500 Families Later 9

Close to 10 years and over 500 Families Later, I sit in this moment to reflect on the lessons I have learned. As is my tradition with every one hundred births, I will share my personal outcome statistics here as well. But more than that, more than numbers on a page, this past year has been powerful, challenging and transformative. I have journeyed to a new land and have grown in unexpected ways. I look forward to returning to my roots but will cherish the care given and lessons learned.

500 Families

A little over one year ago, my Midwifery path took a major new direction that I had never anticipated or expected. My roots and foundation have always been in the Community Birth setting and this is where I always thought I would stay. For 11 years, I poured my heart and soul into a free standing birth center. I started out as an RN and educator; developing and teaching the breastfeeding and newborn care classes. Then I became a CNM and made the transition from nurse to midwife. At the side of many families, I grew my ‘midwife legs’ and got my bearings. Finally, I became the Clinical Director of that birth center. And this was when, as we say, “s@#t got real”. If I thought I had been fiercely devoted to the center before, I learned a whole new depth of passion, dedication and commitment to be tapped. The birth center became my life, in parallel with my family and sometimes I am not proud to say, my family took the back burner.

This is the reality of many midwives and birth centers, this work demands everything. It is the irony of this work; we strive to ensure that pregnant folks and their families get the support, education and options that they deserve but this often means sacrificing some parts of our own families and lives. I am not complaining, I chose this path and did not do so blindly. During my 5 years as Clinical Director; the birth center outgrew our first home so we designed and built a brand new facility, we worked with other centers in our community to open and revise the 30 year old outdated regulations that govern our state, we saw our total births grow to nearly 3,000 families and we thrived. I cannot take full credit for these accomplishments as we had a fantastic team of passionate members who all worked together to provide our services.

Despite all of this, life is full of cycles and some cycles come to an end. I found myself needing to leave the home I had known, loved and nurtured. I was blessed to be offered a new home, with a new opportunity to be involved in the building of a new birth center, in an area of my state that does not have this option available. After, much soul searching and consulting with family and dear friends, I decided to take the leap. It was frightening! It also meant that I would be entering a new phase in my midwifery journey; attending births in a hospital setting while developing and building the new center.

This new phase has been powerful. I have been rocked to my core and I have grown beyond my known bounds. I have provided true and important midwifery care to a group of clients that I never would have been able to care for through the Community Birth setting. I am proud of the Midwifery I am practicing and I know without a doubt that I have empowered and positively impacted many clients. And yet, I yearn to return to my roots, to be back in the birth center and serve my community in that way. I am close, the new center is nearing completion and by this time next year we will have been up and running for months.

So, here I am 500 Families Later, on the precipice of a whole new enterprise sharing my outcome statistics with the world. My outcomes have changed to reflect my current setting and I feel vulnerable and exposed while sharing these data. I thought about whether I should share them at all and eventually came to the decision to carry on my tradition.

***DISCLAIMER: the outcome statistics that I share are my own, personal outcomes and DO NOT represent any group practice that I belong(ed) to.***

