Home birth with certified nurse-midwife attendants in the United States An overview

Home birth with certified nurse-midwife attendants in the United States An overview hsha E ehckson, aa, ELZSN and Ake J. biks, crw, MN midwives attended on&f 15% of all The roots of modem nurse-mid- history with CNMs, review kmture births in the united states women wifery are firmly planted in home regarding home bidl safety, and in- continuedtomoveintothehospital lz&lh-apartdlifesincethe~- tfoduceacurrkulu~forhome~ to give birth and in-hospital births ning of time. Until as late as the increased from 36.9% in 1935 to 1950s almast all births attended by PHu.0soPHlcAl AsPEcrs OF 88%in195Oto%%inlW.By nurse-midwives occurred in the HOMEBIRTH 1973.99.3% of births were attended home (l-4). Atthough nurse-mid- by physicians in hospitals (1. 4). 6lnhisaspecialtimeforwamenand wiveshavebeenattfzndinganever- When it became w&&xy to regis- inuea&gnumberdbWstfuc&- their families. Hourarer. some as- ter birth5 in 1935 (31, the mablnal pects of the birth expeMlc&in- outtheUnitedStatesdncethernid- modify rate was 58 2.I1O.ooO. and &ding inneased client autfk&iy and 1970s. the number of home births attended by ceded nurse-midwives the neonatal mat&y rate was 32.4~? privaql.lqreater-toare- sources, unfettered contact with + loo0 (4). (ClWd has been deereasing 15, 61. lings and family, and undWurM As birth moved into he hcspitd Luaaompiledin1989,ltlefirstye.ar ttlecontrdoverbirthslippedaway bonding-8re uniquely e?tqhed in which attendant and place-of- from the domain of women. Sinus whenbirthoccursathome.Whena delivwy stdslics were available, in- family size has decreased, women womanisathahomedmingcbki- dicated that home births attended and farr,i!k want more assurance bitdl.gmerenergyc8nbelMed~ by CNMs decmased from 3,412 out thatiheirbirthvitlbeasafeandsat- Iabor.andsheandhffrat,kedm&ae of 132,286 CNM-attended births (2.5%) in 1939 to 2,928 out of isfying experience. They are explor- freerloalbwthelaborbunfoklinik ingaflbirthoptionsincludingbirthat ownindividualandnatiuray(9- 285.005 CNM-attended births horne.This8rticlewiuaSsiStCNMsin 151. (1.6%) in 1992 (7. 8). The site and providirg informatioll for these cli- A-l?bOltngandbirchbrq8t attendants at birth have chawd dra- em. ltwiU&o5etwasareswco home retains increased authofily. malically ow?r the ywlrs By 1930. far w wiih or without ex- SheiStheC4HEllf&tEfCWdby whom alf intrapartum plans are per%eintheareadhomebi&ft will include information about the made.whenttberrlc&mf68bKsheY phitosophydhome~,rrviewiis holnetohirifl.hercenL~isdmin- itedhchoaqher~daap in~GQlngledl~thatofaenafe usedathomemybeuIladabJeor hqqmpdn~inahot@Mardras kkdmodesty.~,wrud~- my. nipple atbnuktion, loud mti vocatbm. drums. or cimdng !ll. 18). ~ahofnebbth.lhemather TkACNMS&?!VI@Fltafph~ cansxporleneeamuchgreatersense dprvwyandprwldeafamiliarand phy (19) recognb the importance of acknowledging a woman?s per- comfortable place for herself. She sonal b&f system and cultural iden- can feel less inhibited in eqessing titydurfngthechilåpocgs. her rerponses to labor and less lim- Spiritual and cultural identtty is usu- alfyevdasanormalpartofthe activities of daily living. When a Molsho &. duckum receiued her HornebirthintheUnitedStateshas woman IS at home with her own fam- lNld?qdu* degree in nursing at ily and social group. these aspects of changed dmmatically over the years bward Uniwdy in 1974 and her her identity are unselfconsciously ex- (23. 27). prior to the cn~tion of a MSN fn rime-midwifery jrom perienced. When out of her home medical~aubirthstookplace GeorgaouKl uniuerpitv Ill MI. Fmm and in someone else?s environment, in the home of the laboring woman 19!3lbJCW7shehadasolohome birthproaiccandworkedwith they become much more inaccessi- and were entirely the domain of Cities-inSchools. a sing&i& ble. These aspects of a woman?s women. Birth u~as viewed as a nor- ~*~legn~eyprw~m identity, and their vaIue as a resource malpmcessandwasprobablyleJsof pmddhg hoq&d birth. She ia to her during labor. may be underes- an unknown to the woman in labor. co-jounder, uwwtw. and cmiimor timated by the maternity care system. She may have been present for the o# BitthCore Cp Women?s He& a whose rules may inadvertently dis- births of her own siblings or may CNM pm&e jouncfeff in 1987 that courage or prevent ace= to custom- havebeenoneofagroupofwomen prouick ~~JwW l ; „h se&es in ary cultural dress. objects. or behav- who helped a sister, an aunt. or a W&ington. DC. Wrginia. and ior. k-td to give birth. The mother?s ef- Mwybnd. Since 1992. BirthCare and Bonding can have IG own timeta- forts to birth were supported by other Women?s Health has afso prouided ble when birth takes place at home. frees&n&g birth center services in women whom she knew and tn&ed. Viglnh Ms. da&on chain the Breastfeeding is initiated when She was provided with comfort mea- American Cokge of Nurse-Midwiues mother and baby desire and may sures to co- her strength, nour- (ACNMJ Hone Birth Committee. continue for as long as they both de- ishment to give her energy, and re- sire, unaffected by the routines of a assurance that what she was ew- Ah d. Bailes receiued her BFA in Facility. Parents may select the way in encing was productive and normal dome and theabe jrom New York which they choose to include their P-3, 27. 