Journal of Midwifery & Women’s Health

www.jmwh.org

Original Research

Home Birth in North America: Attitudes and Practice of US Certified Nurse-Midwives and Canadian Registered Midwives Saraswathi Vedam, CNM, RM, MSN, Kathrin Stoll, PhD, MA, Laura Schummers, BSc, Judy Rogers, RM, MA, Lisa L. Paine, CNM, DrPH

Introduction: Scope of practice, competencies, and philosophy of maternity practice are similar among midwives in the United States and Canada. However, there are marked differences in intrapartum practice sites between registered midwives (RMs) and certified nurse-midwives (CNMs). Methods: This study linked data from 2 national surveys: 1) a 2007 survey of CNM members of the American College of Nurse-Midwives (n = 1893); and 2) the Canadian Birth Place Study of maternity providers, including RM members of the Canadian Association of Midwives (n = 451) to compare the demographics, practice experience, and attitudes to home birth between these 2 types of North American midwives. A Provider Attitudes To Planned Home Birth scale–international (PAPHB-i) was developed for this analysis. Descriptive and bivariate analyses are presented. Results: Educational exposure to planned home birth varied greatly when comparing CNMs and RMs, as did practice patterns regarding continuity of care, primary and gynecologic care, and involvement with research and teaching. Registered midwives were almost 4 times more likely than CNMs to have practiced in the home (99.1% vs 26.0%). Certified nurse-midwives scored significantly lower than RMs on the PAPHB-i scale (36.5 vs 41.0), indicating less favorable attitudes toward home birth overall. Certified nurse-midwives were less confident than RMs in their management skills for home birth practice. Age, exposure to planned home birth during midwifery education, and practice experience in the home setting emerged as significant covariates of attitudes toward home birth. Significantly more RMs and CNMs with home birth experience expressed concerns about disapproval of hospital-based peers, but they were significantly less likely to agree that midwives face other systemic barriers than CNMs with no home birth experience. Discussion: Differences in favorability toward and confidence with practice during planned home births among CNMs and RMs were predicted associated with differences in educational and practice exposure to planned home birth. We recommend that clinical experiences and theoretical content about planned home birth and preparation for multidisciplinary collaboration across settings be integrated as essential and required components of all health professional education programs. c 2013 by the American College of Nurse-Midwives. J Midwifery Womens Health 2014;59:141–152  Keywords: home birth, midwifery education, intrapartum care, normal birth, interprofessional education, interprofessional collaboration

Address correspondence to Saraswathi Vedam, CNM, RM, MSN, B542194 Health Sciences Mall, Vancouver, BC V6T1Z3, Canada. E-mail: [email protected]

providers are scarce in the United States, Australia, and much of the developing world. In the United States, consumer interest in planned home birth appears to be rising. After years of decline, home births in the United States rose by nearly 30% between 2004 and 2009.16 The greatest increase was among non-Hispanic white women, for whom 1 in 90 births now occur at home.16 Historically, national rates of planned home birth have been similar in the United States and Canada, and in both countries, midwives are the main providers for planned home birth. Both certified nurse-midwives (CNMs) in the United States and registered midwives (RMs) in Canada possess the clinical skills and competencies to attend births at home.17–19 However, unlike RMs, who all offer planned home birth, fewer than 4% of CNMs practice in the home.20 Because home birth could play a more prominent role in maternity care in the United States, it is prudent to examine the potential etiology of differences in practice settings between midwives in the United States and Canada. Hence, the purpose of this study was to compare the demographic, education, and practice profiles of CNMs and RMs and examine how their attitudes, experiences, and practice contexts relate to planned home birth.

1526-9523/09/$36.00 doi:10.1111/jmwh.12076

c 2013 by the American College of Nurse-Midwives 

INTRODUCTION

Emerging health service delivery models in the United States and Canada value rational health resource allocation and implementation of evidence-based practices that lead to reduced costs and improved clinical outcomes.1–6 Planned home birth with qualified birth attendants is a safe and costeffective way to increase access for women to high-quality maternity care.7–13 The benefits of physiologic birth are well documented,14 and the home setting offers an ideal environment for physiologic labor and birth. Midwives across North America are recognized as experts in physiologic birth, making them logical providers for home birth care.14, 15 Increased access to planned home birth could reduce the adverse impacts of overburdened institutional resources. In Canada, New Zealand, the United Kingdom, and the Netherlands, integrated systems exist to ensure availability of providers in all settings and to prepare and support providers for maternity care across birth sites. In contrast, qualified home birth

141

✦ There was agreement between RMs and CNMs with respect to the physical and psychosocial benefits to mother and new-

born afforded by home birth. CNMs were notably less comfortable than RMs with the role of home birth provider. ✦ Educational and clinical exposures to planned home birth were the most significant covariates of CNM attitudes toward

planned home birth and their confidence in the ability to provide care in the home. Registered midwives, with nearuniversal exposure to home birth in education and clinical settings, reported significantly higher confidence with their skills at home births and had more favorable attitudes overall. ✦ Perceived financial, interprofessional, and structural barriers in the United States may further reduce the willingness of

CNMs to attend births at home. ✦ Interprofessional discomfort with home birth practice remains a significant burden for both RMs and CNMs who attend

home births and may be more pronounced where midwifery practice is scarce or recently integrated.

