Trends in midwife-attended births, 1989 to 2007

Introduction: Rates of births attended by certified nurse-midwives (CNMs) rose throughout the 1990s and into the early part of this century, when rates leveled at about 7%. Methods: The data in this report are based on records gathered as part of the US National Standard Certificate of Live Birth from the public use Web site, VitalStats, that allows users to create and download specialized tables. Results: For the first time since such data were available in 1989, births attended by CNMs declined from the previous year in absolute terms, as a proportion of all births, and as a proportion of vaginal births. After an all-time high of 317,168 in 2006, CNM-attended births declined marginally to 316,811 in 2007. With total births reaching a US record of 4,316,233 births, the CNM proportion of total births declined for the fifth straight year to 7.3%, the same proportion as in 1999. Births attended by "other midwives" rose substantially to 23,943 although some of that increase may be the result of misclassification of CNM births in some states into the other midwife category. Discussion: The proportion of CNM births has remained steady at between 7.3% and 7.6% since 1999. However, when the number of births attended by CNMs is combined with the number attended by other midwives, their number reached an all-time high in 2007.     

Relationship Between Hospital‐Level Percentage of Midwife‐Attended Births and Obstetric Procedure Utilization

Introduction

Research has shown good outcomes among individual low‐risk women who receive perinatal care from midwives, yet little is known about how hospital‐level variation in midwifery care relates to procedure use and maternal health. This study aimed to document the association between the hospital‐level proportion of midwife‐attended births and obstetric procedure utilization.

Methods

This analysis used 2 data sources: Healthcare Cost and Utilization Project State Inpatient Database data for New York in 2014, and New York State Department of Health data on the percentage of midwife‐attended births at hospitals in the state in 2014. Using logistic regression, we estimated the association between the hospital‐level percentage of midwife‐attended births and 4 outcomes among low‐risk women: labor induction, cesarean birth, episiotomy, and severe maternal morbidity.

Results

Hospital‐level percentage of midwife‐attended births was not associated with reduced odds of labor induction or severe maternal morbidity. Women who gave births at hospitals with more midwife‐attended births had lower odds of giving birth by cesarean (eg, adjusted odds ratio [aOR], 0.70; 95% confidence interval [CI], 0.59‐0.82 at a hospital with 15% to 40% of births attended by midwives, compared to no midwife‐attended births) and lower odds of episiotomy (eg, aOR, 0.41; 95% CI, 0.23‐0.74 at a hospital with more than 40% of births attended by midwives, compared to no midwife‐attended births).

Discussion

Our results indicate that hospitals with more midwife‐attended births have lower utilization of some obstetric procedures among low‐risk women; this raises the possibility of improving value in maternity care through greater access to midwifery care.     

Perineal Injury in Nulliparous Women Giving Birth at a Community Hospital: Reduced Risk in Births Attended by Certified Nurse‐Midwives

Introduction : Our objective was to determine if there is a difference in rates of perineal injury sustained by nulliparous women attended by obstetricians compared with certified nurse‐midwives (CNMs) at a US community hospital. Methods : We analyzed retrospective data for 2819 women who spontaneously gave birth to singleton, vertex, term, live infants between 2000 and 2005. The independent variable was attendant type (obstetrician or CNM). The main outcome variables were intact perineum, episiotomy, and spontaneous perineal lacerations. Multivariate logistic regression was used to adjust for six potential confounders: macrosomia, maternal age, epidural anesthesia, oxytocin administration, medical insurance status, and ethnicity. Results : The odds ratios (ORs) for obstetrician‐attended births versus CNM‐attended births were significant for a spontaneous minor perineal laceration versus intact perineum (OR = 1.82; 95% confidence interval [CI], 1.33–2.48), spontaneous major laceration versus intact perineum (OR = 2.29; 95% CI, 1.13–4.66), and episiotomy use versus no perineal injury, with or without extension (OR = 2.94; 95% CI, 2.01–4.29). Discussion : We found that the prevalence and severity of perineal injury, both spontaneous and from episiotomy use, were significantly lower in CNM‐attended births. J Midwifery Womens Health 2010;55:243–249 c̊ 2010 by the American College of Nurse‐Midwives.     

