Outcomes of planned home births with certified professional midwives: large prospective study in North America
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7505.1416 (Published 16 June 2005) Cite this as: BMJ 2005;330:1416All rapid responses
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"According to the CDC, the neonatal mortality rate for 2006 was 4.46
per 1000 live births"
- I think that's for ALL live births
"The CDC published a rate of 1 in 1000 in 2006" - I think that's for
TRULY LOW RISK births
Competing interests: No competing interests
According to the CDC, the neonatal mortality rate for 2006 was 4.46
per 1000 live births. See-
http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_17.pdf
I have not verified your other claims but would do so if I intended
to refer to your response in the future.
Competing interests:
None declared
Competing interests: No competing interests
I am 3.5 years late and maybe a few dollars short, but I have a few
issues with this study and with not necessarily home birth, but with the
idea of lay midwifery.
As for the article:
I have many concerns with both the methods and the interpretation of
results. I do not think it is right to compare "low risk" women giving
birth at home to those singleton, vertex and >37 weeks being born in
the hospital. There are many other factors that would make a pregnancy
high risk--maternal age, maternal medical conditions (hypertension, pre-
eclampsia), maternal medications and recreational drug usage to name but a
few.
I also question the neonatal mortality rate of 1 in 500 for truly low
risk mothers. This is simply too high. The CDC published a rate of 1 in
1000 in 2006, so home birth is doubling this rate.
In addition, there were no morbidity figures published. Did any of
the babies born at home suffer from hypoxic-ischemic encephalopathy from
their low apgars--yet this was non-fatal?
I also question the description of the peripartum and neonatal
deaths. SIDS simply does not occur in the first 24 hours of life. These
babies died from sepsis or metabolic disease, and I believe the symptoms
of these would have been recognized in the hospital setting. The breech
babies delivered at home and en route who died, the post dates baby and
the low apgar baby died perhaps unnecessarily. Persistant pulmonary
hypertension might have been picked up earlier and treated in the
hospital.
Then there is the question of lay midwifery. Since when is it okay
for someone without a formal medical or nursing education to deliver
medical care? I am all for certified nurse midwives and support the
"midwives model of care" but those delivering babies should have attended
nursing school and completed advanced practitioner training. A high
school education and apprenticeship is simply unacceptable. Nursing
school, nurse midwifery programs and medical school and residency are
tough for a reason--we should only allow the best and brightest to deal
with life or death matters. What has happened to our sense of
professionalism?
Competing interests:
None declared
Competing interests: No competing interests
A number of the respondents to a recent epidemiological study of
place of birth published in this journal1 noted the potential for bias in
non-randomised studies in this area. Others indicated that randomised
trials of place of birth would be difficult, if not impossible. We have
been working on this problem for some years now. To date, members of our
group have completed one early feasibility study, two meta-analyses, one
meta-synthesis, and an ethnographic study. We conclude that it is possible
and appropriate to undertake trials in this area, as long as they are
based on a clearly defined hypothesis that accommodates the complexity of
place of birth.
Our studies indicate that phase one and two pre-trial work is
required to establish the proportion of women who would agree to be
randomised, the impact of preference, the level of equipoise amongst
professionals, the important outcomes to be assessed, and techniques for
overcoming the problems of interpretation and generalisibility when units
have the same title (‘birthcentre’, ‘hospital maternity unit’) but differ
subtly in the care provided, or in local philosophies and beliefs about
childbirth.
We are aware that other researchers are also addressing some of these
issues, including the definition of birth centres, and the factors that
influence women’s choice. This preparatory research being undertaken by
our team and by other colleagues is particularly timely in the UK in the
light of recommendations supporting women’s choice of place of birth in
the Children, Young People and Maternity Services National Service
Framework2. We believe that a randomised trial of place of birth based on
the MRC guidance for trials of complex interventions3 is now essential,
especially following the important findings of Johnson and Daviss that out
-of-hospital birth is potentially beneficial for some women and babies.
