Home Birth Summit Opens Dialogue on Improving Care

Yael Waknine

November 03, 2011

November 3, 2011 — For the first time in US history, a cross-section of the maternity care system has met to discuss the future of American home birth, reaching a consensus on 9 recommendations for improving maternal and newborn care.

The Home Birth Consensus Summit was held at the Airlie Center in Warrenton, Virginia, from October 20 to 22, 2011, and involved a novel conglomeration of practitioners, consumers, insurers, lawyers, ethicists, administrators, and policymakers, as well as researchers with expertise in epidemiology, public health, midwifery, obstetrics, pediatrics, nursing, sociology, medical anthropology, the law, and health policy research.

"It was a really incredible experience. There was a lot of good will and professionalism," said Saraswathi Vedam, CNM, MSN, SciD(hc), convener and chair of the multidisciplinary steering committee, in an interview with Medscape Medical News, noting that common goals were shared among physicians, midwives, consumers, and legislators. "The process that we went through with the Future Search model allowed an opportunity for everyone to present their viewpoint." The Future Search Network is a nonprofit agency that strives to reach consensus among diverse stakeholders in areas of high conflict.

The resolutions adopted by the summit encourage pregnant women to share in the decision-making progress, promote effective communication among licensed health professionals, urge improvements in the medical liability system, and affirm the value of physiologic birth for women while providing interventions that are appropriate for achieving optimal outcomes.

"The statements are important, but really, what we do with the statements and how we move forward may take a long time. It may take a decade, but to move forward on some of these areas with consumers, clinicians, policymakers, and researchers requires all of us to work together to facilitate good medical care and access to care." added Dr. Vedam, noting that participants are already taking the information back to their own settings and putting it into practice.

Safety Concerns

Although home birth rates have remained at less than 1% in the United States for several decades, a resurgence of interest in this option has been accompanied by safety concerns and inter-professional conflicts regarding appropriate locations for birth.

As previously reported by Medscape Medical News, a number of studies have shown that the safety of an attended home birth for low-risk women is equal to the risks of giving birth in the hospital or a birthing center.

However, the American College of Obstetricians and Gynecologists (ACOG) opposes home birth on the basis that a seemingly uncomplicated birth can still potentially become a medical emergency without warning, resulting in a 2- to 3-fold increase in the risk for newborn death.

"As physicians, we have an obligation to provide families with information about the risks, benefits, limitations and advantages concerning the different maternity care providers and birth settings," said Richard N. Waldman, MD, ACOG president, in a committee opinion news release. "It's important to remember that home births don't always go well, and the risk is higher if they are attended by inadequately trained attendants or in poorly selected patients with serious high-risk medical conditions such as hypertension, breech presentation, or prior cesarean deliveries." On the basis of the available data, ACOG believes that hospitals and birthing centers are the safest place for labor and delivery.

Value of Summit Findings Questioned

According to the summit news release, addressing "our shared responsibility" allowed the identification of "several important and relevant topics" that might benefit from ongoing multidisciplinary engagement.

Not everyone agrees on the potential benefits of the resulting resolutions, however.

"I [blogged] about the whole birth summit because I thought it had tremendous potential until I saw what it actually was: a conference organized by home birth advocates in which they selected participants based on whether they would agree beforehand with the goals of the summit," said Amy Tuteur, MD, in an interview with Medscape Medical News. "On any substantive issues there was no agreement: The idea that women should have autonomy...that there should be some sort of standard,...everyone agreed on that beforehand as no-brainers."

Dr. Tuteur takes exception to the summit's wishes "not to examine, debate, or form a consensus statement regarding the evidence published regarding safety or maternal–newborn outcomes of planned home birth."

"One of the things that I found most disturbing about the summit was that one issue was off the table from the get-go: there would be no discussion of whether home birth is safe, and that's really the key issue," Dr. Tuteur said. "A group of women have decided that birth should be a certain kind of experience that can only be achieved at home; just don't tell women that it's safe to do."

Dr. Tuteur is an obstetrician-gynecologist, former clinical instructor at Harvard Medical School in Boston, Massachusetts, and author of The Skeptical OB blog, as well as a book entitled How Your Baby Is Born, which is an illustrated guide to pregnancy, labor, and delivery.

