+

AMCHP Webinar, July 11, 2013A Home Birth Primer for MCH Programs

Geradine Simkins, RN, CNM, MSNMidwives Alliance, Executive Director

+Benefits of planned home birth:Home births promote normal physiologic birth

.

WHO (1996) call for elimination of unnecessary interventions in childbirth Ever increasing rates of obstetric interventions in US, hospital-based childbirth

Normal physiologic childbirth (JMWH 2012): Includes biological and psychological conditions that promote effective labor; Results in the vaginal birth of the infant and placenta; Facilitates optimal newborn transition; and Supports early initiation of breastfeeding.

Cost-effective (Schroeder 2012, NYT 2013) Births in the US are the most costly of all developed countries yet produce

some of the worst outcomes Planned home births focus on low-intervention, appropriate use of technology Evidence-based distribution of human health resources

+Why Home Birth?A woman’s perspective(Jackson 2012, Blix 2011, Lindgren 2010, Hendrix 2010, Hildingsson 2010, Janssen 2006, Davies 1996, Cunningham 1993)

Control of environment and process of care Privacy Comfort and convenience Low intervention Safety Cultural congruency Family involvement Relaxed, peaceful

+Home births are on the rise

Midwives provide high-quality care at home births meeting national & international standards

+Framework for Optimal CareMidwives and planned home birth

Birth site selection & risk screening

Basic skills necessary for birth attendants

Standard equipment

Continuity of care

Strong provider/patient relationships

Shared decision-making

Timely access to consultation and referral

Seamless transfer from home to hospital, when necessary

+Preparing for a planned home birth

+

+Guidelines for newborn care: alignment across organizations

American Academy of Pediatrics (AAP)

Midwives Alliance of North America (MANA)

American College of Nurse Midwives (ACNM)

National Association of Certified Professional Midwives (NACPM)

Professional competencies recommended by AAP Policy Statement on Planned Home Birth (2013)—medical

equipment, emergency transfer plans, thorough newborn exams, and so forth—are integrated into the practice of

credentialed midwives

regardless of place of birth

+Collaborative care of the at-risk mother & neonate

Ongoing screening for conditions requiring consultation and/or transfer of care

Anticipation and preparation for unforeseen complications

Communication with obstetric or pediatric staff

Continuous primary care during transport

Various roles in ongoing care (Midwives are on staff at the hospital and/or resume primary care role in postpartum phase)

+Standard practices for ensuring high-quality newborn care at home Routine newborn APGAR assessment

Comprehensive head-to-toe physical examinations

Monitoring vital signs including thermoregulation

Assessment of respiratory sounds and patterns

Assessments of cardiac sounds and peripheral pulses

Assessment of gestational age and physical maturity

Neuromuscular assessments

Assistance with initiation and ongoing assessment of breastfeeding

Recording of all findings in patient record

+Standard practices continued Vitamin K treatment

Antibiotic eye ointment

Umbilical cord care

Metabolic newborn screening

Glucose and bilirubin testing, as indicated

OAE hearing screens

Pulse-oximetry

http://www.mana.org/news-events/mana-responds-to-aap-statement-on-home-birth

In the rare cases when newborns require consultation or referral, infants are transferred to the tertiary care system, and pediatricians where available, for active management

+The MANA Statistics Project: Key outcomes from planned home births in the USData source and years: The MANA Statistics Registry, 2004 – 2009.

Total dataset: 24,848; planned home births: 16,924 planned home births

Key Outcomes Spontaneous vaginal birth rate: almost 94% Cesarean section rate: under 6% Intrapartum transfer rate: less than 11% (failure to progress as

primary reason) Oxytocin augmentation or epidural anesthesia: less than 5% Low five minute Apgar score rate: less than 2% Exclusive breastfeeding at 6 week postpartum: 86% Newborn mortality: consistent with previously published literature

(<0.50/1000) Key outcomes did not vary by provider type (CPM, LM, or CNM/CM) (2012) MANA Division of Research Update: Research Roundup. Midwives Alliance Annual Conference, Asilomar, CA.

+Reducing costs andincreasing health equity

US maternity care most costly in the world The majority of low-risk women receive numerous unnecessary &

expensive interventions during pregnancy, labor & birth Most people have to pay a large percentage out of pocket

High cost to insurers and Medicaid programs Childbirth in the US is uniquely expensive, and maternity and

newborn care constitute the single biggest category of hospital payouts for most commercial insurers and state Medicaid programs

Cesarean deliveries cost thousands of dollars more than vaginal births, and Medicaid pays nearly $4000 more for each cesarean section than vaginal birth

If the cesarean rate was reduced to 15% (WHO recommendation) it would save $5 billion a year

+Reducing costs andincreasing health equity

Midwives keep costs down while increasing access to high quality of care

Extensive use of midwives is what keeps maternity care cost-effective in other countries, where midwives do the majority of prenatal, intrapartum & postpartum care

Midwives’ outcomes are excellent regardless of setting—home, hospital, birth center

Midwives provide low-tech, high-touch, high quality care across all birth settings

