Thoughts on "planned home births are associated with double to triple the risk of infant death than are planned hospital births." - Page 2 - Mothering Forums

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#31 of 394 Old 03-08-2013, 01:55 PM
 
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What are you talking about!??!!  What you describe is simply not the result of the UK's Birthplace Study.

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I support homebirth that meets the qualifications set forth in the AAP's 2013 policy on homebirth.

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#32 of 394 Old 03-08-2013, 01:58 PM
 
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"The standard is that only women with no identifiable risk factors before or during pregnancy, or during or after labor, should be birthing OOH."

 

I believe the Birthplace Study in the UK also found elevated risk for primiparas.  Out of curiosity, in your analysis are you including them as homebirth eligible or do you consider an untried pelvis as an "indentifiable risk factor" that should cause a woman to be ruled out of homebirth?


I support homebirth that meets the qualifications set forth in the AAP's 2013 policy on homebirth.

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#33 of 394 Old 03-08-2013, 02:43 PM
 
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Stats can only take you so far, you really need to look at your available options too.  If your only available hospitals are large, chaotic with a high infection rate and a high intervention rate, but there are highly skilled midwives available, then the situation is much different than if the only available midwives have questionable training and skills, and there's a nearby hospital with a suitable level of skill and respect for the birthing mother and the birthing process.

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#34 of 394 Old 03-08-2013, 04:11 PM
 
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Here are findings from the birthplace study:

 

https://www.npeu.ox.ac.uk/files/downloads/birthplace/Birthplace-key-findings.pdf

 

https://www.npeu.ox.ac.uk/files/downloads/birthplace/Birthplace-Q-A.pdf


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#35 of 394 Old 03-08-2013, 04:18 PM
 
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Studies in the UK showed that out of hospital births had better outcomes at every risk level.

 

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What are you talking about!??!!  What you describe is simply not the result of the UK's Birthplace Study.

 

If it's true, I can see the stat making sense... in the UK if there are complications, you're transferred to a hospital. In addition to just labor complications, hospitals also have to deal with birth defects, traumas, drug addicts, etc.

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#36 of 394 Old 03-08-2013, 06:11 PM
 
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I would be intrigued to learn how the UK is managing, for example, pre-eclampsia or placenta previa at a home birth just as well as in the hospital.  Otherwise, every risk level is NOT having the same outcomes.


I support homebirth that meets the qualifications set forth in the AAP's 2013 policy on homebirth.

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#37 of 394 Old 03-08-2013, 06:21 PM
 
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"The standard is that only women with no identifiable risk factors before or during pregnancy, or during or after labor, should be birthing OOH."

 

I believe the Birthplace Study in the UK also found elevated risk for primiparas.  Out of curiosity, in your analysis are you including them as homebirth eligible or do you consider an untried pelvis as an "indentifiable risk factor" that should cause a woman to be ruled out of homebirth?


No, an untried pelvis is not an identifiable risk factor.  Although from stats tracked by AABC, they indicate that about 40% of primips will transfer to hospital from birth center care, but that doesn't mean it was a problem with the pelvis. Most of those are prolonged labor or a request for pain medication.


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#38 of 394 Old 03-09-2013, 07:24 AM
 
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I would be intrigued to learn how the UK is managing, for example, pre-eclampsia or placenta previa at a home birth just as well as in the hospital.  Otherwise, every risk level is NOT having the same outcomes.

 

They don't, at the first sign of complications they're transferred to the hospital. That's why their home birth stats are so good.

 

It's kind of like my mom's logic: she always gets the new car which require zero maintenance, then when they get older she gives them to my dad and she gets another new one. When my dad drives them, they all start to require repairs and maintenance... she insists because it's the way she drives the cars that her cars have never required new batteries, tires, etc. but as soon as he starts driving them, "all sorts of things start to go" lol

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#39 of 394 Old 03-09-2013, 11:15 AM
 
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Except that what all do they consider " risk factors" they do midwife managed breeches and consider that normal...
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#40 of 394 Old 03-09-2013, 12:12 PM
 
