Laura Schummers

Risk of Adverse Pregnancy Outcomes by Prepregnancy Body Mass Index: A Population-Based Study to Inform Prepregnancy Weight Loss Counseling

OBJECTIVE: To estimate the absolute risks of adverse maternal and perinatal outcomes based on small differences in prepregnancy body mass (eg, 10% of body mass or 10–20 pounds). METHODS: This population-based cohort study (N=226,958) was drawn from all singleton pregnancies in British Columbia (Canada) from 2004 to 2012. The relationships between prepregnancy body mass index (BMI) (as a continuous, nonlinear variable) and adverse pregnancy outcomes were examined using logistic regression models. Analyses were adjusted for maternal age, height, parity, and smoking in pregnancy. Adjusted absolute risks of each outcome are reported according to incremental differences in prepregnancy BMI and weight in pounds. RESULTS: A 10% difference in prepregnancy BMI was associated with at least a 10% lower risk of preeclampsia, gestational diabetes, indicated preterm delivery, macrosomia, and stillbirth. In contrast, larger differences in prepregnancy BMI (20–30% differences in BMI) were necessary to meaningfully reduce risks of cesarean delivery, shoulder dystocia, neonatal intensive care unit stay 48 hours or longer, and in-hospital newborn mortality. Prepregnancy BMI was not associated with risk of postpartum hemorrhage requiring intervention, severe maternal morbidity or maternal mortality, or spontaneous preterm delivery before 32 weeks of gestation. CONCLUSION: These results can inform prepregnancy weight loss counseling by defining achievable weight loss goals for patients that may reduce their risk of poor perinatal outcomes. LEVEL OF EVIDENCE: II

The Canadian Birth Place Study: Describing maternity practice and providers' exposure to home birth

OBJECTIVES (1) to describe educational, practice, and personal experiences related to home birth practice among Canadian obstetricians, family physicians, and registered midwives; (2) to identify barriers to provision of planned home birth services, and (3) to examine inter-professional differences in attitudes towards planned home birth. DESIGN the first phase of a mixed-methods study, a quantitative survey, comprised of 38 items eliciting demographic, education and practice data, and 48 items about attitudes towards planned home birth, was distributed electronically to all registered midwives (N=759) and obstetricians who provide maternity care (N=800), and a random sample of family physicians (n=3,000). SETTING Canada. This national investigation was funded by the Canadian Institutes for Health Research. PARTICIPANTS Canadian registered midwives (n=451), obstetricians (n=245), and family physicians (n=139). FINDINGS almost all registered midwives had extensive educational and practice experiences with planned home birth, and most obstetricians and family physicians had minimal exposure. Attitudes among midwives and physicians towards home birth safety and advisability were significantly different. Physicians believed that home births are less safe than hospital births, while midwives did not agree. Both groups believed that their views were evidence-based. Midwives were the most comfortable with including planned home birth as an option when discussing choice of birth place with pregnant women. Both midwives and physicians expressed discomfort with inter-professional consultation related to planned home births. In addition, both family physicians and obstetricians reported discomfort with discussing home birth with their patients. A significant proportion of family physicians and obstetricians would have liked to attend a home birth as part of their education. CONCLUSIONS the amount and type of education and exposure to planned home birth practice among maternity care providers were associated with attitudes towards home birth, comfort with discussing birth place options with women, and beliefs about safety. Barriers to home birth practice across professions were both logistical and philosophical. IMPLICATIONS FOR PRACTICE formal mechanisms for midwifery and medical education programs to increase exposure to the theory and practice of planned home birth may facilitate evidence based informed choice of birth place, and increase comfort with integration of care across birth settings. An increased focus among learners and clinicians on reliable methods for assessing the quality of the evidence about birth place and maternal-newborn outcomes may be beneficial.

The Canadian birth place study: examining maternity care provider attitudes and interprofessional conflict around planned home birth.