Context for Midwifery Practice in the United States

In the United States, CNMs and certified midwives (CMs) can offer a full range of primary maternity care services for women, as well as well-woman gynecologic, family planning, and perimenopausal care. Both CNMs and CMs provide these services in a variety of settings including ambulatory care clinics, homes, hospitals, and birth centers.21 The majority of CNMs/CMs only attend births in the hospital (92%), and only 3.6% offer planned home birth services.20 More planned home births in the United States are attended by certified professional midwives (CPMs), licensed midwives, and traditional midwives, but currently not all states permit licensure for CPMs, and most CPMs cannot be primary maternity providers in the hospital. In 2009, 62% of US home births were attended by midwives, of which 43% were attended by CPMs and direct-entry midwives and 19% by CNMs.16 Competency-based midwifery education programs exist for CNMs, CMs, and CPMs, but clinical practice exposure to various birth settings differs. In CNM/CM programs, hospital-based intrapartum clinical practicums are a core component of curricula, birth center practicum exposure is occasional, and home birth practicums are rare and not required. In contrast, attendance at home birth is a standard requirement for CPM credentialing, but opportunities for hospital practice education are rare and not required.21–24 Continuity of care and an evidence-based, low-intervention philosophy are common values for all types of US midwives, but they are not embedded in regulatory practice requirements. Context for Midwifery Practice in Canada

In Canada, midwifery registration is available in 8 of 10 provinces and 1 of 3 territories. In these jurisdictions, RMs are publicly funded to provide comprehensive maternal-newborn care as primary maternity care providers. In most provinces, midwives work in small teams or solo to care for women in midwife-led, community-based office practices. All midwives offer choice of place of birth and attend births in all available settings. Provincial regulators affirm home birth as a core component of standard practice, and in several provinces, to maintain registration, midwives must provide continuity of care to clients and attend a minimum number of births in both home and hospital settings.18, 25 To date, birth centers are 142

integrated into the system of care only in the province of Quebec. Competency-based midwifery education programs require exposure to clinical practice in all available settings. Nationally, Canadian midwives report that 20% to 30% of their intrapartum care is provided at planned home births.26, 27 Aside from preparation for practice in different birth settings, requisite competencies, scope of maternity practice, interprofessional role, and professional self-image are very similar between CNMs and RMs.18, 28, 29 The criteria for selection of place of birth, prerequisite equipment and skills, and indications for medical consultation are also common to both countries.30–32 Examining Midwives’ Attitudes

Although variations in models of practice for CNMs and RMs are apparent, few studies have examined the attitudes of each professional group with respect to practice site. A few studies have reported on CNM attitudes toward maternity care procedures, for example, attitudes toward epidural analgesia,33 timing of umbilical cord clamping,34 abortion care,35 and depression screening during pregnancy.36 Other studies have assessed RMs’ attitudes about extending their scope of practice37 and their experiences with supervising new graduates.38 In a Canadian study that examined midwives’ and physicians’ attitudes toward maternity care practices,39, 40 RMs (n = 400) were critical of elective obstetric interventions, such as epidural anesthesia, episiotomy, and continuous fetal monitoring; supported women’s autonomy and shared decision making; and strongly believed in the safety of home birth. In 2007, Vedam et al. conducted a study to assess CNMs’ experiences with and attitudes toward planned home birth. The survey included items on sociodemographic, practice experience, education, and personal experience variables, as well as attitude items about home birth that enabled the research team to develop and evaluate a 20-item Provider Attitudes To Planned Home Birth scale (PAPHB).41 Increased education and practice exposure to planned home birth and younger age predicted more favorable attitudes toward planned home birth. Practice experience in freestanding birth centers was associated with more favorable attitudes, but experience with inhospital birth centers was not associated with increased favorability scores.22 Certified nurse-midwives’ lack of confidence in their ability to manage complications in the home was Volume 59, No. 2, March/April 2014

associated with less favorable attitudes. Several external barriers were identified that significantly predicted unfavorable attitudes toward planned home birth: belief that home birth practice is too time consuming, is not sufficiently lucrative, and invites interprofessional peer censure. For example, respondents believed that hospital-based colleagues disapproved of home birth practice, and they also expressed discomfort about seeking medical consultation for home birth cases. Fear of lawsuits also predicted negative attitudes toward planned home birth. Both unfavorable attitudes and perceived external barriers were strongly correlated with CNMs’ unwillingness to practice in the home. In 2010, Vedam et al. adapted the 2007 CNM survey to the Canadian context and, in the quantitative phase of the Canadian Birth Place Study, administered it to multidisciplinary maternity care providers, including RMs, obstetricians, and family physicians.43 Separate but very similar versions of the survey were administered to midwives and physicians. All items in both survey tools were subjected to rigorous content validation via review by expert panels. Detailed descriptions of the methods used to adapt and validate the surveys have been published.41, 42 Obstetricians and family physicians had significantly less favorable attitudes toward home birth than registered midwives, as well as less exposure to home birth in education and practice. A recent article reported on the divergence in attitudes, education, and practice among these groups of Canadian providers.43 Similarities and differences between maternity providers in the United States and Canada with respect to attitudes toward home birth and the reasons for any differences in home birth practice remain unstudied. The availability of data from the 2007 CNM study and the 2010 Canadian Birth Place Study makes a comparative analysis of RM and CNM attitudes possible. METHODS Design

We conducted a comparative study by linking data generated from the aforementioned national cross-sectional surveys of midwives. The significant overlap in the demographic, practice experience, and attitude items in the 2 distinct surveys allowed for the comparative analyses presented here. An example of such a design was reported by Paine et al, who used data from 2 national surveys to compare ambulatory visits and practices of CNMs with those of obstetrician-gynecologists.44 Data Sources Certified Nurse-Midwife Data Source

