class: title-slide <style type="text/css"> .title-slide { background-color: #002145; background-image: url("web-img/AdobeStock_380794368_sm.jpg"); background-size: cover; background-position: right center; } .title-slide h1, .title-slide h2, .title-slide h3 { text-align: right; color: #002145; } </style> .pull-right[ #Birth Outcomes for Planned Home and Licensed, Freestanding Birth Center Births in Washington State <br> ### Elizabeth Nethery, RM, PhD ### Jan 4, 2023 <img src="web-img/SPPH Logo1.png" align="right" width="300px"/> ] --- class: left .pull-left[ #Publication <a href="https://journals.lww.com/greenjournal/Fulltext/2021/11000/Birth_Outcomes_for_Planned_Home_and_Licensed.2.aspx"> <img src="web-img/November 2021 Cover Image_edit.png" width="400px" align="left"/></a><br><br><br><br><br> ] .pull-right[ ## Authors: Elizabeth Nethery, RM, PhD <sup>1</sup><br> Laura Schummers, ScD <sup>2</sup><br> Audrey Levine, LM, CPM(retired), BA <sup>3</sup><br> Aaron B. Caughey, MD, PhD <sup>4</sup><br> Vivienne Souter, MBChB, MD <sup>5</sup><br> Wendy Gordon, LM, CPM, DM, MPH <sup>6</sup><br> <img src="web-img/SPPH Logo1.png" width="240px"/> <img src="web-img/Bastyr.png" width="60px"/> <img src="https://www.ohsu.edu/sites/default/files/2019-03/OHSU.png" width="50px"/><br><br> <img src="web-img/MAWSLogo2.png" width="140px" align="left"/> <img src="web-img/OB COAP Logo.jpg" width="190px" align="left"/> ] .footnote[ 1. School of Population and Public Health, University of British Columbia, Vancouver, Canada 1. Department of Family Practice, University of British Columbia, Vancouver, Canada 1. Smooth Transitions, Foundation for Health Care Quality, Seattle WA 1. Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon 1. Obstetrical Care Outcomes Assessment Program and Department of Health Services, School of Public Health, University of Washington 1. Bastyr University ] ??? https://www.spph.ubc.ca/files/2017/04/Logo.png Image source from MAWS website https://www.washingtonmidwives.org/uploads/1/1/3/8/113879963/background-images/1426179152.jpg <img src="https://www.spph.ubc.ca/files/2017/04/Logo.png" width="180px"/> _[Read the paper:](https://journals.lww.com/greenjournal/Fulltext/2021/11000/Birth_Outcomes_for_Planned_Home_and_Licensed.2.aspx)_ <img src="web-img/og-green-journal.jpg" width="280px" align="left"/> <a href="https://journals.lww.com/greenjournal/Fulltext/2021/11000/Birth_Outcomes_for_Planned_Home_and_Licensed.2.aspx"> <img src="web-img/ArticleHead.jpg" width="440px" align="left"/></a> --- class: left, top background-image: url("web-img/HospitalWords.jpg"), url("web-img/HomeFBC.jpg") background-position: 10% 88%, 85% 85% background-size: 30%, 27% #Reframing - Birth planning _(medical/ob risk, personal values/beliefs, access, costs)_ -- ###Planned setting for birth: .pull-left[ * Hospital * 'Along-side midwifery unit'] .pull-right[ * Freestanding birth center * Home ] .footnote[ 1. ACOG [Informed consent and shared decision-making in obstetrics (2021)](https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2021/02/informed-consent-and-shared-decision-making-in-obstetrics-and-gynecology) ] --- class: top #Reframing - Birth planning with shared decision-making _(medical/ob risk, personal values/beliefs, access, costs)_ .pull-left[ ##Planned setting for birth: * Hospital * 'Along-side midwifery unit' * Freestanding birth center * Home ] .pull-right[ ## Planned birth attendant: * Obstetrician * Family-practice physician * Midwife* ] --- class: middle, center background-image: url("web-img/AdobeStock_320811117_sm.jpg") background-position: center center background-size: cover ###Birth setting - language #**Community birth ~~(out-of-hospital)~~** = -- ###birth at #**Freestanding* Birth Centers** & / or **Home** ####(*NOT attached to,<br> or located within a hospital) --- class: middle, center, inverse # Midwife* in the US -- ## **TWO** 'types' of midwives --- class: middle, left .pull-left[ # Direct-entry Midwives ### Educated in Midwifery * Direct-entry RM: UK, Canada, NL, NZ, Germany * In the US: CPM, LM, LDM, RM * Legal/licensed in ~35 states * Variable access to Rx/acquire drugs/devices, liability insurance, medicaid or other insurance payors, birth centers (Effland et al. 2022) * National exams, state-level licensure * Training: university degrees (BSM, MSM), accredited schools or apprenticeship* * MEAC-accredited programs meet ICM standards * __Training in planned community birth settings__ ] -- .pull-right[ # Nurse-Midwives ### Educated as Nurses first*, then Midwifery * Nurse-midwives: US, Isreal (less common model) * In the US: CNM * *Legal* in all states * Some states restrict scope or autonomy * Full scope: Rx, well-woman care, birth, infant * National exams * Training: Masters (~2-year) or DNP * CNM training in hospital birth settings * __Most training do not require community (home or FBC) birth experience__ ] --- class: middle, center # ACTUAL Birth setting and attendant in the US (2020) <img src="CommunityBirthPresentation2023_Boston2_files/figure-html/unnamed-chunk-4-1.svg" width="792" /> --- class: inverse, center, middle # Why did we do this study? --- class: middle center #Trends in community birth <img src="CommunityBirthPresentation2023_Boston2_files/figure-html/unnamed-chunk-5-1.svg" width="648" /> ??? 1. Increase in PLANNED Community births (home or birth center) across the US - (many reasons why people choose community birth: fewer interventions for birthing person/mother, high patient satisfaction, autonomy, continuity of care) - As high as 1.7 % completed births outside the hospital in 2019 (this includes unplanned or unknown locations) - These numbers do not account for hospital transfers --- class: middle center ##"U.S. Home births aren't as safe as many abroad" >"Home birth doesn’t have to be a dangerous and deadly proposition–but in the United States, it often is" - Kat Eschner, May 5, 2017, Smithsonian Magazine <hr> ##ACOG Committee opinion on Planned Home Birth >"Hospitals and **accredited birth centers** are the _safest_ places for birth" ??? - (https://www.smithsonianmag.com/smart-news/us-home-births-may-never-be-successful-those-other-countries-180963108/) - Increased neonatal mortality and morbidity from studies using US birth certificate data - However, research from other countries shows that home birth can have comparable outcomes for neonates as hospital deliveries --- class: middle, center, inverse # Why Washington State? --- class: left background-image: url("web-img/WA-MISS.jpg") background-position: 50% 45% background-size: 50% .footnote[ 1.Vedam S, Stoll K, MacDorman M, et al. [Mapping integration of midwives across the United States: Impact on access, equity, and outcomes.](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0192523) PLoS One. 2018;13(2):1-20] --- class: left background-image: url("web-img/WA-LM-History.jpg") background-position: center center background-size: 90% #WA Licensed Midwives (LMs) -- ##Midwifery Landscape - 90% of community births by LM/CPMs<sup>1</sup> - State-licensed birth centers (currently ~23) - Smooth Transitions - WA-LM meets ICM requirements .footnote[ 1.Midwives' Association of Washington State [FAQ](https://www.washingtonmidwives.org/uploads/1/1/3/8/113879963/licensed_midwifery_in_washington_state_fact_sheet_2019.pdf)] --- class: middle center #Trends in community birth in Washington State <img src="CommunityBirthPresentation2023_Boston2_files/figure-html/unnamed-chunk-6-1.svg" width="864" /> --- class: inverse, middle, center # Research Questions --- class: middle ##1. What are community birth outcomes in a US State with integrated<sup>*</sup> midwifery? ##2. Is a planned home birth any different than a birth center birth (in this state)? --- class: inverse, middle, center # Who did we study? --- # Data source - Chart-abstracted data entered by midwives into the MANAStats data registry: - Records for [MAWS (Midwives' Association of