quinta-feira, 27 de janeiro de 2011

Science and Sensibility: Choice of Birth Place in the United States

From Medscape Ob/Gyn & Women's Health
Science and Sensibility: Choice of Birth Place in the United States
Saraswathi Vedam, CNM, MSN, SciD(hc); Patricia A. Janssen, RN, BSN, MPH,
PhD; Ronnie Lichtman, CNM, PhD
Posted: 02/25/2010
Rates of planned home birth in the United States have remained at less than
1% for several decades, but current public discourse suggests that women are
increasingly interested in this option. International investigators have
defined "planned home birth" as the care of selected pregnant women by
qualified practitioners within a system that provides for hospitalization
when necessary. Safety of birth in any setting is of utmost priority and has
been the focus of home-birth research and current professional and public
debate. Many women and their families are aware that, in national and
international settings, home births conducted in environments of
multidisciplinary communication and integration of resources are associated
with similar perinatal outcomes and fewer obstetric interventions compared
with hospital births.[1-10]
In the United States, concerns about planned home birth are frequently the
result of accepting findings from flawed studies. These studies fail to use
reliable methods to differentiate between planned and unplanned home birth,
or between attendance by qualified and unqualified attendants.[11-16] Other
often-cited studies were based on retrospective and incomplete birth
certificate data that did not provide accurate information about birth
attendants and did not clearly define appropriate inclusion criteria to
limit the findings to the usual clientele for planned home births: women at
low risk.[15-19] Thus, some professional bodies have concluded that the
evidence on safety is insufficient to support provision of home-birth
services. The American Congress of Obstetricians and Gynecologists (ACOG)
published a strong policy statement, supported by the American Association
of Pediatrics and the American Medical Association, which questions the
safety and advisability of home birth.[20] Their leaders have suggested that
only a large North American randomized prospective controlled study can
answer the safety question. However, despite attempts to design a randomized
controlled study, to date sufficient numbers of women have not consented to
be randomly assigned according to birth site.[21,22]
Other North American professional bodies rely instead on evidence derived
from investigations that evaluate outcomes from well-controlled
observational cohort studies with credible comparison groups of women. The
Society of Obstetricians and Gynaecologists of Canada and the Canadian
Association of Midwives, the American midwifery professional societies
(American College of Nurse-Midwives, Midwives Alliance of North America, and
the National Association of Certified Professional Midwives), consumer
groups (Lamaze International, Childbirth Connection), and public health
bodies (World Health Organization, American Public Health Association,
American Association of Birth Centers) have all issued policy statements in
support of planned out-of-hospital birth,[23-27] citing reduced
interventions, increased maternal satisfaction, safety, and the importance
of informed choice for women.
Recent Improvements in Quality of the Evidence
Since 1996, several increasingly credible trials and observational studies
have been conducted in European settings where systems for evaluation of
maternity care delivery across birth settings are in place. Critics noted
that although no apparent differences in morbidity or mortality were found
between home and hospital births for well-matched low-risk women, the
conclusions from these investigations were made on the basis of small sample
sizes or homogenous groups and were influenced by regional differences in
available infrastructure. Because of the low rate of adverse events in the
developed world, it has been difficult to assess significant differences
between birth settings with respect to perinatal mortality and serious
In 2009, 3 new reports, including 2 in North America, have addressed the
methodologic flaws of previous trials on home birth.[1-3] De Jonge and
colleagues[3] conducted the largest cohort study to date (N = 529,688),
which evaluated obstetric outcomes of low-risk women in The Netherlands who
were in primary midwife-led care at labor onset.[3] The study compared
perinatal mortality and morbidity between planned home births (321,301;
60.7%), planned hospital births (163,261; 30.8%), and unknown place of birth
(45,120; 8.5%) using the national perinatal and neonatal registration data
from 2000-2006. Groups were matched according to parity, gestational age,
maternal age, ethnic background, and socioeconomic status. Inclusion
criteria ensured that the women were strictly low-risk. The main outcomes
were intrapartum death of the infant, neonatal death within 24 hours or 7
days after birth, and admission to a neonatal intensive-care unit (NICU). No
significant differences were found between planned home and planned hospital
births for any of the main outcomes. The study authors concluded that
planned home birth in a low-risk population is not associated with higher
perinatal mortality rates or an increased risk for admission to a NICU
compared with planned hospital birth.
