Journal of Midwifery & Women’s Health
www.jmwh.org
Original Research
Formulating Evidence-Based Guidelines for Certified Nurse-Midwives and Certified Midwives Attending Home Births Elizabeth Cook, CNM, CPM, WHNP, DNP, Melissa Avery, CNM, PhD, Melissa Frisvold, CNM, PhD
Introduction: Implementing national home birth guidelines for certified nurse-midwives (CNMs) and certified midwives (CMs) in the United States may facilitate a common approach to safe home birth practices. Guidelines are evidence-based care recommendations for specified clinical situations that can be modified by individual providers to meet specific client needs. Methods: Following a review of home birth guidelines from multiple countries, a set of home birth practices guidelines for US CNMs/CMs was drafted. Fifteen American Midwifery Certification Board, Inc. (AMCB)-certified home birth midwives who participate in the American College of Nurse-Midwives (ACNM) home birth electronic mailing list considered the use of such a document in their practices and reviewed and commented on the guidelines. Results: The proposed guidelines addressed client screening, informed consent, antepartum care, routine intrapartum care, obstetric complications and hospital transports, postpartum care, neonatal care, gynecologic care, primary care, peer reviews, recordkeeping, and physician collaboration. The reviewers had varying assessments as to whether the guidelines reflected international standards and current best evidence. The primary concern expressed was that an adoption of national guidelines could compromise provider autonomy. Discussion: Incorporation of evidence-based guidelines is an ACNM standard and was recommended by the Home Birth Consensus Summit. Clinical practice guidelines are informed by current evidence and supported by experts in a given discipline. Implementation of guidelines ensures optimal patient care and is becoming increasingly central to reimbursement and to medicolegal support. A set of practice guidelines based on current best evidence and internationally accepted standards was developed and reviewed by an interested group of US CNMs/CMs. Further discussion with home birth midwives and other stakeholders about the development and implementation of home birth guidelines is needed, especially in light of this project’s finding of less support for national home birth guidelines among the reviewers subsequent to versus prior to their review of the draft guidelines. c 2014 by the American College of Nurse-Midwives. J Midwifery Womens Health 2014;59:153–159 Keywords: clinical practice, guidelines, health policy, home birth, low risk, normal birth
INTRODUCTION
Low-risk women comprise 70% to 85% of the maternity population and are suited to midwifery care,1, 2 which may be provided in home settings.3, 4 In the United States, the home birth rate rose 41% from 2004 to 2010; the current rate is 0.79% of all births.5 Although the overall number of home births is low, the increase suggests that consumers are looking for alternatives to traditional hospital-based maternity care. Women have the ability to make their own best-informed maternity choices6 and deserve to receive quality care from skilled providers, regardless of their chosen birth locations.7, 8 Practice variability is often present in the absence of common clinical practice guidelines.9 Thus, a consistent approach to safe home birth practice is needed to support consumers who desire to utilize this model of maternity care. Certified nursemidwives (CNMs) and certified midwives (CMs) attend 20.6% of US home births (Table 1)5 and are well poised to initiate home birth guideline development in the United States. The American College of Nurse-Midwives (ACNM) Standards for the Practice of Midwifery includes the utiAddress correspondence to Elizabeth Cook, CNM, CPM, WHNP, DNP, 2719 28th Ave SW, Cedar Rapids, IA 52404. E-mail: [email protected]
1526-9523/09/$36.00 doi:10.1111/jmwh.12142
lization of practice guidelines by CNMs/CMs.10 The organization’s position statement on patient safety, based on reports from the Institute of Medicine and the Joint Commission, states that “care should be based on scientific knowledge about best practices with the use of evidence-based standards and guidelines.”11 Maternity care experts in the United States echoed the value of practice guidelines at the 2011 Home Birth Consensus Summit.12 With the current absence of a single set of national guidelines, CNMs/CMs with home birth practice must independently develop their own guidelines in a time-intensive endeavor resulting in variable care. A common national approach to CNM/CM home birth practices may foster consistency among these providers. It is likely that CNMs/CMs already use individual practice guidelines; therefore, adopting nationally promulgated guidelines should not significantly alter their practices but should simply encourage a common approach. A definition of clinical practice guidelines proposed by the Institute of Medicine in 1990, and endorsed by the US Department of Health and Human Services Agency for Healthcare Research and Quality, is “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”13 In 2011 the definition was amended to “statements that
c 2014 by the American College of Nurse-Midwives
153
✦ Low-risk women should have the option to give birth at home attended by midwives using consistent, evidence-based
practices. ✦ Nationally or provincially recognized home birth midwifery guidelines are used in some countries with integrated home
birth midwifery practice. ✦ Guidelines are evidence-based recommendations for care that may be adapted by midwives to their individual practices to provide evidence-based care. ✦ Implementing national home birth guidelines in the United States may facilitate a common approach to safe home birth practices. ✦ Further discussions among home birth midwives and other stakeholders are needed on a national level to explore the usefulness of national home birth guidelines in the United States.
include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.”14 Practice guidelines are designed to inform the provider about current evidence-based practices based on the best research evidence and expert consensus in a given discipline.15, 16 Implementation of guidelines ensures optimal patient care,17 particularly in disciplines where research is continuously evolving. Guidelines for conditions from diabetes to head injuries have helped to improve patient outcomes associated with these conditions.17 Use of practice guidelines is also becoming increasingly central to reimbursement and to medicolegal support.18 Therefore, it is reasonable to suggest that care of the home birth client may be optimized with the utilization of nationally promulgated home birth practice guidelines. This article will explore the idea that one way to foster a common approach to safe home birth practice is to develop national guidelines for midwives who provide home birth services. This project was intended to be a springboard for a future systematic review and multidisciplinary discussions. GUIDELINE DEVELOPMENT
The primary author (E.C.) developed a set of guidelines for possible use by CNMs/CMs in the United States who attend home births. Fundamental to this undertaking
Table 1. Providers Attending Home Births in the United States, 2010
Maternity Care Providers
Home Birth 4.3
Certified nurse-midwives/certified
20.6
midwives 31.6
medical technician, etc) Other midwives Source: MacDorman et al.5
154
Methods
Using an Internet search engine, the following terms were used to identify countries with published home birth guidelines: “home birth midwives,” “home birth guidelines,” “home birth standards of practice,” “midwifery guidelines,” and “midwifery standards of practice.” It was beyond the scope of this project to review midwifery practice in all countries. Attention was given to countries with maternity systems comparable to those in the United States, but where home birth rates are higher. Five countries with provincially or nationally promulgated home birth midwifery guidelines met these criteria: Australia, Canada, the Netherlands, New Zealand, and the United Kingdom. Published guidelines of these countries were then reviewed for common themes (Table 2).19–25 The following criteria for planning a home birth emerged: determination of low-risk pregnancy, informed consent, hospital transfer if complications arise, singleton pregnancy, fetus in the cephalic presentation, no history of previous cesarean birth, and term pregnancy.