RECENT CHANGES IN BIRTH ATTENDANT,PLACE OF BIRTH,AND THE USE OF OBSTETRIC INTERVENTIONS,UNITED STATES, 1989–1997*

Although more than nine out of every ten births are attended by physicians, the percent of births attended by midwives increased during the 1989 to 1997 period and accounted for 7% of all births in 1997. About 99% of births in 1997 were in hospitals, basically unchanged from 1989, but the percent of out-of-hospital births that occurred in residences increased over the period, while those in freestanding birthing centers declined. The percent of mothers receiving electronic fetal monitoring, ultrasound, and induction and stimulation of labor increased. The most dramatic increase was a doubling of the use of induction. In 1997, approximately 18% of all births were induced. Midwives as well as physicians increased the use of these obstetric procedures over the 1989 to 1997 period, and the use of many procedures by CNMs was as high, or nearly as high, as use by physicians. The rate of cesarean births dropped by 9%, from about 23% in 1989 to about 21% in 1997, while the rate of vaginal birth after a previous cesarean increased by 50%. The proportion of births assisted by forceps consistently declined during the period, while the use of vacuum extraction consistently increased. The number of episiotomies performed in the United States declined each year during the 1990–1996 period. J Nurse Midwifery 1999;44:349–54 © 1999 by the American College of Nurse-Midwives.     

Recent changes in birth attendant, place of birth, and the use of obstetric interventions, United States, 1989-1997.

Although more than nine out of every ten births are attended by physicians, the percent of births attended by midwives increased during the 1989 to 1997 period and accounted for 7% of all births in 1997. About 99% of births in 1997 were in hospitals, basically unchanged from 1989, but the percent of out-of-hospital births that occurred in residences increased over the period, while those in freestanding birthing centers declined. The percent of mothers receiving electronic fetal monitoring, ultrasound, and induction and stimulation of labor increased. The most dramatic increase was a doubling of the use of induction. In 1997, approximately 18% of all births were induced. Midwives as well as physicians increased the use of these obstetric procedures over the 1989 to 1997 period, and the use of many procedures by CNMs was as high, or nearly as high, as use by physicians. The rate of cesarean births dropped by 9%, from about 23% in 1989 to about 21% in 1997, while the rate of vaginal birth after a previous cesarean increased by 50%. The proportion of births assisted by forceps consistently declined during the period, while the use of vacuum extraction consistently increased. The number of episiotomies performed in the United States declined each year during the 1990-1996 period.     

Do Birth Certificate Data Accurately Reflect the Number of CNM‐Attended Births? An Exploratory Study

The number of midwife-attended births is increasing as reported on birth certificates in the United States. However, there is some evidence that births attended by certified nurse-midwives (CNMs) may not be accurately recorded. In this exploratory study, data on birth attendants for those clients giving birth during the study period were compared by using four sources: the client's hospital chart, the CNM birth log, hospital birth certificate records, and state vital statistics records. Researchers sought to determine the accuracy of birth attendant data as reflected in these four sources and whether other providers were listed as the birth attendant for actual CNM-attended births. During the study period, the CNM birth log showed that CNMs attended 97 vaginal births, whereas the client hospital charts for these same births noted 92 births as attended by CNMs (the other five were operative vaginal births). Hospital birth certificate and state vital statistics data during the study time period credited 88 and 82 of the client's births, respectively, to the CNMs. Exploration of the inaccurately reported birth attendant data, implications for practice, and recommendations for accurately recording birth certificate data are discussed.     

Birth outcomes of planned home births in Missouri: a population-based study

We evaluated the birth outcomes of planned home births. We conducted a retrospective cohort study using Missouri vital records from 1989 to 2005 to compare the risk of newborn seizure and intrapartum fetal death in planned home births attended by physicians/certified nurse midwives (CNMs) or non-CNMs with hospitals/birthing center births. The study sample included singleton pregnancies between 36 and 44 weeks of gestation without major congenital anomalies or breech presentation ( N?=?859,873). The adjusted odds ratio (aOR) of newborn seizures in planned home births attended by non-CNMs was 5.11 (95% confidence interval [CI]: 2.52, 10.37) compared with deliveries by physicians/CNMs in hospitals/birthing centers. For intrapartum fetal death, aORs were 11.24 (95% CI: 1.43, 88.29), and 20.33 (95% CI: 4.98, 83.07) in planned home births attended by non-CNMs and by physicians/CNMs, respectively, compared with births in hospitals/birthing centers. Planned home births are associated with increased likelihood of adverse birth outcomes.     

