Melissa Cheyney

Homebirth as Systems-Challenging Praxis: Knowledge, Power, and Intimacy in the Birthplace

In this article, I examine the processes and motivations involved when women in the United States choose to circumvent the dominant obstetric care paradigm by delivering at home with a group of care providers called direct-entry midwives. Using grounded theory, participant observation, and open-ended, semistructured interviewing, I collected and analyzed homebirth narratives from a theoretical sample of women ( n = 50) in two research locales. Findings interpreted from the perspective of critical medical anthropology suggest that women who choose to birth at home negotiate fears associated with the “just in case something bad happens” argument that forms the foundation for hospital birth rationales through complex individual and social processes. These involve challenging established forms of authoritative knowledge, valuing alternative and more embodied or intuitive ways of knowing, and knowledge sharing through the informed consent process. Adherence to subjugated discourses combined with lived experiences of personal power and the cultivation of intimacy in the birthplace fuel homebirth not only as a minority social movement, but also as a form of systems-challenging praxis.

Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009

INTRODUCTION Between 2004 and 2010, the number of home births in the United States rose by 41%, increasing the need for accurate assessment of the safety of planned home birth. This study examines outcomes of planned home births in the United States between 2004 and 2009. METHODS We calculated descriptive statistics for maternal demographics, antenatal risk profiles, procedures, and outcomes of planned home births in the Midwives Alliance of North American Statistics Project (MANA Stats) 2.0 data registry. Data were analyzed according to intended and actual place of birth. RESULTS Among 16,924 women who planned home births at the onset of labor, 89.1% gave birth at home. The majority of intrapartum transfers were for failure to progress, and only 4.5% of the total sample required oxytocin augmentation and/or epidural analgesia. The rates of spontaneous vaginal birth, assisted vaginal birth, and cesarean were 93.6%, 1.2%, and 5.2%, respectively. Of the 1054 women who attempted a vaginal birth after cesarean, 87% were successful. Low Apgar scores (< 7) occurred in 1.5% of newborns. Postpartum maternal (1.5%) and neonatal (0.9%) transfers were infrequent. The majority (86%) of newborns were exclusively breastfeeding at 6 weeks of age. Excluding lethal anomalies, the intrapartum, early neonatal, and late neonatal mortality rates were 1.30, 0.41, and 0.35 per 1000, respectively. DISCUSSION For this large cohort of women who planned midwife-led home births in the United States, outcomes are congruent with the best available data from population-based, observational studies that evaluated outcomes by intended place of birth and perinatal risk factors. Low-risk women in this cohort experienced high rates of physiologic birth and low rates of intervention without an increase in adverse outcomes.

Homebirth Transfers in the United States: Narratives of Risk, Fear, and Mutual Accommodation

The purpose of this study was to explore the contested space of home-to-hospital transfers that occur during labor or in the immediate postpartum period, as a means of identifying the mechanisms that maintain philosophical and practice divides between homebirth midwives and hospital-based clinicians in the United States. Using data collected from open-ended, semistructured interviews, participant observation, and reciprocal ethnography, we identified six key themes—three from each provider type. Collectively, providers’ narratives illuminate the central stressors that characterize home-to-hospital transfers, and from these, we identify three larger sociopolitical mechanisms that we argue are functioning to maintain fractured articulations at the time of transfer. These mechanisms impede efficient and mutually respectful interactions and can result in costly delays. However, they also contain the seeds of possible solutions, and thus are important starting points for developing an integrated maternity system premised on mutual accommodation and seamless articulations across all delivery locations.

Transfer from planned home birth to hospital: Improving interprofessional collaboration

Womens heightened interest in choice of birthplace and increased rates of planned home birth in the United States have been well documented, yet there remains significant public and professional debate about the ethics of planned home birth in jurisdictions where care is not clearly integrated across birth settings. Simultaneously, the quality of interprofessional interactions is recognized as a predictor of health outcomes during obstetric events. When care is transferred across birth settings, confusion and conflict among providers with respect to roles and responsibilities can adversely affect both outcomes and the experience of care for women and newborns. This article reviews findings of recent North American studies that examine provider attitudes toward planned home birth, differing concepts of safety of birthplace as reported by women and providers, and sources of conflict among maternity care providers during transfer from home to hospital. Emerging evidence and clinical exemplars can inform the development of systems for seamless transfer of women and newborns from planned home births to hospital and improve experience and perceptions of safety among families and providers. Three successful models in the United States that have enhanced multidisciplinary cooperation and coordination of care across birth settings are described. Finally, best practice guidelines for roles, communication, and mutual accommodation among all participating providers when transfer occurs are introduced. Research, health professional education, and policy recommendations for incorporation of key components into existing health care systems in the United States are included.