References
1 Johnson K.& Daviss B. 2005, ‘Outcomes of planned home births
with certified professional midwives: large prospective study in North
America’ BMJ 2005; 330: 1416
2. DH and DES 2004 National Service Framework for Children, Young
People and Maternity Services. Department of Health, London
3 Medical Research Council 2000 A framework for development and
evaluation of trials of complex interventions to improve health. MRC,
London
Competing interests:
All authors are engaged in research relating to place of birth. They have no other competing interest
Competing interests: No competing interests
Johnson and Daviss have made a long awaited, difficult, and extremely
significant contribution to the obstetric literature. In a day when
health care contributes 15% to the crippling national debt the United
States is facing, an authoritative article supporting a health care choice
that is both satisfying to the families and has the potential to markedly
impact health care debt is a important beacon of a direction that is not
only sane but likely imperative.
The United States currently has a debt of 7.800,000,000,000. Thirty
billion of that is from childbirth (1). Privately insured and uninsured
families struggling under the burden of health care expense from rising
health insurance cost and for the growing number of uninsured, hospital
bills. In addition large corporations are being threatened by bankruptcy
in part from the cost of health insurance for employees.
The one health service that every family needs deserves further
attention. In research published in 1999, we found that the average
uncomplicated vaginal birth in the United States cost 68% less in the home
then in the hospital (1). This reduction in fees is because of the
elimination of hospital fees and the significant reduction in medical
intervention including cesarean section shown in this, as well as other
studies (2,3,4,5). If all low risk women in the United States began labor
with the intention of giving birth at home with a midwife, there would be
an average saving of 3,600 dollars per birth, which would save the United
States and private insurers 14 billion dollars per year(1). This saving
would occur without increase in risk to mother and baby--thus allowing the
United States to devote more resources to other urgent priorities.
It behooves those in power over public health decisions to educate
the health care community and the public to stop the unnecessary use of
financially burdensome over hospitalization that has no over all health
benefit, and support the implementation of regulations and health care
delivery systems that support midwives and home birth.
References
1. Anderson RE, Anderson DA. The cost-effectiveness of home birth. J
Nurse Midwifery 1999;44: 30-5.[CrossRef][ISI][Medline
2. Johnson K.& Daviss B. 2005, ‘Outcomes of planned home births with
certified professional midwives: large prospective study in North America’
BMJ 2005; 330: 1416
3. Anderson RE, Murphy PA. Outcomes of 11,788 planned home births attended
by certified nurse-midwives. A retrospective descriptive study. J Nurse
Midwifery 1995;40: 483-92.[CrossRef][ISI][Medline]
4. Murphy PA, Fullerton J. Outcomes of intended home births in nurse-
midwifery practice: a prospective descriptive study. Obstet Gynecol
1998;92: 461-70.[Abstract/Free Full Text
Competing interests:
None declared
Competing interests: No competing interests
When a study is published with scientifically valid evidence against
an important position of a clinical group, clinicians have two common
reactions: ignore the study and hope it goes away; torture the data until
it confesses to what they want it to say.
It is instructive to observe who has and who has not responded, to
date, to the study of planned home birth by Johnson and Daviss. The
largest group of responders consists of midwives and other supporters of
the demedicalization of birth. This group recognizes the excellence of
the methodology, the importance of the findings, and the consistency with
the existing weight of evidence. The second largest group of responders
is primary care physicians, some of whom are generally positive about the
findings while others try to torture the data to justify running from the
heresy of agreeing to health care which is not in some kind of medical
setting: “this information does not change my practice”.