The CNM survey included 10 sociodemographic questions, 22 questions about home birth education and practice, and 40 statements that assessed CNM attitudes toward home birth, measured on a Likert scale, from 1 = strongly disagree to 5 = strongly agree. The attitude items measured 6 distinct domains: 1) beliefs about the safety of home birth, 2) ideas about maternal-newborn home birth outcomes, 3) attitudes toward maternal-newborn home birth benefits, 4) attitudes toward home birth as a business, 5) personal attitudes toward Journal of Midwifery & Women’s Health r www.jmwh.org

home birth, and 6) perceived external barriers to home birth practice. In 2007, after approval of the study by the institutional review board of Yale University, the survey was sent to the full CNM membership of the American College of Nurse-Midwives (ACNM) (N = 5466). Members for whom e-mail addresses were available (n = 4365) received a link to the survey via e-mail; the remaining 1101 were mailed hard copies. More than one-third of the CNM members (n = 1893) completed the US-based CNM survey, and of those who responded, 93.8% were practicing clinically at the time of data collection. Certified nurse-midwives from all ACNM regions responded to the survey: Region I (New England), 11.5%; Region II (Mid-Atlantic), 15.5%; Region III (Southeast), 14.3%; Region IV (Central), 20.7%; Region V (Southwest and Mountain), 17.0%; and Region VI (Western), 21.0%. Predictors of attitudes among CNMs were assessed through a linear regression analysis with a 20-item Provider Attitudes to Planned Home Birth (PAPHB) scale. The scale had a high Cronbach’s alpha (0.94) and measured one underlying construct, namely, attitudes toward planned home birth. Registered Midwife Data Source

In 2010, funding from the Canadian Institutes of Health Research enabled Vedam and a multidisciplinary team of coinvestigators to conduct the national mixed-methods Canadian Birth Place Study of all maternity providers, which examined practice experiences and opinions about birth settings. Following construction and expert content validation of provider-specific versions of a quantitative survey, the Canadian Association of Midwives (CAM) sent a midwiferyspecific survey by e-mail to its membership (all RMs in Canada, N = 759). The research team also sent invitations by mail and fax to all midwifery practices. This RM survey instrument included 39 sociodemographic, education, and practice questions and 48 statements that assessed RM attitudes toward home birth, measured on a Likert scale, from 1 = strongly disagree to 5 = strongly agree. Of the RMs invited, 59.4% (n = 451) participated. The distribution of respondents was reflective of the distribution of midwives across Canada. More than half of respondents lived in Ontario at the time of data collection (51.2%; n = 231), the province with the highest number of RMs. Midwives from British Columbia and Quebec made up 20.6% and 14.2% of the sample, respectively. The remaining 14% of midwives practiced in provinces and territories where midwifery is either not regulated or recently regulated. The Canadian Birth Place Study was approved by the institutional review board of the University of British Columbia. Both survey instruments collected data on potential facilitators or barriers to practice for each provider type. Development and Psychometric Testing of the Provider Attitudes To Planned Home Birth-International Version Scale

The items of the PAPHB scale, which were validated during administration of the CNM survey, were assessed for congruence with the attitude items contained in the RM survey. Of these items, 9 were identical (ie, exact wording) 143

Table 1. Provider Attitudes To Planned Home Birth International (PAPHB-i) Scale Items: Item to Total Correlations and Factor Loadings

Corrected Item to

Factor

Total Correlations

Loadingsa

The home setting is an ideal birth environment for mother–baby bonding.

0.60

0.70

A mother’s cultural background is easier to respect at home births than hospital births.

0.47

0.57

First-time mothers should have the option of having a planned home birth.

0.67

0.78

A move toward more home births in this country would save our medical system a

0.63

0.72

0.51

0.61

Scale Items

significant amount of money. Women who give birth in the hospital are more likely to experience morbidity associated with medical interventions than women who give birth at home. I am a home birth advocate.

0.70

0.80

Home birth is more empowering for the mother than hospital birth.

0.42

0.49

I would consider having my own (or my spouse’s) planned home birth with a CNM/RM.

0.71

0.81

RMs/CNMs who practice home birth have sufficient skills to handle emergencies safely.

0.65

0.75

Abbreviations: CNM, certified nurse-midwife; RMs, registered midwives. a Principal components factor analysis (unrotated), one factor selected.

in both survey instruments, and so were retained for inclusion in a new Provider Attitudes To Planned Home Birth scale–international version (PAPHB-i). This PAPHB-i was developed for use in this comparison study (Table 1). The remaining 9 items were nearly identical in the topic and domain of attitude measured, but did not use exactly the same wording, so they were not included in the international version of the scale. Internal consistency, as measured by Cronbach’s alpha, was high for the 9-item PAPHB-i scale (0.86). The alpha would not have improved with deletion of any of the scale items. Corrected item to total correlations ranged from 0.42 to 0.71. A Scree plot indicated a 1-factor solution, and all items loaded above 0.45 on 1 factor, which contributed close to half of the variance (48.95) and had an eigenvalue of 4.41. These assessments provide strong evidence that the PAPHB-i is a reliable and internally consistent unidimensional scale that measures one construct: provider attitudes to planned home birth. Several of the validated attitude items in both surveys concerned external barriers to home birth practice (interprofessional and systemic) that are specific to regional and local conditions and subject to intercountry variations in the organization of maternity care. The wording of these items was either the same or very similar on the CNM and RM surveys, and topics included practice location (urban, rural) and type (solo, shared), financial and logistic conditions, and inter- and intraprofessional factors. External barrier items were not included in the PAPHB-i scale because the purpose of the scale was to create a measure of core attitudes toward home birth that can be applied to midwives across countries. Analysis

