Is intravenous glucose given? If so, in what situations, and can the mother refuse it? Are analgesic drugs used? Do they offer epidural anesthesia?
Do they have a time limit on the second stage of labor? What percentage of their women have episiotomies? Do they ever provide assisted deliveries with forceps or suction? If so, in what situations? Can I walk around during labor? Can I give birth on the floor if I wish? Can I give birth standing up?
How do you help a woman who is having back labor? Can I take a bath or shower during labor? Can I eat and drink during labor? Will there be a midwife with me throughout the first stage? Is there a birth pool? Your Next Steps: Contact your local hospital to find out if they are affiliated with any birth centers Read more about using a midwife for your birth Want to Know More?
Can I get pregnant if…? Share this post:. Share on facebook Facebook. Share on twitter Twitter. Share on linkedin LinkedIn. Share on email Email. Similar Post. Labor and Birth. Preparing for Labor Checklist Are you prepared for labor? Being informed about general anesthesia will help prevent mothers from being caught by surprise…. By , there were more home births in the United States than in any other industrialized country Martin et al. Who is available to provide births outside the hospital in the US?
Clearly these groups specialize in birth in the larger community outside the hospital. Again, CPMs rarely—if ever—have hospital privileges. CPMs are not currently recognized under Medicaid at the federal level. However, as of December , 14 of the states in which CPMs are legal have also opted, through a state plan amendment, to cover CPM services 6. CPMs and families who want access to their services are seeking federal recognition to secure Medicaid coverage in all states in which CPMs are licensed and meet certain educational requirements 7.
It is important to emphasize that births attended in private homes and freestanding birth centers require providers specifically trained to do so with proper equipment, protocols in place for transport to hospital, and back up hospitals pre-arranged.
As one physician reports: I have served as a collaborative physician for several CNMs making the transition from hospital to home birth practice and have seen how steep the learning curve is, especially in their first year. To focus on safety in home and birth center birth, then we have to admit that it requires a different skill set than hospital birth and that providers practicing in the community setting must be trained in that skill set to maintain the safety of the environment Personal communication, Sarita Bennett, DO, CPM.
Although many Americans have assumed that more CNMs could start doing home births if they so desired, it appears difficult for the US administrative facilities to consider something the other way around--that CPMs could work in hospitals.
Because Canada deliberately chose not to create distinctions between nurse-midwives and other midwives at legislation, it is rare that Registered Midwives in Canada are also nurses. Yet all midwives in the standard Canadian model must have hospital privileges and do at least some hospital births, as well as home births.
In Canada, in the US states that have legislated and adopted insurance coverage for CPMs, and in other countries that have discovered or continued to recognize the importance of midwives who provide care in the community outside the hospital, a critical commonality has emerged.
In the US in , midwives attended There are no data yet available to establish how much home births and freestanding birth center births are on the rise with COVID, but there is ample suggestive evidence from across the country that it is: in professional journals see Davis-Floyd et al.
Thus, investigating the efficacy and feasibility of better integrating and increasing birth in alternative settings seems timely. The two most recent meta-analyses examining perinatal outcomes for birthing people with low-risk pregnancies in high-income countries have demonstrated similar levels of safety for hospital and planned, midwife-attended births in private homes or freestanding birth centers. An Australian meta-analysis Scarf et al. That meta-analysis of four studies of planned home births also identified significantly lower odds of NICU admission than for planned hospital births, with an odds ratio OR of 0.
Scarf et al. A Canadian meta-analysis found 14 eligible international studies—representing more than , home births—which met their strict criteria for comparing planned home to planned low-risk hospital birth Hutton et al. Stratifying their analyses by whether or not the midwives attending the home births were well integrated into the health services, they found that in jurisdictions where midwives were well integrated, perinatal and neonatal mortality summary risk estimates were essentially identical for intended home births and intended hospital births.
The summary OR was 1. In less integrated settings, Hutton et al. However, because both estimates had large confidence limits due to the small numbers of deaths on which they were based, chance cannot be ruled out for the increase—the estimate on primips was based on 1 newborn death in home births The estimate for primips was OR 3.