281. The laboring mother Uniuersi~ in 1970. She receiued her other children in the birthing experi- had the help of other women who undcrgrodw& degree in nursing al gathered with the specik goal of am- ence. In this way, siblings are less George km Uniuersify in 1980 and likely to be challenged by distur- plifying her ability to cope with the her MSN in nurse-midu$eery (mm bances in their routines, separation demands of labor. Thus, many CSeargdown Uniwnity in I981 Since 1972. Ms. B&s has umked in the from their mother. o: a strange and women who had assisted other home btlth sefiing. frrsf as a childbirth unfamiliar environment (20, 21). women during birth could call them- edumtor ond later us a birth a&.stan~ Distorted perceptions regarding selves midwiws (1). )or jarnik birthing ot home Fmm home birth persist in the general pop Although the vast maja&y of births 1982 to 1987. she worked as o CNM ulation as well as among CNMs (17. resulted in a healthy mother and a with Family Birth Associates. a home 22). and home birth is often mistak- healthy baby. tbii outcome was not birrh seruice Ms. Baiks is co-founder. enly perceived as an action against guaranteed. Women may have been ccbowner, and co-director oj BirthCare the medical establishment (23). It is confident in their ability to birth. but and Worn+ n?s He&h, a CNM pmctice important tc note that the same stan. they a!so had very real fears regzud- Jounded Ill 1987 speraimng In dards of are govern births attended ing loss of h& or lifdther theii our+hasprtol buths MS B&s ts by CNMs whether they be in the own or that of their babies. Ob- uice-choir oj the ACM?s Home Birth Committee home, the birth center. or the hospi- structed labor, hemorrhage. and in- tal (24. 25:. Additionally. clients for feclion were only so.7e of the threats 494 - * hthedy2othcentuiy*theshiIt kunlrawik-bbirthio g-~yga,g-~~ wiseryeinIargepa!rtbQcalJsQ Other factors mt diiectly ad- the midwiws w a&o km&s (1). fLl!lBdpecred-h~~ TheywefQpaftofchQlabolingwom- QfltidpOSiWWb!~J.„chsbsk- an?s community and ethnic QMIP. tars induded lack of financial re- spokethesamekmguage.shadthe sources. radsm. sezwhq lablgwgz sameualues,andoftenerqqedina barriersand-- ThfeatsofiuhealthandbssoflifQ uafiQtyof-dutiQsnotpQf- ties (1. 4, 16, 23). By contra, the wefQleducQdcorthQnwtherthrough fonnd by the dochm (1.29:- Addi- opponentsofllawvQswere~ the discovery of ergot to provide tilmdy.accQsstohospitalmatQmity well-organized male physicIan uterinestknulattonandprewmthem~ carewasoftenltmitedtyftnancialre- sww&~~~ to - h soufces, inadequate transporlation. -*- orhge.ThQlKeofit3QQ&rQduced thQ in&lQrtce ol infertion. wtth the lackofservicesinrumlareas,an&of matioll QffQctiuQly. Physmns UEn? fear of experimentation and death. intmductionofanestfesiainthelate also concerned about the over- Destitutewomenwhogavebifthin 180&therewasanaddiW4prom- &IQ hospital often received free or iseofpainfQliQffmdeauailabIQto i~ph@cianscouldmaint&neare women in chii~ng (1, 23. 27. low-costcare.Ahhoughitwaswell known that physicians used these for cltents who might other&e be 281. women for training purposes, doctors cared for by mkiwiws (1, 2, 4. 16, Once pain n&i&ions for labor 17.27). WQIE added to the b&thing scenario, -d- thatpoofwcmn As the debate continued. some received better care than was avail- management became more com- able to women of higher clalr~es (1) wanted :a a&Ash midwifery ako- plex. With new procedures and equtpfnentto&ezitthesideeff~of In an effort to enhance ttzeir own gether. Others preferred impaslns status. discredit midwives. and in- rquMonsthatwouklresbictmtd- thenewmedicatiorqitwasbeIiewd cnzas~ the number of hospital births. wi1eypfadceoutofexbknceAn thatthepfwed~wouIdbtzbQttQT additional group pmposed the lq@- some physicians began a successful canjed out by physicians. who were izatilmandrQgulatianof~* mpaign tdozsigned to persuade the mosdymen,inO~CentibtiO~ as had occurred in England and thehospMRulesweredes@wdto pubtic that childbirth was a path* icaleventAsaresukmanyfIm~- enablethehospititomeettheneeds *E-W= c4lunes (1. 2). h ofmanywonensim~.The can women reduced their ass&a- difQctlepnsetothQcon~~ tions with midwives and gradualiy laboring mother thus became only sRleriJchanges-- changed their preference to male IawswemenactedinsomesWes, ~ofagroupofwomen inneedof physicians and hospitals (1.23.301. and in 1921 the Sheppard-Townez cm. One umdty of group manage- ment was excluding family and Debate ensued among the medical Actwaspassedinaneffofttohelp dQcreasQmaternaIandinftrnt~ community and in medicA literature friendswhopreviou4yhadbeenthe ity.Thisactakataltithzc& laboring woman?s major source of regarding the “midwife problem” the C~~I&QC.„s Bumu to help edu- support. T~IQSQ labor companions (311, rrld midwives were among who had been guides and resources chose blamed for the high rate of in- catQkymichhesandpubiichaalth nwesintnbdwky.Edwt!bnpo- tohelphercopewithfear,@xance. fant and matemal fruxMty. In 1910, discomfort and pain were bvred the infant mortality rate was esti- garmvmzsetupinkwYofkMEw fromthehospitaLlkewasanL,- mated to bQ 124I1,cKIcJ tive births (1. Jemy, PeMsytvania llhM and 23); howQuQr. the Mlidtty of ttlge healthdepartmentsth~the crease in tFe USA of potent medica- k#ttieFNs~1952wd1954 was 17.Yl.anI RR births wheres thed-tideathratefor thetblitdsfelesin 1853ws19.U Loo0 lhre biroIs (351. ne cathofic Matemtty Institute (CMI)~fokmd8din19448sads mk&ay&thservleeinSantiFe. Thectmeptofretumilybtrillb~ NewMexko(36l.Theprapclsepof homedevelopedoueraperiodof cMlwetetoplovidenMtemityser- vices by nurse-miciwiw, estabiish a ~wyears~Fough~faedas nurse-midwifery education prqam. In the 19405 in En&d. Grantky Dick-Read in- “natural child- Inane#orttoheIpcombatNewYork and promote maternal and infant cyr?s h& infant mork3ky mte. the health (3.37). Au three of these early bii.” advocating birth erhIcatim, relaxation, and deep breathing (38). Maternity Center ksociation (MCA) nurse-midwiferyserukes and theiraf- &edbyasmaUnumberofAm&can filiated education programs were urns founded in 2918. The MCA -s women and physicians in the early tzhbhed 30 health centers that pro originally created as home birth ser- dded he&h edwilkm to rnirlwiw vices and continued for years with 1950s. Dick-Read?s methods en- the majortty of their intrapartal piac- abled women to remain at home with andthegenemlpublic. aswellaspre- nati are and birtlr services. The tice in the home. their families and bii with a sense of great majority of MCA births took confidence and contro1 (16. 