2016 was a year of huge growth for Salmonberry Birth Center, our midwives and all the families we cared for. It was by far our fastest year of growth and that growth brought huge joys and some challenges to all of us. As we move into 2017 we’re thrilled to present our annual statistics review, but first a couple of news items!
We can report that in the coming months we will complete the merger between Gumnut Blossom Midwifery, LLC (our homebirth practice) and Salmonberry Birth Center. Shortly there will just be Salmonberry Midwives and the same group of midwives Louisa Wales, LM CPM, Melanie Brindle, LM, CPM, Julie Bennett, LM, RN and Holly Campbell LM, CPM will continue providing both home and birth center services out of the birth center in Poulsbo. Holly graduated from Bastyr University in 2014 and brings with her a background in child and family mental health counseling. She will be the third midwife attending births in the call rotation.
In order to meet demand from neighboring counties we have offered privileges to the wonderful Peninsula Midwives (Kathy Luch, LM, CPM and Maya Horrocks LM, CPM) in Port Townsend. This will allow families in Jefferson and Clallam counties desiring birth center care to have their prenatal and postpartum care on that side of the bridge and then come to Salmonberry to have their babies. We’re excited to be able to expand our community of providers and thus our reach to more families in surrounding communities.
As proud members of the Midwives Association of Washington State (MAWS) our practice contributes prospective data to both the Midwives Alliance of North America (MANA) dataset but also to the Foundation for Healthcare Quality OBCOAP data project which compares MAWS member data with the maternal child health outcomes of several large hospital systems in the state too. We can now say that we can hold our outcomes up to our hospital colleagues for comparison and to continue to work towards the very best health outcomes for pregnant and birthing families. While this data has yet to be published, we’re encouraged by early results which indicate that Washington licensed midwives lead the nation in community based birth outcomes.
In 2016 our practice almost doubled in size again from 2016. We cared for 146 families with a roughly 3:1 birth center/home birth split. Of those 146 families, 18 sadly suffered early pregnancy loss, or miscarriage. Their courses of care while short are still important to us, and underscore for us the importance of having ready access to a care provider in the very earliest weeks of pregnancy when these losses are more common. We’re fortunate to have a growing network of family medicine and OB physicians who we can liaise with to ensure our clients are taken care of sensitively during a really emotional and sad time. Helping families when they experience miscarriage is work which is close to our hearts.
Perhaps our single biggest responsibility in caring for our clients is to ensure to the best of our ability that they are appropriate for low risk care in community settings (at home or birth center, rather than in the hospital). This is a process which unfolds from the very first conversations with our clients and doesn’t end until they graduate from our care at their 6 week postpartum appointment. There are lots of really good reasons why a hospital birth might be the safest choice for a pregnant person or their baby given the complete picture. Sometimes there are clear medical indications, sometimes there are emotional or social factors, and sometimes clients and their families change their minds. A huge part of our work is helping people get to where they need to be based upon all the factors, and it’s always our goal to ensure that when a transfer to higher level care happens, at any stage of pregnancy, labor or postpartum that it happens, as smoothly and with as little disruption to the birthing person and their family as possible.
In 2016 an additional 33 clients left our care during pregnancy (before the onset of labor). Two thirds (22) of those were for medical reasons (complications of pregnancy such as pre-eclampsia, multiple pregnancies, fetal abnormalities or uncontrolled gestational diabetes) and 11 families chose to leave our care for non-medical reasons (insurance problems, preference for another provider, moved during pregnancy). We are fortunate to have many great providers in our extended community here in Washington, and if we aren’t the best provider for a client, we will do all we can to help them locate one. We consider this one of our strengths as a practice of prudent, careful, collaborative providers.
The demographics of our clients are shifting slowly as we attempt to serve more families in our community. In 2016 our clients average age was 29, 39% of our clients were having their first baby, and 56% were having their second or subsequent child. 78% of them are college educated, 40% of them are on, or are eligible for Medicaid. 18.2% of our clients identify as non-white (African America, Native American or Alaskan, Pacific Islander, Asian). This is a significant change from our 97% white client population in 2015. Interestingly the preponderance of male babies continues with a 64%/36% split of boys to girls. Our average baby weight increased slightly to 8lbs 2oz in 2016.
Our health outcomes statistics in 2016 continue to be strong. As we had hoped, the introduction of doulas and childbirth education for our first time (nulliparous) birthing clients dramatically lowered our non-emergent intrapartum (during labor) transfer rate. in 2015 we reported that fully 100% of our first time clients who clients who did not have a doula or comprehensive, independent childbirth education required transfer to hospital for pharmaceutical pain relief and/or other interventions, and only 14.2% of first time clients with either a doula or childbirth education, gave birth where they planned to (that’s an 85% transfer rate!). In 2016 we introduced our Doula and CBE requirement. The transfer rate for nulliparous clients fell to 28%. This massive shift reinforces for us that these tools are profoundly important ones. We’re grateful to the community doulas and childbirth educators Jennifer Watson, Kerry Allen, Angie Hotz, Kristina Kruzan who’s classes and labor support have been so integral to our client’s successes this year.