Demographics and education and practice experiences of CNMs and RMs were compared using Pearson’s chi-square test for categorical variables and the Student t test for continuous variables. Items were selected for descriptive and bivariate analysis whenever corresponding data were available for both countries. Some comparisons were not possible. For example, content validation expert panels advised that race and ethnic144

ity items would not be acceptable in the Canadian survey. In most cases, the response options for survey items were identical. In some cases, response options differed. For instance, in the CNM survey external barriers to home birth practice were measured as attitudes on a 5-point Likert scale. In the RM survey, external barriers could be chosen from a drop-down menu; selected external barriers were measured on a 5-point scale. Hence, we could only assess differences in reported external barriers among RMs and CNMs for items with the same response format. We compared interprofessional and systemic barriers to home birth practice among RMs and CNMs, as well as between CNMs with and without home birth experience, using the Student t test. In addition to examining CNM and RM responses to individual attitude items, we also explored covariates of favorable attitudes using the newly developed PAPHB-i scale. The PAPHB-i has a hypothetical range of 9 to 45 when all the scores for each item are totaled, with higher scores indicating more favorable attitudes toward planned home birth. More specifically, 27 indicates a neutral midpoint (response option 3—neutral—multiplied by the number of scale items), and scores of 36 or higher indicate favorable attitudes toward home birth (response option 4—mildly agree—multiplied by the number of scale items). For the purpose of examining covariates of favorable attitudes toward home birth (analyzed separately for RMs and CNMs), the PAPHB-i scores were recoded into 2 categories: A score of 36 or higher indicated favorability towards planned home birth; scores of less than 36 were categorized as neutral or unfavorable attitudes toward home birth. A box plot was generated to visually compare variations in attitudes toward planned home birth between CNMs and RMs (see Figure 1). RESULTS

The combined sample size of CNMs and RMs was 2344 midwives. Certified nurse-midwives were significantly older and more likely to have completed a graduate degree than RMs (Table 2). The range of engagement in midwifery roles differed between CNMs and RMs in the areas of continuity of Volume 59, No. 2, March/April 2014

Table 3. Practice Roles and Professional Activities of CNMs and RMsa

CNM

RM

n ()

n ()

Antenatal care

1529 (80.8)

433 (96.0)

Intrapartum care

1362 (71.9)

432 (95.8)

Postpartum care

1383 (73.1)

433 (96.0)

Gynecologic and family

1417 (74.9)

157 (34.8)

488 (25.8)

342 (75.8)

planning care Teaching Research

134 (7.1)

65 (14.4)

Other (eg, administration,

199 (10.5)

52 (11.5)

policy, nursing, or medicine) Figure 1. Favorability Toward Planned Home Birth: Median and Interquartile Range of PAPHB-i Scores The horizontal line inside each box represents the median score for each provider group, and the upper and lower boundaries of each box represent the upper and lower quartiles. The vertical lines represent the range of scores, excluding outliers. The horizontal line across the figure indicates the cut off score of 36. Scores above the line fall into the favorable range.

care, primary and gynecologic care, and involvement with research and teaching (Table 3). Certified nurse-midwives provided more gynecologic services to nonpregnant women, and RMs provided more continuity of care across the childbearing cycle. There were no significant differences between groups with respect to experience in freestanding birth centers. Practice experience with planned home birth varied greatly between CNMs and RMs, with almost all RMs reporting some experience with intrapartum care in the home com-

Abbreviations: CNM, certified nurse-midwife; RM, registered midwife. a Respondents could check multiple categories.

pared with a quarter of CNMs (99.1% vs 26.0%; P ⬍ .001). Registered midwives reported that 25% of the births they attended were planned home births, although reported percentages from individual RMs ranged from 0% to 100%. The average number of home births was significantly higher for RMs; however, among CNMs who had ever attended home births, the average number of home births was slightly higher (Table 2). Exposure to home birth before and during midwifery education and the nature of exposure also differed significantly between CNMs and RMs. During midwifery education, 9.9% of CNMs attended a home birth, whereas a large majority of RMs (83.6%) had home birth practice embedded in their education programs (Table 5). Approximately one-fourth of CNM participants (25.3%) reported that while in midwifery school, they were taught by midwives who were currently attending planned home births, compared with almost all RMs (92.0%).

Table 2. Sociodemographic and Practice Experience Profile

CNMs

RMs

P

Sociodemographics Age, mean (SD), y

48.7 (9.5)

41.3 (10.7)

⬍ .001

Master’s degree, n (%)

1491 (78.8)

72 (16.0)

⬍ .001

Doctoral degree, n (%)

109 (5.8)

10 (2.2)

⬍ .002

Site-specific practice experience–intrapartum care Provided intrapartum care in the home, n (%) Provided intrapartum care in the hospital, n (%) Provided intrapartum care in a birth center, n (%)

491 (26.0)a 1740 (92.0) 783 (41.4)

b

447 (99.1)

⬍ .001

441 (97.8)

⬍ .001

179 (39.7)

.516

Volume of planned home births (PHBs) ⬍ .001

PHBs attended during practice/all participants, mean (SD)

29.2 (148.0)

108.5 (173.1)

PHBs attended during practice/participants who have attended at

120 (281.7)

113 (175.3)

Years giving care in the home/all participants, mean (SD)

1.5 (4.6)

9.5 (8.3)

⬍ .001

Years giving care in the home/participants who have attended at least

6.0 (7.4)

9.7 (8.3)

⬍ .001

.65

least one PHB as a midwife, mean (SD)

one PHB as a midwife, mean (SD) Abbreviations: PHB, planned home birth; SD, standard deviation. a Refers to CNMs who had ever provided intrapartum care in the home. b Includes freestanding and in-hospital birthing centers. Journal of Midwifery & Women’s Health r www.jmwh.org

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Table 4. Attitudes Toward Home Birth Among CNMs and RMs: Mean Response Scores

Mean a

CNM

a

RM

Difference

P

PAPHB-i scale items 1. I am a home birth advocate.