Development and Validation of a National Data Registry for Midwife‐Led Births: The Midwives Alliance of North America Statistics Project 2.0 Dataset

INTRODUCTION In 2004, the Midwives Alliance of North Americas (MANAs) Division of Research developed a Web-based data collection system to gather information on the practices and outcomes associated with midwife-led births in the United States. This system, called the MANA Statistics Project (MANA Stats), grew out of a widely acknowledged need for more reliable data on outcomes by intended place of birth. This article describes the history and development of the MANA Stats birth registry and provides an analysis of the 2.0 datasets content, strengths, and limitations. METHODS Data collection and review procedures for the MANA Stats 2.0 dataset are described, along with methods for the assessment of data accuracy. We calculated descriptive statistics for client demographics and contributing midwife credentials, and assessed the quality of data by calculating point estimates, 95% confidence intervals, and kappa statistics for key outcomes on pre- and postreview samples of records. RESULTS The MANA Stats 2.0 dataset (2004-2009) contains 24,848 courses of care, 20,893 of which are for women who planned a home or birth center birth at the onset of labor. The majority of these records were planned home births (81%). Births were attended primarily by certified professional midwives (73%), and clients were largely white (92%), married (87%), and college-educated (49%). Data quality analyses of 9932 records revealed no differences between pre- and postreviewed samples for 7 key benchmarking variables (kappa, 0.98-1.00). DISCUSSION The MANA Stats 2.0 data were accurately entered by participants; any errors in this dataset are likely random and not systematic. The primary limitation of the 2.0 dataset is that the sample was captured through voluntary participation; thus, it may not accurately reflect population-based outcomes. The datasets primary strength is that it will allow for the examination of research questions on normal physiologic birth and midwife-led birth outcomes by intended place of birth.

Navigating Social and Institutional Obstacles: Low-Income Women Seeking Abortion

Nearly half of all women in the United States will have at least one abortion during their lifetime, and many will encounter economic, logistical, and/or social obstacles while attempting to undergo the procedure. The purpose of this project was to examine the abortion-seeking experiences of a volunteer sample of Oregon women, to identify key barriers and the strategies women employed to overcome them. Using a mixed-methods approach combining survey and interview data with participant observation, we found that low-income women experienced structural and economic barriers to abortion even though abortion is covered by the state Medicaid program in Oregon. Social support helped women overcome obstacles, and a lack of support was itself experienced as an obstacle. Women of lower socioeconomic status also encountered more barriers and had a more difficult time overcoming them. Our findings indicate the need for improved advocacy to reduce structural delay, and to improve access to social support and other resources needed for timely abortion care.

The development of a consensus statement on normal physiologic birth: a modified Delphi study.

INTRODUCTION This article describes the process of developing consensus on a definition of, and best practices for, normal physiologic birth in the United States. Evidence supports the use of physiologic birth practices, yet a working definition of this term has been elusive. METHODS We began by convening a task force of 21 individuals from 3 midwifery organizations and various childbirth advocacy and consumer groups. A modified Delphi approach was utilized to achieve consensus around 2 research questions: 1) What is normal physiologic birth? and 2) What practices most effectively support its achievement? Answers to these questions were collected anonymously from task force members during multiple phases that included a preliminary briefing, an initial face-to-face roundtable, 9 iterative Delphi rounds, and reciprocal feedback from a wider audience of stakeholders at national and international conferences. Content analysis identified specific statements and concepts in the first Delphi round, which were subsequently ranked in following rounds. An initial draft was constructed based on the priorities that emerged and presented for feedback to peers and childbirth advocates whose comments were incorporated into the final document. RESULTS Four key themes were identified from our initial questions; these provided the framework for the document: 1) definitions of normal physiologic birth, 2) mechanisms and outcomes of normal physiologic birth, 3) factors that influence normal physiologic birth, and 4) recommendations for increasing normal physiologic birth. These areas comprised the final sections in the multi-organizational consensus statement. DISCUSSION The modified Delphi approach we employed allowed for the development of a consensus statement that will serve as a template for education, practice, and future research in maternity care. The completion of this statement marks the beginning of a project to promote systemic changes that support normal physiologic birth, and thus, have the potential to improve outcomes for mothers and infants.

