Nearly ten years ago, my husband and I birthed our third child, Lyric Bram, in our own home. My husband and I were well familiar with the risks associated with modern medicine and hospital birth after my having worked in this environment throughout my ten year nursing career. The midwifery-model-of-care made a great deal of sense to both of us, and homebirth felt very appropriate and comparable to the level of care delivered within the maternity units of remote hospitals. I dove into every book and article I could find on the subject, worked alongside homebirth midwives in three states, joined in conversations on listservs and attended national midwifery conferences. My husband flew across country, right alongside me to Portland, Oregon and even Ontario, Canada to gather information to better understand this growing passion. I enrolled in the Frontier Midwifery & Family Nursing program and was well on my way to becoming a homebirth midwife. Sadly, our son died following our homebirth, midway through my midwifery program, and the Lord revealed a great deal to us in that journey which would prepare us for the work we continue still today. Our practice, Believe Midwifery Services, LLC is our effort to embrace all that is good and honorable about birthing at home, while also working to improve the standards for homebirth practice.
In 2007, I worked diligently to open my own private practice, again scouring journals and listservs for any bit of guidance I could acquire. With the ACNM Home Birth Practice Handbook in hand, as well as my business plan from graduate studies, I stepped out in faith. I’ll admit to being an eternal optimist, but even this didn’t prepare me for all the intricacies of opening my own practice, particularly within a discipline that is considered “fringe,” or even “rogue.” I struggled with the basics, such as how I would translate what I understood about sterilization of birth instruments from the hospital to my now homebirth practice. Many midwives shared advice of boiling instruments in water and then hanging them to dry or placing them in cloth pouches, yet neither of these methods maintained sterility beyond the boiling water. Disconcerted with the advice I had received thus far, I began to experiment on my own. After purchasing indicator strips, pouches, tapes, and wraps, I quickly learned which products could not withstand the heating point for proper sterilization, and perfected the thickness of my instrument packages so that even the core of each package proved sterile after baking. I created lists of supplies by navigating my way through various homebirth websites and browsing the birthing rooms of the hospital I had previously worked, considering how I might manage obstetrical emergencies in the home environment. Midwives with whom I had worked, or had communicated, shared their own strategies, and a few were so gracious as to allow me to visit and peruse their supplies and equipment (thanks Lynn McDonald CNM). The examples ranged from a single backpack of loose, and fairly random items, to an extensive inventory of very organized material. It was quickly apparent that homebirth practices ranged greatly in their organization and extension of care.
As I gathered my plans and organized my efforts, I sought to identify those organizations and boards with which I was required to register and report my practice development. I anticipated review and regulation beyond my own midwifery credential, but rather specific to the practice itself, similar to the efforts of the Joint Commission or the Board of Health. As I could determine, none were required, as no one recognized the home birth-based attendant as a credible member of the healthcare infrastructure. While this offers some advantage, I was quickly learning this also limits resources for identifying the minimum standard of care. What might I be forgetting? Frequently, I was turning outside my profession to sources specific to establishing a practice as an herbalist or a massage therapist, or even a chiropractor. I hadn’t any awareness that I would require an NPI number, a CLIA waiver, a tax identification number, sign permits, have to comply with specific fire codes, and to my sincere regret, I delayed establishing a relationship with an accountant and attorney until crisis demanded.
Within months of my initial efforts, ACOG released their May 2007 statement on homebirth, acknowledging for the first time the safety of birth in out-of-hospital birth centers that meet standards of relevant accreditation organizations. It was then that I asked, why doesn’t an organization similar to this exist for homebirth practices? The standards for my own practice has always been to meet or exceed the standards of care for the level one facility. However, without accreditation, there would be no way for an organization such as ACOG, or even my area consultants and hospital organizations to recognize the high level of care we are capable of extending within our practice. I even opened my practice with hopes of becoming Baby-Friendly certified and was told by the certifying body that only hospitals and birth centers were eligible.