Attendance, ()
Physicians
Other attendants (family, emergency
were 2 premises. First, the author recognized that research demonstrates the safety of home birth for low-risk women.3, 4 Second, the author understood that guidelines are evidencebased recommendations for care that respect the provider’s expertise to meet individual client needs.15, 16 No national guidelines have been developed to specifically address US home birth practice; therefore, the practice guidelines of several other countries with home birth midwives integrated into their health care systems were examined. A small group of CNMs/CMs was then asked to review these proposed guidelines and react to the idea of establishing such guidelines as a national standard.
43.6
Assessment of Existing Guidelines
The Netherlands reports the largest proportion of home births internationally, reaching nearly 30%. The Royal Dutch Association of Midwives, the National Association of General Practitioners, and the Dutch Association of Obstetrics and Gynecology jointly support their maternity manual.19 The 17-page List of Obstetric Indications outlines a description of routine midwifery care and conditions requiring consultation or Volume 59, No. 2, March/April 2014
Table 2. Required Components of Home Birth Practice Guidelines from Specific Provinces and Countries
British Criterion
New
Australia Columbia Manitoba
Netherlands
United
Zealand Kingdom
Low risk birth per standardized guidelines
yes
yes
yes
yes
yes
yes
Informed consent is required.
yes
yes
yes
not mentioned
yes
yes
System must be place for transport in the event of complications.
yes
yes
yes
yes
yes
yes
a
b
yes yes
Fetus must be in a cephalic presentation.
yes
yes
no
yes
no
Mother must have a singleton pregnancy.
yes
yes
noa
yes
yes
Mother must have a term pregnancy.
yes
yes
yes
yes
yes
yes
Mother must have no history of a previous cesarean birth.
yes
noc
nod
yes
noc
yes
a Breech and twin births may be attempted if recommended by a physician. b Breech diagnosed in labor may be attempted after physician consultation. c Requires physician consultation. d
Contraindicated with previous lower-segment cesarean birth before 26 weeks’ gestation, interpregnancy interval of less than 18 months, history of impaired scar healing, or prolonged active phase. Sources: Obstetric Working Group19 ; National Institute for Health and Clinical Excellence20 ; Australian College of Midwives21 ; College of Midwives of Manitoba22 ; College of Midwives of British Columbia23 ; College of Midwives of Manitoba24 ; and New Zealand Ministry of Health.25
referral to an obstetrician.19 Home birth midwives are well integrated into the Dutch national health care system, contributing to timely referrals and strong maternity care outcomes.26 New Zealand, another world leader in midwifery, reports a home birth rate of 7%.27 Home birth has been legally supported in New Zealand since 1983, and national consultation and referral guidelines have been available since 1996.28 Their 32-page document of midwifery guidelines, developed by the Ministry of Health and an expert working group, outlines the mechanisms of consultation and referral to obstetric and other medical services.25 Home birth guidelines of 2 Canadian provinces, British Columbia and Manitoba, were evaluated in detail. British Columbia has formally recognized midwifery since 1993. Their 50-page Home Birth Handbook includes home birth practice guidelines developed by the College of Midwives of British Columbia.23 The College of Midwives of Manitoba has a 10-page document on the standards of midwifery that applies to practices in all settings and outlines criteria for discussion, consultation, and the transfer of care.22 Although the 2 sets of guidelines are very similar, there are a few differences. Manitoba guidelines allow a woman with a breech presentation or twin gestation to consider a home birth if recommended by a physician. British Columbia guidelines specify that in order to make a transport timely, even weather conditions must be taken into consideration. The 11-page Australian home birth position statement includes specific guidelines. These were the most concise guidelines evaluated and included only 4 indications for referral to physician services: multiple gestation, noncephalic presentation, labor outside the range of 37 to 42 weeks’ gestation, and a scarred uterus.21 The home birth rate in the United Kingdom is only 2.7%; however, members of the Royal College of Obstetricians and Gynaecologists (RCOG) have estimated that, with informed consent and full client autonomy, 8% to 10% of all births could occur in homes.29 A 2007 RCOG and Royal College of Midwives (RCM) joint statement recommends that home birth midwives have written practice guidelines and operate within a system that allows for seamless consultaJournal of Midwifery & Women’s Health r www.jmwh.org
tion, collaboration, and referral. National home birth standards for the United Kingdom were formulated by the Guideline Development Group, a multiprofessional and lay working group of the National Collaborating Centre for Women’s and Children’s Health at the National Institute for Health and Clinical Excellence. Members of the group represented multiple stakeholders affected by the guidelines, including a senior midwife researcher and representatives from obstetrics, neonatology, obstetric anesthesia, and midwifery—as well as consumers.29
Development of Proposed US Guidelines
After collection, review, and summary of these international guidelines, the primary author synthesized the information into draft home birth guidelines that could be used by US CNMs/CMs. The resulting 10-page document (see Supporting Information: Appendix S1) includes recommendations about licensure, physician collaboration, hospital transports, informed consent, documentation, client screening, equipment, medications, birth assistants, routine care of the mother and newborn, and emergency care of the mother and newborn (Table 3). Guideline development was influenced by the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, including the domains of purpose, stakeholder involvement, rigor of development, clarity and presentation, applicability, and editorial independence.30 REVIEW OF THE GUIDELINES
After completion of the draft guidelines, the authors sought reviews from midwives certified by the American Midwifery Certification Board (AMCB) who are engaged in home birth practice. This evaluation was determined to be exempt from institutional review board oversight. Reviewers were asked to: 1) complete prereview questionnaires, 2) review the guidelines and consider applying them to their practices, and 3) complete postreview questionnaires. The questionnaires were designed by the primary author according to criteria of the American National Standard and Joint Committee on Standards for Educational Evaluation.31 Response 155
Table 3. Components of the Home Birth Guidelines Proposed for the American College of Nurse-Midwivesa
Maintain licensure and certification per AMCB and state regulations Delineate physician involvement through consultation, collaboration, and referral mechanisms Make timely hospital transports when complications arise Participate in peer reviews per state regulations Ensure that clients have full informed consent Maintain appropriate documentation Screen clients based on current and past obstetric and medical conditions, as per stated guidelines Maintain all necessary equipment Carry all appropriate medications Have at least one assistant Use AWHONN guidelines for fetal monitoring Provide routine antepartum, intrapartum, and postpartum care Provide routine neonatal care up to 28 days of life Provide routine primary and gynecologic care Abbreviations: AMCB, American Midwifery Certification Board; AWHONN, Association of Women’s Health, Obstetric, and Neonatal Nurses. a A full copy of the proposed guidelines can be found in Supporting Information: Appendix S1.