Then we have the silence of the lions: why are the obstetricians not
responding? With one possible exception, there are no obstetrician
responders to a study with major implications for obstetric practice. And
the one physician responder who may be an obstetrician rejects supporting
planned home birth, even if safe, because of the “pernicious legal
system”. Fear of litigation is a highly selective excuse used by some
obstetricians when there is something which is not obstetrician-friendly
such as planned home birth (over which they have no control and no
profit). But when there is an obstetrician-friendly intervention they
want to promote such an misoprostol induction of labour, they don’t
mention fear of litigation even though there have been dozens of cases of
litigation in the U.S. after adverse outcomes following misoprostol
induction. (1,2,3)
It is doubtful there will be obstetrician responders to this study
because of their hope that by ignoring it, this study will go away. On
the other hand, when a retrospective study (4)incapable of separating
planned from unplanned home birth was presented in the U.S. suggesting
home birth may be unsafe, the American College of Obstetricians and
Gynecologists (ACOG) issued a press release the next day citing the study
as indicating the dangers of home birth. Since for many years ACOG has
had a published opinion (with no citations from the literature) that home
birth is not safe, an opinion which attempts to deny women a legitimate
choice of place for giving birth, ACOG’s rush to cite the flawed study is
explained. And their silence in the face of the present outstanding study
by Johnson and Daviss of the safety of home birth is to be expected.
One responder questions how quickly the findings of this study will
impact on the maternity care systems, citing the rapidity with which the
finding of the Hannah trial (5) changed the management of breech birth.
But surgical breech birth is obstetrician-friendly and planned home birth
is not, seriously threatening the likely impact of the Johnson-Daviss
study in countries such as the U.S. where organized obstetrics is a major
impediment to the demedicalization and humanization of childbirth.
1) Wagner M Adverse events following misoprostol induction of
labor, Midwifery Today, 2004; 71: 9 – 12
http://www.midwiferytoday.com/articles/cytotecwagner71
2. Medwatch: the FDA Medical Products Reporting Program
http://www.fda.gov/medwatch/safety.htm
Druginfo@cder.fda.gov
3. Searle Pharmaceutical Co., Searle Drug Experience Reports
4) Pang J et al, “Outcomes of Planned Home births in Washington
State: 1989 – 1996” Gynecology and Obstetrics, 100(2) 253-59, 2002
5) Hannah ME et al, Planned cesarean section versus planned vaginal
birth for breech presentation at term: A randomized multi-center trial.
Lancet 356 (9239), 1375-83, 2000
Competing interests:
None declared
Competing interests: No competing interests
I appreciated the article by Johnson and Daviss and will be
submitting it forthwith to my third-party insurer as additional supportive
evidence that they would be well advised to honor my midwives' claims for
prenatal/obstetrical care. I, unfortunately, do not live in a "rural" or
"underserved" area, which is apparently the only way they will reimburse
for these services.
Many responses have noted the battle involved with legislatures and
medical organizations regarding midwifery, but the primary barrier I have
experienced as a patient has been the refusal of my insurance company to
reimburse for their services. Do I pay $2,000 out-of-pocket directly to
my midwives or do I pay the one-time $20 co-payment for my first
participating-provider OB visit? The options, or realistic lack thereof,
give one pause.
I chose to have my first child with midwives in a hospital (their
consulting physician for their birthing center births resigned due to
liability fears), delivered my daughter within 3 hours of being admitted
(no tearing or episiotomy, thank you very much) and was ready to go home 8
hours after that, all with no drugs at all. How can an insurance company
pass up an 11 hour hospital admit with no meds?
Perhaps insurance companies, with much larger political action
committees than midwives (!), can work to influence U.S. lawmakers in
support of midwifery?
Competing interests:
None declared
Competing interests: No competing interests
Wen Bin Liang is concerned that babies born at home with low Apgar
scores, or needing urgent transfer to hospital, may suffer long-term
neurological disability because they are unable to receive effective
treatment. Liang will be reassured to know that homebirth practitioners
carry the equipment necessary for neonatal resuscitation, and newborns are
usually well stabilised at home before transfer.