State regulation of midwives: issues and options

In the United States, state governments play a central role in determining the extent to which midwives can provide care to women and babies. State laws and regulations establish midwives' scope of practice, set licensure requirements, and frequently determine their ability to get paid and obtain access to health care facilities. For certified nurse-midwives (CNMs), state regulation has evolved from a haphazard patchwork of highly variable regulatory models into a fairly uniform set of rules and requirements from one state to the next. For direct entry midwives (DEMs), there is much less uniformity, with some states outlawing practice by any midwife who is not a CNM, whereas other states have established rigorous standards and requirements for the licensure of DEMs. This article provides a broad overview of these state regulatory variables for both CNMs and DEMs, and explores issues and options that both state regulators and midwives should consider when developing or amending state laws and regulations governing their practice. In particular, the role of the state in regulating the practice of the certified midwife (CM) is examined in the context of existing regulatory frameworks for CNMs and DEMs.     

Midwifery Care and Medical Complications: The Role of Risk Screening

ABSTRACT: This study analyzed the 147,293 births attended by midwives in the United States in 1989. It used the revised and expanded standard national certificate of a live birth, which for the first time systematically records prenatal medical risk, intrapartum complications, obstetric procedures, and birth outcomes. It builds on earlier findings of positive outcomes for midwife-attended births to examine the prenatal medical risk profile of mothers sewed by midwives, the performance of obstetric procedures by midwives in different birth settings, more specific measures of outcomes, and possible explanations for these findings. Although midwives attending births in birth centers and homes generally serve mothers who are at much less than average medical risk, and in cases of intrapartum complications risk screening appears to occur nurse-midwife-attended births in hospitals involve mothers whose risk profiles compare with, and in some cases are worse than, the national average. Nonetheless, the outcomes of these births are better than the national average. Mothers attended by midwives in birth centers and homes also have a different pattern of prenatal care, which begins later and includes fewer visits, but gives more apparent attention to self-care, and results in less smoking and alcohol use and greater weight gain.     

Trends and Characteristics of Home Births in the United States by Race and Ethnicity, 1990–2006

Background: After a gradual decline from 1990 to 2004, the percentage of births occurring at home in the United States increased by 5 percent in 2005 and that increase was sustained in 2006. The purpose of the study was to analyze trends and characteristics in home births in United States by race and ethnicity from 1990 to 2006. Methods: U.S. birth certificate data on home births were analyzed and compared with hospital births for a variety of demographic and medical characteristics. Results: From 1990 to 2006, both the number and percentage of home births increased for non‐Hispanic white women, but declined for all other race and ethnic groups. In 2006, non‐Hispanic white women were three to four times more likely to have a home birth than women of other race and ethnic groups. Home births were more likely than hospital births to occur to older, married women with singleton pregnancies and several previous children. For non‐Hispanic white women, fewer home births than hospital births were born preterm, whereas for other race and ethnic groups a higher percentage of home births than hospital births were born preterm. For non‐Hispanic white women, two‐thirds of home births were delivered by midwives. In contrast, for other race and ethnic groups, most home births were delivered by either physicians or “other” attendants, suggesting that a higher proportion of these births may be unplanned home births because of emergency situations. Conclusions: Differences in the risk profile of home births by race and ethnicity are consistent with previous research, suggesting that, compared with non‐Hispanic white women, a larger proportion of non‐Hispanic black and Hispanic home births represent unplanned, emergency situations. (BIRTH 38:1 March 2011)     

Gestational Diabetes Mellitus and Postpartum Care Practices of Nurse‐Midwives

Introduction : Postpartum screening for glucose intolerance among women with recent histories of gestational diabetes mellitus (GDM) is important for identifying women with continued glucose intolerance after birth, yet screening rates are suboptimal. In a thorough review of the literature, we found no studies of screening practices among certified nurse‐midwives (CNMs). The objectives of our study were to estimate the prevalence of postpartum screening for abnormal glucose tolerance and related care by CNMs for women with recent histories of GDM and to identify strategies for improvement. Methods : From October through December 2010, the Ohio Department of Health sent a survey by mail and Internet to all licensed CNMs practicing in Ohio. We calculated prevalence estimates for knowledge, attitudes, clinical practices, and behaviors related to postpartum diabetes screening. Chi‐square statistics were used to assess differences in self‐reported clinical behaviors by frequency of postpartum screening. Results : Of the 146 CNMs who provided postpartum care and responded to the survey (62.2% response rate), 50.4% reported screening women with GDM‐affected pregnancies for abnormal glucose tolerance at the postpartum visit. Of CNMs who screened postpartum, only 48.4% used fasting blood sugar or the 2‐hour oral glucose tolerance test. Although 86.2% of all responding CNMs reported that they inform women with recent histories of GDM of their increased risk for type 2 diabetes mellitus, only 63.1% counseled these women to exercise regularly and 23.3% reported referring overweight/obese women to a diet support group or other nutrition counseling. CNMs reported that identification of community resources for lifestyle interventions and additional training in postpartum screening guidelines may help to improve postpartum care. Discussion : CNMs in Ohio reported suboptimal levels of postpartum diabetes testing and use of a recommended postpartum test. Providing CNMs with additional training and identifying community resources to support needed lifestyle behavior change may improve care for women with recent GDM‐affected pregnancies.     

