Monday, November 7, 2011

Post - Over at 10 Centimeters Blog Today

While I am somewhat skeptical of the Canadian research on homebirth (every other country in the world shows an increase in relative risk to homebirth) - I am very thankful for the relative strength of the Canadian system of midwifery (highly regulated with high levels of credentials - at least in BC) and am thankful for the good work of midwives in Canada providing quality care to pregnant women.

In the US, the situation is much different. My understanding is that CNMs (Certified Nurse Midwives) are similar to Canadian midwives, and are respected professionals who provide quality care to pregnant women - frequently providing that care in hospitals in collaboration with other professionals such as OBGYNs. However, many midwives who provide services to women who desire to birth at home in the US have little more than a post-high school certificate. This is concerning and dangerous. As such my comments on the HomeBirth Consensus Summit apply to the situation (as I understand it) in the US. My post on is as follows:

The Nine Statements of Consensus from the Home Birth Summit: Nine Times Nothing is Still Nothing

There are substantive and real issues confronting the home birth and obstetric communities in the United States. Having a summit could have moved things forward, fairly substantially, if they actually took the 9 pre-determined agreed upon consensus statements and used them as starting points, instead of accomplishments – because nothing is accomplished as a result of the statements made.

#1. We uphold the autonomy of all childbearing women…

Autonomy in the absence of complete and unbiased information is meaningless – there cannot be free informed choice when the information given to women on childbirth is incomplete or biased. A woman must be informed of the risks and benefits of the choice she is making if she is to be empowered to make the choice that best meets her needs and the needs of her child. If the autonomy of childbearing women is to be upheld, there must be a consensus on what the real facts of childbirth are, and a commitment to providing that information to women in an unbiased and accessible way.

#2. We believe that collaboration within an integrated maternity care system is essential for optimal mother-baby outcomes…

Again a really lovely idea, but, clearly there are substantial barriers to making this a reality in the current system. In order to collaborate, midwives and OBGYNs need to speak the same language. In order to collaborate, midwives and OBGYNs would need to hold each other in esteem and respect. In order to collaborate, they need to facilitate the work of one another. This means that when a woman who is at risk in labor is transferred to hospital for care, the hospital is prepared for her arrival before hand and the midwife is capable of giving full and appropriate information about the woman and her labor to the OBGYN upon arrival.

#3. We are committed to an equitable maternity care system without disparities in access, delivery of care, or outcomes…

Homebirth as it exists in the US today does not ameliorate disparities in access, delivery of care, or outcomes – it accentuates them.

Women in the US are far more at risk accessing the homebirth system than the hospital birth system. They are at risk of having a care provider who does not undertake standard and appropriate prenatal care (gestational diabetes testing, group B strep testing, weight and fundal height measurements, and pre-natal ultrasounds). They are at risk of having a provider who does not have adequate and appropriate education and experience. They and their babies are at greater risk of death or disability and they are at risk of having a provider who does not carry malpractice insurance and who would be held accountable to a lower standard of care in the event of death or disability.

There will continue to be disparities in access, delivery of care and outcomes and these seem unavoidable in the current context.

#4. 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…

This begs the question what is the appropriate standard? Furthermore, in the absence of legislation, what would be the consequence of failing to meet the standard?

#5. We believe that increased participation by consumers … is essential to improving maternity care…

Is this the facilitation of informed joint decision making during the care delivery process? If so, See number 1. Or, perhaps more meaningfully, will this mean that consumers would have a way of voicing their concerns and having those concerns heard in much the same way that hospital patients can have a formal review of the care they received?

#6. Effective communication and collaboration across all disciplines caring for mothers and babies are essential for optimal outcomes across all settings…

See #2.

#7. We are committed to improving the current medical liability system …

Another starting point – what medical liability system currently applies to homebirth midwives? Doesn’t a system need to be in place before it can be improved upon? Is there an insurer that would take on the risk in the current environment?

#8. We envision a compulsory process for the collection of patient … data on key … outcome measures in all birth settings….

So. Data is collected. MANA collects data. Does a $#!T load of good – unless you commit to releasing the data, it means nothing. Data existing does nothing without it being available to be analyzed, actually having it analyzed and releasing the results of that analysis. Furthermore, there needs to consensus on what data elements are critical and the definitions of those elements – this is essential if the data across birth settings are to be comparable and the data is to be transformed into meaningful information.

#9 We … affirm the value of physiologic birth … and the value of appropriate interventions based on the best available evidence to achieve optimal outcomes for mothers and babies…

This seems at odds with valuing patient autonomy, particularly when not all pregnant women giving birth would choose physiologic birth if given complete information to make an informed choice. Furthermore, valuing the particular process of birth (physiologic, a.k.a. “normal birth”) places form over function – shouldn’t the ultimate goal be healthy moms, healthy babies regardless of delivery method?

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