20). pIace in the mother?s home. From Among the women using this Reports About Midwtves and 1932 to 1958 a total of 7.099 MCA method were the founding mothers Birth Results births were attended, of whiih 6.116 of La Leche League. With Dr. Gq- were in the client?s home. The ma- Two government-sponsored &dies oy White as their obstet&ian, these ternalmortaktyrateforthecliniiwas published in the early 1930s sup- women began to give birth to their ported the practice of midwives. The 0.9/1.000 live births in contrast to a babies at home. They were sup ported in their decision to breastteed maternal death rate of 10.4/1.000 1930 White Ho- Conference on iivebirthsinthesamegeogmphiclo by pediatrician Dr. Robert Me&+ Child Health and Protection pub- cation for the same period (3). The lished a repon titled, fete/. New&m. sohn who also encouraged them to MCA became a part of the early and Matema/ Morbidity and Moltal- takeacriiicailookatthemedical5ys- 1920s? movement to legitimiw mid- ity. In its conclusion, the report tern and question their physicians? wifery through its association ~;;iiil stated. “it 5eems possible that all the advice (39). nursing. In 1931, the first nurse. advances in medical knowledge have Childbirth information, education. midwifery education program was been almost lost to the parturient and techniques to help women cope started at the Maternity Center Asso- woman through too great a recouIlie with childbirth pain first became ciatbnn. to instrumentai d&very [by the phy- available through the lay press in the The first nurse-midwives to prac- sicianl” (1). The report further re- 1950s (38). In the late 1958s. Mar- tice in thii country were introduced in jected the idea that midwives could jorie Karmel brought the Lamaze 1925 by May Breckinridge (33). be solely biamed for the high mater- method to the United States from These women formed the Frontier nal and neonatal mortality and mor- France. popularized it through her Nursing Setvice (FNS). which pro bidity. The second report, published book Thank You Dr. Lanwree (40). vided m&mity care for women and in 1932 by the Committee on the and co-founded the American Soci- families living in rural Kentucky. Sixty Costs of Medical Care. concurred ety for Psychoprophylaxis in Obtiet- percent of the MS brths took place with the White House Conference re- L-S (APO). Robert Bradley initiated in the client?s home In 1939. the port that the “midwife is not the de- his method of “husband-coached Frontier Graduate School of Nurse. termining factor in the county?s high chiidbii. at about thii same time Midwifery was opened. The clinical maternal mortality rate. . .„* In fact. (41). The goal of childbirth education practice and outcome data of the it maintained that *„untrained mid- was to prepare parents for birth. Ed- FNS were and are exemplary. The wives approach, and trained mid- ucating a significant other (usually Metropolitan Life Insurance Com- wives surpass. the record of physi- the husband) (41. 42) accomplished pany conducted a study of the first cians in normal deliveries. _ The two important objecti- it ptwidsd 10.000 bii of the FNS. which oc- midwife took better care of her pa- the umman with a knowledgeab& la- curred between 1925 and 1954 (34). tients because she waits patientiy and bor and birth companion, and it It found that the neonatal death 10% :2ts nature take its course.” In con- brought someone from outside of the 4% Jomnal of NumAW&uy l Vol. 40. No. 6. NwunberlDccember 1995 mK&aI~iAbuleW~ Fampeoawld~JiBiMWWBd ?arwdcTnadclrrhgmebbaarul bntsadIb0 -lo- mmedtt&a*moaakna& -7a k&ocaiddbe~~the need~~~woukl~ =!iztgzzn of mademal at- tachmentwas--the wil.wofBowlby.Maregw,~ KlausdKennen(43-45).Mothers and~karnedaboutrooming inzawlavuidhgsepuatkmfmmtheir newborns through the mother-to- mothersupportofLaLecheLeague unnlnentonthestat~hb Inthe195fktherewasamovement (46). Groups such as the Irema- cember1974,akttertr2tbeJNMe& fornurse-mi&ve5togainaccessto tional Childbirth Education Assaia- itormspubusbed~outthat hospital pddeges (3). Some nurse- tial (ICEA), ttlnekm Aidemy of “„an officd dcxumnt againstb lredwiwstoppedprovk3nghorne Husband-Coached Childbirth, the bih\rrasiS!SUXIprimbrelbble.~- birthserx&sinanefforttoremaina Amelkansocietyfor~y- ganiaed.aM!!researek...~~l viablepartofthematemitycaresy+ hxbinobzMliqHomeoriented stifling and reactionary. . . . The tern. Urktunady. these actions, l&amity Expemce (HOME), In- ACNM[ELtQjd]tO-L~ combined with other even&. have formed Hombirth, I44iaws of Af- sitins . . . intheilltwitof~ contributed ln the defmase in nurse- rican Descent, HOMEBIRTH Inc.. sional gmwul . . :* (58). Afh?r mlxh midwifmttended home births. a!ldtheNa~Assodamofh* controversy and discussion, the During the 197% the corxurner entsandR&&onakforSafeAher- ACNM statement was revised in movementforhomebirth~arbd natives in Childbirth (NAPSACI or- 1976. However, the revbed of6dal ~CNMsagainbegantoprovide ganized t6 e&x&z the public and ex- pc&mstiuiden!i6ed~and hornebirthseNises(55).Attitime. press concern for the impersonal, maternity homes as the p&erred however. the organizational re- mechanized approach to childbirth sites for birth, a& caritioned pack- sponse of the ACNM was not sup- that was becoming the routine in timers to develop guidethres ensur- portive. Minutes from the ACNM AInelican hospib other twmlen?s ing home birth safety. The poEitkn Board of Directors? meeting in the fail groups such as the Boston Women?s statement was retired in 1980. of 1973 reflected a desire to “rvoid HealthCoswtivejoinedthemove- Shortlythereafter,theMS&&- the assadatim uf ACNM and nwse- ment and queskned conventional ment on Practice Settings was midwives with the promotion of hospital birth practices thai left adopted. In thii statement, ACNM home deliverks at a time when the women feeling out of control, fearful, acknowledged the tton~ as an ae- entire obstetric team has neither en- ceptabie site of pmctke (59). and alone (47). Furally, the status of dorsed such a system nor cmsidered womenandtheimportaxeoftheir nlrougitoutibe1~hoarKbfrtb the development of guidelines for issucswereboostedbytbedevetop CNMs amtinucd lo Movide ssrvices home deliveries. should the entire merit of feminism and the women?s withoutafonnalACNM~b obstetric team deem them appropri- movement (48). address home birth issues- Some ate . . .