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Here is a Cdc paper on the demographics of homebirth families-    http://www.cdc.gov/nchs/data/databriefs/db84.pdf

And here is a report on infant mortality and causes
http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_08.pdf
  

And i would have to say that mothercat, has some good points there are all sorts of chancers out there, drugs for induction increase the risks to dangerous levels for baby and mom , i have heard of this being done by doctors , CNMs and midwives and is in no way low risk in or out of hospitals or birth centers.
And there have been some heart Breaking losses reported on home births, i know in reading over some of the stories things may have turned out differently, in others i have read where mom was seen and tested/screened and then went home i am not sure that anything could have been done to change the outcome in that pregnancy. It does not hurt to review such cases to help learn from other's losses or mistakes.

  
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#41 of 394 Old 03-09-2013, 12:34 PM
 
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Primips risks ----, lifestyle, previously undetected primary disease states and
they are more likely to develope pre eclampsia, untried pelvis is an aspect/ but is bigger like unmapped territory/tolerance...
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#42 of 394 Old 03-09-2013, 12:37 PM
 
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Are you asking me what I'm talking about?  I'm not sure I'm referencing the same specific study you're asking about, so I'm not arguing what that determined. 

 

A Good Birth, a Safe Birth describes a study in which researcher Marjorie Tew classified births into categories of "very low," "low," "moderate," "high," or "very high," and "at each level of risk, perinatal mortality was lower out of hospital."  Furthermore, it states that, "except for very high-risk births, the differences in [perinatal mortality rate] were what statisticians call statistically significant....At the very low and low levels of risk, hospital births had a two-to-three times higher rate of perinatal mortality.  At a a moderate level of risk, the hospital PNMR was more than eight times greater than out-of-hospital PNMR.   Even at a high level of assigned risk to the birth, the hospital PNMR was over three times higher."

 

Apparently, her further studies since have shown an increasing disparity (with hospital PNMR getting worse).

Do I, personally, have any way of verifying this?  No.  But I'm not making it up!
 

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#43 of 394 Old 03-09-2013, 12:47 PM
 
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And here is a report on infant mortality and causes
http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_08.pdf
  

 

These are just looking at live births who died within their first year of age. 

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#44 of 394 Old 03-09-2013, 01:41 PM
 
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Which would be a fair thing to look at because things can be done to temporarly preserve life in the short term but in that first year what does that end up looking like... Since the greatest reason for preterm birth in this day and age is elective delivery-induction or -c-section and that prematurity is one of the greatest componets of infant mortality...
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#45 of 394 Old 03-09-2013, 01:59 PM
 
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I started looking through articles written by M. Tew...

Here is one abstract ---


Br J Obstet Gynaecol. 1986 Jul;93(7):659-74.
Do obstetric intranatal interventions make birth safer?
Tew M.
Abstract
Impartial analyses of the evidence from official statistics, national surveys and specific studies consistently find that perinatal mortality is much higher when obstetric intranatal interventions are used, as in consultant hospitals, than when they are little used, as in unattached general practitioner maternity units and at home. The conclusion holds even after allowance has been made for the higher pre-delivery risk status of hospital births as a result of the booking and transfer policies. It holds even more strongly for births at high than at low predicted risk. It follows that the increased use of interventions, implied by increased hospitalization, could not have been the cause of the decline in the national perinatal mortality rate over the last 50 years and analysis of results by different methods confirms that the latter would have declined more in the absence of the former. Data are presented which point to the deleterious effect of interventions on the incidence of low birthweight and short gestation and their associated mortality. Also presented are data supporting the alternative explanation of the decline in perinatal mortality, namely the improvement in the health status of mothers built up over several generations. The organization of the maternity service stands indicted by the evidence. Despite the beliefs of those responsible, it has not promoted, and cannot promote, the objective of reducing perinatal mortality.




The thing is she is not an OB or a midwife she is an orthopedic doc..... She published several articles into the 90's .

