Ten years ago now, I completed my doctoral work surrounding one of the most controversial topics in #homebirth: neonatal outcomes. Originally my focus was on both fetal heart tone assessments and on neonatal resuscitation, as these are the two greatest contributors to poor outcomes in both homebirth and the birth center setting, but as all good advisors will do, I was reminded I couldn't save the world with one writing so she strongly encouraged me to address neonatal resuscitation. I still feel the wound of abandoning fetal heart tones assessments, but narrowing my focus did help me dedicate more mental space to this very important topic.
My midwifery bags have since been zipped up for the last time, just a few months ago, after twenty years of caring for birthing women and their wee ones. No longer am I attending births in any setting, and gratefully, this work continues in others with the same passion and dedication as myself.
Homebirth is profoundly safe, which hospital birth, particularly in our country, has never demonstrated, but in effort to defend our rights to birth where and with whom we feel is most safe, advocates of homebirth can become a bit over-zealous, blinding ourselves to our own weaknesses. While my position on homebirth has never faltered, the reality is that, like it or not, we could do better for the mommas and babies we provide care. So, here is a smidge of my research from ten years ago, or rather a smidge of my teaching from the neonatal resuscitation course I created, and while a little outdated, it will get you started in what I hope is an introspective look into your own practice and attitudes surrounding your role and responsibility in attending births at home, or cause you to better explore questions you might ask your own midwife, because we don't really hire our birth attendant for her sweet disposition, but rather, because if the rare circumstance arises in which our child needs life saving support, we want to know we've secured a competent provider for saving our lives.
The American College of Nurse-Midwives identifies the Certified Nurse-Midwife as "responsible for providing a safe environment for birth, regardless of whether birth occurs in the hospital, birth center or home" (ACNM, 2011). They further share the key components of a safe birth environment as "having the necessary skills and resources to correctly and promptly perform neonatal resuscitation, extend the ability to effectively stabilize the neonate, and collaborate within the healthcare infrastructure in effort to access care as determined necessary" (ACNM, 2012 & Zaichkin, 2011).
Do You Know the Truth about the Controversial Wax Study?
Homebirth and its safety has been a topic of controversy for several decades. However, the welfare of neonates born in the homebirth setting specifically came into question following the publication of a large meta-analysis, published in 2010, reviewing eleven studies and the outcomes of 500,000 home births (Wax, Lucas, Lamont, Pinette, Cartin & Blackstone, 2010). Overall, neonatal death rate for home born newborns was figured at three-fold those of hospital born newborns, and among nonanomalous neonates, the mortality rate was more than four-fold (Wax, Lucas, Lamont, Pinette, Cartin & Blackstone, 2010). These rates were contributed only to “other midwives,” as studies that included home births attended by certified nurse-midwives demonstrated a neonatal death rate that was not significantly different from those born in the hospital (Wax, Lucas, Lamont, Pinette, Cartin & Blackstone, 2010).
While controversy surrounds the Wax (2010) study and its methodological flaws, a number of other studies have supported the finding that neonates suffer a worse fate if born at home. A retrospective study published the same year as the Wax (2010) study demonstrated neonates to be twice as likely to die in the home birth environment than those born in the hospital, and if the attendant was not a nurse-midwife, neonatal deaths were nearly four-fold (Malloy, 2010). A third study also published in 2010, found perinatal deaths significantly higher among low risk pregnancies supervised by midwives in primary care, than in pregnancies supervised by obstetricians (Evers, Brouwers, Hukkelhowee, Niddels, van Egmond-Linden, Hillegersberg, Snuif, Sterken-Hooisma, Bruinse, & Kwee, 2010). Older studies, which may or may not hold any significance today, add to the debate (Bastian, Keirse, & Lancaster, 1998; Janssen, Lee, Ryan, & Saxell, 2003; Johnson & Daviss, 2005; Kennare, Keirse, Tucker & Chan, 1996; Murphy & Fullerton, 1998; Northern Region Perinatal Mortality Survey Coordinating Group, 1997; Pang, Heffelfinger, Huang, Benedetti & Weiss, 2002).
However, since publication of the Wax et al (2010), Malloy (2010), and Evers et al. (2010) studies, six additional peer-reviewed retrospective studies have been published demonstrating consistency with the aforementioned studies: planned home births are associated with increased neonatal complications but fewer obstetrical interventions (Birthplace in England Collaborative Group, 2011; Chang & Macones, 2011; Cheng, Snowden, King & Caughey, 2013; Cheyney, Bovbjerg, Everson, Gordon, Hannibal, & Vedam, 2014; & Grunebaum, McCullough, Sapra, Brent, Levene, Arabin & Chervenak, 2013).