„* (56). In the 1970s. a number of publi- CNMsfoundaforumfor~ Shortly thereafter. the Board abo cations. including Motkrtng Mago- with other home birth midwives encouraged re-examination of the through the Midwives Alliance of tine and The Pm&icing Midwrje, quality of maternity care. fearing that sewed to educate consumers on how NdlAilWCd(MANAl,~orguli- impersonal servkesmaybecontrib best to plan for bit at home by pro- ation whose purpase is to forlnr uting to the promotion of home viding birth stories, advice to new communication among all n&h&es. births. In January 1974. the Board parents, and instructions for home In 1985. all U.S. nurse-m published the following position birth attendants (9. 11, 13. 47, wemfacedwiha~hsur- statement: 49. 50). Ina May Gaskin?s work ama2 IKWIB crm (6&a). shourJ a particular strength in that WhefetwmebirthsawaitixeWy. AhhoughaYJwagewasfourulfa fore thu 193th 122). Thqr - c&yaa&iiethebqmwmmd nmk!muland~~und wdirally-ti- dtheMhsaptothelm@al@7l.h ~itisirlqdwto~~ thtsistineacasrllyaavldrb ThedebutuuboutwherewomenaIld tiOdllpmtaehfprcfi&b babies are safest for birthing ha m0-m~houshAnubitkn.d benaconcemworldwide.When gmeIaltIez4th.mustabobe~ examining the literature regarding home birth, authors emphasize four zc”” at - sta- . . . -ain points pertinent to the achiwement numbers of pregnancies and in- ln1992,thecammi.tteededed of safe home birth outcomes: creased time between btrths have that &airy data documenting the 1. Theplanbbitthathomeshould alsocontlibutedto~h safety of nurse-midwife-attended bemadedwingtheprenatalpe- outcomes for mothers and babies homebbthswouldbethemosteffec- rioll before the on& of labor tive wuy to influence the insurance a?. 28). (75901, Welld&gned. large-xale intern+ industry. The Committee undertook 2. Thebirthshouldbeattendedbya tional studies demonstmte that fears a retrospective study of 11.788 well-Wned health care provider nurse-mid&&nded home births aboutthesafetyofhanebirthsare (7577, 79. 91). between 1987 and 1991 (67). The not justified (28. 83, 89. 103). 3. Stringent screening should be ap- Planned, professionally attended ACNMHomeBirthCommitteealso pliedtoc~fythe~as homebirthbasbeenshoumtohave identifiedaneedforpraspecliwre- “„iow-risk” (51. 81. 82, 88. 89. search and is supporting the U.S. outcomesform&terandbabythat 92-96). Pmspuctivu CNM Home EKth Study areatleastasgoodas,tfnotbetter 4. An on-going system of communi- currently being conducted through than, hospital birth. fnternatbnafly, cation with consulting physi&ns Columbia University in New York only the Netherlands has maintatned should be established in the event ahomebbthsewiceforalargepor- that lndcal o3mplic.aIions r)ctur ACNMPokcyonUseof tionofitspopulatkmduringthe20th oraneedarisesfortransfertoa Techno@ in Birth Century (104). However, during hospital Q&82. 84. 89. 90. 93. theselast9OyearsinbothHolland Parents and practitioners alike be- 9&98). came extremely concerned with the and En$and perinatal and rnti overuse of birch technology. In the mortality data control6ng for site of When these criteria are met. out. 1970s. birth became more mecha- come data indicate that risks for both birth have been collected on a na- nited duough the introduction of the mother and baby appear to be very tional de (28). f&d monitor and the dramatic rise in IOW. An example of the Dutch research the rate of cesarean sections. There One of the major obstacles to the reparktheexc&nthisIoryof&e has been an increasing amount of acceptance of home birth is wide- homebirthsintheNethe&m&This commentary and research yielding spread fear that home birth is not as study reports national statistics for new data that question the efficacy. safe as hospital birth. Mothers fear 179.190 births occurring in 1985 value. and safety of technology in that they will face hitier risk for Approximately one-third (65.518) biIttl (16, 17, 22, 28. 6a-74). The themselves and their babii if they occurred at home and were attended 1991 ACNM statement regarding stay home (16. 22.68). Birth atten- primarily by mid& The perinatal “The Approprtate Use of Technology dank fear they will face crises that tnort&tymtefortheplannedhome in Childbirth” “advocates nan- they cannot safely handle wtthout the %thS was 1.9/1.o00; in the same intenrention in normal 7. technology available in a hospital. yeartheperinatalmortalityrateforall hdl supports the use of appropriate (84.87,9%102). births was 9.&l,ooO. Not only is the technological interventions where In the United States, health care @natal mortality rate low. it is im- the benefits of such techndogy out- provi&rs and lay people often do portant to recognize that the data weigh the risks.” When labor and not acknowledge that research find- comefromaverylargesamplesizeof bii occur at home. technological in. ings exist showing home birth to be a more than 65,000 pregnant women terventions are pbced at a deliberate safe option. Ro*.+d;i?> /f*;*- -vnd (891. distance to avoid their unnecessary onanemobonalwfe~~r/)andreflect There are several British authors amuse. However, consultation net- on the pr stutiskal outcomes that thathaveshownaparticuhrinterest works are in place to provide for ac- were mated with home birth be- in statisUcs regarding the ongoing 498 -dausikdMQ8,83L ad5himbaaDamwtaLt~ XSE-& ~~~~~~~ by6QkdS~kh&hssruiea Q%-%hnxkdtydd tUSWUNd-~89. lClEZZ:Z 9o*am. 106).~dec -de- -dsSmhgtim 12228,m,d~saabcwl -InUleauLlgbkndhg e4 lu7-109). WbWcoC ~donddy-=-=-&4 kc&m exb& carlq#?M: msc be ndbrrkQsdgenadP==-= benlflou&the-dhorne madeamong~thataremt whwa5dmsliealiy~to~ shicdy comparable. 