Washington State)](https://www.washingtonmidwives.org) members are exported to [Obstetrical Care Outcome Assessment Program (OBCOAP)](https://www.qualityhealth.org/obcoap/) -- ## This study - All MAWS' births in OBCOAP from 2015-January to 2020-June (n=11,442) - Restricted to **10,609 term births (93% of births)** 'within guidelines': 1. None of the criteria for "Transfer of care" based on [MAWS' professional association guidelines]((https://www.washingtonmidwives.org/uploads/1/1/3/8/113879963/final_-_maws_indications_for_discussion_conulstation_and_transfer_of_care_in_a_home_or_birth_center_midwifery_practice_1_.pdf) and 1. Eligible for birth center birth in WA State ###_Excluded LAC(VBAC), breech, multiples, GHTN, others (n=833, 6.7% of births)_ --- <img src="web-img/Figure1.jpg" width="33%" align="left"/> <img src="web-img/Exclusions.jpg" width="55%" align="right"/> --- class: middle, center, inverse .left-column[# Births outside guidelines ] .right-column[ >###"Notably, planned community births outside guidelines were infrequent and no more common than the 7% reported in planned home births in the UK Birthplace cohort study where midwife-attended community births are fully integrated within the health system." > [Nethery et al, 2021](https://journals.lww.com/greenjournal/Fulltext/2021/11000/Birth_Outcomes_for_Planned_Home_and_Licensed.2.aspx) ] .footnote[See also: [MAWS Position Statement on Shared Decision-making](https://www.washingtonmidwives.org/uploads/1/1/3/8/113879963/shared-decision-making-position-statement4.15.pdf)] --- #Midwives - As of 2019, 93% of MAWS' professional members are Licensed Midwives (LM), most also hold a CPM credential; 7% are CNMs - Data collection (in a state or national data registry) is mandatory as a condition of licensure for WA State LMs ## Birth centers - 17 freestanding, state-licensed birth centers - Over half of birth centers also hold national accreditation - Median distance to a hospital for the birth centers in the study was 2.2 miles (range 0.5-12 mi) --- class: inverse, middle, center # Population --- # Study population .pull-left[ <img src="CommunityBirthPresentation2023_Boston2_files/figure-html/unnamed-chunk-7-1.svg" width="504" /> ] .pull-right[ <img src="CommunityBirthPresentation2023_Boston2_files/figure-html/unnamed-chunk-8-1.svg" width="504" /> ] --- class: middle # Population -Planned Home v. Planned Birth Center - **PARITY - 44% Nulliparas planned birth center compared to 25% Nullips at home** * More Medicaid at planned FBC; More self-pay at planned Home * Slightly more rural folks planned Home --- class: inverse, middle, center # Results -- ###1. What are community birth outcomes in a US State with integrated midwifery? --- .pull-left[ <img src="CommunityBirthPresentation2023_Boston2_files/figure-html/unnamed-chunk-9-1.svg" width="100%" /> ] -- .pull-right[ <img src="CommunityBirthPresentation2023_Boston2_files/figure-html/unnamed-chunk-10-1.svg" width="100%" /> ] .footnote[1.Based on data from: [Nethery et al., Birth outcomes for planned home and licensed freestanding birth centers births in Washington State. Obstetrics & Gynecology, 2021](https://journals.lww.com/greenjournal/Fulltext/2021/11000/Birth_Outcomes_for_Planned_Home_and_Licensed.2.aspx)] --- .pull-left[ <img src="CommunityBirthPresentation2023_Boston2_files/figure-html/unnamed-chunk-11-1.svg" width="100%" /> ] -- .pull-right[ <img src="CommunityBirthPresentation2023_Boston2_files/figure-html/unnamed-chunk-12-1.svg" width="100%" /> ] .footnote[1.Based on data from: [Nethery et al., Birth outcomes for planned home and licensed freestanding birth centers births in Washington State. Obstetrics & Gynecology, 2021](https://journals.lww.com/greenjournal/Fulltext/2021/11000/Birth_Outcomes_for_Planned_Home_and_Licensed.2.aspx)] --- # Outcomes for birthing person .pull-left[ ** Delivery: ** - 4.7% Cesarean birth - **Nulliparas**: 11.4% Cesarean - **Multiparas**<sup>1</sup>: 0.87% Cesarean - 94.5% Spontaneous