It's really hard not to get a little butt-hurt with these studies because we know, as midwives, we work really hard to create a safe environment for mom and baby, and we recognize all the horror that occurs in the hospital. Our country's statistics in maternal and child health is truly absurd and ignored. We also know that society has a very skewed perception of midwifery and homebirth so we are often having to be fierce advocates for our clients and even ourselves. However, if we think like scholars and really look at this evidence without taking it personally, there is much we can learn here and a few places we can clean up our skill set for the betterment of the childbearing families who trust us to protect their little ones. Let's look at some of these studies individually.
Birthplace in England Collaborative Study
This study compared 64,538 eligible women who were attended in labor within the home setting, freestanding midwifery unit, midwifery-led hospital setting, or an obstetrical unit and determined that the nulliparous woman attended at home had the poorest perinatal outcomes. Nulliparous is defined as women who have not given birth, so this often confuses readers, but the study enrolled them during their pregnancy so this is how the researchers chose to define these women.
Chang & Macones
Researchers Change & Macones utilized the Missouri vital record system for data gathering, which is considered reliable and adopted as a “gold standard” to validate other vital statistic databases in the United States. This study evaluated 859,873 singleton pregnancies from 1989 to 2005, included only home births which were planned and the attendant was identified as a physician, nurse-midwife or other midwife, and other.
This study observed a higher rate of intrapartum fetal death in planned home births attended by physicians and CNMs, followed by births attended by non-CNMs, compared with births in hospitals and birthing centers attended by physicians or CNMs (2011).
Cheng, Snowden, King, & Caughey
This 2013 study evaluated 2,081,753 term, singleton live births born in the United States in 2008 using the Vital Statistics Natality Data by the CDC. Homebirths were identified as accidental, intended, or unknown and excluded if unclear. Attendants were also identified as MD, DO, CNM, other midwife, others, and unknown.
Infant outcomes with CNMs in planned homebirths did not differ significantly from those attended in the hospital, except those born in the hospital were more likely to be admitted to the NICU. Those infants attended at home by “other midwives” had lower 5-minute APGAR scores <4 and an increased risk of seizure compared with those born in the hospital.
Grunebaum, Sapra & Chervenak
At the time I presented my doctoral work, this was an unpublished research study presented at the Society for Maternal-Fetal Medicine conference in New Orleans in February of 2014. A few years later, I followed up on publication and it remained unpublished. However, it was a retrospective cohort using the CDC linked birth and death dataset from 2007 to 2009.
This study found patients who delivered at home had roughly four times higher risk of neonatal deaths than babies delivered in the hospital by midwives. The increased neonatal mortality risk was associated with the location of a planned birth, rather than the credentials of the person delivering the baby. Again, I have yet to read the published study.
MANA Stats
These were voluntarily submitted statistics provided by approximately 432 different MANA midwifery members (79.2% of who were certified professional midwives), providing a dataset of 24,848 women. Authors calculated the intrapartum fetal death rate as 1.30 per 1000, the early neonatal death rate as 0.88 per 1000, and the late neonatal death rate as 0.41 per 1000. Cheyney, Bovbjerg, Everson, Gordon, Hannibal, & Vedam (2014) conclude the MANA Stats outcomes as consistent with the de Jonge et al (2009) and the Birthplace in England Collaborative Group (2011), yet these two studies are not congruent.
The deJonge (2009) study concluded home and hospital outcomes to be similar, but the Birthplace in England Collaborative Group (2011) determined neonatal mortality outcomes to be significantly higher among nulliparous women who choose to birth at home to those in a freestanding midwifery unit, alongside midwifery units, or the hospital. Further, the overall perinatal death rate is not figured for the reader, which invites the question, why? If we do the math ourselves though, adding the above data points provides an overall rate of death at 2.59 per 1000. Notice the concern?
NRP Steering Committee & Homebirth
Unfortunately, the steering committee for the American Academy of Pediatrics (AAP) and the American Heart Association (AHA) has taken a strong stance that attendants at births within the home and birth center setting are not sufficiently educated or skilled so that they may be trained to efficiently and effectively provide a full resuscitation, nor are they even capable. Although the AAP acknowledged in 2013 that "newborns have a right to effective and efficient resuscitation efforts no matter their birth setting," and Kristi Watterberg MD, FAAP, lead author of the policy from the AAP Committee on Fetus and Newborn states, "We think it's very important that wherever babies are born, they get care that adheres to the same standards that the AAP has set forth that should happen in hospitals" (2014, www.aapnews.aappublications.org), the organization ignores the fact that they disallowed homebirth midwives from certifying as NRP educators in 2008 and renamed their course to be specific to hospital births which created significant barriers for homebirth and birth center midwives to access training. This has yet to be rectified and my conversations with members of the NRP Steering Committee in 2014 and 2015 in attempt to address this oversight were truly disheartening.