3.7

4.7

1.0

⬍ .001

2. I would consider having my own (or my spouse’s) planned home birth with a

3.8

4.8

1.0

⬍ .001

4.1

4.9

0.8

⬍ .001

4. First-time mothers should have the option of having a planned home birth.

4.2

4.9

0.7

⬍ .001

5. A move toward more home births in this country would save our medical system a

4.0

4.6

0.6

⬍ .001

CNM/RM. 3. RMs/CNMs who practice home birth have sufficient skills to handle emergencies safely.

significant amount of money. 6. The home setting is an ideal birth environment for mother–baby bonding.

4.4

4.7

0.3

⬍ .001

7. A mother’s cultural background is easier to respect at home births than hospital

3.9

4.1

0.2

.03

4.1

4.3

0.2

.001

4.1

4.0

− 0.1

.02

1.7

− 1.4

⬍ .001

4.9

0.7

⬍ .001

1.3

− 0.7

⬍ .001

1.1

− 0.8

⬍ .001

1.3

− 2.2

⬍ .001

4.7

− 0.4

⬍ .001

4.5

0

.20

3.5

1.4

⬍ .001

3.7

0.5

⬍ .001

births. 8. Women who give birth in the hospital are more likely to experience morbidity associated with medical interventions than women who give birth at home. 9. Home birth is more empowering for the mother than hospital birth. Attitude items with nearly identical wordingb not include in the PAPHB-i scale CNM: I am not as comfortable with home birth as hospital birth.

3.1

RM: I am more comfortable with hospital birth than I am with planned home birth. CNM: I would feel comfortable if a close family member chose to have a home birth.

4.2

RM: I would feel comfortable if a close family member planned to give birth at home. CNM: Because of the risk of hemorrhage, homes are not an ideal birth setting.

2.0

RM: Because of the risk of postpartum hemorrhage, the home is not an ideal birth setting. CNM: It concerns me when people I care about decide to have home births.

1.9

RM: It worries me when people I care about decide to have home births. CNM: HB clinical experiences within the nurse-midwifery education programs are

4.1

only important for those few students who plan to work in home birth settings. RM: HB clinical experiences within education programs are only important for those providers who work in HB settings. CNM: There is good scientific evidence demonstrating the safety of home births with

4.3

CNMs. RM: There is scientific evidence that supports the greater safety of hospital birth compared with PHBs (reverse scored). CNM: CNMs are able to identify women who are unsuitable for home birth.

4.5

RM: There are evidence-based criteria that can help providers to identify women who are good candidates for HB. CNM: It is very difficult to adequately manage labor pain in the home setting compared

2.1

with the hospital setting. RM: There are more effective pain management options for birth in the hospital. CNM: Resuscitation of the term newborn is more effective in the hospital setting than

3.2

home setting RM: Resuscitation of the term newborn is as effective in the home setting as in the hospital setting. Abbreviations: CNM, certified nurse-midwife; HB, home birth; PHB, planned home birth; RM, registered midwife. a Response options for each item ranged from 1 = strongly disagree to 5 = strongly agree.

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Volume 59, No. 2, March/April 2014

Table 5. Exposure to Planned Home Birth Through Midwifery Education

P

CNMs

RMs

Attended a PHB prior to starting midwifery education, n(%)

450 (23.8)

151 (33.5)

⬍ .001

Attended a PHB during midwifery education, n(%)

187 (9.9)

377 (83.6)

⬍ .001

Attended a PHB as an extracurricular activity during midwifery education, n(%)

221 (11.7)

171 (37.9)

⬍ .001

Taught by home birth providers, n(%)

479 (25.3)

415 (92.0)

⬍ .001

PHBs attended during midwifery education, mean (SD)

1.1 (9.1)

29.9 (36.4)

⬍ .001

Abbreviation: PHB, planned home birth.

Attitudes Toward Planned Home Birth

Attitudes toward planned home birth differed significantly among CNMs and RMs, with CNMs reporting less favorable attitudes toward planned home birth than RMs for all but one of the attitude items that made up the scale. The average PAPHB-i scale score was 36.5 for CNMs and 41.0 for RMs (P ⬍ .0001). Median scale scores were slightly higher than the mean for both groups: 38.0 for CNMs and 42.0 for RMs (see Figure 1). Fewer than two-thirds of CNMs (n = 1185, 62.9%) scored in the favorable range of the scale compared with 93.3% (n = 421) of RMs (␹ 2 = 159.64, df = 1, P ⬍ .001). Bivariate analysis of closely worded items that were not included in the scale showed that CNMs were less confident that they had sufficient skills to handle emergencies at home births than RMs and were more comfortable practicing in the hospital. Certified nurse-midwives had a slightly stronger belief than RMs that home birth is more empowering for women, but they were more worried when friends or family chose home birth. Registered midwives were more likely to believe that scientific evidence supports the safety of home birth (Table 4).

Covariates of Favorability Toward Planned Home Birth

Certified nurse-midwives and RMs who had favorable attitudes toward planned home birth were significantly younger than midwives with unfavorable views (CNMs: 48.1 vs 49.6 years, t = 3.20, P = .001; RMs: 41.0 vs 46.7 years, t = 2.86, P = .004). Significantly more CNMs and RMs had favorable attitudes toward planned home birth if they had attended planned home births prior to entering midwifery school (CNMs: 31.2% vs 11.5%, ␹ 2 = 95.11, P ⬍ .001; RMs: 34.7% vs 16.7%, ␹ 2 = 4.08, P = 0.043). Having attended one or more planned home births as an extracurricular activity during school was significantly associated with favorable attitudes among CNMs, but not RMs (CNMs: 16.3% vs 4.0%, ␹ 2 = 65.56, P ⬍ .001; RMs: 39.0% vs 23.3%, ␹ 2 = 2.90, P = .088). Certified nurse-midwives and RMs who had favorable attitudes toward home birth also had attended more home births while in school compared with midwives with unfavorable attitudes. This association was significant for RMs, but not CNMs (CNMs: 1.2 vs 1.0, t = −0.47, P = 0.64; RMs: 31.0 vs 16.0, t = −2.18, P = 0.029). Certified nurse-midwives who were taught by home birth providers were significantly more likely to have favorable attitudes toward home birth (CNMs: 57.1% vs 46.0%, ␹ 2 = 21.86, P ⬍ .001). This association was not significant for RMs (92.2% vs 90.0%, ␹ 2 = 0.18, P = .67). Journal of Midwifery & Women’s Health r www.jmwh.org

