Alabama Midwives Alliance

So if the medical establishment is playing hardball and must rely on statistics out of context rather than "any persuasive arguments about safety or quality of care", how firm is the ground we are standing on? In addition to the beautiful physiologic Design which is allowed to show its power in an undisturbed birth, and in addition to the sacredness of marital and family relationships that are nurtured in an undisturbed birth, we offer the following …

History of Success - Of the 27 states where CPMs practice legally, none has ever reversed its law. All states reporting results have described favorable outcomes for mother and baby and reduction in expense to the state for initial and follow-up care.

Cost Savings - Ten states currently provide Medicaid reimbursement for Certified Professional Midwives assisting at home births, and more states are considering it because of the good outcomes and huge financial benefits to consumers, insurance companies and the state. An economic analysis of the cost benefits of a licensed midwife program indicates that “The cost savings to the health care system (public and private) is estimated to be ten times the cost of the program.”i

Recommendations –

1. The World Health Organization recommends that midwives should be the principal providers of care for pregnant women.

2. The American Public Health Association supports efforts to increase access to out-of-hospital maternity care services.

3. Pew Health Professions Commission states that the Midwives Model of Care should be embraced by and incorporated into the health care system in order to make it available to all women and their families.

4. The Reforming States Group along with Childbirth Connections and the Milbank Memorial Fund recommends the U.S. “foster broad access to safe, effective midwifery care by setting adequate Medicaid and Medicare reimbursement rates for certified nurse –midwives, certified midwives, and certified professional midwives.”ii

Performance Research - The largest study of home births attended by Certified Professional Midwives was published in the British Medical Journal in 2005.iii It found that home birth is safe for low-risk women and involves far fewer interventions than similar births in hospitals. There are many published articles about home birth and midwifery, but this one is the best and most current research relevant to the type of midwifery legislation being proposed.

What makes the CPM2000 study "the best"? The research design and the population being studied make for a relevant and useful reference for the following reasons.

1. It deals with US home birth families who planned and prepared for their birth using the services of a Certified Professional Midwife. There are plenty of articles about The Netherlands, Great Britain and Australia, but they are easily discounted because "things are different over there." There are plenty of articles about home birth with Certified Nurse Midwives, but they do not address the unique educational background and qualifications of a Certified Professional Midwife. There are also plenty of articles about births that happened at home though without preparation and access to a midwife. While these other articles suggest trends worth noting, the CPM2000 study is the largest study dealing with CPM-attended home births in the US.

2. It offers the most rigorous research design possible for studies of place of birth and birth attendant. (While a "randomized controlled trial" is often cited as the gold standard for research, it is not possible to randomize families to home or hospital, obstetrician or midwife. When such randomized trials have been attempted it is soon obvious that personal preferences are too strong for randomization to be accepted.) The CPM2000 research followed all pregnancies under the care of all CPMs during the year 2000. There was no "selective reporting" for only those cases which turned out as desired, and no "selective reporters" where only more conscientious/qualified midwives provided data.

3. The CPMs submitting data for this study were 98% US midwives (very few Canadian) and 99% had obtained their credentials via the Portfolio Evaluation Process (one-on-one instruction) rather than by attending a MEAC (accredited) school or other "formal education" program. There has yet to be any research comparing the outcomes of CPMs who have had one-on-one education vs. those attending accredited educational programs. NARM (the organization who administers the CPM credential) regards the PEP and MEAC pathways as equivalent, as do all states currently licensing CPMs.

The outcomes for the CPM study are outstanding. In the 5,418 births followed during the year, there were no dead mothers and when compared to carefully risk-matched hospital births, there were no more (and possibly slightly fewer) dead and "damaged" babies than would have been expected had those births been in the hospital. About one in ten women ended up going to the hospital at some point (mostly for exhaustion, pain or slow progress), though none of the transfers to the hospital were "emergent" (defined as requiring lifesaving measures within the first 30 minutes after arrival to the hospital). So the ethic of "do no harm" was fully satisfied.

Better than just "no harm" though, are the benefits. Through risk assessment and risk management the women in CPM care were:

1. ten times less likely to be induced. Induction carries risks for mother and baby as well as expense.

2. six times less likely to have the labor stimulated with oxytocin (done by a physician following transfer to a hospital). Augmenting labor with oxytocin has risks for both mother and baby.

3. twenty times less likely to have their baby pulled out with a vacuum (by a physician after transferring to a hospital). Extraction carries risk of trauma to both mother and baby, as well as expense.

4. six times less likely to need a cesarean section (done by a physician after transferring to a hospital), thus avoiding significant immediate and long-term risks to mom and baby, as well as a large expense.

5. nine times less likely to have breastfeeding fail in the weeks after the birth. Breastfeeding is not a private issue of "personal preference", it offers significant cost benefits to the state and to individual families and employers, long-term health benefits to mom and baby, and decreased risk of hospitalization and death in the first year of life - even in the US. Breastfeeding is a delicate physiologic process that is likely to fail in spite of education, good intentions and "support", when the Design of birth has been disturbed.

References – Citizens for Midwifery offers a one-sheet summary of the CPM 2000 study on their website.

1. Midwifery Licensure and Discipline Program in Washington State: Economic Costs and Benefits, (a report to the Washington Department of Health), Health Management Associates, October 2007.

2. “Evidence-Based Maternity Care: What It Is and What It Can Achieve.” Carol Sakala and Maureen P. Corry, published by Childbirth Connections, Reforming States Group & Milbank Memorial Fund, October 2008, p70.

3. “Outcomes of planned home births with certified professional midwives: large prospective study in North America.” Kenneth C Johnson and Betty-Anne Daviss. BMJ 2005;330:1416 (18 June).

Detailed information regarding the CPM credential may be found in the joint Issue Brief titled, Certified Professional Midwives in the United States, which was issued in June 2008 by NARM, MEAC, NACPM and MANA.