However, this raises another important point in this debate: what is
the impact of birth (and place of birth) on future development of the
offspring? Unfortunately this aspect of obstetric care has been poorly
studied, but the information that we do have raises serious concerns about
the long-term impact of our current model of medicalised maternity care,
and the high rates of medical interventions associated with its use.1 2
For example, Jacobson et al compared the rates of adult drug
addiction between siblings born with and without exposure to opiates,
barbiturates, and nitrous oxide in labour. Exposure to more than three
doses of any of these analgesics was associated with an almost five times
increased risk of drug addiction in adulthood.1
Caesarean section is another major birth intervention with poorly
researched long-term implications for the offspring. Studies show that
caesarean babies have lower levels of neonatal brain oxygenation,2 and
slower neurological adaptation after birth.3-5 Animal studies have linked
uncomplicated caesarean birth with abnormalities of dopamine pathways in
adult rats and guinea pigs.6 Dysregulation of dopamine function has been
implicated, in human studies, with the development of schizophrenia, as
well as substance abuse and attention deficit hyperactivity disorder.6
Other researchers have studied the effects of epidurals and
pethidine, administered at term to rhesus monkeys, and found abnormalities
in behavioural maturation during specific periods of infancy.7 Golub
comments, “Probably the most widespread exposure of the developing brain
to central nervous system agents occurs at birth.”8
Csaba’s research into hormonal imprinting raises more concerns about
perinatal exposure to drugs and hormone-like substances.9 For example, he
found that a single perinatal exposure to exogenous beta-endorphin altered
adult sexual and aggressive behaviour in rats.10 This author states,
“Perinatally, the first encounter between the maturing receptor and its
target hormone results in hormonal imprinting, which adjusts the binding
capacity of the receptor for life. In the presence of an excess of the
target hormone or foreign molecules than can be bound by the receptor,
faulty imprinting carries life-long consequences.”11 Hormonal imprinting
effects can persist for three generations.12
New thinking about brain development emphasises the plasticity of the
developing brain,13 and the vulnerability of the brain, during the
prenatal period of neuronal mulitiplication, migration and
interconnection, to irreversible damage.14
These findings add important information in interpreting Johnson and
Daviss’ study. Not only are the babies represented here equally safe, in
terms of mortality, compared to low-risk babies born in hospital; they may
also have significant long-term neurological and developmental advantages
because of their low rates of exposure to obstetric drugs and procedures.
1. Jacobson B, et al. Opiate addiction in adult offspring through
possible imprinting after obstetric treatment. Br Med J
1990;301(6760):1067-70.
2. Isobe K, et al. Measurement of cerebral oxygenation in neonates after
vaginal delivery and cesarean section using full-spectrum near infrared
spectroscopy. Comp Biochem Physiol A Mol Integr Physiol 2002;132(1):133-8.
3. Kim HR, et al. Delivery modes and neonatal EEG: spatial pattern
analysis. Early Hum Dev 2003;75(1-2):35-53.
4. Otamiri G, et al. Delayed neurological adaptation in infants delivered
by elective cesarean section and the relation to catecholamine levels.
Early Hum Dev 1991;26(1):51-60.
5. Vladimirova E, Smirnova EE. [The CNS status of newborn infants
delivered by cesarean section (based on EEG data)]. Zh Nevropatol
Psikhiatr Im S S Korsakova 1994;94(3):16-8.
6. Boksa P, El-Khodor BF. Birth insult interacts with stress at adulthood
to alter dopaminergic function in animal models: possible implications for
schizophrenia and other disorders. Neurosci Biobehav Rev 2003;27(1-2):91-
101.
7. Golub MS. Labor analgesia and infant brain development. Pharmacol
Biochem Behav 1996;55(4):619-28.
8. Golub MS. Labor analgesia and infant brain development. Pharmacol
Biochem Behav 1996;55(4):619-28, p 619.
9. Csaba G. Hormonal imprinting: its role during the evolution and
development of hormones and receptors. Cell Biol Int 2000;24(7):407-14.
10. Csaba G, et al. Effect of neonatal beta-endorphin imprinting on sexual
behavior and brain serotonin level in adult rats. Life Sci 2003;73(1):103-
14.
11. Csaba G, et al. Endorphin excess at weaning durably influences sexual
activity, uterine estrogen receptor's binding capacity and brain serotonin
level of female rats. Horm Metab Res 2004;36(1):39-43, p 39.
12. Csaba G, et al. Three-generation investigation on serotonin content in
rat immune cells long after beta-endorphin exposure in late pregnancy.
Horm Metab Res 2005;37(3):172-7.