8e!cause ran- aboW1%,tkhClfWbkthpogram <id~tliakof~siteae us5-phasedatt~(z8). St&ngin1975,Mz@tieTewbe- s~oeii22z ganto-Mtionaltrendsin andpityaamhhosgttdbirth.a thesiimng~thatu5anen m-=df=-Yti founderrorsintiwaythesena- mketohcRilebirthwhentheyafe tioWlld&lwlereinterpeted.br1978 plramhgtobirthathonte*odlerre- she pubkhed work that anal+ seearch sirakgis must be used (83). Intkt.hi&dSraaeS,the~ and rweded these rrrisinterprela- euabtingholnebilthcndperinatil tions(10S).SheconttnlKdBDlMRkb dlaengetbeufidqmd~that outmm6havelake!nptacetargeiy inEn#wIkpilalswerethesatesl outsideofanehu&ofinforrnation sharing. These studies may be pketo$vebtrthG8.87,105).fn gmupedintotwot2ee@es:those 1978, Tew called for a “CritisJ and impmthlirws&db... to6nda that examine outcome statistics ValidocpBnationdthe~higher thro&largedatase&fnrmbirlh cedkate analysis (5. E-80, 91) llllwkyin -hoepitals... andthosethat~ detailed &- so that futurtz po-ii for maternity alremaytJedireadtowardprwid- ~ld3nid pactice (51. 81. ing a b&nce between home and iillAcm -hers have mostly hos@ai amfinement that is based on demonstratable fact” (10!3. She unde&&enthesestudieswithoutdre mntizwestocompkheranaty&of bene6tdgovemmentarlargeaga- nizational support. This has z!ten nabioaral&ta~daijngbacktothe 1tHl@fkla&g~re- hammed the sopilistiatioll of ttw researchrrwtbds. Ins@tedthelirn- search that m the safety of titions+asmaObutconsistentfkwof home birth (28). resarch on U.S. home birth tends to Notonlyhavethesefindiibuifta gxxlcasewiths.tmngevidencesup wr&ofatethefindiq5oftbeEu~ poi?ingbomebirth~ety,thqrhaw peanstudie5. Asawh&.thebodydpublished illuminated ways to approach the complexities presented by the re- rewarchonlIwAmericanhomebirth search questions. Campbell and experienceisnotas-asttw rkFallane (84) point out the mm- European r-h. In rhdies d wiea&ing the reMon- contxast to the . . ~studisofiargepopu- shpofbirthsile!0outcome. wdt- tatiolEint-ldandand6Kitain,most Anerican5h&sreportonaAcome5 dafsigd reseati must conlrd for the w of pWttt5onefs. prenatat forasingkorsmaIlnumberofprac- tices or a very limited geographic G?lestrateg&W!dbydifferentplac~ titioners. and risk status of the area. III an article pubkhed in 1980. mother.tnaneffolttoaddressthere mmpkx mncems, authas have 01- 8umet&etatbKaughttothetaethe aminedvarimn =I=- =P-*- impottance d the influence of in- kctthecawraeirredwhiieattfle kdityforao~inthisshdY. hO@td(8o).AlttWU&ttWdatsdGC- irtdudtngthosesueenedoutandde- ument that maternal and neonatal ~~wMI in the hospital, was 9.S outcomes are excellent for home 1.000.lnthesameyeactkperina~ biIths.llewabgandcommunica- death rate was 20.3/1.000 in the tionarecrucialtothemaintenanced satedC&fomia.Apgarscoresfor these slamcs (112). those infants born at home were Atonettme,homebird~wasccn- htghavemgbq8.9at 1 mhuteand sideredanappDopabtechoiceanly 9.7atSnlinu~Therewerenoma- when the client lacked financial me- ted deaths. he au&oTs concluded sourcesortivedinakxdionfarfrom that *„in a self-selected. medically aho@taLThiiisnotthecasetoday. sc#& Iow-risk population. home Accolding to Aklers. “Women who debmy with medical facility back-up seek care in alternative settings are aan be a reasonable alternative to known to be different from those tllxpid delivery” (81). choosing tradiinal sites. They tend Only two published studies exiti HOME STUDY AND BASIC to be older, ma&d. more educated, that document the outcomes GI ElWCATlON IN H0MEBIKY-R and of higher socioeconomic status” home births managed exclusively by (113). Clients choosing home birth Although there has been a decrease CNMs (67. 110). Published else- represent a healthier prenatal popu- in the number of nurse-midwhres at- where in this issue of JNM is “Out- t&ion and are highly motivated and comes of 11.788 planned Home tending home births, the number of Births Attended by Certified Nurse- interested in minimizing obstetrical women committed to the home birth interuention (%I. option continues to increase (116). Midwives: A Retrospeciive Descrip Not a single study exists that defin- The majority of these consumers tive Study” from 1987-1991 (67). The overall perinatal rnortaiity rate itively shows that ho@& are the consciously seek home birth after was 4.2?1.000; the neonatal mortal- safest bii place for women and ba- careful rewsrch and preparation (113). Many nurse-midwifery stu- ityratewas I.3MKXl. Theincidence bies (28. 83. 114). In comparison of complications and problems is with other counties, the infant mor- dents initially plan to attend home vey low. and the reasons cited for tality rate in the United States is high Mhs. only to find that their educa- tmnsfer are presented in great detail. for a well-developed nation (24th in tional program does not provide ad- 19901 (115). Sweden, the Nether- equate preparation for borne birth The authors specifically analwd the timeliness of emergency Bansfers to lands, Australia, and England all services. The rnajodty of nurse-mid- the hospital. Transport time was have lower infant mortality rates. wifery educational programs do not found to be within the 30 minute rec- These countries all have maternity include a home birth cunicuk.~m or ommended time limit suggested by programs that include midwifery- home birth intmpartum integration the ACNM Home Birth Guidelines managed home births. sites. and most midwifery students In summary. studies from the comptete their program without at- “Ze importance of an on-going United States and other counties in- tending a home birth (116. 