Date: September 2005

From: Karen Ehrlich, LM Felton, CA

To: Dominican Hospital ( Santa Cruz , CA ) Grand Rounds Committee

Dear Colleagues:

Perhaps you read the article this past Sunday in the Santa Cruz Sentinel that highlighted the recent British Medical Journal research study on midwife-attended homebirth. As one of the certified professional midwives (CPMs) whose birth data is included in this research, I am proud to give you a copy of our study for your consideration. It comes with my deep gratitude for being there for the homebirth community when we are in need of medical help.  

There has been discussion about the status of scientific data to support the safety of homebirth. This BMJ study reports on research that is the most epidemiolgically defensible research ever done anywhere in the world on homebirth. It is a prospective, large cohort, and validated study. While it is not double blind and case controlled, it is highly unlikely that such research will ever be done, as is noted by the study’s authors (p. 4). Thus a study such as this one must carry significant weight in our discussions.  

I’d like to point out a few items to be aware of as you read this study:

          * The authors write of the fact that most of the CPMs in North America are not well-integrated into the health care system. Here in California , due to the fact that most malpractice insurance carriers will not allow MDs to back up homebirth families and midwives, homebirth midwives generally are not well-integrated into our system. Despite that fact, the outcomes that CPMs have attained in this study are undeniably excellent.

          * The standard of care that CPMs follow is a midwifery model of care. When transfers to hospital become necessary, we are often criticized for not following medical standard of care. Please consider that our excellent outcomes are attained through the use of midwifery models, standards of care, and practice guidelines.

          * The transfer rate of 12.1% is alarming to some who have read this study. However the rate of urgent transfer was 3.4%. Most of our transfers are far from emergencies. I hope that you will recognize that the transfer rate indicates that the midwife in attendance is doing her job--protecting mother and baby--and that 87.9% of births were completed at home.

          * The perinatal mortality rate among the 5418 who began labor out-of-hospital was 1.7 per thousand. This is consistent with the reported rate of perinatal mortality for low risk, healthy women in planned hospital births (see p. 3 & p. 5).

          * While all homebirth midwives work hard to make appropriate transfers, we are all--midwives, doctors, and nurses--at a disadvantage because of the institutional restrictions that prohibit fluid collaboration among us. We can reasonably surmise that planned homebirth could be even safer if we did not have to tiptoe around these constraints.         

The issue of vicarious liability is huge for medical personnel and for malpractice carriers. Licensed midwives in California are working toward legislation that would address this problem, so that we can work toward a statewide true collaboration between homebirth midwives and hospital-based care providers. We want to insure that those mothers who would benefit from medical care can gain access to the next level of care in a timely, seamless manner. We are hoping for a clause in law that would hold physicians harmless for any care that was rendered prior to transfer to the physician.

I would be pleased to address any questions or concerns that might arise for you about this CPM research.


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