And i wanted to include this link to the BC study- their law changing from CPM level education to include in hospital care as well did not occur until 2002 half way thru this study in 2004 , so it is showing some validity to licensed midwives even at the CPM level....which applies to the US in some areas.

http://www.cmaj.ca/content/181/6-7/377.full
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#46 of 394 Old 03-09-2013, 10:16 PM
 
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That's from almost 30 years ago. Also, how do they define perinatal mortality? If a baby is stillborn, are they counting that? A frail, sick baby born in hospital who subsequently dies would be counted; would a stillborn baby at home be counted, or do they have to have drawn breath? There are countries where stillbirths don't count in perinatal mortality stats, which is one reason the US looks bad compared to some places. We'd want to look at the study to make sure apples are being compared to apples; you can't conclude anything from the abstract. 

 

Infant mortality is not the right comparator to use either, because it measures pediatric care in addition to OB care. 

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#47 of 394 Old 03-10-2013, 05:22 AM
 
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Subbing to try to join in this discussion...a bit late, I know. shy.gif

 

As I recall when re-researching HB again for my second birth a couple of years ago, I did come to the conclusion that HB presented a slight increased risk in mortality/morbidity from pregnancy-maybe 1 year of life (can't quite remember).  To me, the small increased risk was weighed against the increased risk of an already relatively small risk. I weighed that against very large chance of a variety of negative outcomes in a hospital birth. 

 

I just lost a bunch of my post but will come back when I have more time to read the links and videos posted. 

 

I'll also see if I can find some threads here on the subject because I'm sure I've discussed this back when I was pregnant with my LO. 


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#48 of 394 Old 03-10-2013, 05:58 AM
 
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I'm remembering more about this topic as I post around the forum today.  I have a pretty terrible time of retaining some of this stuff after I've made my decision so I'll just share a few thoughts that maybe can be added to the discussion by members who are currently reading the stats and etc. 

 

I remember reading the studies and one thing that struck me is that a lot of hospital practices that I would consider morbidity are not listed as such. So, if in a HB setting the mother or child needed abdominal surgery...I think that would be listed as a form of morbidity. But I don't think c-section is listed like that in most of the studies. Correct me if I'm wrong. So, there's also things like forceps delivery, prolonged separation of mother and baby, and lots of other  things that were factors for me in terms of morbidity but that weren't applied to the studies the way I would have liked. 

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#49 of 394 Old 03-10-2013, 10:54 AM
 
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...If we're objectively comparing statistics, shouldn't they be studies from at least the same period? Not one from 1990-2009, the other from 2005-2009 and then an abstract from 1986? That just makes it seem as though someone has made up their mind on a subject and has searched for sources to back up their statement. 

 

This is the reason we'll never be able to obtain unbiased data. Someone always has a dog in the fight. When you get past the data and people's personal preferences, there is still the indisputable fact that some babies will do well and some will do poorly no matter what type of birth is chosen. There will never be an available control group, one baby can never be compared to another. One baby can be born on a sidewalk in -20C temperatures, to a young mom who hid her pregnancy and received no prenatal care, be pronounced dead, spend 3 hours in a morgue and be discovered alive (which happened here about two weeks ago), another baby may not be able to survive the most delicate birth attended by the most skilled and qualified professional. The fact that statistics need to be argued and picked apart at such lengths leads me to believe that almost any option available today as just as safe as another. It's six of one, half a dozen of the other. 

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#50 of 394 Old 03-10-2013, 11:41 AM
 
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Has this been linked yet? http://www.midwiferytoday.com/articles/ajog_response.asp


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#51 of 394 Old 03-10-2013, 12:28 PM
 
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#52 of 394 Old 03-10-2013, 06:20 PM
 
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I just referenced the Tew info because someone else mentioned it- just so we could actually look and see what it was about... She has some valid alalysis for the time period and a perspective / a way for this to be approached they could be useful... Although the info is dated- and the issues are the same and going on between medicine and midwives for atleast 100 years now. I can find very old large studies that showed that doctors had worse outcomes than trained midwives outcomes that could not be matched by doctors until1950's early 60's and yet they were able to outlaw and marginalize midwifery in this country.
So in the 80's and 90's doctor M Tew was saying that medicine was not matching cases to cases- certainly we have made headway on very eary preterm survival . There have actually been increases in infant and maternal mortality in recent years as c-sections have increased-
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#53 of 394 Old 03-10-2013, 07:27 PM
 