“The Midwifery Two‐Step”: A Study on Evidence‐Based Midwifery Practice

Introduction: To date, there has been little documentation of how practice‐based midwifery networks in the United States might influence the transfer and development of knowledge in childbearing and women's health care. The first phase of this participatory action research project was to conduct a qualitative study with a community of midwifery practices to understand their perspectives on evidence‐based practice and how an organized network could facilitate their work. Methods: Midwives within the community of interest were invited by letter or e‐mail to participate in individual or small group interviews about knowledge transfer, primary concerns of evidence‐based practice, and potential for a midwifery practice‐based research network. Participatory action research strategies and organizational ethnographic approaches to data collection were used to guide qualitative interviews. Results: Eight midwifery practices enrolled in the study with 23 midwives participating in interviews. They attended births at 2 hospitals in the community. Two broad areas of discourse about evidence‐based practice were identified: 1) challenges from influential persons, finances and resources, and the cultural perception of midwifery, and 2) strategies to foster best practice in the face of those challenges. The midwives believed a research network could be useful in learning collectively about their practices and in the support of their work. Discussion: Evidence‐based practice is a goal but also has many challenges in everyday implementation. Practice‐based research networks hold promise to support clinicians to examine the evidence and form strong coalitions to foster best clinical practice. The second phase of this study will work with this community of midwives to explore collective strategies to examine and improve practice.     

Serving women in need: nurse-midwifery practice in the United States

OBJECTIVE: Nurse-midwifery practices in the United States were examined to study the relationship between certified nurse-midwives' (CNMs) demographic, work setting, and practice characteristics in terms of clientele, practice size, and practice type. Factors that might influence the ability of CNMs to serve populations at risk for poor outcomes were given particular attention. METHODOLOGY: A total of 2,405 responses to a 1998 mailed survey of 6,365 nurse-midwives ever-certified by the American College of Nurse-Midwives were analyzed. RESULTS: Study results indicated that CNMs continue to serve a population who are, based on a social risk profile, disproportionately at risk for poor pregnancy outcomes, including women who are uninsured (16%), immigrant (27%), adolescent (29%), and women of color (50%). It was also found that clientele varied according to practice settings: CNMs working in non-hospital, nonprofit settings served a clientele that was 65% nonwhite, 44% immigrant, 40% adolescent, and 29% uninsured; these CNMs received 61% of their client payments from Medicaid. CNMs working in private offices or for managed care organizations were less likely to serve women with these characteristics. CONCLUSION: Study results, taken in conjunction with research that documents the safety of nurse-midwifery practice, reinforce policy recommendations that support expanded access to nurse-midwifery services. Findings also indicate a need for further research in the areas of CNM workload and productivity in managed care settings and the association between CNM race and ethnicity and the race and ethnicity of their clients.     

Midwives and Liability: Results from the 2009 Nationwide Survey of Certified Nurse‐Midwives and Certified Midwives in the United States

Introduction: In partnership with the American College of Nurse‐Midwives (ACNM), the authors conducted a survey of ACNM members to examine the incidence of lawsuit involvement, the outcomes of the litigation in which they were involved, and coping mechanisms among midwives who had been involved in a lawsuit. Methods: In the spring of 2009, a nationwide Web‐based survey was completed by ACNM members. In addition to using chi‐square tests and nonparametric testing in data analysis, a logistic regression model was used to evaluate predictors of lawsuit involvement. Results: Among 1340 midwives responding to the survey, 32% had been named in a lawsuit at least once. The median number of years in practice when the event leading to lawsuit occurred was 6. The majority of midwifery lawsuits involved hospital births and were settled prior to going to court. Three variables were statistically significant for involvement with litigation: the midwife's age, the number of births attended, and the ACNM region of practice in the United States. Discussion: Lawsuits among midwives were significantly related to exposure to births over time. Practice patterns and job security were not greatly affected by the experience of a lawsuit. Future cyclic surveys are needed to track the frequency of litigation and the outcomes that lead to lawsuits and to better define the relationships between midwifery practice and medical malpractice litigation.     

