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Transfer from Planned Home Birth to Hospital: Improving Interprofessional Collaboration

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Women's heightened interest in choice of birthplace and increased rates of planned home birth in the United States have been well documented, yet there remains significant public and professional deb...

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New home birth study from the MANA Statistics Dataset shows that Planned Home Birth with Skilled Midwives is Safe for Low-Risk Pregnancies

The largest study of planned, midwife-led home birth in the U.S. to date, reported outcomes for nearly 17,000 women who went in to labor intending to deliver at home between 2004 and 2009.

Safe Outcomes with Positive Benefits

High rate of completed home birth (89.1%)

High rate of vaginal birth (93.6%)

High rate of completed vaginal birth after cesarean (VBAC; 87.0%) Low intrapartum and neonatal fetal death rate overall:

o 2.06 per 1000 intended home births (includes all births)

o 1.61 per 1000 intended home births excluding breech, vbac, twins,

gestational diabetes, and preeclampsia.

Low rate of low APGAR scores

Extremely high rate of breastfeeding (97.7%) at 6 weeks

Few Emergency Transfers to Hospital Care

Primary reason for transport was "failure to progress." Transfer for urgent reasons, such as "fetal distress" was rare.

Low Rates of Intervention

Cesarean section rate of 5.2%

Less than 5% used pitocin or epidural anesthesia

More Information

Results for low-risk mothers are consistent with most studies of planned homebirth. For more information on relative risks and decision making see MANA Home Birth Data 2004- 2009 Consumer Considerations at http://www.cfmidwifery.org/pdf/MANAHBStudy04-09Considerations.pdf and "Safety" in Childbirth: What Does This Mean? What is "Safe" Enough? at http://cfmidwifery.org/pdf/Safety%20FINAL.pdf.

Data were collected prospectively. Midwives logged in information for each client throughout her pregnancy, birth, and up to 6 weeks postpartum. This method of data collection reduces selection bias since outcomes were not known at the time they were entered into the MANA Stats system at onset of care.

References:

1. Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., and Vedam, S. (2014). Development and Validation of a National Data Registry for midwife-led births: The Midwives Alliance of North America Statistics Project 2.0 dataset. Journal of Midwifery and Women's Health, 59(1).

2. Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., and Vedam, S. (2014). Outcomes of care for 16,924 planned home births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. Journal of Midwifery and Women's Health, 59(1).

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New home birth study from the MANA Statistics Dataset shows that Planned Home Birth with Skilled Midwives is Safe for Low-Risk Pregnancies The largest study of planned, midwife-led home birth in the U.S. to date, reported outcomes for nearly 17,000 women who went in to labor intending to deliver at home between 2004 and 2009.

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Commentary

Letters to the Editor from our readers

News

ObGyns have a long history of collaboration with their nurse-midwife colleagues-possibly one of the strongest collaborative traditions in medicine...

Clinical Review

New data confirm that the combination of forceps and vacuum extraction should be avoided and demonstrate that use of midcavity rotational forceps...

From the Editor

Next time you face this hazardous scenario, try reverse breech extraction

Clinical Review

New guidance on timing of elective delivery, screening for thrombophilias, and use of magnesium sulfate for fetal neuroprotection

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Transfer to the hospital for women planning a home birth: A high-risk obstetrics problem

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Letters to the Editor from our readers ObGyns have a long history of collaboration with their nurse-midwife colleagues-possibly one of the strongest collaborative traditions in medicine... New data confirm that the combination of forceps and vacuum extraction should be avoided and demonstrate that use of midcavity rotational forceps...

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The one we have is irreparably broken, scarred by a history steeped in misogyny and white supremacy, where women's bodies have been subject to involuntary experimentation, obstetric violence, and a parade of interventions proven to cause harm only after decades of being hailed as standard practice - interventions ranging from DES and Thalidomide, to twilight sleep, routine episiotomy, and the still-entrenched continuous electronic fetal monitoring debacle.

It's no wonder our maternity care system produces dismal results.

To say "our maternity care system" is a misnomer in the first place. The word "system" implies that somehow it has been designed or engineered to achieve certain health outcomes (it hasn't), or that there are certain standards for how care is organized and delivered (there aren't).

There is very little that is designed or standardized in our fragmented, poorly performing maternity care system. The dominant care delivery model - 12 or so doctor visits per pregnancy, confinement to a hospital bed for labor and birth, minimal opportunity for education, separate medical appointments for moms and babies after birth - this has all just been passed down as the way it's always been done, and became the way things are done during our fraught history, without evidence, and against the protest of midwives.
Midwives were the dominant maternal and newborn practitioners throughout almost all of human history.
Midwives have been the experts on pregnancy, birth, and postpartum and newborn care for over a million years, all the way up until the early 20th century in the United States. Then came a profit-driven campaign to pathologize pregnancy and childbirth, silence midwives, and move birth out of the realm of family and community and into the four walls of the hospital.

Despite being marginalized, maligned, and misunderstood, midwives have continued to provide primary, community-integrated maternity care for families throughout each problematic period in our history of modern maternity care, persisting despite a range of regulatory environments that have made it anything from impractical to illegal to practice in a community-based midwifery model.

Midwives also continued to dominate the maternity care workforce throughout the 20th century in nearly every other country around the globe, modernizing the profession and integrating community-based midwifery models with physician practices and hospitals to coordinate care across the risk spectrum.

Midwives and midwifery practices are credited with playing a key role in substantial reductions in maternal and infant death seen worldwide during the same eras in which American rates plateaued or increased. In fact, on the heels of a 2014 Lancet series that identified continued large opportunities to reduce mortality and morbidity rates globally through expanded use of midwives, The World Health Organization has designated 2020 The Year of the Nurse and Midwife.

Seriously, we need a new maternity care system in the United States.

One that reliably provides access in the communities where people live and work.

One that upholds fertility, pregnancy, childbirth, and the postpartum period as whole-person, whole-family experiences.

One that educates, activates, and empowers people and invites shared decision making.

One that elevates the role of the community and society in promoting and protecting the health of women and infants.

One that fights and dismantles misogyny, racism, homophobia, and all forms of bias and injustice.

One that works towards families thriving, not just surviving.

One where women and babies, especially black women and babies, aren't dying every day of preventable complications.

Let's midwife the system.

Yes, that means growing the midwifery workforce and making midwives more accessible and integrated. But it also means putting the components of the midwifery model into more widespread use, regardless of who is delivering care.

I never cease to be amazed at how often the latest "healthcare innovation" is something midwives have been doing all along. Over recent years, ACOG has issued a series of practice recommendations and toolkits that promote supportive care, shared decision making, and reduced use of interventions, such as labor augmentation, cesarean delivery, and immediate clamping of the umbilical cord. I've hailed these developments - it's amazing progress from their previous conservative stances, and we need their leadership on this.

But let's be clear on who led the creation of research evidence and practice standards they now espouse. In many cases, it's been midwives, and investigators studying midwife-led care systems.

You see this even in the broader healthcare system, outside of maternity care. If you go to any healthcare innovation conference, the kinds of newfangled ideas you will encounter are things like home visits, group visits, moving care outside of the hospital, interprofessional collaboration, addressing social determinants of health, implementing shared decision making, or addressing lifestyle and behavior.

(Midwives, do any of these things sound familiar? It's all the stuff we already do! We just are used to calling it "the midwifery model.")
Midwives have only recently gained a seat at the tables shaping our healthcare system. A century of marginalization leaves major power imbalances and structural forces still intact, but midwives know persistence and resilience and creativity and team building - these are foundational to supporting people through pregnancy, birth, and postpartum. They are the qualities we work to foster through our care, and that we are privileged to see on full display when our informed, empowered, activated clients give birth and take on new parenthood, or any of life's other journeys.
These are also qualities that make us good leaders. So let's midwife the system.

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The one we have is irreparably broken, scarred by a history steeped in misogyny and white supremacy, where women's bodies have been subject to involuntary experimentation, obstetric violence, and a parade of interventions proven to cause harm only after decades of being hailed as standard practice - interventions ranging from DES and Thalidomide, to twilight sleep, routine episiotomy, and the still-entrenched continuous electronic fetal monitoring debacle.

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right to respectful, safe, and seamless consultation,

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The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Editorial by Marsden Wagner on "A global witch-hunt"

Reprinted from 'The Lancet' - vol 346

A global witch-hunt

Marsden Wagner

5 years ago a midwife working in the University hospital in Uppsala, Sweden, told the chief of obstetrics that she was going to assist occasionally at home births. Although he was angry, he could not stop her since home births attended by a midwife are not unlawful. Nevertheless, the pressure from the hospital doctors became so unpleasant that, after a while, she felt she had no option other than to resign from her hospital post. Her independent practice flourished, although she was unable to get any local doctor to back her up or even give her occasional advice. She was denied hospital privileges and was unable to follow labouring women to hospital if the planned home birth needed transfer. She had no perinatal deaths and encountered no problems with the families she served. Yet in 1994 the chief of obstetrics asked the local government authority to investigate her practice.

There is a global witch-hunt in progress - the investigation of health professionals in many countries to accuse them of dangerous maternity practices. This witch-hunt is part of a global struggle for control of maternity services, the key underlying issues being money, power, sex, and choice. The investigation often leads to a public court, a medical review board, or a health insurance review board. Over the past 10 years I have been asked to consult, and in some instances testify, in twenty cases in ten countries - a very small proportion of the actual cases. In the USA alone: "Though no one knows how many out-of-hospital midwives have actually been charged, we have reports of legal altercations involving more than 145 out-of-hospital midwives in 36 states"

Whilst the profession of the accused in my twenty cases includes obstetrics (Austria, Italy, UK), general practice (Australia, New Zealand), and midwifery (Canada, France, Germany, Italy, Sweden, UK, USA), the striking thing is that, of the accused, 70% were midwives and 85% were women.

Bringing a health professional before a court of review board is the last and most extreme sanction for professional deviances. In the cases I am familiar with, other sanctions have included loss of hospital privileges (Australia, Canada, France, Italy, Sweden, USA), refusal of insurance companies to provide malpractice insurance (USA), and refusal of insurance companies or governments to reimburse certain practices such as home births or alternative birth centres (Australia, New Zealand, Germany, USA).

In the twenty cases, all of the accused have one thing in common; at least some of their practice is not mainstream. In other words, what they do is not what the local doctors in authority most commonly do. For example, of the twenty accused, fifteen practised home births, three practised in alternative birth centres, and two were doctors in hospital practice. All of the midwives were in independent practice. Orthodox maternity care providers are seldom brought to review boards but, in the USA and Britain, over 70% of obstetricians have been sued one or more times by parents. Unorthodox providers are rarely sued by parents but are now being brought to review boards or public courts by the medical establishment.

Irrespective of the country, certain methods are commonly used by the obstetric establishment to accrue evidence against the accused. For example, in most cases, the doctors notify the legal authorities only after a perinatal death. One death, even if not preventable and not the result of any mistake, suddenly negates years of impeccable statistics. This is in stark contrast to what happens when an orthodox doctor is involved in a perinatal death in the hospital - there may be a hospital review committee meeting behind closed doors but it will not come to the attention of the public or legal authorities. After 25 years of successful practice, an obstetrician in Rome who favours the Leboyer approach had a perinatal death. She was immediately sued after other doctors told the family that the death was due to the "soft" methods used at birth. 10 years ago midwifery was illegal in Canada but the obstetricians knew there were a few midwives managing home births. The medical establishment waited until there was a death during a home birth in Toronto, and then immediately went to the provincial prosecutor claiming it was a preventable death. The midwife who assisted at the home birth was taken to court.

Another ploy is to scrutinise obstetric patients records connected with the accused looking for possible mistakes. This method was used against doctors in London, Vienna, and Melbourne. With midwives, a common method is to accuse them of practising medicine without a license. Sometimes local law-enforcement officers (police) will arrest the accused individuals, search their records, cause them to spend money on legal assistance, and then just before the court date, drop the charges. Such a strategy creates fear in all those in that community who might deviate from orthodox practice.

Once the case is brought before a court or review board, other methods are commonly adopted. Threats may be used to pressure local doctors who are perceived to be sympathetic to the accused so they will be too afraid to testify. A local doctor in the Toronto case mentioned above informed me that he was told he would lose his hospital privileges if he testified on behalf of the accused midwife. Because the defence lawyer in this case could not find a local doctor to testify, the lawyer turned to me because I am a physician and perinatal scientist with many years experience as a specialist in maternity services in the World Health Organisation.

The local professor of obstetrics usually testifies for the prosecution, and the testimony is based on what the professor believes to be acceptable practice rather than on the scientific evidence. Attempts are made by the prosecution to prevent outside experts from testifying. For example, a judge in a court in Vienna would not allow me to testify because I was a "foreigner", and in Sicily a judge would not allow me in the courtroom except when I gave testimony for the defence, although a local professor of obstetrics, who testified for the prosecution was allowed in the courtroom at all times. Moreover, tribunals, especially if they are medical or insurance review boards, usually try to forbid the public or media from being present. In London in the 1980s. Mrs Wendy Savage, an obstetrician, caused an enormous upheaval when she demanded - ultimately successfully - a public hearing.

The results of these cases have been mixed. The circumstances of the trial affect the chances that the accused will win the case. The accused who comes before a public court with a jury has the greatest chance of winning. The chances are progressively less with a public court with a judge, then a medical review board open to the public and the media, and finally a closed medical review board. If the accused is allowed to bring in experts to testify, including those from other countries, the chances of winning are higher. If the case has media coverage and the accused has visible media support, again there is a better chance of winning, as was the case with Mrs Savage and the California and Toronto midwives.

If the accused loses, that often means losing the possibility, at least temporarily, of continuing to practise. Apart from the great personal losses entailed there is an impact on the health professionals. Midwives in that country feel threatened in their independent practise rightly fearing loss of medical backup and/or hospital privileges. Doctors are afraid to support midwives or to go along with the wishes of their patients when the requests are outside mainstream policy - eg, water births. Women in that community therefore lose the freedom to choose among a broader set of options for giving birth.

Conversely, investigation of independent midwives and unorthodox doctors, with a possible board hearing or court case, can sometimes have the opposite effect, leading to solidarity among midwives and between midwives and unorthodox doctors, and women, irrespective of whether the accused wins or loses. The trial of the midwife in Toronto began with a process which resulted in the eventual legislation of midwifery in the province of Ontario. Similarly, the case of Mrs Savage in London brought about a re-examination of the medical review board system. In a case I was involved with in California, the state board of medical quality assurance recruited the local police to assist them in organising an entrapment operation, arrested a breastfeeding midwife, took her infant away, and threw her in jail because a local obstetrician accused her of practising medicine without a license. In another case, as reported by Korte,' "In 1994, the 13-year-old daughter of a California midwife was kept on the floor at gunpoint while law enforcement personnel searched for evidence of a midwifery practise. Such harassment and many trials of midwives in California eventually led to new state legislation strengthening midwifery."

Nevertheless, there is no apparent slowing of the global witch-hunt. In the 1980s, the German society of Obstetrics and Gynaecology demanded that their government abolish the law requiring the presence of midwives at all births, and in 1990 the same society wrote to their national government demanding that home births be outlawed. This plea failed and the society has now turned to Lander (state) governments with the same demands. In 1994, there were attempts in France to forbid independent midwives from entering the hospital when a home birth patient had to be transferred. Last year also saw the first attempt in Sweden to bring an independent midwife to tribunal.

The witch-hunt is part of a global struggle for control of maternity systems and there are several key issues, one of which is economic. An obstetrician in private practise in Des Moines, USA, told me that he and the other obstetricians in that city were determined to close down the only alternative birth centre, staffed by midwives, because "it is stealing our patients" (Shortly after this remark, the only doctor in the city willing to back up the alternative birth centre retired and, since no other doctor would provide such support, the centre had to close.) As birthrates fall, the competition for pregnant patients increases, especially in countries largely reliant on private medical care; and as more and more countries move towards pluralistic health care systems with private practice, maternity care becomes more competitive. However, in the face of increasingly limited economic resources, governments and insurance companies are becoming more and more concerned with the waste associated with high-technology, high-intervention obstetrics. It is much more difficult for obstetricians to defend this expensive type of practice when midwives and a few doctors are meanwhile showing that a much less expensive type of maternity care is equally safe. The witch-hunt is an attempt to display lack of safety among the competitors.

A second issue is the control of maternity services. Until recently, government regulations in most countries have given medical doctors a monopoly in providing health services. Medical licensure represents "a social tolerance for a monopoly in return for a promise of social benefit in the form of competent and dedicated medial care".' But this monopoly can easily be abused, especially behind closed doors. The issue becomes one of peer control versus accountability to the public. In medical board reviews of professional behaviour, if the medical profession can make secret judgments on the accused, the doctors have absolute control of their monopoly, and there is the possibility of abusing the system for professional gain.

On the other hand, in a public court in which a judge makes the final decision, there is a danger that the judge, as part of power elite in the community, will be more influenced by another member of the same elite-the local professor- than by a midwife or even by outside scientific opinion. From my experience in the courtrooms in Sicily and Vancouver, where the judge made all decisions, the judge and the local professor of obstetrics testifying for the prosecution in both places made no attempt to hide that they knew each other well and that they shared their annoyance that the defence had brought in a foreign expert. But if the public court uses a jury to make the final decision, there is a greater possibility that the midwife or outside will be listened to. There is a great difference between unorthodox doctors and midwives being judged by orthodox doctors and judges or being judge by the public - and that is why it is so important to have a medical review board open to the public.

Fortunately the pendulum is swinging, at least in some places, with the coming of quality assurance systems that include public accountability of health care and health care professionals. Maternity services are in the forefront of the controversy over peer control and public accountability because birth, like death, is a deeply personal social and family event and does not fit the doctors disease model. So today the medical monopoly of maternity services is coming into question and the witch-hunt is one means of reasserting the orthodox doctor's control

Choice and freedom for health care consumers are at issue here. In the USA and UK, consumers of health care have been asserting themselves for some time. The health consumer movement is slowly coming to continental Europe but it is still almost non-existent in central and eastern Europe. This lack of freedom of consumer choice is illustrated by a statement in an article about home birth, published in 1994 in a German journal of obstetrics and gynaecology: "It remains to be tested in law whether the infant has legal claims, independent of the mother, to the best possible standard of safety in obstetrics." 'The claim is made that the obstetrician must protect the best interest of the fetus by overriding any woman's choice not approved by orthodox obstetricians. As pluralistic health care systems increase in Europe, so will consumer choice; the witch-hunt is one way of limiting that freedom of choice.

Choice and freedom for healthcare providers are also at stake here. There is considerable peer pressure to conform because deviations may threaten the legitimacy of supremacy of a standard of practice based on opinion rather than evidence. It is no coincidence that 90% of the accused in my sample were involved in homebirth or alternative birth centres. It is important to distinguish between the quality assurance function and the witch-hunt function so that the courts are not inappropriately used for professional gain. When making that distinction in a particular case, think about who might gain from a successful prosecution; is the evidence brought against the accused scientifically based ?

Whilst tribunals may have a declared function to weed out true incompetence and protect the public in the cases I describe the real function was to punish deviant professional behaviour that could threaten the income, practise style, prestige, and power of mainstream doctors.

For example, the time and effort spent recently by the California state board of medical quality assurance trying to prosecute independent midwives might have been better spent pursuing incompetent doctors. A recent review of state medical boards in the USA showed that most states have a long way to go before "they are even beginning to seriously protect their residents from doctors who are incompetent, sexually abuse patients, or otherwise have serious problems that interfere with delivering high-quality medical care in a compassionate way"

Another issue is the two-hundred-year-old struggle of doctors to control midwifery. It is no coincidence that 70% of the accused in my sample are midwives, all in independent practice where they are not under the immediate control of doctors. Fear of being investigated by authorities is a strong deterrent to independent midwives.

Solutions begin with increasing the public's awareness of the witch-hunt and its basis in political not medical issues. As quality assurance systems develop in health care, public accountability must be built in. There should be no closed doors in health policy making, in health service delivery, or when the behaviour of health professionals is being judged. The evaluation of professional behaviour must be based on deviations from practice based on scientific evidence rather than on deviations from peer-controlled opinions of what constitutes good practice.

This Web page is referenced from another page containing related information about Midwifery Advocacy and Statistics

Permission to link to this page is hereby granted.

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Editorial by Marsden Wagner on "A global witch-hunt" - from Ronnie Falcão's Midwife Archives

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The gentlebirth.org website is provided courtesy of Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA Reprinted from 'The Lancet' - vol 346 A global witch-hunt Marsden Wagner 5 years ago a midwife working in the University hospital in Uppsala, Sweden, told the chief of obstetrics that she was going to assist occasionally at home births.

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[Birth Summit IV]

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You can download the MODEL MATERNAL FORM here, the MODEL INFANT FORM here, and the MODEL SBAR NURSE FORM here.

As a reminder, here are the terms of use:

The use of the Model Maternal, Infant, and Nurse Transfer Forms are subject to the following conditions:

1. Use of the Model Maternal, Infant, and Nurse Transfer Forms by not-for-profit/academic organizations, health care providers, and health care institutions is free of charge.

2. Modifications or adaptations to the Model Maternal, Infant, and Nurse Transfer Forms must (i) be approved by the copyright holder and (ii) must cite the original tool (SEE ITEM 5).

3. Use of the Model Maternal, Infant, and Nurse Transfer Forms or any derivative in whole or in part thereof by for-profit organizations or by any organization or individual for a commercial purpose or for monetary gain (e.g., use in training courses, consultation) is strictly prohibited without the explicit permission of the copyright holder.

4. Distribution of the Model Maternal, Infant, and Nurse Transfer Forms is permitted (e.g., web links, sharing of the tool with others) for not-for-profit research or educational purposes.

5. Use and/or modifications of the Model Maternal, Infant, and Nurse Transfer Forms requires citing the original tool: Model Transfer Forms for Best Practice Guidelines: Transfer from Planned Home Birth to Hospital. (15, January 25). Retrieved from http://www.homebirthsummit.org/transfer-guidelines-model-forms/ ‎

We look forward to your feedback on the use of the Model Forms. Please feel free to share your feedback with us via email at transfer-guidelines@homebirthsummit.org.

Sincerely,

Saraswathi Vedam RM FACNM MSN Sci D(hc)
Chair and Convener, Home Birth Summit

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You can download the MODEL MATERNAL FORM here, the MODEL INFANT FORM here, and the MODEL SBAR NURSE FORM here. As a reminder, here are the terms of use: The use of the Model Maternal, Infant, and Nurse Transfer Forms are subject to the following conditions: Use of the Model Maternal, Infant, and Nurse Transfer Forms by not-for-profit/academic organizations, health care providers, and health care institutions is free of charge.

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By Marsden Wagner (MD, MSPH)

The need to humanize birth in Australia
This paper was presented at the Homebirth Australia Conference, Noosa, Australia, November 2000
Humanizing birth means understanding that the woman giving birth is a human being, not a machine and not just a container for making babies. Showing women - half of all people - that they are inferior and inadequate by taking away their power to give birth is a tragedy for all society. On the other hand, respecting the woman as an important and valuable human being and making certain that the woman's experience while giving birth is fulfilling and empowering is not just a nice extra, it is absolutely essential as it makes the woman strong and therefore makes society strong.

But we do not have humanized birth in many places today, including Australia. Why? Because fish can't see the water they swim in. Birth attendants, be they doctors, midwives or nurses, who have experienced only hospital based, high interventionist, medicalised birth cannot see the profound effect their interventions are having on the birth. These hospital birth attendants have no idea what a birth looks like without all the interventions, a birth which is not dehumanized. This widespread inability to know what normal, humanized birth is has been summarized by the World Health Organization:

"By medicalising birth, i.e. separating a woman from her own environment and surrounding her with strange people using strange machines to do strange things to her in an effort to assist her, the woman's state of mind and body is so altered that her way of carrying through this intimate act must also be altered and the state of the baby born must equally be altered. The result it that it is no longer possible to know what births would have been like before these manipulations. Most health care providers no longer know what 'non-medicalised' birth is. The entire modern obstetric and neonatological literature is essentially based on observations of 'medicalised' birth." - World Health Organization[1]

Why is medicalised birth necessarily dehumanizing? In medicalised birth the doctor is always in control while the key element in humanized birth is the woman in control of her own birthing and whatever happens to her. No patient has ever been in complete control in the hospital-if a patient disagrees with the hospital management and has failed in attempts to negotiate the care, her only option is to sign herself out of the hospital. Giving women choice about certain maternity care procedures is not giving up control since doctors decides what choices women will be given and doctors still have the power to decide whether or not they will acquiesce to a woman's choice.

Birth, which has been taken from the community and slowly but surly changed into hospital-based care during the last hundred years, must be given back to the community - back to the woman and her family. Doctors are human; birthing women are human. To err is human. Women have the right to have any errors committed during their birthing be their own and not someone else's.

Labour and birth are functions of the autonomic nervous system and are therefore out of conscience control. Consequently there are, in principle, two approaches to assisting at birth: work with the woman to facilitate her own autonomic responses - humanized birth; override biology and superimpose external control using interventions such as drugs and surgical procedures - medicalised birth.

In practice, care during birth may include a combination of the two approaches: facilitation of the woman's own responses usually dominating out-of-hospital management of birth while the superimposition of external controls usually dominates hospital birth management. But whether the care is medicalised or truly humanized depends on whether or not the woman giving birth is in absolute control.

Why Medicalised Birth

The past fifteen years has seen a struggle between these two approaches to maternity care become intense and global. Today there are three kinds of maternity care: the highly medicalised, 'high tech', doctor centered, midwife marginalised care found, for example, in the USA, Ireland, Russia, Czech Republic, France, Belgium, urban Brazil; the humanized approach with strong, more autonomous midwives and much lower intervention rates found, for example, in the Netherlands, New Zealand and the Scandinavian countries; a mixture of both approaches found, for example, in Britain, Canada, Germany, Japan, Australia.

Before 200 years ago all birth care was humanized as it kept the woman in the center and, in general, respected nature and culture. Today in developing countries there are usually medicalised maternity services in the big cities while in the rural areas medicalised services have not yet penetrated and humanized services remain.

Today prevalent medical opinion is that 'modern', i.e. Western obstetric-intensive maternity care saves lives and is part of development and attempts to bring maternity care excesses under control are retrogressive. The present situation in developing countries reinforces the idea that the only reason out-of-hospital, midwife intensive birth still exists in places is because modern medical practice is not yet available.

But we override biology at our peril. For example, if we stop using our bodies, they go wrong. It is 'modern' to get around in a car or public transport resulting in little walking much less running. Then science finds out that our bodies need such exercise or we get cardiovascular problems. So today the post-modern idea is to go back to walking and running (jogging) and this is seen as progressive, not retrogressive. By the same token, humanizing maternity services is not retrogressive but post-modern and progressive.