Although current statistics suggest a 2- to 3-fold increase in the risk for newborn death with home birth, the reality may be far worse. The Midwives Alliance of North America, although announcing the existence of extensive safety data gathered in the past decade, has put stringent requirements in place for researchers wishing access to those data.

"It does not take a rocket scientist to surmise that [the Midwives Alliance of North America's] own data show that homebirth with an American homebirth midwife is not safe," Dr. Tuteur noted. "Withholding that information from patients is both unethical and immoral."

Lack of adequate education and training for certain midwives may represent a key safety factor.

"One thing that most Americans don't realize is that American homebirth midwives have a pretend credential they give themselves, called 'Certified Professional Midwife,' and any similarity to Certified Nurse Midwife is confusing and deliberate," Dr. Tuteur charged, noting that the certificate can be obtained by mail. "There is no possible way that a high school graduate with a mail-order certificate is qualified to take care of anyone," she emphasized.

According to the news release, the summary statements may be subject to differential interpretation; words such as "autonomy," "independence," and "collaboration" may have different implications for practitioners, policymakers, and consumers.

"It's defining specifically how concepts like those are turned into practice that will require much more discussion," commented John Kattwinkel, MD, consultant for the American Academy of Pediatrics and professor of neonatology at the University of Virginia, Charlottesville, in an interview with Medscape Medical News.

Home Birth Consensus Summit Recommendations

  • Statement 1: We uphold the autonomy of all childbearing women.
    All childbearing women, in all maternity care settings, should receive respectful, woman-centered care. This care should include opportunities for a shared decision-making process to help each woman make the choices that are right for her. Shared decision making includes mutual sharing of information about benefits and harms of the range of care options, respect for the woman's autonomy to make decisions in accordance with her values and preferences, and freedom from coercion or punishment for her choices.

  • Statement 2: We believe that collaboration within an integrated maternity care system is essential for optimal mother-baby outcomes. All women and families planning a home or birth center birth have a right to respectful, safe, and seamless consultation, referral, transport and transfer of care when necessary. When ongoing inter-professional dialogue and cooperation occur, everyone benefits.

  • Statement 3: We are committed to an equitable maternity care system without disparities in access, delivery of care, or outcomes. This system provides culturally appropriate and affordable care in all settings, in a manner that is acceptable to all communities.
    We are committed to an equitable educational system without disparities in access to affordable, culturally appropriate, and acceptable maternity care provider education for all communities.

  • Statement 4: It is our goal that all health professionals who provide maternity care in home and birth center settings have a license that is based on national certification that includes defined competencies and standards for education and practice.
    We believe that guidelines should:

    • allow for independent practice,

    • facilitate communication between providers and across care settings,

    • encourage professional responsibility and accountability, and

    • include mechanisms for risk assessment.

  • Statement 5: We believe that increased participation by consumers in multi-stakeholder initiatives is essential to improving maternity care, including the development of high quality home birth services within an integrated maternity care system.

  • Statement 6: Effective communication and collaboration across all disciplines caring for mothers and babies are essential for optimal outcomes across all settings.
    To achieve this, we believe that all health professional students and practitioners who are involved in maternity and newborn care must learn about each other's disciplines, and about maternity and health care in all settings.

  • Statement 7: We are committed to improving the current medical liability system, which fails to justly serve society, families, and health care providers and contributes to:

    • inadequate resources to support birth injured children and mothers;

    • unsustainable healthcare and litigation costs paid by all;

    • a hostile healthcare work environment;

    • inadequate access to home birth and birth center birth within an integrated healthcare system, and;

    • restricted choices in pregnancy and birth.

  • Statement 8: We envision a compulsory process for the collection of patient (individual) level data on key process and outcome measures in all birth settings. These data would be linked to other data systems, used to inform quality improvement, and would thus enhance the evidence basis for care.

  • Statement 9: We recognize and affirm the value of physiologic birth for women, babies, families and society and the value of appropriate interventions based on the best available evidence to achieve optimal outcomes for mothers and babies.

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