Institute of Medicine Workshop:Research Issues in the Assessment of Birth Settings

Brynne Potter, CPMProvider Perspectives:

Midwives and Home BirthMarch 7, 2013

Disclosure

CEO and FounderEHR and HIT Platform for Maternity Care

Home Birth in the US❖ Polarized

❖ Marginalized

❖ Disruptive

❖ Racialized

❖ Politicized

Wax Analysis: (mis)conclusions❖ Discrepancies in sample size and inclusion

criteria for neonatal and perinatal death rates

❖ Causation of low morbidity/intervention in home birth erroneously linked to mortality

❖ Questionable cohort for neonatal death drives widely influential ACOG published opinion

Planned Home vs Hospital Birth: A Meta-Analysis Gone Wrong; 2011 Carl A. Michal, PhD; Patricia A. Janssen, PhD; Saraswathi Vedam, SciD; Eileen K. Hutton, PhD; Ank de Jonge, PhD,

“In an era of evidence-based medicine, it is incomprehensible that medical society opinion can be formulated on research

that does not hold to the most basic standards of methodological rigor.”-Michal, Janssen, Vedam, Hutton, deJonge

Why do women choose home birth?❖ Safety" " " "❖ Control of environment & process of care❖ Privacy ❖ Cultural Congruency ❖ Comfort and Convenience"❖ Spiritual Accommodation❖ Self-Determination""❖ Low Intervention" "❖ Family Involvement❖ Relaxed and peaceful

(Jackson 2012, Blix 2011, Symon 2010, Lindgren 2010, Hendrix 2010, Boucher 2009, Janssen 2006, Hildingsson 2010, 2003,)

“Comfortable setting, we can make decisions without pressure $om staff ”

— 1st baby born in hospital

“I want to feel safe and comfortable. I have confidence in myself to have a natural birth. I like the one on one attention I wi& receive using a midwife.

—1st born in a birth center

I think that I wi& be able to relax in a home setting and not feel pressured by time constraints”

— Expecting 1st baby

Why do women choose home birth?

Home Birth SafetyOlsen and Clausen, Cochrane 2012

❖ Conclusions:

❖ Only one trial (n=11) met rigorous criteria, but quality of observational studies greatly increased

❖ “..there is no strong evidence to favor either planned hospital or planned home birth for selected, low risk pregnant women”

❖ Recommend all countries facilitate evidence-based integration of home birth services for low-risk women

“From an autonomy-based ethical perspective the only justification for practices

that restrict a woman’s autonomyand her $eedom of choice, would be clear evidence that these restrictive practices do

more good than harm— Enkin (1995), Olsen (1998, 2012)

Olsen, Clausen, (2012 Cochrane Collaborative Review) Planned hospital birth versus planned home birth

Best Observational Data❖ de Jonge, et al, 2009

❖ 529,688 women - Netherlands (2000-2006)

❖ Planned home births: 321,301 (60%)

❖ Planned hospital births: 163, 261 (31%)

❖ No significant differences between home and hospital for any of the main outcomes including perinatal death

❖ Janssen, 2009❖ Prospective five-year matched cohort study -

British Columbia

❖ midwife-attended planned home birth (N=2802)

❖ physician attended hospital birth group (N=5985)

❖ midwife attended hospital birth group (N=5984).

❖ Similar or reduced rates of adverse outcomes with significantly fewer intrapartum interventions

de Jonge A, van der Goes B, Ravelli A, Amelink-Verburg M, Mol B, Nijhuis J, et al.Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG 2009

Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee Sk. Outcomes of planned home births with registered midwife versus versus planned hospital birth with midwife or physician. CMAJ 2009

Making home birth as safe as possible❖ Access to qualified care providers with appropriate equipment

❖ Appropriate risk assessment

❖ Respectful communication/collaboration that maintains continuity and relationship

❖ Integrated transfer of data

❖ Fully implemented QI measures

❖ Mechanisms to address unprofessional conduct. (Licensure)

❖ Reimbursement, including Medicaid

Risk Assessment❖ Home Birth is a safe choice for

“essentially healthy women”.

❖ What factors should influence choice of birth setting, and which factors have no bearing on that choice?