Vaginal Birth (SVB) ** Other: ** - 1% 3rd or 4th degree lacerations - 9% Epidural analgesia (in hospital!) (22% nullips) - 85.3% had a physiologic birth ] -- .pull-right[ **Transfers to hospital: ** - Overall, 16.2% had any transfer within 6h of delivery to hospital - 13.7% intrapartum transfer (in labor) - **Nulliparas**: 30% had an in-labor transfer to hospital - **Multiparas**: 4.2% had an in-labor transfer to hospital ] .footnote[[1] prior vaginal birth] --- ## Intrapartum transfers to hospital - 1455/10690 (14%) of births did not occur in the planned setting - Among the transfers: - 66% had a vaginal birth after transfer - **Nulliparas**: 37% had a Cesarean birth after transfer - **Multiparas**: 20% had a Cesarean birth after transfer -- ### Despite a change in planned birth setting, the majority went on to have a vaginal delivery in hospital --- class: center, bottom background-image: url("web-img/AdobeStock_329767600_sm1.jpg") background-position: center right background-size: cover .left-column[#On transfers ] .right-column[ >###"Our finding that 30% of nulliparous individuals planning a community birth ultimately delivered in hospital is comparable with the UK (32%) but higher than in a national U.S. study (23%) and in Oregon (27%). Multiparous individuals were less likely to transfer to hospital. ><br> > >###Detailed transfer data for this cohort were not available; however, others have reported slow labor progress as the most common indication for transfer in nulliparous individuals and the rate of “potentially urgent” hospital transfers was 0–5% of all births." >[Nethery et al, 2021](https://journals.lww.com/greenjournal/Fulltext/2021/11000/Birth_Outcomes_for_Planned_Home_and_Licensed.2.aspx) ] --- .pull-left[ ## Neonatal outcomes - 2.2% NICU - 1.8% post-delivery transfer to hospital - 5.2% SGA - 18.4% LGA - 93% breastfeeding at discharge from LM care ] -- .pull-right[ ## Perinatal deaths - 4 Intrapartum deaths (stillbirth): - 0.38 per 1000 (95%CI 0.09-0.75) - 2 Neonatal deaths (0-6d): - 0.19 per 1000 (95%CI 0.09-0.57) ] ### Perinatal (combined intrapartum and neonatal (0-6d)) mortality rate: - **0.57 per 1000** (95%CI 0.19-1.04) - 0.87 per 1000 (95% CI 0.44-1.31) (including births outside eligibility criteria) --- class: inverse, middle, center # Comparing perinatal mortality to other studies of home and birth center birth --- class: left # Confidence Intervals (CIs) - The true "measurement" of something is always subject to uncertainty <img src="web-img/Working_CIs.png", align="center", width="500px"/> ###Rare events (like perinatal deaths) - Very few cases (often <5) - Community births represent small study populations -> "wide" CIs (more uncertainty) --- class: inverse, middle, center # Comparing perinatal mortality to other studies of home and birth center birth ### Births within guidelines ### Studies that include all births ??? What I am going to present now is a visual representation of what we report in a table in the paper. What we did was try to put the perinatal mortality **RATE** from this study in context with other studies of home and birth center birth from the US and internationally. We looked at 2 groups - first, those who restricted their study group to pregnancies that met some local 'eligibility' criteria for community birth; and those who included all births regardless of whether they met local standards. --- class: middle, center # Births within guidelines <img src="CommunityBirthPresentation2023_Boston2_files/figure-html/unnamed-chunk-13-1.svg" width="792" /> --- class: middle, center # All births studies <img src="CommunityBirthPresentation2023_Boston2_files/figure-html/unnamed-chunk-14-1.svg" width="792" /> --- class: inverse, middle, center #Results ###2. Is a planned home birth any different than a birth center birth (in this state)? --- #Home compared to birth center ###Method - Compared outcomes by planned birth setting (home v birth center) - Calculated crude