BackgroundAvailable birth settings have diversified in Canada since the integration of regulated midwifery. Midwives are required to offer eligible women choice of birth place; and 25-30% of midwifery clients plan home births. Canadian provincial health ministries have instituted reimbursement schema and regulatory guidelines to ensure access to midwives in all settings. Evidence from well-designed Canadian cohort studies demonstrate the safety and efficacy of midwife-attended home birth. However, national rates of planned home birth remain low, and many maternity providers do not support choice of birth place.MethodsIn this national, mixed-methods study, our team administered a cross-sectional survey, and developed a 17 item Provider Attitudes to Planned Home Birth Scale (PAPHB-m) to assess attitudes towards home birth among maternity providers. We entered care provider type into a linear regression model, with the PAPHB-m score as the outcome variable. Using Students’ t tests and ANOVA for categorical variables and correlational analysis (Pearson’s r) for continuous variables, we conducted provider-specific bivariate analyses of all socio-demographic, education, and practice variables (n=90) that were in both the midwife and physician surveys.ResultsMedian favourability scores on the PAPHB–m scale were very low among obstetricians (33.0), moderately low for family physicians (38.0) and very high for midwives (80.0), and 84% of the variance in attitudes could be accounted for by care provider type. Amount of exposure to planned home birth during midwifery or medical education and practice was significantly associated with favourability scores. Concerns about perinatal loss and lawsuits, discomfort with inter-professional consultations, and preference for the familiarity of the hospital correlated with less favourable attitudes to home birth. Among all providers, favourability scores were linked to beliefs about the evidence on safety of home birth, and confidence in their own ability to manage obstetric emergencies at a home birth.ConclusionsIncreasing the knowledge base among all maternity providers about planned home birth may increase favourability. Key learning competencies include criteria for birth site selection, management of obstetric emergencies at planned home births, critical appraisal of literature on safety of home birth, and inter-professional communication and collaboration when women are transferred from home to hospital.

Home birth in North America: attitudes and practice of US certified nurse-midwives and Canadian registered midwives.

INTRODUCTION Scope of practice, competencies, and philosophy of maternity practice are similar among midwives in the United States and Canada. However, there are marked differences in intrapartum practice sites between registered midwives (RMs) and certified nurse-midwives (CNMs). METHODS This study linked data from 2 national surveys: 1) a 2007 survey of CNM members of the American College of Nurse-Midwives (n = 1893); and 2) the Canadian Birth Place Study of maternity providers, including RM members of the Canadian Association of Midwives (n = 451) to compare the demographics, practice experience, and attitudes to home birth between these 2 types of North American midwives. A Provider Attitudes To Planned Home Birth scale-international (PAPHB-i) was developed for this analysis. Descriptive and bivariate analyses are presented. RESULTS Educational exposure to planned home birth varied greatly when comparing CNMs and RMs, as did practice patterns regarding continuity of care, primary and gynecologic care, and involvement with research and teaching. Registered midwives were almost 4 times more likely than CNMs to have practiced in the home (99.1% vs 26.0%). Certified nurse-midwives scored significantly lower than RMs on the PAPHB-i scale (36.5 vs 41.0), indicating less favorable attitudes toward home birth overall. Certified nurse-midwives were less confident than RMs in their management skills for home birth practice. Age, exposure to planned home birth during midwifery education, and practice experience in the home setting emerged as significant covariates of attitudes toward home birth. Significantly more RMs and CNMs with home birth experience expressed concerns about disapproval of hospital-based peers, but they were significantly less likely to agree that midwives face other systemic barriers than CNMs with no home birth experience. DISCUSSION Differences in favorability toward and confidence with practice during planned home births among CNMs and RMs were predicted associated with differences in educational and practice exposure to planned home birth. We recommend that clinical experiences and theoretical content about planned home birth and preparation for multidisciplinary collaboration across settings be integrated as essential and required components of all health professional education programs.