117). In system of communication between voIvin5 po@ations of tens of thou- response to concerns w ovex the home birth practitioner and con. sands, as well as studies over the last the lack of home birth exposure for suhing physicians and hospitals is re- 2 decades involving smaller sample students, the Board of Directors of peatedly emphasized in the literature. sizes. have repeatedly documented the ACNM charged its Home 6ii Studies from counnies that wcognize that planned home births are safe. Committee to prepare a cunicuium home birth as a standard of care con- Some limitations exist in these stud- guide for home birth. A com@wn- tinually strive to improve the on- ies primarily that rehospective stud- sntecurriculumwascumpiledbythe going system of communication with ies conMute the majority of home Home Birth Committee that ad- consulting physicians and hospitals. birth research. Although these r&o- dressed issues such as the pracU&- This ensures that when indicated, the spective studies repon similar out- tiesofsetiingupahomebirthptac Eansfer mechanism to a more tech- comes. additional limitations do exist. Me. the cultural aspects of home nological level of care can be effected These limitations include retiance on birth, and the challenges encoun- swiftly. It has been noted in some birth certificate data. which are ex- tered in a home birth practice (see U.S. studies that mothen or babies tremely important but require other Appendix, A Home Birth Curriculum requiring transfer from home to the supplemental information to assure Guide). The information contained in hospital may experience hostility validity. lack of control for planning The Home Study Program on HOme from the hospibl staff. This may af- status of the home birth lack of con- Birth. whiih appears in this tssue of aywataadtlllaIhe- pdikmer,lfrehmlebirtk- whomyfeel&dmdanl~ta- dwhkwardtbedma kldtki?~kWpdki!Zbd- -nKEetlhms~~lmcne tlbthiranet~t~k tmdpEwfeadameertand ttp5tUChtWhOk~edae- rueAtlbu$l~view5- 6cwakinthe amidlmahpslepa- ~=-.Bsc$ atknborJBlthecbaai~tder -hHY-ofd dw?5lqew&nofim~noad ~notWJ=byfad(3.17.P 28. 74. 117, 118). Mk#nqW& hornebilhcNM Thellomebirthndduricemu5tbe -among--many pmkientinanumberof~of ofwhamhmwnewratbendedan pta&e.Th!ishamebirt)thamestudy outd-~bathltisvuallytm- praqarnhrdudese@tackMmalar- poslantthathuwbirthi&mMon tides divided into themew and and-bemademoreeasily ctMAareasTheMmqmtke&- ac&bIe to 5tude11ts and e&b- 5dptive mldy (67) and the national lishedplzlabmaFilu?.Tlli5willex- reporteddataonhamebirth(6)ex- pand-ndingwthecNM amineh~pookd~evi- community, assi5testablished pmcti- &rKespesi~releventtohome tianerswhowanttbaddhornebirth birth. “Informed Consent and toanex&ingpmclice.preparekiic midwifery students who want to Home Birth” and “In PUTS& of Ex- practice in the home bii setting cellence: Quality Asnrrance, Docu- upon graduation, and meet the mentation, and Peer Review by Home Birth CW? provide a frame- needs of a growing number of con- work thou& whkh the nurse-mid- sxnets in search of home birth atten- dants. wifecanoqanizethepmctk&%of clinical practke. “Guidelines for Cfi- There are no studies that dosu- ent!XxtionintheUomeE3irthf4id- mentthateitherthehomerxthehos- wifery plactke.” “preparing couples pital is the safest birth place for for Home Birth: Pmctkal Surges- women and bat&s 122.2& 83). FL search from the United Slates and tiON. *? “Neonatal Considerations When Birth Occuts at Home,” and other counGe5 involving popuMons “Care of the At-Risk Neonate Bom of fens of thousands. as well = stud- at Home: A Model for Nurse- ies involving smaller samples over the pas! 2il years have rep;;ltedly Midwife-Physician Collaboration” colkctively ptovide concrete guide- documented tht plannerI home lines regardhg the common realities bii are safe. The U.S. Pmqective of clinical pm&e. CNM Home Birth Shdy has been blitiied to further arpport hi5 Con- cept DISCUSION f-knnebirthisantiofmidwifery thtmustlKdbelo5LThebeginnings Home birth midwifety is labor-inten. of certified nurse-midwifery were in sive and time--, both men- the home. and nurse-w must tally and physically. Healthy mothers notlosetouchwithIhepastasthey wboareewcriendngnotmalptep move forward into the 21st Centwy. nancy and childbirth are the appro ptiate clients for home bii. working in the client?s home affords the CNM an opporhmtty to spend more con- tinuous time with the laboring 1. Litoif JB American ntidwives MXM~ and her farify. Being in the 1860 to Ihe prezent. Westport (CT) Greenurood Press. 1978 mother?s environment enriches the CM8sunderstandingofthecfients 2. Tom SA. The eudution d nutse- safe chw Marble Hill (Ho): l@th&sAmaleanCdfegeufN~~~e- FlApsAc Reproduaba 1981. &huives statement of philosophy. lbhhgfm (lx): XNM 1989. 55. V~treF.S@i&pG.Bo&nd KThetraru&.imfruntayrmdwiktocer- 20. Tanp!son~Tur~lCR~;a: tt6ednurse-mi&&intheurddeds8oBg Ffi9y~whyfamB=should~ Nulse Mtdwd0y 19%4042&38 t0@hefatbirth&whyuiectn3sebthat 37. LmgDM.neAmerican~ ~h:%wartL,SteweutDfedsl. dNUISl?#4l&WSW~kthefU~~ 56. American College of Nurse- 2ls.t Century obstetrics M)ry, vol 1. & nurse-m? bl hospiblls? MidWMS MllUdeodEhdOfDh2CWS c$clpeJ km (NC): NAPSAC. 197723% chlldb~ centers? hume birtk? In: Meeabrg Quldwnlltg 1973 Lk3. Swmt L, Stew& D (e&L 21st Century 57. American College of Nurse- 43lmlrbnow.vd1.chapelHulINc): 21. Hathaways J. Hathaway M, Middues. ACNM stabemen~ a: home NAPSAC. 3977:B%l. Flahway 0. et al. Clddmn at birth. bid. wzishhgm iDcl: ACNM. 1973. 38 Dick-Read G. ChiMbinh without 58. w-F&SJ.Let&rtothed- fear.2ndreued.NewYofkHarper& x fcA)z - -- tar Nurse Midwifery 1975;2Ofsping):6. Row. 1959. 22. Wagner M. Pursuing the birth 59 American Coiiege of Nurse- mwhhe. Ckmpdwm USW (Austrabl: 39. Mendebohn R Make) Practice: Midwiws. ACNM statement on prwice how doctors manipulate women. Chi ACE Gmphic?& 1994. settings: Washington (DC): ACNM. ago: contemporaly Books. ml. 23. Leauln JW. Brought to bed. 1980 40. Kannel M. i-hank you. Dr. IA. childbearing In America 175&1950. 60. Ya?es S. President?s pen Q&k- maze. Garden City (NY): Doubleday & f;g York: Oxford University Press. ening 1985 July?Aug:23. Co.. i965. 61. Rah MR Update on malpractice 41. Bradley RA. Husbandcoached 24. American College of Nurse. childbirth. 