relative risks - Statistical models to adjust for differences (parity, etc) and reported adjusted relative risks for planned home v. planned birth center<sup>1</sup> -- ###Results - **No increased risk of adverse birth outcomes comparing planned home v. planned birth center births** .footnote[ 1. Statistical models not done for perinatal mortality because of insufficient power] --- class: center, middle ## Comparing home and birth center <img src="CommunityBirthPresentation2023_Boston2_files/figure-html/unnamed-chunk-16-1.svg" width="864" /> --- .pull-left[ <img src="CommunityBirthPresentation2023_Boston2_files/figure-html/unnamed-chunk-17-1.svg" width="504" /> ] .pull-right[ <img src="CommunityBirthPresentation2023_Boston2_files/figure-html/unnamed-chunk-18-1.svg" width="504" /> ] .footnote[Models adjusted for parity, age>=35 y, BMI>=30 kg/m2, rural residence, onset of labor >41w+4d, rural residence and insurance payor (commercial v. government v. self-pay/none). Subgroup models are adjusted for all covariates except parity.] --- class: inverse, left .left-column[ ###Home birth: Midwife brings equipment/meds and sets up in the home... ###Birth center: **The same** equipment/meds is stored in closets or cabinets... ] .right-column[ <img src="https://www.tender-beginnings.com/wp-content/uploads/2011/04/equipped1.jpg" width='240px' align="left"/> <img src="https://images.squarespace-cdn.com/content/v1/5d0a854017e3df000131cc68/1571924296471-0ROI7T9NRQBY08IC7YD0/AOM_HBE-50.jpg" width='300px' align="right"/> <br> <br> <br> <br> <br> <br> <br> <hr> <img src="web-img/Cabinet_BC2.jpg" width="200px" align="left"/> <img src="web-img/Bed_BC2.jpg" width="290px" align="right"/> ] ??? <img src="https://bellinghambirthcenter.com/wp-content/uploads/2014/07/bbc_0905_suite01.jpg" width="250px" align="left"/> <img src="https://images.squarespace-cdn.com/content/v1/587184023a0411b6dbc78dc7/1502673253217-6XQZBLYKTR6M7G37P06O/IMG_5090.jpg" width="300px" align="left"/> <img src="https://www.clickprophotographers.com/dailyproject/wp-content/uploads/2018/10/Aaron047BWdp.jpg" width="250px" align="center"/> <img src="https://images.squarespace-cdn.com/content/v1/5d0a854017e3df000131cc68/1571925622161-TY9LOV5BY86H5V8M26DZ/AOM_HBSETUP-576.jpg" width="250px" align="left"/> --- class: inverse, middle, center .left-column[ #Home v. birth center ] .right-column[ >###"We found no increased risk of maternal or perinatal adverse outcomes by birth setting, which may be expected given the same availability of emergency medication, medical equipment and the midwives’ management at home or at a state-licensed birth center. >###Antepartum, intrapartum and postpartum management by community midwives (LMs, CPMs and CNMs) is essentially the same in both settings and midwives follow national and international standards and guidelines for low-risk birthing people." >[Nethery et al, 2021](https://journals.lww.com/greenjournal/Fulltext/2021/11000/Birth_Outcomes_for_Planned_Home_and_Licensed.2.aspx) <img src="https://images.squarespace-cdn.com/content/v1/5d0a854017e3df000131cc68/1571925622161-TY9LOV5BY86H5V8M26DZ/AOM_HBSETUP-576.jpg" width="280px" align="center"/> ] ??? <img src="https://www.tender-beginnings.com/wp-content/uploads/2011/04/equipped1.jpg" width='300px' align="right"/> https://images.squarespace-cdn.com/content/v1/5d0a854017e3df000131cc68/1571925622161-TY9LOV5BY86H5V8M26DZ/AOM_HBSETUP-576+2.jpg?format=750w https://riverdalemidwives.com/home-birth --- # Limitations and what we did not do... - limited data on transfers; _can discuss based on other studies or personal experience_ - no comparable hospital data - includes MAWS midwives data only ## Strengths - Intent to treat - Relatively large study group within a single state and professional association - Data collection is mandatory as a condition of licensure - Compared to other community birth studies - Includes those meeting eligibility for birth centers/within MAWS Guidelines **and** also reports