sound practice in action
Posted by Shannon Palmer on June 17, 2015 12:06 AM
Imagine a family anxiously anticipating the birth of their child. Mom gives birth to a healthy baby girl in a hospital in Michigan. Michigan is a state that has implemented universal newborn hearing screening. The baby’s hearing is screened and they are immediately referred to an audiologist. Hearing tests reveal that the baby has a permanent hearing loss. The baby is fit with hearing aids and the family is enrolled in an early intervention program to help the baby learn to listen, understand and use spoken language.
For many parents of children born with hearing loss, this is a common scenario due to the ability to identify children with hearing loss at a young age that is made possible by universal newborn hearing screening.
According to the Joint Committee on Infant Hearing (2007), when a baby with permanent hearing is identified and enrolled in an early intervention program by 6 months of age, that baby will have the potential to develop age appropriate listening and spoken language skills. For this reason, universal newborn hearing screening programs have been implemented in all 50 states of the United States and early intervention is a reality for many children born with hearing loss. However, there is a population of children who are routinely missing out on this opportunity—children born at home.
Families choose home births for many reasons: proximity to a hospital, religious reasons, a desire for limited medical interventions, or cultural reasons. Unfortunately, these families often face obstacles when trying to obtain a newborn hearing screening for their babies and, therefore, do not get a hearing screening (American Academy of Pediatrics (2011). The obstacles faced by home birth families are often specific to the population of home birth families and the region where they live. In discussion of potential obstacles with home birth families in MI, several common barriers arose.
The first obstacle is simply making and getting to an appointment at a hospital or clinic for the screening. It may be difficult or inconvenient to travel to an outside appointment shortly after the birth of a baby. This is especially true for Amish families who must arrange a ride from someone in their community to travel to the nearest audiology facility. The family may also prefer to avoid hospitals or other medical offices to prevent exposure of their baby to those environments.
Families may also encounter a financial barrier when trying to get a hearing screening for their baby. When a baby is born in a hospital, the cost of the newborn hearing screening is often bundled in with the other services provided and covered by their insurance coverage. If it is not bundled with routine infant care, insurance may or may not cover the cost. Outpatient hearing screening can often result in a higher charge to the parent. Paying for this testing, out of pocket, may not be feasible or be deemed unimportant for many home birth families.
Midwives who attend home-births and provide routine care to these families are in a unique position to help overcome these barriers and obstacles. Midwives are trained healthcare providers who have an expertise in prenatal care, natural childbirth, and postpartum care. They provide care for mothers and their babies, often in the family’s home. It has been concluded that training midwives to complete newborn hearing screening would remove the barriers of time and travel. Further, if midwives were to include the cost of the hearing screening in the price of their services, the financial barrier would be reduced as well.
Unfortunately, most midwives have not been previously trained in how to complete this type of testing and they, typically, do not own the equipment necessary to do a hearing screening. The cost of an automated auditory brainstem response (AABR) unit can be up to $15,000USD and most home birth midwives would not be able to afford this equipment on their own. In the state of Michigan, efforts have been underway making important changes, to ensure that this becomes standard procedure independent of where births take place.
Nan Asher, from the Michigan Early Hearing Detection and Intervention Program, Wendy Switalski from Audiology Systems, and I have been working together to provide AABR equipment to midwives across the state of Michigan. Funded by a grant from the Carls Foundation through the Michigan Coalition for Deaf, Hard of Hearing, and DeafBlind People, fifteen AABR units have been purchased and distributed them around the state. Midwives who will be using this equipment have completed an online newborn hearing screening training module and have received hands-on training with the screening equipment. The training module was created by the MI Early Hearing Detection and Intervention program for all providers who will be completing newborn hearing screening. This module covers information about hearing and hearing loss, risk factors for hearing loss, the type of screening tests that are done, and how to complete and report the results of the screening. The midwives completed this online training on their own time before attending a hands-on training session. The hands-on sessions showed the midwives how to use the equipment, how to report the screening results, and what to tell parents about the results of the screening. Midwives were then able to complete a practice screening using the equipment and a baby doll with a simulated hearing loss.