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I just referenced the Tew info because someone else mentioned it- just so we could actually look and see what it was about... She has some valid alalysis for the time period and a perspective / a way for this to be approached they could be useful... Although the info is dated- and the issues are the same and going on between medicine and midwives for atleast 100 years now. I can find very old large studies that showed that doctors had worse outcomes than trained midwives outcomes that could not be matched by doctors until1950's early 60's and yet they were able to outlaw and marginalize midwifery in this country.
So in the 80's and 90's doctor M Tew was saying that medicine was not matching cases to cases- certainly we have made headway on very eary preterm survival . There have actually been increases in infant and maternal mortality in recent years as c-sections have increased-

 

And, personally, I find the fact that she's not a dr. or midwife a GOOD thing in a study like this - she doesn't have a vested interest in skewing the data to show what she wants it to show.

 

Yes, it's dated.  I didn't go digging for it; I have better things to do with my time at the moment than go digging for new information to back up a decision I already researched and made years ago. ;)  I just shared what I remembered having already read.  Feel free to ignore it if you like.  But I think it's still relevant, particularly since I don't know of any truly similar study having been done since.

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I was agreeing with you smile.gif
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Wow, that's some dense stuff right there!  Thanks for a GREAT link. bow2.gif  

 

When I was making my decision (again, I re-researched for my second planned HB...and it was a much different experience with the internet being my friend) I made some peace with a slight increase in risk of HB (and I chose my personal risk factors and quality of midwifery care accordingly) but I would have loved to have seen this just the same. 

 

Thanks for linking!  


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#56 of 394 Old 03-11-2013, 09:04 AM
 
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Wow, that's some dense stuff right there!  Thanks for a GREAT link. bow2.gif  

 

When I was making my decision (again, I re-researched for my second planned HB...and it was a much different experience with the internet being my friend) I made some peace with a slight increase in risk of HB (and I chose my personal risk factors and quality of midwifery care accordingly) but I would have loved to have seen this just the same. 

 

Thanks for linking!  

 

AND it's written by doctors! LOL

 

I don't mean any offence to my lovely American friends but it's tough to trust studies from a country where one's bread and butter is either from the "pharmaceutical industry", the "health care industry" or the "home birth industry". Their objective is always to prove why theirs is better and why you, the customer should give them your money. In our system, the government takes all of our money up front via income tax and they decide for us which is safer saves them the most money in the long run. They take into account what lifestyle choices will produce the least expensive and most productive tax payers. So far there haven't been any studies convincing enough for them to suggest that one is actually safer than another. As a result, we have complete freedom at this point to choose home birth (if we qualify)(which is the least expensive for them), midwife (at home or in a hospital), an OB or elective caesarean. They have absolutely no interest in saving a few bucks on a birth if it means long term harm because they'd just be on the hook for further tax dollars whether it's medical care, psychological treatment or a person will require social assistance.

If home births were as significantly better as US midwives claim they are, our government would be all over them. Elective caesareans cost about $4,800, hospital births $2,400 and a midwife assisted birth is about $1,000. If one was SO much safer AND 5 times less expensive, wouldn't our government be behind them 100%?

I'm not advocating for one type or another, I'm just thinking the proof isn't there yet for there to be enough to argue over. 

...and on the third hand, I'm very much "pro choice" and believe women should be able to choose the type of birth that is right for them. While caesarean is inhumane for one woman, a home birth will be for another. No woman should be bullied by either the medical community or other mothers (especially not other mothers) about what choice they feel is right for them.

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#57 of 394 Old 03-11-2013, 09:52 AM
 
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I'm not advocating for one type or another, I'm just thinking the proof isn't there yet for there to be enough to argue over. 

...and on the third hand, I'm very much "pro choice" and believe women should be able to choose the type of birth that is right for them. While caesarean is inhumane for one woman, a home birth will be for another. No woman should be bullied by either the medical community or other mothers (especially not other mothers) about what choice they feel is right for them.