Despite limited institutional support for credentialed midwives in the United States attending births in private homes and freestanding birth centers, the weight of evidence in US cohort studies indicates that births in these settings have good outcomes when the studies: 1 are based on charts rather than birth certificates, because the latter often lack accurate outcome and care details; 2 identified low-risk women; 3 are able to discern the planned place of birth, thereby avoiding counting accidental, unplanned out-of-hospital births; and 4 are conducted on a defined group of midwives with training standards.
Even where the defined group of practitioners had questionable homogeneity of education and a varying degree of integration into the US maternity care system, outcomes were similar to those in the other studies cited for low-risk birthing people Cheyney et al.
This section demonstrates that births in homes and freestanding birth centers are far less expensive to society than hospital births. Combined with the evidence that outcomes are similar among low-risk mothers who plan their births in private homes, birth centers, or hospitals, this fact reveals a win-win situation: childbearers choosing their own home or a freestanding birth center can have the safety of hospital births at a fraction of the cost to families or insurers.
There are approximately 3. Table 1 summarizes the potential savings from a modest increase in the use of private homes or freestanding birth centers in the United States. For this analysis, we make the simplifying assumption that those transferred to hospital would pay the average costs associated with hospital births. Table 1 is reproduced from Anderson et al. TABLE 1. In the Scarf meta-analysis , women planning a hospital birth were nearly three times as likely to have a cesarean or instrumental forceps or vacuum delivery as those planning a home birth, and nearly twice as likely to have a cesarean as those planning a birth center birth.
Similarly, there has been consensus across the literature for decades that planned home and birth center births in the United States entail significantly less medical intervention than planned hospital births Johnson and Daviss a ; Cheyney et al. Our cost analysis of interventions focuses on cesareans because they are both the costliest intervention and the cause of numerous safety concerns. It is beyond our scope here to quantify the economic costs of a current cesarean on future pregnancies.
Although the risk of a serious problem during a typical cesarean birth is low, with almost one-third of US births being cesareans, problems occur and costs are high. When prenatal care is provided by credentialed midwives, the incidence of low birthweight decreases.
For example, the rate decreased from 2. Competition is a moderating force for prices and an incentive for improved quality. Robinson found that hospitals with limited competition charged commercial insurers Again, CPMs can practice legally in only 36 states If legislation enables them to serve more of the 50 states and territories and join forces with the Certified Nurse-Midwives CNMs and Certified Midwives CMs who also attend births in homes and freestanding births centers, midwives can become low-cost, service-oriented hospital competitors.
The Big Push for Midwives is a national campaign in the US initiated and driven by consumers wanting to increase access to care by midwives attending births in the broader community, not just in the hospital.
It focuses on increasing access to CPMs by pushing for legislation that legalizes them in the 14 holdout states and also on the need for CNMs to come out from the requirement of physician sign-off on their care: We like to emphasize that competition is valued as an economic concept because it reduces costs and increases access and quality of goods and services for consumers.
As the Big Push for Midwives Campaign posted on social media December 30, , 12 to the extent that public policy mandates hospitals or physicians to sign-off for a single visit, or that midwife-guidelines approval is granted to physicians, they have been handed the weapon they can use to limit the financial and clinical impact of competition.
Because hospitals would still be the exclusive providers of care for complications, we assume here that only the price for an uncomplicated birth would decrease. There is substantial evidence that competition also affects treatment decisions in hospitals Gaynor et al. Intensified competition from CPM-attended home births, which have a 5. This proposal to facilitate an increase in births at home or in freestanding birth centers, if implemented, would represent a huge win for the many constituents who want access to safe and normal physiologic childbirth with fewer interventions, freedom of choice for a variety of ideological, religious, cultural, financial or personal reasons, and lower maternity care costs for American society.
The successful implementation of US policy to increase rates of home and freestanding birth center births would be facilitated by at least tacit support from the national obstetric and public health communities. A detailed description of the history and politics behind the American College of Obstetrics and Gynecology ACOG statements on home birth and a rationale for better integrating midwives specializing in births at home and in freestanding birth centers in the US can be found in Anderson et al.