Figure 1. States Represented by the 16 Reviewers of the Proposed Home Birth Guidelines Reviewers of the draft guidelines were from the states highlighted in blue.
options were based on the 5-item ordinal Likert scale. Participation was solicited through the ACNM home birth electronic mailing list. Nineteen midwives initially expressed interest, and 15 AMCB-certified midwives completed reviews, representing 13 practices in 13 states (Figure 1). One certified professional midwife (CPM) who practiced with a responding CNM also completed a review. The review process occurred from January through March 2012. The prereview questionnaire included 7 questions to assess the reviewers’ perspectives on whether a national set of home birth guidelines would improve physician collaboration, hospital reception of home birth transports, availability of liability insurance, and general respect from the medical and lay communities. Two additional questions assessed how the reviewers perceived that guidelines would impact their autonomy and provide overall benefit. These 9 156
questions were duplicated on the postreview questionnaire to compare the reviewers’ perceptions of the guidelines before and after review. Three additional questions addressed the reviewers’ perceptions of the guidelines’ clarity, reflection of the literature, and reflection of international midwifery standards. Table 4 summarizes the results of this review. Concern was expressed that having national guidelines may not improve physician collaboration, hospital acceptance of home birth transports, liability coverage, or medical and lay community respect for home birth midwifery. The reviewers were equally split in their agreement or disagreement over the guidelines’ clarity. They tended toward neutrality or disagreement that the guidelines were supported by the literature. Most took a neutral position regarding the guidelines’ consistency with international maternity standards, while the Volume 59, No. 2, March/April 2014
Table 4. Results of Formal Guideline Reviews (N = 16)
Pretest/Posttest, () Strongly Disagree
Strongly Disagree Neutral Agree
Agree
Question: National guidelines would: Improve physician collaboration
0/30
Improve hospital reception of home birth transports
0/40
Improve liability coverage of home birth midwives
0/30
Increase recognition among the medical community of the safety of home births
0/0
Increase respect among the medical community for the midwifery profession
8/40
Increase recognition among the lay community of the safety of home births Increase respect among the lay community for the midwifery profession Threaten the autonomy of home birth midwives Be overall beneficial
33/30
33/30
25/10
8/0
17/0
25/0
58/50
0/10
17/10
33/30
50/10
0/0
17/40
0/0
66/40
17/20
8/10
17/20
58/10
8/20
0/0
17/40
17/0
58/50
8/10
0/10
17/30
33/0
42/50
8/10
25/0
42/10
25/40
8/40
0/10
0/0
0/40
17/0
66/40
17/20
Clear
–/0
–/40
–/10
–/40
–/10
Supported by the literature
–/0
–/35
–/35
–/20
–/10
Consistent with international standards
–/0
–/20
–/40
–/20
–/10
Question: The proposed guidelines are:a
a
These questions were only asked after review of the guidelines; therefore, there are no pretest scores.
other reviewers were equally split in this regard. The reviewers expressed greater favorability toward national home birth guideline adoption prior to reviewing the proposed guidelines versus after their review. Subsequent to this assessment, minor revisions were made to the guidelines based on feedback from the reviewers, such as recommending physician collaboration versus referral for some client conditions, and eliminating a specific time frame for hospital transports. A copy of the current proposed guidelines is available (see Supporting Information: Appendix S1). DISCUSSION
An international review of home birth guidelines and a review by US home birth midwives of a proposed set of US home birth guidelines demonstrate the multifaceted ramifications of implementing a set of national guidelines. Discussion of the usefulness and content of a possible set of guidelines for CNMs/CMs is timely; those discussions can be expanded at a national level. However, the authors were surprised that the reviewers expressed greater interest in developing and implementing national home birth midwifery guidelines prior to reviewing the proposed guidelines versus after their review. It is unclear why these reviewers’ assessments of the proposed guidelines were so varied, yet most reviewers expressed interest in further discussion of the benefits of adopting national home birth guidelines. Thus, a broader qualitative study is needed to understand midwives’ perspectives on US home birth guideline development. The primary concern raised by the reviewers was whether or not guidelines would impact their autonomy. Guidelines are intended to provide best practices from which providers can meet individual client needs but also discourage providers from diverging from safe practices. The reviewers specified that the proposed guidelines might not support them if they choose to attend the home birth of a woman with a breech Journal of Midwifery & Women’s Health r www.jmwh.org
presentation or a twin gestation or a woman who desires a trial of labor after a previous cesarean. While CNMs/CMs attending home births may have the skill to attend such births, the safety net available in an institutional setting is advantageous and may be preferable for such births.32 Although ensuring client safety may at times conflict with provider and client preferences,33 safety is the first priority for improving the quality of health care.34 We recognize that current practice at some hospitals does not allow vaginal birth options for women with breech presentations, multiple gestations, or previous cesareans. These represent areas for ongoing discussion among women, providers, and health systems to provide safe options that women desire. This project targeted CNMs and CMs in order to provide an opportunity to develop home birth guidelines for ACNM in accordance with its published practice standards. Having these guidelines would then provide a springboard for future collaboration on joint home birth guideline development with CPMs, nurses, physicians, consumers, insurers, and other stakeholders. The 2012 joint statement on physiologic birth35 and the second meeting of the Home Birth Consensus Summit in 201336 are examples of similar collaborations. Development of ACNM guidelines for US practice is a first step in such collaborations. Critical to this is further discussion and review to create guidelines that meet standards for safe practice while protecting choice. Fundamental to international home birth guidelines that were examined in this project is a distinction between lowrisk and high-risk maternity criteria. Normal birth has been defined in a joint statement by the Society of Obstetricians and Gynaecologists of Canada; the Association of Women’s Health, Obstetric, and Neonatal Nurses of Canada; the Canadian Association of Midwives; the College of Family Physicians of Canada; and the Society of Rural Physicians of Canada as spontaneous labor with a singleton fetus in a vertex presentation at 37 to 42 weeks’ gestation after an 157
uncomplicated pregnancy.37 This definition is consistent with the World Health Organization definition2 and the UK Maternity Care Working Party definition supported by the RCOG and RCM.38 Thus, it was used to direct the development of the proposed US home birth guidelines. It would be advantageous for maternity experts in the United States to soon define low risk. The 2012 joint statement on physiologic birth by ACNM, the Midwives Alliance of North America, and the National Association of Certified Professional Midwives35 may provide the groundwork for such common definitions. In the meantime, we may consider the definitions that were used internationally as precedents. CONCLUSION
Low-risk maternity clients should have the option of giving birth in a hospital, birth center, or home setting with skilled providers using evidence-based practices. A common approach to safe home birth midwifery practices may further support clients who desire this model of care. We propose that further discussion of guidelines for home birth practices in the United States is warranted, considering international standards, ACNM standards for practice, and current research evidence. Accepting a common definition of low risk would enhance the discussion. Furthermore, because home birth is an interdisciplinary issue involving not only AMCBcertified midwives, but also CPMs, physicians, nurses, insurers, and consumers engaged in home birth practice, discussions need to include all stakeholders. Developing and implementing nationally recognized, evidence-based home birth guidelines may be one means to foster a common approach to safe home birth practices. AUTHORS
Elizabeth Cook, CNM, CPM, WHNP, DNP, is a Clinical Assistant Professor at the University of Iowa Hospitals and Clinics. Melissa D. Avery, CNM, PhD, FACNM, FAAN, is a professor and Chair of the Child and Family Health Co-operative, University of Minnesota, School of Nursing, Minneapolis, MN. Melissa Frisvold, CNM, PhD, has worked in private practice and most recently served at the University of Minnesota as a Clinical Assistant Professor and the Nurse-Midwifery Program Director. CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose. REFERENCES 1.World Health Organization. The World Health Report: Make Every Mother and Child Count. Geneva, Switzerland: World Health Organization Press; 2005. 2.World Health Organization. Care in Normal Birth: A Practical Guide. Geneva, Switzerland: WHO Safe Motherhood Technical Working Group; 1996. 3.Janssen P, Saxell L, Page L, Klein M, Liston R, & Lee S. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. Can Med Assoc J. 2009;181(6-7):377383.