3rd ed New York Harper & insurance. Quicker&g 1% SeptOct13. Midwives. Standards for the pm&co of Row, 1981. nurse-midwifery. Washington (DC), 62 Yates 5. President?s pen. Quick- Aclw 1993. 42. Bing E. Sii practU lessons for ening 1986 JanrFeb:2. an easier childbirth. 2nd rev ed. Toronto: 25. American College of Nurse- 63. Ernst E. l?.e hell tolis. Quick. Bantam Books, 1982. Ma GuklaUnes for homebirth by ening 1986 JarvFeb2.5. ihe Ad Hoc cammmee lor Homebi. 43. Bowlby J. Attachment and tass 64. American College of Nurse- Washington (DC): ACNM. 1991. New York: Basic Books Inc.. 1969. Midwives Insurance update. Quickening 26. American College of Nurse- 44. Montague A Touching: the hu. 1991 July,Aug:24. Mldwtvcs Statement on the appropriate man signifiiance of skin. New York: 65. Hammond-T&e M. Surcey of use d technology in chiklbi& Washing- Harper Rr Rw, !972 CNMs attending home birth. Quickening ton (DC): ACNM. 1991. 45* Klaus MH. Kennell JH. Parent- 1992 Novnec 15-6. 27. Wertz RW, Wertz DC. Lying-in. infant bonding. 2nd ed. St Louis: CV 66. Coxspondence from vice pres- exp ed New Haven [ClI Yale Univer- Mosby Co., 1982. ident, Maginnis & Assoc., to Karen Fen- slrvm1989. 46. IA Leche League lnt. The wom- nel, sr. policy analyst ACNM. June 1993. 28. few M. A mfer childbirth? Lon- anly art of breastfeeding. 35th ed rev 67 Anderson RE. Murphy PA Gut- don Enghdl: Chapman & Hall. 1990. ~;lklin Park La Leche League Inc.. comes of 11.788 planned home births at. 29. DecIercq ER, Lacroix R. The im- tended by certified nursemidwives a ret- lnlgiant midwives of Lawrence: the con- 47. Boston Women?s Health Book rospective. descriptive study. J Nurse flict betwzen law and culture in early Colleaive. Our bodies, outs&es: a book Midwifery 1995:40%%92. Twentieth Century Massachusem Bull by and for women, 2nd rev ed. New Hiwy Med 198559X32-46. York Simon and Schuster, 1976. 68. Cohen NW, Esmet JL Silent knife. South Hadley (MA): Bergin 8 48. Morgan R. Siierhotxl is po*ucr- 30. Stat7 P. The social transforma- Garuey Publishers Inc., 1983. ful New York: Vintage Books. 1970. tion of Anrerkan medicine. New York. Basic Books. 1982. 69. Cohen NW. Qpen mn. New 49. HazelI LD A study of 300 eler- York: Bergin & Garvey. Publishers Inc., tive home births. Birth Fam J 1975 win 31. Williams JM. Medical educarion 1991 ten2 1 t -8. and the midwife problem in the United srabes. JAMA 1912;LVKI( 1): l-7. 50. Haire D. The cultural warping of 70 Haverkamp AD. Qrleans M. An childbuth. Minneapolis: International =essment of electronic fetaf monitoring. 32. Hedger C. Midwives and blind. In: Young D led). Obstetrical intervention Chidbii Education Assoc. 1977 nes II Med J 1912;21:41%24. and technology in the 19805. New York: 51. Dumnd AM. The safety of nome 33. Breckenridge M. WI& neighbor- The Hawthorne Rets. 1982. birth: The Farm study. Am J Public hoods. Lexington IKYI: Universrty of Health 1992.82:45&3. 71. Freeman R. Intrapartum fetal Kentucky Press. 1981. monitoring-a disappointin story. N 52. Stewart L. Stewart D fed). Safe 34 Metropolitan Life Insurance Co Engl J Med 1990322.6244 alternanves in childbirth. Chapel Hill Summary of the tenth thousand confine- (KC). NAPSAC. 1976. ment records of the Frontier Nurang Set- 72 Tew M. Do obstetric intmnatal vice. Q Bull Frontier Nun 5eMce 195g interventions make births safer? Br J Qb- 53. Stewan L. Stewart D kds~ 21st splirlg:~55 Century obstetrics now, vols 1.2. MarbIe 5let Gyllaecd 1986;93.459-74 Hill (MO). NAPSAC. 1977. 35 bum H. Isaac HE The frontier 73. Enkin M. Keirse MJNC, Renfrmu musing senke: the mimarv care nut5e 54. Stewart D. The five standards for M.N&onJ.A@detoeffe&vecarein 502 Journal of Nuts&Udwttay l Vd. 40. No. 6. IbembefJkazmber 1995 91. SuEhml DR Beerrran R Fctur s=y-=- wmlhanebirthbyc fmdwivein-Amd~ f-kalh 1983;736415. %?.Tre&rsPEbkesM,Kkivw&~ GAlIE9lW.LetterflOiaAIMbRhK hombirlil5andminimalme&alinter- venliomJAMA19%3--22a3-8. 93.skBkvmJMLFiveyearpaspg- tiveridtdlxxtkngforahonwbirthin Esrer Et r&d J 1985;291:1478&0. 79. JanssenP4Holt~MyRsSJ. 94. KlehedaG.SteenAM.~ Licensed midwife-attended. out *of- ~Tnzffers~EuemadW.Pk~~~of&~ h0!@&lbi&SiIlW&Ii@UistaBe:ate Netkhmkacluai~Iion they safe? Birh 199+21(3): 141-8. !iYzzLl t. Eur J O&tet Gynecol RqJmd B&l 199m91=. 80. CamemnJ.ChaseES.o?NeaIS. HomebitlhinSaltLakeCounty,Utah. 95. Dam-wjntenga SMI. Home Am J Public l-f&h 1979@716-7. confinement the positive resuk in f-iol- land.JRCdiGenRad1984;34:~ 8i. MehI LE Peterson GH. Shaw 30. Is. creevy DC. edhome birth. Bbth Fam d 19;k;2:12331. 96 Achrs.Harri6sE.2yzanski !XPatient&ztionandou%omesfor 82. MehlLE.PetecmGti,Whi?tM, OUI-of-m birth!3 in one htnily pat- HawswEoutconlesdelecIivehome tice. J Fam Fkt 19#,31:128-36. bitlfir:aseriesof1,146casesJRepmd Med 1977;19.281-90. 97. Woodcock HC. Read AW. MooreDJ,Sta&yFJ,&werC. planned 83. Campbell R. MacFarlane A. home binhs in Western Aumalia l%l- Placeofdelivery:aneuiew.&JObstet 198:: d descripfiw study Med .I Aust Gynad l-93:67=. 1990.153672-8. 84. Campbetl R. MacFarlane A. 98. Child A. The home birth debate. Wheretobebom?Theclebateandthe hkd J Aust 1990.153637-9. euidmm2nded~NacionalPeri- natalEpidemidogyUnit.Raddiffelnfir- W. Adamson GD. Gare IN. Home mary. 1994. or hospital births? JAMA 1980;243: 17324. 85. Ab.zrnathy TJ. LentIes DM. Plannedanclunpbnnedhomebirthsand 100. Pea= W. Home birth [editorial]. ~biIthshl~.~19&1 JAMA 1979;241:1a39-40. 87. Public l-htth Rep 1989:1011:373-7. 101. Phillipps E. finned and un- 86. Murphy JF. Dauncey M. Gmy pbnned&veriesathxne. BrMedJ OP. Chalmets L Planned and unp&nned 1984:1:1%7. &liveries at home: lmplic3tion of a 102. sakbna LR. Rivma+Ikina ME, changing ratiu Br Med J 1984.288. Arias JW. Ross PJ. Pdurmy SF. Home 1429-32. birth: negative implications derived from 87. Tew M. Place of birth and peri- a hospital-based birthing suite. Sot&~ ion. 1993. natd mortalt~. J R Cd Gen Raa 1985: Med J 19!%3;76: 170-3. 118. SwnwSH. h4tdwkyismk 3FzdO-4. 