  • Births 500, labors partially managed 58 for an Intrapartum transfer rate of 10.4%. This one requires clarification, as this rate at last tally was 12.1%. My rate has not declined, I simply have not had any of these types of transfers as my practice location changed from a Community Setting to the hospital. So, the rate only dropped because my overall pool of births increased.
  • Cesarean Birth Rate is 4.6%. This is the percentage of births that I managed who then required a cesarean birth. So, these are part of the 58 births that I started out managing alone and then had to either transfer or bring in a consulting physician. This does not include scheduled cesarean births that I have attended as First Surgical Assist, as these were not labors that I managed.
  • Waterbirths 27.2% This one also requires clarification, at 401 birth this rate was 31.3%. The decline has to do with the fact that my current practice setting does not offer waterbirth.
  • The youngest pregnant person I have attended was 15 years old and the oldest was 45.
  • Baby Sexes Assigned at Birth: Boys 49.1% and Girls 50.9%. The biggest baby that I have caught weighed 10# 10oz. and the smallest weighed 5# 3oz.
  • Group Beta Strep Positive 17.9%
  • Artifical Rupture of Membranes (AROM) 13.4%. This rate has increased from 9%, I think this has to do with the fact that working in the hospital setting means that I care for more moderate-risk clients who require IOL (Induction of Labor) for various medical reasons. Part of the IOL process often includes AROM. Whenever, I plan IOL’s it is after clear and thorough Informed Consent with the family and for reasons such as Gestational Hypertension, PreEclampsia and Cholestasis.
  • Meconium stained fluid 11.3% of births.
  • Position for birth: Hands and Knees 36.4%, Semi-reclining 22.5%, Birth Stool 12.7%, McRoberts 10.2%, Side Lying 7.7%, Squatting 6.6%, Standing 3.2% and Semi-fowler 0.7%
  • Perineal Outcomes: Intact and/or not requiring repair 41%, 1st degree 18.9%, 2nd degree 27.3%, 3rd degree 2.7%, 4th degree 0.7%, labial and peri-urethral 7.3%, and an episiotomy rate of 2.1%
  • Postpartum Hemorrhage (PPH) 5%. If you have read my other posts sharing my outcomes, you will know that this is sticky one for me. I have long argued that the 500cc marker for PPH after vaginal births is inappropriate. That we should look at the hemodynamic response of the individual and take into account the increased blood volume at the end of a term pregnancy. Recently, the American College of Obstetricians and Gynecologists (ACOG) and several other major organizations, have been re-thinking the strict 500cc definition and are now looking at a blood loss of “greater than or equal to 1,000ml or blood loss with symptoms of hypovolemia” Taking into account these new definitions, my rate of blood loss over 1,000ml is 5%. In my previous outcome posts, I had included all blood loss over 500ml, this is what accounts for the apparent drop in my PPH rate. It is essentially the same as my rate of loss of 1,000 or higher has remained relatively consistent.
  • Shoulder Dystocia 6.4% This is another outcome that has been a personal sticky wicket of mine. Various sources report the rates of this complication as 0.5-9% depending on fetal weight. I have spent a lot of time looking at my rates and attempting to understand my high rate. Early in my career, I believe that I was too quick to label a shoulder dystocia. I have become more particular about what I consider a shoulder dystocia; now I apply this label if intervention required more than one simple position change and/or internal maneuvers. I made a choice long ago to not “go back” and change my statistics. The vast majority of my shoulder dystocias have lasted under two minutes. My two outliers were 5 and 7 minutes. All of these babies did well, the 7 minute dystocia babe was transferred to the NICU but was discharged home within 48 hours with no major sequelae.
  • Retained Placenta 1.8% At the birth center, based on the state regulations, a placenta was considered retained if it had not been delivered within 30 minutes of the birth. By the way, this is one of the issues that was addressed and changed when we opened and re-wrote our state regulations.
  • Manual Removal of Placenta 1.1% (6) These have all been done in response to heavy maternal bleeding in the third stage of labor before the delivery of the placenta.
  • Umbilical Cord Avulsion 1.2%  This happens when the cord “snaps” either at the placental site or in the length of the cord. Only one of these instances caused any potential harm to the baby; this baby was transferred to the NICU for observation but was later released in good health. Additionally, I have had two true knots in umbilical cords, both of which did not cause any concerns for the baby in labor.
  • Babies Born En Caul 3%  These are sweet little ones that are born in their amniotic membranes. You can read more of my thoughts about this here .
  • NICU Transfers. My over all NICU transfer rate is 2.5% of babies, the vast majority of these are due to Transient Tachypnea of the Newborn (TTN), there have been a few babies born with undiagnosed anomalies (imperforate anus and cleft palate for example), followed by one after a 7 minute shoulder dystocia, one after a cord avulsion, one pneumothorax. All of these babies have recovered well and are thriving today.
  • Apgars. For the 1 minute Apgar, 86.5% have been 7 or above. With 48.9% of them being 8. For the 5 minute Apgar, 98.7% have been 7 or above. With 81.2% of them being 9. For the majority of my births, I have practiced at a free standing birth center, so the women admitted in labor were full term and without major health complications. My numbers reflect this population.

