Introduction to Midwifery
COURSE PURPOSE & OVERVIEW This course will provide the learner with a solid understanding of childbirth as a human right, the Midwives Model of Care and the safety of community birth. Through narrative accounts, research documents and the powerful imagery of birth, students will emerge from this course understanding the power, value and importance of access to midwifery care for all who choose this maternity care option.
SPECIFIC LEARNING OBJECTIVES At the completion of this course, the students will be able to demonstrate knowledge and skills in the following areas:
1. Birth as a human right and how women’s fundamental human rights are routinely violated in industrialized birth settings.
2. Why the maternal mortality rate is increasing in the United States and how midwifery care can stem the tide.
3. Each principle of the Midwives Model of care, their meaning and application in the childbearing year.
4. The safety of out-of-hospital birth.
5. Local, national and international professional and consumer based organizations dedicated to the support of midwives and increased access to midwifery care.
Safety of Homebirth
MDWF 100 winter 2017
Instructor: Ruth Ann Colby Martin
Prior to 1940 almost half of all births took place at home. By 1955 less than 1% of births took place outside of a hospital. There is a growing number of families choosing home birth in the United States today. Between 2004 and 2010, home births rose by 41%. (Cheyney, Bovbjerg ,Everson, Gordon, Hannibal & Vedam. 2014 ) Today, 1% of all births occur out of hospital. Homebirth adversaries in the United States, claim that giving birth outside of a hospital setting is a dangerous choice for both mother child. Home birth advocates maintain that planned, midwife led home birth is a safe, viable choice for healthy women with low risk factors. In addition to being safe, planned home birth is also associated with lower intervention rates such as vacuum assisted vaginal births, cesarean births and episiotomies.
Women who choose home birth, do so for a variety of reasons. One study, using a small sample size (Boucher, Bennett, McFarlin & Freeze, 2008 ) indicated that some of the reasons women choose to birth at home included a belief that home was the safest place to give birth and allowed the opportunity for better health outcomes. Another common reason was a desire to avoid medical interventions, routine procedures, and interference's.
Most home birth safety studies are often focused on infant outcomes, reported as Apgar scores, stillbirths or neonatal deaths. While infant outcomes are vital to the safety of home birth, maternal mortality and morbidity are also important and less often mentioned in these studies. A large prospective cohort study conducted in the United States and Canada in 2000, (Cheyney et al., 2014) did indeed show low intervention rates.Among the 5418 intended home births there were 655 hospital transfers (12.1%), 2.1% received an episiotomy, 0.6% vacuum extraction and 3.7% cesarean section. Another large study conducted between 2004 and 2009 showed similar results (Cheyney et al., 2014). Among the 16, 924 participants, there was a 10.9% intra-partum transfer rate. 1.5% postpartum maternal transfer rate and a .09 neonatal transfer rate. Assisted vaginal birth with vacuum or forceps was 1.2%, and cesarean section rate was 5.2%. There was one maternal death in this group. That works out to about six in every 100,000. According to the World health Organization the national average for all maternal mortality in the U.S is between 12 and 28 per 100,000. A 2013 study in the Netherlands concluded that planned home birth with women in primary care who were low risk at the onset of labor, had lower rates of severe acute maternal morbidity, postpartum hemorrhage, and manual removal of placenta than those with a planned hospital birth. (Jonge, Mesman, Manniën, Zwart, Dillen & Roosmalen, 2013). A meta-analyses involving 23 primary quantitative reports and nine qualitative study reports, showed that studies indicated lower rates of maternal complications related to birth. Data from Canada, Australia and the United States saw lower rates postpartum hemorrhage and third and fourth degree perineal lacerations in women who had planned home births. (Ackerson, Kane Low & Zielinski, 2015) Rates of other maternal complications such as retained placenta or endometritis were also low in home birth populations. In comparison to planned hospital birth, postpartum hemorrhage rates (>500 mL blood loss) are either the same or lower in women who plan home birth.
Women who home birth are more likely to experience a spontaneous birth without medical intervention and are less likely to sustain pelvic floor injuries. (Cheyney et al., 2014). Out of the 16,039 women who birthed vaginally at home, 49.2% had an intact perineum. Episiotomy was low at 1.4%. First- or second-degree perineal lacerations were sustained at a rate of 40.9%. Only 1.2% had a third- or fourth-degree perineal laceration. Labial lacerations or skin splits that did not require suturing occurred in 12.8% of the women. 4.8% women had more substantial labial lacerations that required suturing.
While it is clear that mothers are safer birthing at home, there is less clarity about how safe homebirth is for babies. There is a lot more conflicting information. Part of the conflict is how data is collected. Often times, studies that show higher rates of neonatal mortality and morbidity are using data that is inconclusive. For example selected perinatal outcomes associated with planned home births in the United States. (Ackerson, Kane Low & Zielinski, 2015) showed that poor neonatal outcomes were associated with home birth, however they collected their data from birth certificates which has been shown to contain unreliable data (Zollinger , Przybylski & Gamache, 2006). Important information is excluded from a birth certificate such as a 5-minute Apgar score of 0 does not determine whether events occurred during the antepartum or intrapartum period. Also what kind of midwife (Certified Professional Midwife, Certified Nurse Midwife or Ley Midwife) attended the birth is omitted. The MANA study showed no significant increase in early or overall neonatal mortality when higher risk women were excluded from the study. A higher risk birth includes a trial of labor for vaginal birth after cesarean, multiples, gestational diabetes, and breech presentation.
A descriptive analysis of planned home birth among mostly Amish women in Pennsylvania, the overall rate of neonatal death was very low, 0.4%. All were caused by fetal anomalies. (Cox, Schlegel, Payne, Teaf, & Albers, 2013)
It is abundantly clear that home birth with a skilled attendant, is safer at home or birthing center for birthing persons than it is in hospital settings. The evidence shows there is less morbidity and less mortality. While there is some conflicting information on the safety of home birth for babies, when the data is looked at fairly, we can see that a low risk pregnancy with a skilled attendant is as safe out of hospital for babies as it is in hospital.
Boucher D, Bennett C, McFarlin B, Freeze R (2008) Staying Home to Give Birth:Why Women in the United States
Choose Home Birth. Journal of Midwifery & Women's Health 54, (2), 119-126.
(Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D. and Vedam, S. (2014), Outcomes of Care for 16,924
Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to
2009. Journal of Midwifery & Women's Health, 59: 17–27. doi:10.1111/jmwh.12172BMJ 2005; 330 doi:Cox KJ1,
Schlegel R, Payne P, Teaf D, Albers L. ( 2013) Outcomes of planned home births attended by certified nurse-midwives
in southeastern Pennsylvania, 1983-2008. Journal of midwifery & women's health, 58(2):145-9. doi: 10.1111/j.1542-
Jonge, A., Mesman, J., Mannien., J., Zwart. J, Dillen. J, Roosmalen, J. (2013) Severe adverse maternal outcomes among
low risk women with planned home versus hospital births in the Netherlands: nationwide cohort study.
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3263
Zollinger TW, Przybylski MJ, Gamache RE. (2006) Reliability of Indiana birth certificate data compared to medical
records. Annals of Epidemiology, 16, (1), 1-10https://doi.org/10.1016/j.annepidem.2005.03.005