1. Institute of Medicine Workshop:
Research Issues in the Assessment of Birth Settings
Brynne Potter, CPM
Provider Perspectives:
Midwives and Home Birth
March 7, 2013

2. Disclosure
CEO and Founder
EHR and HIT Platform for Maternity Care

3. Home Birth in the US
❖ Polarized
❖ Marginalized
❖ Disruptive
❖ Racialized
❖ Politicized

4. 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
“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
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,

6. 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,)

7. Why do women choose home birth?
“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

8. Home Birth Safety
Olsen and Clausen, Cochrane 2012
❖ Conclusions:
❖ Only one trial (n=11) met rigorous criteria,
“From an autonomy-based ethical
but quality of observational studies greatly
increased perspective the only justification for practices
❖ “..there is no strong evidence to favor that restrict a woman’s autonomy
either planned hospital or planned home and her $eedom of choice, would be clear
birth for selected, low risk pregnant
women”
evidence that these restrictive practices do
more good than harm
❖ Recommend all countries facilitate
— Enkin (1995), Olsen (1998, 2012)
evidence-based integration of home birth
services for low-risk women
Olsen, Clausen, (2012 Cochrane Collaborative Review) Planned hospital birth versus planned home birth

9. Best Observational Data
❖ de Jonge, et al, 2009 ❖ Janssen, 2009
❖ 529,688 women - Netherlands (2000-2006) ❖ Prospective five-year matched cohort study -
British Columbia
❖ Planned home births: 321,301 (60%)
❖ midwife-attended planned home birth (N=2802)
❖ Planned hospital births: 163, 261 (31%)
❖ physician attended hospital birth group (N=5985)
❖ No significant differences between home and
hospital for any of the main outcomes including ❖ midwife attended hospital birth group (N=5984).
perinatal death
❖ 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

10. 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

11. Risk Assessment “Risk equals probability times consequence.
Safety is the level of acceptable risk”
❖ Home Birth is a safe choice for — Ron DuPlain,
“essentially healthy women”. Private Practice-Maternity, Systems Engineer
❖ 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.

12. 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

13. 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

14. Intrapartum Transport
Develop standards to improve quality and safety during non-emergent and
emergent transfers of care

15. Human Rights and Birth Choices
“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
❖ 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

16. 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)

17. 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

18. Factors that Disturb Birth
Joint Normal Physiologic Birth Statement (2012)
❖ Unsupportive environment, i.e., bright lights, ❖ Opiates, regional analgesia, or general
cold room, lack of privacy, multiple providers, anesthesia
lack of supportive companions
❖ Episiotomy
❖ Time constraints, including those driven by
institutional policy and/or staffing ❖ Operative vaginal (vacuum, forceps) or
abdominal (cesarean) birth
❖ Separation of mother and infant
❖ Immediate cord clamping
❖ Any situation in which the mother feels
threatened or unsupported ❖ Induction or augmentation of labor
❖ Nutritional deprivation, e.g., food & drink

19. Benefits of physiologic labor and birth
Value of Home Birth
❖ Reduces likelihood of fetal compromise ❖ Increased confidence and capacity to mother
❖ Reduces instrumental or surgical ❖ Enhanced infant growth & development
intervention.
❖ Mother-infant attachment
❖ Improves physical & mental health – mother
and baby ❖ Diminished incidence of chronic disease
❖ Maintains delicate hormone physiology ❖ 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, WA
Fahy, Fourer, Hastie. (2008) Birth Territory & Midwifery Guardianship, Elsevior Publishing, Philadelphia, PA
The Hormonal Physiology of Childbearing (Buckley, Childbirth Connection; 2013-draft)

21. Thank You
Brynne Potter, CPM
Provider Perspectives:
Midwives and Home Birth
March 7, 2013