2016 saw our practice record its lowest primary cesarean section rate ever. All the clients who entered labor in our care enjoyed a 96.3% vaginal birth rate. As is usually the case the cesarean section rate was somewhat higher (7%) for people having their first baby, but still very low. Cesarean is an important tool for clients who need it, and we try incredibly hard to ensure that our cesarean births are sweet, loving births too and we're grateful that we have skilled hospital partners who help us with these. Interestingly fewer people delivered their babies in water this year than last. 30% of clients delivered their babies in the water either at home or in the birth center, down from 40% in 2015.
Non-urgent intrapartum (during labor) transfer rates in the aggregate this year were also significantly lower than last year, shifting to 17%. We attribute this in large part to the birth center facility itself. It’s been fascinating to watch the ways in which our clients chose their intended site of birth. Many nulliparous clients gravitate strongly towards the birth center, over home, despite the identical providers and resources available in both settings. This is likely because there’s still a powerful narrative in our culture that one must go somewhere to have a baby. We care for some clients who would absolutely never consider home birth, but who achieve beautiful, un-medicated births with little or no intervention at the birth center. Similarly, those who chose homebirth are doing so deliberately, not because they want midwifery care and can’t find it anywhere else. And again, the interventions of doula support and excellent birth preparation are key in their success at birthing where they plan to. These non-urgent transfers were usually due to labor irregularities, presence of meconium stained amniotic fluid, or need for additional labor monitoring not available at the birth center. The vast majority of those clients went on to give birth vaginally (78.6% vaginal birth rate after transfer).
The rise in risk of cesarean birth from our background rate of around 3-7% depending on the year to around 20% after transfer to hospital is largely attributable to the fact that if the labor winds up in hospital it’s already not unfolding normally and there are additional tools needed to help baby be born. So, in other words, if a healthy, normal pregnancy results in a straightforward, uncomplicated labor, the risk of cesarean in our practice is very low. If the labor is complicated in any way, for example labor progress, fetal tolerance of labor, meconium stained fluid, hypertension, the risk of cesarean birth - and other complications- increase (both good reasons to consider a change of venue, and a hospital birth).
Urgent (ambulance) transfer rates continue to hover around 3% for intrapartum (usually due to fetal heart rate irregularities) and postpartum and around 1% for neonates (usually for breathing issues after birth).
Complications occasionally arise at the birth center and are managed there or stabilized prior to transfer if transfer is necessary. The most common complication we manage is hemorrhage (greater than normal blood loss). This is managed with most of the same tools used for this in the hospital and the majority are handled without incident at home or the birth center. Shoulder dystocia is another feared complication which also happens occasionally and our rate of this in the last year is only slightly higher (3.5%) than the incidence generally reported in the medical literature (2-3%). This might be because average baby weights in midwifery care are slightly bigger on average than hospital based populations. We’ve been fortunate to have helped those few babies out without incident and are happy to report that all of them have done well despite their sticky beginnings.
This year we helped two of our stellar student midwives complete their clinical training. Lauren Collins (Bastyr University Class of 2016) managed to do this while gestating and birthing her own sweet baby (at home!). She returns to her home state of Alabama to begin practice there. Michigan transplant Morgan Hughes also graduated at the end of 2016 from Midwives College of Utah. We’re delighted that she’s staying on in Kitsap county and will launch her own home birth practice in the community once she’s licensed. It’s been an honor and privilege to watch these two midwives grow into competent, confident providers. This year we have Emily Joy Tyde (Bastyr University Class of 2017) completing her training with us and shortly we will be joined by Tamara Trinidad-Gonzalez (Bastyr University Class of 2018). We’re excited to be working with them and value deeply their contributions to our practice and the community.
Gratitude also for our local EMS crews at Poulsbo Fire and Rescue who have been so great to work with in our first year at Salmonberry. We’ve enjoyed our budding relationships with the on-call Laborist physicians and nursing staff at Harrison Medical Center, Silverdale and as always our physician and nursing friends and colleagues at Jefferson Healthcare Hospital in Port Townsend. We enjoyed visits this year from OB physicians from both county OB practices: Kitsap OB GYN and The Doctors Clinic, Family Medicine teams from Northwest Family Medicine, as well as the OB and Nurse Midwifery teams from Multicare Gig Harbor, Tacoma General and CHI St Joseph’s Hospital. We are always grateful for the pediatric and family medicine physicians in our community who assume care for our Salmonberry babies when they leave our care. Special mention of Dr. Jonathan Mendelsohn (The Drs Clinic), Dr. Niran Al Agba (Silverdale Pediatrics), and the physicians at Sound Family Health, Pacifica Wellness and Bainbridge Pediatrics. We’re grateful for your care of our mutual clients and willingness to collaborate with us in our shared vision for the best maternal child health outcomes possible.
Thanks to our midwives and staff, our spouses and children for enduring our absences and for our delightful clients who share their families and their experiences of their most precious journeys with us. It is always an honor and a privilege. Let’s see what miracles 2017 has in store for us all!