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New Policy Statement on HB from the AAP

post #1 of 23
Thread Starter 

http://pediatrics.aappublications.org/content/early/2013/04/24/peds.2013-0575.full.pdf+html

 

 

From the abstract:
The American Academy of Pediatrics concurs with the recent statement of the American College of Obstetricians and Gynecologists affirming that hospitals and birthing centers are the safest settings for birth in the United States while respecting the right of women to make a medically informed decision about delivery. This statement is intended to help pediatricians provide supportive, informed counsel to women considering home birth while retaining their role as child advocates and to summarize the standards of care for newborn infants born at home, which are consistent with standards for infants born in a medical care facility.
post #2 of 23

From the Huffington Post article about it: "The policy does include provisions that could easily ruffle many home birth advocates. It specifies that planned home births should be attended only by midwives who have been certified by the American Midwifery Certification Board, effectively excluding many direct-entry midwives."

http://www.huffingtonpost.com/2013/04/29/aap-home-birth_n_3165452.html

 

I am not surprised that there is a nod to CMs (who are only recognized in three states last time I checked) and CNMs, while CPMs are excluded.

 

I would support increasing certification requirements for CPMs (and am currently enrolled in a MEAC program, having chosen not to go the PEP route), but I don't like the divide where the groups of caregivers (CPMs, CNMs, OBs) are at odds with each other. This statement is an example of that divide.

 

Another issue with the statement specifying the type of midwives that they're approving to attend home births is that, in many parts of the US, there are not CMs or CNMs who are attending home births. 

post #3 of 23

I think the statement is more a recognition of the vastly different educational requirements of the 2 groups of midwives.

 

While there may be a few DEMs and CPMs who have the university based education at a Master's level that CMs and CNMs do, I don't know of very many. There is a long thread about the increased death rate of home birth babies in this forum and multiple times within that thread the differences in education between CMs/CNMs and CPMs/DEMs was discussed. It is the same within nursing. You have different educational backgrounds among those in the nursing profession and they are not expected or permitted to provide the same care because they don't have the same knowledge, or skills. 

 

I would not expect a CNA or STNA (nurse's aids) to administer medication or start an IV. They do not assess patients or administer treatments because they don't have the background knowledge to do this safely. LPNs need additional classes to administer medications, but are still restricted in medications they can administer as compared to an RN. Same as an ICU RN, who may be very skilled at caring for patients, but would not be expected to administer anesthetics, which only the CRNA has the skills, education, and knowledge to do.
 

 

To get back to the original post about the AAP statement. Pediatricians in some cases will refuse care to a baby born at home. Some of this is the midwife's fault. We have not always been terribly good at risking out the moms and babies who should have a hospital birth, and the Peds may then have years of dealing with the fallout. I do not think this is some grand conspiracy. I think it is a statement that babies deserve the same level of care no matter where they are born. The article included a chart and explanations of the screening tests and the other care to be provided based on the best available evidence. I plan to provide a copy to my clients to further discussions of the care they can expect for their baby, and the parents can make an informed decision.  Rather than looking for ways to take this statement apart, why aren't we looking at why this EBC is not the standard for all babies no matter where they are born?


Edited by mothercat - 5/3/13 at 9:27am
post #4 of 23

Here is MANA's response to the AAP's policy:

 

http://www.scienceandsensibility.org/?p=6627#.UYKUnTfTf-k.facebook

 

This statement:   "The Certified Professional Midwife is the only national midwifery credential that requires practitioners to be trained specifically to provide prenatal, intrapartum, and postnatal care in out-of-hospital settings"  is one I have seen frequently from CPMs to distinguish themselves and their practice from CNMs.

 

In looking at that issue, I think it would be very helpful to understand exactly what *kinds* of things CPMs (who will be practicing OOH) are learning that are substantively different and better for having a homebirth than what CNMs learn during their standard course of study.   

post #5 of 23

I found the table in the AAP statement very interesting. It goes right along with our discussions about risk, and whether risk is on a spectrum or if risks are more absolute. Here's the table, which I pulled from the AAP statement here.