However, unfortunately, ACOG has not updated its analysis to include the two new home birth meta-analyses Scarf et al. In short, the Snowden et al. A subsequent interview published between the principal author of the study, Jonathan Snowden, and Melissa Cheyney, the midwife in the state who happened to be the principal author of the national homebirth study of the Midwives Alliance of North America Cheyney et al. However … over 1 in 6 women would definitely want midwives or labor doulas for a future birth.
In addition, more than 1 in 3 would consider using these care team members Some of this was the result of the lack of options of available insurance providers. For example, nearly 1 in 4 Black or Latina women had their prenatal care provider assigned to them, apparently by their primary provider, compared to less than 1 in 8 white women See Figures 4 , 6 , what Indigenous, Black and Latina women deserve to have offered, and Figure 5 , how it was taken from them in the s. She attended circa babies at home in Alabama, many during times when African American women were denied entry to hospitals.
She discovered their outcomes were good, but a Medicaid pay hike for physicians and the introduction of nurse-midwives had made poor African American pregnant women financially lucrative for hospital practitioners Financial Planning Division, Alabama Medicaid Interviewing the midwives and women, Betty-Anne realized that nobody had asked the women what they wanted. Photo by Ken Johnson. Midwives like Jennie Joseph left , who practices in Florida, are picking up from where Miss Margaret and the other Grand Midwives of the South have left off -because the latter are no longer permitted to practice.
However, even with her Certified Professional Midwife credential and state license, and in spite of the fact that she and her team have reduced prematurity and low birth weight rates within the Black, Indigenous, and People of Color community, their attempts to get any government support from grants or other public health or civic funds have been unsuccessful.
Not supporting all pregnant women to have health care, during pregnancy or any other time of their life, is unheard of in countries like the UK where Jennie was originally trained as a midwife.
These intimate moments of shared trust and respect, illustrated here between client Kristen April Brown on the right and Jennie, is what researchers have determined may be behind the consistently better outcomes compared to other clinics and services where women from the same demographic receive maternity care Joseph The current President of the Midwives Alliance of North America, Sarita Bennett, emphasizes that there is a balancing place in US society for those not ready to choose birth in their own home but do not want to go to a hospital, especially during the pandemic: While we can talk about legalizing CPMs, unless we also address changing birth center legislation that is restrictive rather than evidence-based, there will still be limited options, especially for those who might accept birth center birth but aren't ready to make the leap to home birth.
My birth center in a state with no birth center legislation has lots of those families who then choose home birth the next time Sarita Bennett DO, CPM, personal communication, Jan. Pain relief is a major concern of birthing persons, may determine where they seek care, and is related to delivery cost. Some childbearers want to be more physically involved with their births and have fewer interventions.
It is cheaper for birthing persons to use nitrous in home or birth centers, as hospitals can take advantage of the lack of regulation to charge what they want. They pointed to a growing shortage of obstetricians due to job dissatisfaction and early retirement and to the next logical step—to use the already nationally credentialed midwives as primary care providers, as most other countries do.
See Figures 5 and 6. As the pandemic increased the demand for birth setting options, frustrations for childbearers wanting care in their homes also increased, as did the racial and socio-economic disparities between those who can and cannot afford choice of birth setting.
Countries like Canada with universal health care coverage have removed this artificial financial barrier to home births and also established some freestanding birth centers, articulating the obvious—that births outside the hospital are cheaper and more welcoming than engagement with the hospital enterprise; almost all provincial Canadian governments now cover the birth wherever it occurs.
Canada provides a good example of how it is easier to adapt when pandemics or other challenging events occur if midwives are available who can offer a choice of birth settings This increase was easily facilitated because all infrastructures—legislation, insurance coverage, quality assurance programs and integration—were already well established for homebirth providers.
In March and April, clients who had formerly considered a hospital birth did not have to switch providers. They simply told their midwives that they now preferred to stay home. The US states without adequate provisions for care at home or in freestanding birth centers even in normal times have been caught more unprepared than those that already had instituted providers for those birth options prior to COVID Some jurisdictions like Washington, D.
Others like Illinois, which has had a Home Birth Safety Act that would legalize CPMs on the books for about 10 years 23 have remained sluggish at passing such legislation, in spite of obvious need Ayres-Brown, This highlighted, and brought into question, the fact that in normal times, CPMs cannot legally practice there, just as they cannot in Illinois nor in the other states where they are not legal. This is also despite the fact that New York CPMs would qualify for licenses if the state midwifery board had properly implemented the licensing statute that was approved by the state legislature in More and more people are asking for our CPM services and wanting home birth because of the safety aspects.