Every change in the human condition, including development, has the potential for positive and negative effects. The positive effects of development overwhelm the negative effects until a level is reached where social and economic benefits reach everyone, then hidden negative effects begin to emerge. The data are overwhelming that social and economic development, most especially maternal education, brings down the infant mortality rate. But such development also increases the rate of sudden infant death syndrome (SIDS or 'cot death') by bringing 'modern' ways such as parental smoking and how the infant is placed for sleeping, factors associated with SIDS. So in highly developed places such as the Czech Republic SIDS rates are lower in less developed rural areas than in Czech cities and in Hong Kong SIDS rates are lower among the less developed families still following traditional Chinese ways.[2] The negative effects of development on infant mortality, always there, have now emerged.

The negative effects of development on maternal mortality are also emerging. Obstetric interventions such as caesarian section sometimes save lives and sometimes kills - maternal mortality even for elective (non-emergency) caesarian section is 2.84 fold or nearly three times higher than for vaginal birth.[3] For fifty years the maternal mortality ratio in the US came down. Then in the 1980's the maternal mortality ratio began to rise and, according to the US Centers for Disease Control and Prevention, it rose from 7.2 in 1987 to 10.0 in 1990.[4] While this ratio continued to decline in other industrialized countries, in the US the maternal death rate continued a slow but steady rise through the 1990s and according to the World Health Organization is now higher than at least twenty other highly industrialized countries.[5]

Because WHO relies heavily on obstetricians from highly developed countries with little or no experience in developing countries, their programs in the past emphasized the role of doctors in birth care. This is a double edged sword - when Safe Motherhood Programs started in Brazil, it was gratifying to see maternal mortality fall significantly but meanwhile caesarian section rates soared, even in the poorest States. (see below)

Obstetricians often claim the use of 'high tech' medicalised maternity care in rich countries is real progress but the scientific evidence suggests it is sometimes otherwise. There has been no significant improvement in highly industrialized countries the past 20 years in low birth weight rates or cerebral palsy rates. The slight fall in the perinatal mortality rate the past 10 years in these countries is due, not to any fall in fetal mortality, but only to a slight improvement in neonatal mortality associated with neonatal intensive care and not with obstetric care. In highly developed countries, all attempts to show lower perinatal mortality rates with higher obstetric intervention rates have failed. A US National Center for Health Statistics study comments: "The comparisons of perinatal mortality ratios with caesarian section and with operative vaginal rates finds no consistent correlation's across countries". [6] A review of the scientific literature on this issue by the Oxford National Perinatal Epidemiology Unit states: "A number of studies have failed to detect any relation between crude perinatal mortality rates and the level of operative deliveries".[7]

This suggests that we are now at the point in maternity care in industrialized countries where the positive effects of development and technology are approaching the maximum and the negative effects are surfacing. This helps to explain why advances in technology and in development cannot lead to improvements in health unless the technology is in harmony with natural biological processes and is accompanied by humanized health care. Here a simple example. If an elective caesarian section is done after labour has started, it may in some cases facilitate natural processes. But waiting until labour starts means doctors lose the possibility of scheduling the procedure at their convenience. But if, as is almost always the case today, the doctor tries to circumvent natural processes by performing elective caesarian section before labour starts, there is a greater risk of respiratory distress syndrome and prematurity, both leading killers of newborn infants. We override nature at our peril.

All of this helps to explain why international development agencies such as the World Bank are now acknowledging that economic development cannot lead to improvements in the human condition unless accompanied by social development, including education.

The greatest danger with Western, medicalised management of birth is its widespread export to developing countries. Scientific evidence shows giving routine IV infusion to every woman in labour is unnecessary but such a practice in a rich country, while a waste of money, is not a tragedy. But I have seen such routine IV infusion during labour in small rural district hospitals in developing countries where the same hospitals have so little money they are reusing disposable syringes. Routine IV infusion during labour in developing countries is a tragic waste of extremely limited resources. When developing countries adopt Western obstetric practices which are not evidence based, the result is other women in those countries dying of cancer not found early enough because of lack of attention and funds for such unglamorous but essential care as outreach cancer screening programs for poor women.

Obstetricians, like all clinicians, work hard to help one patient at a time. In balancing efficacy and risks, doctors desire to help puts the focus on efficacy rather than risks resulting in a number of examples of interventions which went into widespread use before adequate scientific evaluation. Prenatal X-ray pelvimetry in the 1930s, di-ethyl-stillbesterol (DES) for pregnant women in the 1950s and thalidomide for pregnant women in the 1970s are examples of obstetric interventions which have had tragic consequences because they went into widespread use before adequate scientific evaluation. Routine electronic foetal monitoring during labour became widespread and yet scientific evaluation proves it does not lower perinatal mortality but does increase unnecessary caesarian section. And we are still not certain of the long-term consequences of routine prenatal ultrasound scans and routine epidural block for normal labour pain.

Behind these misunderstandings in interpreting scientific data is the reality that most practicing doctors have little or no training in science. Furthermore, there is a fundamental difference between the practice of science and the practice of medicine. To generate hypotheses, scientists must believe they don't know while practicing doctors, to have the confidence to make life and death decisions, must believe they do know.

Clinicians also have little or no training in public health and epidemiology and cannot understand how population based scientific data applies to individual patients, resulting in, for example, publishing in prominent clinical journals objections to using recommended rates for caesarian section.[8] This failure of some clinicians to understand public health and epidemiology is too often combined with the failure of public health professionals to confront clinicians regarding excesses in clinical practice because of their fear of the power of clinicians and their tribal loyalty to doctors.[9]

For guidance in practices, clinicians in most places still rely on peer review and community standards of practice. Using fellow doctors as a central element in developing and monitoring practice guidelines predictably has failed, in large part due to tribal loyalties. 'Community standards of practice', based on leading clinicians practices on individual patients, still are the gold standard even though they have been revealed as nothing more than 'that's what we all do' leading to a lowest common denominator standard of care rather than a best care standard based on evidence.

The one approach clinicians can understand is single case, anecdotal evidence. This approach leads to the 'what if' scenario in which applying population data to their practices is rejected by clinicians because 'what if' this or that goes wrong with an individual patient. There is no better example of this than planned out-of-hospital birth.

Many clinicians and their organizations continue to believe in the dangers of planned out-of-hospital birth, either in a center birth or at home, rejecting the overwhelming evidence that planned out-of-hospital birth for low risk women is safe. The clinician's response to this evidence is 'But what if there is an out-of-hospital birth and something happens?' Since most clinicians have never attended an out-of-hospital birth, their 'what if' question contains several false assumptions. The first assumption is that in birth things happen fast. In fact, with very few exceptions, things happen slowly during labour and birth and a true emergency when seconds count is extremely rare and, as we will see below, often in these cases the midwife in the birth center or home can take care of the emergency.

The second false assumption, that when trouble develops there is nothing an out-of-hospital midwife can do, can only be made by someone who has never observed midwives at out-of-hospital births. A trained midwife can anticipate trouble and usually prevent it from happening in the first place as she is providing constant one-on-one care to the birthing woman, unlike in the hospital where usually nurses or midwives can only look in occasionally on the several women in labour for which they are responsible. If trouble does develop, with few exceptions the out-of-hospital midwife can do everything which can be done in the hospital including giving oxygen, etc. For example, when a baby's head comes out but the shoulders get stuck, there is nothing which can be done in the hospital except certain maneuvers of the woman and baby, all of which can be done just as well by the out-of-hospital midwife. The most recent successful maneuver for such shoulder dystocia reported in the medical literature is named after the home birth midwife who first described it (Gaskin maneuver).[10]

The third false assumption is there can be faster action in the hospital. The truth is that in private care the woman's doctor often is not even in the hospital most of the time during her labour and must be called in by the nurse when trouble develops. The doctor 'transport time' is as much as the 'transport time' of a woman having a birth center or home birth. Even when a caesarian section is indicated, it takes on average 20 minutes for the hospital to set up for surgery, locate the anesthesiologist, etc. and during this 20 minutes either the doctor or the birth center or home birthing woman are in transit to the hospital. This is why it is important for a good collaborative relationship between the out-of-hospital midwife and the hospital so when the midwife calls the hospital to inform them of the transport, the hospital will waste no time in making arrangements for the incoming birthing woman. These are the reasons there are no data whatsoever to support the single case, anecdotal 'what if' scenario used by some doctors to scare the public and politicians about out-of-hospital birth.

Recently there is a desirable movement towards basing medical practice on evidence but still today many doctors are not familiar with recent evidence nor with the means to obtain it. In a 1998 British study 76% of practicing physicians surveyed were aware of the concept of evidence based practice, but only 40 % believe that evidence is very applicable to their practice, only 27% were familiar with methods of critical literature review and, faced with a difficult clinical problem, the majority would first consult another doctor rather than the evidence.[11] This helps explain the continuing gap between clinical practices and the evidence.

Although obstetric care is gradually becoming more evidence based, there is a tendency not to evaluate obstetric interventions for their subtle and/or long term risks. For example, evidence suggests an increasing incidence of certain neurological problems such as attention deficit disorder, dyslexia and autism. While attempts are being made to find causes for these problems, I know of no attempt to determine any correlation's with simultaneously increasing obstetric interventions such as prenatal ultrasound scanning, pharmacological labour induction, epidural block for normal labour pain, elective CS.

Another reason for the gap between evidence and practice is the excuses often given by physicians for why they reject evidence in their medical practice. These excuses include: the evidence is out of date; collecting evidence is too slow and prevents progress; I use clinical judgment and my experience; using anecdotal 'horror stories' to try to prove the need for an intervention which the evidence has found unnecessary; quoting evidence which is of poor and/or inadequate quality; 'trust me, I am a doctor'; 'stop doctor-bashing'; evidence erodes physician autonomy. In addition to these excuses, in maternity care common excuses include: our women have smaller pelvises (no evidence), our babies are getting bigger (no evidence), our population is not as homogenous (no evidence).

Obstetricians, as members of society, tend to blind faith in technology and the mantra: technology = progress = modern. The other side of the coin is the lack of faith in nature, best expressed by a Canadian obstetrician: 'Nature is a bad obstetrician.' So the idea is to conquer nature and results in the widespread application of attempts to improve on nature before scientific evaluation. This has led to a series of failed attempts in the twentieth century to improve on biological and social evolution. Doctors replaced midwives for low risk births, then science proved midwives safer. Hospital replaced home for low risk birth, then science proved home as safe with far less unnecessary intervention. Hospital staff replaced family as birth support, then science proved birth safer if family present. Lithotomy replaced vertical birth positions, then science proved vertical positions safer. Newborn examinations away from mothers in the first 20 minutes replaced leaving babies with mothers, then science proved the necessity for maternal attachment during this time. Man-made milk replaced woman-made milk, then science proved breast milk superior. The central nursery replaced the mother, then science proved rooming-in superior. The incubator replaced the mother's body for care of low-weight newborns, then science proved the kangaroo method better in many cases. If more doctors experienced an earthquake or volcano, they would realize their ideas of controlling nature are nothing more than stories to rewrite insignificance.

Unnecessary Caesarean Section: Symbol of Dehumanization

The quintessential example of medicalisation and dehumanization of birth is unnecessary caesarian section (CS) in which the surgeon is in charge and the woman no longer has any control. CS saves lives but there is no evidence that rising CS rates the past two decades in many countries has improved birth outcomes.[6,7] How can this be? As indications for CS broaden and rates go up, lives are saved in a smaller and smaller proportion of all CS cases. But the risks of this major surgical procedure do not decrease with increasing rates. It is only logical that eventually a rate is reached at which CS kills almost as many babies as it saves.

Women and their babies are currently paying a big price for the promotion of CS. The scientific data on maternal mortality associated with CS suggest the rising maternal mortality rates in the US and Brazil may be, at least in part, the result of their high CS rates.[3] Both these countries need to carefully audit all maternal deaths to test the strong hypothesis that rising rates of maternal death are associated with high rates of caesarian section. The data on other risks for both woman and baby associated with CS mean both are paying a big price both in the current birth and in future pregnancies as well.[12]

So why so much unnecessary CS? When maternity care is controlled by doctors and midwives are marginalised or absent, higher CS rates are found. Many studies have shown lower obstetric intervention rates when midwives attend low risk birth than when doctors are providing primary birth care to low risk women.[13] It is no coincidence that in the US, Canada and urban Brazil, where obstetricians attend the majority of normal births and there are few midwives attending few births, the highest CS rates in the world are found. Having a highly trained gynecological surgeon attend a normal birth is analogous to having a pediatric surgeon baby-sit a normal two-year old child. It would be a waste of the pediatric surgeon's time and skills and, when the young child gets tired and fussy, the surgeon might be tempted inappropriately to use drugs, where a properly trained baby-sitter would soothe the baby with a variety of non-medical techniques-the medicalisation of normal childhood similar to the medicalisation of normal birth. High CS rates are a symbol of the lack of humanization of birth.

The overuse of elective CS and other unnecessary obstetric interventions also threatens the larger community. Not even the richest countries in the world have the financial resources to transplant all the hearts, dialyze all the kidneys, give new hips to all the people who might benefit from these procedures. Choices must be made about which medical and surgical treatments to fund and these choices will determine who shall live. A CS which is done without any medical indication but only because a woman chooses it requires a surgeon, possibly a second doctor to assist, an anesthesiologist, surgical nurses, equipment, an operating theatre, blood ready for transfusion if necessary, a longer post-operative hospital stay, etc. This costs a great deal of money and, equally importantly, a great deal of training of health personnel, most of which is at government expense, even if the CS is done by a private physician in a private hospital. If a woman receives an elective CS simply because she prefers it, there will be less human and financial resources for the rest of health care.

This dangerous drain on financial resources, as noted earlier, is far greater when CS practices in places like the US and Australia are exported to developing countries with far fewer resources for health services. For example, in one State in Brazil 59 hospitals have CS rates over 80%, three health districts have CS rates over 70% while an additional 13 health districts have CS rates over 60% and the entire State has a CS rate of 47.7 %.[14] Clearly this is a huge drain on Brazil's limited health resources. And the women of Brazil also are paying another price. The data given above proving the higher maternal mortality with elective CS in the UK is further substantiated by data showing a recent rise in maternal mortality rates in those areas of Brazil with these shockingly high CS rates.[15] CS on demand is an expensive and dangerous luxury.

In the light of these issues, the Committee for the Ethical Aspects of Human Reproduction and Women's Health of FIGO (the international umbrella organization of national obstetric organizations) states in a 1999 report: " Performing caesarian section for non-medical reasons is ethically not justified."[16]

Is Hospital Birth Safe in Australia?

While many obstetricians are prone to ask 'Is home birth safe?', a more appropriate and urgent question in Australia is: 'Is hospital birth safe?'. Many Australian obstetricians fortunately have jumped on the bandwagon urging evidence based practice. This is an encouraging trend but there is an enormous gap between what the scientific evidence says is the best practice and what goes on in Australia as illustrated by table 1 'No evidence based practice in low-risk primips'.

At least 80% of all women are capable of a normal birth without intervention but we see in Table I that among low-risk Australia women having their first birth in private hospitals only 18% are judged by doctors as capable of a normal birth without serious intervention. Over half of low-risk Australian women having their first baby are judged by doctors as incapable of initiating their own labour: 47% of low-risk primips in private hospitals in Australia have spontaneous labour. These figures are truly shocking.

That half of low-risk primips in private hospitals in Australia have an epidural block for labour pain can only mean two things: doctors and hospitals increase labour pain; women are not told the truth about the risks of epidural block.

To understand why there is now an epidemic of epidural block for normal labour pain, it is necessary to understand what happens to the woman before she is offered the epidural. The care she receives when she comes to the hospital to give birth markedly increases the pain she will have. Scientific evidence shows labour pain is significantly increased: by laboring in an unfamiliar place; by being surrounded with unfamiliar people; by having unfamiliar procedures done; by being left unattended during labour; by being put in a horizontal position and not allowed to freely walk about; by having the membranes artificially ruptured; by having induction or augmentation with drugs. So the woman comes into the hospital in labour, has a number of things done which all increase her pain, is then offered an epidural and is so grateful to the staff for the relief of the pain, much of which the staff created.

The epidemic use of epidural block for normal labour pain has closely followed on the rapid increase in the use of powerful and dangerous drugs for induction and augmentation. The Australian obstetric cascade of the past 10 years has been pharmacological induction leading to increase pain leading to epidural block leading to operative birth with forceps or vacuum extraction. Since each of these interventions carry significant risks, this cascade multiplies the risks for both the woman and the baby. For example, the contractions induced by the drugs have a different intensity and different interval which not only increases the pain but also increases the risk of fetal hypoxia.

Why does epidural block lead to operative birth? Two reasons. First, with the woman already having lost all feeling from the waist down because of the epidural, the temptation is great for the doctor to go right ahead and carry out surgical procedures. The second reason is fundamental to the basic understanding of the birth process. The pain of labour is an essential component of normal labour as it stimulates the brain to release hormones which, in turn, stimulate the uterus to contract at normal levels of intensity and at normal intervals so that placental blood flow will be maintained and there will be no fetal hypoxia. This is a delicate feedback process. With an epidural block there is an interruption of this process leading to a slowing or cessation of normal labour. Attempts can be made to overcome this with more and more stimulation of the uterus with more and more doses of drugs such as oxytocin - a rather typical scenario found in high tech birth where one intervention requires another intervention to try to overcome the complications of the first intervention. Nevertheless the scientific evidence is clear - even with such efforts to overcome the slowing of labour caused by epidural block, there is still a four times greater chance forceps or vacuum extraction will be necessary after epidural block and at least a two times greater chance caesarian section will be required. This is no surprise - this is the inevitable result of using an intervention, epidural, which essentially stops the birth process in its tracks. The only way an epidemic of epidural block for normal birth has been able to happen is because the procedure has been given a very 'hard sell' to women by doctors. The only way that so many women agree to an epidural for normal labour is if they are told it is 'safe'.

Is epidural block safe? The single most important new trend in modern obstetrics is a universally agreed principle that all obstetric practice must be based on the best scientific evidence. What is the evidence on the safety of epidural block? A thorough literature review of the scientific evidence for risks of epidural block as discussed above and below is found in two books[17,18].

First, a procedure can hardly be called 'safe' when close to a quarter (23%) of women receiving epidural block have complications. The risks to the woman are many and serious, starting with the possibility the woman will die because of the epidural. The maternal death rate for women having epidural block for normal labour pain is three times higher than for women with normal labour not having the block. For every 500 epidurals performed there will be one case of temporary paralysis of the woman and the paralysis will be permanent in one of every half million epidurals. The woman has a fifteen to twenty percent chance of fever after receiving an epidural, necessitating a diagnostic evaluation for possible infection in the woman and baby which can sometimes be invasive such as requiring a spinal tap of the baby. Between fifteen and thirty five percent of women given an epidural will suffer from urinary retention after the birth.

How effective is epidural block in relieving pain? In around 10% of epidural blocks it doesn't work and there is no pain relief. Even when it works, around a third of women given an epidural will trade a few hours of pain-free labour for days or weeks of pain after the birth. Thirty to forty percent of women receiving an epidural during labour will have severe backs pain after the birth and 20% will still have back pain a year later.

A great deal of scientific research has shown that women receiving epidural block for normal labour pain will have a significantly longer second stage of labour. This, in turn, results in a four times greater risk of using forceps or vacuum extraction and at least a two times greater risk of caesarian section and these operative interventions during birth carry their own serious risks as well. While many women might be willing to take risks with their own bodies to gain pain relief, it is highly unlikely they are willing to put their babies at risk. One common complication in the woman after an epidural is started is sudden loss of blood pressure leading to a sharp drop in blood flow through the placenta to the fetus, resulting in mild to severe lack of oxygen to the fetus as shown on a fetal heart rate monitor. In another typical high-tech strategy of using a second intervention to try to stop the bad effects of the first intervention, doctors give the woman a great big dose of fluid through an IV to try to prevent the drop in blood pressure from the epidural but this does not always work. So lack of oxygen to the baby during the epidural remains a possibility and the American College of Obstetricians and Gynecologists reports that the electronic fetal heart monitor shows severe fetal hypoxia in eight to twelve percent of infants whose mother's are given an epidural block for normal labour pain.

There are other risks to the infant including some data suggesting poor neurological function at one month of age in some babies whose mothers had epidural block. More recent innovations in epidural block, such as changing the type of drugs used or the drug doses used or the 'walking epidural', do not eliminate these risks to the woman and her baby.

One reason for the epidemic of epidural in many countries is that women are not told the scientific facts about all of the risks to them and their babies when epidural block is used for normal labour pain. Indeed, at one meeting of obstetric anesthesiologists in the US, discussions were held on how to prevent any information on risks of epidural from reaching the public. The excuse used was the typical patronizing approach of some doctors: "We don't want to scare the ladies." It is absolutely essential that any women offered epidural must be told all the scientific facts about the risks before she gives informed consent to the procedure.

With all these risks of epidural block to woman and baby, why are doctors urging women to use it? Research shows that doctors prefer the woman to have an epidural because then she is quiet and compliant. Furthermore, it is the frequent use of epidural for normal labour which has created a new specialty, obstetric anesthesiology, which is highly lucrative and flourishing - witness that obstetric anesthesiology journals contain advertisements urging doctors to purchase private jet airplanes.

Table 2 shows the tragic Australian obstetric cascade starting with overuse of drugs for induction and augmentation leading to the excessive use of epidural block inevitably resulting in the extreme rates of forceps and vacuum extraction found in Australia - the highest rates recorded anywhere in the world. How can it be that a third of babies born in Australia must be pulled out of their mothers? Such aggressive extraction results in damage to the neonate including swelling and bruises of the head. Using a surgical instrument also means frequent episiotomy and all these invasive surgical procedures on the woman results in damage to the woman still evident six months postpartum including 54% with perineal pain, 18% with urinary incontinence, 19% with bowel problems, 36% with haemmorrhoids and 39% with sexual problems. This is why it is appropriate to define rates of episiotomy over 20 % (it is 46.6 % in Table 1) as female genital mutilation.[19]

Table 3 shows the situation in Australia regarding caesarian section. The rate of 25.9% in private hospitals is double the rate recommended by the World Health Organization and double the rate found in a number of countries with far lower perinatal mortality rates than Australia. The emergency caesarian section rates are not extreme but the elective rates are indeed extreme. One third of all caesarian section is because of "failure to progress/ disproportion" [20], a loose, imprecise diagnostic label which has been shown to be very popular among private obstetricians who have become impatient with the length of a perfectly normal birth.[21]

Because, as shown in Table 3, women in private care have far higher rates of caesarian section than women in public care, the Australian National Parliament held an inquiry. As shown in Table 4, repeated submissions to the inquiry claimed without presenting any scientific evidence that these higher rates in private care is because many women at high risk take out private health insurance. A subsequent Australian study[22] has shown that the claims made at the inquiry were false testimony as women in private care have fewer medical and obstetric complications which might require caesarian section.

So why is there more caesarian section with private patients? The cascade shown above also results in excessive unnecessary caesarian section and women in private care are given more epidural and induction which leads to caesarian section. In addition, fewer midwives attend births in private care and, as we will soon see, there is good scientific evidence that there is far less unnecessary intervention when the midwife is the principle birth attendant. And the convenience factor must be mentioned. Caesarian section can be scheduled for the convenience of the doctor and hospital and, instead of taking 12 hours, can take 30 minutes. The latest excuse given by obstetricians for excessive unnecessary caesarian section is that women prefer caesarian section and are asking for it - an unfounded and unethical excuse I address at length in a paper "Choosing caesarian section".[12]

Is hospital birth safe in Australia? After reviewing the above information, the only rational answer must be a resounding no, most especially for women in private care.

Solutions

So far we have not been clever enough, in developed or developing countries, to take the advantages of medicalised birth care while avoiding the disadvantages such as the drift to obstetric excesses. Humanizing birth has the potential to combine the advantages of Western medicalised birth with the advantages of redirecting the care so as to honor the biological, social, cultural and spiritual nature of human birth. There are several strategies for humanization of birth - strategies which will put the woman and the family back in control of the birth of their own child while empowering the woman to believe in herself through experiencing what her own body can accomplish.

The first strategy is education. Those who control information hold the power. In the past the medical profession has maintained control of medical care through protecting and withholding information. Patient confidentiality, a legitimate excuse for limiting access to information on individual patients, is now understood not to be an excuse for limiting information on grouped data such as hospital data and community data. The information revolution is profoundly changing medical care. The advent of the internet and world wide web is having a profound effect on bringing medical information to everyone. In the new millenium a global movement is demanding accountable and transparent health care practitioners and health care facilities (including hospitals) as a basic requirement of any democracy. Several years ago during a lecture in Australia I gave data on the excessive obstetric interventions in private hospitals in Queensland. The next day irate obstetricians in Queensland called the State Health Department trying to find out where I got my data on their private hospitals. Their concern was not their excessive practices but their need to hide these practices from the public. The days of practice secrets are gone. Complete and honest information must be given to the public, even when it means giving up power and, in some cases, can be dangerous to the continuation of certain practices.

Full information on the good and bad results of medicalised birth must be given to health care practitioners, public health officials, politicians and the public. In other words, everyone must begin to see the water that many doctors and hospitals are swimming in and see that in many cases it is full of sharks which may not eat the doctors but may sometimes eat women and babies.

The need to broaden the horizon of doctors concerning maternity care is not a new problem. In a medical book published in the year 1668 is the statement: 'Doctors who have never seen a home birth and yet feel competent to argue against it resemble those geographers who give us the description of many countries which they never saw'.We must start by requiring doctors to look at the water in which modern maternity care exists in order to get a physiological standard against which they can measure all their experiences. In an obstetric training program in The Philippines, every doctor must attend a minimum number of planned home births. Every obstetric training program should require visits to planned out-of-hospital births, including birth centers and home births. Midwives and obstetric nurses in training need the same experience.

The education of women, especially pregnant women, is of paramount importance but here the issues is: what are the women told. In some places prenatal education programs are controlled by obstetricians who insist on giving only doctor-friendly information to pregnant women. Anesthesiologists have managed to gain access to prenatal classes where they preach the wonders of epidural block and usually say nothing about the considerable risks.

More recently, for doctors to succeed in promoting women choosing caesarian sections for which there are no medical indications it is necessary to provide limited, highly selected information.[12] It is highly unlikely women would ever consider choosing CS if they were given the full scientific evidence on the risks for themselves and their babies. The key ethical issue is not the right to choose or demand a major surgical procedure for which there is no medical indication but the right to receive and discuss full, unbiased information prior to any medical or surgical procedure.

