Today's post on Science & Sensibility coincides with the release of a long awaited study looking at the home birth data collected by the Midwives Alliance of North America MANAStats project, 2004-2009. Judith Lothian, PhD, RN, LCCE, FACCE reviews the research that examines outcomes of almost 17,000 planned home births in the United States. To date, this is the largest dataset of planned home births available. Dr. Lothian takes a look at what the research found and helps S&S readers to understand the key points of the published paper. - Sharon Muza, Community Manager, Science & Sensibility.

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The American College of Nursing today announced the publication in the Journal of Midwifery and Women's Health of important new US research on the outcomes of home birth: "Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009". This research is important for two reasons: it adds to the increasing body of research that supports the safety of home birth for healthy women in the US, and it demonstrates the value and importance of the National Data Registry for Midwife-Led Birth, the Midwives Alliance of North America (MANA) Statistics Project 2.0 dataset(2). This is the first publication of home birth outcomes research in the US since 2005, nearly a decade. Just as importantly, it is the first major research study published using the MANA dataset.

Studying planned home birth presents unusual challenges. A randomized control trial is not possible because women are not willing to consent to randomization to home or hospital. Unlike other countries, data in the US are collected state by state and most birth certificates (the most common, although often unreliable, way to collect birth data) do not collect information about planned home birth. As a result, unlike in countries like the Netherlands, population based research is not possible. There is a need in the US for a system for universal maternity care data collection. In response to this need, and the need for high quality data on midwifery outcomes, MANA in 2004 began the momentous work of developing a national data registry for midwife-led birth. The result is the National Data Registry for Midwife-Led Births, the Midwives Alliance of North America (MANA) Statistics Project 2.0 dataset. A companion article in the same issue of the Journal of Midwifery and Women's Health is available to read more about the development and validations of the National Registry for Midwife-Led Births.

About the study

For this study, data were collected from 2004-2009 using the MANA Stats 2.0 Web-based tool. Midwifery participation was voluntary. Data were contributed by 432 different midwives: 20 to 30 percent of all active Certified Professional Midwives (CPMs) and a much lower percentage of active Certified Nurse Midwives (CNMs) contributed to the dataset. Other types of midwives who also participated included Licensed Midwives (LMs), Licensed Direct Entry Midwives (LDMs), Certified Midwives (CMs), and a small percentage of unlicensed direct entry midwives. The midwives obtained written informed consent from the women at the onset of care to contribute data, including outcomes, to the registry. It's important to note that women were entered into the registry by the midwives at the onset of care before outcomes were available. More than 95% of the women cared for by the midwives who participated in the registry provided consent. The sample for the study included all women who intended to give birth at home at the time they went into labor. The final sample of women was 16,924.

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The women were mostly white, married, and college educated. Almost 2/3 of the woman paid for midwifery services out of pocket. The sample came largely from the Western United States. Almost 78% of the women had previous babies (8% having had a previous cesarean) and a just over 22% were expecting their first babies. Some, but very few, of the women in the sample had complications or co-morbidities (for example, 1.3 % breech, 0.4% multiple gestation, 1.4% pregnancy induced hypertension, 0.8% gestational diabetes).

What follows is a snapshot of some of the most important findings of the study. The authors go into great detail presenting and discussing the findings and then comparing their findings to previous published studies of planned home birth. I encourage you to read the full article.

Study results

Almost 94% of the women had spontaneous vaginal births. There was a 5.2% cesarean rate and an 87% VBAC rate. Only 4.5% of the sample required oxytocin augmentation and/or epidural. Ninety two percent of the births were full term, 2.5% were pre-term and 5.1% were post-term. Less than 1% of the babies were low birth weight. There was an intrapartum transfer rate of 10.9%. Women giving birth for the first time were three times more likely to transfer during labor, most often for failure to progress. Postpartum transfers were 1.7% for women who gave birth at home. The most common reason (over 70%) was for complications related to hemorrhage and/or retained placenta. Neonatal transfer was 1.0% with the most common reason being respiratory distress or low Apgar.

In this sample, the rate of postpartum hemorrhage (defined as over 500cc in a vaginal birth and 1000 cc in a cesarean) was 15.4%, higher than previous research has reported. That said, the transfers for excessive bleeding were low. Active management of third stage is infrequent in this sample. The authors posit that without intravenous oxytocin administration, the 500cc benchmark for diagnosing hemorrhage may not be appropriate in this physiologic birth population.

The intrapartum neonatal death rate was 1.3 per 1000, consistent with rates reported in some studies, but higher than the rates reported in others. While the rate is still relatively low, it might, the authors suggest, be partially explained by a sample that included women who are at higher risk for adverse outcomes (multiple gestations, breech presentations, VBAC, gestational diabetes or pre-eclampsia). When these women were removed from the sample, the intrapartum death rate drops to 0.85 per 1000, a rate that is statistically congruent with rates reported in most studies, with the exception of large population studies in the Netherlands that report somewhat lower rates.(deJonge et al, 2009). The authors also note that the lack of an integrated system and possible delays in transfer may contribute to the small but somewhat higher rate of intrapartum neonatal death in the sample.

There was one maternal death in the study, as a result of a blood clot in the heart at three days postpartum after an uncomplicated pregnancy, labor, birth and postpartum.