Statements such as, "Well, the midwives we have around here could not possibly manage intubation or an umbilical line placement," although the risk of not achieving either of these when necessary is death, therefore, there is no risk that would supersede this effort. Better for a child to complain their jaw had been broken and recovered, than for them to demise because an airway could not otherwise be established. What I find more arduous about this argument is the clear lack of appreciation for the plethora of emergency skills midwife have to master otherwise? This position by the NRP Steering Committee and the ultimate barrier to training that exists for midwives stems from a lack of familiarity with our profession and to be quite frank, it's both reckless and oppressive.
The evidence is clear that training in obstetrical emergencies significantly reduces the incidence of infants born with a 5-minute APGAR score of 6 or less, and hypoxic-ischemic encephalopathy (HIE), and that this improvement is sustained over time (Draycott, Sibanda, Owen, Akande, Winter, Reading & Whitelaw, 2006). A large systematic review evaluating the mortality effect of immediate newborn assessment, stimulation, and basic resuscitation on neonatal deaths, due to term intrapartum-related events or preterm birth for facility and homebirths, concluded that neonatal resuscitation training reduces term intrapartum-related deaths by 30 percent (Lee, Cousens, Wall, Niermeyer, Darmstadt, Carlo, Keenan, Bhutta, Gill & Lawn, 2011).
My hope with my doctoral work was to address the misconception about midwifery while also creating an accessible training for midwives that would ultimately raise the standard for homebirth with regards to neonatal care. It was my belief that integrating this training with a few fairly simple adjustments that would help establish the setting would allow the hospital-based attendant to gain greater understanding on both the profession and the level of care which can be provided in these settings, and allow the homebirth-based and birth center-based provider to also develop relationships for collaboration. It behooves the midwife to well understand the challenges practitioners face in receiving homebirth and birth center transfers, but certainly each can learn from the other's expertise which builds trust and respect.
Homebirth Equipment
This important aspect of neonatal resuscitation, is an example of an area left unaddressed within the hospital-based NRP course with respect to birth center and homebirth-based providers. While there is some consistency for birth center providers, there is little to no consistency for homebirth attendants. Birth centers are still challenged to consider all the potential possibilities that come with a transfer and this course doesn't address those, which is exceedingly important if our goal really is to improve outcomes for the neonate. No matter your setting, each practice should have an equipment checklist. As part of my doctoral work, I created a list of equipment for my own homebirth practice. In fact, we were the first practice in the country to implement the Neo Tee in our homebirth practice for resuscitation of the newborn.
Do You Have a Plan? Do You Know Your Midwife's Plan?
As a practice, have you created a plan to effectively and efficiently manage neonatal emergencies? What plan have you created for calling 9-1-1? Whose responsibility is this? Who talks to the dispatcher and what is their script? Who talks to emergency personnel once they arrive and do you have specific details in place to optimize their speedy arrival? How might you handle the scenario if your first attendants were first responders verses emergency medical technicians or paramedics? No joke, this is often when utter chaos ensues because emergency responders, particularly first responders and EMS, not as much paramedics, can absolutely ignore the report of the midwife, attempt to over power her expertise, and compromise safety. Emergency responders are not trained in neonatal resuscitation. Many remote ambulance teams, even remote hospitals, lack the basic equipment for a neonate, in spite of recommendations otherwise.
How will you warm your neonate when they are vulnerable during a resuscitation? How will you maintain that during transport? How will you maintain a proper airway through transfer and while you may have sufficient equipment and supplies for immediate use, what might you need in transfer that the ambulance is not typically equipped? All important and unaddressed questions in the current hospital-based training program.
Surveying Midwives regarding Neonatal Resuscitation
One of the most common questions among midwives when they are first opening their practice is what equipment and supplies should they have available for each and every birth. There is a great deal of controversy here as well, because many hold the belief that some skills should only be done in the hospital, yet they lack the appreciation for how long that care can sometimes take to access and the fact that again, "all babies, no matter their birth setting, deserve access to the same level of care they can achieve in any other setting." We are very capable, as midwives, of providing all the same care for the neonate that is provided in our remote hospitals. We are experts in far more complicated emergency scenarios; however, there is no risk greater than that of death, and a neonate without an adequate airway or heart rate will result in death.
A few surveys of midwives have been conducted, although older, to determine what they felt appropriate for a safe homebirth and this helps create a standard of care. Additionally, studies such as the College of Midwives of British Columbia, published in 2003, helps us establish a standard regarding neonatal resuscitation efforts in the homebirth setting.
College of Midwives of British Columbia
This publication was the results of the British of Columbia evaluating outcomes of their homebirth-based midwives and they found that competency in intubation skills needed further evaluation, as not all distressed babies exposed to thick meconium during the study were suctioned by the trachea (Janssen, Lee, Ryan, & Saxell, 2003). This recommendation by NRP to visualize the cords prior to the first breath and suction away any identified meconium retired around 2014-2015. While found unnecessary, it was a skillset that helped midwives gain experience in initiating intubation skills. Certainly opportunity for gaining experience doesn't supersede The LMA further reduced opportunity
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