A liberated woman correctly strives not to be controlled by men, an effort even more difficult if she lives in a male chauvinist society. There are many ways in which women giving birth in hospitals in 'macho' cultures are oppressed and given the message that they are not important and not free but controlled by an often belligerent staff. But if a woman accepts the medicalised, male dominated obstetric model of care with its selected information, she gives up any chance to control her own body and make true choices. Volumes have been written about how liberating and empowering it is for a woman to give birth when she controls what happens. Without fully informed choice, she will give up any control and comply with the wishes of the doctors and hospitals. Women who demand choice but get only selected doctor-friendly information unwittingly buy into the medical position and call it feminism.

A second strategy for humanization of birth is the promotion of evidence based maternity care practices. As mentioned earlier, using peer review and community standards of practice has failed to close the gap between present obstetric practices and the evidence. And in many places public health professionals and government agencies have failed to aggressively pursue closing the gap between obstetric practices and evidence, often out of fear of the power of the medical establishment.[9]

It has been an interesting and educational exercise for me to come to hospital obstetric units and present to the staff a simple table with their own rates of interventions (induction, episiotomy, lithotomy, operative vaginal, caesarian section) in a column on the left and the evidence based rates opposite in a column on the right-similar to Table 1 in this paper. The ensuing discussion is often characterized by more heat than light. As we enter the era of post- modern medical care, the GOBSAT (Good Old Boys Sit Around Table) clinical practice guidelines of yore, royalist in sentiment and pompous in tone, will be replaced by evidence based practice guidelines approved by the community.

Another essential strategy in humanizing birth is: who is the primary care giver for women during pregnancy and birth. The tradition of doctors insisting on controlling their own practices with little or no interference from the community or its representatives goes back a long time. During the course of the twentieth century, the practice of doctors going on 'house calls' disappeared for good reason-doctors are uncomfortable in the patient's home as the family is in control. As long as doctors provide primary care to normal, healthy pregnant and birthing women, women will not be in control and humanization of maternity care will not happen.

Countries must work hard not to allow doctors to try to take over the primary care of low-risk pregnant and birthing women. Data from the Victorian Perinatal Data Collection Unit show that in 1998 in that State, 58.7 % of all birth (public and private) was attended by either a GP or an obstetrician with no midwife involved.. Good scientific research shows that unnecessary interventions go up and women's satisfaction goes down when doctors rather than midwives attend low-risk hospital birth.[13] When doctors give primary care to over half of normal, healthy women giving birth, birth becomes a surgical procedure with high rates of unnecessary interventions. Women giving birth in such maternity care systems are disempowered and there are huge wastes of resources, financial and professional. Midwives are marginalised and more and more obstetricians are trained.

By contrast, midwifery has a long tradition of placing the birthing woman in the center with all the control in the woman's hands and with the midwife providing the kind of support which will empower the woman and strengthen the family. For this reason, having primary maternity care in the hands of midwives is a central strategy in humanization of birth.

Countries might want to study the maternity care in countries much further along the road to humanization such as New Zealand, The Netherlands, Scandinavian countries. In these countries, over 80% of women see only midwives during pregnancy and birth (in or out of hospital) and they have some of the lowest maternal and perinatal mortality rates in the world.

Considerable scientific research has demonstrated four major advantages to autonomous midwifery: midwives are safer for low risk birth, midwives use less unnecessary interventions, midwives are cheaper, midwives provide more satisfaction.

First, there can no longer be any doubt that midwives are the safest birth attendant for low risk birth. One meta-analysis of 15 studies comparing midwife-attended birth with physician attended birth found no difference in outcomes for women or babies except for fewer low birth weight babies with midwives.[23] Two randomized controlled trials (RCT) in Scotland[24,25] and 6 RCTs in the US all found no increase in adverse outcomes with midwife attended birth.[13]

The most definitive study of the safety of midwife attended birth, published in 1998, looked at all births in one year in the US-over four million births. Selecting only singleton, vaginal births and removing cases of social or medical risk factors, they compared outcomes between midwife-attended births and physician attended births. Compared with physician attended births, midwife attended births had 19% lower infant mortality, 33% lower neonatal mortality and 31% lower low birth weight rates.[26]

After reviewing the extensive evidence for the safety of midwives, a recent article in an obstetric journal concludes: "A search of the scientific literature fails to uncover a single study demonstrating poorer outcomes with midwives than with physicians for low-risk women--evidence shows primary care by midwives to be as safe or safer than care by physicians."[13].

The second advantage of midwives over doctors as primary birth attendants is a drastic reduction in rates of unnecessary invasive interventions. Scientific evidence shows that, compared to physician attended birth, midwife attended birth has statistically significantly: less amniotomy, less IV fluids or IV medication, less routine electronic fetal monitoring, less use of narcotics, less use of anesthesia including epidural block for labour pain, less induction and augmentation, less episiotomy, less forceps and vacuum extraction, less caesarian section, more vaginal birth after caesarian section.[13]

The third advantage of using midwives as the principal birth attendant for most births is cost savings. While it varies from country to country, midwives salaries are almost always considerably less than doctor's salaries. And of course, the lower intervention rates with midwives mean major cost savings. The data on cost saving is reviewed in a paper on midwifery in industrialized countries[13] where, for example, one study found a cost saving of US$500 for every case where a midwife is birth attendant.

Another advantage of midwifery care, often disparaged by advocates of medicalised birth, is the pregnant and birthing woman's satisfaction with her care. The midwifery approach emphasizes the importance of women's satisfaction. The evidence in the literature is overwhelming: midwifery care is statistically significantly more satisfying to the woman and her family.[13]

In order to maintain their hegemony over midwives, doctors attack midwives, especially midwives in independent practice where they are not under the control of doctors or hospitals. The past two decades has seen a global witch hunt of midwives.[27] One of the most frightening examples of a witch hunt against a midwife occurred here in Australia with an independent midwife Maggie Leaky-Thompson. Regardless of any individual opinion of this midwife's practices, the methods used to attack her ran roughshod over any chance of a just hearing, as described in my paper 'The Australian Witchhunt' found in the appendix to this paper.

Since hospitals are doctor territory and no woman has ever been in control of her own care in a hospital setting, another important strategy for humanization of birth is to move birth out of the hospital. There have always been and always will be women everywhere who choose planned home birth and need a midwife to attend the birth. But today, as a result of decades of propaganda about how dangerous birth is, told by doctors who are themselves afraid of birth and are told how safe hospital birth is, told by doctors who themselves need the security of hospitals, there are many women who have bought into the myth that home birth is dangerous.

It is unbelievable that obstetric organizations in some highly industrialized countries such as the US still have the same official policy against home birth which they wrote in the 1970's. At that time planned home birth was not separated from unplanned precipitous out-of-hospital birth which, of course, had high mortality due to preemies born in taxis, etc. Then when scientists separated out planned home birth, it proved to have perinatal mortality rates as low or lower than low risk hospital birth. A large scientific literature documents this, including when the home birth practitioner is a nurse midwife[28] or when it is a direct entry midwife[29-31]. A meta-analysis of the safety of home birth, published in 1997, conclusively demonstrates the safety of home birth and includes an excellent review of the literature.[32]

It is important to be aware of attempts to distort home birth research findings in attempts to hang on to the untenable position that home birth is dangerous. Several years ago on the Australian television program 'Lateline' Dr Brunello attempted to defend his anti-homebirth position by giving data from research in South Australia which he claimed suggested homebirth has higher perinatal mortality.[33] He must not be a scientist as he was apparently unaware that the findings of this particular study are suspect for a number of reasons including: far too small a sample size, no matched control group and no data linkage to find lost cases. The authors themselves conclude: "Close examination of the individual deaths led to the conclusion that the majority could not directly be attributed to the place of birth."

Another more recent publication on homebirth in Australia[34] has methodological flaws so serious as to make their conclusions unjustified. The appendix to this paper includes my scientific critique of this Australian study in which I conclude: "It is well known in Australia that the reason for the several shifts in data collection methods in this study (which effectively eliminated any possibility of scientific validity) is because so many midwives felt betrayed by the researchers that they refused further participation in the research. It is intellectually dishonest not to report this fact in this paper."

In spite of all attempts by doctors to stamp out home birth, it has never disappeared and now is showing clear evidence of making a slow but sure comeback in a number of countries including Great Britain, Denmark, US, Japan (Birth Houses). And of course the great thorn in the side of anti-homebirth doctors has always been and still is The Netherlands where planned homebirths have never fallen below 30% with birth outcomes such as maternal and perinatal mortality rates comparable to Australia.

So the real issue with home birth is not safety but the issues are freedom and sanctity of the family. For the over eighty percent of women who have had no serious medical complications during pregnancy, planned home birth is a perfectly safe choice. Any doctor, hospital or medical organization attempting to discourage a low risk woman from choosing home birth is denying basic human rights by withholding full unbiased information and limiting a woman's freedom of choice of place of birth. Doctors who believe they know best how others should live and attempt to impose their beliefs on others are practicing medical fascism. The birth of a baby is one of the most important events in the life of the family and when the family chooses a planned home birth, the sanctity of the family must be honored.

Because of the frightening propaganda of the obstetrical profession about how dangerous birth is, many women want the freedom to control their own birthing but need the 'security' of an institution. How can women today be in control of giving birth and be empowered by birth and be assisted by a midwife and still feel comfortable and protected by an institution? By choosing an alternative birth center (ABC) which is 'free-standing' (i.e. out-of-hospital) and staffed by midwives.

The first essential characteristic of an ABC is that it is free of any control by a hospital. A hospital which claims to have a 'birth center' is like a bakery which claims to sell 'home-baked bread. To be a birth center, the birthing woman must be in control of everything that happens to her and her baby. This means the ABC must be staffed by midwives using protocols made by midwives, not doctors.

The type of care provided in an ABC is quite different from a hospital. In a hospital the doctor is always in absolute control while in an ABC the woman is in control. In the hospital the emphasis is on routines while in the ABC the emphasis is on individuality and informed choice. Hospital protocols are designed with all the possible complications in mind while ABC protocols focus on normality, screening and observation. In hospitals pain is define as an evil to be stamped out with drugs while in the ABC it is understood that labour pain has a physiological function and can be relieved with scientifically proven, non-pharmacological methods such as immersion in water, changing position and moving about, massage, presence of family, continuous presence of the same birth attendant.

In the hospital induction is frequent and uses powerful drugs which increase the pain and has many risks while in the ABC labour is stimulated with non-pharmacological methods including walking and sexual stimulation. In the hospital staff are not always present but come and go and change every eight hours while in the ABC there is the continuous presence of one midwife throughout the labour. In the hospital the new baby is taken away from the mother for various reasons such as doing a newborn examination while in the ABC the new baby is never taken from the mother.

Are ABCs a safe place for a woman to give birth if she has had no complications during the pregnancy? This is a key question because in the struggle between the medicalised and humanized approaches to maternity care, the ABC is a big threat to doctors and hospitals and the industry producing all the obstetric technologies. Because medicalised birth is so expensive with costly hospital stay, highly paid obstetricians using so much costly high tech intervention, the doctors and hospitals must convince the public and those who control funding of health services that their way is the only safe way. Otherwise they will quickly lose much of their business. So obstetric organizations fight against all birth where they are not in control. Their first line of defense against any planned out-of-hospital birth is to label it unsafe.

The only way to determine if ABCs are safe is to turn to the scientific evidence. A thorough review of the scientific evidence on ABCs [35] reports that in the 1970s and 1980s there were a number of descriptive studies on ABCs. Then in 1989 a most important paper on ABCs was published: 'The US National Birth Center Study' involving 84 ABCs and 11,814 births.[36] In the 1990s seven more studies compared ABC birth with hospital birth and one RCT was reported. The results of this research follows.

Regarding safety, the US National Birth Center Study had no maternal mortality and an intrapartum and neonatal mortality rate of 1.3 per 1000 live births, a rate comparable to the rates in low risk hospital births. The infant mortality rate and Apgar scores in the ABCs was also comparable to low risk hospital rates. Sixteen percent of ABC births were transferred to the hospital. Such rates of transfer of planned ABC birth to hospital because of complications compare favorably with the number of planned hospital births which are transferred to the surgical suite because of complications. The intention to treat analysis was used in which all complications, interventions and outcomes from ABC births transferred to hospital are included in the ABC statistics.

The safety of ABC birth is further substantiated by additional studies done in the 1990s in which the outcomes of ABC births-perinatal mortality, neonatal mortality, apgar scores, low birth weight rates-in all studies were as good or better than the outcomes with hospital birth.

In addition to the evidence for the safety of ABCs, these studies had further data on the characteristics of women choosing ABCs. After their ABC birth was over, 99% said they would recommend ABC birth to their friends and 94% said they would return themselves to the ABC for any future births. A RCT found that 63% of ABC women had an increase in self-esteem while 18% of women with hospital birth had an increase in self-esteem.[35]

With regard to the promotion of breastfeeding, studies in the US, Denmark and Sweden all found significantly increased rates of successful breast-feeding in ABC women.

Table 5 compares the intervention rates in the US National Birth Center Study[36] with the rates of obstetrical intervention in low-risk primiparous women in private care in Victoria presented earlier in this paper.[22] In ABCs, 99% were spontaneous vaginal births compared to 18% of low risk primips in private hospitals in Victoria. Less than 4% of ABC births had induction or augmentation with artificial rupture of membranes and/or oxytocin compared with 48.8% of low-risk private hospital births. Regional or general anesthesia (including epidural block) was done in 13% of ABC births and 50.8% of low-risk private hospital births in Victoria. Operative vaginal birth (forceps or vacuum) was done in less than 1% of ABC births and 33.9% of private hospital births in low-risk primips in Victoria. Caesarian section was done in less than 5% of ABC births and in 25.9% of all births in private hospitals in Victoria. Looking at these comparisons of interventions, clearly the logical question is not if ABC birth is safe but if hospital birth is safe.

As the news about the safety of ABCs spreads, more and more are being established. In the past ten years, Germany has gone from having one ABC to now having over 50 ABCs. In Japan, a network of midwife birth houses provided a significant part of maternity services the first half of the last century but during the American occupation, US Army doctors and nurses put pressure on the Japanese to close the birth houses. Now, however, there is a resurgence of birth houses in Japan.

Compared to hospital births, home births and births in ABC's are safe, much cheaper, use far less unnecessary interventions, are more satisfying to the woman and family. In other words, out-of-hospital birth is an important strategy in humanizing birth care.

Birth is political. An essential strategy is for advocates of humanized birth to be politically active. Politicians and government agencies make crucial decisions about maternity care and their education about and involvement in humanization of birth is essential.

Advocates of humanized birth must warn politicians and policy makers of the use of scare tactics by some of the more reactionary elements of the medical establishment who raise the issue of safety and claim without a shred of evidence that humanized birth is dangerous-that midwives are less safe than doctors and out-of-hospital birth less safe than hospital birth.

Another common scare tactic is for obstetricians to say that every out-of-hospital birth transported to the hospital is a 'train wreck'. The answer to this criticism is "of course". A competent out-of-hospital midwife will only transport those few cases where there is a serious problem requiring surgical interventions not available in the home. So for the obstetricians who have never attended a home birth (in many places this is nearly all obstetricians), these out-of-hospital transports with problems are their only experience with out-of-hospital birth and they erroneously assume these cases are representative of all out-of-hospital birth. This is like the auto mechanic who sees several Mercedes with mechanical problems and concludes all Mercedes are no good, forgetting that for every Mercedes he sees in his shop, there are a thousand Mercedes running fine and therefore not brought to his shop. This is why doctors need to experience out-of-hospital birth first hand.

These scare tactics are motivated by the attempt of some doctors to protect maternity care as their territory. Often doctors attempt to overwhelm legislators with technical language which implies that only doctors can possibly understand so the listener must simply "trust me, I'm a doctor". Politicians and policy makers should be urged to ask those making these scare statements "Please show me the scientific data to prove what you are saying." It can also be illuminating for legislators to ask those making scare statements how many out-of-hospital births they have attended.

Conclusion

The final solution is to evolve new social and political forms for the medical profession and for medical care. Maternity care needs turning around so that, instead of drifting away from physiology and from the social and cultural environment, the process moves toward respecting and working with nature and with the woman and family, turning control of medical care over to the people. For those who fear chaos, remember Churchill's warning: democracy is the worst form of government until one considers the alternatives.

This turn around has started in places with local public committees deciding on health care policies and priorities - post-modern maternity care. Everything about pregnancy and birth - how it is perceived by society, how the pain of birth is endured by women, how birth is 'managed' by birth attendants - are highly cultural. Local control leads to empowerment of women which, in turn, leads to a stronger family and society - local women need to give birth in local waters. People have been swimming in the physiological, social and cultural primordial sea for a long, long time, can see the water, know where the sharks are and are adept at eventually finding their way forward to reclaiming humanized birth.

Eventually the new millennium will see a system of maternity services in Australia which are midwife-intensive, evidenced based, focus on out-of-hospital low-risk births, and honors the freedom of women and families. Why? Because:

"Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has." - Margaret Mead

References

1. World Health Organization "Having a Baby in Europe", European Regional Office, 1985

2. Wagner M "Public health aspects of infant death in industrialized countries: the Sudden emergence of sudden infant death." Annales Nestle 50: 2 1992

3. Hall M, Bewley S "Maternal mortality and mode of delivery" Lancet 354, p 776, 1999

4. McCarthy B "US maternal death rates are on the rise" Lancet 348:394, 1996

5. World Health Organization. WHO revised estimates of maternal mortality: a new approach by WHO and UNICEF. Geneva, WHO 1996; report no. WHO/FRH/MSM/96.11

6. Notzon F "International differences in the use of obstetric interventions" JAMA 263:24, 3286-3291, 1990

7. Lomas J, Enkin M "Variations in operative delivery rates", in Effective Care in Pregnancy and Childbirth. Eds I Chalmers, M Enkin, M Keirse, Oxford University Press, 1989

8. Sachs B, Castro M, Frigoletto F "The risks of lowering the cesarean-delivery rate" New Eng. J. Med. 340:1, 54 - 57, 1999

9. Wagner M "The Public Health versus Clinical Approaches to Maternity Services: The Emperor Has No Clothes." Journal of Public Health Policy 19: 1, 25 - 35, 1998

10. Bruner, J et al. "All-fours maneuver for reducing shoulder dystocia during labor." J Reprod. Med. 43:439-443, 1998

11. Olatunbosun O, Edouard L, Pierson R "British physician's attitudes to evidence based obstetric practice" Br. Med J 316:365, 1998

12. Wagner M "Choosing Caesarian Section" Lancet, 356:, p 1677-1680, 2000

13. Wagner, M "Midwifery in the Industrialized World" J. Society Obst. Gyn Canada, 20, 13, 1225-34, 1998

14. Rattner, D "Sobre a hipotese de estabilizacao das taxas de cesarea do Estado de Sao Paulo, Brasil" Rev. Saude Publica, 30:1, 19-33 1996

15. Secretariat of Health, Sao Paulo State, Brazil, 1999

16. FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health: "Ethical aspects regarding cesarean delivery for non-medical reasons" Int J Obs & Gyna, 64, 317- 322, 1999

17. Wagner M Pursuing the Birth Machine: the Search for Appropriate Birth Technology, ACE Graphics, Sydney & London 1994 (available at www.amazon.com)

18. Goer, H The Thinking Woman's Guide to a Better Birth Penguin Putnam, New York, 1999 (available at www.amazon.com)

19. Wagner M "Episiotomy: a form of genital muilation ". Lancet Vol 353, p 1977-98, 1999

20. Victoria State Consultative Council on Obstetric and Paediatric Mortality and Morbidity, Annual Report 1998, Table 28

21. Stephenson P "International differences in the use of obstetrical interventions", World Health Organization European Regional Office, Copenhagen, 1992

22. Roberts C, Tracy S, Peat B "Rates for obstetric intervention among private and public patients in Australia: population based descriptive study." BMJ 321, 137-141, 15 July 2000

23. Brown S, Grimes D "A meta-analysis of nurse practitioners and nurse midwives in primary care." Nurs Res, 44, 332-9, 1995

24. Hundley V, Cruickshank R, Lanf G, Glazener C et al "Midwifery managed delivery unit: a randomised controlled comparison with consultant led care." BMJ 309, 1401-1404, 1994

25. Turnbull D, Holmes A, Shields N Cheyne H et al "Randomised, controlled trial of efficacy of midwife-managed care" Lancet 348, (9022), 213-218. 1996

26. MacDorman M, Singh G "Midwifery care, social and medical risk factors, and birth outcomes in the USA" J Epidemiol Community Health 52, 310-317, 1998

27. Wagner M "A global witch-hunt" Lancet, 346: 1020-22, 1995

28. Murphy P, Fullerton J "Outcomes of intended home births in nurse-midwifery practice: a prospective descriptive study." Obstet & Gynecol 92, 3, pp 461-470, 1998

29. Durand AM "The safety of home birth: The Farm study" Am J Public Health, 82:450-453, 1992

30. Schramm W et al "Neonatal mortality in Missouri home births." Am J Public Health 77:930-935, 1987

31. Hinds M et al "Neonatal outcome in planned v. unplanned out-of- hospital births in Kentucky" JAMA 253:1578-1582, 1985

32. Olsen O "Meta-analysis of the safety of home birth" Birth 24:1, p 4-16, 1997

33. Crotty M, Ramsey A, Smart R et al. "Planned homebirths in South Australia 1981 - 1987: a descriptive study." Med J Aust 153, p 664-671, 1990

34. Bastian H, Keirse M, Lancaster P "Perinatal death associated with planned home birth in Australia: population based study". BMJ Vol 317, 8 Aug. 1998

35. Stephenson P, Ford Z, Schaps M "Alternative Birth Centers in Illinois: A resource guide for policy makers" University of Illinois at Chicago Center for Research on Women and Gender, and the Health and Medicine Policy and Research Group. June 1995

36. Rooks J. et al "The National Birth Center Study", New England J Med, 321, 1804 - 1811, 1989

Tables

Is hospital birth safe in Australia? No evidence based practice in low-risk primips

Is hospital birth safe in Australia? Australian obstetric cascade

Is hospital birth safe in Australia? Caesarian section rates in Victoria in 1998

Is hospital birth safe in Australia? Obstetric false testimony

Is hospital birth safe in Australia? Interventions low-risk private hospital births versus alternative birth center births

Appendix

Wagner M "The Australian Witchhunt"

Wagner M "A Critique of: Bastian H, Keirse M, Lancaster P; Perinatal death associated with planned home birth in Australia: population based study". British Medical Journal Vol 317, 8 August 1998

© Marsden Wagner 2000. This paper was presented at the Homebirth Australia Conference, Noosa, Australia, November 2000

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Fish Can't See Water | Birth International

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By Marsden Wagner (MD, MSPH) This paper was presented at the Homebirth Australia Conference, Noosa, Australia, November 2000 Humanizing birth means understanding that the woman giving birth is a human being, not a machine and not just a container for making babies.

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List of Guidelines From Across the World

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List of Guidelines From Across the World

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Home birth : Guidelines, reviews, statements, recommendations, standards

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Obstetrics and gynecology guidelines Geneva Foundation for Medical Education and Research

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List of Hospital Specific Transfer Guidelines & Algorithims Examples

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List of Hospital Specific Transfer Guidelines & Algorithims Examples

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Maternal Transfer Form Neonatal Transfer Form Hospital Specific Transfer Algorithms

Alta View Hospital (Sandy, UT)

Davis Hospital and Medical Center (Layton, UT)

Heber Valley Hospital (Heber Valley, UT)

Intermountain Medical Center (Murray, UT)

Jordan Valley Medical Center (West Jordan, UT)

LDS Hospital (Salt Lake City, UT)

Lone Peak Hospital (Draper, UT)

Park City Hospital (Park City, UT)

Riverton Hospital (Riverton, UT)

St. Mark's Hospital (Salt Lake City, UT)

Timpanogos Regional Hospital (Orem, UT)

University of Utah Health Care (Salt Lake City, UT)

Hospital Specific Transfer Referral Guides

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Utah Women and Newborn Quality Collaborative | Out of Hospital Births Resources

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Maternal Transfer Form Neonatal Transfer Form Hospital Specific Transfer Algorithms Alta View Hospital (Sandy, UT) Davis Hospital and Medical Center (Layton, UT) Heber Valley Hospital (Heber Valley, UT) Intermountain Medical Center (Murray, UT) Jordan Valley Medical Center (West Jordan, UT) LDS Hospital (Salt Lake City, UT) Lone Peak Hospital (Draper, UT) Park City Hospital (Park City, UT) Riverton Hospital (Riverton, UT) St.

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Guidelines for Collaborative Development PDF

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Guidelines for Collaborative Development PDF

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Fillable Transfer Provider Maternal Transfer Chart

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Fillable Transfer Provider Maternal Transfer Chart

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Australian College of Midwives Transfer Guide

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Australian College of Midwives Transfer Guide

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Unique Dataset

MANA Stats is a project of the Division of Research of the Midwives Alliance of North America, an organization inclusive of all forms of midwifery. Midwives Alliance midwives have been collecting their statistics for research purposes since the 1990s. The MANA Statistics Project (MANA Stats) online data collection was launched in November 2004 and continues today.

Are you a researcher interested in accessing the MANA Stats data?

See our researcher page for more information.

Are you a midwife who would like to contribute your data?

In order to submit birth data to the MANA Statistics Project, you must enroll as a contributor. In doing so, you agree to log every client who comes into your care, that consents to be in MANA Statsand to enter complete data for every birth you attend, using our easy and secure Web-based system.

You can try out a demo version of the system at demo.manastats.org with the username guest and password 'demoguest'.
For more information and to enroll as contributor, click here

Want to enroll?

Download the Enrollment Form, print and complete it, and mail it to the address printed on the form. Ideally all members of a practice should enroll. An account will be set up for you upon enrollment; you will be notified by e-mail of your account name and asked to select your own password. The site features extensive documentation to explain the system and how to use it.

You do not need to be a member of the Midwives Alliance to enroll, though we would love you to consider joining to support this great work! There is no fee to use the MANA Stats system. You do not have to practice in the home or birth center setting; hospital-based midwives are welcome to enroll as well. Questions regarding enrollment and participation can be addressed to the MANA Stats Support Team at support@manastats.org.

Certified Professional Midwives can earn CEUs towards recertification by contributing to MANA Stats. See NARM's CPM recertification bulletin for details

Contributors and organizations of contributors (such as state professional midwifery associations) may access summary statistics of their own data at any time. Contact the Support Team for more details.
See our FAQ page for answers to frequently asked questions about the MANA Statistics Project. Enroll to submit your data to MANA Stats.

# data[].attributes.attachment_link.description
MANA Stats is a project of the Division of Research of the Midwives Alliance of North America, an organization inclusive of all forms of midwifery. Midwives Alliance midwives have been collecting their statistics for research purposes since the 1990s. The MANA Statistics Project (MANA Stats) online data collection was launched in November 2004 and continues today.