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4.Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for health women with low risk pregnancies: The birthplace in England national prospective cohort study. BMJ. 2011; 343:d7400. 5.MacDorman MF, Declerq E, Mathews TJ. Recent trends in out-ofhospital births in the United States. J Midwifery Womens Health. 2013;58(5):494-501. 6.Kennedy H, Grant J, Walton C, Shaw-Battista J, & Sandall J. Normalizing birth in England: A qualitative study. J Midwifery Womens Health. 2010; 55(3), 262-269. 7.National Association of Certified Professional Midwives. Maternity Care and Health Care Reform: Opportunities to Improve Quality and Access, Reduce Costs, and Increase Evidence-Based Practice. NACPM Recommendations to the Obama-Biden Transition Team. 2009. Putney, VT: NACPM. 8.Rooks J. Oregon State Legislation Committee Meeting Document 8585. 2013. Available at: https://olis.leg.state.or.us/liz/2013R1/ Downloads/CommitteeMeetingDocument/8585. Accessed July 5, 2013. 9.Canadian Association of Emergency Physicians. Standardization of Care and Clinical Practice Guidelines: Improving Patient Outcomes. 2013. Available at: http://caep.ca/advocacy/romanowcommission/standardization Accessed July 1, 2013. 10.American College of Nurse-Midwives. Standards for the Practice of Midwifery. Silver Spring, MD: American College of Nurse-Midwives; 2009. 11.American College of Nurse-Midwives. Position Statement: Creating a Culture of Safety in Midwifery Care. Silver Spring, MD: American College of Nurse-Midwives; 2006. 12.Home Birth Consensus Summit. What Were the Outcomes of the Home Birth Summit? 2011. Available at: http://www. homebirthsummit.org/summit-outcomes.html. Accessed November 26, 2011. 13.Institute of Medicine, Committee on Quality Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. 14.National Institutes of Health. About Systematic Evidence Reviews and Clinical Practice Guidelines. 2013. Available at: http://www. nhlbi.nih.gov/guidelines/about.htm#cpg Access June 25, 2013. 15.Canadian Association of Emergency Physicians. Standardization of Care and Clinical Practice Guidelines: Improving Patient Outcomes. 2013. Available at: http://caep.ca/advocacy/romanowcommission/standardization Accessed July 1, 2013. 16.Institute of Medicine. Consensus Report: Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academy of Sciences; 2001. 17.National Institute of Clinical Health Studies. Do Guidelines Make a Difference to Health Care Outcomes? Melbourne, Australia: NICS; 2006. 18.Kenefick H, Lee J, & Fleishman V. Improving Physician Adherence to Clinical Practice Guidelines: Barriers and Strategies for Change. Cambridge, MA: New England Healthcare Institute; 2008. 19.Obstetric Working Group. Obstetric Manual: Final Report of the Obstetric Working Group of the National Health Insurance Board of the Netherlands. The List of Obstetric Indications. Amstelveen, Netherlands: Royal Dutch Association of Midwives; 2010. 20.National Institute for Health and Clinical Excellence. Clinical Guideline No.55: Care of Healthy Women and Their Babies During Childbirth. London, UK: National Institute for Health and Clinical Excellence; 2007. 21.Australian College of Midwives. Position Statement on Homebirth. Deakin, Australia: Australian College of Midwives; 2011. 22.College of Midwives of Manitoba. Standards of Practice for Midwives in Manitoba. Manitoba, Canada: College of Midwives of Manitoba; 2005. 23.College of Midwives of British Columbia. Standards of Practice. Vancouver, BC, Canada: College of Midwives of British Columbia; 1996. 24.College of Midwives of Manitoba. Standards for Planned Out of Hospital Birth. Winnipeg, MB, Canada: College of Midwives of Manitoba; 2005. Volume 59, No. 2, March/April 2014
25.New Zealand Ministry of Health. Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines). 2012. Wellington, New Zealand: Ministry of Health. 26.Amelink-Verburg M, Verloove-Vanhorick S, Hakkenberg R, Veldhuijzen I, Bennebroek-Gravenhorst J, & Buitendijk S. Evaluation of 280,000 cases in Dutch midwifery practices: A descriptive study. Brit J Obstet Gynae. 2008;115:570-578. 27.Home Birth Aotearoa. What Are the Statistics of Home Births? 2013. Available at: http://www.homebirth.org.nz/index.php/information/ faq-s-about-home-birth/8-information/faqs/68-statistics Accessed July 5, 2013. 28.Guilliland K. Birth at Home: NZ’s Position. Richmond, New Zealand, New Zealand College of Midwives; 2011. 29.Royal College of Obstetricians and Gynaecologists and Royal College of Midwives. Joint Statement No.2: Home Births. London, UK; 2007. 30.AGREE Next Steps Consortium. Appraisal of Guidelines for Research & Evaluation II Instrument. Hamilton, Ontario, Canada: AGREE Next Steps Consortium. 2009. 31.American Evaluation Association. The Program Evaluation Standards. n.d. Available at: http://www.eval.org/evaluationdocuments/ progeval.html Accessed March 2, 2012. 32.Mehl-Madrona L, Mehl-Madrona M. Physician- and midwifeattended home births: Effects of breech, twin, and post-dates outcome data on mortality rates. J Nurse-Midwifery. 1997;42(2): 9198. 33.Larson L. Physician autonomy vs. accountability: Making quality standards and medical style mesh. Trustee. 2007;60(7):14-6,21,1.
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34.National Institutes of Health. About Systematic Evidence Reviews and Clinical Practice Guidelines. 2013. Available at: http://www. nhlbi.nih.gov/guidelines/about.htm#cpg Accessed June 25, 2013. 35.American College of Nurse Midwives, Midwives Alliance of North American, and National Association of Certified Professional Midwives. Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by ACNM, MANA, and NACPM. 2012. 36.Home Birth Consensus Summit. Home Birth Consensus Summit Review Meeting. 2013. Available at: http://www. homebirthsummit.org/news-and-events Accessed July 8, 2013. 37.Society of Obstetricians and Gynaecologists of Canada. Joint policy statement on normal childbirth. J Obstet Gynaecol Canada. 2008;30:1163-1165. 38.Maternity Care Working Party. Making normal birth a reality: Consensus statement from the Maternity Care Working Party. Our shared views about the need to recognise, facilitate and audit normal birth. 2007. NCT/RCOG/RCM. Available at: http://www.nct.org.uk/sites/ default/files/related documents/Making Normal Birth A RealityNormal Birth Consensus Statement.pdf Accessed August 10, 2013.
