“In other words, every study acknowledged that a woman’s choice of birth attendant and birth setting had a very powerful, perhaps even determining effect upon birth outcomes.” -KLM

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Text of a paper I originally submitted December 9, 2013 for MDWF 100 at Midwives College of Utah

In the largest study of its kind to date, researchers Johnson & Daviss used five metrics to determine the safety of homebirth for women in North America attended by certified professional midwives, CPMs (2005). With help from NARM, the North American Registry of Midwives, which is the licensing organization for CPMs, 5,218 women across the United States and Canada who hired CPMs to assist them in homebirth were prospectively enrolled in the study. To directly address fears related to the overall safety of homebirth, Johnson and Daviss analyzed mortality rates and hospital transfer levels (2005; Haines, Rubertsson, Paliant & Hildingsson, 2012). To address fears regarding safety and pain, the team appraised data on intrapartum care practices to examine levels of medical intervention (Johnson & Daviss, 2005; Haines et al, 2012). Finally, these scholars measured issues of safety and control by evaluating two categories of birth outcome: breastfeeding and maternal satisfaction (Johnson & Daviss, 2005; Haines et al, 2012). Since the publication of the landmark Johnson & Daviss study, researchers have continued to present confirming scientific evidence that for low-risk women, midwife-attended homebirth is safe.

In the past decade, midwives have noticed a rising trend in the rates of fear of birth, FOB (Haines et al, 2012). Haines et al divided women into three categories of belief about birth: those who were fearful, those who believed “whatever would be, would be”, and those who were self-determined: opinionated individuals who were not afraid of birth (2012). Only the self-determined group believed birth was a natural event; only the “whatever” group did not exhibit safety concerns; and only the fearful group exhibited FOB (Haines et al, 2012). The Haines study advanced the suggestion that women select “a particular care provider according to… pre-existing attitudes, or alternately the attitudes of… women could be influenced by the information they receive from their caregiver” (2012, p. 2). Therefore, the beliefs of mothers and their health care providers, as well as the information about birth that women receive are matters that should be taken very seriously. ACOG, the American College of Obstetrics and Gynecologists has continued to assert that mothers who seek homebirth are sacrificing the quantitative aspect of childbirth – the very well-being of their babies – in pursuit of less important qualitative ideals (Janssen et al, 2009). The ‘Harsanyi Doctrine’, a theory that “differences in individual’s beliefs can be attributed entirely to differences in information” informed the birth study conducted by Haines et al (2012, p.2). Therefore, it is interesting that Hutton, Reitsma and Kaufman (2009) validated the Harsanyi Doctrine in their study of homebirth by concluding that “appropriate self-selection by women themselves and good screening by midwives likely contribute” to the low rates of maternal morbidity and medical intervention found among women who homebirth (p.9).

Based on the evidence cited above, this author asserts that homebirth safety is directly connected to caregiver and maternal attitudes of fear that are based on specific information. Thus we see the crucial importance of providing evidence-based care, as advocated by CIMS, the Coalition for Improving Maternity Services, in their platform, The Ten Steps of Mother-Friendly Care (CIMS, 2007). CIMS asserts that birth is safe and is meant to be an empowering experience (2007). It holds that each woman is ultimately sovereign in the birth decisions she makes (CIMS, 2007). Logic tells us that the safest birth practices are those proven to promote safe birth and to do no harm (CIMS, 2007). Therefore all members of a birth team – mothers, care-providers and institutions – are severally responsible to inform themselves on best practices for safe birth (CIMS, 2007).

Johnson and Daviss found that midwife care in the homebirth setting had low rates of hospital transfer and low infant and maternal mortality rates (2005). A total of 655 women, or 12% of the study population, transferred care to the hospital (Johnson & Daviss, 2005). Of that number, half of them, or about 327 women, transferred because of pain, exhaustion or dystocia (Johnson & Daviss, 2005). Five out of six, or approximately 545 women, were transferred before delivery (Johnson & Daviss, 2005). The midwives surveyed in this study classified only 3.4% of all transfers as urgent, about 22 cases (Johnson & Daviss, 2005). Midwives are taught the value of collaborative care and encouraged to refer patients with health issues to providers who can help them achieve best outcomes (CIMS, 2007). The risk of intrapartum and neonatal mortality was found to be 1.7 deaths per 1000 births, results Johnson and Daviss found to be “consistent with most North American studies of intended births out of hospital and low risk hospital births” (2005). There were no maternal deaths (Johnson & Daviss, 2005). Four years later, in 2009, Hutton et al conducted a comprehensive study comparing homebirths and hospital births attended by the same cohort of midwives, since Canadian law allows midwives to practice in both settings. With the only difference being the location of birth, these researchers determined no difference: They found an infant morbidity and mortality rate of 1 death per 1000 births for both study populations, while maternal morbidity was significantly lower in the planned home birth group (Hutton et al, 2009). Hutton et al also discovered very low intrapartum transfer rates for midwives attending homebirth (2009). Again, there were no maternal deaths (Hutton et al, 2009).

Midwives provide continuous labor support, a factor that has been found to reduce the use of pharmaceutical or instrumental interventions for pain relief, thus reducing the numerous health risks that are associated with these interventions (CIMS, 2007). Perhaps this support is so efficacious because midwives provide excellent levels of antenatal care and education, by which they form a positive bond with their clients and can therefore reap all the associated health benefits that go with continuity of care (CIMS, 2007). It has been shown that midwives also advocate for culturally competent care and informed consent, two other important aspects of labor support (CIMS, 2007).