❖ Perceptions of risk and safety linked to medical perspective. (Bryers, 2010)

❖ Recognize impact of imposing limitation of scope in one setting on demand for services in another.

“Risk equals probability times consequence. Safety is the level of acceptable risk”

— Ron DuPlain, Private Practice-Maternity, Systems Engineer

Access❖ Research should address lack of access

to birth services using same criteria identified by home birth opponents:

1. Safety

2. Patient Satisfaction

3. Cost

4. Ethics

Mutual Accommodation❖ How can we develop mutual respect and understanding between

providers with different approaches to care?

❖ How can we optimize the expertise of providers in each setting?

“Instead of a maternity system based on fear and misinformation, we need a system based on co&aboration and mutual respect.”

— Melissa Cheyney, PhD, LM, CPM

http://www.huffingtonpost.com/melissa-cheyney/post_812_b_709215.html

Intrapartum Transport

Develop standards to improve quality and safety during non-emergent and emergent transfers of care

Human Rights and Birth Choices

❖ Choice of Birth Setting

❖ Shared Decision Making

❖ Patient Autonomy

Plante LA. Mommy, What Did You Do in the Industrial Revolution? Meditations on the Rising Cesarean Rate. The International Journal of Feminist Approaches to Bioethics. Spring 2009;2(1):140-147. DOI: 10.2979/FAB.2009.2.1.140

“Is it not the opposite of autonomy to support only those choices which increase the woman’s reliance upon the physician?”

— Lauren A. Plante, MD, MPH, FACOG

Suggestions for Comparative Effectiveness Research

1. Include birth setting in review of low-risk cesarean rates (Harmann 2012)

2. Address race disparity for birth options. Development of community-based health workers.(Doula Care Reduces Cesarean Deliveries in Medicaid Patients. Medscape. Feb 19, 2013.)

3. Patient derived data in EHR and other HIT innovations to address patient satisfaction and shared decision making.(Dhanireddy, S 2012; Leveille, S 2012, Delbanco, T 2010)

4. Relocation; Impact on rural women (Kaczorowsk, J. 2000; Kornelsen, 2005, 2011; Gao, 2010; Klein,M. 2002; Thomassen, H. 2005; Grzybowski, S. 2007; Godwin,M. 2002)

Home Birth-Like❖ Woman-centered, family friendly,

community based

❖ Pregnancy and birth are treated as a unified process of care that includes social, emotional, physical, cultural and spiritual accommodation

❖ A resolute environment for undisturbed, physiologic birth

Factors that Disturb BirthJoint Normal Physiologic Birth Statement (2012)

❖ Unsupportive environment, i.e., bright lights, cold room, lack of privacy, multiple providers, lack of supportive companions

❖ Time constraints, including those driven by institutional policy and/or staffing

❖ Separation of mother and infant

❖ Any situation in which the mother feels threatened or unsupported

❖ Nutritional deprivation, e.g., food & drink

❖ Opiates, regional analgesia, or general anesthesia

❖ Episiotomy

❖ Operative vaginal (vacuum, forceps) or abdominal (cesarean) birth

❖ Immediate cord clamping

❖ Induction or augmentation of labor

Benefits of physiologic labor and birthValue of Home Birth

❖ Reduces likelihood of fetal compromise

❖ Reduces instrumental or surgical intervention.

❖ Improves physical & mental health – mother and baby

❖ Maintains delicate hormone physiology

❖ Increased confidence and capacity to mother

❖ Enhanced infant growth & development

❖ Mother-infant attachment

❖ Diminished incidence of chronic disease

❖ Epigenetic impact of childbirth

References:Dahlen HG et al. The EPIIC hypothesis: Intrapartum effects on the neonatal epigenome and consequent health outcomes. Med Hypotheses (2013)Goer H. & Romano A. (2012) Optimal Care in Childbirth; The case for a physiologic approach, Classic Day Publishing, Seattle, WAFahy, Fourer, Hastie. (2008) Birth Territory & Midwifery Guardianship, Elsevior Publishing, Philadelphia, PAThe Hormonal Physiology of Childbearing (Buckley, Childbirth Connection; 2013-draft)

Thank You

Brynne Potter, CPMProvider Perspectives:

Midwives and Home BirthMarch 7, 2013