SUPPORTING INFORMATION
Additional supporting information may be found in the online version of this article: Appendix S1: CNMs/CMs
Proposed
Guidelines
for
Homebirth
159
www.jmwh.org
Original Research
Formulating Evidence-Based Guidelines for Certified Nurse-Midwives and Certified Midwives Attending Home Births Elizabeth Cook, CNM, CPM, WHNP, DNP, Melissa Avery, CNM, PhD, Melissa Frisvold, CNM, PhD
Introduction: Implementing national home birth guidelines for certified nurse-midwives (CNMs) and certified midwives (CMs) in the United States may facilitate a common approach to safe home birth practices. Guidelines are evidence-based care recommendations for specified clinical situations that can be modified by individual providers to meet specific client needs. Methods: Following a review of home birth guidelines from multiple countries, a set of home birth practices guidelines for US CNMs/CMs was drafted. Fifteen American Midwifery Certification Board, Inc. (AMCB)-certified home birth midwives who participate in the American College of Nurse-Midwives (ACNM) home birth electronic mailing list considered the use of such a document in their practices and reviewed and commented on the guidelines. Results: The proposed guidelines addressed client screening, informed consent, antepartum care, routine intrapartum care, obstetric complications and hospital transports, postpartum care, neonatal care, gynecologic care, primary care, peer reviews, recordkeeping, and physician collaboration. The reviewers had varying assessments as to whether the guidelines reflected international standards and current best evidence. The primary concern expressed was that an adoption of national guidelines could compromise provider autonomy. Discussion: Incorporation of evidence-based guidelines is an ACNM standard and was recommended by the Home Birth Consensus Summit. Clinical practice guidelines are informed by current evidence and supported by experts in a given discipline. Implementation of guidelines ensures optimal patient care and is becoming increasingly central to reimbursement and to medicolegal support. A set of practice guidelines based on current best evidence and internationally accepted standards was developed and reviewed by an interested group of US CNMs/CMs. Further discussion with home birth midwives and other stakeholders about the development and implementation of home birth guidelines is needed, especially in light of this project’s finding of less support for national home birth guidelines among the reviewers subsequent to versus prior to their review of the draft guidelines. c 2014 by the American College of Nurse-Midwives. J Midwifery Womens Health 2014;59:153–159 Keywords: clinical practice, guidelines, health policy, home birth, low risk, normal birth
INTRODUCTION
Low-risk women comprise 70% to 85% of the maternity population and are suited to midwifery care,1, 2 which may be provided in home settings.3, 4 In the United States, the home birth rate rose 41% from 2004 to 2010; the current rate is 0.79% of all births.5 Although the overall number of home births is low, the increase suggests that consumers are looking for alternatives to traditional hospital-based maternity care. Women have the ability to make their own best-informed maternity choices6 and deserve to receive quality care from skilled providers, regardless of their chosen birth locations.7, 8 Practice variability is often present in the absence of common clinical practice guidelines.9 Thus, a consistent approach to safe home birth practice is needed to support consumers who desire to utilize this model of maternity care. Certified nursemidwives (CNMs) and certified midwives (CMs) attend 20.6% of US home births (Table 1)5 and are well poised to initiate home birth guideline development in the United States. The American College of Nurse-Midwives (ACNM) Standards for the Practice of Midwifery includes the utiAddress correspondence to Elizabeth Cook, CNM, CPM, WHNP, DNP, 2719 28th Ave SW, Cedar Rapids, IA 52404. E-mail: [email protected]
1526-9523/09/$36.00 doi:10.1111/jmwh.12142
lization of practice guidelines by CNMs/CMs.10 The organization’s position statement on patient safety, based on reports from the Institute of Medicine and the Joint Commission, states that “care should be based on scientific knowledge about best practices with the use of evidence-based standards and guidelines.”11 Maternity care experts in the United States echoed the value of practice guidelines at the 2011 Home Birth Consensus Summit.12 With the current absence of a single set of national guidelines, CNMs/CMs with home birth practice must independently develop their own guidelines in a time-intensive endeavor resulting in variable care. A common national approach to CNM/CM home birth practices may foster consistency among these providers. It is likely that CNMs/CMs already use individual practice guidelines; therefore, adopting nationally promulgated guidelines should not significantly alter their practices but should simply encourage a common approach. A definition of clinical practice guidelines proposed by the Institute of Medicine in 1990, and endorsed by the US Department of Health and Human Services Agency for Healthcare Research and Quality, is “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”13 In 2011 the definition was amended to “statements that
c 2014 by the American College of Nurse-Midwives
153
✦ Low-risk women should have the option to give birth at home attended by midwives using consistent, evidence-based
practices. ✦ Nationally or provincially recognized home birth midwifery guidelines are used in some countries with integrated home
birth midwifery practice. ✦ Guidelines are evidence-based recommendations for care that may be adapted by midwives to their individual practices to provide evidence-based care. ✦ Implementing national home birth guidelines in the United States may facilitate a common approach to safe home birth practices. ✦ Further discussions among home birth midwives and other stakeholders are needed on a national level to explore the usefulness of national home birth guidelines in the United States.
include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.”14 Practice guidelines are designed to inform the provider about current evidence-based practices based on the best research evidence and expert consensus in a given discipline.15, 16 Implementation of guidelines ensures optimal patient care,17 particularly in disciplines where research is continuously evolving. Guidelines for conditions from diabetes to head injuries have helped to improve patient outcomes associated with these conditions.17 Use of practice guidelines is also becoming increasingly central to reimbursement and to medicolegal support.18 Therefore, it is reasonable to suggest that care of the home birth client may be optimized with the utilization of nationally promulgated home birth practice guidelines. This article will explore the idea that one way to foster a common approach to safe home birth practice is to develop national guidelines for midwives who provide home birth services. This project was intended to be a springboard for a future systematic review and multidisciplinary discussions. GUIDELINE DEVELOPMENT
The primary author (E.C.) developed a set of guidelines for possible use by CNMs/CMs in the United States who attend home births. Fundamental to this undertaking
Table 1. Providers Attending Home Births in the United States, 2010
Maternity Care Providers
Home Birth 4.3
Certified nurse-midwives/certified
20.6
midwives 31.6
medical technician, etc) Other midwives Source: MacDorman et al.5
154
Methods
Using an Internet search engine, the following terms were used to identify countries with published home birth guidelines: “home birth midwives,” “home birth guidelines,” “home birth standards of practice,” “midwifery guidelines,” and “midwifery standards of practice.” It was beyond the scope of this project to review midwifery practice in all countries. Attention was given to countries with maternity systems comparable to those in the United States, but where home birth rates are higher. Five countries with provincially or nationally promulgated home birth midwifery guidelines met these criteria: Australia, Canada, the Netherlands, New Zealand, and the United Kingdom. Published guidelines of these countries were then reviewed for common themes (Table 2).19–25 The following criteria for planning a home birth emerged: determination of low-risk pregnancy, informed consent, hospital transfer if complications arise, singleton pregnancy, fetus in the cephalic presentation, no history of previous cesarean birth, and term pregnancy.