Innovations in Midwifery Education: The Academic Medical Center Model

Workforce analyses project a need for women's health care providers, especially in maternity care. With a stagnant number of certified nurse‐midwife/certified midwife (CNM/CM) education programs, the present production of new CNMs/CMs is not robust enough to meet the growing demand. This article describes an existing but underutilized model for CNM/CM education programs, based in an academic medical center with an existing academic affiliation. Advantages include a federal funding source through the Centers for Medicare and Medicaid Services, lower tuition costs than most current programs, and expanded job satisfaction for CNMs/CMs in clinical practice.     

Examining Autonomy’s Boundaries: A Follow‐up Review of Perinatal Mortality Cases in UK Independent Midwifery

Abstract: Background: An earlier matched cohort study in the United Kingdom found a significantly higher perinatal mortality rate for births booked under an independent midwife compared with births in National Health Service units (1.7% [25/1,508] vs 0.6% [45/7,366]). This study examined independent midwives’ management and decision making in the 15 instances of perinatal death that occurred at term. Methods: Thematic analysis of independent midwives’ case notes was performed in instances of perinatal mortality. Semi‐structured interviews were conducted with the midwives concerned. Results: Home birth was attempted in 13 of the 15 cases. Significant (often multiple) antenatal risk factors were identified in 13 cases, including twin pregnancy, planned vaginal births after cesarean section, breech presentations, and maternal illness. Several women had declined some or all routine antenatal screening. Three deaths occurred before labor onset. Postmortem results were known in only four cases; many causes of death remained unexplained. Professional consensus was that seven deaths were unpreventable; elective cesarean section may have changed the outcome in eight cases. However, the pregnant women had declined this option; some were reported to be avoiding National Health Service care because of previous bad experiences. Transfer to hospital care, when it occurred, was often problematic. Care management was judged to be clinically acceptable within the parameters set by the mothers’ choices. Conclusions: Information about clinical processes (and outcomes) is essential if informed decisions are to be made. The women in this review had reportedly accepted the potential consequences of their high‐risk situations. If reality is to match rhetoric about “patient” autonomy, such decision making in high‐risk situations must be accepted. (BIRTH 37:4 December 2010)     

NURSE-MIDWIFERY CARE TO VULNERABLE POPULATIONS Phase I: Demographic Characteristics of the National CNM Sample

The purpose of this article is to describe the extent to which certified nurse-midwives (CNMs) provide care to vulnerable populations in the United States and the source of reimbursement for this care. The data were obtained from the first phase of a national study to address the characteristics of women served and cost of care provided by CNMs. Results were analyzed nationally and by American College of Nurse-Midwives regions. Certified nurse-midwives in all types of practices are providing care to women from populations that are vulnerable to poorer than average outcomes of childbirth because of age, socioeconomic status, refugee status, and ethnicity. Ninety-nine percent of CNMs report serving at least one group of vulnerable women, and CNMs in the inner city and rural practices serve several groups. The vast majority of CNMs are salaried; only 11% receive their primary income from fee-for-service. Fifty percent of the payment for CNM services is from Medicaid and government-subsidized sources whereas less than 20% comes from private insurance. Source of income varies by type of setting in which the CNM attends births. The results suggest that CNMs, as a group, make a major contribution to the care of vulnerable populations.     

Nurse-midwifery care to vulnerable populations. Phase I: Demographic characteristics of the National CNM Sample.

The purpose of this article is to describe the extent to which certified nurse-midwives (CNMs) provide care to vulnerable populations in the United States and the source of reimbursement for this care. The data were obtained from the first phase of a national study to address the characteristics of women served and cost of care provided by CNMs. Results were analyzed nationally and by American College of Nurse-Midwives regions. Certified nurse-midwives in all types of practices are providing care to women from populations that are vulnerable to poorer than average outcomes of childbirth because of age, socioeconomic status, refugee status, and ethnicity. Ninety-nine percent of CNMs report serving at least one group of vulnerable women, and CNMs in the inner city and rural practices serve several groups. The vast majority of CNMs are salaried; only 11% receive their primary income from fee-for-service. Fifty percent of the payment for CNM services is from Medicaid and government-subsidized sources whereas less than 20% comes from private insurance. Source of income varies by type of setting in which the CNM attends births. The results suggest that CNMs, as a group, make a major contribution to the care of vulnerable populations.