outcomes for all births (online supplemental to the paper) --- #Take-home ###1. Outcomes from midwifery care and planned community birth in this study - low intervention rates - high vaginal birth rates, high rates of breastfeeding, high rates of physiologic birth - higher transfer rates than in other US studies, but similar to the UK, lower than Canada - Perinatal mortality rates are comparable to international home birth rates where midwifery is well-integrated into the health care system - _both "within guidelines" and including "all births"_ ###2. Midwife-led care by birth setting (home v. freestanding birth center) **No difference** in adverse birth outcomes for planned home and planned birth center births. --- class: middle, center, inverse .left-column[# On births outside guidelines<sup>*</sup> ] .right-column[ >###"Greater availability in U.S. hospital obstetric units of ACOG-supported practices such as trial of labor after cesarean, vaginal twin birth and vaginal breech in carefully selected cases may reduce the likelihood of pregnant people choosing planned home births outside of guidelines." > [Nethery et al, 2021](https://journals.lww.com/greenjournal/Fulltext/2021/11000/Birth_Outcomes_for_Planned_Home_and_Licensed.2.aspx) ] .footnote[*See also: [MAWS Position Statement on Shared Decision-making](https://www.washingtonmidwives.org/uploads/1/1/3/8/113879963/shared-decision-making-position-statement4.15.pdf)] --- class: middle, center, inverse ##Our findings demonstrate that outcomes from community-based midwifery and either a planned home birth or a planned state-licensed birth center birth were comparable to international settings, in a US state with well-established community midwifery. ##Improving the integration of community midwives in the US could be important to achieve comparable outcomes in other US states. [Nethery et al, 2021](https://journals.lww.com/greenjournal/Fulltext/2021/11000/Birth_Outcomes_for_Planned_Home_and_Licensed.2.aspx) --- ##Useful links * Midwifery Professional Association Guidelines referred to in this study [Midwives' Association of Washington State Indications for Transfer, Consultation and Discussion](https://www.washingtonmidwives.org/uploads/1/1/3/8/113879963/final_-_maws_indications_for_discussion_conulstation_and_transfer_of_care_in_a_home_or_birth_center_midwifery_practice_1_.pdf) * [Smooth Transitions][https://www.qualityhealth.org/smoothtransitions/resources/] * American College of Obstetricians and Gynecologists' [Committee Opinion on Planned Home Birth](https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/04/planned-home-birth) reaffirmed 2020 * ACOG [Statement on Birth Settings](https://www.acog.org/news/news-releases/2020/04/acog-statement-on-birth-settings) * Washington State [Laws and Regulations](https://www.doh.wa.gov/LicensesPermitsandCertificates/ProfessionsNewReneworUpdate/Midwife/Laws) * Washington State Department of Health [Midwifery information page](https://www.doh.wa.gov/LicensesPermitsandCertificates/ProfessionsNewReneworUpdate/Midwife) * Washington State Department of Health [Childbirth Centers page](https://www.doh.wa.gov/LicensesPermitsandCertificates/FacilitiesNewReneworUpdate/BirthingChildbirthCenters) * This paper [Nethery et al, 2021](https://journals.lww.com/greenjournal/Fulltext/2021/11000/Birth_Outcomes_for_Planned_Home_and_Licensed.2.aspx) (Open Access) --- ##Resources p1 - On midwifery laws, scope and medications with comparisons to WA state: - [Effland KJ, Hays K, Zell BA, Lawal TK, Grantham RL, Koontz M. Increasing Access to Medications and Devices for the Care of Low‐Risk Childbearing Families: An Analysis of Existing Law and Strategies for Advocacy. J Midwifery Womens Health. 2021:1-20](https://onlinelibrary.wiley.com/doi/abs/10.1111/jmwh.13275) - [Effland KJ, Hays KE, Zell BA, Lawal TK, Koontz M. Medication access and midwifery integration: An example of community midwifery advocacy for access in Washington State , USA. Birth. 