Attendance, ()
Physicians
Other attendants (family, emergency
were 2 premises. First, the author recognized that research demonstrates the safety of home birth for low-risk women.3, 4 Second, the author understood that guidelines are evidencebased recommendations for care that respect the provider’s expertise to meet individual client needs.15, 16 No national guidelines have been developed to specifically address US home birth practice; therefore, the practice guidelines of several other countries with home birth midwives integrated into their health care systems were examined. A small group of CNMs/CMs was then asked to review these proposed guidelines and react to the idea of establishing such guidelines as a national standard.
43.6
Assessment of Existing Guidelines
The Netherlands reports the largest proportion of home births internationally, reaching nearly 30%. The Royal Dutch Association of Midwives, the National Association of General Practitioners, and the Dutch Association of Obstetrics and Gynecology jointly support their maternity manual.19 The 17-page List of Obstetric Indications outlines a description of routine midwifery care and conditions requiring consultation or Volume 59, No. 2, March/April 2014
Table 2. Required Components of Home Birth Practice Guidelines from Specific Provinces and Countries
British Criterion
New
Australia Columbia Manitoba
Netherlands
United
Zealand Kingdom
Low risk birth per standardized guidelines
yes
yes
yes
yes
yes
yes
Informed consent is required.
yes
yes
yes
not mentioned
yes
yes
System must be place for transport in the event of complications.
yes
yes
yes
yes
yes
yes
a
b
yes yes
Fetus must be in a cephalic presentation.
yes
yes
no
yes
no
Mother must have a singleton pregnancy.
yes
yes
noa
yes
yes
Mother must have a term pregnancy.
yes
yes
yes
yes
yes
yes
Mother must have no history of a previous cesarean birth.
yes
noc
nod
yes
noc
yes
a Breech and twin births may be attempted if recommended by a physician. b Breech diagnosed in labor may be attempted after physician consultation. c Requires physician consultation. d
Contraindicated with previous lower-segment cesarean birth before 26 weeks’ gestation, interpregnancy interval of less than 18 months, history of impaired scar healing, or prolonged active phase. Sources: Obstetric Working Group19 ; National Institute for Health and Clinical Excellence20 ; Australian College of Midwives21 ; College of Midwives of Manitoba22 ; College of Midwives of British Columbia23 ; College of Midwives of Manitoba24 ; and New Zealand Ministry of Health.25
referral to an obstetrician.19 Home birth midwives are well integrated into the Dutch national health care system, contributing to timely referrals and strong maternity care outcomes.26 New Zealand, another world leader in midwifery, reports a home birth rate of 7%.27 Home birth has been legally supported in New Zealand since 1983, and national consultation and referral guidelines have been available since 1996.28 Their 32-page document of midwifery guidelines, developed by the Ministry of Health and an expert working group, outlines the mechanisms of consultation and referral to obstetric and other medical services.25 Home birth guidelines of 2 Canadian provinces, British Columbia and Manitoba, were evaluated in detail. British Columbia has formally recognized midwifery since 1993. Their 50-page Home Birth Handbook includes home birth practice guidelines developed by the College of Midwives of British Columbia.23 The College of Midwives of Manitoba has a 10-page document on the standards of midwifery that applies to practices in all settings and outlines criteria for discussion, consultation, and the transfer of care.22 Although the 2 sets of guidelines are very similar, there are a few differences. Manitoba guidelines allow a woman with a breech presentation or twin gestation to consider a home birth if recommended by a physician. British Columbia guidelines specify that in order to make a transport timely, even weather conditions must be taken into consideration. The 11-page Australian home birth position statement includes specific guidelines. These were the most concise guidelines evaluated and included only 4 indications for referral to physician services: multiple gestation, noncephalic presentation, labor outside the range of 37 to 42 weeks’ gestation, and a scarred uterus.21 The home birth rate in the United Kingdom is only 2.7%; however, members of the Royal College of Obstetricians and Gynaecologists (RCOG) have estimated that, with informed consent and full client autonomy, 8% to 10% of all births could occur in homes.29 A 2007 RCOG and Royal College of Midwives (RCM) joint statement recommends that home birth midwives have written practice guidelines and operate within a system that allows for seamless consultaJournal of Midwifery & Women’s Health r www.jmwh.org
tion, collaboration, and referral. National home birth standards for the United Kingdom were formulated by the Guideline Development Group, a multiprofessional and lay working group of the National Collaborating Centre for Women’s and Children’s Health at the National Institute for Health and Clinical Excellence. Members of the group represented multiple stakeholders affected by the guidelines, including a senior midwife researcher and representatives from obstetrics, neonatology, obstetric anesthesia, and midwifery—as well as consumers.29
Development of Proposed US Guidelines
After collection, review, and summary of these international guidelines, the primary author synthesized the information into draft home birth guidelines that could be used by US CNMs/CMs. The resulting 10-page document (see Supporting Information: Appendix S1) includes recommendations about licensure, physician collaboration, hospital transports, informed consent, documentation, client screening, equipment, medications, birth assistants, routine care of the mother and newborn, and emergency care of the mother and newborn (Table 3). Guideline development was influenced by the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, including the domains of purpose, stakeholder involvement, rigor of development, clarity and presentation, applicability, and editorial independence.30 REVIEW OF THE GUIDELINES
After completion of the draft guidelines, the authors sought reviews from midwives certified by the American Midwifery Certification Board (AMCB) who are engaged in home birth practice. This evaluation was determined to be exempt from institutional review board oversight. Reviewers were asked to: 1) complete prereview questionnaires, 2) review the guidelines and consider applying them to their practices, and 3) complete postreview questionnaires. The questionnaires were designed by the primary author according to criteria of the American National Standard and Joint Committee on Standards for Educational Evaluation.31 Response 155
Table 3. Components of the Home Birth Guidelines Proposed for the American College of Nurse-Midwivesa
Maintain licensure and certification per AMCB and state regulations Delineate physician involvement through consultation, collaboration, and referral mechanisms Make timely hospital transports when complications arise Participate in peer reviews per state regulations Ensure that clients have full informed consent Maintain appropriate documentation Screen clients based on current and past obstetric and medical conditions, as per stated guidelines Maintain all necessary equipment Carry all appropriate medications Have at least one assistant Use AWHONN guidelines for fetal monitoring Provide routine antepartum, intrapartum, and postpartum care Provide routine neonatal care up to 28 days of life Provide routine primary and gynecologic care Abbreviations: AMCB, American Midwifery Certification Board; AWHONN, Association of Women’s Health, Obstetric, and Neonatal Nurses. a A full copy of the proposed guidelines can be found in Supporting Information: Appendix S1.