Yes, I feel the same way. I didn't make my birth choices based on this strong feeling that I'm right. It was more complicated and all the choices were very subtle and the factors were woven together. I assume that many other mothers make their choices in a similar way and are perfectly able to do so and come up with another perfectly valid choice. 

 

In the end of the day, though, how we choose birth and the factors we use and all of that are just one of a zillion choices we make for our kids. If I didn't think I could trust another mother's choice about where to give birth...I would be so stressed over the welfare of the children of the world that I don't think I could go on. Seriously. 

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So "Escaping" in the Canadian health care system I am assuming it is mostly RM doing home births, although as a member of the MDGC list I know that there are a fair number of FPs and OBs who also support those midwives and home birth.

There have been some well done home birth studies like Vedam's Vancouver study. And I think there was another one that was in Ontario before that.  Both of these studies used university educated midwives (RM) compared to the CPM study in the US where the educational background of the midwives was not mentioned. However, from NARM documents it is known that until very recently that completing even a high school education was not a requirement for becoming a midwife, and almost none of the CPMs have a university based education. This means that they most probably do not have the university classes that are required to meet the ICM standards for anatomy and physiology, microbiology, and the other sciences and none of their placements or clinicals takes place in hospital.

I think it would be very difficult to compare the results from a study about home birth with midwives (CPMs and other non in US and a study in Canada with RMs. The World Health Organization has found that increasing the educational requirements for midwives to a university based system decreases  maternal and neonatal mortality and morbidity.


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#59 of 394 Old 03-11-2013, 10:42 AM
 
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So "Escaping" in the Canadian health care system I am assuming it is mostly RM doing home births, although as a member of the MDGC list I know that there are a fair number of FPs and OBs who also support those midwives and home birth.

 

Sorry, I'm not sure what you mean by FP, but all midwives in Ontario are registered, regulated and university educated and have been since 1993. I'll just copy and paste their requirements at the end of this post.

Midwives are very much supported in the Canadian system, but it isn't as much an adversarial system as it seems to be in the US. Neither one is promoted as better or worse, the focus seems more to be on respecting the wishes of the mother (lol for once! I don't agree with much that goes on around here, but I must say I was very satisfied with the way I was treated throughout my pregnancy). I'm not one of those "loud and proud" Canadians, overall I think I would enjoy living in the US more, but as far as having children goes, I think I'd rather be pregnant in Canada. 

 

 

 

 

Midwives in Ontario are regulated by the College of Midwives of Ontario (the College). You cannot practice midwifery, call yourself a 'midwife' or hold yourself out to be such unless you are registered with the College.

Midwives in Ontario are primary caregivers. As such, they hold full legal responsibility for their clients and are not supervised by a physician or obstetrician. Midwives in Ontario never work in only one area of client care, such as prenatal or intrapartum care. They are required to provide full service to their clients in all trimesters, throughout labour and birth and for six weeks postpartum. Under normal circumstances, a midwifery client and her newborn do not see any other health care practitioner during this time.

All midwives must attend both home and hospital births. Midwives are required to hold admitting privileges in at least one hospital and to attend a minimum number of both home and hospital births per year in order to maintain their registration.

Midwives in Ontario work as independent practitioners in group practices that are funded by the provincial Ministry of Health and Long-Term Care. They are not salaried employees of hospitals, health centres or clinics and do not work shifts. Midwifery practices provide 24 hour on-call service to their clients. This means that every midwife works on call for set periods of time and while on call must be available 24 hours a day.

ELIGIBILITY FOR REGISTRATION AS A MIDWIFE IN ONTARIO

To be eligible for registration with the College of Midwives of Ontario you must:

  1. Be a graduate of the Ontario Midwifery Education Program (MEP), be a graduate of the International Midwifery Pre-registration Program (IMPP) or be a general registrant in another province of Canada.
    1. The Ontario Midwifery Education Program (MEP) is a four-year, baccalaureate degree offered at three Ontario universities. For information on the MEP, contact Ryerson University at www.ryerson.ca, Laurentian University at www.laurentian.ca or McMaster University at www.mcmaster.ca.
    2. The International Midwifery Pre-Registration Program (IMPP) is a one-year bridging program offered at Ryerson University. It is designed to offer assessment and upgrading to internationally trained midwives, in order to ensure that they meet the required standards to practice in Ontario. For information on the program, contactwww.ryerson.ca/ce/midwife.
    3. Midwives who are general registrants in another province of Canada where midwifery is regulated may be eligible for reciprocity registration. Please contact the College for more information.
  2. Be currently certified in Cardiopulmonary Resuscitation (CPR), Obstetrical Emergency Skills (ES), and Neonatal Resuscitation (NRP)
    1. CPR and ES certification must be within the previous 24 months, NRP certification must be within the previous 12 months. The standard for NRP is the Heart and Stroke Foundation of Canada, the standard for CPR is Basic Rescuer Level C and standard for ES is the Association of Ontario Midwives' ES workshop, ALARM, ALSO or MORE OB.
  3. Have demonstrated proficiency in either French or English
    1. Proficiency in either French or English is demonstrated by one of the following: having obtained a midwifery degree in Canada; being registered in another province of Canada in which midwifery is regulated; or passing the Ontario Midwifery Language Proficiency Test (MLPT). The International Midwifery Pre-Registration Program administers the MLPT. For information on the test, please visitwww.ryerson.ca/ce/midwife.
  4. Be legally entitled to work as a midwife in Canada
    1. In order to demonstrate entitlement to work in Canada, proof of one of the following is required: Canadian citizenship, landed immigrant status, or an open employment authorization.
  5. Hold membership with the Association of Ontario Midwives (AOM).
  6. Have arranged professional liability insurance.
    1. Professional liability insurance is arranged for each midwife through the Association of Ontario Midwives (AOM).

Classes of Registration

There are three classes of registration with the College of Midwives of Ontario: 
General, General with Conditions, and Supervised.

General

Registrants in the General class practice with no restrictions on their registration.

General with Conditions

Graduates of the Ontario Midwifery Education Program (MEP) are registered in the General with Conditions class. The conditions imposed on their registration are those of the College's New Registrant's Policy. This policy states that for the first year of practice, all new registrants must practice within an established Ontario practice, must work full time and must attend births with an experienced midwife. Other than these conditions, the new registrant is like any other midwife in the province, and provides the full scope of midwifery care. Once the conditions of this policy have been met, the member's registration class is changed to General.

Supervised

Graduates of the International Midwifery Pre-Registration Program (IMPP) are registered in the Supervised class. The supervision is imposed in order to enable the supervised midwife to meet the clinical birth numbers required by the College's Registration Regulation, as well as to make up any gaps in clinical skills identified during the International Midwifery Pre-Registration Program. Supervised midwives are fully registered members of the College and provide the full scope of midwifery care to their clients. They are paid at the same rate as all other new registrants. Supervision will typically last anywhere from 6-12 months. Each supervised midwife has an individualized supervision plan prepared by the College prior to registration. Once the supervision plan is complete, the member's registration class is changed to either General with Conditions or General, depending on whether the midwife is still in her new registrant's year. A supervised certificate may only be issued for twelve months or less.

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FPs are Family Practice doctors. The MDCG is a discussion list of FPs who do OB along with OBs, MFMs, and midwives, mostly Canadian, but from various countries also.
 

I think part of why some of the US system is adversarial is  physicians and the university educated midwives worrying about the knowledge, skills, and proficiency of the CPMs and non- CPM midwives because of their lack of advanced education in the sciences and  midwifery.  RMs in Canada are more integrated into the larger health system, but in the US a general statement is that the non-CNMs  prefer to see themselves as the alternative to CNMs and OBs rather than part of the larger system. The stories I have heard women tell about the fear-mongering propagated by some OOH midwives is horrific. The women become fearful of the OBs and  transferring in when appropriate. Then when they do come  in, the situation is quite serious, so the hospital staff is quite upset because if the woman had presented earlier there would have been more options for her.  The hospital staff becomes upset with the midwife for the lack of good judgement and it all becomes a vicious cycle. And their lack of a university based education (science)  puts the non-nurse midwives at a disadvantage in the larger discussion of appropriate patient care.


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