Having provided intrapartum care at home was significantly associated with favorable attitudes toward home birth among CNMs (CNMs: 36.1% vs 8.9%, ␹ 2 = 171.21, P ⬍ .001). This association was not significant for RMs because of their universal practice in the home (100% vs 100%, ␹ 2 = 0.29, P = .59). Of CNMs and RMs who had provided intrapartum care in the home as part of their practice, years of home birth experience was not significantly associated with favorability scores (CNMs: 5.62 vs 4.02 years, t = −1.16, P = .11; RMs: 9.42 vs 11.10 years, t = 1.07, P = .29). External Barriers to Home Birth Practice Interprofessional

Registered midwives were significantly more likely than CNMs to agree that physicians in their area were comfortable providing consultation and accepting transfers from home births, (4.41 vs 3.36, t = −19.73, P ⬍ .001) and significantly more likely to agree that home birth providers experience disapproval from hospital-only maternity care providers (3.47 vs 2.89, t = −9.43, P ⬍ .001). However, CNMs who have provided intrapartum care in the home were more likely to agree that home birth CNMs “are looked down” on by hospital staff, compared with CNMs who had never provided care in the home (3.05 vs 2.84, t = −3.41, P = .001). Overall, CNMs were significantly more likely than RMs to agree that they would feel uncomfortable consulting with a physician about clients planning home births (3.01 vs 2.39, t = 9.23, P ⬍ .001). Systems

In general, CNMs perceived more systemic barriers to home birth practice than RMs. Approximately one-third of CNMs believed that regulation (37.7%) and financial factors (31.2%) are barriers to attending home births, compared with only 5.0% and 4.9% of RMs, respectively. More than two-thirds of CNMs (69.0%) believed that it is too difficult to obtain liability insurance, whereas only 6.2% of RMs reported that liability concerns reduced their willingness to attend planned home births. Half of RMs (50.7%) indicated they experienced no barriers to home birth practice, although other RMs identified the following barriers to home birth practice: lack of demand (17.5%), on-call responsibilities (14.2%), travel to attend home births (13.9%), and lack of call group (12.2%). Certified nurse-midwives were significantly more likely than RMs to agree with the statement that providers who attend home births are at a higher risk of lawsuits than those 147

Table 6. Perceived Barriers to Home Birth Practice Among CNMs: Mean Response Scores (n = 1893)

CNMs With Home

CNMs Without Home

Birth Experience

Birth Experiencea

P

3.1

2.9

⬍ .001

It is too difficult to obtain liability insurance in a home birth practice.

4.1

4.0

.004

It would cost too much to start up a home birth practice.

2.6

3.2

⬍ .001

CNMs who deliver at home are at higher risk for lawsuits than those

2.1

2.6

⬍ .001

2.4

3.2

⬍ .001

3.0

2.8

⬍ .001

a

It is possible to thrive financially in a home birth practice.

who deliver in the hospital. I would not be comfortable asking a physician to back me up in a home birth practice. Home birth CNMs are looked down upon by hospital birth CNMs. a

Response options for each item ranged from 1 = strongly disagree to 5 = strongly agree.

who only attend hospital births (2.47 vs 1.75, t = 12.70, P ⬍ .001). However, when CNMs’ responses were analyzed by home birth experience, significantly different perceptions emerged (Table 6). DISCUSSION

Overall, scale scores indicated that CNMs are moderately favorable toward planned home birth, whereas RMs are overwhelmingly favorable. Registered midwives are significantly more likely than CNMs to identify as home birth advocates, to consider a home birth for themselves, and to feel confident in midwives’ emergency skills in the home setting. Certified nurse-midwives are more likely than RMs to express discomfort with home birth, but also more likely to rate home births as more empowering for women than hospital birth. Although there was agreement between both types of midwives with respect to the physical and psychosocial benefits to mother and newborn afforded by home birth, CNMs were notably less comfortable than RMs with the role of home birth provider. The similarities and differences in US and Canadian education and practice environments contextualize these findings.

Education

The differences in the content of midwifery education between the 2 countries may explain some of our results on attitudes, comfort, and confidence among RMs and CNMs. Exposure to clinical practice and curriculum content about home birth is routine and required in Canada, but is serendipitous, extracurricular, or inconsistent in education programs for US CNMs.18, 19, 22, 43 Moreover, most CNMs did not have faculty who had personal practice experience with home birth. Almost all RMs did have mentors who were currently engaged in home birth practice. Most Canadian midwives are required by regulation to offer home birth, and the majority of Canadian midwives reported that they were engaged in teaching. Hence, mentorship and modeling opportunities appear to be much greater for RM learners than CNM learners. The differences in responses between RMs and CNMs about whether they believed they have “sufficient skills to handle emergencies safely in the home” could be explained by the differences in specific learning activities that are part of each core curriculum. Canadian midwifery students rou148

tinely engage in simulation and structured clinical examinations to assess emergency skills and initiation of consultation and transfer of care across birth settings.45, 46 Both objective structured clinical examinations and problem-based learning cases are often based in home, birth center, or rural/remote settings. Lecture content on the evidence basis for choice of place of birth and tips for screening, management, and documentation across birth sites are integrated throughout the curriculum. Clinical placement experiences with home birth care are mandatory. In the United States, in CNM/CM education programs, the content of lectures on place of birth, clinical placements, and application of simulation practice to out-ofhospital settings varies according to availability and expertise of core faculty and/or home birth CNM clinical preceptors in the jurisdiction.47 Covariates of Attitudes to Planned Home Birth

