Wednesday, September 02, 2009

New Canadian home birth study

A study comparing the outcomes of all planned home births with registered midwives in BC is just out in the Canadian Medical Association Journal: Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. Other bloggers have already written up detailed explanations of the study's design and analysis, so I will suggest you read more on Lamaze's Science & Sensibility.

In short, this study compared all BC planned midwife-attended home births with midwife-attended hospital births (the same midwives, since Canadian midwives practice both in home and hospital) and physician-attended hospital births. Both hospital groups met the same eligibility requirements for home births, meaning they were equivalent in health factors, risk status, etc. In other words, all of these women having hospital births could have chosen home births if they had so desired, under the BC midwifery regulations. From the abstract's conclusion:
Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.
Like the Dutch home birth study that came out earlier this year (abstract available here), this Canadian study has a strong comparison group--something lacking in the CPM 2000 study in the BMJ.

I found the comment section in this news article about the study quite interesting. I really don't think most of the commenters actually read, or understood, what the study was saying. Rather, the comments were a series of emotional reactions for and against home birth. You know, "my baby would have DIED if I had been at home!" and "I will NEVER go to a hospital for childbirth again because it was so AWFUL!" Sometimes evidence from really good studies simply doesn't matter. It's more about emotion, perceptions of risk, and the need for a compelling narrative that makes sense of and gives finality to their birth experience.

I'm sure there is lots of discussion going on out there. For example, Woman to Woman Childbirth Education includes a comment by Gloria Lemay, in which she argues that the registration of BC midwives has not been a good thing overall. Any other good links/commentary about this study?


  1. this study was highlighted on Canada AM yesterday morning, and I wondered whether you had seen it at all- the Doctor that was interviewed was quite fair- it sounds like British Columbia is supportive of midwife home births - at least for low-risk pregnancies

  2. I agree with you that so many of the discussion about this issue end up in an emotional imbroglio. I do wish we had more factual discussions...

  3. I noticed, out of 1294 C-sections done in this study, only 2 were performed with the main indication being "repeat c-section". WoW, way to VBAC! I noticed that women with one previous c-section were considered low risk (Box 1) and eligible for home birth with midwife.

  4. Okay. I'm going to steel my nerves and play devil's advocate for a moment here. Let me preface this my saying that I am a passionate home birth advocate, I had one myself, and absolutely adored my CPMs to the point where I had separation anxiety when our postpartum visits were drawing to a close. And I'm strongly considering becoming a midwife myself, after gaining some experience as a doula and once my child is a bit older.

    So. At risk of summoning the presence of a certain former-doctor-turned-blogger with an ax to grind against home birth, I have to admit I've been wondering about a point she's been trumpeting a lot lately. In a recent recurring refrain, she claims that this study, and others that taking place outside the US, are irrelevant to home birth in the United States because midwives in Canada and Europe are not comparable to CPMs here in the US; they are the equivalent of Certified NURSE Midwives, but nothing else, and the training for CPMs in America is inadequate. Therefore any study, even an airtight one like this, has no bearing in the US unless the midwife happens to be one of the few CNMs who practice outside a hospital or hospital birth center setting.

    What do you think about this? Does she (it PAINS me to say it, it really does) have something of a point? Does this study have any relevance to home birth as it stands in the US? If this is too much of a tangent from your post, Rixa, I understand and you can pass on it, but I'm really interested in your opinion on this, as I deeply respect your experience, knowledge, and point of view.

  5. doul-la-la, I have lots to say about that and will get back to you soon. Pressed for time at the moment...

  6. Take your time - thanks for considering the question! It's a complicated one.

  7. Needing to remain anonymous here, but I have posted some responses to the bitter doctor on her blog addressing this issue. Her response was akin to "you're wrong and I'm not going to talk about it anymore." I'm reposting my comments here, stringing several of them together -- hope it adds to the conversation. Sorry for the length!

    Many Canadian midwives are educated in U.S. direct-entry midwifery schools, at least as many as (if not more than) the number of Canadian midwives educated in Canadian schools. Seattle Midwifery School regularly admits a number of Canadian students every year, as does the Midwives College of Utah. Canadian midwifery programs are generally quite small and local preceptors are lacking. Unlike the U.S., Canada values home birth and midwives, and there is a tremendous shortage of midwives there. They have to bring in foreign-trained midwives to meet the consumer demand, and the U.S. trains many, many of them.

    Canada doesn't distinguish between direct-entry midwives and nurse-midwives. (In fact, Canadian midwives are not required to be nurses at all, so by definition, they technically ARE direct-entry midwives.) Canadian midwives must have both hospital and homebirth experience in order to practice, which seems quite prudent.

    Canadian midwives are required to meet competency standards, not educational standards. Look it up. This is exactly the way that the North American Registry of Midwives measures competency to receive the CPM credential in the U.S. In fact, if you were to compare the Canadian Competencies side-by-side with the NARM Competencies, you would find very few differences at all, aside from pharmacological treatments (most direct-entry midwives in the U.S. have a narrow range of drugs that can be administered).

    So aside from some prescriptive differences and the fact that Canadian midwives can flow seamlessly between home and hospital (as is the case in the Netherlands where outcomes are also spectacular), there is virtually no difference between Canadian midwives and U.S. direct-entry midwives. They are being trained here.

    In order for Canada to ensure a single set of standard competencies for entry-level midwives, they have an additional process that foreign-trained midwives must complete. This used to be the PLEA process, but it has been replaced by the Multi-jurisdictional Midwifery Bridging Project in most provinces. It includes an assessment of the midwife's skills and knowledge, as well as education on the Canadian healthcare system. Seems reasonable.

    It's important to note first that ALL foreign-trained midwives must complete some amount of time under supervision. For example, British midwives usually take 3-6 months and U.S.-trained CNMs take 2-6 months of supervised practice ("often focused on community-based and out-of-hospital midwifery care"). The wider range of potential supervision for U.S. direct-entry midwives [3-12 months] reflects the wide variety of training programs in the U.S.

  8. That is really very helpful, anonymous. Are you a midwife in Canada yourself? (If you feel comfortable saying so?)

  9. No, not a midwife in Canada. Only remaining anonymous here because I posted anonymously on the doc's blog. She has a long history of trying to discredit people she disagrees with, so it seems better to just stay anonymous. :-)


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