Discussion

As in any research there are limitations. This is not a population based study. Not all midwives in the US contributed data to the registry. The births took place mostly in the Western United States. The women were largely white, college educated and married. Nonetheless, the findings make a major contribution to the literature on planned home birth supporting the findings of previous research conducted both in the US and in Canada, the Netherlands, and the United Kingdom (Johnson & Daviss, 2005; Janssen et al 2009; Hutton et al, 2009; Janssen et al, 2002; deJonge et al, 2009; Birthplace in England, 2011).

In spite of the meticulous development and validation of the dataset and the acknowledged limitations of the data, I suspect the usual naysayers will question the validity and the usefulness of the dataset. I suspect those opposed to planned home birth will exaggerate the implications of findings related, for example, to maternal bleeding in spite of the fact that almost no mothers required transfer or intervention, and point out the higher intrapartum neonatal mortality numbers than other studies have reported without discussing the fact that the increase is largely accounted for by infants of women at higher risk for adverse outcomes (pre-eclampsia, gestational diabetes, multiple gestation, VBAC, breech). It is difficult for anyone to dismiss the importance of the overall excellent outcomes for both mothers and babies.

The excellent outcomes in this study, (with care provided mostly by CPMs & LMs, in a country that does not have integrated systems of care including seamless transfer and collaboration between providers, and with a sample that included women who are usually considered at higher risk for planned home birth {breech, VBAC, multiple gestations, pre-eclampsia, gestational diabetes}), should make us pause. Could it be that even for women with some risk factors, planned home birth could be as safe as hospital birth? What would the outcomes be if we had an integrated system of care?

Personal "Take Aways"

• The MANA dataset is an extremely valuable resource for researchers. Thanks to the work of MANA, the dedicated midwives who participate in the registry, and the women who consent to having their outcomes registered, we have further evidence, this time in the US, that planned home birth reduces interventions including cesarean, and has outcomes similar or better than planned hospital births. CPMs, CMs and LDMs, who are the largest group of midwives contributing to the dataset, deserve recognition and respect. The positive outcomes reflect the excellence of care that they provide for women. With the publication of this important study, and the publication of the companion article describing the development and validation of the dataset, hopefully, many more midwives, including CNMs and those who practice in other parts of the country, will be persuaded to contribute to the registry.
• I encourage you to share the findings of this study with the women you teach, talk to and touch. Most women will not choose home birth but knowing that women today give birth safely at home without routine interventions or tied to machines, and subjected to the ticking clock, should give all women a boost of confidence in their ability to give birth. And, it just might encourage some women to think about having a planned home birth.
• We might think of a childbirth education registry. We have wanted high quality data for decades to track the outcomes of childbirth education. Perhaps this is a way to collect quality data?

Conclusion

This is a landmark study of US home birth. Hats off to MANA for its ground breaking contribution in collecting and providing data that will further advance our knowledge of planned home birth and midwifery. Hats off to the dedicated midwives who contributed their outcomes to the dataset, and to the women who were so willing to share their information with the world. And, hats off to the dedicated researchers, Melissa Cheyney, Marit Bovbjerg, Courtney Everson, Wendy Gordon, Darcy Hannibal and Saraswathi Vedam who continue to contribute in groundbreaking ways to promoting and supporting normal, physiologic birth and the health and safety of childbearing women and babies.

References

Birthplace in England Collaborative Group. (2011). Perinatal and Maternal Outcomes by Planned Place of Birth for Healthy Women with Low Risk Pregnancies: The Birthplace in England National Prospective Cohort Study, British Medical Journal 343, d7400.

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D. & 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 and Women's Health.

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D. & Vedam, S. (2014). Development and Validation of a National Data Registry for Midwife-Led Births: The Midwives Alliance of North America Statistics Project 2.0 Dataset. Journal of Midwifery and Women's Health.

de Jonge, B. van der Goes, A. Ravelli, M. Amelink-Verburg , et al.(2009). Perinatal Mortality and Morbidity in a Nationwide Cohort of 529,688 Low-risk Planned Home and Hospital Births. British Journal of Obstetrics and Gynecology 16, no. 9, 1177-84.

Hutton, E., Reitsma, A., Kaufman, K. (2009). Outcomes Associated with Planned Home and Planned Hospital Births in Low-Risk Women Attended by Midwives in Ontario, Canada, 2003-2006:A Retrospective Cohort Study. Birth 36, no. 3, 180-89.

Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee Sk. (2009). Outcomes of Planned Home Births with Registered Midwife versus Attended by Regulated Midwives versus Planned hospital Birth in British Columbia. Canadian Medical Association Journal 181, no. 6, 377-83.

Janssen, P. Lee,S., Rya,E, et al. (2002). Outcomes of Planned Home Births versus Planned Hospital Births after Regulation of Midwifery in British Columbia. 166, no. 3, 315-23.

Johnson, K. & Davis, B.A. (2005). Outcomes of Planned Home Brth with Certified Professional Midwives: A Large Prospective Study in North America. British Medical Journal 330, 1416-19.

About Judith Lothian

@ Judith Lothian

Judith Lothian, PhD, RN, LCCE, FACCE is a nurse and childbirth educator. She is an Associate Professor at the College of Nursing, Seton Hall University and the current Chairperson of the Lamaze Certification Council Governing Body. Judith is also the Associate Editor of the Journal of Perinatal Education and writes a regular column for the journal. Judith is the co-author of The Official Lamaze Guide: Giving Birth with Confidence. Her research focus is planned home birth and her most recent publication is Being Safe: Making the Decision to Have a Planned Home Birth in the US published in the Journal of Clinical Ethics (Fall 2013 ).

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