SimkinsSlides0713 - Association of Maternal & Child Health Programs

AMCHP Webinar, July 11, 2013
A Home Birth Primer for MCH Programs
Geradine Simkins, RN, CNM, MSN
Midwives Alliance, Executive Director
+ Benefits of planned home birth:
Home births promote normal physiologic birth
WHO (1996) call for elimination of unnecessary interventions in childbirth
Normal physiologic childbirth (JMWH 2012):
Ever increasing rates of obstetric interventions in US, hospital-based childbirth
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
Comfort and convenience
Low intervention
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 Care
Midwives and planned home birth
 Birth
site selection & risk screening
 Basic
skills necessary for birth attendants
 Standard
 Continuity
 Strong
of care
provider/patient relationships
 Shared
 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
 Communication
 Continuous
with obstetric or pediatric staff
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
Glucose and bilirubin
testing, as indicated
OAE hearing screens
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 US
Data 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
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
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 and
increasing 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
If the cesarean rate was reduced to 15% (WHO recommendation) it would
save $5 billion a year
Reducing costs and
increasing 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 message
1. Planned home birth means
appropriate use of intervention,
focusing on safe, healthy,
normal physiologic birth
2. Planned home birth is cost
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
+ References
American Way of Birth, Costliest in the World, New York Times, June 30, 2013.
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,
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.
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 discretechoice 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.
How to Save $5 Billion in Healthcare Spending for Employers & 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.
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.
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.
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, 6. Maternity Care, Center for Healthcare Quality and Payment Reform,
Thank you
Midwives Alliance
1500 Sunday Drive Suite 102
Raleigh, NC 27607
PH 919-861-4530
FAX 919-787-4916
Geradine Simkins, Executive Director
[email protected]

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