103 Trrffers PE. bn R Perinatal pmcrkeotmdiane.Y~dLauFrmi- nisll 1993Lsz315-57 88. Tyson H. Outcomes of 1001 mortality and hospiwlion at d&wery in AHOMEElRIHCURRlCUlUMGU(DE? J. K L F. Someo;thetaaasstimayaffecttheouwlcomes dhomebidls H. WhyitisimpoMnttopwsewethehomeasaberh &lee in today?s cldtufe A lisl ths @semial docmt bws. and mqu&ms nlewnttohomebblh 6 Dkcuashowtoacmscanmuniwneecbfahome bitth C. Dcseurs informed eonwnt NIX home buth and Equqrnent and SeUJp for Home Balh d4tdbe elements d an adequale Mumed Choice Agsxmeni KAl inddhg: A Lk, tie muwnum equaptnent needed for a safe 1 Rdswdbnehtsofhomebirth tmaebd 2 ziewkes and praedllles ofkred by 1. Heat awi hands and nundfulnes rturtemdwiues~~ domg home biaths 2 Ilxsm~.mlts 3 „hnsfer of care Satement for m-1 reasonr. 3 ~honeqwpment pmstmhy diffmncs. andm for breahdovm 4. hugs and medication3 of muhral trust in the relsllortship 5 t-xqcsablesupplier D Dlscuas difference ketwen matptactlce and bQ&- mdoccurrence 6 Discuss the community standards In rebhon to E Discuss malptacwe inswancr issues eaumment. soeci~yV F list what should be Included n paachce agreements How to &I lo b&h supplivs to inuwse one?s withrdeldtias capddly ot safety G k&e apprqxiate medical consultabon and How addmg techno&@ sadspls may reted amngmmm unth midwky. obstetk. wrease the risk of home bmh eah farmly pmcke dockxs. and the Impataxe of equipment bemg organmed awl readyfofafaslbinh H. kuss emergency sewices dnd QdrnW pkms Choke of a twm with uarmth and rpace thaw spedc IO local pralllcv * e.3.q~ lo emt in emergency 1 fkus~ money i*sucs in relatxmship to Howlosetupforahomebmh.consvdenng : Cd and pityrnenl expertaitons fhnbttity. conuenkuce. and smshvhy 2 Differenl accountmg and billing systems and taa~ Safe &sues. eg. univewl precautionr for all Law altmda-la 3 Pme and con5 of uping a computet systPm or setupiatepBirofbceraaons paper and pvncJ Ihspeal of contamiruted m 4 Sdo. mrship. rd group ~~8rer and Mdwdey WI.5 - A Screerung. interwwing and otienhng ptw „!hb& by liate &n&ml. ChM and Peggy &And Spmdel. CSM CbQlllS m cdbborahon wrth the Home 3uth Commlw Rev& 9 95 1 Rnlvplaythevreeningofachentla IWe. ThzS guide wds witten wth kt.u asrumptions tfirt all n- psychosocidl issues. m&cdl criteria. and ntidunfety students would be offered the o(lpurtumty fog suprnmed penonahh; match eduCaaoMi ellp&t~es wthin the home birth seitmg and t&t tip con. tent presented herem be rityrcd bs suppkmentaty to tlu know- 2 DrscussthQI rllpmceddcartysgllngchent dnd Sld5 aUped In he b2wc rnmemldwifery cufnculum. ~CifKsny andmidwiferqetta~ lW&tYOfthPCiXeCOlTlpFlPnClpS 3 Dtx~~pmsmdmnsoiconmuhfyslan~ Bonding fsues *ussmtfdfawtngisarestnf&8oAiptothe prommton of bondtng A Advan~dtsaduantages of father catching the bbv B AduantagesdhandingawannwQtbabytomothQ!r immediately C USQ d privacy for bonding D. Advantages and &advantages of passing Ihe baby tram mc+hef to n&W dnd fnonck E. When to mpatr laceratiens and where the bab,~ shcnkl be F. Thenewbomexarnandhowtousedtosupport honcbng G The impo8tance of patktnt parWpati011 m the “kr&? of rtewtmm cafe. the bathtng. the diapering. IhQdrPssing PItfalLs and hobhs in Home Biirlh Pmcke rkussinlpllcattonsof: A kfahng etuepaanr tn your cam pmtocok 1. Ma#al&nking”EvqthtngwiRbed~ghttfI don?t wony a&t a” 2 LackoflimitWtingdndnotsaymgno 3.0mgp2n~dbyihernoth&sdestrQfota home birrh 6 Failure to maintain self and equipment in uotfdng ceder 1 GemgtootirQd 2 Notnurturingyou4f.fatbngtocareforyow family and porsond & 3 Fadule to pacbcQ YEklom-rued sklk 4 Unrsvn trammg m advanced mufwky skik 5. Fiulure to have bitth bt stocked. in order. md StQlilQ 6 Fahrrptoha~~tankfukchildmrecrwem!. llldp t0 b:.” MlmQ C Ntisbwing~p L.Et-dodyo?~ 2 Amvhg late. ledvhg and nltuming. hvlng loo socmafterthebtrth 3 Notsbyhguith -dtthQhospiti 4 Beuqtm cggesmwalthQhodptalwlthruks and staff-pick w lEmfQs carptuny D fssues for the affecting mother and fardy 1 lackofp8tvx!ylnhclursandck$5afterblrth 2 Lack of postpartum care. Mold he+. ind ubbng care 3 ~thatth@~mothslmO(hRtoher uuatldeun~bQcausebDthwds “~caqrlnlthathane” J.Afeminisrperrpectiveonthestudyd Suggmed Readings KifzlngerS.H~:Ihe~ honw birth: apphcaticm d a midwifery pidetogiulngbirthoar$ldedtheIrab Abraham-Van &r Mark E. Successful cxue framewwk J Nurse Midwifery 1992. PitdNlWYOlkIDhlglfhNk+fbK., home birth and midwifey: the Dutch 37: 142-9 1991. model. Westport (CT). Bergm and Bun-ten CA. 3ones &I. Rook J. Chw Met1 LE. Peterson GH. whin M. Garvey. 1993. Cl-l. Tyler CW, Miller CA Home deltvmy HawsWEOutcomesdeDectivetwme A&msonGD.GareRI.Homeorhos- andnematalmortaktyinNorthGmlina. birth:aserksd1146cases.JRegwj pital krhs? JAM 19aik243 1732-6. JAMA 1980;244.2741-5 Med 3977;19281-90. AdHocCommttHouse of Chmmonc Cham child. Sagov SE. Fet- Fl. sphdel P, wforHwne8irth-forhomebi&.-&I- birth. London [En-d): by Dqwtment lkdSk!JA~bktka~S X . . lege of Nurse Mdwives publication d Health. &tam HMSO. 1992. glicktobkrtholl~rhehospiBL~- #413261-C%. Washington [LX): ACNM. vine MD): Aspe!n syafalq lwkl7-24, Dati-FloydRE.&thasan~n 1991 7743.151-9.161-218. rite of passage. Eddey (CAl. UMty AlbeTsL1Kat2vK.6irthsetthgh dC.dhniaPresf. 1992 schlarmwF.l3amesDE.BaLnrell lour-rirlrmncies,anandyskdthe JM.Neonatal~in~lmlfI current literature. J Nurse Midwifery. EIhM.ICebseMlNC.RdIWM, bbIk1!LVW34.AmJhbkHES&n: 1991.36:21~m3. fSekm3 Guidetoeftectiuecareinpreg- 93&5 Mncyanddrildbirth.~Urd\rersity Andersor,R,-D.Adesu@ve Rf!ss. 1995. SuEivanlM.BeerrranRFar~ aumlpisdt.xnebathanendedtyCNMs aapd?metihunebwIby- in two l-use-w SewIces J Nurse Hinds WM. Berg&n GH. Akn DT. midwiwstnAriawra.AmdF%bkk&h Midwifery 1991:36:9%103. Neonatal outcome in planned v. un- 1983;73:641-5. planned out of-hospital b&s in Ken thger MK. Lops VR. Fullerton JT. ruckii JAMA. 1485.253 1578&L Rho& MA Rotacols for gyne- TewMThes&st@acedtwhton- cet 1w.1=90. and o&smtc he& csre Phtilphla. ShahMkd5 Homebuwhomestudy W. B. !5aunckrs. 1988 l-2. pogram [special suet J Nurse Mid- W~M.PlUsU~Ihe&thllS BortinS.MM.DburdJ.Kalnw wifery 19!3540(61 chino.AU&itRkAcf~1994. . . .