2020;(November):1-10](https://onlinelibrary.wiley.com/doi/10.1111/birt.12523) - On midwifery integration in the US: - [Vedam S, Stoll K, MacDorman M, et al. Mapping integration of midwives across the United States: Impact on access, equity, and outcomes. PLoS One. 2018;13(2):1-20](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0192523) --- ## Resources p2 - On Integration and improving data collection: - [Levine A, Souter V and Sakala C. Are Perinatal Quality Collaboratives Collaborating Enough? How Including All Birth Settings Can Drive Needed Improvement in the U.S. Maternity Care System. Birth. 2021](https://onlinelibrary.wiley.com/doi/full/10.1111/birt.12600) - Comparison to other countries: - [Kennedy HP, Balaam MC, Dahlen H, et al. The role of midwifery and other international insights for maternity care in the United States: An analysis of four countries. Birth. 2020;47(4):332-345](https://onlinelibrary.wiley.com/doi/abs/10.1111/birt.12504) - Commentaries: - [Leeman L, Goldstein JT. Promoting safety in community-based birth settings. Am Fam Physician. 2021;103(11):650-652](https://www.aafp.org/afp/2021/0601/p650.html) - [Caughey AB, Cheyney M. Home and Birth Center Birth in the United States. Obstet Gynecol. 2019;133(5):1033-1050](https://journals.lww.com/greenjournal/Abstract/2019/05000/Home_and_Birth_Center_Birth_in_the_United_States_.25.aspx) --- # Recent WA State Midwifery - Expanding scope of practice for midwives: - MAWS working to request a [Sunrise review](https://www.washingtonmidwives.org/sunrise-review--information-for-legislators-2021.html) of the Midwives' legislation to expand scope of practice include prescribing (common perinatal care medications) and all contraceptive options - [Smooth Transitions](https://www.qualityhealth.org/smoothtransitions/): - a Washington state-based quality improvement program that brings together community midwives, hospital providers and staff, and EMS personnel to build a collaborative model of care that puts birthing families at the center. - offers presentations, provides direct support to participating hospitals - consults with perinatal collaboratives and organizations in other states interested in replicating this work. --- background-image: url("web-img/AdobeStock_162133128_sm.jpg") background-size: cover background-position: center #Acknowledgments <img src="web-img/MAWSLogo2.png" width="180px" align="right"/> .pull-left[ ###MAWS Data committee: - Emily Stephens - Beth Arcese - Susan Rainwater - Melissa Denmark - Wendy Gordon - Audrey Levine - Elizabeth Nethery - Faisa Farole ###MANAStats and DoR: - Melissa Cheyney, Bruce Ackerman, Jennifer Brown, Marit Bovbjerg, Courtney Everson ] .pull-right[ ###OB COAP: - Kristin Sitcov, Ellen Kauffman, Vivienne Souter ###MAWS: - Melanie Dickson, Marge Mansfield, Jen Segadelli **_Countless other midwives, supporters and health care colleagues who have contributed to lobbying, developing and updating guidelines and building the many, many structures that have made MAWS and WA State midwifery what it is today._** ] ??? <img src="web-img/MAWSOBCOAP.png" width="400px" align="right"/> --- class: left, bottom background-image: url("web-img/AdobeStock_403646448_sm.jpg") background-size: cover background-position: right #THANK YOU to ## Midwives and birthing families ## who have graciously contributed data --- class: middle ##Thank you for your interest .left-column[ ###Contact <svg viewBox="0 0 512 512" style="height:1em;position:relative;display:inline-block;top:.1em;" xmlns="http://www.w3.org/2000/svg"> <path d="M464 64H48C21.49 64 0 85.49 0 112v288c0 26.51 21.49 48 48 48h416c26.51 0 48-21.49 48-48V112c0-26.51-21.49-48-48-48zm0 48v40.805c-22.422 18.259-58.168 46.651-134.587 106.49-16.841 13.247-50.201 45.072-73.413 44.701-23.208.375-56.579-31.459-73.413-44.701C106.18 199.465 70.425 171.067 48 152.805V112h416zM48 400V214.398c22.914 18.251 55.409 43.862 104.938 82.646 21.857 17.205 60.134 55.186 103.062 