Figure 1. States Represented by the 16 Reviewers of the Proposed Home Birth Guidelines Reviewers of the draft guidelines were from the states highlighted in blue.
options were based on the 5-item ordinal Likert scale. Participation was solicited through the ACNM home birth electronic mailing list. Nineteen midwives initially expressed interest, and 15 AMCB-certified midwives completed reviews, representing 13 practices in 13 states (Figure 1). One certified professional midwife (CPM) who practiced with a responding CNM also completed a review. The review process occurred from January through March 2012. The prereview questionnaire included 7 questions to assess the reviewers’ perspectives on whether a national set of home birth guidelines would improve physician collaboration, hospital reception of home birth transports, availability of liability insurance, and general respect from the medical and lay communities. Two additional questions assessed how the reviewers perceived that guidelines would impact their autonomy and provide overall benefit. These 9 156
questions were duplicated on the postreview questionnaire to compare the reviewers’ perceptions of the guidelines before and after review. Three additional questions addressed the reviewers’ perceptions of the guidelines’ clarity, reflection of the literature, and reflection of international midwifery standards. Table 4 summarizes the results of this review. Concern was expressed that having national guidelines may not improve physician collaboration, hospital acceptance of home birth transports, liability coverage, or medical and lay community respect for home birth midwifery. The reviewers were equally split in their agreement or disagreement over the guidelines’ clarity. They tended toward neutrality or disagreement that the guidelines were supported by the literature. Most took a neutral position regarding the guidelines’ consistency with international maternity standards, while the Volume 59, No. 2, March/April 2014
Table 4. Results of Formal Guideline Reviews (N = 16)
Pretest/Posttest, () Strongly Disagree
Strongly Disagree Neutral Agree
Agree
Question: National guidelines would: Improve physician collaboration
0/30
Improve hospital reception of home birth transports
0/40
Improve liability coverage of home birth midwives
0/30
Increase recognition among the medical community of the safety of home births
0/0
Increase respect among the medical community for the midwifery profession
8/40
Increase recognition among the lay community of the safety of home births Increase respect among the lay community for the midwifery profession Threaten the autonomy of home birth midwives Be overall beneficial
33/30
33/30
25/10
8/0
17/0
25/0
58/50
0/10
17/10
33/30
50/10
0/0
17/40
0/0
66/40
17/20
8/10
17/20
58/10
8/20
0/0
17/40
17/0
58/50
8/10
0/10
17/30
33/0
42/50
8/10
25/0
42/10
25/40
8/40
0/10
0/0
0/40
17/0
66/40
17/20
Clear
–/0
–/40
–/10
–/40
–/10
Supported by the literature
–/0
–/35
–/35
–/20
–/10
Consistent with international standards
–/0
–/20
–/40
–/20
–/10
Question: The proposed guidelines are:a
a
These questions were only asked after review of the guidelines; therefore, there are no pretest scores.
other reviewers were equally split in this regard. The reviewers expressed greater favorability toward national home birth guideline adoption prior to reviewing the proposed guidelines versus after their review. Subsequent to this assessment, minor revisions were made to the guidelines based on feedback from the reviewers, such as recommending physician collaboration versus referral for some client conditions, and eliminating a specific time frame for hospital transports. A copy of the current proposed guidelines is available (see Supporting Information: Appendix S1). DISCUSSION
An international review of home birth guidelines and a review by US home birth midwives of a proposed set of US home birth guidelines demonstrate the multifaceted ramifications of implementing a set of national guidelines. Discussion of the usefulness and content of a possible set of guidelines for CNMs/CMs is timely; those discussions can be expanded at a national level. However, the authors were surprised that the reviewers expressed greater interest in developing and implementing national home birth midwifery guidelines prior to reviewing the proposed guidelines versus after their review. It is unclear why these reviewers’ assessments of the proposed guidelines were so varied, yet most reviewers expressed interest in further discussion of the benefits of adopting national home birth guidelines. Thus, a broader qualitative study is needed to understand midwives’ perspectives on US home birth guideline development. The primary concern raised by the reviewers was whether or not guidelines would impact their autonomy. Guidelines are intended to provide best practices from which providers can meet individual client needs but also discourage providers from diverging from safe practices. The reviewers specified that the proposed guidelines might not support them if they choose to attend the home birth of a woman with a breech Journal of Midwifery & Women’s Health r www.jmwh.org
presentation or a twin gestation or a woman who desires a trial of labor after a previous cesarean. While CNMs/CMs attending home births may have the skill to attend such births, the safety net available in an institutional setting is advantageous and may be preferable for such births.32 Although ensuring client safety may at times conflict with provider and client preferences,33 safety is the first priority for improving the quality of health care.34 We recognize that current practice at some hospitals does not allow vaginal birth options for women with breech presentations, multiple gestations, or previous cesareans. These represent areas for ongoing discussion among women, providers, and health systems to provide safe options that women desire. This project targeted CNMs and CMs in order to provide an opportunity to develop home birth guidelines for ACNM in accordance with its published practice standards. Having these guidelines would then provide a springboard for future collaboration on joint home birth guideline development with CPMs, nurses, physicians, consumers, insurers, and other stakeholders. The 2012 joint statement on physiologic birth35 and the second meeting of the Home Birth Consensus Summit in 201336 are examples of similar collaborations. Development of ACNM guidelines for US practice is a first step in such collaborations. Critical to this is further discussion and review to create guidelines that meet standards for safe practice while protecting choice. Fundamental to international home birth guidelines that were examined in this project is a distinction between lowrisk and high-risk maternity criteria. Normal birth has been defined in a joint statement by the Society of Obstetricians and Gynaecologists of Canada; the Association of Women’s Health, Obstetric, and Neonatal Nurses of Canada; the Canadian Association of Midwives; the College of Family Physicians of Canada; and the Society of Rural Physicians of Canada as spontaneous labor with a singleton fetus in a vertex presentation at 37 to 42 weeks’ gestation after an 157
uncomplicated pregnancy.37 This definition is consistent with the World Health Organization definition2 and the UK Maternity Care Working Party definition supported by the RCOG and RCM.38 Thus, it was used to direct the development of the proposed US home birth guidelines. It would be advantageous for maternity experts in the United States to soon define low risk. The 2012 joint statement on physiologic birth by ACNM, the Midwives Alliance of North America, and the National Association of Certified Professional Midwives35 may provide the groundwork for such common definitions. In the meantime, we may consider the definitions that were used internationally as precedents. CONCLUSION
Low-risk maternity clients should have the option of giving birth in a hospital, birth center, or home setting with skilled providers using evidence-based practices. A common approach to safe home birth midwifery practices may further support clients who desire this model of care. We propose that further discussion of guidelines for home birth practices in the United States is warranted, considering international standards, ACNM standards for practice, and current research evidence. Accepting a common definition of low risk would enhance the discussion. Furthermore, because home birth is an interdisciplinary issue involving not only AMCBcertified midwives, but also CPMs, physicians, nurses, insurers, and consumers engaged in home birth practice, discussions need to include all stakeholders. Developing and implementing nationally recognized, evidence-based home birth guidelines may be one means to foster a common approach to safe home birth practices. AUTHORS
Elizabeth Cook, CNM, CPM, WHNP, DNP, is a Clinical Assistant Professor at the University of Iowa Hospitals and Clinics. Melissa D. Avery, CNM, PhD, FACNM, FAAN, is a professor and Chair of the Child and Family Health Co-operative, University of Minnesota, School of Nursing, Minneapolis, MN. Melissa Frisvold, CNM, PhD, has worked in private practice and most recently served at the University of Minnesota as a Clinical Assistant Professor and the Nurse-Midwifery Program Director. CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose. REFERENCES 1.World Health Organization. The World Health Report: Make Every Mother and Child Count. Geneva, Switzerland: World Health Organization Press; 2005. 2.World Health Organization. Care in Normal Birth: A Practical Guide. Geneva, Switzerland: WHO Safe Motherhood Technical Working Group; 1996. 3.Janssen P, Saxell L, Page L, Klein M, Liston R, & Lee S. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. Can Med Assoc J. 2009;181(6-7):377383.