The problem is access. We are in a Catch Of course, these issues need to be addressed in order to create the access for birthing families that is so desperately needed Personal communication, December 5, It needs some better language before being submitted and the midwives are trying to communicate with the office about it. The executive order is renewed monthly, but that means only that midwives with a license in another state can practice legally until that expiration date.
Midwives and clients need more certainty than one month of legal status! Personal communication December 5, This ambiguous month-to-month situation puts the CPMs currently practicing in New York in a vulnerable state: being legal for a few months, but then with the potential to have their licensure removed just when their clients are actually due to have their babies! ACOG and ACNM recognized early on that the pandemic had created an interest in home birth, alerting them to the fact that families were nervous about institutional birth settings.
Obstetrician-gynecologists see first hand the stress and uncertainty facing pregnant people, families, and their support networks during the COVID pandemic, and this includes questioning the settings in which to give birth.
However, even during this pandemic, hospitals and accredited birth centers remain the safest places to give birth [italics added]. Physicians, certified nurse-midwives and certified midwives, and the entire health care team will work to ensure that precautions are taken to make labor and delivery safe, supportive and welcoming for their patients Phipps, Instead, the states that legalize nationally certified midwives can benefit from cohort studies on midwives with like certification that demonstrate similar outcomes between home and hospital births Murphy and Fullerton, ; Johnson and Daviss, a ; Stapleton et al.
As far as we know, there have been no data in the US comparing outcomes of different birth settings since COVID began its surge across the country. There is, on the other hand, some data to indicate that it is reasonable for families to have concerns about entering the hospital if it is not necessary.
Indeed, it is not necessary--in fact, may not be advisable—if you are a low risk birthing person. Manoj Jain, an infectious disease specialist from Memphis, TN who recognized that a patient of his had likely acquired COVID from staff Jain, provides an example of what the academic literature has brought to light about possible infection in hospital.
These providers can be highly contagious if they have COVID themselves, prior to having any symptoms. While obstetricians, CNMs, and obstetric nurses are not usually considered front-line workers who deal with COVID patients, they are walking in and out of the hospitals where COVID patients gather, and, as the physician in the Memphis story points out, eat lunch without their masks on, with other health care workers, in the lounge or cafeteria.
The true wild cards in the hospital are the anesthesiologists and nurse anesthetists who, unlike obstetric providers, cannot limit where they work to one floor of the hospital. They don and doff—and sanitize--faithfully, but they may have to quickly move from an intubation on a COVID patient in one ward to doing an epidural on a pregnant patient in another section of the hospital.
COVID also adds a new dimension to avoiding the reality that ACOG has admitted: that there are increased cesarean births when low risk women choose hospital birth. Even if low risk women hope to be able to manage without an epidural, their likelihood of having a cesarean increases from 3.
The present liability system can create insurmountable financial risks for practitioners that make them reticent to offer valued services that childbearers are increasingly seeking. They concluded: Ten strategies seem to have potential to improve liability matters in maternity care across multiple aims. The most promising strategy--implementing rigorous maternity care quality improvement QI programs--has led to better quality and outcomes of care, and impressive declines in liability claims, payouts, and premium levels.
A number of promising strategies warrant demonstration and evaluation at the level of states, health systems, or other appropriate entities. Rigorous QI programs have a growing track record of contributing to diverse aims of a high-functioning liability system and seem to be a win-win-win prevention strategy for childbearing families, maternity care providers, and payers.
Effective strategies are also needed to assist families when women and newborns are injured. COVID raises new questions about liability for midwives who practice in private homes or freestanding birth centers. If there is a shortage of legal midwives based outside of hospital in any state, whether or not they are invited to temporarily practice as in New York state, or left without legal accommodation as in Illinois, midwives from neighboring states will inevitably come to the rescue of women in need in the state, regardless of their legal status Ayers-Brown, Ida Darragh and Vicki Hedley explain that many hospitals are now allowing the father of the baby to attend the birth, and just recently in some places, a doula often only if she is certified by the hospital or by an organization recognized by that hospital.