That same year I organized a peer review of fellow midwives, yet quickly learned that there is little sincerity among competing midwives. I was increasingly feeling isolated and yearning for a peer group to challenge and inspire me. Turning my attention to further development of my practice, I sought out hospital privileges at a local tertiary center and wrote a plethora of practice documents, including: informed consents, clinical practice guidelines, educational handouts, and clinical forms for documenting the delivery of clinical care. These developed largely from my ten years of experience in both hospital and birth center environments, as templates for home birth-based care were largely unavailable. MANA offered a limited few, but I did not feel they addressed all the primary care components I wanted to ascertain from my consultations, nor did they allow for the more complex clinical skill set of the nurse-midwife. It seemed too often I was learning the hard way, and as importantly, I felt I was accumulating a tremendous amount of knowledge that should be documented and shared with fellow midwives who also had vision for establishing their own independent practices.
During my second year of practice, Cindi Denbow MSN, CNM a great midwifery sister of mine from graduate school, shared that she intended to open her own homebirth practice in Niceville, Florida. I invited her to join me in Central Indiana to gather ideas, and she took me up on the opportunity. It was during this visit that I became convinced that an accreditation body would not only benefit the consumer, but was vital for supporting the practitioner. Cindi gathered ideas, copied my documents, edited and added to my resources, created a database of my supplies and equipment, enhanced my electronic communications, organized my billing and insurance claims, and most importantly, helped me to establish boundaries. Although I didn’t know it at the time, these two weeks were the saving grace my practice required. Since that time, we have continued to visit each other at least annually, continuing to gather ideas, offer constructive criticism, train each other’s staff, inspire each other to improve and enhance our services, and also to encourage each other in the work that we both sacrifice ourselves for daily. I imagined sharing this mentorship with non-competing, but equally driven midwives throughout the country.
Homebirth is growing increasingly popular and subsequently, is being placed under the very watchful eye of our adversaries, including legislative bodies. Our culture expects a level of accountability and trusts the accreditation process. We witnessed the successful integration of birth centers through the efforts of the American Association of Birth Centers. A homebirth accreditation body could provide a plethora of resources for both the business owner and the clinician practicing within the home environment. It could also guide legislative leaders, or more importantly, extend them the confidence to back out of this arena and let the experts manage this practice setting.
Research specific to homebirth is currently inundated with methodological challenges, which accreditation could work to address. Neonatal outcomes for example, could be evaluated within the variables specific to an accredited homebirth practice. A body of experts could be identified and corralled for counsel on a plethora of concerns within the discipline. As an expert witness myself, I’ve questioned while working on legal cases within the community, who would be my peer support if I were to face some sort of persecution within my practice by an unfamiliar or hostile adversary? Having an accreditation body available that could work to educate consumers and professional groups, as well as extend advocacy efforts and provide expert witness is a tremendous comfort. The accreditation body could foster excellence in homebirth practice and using current literature, develop evidence-based recommendations.
Certainly there are opponents of this vision who argue that accreditation will work to oppress midwifery. While I prefer to think of creative strategies and again, am an eternal optimistic, it may be that there is no organizational plan that will satisfy every side of the argument; however, accreditation is voluntary. Public policy via state statute is not, and that is the direction our legislative bodies will take if we do not assume responsibility and provide some form of assurance for those who view homebirth as unruly and rogue.
It has also been argued that homebirth midwives with small practices struggle to even pay for supplies and equipment and therefore could not afford accreditation and would be left out of this movement. My question is, if the practice struggles to provide the basic safety precautions, can they extend a safe level of care? If the practice is not capable of paying wages for support staff, should they extend services to the public? Isn’t this the essence of accreditation, the identification of those practice that can extend a minimum level of safety?
A common thread I hear from those who have shared in support of this vision, is the desire to be recognized for the high level of care that is extended within their own practices. They want to be counted among the best of maternity providers no matter their practice setting! This doesn’t mean there are bad homebirth attendants, but accreditation outlines a minimum standard for the consumer, the potential collaborator, and even third party payers. It allows the community to become familiar with the level of care capable in the home setting.
