Tuesday, February 12, 2013

Five Surprising Things You Should Know About the Birth Center Study

If you're involved with midwifery at all, you may have heard about a study that was recently published in the Journal of Midwifery and Women's Health. Outcomes of Care in Birth Centers: Demonstration of a Durable Model has been touted as a "Landmark Study" confirming the safety and cost-effectiveness of birth centers in the US. We read the study, and found some interesting details that many people are not aware of. We support out of out-of-hospital birth attended by licensed, qualified midwives. We expect out-of-hospital providers to adhere to standards that make midwifery safer. This study, on the surface, appears to confirm that, but we would like you to know some things that we think you should know.

1) It doesn't demonstrate a reduction in c-section rates

This study did not actually compare two groups of expecting women and determine a cause and effect relationship. If the study had done this - they could provide some evidence to support the statement that giving birth in a midwife-led birth center lowers the c-section rate. The study was a descriptive study - one where they examined one group of women, in this case, low-risk women giving birth at birth centers, and described the results. The reported c-section rate was about 6% in this study. A better comparison group (even though it still doesn't prove anything) would be to women giving birth with CNMs in hospitals. The ACNM tracks this data, and in 2010, the estimated c-section rate for CNM-attended births in the hospital was between  9-10.7%.

Comparing a 6% c-section rate with a 10% c-section isn't that compelling.

2) It doesn't describe outcomes for most US birth centers

The AABC estimates that there are approximately 248 freestanding birth centers in the US. This study was restricted to birth centers that had CABC accreditation, or those birth centers that agreed to abide by the same standards as accredited birth centers. Only 79 birth centers from 33 states contributed data to this study. The publicity surrounding this study make broad claims about the safety of "birth centers."

Nowhere in the article did it discuss the estimated number of births that occurred in the known 248 birth centers during the same period, their standards of practice, or their outcomes.

The authors of the article weakly acknowledge that these results pertain only to those birth centers that follow the standards set forth by the AABC. But they gloss over the fact that an overwhelming majority of birth centers (~80%) in the US are not accredited, and have no impetus to follow these standards.
"The birth centers contributing data to the AABC UDS may have been different from those birth centers not contributing data. The study birth centers are AABC members and thus have access to continuing education activities and support the organization's model and Standards for Birth Centers. This potential difference means that the findings may not be generalizable to all birth centers."

If less than a third of the birth centers contributed data to this study, and only about 20% of birth centers are accredited, how do we know if these good outcomes can be extrapolated to all birth centers?

A side-note for our Michigan readers: Greenhouse Birth Center is/was an AABC member. How do you think their "access to continuing education and support" as an AABC member influenced their practices?

3) It doesn't even describe outcomes for the practices included in the study (since homebirths were excluded)

There were only 35 home births included in the 3 year study with 15,574 births in 79 midwifery practices. Many birth centers offer home birth as well as birth center birth. The study says that only data from  precipitous or unplanned home births were included. This makes sense, because 35 births is a considerably small percentage of births considering the size of the study, and the number of practices participating. So there must have been many more births in these practices - but they weren't counted because they were planned home births.

Would inclusion of the home birth data change the results? Did exclusion of the planned home births allow the "prohibited" (VBAmCs, twins, breech, post-dates) births to occur with the practice, but outside of the birth center?

4) It not only includes data from dicey places like The Birth Place in Taylor, Michigan. But also from birth centers that list services on their websites that were explicitly restricted by the study:


CABC accredited center recommending the client transfer to "The Farm" for a vaginal breech birth:

"The Birth Center wasn’t allowed to do breech births, so that meant that after preparing for months for a natural birth, we were looking at an automatic C-section. That just wasn’t acceptable to us, not without looking at our options."
"It was a very frustrating and stressful week, but luckily my midwives at the Birth Center recommended that I call the Farm Midwifery Center"

CABC accredited center offering twins and breech deliveries:
"Our midwives are experienced with twins and breeches. We ask that our clients wanting a twin and/or breech birth be well informed on the risks & benefits. We fully support women in their choice of how and with whom to birth their baby. For more information about breech birth studies and abstracts see our resources section."

CABC accredited center suggests a breech delivery to her birth center client with a breech because accreditation doesn't allow it to occur at the birth center:
"Because of the accreditation process for the birth center, we could not deliver a breech baby there. Because the current recommendations from ACOG are to c-section for breech presentation, we did not want to deliver at our local hospital and have an automatic c-section. So [the midwife] asked us to think about whether or not we would like a home birth."
AABC study participating birth center (currently applying for accreditation) midwife moonlights with other area midwives to attend an OOH breech birth.
"I was privileged to help another midwife ... the birth of [a] seventh baby.... This was [the mother's] 7th home birth, but their first to come out breech!
I was asked to come and help, but things went very smoothly and their was very little for me to do. I am so happy to have gotten to be part of this joyous birth. All my best wishes to a wonderful family!"
AABC study participating birth center loses ability to practice after a string of newborn deaths.
"The midwives acted in “serious, unprofessional” ways and broke the rules of their profession, the Board of Midwifery said. It suspended the Goodwins in the spring, after claims that the women acted wrongly while overseeing births."
"State investigators said the Goodwins delivered babies with dangerously low heartbeats, interfered with emergency hospital transfers, failed to send a woman to the hospital when she had persistent vomiting and diarrhea, and allowed a baby’s umbilical cord to hemorrhage blood."

Read more here: http://www.idahostatesman.com/2012/08/08/2222027/board-bans-meridian-midwives.html#storylink=cpy

We didn't go through the entire list of birth centers. Just a few. But we were surprised at how quickly we could find that multiple midwifery practices openly advertised these high-risk birth services.

For comparison, we'd like to show you an example of an accredited birth center that CLEARLY STATES that they abide by the CABC standards:
"[T]here are some very strict guidelines that risk women out of birthing at our birth center such as: Twins, breech presentation, labor before 37 weeks gestation, labor after 42 weeks gestation, certain medical conditions including but not limited to insulin dependent diabetes.. These are conditions that are best cared for in the hospital setting."
From our internet research, unless a birth center specifically makes a statement like the one above, that "certain conditions are best cared for in the hospital setting" we're dubious about whether or not those birth centers will appropriately risk out their high-risk clients.

5) The "top notch" findings are only applicable if the birth centers follow strict standards

From the examples above, it's hard to know how many of the birth centers in the US, let alone those that participated in the study, are abiding by their own standards. And that's a shame. Because at Safer Midwifery, we believe there should be safe options for women wanting OOH births. We believe the standards set forth by the AABC and required for CABC accreditation are good standards. And we recognize that many accredited birth centers do follow these standards and provide excellent and safe care to their clients. But we're disappointed that they these standards appear to be so easily flouted and that families are left to figure out themselves whether their birth centers are truly safe.

Stapleton, S. R., Osborne, C. and Illuzzi, J. (2013), Outcomes of Care in Birth Centers: Demonstration of a Durable Model. Journal of Midwifery & Women’s Health, 58: 3–14. doi: 10.1111/jmwh.12003

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