# data[].attributes.attachment_link.readable_text
Community birth (planned home and birth center births) has been demonstrated to be a safe option for low-risk women. New research recently published in the journal Birth: Issues in Perinatal Care, entitled Perspectives on risk: Assessment of risk profiles and outcomes among women planning community birth in the United States and authored by Marit L. Bovbjerg PhD MS, Melissa Cheyney PhD, CPM, LDM, Jennifer Brown LM, Kim J. Cox PhD, CNM, and Lawrence Leeman MD, MPH asks the question "safe for whom?"
This research is the first ever look at the relative risks of community birth and based on the largest available dataset in the US on physiologic birth. Jeanette McCulloch interviewed one of the article's researchers, Melissa Cheyney PhD, CPM, LDM, to help practitioners and policy makers interpret the findings. Jeanette: I understand this research is designed to help us clarify how different risk factors impact outcomes for planned community births. Why did you undertake this research?
Melissa: In 2015, I participated in a debate within the British Journal of Obstetrics and Gynaecology where two groups of researchers took sides around the prompt "home birth is unsafe." Grunebaum, Chervenak and their colleagues wrote a piece arguing that safe planned home birth is clinical fiction. The opposing viewpoint, which I wrote with Marit Bovbjerg and Paul Burcher, questioned, Safe For Whom? We started with the premise that given the larger literature on planned home and birth center births with trained midwives in high-resource countries, home birth clearly can be safe and for some outcomes safer than hospital births for a certain segment of the population. The Dutch, UK, and Canadian studies have clearly shown us this.

But we also know that safety in community birth settings is contingent upon getting some things right, including an essentially healthy client, a well-trained midwife, and a plan for transfer to a higher level of care should a complication arise. Community births are also safest when they occur within an integrated system so that transitions between levels of care are seamless and collaborative.

This caused us to question whether we were asking the right questions. Instead of asking, is home birth safe?, we argued that we should be asking, safe for whom?, under what circumstances?, and using whose definition of safe? This study was born out of a commitment to maternal autonomy and informed, shared decision making.

Since most of our authors are also practitioners who are currently working on the ground with women who are making these choices, we know that when clients are faced with options, they do not necessarily choose what we as practitioners would choose. I think we have all experimented with different methods and strategies for conveying information about risk. What I see happening is that women take information - statistical, numerical, written, verbal, graphic, however we present it to them - and then they filter it through their own value systems and individual histories. What comes out the other side can be quite variable, depending on a client's religious affiliation, their view of their own body, and their experiences with the medical establishment prior to having this baby. All of these things shape where a pregnant person is going to draw the line for what constitutes acceptable risk.

Many families who consider community birth do not see hospital birth as risk-free, but as an option that carries a different set of risks. They may be negotiating the possibility of having an intervention like cesarean that they did not want or need and then grappling with regret, having to process that in the months and years following their birth. They also understand that having distance between themselves and a hospital means if an emergency does occur, they could be placing themselves at risk. The point is, they do not see one risk-free option. They see two different options with some level of risk associated with each setting. We wanted to be able to provide data that could be used to help inform these kinds of decisions. That was our goal.
Jeanette: The research examines those who are very low-risk in the community birth setting - those who have already given birth vaginally and have no other risk factors - to help us understand how other groups compare. Can you tell us how this research was designed?
Melissa: If you look globally at systems that have integrated maternity care, what you will see is that the definition of "low-risk" varies markedly between systems. There is really no consensus on what constitutes a low-risk client.

What we wanted to do is take some of the exposures (risk factors) that in different systems are considered to put women at higher risk, either based on evidence or based on fears of litigation and ask the question: What are the relative and absolute risks ›associated with a variety of maternal/fetal characteristics that may render a pregnancy at increased risk for adverse perinatal outcomes within the context of planned, physiologic birth in the community setting?

We started out by really thinking through what those main exposures are. What are some of the things that we often think about as adding risk? We looked at primiparity (having your first baby), multiple pregnancies, breech, gestational diabetes, preeclampsia, postterm pregnancy, which we defined as 42 weeks or greater, older than average women (35 years or older), and women of size, which in the United States we currently define as having a pregravid body mass index of greater than 30. We also looked at having a history of a prior cesarean, because a number of people seeking community care desire to labor after a cesarean, especially in communities where hospital protocols severely limit or fully ban access to vaginal birth after cesarean (VBAC). Next we created a comparison group: multiparous women (those who have already given birth) with no other comorbidities, so a very healthy population. These are the people who would be considered by nearly all providers to be good candidates for community birth. We then compared groups of women with risk factors to the lowest risk comparison group and asked: how do these exposures or risk factors affect some of the key outcomes of maternity care where outcomes included transfers, cesarean sections, hospitalization, NICU admission, and combined fetal and neonatal death rates?
Jeanette: The findings appear to identify three levels of risk, some of which challenge current conventional thinking around what constitutes risk in the community birth setting. Can you tell us about the findings?
Melissa: This is a very complex study, because for every exposure or risk factor, we looked at the risk of several outcomes. We looked at 10 different exposures and 11 different outcomes, so there are hundreds of specific findings in this study. However, what our study showed us more generally is that some exposures are associated with far lower risk than we anticipated, some are about what we thought, and others are higher risk than anticipated.

I would group findings into three categories. Advanced maternal age, multiparous women with a history of cesarean and a history of vaginal birth, and pregravid obesity are the groups at the lowest risk for the adverse outcomes we studied. These risk factors do very little to increase the chance of a negative outcome, including a fetal or neonatal death. Birthing parents with these risk factors, who have been excluded from community birth by some state regulations, may actually be excellent candidates for community birth. That was a surprising finding.

Then there is a middle category where risk is moderately elevated relative to the comparison group. Gestational diabetes that is well-controlled with diet or with oral medications, postdates greater than 42 weeks, primips, and twins all fell into a middle or moderate risk category. It is very important to note here that our sample is biased in that it represents the lowest risk groups within these larger groups as most of the women with complications associated with these conditions (like prematurity in twins or low amniotic fluid levels in postdates), have been referred to a higher level of care prior to the onset of labor. Thus, most of the pregnancies in these groups are at term, well-managed, and for twins, both babies are in vertex positions - so the healthiest of these moderate risk subgroups. Our results then do not apply to all twins, all clients with GDM etc., but just to those for whom these risk factors are well-managed at the onset of labor.

Then there is a third category, which was associated with much higher than anticipated fetal and neonatal mortality and morbidity: women presenting with a breech infant, multiparous women with a history of cesarean but no vaginal birth, and preeclampsia. The breech and preeclampsia findings were not surprising to us, but one of the outcomes we are really grappling with is the risk associated with a labor after cesarean in the community setting when there has been no previous vaginal birth. That is higher risk than we anticipated going into the study.
Jeanette: How should these findings influence the kinds of informed consent conversations that you have as a practitioner when you're talking with a family?
Melissa: It is important to remember that when you are performing a study like this, you are working with very large numbers. Our study has 47,394 pregnancies. We need large sample sizes in order to have enough power to analyze the differences between groups. However, studies like this can never tell one individual woman what her risk will be or what path she should take, because any one woman can have mitigating or complicating factors that make her lower or higher risk than the category she would be placed in for the purposes of a study.

For example, let's go back to the finding that labor after cesarean without a prior vaginal birth is associated with greater risk of fetal and neonatal death. We know that within this group, there exists variability. If you have a client who had a cesarean section with her first baby for breech presentation, and now she's 39 weeks with a favorable cervix, lives close to the hospital, and she has a supportive team of providers who want to enable her to labor after cesarean, the odds of that woman being able to complete a VBAC and do so safely are quite different than someone who had an obstructed labor in their first birth and now has a thick, closed cervix at term with a second pregnancy.

The practitioner will always need to nuance these findings in their discussions with an individual family. Practitioners can begin by giving families a broad sense of the risk landscape. But then the conversation will have to narrow back in, not only to the mother's individual risk profile, but also to her value system. It is her body, and until the baby is born, she has full autonomy in decision making. She will need to make choices about her care that fit with her worldview and her value system, because she is the one who will live in that body and raise that baby afterwards.

These findings are not directive. They provide tools for a conversation. The same kind of individualized, nuanced care that characterizes the Midwives Model of Care™ will have to continue. However, this research provides far more data than we have ever had before that is specific to the community context to help guide these conversations.
Jeanette: The question of whether or not VBACs at home should be a decision between a provider and a client, or should be in some way regulated by legislation is currently contested in a number of states. How do you think that these findings should influence policy decisions?
Melissa: I think that states need to have general statutes that allow for the practice of community birth in their state. The appropriate state organization or state regulatory body is then obligated to set the rules and regulations for practice. Those rule-making entities and the rules themselves need to be very responsive to the evidence.

When I started in this field in the late '90s, there were so few articles on outcomes associated with community birth that you could become an expert in the field in a few weeks. Now, the body of literature that is available is staggering, and it is certainly a full-time job to stay on top of it. We need experts in this field to track the literature and to make recommendations every few years about how rules and regulations may need to be modified to reflect the growing body of evidence. This cannot happen adequately when specific practice guidelines are laid out in statute as these can be very difficult and time consuming to change. Evidence based rules require flexibility and nimbleness. We need statutes that enable practice and then regulatory bodies and professional organizations that are responsive to the literature in setting the rules.

I have talked about how this study provides information that can be used for shared decision making, but the other very important thing about what studies like this do is they offer us the opportunity to be self-critical and reflective. They enable us to turn the lens inward and look at our practice as midwives and say, "Where do we need to improve?" This is another place that rules and regulations can play a role. This study is one of two studies that we are working on right now that help us to understand how we can improve outcomes around VBAC. This is something that researchers can work on with educators, professional organizations and regulators. We should be working together to increase access to the safest possible care that continues to honor maternal autonomy.

We can see that there is a very high success rate for vaginal birth after cesarean in our sample, both for women who have had a prior vaginal birth and for those who have not. We can also look at each VBAC case in detail in our registry. Because MANA Stats has so many variables per mother-baby dyad, we can gain a very rich understanding of what is happening in each one of these births.

In this data set we can see approaches to VBAC care that optimize safety and those that may place the pregnancy at greater risk. One example of increased safety is a lower threshold for transfer. This implies some kind of collaborative relationship where midwives and families can make a decision to go to the hospital in a labor after cesarean when labor is not progressing normally. Willingness to transfer early is dependent upon the expectation that families will receive high-quality, respectful care once they arrive. A smooth transfer has a major impact on the outcome of that pregnancy, of that labor. In states where midwives know that a transfer means an automatic cesarean, not surprisingly, families may choose to stay home longer than, in retrospect, is wise or safe.

This kind of work shows us the ways we can shape our practice to improve outcomes. It shows us where there are problems with integration in our maternity care system that we need to work on to improve outcomes for mothers and babies. However, I do not think this kind of work is most effectively done at a statutory level. Our system takes too long to be responsive at that level. Rules, regulations and transfer relationships must be built together through a collaborative community process that is responsive to unique regional, economic and cultural needs.
Jeanette: In other areas of health care in the United States, patient autonomy is recognized as paramount. Why do you think these conversations are more complex when discussing place of birth?
Melissa: I would say part of why this conversation is so hard to have in our country is that we have something that anthropologists call "the home-hospital divide." There is a gulf between community birth providers and hospital birth providers in many areas. When you have a gulf like that, women are pushed into a position of making an either/or decision. I can birth in the hospital, or I can birth at home. There is a chasm in the middle of this that actually increases risk. I would prefer to see an integrated system where we talk about where a woman starts care and where a woman completes her care.

Any person who begins care with an obstetrician may, at some point, present significant enough complications that they are referred to a perinatologist. That transfer of care is part of a system designed to provide the best possible outcomes for mothers and babies. It is not a failure when women have to move to a higher level of care. I would like to see that same thinking applied to midwifery care and to community birth. A woman should be able to begin care with a community midwife and then collaborate or transfer care as needed. If a risk factor resolves by the onset of labor, then perhaps she can return to the community setting. If not, the midwife could follow her to the hospital as a team member for her birth in the hospital.

We have to get beyond this either/or thinking and realize that there are actually multiple points of collaboration across the entirety of a woman's pregnancy, birth, and postpartum period where we can be working together.
Jeanette: How should these findings influence how practitioners care for birthing people who fall outside of that very low-risk category?
Melissa: There are three ways that I see these findings influencing practitioners. The first two we've discussed already.

First, these findings help us to put information and evidence at the center of discussions around informed, shared decision-making.

Second, they offer an opportunity to identify the specific practices that can improve outcomes in midwifery practice. These findings show that we need to focus our attention on labor after cesarean where there has been no prior vaginal births. We need to ask ourselves, how can we improve outcomes for women who will continue to choose to labor after cesarean in the community environment?

The third thing the findings should inspire us to is collaboration. What these findings show is that while we do not have an integrated maternity care system in the US now, our outcomes are intertwined nonetheless. When you have a region where the only option a woman has for labor after cesarean is in the community setting, this impacts not only families but also midwives, who now carry the responsibility of taking care of a woman who may be at elevated risk. The hospital may also take part in that if a transfer is required.

This study should inspire us to find ways to speak across the divide, to work together to find ways to open the door for all pregnant people to have a full range of options. As they begin to understand their particular risk profile and their own value system around childbirth, clients should be able to have a full range of options before them, and they should be able to move fluidly between each of these levels of care as pregnancy and labor progress, as ongoing risk assessment is a critical part of our model of care.

We need to be asking ourselves why, in a community birth registry, can we find so much data on breech, labor after cesarean, preeclampsia, and GDM? Women are clearly looking for another option that better fits their psychosocial and clinical needs. We need to find ways to respect maternal autonomy and choice while also facilitating the healthiest births possible.

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Understanding Relative Risks In The Community Birth Setting: An Interview With Researcher Melissa Cheyney

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Community birth (planned home and birth center births) has been demonstrated to be a safe option for low-risk women. New research recently published in the journal Birth: Issues in Perinatal Care, entitled Perspectives on risk: Assessment of risk profiles and outcomes among women planning community birth in the United States and authored by Marit L.

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Abstract

The American Academy of Pediatrics concurs with the recent statement of the American College of Obstetricians and Gynecologists affirming that hospitals and birthing centers are the safest settings for birth in the United States while respecting the right of women to make a medically informed decision about delivery. This statement is intended to help pediatricians provide supportive, informed counsel to women considering home birth while retaining their role as child advocates and to summarize the standards of care for newborn infants born at home, which are consistent with standards for infants born in a medical care facility. Regardless of the circumstances of his or her birth, including location, every newborn infant deserves health care that adheres to the standards highlighted in this statement, more completely described in other publications from the American Academy of Pediatrics, including Guidelines for Perinatal Care. The goal of providing high-quality care to all newborn infants can best be achieved through continuing efforts by all participating health care providers and institutions to develop and sustain communications and understanding on the basis of professional interaction and mutual respect throughout the health care system.

Introduction

Women and their families may desire a home birth for a variety of reasons, including hopes for a more family-friendly setting, increased control of the process, decreased obstetric intervention, and lower cost. Although the incidence of home birth remains below 1% of all births in the United States, the rate of home birth has increased during the past several years for white, non-Hispanic women. However, a woman's choice to plan a home birth is not well supported in the United States. Obstacles are pervasive and systemic and include wide variation in state laws and regulations, lack of appropriately trained and willing providers, and lack of supporting systems to ensure the availability of specialty consultation and timely transport to a hospital. Geography also may adversely affect the safety of planned home birth, because travel times >20 minutes have been associated with increased risk of adverse neonatal outcomes, including mortality. Whether for these reasons or others, planned home birth in the United States appears to be associated with a two- to threefold increase in neonatal mortality or an absolute risk increase of approximately 1 neonatal death per 1000 nonanomalous live births. ⁻ Evidence also suggests that infants born at home in the United States have an increased incidence of low Apgar scores and neonatal seizures., In contrast, a smaller study of all planned home births attended by midwives in British Columbia, Canada, from 2000 to 2004 revealed no increase in neonatal mortality over planned hospital births attended by either midwives or physicians. Registered midwives in British Columbia are mandated to offer women the choice to deliver in a hospital or at home if they meet the eligibility criteria for home birth defined by the College of Midwifery of British Columbia ( Table 1).

In a recent position statement, the Committee on Obstetric Practice of the American College of Obstetricians and Gynecologists (ACOG) stated, "although the Committee on Obstetric Practice believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery. Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence." The statement reviewed appropriate candidates for home delivery and outlined the health care system components "critical to reducing perinatal mortality rates and achieving favorable home birth outcomes" ( Table 1).

Pediatricians must be prepared to provide supportive, informed counsel to women considering home birth while retaining their role as child advocates in assessing whether the situation is appropriate to support a planned home birth ( Table 1). In addition to apprising the expectant mother of the increase in neonatal mortality and other neonatal complications with planned home birth, the pediatrician should advise her that the American Academy of Pediatrics (AAP) and ACOG support provision of care only by midwives who are certified by the American Midwifery Certification Board and should make her aware that some women who plan to deliver at home will need transfer to a hospital before delivery because of unanticipated complications. This percentage varies widely among reports, from approximately 10% to 40%, with a higher transfer rate for primiparous women., The mother should be encouraged to see successful transfer not as a failure of the home birth but rather as a success of the system.

Care of the newborn infant born at home is a particularly important topic, because infants born at home are cared for outside the safeguards of the systems-based protocols required of hospitals and birthing centers. This situation places a larger burden on individual health care providers to remember and carry out all components of assessment and care of the newborn infant. To assist providers, this policy statement addresses 2 specific areas: resuscitation and evaluation of the newborn infant immediately after birth and essential elements of care and follow-up for the healthy term newborn infant.

Assessment, Resuscitation, and Care of the Newborn Infant Immediately After Birth

As recommended by the AAP and the American Heart Association, there should be at least 1 person present at every delivery whose primary responsibility is the care of the newborn infant. Situations in which both the mother and the newborn infant simultaneously require urgent attention are infrequent but will nonetheless occur. Thus, each delivery should be attended by 2 individuals, at least 1 of whom has the appropriate training, skills, and equipment to perform a full resuscitation of the infant in accordance of the principles of the Neonatal Resuscitation Program. To facilitate obtaining emergency assistance when needed, the operational integrity of the telephone or other communication system should be tested before the delivery (as should every other piece of medical equipment), and the weather should be monitored. In addition, a previous arrangement with a medical facility needs to be in place to ensure a safe and timely transport in the event of an emergency.

Care of the newborn infant immediately after delivery should adhere to standards of practice as described in Guidelines for Perinatal Care and include provision of warmth, initiation of appropriate resuscitation measures, and assignment of Apgar scores. Although skin-to-skin contact with mother is the most effective way to provide warmth, portable warming pads should be available in case a newborn infant requires resuscitation and cannot be placed on the mother's chest. A newborn infant who requires any resuscitation should be monitored frequently during the immediate postnatal period, and infants who receive extensive resuscitation (eg, positive-pressure ventilation for more than 30-60 seconds) should be transferred to a medical facility for close monitoring and evaluation. In addition, any infant who has respiratory distress, continued cyanosis, or other signs of illness should be immediately transferred to a medical facility.

Care of the Newborn

Subsequent newborn care should adhere to the AAP standards as described in Guidelines for Perinatal Care as well as to the AAP statement regarding care of the well newborn infant. ⁻ Although a detailed review of these standards would be far too lengthy to include in this statement, a few practice points are worthy of specific mention:

Transitional care (first 4-8 hours): The infant should be kept warm and undergo a detailed physical examination that includes an assessment of gestational age and intrauterine growth status (weight, length, and head circumference), as well as a comprehensive risk assessment for neonatal conditions that require additional monitoring or intervention. Temperature, heart and respiratory rates, skin color, peripheral circulation, respiration, level of consciousness, tone, and activity should be monitored and recorded at least once every 30 minutes until the newborn's condition is considered normal and has remained stable for 2 hours. An infant who is thought to be <37 weeks' gestational age should be transferred to a medical facility for continuing observation for conditions associated with prematurity, including respiratory distress, poor feeding, hypoglycemia, and hyperbilirubinemia, as well as for a car safety seat study.

Monitoring for group B streptococcal disease: As recommended by the Centers for Disease Control and Prevention and the AAP, all pregnant women should be screened for group B streptococcal colonization at 35 to 37 weeks of gestation. Women who are colonized should receive ≥4 hours of intravenous penicillin, ampicillin, or cefazolin. If the mother has received this intrapartum treatment and both she and her newborn infant remain asymptomatic, they can remain at home if the infant can be observed frequently by an experienced and knowledgeable health care provider. If the mother shows signs of chorioamnionitis or if the infant does not appear completely well, the infant should be transferred rapidly to a medical facility for additional evaluation and treatment.

Glucose screening: Infants who have abnormal fetal growth (estimated to be small or large for gestational age) or whose mothers have diabetes should be delivered in a hospital or birthing center because of the increased risk of hypoglycemia and other neonatal complications. If, after delivery, an infant is discovered to be small or large for gestational age or has required resuscitation, he or she should be screened for hypoglycemia as outlined in the AAP statement. If hypoglycemia is identified and persists after feeding (glucose <45 mg/dL), the infant should be transferred promptly to a medical facility for continuing evaluation and treatment.

Eye prophylaxis: Every newborn infant should receive prophylaxis against gonococcal ophthalmia neonatorum.

Vitamin K: Every newborn infant should receive a single parenteral dose of natural vitamin K ₁ oxide (phytonadione [0.5-1 mg]) to prevent vitamin K-dependent hemorrhagic disease of the newborn. Oral administration of vitamin K has not been shown to be as efficacious as parenteral administration for the prevention of late hemorrhagic disease. This dose should be administered shortly after birth but may be delayed until after the first breastfeeding.

Hepatitis B vaccination: Early hepatitis B immunization is recommended for all medically stable infants with a birth weight >2 kg.

Assessment of feeding: Breastfeeding, including observation of position, latch, and milk transfer, should be evaluated by a trained caregiver. The mother should be encouraged to record the time and duration of each feeding, as well as urine and stool output, during the early days of breastfeeding.

Screening for hyperbilirubinemia: Infants whose mothers are Rh negative should have cord blood sent for a Coombs direct antibody test; if the mother's blood type is O, the cord blood may be tested for the infant's blood type and direct antibody test, but it is not required provided that there is appropriate surveillance, risk assessment, and follow-up. All newborn infants should be assessed for risk of hyperbilirubinemia and undergo bilirubin screening between 24 and 48 hours. The bilirubin value should be plotted on the hour-specific nomogram to determine the risk of severe hyperbilirubinemia and the need for repeat determinations.

Universal newborn screening: Every newborn infant should undergo universal newborn screening in accordance with individual state mandates, with the first blood specimen ideally collected between 24 and 48 hours of age. (A list of conditions for which screening is performed in each state is maintained online by the National Newborn Screening and Genetic Resource Center, available at http://genes-r-us.uthscsa.edu/resources/consumer/statemap.htm.)

Hearing screening: The newborn infant's initial caregiver should ensure that the hearing of any infant born outside the hospital setting is screened by 1 month of age, in accordance with AAP recommendations.

Provision of follow-up care: Comprehensive documentation and communication with the follow-up provider are essential. Written records should describe prenatal care, delivery, and immediate postnatal course, clearly documenting which screenings and medications have been provided by the birth attendant, and which remain to be performed. All newborn infants should be evaluated by a health care professional who is knowledgeable and experienced in pediatrics within 24 hours of birth and subsequently within 48 hours of that first evaluation. The initial follow-up visit should include infant weight and physical examination, especially for jaundice and hydration. If the mother is breastfeeding, the visit should include evaluation of any maternal history of breast problems (eg, pain or engorgement), infant elimination patterns, and a formal observed evaluation of breastfeeding, including position, latch, and milk transfer. The results of maternal and neonatal laboratory tests should be reviewed; clinically indicated tests, such as serum bilirubin, should be performed; and screening tests should be completed in accordance with state regulations. Screening for congenital heart disease should be performed by using oxygen saturation testing as recommended by the AAP.

Conclusions

The AAP concurs with the recent position statement of the ACOG, affirming that hospitals and birthing centers are the safest settings for birth in the United States, while respecting the right of women to make a medically informed decision about delivery. In addition, the AAP in concert with the ACOG does not support the provision of care by lay midwives or other midwives who are not certified by the American Midwifery Certification Board.

Regardless of the circumstances of his or her birth, including location, every newborn infant deserves health care that adheres to the standards highlighted in this statement and more completely described in other AAP publications. ⁻ The goal of providing high-quality care to all newborn infants can best be achieved through continuing efforts by all participating providers and institutions to develop and sustain communications and understanding on the basis of professional interaction and mutual respect throughout the health care system.

Lead Author

Kristi L. Watterberg, MD

Committee on Fetus and Newborn, 2012-2013

Lu-Ann Papile, MD, Chairperson

Jill E. Baley, MD

William Benitz, MD

James Cummings, MD

Waldemar A. Carlo, MD

Eric Eichenwald, MD

Praveen Kumar, MD

Richard A. Polin, MD

Rosemarie C. Tan, MD, PhD

Past Committee Member

Kristi L. Watterberg, MD

Liaisons

Capt. Wanda Denise Barfield, MD, MPH - Centers for Disease Control and Prevention

George Macones, MD - American College of Obstetricians and Gynecologists

Ann L. Jefferies, MD - Canadian Pediatric Society

Erin L. Keels, APRN, MS, NNP-BC - National Association of Neonatal Nurses

Tonse N. K. Raju, MD, DCH - National Institutes of Health

Kasper S. Wang, MD - Section on Surgery

Footnotes

This document is copyrighted and is the property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

View Abstract

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The American Academy of Pediatrics concurs with the recent statement of the American College of Obstetricians and Gynecologists affirming that hospitals and birthing centers are the safest settings for birth in the United States while respecting the right of women to make a medically informed decision about delivery.

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Saraswathi Vedam,

Kathrin Stoll,

Marian MacDorman,

Eugene Declercq,

Renee Cramer,

Melissa Cheyney,

Timothy Fisher,

Emma Butt,

Y. Tony Yang,

Holly Powell Kennedy

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Abstract

Poor coordination of care across providers and birth settings has been associated with adverse maternal-newborn outcomes. Research suggests that integration of midwives into regional health systems is a key determinant of optimal maternal-newborn outcomes, yet, to date, the characteristics of an integrated system have not been described, nor linked to health disparities.

Methods

Our multidisciplinary team examined published regulatory data to inform a 50-state database describing the environment for midwifery practice and interprofessional collaboration. Items (110) detailed differences across jurisdictions in scope of practice, autonomy, governance, and prescriptive authority; as well as restrictions that can affect patient safety, quality, and access to maternity providers across birth settings. A nationwide survey of state regulatory experts (n = 92) verified the 'on the ground' relevance, importance, and realities of local interpretation of these state laws. Using a modified Delphi process, we selected 50/110 key items to include in a weighted, composite Midwifery Integration Scoring (MISS) system. Higher scores indicate greater integration of midwives across all settings. We ranked states by MISS scores; and, using reliable indicators in the CDC-Vital Statistics Database, we calculated correlation coefficients between MISS scores and maternal-newborn outcomes by state, as well as state density of midwives and place of birth. We conducted hierarchical linear regression analysis to control for confounding effects of race.

