicine? Oh wait, yeah, you were banned! LOL Still arguing that medical science reached its apex in the 30s and has gone downhill since then? Still complaining about people romanticizing the past...then advocating the "ancient wisdom" of circumcision? You make us real skeptics look bad.

I'm not even convinced you're a real doctor and not just a spambot invented by some alternative medicine quack as a strawman.

Homebirth is, of course, potentially unsafe. (The only reason I was born at home was because of a history of coercive sterilization at the hands of IHS.) But I can't help but denounce you as well.

kathybeckerblease
kathybeckerblease like.author.displayName 1 Like

@ATuteur  

There is a debate to be had here, but personal attacks don't bolster your case at all.Melissa Cheney has a Ph.D., so she is not personally less educated than midwives elsewhere, and it's silly to say one person is somehow responsible for intentionally hiding data from women. 

I am a Ph.D. developmental psychologist ahout to have my third homebirth (this one in Oregon). I'd agree that there is a real debate about what kind of credentialing should be required, and that mothers and babies would be better off if both providers and parents had access to and made use of evidence to make these decisions.

Here, as explained in the article, the AAP copied the recommendation of ACOG about credentialing midwides, with the express caveat that they are not experts on midwifery. Cheney points out that this decision deserves a closer look for reasons she gives i the article. The article authors asserts that midwives are "rattled" and "upset", but really it sounds like a professional disagreement among people who all agree that mothers and babies do best when providers follow a specific standard of care, when parents make informed decisions, and when homebirth is supported by medical backup when necessary.

The only way forward is with a rational debate based on evidence, and that's where we should put our energy.

 

ATuteur
ATuteur like.author.displayName 1 Like

Cheyney has a PhD in anthropolgy, so as a midwife, she is indeed less educated than any of the midwives in the Netherlands, the UK, Australia, Canada or any other first world country, as well as far less educated than US certified nurse midwives.. She would be ineligible for licensure in any industrialized nation.

The CPM is a credential made up by lay midwives to award to themselves in an effort to confuse women about their training. That's why it is hardly surprising that their death rates are hideous. Melissa Cheyney is well aware that the 2012 statistics show that planned homebirth with a licensed Oregon midwife has a 800% higher than term hospital birth, but she didn't bother to mention that in the article, and she hasn't addressed it in her role as Head of the Board of Direct Entry Midwifery in Oregon. Indeed she refuses to release the death rates for the 27,000 homebirths in the MANA database because they are also hideous.

The CPM credential should be abolished. It does not meet the international standards for licensing midwives. CPMs lack the education and training of ALL other midwives and their death rates are so horrible that they are hiding them. If they are not good enough to meet the standards of any other first world countries, why should they be licensed here?

ATuteur
ATuteur

I am working to make homebirth safer. CPMs are unsafe practitioners. That's why the AAP does not endorse them.

ATuteur
ATuteur

The death rate for planned homebirth with a licensed Oregon midwife is 9X higher than term hospital birth and that's AFTER the babies with fatal conditions are removed.

KathyHennessy
KathyHennessy

one last point. Why don't you work to make homebirth safer, Amy, instead of being the enemy of midwives?  You could contribute something positive to the world but you choose to attack and belittle midwives.  Why not advocate for more training for midwives so homebirth can be safer for low risk women?

KathyHennessy
KathyHennessy

Also, when you factor out planned homebirths for babies with fatal conditions, what do the statistics look like then? 

KathyHennessy
KathyHennessy

@ATuteur Melissa Cheyney has a PhD in biological anthropology. Her dissertation was on homebirth practices in the USA. She also studied for two years at the Oregon School of Midwifery, after which she passed state licensure. Neither ACOG nor AAP have any power over state's rights to license practitioners as they see fit, per their state laws. 


mamasadvocate
mamasadvocate

Oh, Amy. You are still trying to scare women away from normal birthing practices. Women are strong. Our bodies are made to have babies. As a doula, it is my passion and responsibility to inform and educate women and their partners about birth and birth options. Using a midwife at home or in a hospital is a good choice. Using an OB/GYN is also a good choice. However, when people like you try to browbeat negativity and fear into women so they have a hospital birth with an OB, I have to say, "SHAME ON YOU!!"

DoulaDani
DoulaDani like.author.displayName like.author.displayName like.author.displayName 3 Like

@mamasadvocateAs a doula myself, I am passionate about women making informed decisions as well. It's hard to do that when choosing a home birth b/c many women don't even know there is a difference in midwives in the US and they don't understand there is a difference between our midwives vs midwives in other first world countries. They don't know the difference in the standard of care. They don't know if they are seeing a midwife who is practicing safely and ethically vs a midwife whose personal philosophy means minimizing high risk situations without fully informing her client of the risks.

Shame on anyone who tries to hide information.