Janssen and colleagues[1] recently published results from their prospective
5-year cohort study that compared outcomes among women in a midwife-attended
planned home-birth group (n = 2802) with women in a physician-attended
hospital-birth group (n = 5985) and midwife-attended planned hospital-birth
group (n = 5984). Women in the home-birth group who needed intrapartum
transfer to the hospital were retained in their original cohort. This study
reported similarly low rates of perinatal death in all 3 cohorts and similar
or reduced rates of adverse outcomes in the planned home-birth group with
significantly fewer obstetric interventions. Findings indicate that women
who planned a home birth had significantly fewer intrapartum interventions,
including narcotic or epidural analgesia, augmentation or induction of
labor, assisted vaginal births, or cesarean section (c-section). In
addition, women in the home-birth group were less likely to have postpartum
hemorrhage, pyrexia, and third- or fourth-degree tears. Babies of women who
had planned a home birth were less likely to have Apgar scores of < 5 at 1
minute and the babies were less likely to need drugs for resuscitation.
These differences were associated with planned place of birth and persisted
regardless of actual place of birth. Women in all 3 groups of the study met
eligibility criteria for home birth and thus had comparable maternal and
fetal risk profiles.
Hutton and colleagues[2] used the Ontario Ministry of Health Midwifery
Program database to compare outcomes of all women planning homebirths
between 2003 and 2006 (n = 6692) with a matched sample of women planning a
hospital birth (n = 6692) (women with contraindications for home birth were
excluded). The home-birth group had lower rates of c-section (relative risk
[RR], 0.64), maternal morbidity/mortality (RR, 0.77), and neonatal
morbidity/mortality (RR, 0.80). Results suggested that Ontario midwives
provided adequate screening and safe care for low-risk women planning a home
birth and had lower c-section rates compared with hospital births.
Researchers have described the factors affecting a woman's choice of planned
home birth and satisfaction with home birth as the perceived differences in
her ability to control the environment and process of care. Specifically,
women note that planned home births increase their privacy, comfort, and
convenience; reduce the rates of medical interventions; provide greater
cultural and spiritual congruency; change the provider-patient power
dynamics; and facilitate family involvement and a relaxed, peaceful
atmosphere. Women consistently report that these factors increase their
sense of safety and allow them the self-determination and empowerment
necessary to fully participate in decision-making about aspects of their
However, a woman can exercise choice of birth site only if she has a range
of options and unrestricted access to qualified providers and resources. A
qualified provider can assist a woman in assessing her birth-site options
according to her health status and distance to appropriate maternity care
resources. Ideally, those providers offer care across all settings and are
fully integrated into a network of maternity care services at all levels.
Unfortunately, very few regions in the United States integrate home-birth
providers into interprofessional care-provider networks. Differences in
regional conditions for practice and/or differences in cultural expectations
about site of birth also exist.
Many jurisdictions have significant regulatory, logistic, financial, and
legislative barriers to provision of home-birth services. Attitudes and
beliefs that are particular to the professional culture may be partly
responsible for these restrictions. Some health authorities recognize
deficiencies in resources and networks of professional healthcare providers
that are essential to providing safe home birth. The malpractice environment
and regional differences in malpractice legislation also likely contribute
significantly to variations in availability of home-birth options.