When care providers and their clients fear birth and do not view it as a natural, empowering process, both parties may make birth choices based on fear rather than scientific evidence (Haines et al, 2012, CIMS 2007). For example, the routine use of continuous external fetal monitoring, or EFM, is not evidence-based and the association between lowered fetal heart tones and negative birth outcomes is poor (CIMS, 2007). EFM, even the admissions test strip, has not been shown to reduce perinatal death rates, cerebral palsy, or NICU admissions (2007). However, EFM has been proven to decrease women’s mobility and hands-on nursing support, while increasing their chance of vaginal instrumental birth and cesarean section (CIMS 2007).  Midwives do not use continuous EFM in favor of evidence-based intermittent auscultation.

Johnson and Daviss reported hospital medical intervention rates were twice as high as homebirth intervention rates (2005). Scholars in the two other studies cited confirmed their findings, stating that for every variable investigated, women experienced “significantly less” (Janseen et al, 2009) medical intervention in the home birth setting (Hutton et al, 2009). In studies comparing physicians and midwives, midwives are associated with fewer inductions and augmentations of labor (Hutton et al, 2009) as well as lower rates of episiotomy (Hutton et al, 2009) analgesia and anesthesia (CIMS 2007, Johnson & Davis, 2005). Midwives are also associated with lower rates of damage to the perineum and vaginal instrumental birth (Hutton, et al, 2009; Janssen et all, 2009), less cesarean birth (Hutton et al, 2009), less serious shoulder dystocia, less retained placenta, less maternal postpartum hemorrhage (Janssen et al, 2009) and less maternal infection (CIMS 2007, Johnson & Davis, 2005). Individuals under the care of midwives experienced lower incidences of meconium aspiration (Janssen et al, 2009), preterm birth, low birth-weight (Hutton et al, 2009), fetal distress, fetal resuscitations and fetal birth trauma (Janssen et al, 2009) while admission into intensive care or readmission into the hospital was low (CIMS, 2007). During labor, midwives were more likely than doctors to encourage evidence-based practices such as walking, nutrition, hydration, free choice of birth position and drugless pain relief such as hydrotherapy (CIMS,2007). They were less likely to utilize non-evidence-based procedures such as shaving before vaginal birth, enemas, IV, EFM (Janssen et al, 2009), denying solid and fluid nutrition, or prematurely rupturing membranes (CIMS, 2007). Midwives were associated with equal or higher levels of vaginal birth, vaginal instrumental birth and VBACs than doctors (CIMS, 2007). Significantly, researchers in all four studies specifically asserted the connection between the familiar home setting, lack of unnecessary intervention and positive birth outcomes (Johnson & Daviss, 2005; CIMS, 2007; Janssen et al, 2009; Hutton et al, 2009.)

Johnson and Daviss included breastfeeding in their study of homebirth safety as an indicator of physical and mental health (2005). Absence of breastfeeding has been connected to a 25% higher likelihood of infant mortality from the second to twelfth months of life (CIMS, 2007). Furthermore, the physical and emotional intimacy of breastfeeding promotes maternal and infant mental health through the natural biological mechanisms of attachment (CIMS, 2007). 95.8% of women in the Johnson and Davis homebirth sample had continued to breastfeed their babies six weeks after giving birth, with 89.7% still choosing to nurse exclusively (2005). Hutton et al learned that women who homebirth were twice as likely to exclusively breastfeed than nourish their children partially or wholly with infant formula (2009).

Haines et al found that fear surrounding childbirth produced more serious negative consequences than any other factor they studied (2012). Women in the self-determining group had the most unassisted vaginal births (2012). Unlike women in the other two groups, they did not request or easily acquiesce to interventions suggested by caregivers (Haines et al, 2012). Johnson and Davis randomly sampled 10% of their study population for rates of maternal satisfaction (2005). 97% of the women surveyed were extremely or very satisfied with their planned homebirth experience, with 98.2% indicating they would choose a CPM to attend them again (Johnson & Davis, 2005).

Though they could not easily quantify its influence, every scholar referenced in this paper recognized the power of self-selection. In other words, every study acknowledged that a woman’s choice of birth attendant and birth setting had a very powerful, perhaps even determining effect upon birth outcomes. Research indicates that women who choose to birth at home with a midwife achieve very high maternal and infant survival rates. Furthermore, women were able to safely and effectively manage their pain through the evidence-based care and constant companionship inherent to the Midwives Model of Care. Finally, women’s feelings of self-efficacy were successfully maintained and enhanced by their homebirth experiences. Homebirth is a safe and viable choice for the majority of low-risk women in North America.

References

Johnson, K., & Daviss, B. (2005). Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ 2005;330:1416. Retrieved from http://www.bmj.com/content/330/7505/1416

Coalition For Improving Maternity Services (2007). The coalition for improving maternity services: Evidence basis for the ten steps of mother-friendly care. Journal of Perinatal Education, 16, (1-Supplement). Retrieved from http://www.motherfriendly.org/Resources/Documents/CIMS_Evidence_Basis.pdf

Haines, H., Rubertsson, C., Paliant, J., & Hildingsson, I. (2012). The influence of women’s fear, attitudes and beliefs of childbirth on mode and experience of birth. BMC Pregnancy and Childbirth, 12:55. Retrieved from http://www.biomedcentral.com/1471-2393/12/55

Hutton, E., Reitsma, A., & Kaufman, K. (2009). 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, 36:3 Sep, 180-189.

Janssen, P., Saxell, L., Page, L., Klein, M., Liston, R., & Lee, S. (2009). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ, Sep 15, 181(6-7), 377-383. doi: 10.1503/cmaj.081869.

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In other words, every study acknowledged that a woman’s choice of birth attendant and birth setting had a very powerful, perhaps even determining effect upon birth outcomes. – KLM

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