A Crusade Against Home Birth

A recent study by Grunebaum et al examined the relationship between place of birth and adverse neonatal outcomes (Apgar of 0 at 5 minutes, and neonatal seizures or serious neurologic dysfunction—hereafter referred to as neonatal seizures) as reported in birth certificate data from 2007 to 2010 for term newborns (n = 13,891,274) (1). Outcomes were analyzed by four practitioner types: hospital physician, hospital midwife, freestanding birth center midwife, and home birth midwife. The authors claim that babies born at home and in freestanding birth centers were at a significantly higher risk of having a 5-minute Apgar score of 0 (RR = 10.55 and 3.56, respectively) and neonatal seizures or serious neurologic dysfunction (RR = 3.80 and 1.88). However, these findings must be interpreted with caution for several reasons. Limitations of birth certificate data for epidemiologic analysis have been widely discussed in the literature, and include concerns about the completeness and accuracy of reporting of specific items on birth certificates, and the inability of birth certificates to provide longitudinal information (such as for planned home births that transfer to the hospital) or information on clinical intentions (2–4). The neonatal seizure variable, for example, is one of several medical variables unreliably reported on birth certificates (4–6). Two detailed studies comparing birth certificate data to medical records in New Jersey and Tennessee yielded sensitivity rates for neonatal seizures of 0.226 and 0.182, respectively (5,6). This means that approximately 80 percent of cases of neonatal seizures identified on medical records are not reported on birth certificates. Data of this poor quality should not be used as the main outcome measure in any study. Although reporting of data on 5-minute Apgar scores in broad categories (such as <7 or ≥7) is a bit better (7), no studies have examined the validity of reporting of 5-minute Apgar score = 0. However, there is substantial evidence that the reporting of this item on birth certificates is very problematic. Watterberg found that although large differences existed between home, birthing center, and hospital settings for reported Apgar scores of 0 and 10, these differences were greatly reduced for Apgar <4, and virtually eliminated for the combined category of Apgar 9 or 10 (8). There appear to be real differences between how physicians and home and birth center midwives perceive and report Apgar scores at the edges of the Apgar spectrum. Physicians are more likely to report fine gradations of either very low or very high Apgar scores, whereas home and birth center midwives are more likely to report Apgar scores of 0 or 10 more absolutely. Apgar score <4 is the more commonly used measure of early neonatal compromise, and has the added advantage of providing greater numbers of cases for analysis. The reported odds ratios for 5-minute Apgar score of 0 and neonatal seizures in the Grunebaum et al study are based on very small numbers of cases, and thus have limited generalizability or clinical relevance. It is also well-established that Apgar scores are poor predictors of neonatal outcomes (9), so even if these data could be improved, they

Birth and the Big Bad Wolf: An Evolutionary Perspective1

Once upon a time, there were six little pigs who set out to seek their fortunes in the world (okay, we know that in the original story there were only three, but just bear with us here!). Far away from home they journeyed, until the first little pig spied a peaceful meadow with a stream running through it; there he stopped his hot and weary journey. In 2 hours he had built himself a house of straw, then he spent another hour building animal traps, after which he set about to laugh and dance and play all day. It was like that every day – he would spend 3–5 hours hunting wild game, after which he could do as he pleased. The female pigs gathered wild grains, tubers and fruits so that food was available even when the hunt failed. Although the first little pig didn’t always like to admit it, the female pigs brought in 70–80% of the diet from foraging, and often helped with the hunting and trapping as well. He was feeling very content, for he had wished to find an environment that could sustain him and his small band of kin pigs, and he had. Sure, he and his like-minded friends experienced high infant mortality rates and a resulting life expectancy of around 35 years, as well as high death rates from endemic disease and accidental death. However, as they discussed frequently in their abundant leisure time (in between the long stories they loved to tell), these problems were offset by their varied and nutritious diets and high mobility, which made sanitation and infectious disease transmission non-issues. Life was good and gender relationships egalitarian for the most part.

Mapping integration of midwives across the United States: Impact on access, equity, and outcomes

Poor coordination of care across providers and birth settings has been associated with adverse maternal-newborn outcomes. Research suggests that integration of midwives into regional health systems is a key determinant of optimal maternal-newborn outcomes, yet, to date, the characteristics of an integrated system have not been described, nor linked to health disparities. Methods Our multidisciplinary team examined published regulatory data to inform a 50-state database describing the environment for midwifery practice and interprofessional collaboration. Items (110) detailed differences across jurisdictions in scope of practice, autonomy, governance, and prescriptive authority; as well as restrictions that can affect patient safety, quality, and access to maternity providers across birth settings. A nationwide survey of state regulatory experts (n = 92) verified the ‘on the ground’ relevance, importance, and realities of local interpretation of these state laws. Using a modified Delphi process, we selected 50/110 key items to include in a weighted, composite Midwifery Integration Scoring (MISS) system. Higher scores indicate greater integration of midwives across all settings. We ranked states by MISS scores; and, using reliable indicators in the CDC-Vital Statistics Database, we calculated correlation coefficients between MISS scores and maternal-newborn outcomes by state, as well as state density of midwives and place of birth. We conducted hierarchical linear regression analysis to control for confounding effects of race. Results MISS scores ranged from lowest at 17 (North Carolina) to highest at 61 (Washington), out of 100 points. Higher MISS scores were associated with significantly higher rates of spontaneous vaginal delivery, vaginal birth after cesarean, and breastfeeding, and significantly lower rates of cesarean, preterm birth, low birth weight infants, and neonatal death. MISS scores also correlated with density of midwives and access to care across birth settings. Significant differences in newborn outcomes accounted for by MISS scores persisted after controlling for proportion of African American births in each state. Conclusion The MISS scoring system assesses the level of integration of midwives and evaluates regional access to high quality maternity care. In the United States, higher MISS Scores were associated with significantly higher rates of physiologic birth, less obstetric interventions, and fewer adverse neonatal outcomes.