The current debate on home birth in the United States indicates the need for
constructive discussion and consensus-building about how best to serve women
and their families who choose home birth. Ultimately, women and families are
ill-served by interprofessional conflict and confusion about best practice
in healthcare. Consumers and home-birth providers frequently encounter a
lack of receptivity, and even hostility, when transfer to acute care is
warranted. This condition may delay timely transfer and significantly reduce
continuity of care. Models for effective collaboration and communication
exist in some local maternity care systems, but no existing national venue
is available to consider these problems and replicate solutions. In
addition, many consumers and providers are not well informed about existing
systems that assure standardization, quality assessment and evaluation of
the essential knowledge base, and professional competencies required for
home-birth providers.
Qualified Home-Birth Providers
Fortunately for the American public, evaluations that compare professional
competencies and practices among maternity provider groups have found more
similarities than differences in the basic skills and components of care
that are offered to healthy women across birth settings.[37,38] Scopes of
practice and educational pathways to certification and licensure differ
among certified nurse-midwives (CNM), certified midwives (CM), certified
professional midwives (CPM), family physicians, and obstetricians, but
similar standardized competency assessment, quality assurance, and
professional accountability measures are in place for each credential. All
of the credentialing bodies for these US-based maternity health
professionals expect candidates to demonstrate acquisition of both
theoretical content and specific clinical skills that are appropriate to
their scope of practice.
In the United States today, midwives are the main maternity care providers
who offer choice of birth place. Much confusion exists among both consumers
and health professionals regarding the education, credentialing, and
licensing of midwives in the United States. As in many countries worldwide,
midwives either pass through nursing programs or enter midwifery directly.
Nurses often become CNMs; those entering the profession with other
backgrounds may become CMs or CPMs. Each of these credentials is recognized
as a basis for licensing in all or some states. Although certification is
national, the right to recognize and license any or all of these types of
midwives is granted to the states. To date, all states recognize the CNM
credential; 3 states recognize the CM credential, and 26 states recognize
the CPM credential.
The CNM, CM, and CPM credentials are all evaluated and accredited by the
National Commission for Certifying Agencies, the accrediting arm of the
National Organization for Competency Assurance. The US Secretary of
Education has recognized both of the accrediting bodies for midwifery
educational programs, the Midwifery Education Accreditation Council and the
Accreditation Commission for Midwifery Education, and candidates for all 3
types of certification must complete national board examinations.
Eligibility to take these examinations is based on the documentation of
completion of an accredited midwifery educational program (CNM/CM/CPM),
demonstration of licensure from jurisdictions with equivalent requirements
and scopes of practice (CPM), and a Portfolio Evaluation Process (CPM). The
core content of the education and the required clinical performance of
skills are based on core competencies as defined by national and
international midwifery professional bodies. CPMs must demonstrate specific
competencies in out-of-hospital care, and CNMs and CMs must demonstrate
competencies in maternity care that are applicable to all settings. The term
"lay midwives" does not apply to midwives holding any of the 3 recognized
Quality Assurance in Education and Practice, and Professional Accountability
Consumers and health-professional educators are also concerned about the
quality of teaching with respect to low-intervention maternity care across
practice sites. Students have noted gaps between theory and practice as well
as large variations in application of new evidence to practice when they are
placed with clinician educators.[38-40] These gaps have been noted primarily
in hospital maternity practice. Medical and midwifery programs around the
world are still developing methods to consistently assess and support the
teaching of evidence-based clinical practices and to evaluate and enhance
currency of knowledge among clinician educators.
All US-based credentialed health professionals are required to participate
in ongoing quality-assurance programs and demonstrate continuing competency.