Results

MISS scores ranged from lowest at 17 (North Carolina) to highest at 61 (Washington), out of 100 points. Higher MISS scores were associated with significantly higher rates of spontaneous vaginal delivery, vaginal birth after cesarean, and breastfeeding, and significantly lower rates of cesarean, preterm birth, low birth weight infants, and neonatal death. MISS scores also correlated with density of midwives and access to care across birth settings. Significant differences in newborn outcomes accounted for by MISS scores persisted after controlling for proportion of African American births in each state.

Conclusion

The MISS scoring system assesses the level of integration of midwives and evaluates regional access to high quality maternity care. In the United States, higher MISS Scores were associated with significantly higher rates of physiologic birth, less obstetric interventions, and fewer adverse neonatal outcomes.

Citation: Vedam S, Stoll K, MacDorman M, Declercq E, Cramer R, Cheyney M, et al. (2018) Mapping integration of midwives across the United States: Impact on access, equity, and outcomes. PLoS ONE 13(2): e0192523. https://doi.org/10.1371/journal.pone.0192523

Editor: Dongmei Li, University of Rochester, UNITED STATES

Received: June 27, 2017; Accepted: January 16, 2018; Published: February 21, 2018

Copyright: © 2018 Vedam et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data are available from the UBC Abacus Dataverse Network: https://dx.doi.org/10.14288/1.0363296. AIMM Report Card data and corresponding data maps are available at http://www.birthplacelab.org/how-does-your-state-rank and http://birthplacelab.org/maps.

Funding: This work was made possible by a grant from the Transforming Birth Fund of the New Hampshire Charitable Foundation https://www.nhcf.org/ and with infrastructure support by the University of British Columbia. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The Lancet Series on Midwifery (2014) concluded that "national investment in midwives and in their work environment, education, regulation, and management ... is crucial to the achievement of national and international goals and targets in reproductive, maternal, newborn, and child health" [ 1]. In countries where midwives are integrated into the health care system, the benefits of midwifery care are well-documented [ 2]. Global health experts recommend scaling up midwifery to improve maternal and newborn outcomes, reduce rates of unnecessary interventions, and realize cost savings [ 3, 4]. However, access to midwifery care in the United States (US) is markedly lower than in most other "Organisation for Economic Co-operation and Development" (OECD) countries, with approximately 10% of US births attended by midwives compared to 50-75% in other high-resource countries [ 5]. In addition to low density of midwives per state, all midwives are not universally licensed to practice or integrated into regional health care systems. American midwives face multiple challenges to practice, including numerous regulatory barriers and inability to secure third party reimbursement [ 6]. As a result, women in many states cannot access midwives because of legal or payor restrictions [ 7, 8].

Regulation has been identified by the International Confederation of Midwives as one of the pillars of a strong midwifery profession [ 9]. Regulation refers to a set of criteria and processes arising from the legislation that describes the scope of midwifery practice (activities which midwives are educated for, competent in, and authorized to perform, consistent with the ICM Definition of the Midwife) [ 9]. On a global scale, maternal and perinatal outcomes are better in jurisdictions where midwives are regulated and have the legislative authority to practice to their full scope across birth settings, including collaborating with or referring to other health professionals [ 2]. To date, it has been difficult to examine the impact of variations in midwifery regulation and integration across the United States on perinatal outcomes or on consumer access to maternity care. To address these gaps, a panel of maternity care and health policy experts who were delegates to the Home Birth Summit III [HBS] in 2014 ( http://www.homebirthsummit.org/) designed The Access and Integration Maternity Care Mapping (AIMM) Study. The aim of this transdisciplinary, national research project was to examine the impact of state regulatory environments on access to midwives and association with perinatal outcomes across populations in the United States.

Why does integration matter?

There are very few jurisdictions in the United States (US) where all types of midwives, irrespective of practice site, are fully integrated as regulated health professionals into interprofessional care provider networks. However, interprofessional teamwork is essential to the provision of high-quality maternity care [ 10]. For example, research indicates that, when professionals collaborate on decision-making and when coordination of care is seamless, fewer intrapartum neonatal and maternal deaths occur during critical obstetric events [ 11]. Poor communication, disagreement, and lack of clarity around provider roles are identified as primary determinants of these adverse outcomes [ 10- 12]. Beliefs about risk, beneficence, non-maleficence and patient autonomy are often discipline-specific and divergent [ 13, 14]. Rates of intervention, and labour management options that facilitate normal, physiologic birth are known to differ by type of provider [ 15], by birth setting [ 16, 17], and by provider education. When differences around defining risk and responsibility exist among providers, interprofessional cooperation and access to options for care are reduced [ 18- 20]. Moreover, when patients perceive interprofessional conflict, the culture of safety is diminished [ 21- 23].

Conversely, collaboration among health professionals can improve safety and quality, particularly when care is transferred from low to high resource settings [ 10]. For example, when a woman plans to give birth in a community setting (home or birth center) she benefits when her midwife can facilitate access to specialized hospital personnel, equipment, or medications when necessary. The ability of midwives to function autonomously to their full scope of practice in community settings, in collaboration with other members of the health system, can enhance cost-effectiveness of maternity care [ 24, 25]. Regardless of birth setting, midwife-led care has been linked to significantly improved perinatal outcomes, and maternal experience, in both healthy and at-risk populations [ 26- 28]. In the US, current evidence suggests that scope of practice laws, as well as other aspects of state policy and regulation, may be reducing the maternity care workforce and access to services [ 26]. An integrated maternity care system facilitates the full exercise of scope of practice, autonomy, self-regulation, and collaboration across disciplines.

The diverse context for American midwifery practice

Over 15 years ago, the American Public Health Association issued a position statement, calling for increased access and integration of midwifery services in the United States. [ 29](29) Yet, consistent U.S. standards for regulation, scope of practice, and access to reimbursement for midwives are still lacking, resulting in a fragmented system of care.

Wide variations in state regulatory conditions for midwifery practice, especially with respect to birth place, have created an environment of interprofessional hostility in some jurisdictions and interprofessional cooperation in others. Given the emerging evidence on the adverse impact of interprofessional disarticulation on maternal experience and outcomes [ 31, 32], it is important to understand the connections between different regulatory environments and differences in health outcomes, especially when significant disparities exist across populations. Differences in adverse perinatal outcomes between Caucasian women and women of colors are well-documented [ 33- 36], and persist even when controlling for socio-economic status and access to quality prenatal care [ 33, 37]. There is a dearth of information about whether health disparities can be attributed to differences in health insurance coverage, or access to providers, or quality of care [ 36, 38, 39].

In 2015, 89.8% of US births were attended by physicians, 8.5% by CNMs/CMs, 0.8% by other midwives (including CPMs), and 0.8% by other providers [ 40]. In 2014, methods of payment varied by place of birth: 44.2% of hospital births were paid for by Medicaid, 48.0% by private insurance, 3.4% were self-pay, and 4.4% via other sources. In contrast, 16.4% of community births (birth center or home) were paid for by Medicaid, 29.4% by private insurance, 50.0% through self-pay and 4.2% via other sources. Most community births are attended by midwives and half are not covered by insurance [ 41]. The regulatory environment for payors has been shown to significantly impact the extent of midwifery practice in a state and autonomy of midwives [ 42].

In the Access and Integration Maternity Care Mapping (AIMM) Study, we went beyond CNM autonomy to create an evidence-based scoring system to rank the level of integration of all types of midwives into health systems. We then examined the relationships between state Midwifery Integration Scores, density of midwives, access to midwives across practice settings, rates of obstetric interventions, and maternal and newborn outcomes.

Methods

We convened a multi-disciplinary Task Force with expertise in maternity services research, public health, midwifery, obstetrics, epidemiology, consumer advocacy, and/or roles in midwifery regulation, legislation, and law. They identified the key variables needed to populate a database of published regulatory data across all 50 states and the District of Columbia, detailing rules regarding scope of practice, and requirements for licensure of CNMs, CPMs, and CMs and practice across birth settings. We then employed a formal, process (see Table 1), modeled on the Delphi method [ 45, 46], best practices for transdisciplinary research, and legal epidemiology [ 47], to identify and validate the most important items for inclusion in a composite measure of midwifery integration.

Round 1 -Concept generation

The Task Force self-organized into two teams, one with regulatory, law, and consumer access expertise, and another with expertise in public health, legal anthropology, and perinatal epidemiology research methods, including instrument development. Both teams included clinicians, and consumers. Over three rounds of drafts, edits, and consensus-based discussions, Team 1 identified seven relevant domains that were important to identify in state regulations on midwifery. Four domains describe midwifery practice: scope of practice, provider autonomy, governance, access to referral and medications; and three domains describe patient safety, quality, and access to maternity providers across birth setting. The team identified 110 indicators that differentiate the regulatory environment by domain for each type of midwife (CM, CPM, or CNM), and assigned numeric values to describe the diverse conditions, permissions, or restrictions delineated in the state laws (see Table 2).

We then widened the consultant pool to include experts from national regulatory, legal, payor, professional and perinatal surveillance bodies. These policy leaders noted that the statutory language does not always accurately represent the realities of how rules and laws are interpreted and implemented. Language used in rule-making may be interpreted in more or less restrictive ways, and some rules are not actionable given infrastructure constraints and systems-level limitations. For example, in one state, CPMs have statutory authority to access emergency medications for the management of complications, such as maternal hemorrhage; however, pharmacists in that state are restricted from furnishing these medications to practitioners who are not affiliated with hospitals. Because CPMs cannot gain access to hospital privileges, they must find alternate ways to exercise their authority to carry these lifesaving medications.

Round 2 -Expert content validation

Hence, to verify the realities of implementation of the law within each state, Team 2 identified and recruited state and national regulatory experts (n = 92) to complete an online survey. Participants included 75 state-specific regulatory board representatives; the presidents, regional and chapter chairs for state midwifery associations, state legislative and policy chairs for the American College of Nurse Midwives (ACNM) and National Association of Certified Professional Midwives (NACPM). They evaluated the connections and discordances between theory and practice for each of the identified indicators within the state regulatory environment. In poorly integrated states our national experts (ACNM, NACPM legislative directors) referred us to local midwifery or consumer experts who could reliably speak to 'on the ground' conditions. When two state experts disagreed on an indicator or experts did not know the answer, we further consulted with 17 state or national regulators, to resolve discrepancies.

We harmonized expert responses with our regulatory database through a systematic line-by-line comparison. We validated and/or deferred to the statutory language when there were no discrepancies between statutes and local interpretation or implementation. When state experts provided evidence of local interpretation that differed from the apparent intent of laws or rules, we added or adapted response options to reflect the realities of midwifery practice, consumer access, and/or the interprofessional environment.

Round 3-Development and application of composite measure

A final Delphi process (see Table 1), involving both multidisciplinary teams, led to selection of 50/110 indicators of midwifery integration, and the development of a weighted Midwifery Integration Scoring System (MISS) (50 items, maximum summary score 100) that quantifies the potential impact on patient access to high-quality maternity care across birth settings. Both teams reviewed the 110 items and only retained those that were deemed, by consensus, important or very important to the assessment of midwifery integration. In some cases, 2-3 items were combined into one stem query, and response options expanded. Some items were excluded because team members felt that the items were not directly pertinent to midwifery integration. For example, one item (Does informed consent language in statute and/or regulations allow for informed refusal by client?) was excluded because the item relates more to human rights issue rather than quantifying the level of midwifery integration. To create the weighting system, using a scale of 0 (not important), 1 (somewhat important), 2 (important), 3 (very important), 4 (essential), the teams assessed each item for its potential impact on patient access to high-quality maternity care. They assigned higher item-level scores to indicators of greater integration, more interprofessional collaboration, and/or wider consumer access across birth settings. The final list of items describe the range of possible options for scope of practice, regulatory body, prescriptive authority, requirements for physician supervision, access to Medicaid, etc. that vary in both statutory language and implementation across states. See S1 Table for a full list of the indicators and scoring system.

Ranking states by MISS scores and outcomes

We used the MISS composite summary scores to rank states by degree of integration. Then, using the 2014 CDC-Vital Statistics Database, we calculated Spearman's rho correlation coefficients between the continuous MISS integration scores and selected maternal-newborn outcomes in each state. We used Spearman's rho because the MISS scores were normally distributed as indicated by the Shapiro-Wilk Test (0.960, p = 0.08), but the outcomes data were not. We selected indicators that represent cost-effectiveness and quality in perinatal care (e.g. rates of spontaneous vaginal birth, exclusive breastfeeding, cesarean, induction, VBAC, preterm birth, low birth weight, neonatal mortality) [ 43, 48], and were available and reliable in the CDCs Vital Statistics database [ 47]. Finally, based on data from the Area Health Resource File, and Centers for Medicare and Medicaid Services, we calculated correlations between MISS scores; state density of midwives (per 1000 births); and consumer access to midwives across birth settings, defined as the proportion of all births at 1) hospital, 2) home and 3) birth centers for two categories of midwives a) CNMs/CMs and b) CPMs and other direct entry midwives as reported on the birth certificates for each state.

In addition, we calculated the correlations between 1) CM and 2) CPM licensure and perinatal outcomes, to examine the differential effects of licensure versus integration scores by state for all outcomes. We also identified states with the highest increases in community births (at home and birth centers) over the past 8 years and examined correlations with MISS scores.

Finally, appreciating the complex nature of health disparities, to understand the relative importance of midwifery integration on perinatal outcomes, we conducted hierarchical linear regression modelling, to control for the proportion of Non-Hispanic Black births in each state, when examining the relationship of MISS scores with rates of five outcomes: caesarean, preterm birth, neonatal death, low birth weight, and breastfeeding at birth.

Results

State MISS scores ranged from 17 in North Carolina to 61 in Washington State, with notable regional variation (see Figs 1 and 2). Higher MISS integration scores were correlated to a higher density of midwives per state and higher proportion of midwife-attended births across settings (see Table 3). Higher MISS scores, and improved access to midwives in all settings, were associated with significantly higher rates of spontaneous vaginal delivery, vaginal birth after cesarean (VBAC), and breastfeeding at birth and at six months; and significantly lower rates of cesarean section (CS), preterm (PTB), and low birth weight (LBW) infants (see Table 4). Higher MISS scores were correlated strongly with lower rates of neonatal mortality (see S1 Fig) and race-specific neonatal mortality (see S2 Table).

Levels of integration displayed by quartiles of MISS scores. Deeper shades of purple represent higher integration and lighter shades represent lower integration of midwives.

Between 2004 and 2014, community birth rates increased significantly (p< 0.05) in all states, except Vermont, Rhode Island, Oklahoma, Maine and DC. The average increase over the time period was 72%. [ 41] The states with the largest increases were Montana, Oregon, Washington, Utah and Wyoming. States with higher MISS scores had significantly higher rates of community births in 2014 (r s = 0.445, p = 0.01) and significantly larger increases in community birth rates from 2004-2014 (r s = 0.328, p = 0.02).

Our regulatory data described conditions for 2014-2015, when CPMs had regulatory authority to practice in 27 states and CMs in 5 states. CPM licensure significantly correlated to access to midwifery care in community settings (r s = 0.440, p = 0.001). Licensure alone was not synonymous with integration, and did not confer the same benefits on outcomes or interventions ( see S4 Table).

MISS scores were significantly lower in states with a higher proportion of non-Hispanic Black births (r s = - 0.370; p = 0.007). Access to midwives across settings and density of midwives were also significantly lower in states with a higher proportion of black births (r s = - 0.375, p = 0.007 and r s = - 0.298, p = 0.04). To determine the amount of variance that is accounted for by integration of midwives, when taking into account disparities in neonatal mortality by race, we undertook further analysis. Differences in the percent of Non-Hispanic black birth across states accounted for 38.5% of the differences in neonatal mortality scores, and MISS scores explained another 11.6% of variance ( see Table 5). This change was significant (p = 0.002) meaning that the level of integration can explain differences in neonatal mortality rates, above and beyond the percent of black births. These two factors, state-level percent of black births and level of midwifery integration, can predict half of the variance (50.1%) in neonatal mortality rates. MISS scores also explained significant additional variance in rates of preterm birth and breastfeeding at birth scores ( see Table 5). Integration scores did not add significant explanatory power to disparities in cesarean and low birth weight rates.

Discussion

Our analyses showed that a state regulatory environment that supported greater integration of midwives into the health system was associated with a greater number of midwives and midwife-attended births in a state. This greater integration was significantly associated with higher rates of spontaneous vaginal birth, VBAC and breastfeeding at birth and at six months, as well as lower rates of obstetric interventions, preterm birth, low birth weight infants, and neonatal death. These findings are especially significant in the light of increased costs to any health care system associated with high cesarean and preterm birth rates, and low breastfeeding rates. This is a pathognomonic example of the current global public health focus on, "too much too soon, too little too late" [ 48].

While the associations illustrated do not imply causation, the MISS scores nonetheless can be a tool for generating testable hypotheses on the effects of midwifery integration on key outcomes. The observed relationships may help us identify states where childbearing women are at increased risk for poor outcomes and experience reduced access to high quality maternity care due to poor integration of midwives across birth sites (e.g. North Carolina, Alabama).

Model states (i.e. states with the highest MISS scores) can inform mechanisms to enhance integration of midwives in other states. However, it is important to note that no state enjoys regulatory conditions that are optimal to support quality and safety for families during pregnancy, birth and the postpartum period. The most integrated states now achieve scores that represent less than two thirds (61/100) of condition requirements for a fully integrated system for care.

Can integration of midwives reduce health disparities?

Does midwifery integration affect outcomes across birth settings?

Some investigators have suggested that poor neonatal outcomes may rise with increased access to midwives who attend home and birth center births [ 57, 58]. In our state-by-state comparison, however, the best outcomes for mothers and babies occur in states where all types of midwives are regulated and integrated into the health care system regardless of birth setting.

Nonetheless, significant interprofessional conflict persists around recommendations for safe birth care. For example, despite the emergence of high quality prospective observational studies supporting the safety and cost-effectiveness of planned home birth [ 16, 24], leading maternity providers in North America have been in conflict about birth at home and birth centers, debating issues related to safety, access, the value of obstetric intervention, and patient autonomy [ 57- 59].These debates are reflected in widely varying state regulatory environments that may, in turn, influence conditions for maternity practice and public access to choice of birth place. Differences in community birth rates across regions may simply represent the influence of pre-existing provider philosophies and attitudes [ 60], which in turn affect informed consent discussions with patients as well as comfort with collaboration across disciplines [ 20].

Rates of planned home and birth center birth in the US and Canada remained at less than 1% for several decades, but current data suggest that American women are increasing their interest in this option [ 41]. Midwives are the only maternity care providers who currently offer choice of birth setting. However, because not all types of American midwives can legally practice in all birth settings, choice of birth place is functionally quite limited for a majority of US women. In some regions, women who plan to deliver at home or in a birth center, will (along with their midwives) encounter hostility, judgment, and, reprimand when they transfer across birth settings [ 31, 61]. Person-centred maternity care should define quality and safety within a multi-faceted context that includes patient choice, access, experience, and cost-effectiveness.

Policy implications: Improving access to high quality maternity care

Our ranking system highlights discrepancies in integration and related outcomes and could inspire political will, and guide legislative reform. The Midwifery Integration Scoring System can help to identify states where childbearing women and newborns might benefit from improved integration of midwives. In communities where access to any maternity provider is scarce [ 62], our findings suggest that expanding access to midwifery care may be an important part of the solution to both public health and human health resource challenges. All three types of midwives share a model of maternity care that has been associated with optimal outcomes and cost-effectiveness [ 1, 63]by prioritizing person-centered care; promoting of normal, physiologic birth; judicious evidence-based use of obstetric interventions and procedures; and collaborating with and/or referring to obstetric specialists when indicated [ 7, 64]. Our results align with this evidence suggesting that increased reliance on midwives could reduce the costly overuse of obstetric interventions, reduce rates of preterm birth and neonatal loss, and improve breastfeeding and vaginal birth rates, thereby helping to address serious maternal-newborn health deficits in the United States.

The US precedent of health systems restricting access to qualified attendants across birth settings, and placing high value on institutional birth, has been very influential in low and middle resource countries. [ 65, 66]Unfortunately, the system of incentivizing institutional birth and physician management of healthy pregnancies has exacerbated the gaps between demand and available health human resources both in the US and in low resource settings. [ 66, 67]Skilled midwives can assist a woman to assess her birth site options according to her health status and facilitate access to appropriate resources. Ideally, they would practice in a legal environment that allows them to practice to full scope, and collaborate seamlessly with other health professionals, across birth settings.

To enable midwives to work autonomously within their full scope of practice, the International Confederation of Midwives has identified standards for regulatory mechanisms that protect the public by ensuring that midwives provide high quality midwifery care to every woman and baby [ 68]. Based on these ICM Standards, the US Midwifery Education, Regulation and Association (USMERA) workgroup has described Principles for Model Midwifery Legislation [ 69]that include many of the same components that comprise the MISS scores. If applied to state regulatory reform, they could contribute to state scores that are closer to the ideal (i.e. 100).

A recent Lancet analysis of maternal health policy revealed that countries with a sustained 20-year decrease in maternal mortality had increased country-wide access to health care through targeted investment in midwifery services. [ 4] In countries like India, Mozambique, Uganda, and Nepal skilled birth attendants are scarce in all settings and the consequences are disastrous-"too little too late" [ 48]. In high resource countries that are experiencing the phenomena of "too much, too soon", expanding availability of midwives across health systems also has important implications for quality, safety, and cost-effectiveness [ 43, 48].

Limitations and opportunities

While this analysis represents a significant step forward, it has some limitations. We are using aggregated state measures and hence potentially subject to the ecological fallacy of making inferences concerning individual behavior, based on group data [ 70]. However, our goal is to measure systems of care at the state level rather than the relationship between individual providers and specific neonatal outcomes. We cannot conclude that a more integrated system of midwifery directly causes improved outcomes. It may simply reflect a state culture of better interprofessional cooperation that affects patterns of practice. Variations in access to any maternity care at the local level may have more impact on outcomes, and data derived from Area Resource maps on provider availability may be more informative. Functional levels of integration may vary by the interpretation of statutes by providers or referral institutions at the local level.

Our analysis captured relationships as relevant to the regulatory environment in the US in 2014-2016. As regulatory and practice conditions change, MISS scores will also change, so ongoing revisions of the source database will be necessary. Our team plans to partner with NACPM, ACNM, and regulatory boards to tri-annually update the data-informed AIMM maps.

Our findings could inform site selection for a national prospective cohort study, such that studies of midwifery outcomes can be restricted to states with high MISS scores or can control for level of integration. Cohort studies that take into account the level of midwifery integration could inform state regulatory language that supports increasing access to high quality care across settings and jurisdictions.

Finally, the MISS scoring system is based on evidence-based metrics that are relevant to midwifery regulation and practice globally. This composite scoring system could be adapted to country-level realities where items describe the domains according to the available maternity providers and regional conditions for practice, restrictions, and state of collaboration. It is likely that other high resource countries would achieve scores that represent a more fully integrated system, consistent with their reported improved outcomes.

The 2014 Lancet Series on Midwifery, in collaboration with the WHO, identified the top 11 research priorities needed to improve quality maternal and newborn care. [ 71] Global experts recognized that it is critical to ask "different questions" if we are to understand which outcomes are most important to track and which factors most contribute to those essential outcomes. To fully understand the relationships between health systems, model of care, access to care, and childbearing outcomes, more investigations on the impacts of the regulatory environment at the local, regional, and country level is needed.

The AIMM Report Card

To make our findings more accessible to policy makers and consumers, Team 2 worked closely with a GIS specialist to create the AIMM "Report Card", a visual representation of the data via a series of color-coded, interactive maps. The maps illustrate the range of midwifery integration across the United States by quartiles, as well as density and access to midwives in different settings. The AIMM Report Card displays how integration, access, and density of midwives link to outcomes by distinguishing states that are in the highest and lowest quartiles for indicators of optimal health according to global health agencies (e.g. WHO-recommended rates for cesarean). For example ( see Fig 3A & 3B), on each map, upon selection of outcomes, green outlines appear for states that report the highest rates of spontaneous vaginal birth, vaginal birth after cesarean (VBAC), and breastfeeding. Red outlines appear for states in the highest quartile for rates of cesarean, induction, neonatal mortality, prematurity, and low birth weight infants.

3A: Levels of integration displayed by quartiles of MISS scores. Deeper shades of purple represent higher integration and lighter shades represent lower integration of midwives. Green outlines show where rates of neonatal mortality are lowest and red outlines show where rates are highest. 3B: Percent of black births per state by quartiles. Deeper shades of orange represent a higher proportion of black births and lighter shades represent a lower proportion of black births. Green outlines show where rates of neonatal mortality are lowest and red outlines show where rates are highest.

The maps also show race-specific outcomes by MISS scores, and display outcomes by the proportion of Black women giving birth in each state. Fig 3A displays that, in most states where black women give birth, they do not have access to midwives who are well integrated into the system. These states also report the highest rates of neonatal mortality. New York State is a notable exception, reporting a high density of black births, among the lowest rates of neonatal mortality in the country, and a MISS score in the highest quartile.

Through the AIMM Report Card, the viewer can visualize how perinatal outcomes, interventions, and access to choice of birth place differ in states where midwives are well integrated, compared to states where disarticulations exist. Similarly, pop-up bar and pie graphs display state-level data for the proportion of women giving birth by settings, proportion of births attended by midwives that are covered by Medicaid, and state level rates of perinatal outcomes.

The data maps are available at http://birthplacelab.org/maps. State-specific report cards can be viewed at http://www.birthplacelab.org/how-does-your-state-rank.

These tools may be valuable to advocates, policy makers and other key stakeholders who seek to identify regions with reduced access to collaborative practice and options for maternity care.

Conclusions

The Midwifery Integration Scoring System (MISS) is a powerful new tool to track the impact of the regulatory environment on patient access to health care, as well as choice of provider and birth place. The Access and Integration Maternity care (AIMM) Maps illustrate effective health human resource allocation in maternity care, based on population-level health outcomes data. Higher MISS Scores were associated with significantly more access to midwives, significantly higher rates of physiologic birth outcomes, lower rates of obstetric interventions, and fewer adverse neonatal outcomes. Race is associated with significant differences among states in neonatal outcomes; and the level of integration of midwives accounts for additional differences that persist after controlling for African American births. Our findings can inform health policy to improve regional access to high quality maternity care across populations and birth settings.

