The sad case involving a Maryland based Certified Professional Midwife and an infant death following a birth at home in Alexandria has ignited a tinder box of ongoing frustrations and accusations from both sides of a cultural divide between medicine and midwifery. It is time for both physicians and midwives to re-examine their assumptions about birth. Mutual antagonism amongst providers creates the biggest threat to the well being of mothers and babies by maintaining obstacles to integration of the best of both models of care.
In a recent Washington Post article, [Midwife Karen Carr, convicted in Alexandria baby’s death, is under investigation in Md. May 13th] Carr commented, “institutionalization has taken the heart out of health care”. While this may be partly true, we also need to acknowledge that those same institutions provide a critical safety net for mothers and babies who both desire and deserve a satisfying birth experience and good outcomes outside of hospitals.
In that same article, Dr. George Macones (ACOG), made the erroneous statement, that: “The newborn death rate is two to three times higher for planned home births than for those that take place in hospitals”. Actually, neonatal death is rare in home birth and no more frequent than low risk hospital birth. [1,2,3]
Macones is likely citing a statistic published in his organization’s revised position statement on home birth [4], which utilized a single meta-analysis published by Wax, et al.[5] As described in a recent Medscape article by five prominent home birth researchers [6], 4 of the 7 studies that were included in the meta-analysis to calculate the neonatal death rate were included inappropriately. These studies did not exclude for planned and unplanned home births and/or did not exclude for congenital birth defects.
Why is ACOG willing to promote unsound evidence as justification for its position of aversion to home birth? Possibly due to sensationalized stories of home births gone wrong or their individual member’s experiences with birth, they cannot believe the large body of evidence from the US, Canada, and Europe that show planned home birth to be safe for mothers and babies. In a recent conversation I participated in with Dr. Macones and others on NPR’s Kojo Nnamdi show, Dr. Macones said, “it shouldn’t come as a surprise to anyone [that there would be an increased risk to newborns in home birth]“. [7]
Actually, it would be a great surprise to myself, US midwives, international midwives, and even the OB organizations of European Union countries like the UK, all of which are striving to make midwifery and home birth available to more women because of the significant cost savings and excellent outcomes for mothers and babies associated with this model of care. [8,9,10,11]
All maternity care providers, midwives and physicians alike, adhere to the fundamental ethical principles of beneficence, to do good, and non-malfeasance, or do no harm. We all make decisions based on the best evidence available to provide women information about risks and benefits of all options for their care. Though many midwifery advocates would argue that there is a significant body of evidence to show the safety of home birth, US physicians continue to argue that the evidence is outside of the country and therefore irrelevant. Rather than continue the finger pointing over why things are different for US women, let’s take the next step from the productive conversation that was led by Kojo Nnamde in May. Let’s start talking about what we agree on and start coming up with solutions to identified problems.
Women have the right to choose their provider and place of delivery. Home birth will continue to be a reasonable choice for many mothers and is on the rise in the United States. Midwifery care leads to fewer interventions for mothers. Fewer interventions like cesarean section, when combined with good outcomes for babies will amount to significant cost savings for everyone. Systems of care that integrate midwifery and medical models will allow for increased choices for women and optimal outcomes. Legislation offering licensure and regulation of CPMs in all 50 states, including Maryland and the District of Columbia, will allow for improved mechanisms of accountability and remove obstacles to communication, collaboration, and integration between physicians, midwives, and the women we all serve.
Citations:
1. Johnson K, Daviss BA. Outcomes of planned home birth with certified professional mid-wives: large prospective study in North America. BMJ 2005;330;1416.
2.Hutton EK, Reitsma AH, Kaufman K. Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: a retrospective cohort study. Birth. 2009;36:180-189.
3. de Jonge A, van der Goes BY, Ravelli ACJ, et al. Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births.BJOG. 2009;116:1177-1184.
4.American College of Obstetricians and Gynecologists issues opinion on home births. http://www.acog.org/from_home/publications/press_releases/nr01-20-11.cfm
5.Wax JR, Lucas FL, Lamont M, et al. Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol 2010;203:243.e1-8.
6.Carl A Michal, PhD, Patricia A Janssen, PhD, Saraswathi Vedam, SciD, Eileen K Hutten, PhD, Ank de Jonge, Phd. Planned Home Birth vs. Hospital Birth: A Meta Analysis Gone Wrong. Medscape Ob Gyn 4/01/2011; http://www.medscape.com/viewarticle/739987
7. Midwifery in Our Region, 5/16/2011. Kojo Nnamdi http://thekojonnamdishow.org/shows/2011-05-16/midwifery-our-region
8. American College of Nurse-Midwives. The American College of Nurse-Midwives expresses concerns with recent AJOG publication on home birth. Available at: http://www.medscape.com/viewarticle/725382 Accessed March 28, 2011.
9. Simkins G. Letter. RE: Maternal and newborn outcomes in planned home birth vs. planned hospital births: a meta-analysis. July 6, 2010. Available at: http://mana.org/pdfs/MANA-Response-AJOG-Article-7-6-2010.pdf Accessed March 28, 2011.
10. National Association of Certified Professional Midwives. Press release. July 6, 2010. Available at: http://www.nacpm.org/documents/070610-NACPM-Press-Release-Wax-etal.pdf Accessed March 28, 2011.
11. Royal College of Obstetricians and Gynaecologists Position on Home Birth. 1/04/2007. http://www.rcog.org.uk/womens-health/clinical-guidance/home-births
Amen and amen! Thank you, once again, Brynne for your brilliant articulation of the issues that face modern midwifery.
You are much appreciated for your midwifing of the licensure of CPMs across the U.S.
Very well said. It is only when midwives are defined separately from physicians and nurses, and regulated as a profession, that midwife-attended homebirth may become the standard for maternal/child care in the U.S. While I appreciate the good intentions of those who oppose licensure, they are short-sighted. If midwifery is to survive, it will be as a profession that is accessible, accountable, and able to work with other health care professionals.
I agree, Valerie. Though licensure doesn’t come without a cost, both financial and philosophical, there is no doubt that it is the best and most clear path towards bringing midwifery care to more women and babies.
It is truly time for a wake up call in Maryland, which is one of only 11 States that does NOT ALLOW licensure of a CPM (Certified Professional Midwife).
It is amazing that small countries like New Zealand are light years ahead in recognizing that midwifery in NOT nursing and is not treated as advanced nursing. It is a completely seperate positin as in Europe that received the complete support of the medical profession.
The political aspect of mangaged healthcare and member organizations is very well articulated by Hilary Schlinger in this article below:
http://erinmidwife.com/2011/05/01/so-long-nurse-midwives-hilary-schlinger-cnm-cpm-puts-acnms-proposed-name-change-in-20-years-of-context
To further clarify the position of ACNM, read their response to this tradegy as they outline their position regarding “educated” nurse midwives within managed healthcare.