158
4.Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for health women with low risk pregnancies: The birthplace in England national prospective cohort study. BMJ. 2011; 343:d7400. 5.MacDorman MF, Declerq E, Mathews TJ. Recent trends in out-ofhospital births in the United States. J Midwifery Womens Health. 2013;58(5):494-501. 6.Kennedy H, Grant J, Walton C, Shaw-Battista J, & Sandall J. Normalizing birth in England: A qualitative study. J Midwifery Womens Health. 2010; 55(3), 262-269. 7.National Association of Certified Professional Midwives. Maternity Care and Health Care Reform: Opportunities to Improve Quality and Access, Reduce Costs, and Increase Evidence-Based Practice. NACPM Recommendations to the Obama-Biden Transition Team. 2009. Putney, VT: NACPM. 8.Rooks J. Oregon State Legislation Committee Meeting Document 8585. 2013. Available at: https://olis.leg.state.or.us/liz/2013R1/ Downloads/CommitteeMeetingDocument/8585. Accessed July 5, 2013. 9.Canadian Association of Emergency Physicians. Standardization of Care and Clinical Practice Guidelines: Improving Patient Outcomes. 2013. Available at: http://caep.ca/advocacy/romanowcommission/standardization Accessed July 1, 2013. 10.American College of Nurse-Midwives. Standards for the Practice of Midwifery. Silver Spring, MD: American College of Nurse-Midwives; 2009. 11.American College of Nurse-Midwives. Position Statement: Creating a Culture of Safety in Midwifery Care. Silver Spring, MD: American College of Nurse-Midwives; 2006. 12.Home Birth Consensus Summit. What Were the Outcomes of the Home Birth Summit? 2011. Available at: http://www. homebirthsummit.org/summit-outcomes.html. Accessed November 26, 2011. 13.Institute of Medicine, Committee on Quality Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. 14.National Institutes of Health. About Systematic Evidence Reviews and Clinical Practice Guidelines. 2013. Available at: http://www. nhlbi.nih.gov/guidelines/about.htm#cpg Access June 25, 2013. 15.Canadian Association of Emergency Physicians. Standardization of Care and Clinical Practice Guidelines: Improving Patient Outcomes. 2013. Available at: http://caep.ca/advocacy/romanowcommission/standardization Accessed July 1, 2013. 16.Institute of Medicine. Consensus Report: Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academy of Sciences; 2001. 17.National Institute of Clinical Health Studies. Do Guidelines Make a Difference to Health Care Outcomes? Melbourne, Australia: NICS; 2006. 18.Kenefick H, Lee J, & Fleishman V. Improving Physician Adherence to Clinical Practice Guidelines: Barriers and Strategies for Change. Cambridge, MA: New England Healthcare Institute; 2008. 19.Obstetric Working Group. Obstetric Manual: Final Report of the Obstetric Working Group of the National Health Insurance Board of the Netherlands. The List of Obstetric Indications. Amstelveen, Netherlands: Royal Dutch Association of Midwives; 2010. 20.National Institute for Health and Clinical Excellence. Clinical Guideline No.55: Care of Healthy Women and Their Babies During Childbirth. London, UK: National Institute for Health and Clinical Excellence; 2007. 21.Australian College of Midwives. Position Statement on Homebirth. Deakin, Australia: Australian College of Midwives; 2011. 22.College of Midwives of Manitoba. Standards of Practice for Midwives in Manitoba. Manitoba, Canada: College of Midwives of Manitoba; 2005. 23.College of Midwives of British Columbia. Standards of Practice. Vancouver, BC, Canada: College of Midwives of British Columbia; 1996. 24.College of Midwives of Manitoba. Standards for Planned Out of Hospital Birth. Winnipeg, MB, Canada: College of Midwives of Manitoba; 2005. Volume 59, No. 2, March/April 2014
25.New Zealand Ministry of Health. Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines). 2012. Wellington, New Zealand: Ministry of Health. 26.Amelink-Verburg M, Verloove-Vanhorick S, Hakkenberg R, Veldhuijzen I, Bennebroek-Gravenhorst J, & Buitendijk S. Evaluation of 280,000 cases in Dutch midwifery practices: A descriptive study. Brit J Obstet Gynae. 2008;115:570-578. 27.Home Birth Aotearoa. What Are the Statistics of Home Births? 2013. Available at: http://www.homebirth.org.nz/index.php/information/ faq-s-about-home-birth/8-information/faqs/68-statistics Accessed July 5, 2013. 28.Guilliland K. Birth at Home: NZ’s Position. Richmond, New Zealand, New Zealand College of Midwives; 2011. 29.Royal College of Obstetricians and Gynaecologists and Royal College of Midwives. Joint Statement No.2: Home Births. London, UK; 2007. 30.AGREE Next Steps Consortium. Appraisal of Guidelines for Research & Evaluation II Instrument. Hamilton, Ontario, Canada: AGREE Next Steps Consortium. 2009. 31.American Evaluation Association. The Program Evaluation Standards. n.d. Available at: http://www.eval.org/evaluationdocuments/ progeval.html Accessed March 2, 2012. 32.Mehl-Madrona L, Mehl-Madrona M. Physician- and midwifeattended home births: Effects of breech, twin, and post-dates outcome data on mortality rates. J Nurse-Midwifery. 1997;42(2): 9198. 33.Larson L. Physician autonomy vs. accountability: Making quality standards and medical style mesh. Trustee. 2007;60(7):14-6,21,1.
Journal of Midwifery & Women’s Health r www.jmwh.org
34.National Institutes of Health. About Systematic Evidence Reviews and Clinical Practice Guidelines. 2013. Available at: http://www. nhlbi.nih.gov/guidelines/about.htm#cpg Accessed June 25, 2013. 35.American College of Nurse Midwives, Midwives Alliance of North American, and National Association of Certified Professional Midwives. Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement by ACNM, MANA, and NACPM. 2012. 36.Home Birth Consensus Summit. Home Birth Consensus Summit Review Meeting. 2013. Available at: http://www. homebirthsummit.org/news-and-events Accessed July 8, 2013. 37.Society of Obstetricians and Gynaecologists of Canada. Joint policy statement on normal childbirth. J Obstet Gynaecol Canada. 2008;30:1163-1165. 38.Maternity Care Working Party. Making normal birth a reality: Consensus statement from the Maternity Care Working Party. Our shared views about the need to recognise, facilitate and audit normal birth. 2007. NCT/RCOG/RCM. Available at: http://www.nct.org.uk/sites/ default/files/related documents/Making Normal Birth A RealityNormal Birth Consensus Statement.pdf Accessed August 10, 2013.
SUPPORTING INFORMATION
Additional supporting information may be found in the online version of this article: Appendix S1: CNMs/CMs
Proposed
Guidelines
for
Homebirth
159
