Home Births and the Public Health Response Webinar

Home Births and the Public Health Response: Promoting Informed Choices and Healthy Outcomes

This seminar took place Wednesday, July 20, 2011 from the John Hopkins Bloomgberg School of Public Health in Maryland and was broadcast live online. These are my notes from the webinar, along with some of Dr. Declerq's slides. 

Eugene Declerq, PhD Assistant Dean, Doctoral Education Professor, Community Health Sciences
Boston University School of Public Health

We're talking very small numbers

Historical Context:

• As the number of hospital beds increased, out of hospital birth decreased. 
• Supreme Court determines that even though midwife's (Porn) birth outcomes were as god or better than local doctors, they could not separate midwifery from medicine, so she was charged with practicing medicine without a license. 
• Nurse midwifery came about so midwives could work unders direct supervision of doctors
• Netherlands remain the only industrialized country with a sig. portion of births at home, now at 26% of all births are at home. 
• Trend in England and Wales - only industrialized country other than US showing a sig. increase in home birth. 
• U.S. post 1989 - Decrease in out of hospital birth but a jump at around 2008... but very small numbers. 
• 2003 live birth certificate asked "planning status" of home birth. 83% of home births in 2006 are planned home births. 

Present Day

• Planned home births in the U.S. are white/non-hispanic. Small numbers of other ethnic/racial groups. The increases have occurred almost completely in white/non-hispanic mothers. 
• Overwhelmingly married, usually over 30, full gestation. More likely to be in rural areas, well-educated, nonsmokers. 75% of cases tend to be mothers who have given birth before. The people having home birth in the U.S. are a selective group.
•  The primary group attending home births (planned or unplanned) are Certified Professional Midwives. CNM's have dropped off, esp. because of legal constraints (also physicians).
• Gestational age distribution - the average in the U.S. is 39th week. The planned home birth distribution shows the classic distribution with the peak at 40 weeks. 
• Significant increases have occurred in California, MD, Vermont, Ohio, Kentucky, VA, NC, 

"Other" could actually be attended by an "illegal" midwife but signed off on by a father, for example.

So many inferences can be made from this slide

Maryland

• Home birth rates jumped in 1994 but declined until 1999, until a slow general increase. 
• Not all planned home births end up at home. The transfer rate for home births is roughly 15%. 
• Much higher proportion of black/non-hispanic home births in MD than in the rest of the US, but could be unplanned home births. 

Mairi Breen Rothman, CNM, MSN Certified Nurse Midwife
Metro Area Midwives and Allied Services

• Birth center births are like having a home birth at someone else's house. There is nothing there that a midwife wouldn't have at your home. They both involve trained midwives who know how to use medications, IV fluids, oxygen, resuscitation, acute care period, etc. 
• In a home birth you have no institutional bacteria, and it doesn't require a nervous woman and partner to get in a car and drive somewhere and then leave in a few days.
• The safety of home birth has been established again and again (Olsen 1977, Johnson & Daviss 2005, Leslie and Romano, Janssen Saxell et al 2009), in North American and abroad. 
• Wax et al, recent meta analysis AJOG - deeply flawed inclusion data 
• included pre-term infants in hospital; includes data from birth certificates that do not differentiate between planned and unplanned home births; did not consider culture, geography, health care systems impact)
• Why women choose home birth (Boucher-Bennett et al 2009)
• Number one reason: SAFETY
• Avoidance of unnecessary medical interventions
• Previous negative hospital experience
• More control
• Comfortable, familiar environment
• Home birth patients feel they are not listened to and respected in the hospital
• Public Health: more women are choosing midwives, so how can we make this option safe.
• Ideal scenario is that everyone who is qualified to attend births is licensed, operating within the system, has access to the model of care she chooses, we have enough midwives and no unattended home births, streamlined way to do hospital transfers, midwives can collaborate or consult with physicians, and that Medicaid covers all services. 
• Bottom line: Birth is about Women. The discussion is about the Sovereignty of Women.
• Frequently we hear "Should women be allowed...?" Have you ever heard "Should men be allowed...?"
• "If we take good care of the mothers, the mothers will take care of the babies" - Kitty Ernst

Notes from the Q&A Discussion:

We can't have randomized trials of birth, so they are typically retrospective and women are matched. Frequent limitation: can't distinguish planned home birth and which home births become hospital births. 

Studies frequently find that low-risk pregnancy/births are comparable at home and in the hospital.

One study found that matched women being cared for by midwives prenatally other than physician care had a 19% lower infant mortality rate and 33% lower low-birth weight rate. Midwifery care is designed to optimize women's self-care during pregnancy.

Midwives are extremely selective at picking women to attend at birth at home because they don't want anything to go wrong at home. Age is generally no issue. 

Problem with Medicaid - payment doesn't cover everything. Midwives get a very low payment that doesn't cover all over-head. 

The Healthcare Reform Act has this impact on pregnant women - will cover all pregnant women who are not covered. Also, pay for certified professional midwives but only in a birth center. CNMs will be paid by medicaid at 100% of the physician fee schedule. 

Low risk moms in any setting - 97% of babies are fine. What's important is to have emergency pathways to deal with babies that need help. The best thing to do for women choosing home births is to have those systems in place, so that women can access the medical system without being punished. 

The British system is instructive - give people a real option to have home birth - they are at about 3%. The U.S. has a more antagonistic view of home birth so we might at some point get up to 1.5%. Probably no huge shift in the future. But maybe there will be a much more activist maternity movement in the U.S.

Quiet revolution - women are quietly examining their options, looking at research, making a choice. More and more true as time goes on. 

Physician-attended home births data - who are these physicians? Could be a physician sign-off at a home birth transfer or an unplanned home birth on birth certificates. Highly unlikely that physicians are at home with mother while she is laboring, attending the delivery, cleaning up, and leaving. 

From a historical perspective, CNMs and CPMs have has some divisions and competition. These days there is an attempt by the ACNM and MANA to work together. 

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The presenters' slideshows are posted under "Documents" here 
There will be a link online at the Johns Hopkins Bloomberg School of Public Health archiving this webcast for future viewing.
Learn more about Eugene Declerq's work (and what he looks like) in his video Birth by the Numbers