Midwives increase access to a model of care that is suited to individual needs, including for the most vulnerable and marginalized women & infants

+Summarizing planned home birth: 3 key points and 1 take home message1. Planned home birth means

appropriate use of intervention, focusing on safe, healthy, normal physiologic birth

2. Planned home birth is cost effective

3. Midwives (as the main home birth providers) improve access to high quality maternity care

MCH programs could increase access to high quality, cost effective maternity care, and promote health equity, by facilitating Medicaid coverage of midwifery services for all women, in all birth settings

+ReferencesAmerican Way of Birth, Costliest in the World, New York Times, June 30, 2013. http://mobile.nytimes.com/2013/07/01/health/american-way-of-birth-costliest-in-the-world.html. http://truvenhealth.com/ Blix, E. (2011). Avoiding disturbance: midwifery practice in home birth settings in Norway. Midwifery, 27(5), 687–692. doi:10.1016/j.midw.2009.09.008

Cost of Having A Baby in the United States, http://www.chqpr.org/downloads/CostofHavingaBaby.pdf

Cunningham, J. D. (1993). Experiences of Australian mothers who gave birth either at home, at a birth centre, or in hospital labour wards. Social science & medicine (1982), 36(4), 475–483.

Davies, J., Hey, E., Reid, W., & Young, G. (1996). Prospective regional study of planned home births. Home Birth Study Steering Group. BMJ (Clinical research ed.), 313(7068), 1302–1306.

Hatem, M., Sandall, J., Devane, D., Soltani, H., & Gates, S. (2008). Midwife-led versus other models of care for childbearing women. Cochrane database of systematic reviews (Online), (4), CD004667. doi:10.1002/14651858.CD004667.pub2

Hendrix, M., Pavlova, M., Nieuwenhuijze, M. J., Severens, J. L., & Nijhuis, J. G. (2010). Differences in preferences for obstetric care between nulliparae and their partners in the Netherlands: a discrete-choice experiment. Journal of psychosomatic obstetrics and gynaecology, 31(4), 243–251. doi:10.3109/0167482X.2010.527400

Hildingsson, I., Rådestad, I., & Lindgren, H. (2010). Birth preferences that deviate from the norm in Sweden: planned home birth versus planned cesarean section. Birth (Berkeley, Calif.), 37(4), 288–295. doi:10.1111/j.1523-536X.2010.00423.x

How to Save $5 Billion in Healthcare Spending for Employers & Taxpayers, http://chqpr.org/blog/index.php/2013/01/how-to-save-5-billion-in-healthcare-spending-for-employers-and-taxpayers/

Jackson, M., Dahlen, H., & Schmied, V. (2012). Birthing outside the system: perceptions of risk amongst Australian women who have freebirths and high risk homebirths. Midwifery, 28(5), 561–567. doi:10.1016/j.midw.2011.11.002

Janssen, P. A., Carty, E. A., & Reime, B. (2006). Satisfaction with planned place of birth among midwifery clients in British Columbia. Journal of midwifery & women’s health, 51(2), 91–97. doi:10.1016/j.jmwh.2005.10.012

Janssen, P. A., Saxell, L., Page, L. A., Klein, M. C., Liston, R. M., & Lee, S. K. (2009). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ : Canadian Medical Association Journal, 181(6-7), 377–383. doi:10.1503/cmaj.081869

Lindgren, H. E., Rådestad, I. J., Christensson, K., Wally-Bystrom, K., & Hildingsson, I. M. (2010). Perceptions of risk and risk management among 735 women who opted for a home birth. Midwifery, 26(2), 163–172. doi:10.1016/j.midw.2008.04.010

MacDorman, M., TJ Mathews & E DeClercq, Homebirth in the United States-1990-2009, January 2012. http://www.cdc.gov/nchs/data/databriefs/db84.pdf

Olsen, O., & Clausen, J. A. (2012). Planned hospital birth versus planned home birth. Cochrane database of systematic reviews (Online), 9, CD000352. doi:10.1002/14651858.CD000352.pub2

Schroeder, E., Petrou, S., Patel, N., Hollowell, J., Puddicombe, D., Redshaw, M., & Brocklehurst, P. (2012). Cost effectiveness of alternative planned places of birth in woman at low risk of complications: evidence from the Birthplace in England national prospective cohort study. BMJ (Clinical research ed.), 344, e2292.

Supporting healthy and normal physiologic childbirth: a consensus statement by the American College of Nurse-Midwives, Midwives Alliance of North America, and the National Association of Certified Professional Midwives. (2012). Journal of midwifery & women’s health, 57(5), 529–532. doi:10.1111/j.1542-2011.2012.00218.x

Transforming Maternity Care, Childbirth Connection, www.childbirthconnection.org/ 6. Maternity Care, Center for Healthcare Quality and Payment Reform, http://www.chqpr.org/maternitycare.html

+

Geradine Simkins, Executive Directorexecutivedirector@mana.org

Thank you

Midwives Alliance 1500 Sunday Drive Suite

102Raleigh, NC 27607PH 919-861-4530FAX 919-787-4916

www.mana.org

.