Accreditation of healthcare entities was introduced in the 1970s, and has since spread across the world and become thoroughly implemented into our healthcare system (Greenfield & Braithwaite, 2009). Our culture depends on this process as an important driver for improving quality and safety in healthcare organizations. Accreditation allows for transparency and drives innovation within individual practice settings.
The Joint Commission was founded in 1951 and seeks to continuously improve health care for the public by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. The history of the Joint Commission can be read here.
The Commission for the Accreditation of Birth Centers (CABC) was established in 1985, after the American Association of Birth Centers (AABC) had evaluated the quality of birth centers, encouraged national guideline development, reviewed state regulations, and explored and evaluated programs of other accrediting agencies. The group developed the first set of national standards for birth centers, conducted a two-year pilot program to develop and test the optimum mechanism for evaluating the quality of birth centers, and consulted with the Commissioner on the JACHO (currently the Joint Commission) on the best structures for the CABC (www.birthcenteraccreditation.org/about-commission-accreditation-birth-centers, 2013).
On January 1st, 2002, the CABC incorporated as a separate 501c3 and today, the process of accreditation is continually reviewed and revised to assure that the program continues to “meet the standards of applicant centers,” provides “for the highest level of quality improvement,” and evaluates “the criteria for accreditation based on the best available evidence for maternity care” (www.birthcenteraccreditation.org/about-commission-accreditation-birth-centers, 2013). The CABC is a combination of diverse healthcare professionals and birth center consumers. They work to establish and evaluate birth centers based on compliance with the CABC Indicators.
It has been suggested that the CABC assume the responsibility of accrediting homebirth practices, as many birth center practices already have both a birth center and home birth presence. CABC has the infrastructure in place for accreditation, and stakeholder investment. For many reasons, this can be argued as a wise approach. However, a few important considerations must not be ignored. First, practices with both birth center and home birth clientele typically have a larger budget with which to draw for assuming the cost of accreditation, than those practices that serve homebirth exclusively. A new fee structure would need to be considered. Second, restrictions on practice that the current CABC indicators have implemented such as the exclusion of breech and multiples, has driven many birth centers to incorporate homebirth into their practice model so they can extend care to these clients outside the birth center setting. Third, while there are a number of similarities in birth center and homebirth practice settings, there are distinct differences that would require a body of experts specific to this practice setting for evaluating the evidence, establishing recommendations and implementation of standards, consulting on public policy matters and providing peer support and review.
Regulation of Practice
Dr. Elizabeth Cook CNM, CPM with co-authors, Melissa Avery CNM, PhD and Melissa Frisvold CNM, PhD published an article in the Journal of Midwifery & Women’s Health last month (March, 2014), titled Formulating Evidence-Based Guidelines for Certified Nurse-Midwives and Certified Midwives Attending Home Births. The intent was to seek commentary from fifteen certified nurse-midwives/certified midwives on drafted practice guidelines created by the authors specifically for the homebirth setting. Their findings were that not only did those reviewing the guidelines have a difference of opinion on whether the recommendations reflected international standards and current best evidence, but there was concern that the adoption of national guidelines would compromise provider autonomy.
The American College of Nurse-Midwives (ACNM) calls for the utilization of written practice guidelines within each practice setting, as part of the Standards for the Practice of Midwifery. However the college does not make blanket recommendations across the profession, for all midwives, in all settings, assuming that each and every midwife should practice identically. It is recognized that nurse-midwives are highly trained, expert clinicians and bring with them a background that may include expertise beyond the core practice of midwifery. The college offers an avenue for identifying such expertise so that nurse-midwives can appropriately integrate innovative skills which work to advance the profession of midwifery. The issue comes in midwives implementing advanced skill sets without evidence of advanced training and expertise. Blanket practice standards also ignores the unique nature of each community of support. The same midwife for example, would alter her clinical practice guidelines independent of her own expertise, when relocating to a new practice setting or community to reflect the collaborative infrastructure and standard of care specific to her new environment.
The accreditation of individual homebirth practices would not require establishing a universal standard, but instead identify those practices which have developed thorough written documentation of the parameters of service for independent and collaborative midwifery management, and those who have not. It would identify those practices that have made the concerted effort to seek out advanced training and expertise, if such skills are extended within their practice and those who might be under-prepared. It would however, develop a minimum standard of care that should be extended, without limiting advanced expertise.
