labor nurse has been reborn and shares her experiences as a new nurse-midwife, woman, and blogger

Friday, April 17, 2009

Did You Hear?

I've been reading on a few blogs around the web that the British Journal of Obstetrics & Gynaecology has published a study from Holland that shows home birth is as safe as hospital birth in low risk women.

I don't have access to the full article so I can't really comment much on it. But, I'll be obvious and say that I am very happy to see such a large study sample and the conclusion that home birth is as safe when women are cared for by skilled midwives and have smooth access/transfer to hospitals when indicated.

It does make me curious how the home birth naysayers will criticize this the study. Like I said, I don't have access to the full article, so I can't critique it myself. But it sounds like it might be hard to ignore this evidence as good evidence!

15 comments:

womantowomancbe said...

I've already heard some of the backlash, including one person saying that there was a 51% transfer rate -- but that was only with primips, not study-wide. So that's one anti-conclusion caveat already to look out for. :-)

Of course, we don't have a smooth path in the US for home-to-hospital transfers, which I'm certain that some naysayers will give as a reason why this study is not valid on this side of the Atlantic... but I say, why not make the changes in the t/f process so that it *can* be as smooth (and especially so that home-birthing women who do t/f don't feel like they're going to be getting a load of attitude from hospital personnel for having attempted a homebirth -- I've heard some really good stories, and some horror stories about transfers).

-Kathy

Labor Nurse said...

Kathy, I think I may have mentioned this before somewhere on the blog, but I no longer read anti-midwifery or anti-homebirth stuff so I know I won't come across what people are saying about the study. I agree totally that we need to make that transfer process easier and safer; all will benefit.

Basiorana said...

I've always thought we should have an OB-ready ambulance free at all times except on a call. Besides being availiable for transfers, it could handle all OB emergencies and because it would have to be set up for newborns too, it could handle very young baby emergencies. Then, give the EMTs in it extra specialized training so they can keep the mom stable for transport. Or maybe midwives should have an assistant who is trained to operate an emergency vehicle and a van with a siren and gear in the back, so they can convert it into a sort-of ambulance.

About the study:
1) What level of prenatal care did they have? Did they perform appropriate prenatal screenings to wean out high-risk or medium-risk women? A lot of homebirth advocates eschew prenatal testing in whole or in part, and I bet that drives up the US rate of homebirth deaths.
2) Holland is densely populated compared to much of the US. How far was the farthest woman from the hospital? I think radius standards are very important-- if it takes more than 20 minutes from dialing 911 to reaching the ward, it's too long.
3)Did they determine risk ahead of time and risk out women, then count every single woman who went ahead as a "low-risk" even if in retrospect she might have been high-risk, or was the label determined after the fact? Saying in retrospect they were low risk isn't as useful or powerful, since high risk can start out as low risk.
4)What level of training did the midwives have? Comparable to a CNM, or to a DEM, or in between somwhere?

I wish I could find the study.

womantowomancbe said...

I've not read the study, but I would say that in response to qu#1 -- they would likely have weeded out non-lowrisk women. I would say that the prenatal screenings most homebirthing women in the US would decline relate to the baby, such as genetic screening. Some high-risk babies can therefore be born to low-risk women. Yes, it would be interesting to see if these women had late-term ultrasounds to look for things like cord issues or congenital defects, that many homebirthing women in the States (myself included) would typically forgo.

Re#2 -- sometimes population density can be a bad thing -- too much traffic when trying to get to a hospital, which lengthens response times even if it's a very short distance as the crow flies. Driving a couple of miles through downtown Chicago is quite a bit different from diving a couple of miles in rural Mississippi!

Re: qu#3 -- Yes, that is a very interesting point. It also would be interesting to see if there were women who started off low-risk and then changed risk assessment due to a difference in midwifery and obstetric care. I remember a study that was released in the past year that showed that women who had midwifery care were less likely to suffer a fetal loss prior to 24 weeks, although the perinatal mortality after that point was the same for both midwifery and obstetric care. There are two sides to the coin. If a greater percentage of low-risk women become high-risk under obstetric care than under midwifery care, that has consequences. For example, if women who have midwifery care are less likely to develop preeclampsia than those under obstetric care, they are more likely to avoid an early induction or C-section, or otherwise give birth prior to 37 weeks, or the natural onset of labor. Going to term and waiting for labor to begin naturally has benefits for the baby, as long as s/he is not compromised by poor maternal or fetal health.

Re: qu#4 -- I think they were probably comparable to a CNM. It is my understanding that most if not all European midwives are of one type, which is basically our CNM. I could be wrong. But many CNMs are prevented for one reason or another from attending home births in the United States, which is a detriment to birthing women.

-Kathy

Ciarin said...

I can answer #4!!!! There's a Frontier student in my area who I have become friends with (and she may use our practice for clinicals too) and she's from Britain!

There are two midwifery tracks in Britain - non-nurse and nurse, however the two both get the same midwifery training. It's a three year program I believe. There are Registered Nurse Midwives and Registered Midwives, but the RNMs are actually looked down upon! It was really fascinating to hear her speak about the differences between here and there.