However, when there is a transport from a home birth, the community midwife may not be able to enter the hospital along with her own client to provide the continuity of care that is so well proven in the literature to improve outcomes Sandall et al. This could implicate both the midwife and the hospital in subsequent litigation. Although legal reform is beyond the scope of this article, we would like to point out here that there are underutilized options to discuss and disseminate transfer and practice guidelines, to encourage swift and fair settlements in legal disputes Anderson, , and there are less litigious societies whose policies can serve as models, such as those of Sweden and Germany Lowes, Many US women have already switched to these options to avoid both hospital contagion and the forced choice of only one or no personal birthing companion during these Covidian times.
Outcomes are similar for low-risk mothers regardless of setting in countries where midwives are well-trained and integrated into the Reproductive, Maternal, Newborn and Child Health RMNCH Continuum of Care in the community The US studies on birth settings demonstrate good and similar outcomes among home, birth center, and hospital births when: 1 they are based on charts for an identified cohort rather than on birth certificates; 2 they can identify low risk women; 3 they discern the planned place of birth, thereby avoiding counting accidental, unplanned out-of-hospital births; and 4 they have studied a defined group of midwives with training standards.
Cost and safety issues suggest expanded access to home and freestanding birth centers as a solution to the shortage of appropriate services and maternity-care service providers that existed even before COVID Increased access to credentialed maternity-care providers requires new legislation for CPM licensure in some states and extended public insurance for home and freestanding birth center settings in all states.
While the data on the safety of home and freestanding birth centers has convinced the APHA and many state legislatures over the last two decades to promote birth in these settings, COVID and pure practicality have convinced more state politicians of the importance of credentialed and licensed midwives who offer these alternatives to hospital birth.
There are now two other important givens that mark change: First, ACOG has admitted that safe home birth is possible in other countries where midwives are well-integrated and in accredited birth centers in the US.
Second, the New York State governor has invited licensed midwives, including CPMs from other states, to help out in his state during the pandemic Executive Order, , thereby recognizing their value and essential services in a state that has had former reserve towards CPMs.
Taking two critical further steps could integrate nationally credentialed midwives into the larger US health care system and help these midwives to meet demands of birthing people. The first is to build the infrastructure of legislation, insurance, and healthy Quality Improvement programs needed to support home, freestanding birth center, and hospital maternity care providers so they can be fully integrated into their local RMNCH Continuum of Care. The second step is to encourage a culture in which all healthcare professionals recognize and encourage each other to offer the services for which they are best suited.
This would include opening rather than limiting scope of practice, eliminating physician supervision but increasing collaboration, and encouraging autonomy of midwives and clients. The first step is foreseeable and has been accomplished at least in part in about two-thirds of the United States.
One would think it should be relatively easy, given the models in the other states, but of course it requires some buy-in to the second step. The second step is dependent on the first; in fact one might say the two steps are co-dependent.
The second step requires visionary leaders who can turn over years of conflict aside, expose the overlapping systems of self-protective competitors, and transmute the US maternity care system into a best-practice, safer and less costly model that puts the interests of the birthing population first.
Whether the primary goal is safety, reproductive justice, cost savings, avoiding infection, or increasing freedom of choice and access to birth options for birthing people, public policies that support planned, midwife-attended births in private homes and freestanding birth centers are the appropriate and long overdue response. All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. CMs go through the same training as CNMs excluding the nursing component and are certified by the same board.
See May and Davis-Floyd for a full description of the creation of the CM and why it has not gone far. The point is that the homebirth rate is rising in the US.
In seven states in it was 2. At first we thought they meant that the 3. ACOG has continued to use the single study by Snowden et al. Accessed December 17, In our report we were able to obtain it.
April Committee opinion and confirmed as in , and with a qualification that it is an interim statement changed slightly to replace it. Google Scholar. Aetna Home births. American Association of Birth Centers Practice profile data from AABC perinatal data registry. American College of Nurse Midwives Fact sheet: essential facts about midwives.
Increasing access to out-of-hospital maternity care services through state-regulated and nationally-certified direct-entry midwives.
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