 

The AAP considers these recommendations a firm line in the sand:

 

Quote:
TABLE 1 - Recommendations When Considering Planned Home Birth
Candidate for home delivery
 • Absence of preexisting maternal disease
 • Absence of significant disease occurring during the pregnancy
 • A singleton fetus estimated to be appropriate for gestational age
 • A cephalic presentation
 • A gestation of 37 to <41 completed weeks of pregnancy
 • Labor that is spontaneous or induced as an outpatient
 • A mother who has not been referred from another hospital
Systems needed to support planned home birth
 • The availability of a certified nurse-midwife, certified midwife, or physician practicing within an integrated and regulated health system
 • Attendance by at least 1 appropriately trained individual (see text) whose primary responsibility is the care of the newborn infant
 • Ready access to consultation
 • Assurance of safe and timely transport to a nearby hospital with a preexisting arrangement for such transfers
  • Data are from refs 6, 7, 10, 11, and 13.

  • a ACOG considers previous cesarean delivery to be an absolute contraindication to planned home birth.7

 

So, if the following risk factors are present, AAP considers the delivery high-risk and strongly recommend it take place in a hospital:

  • Multiples (twins, etc.)
  • Breech
  • Labor before 37 weeks
  • Labor after 41 weeks
  • VBAC
  • A baby that is measuring big/small for gestational age

 

I also think it's really interesting that they recommend that there is at least 1 person at the birth whose primary responsibility is the care of the newborn. They say that "Situations in which both the mother and the newborn infant simultaneously require urgent attention are infrequent but will nonetheless occur. Thus, each delivery should be attended by 2 individuals, at least 1 of whom has the appropriate training, skills, and equipment to perform a full resuscitation of the infant in accordance of the principles of the Neonatal Resuscitation Program." I hadn't thought about that before, but it makes so much sense.

 

In the home births you've experienced or heard about, was there a trained person there whose primary responsibility was the baby once it was born?

post #6 of 23
How are doctors able to turn away patients? In Ontario (and probably the rest of Canada) it is contrary to the Human Rights Code to turn away patients. If they are registered as accepting new patients they must take them as they come.
post #7 of 23
Quote:
Originally Posted by Pillowy View Post


In the home births you've experienced or heard about, was there a trained person there whose primary responsibility was the baby once it was born?

This actually was a big deal breaker for me. I wanted to have two experienced midwives attending my birth for exactly this reason. And it is one of the things I am most critical about when I hear of solo midwife practices or a midwife and an apprentice teaming up. Emergency skills take practice and since most occur about 1-5% of the time (Like a dystocia for example), I knew I wanted someone who had actually seen more than a couple of critical situations.

These restrictions are pretty comparable to what my local birth center uses, and pretty much what I used in deciding about my own home birth. There isn't much definition of what constitutes a "previous medication condition", so that seems open to various interpretation. Also, I'm surprised at the 41 week, and not 42 week recommendation.
post #8 of 23

Here is the best "quick summary" I could find of that issue:

 

"One of the key principles of medical ethics in the United States is that physicians should be free to treat patients of their own choosing and vice versa. The key justification for this approach is that all patients and physicians will be better served if they enter into voluntary relationships. In a sense, physicians are free to choose the patients they wish to treat."  See http://www.uic.edu/depts/mcam/ethics/duty.htm

 

This freedom is subject to limitations and once care has been established there are further requirements before the doctor can terminate the relationship.

post #9 of 23
Quote:
In the home births you've experienced or heard about, was there a trained person there whose primary responsibility was the baby once it was born?

 

In home births I've attended, there have always been two people present two are trained in NRP.

post #10 of 23
I like all if their recommendations. I know of a few MWs that attend births alone or with just an apprentice. What do they do if baby is unresponsive and mom is hemorrhaging? We refuse vax, erythromycin, vit k in the hospital so of course we can refuse it at home. MWs, no matter how skilled, are not pediatricians. Baby's should be checked out by doctors. I ama firm believer in not delivering twins, breeches or early babies at home. I am fortunate that I live in a place where there are doctors that attend these birth in a hospital.
post #11 of 23

Although this is the AAPs official stance, my pediatrician (well respected and highly recommended) has no problems with me having a homebirth with my CPMs. It's my third baby, I have no complications so far. She has worked with them before and really likes them.

post #12 of 23

This may be the AAP's stance, but it doesn't mean it's universal among pediatricians.  When I was interviewing pediatricians for my twins, the one we choose (at a major university hospital) was the only medical doc who wished me a full 40 week gestation. 