Acknowledgments

We collaborated with many wise advisors over five years in this project including state and national experts on midwifery regulation and policy, including Ida Darragh, Cara Kinzelman, Mary Lawlor; lawyers, Rebecca Spence and Tara Gaston who led the identification of relevant statutory data; and experts on perinatal epidemiology, interprofessional collaboration, maternity care workforce, health disparities, and person-centred outcomes research, especially Zsakeba Henderson, Lisa Kane Low, Nicholas Rubashkin, Caroline Homer, and Lesley Barclay. We could not have completed this work without the keen attention to detail, and hours of data management provided by Eleanor Rushton, Kari Bengston, and Nicole Zickler; research coordination by Barbara Karlen; and remarkable knowledge translation to accessible, interactive data maps by Alex Annejohn, Elizabeth Nethery, Jeanette McCullough, Ian Allison, and Lynsey Hamilton.

References

54. McRae DN, Muhajarine N, Vedam S, Mayhew M, Mpofu D, Teucher U, Janssen PA. Saskatoon S. Antenatal Midwifery Care: Reducing Prevalence of Small-for-Gestational-Age Birth and Preterm Birth for Women of Low Socioeconomic Position. Dep Community Heal Epidemiol Student Resid Res Day, Univ Saskatchewan, Saskatoon. 2017;Feb 10.

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Mapping integration of midwives across the United States: Impact on access, equity, and outcomes

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Poor coordination of care across providers and birth settings has been associated with adverse maternal-newborn outcomes. Research suggests that integration of midwives into regional health systems is a key determinant of optimal maternal-newborn outcomes, yet, to date, the characteristics of an integrated system have not been described, nor linked to health disparities.

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NEJM Birth outcomes Study

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Planned home birth: benefits, risks, and opportunities

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While the number of women in developed countries who plan a home birth is low, the number has increased over the past decade in the US, and there is evidence that more women would choose this option if it were readily available. Rates of planned home…

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Podcast on Current Research in Safety of Home Birth

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Podcast on Current Research in Safety of Home Birth

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Level up your nutrition game with a superfood mix from Your Super! Use the code KWEENS at checkout for 15% off your order.

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In part one of our three part series on home birth, we're diving into the research. You'll hear about some notable studies on the safety of having your baby in an out-of-hospital setting both in America and abroad. The following links lead to the studies and resources we used when researching this episode:

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SUPPORT OUR SPONSOR! Level up your nutrition game with a superfood mix from Your Super! Use the code KWEENS at checkout for 15% off your order. --- In part one of our three part series on home birth, we're diving into the research.

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The Access and Integration Maternity care Mapping (AIMM) Study brought together a multidisciplinary group of experts to develop the Midwifery Integration Scoring System (MISS) that rates the key indicators of integration of midwives in the United States. Each state was ranked on the 50-item scale, with no state achieving 100, the highest possible score.

State Ranking of Midwifery Integration Scores 2014-2015

A MISS score of 100 would indicate that a family in that state would have full access to high quality maternity care in all settings without third-party payer (or health insurance/Medicaid) restrictions. All maternity care providers, including midwives, in that state would be regulated and have the legislative authority to practice to their full scope in homes, birth centers and hospitals, and collaborate with or refer to other health professionals. Currently, the highest ranking state is Washington state. The lowest ranking state is North Carolina.

States Ranked From Most to Least Integrated (based on 2014-2015 data)

Click on a state to find their report card.

Do you have feedback on one or more of the State Report Cards? Share your input here.

Do you have feedback on one or more of the State Report Cards? Share your input here.

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How Does Your State Rank - Birth Place Lab

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States with higher integration of midwives in the maternity health care system are linked to improved outcomes, including lower cesarean section rates, higher VBAC rates, fewer preterm births, and increased breastfeeding. How does your state rank? Find your state's report card here.

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CNM/CM numbers: American Midwifery Certification Board 8/2016 Sources:
CPM numbers: North American Registry of Midwives 2016. By residence, practice site might differ
Births per state: 2015 CDC data
Births attended: 2014 CDC data VBAC: vaginal birth after cesarean section Physiologic birth: not induced, labor started spontaneously, vaginal delivery without forceps or vacuum Premature birth: before 37 weeks gestation Low Birth Weight: less than 2500 grams Neonatal mortality: up to 28 days Breastfeeding: exclusive

Perinatal outcomes from 2014 CDC data except:
Neonatal mortality: 2013 CDC data
Breastfeeding at 6 months: National Immunization Survey, 2012 CDC
CPM and CM data: 2014 Area Health Resource File, Centers for Medicaid Services

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CNM/CM numbers: American Midwifery Certification Board 8/2016 Sources: CPM numbers: North American Registry of Midwives 2016.

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Medical Board of California Transfer Form

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Medical Board of California Transfer Form

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On Tuesday, readers learned about the history and objectives of the Home Birth Consensus Summit, a collective of stakeholders, whose goal is to improve maternal infant health outcomes and increase collaboration between all those involved in serving women who are planning home births. The interdisciplinary collaboration that occurs during the Summits brings representatives from many different perspectives to the table in order to improve the birth process for women and babies. You may want to start with the post "Finding Common Ground: The Home Birth Consensus Summit" and then enjoy today's post on the Home Birth Consensus Summit's just released "The Best Practice Guidelines: Transfer from Home Birth to Hospital." Today's post was written by Dr. Lawrence Leeman and Midwife Diane Holzer, two of the members on the HBCS Collaboration Task Force, a subgroup tasked with developing these transfer guidelines. Share your thoughts on these new guidelines and your opinion on if you feel that they will improve safety and outcomes for mothers and babies. - Sharon Muza, Community Manager, Science & Sensibility
Leea Brady was a second-time mother whose first baby was born at home. One day past her due date, an ultrasound revealed high levels of amniotic fluid, which can pose a risk during delivery. Although she planned to have her baby at home, on the advice of her midwife, Leea transferred to her local hospital.

"I knew that we needed to be in the hospital in case anything went wrong," said Brady. "I was really surprised when I arrived and the hospital staff told me they had read my birth plan, and they would do everything they could to honor our intentions for the birth. My midwife was able to stay throughout the birth, which meant a lot, because I had a trusting relationship with her. She clearly had good relationships with the hospital staff, and they worked together as a team."

A recent descriptive study (Cheyney, 2014) reports that about ten percent of women who plan home births transfer to the hospital after the onset of labor. The reason for the overwhelming majority of transfers are the need for labor augmentation and other non-emergent issues. Brady's transfer from a planned home birth to the hospital represents the ideal: good communication and coordination between providers in different settings, minimizing the potential for negative outcomes.

However, in some communities, lack of trust and poor communication between clinicians during the transfer have jeopardized the physical and emotional well being of the family, and been frustrating for both transferring and receiving providers. Lack of role clarity and poor communication across disciplines have been linked to preventable adverse neonatal and maternal outcomes, including death.(Guise, 2013,Cornthwaite, 2008) With optimal communication and cooperation among health care providers, though, families often report high satisfaction, despite not being in the location of their choice.

Recent national initiatives have been directed at improving interprofessional collaboration in maternity care.(Vedam, 2014) This is why a multi-disciplinary working group of leaders from obstetrics, family medicine, pediatrics, midwifery, and consumer groups came together to form a set of guidelines for transfer from home to hospital. The Best Practice Guidelines: Transfer from Planned Home Birth to Hospital are being officially launched today by the Home Birth Consensus Summit and will be highlighted at a series of upcoming presentations at conferences and health care facilities.

The authors of the guidelines, known as the Home Birth Summit Collaboration Task Force, formed as a result of their work together at the Home Birth Summits.

"Some hospital based providers are fearful of liability concerns, or they are unfamiliar with the credentials and the training of home birth providers," said Dr. Timothy Fisher, MD, MS, at the Hubbard Center for Women's Health in Keene, NH and an Adjunct Assistant Professor of Obstetrics and Gynecology, Dartmouth Medical School. "But families are going to choose home birth, for a variety of cultural and personal beliefs. These guidelines are the first of their kind to provide a template for hospitals and home birth providers to come together with clearly defined expectations."

The guidelines provide a roadmap for maternity care organizations developing policies around the transfer from home to hospital. They are also appropriate for transfer from a free-standing birth center to hospital.

The guidelines include model practices for the midwife and the hospital staff. Some guidelines include the efficient transfer of records and information, a shared-decision making process among hospital staff and the transferring family, and ongoing involvement of the transferring midwife as appropriate.

"When the family sees that their midwife trusts and respects the doctor receiving care, that trust is transferred to the new provider," said Dr. Ali Lewis, a member of the HBCS Collaboration Task Force. She became involved with the work of the committee in part because of her experiences with a transfer that was not handled optimally. "It is rare that transfers come in as true emergency. But when they do, if the midwife can tell the family she trusts my decisions, then I can get consent much more quickly, which results in better care and higher patient satisfaction."

The guidelines also encourage hospital providers and staff to be sensitive to the psychosocial needs of the woman that result from the change of birth setting.

"When families enter into the hospital and feel as if things are being done to them as opposed to with them, they feel like a victim in the process," said Diane Holzer, LM, CPM, PA-C, and the chair of the HBCS Collaboration Task Force. "When families are incorporated in the decision-making process, and feel as if their baby and their body is being respected, they leave the hospital describing a positive experience, even though it wasn't what they had planned."

The guidelines are open source, meaning that hospitals and practices can use or adapt any part of the guidelines. The Home Birth Summit delegates welcome endorsements of the guidelines from organizations, institutions, health care providers, and other stakeholders.
References
Cornthwaite, K., Edwards, S., & Siassakos, D. (2013). Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies. Best Practice & Research Clinical Obstetrics & Gynaecology, 27(4), 571-581.

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. (2014). Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. Journal of Midwifery & Women's Health.

Guise, J. M., & Segel, S. (2008). Teamwork in obstetric critical care. Best Practice & Research Clinical Obstetrics & Gynaecology, 22(5), 937-951.

Vedam S, Leeman L, Cheyney M, Fisher T, Myers S, Low L, Ruhl C. Transfer from planned home birth to hospital: inter-professional collaboration leads to quality improvement . Journal of Midwifery and Women's Health, November 2014, In Press.
About the Authors:
Dr. Lawrence Leeman, MD, MPH/Medical Director, Maternal Child Health, received his degree from University of California, San Francisco in 1988 and completed residency training in Family Medicine at UNM. He practiced rural Family Medicine at the Zuni/Ramah Indian Health Service Hospital for six years. He subsequently earned a fellowship in Obstetrics. He is board certified in Family Medicine. He directs the Family Medicine Maternal and Child Health service and fellowship and co-medical director of the UNM Hospital Mother-Baby Unit. Dr. Leeman practices the family medicine with a special interest in the care of pregnant women and newborns. He is Medical Director of the Milagro Program that provides prenatal care and maternity care services to women with substance abuse problems. Dr. Leeman is a Professor in the Departments of Family & Community Medicine, and Obstetrics and Gynecology. He is currently the Managing Editor for the nationwide Advanced Life Support in Obstetrics (ALSO) program. Areas of research include rural maternity care, pelvic floor outcomes after childbirth, family planning, and vaginal birth after cesarean (VBAC). Clinic: Family Medicine Center

Diane Holzer, LM, CPM, PA-C, has been a practicing midwife for over 30 years with experience in both home and birth center. She was one of the founding women who passionately created an infrastructure for the integration of home birth midwifery into the system. She sat on the Certification Task Force which led to the CPM credential and also was a board member of the Midwifery Education and Accreditation council for 13 years. She served the Midwives Alliance of North America on the board for 20 years and is the chair of the International Section being the liaison to the International Confederation of Midwives. Diane is the Chair of the Collaboration Task Force of the Home Birth Summit and currently has a home birth practice and works as a Physician Assistant doing primary health care in a rural Family Practice clinic.

Tags

Home Birth Midwives Professional Resources Midwifery collaborative maternity care Home Birth Consensus Summit Diane Holzer HBCS Home Birth Transfer Lawrence Leeman

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The Best Practice Guidelines: Transfer from Home Birth to Hospital - Collaboration Can Improve Outcomes

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By Lawrence Leeman, MD, MPH and Diane Holzer, LM, CPM, PA-C © http://www.mybirth.com.au/ On Tuesday, readers learned about the history and objectives of the Home Birth Consensus Summit, a collective of stakeholders, whose goal is to improve maternal infant health outcomes and increase collaboration between all those involved in serving women who are planning home births.

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Corresponding Author

Research Professor

Maryland Population Research Center, University of Maryland, College Park, MD, USA

Address correspondence to Marian F. MacDorman, PhD, Maryland Population Research Center, 2015 Morrill Hall, University of Maryland, College Park, MD, USA 20742; email: [email protected] .
Search for more papers by this author
First published:

Abstract

Background

Out‐of‐hospital births are increasing in the United States. Our purpose was to examine trends in out‐of‐hospital births from 2004 to 2014, and to analyze newly available data on risk status and access to care.

Methods

Newly available data from the revised birth certificate for 47 states and Washington, DC, were used to examine out‐of‐hospital births by characteristics and to compare them with hospital births. Trends from 2004 to 2014 were also examined.

Results

Out‐of‐hospital births increased by 72 percent, from 0.87 percent of United States births in 2004 to 1.50 percent in 2014. Compared with mothers who had hospital births, those with out‐of‐hospital births had lower prepregnancy obesity (12.5% vs 25.0%) and smoking (2.8% vs 8.5%) rates, and higher college graduation (39.3% vs 30.0%) and breastfeeding initiation (94.3% vs 80.8%) rates. Among planned home births, 67.1 percent were self‐paid, compared with 31.9 percent of birth center and 3.4 percent of hospital births. Vaginal births after cesarean (VBACs) comprised 4.6 percent of planned home births and 1.6 percent of hospital and birth center births. Sociodemographic and medical risk status of out‐of‐hospital births improved substantially from 2004 to 2014.

Conclusions

Improvements in risk status of out‐of‐hospital births from 2004 to 2014 suggest that appropriate selection of low‐risk women is improving. High rates of self‐pay for the costs of out‐of‐hospital birth suggest serious gaps in insurance coverage, whereas higher‐than‐average rates of VBAC could reflect lack of access to hospital VBACs. Mandating private insurance and Medicaid coverage could substantially improve access to out‐of‐hospital births. Improving access to hospital VBACs might reduce the number of out‐of‐hospital VBACs.

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Trends and Characteristics of United States Out‐of‐Hospital Births 2004-2014: New Information on Risk Status and Access to Care

# data[].attributes.attachment_link.description
Corresponding Author Research Professor Maryland Population Research Center, University of Maryland, College Park, MD, USA Address correspondence to Marian F. MacDorman, PhD, Maryland Population Research Center, 2015 Morrill Hall, University of Maryland, College Park, MD, USA 20742; email: [email protected] . Search for more papers by this author First published: Out‐of‐hospital births are increasing in the United States.

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Saraswathi Vedam,

Chris Rossiter,

Caroline S. E. Homer,

Kathrin Stoll,

Vanessa L. Scarf

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Abstract

Objective

Place of birth is a known determinant of health care outcomes, interventions and costs. Many studies have examined the maternal and perinatal outcomes when women plan to give birth in hospitals compared with births in birth centres or at home. However, these studies vary substantially in rigour; assessing their quality is challenging. Existing research appraisal tools do not always capture important elements of study design that are critical when comparing outcomes by planned place of birth. To address this deficiency, we aimed to develop a reliable instrument to rate the quality of primary research on maternal and newborn outcomes by place of birth.

Study design

The instrument development process involved five phases: 1) generation of items and a weighted scoring system; 2) content validation via a quantitative survey and a modified Delphi process with an international, multi-disciplinary panel of experts; 3) inter-rater consistency; 4) alignment with established research appraisal tools; and 5) pilot-testing of instrument usability.

Results

A Birth Place Research Quality Index (ResQu Index) was developed comprising 27 scored items that are summed to generate a weighted composite score out of 100 for studies comparing planned place of birth. Scale content validation indices were .89 for clarity, .94 for relevance and .90 for importance. The Index demonstrated substantial inter-rater consistency; pilot-testing confirmed feasibility and user-friendliness.

Conclusion

The ResQu Index is a reliable instrument to evaluate the quality of design, methods and interpretation of reported outcomes from research about place of birth. Higher-scoring studies have greater potential to inform evidence-based selection of birth place by clinicians, policy makers, and women and their families. The Index can also guide the design of future research on place of birth.

Citation: Vedam S, Rossiter C, Homer CSE, Stoll K, Scarf VL (2017) The ResQu Index: A new instrument to appraise the quality of research on birth place. PLoS ONE 12(8): e0182991. https://doi.org/10.1371/journal.pone.0182991

Editor: Kelli K. Ryckman, Univesity of Iowa, UNITED STATES

Received: June 22, 2017; Accepted: July 27, 2017; Published: August 10, 2017

Copyright: © 2017 Vedam et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: This work was supported by the National Health and Medical Research Council (Australia), https://www.nhmrc.gov.au/, Award Number: 1022422, Birthplace in Australia.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The selection of birth place has important implications for the health and wellbeing of women and newborns, as well as for health services planning and healthcare costs [ 1- 3]. Decisions about place of birth are largely based on the preferences of women and their families, but are also influenced by the availability of services, equipment and providers in their communities, and their understanding of the available scientific evidence [ 4, 5]. Women's preferences about place of birth are most often based on provider or peer recommendations, or information gained via the Internet [ 6- 11]. However, these sources do not always provide unbiased information about benefits and risks associated with different birth settings.

Evidence on the relative safety of different places of birth is complex and frequently controversial [ 12]. Several studies [ 13- 19] have found reduced obstetric interventions and optimal outcomes among healthy women who planned to give birth at home or a birth centre under the care of midwives. In some high-income countries, where maternity care is integrated across birth settings, researchers have concluded that there are no significant differences between birth places in morbidity or mortality for newborns [ 15, 16, 19] and/or that the absolute risks of mortality are extremely low [ 13, 14]. Other investigators have reported a significant increase in adverse perinatal outcomes related to planned home births, especially where skilled birth attendants are not universally integrated into regional health systems, or in population-based studies that include at-risk pregnancies [ 20- 22].

Policy makers and clinician leaders have responded to the research with similar discordance. Some clinical guidelines and policy statements in high-income countries support access to midwife-led care in birth centres and home births as cost-effective options for women with uncomplicated pregnancies [ 23- 26]. Other professional organisations have issued statements questioning the evidence basis for support of women's choice of birth place, and stating that hospital birth is the only setting that assures safe outcomes [ 27, 28]. In low- and middle-income countries, these latter views have led to policy initiatives and incentives towards universal institutional birth [ 29- 31].

Inconsistency in the design and quality of research on place of birth underpins the difficulty of crafting universally acceptable recommendations for service provision across birth settings. Further, the interpretation and dissemination of research findings can be subject to publication and critical bias, and the influence of professional viewpoints and culture [ 12, 32].

Accurate information about relative and absolute risk is vital to inform women and their families, clinicians and health administrators as they work together to select optimal birth places within the context of a person-centred care plan and regional resources. However, without a reliable means to assess the quality of the evidence, it is not possible to interpret the best available data and its implications for the safety of women and infants. This study was designed to address the need for a standardised system for evaluating research on the safety of birth place. It aimed to develop and pilot test a novel instrument for appraising the quality and rigour of research that examines the impact of place of birth on maternal and perinatal outcomes.

Why develop an instrument specific to birth place?

While there are several valuable instruments for assessing the quality of randomised and non-randomised clinical studies [ 33- 38], these are not always appropriate to studies of place of birth. Some rating tools are only applicable to randomised studies; others focus on the extent to which non-randomised studies emulate randomised trials (e.g. by reducing selection bias) [ 34, 38- 41]. However, birth place represents an intervention that is difficult to evaluate through randomised trials. Women are not inclined to relinquish their choice of birth place and participate in trials that present major practical and ethical limitations [ 42]. Another limitation of conventional rating instruments in this context is that, unlike many medical conditions where the impact of interventions on recovery or amelioration can be studied, pregnancy, labour and birth are not diseases or injuries (although they may be accompanied by morbidity). A woman may have multiple pregnancies, but each birth is a unique and finite event. Therefore instruments focused on longer-term recovery may not be relevant to studies on labour and birth, e.g. items on proportion of participants followed-up over time to ascertain whether symptoms have recurred.

When comparing outcomes across birth settings, the use of consistent definitions and inclusion criteria across cohorts, and reliable outcome measures, is imperative. A significant error in some published research on birth place is amalgamating data from unplanned home births (without skilled birth attendants) with data from planned births at home or in birth centres within integrated systems.

Aims

Following revelations of critical flaws in some published studies [ 43- 46], researchers developed key principles for appraising the quality of research on place of birth [ 45, 47- 49]. Our team designed the Birth Place Research Quality Index (ResQu Index) as a quantitative scoring system based on these key principles, as well as best practices for critical appraisal of research [ 39, 50]. The objective of this paper is to describe the development and testing of the ResQu Index which aims to facilitate consistent assessment of the quality of research on place of birth.

Methods

Development of the ResQu Index involved five distinct phases: 1) generating items and a weighted scoring system; 2) conducting expert content validation via a quantitative survey and a modified Delphi process; 3) testing inter-rater consistency; 4) assuring compatibility with established research quality checklists and 5) piloting the ResQu Index in a large systematic review to assess instrument usability and feasibility.

We developed this instrument to conduct an extensive systematic review of the literature on outcomes related to place of birth, within a larger research project [blinded]. A protocol was lodged with PROSPERO (CRD42016042291). Ethics clearance was not required for the instrument development.

Phase 1: Item generation and scoring

Item generation was informed by a literature review and the principles proposed by Vedam [ 45], Hutton [ 51] and Nove [ 47]. Each item was selected to be consistent with other systems for appraisal of research quality [ 34, 35, 37, 38, 52] but adapted, when necessary, to focus on the unique aspects of comparing outcomes across birth settings.

Some items in the Index relate to rigour common to all research studies, addressing issues such as clarity of key terms, definitions of the 'intervention' (i.e. place of birth), integrity of data, appropriateness of sample size and selection, transparency of methods and comparability of cohorts. Other items relate specifically to studies of birth place as outlined by Vedam [ 49] and Nove [ 47], and to address issues identified as problematic in critiques of previous research in this field [ 43, 44, 46]. These items include identifying the timing of birth place decisions in relation to an intention-to-treat model and ensuring that studies of home birth clearly distinguish data from planned home births with skilled attendants, from data generated by unplanned home births or "free births" without professional support. The individual items need to be relatively broad to be applicable to studies of different birth settings available across various regions. However, they also need to be sufficiently focused to identify meaningful differences in the rigour of research methodology.

Each item incorporates a rubric that scores the level of quality of the study design and interpretation of findings. Item scores are summed to generate a total composite Index score for a study. Scoring options vary from a simple yes/no response to a range of potential criteria. The expert content validation process (Phase 2) evaluated both the wording of the scoring rubrics and their relative numerical value (weighting).

The first draft version of the ResQu Index contained 25 items, relating to five domains addressing: quality of design, sample definition, measurement of outcomes, comparability of cohorts, and accuracy of interpretation and reporting (domains indicated in Fig 1). The Index scores total to 100, with higher scores indicating higher quality. The wording and scoring scale of items in the first draft version are included under Results.

Phase 2: Expert content validation

Participants.

An international multidisciplinary expert panel was invited to examine the draft ResQu Index for face and content validity via a quantitative survey and a modified Delphi process involving multiple rounds of consultation. The panel constituted both content experts and potential users of the Index, both of whom should be included in a content validation [ 53, 54]. In line with best practice for expert panel review, the invited panel of 42 experts spanned a range of perspectives in terms of profession, expertise, country of residence/practice, and acknowledged attitudes about place of birth [ 53, 54]. In total, 21 experts completed the validation process.

The panel included 15 academics, 12 researchers, 8 midwives, 6 perinatal epidemiologists, 4 statisticians, 2 policy makers and one each of consumer, nurse and obstetrician (more than one response was possible). Their areas of expertise included: research on birth place (16 experts), planned home birth (13), research methodology/study design (11), midwifery practice (11), evidence-based practice (10), health services (10), appraisal of evidence (10), public health (9), hospital maternity care (7), birth centres (7), health systems (5), statistics (5), population-based services (4), patient-oriented outcomes (4), global health (3). Two experts indicated professional interest in 'transfer' and one each 'law or policy', 'nursing practice' and 'medical practice'. Anonymous response was possible, but twelve of the 21 experts supplied their names. All supplied the country/region in which they were based, including North America (11), Australia (7), United Kingdom (2), and the Netherlands (1). Several indicated that they also worked in a range of other countries or regions.

Procedure.

Panel members were contacted using publicly-available contact details, and participation was voluntary. We emailed the panel of 42 experts explaining the background and purpose of the Index, and inviting them to participate in the expert review process. We outlined the conceptual basis and scope of the Index [ 53] and explained how the process differed from content validation for instruments assessing skills or attitudes.

The content validation took place during June 2016, online via Survey Gizmo. Experts considered each item on the first draft version for clarity, importance and relevance, rating each aspect on a four-point ordinal scale from 'very clear/important/relevant' (1) to 'not clear/important/relevant' (4). In addition to the quantitative rating process, they were invited to provide written feedback on the wording and scoring rubric for each item, to suggest non-essential items that might be omitted, and to comment on individual items and/or the overall purpose, utility and scope of the draft Index [ 55].

Following expert review, several items were amended in line with the experts' quantitative responses and qualitative feedback ( S1 and S2 Tables give examples of this process). Two team members used the updated version to assess 41 studies, and made small adjustments in wording to arrive at a second draft version. The second draft version was re-circulated for review and approval to the expert panel.

To assess utility and user-friendliness, we invited the same experts to beta-test the second draft ResQu Index, by supplying them with two published articles on birth place to assess. The articles were selected to reflect different settings, methodologies, and eras. They were from two different countries, one a relatively recent study comparing outcomes from freestanding midwifery units with hospital obstetric units and the other a pre-2000 study comparing home births and hospital births. Four completed this beta-testing process, including two who did not participate in the first stage of content validation. Responses and recommendations were incorporated into the final draft before pilot testing.

Data analysis.

Responses from the online survey were imported into MS Excel for simple descriptive analysis. An item content validation index (I-CVI) was calculated for the three aspects (clarity, importance and relevance) of each item, being the proportion of experts that gave it a positive response (1 or 2). Items that achieved a total score above .80 for relevance were retained (except for one which scored low in importance). Those items below .80 for clarity were rephrased or modified to reflect the expert comments ( S1 and S2 Tables) or discarded. The overall scale content validity index (S-CVI) was calculated for each aspect, being the average (mean) of the I-CVIs of the retained items. Polit and Beck recommend that a level of .90 for the S-CVI be used as the standard for excellent content validity using this approach [ 56].