A baby having their infant hearing screening done by a midwife. (photo: Martin Lux)
Each AABR unit was given to a midwife or birthing center in a different region of the state and the equipment is being shared among all midwives in that area who have completed both phases of the training. The equipment was distributed based on need — areas with busier midwives received more AABR units. Generally, areas with more the 5-6 midwives or more than 2-3 midwifery practices were considered busy. Annual calibration and refresher training will be provided to make sure that all equipment is functioning correctly, and any problems or questions from the midwives can be answered.
So far, this project has been very successful: 50 midwives*, doulas, and midwifery students have completed the entire training process. Prior to the implementation of these training sessions and equipment, only 19% of home birth babies in Michigan were getting a hearing screening. As of September 2014, that number has increased to 66% — a huge increase! Although we would like to get the number closer to what is seen in hospital births (97% in Michigan), this has been a great start. The midwives we have talked to have been very interested and supportive. They have reported that many of the families they work with have also been open and enthusiastic about having their babies screened.
Typically, Michigan midwives complete the initial hearing screening at their 1 week check-up appointment and if the baby refers in either or both ears, they are re-screened at a subsequent visit. This allows the midwives to meet the Early Hearing Detection and Intervention Program’s goal of completing the newborn hearing screening by one month of age. Babies that refer in either or both ears on the re-screen are referred to an audiologist in their community for a diagnostic auditory brainstem response (ABR) test.
A similar project has been conducted in the state of Utah. From 2007-2013 Utah purchased 23 Otoacoustic Emissions (OAE) screening units and distributed them to midwives in their state. Following implementation of their program the rate of newborn hearing screening for out of hospital births has increased from 2.5% in 1999 to 80.6% in 2013 (Smith, S., Wnek, S., & Badger, K., 2015).
The success of both the Michigan and Utah programs demonstrate several important things.
1. Many midwives are open to the idea of performing hearing screenings for their clients — Many of the midwives that participated in the Michigan project expressed excitement about being able to provide a service that is routinely offered in a hospital, in the comfort of a family’s own home. Midwives want to provide the best possible care for their clients and by conducting hearing screenings they are able to provide truly comprehensive postnatal care.
2. Home birth families are open to the idea of having their baby’s hearing screened — Families that choose a home birth are not always opposed to traditional medical care. Regardless of the reason for choosing a home birth, these parents want the best possible care for their babies.
3. Providing the hearing screening in the family’s home or at a local midwife’s office overcomes many of the barriers of travel or aversion to hospitals — Training and providing midwives with the needed equipment allows them to conveniently conduct hearing screenings as part of their routine follow-up care. Families will no longer be required to make a separate trip to complete the hearing screening.
So what can you do in your own community?
1. Contact your local midwives. Talk to them about their needs, level of interest in performing hearing screenings, barriers in place for their clients, etc. This will give you a good idea of the current situation that they are facing. Find out if there are other ways to overcome some of the obstacles. These solutions could include some educational materials for midwives and their clients, a better referral process for a hearing screening or transportation assistance.
2. Identify some funding agencies that would be interested in providing hearing screening equipment to midwives and find out what their requirements are to obtain funding.
3. Gain a good understanding of the current climate in your area you may be able to come up with some creative solutions that will make a difference.
Before the implementation of universal newborn hearing screening, the average age of identification for children with hearing loss was two years old meaning that children born with hearing loss missed out on two years of sound. This can have a profound impact on speech and language development. Hospital-based newborn hearing screening programs, have brought the average age of identification to six months. The implementation of newborn hearing screening program for home birth babies can allow children born at home to take advantage of the same opportunities provided to children born in a hospital.
* Midwives are not licensed in the state of Michigan
Reference: American Academy of Pediatrics [AAP] (Feb, 2011). Reducing Lost to Follow-Up Rates in Out-Of-Hospital Birth Populations. EHDI E-Mail Express. Accessed November 15, 2014.
Smith, S., Wnek, S., & Badger, K. (2015). Out of hospital midwives: Improving compliance with hearing screening in Utah. The National Early Hearing Detection & Intervention Meeting. Louisville, KY.
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KAREN MACIVER LUX