Analyzing covariates of favorable attitudes toward home birth using the 9-item PAPHB-international scale confirmed the significance of pre-training and extracurricular home birth opportunities. In addition, we found that exposure to home birth need not be extensive to influence attitudes. Practice experience in the home, regardless of how long, was associated with increased favorability toward home birth among CNMs. Because of the near-universal exposure of RMs to home birth during education and practice, few variables emerged as significant covariates of favorability among them. However, the number of planned home births attended during school and having home birth providers as faculty were associated with significantly more favorable attitudes. This suggests that increased exposure to planned home birth during midwifery school is an important factor in the development of favorable attitudes towards home birth for all midwives. Although favorability among RMs showed little variance and they were 4 times more likely to offer home birth compared with CNMs, among individual RMs there is still significant variance in home birth rates. This may be because of the external or structural barriers noted or of perceptions around interprofessional collaboration and collegiality. Interprofessional Relationships

Certified nurse-midwives were both less comfortable with consultation discussions and less confident about the Volume 59, No. 2, March/April 2014

availability of physician consultants than RMs. Perceptions of peer censure related to home birth practice were reported by both RMs and CNMs with home birth experience. Although there are significant infrastructural supports in place for Canadian midwives to attend home births, interprofessional discomfort with home birth practice remains a significant burden to many RMs and may be more pronounced for RMs in jurisdictions where midwifery practice is scarce or recently integrated.48 The documented divergence in attitudes across collaborating maternity providers (obstetricians and family physicians) with respect to planned home birth may explain these findings.40, 43 Exposure to other types of maternity professionals and preparation for multidisciplinary practice across settings were identified from the results of the Canadian Birth Place Study as significant and essential components to integrate into all health professional education programs.43 Systemic Barriers

Reported external barriers to home birth practice differed between RMs and CNMs. These issues may reflect the variance between countries in systemic and structural supports across birth settings. Certified nurse-midwives reported concerns about securing liability insurance, financial viability, and retaining professional credentials. In a few jurisdictions, CNMs are restricted from home birth practice by regulation, whereas in provinces where RMs practice, provincial regulation mandates their practice in all settings. However, most US states do not regulate the site of intrapartum practice for CNMs, so this perceived barrier cannot account for significant differences in attitudes. In both countries access to hospital credentials may be dependent on interprofessional opinion of home birth.48 Registered midwives are reimbursed in a uniform provincial-based payer model, with some provinces specifying reimbursements according to birth site–related costs (eg, home birth supplies, second midwife/birth assistant fees), whereas CNMs who offer home birth often must negotiate with private insurers and varying state-based public payers. However, because RMs and CNMs who reported current home birth practice did not identify financial viability or difficulty obtaining insurance as barriers, this may be more perception than reality (Table 6). Similarly, CNMs also believed that home birth practice would increase their liability risk, although this is not validated by risk management evidence.49 In Canada, liability coverage is available to midwives regardless of practice site, and risk management programs are not specific to place of birth.50, 51 For RMs the noted external barriers (on call, travel, isolation) were logistical and reflected the realities of practice when all birth sites are offered. Limitations

As this was a comparative analysis of existing data sets, it was not possible to evaluate information that might have provided more insight into the development of attitudes and the nature of barriers and facilitators to midwives offering home birth. For example, the Canadian Birth Place study collected data on the amount of positive and negative content of curricula, but the CNM study did not collect detailed information about edJournal of Midwifery & Women’s Health r www.jmwh.org

ucational content. The surveys also used different descriptors to evaluate routes of entry to midwifery practice and regional variations in practice. Etiology of attitudes is especially complex when there are differences between countries in practice context. Membership in the Canadian Association of Midwives is a requirement for RMs practicing in Canada, but membership in ACNM is not a requirement for US CNMs, so the sampling frame, although robust, was not identical for both groups and did not include all CNMs in the United States. Nonetheless, both the CNM sample and the RM sample were regionally representative. Similarly, practice patterns of CNMs versus CPMs with respect to intrapartum practice site may imply a professional preference based on attitudes to home birth. However, this is belied by the findings of the 2007 CNM study, which showed moderate favorability to home birth among CNMs overall; unwillingness to practice in the home was linked to confidence and exposure. Finally, as this was a cross-sectional study, our findings can only highlight associations between variables. Although the reported associations may not be causal, the current analysis represents an important contribution to the literature. Both the design of the surveys and the interpretation of our findings were grounded in our research team’s considerable expertise with practice and education in both countries. However, studies that assess attitudes longitudinally throughout the course of professional education and/or practice are needed to more definitively understand the causes of attitudes toward planned home birth. Although the homogeneity of RM attitudes toward home birth limited multivariate statistical analysis to identify predictors of home birth attitudes, the results on education and practice exposure align with regression analysis results from the CNM study22 and findings from the Canadian Birth Place study.43 Implications for Maternity Professional Education and Collaborative Practice