Phase 3: Inter-rater consistency and consensus

To test inter-rater reliability, two members of the research team (VS and CR) used the second draft version of the ResQu Index (revised but still 25 items) to independently rate 20 studies. Stemler [ 57] describes different purposes and methods for measuring inter-rater reliability. We used Spearman's rho coefficient to explore the consistency of our total scores for the articles because the scores were continuous but not necessarily normally distributed [ 57]. Secondly, we converted each study's score to a simple scale of research evidence: strong (scores of 75% and above), moderate (65-74%) and weak (less than 65%). We then examined inter-rater consensus on the three-tier scale using Cohen's kappa statistic [ 58]. We used SPSS version 23 to analyse inter-rater consistency and consensus.

In addition to investigating inter-rater consistency and consensus, this process enabled us to review each study's total Index scores, with particular attention to where the two raters diverged. In conjunction with further comments from expert reviewers, this contributed to the final version of the Index ( Fig 1).

Phase 4: Research quality checklists

To ascertain comprehensiveness, the ResQu Index was compared to the taxonomy of domains developed by Deeks and colleagues [ 39] in their extensive evaluation of scales and checklists for assessing quality in non-randomised studies. We matched ResQu items to domains identified by these authors as critical to study quality, internal and external validity, and standard of reporting. We also compared the Index to the Cochrane tool for assessing Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) [ 38], which is widely used to assess research quality in systematic reviews [ 59].

Phase 5: Pilot testing

As a final stage of development, two authors (VS and CR) assessed usability and feasibility by using the ResQu Index in a systematic review on maternal and perinatal outcomes related to place of birth for women at low risk of obstetric complications in high-income countries. We used the updated ResQu Index to rate 68 articles, comparing and discussing their ratings when total scores diverged. This process was done iteratively, in conjunction with the search and screening stages of the review. Having identified studies that met the eligibility criteria for the systematic review, one or both authors applied the current version of the Index.

Results

Item generation and scoring

The final ResQu Index contains 27 items across five domains, each rated on a numerical scale where higher values indicated higher quality with respect to the aspect of quality being measured. The items and the final scoring rubrics are shown in Fig 1. The total possible composite score is 100, to guide categorisation of studies into strong, moderate, and weak quality.

Expert content validation

The experts' quantitative responses about the clarity, importance and relevance of the items in the first draft version are summarised in Table 1. I-CVIs are the proportion of respondents who rated each item positively (1 or 2).

Table 2 summarises the experts' quantitative responses about the scoring of items, showing the proportion of those who gave the proposed rubric for each item either 1 or 2.

In addition to responding to the online survey, several experts corresponded directly with the project team, providing comments on the draft Index or the validation process, or seeking clarification. This correspondence, together with the quantitative and qualitative survey responses contributed to further revision of the Index. Accordingly, the wording and/or the relative weighting of scoring rubrics was refined, specifically to enhance clarity: three items were removed as feedback indicated that they were not perceived as relevant as others (items 15, 17 and 22 in Table 1); two new items were added (on sample size calculation and ethical research); one item was split into two (item 24); and two were collapsed (items 7 and 8) into one. Another (item 19) was split into two, to address separately the reliable use of statistical methods and the clarity of presentation of comparisons between birth places, and to increase the relative weighting of items on statistical rigour. We also amended the wording or scoring language for some items ( S1 and S2 Tables).

The S-CVIs were calculated following the removal of the three items (items 15, 17 and 22), as described above. The average (mean) of the I-CVIs for the retained items was 0.89 for clarity, 0.94 for relevance and 0.90 for importance ( Table 1). These levels are close to or above the recommended level for excellent content validity of .90 [ 56].

In relation to the proposed scoring rubric for the retained items, the average S-CVI was 0.85. Of the 22 retained items, seven received a positive rating of 80% or less. Of these, five were substantially reworded and or reweighted. The other two (items 7 and 8) were merged into one with a revised scoring rubric ( Table 2).

The four experts who used the Index to beta-test its applicability in scoring the two sample articles reported positive experiences in terms of usability and acceptability. Following their comments, the wording and scoring in the final version were fine-tuned.

Inter-rater reliability

Table 3 indicates results of inter-rater reliability testing for 20 studies. Four articles received identical scores. Another 11 were scored within five percentage points. There was a very strong positive correlation between the scores from the two raters (Spearman's rho = .868, p<0.001), indicating a high degree of consistency in ratings. Comparing the two raters' scores on the three-tier scale (strong, moderate, weak) also demonstrated substantial levels of consensus on the relative strength of the articles ( kappa = .697, p<0.001) [ 57, 58].

Research quality checklist

The comparison of the ResQu Index with the domains identified by Deeks and colleagues [ 39] demonstrated considerable congruence between the Index and most of the Deeks domains ( Table 4). The ResQu Index addresses some items in the Background/Context domain. However, the Blinding and Follow-up domains were not included because items related to randomisation, blinding or follow-up are not relevant to research into place of birth. Following this process of comparison, two items were added to the final version (items 1 and 9 in Fig 1).

Three ResQu items (items 10, 13 and 14 in Fig 1) are not compatible with any of the domains identified, as they constitute birth setting-specific items i.e. timing of decision about birth place and instances where women transfer from home or birth centre to give birth in hospital. Item 6 is also unique to birth place research, and was included in the Index because it identifies a potential source of bias.

We also compared the Index to the domains identified in the Cochrane ROBINS-I tool [ 38] devised to assess risk of bias ( Table 5).

Pilot testing

The pilot testing phase was conducted concurrently with a systematic review of literature on outcomes by place of birth, where the ResQu Index scores were used to assess the research quality of studies that met the review's inclusion criteria. This process confirmed its utility, feasibility and applicability in a systematic review process. We were able to generate scores for each reviewed study, with congruence between reviewers, and excluded studies scoring less than 75% in the sensitivity analyses.

Team members also recorded how long it took them to read and assess a sample of 24 articles using the ResQu Index. This ranged from 15 to 45 minutes per article depending on article length, clarity and detail, with a mean of 31.25 minutes per article. The scoring process became quicker over time, as raters became more familiar with the items and scoring rubrics.

The pilot testing phase highlighted a few limitations in the Index and suggested potential new items or, more commonly, new levels or examples within the scoring rubric. We discussed discrepancies in scores until these could be resolved by team consensus; we also used this experience to refine the Index by clarifying the wording of items and scoring rubrics. The final Birth Place ResQu Index appears in Fig 1.

Discussion

We undertook a formal, rigorous process to develop and validate a Birth Place Research Quality Index that provides a reliable means of assessing the quality of research on place of birth. The ResQu Index provides a consistent, transparent, and pragmatic solution to the dilemma presented by the ongoing scientific debate on the significance of results from studies on birth place [ 12]. The inclusion of 21 experts from various disciplines in the development and content validation process has added to the scope, acceptability, and utility of the Index [ 55]. Our collaborative approach involved ongoing correspondence and exchange with several experts, to ensure applicability for researchers and clinicians across the health professions. The S-CVI scores, close to or above .90, indicate excellent content validity as assessed by this large panel of international, multi-disciplinary experts.

The resulting ResQu Index is a more comprehensive, nuanced, and workable tool to assess the relative significance of studies than checklists which simply identify whether research adequately incorporates certain essential elements [ 40]. While the ResQu Index includes items fundamental to research integrity, such as clarity of objectives, appropriate sampling, treatment of confounders and use of statistical analysis [ 60], it also requires users to consider issues specific to childbirth and potentially attributable to place of birth. Moreover, the formal content validation process reflects expert consensus on wording and parameters of items to be included, as well as scoring and weighting of each aspect.

The compatibility of the ResQu items with most research quality domains [ 39] ( Table 4) and with the ROBINS-I framework [ 38] ( Table 5) indicates the comprehensiveness of the Index and its capacity to evaluate research rigour according to commonly-accepted standards. It excludes items not pertinent to birth place research, such as randomisation and blinding. Conversely, it does address critical items to assess quality of studies on birth place, such as maternal transfer, and ensuring that data on planned place of birth are not tainted by unintended home births or those without a qualified birth attendant [ 43- 46].

The ResQu Index identifies birth place as the 'intervention'; however, childbirth is a unique phenomenon within healthcare because birth place cannot be considered in terms of 'dose' or 'exposure'. Issues of withdrawal or drop-out from the intervention have very distinct implications within a study on birth setting and must be treated differently from withdrawal in studies of other interventions. The process of developing the items required attention to the distinction between the quality of a study's methods and the quality of reporting results [ 61]. This generated discussion within the project team during the development and pilot stages about the extent to which we were rating the research or the article.

The final stage of developing the ResQu Index was to use it in a systematic review to assess the quality of studies (published between 2000 and 2016) on the maternal and perinatal outcomes of different places of birth, for women with healthy, low-risk pregnancies in high-income countries. Two authors separately and jointly used the ResQu Index system to inform a rigorous process of inclusion and exclusion of identified studies. They also developed a user dictionary (available on request) to assist with using the Index to assess studies in practice. While several low-scoring studies were excluded by the parameters of our systematic review (e.g. because they did not follow an intention to treat approach, or they included births to women at different levels of risk), we were able to utilise the Index to examine the quality of studies to inform inclusion in our meta-analysis of data.

Place of birth research has been plagued with controversy over study design, variables to be measured, cohort definition and other factors specific to this context. A growing volume of academic literature and media attention has focused on research about birth place. The availability of a reliable method to assess quality of the evidence has the potential to create consensus about the quality of studies among clinicians and researchers who have been (often fiercely) divided on the issue [ 12, 62, 63]. Women and families are ill-served by inter-professional conflict, given that their choices are influenced by provider attitudes [ 11, 32, 64, 65]. In the age of increased consumer access to scientific findings, it is imperative that public health information and recommendations are based on the best available data. Studies that score higher on the Index thus have greater potential to reliably inform the evidence base for decisions about birth place by women and health professionals.

The ResQu Index could facilitate the development of clinical guidelines on provision of maternity services across places of birth. For example, following a review of the evidence, some professional clinical bulletins [ 28] have relied on conclusions from publications that are widely cited [ 22] but have been subject to critical reviews questioning their quality [ 44, 46]. Other investigators have published ethical practice recommendations based on findings from research that would not meet the ResQu Index scoring threshold to support a recommendation [ 62]. Consumers and clinicians will benefit from having a consistent, transparent and reliable method to distinguish and rate the relative importance of research conclusions and recommendations related to place of birth. In addition to guiding the design of studies, the ResQu Index could provide a framework for peer review for publication or serve as a quality assurance guide for research grant funding agencies. The Index could also be used to appraise research on birth place across population cohorts, taking adequate account of the characteristics of women in different settings, and applying the same principles of comparability between cohorts and transparency of research methods. Finally, the Index may help to contextualise results of research in jurisdictions where care is not integrated across settings.

Strengths and limitations

The development of a quality assessment instrument is a complex process, benefiting from the contributions of a multidisciplinary team. Despite careful measures to maximise content validity and consistency, it inevitably involves subjective judgements, both in the selection and weighting of items, and their application to appraise published studies of place of birth. Other researchers may debate its relative emphasis on some aspects of this literature at the expense of others.

The results of pilot-testing confirm that the Index is, like other such scales, subject to some personal interpretation. However, comparison of the inter-rater consistency and consensus of scores from two raters, including one non-clinician researcher, with a large selection of studies showed considerable similarity. One of the strengths of the Index is its capacity to facilitate multi-disciplinary, collaborative evaluation of research outputs, by using commonly-defined terms.

The ResQu Index was not designed to assess qualitative studies and would not, by virtue of its focus on specific aspects of methodology, rate them highly. We acknowledge that some important questions about quality and safety of birth place, or person-centred care, cannot be answered by quantitative methods alone.

Conclusions

The Birth Place Research Quality Index is a reliable, pragmatic tool to systematically appraise the quality of research on place of birth. The composite scoring system highlights the unique nature of childbirth and the specific characteristics of study design and analysis that must be considered when evaluating reported findings. We used a detailed, formal process to design and content validate the Index in consultation with an international panel of multi-disciplinary experts in this field. Pilot testing demonstrated usability, feasibility, and inter-rater consistency. The Index was well suited to systematic review of research on birth place. It could also be used to inform clinical guidelines on maternity service provision across birth settings, to inform the design of studies, or to provide a framework for peer review for publication.

Acknowledgments

We sincerely thank the panel of international experts who contributed thoughtfully and enthusiastically to the content validation process, and our colleagues on the [blinded] research study.

References

9. Declercq E, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to mothers III: pregnancy and birth. New York: Childbirth Connection; 2103. https://doi.org/10.1111/birt.12135

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The ResQu Index: A new instrument to appraise the quality of research on birth place

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Objective Place of birth is a known determinant of health care outcomes, interventions and costs. Many studies have examined the maternal and perinatal outcomes when women plan to give birth in hospitals compared with births in birth centres or at home. However, these studies vary substantially in rigour; assessing their quality is challenging.

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The American Association of Birth Centers; the American College of Nurse-Midwives; the Association of Women's Health, Obstetric and Neonatal Nurses; the Commission for the Accreditation of Birth Centers; and the Society for Obstetric Anesthesia and Perinatology endorse this document. The American Academy of Family Physicians and the American Hospital Association support this document. The American Society of Anesthesiologists has reviewed this document. This document was developed jointly by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine in collaboration with Sarah J. Kilpatrick, MD, PhD; M. Kathryn Menard, MD, MPH; Christopher M. Zahn, MD; and the Centers for Disease Control and Prevention's representative William M. Callaghan, MD, MPH. The findings, conclusions, and views in this Obstetric Care Consensus do not necessarily represent the official position of the Centers for Disease Control and Prevention or the U.S. government.
This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publications may not reflect the most recent evidence. Any updates to this document can be found on www.acog.org or by calling the ACOG Resource Center. While ACOG makes every effort to present accurate and reliable information, this publication is provided "as is" without any warranty of accuracy, reliability, or otherwise, either express or implied. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither ACOG nor its officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented. All ACOG committee members and authors have submitted a conflict of interest disclosure statement related to this published product. Any potential conflicts have been considered and managed in accordance with ACOG's Conflict of Interest Disclosure Policy. The ACOG policies can be found on acog.org. For products jointly developed with other organizations, conflict of interest disclosures by representatives of the other organizations are addressed by those organizations. The American College of Obstetricians and Gynecologists has neither solicited nor accepted any commercial involvement in the development of the content of this published product.
ABSTRACT: Maternal mortality and severe maternal morbidity, particularly among women of color, have increased in the United States. The leading medical causes of maternal mortality include cardiovascular disease, infection, and common obstetric complications such as hemorrhage, and vary by timing relative to the end of pregnancy. Although specific modifications in the clinical management of some of these conditions have been instituted, more can be done to improve the system of care for high-risk women at facility and population levels. The goal of levels of maternal care is to reduce maternal morbidity and mortality, including existing disparities, by encouraging the growth and maturation of systems for the provision of risk-appropriate care specific to maternal health needs. To standardize a complete and integrated system of perinatal regionalization and risk-appropriate maternal care, this classification system establishes levels of maternal care that pertain to basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). The determination of the appropriate level of care to be provided by a given facility should be guided by regional and state health care entities, national accreditation and professional organization guidelines, identified regional perinatal health care service needs, and regional resources. State and regional authorities should work together with the multiple institutions within a region, and with the input from their obstetric care providers, to determine the appropriate coordinated system of care and to implement policies that promote and support a regionalized system of care. These relationships enhance the ability of women to give birth safely in their communities while providing support for circumstances when higher level resources are needed. This document is a revision of the original 2015 Levels of Maternal Care Obstetric Care Consensus, which has been revised primarily to clarify terminology and to include more recent data based on published literature and feedback from levels of maternal care implementation.

1. To reaffirm the need for levels of maternal care, as initially presented in the 2015 Obstetric Care Consensus, which includes uniform definitions, a standardized description of maternity facility capabilities and personnel, and a framework for integrated systems that addresses maternal health needs.

2. To reaffirm that the goal of levels of maternal care is to reduce maternal morbidity and mortality, including existing disparities, by encouraging the growth and maturation of systems for the provision of risk-appropriate care specific to maternal health needs. Central to systems is the development of collaborative relationships between hospitals of differing levels of maternal care in proximate regions, which ensures that every maternity hospital has the personnel and resources to care for unexpected obstetric emergencies, that risk assessment is judiciously applied, and that consultation and referral are readily available when high-risk care is needed. These relationships enhance the ability of women to give birth safely in their communities while providing support for circumstances when higher level resources are needed.

3. To clarify definitions and revise criteria by applying experience from jurisdictions that are actively implementing levels of maternal care.

Maternal mortality and severe maternal morbidity, particularly among women of color, have increased in the United States. The Centers for Disease Control and Prevention (CDC) reported that pregnancy-related deaths increased from 7.2 per 100,000 live births in 1987 to 18.0 in 2014 ( 1), and non-Hispanic black women had a 3.3 times greater pregnancy-related mortality ratio compared with non-Hispanic white women (1, 2). Furthermore, severe maternal morbidity increased by nearly 200% between 1993 and 2014 (1, 3-6). In addition, data shared by 13 maternal mortality review committees showed that as many as 60% of pregnancy-related deaths during 2013-2017 were potentially preventable (2). These data underscore the need to focus on the quality and safety of maternal care systems. Implementation of levels of maternal care has been identified as a common theme when identifying actionable opportunities to prevent maternal mortality (2, 7). The leading medical causes of maternal mortality include cardiovascular disease, infection, and common obstetric complications such as hemorrhage, and vary by timing relative to the end of the pregnancy (2). Although specific modifications in the clinical management of some of these conditions have been instituted (eg, the use of thromboembolism prophylaxis and development of hemorrhage and hypertension practice management bundles), more can be done to improve the system of care for high-risk women at facility and population levels ( 8, 9). This document is a revision of the original 2015 Levels of Maternal Care Obstetric Care Consensus, which has been revised primarily to clarify terminology and to include more recent data based on published literature and feedback from levels of maternal care implementation.

In the 1970s, most states developed coordinated regional systems for perinatal care that were predominantly focused on neonatal outcomes ( 10). The designated regional or tertiary care centers provided the highest levels of obstetric and neonatal care and served smaller facilities' needs through education and transport services. Numerous studies validated the concept that improved neonatal outcomes were achieved through the application of risk-appropriate maternal transport systems ( 11, 12). A comprehensive meta-analysis showed an increased risk of neonatal mortality for very-low-birth-weight infants (less than 1,500 g) born outside of a neonatal intensive care unit level III hospital (38% versus 23%; adjusted odds ratio [adjusted OR], 1.62; 95% CI, 1.44-1.83) ( 13). Similarly, neonatal mortality was higher for very-low-birth-weight infants born in hospitals staffed by neonatologists in the absence of a more complete multidisciplinary team (level II), compared with those born in level III centers ( 14). However, although regionalized systems that promote maternal transfer to improve neonatal outcomes are well established, similar safety networks focused on maternal medical risk-based needs are not well defined and, thus, not established in many areas of the United States.

Importantly, accredited birth centers and hospitals that offer basic and specialty maternity services provide needed obstetric care for most women who are giving birth in the United States ( 15). Furthermore, they often provide maternity care in rural and underserved communities, which offers the benefit of keeping women with low- or moderate-risk pregnancies in their local communities. Closing hospitals with low-volume obstetric services could have counterproductive adverse health consequences ( 16, 17) and potentially increase health care disparities ( 18, 19) by limiting access to maternity care.

Women with complex high-risk conditions often benefit from giving birth in hospitals that offer a broad array of specialty and subspecialty services. Perhaps the most direct evidence that caring for the sickest women in higher acuity centers is associated with improved outcomes is that women with a high comorbidity index had a significantly higher adjusted relative risk of severe maternal morbidity when they gave birth in hospitals of low acuity (adjusted OR, 9.55; 95% CI, 6.83-13.35) compared with hospitals of high acuity (adjusted OR, 6.50; 95% CI, 5.94-7.09) ( 20). Additional recent data suggest that hospital delivery volume, health care provider patient volume, and hospital level or rating can all affect maternal outcomes ( 20-27). Furthermore, data indicate that outcomes are better if women with certain conditions, such as placenta previa or placenta accreta, are managed in hospitals with high delivery volume ( 28, 29).

This information should not be interpreted to imply that hospitals with low delivery volumes are not safe for care of women with low-risk pregnancies, or as a call to close hospitals with a lower volume or acuity. In remote or rural areas, hospitals with low delivery volumes are often the only local delivery option. Rather, these data, combined with the fact that 59% of hospital births in the United States occur at hospitals where fewer than 1,000 newborns are delivered annually (15), underscore the importance of adequately staffed and equipped level I and II hospitals; regionalized care with defined relationships between different level facilities; continuous risk assessment; and the potential benefit of caring for women with high risk of maternal morbidity in centers with higher level, acuity-focused resources and specialty and subspecialty personnel.

Goals for Regionalized Maternal Care

Regionalized maternal care is intended to maintain and increase access to care by developing, strengthening, and better defining relationships among facilities within a region. In turn, this should facilitate consultation and transfer of care when appropriate so that low- to moderate-risk women can stay in their communities while pregnant women with high-risk conditions receive care in facilities that are prepared to provide the required level of specialized care. Each facility should have a clear understanding of its capability to handle increasingly complex levels of maternal care and should have a well-defined threshold to transfer women to health care facilities that offer a higher level of care. In emergency situations, the nearest level-appropriate hospital should be used if added travel to a farther level-appropriate hospital increases risk. An important goal of regionalized maternal care is for level III or IV facilities to provide training for quality improvement initiatives, support for education, and severe morbidity and mortality case review for hospitals in their regional system. These recommendations should be considered guidelines, not mandates, and it should be acknowledged that geographic and local issues will affect systems of implementation for regionalized maternal and neonatal care.

Ongoing Levels of Maternal Care Programs

Development of levels of maternal care programs are increasing. Several states, including Georgia, Indiana, Texas, and Iowa, passed legislation or changed their administrative codes to establish a specific maternal level of care designation for all hospitals that provide maternity care. An essential component of all of these programs is the concept of an integrated system in which level III or IV maternal centers provide education and consultation, including training for quality improvement initiatives and severe morbidity and mortality case review, to level I and II facilities and provide for a streamlined system for maternal transport when necessary.

The CDC developed the Levels of Care Assessment Tool (LOCATe) ( 30) in 2013 to address a need identified by states and national partners for a simple, web-based tool that standardizes the assessment of maternal and neonatal care capabilities of facilities. It is in alignment with the national guidelines published by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine and the national guidelines published by the American Academy of Pediatrics. ( 31). The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, in collaboration with the CDC, the Arizona Perinatal Trust, and the National Perinatal Information Center, expanded on the work achieved with LOCATe to develop the Levels of Maternal Care verification program. The verification program involves an on-site survey to assess levels of maternal care in an obstetric facility according to the Levels of Maternal Care Obstetric Care Consensus criteria. A multidisciplinary team that represents organizations with expertise in maternal risk-appropriate care piloted this program with 14 facilities across three states (Georgia, Illinois, and Wyoming). The team performed an on-site comprehensive review of the maternal services available in each facility using the hospital's LOCATe results as the initial step in the verification process ( 32). Experience from LOCATe and the pilot verification program have informed the revisions of this document to better enable implementation.

To standardize a complete and integrated system of perinatal regionalization and risk-appropriate maternal care, this classification system establishes levels of maternal care that pertain to basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). Definitions, capabilities, and health care providers for each of the four levels of maternal care and for birth centers are delineated in Table 1. Maternal care refers to all aspects of antepartum, intrapartum, and postpartum care. Table 1 also refers to low-, moderate-, and high-risk care; defining what constitutes these levels of risk should be individualized by facilities and regions, with input from their obstetric care providers. Accredited birth centers (freestanding facilities that are not hospitals) (see Accredited Birth Centers section for more information) are an integral part of many regionalized care systems and are, therefore, included in the table; however, capabilities and health care providers are not delineated in the table because well-established standards governing birth centers in the United States are already available ( 33).

One of the most common questions that arose subsequent to the publication of the first Levels of Maternal Care Obstetric Care Consensus was related to the availability of personnel, particularly the requirements for personnel to be "available" or "present" on-site. This revised document provides clarification related to the availability of personnel by providing more specific terminology as defined below.

Physically present at all times: the specified person should be on-site in the location where perinatal care is provided, 24 hours a day, 7 days a week.

Readily available at all times: the specified person should be available 24 hours a day, 7 days a week, for consultation and assistance, and able to be physically present on-site within a time frame that incorporates maternal and fetal or neonatal risks and benefits with the provision of care. Further defining this time frame should be individualized by facilities and regions, with input from their obstetric care providers. If referring to the availability of a service, the service should be available 24 hours a day, 7 days a week unless otherwise specified.

General Considerations Relevant for All Levels of Maternal Care

All facilities need to have the capability to stabilize and provide initial care for any patient while being able to accomplish transfer if needed and, thus, must have resources to manage the most common obstetric emergencies such as hemorrhage and hypertension (Table 2). Because all facilities cannot maintain the breadth of resources available at subspecialty centers, interfacility transport of pregnant women or women in the postpartum period is an essential component of a regionalized perinatal health care system. To ensure optimal care of all pregnant women, all birth centers, basic (level I), and specialty care (level II) hospitals should collaborate with subspecialty care and regional perinatal health facilities to develop and maintain maternal transport plans and cooperative agreements to meet the health care needs of women who develop complications.

Collaborating receiving hospitals should openly accept transfers. Of note, the decision to transfer a patient is not only based on guidelines but also dependent on the health care provider's judgment of the severity of illness, balancing the need for a higher level of care with the risks associated with moving the woman out of her community.

Trauma is not integrated into the levels of maternal care because trauma center levels are already established. Pregnant women should receive the same level of trauma care as nonpregnant patients.

The appropriate care level for patients should be driven by their medical need and not limited to or governed by financial constraints.

Because obesity is extremely common throughout the United States, all facilities should have appropriate equipment for the care and delivery of pregnant women with obesity, including appropriate birth beds, operating tables and rooms, and operating equipment (34). The degree of obesity may be one of the factors that affects decisions for transfer of a woman to a higher level of care, although there are no well-established body mass index cut-off levels to determine level-specific care for pregnant women or women in the postpartum period with obesity.

Because of the importance of accurate data for the assessment of outcomes and quality indicators, all facilities should have infrastructure and guidelines for data collection, storage, and retrieval that allow regular review for trends.

Although this document focuses on maternal care and does not include an in-depth discussion about risk-based neonatal care capability, optimal perinatal care requires synergy in institutional capabilities for the woman and the fetus or neonate. Levels of maternal and neonatal care may not match within facilities. However, a pregnant woman should be cared for at the facility that best meets her needs as well as her neonate's needs.