54.955 42.717.231 80.509-37.199 103.053-54.947 49.528-38.783 82.032-64.401 104.947-82.653V400H48z"></path></svg> _elizabeth.nethery@ubc.ca_ <svg viewBox="0 0 512 512" style="height:1em;position:relative;display:inline-block;top:.1em;" xmlns="http://www.w3.org/2000/svg"> <path d="M459.37 151.716c.325 4.548.325 9.097.325 13.645 0 138.72-105.583 298.558-298.558 298.558-59.452 0-114.68-17.219-161.137-47.106 8.447.974 16.568 1.299 25.34 1.299 49.055 0 94.213-16.568 130.274-44.832-46.132-.975-84.792-31.188-98.112-72.772 6.498.974 12.995 1.624 19.818 1.624 9.421 0 18.843-1.3 27.614-3.573-48.081-9.747-84.143-51.98-84.143-102.985v-1.299c13.969 7.797 30.214 12.67 47.431 13.319-28.264-18.843-46.781-51.005-46.781-87.391 0-19.492 5.197-37.36 14.294-52.954 51.655 63.675 129.3 105.258 216.365 109.807-1.624-7.797-2.599-15.918-2.599-24.04 0-57.828 46.782-104.934 104.934-104.934 30.213 0 57.502 12.67 76.67 33.137 23.715-4.548 46.456-13.32 66.599-25.34-7.798 24.366-24.366 44.833-46.132 57.827 21.117-2.273 41.584-8.122 60.426-16.243-14.292 20.791-32.161 39.308-52.628 54.253z"></path></svg> [@e_nethery](http://twitter.com/e_nethery) ] --- class: middle, center, inverse .left-column[# Generalizability ] .right-column[ >###Demographics and obstetric characteristics of this cohort were similar to home and birth center births in other US states; however, results reported in this study may not be generalizable to states with different legislation, training, and integration of community midwives. >###While this cohort is not representative of the broader US birthing population (including planned hospital births), this reflects eligibility for community birth and does not limit the internal validity of the comparison between home and birth centers or the generalizability of our findings to a low-risk, more racially diverse cohort within a state with a similar level of midwifery integration. >[Nethery et al, 2021](https://journals.lww.com/greenjournal/Fulltext/2021/11000/Birth_Outcomes_for_Planned_Home_and_Licensed.2.aspx) ] ??? Generalizability As far as population is concerned, our study group is similar to other US studies of home and birth center births. However, where this study group differs is in levels of midwifery integration and systems that support home and community birth. In terms of comparing this study population to those planning hospital births in the US, there is no doubt that there are differences, but we would argue that this reflects, in part, those eligible for community birth - Further, this does not limit the internal validity of our findings (comparing home to birth centers)- these could still apply to a more racially diverse cohort within a state with a similar level of integration. --- class: left background-image: url("web-img/CNM_WA_MISS.jpg") background-position: 100% 10% background-size: cover --- class: left background-image: url("web-img/SmoothTransitions.jpg"), url("web-img/SmoothTransitionsLogo.jpg") background-position: 80% 10%, left bottom background-size: 70%, 40% --- class: middle, center #ACOG Committee opinion on Planned Home Birth >"Although the College believes that hospitals and accredited birth centers are the safest settings for birth, _each woman has the right to make a medically informed decision about delivery._" > "Importantly, women should be informed that several factors are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes. These factors include the appropriate selection of candidates for home birth; the availability of a certified nurse–midwife, certified midwife or __midwife whose education and licensure meet International Confederation of Midwives’ Global Standards for Midwifery Education__ ... within an __integrated and regulated health system__; ready access to consultation; and access to safe and timely transport to nearby hospitals." --- class: middle, center # All studies <img src="CommunityBirthPresentation2023_Boston2_files/figure-html/unnamed-chunk-19-1.svg" width="792" />