Both CNMs and RMs are educated to practice as autonomous maternity care providers. Results from the current comparative analysis and earlier analyses suggest that the pronounced differences between RMs and CNMs in their preferred sites for practice are most likely accounted for by their individual level of confidence and sense of adequate preparation for the clinical role in the home.22 It is well documented that providers tend to frame their own clinical practice style by what they were exposed to during their education52–54 ; hence, providers may present birth site options that are congruent with their own education, experience, and scope of practice.55–59 Thus, it follows that home birth learning opportunities during midwifery education could result in better preparation for CNMs and more openness to practicing in the home setting if the opportunity were to arise. Learners who have clinical education experiences at home may improve their understanding of how the midwife functions in an autonomous role, how complex site selection decisions are made and effected, and how to anticipate and prepare for emergency care and transfer. Certified nurse-midwives are at a disadvantage when their choices for setting of practice and 149

education are limited and when theory of midwifery philosophy and practice is not actualized in clinical settings.60 This is especially poignant when considering the current context for midwives’ ability (or inability) to preserve normal, physiologic birth in hospital settings.14 In states where the practice of certified professional midwives (CPMs) is regulated, they benefit from both autonomous roles in practice and practice settings that align with their educational preparation for practice.16 However, women will continue to seek home birth care from CNMs because the number of CPMs is limited nationally, and they remain unable to practice in all states or across all practice settings (eg, birth center and hospital). On April 19-21, 2013, leaders from all US midwifery regulatory and educational organizations met to examine US midwifery in relationship to the International Confederation of Midwives (ICM) global standards for education and practice. One strategy suggested has been to create education exchanges between CNM and CPM education programs (Home Birth Consensus Summit proceedings, unpublished, October 2011).61 Such collaboration could provide increased access to clinical experiences at home births and freestanding birth centers, many of which are owned or co-owned by CPMs.62 Certified nurse-midwife educators may also benefit from information exchanges with RM educators regarding the integration of birth setting as a core course topic and preparation for private practices that offer home and birth center births. Perceptions about access to insurance (liability and payer) and credential regulation may affect willingness to practice in the home among some CNMs. However, concerns about access to liability insurance are not limited to home birth providers in the United States, and financial viability for private practices is a concern for all maternity care providers in all settings. Current initiatives exploring tort reform may benefit from a survey of successful models for liability coverage in Canada. Over the last 70 years, attitudes toward birth at home have been a source of conflict and debate among maternity care providers in the United States.62–64 Simultaneously, insurers and public health policy makers have instituted regulatory and financial barriers to the provision of home birth services in some jurisdictions. In 2011, a multidisciplinary group of national and international experts participated in a historic Home Birth Consensus Summit, which resulted in a common-ground agenda around maternity care and place of birth in the United States. Delegates affirmed their commitment to “an equitable maternity care system without disparities in access, delivery of care, or outcomes” and “collaboration within an integrated maternity care system. . . . [toward] respectful, safe, and seamless consultation, referral, transport, and transfer of care when necessary.” They further agreed that “all health professional students and practitioners who are involved in maternity and newborn care must learn about each other’s disciplines and about maternity and health care in all settings.”61 The findings from this study are consistent with the outcomes of this summit and may inform policy on human health resource allocation, credentialing of home birth providers, and/or curriculum revision in health professional education programs to address care across birth settings, as well as interprofessional communication and collaboration. 150

CONCLUSION

This comparative study about attitudes and practices of CNMs in the United States and RMs in Canada has elucidated important differences in favorability toward planned home birth as well as differences in practice experience and education. The factors most strongly associated with reduced confidence and less favorable attitudes toward planned home birth among CNMs were limited educational and clinical exposure to birth outside hospitals. Perceived financial, interprofessional, and structural barriers in the United States may further reduce the willingness of CNMs to attend births at home. These barriers have been partially addressed by the model of practice for RMs in Canada. Registered midwives, with near-universal exposure to home birth in education and clinical settings, reported significantly higher confidence with home birth and had more favorable attitudes overall. Further investigation of the impact of education and exposure to practice across birth settings through longitudinal studies is necessary. Within the context of limited health resources, facilitating access to planned home birth and preparation of an adequate workforce is a logical component of rational health care reform in both countries. AUTHORS

Saraswathi Vedam, CNM, RM, MSN, FACNM, SciD(h.c.), is an Associate Professor in the Division of Midwifery in the Faculty of Medicine at the University of British Columbia. She has been in clinical practice and midwifery education as a certified nurse-midwife for 25 years in the United States and as a registered midwife for 6 years in Vancouver, British Columbia, Canada. Kathrin Stoll, PhD, MA, is a postdoctoral fellow in the Division of Midwifery in the Faculty of Medicine at the University of British Columbia and a part-time lecturer with the Midwifery Education and Research unit at Hannover Medical School in Germany. Laura Schummers, BSc, is a research consultant with the Division of Midwifery in the Faculty of Medicine at the University of British Columbia and is a Master of Science student in the Department of Epidemiology at the Harvard School of Public Health. Judy Rogers, RM, MA, is an Associate Professor in the Midwifery Education Program at Ryerson University. She is in clinical practice as a registered midwife and partner in Midwifery Care-North Don River Valley in Toronto, Ontario, Canada. Lisa L. Paine, CNM, DrPH, FACNM, is a Visiting Professor with the Division of Midwifery, Department of Family Practice, Faculty of Medicine at the University of British Columbia. She is also Principal and Senior Consultant at the Hutchinson Dyer Group, Cambridge, Massachusetts.

CONFLICT OF INTEREST

The authors have no conflicts of interest to disclose. Volume 59, No. 2, March/April 2014

ACKNOWLEDGMENTS

The Canadian study was supported by the Canadian Institutes for Health Research. The authors thank the full investigator team from the Canadian Birth Place Study (Michael Klein, Jude Kornelsen, Robert Liston, Shafik Dharamsi, Nichole Fairbrother, and Janusz Kaczorowski) and from the study of certified nurse-midwives in the United States (Sarah White and Jessica Aaker). The authors also thank Gua Khee Chong and Kerri Blackburn, research assistants with the Division of Midwifery at the University of British Columbia.

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Volume 59, No. 2, March/April 2014