Consistent with the levels of neonatal care published by the American Academy of Pediatrics (35), each level of maternal care reflects required minimal capabilities, physical facilities, and medical and support personnel. Each higher level of care includes and builds on the capabilities of the lower levels.

All maternity facilities should have the necessary institutional support, including financial, to meet the needs of level-appropriate maternal care, including provision of health care personnel, facility resources, and collaborative relationships with perinatal hospitals within their region.

Accredited Birth Centers

The American Association of Birth Centers (AABC) initially published the Standards for Birth Centers in 1985; the most recent version was published in 2017 (33). Birth centers are freestanding facilities that are not considered hospitals. Birth centers provide peripartum care for low-risk women with uncomplicated singleton term vertex pregnancies who are expected to have an uncomplicated birth. Birth centers are part of the health care system in the United States. Although state regulations vary regarding licensure and accreditation, the AABC's national standards outline that each birth center should have an established consultation, collaboration, or referral system to meet the needs of the woman or infant (33). The Commission for the Accreditation of Birth Centers is the only accrediting agency that chooses to use the national AABC's Standards for Birth Centers in its accreditation process. The American College of Obstetricians and Gynecologists recognizes accredited birth centers as an integral part of regionalized care. Further details, including the standards for birth centers, are available from the AABC ( www.birthcenters.org).

Regional centers, which include all level IV facilities and any level III facility that functions in this capacity, should develop relationships with level I and level II hospitals in their referral network. Likewise, Level I and II hospitals should be open to collaboration and establishing relationships with a level III or IV facility in their region. Birth centers, according to the AABC 2017 Standards, should have relationships with a higher-level facility. The regional center should coordinate access to risk-appropriate health services, provide support for quality and safety monitoring, and provide outreach education. These functions are ideally accomplished in collaboration with, and supported by, public health agencies.

Listed in Table 3 are suggested examples of conditions or complications for which care may be provided at specific levels. It is important to emphasize that these examples are listed as suggested maternal conditions, and the table is not designed to be exhaustive or definitive. Some conditions present across a range of severity and, depending on the severity, geography, and available resources, it may be appropriate to care for some patients at a level different from what is listed in Table 3. Facilities, with input from their obstetric care providers, should individualize the types of conditions or complications that they are capable of caring for based on the actual resources available for their level of care, as well as other considerations such as location, availability of transport, access to readily available resources in the local or regional area, and coordination with other centers. To standardize approaches within and among facilities and regionalized systems, it may be reasonable for individual facilities and regionalized systems, with input from their obstetric care providers, to develop their own specific lists of conditions or complications that warrant consultation or consideration for transfer.

Concentrating care of women who have the most complex pregnancies at designated regional perinatal health care centers will allow these centers to maintain the expertise needed to achieve optimal outcomes. In agreement with this concept, a 2018 collaborative report from nine maternal mortality review committees recommended that adopting levels of maternal care would have a considerable effect nationally on reducing maternal mortality (6).

Regionalization of maternal health care services requires that there be available and coordinated specialized services, professional continuing education to maintain competency, facilitation of opportunities for transport and back-transport, and collection of data on perinatal outcomes to evaluate the effectiveness of delivery of perinatal health care services and the safety and efficacy of new therapies. Because the health statuses of women and fetuses may differ in acuity, referral should be organized to meet the greatest needs of either or both. In some cases with specific care needs, optimal coordination of care will not be delineated by geographic area, but rather by availability of specific expertise (eg, transplant services or fetal surgery). However, it is equally important to keep women in the care of the birthing facilities in their communities unless risk factors or comorbidities evolve such that the indicated level of care needed is beyond the capabilities of those birthing facilities. Regionalization and support of perinatal services in level I and II facilities would help to maintain such birthing facilities as opposed to threatening closure.

Measurement and Evaluation of Regionalized Maternal Care

If regionalization improves care, then implementation of levels of maternal care should be associated with a decrease in preventable maternal severe morbidity and mortality. There also should be a shift toward less severe morbidity in level I and II facilities. Therefore, facilities and regional systems should develop methods to track transports, severe maternal morbidity, and mortality and to assess preventability so that they can measure the efficacy of their system using levels of maternal care. Quantitative and qualitative evaluation of equity in outcomes should be an integral part of tracking and assessing the efficacy of the system.

Operational definitions are needed to compare data and outcomes between levels of maternal care. Two concepts to implement with the use of levels of maternal care are proposed: 1) identify women at highest risk of morbidity and 2) identify outcomes that may improve with appropriate assignments of levels of maternal care.

Some women at extreme risk of severe morbidities such as stroke, cardiopulmonary failure, or massive hemorrhage can be identified during the antepartum period and should give birth in the appropriate level-of-care hospital. Examples of such women include those with suspected placenta accreta spectrum disorders or those with severe heart disease, such as complex cardiac malformations and pulmonary hypertension, coronary artery disease, or cardiomyopathy. Other less predictable but high-acuity maternal conditions include preeclampsia with difficult to control hypertension, and hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome.

Improved maternal outcomes that may accrue with appropriate use of levels of maternal care assignments include reduction in preventable severe morbidity and mortality such as stroke, returns to the operating room, complications from known or suspected placenta accreta, and unplanned intensive care unit admissions. The incidence of these outcomes could decrease or be shifted from level I and II to level III or IV hospitals. The development of comprehensive lists of conditions that comprise extreme morbidity risks and of which outcomes should be measured is currently an evolving process. Therefore, prospective measurement with continuous monitoring and evaluation of any regionalized maternal care system is critical to improving care processes and outcomes.

Determination and Implementation of Levels of Maternal Care

The determination of the appropriate level of care to be provided by a given facility should be guided by regional and state health care entities, national accreditation and professional organization guidelines, identified regional perinatal health care service needs, and regional resources ( 36). State and regional authorities should work together with the multiple institutions within a region, and with input from their obstetric care providers, to determine the appropriate coordinated system of care and to implement policies that promote and support a regionalized system of care.

The first step in implementation is development of the classification system for maternal care that is appropriate for the specific state or geographic area. The next step is establishing defined levels in all facilities that provide maternal care within the system. More information is needed to help optimize implementation, including further understanding of perceived barriers to implementation by hospitals and obstetric facilities, identifying or developing tools and resources to address these barriers, and identifying examples and best practice of successful implementation of a levels of care system. Making such information available to other facilities and systems that are in the process of or planning to implement a level of care system can accelerate the uptake. Furthermore, it is critical to implementation to identify how best to provide the financing needed to establish a levels of maternal care system, how to manage different payer programs, and how to identify which financial models are most sustainable. An important consideration related to the financial concerns is to ensure that facilities are not financially "penalized" for appropriately transferring a woman to a higher-level facility.

Interdisciplinary work groups are needed to further explore what is needed to adopt the proposed levels of maternal care classification system in all facilities that provide maternal care. In addition to information needed to optimize implementation, research is needed to assess the effect of implementing a levels of maternal care system on maternal and perinatal outcomes with a particular focus on reducing maternal morbidity and mortality.

The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/LOMC.

These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists' endorsement of the organization, the organization's website, or the content of the resource. The resources may change without notice.

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24. Guglielminotti J, Deneux-Tharaux C, Wong CA, Li G. Hospital-level factors associated with anesthesia-related adverse events in cesarean deliveries, New York State, 2009-2011. Anesth Analg 2016;122:1947-56.

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26. Sullivan SA, Hill EG, Newman RB, Menard MK. Maternal-fetal medicine specialist density is inversely associated with maternal mortality ratios. Am J Obstet Gynecol 2005;193:1083-8.

27. Ananth CV, Lavery JA, Friedman AM, Wapner RJ, Wright JD. Serious maternal complications in relation to severe pre-eclampsia: a retrospective cohort study of the impact of hospital volume. BJOG 2017;124:1246-53.

28. Wright JD, Herzog TJ, Shah M, Bonanno C, Lewin SN, Cleary K, et al. Regionalization of care for obstetric hemorrhage and its effect on maternal mortality. Obstet Gynecol 2010;115:1194-200.

29. Olive EC, Roberts CL, Algert CS, Morris JM. Placenta praevia: maternal morbidity and place of birth. Aust N Z J Obstet Gynaecol 2005;45:499-504.

30. Centers for Disease Control and Prevention. CDC Levels of Care Assessment Tool (CDC LOCATe). Atlanta (GA): CDC; 2019. Available at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/LOCATe.html. Retrieved April 15, 2019.

31. Catalano A, Bennett A, Busacker A, Carr A, Goodman D, Kroelinger C, et al. Implementing CDC's Level of Care Assessment Tool (LOCATe): a national collaboration to improve maternal and child health. J Womens Health (Larchmt) 2017;26:1265-9.

32. Zahn CM, Remick A, Catalano A, Goodman D, Kilpatrick SJ, Menard MK. Levels of maternal care verification pilot: translating guidance into practice. Obstet Gynecol 2018;132:1401-6.

33. American Association of Birth Centers. Standards for birth centers. Perkiomenville (PA): AABC; 2017. Available at: http://www.birthcenters.org/resource/resmgr/AABC-STANDARDS-RV2017.pdf. Retrieved April 2, 2019.

34. Obesity in pregnancy. Practice Bulletin No. 156. American College of Obstetricians and Gynecologists [published erratum appears in Obstet Gynecol 2016;128:1450]. Obstet Gynecol 2015;126:e112-26.

35. Levels of neonatal care. American Academy of Pediatrics Committee on Fetus And Newborn. Pediatrics 2012;130:587-97.

36. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 8th ed. Elk Grove Village (IL): AAP; Washington, DC: American College of Obstetricians and Gynecologists; 2017.

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The American Association of Birth Centers; the American College of Nurse-Midwives; the Association of Women's Health, Obstetric and Neonatal Nurses; the Commission for the Accreditation of Birth Centers; and the Society for Obstetric Anesthesia and Perinatology endorse this document. The American Academy of Family Physicians and the American Hospital Association support this document.

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Learn about the Best Practice Guidelines: Transfer from Planned Home Birth to Hospital from the Home Birth Summit Collaboration Work Group and how they can support practice and care in your own community. Hear from regional perinatal collaboratives around the country, and the perspectives of the various provider groups, from midwives to receiving physicians to emergency medical personnel, on improving care for women across providers and birth settings. (1.5 MEAC CEUs Approved - visit our website for details http://nacpm.org/webinars2014-1/).

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Person Centered Decision Making Model - Birth Place Lab

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Learn about the four ongoing responsibilities and eight elements of shared decision making in this 40-second animation.

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ACOG committee opinion on planned home birth

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ACOG committee opinion on planned home birth

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Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although planned home birth is associated with fewer maternal interventions than planned hospital birth, it also is associated with a more than twofold increased risk of perinatal death (1-2 in 1,000) and a threefold increased risk of neonatal seizures or serious neurologic dysfunction (0.4-0.6 in 1,000). These observations may reflect fewer obstetric risk factors among women planning home birth compared with those planning hospital birth. Although the American College of Obstetricians and Gynecologists (the College) believes that hospitals and accredited birth centers are the safest settings for birth, each woman has the right to make a medically informed decision about delivery.

Women should be informed that several factors are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes. These factors include the appropriate selection of candidates for home birth; the availability of a certified nurse-midwife, certified midwife or midwife whose education and licensure meet International Confederation of Midwives' Global Standards for Midwifery Education, or physician practicing obstetrics within an integrated and regulated health system; ready access to consultation; and access to safe and timely transport to nearby hospitals.

The Committee on Obstetric Practice considers fetal malpresentation, multiple gestation, or prior cesarean delivery to be an absolute contraindication to planned home birth.

In the United States, approximately 35,000 births (0.9%) per year occur in the home ( 1). Approximately one fourth of these births are unplanned or unattended ( 2). Among women who originally intend to give birth in a hospital or those who make no provisions for professional care during childbirth, home births are associated with high rates of perinatal and neonatal mortality ( 3). The relative risk versus benefit of a planned home birth, however, remains the subject of debate.

High-quality evidence that can inform this debate is limited. To date, there have been no adequate randomized clinical trials of planned home birth ( 4). In developed countries where home birth is more common than in the United States, attempts to conduct such studies have been unsuccessful, largely because pregnant women have been reluctant to participate in clinical trials that involve randomization to home or hospital birth ( 5, 6). Consequently, most information on planned home births comes from observational studies. Observational studies of planned home birth often are limited by methodological problems, including small sample sizes ( 7-10); lack of an appropriate control group ( 11-15); reliance on birth certificate data with inherent ascertainment problems (2, 16-18); reliance on voluntary submission of data or self-reporting (7, 12, 14, 15, 19); limited ability to distinguish accurately between planned and unplanned home births (16, 20); variation in the skill, training, and certification of the birth attendant (14-16, 21); and an inability to account for and accurately attribute adverse outcomes associated with antepartum or intrapartum transfers ( 8, 16, 22). Some recent observational studies overcome many of these limitations, describing planned home births within tightly regulated and integrated health care systems, attended by highly trained licensed midwives with ready access to consultation and safe, timely transport to nearby hospitals (7, 8, 10, 11, 16, 19, 23-28). However, these data may not be generalizable to many birth settings in the United States where such integrated services are lacking. For the same reasons, clinical guidelines for the intrapartum care of women in the United States that are based on these results and are supportive of planned home birth for low-risk term pregnancies also may not currently be generalizable ( 29). Furthermore, no studies are of sufficient size to compare maternal mortality between planned home and hospital birth and few, when considered alone, are large enough to compare perinatal and neonatal mortality rates. Despite these limitations, when viewed collectively, recent reports clarify a number of important issues regarding the maternal and newborn outcomes of planned home birth when compared with planned hospital births.

Women planning a home birth may do so for a number of reasons, often out of a desire to avoid medical interventions and the hospital atmosphere ( 30). Recent studies have found that when compared with planned hospital births, planned home births are associated with fewer maternal interventions, including labor induction or augmentation, regional analgesia, electronic fetal heart rate monitoring, episiotomy, operative vaginal delivery, and cesarean delivery (Table 1). Planned home births also are associated with fewer vaginal, perineal, and third-degree or fourth-degree lacerations and less maternal infectious morbidity ( 18, 27, 31, 32). These observations may reflect fewer obstetric risk factors among women planning home births compared with those planning hospital births. Parous women comprise a larger proportion of those planning out-of-hospital births (27, 32). Compared with nulliparous women, parous women collectively experience significantly lower rates of obstetric intervention, maternal morbidity, and neonatal morbidity and mortality, regardless of birth location. Those planning home births also are more likely to deliver in that setting than nulliparous women (15, 27, 33). For these reasons, recommendations regarding the intrapartum care of healthy nulliparous and parous women may differ outside of the United States (29). Also, proportionately more home births are attended by midwives than planned hospital births, and randomized trials show that midwife-led care is associated with fewer intrapartum interventions ( 34).

Strict criteria are necessary to guide selection of appropriate candidates for planned home birth. In the United States, for example, where selection criteria may not be applied broadly, intrapartum (1.3 in 1,000) and neonatal (0.76 in 1,000) deaths among low-risk women planning home birth are more common than expected when compared with rates for low-risk women planning hospital delivery (0.4 in 1,000 and 0.17 in 1,000, respectively), consistent with the findings of an earlier meta-analysis (15, 31, 33). Additional evidence from the United States shows that planned home birth of a breech-presenting fetus is associated with an intrapartum mortality rate of 13.5 in 1,000 and neonatal mortality rate of 9.2 in 1,000 (15). United States data limited to singleton-term pregnancies demonstrate a higher risk of 5-minute Apgar scores less than 7, less than 4, and 0; perinatal death; and neonatal seizures with planned home birth, although the absolute risks remain low (Table 2) ( 17, 18, 32).

Although patients with one prior cesarean delivery were considered candidates for home birth in two Canadian studies, details of the outcomes specific to patients attempting home vaginal birth after cesarean delivery were not provided ( 24, 25). In England, women planning a home trial of labor after cesarean delivery (TOLAC) exhibited fewer obstetric risk factors, were more likely to deliver vaginally, and experienced similar maternal and perinatal outcomes compared with those planning an in-hospital TOLAC ( 35). In contrast, a recent U.S. study showed that planned home TOLAC was associated with an intrapartum fetal death rate of 2.9 in 1,000, which is higher than the reported rate of 0.13 in 1,000 for planned hospital TOLAC ( 36, 37). This observation is of particular concern in light of the increasing number of home vaginal births after cesarean delivery ( 38). Because of the risks associated with TOLAC, and specifically considering that uterine rupture and other complications may be unpredictable, the College recommends that TOLAC be undertaken in facilities with trained staff and the ability to begin an emergency cesarean delivery within a time interval that best incorporates maternal and fetal risks and benefits with the provision of emergency care.

The decision to offer and pursue TOLAC in a setting in which the option of immediate cesarean delivery is more limited should be considered carefully by patients and their health care providers. In such situations, the best alternative may be to refer patients to facilities with available resources. Health care providers and insurers should do all they can to facilitate transfer of care or comanagement in support of a desired TOLAC, and such plans should be initiated early in the course of antenatal care ( 39).

Abbreviation: CI, confidence interval.

Cheng YW, Snowden JM, King TL, Caughey AB. Selected perinatal outcomes associated with planned home births in the United States. * Am J Obstet Gynecol 2013;209:325.e1-8.

Snowden JM, Tilden EL, Snyder J, Quigley B, Caughey AB, Cheng YW. Planned out-of-hospital birth and birth outcomes. ‡ N Engl J Med 2015;373:2642-53.

Grunebaum A, McCullough LB, Sapra KJ, Brent RL, Levene MI, Arabin B, et al. Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting. † Am J Obstet Gynecol 2013;209:323.e1-6.

§ Includes planned birth center and home births.

Recent cohort studies reporting comparable perinatal mortality rates among planned home and hospital births describe the use of strict selection criteria for appropriate candidates (23-25). These criteria include the absence of any preexisting maternal disease, the absence of significant disease arising during the pregnancy, a singleton fetus, a cephalic presentation, gestational age greater than 36-37 completed weeks and less than 41-42 completed weeks of pregnancy, labor that is spontaneous or induced as an outpatient, and that the patient has not been transferred from another referring hospital. In the absence of such criteria, planned home birth is clearly associated with a higher risk of perinatal death (15, 26, 40). The Committee on Obstetric Practice considers fetal malpresentation, multiple gestation, or prior cesarean delivery to be an absolute contraindication to planned home birth.

Another factor influencing the safety of planned home birth is the availability of safe and timely intrapartum transfer of the laboring patient. The reported risk of needing an intrapartum transport to a hospital is 23-37% for nulliparous women and 4-9% for multiparous women. Most of these intrapartum transports are for lack of progress in labor, nonreassuring fetal status, need for pain relief, hypertension, bleeding, and fetal malposition (27, 41, 42). The relatively low perinatal and newborn mortality rates reported for planned home births from Ontario, British Columbia, and the Netherlands were from highly integrated health care systems with established criteria and provisions for emergency intrapartum transport (23-25). Cohort studies conducted in areas without such integrated systems and those where the receiving hospital may be remote, with the potential for delayed or prolonged intrapartum transport, generally report higher rates of intrapartum and neonatal death (6, 9, 11, 15, 22). Even in regions with integrated care systems, increasing distance from the hospital is associated with longer transfer times and the potential for increased adverse outcomes. However, no specific thresholds for time or distance have been identified ( 43, 44). The College believes that the availability of timely transfer and an existing arrangement with a hospital for such transfers is a requirement for consideration of a home birth. When antepartum, intrapartum, or postpartum transfer of a woman from home to a hospital occurs, the receiving health care provider should maintain a nonjudgmental demeanor with regard to the woman and those individuals accompanying her to the hospital.

A characteristic common to those cohort studies reporting comparable rates of perinatal mortality is the provision of care by uniformly highly educated and trained certified midwives who are well integrated into the health care system (23-25, 27). In the United States, certified nurse-midwives and certified midwives are certified by the American Midwifery Certification Board. This certification depends on the completion of an accredited educational program and meeting standards set by the American Midwifery Certification Board. In comparison with planned out-of-hospital births attended by American Midwifery Certification Board-certified midwives, planned out-of-hospital births by midwives who do not hold this certification have higher perinatal morbidity and mortality rates (18). At this time, for quality and safety reasons, the College specifically supports the provision of care by midwives who are certified by the American Midwifery Certification Board (or its predecessor organizations) or whose education and licensure meet the International Confederation of Midwives Global Standards for Midwifery Education. The College does not support provision of care by midwives who do not meet these standards.

Although the College believes that hospitals and accredited birth centers are the safest settings for birth, each woman has the right to make a medically informed decision about delivery ( 45). Importantly, women should be informed that several factors are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes. These factors include the appropriate selection of candidates for home birth; the availability of a certified nurse-midwife, certified midwife or midwife whose education and licensure meet International Confederation of Midwives' Global Standards for Midwifery Education, or physician practicing obstetrics within an integrated and regulated health system; ready access to consultation; and access to safe and timely transport to nearby hospitals.

For More Information

The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/PlannedHomeBirth.

These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists' endorsement of the organization, the organization's website, or the content of the resource. The resources may change without notice.

References

1. Murphy PA, Fullerton J. Outcomes of intended home births in nurse-midwifery practice: a prospective descriptive study. Obstet Gynecol 1998;92:461-70. [PubMed] ⇦

2. Pang JW, Heffelfinger JD, Huang GJ, Benedetti TJ, Weiss NS. Outcomes of planned home births in Washington State: 1989-1996. Obstet Gynecol 2002;100:253-9. [PubMed] [Obstetrics & Gynecology] ⇦

3. Worley KC, McIntire DD, Leveno KJ. The prognosis for spontaneous labor in women with uncomplicated term pregnancies: implications for cesarean delivery on maternal request. Obstet Gynecol 2009;113:812-6. [PubMed] [Obstetrics & Gynecology] ⇦

4. MacDorman MF, Declercq E, Mathews TJ, Stotland N. Trends and characteristics of home vaginal birth after cesarean delivery in the United States and selected States. Obstet Gynecol 2012;119:737-44. [PubMed] [Obstetrics & Gynecology] ⇦

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Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although planned home birth is associated with fewer maternal interventions than planned hospital birth, it also is associated with a more than twofold increased risk of perinatal death (1-2 in 1,000) and a threefold increased risk of neonatal seizures or serious neurologic dysfunction (0.4-0.6 in 1,000).

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Highlights

*

Intrapartum transfer from home to hospital can challenge the midwife, woman and health services.

*

Communication emerged as the mainstay in facilitating the transfer process.

*

"Under Scrutiny" captures midwives' experience of intrapartum transfer from home to hospital.

Abstract

Background

Women's experience of homebirth has been a focus of research, with limited international research and no Australian evidence of the experiences of midwives in relation to their experience of intrapartum transfers within the context of a planned homebirth.

Objective

To explore the experience of Western Australian midwives involved in an intrapartum transfer from home to hospital.

Methods

A descriptive phenomenological study was conducted. Women who elect to have a homebirth in Western Australia have the choice of care from privately practising midwives or a publicly funded program. Midwives who were currently practising or had practised within the past three years and experienced an intrapartum transfer were invited to participate. In-depth interviews were conducted with 13 midwives and data analysed using the Stevick-Colaizzi-Keen method.

Results

Analysis revealed an overarching theme "under scrutiny" which captured four themes: "decision to transfer: getting the timing right"; "reception at the hospital: welcoming or not"; "maintaining continuity of carer" and "reflections: coming to terms with the experience".

Conclusion

The decision to transfer to hospital represents a profound shift in expectations for the woman and midwife that is often not recognised by hospital staff. Intrapartum transfer is a challenging clinical decision for all parties; midwives, women, partners and health services. Increased effort by maternity health professionals to improve communication and collaboration must be a priority to better support women and their partners who make an informed decision to have a planned homebirth.

View full text

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Under scrutiny: Midwives' experience of intrapartum transfer from home to hospital within the context of a planned homebirth in Western Australia

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Women's experience of homebirth has been a focus of research, with limited international research and no Australian evidence of the experiences of mid...

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Interprofessional collaboration optimizes maternal-newborn outcomes and satisfaction with care. Since 2002, midwives have provided an increasing proportion of maternity care in British Columbia (BC). Midwives often collaborate with and/or refer to physicians; but no study to date has explored Canadian medical trainees' exposure to, knowledge of, and attitudes towards midwifery practice.

We designed an online cross-sectional questionnaire that included a scale to measure attitudes towards midwifery (13 items) and residents' knowledge of midwifery (94 items across 5 domains). A multi-disciplinary expert panel rated each item for importance, relevance, and clarity. The survey was distributed to family medicine (n = 338) and obstetric (n = 40) residents in BC.

We analyzed responses from 114 residents. Residents with more favourable exposures to midwifery during their education had significantly more positive attitudes towards midwives (r s = 0.32, p = 0.007). We also found a significant positive correlation between residents' attitudes towards midwifery and four of five knowledge domains: scope of practice (r s = 0.41, p < 0.001); content of education (r s = 0.30, p = 0.002), equipment midwives carry to home births (r s = 0.30, p = 0.004) and tests that midwives can order (r s = 0.39, p < 0.001). The most unfavourable exposures were observing interprofessional conversations (66.2%), and providing inpatient consultations for midwives (61.4%). Findings suggest increased interprofessional education may foster improved midwife-physician collaboration.

Abbreviations: BC - British Columbia; UBC - University of British Columbia

Additional information

Funding

The University of British Columbia provided $200 of funding to each family medicine resident completing a graduation research project in 2016. Dr. Kathryn Lefebvre and Dr. Jennifer Wild were awarded the Lloyd Collins Jones Award for outstanding resident scholarship project in 2016. This award, through the University of British Columbia, Faculty of Medicine, Department of Family Practice, is to assist with the cost of publishing scholarship papers;Lloyd Collins Jones Award, Department of Family Practice, University of British Columbia [NA].

Acknowledgments

We would like to acknowledge Dr. Evelyn Cornelissen, UBC Rural Okanagan Family Medicine Residency Program, Faculty for Scholarship, for her contribution to the completion of our research project. We would like to thank Shirley Tam, with the Department of Family Practice at UBC, and Scott Lewis, with the Department of Obstetrics and Gynecology at UBC, for helping to distribute our survey to the study population. We would also like to thank Michelle Main at the medical library, Clinical Academic Campus - UBC, Kelowna General Hospital, for her assistance with resources for our literature review.

Disclosure Statement

The authors report no conflict of interest

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Through the resident lens: examining knowledge and attitudes about midwifery among physician trainees

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Interprofessional collaboration optimizes maternal-newborn outcomes and satisfaction with care. Since 2002, midwives have provided an increasing proportion of maternity care in British Columbia (BC). Midwives often collaborate with and/or refer to physicians; but no study to date has explored Canadian medical trainees' exposure to, knowledge of, and attitudes towards midwifery practice.