An Interview with Dr. Susan Stapleton, President of CABC
The idea of homebirth practice accreditation has culminated in me for the past ten years. Initially, this was a discussion that sparked great hostility among homebirth midwives, but as my career has advanced, so has my network. More recently I am finding not only significant support, but more adamant demands to bring this vision to fruition. I have tossed the idea around very informally with various experts, including Dr. Kathryn Osborn CNM, Dr. Janet Engstrom CNM, Dr. Rebecca Barroso CNM, Dr. Linda Cole CNM, and Dr. Susan Stone CNM. Each have been very intrigued and shared a similar response, “It never occurred to me to extend accreditation to homebirth practices, but this makes perfect sense.” Dr. Stone, CNM, president of the Frontier Nursing University, challenged me during my dissertation to put this vision into action, and shared that because the Frontier Nursing University highly values accreditation for their clinical sites, it has challenged their ability to utilize homebirth practices for student experiences.
Dr. Linda Cole CNM, previous president of the American Association of Birth Centers, encouraged me to speak with Dr. Stapleton who is the current president of the CABC, and was gracious enough to coordinate this connection for me. I had approached this discussion with hopes of better understanding the history of AABC and how that might be applied to a homebirth accreditation body, or if it would even be appropriate, but instead, was surprised to learn that not only has Dr. Stapleton marinated this idea for many years as well, but she is increasingly eager to gain stakeholder support.
Dr. Stapleton was very giving of her time and shared great insight into the structure, purpose and role of an accreditation body, and how it might or might not coordinate efforts with birth center organizations and various midwifery organizations. I was encouraged by her arguments for this movement, and was grateful that our ideas resonated so perfectly, as my attempts to think through this idea with homebirth midwives in previous years proved to be a catastrophically failure. We were like-minded and at this point, needed to roll forward with engaging others in the conversation. Dr. Stapleton suggested that I meet next with the Executive Director of the Commission for the Accreditation of Birth Centers, Rosemary Senjem, as she is coordinating initial steps with a familiar university with similar vision.
Dr. Stapleton and I had a very delightful conversation and true to all those with whom I genuinely adore, she challenged me to deepen my understanding on one particular point: the appropriateness of homebirth attendants in extending vaginal breech birth services. Vaginal breech birth is prohibited by those who work within an accredited birth center. Dr. Stapleton shared that it would be the role of the homebirth accreditation board to determine the appropriateness of care for that setting, but vaginal breech birth was not supported by the birth center accreditation body.
She asked me to consider the recently published MANA stats, although admittedly she hadn’t read them herself yet. It was her understanding however, that these outcomes supported the restriction of attending vaginal breech birth outside the hospital setting. Her opinion is common to those that have a voice about out-of-hospital birth, and certainly those that seek to regulate its practice. I think too, this sort of argument is exactly why homebirth midwives refuse to even engage in the conversation of homebirth accreditation because they are not willing to be told what they can and cannot do. After all, we are expert clinicians and are insulted by the idea of being held to a different standard than our hospital-based sisters.
My argument is this… First, we haven’t any knowledge of whether the attendants who shared their outcomes with MANA were trained in attending the vaginal breech birth, or if whether they evaluated their client as appropriate for vaginal birth. Certainly, there may even have been midwifery students among those catching breech babies, as was true of the Hannah 2000 study, or even neonates with fatal-anomalies which occurs with increased incidence with breech presentation, elevating poor outcomes for vaginal breech birth.
Rationalizing the restriction on vaginal breech birth for accreditation because of studies similar to this, encourages rogue midwifery and prevents highly trained attendants from continuing to offer safe care to childbearing families. Most importantly, this restriction eliminates the ability of the provider to offer high quality informed consent with extensive candidacy evaluation. Instead, providers and couples in their care are motivated to ignore indications of breech presentation prenatally and skip obtaining consultations for external versions or ultrasounds, because these would confirm knowledge beforehand. Rather, the attendant would be inclined to overlook indicators so she can innocently claim she was simply managing a surprise breech. The completely oblivious client however, may be denied opportunities for optimizing outcomes and even basic informed consent. Restrictions such as these do not advance the cause of midwifery, and more importantly, they fail to extend the highest and most credible level of care to those with whom we are entrusted to care.