Typically this is accomplished through formal peer review, attendance at
continuing-education programs, regular recertification, and transparent
avenues for vetting complaints, grievances, and case review. Accountability
for professional practice is provided through mechanisms offered by state
licensing boards, healthcare institutional boards, professional
associations, and credentialing bodies. These mechanisms are in place for
CNMs, CMs, CPMs, and MDs regardless of practice setting.[41-44]
Planned Home Birth and Interprofessional Collaboration
Successful interprofessional collaboration to provide a range of maternity
services has been correlated with mutually compatible attitudes and
professional preparation.[45] A significant body of research demonstrates
that provider attitudes towards, and knowledge of, maternity care options
have a significant influence on patient choice. Providers present options
that are congruent with their own education, experience, and scope of
practice.[35,46-52] Differences in home-birth rates according to type of
provider may represent differences in the knowledge base among different
types of maternity care providers. Currently, expertise related to birth
site is limited by a lack of knowledge exchange across disciplines.
Home-birth providers could enhance practice by understanding the context of
hospital-based care, and those who only serve families in institutions could
improve practice by understanding the context of planned home birth.
Lessons learned from the integration of midwifery in Canada and other
international settings include the need to have midwives participate
actively in the community of maternity practice. All midwives should be able
to access hospital admission privileges appropriate to their scope;
participate in quality-assurance committees, clinical and academic teaching,
and academic rounds; and attend women across birth settings. Clear
protocols, vetted across all disciplines, should be established for
communication between professionals when labor and delivery is in progress
at home and for transport and hospital triage. Clinical and didactic
education should prepare all maternity professionals for their respective
roles in supporting safe and compassionate care regardless of planned place
of birth.
Finally, when all professional midwives have access to licensure and
institutional credentialing, systems for data collection and representative
reporting of perinatal outcomes across birth settings can be established.
Only when these conditions are met can a large-scale study, comparing
planned home birth with planned hospital birth, be designed and conducted in
a credible manner in the United States. Until then, maternity professionals
must continue to examine, account for, and collaborate to minimize the
impact of regional conditions for practice and healthcare delivery on the
health and safety of women and babies. Reflective practice is a component of
safety in all healthcare disciplines and settings and is best done in the
context of a multidisciplinary approach with mutual goals and respect.
Clinical Pearls
a.. An increasingly sound body of research has shown no significant
differences in maternal and fetal outcomes between planned home birth and
planned hospital birth in women who have been identified as low-risk, have
qualified birth attendants, and have timely access to specialized care when
b.. Research has shown that women believe that planned home births increase
privacy, comfort, and convenience; are associated with reduced rates of
medical interventions; provide greater cultural and spiritual congruency;
enhance their sense of partnership with their care provider; and facilitate
family involvement and a relaxed, peaceful atmosphere. These factors
increase women's sense of safety and allow them to fully participate in
decision-making about aspects of their care.
c.. Evaluations that compare professional competencies and practices among
maternity provider groups have found more similarities than differences in
the basic skills and components of care offered to healthy women across
birth settings.
d.. Clear practice guidelines, vetted across all disciplines, for
communication between professionals when labor and delivery is in progress
at home and for transport and hospital triage are a vital component of
quality care.
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Authors and Disclosures
Saraswathi Vedam, CNM, MSN, SciD(hc)
Associate Professor and Director, Division of Midwifery, University of
British Columbia, Vancouver, British Columbia, Canada
Disclosure: Saraswathi Vedam, CNM, MSN, SciD(hc), has disclosed no relevant
financial relationships.
Patricia A. Janssen, RN, BSN, MPH, PhD
Associate Professor and Director, Master of Public Health Program, School of
Population and Public Health, University of British Columbia, Vancouver,
British Columbia, Canada; Co-Director, Women's Reproductive Health Research
Training Program, Child and Family Research Institute, University of British
Columbia, Vancouver, British Columbia, Cananda
Disclosure: Patricia A. Janssen, RN, BSN, MPH, PhD, has disclosed no
relevant financial relationships.
Ronnie Lichtman, CNM, PhD
Professor and Program Chair, Midwifery Education Program, State University
of New York at Downstate Medical Center, Brooklyn, New York
Disclosure: Ronnie Lichtman, CNM, PhD, has disclosed no relevant financial

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