 

And he knew we wouldn't get that in a hospital.  thumb.gif

 

An unmedicated babe who's allowed to come in their own time, kept with their mother, physiological cord clamping, breastfeed early and often, etc. should be the wish of every pediatrician.  And that usually means a homebirth.  Those are some of the biggest reasons we stayed home, and why we trusted the interests of our pediatrician.  He was nothing but supportive of our home birth, and was actually interested in the well being of our twins, not the party line. 

 

Our doc didn't appear to have a preference for our birth location, only on the health of our babies.  As it should be.

post #13 of 23
Quote:
Originally Posted by eabbmom View Post
I ama firm believer in not delivering twins, breeches or early babies at home. I am fortunate that I live in a place where there are doctors that attend these birth in a hospital.

 

While I can understand your and PPs' opinions, reasonable people can disagree.  I am a firm believer in giving mothers the ultimate choice where and how they give birth, and as a society do what we can to support the different choices women make.

post #14 of 23
Thanks for pointing that list out Pillowy, thse are for OOH inductions.....this just shows how common induction is, and how there is a disconnect even in supposedly highly educated providers .
The question keeps being asked what do trained OOH providers do that may be different. Most would reject this recommendation.
Edited by mwherbs - 5/13/13 at 9:39am
post #15 of 23

Yeah, no problem. Where did you see that they're for OOH inductions? I didn't see that anywhere. It doesn't seem like something they'd support.

post #16 of 23
In your post on table 1
Second to the last one, spontaneous labor or induction as an out patient
post #17 of 23
Quote:
Originally Posted by Pillowy View Post

 

In the home births you've experienced or heard about, was there a trained person there whose primary responsibility was the baby once it was born?

 

Yes, my first home birth was attended by my midwife, a back-up midwife with the same training and even more years of experience, plus my midwife's apprentice.  The apprentice was awesome but not considered an appropriate backup.  We were lucky and did not need all the expertise, but my midwife always plans on having another fully trained and practicing midwife present.

 

I was at a friend's birth where the back-up midwife had another birth to attend so both midwives had no second trained back up person.  My friend's little one came out a little too purple/blue so midwife immediately cared for the newborn with oxygen and other care that I did not see (I was caring for the baby's older sibling). My friend was heading into shock and could have used a 2nd midwife to attend her, but the baby was prioritized 1st and luckily friend's mom was trained as a paramedic and stepped in.  The shock did not progress and the little one pinked up immediately but I saw enough to appreciate my midwife's policy of having 2 trained care providers at all births.

post #18 of 23
Quote:
Originally Posted by OrmEmbar View Post

 

 My friend's little one came out a little too purple/blue so midwife immediately cared for the newborn with oxygen and other care that I did not see (I was caring for the baby's older sibling). My friend was heading into shock and could have used a 2nd midwife to attend her, but the baby was prioritized 1st and luckily friend's mom was trained as a paramedic and stepped in.  The shock did not progress and the little one pinked up immediately but I saw enough to appreciate my midwife's policy of having 2 trained care providers at all births.

 

I can appreciate that you did not see all the care that was provided to the baby and your friend's midwife may have done things correctly, but giving oxygen to the baby is not the first step in caring for a baby in need of resuscitation. I'm a neonatal resuscitation instructor and there are several, more effective action to take first.

 

Happy that it all turned out well.

post #19 of 23
Quote:
Originally Posted by mwherbs View Post

In your post on table 1
Second to the last one, spontaneous labor or induction as an out patient

 

What type of induction are you assuming they did?

post #20 of 23
Since i have seen CNMs use miso quite freely in and out of hospital.... But yes they may mean foley.... But the thing is they didnt couch that statement like they did others so it is left pretty wide.
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