Second, hospital-based midwives do not have a universal mandate that prevents them from attending vaginal breech births. Intown Midwifery, in Atlanta, Georgia, is perfect example. These nurse-midwives have developed a reputation for offering a high standard of care with excellent outcomes for vaginal breech birth. The difference however, is that this practice works within an environment that offers peer regulation, which solo homebirth practitioners often do not. Hospital boards can either support innovative models or not, but typically this occurs within an infrastructure of a diverse team evaluating current evidence, ethics, legal, and risk management. Rather than outright eliminate any option for advanced midwifery skills in the homebirth setting, it would be my proposal that the homebirth accreditation body would offer the infrastructure for evaluating whether individual practices have established certain criteria for extending advanced skill sets, while also offering a minimum standard of care.
What a Homebirth Accreditation Body is Not
Homebirth accreditation is specific to the practice, not the individual midwife. Individual state boards of nursing, midwifery, or medicine regulate the practice of midwifery. Accreditation would assure that attendants are actively licensed within their respective state and that support staff receive appropriate training, but regulation of individual clinicians is not the purpose of an accreditation body. It would most likely be that a report of negligence or malpractice regarding an individual provider would be referred to the individual’s regulating body, and a subsequent site visit would be conducted in effort to determine if such site continues to operate within the guidelines of accreditation.
There have been opponents to homebirth accreditation share that if nothing else, this model might help to regulate meritless complaints against individual midwives by authorities unfamiliar with homebirth. It is true that complaints might be directed to the accreditation body where education could be provided encouraging the resolution of frivolous pursuits, but regulation of individual practitioners is a matter of jurisdiction and not a role accreditation bodies would partake. It could be reasoned that similar to the increased credibility gained by the establishment of CABC for birth centers, an accreditation body for homebirth practices would also increase acceptance for homebirth-based providers. It is nothing short of miraculous that ACOG recognized in their policy on homebirth (2007) the safe infrastructure of care extended by accredited birth centers within a single decade of the establishment of the National Association of Childbearing Centers (now AABC).
We are all familiar with extended home care centers, particularly for the elderly, or even restaurants and hair salons that are shut down after site inspections, often following consumer complaint. In fact, there are a number of birth centers that have substandard outcomes, and fail to meet accreditation standards. Accreditation bodies typically do offer a mode for reporting. As much as anyone of us hate to admit, there are practices that work outside any facet of safety, and the public does have the right to be protected from these entities.
Homebirth accreditation would not be a rigorous standard of care that all providers must comply, as the care delivery is specific to the setting, not the practitioner. Clinicians would be expected to adhere to their professional body’s practice standards, and remain responsible and accountable to their individual state regulations. The professional body for nurse-midwives and certified midwives (ACNM) allows for expanding one’s practice beyond the core competencies to incorporate additional skills and procedures that improve care for women and their families. ACNM values practitioner autonomy and consumer rights. This is not contrary to safe guidelines and the accreditation process.
Stay tuned for my post in which I offer a proposed vision, mission, purpose and goals for the homebirth accreditation body. However, my current goal is to gather thoughts on advantages and disadvantages of this vision, so please share your thoughts in the comments section below!
Cook, E., Avery, M., Frisvold, M. (2014). Formulating evidence-based guidelines for certified nurse-midwives and certified midwives attending home births. Journal of Midwifery & Women’s Health, 59(2), 153-159.
Greenfield, D. & Braithwaite, J. (2009). Developing the evidence base for accreditation of healthcare organisations: a call for transparency and innovation. Qual Saf Health Care, 18, 162-163. doi: 10.1136/qshc.2009.032359
Indiana Perinatal Network. (2008). Levels of hospital perinatal care in Indiana. Retrieved from the Indiana Section of ACOG and AAP, Indiana Chapter