And now, let the games begin! In the past when I have shared these data it has led to some lively discussion, I look forward to the same this time.

Image Credit Monet Nicole

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9 thoughts on “500 Families Later

  • Corie Parada

    I love that you are willing to share your personal statistics and explain your outcomes! Your transparency speaks volumes about your character. Your dedication to keeping such complete records of your outcomes is not just a testament to the kind of care you provide but also highlights the difference between midwifery care and obstetrics. I don’t know any OB’s that keep records like this. Thank you for all you do! You are an inspiration to me and all of the other baby midwives finding our own paths!

    • aubrekate Post author

      Thank you. I believe strongly about maintaining statistics, it is the only way to be truly objective and assess our practices.

  • Michelle Van Bogart

    When Midwives share their statistics, who is the intended audience? Is the purpose for peer review or for clients looking for stats on potential Midwives? I’m just curious b/c if it’s the latter, I would probably need to know your stats compared with averages. Just coming from someone who has NO clue what would be considered normal. Either way, this is SUCH a great thing to do, to invite eyeballs on work that is so personal and cherished sounds scary, but ultimately a great way to improve practice. Cheers!

    • aubrekate Post author

      Good question! I think the intended audience is potential clients and other folks in the birth world; midwives, doulas, physicians. Sadly, most providers do not keep or share statistics, so I also have an ulterior motive of trying to encourage others to do this. It is very humbling and feels vulnerable to put these data out there, but I feel strongly about it. An example for you; the current national average for cesarean birth is at 32% compared to my 4.6%

  • Susan

    APGAR scores? NICU admissions? Average length of shoulder dystocia times? There is no mention here of your neonatal/peripartum morbidity and mortality outcomes.

    • aubrekate Post author

      Excellent questions, thank you. In my sharing all my previous outcomes I have included this information and for some reason I forget them this time. I have just edited my post to include them, please check them out.

  • Vladimira Ilieva

    I believe you can do so much, much better. For example your tearing rate is atrocious per Ina May Gaskin’s work. And so forth…There is so much free education by Ina May Gaskin on YouTube, which could be helpful for you.

    • aubrekate Post author

      I am sorry for the delay in posting and responding to your comment. My first, human response, was to not post it publicly. But then I thought about it and decided to share it. In opening up to publicly share these outcomes, I must accept that there will be harsh words like “atrocious”, I made the choice to put this out there so I will respond. Your observations threw me off a bit as over the years, my perineal outcomes are not what have been criticized so I didn’t see this one coming. Most providers do not share these data publicly and the ones who do rarely share perineal laceration rates, or only share third and fourth degree rates. I have shared them all to give a broader picture.
      I have several thoughts. First, there is a midwifery saying, “your ego does not belong in the perinuem” and I find this to be so true. The longer I practice, the more I realize that so much of the perineal outcomes have nothing to do with me, they are more influenced by the laboring persons tissue integrity, nutrition status and genetics. I offer midwifery care; maternal directed pushing, upright and side lying birth positions, guided gentle pushing through crowning…and still lacerations will happen. I have had births of over 9 pound babies in direct OP position that required some extra help with the shoulders who have had no lacerations. I have had births of sweet 7 pound babies in perfect OA position in the water with with a fourth degree laceration. So much of this work is out of our “control”. I am very familiar with the work of Ina May Gaskin, I have actually had in person conversations with her about this exact topic. The statistics from The Farm and the midwives she worked with represent a very specific client population that in many cases in not representative of a more main stream group and are not applicable to the broader population.
      If you are a midwife or a midwifery student, I hope that you have a strong and positive journey on this path. Blessings.