Ethel said...

OOOOOOOH I am SO glad I read the comments! Kathy has some interesting points (in particular #3).

womantowomancbe said...

Ciarin,

This is interesting. As I said, I haven't really researched it -- much of what I know I have gleaned from various sources (both pro and anti non-nurse midwives), so it's good to have more solid knowledge.

Some proponents of CPMs here in the States say that the biggest difference between the education they get, vs. the education of CNMs, is the "nursing" stuff they need to know in order to practice in a hospital (assisting at C-sections, dosing Pitocin, etc.), which they don't need to know to be a midwife at home births. They basically say that they get similar *midwifery* training, even if they don't have the exact same training altogether.

Would you agree with that assessment, or do you think that CPMs are lacking essential training to attend home births?

-Kathy

Labor Nurse said...

CPM and CNM training is very different, in my opinion. For one, I think CPMs are much better trained at homebirth. I think this is because, overall, CNM students have very limited opportunity to do any birth outside of a hospital or birth center. On the other hand, was recently at a conference with almost exclusively CPMs and was shocked when questions such as: "What is a 'subcutaneous'?" or "What is a capsule?" (in reference to pelvic muscle anatomy).

I also believe the required births, etc, that we have to attend is different (CPMs needing more for certification eligibility than CNMs).

Ciarin said...

Kathy - I am not all familiar with what training CPMs are going through. So that makes this question difficult to answer. The 'nursing' stuff you mention is certainly one difference but not the only. We are trained to manage more high risk stuff than I imagine CPMs are? But again, hard to answer this question without really knowing specifics about their training.

I agree with labor nurse in that CPMs are probably trained better for homebirth! I have never done anything but hospital birth unfortunately.

How many births do CPMs have to have for certification? ACNM requires 20 births for us however my school (FSMFN) required 40 for graduation - which I was very glad to have!

womantowomancbe said...

Ok, from the NARM website says the following:

I. As an active participant, you must attend a minimum of 20 births.
II. Functioning in the role of primary midwife* under supervision, you must attend a minimum of an additional 20 births:
A. A minimum of 10 of the 20 births attended as primary under supervision must be in homes or other out-of-hospital settings; and
B. A minimum of 3 of the 20 births attended as primary under supervision must be with women for whom you have provided primary care during at least 4 prenatal visits, birth, newborn exam and 1 postpartum exam.
C. At least 10 of the 20 primary births must have occurred within three years of application submission.

III. Functioning in the role of primary midwife* under supervision, you must document:
A. 75 prenatal exams, including 20 initial exams;
B. 20 newborn exams; and
C. 40 postpartum exams.

*The primary midwife has full responsibility for provision of all aspects of midwifery care (prenatal, intrapartal and postpartal) without the need for supervisory personnel.

A MEAC website says that DEMs "attend the majority of normal births in hospitals and other settings in many western European countries. Direct-entry midwives are also utilized in the Canadian healthcare system."

So this does make it sound more like most European midwives are more similar to American CPMs than to CNMs.

-Kathy

Labor Nurse said...

I don't find that very clear....so they must have a minimum of 20 births they have actively participated in, AND an additional 20 where they functioned as the primary midwife? Am I understanding this correctly?

womantowomancbe said...

Yes, I think that's what it means -- student midwives have to attend 20 births, probably as the midwife's assistant. It sounds almost like a kind of internship program, where at first they observe the supervisory midwife and learn directly under her, and then they have to "be the midwife" at another 20 births. They would have their training midwife basically looking over their shoulder, but the students or apprentices are the ones making all the decisions for the laboring woman's care.

I used a CPM for my second pregnancy, and she had an assistant as an apprentice. I don't remember too much of what she did, except she was always there and sometimes did the prenatal exams, with the primary midwife observing her, guiding and directing her, if needed. Unfortunately for her, I didn't call them in time, so she didn't get to either observe my birth nor play the role of a primary midwife, but she did do the newborn exam.

-Kathy

Ciarin said...

The numbers required by ACNM are as follows...

a. 10 Preconception care visits
b. 15 New antepartum visits
c. 70 Return antepartum visits
d. 20 Labor management experiences
e. 20 Births
f. 20 Newborn assessments
g. 10 Breastfeeding support visits
h. 20 Postpartum visits (0-7 days)
i. 15 Postpartum visits (1-8 weeks)
j. Primary care visits:

1) 40 common health problems
2) 20 family planning visits
3) 40 gynecologic visits including perimenopausal and postmenopausal visits.

Some schools, such as my alma mater, may require more. For example....

FRontier required 40 births, 40 labor managements, 40 newborn exams, 140 prenatal visits, 30 new OB appts, 40/30 postpartum visits.

I think it's really difficult to compare these two tracks...like apples and oranges. I also think it's less important to dissect 'who's better or more qualified to do what' and spend more time figuring out how to further the cause of midwifery model of care - which I do believe all types of midwives are trained to provide.

MomTFH said...

I have the article if you haven't gotten a copy yet. Email me.

Labor Nurse said...

MomTFH- thank you, I did get my hands on a copy!