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AMCHP Webinar, July 11, 2013 A Home Birth Primer for MCH Programs Geradine Simkins, RN, CNM, MSN Midwives Alliance, Exec

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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

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AMCHP Webinar, July 11, 2013A Home Birth Primer for MCH ProgramsGeradine Simkins, RN, CNM, MSNMidwives Alliance, Executive Director

benefits of planned home birth home births promote normal physiologic birth
Benefits of planned home birth:Home births promote normal physiologic birth
  • WHO (1996) call for elimination of unnecessary interventions in childbirth
    • Ever increasing rates of obstetric interventions in US, hospital-based childbirth
  • Normal physiologic childbirth (JMWH 2012):
    • 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

  • Privacy
  • Comfort and convenience
  • Low intervention
  • Safety
  • Cultural congruency
  • Family involvement
  • Relaxed, peaceful
home births are on the rise
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
Framework for Optimal CareMidwives and planned home birth
  • Birth site selection & risk screening
  • Basic skills necessary for birth attendants
  • Standard equipment
  • Continuity of care
  • Strong provider/patient relationships
  • Shared decision-making
  • Timely access to consultation and referral
  • Seamless transfer from home to hospital, when necessary
guidelines for newborn care alignment across organizations
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
Collaborative care of the at-risk mother & neonate
  • Ongoing screening for conditions requiring consultation and/or transfer of care
  • Anticipation and preparation for unforeseen complications
  • Communication with obstetric or pediatric staff
  • Continuous 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
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
Standard practices continued
  • Vitamin K treatment
  • Antibiotic eye ointment
  • Umbilical cord care
  • Metabolic newborn screening
  • Glucose and bilirubin testing, as indicated
  • OAE hearing screens
  • Pulse-oximetry

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 h ome b irths in the us
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 reason)
    • 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 (<0.50/1000)
    • 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
Reducing costs andincreasing 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 birth
  • If the cesarean rate was reduced to 15% (WHO recommendation) it would save $5 billion a year
reducing costs and increasing health equity1
Reducing costs andincreasing 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
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 effective

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 allbirth settings


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. doi:10.1002/14651858.CD004667.pub2

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 discrete-choice 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. doi:10.1111/j.1523-536X.2010.00423.x

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. doi:10.1016/j.midw.2011.11.002

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. doi:10.1016/j.jmwh.2005.10.012

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,

geradine simkins executive director executivedirector@mana org

Thank you

Midwives Alliance

1500 Sunday Drive Suite 102

Raleigh, NC 27607

PH 919-861-4530

FAX 919-787-4916


Geradine Simkins, Executive