13. Shore R. Rethinking the Brain: New Insights into Early Development.
New York: Families and Work Institute, 1997, p 15.
14. Livezey GT, et al. Prenatal exposure to phenobarbital and quantifiable
alterations in the electroencephalogram of adult rat offspring. Am J
Obstet Gynecol 1992;167(6):1611-5, p 1614.
Competing interests:
I have attended home births as a GP and am the mother of four children, all born at home
Competing interests: No competing interests
I want to thank the researchers for this important paper.
For the past few years we have growing evidence for the safety of
homebirth in low risk pregnancies.
Medicalization of birth, as the medicalization of death and sexuality, are
three extreme examples of the expansion of medicine into natural life
events. Hospital medicine grasps the birth process as a medical emergency
– a catastrophe waiting to happen. The caution of hospitals has increased
in the last decades with malpractice litigation anxiety, giving birth to
more and more intensive monitoring, medical and surgical procedures during
the birth process.
Primary care physicians, serving in the community, have a pivotal role in
helping medicine learn its boundaries. Primary care physicians are playing
this pivotal role by giving home based palliative care. It is now time to
start helping the other side of life.
How can we, as Primary care physicians assume our role in the birth
process?
1.Physicians practicing good evidence based medicine must not avoid the
evidence and offer homebirth as an option for low risk patients.
2.Primary care physicians should perform normal evidence based pregnancy
preventive medicine and follow up, avoiding the growing amount of unproved
tests and procedures available.
3.Primary care physicians may learn about the midwives in the community
performing homebirths, and recommend experienced, responsible, and well
trained midwives. We should also contact the midwives and discuss the
details. Who examines the baby after birth? What type of follow up will
the midwife perform? Who gives vitamin K and how? And more. We should be
able to recommend a good midwife in the same way we help our patients find
a medical specialist for consultation.
4.Primary care physicians can assume an active role by making a house call
following the birth to examine the newborn and the mother.
Birth is one of the blissful moments of life. By assuming an active role
in the process of birth, we have an opportunity to share a happy, major
life event with our patients. The evidence is here. The opportunity for
change is here. We must not miss it.
Competing interests:
None declared
Competing interests: No competing interests
Re: Outcomes of planned home births with certified professional midwives: large prospective study in North America
From the article "In autumn 1999, the North American Registry of Midwives made participation in the study mandatory for recertification and provided an electronic database of the 534 certified professional midwives whose credentials were current. We contacted 502 of the midwives (94.0%); 32 (6.0%) could not be located through email, telephone, post, or local associations, 82 (15.4%) had stopped independent practice, and 11 (2.1%) had retired. We sent a binder with forms and instructions for the study to the 409 practising midwives who agreed to participate."
So NARM got in touch with and received confirmation of participation from 409 midwives. However, not all 409 midwives that initially *agreed* had their birth outcomes used as a part of the study.
Again to quote the study: "Eighteen of the 409 midwives (4.4%) and their clients were excluded from the study because they failed to actively participate and had decided not to recertify or left practice."
I have questions regarding this.
1. Correct me if I am wrong but for any (or all) of the 18 midwives whose births were not included in the study, if they experienced an unfavorable outcome (like a fetal or maternal loss), all they would have to do is stop participating in the study and their outcome would not be known. Correct? How do we know this is not the case for any (or all) of the 18 midwives that initially agreed to participate but whose outcomes were not included because "failed to actively participate"?
2. Are any of these 18 midwives still practicing as lay midwives?
3. Are any of these 18 midwives still practicing as Licensed Midwives?
4. Were they *able* to become (or continue to be certified as) a Licensed Midwife?
5. Were any of these 18 midwives ever able to recertify as a CPM again?
If I am reading the study correctly, a midwife could basically decide whether or not to include their births in the study based on their outcomes. If they had an unfavorable outcome (or more than one), they could simply stop participating and their outcomes would not be included in the study. They would not be able to recertify as a CPM *but* that does not mean that they are no longer practicing as a home birth midwife.
I look forward to your response.
Thank you,
Danielle
Competing interests: No competing interests