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The Role of the Midwife's and/or Out of Hospital Births

Michigan has a mandated screening and reporting system for universal newborn hearing screening. Therefore, each homebirth attendant should have a procedure in place to assist families in obtaining a hearing screen for their newborn. Michigan Early Hearing Detection and Intervention (EHDI) program is available to assist in setting up your procedure and following this mandate.

Why is Hearing Screening Important for newborns?

Important language skills are learned before the age of three and this is a critical time period for infants to acquire language. Brain development of the auditory pathways and language cortex is occurring in young children as they respond to auditory and visual language. Deaf parents automatically sign from day one, so their babies are learning visual (sign) language, and the appropriate brain development is occurring.

However, children with an undiagnosed hearing loss with unware parents will not receive the needed language stimulation, and the expected brain and language development won’t take place. So it’s very important that a child have access to language very early.

There are a number of myths and misconceptions on testing newborn babies hearing, learn the clinical facts so you can address them if they come up when counseling families.

Midwives have options to follow this mandate:

Midwives play an important role in communicating the importance of the newborn hearing screen to the baby’s family prior to the baby’s birth. They can use a midwife flyer and/or the EHDI Newborn Hearing Screening Brochure.

Hearing screenings should be completed no later than one month of age. Michigan strongly supports the A-ABR method for newborns due to its increased accuracy in detecting possible hearing disorders early in life and fewer refers and missed hearing losses vs. the OAE methods. Newborns that refer twice on their newborn screenings (both should be prior to one month of age) should have a full hearing assessment and evaluation by a pediatric audiologist no later than three months of age at a diagnostic evaluation location. Babies identified with a hearing loss should be receiving early intervention services no later than six month of age.

Statistically, the approximately 150-160 babies identified annually in Michigan should actually be closer to 200-300, indicating that not all babies are being identified as intended. The majority reason is that nearly 50% of babies who fail their initial screens are not being follow-up consistently. Parents do not take the child in for more testing as indicated, or the baby’s Primary Care Physician has not strongly or appropriately encouraged the families to follow up. Here is a flowchart how the process should work.

Historically some babies did not have easy access to hearing screening, such as can be the case with an out of hospital birth. Michigan EHDI staff has worked diligently in partnership with midwives all over the state on this matter to ensure these babies have access to hearing screenings so that these babies are not missed.

How is Newborn Hearing Screening Done?
Newborn hearing screening does not require the infant’s active participation. Unlike the hearing tests done with older children and adults, babies do not have to raise their hands in response to a beep. While the baby is quiet and asleep, (this is vitally important for successful screens) computerized equipment measures responses to a series of tones and evaluates the baby’s hearing. The testing is simplified so that a variety of individuals with training can effectively screen babies. The testing is not uncomfortable and is best done with the baby sound asleep.

Where can a Baby's Hearing Be Screened?

Michigan babies born out of a hospital setting have access to hearing screening through a variety of ways.  Midwives may refer the family to a local community site which has the proper equipment and trained personnel who can perform newborn hearing screenings. These are located in a variety of settings, including hospital nurseries, audiology offices, primary care clinics, public health departments, and intermediate school districts. In addition, midwives who have undergone hearing screening training and have access or an agreement with a HOST site may perform their own screenings, or have a trained associate perform the screening for them. They can also refer their families to another midwife or to a HOST site either of whom can access an AABR machine.

How does the MI-EHDI- Midwife Equipment Distribution Program work?

The Carls Foundation provided a grant to Michigan Coalition for Deaf, Hard of Hearing and DeafBlind People (MCDHHDBP or The Coalition) who purchased and own the machines. MCDHHDBP partners with the MI-EHDI program to distribute them to midwives and or midwife-friendly centers that have undergone proper training, have agreed to follow state protocols, sign an agreement with the MCDHHDBP and report the results of all their screens to EHDI within 14 days.  The grant provided initial funding for the hearing screening equipment, calibration for three years, initial supplies, training costs. In addition, a partnership with Central Michigan University Audiology department assists in providing training personnel for this project. To ensure longevity of the project, participating midwives will be collecting nominal fees from parents to pay the Coalition to ensure ongoing maintenance and supplies for new babies.

In early 2014, nearly 50 midwives, doulas and student midwives have had training to perform hearing screenings and have access to portable A-ABR machines to test babies. Equipment was distributed in the spring of 2014, and will be assessed annually by the Michigan Coalition for Deaf, Hard of Hearing and DeafBlind People and MI-EHDI to ensure continual optimal placement. Nearly 50 midwives, doulas and student midwives have had training to perform hearing screenings and have access to portable A-ABR machines to test babies which are located throughout the state.

Reporting Hearing Results and Follow-Up:

Midwives who have undergone the training and have access to a machine or an agreement with a HOST site may perform their own screenings, or have a trained associate perform the screening for them. All screeners are obligated to report results obtained by their screenings, either using the hearing card provided by the metabolic blood spot card, or using the midwife reporting form. They may also use a log sheet to record their results. For babies that refer on their initial test, midwives may offer to do it a second time before the baby is a month old, or midwives may refer them to a community site. After two refers, the babies are to be referred for a diagnostic evaluation.

Are there any risk factors for Hearing Loss?

Only half the babies identified with hearing loss have a known risk factor. Risk factors have been identified that indicate which children are at an increased risk for hearing loss. If a baby has any of these risk factors at birth or in childhood, it is especially important to schedule on-going hearing tests. Be mindful that a passing test now does not rule out hearing loss at a later date. This is true, especially babies born with Cytomeglovirus (CMV).

Counseling families on hearing screenings:

Why hearing screening? (See previous section on why hearing loss important.)

What if they passed?  

What if they referred?

Sample scripts to use when counseling families:

How can I learn to perform screenings and have access to a machine?

There are several steps you need to take to be able to offer the hearing screening for your families:
a. Inform MI-EHDI that you wish to learn how to perform a hearing screening.
b. Take the online course at http://learning.mihealth.org
c. Attend hands-on training from EHDI or approved provider
d. Sign the agreement with the Michigan Coalition for Deaf, Hard of Hearing and Deaf/Blind people.    

If you also wish to be a host site:            
1. Fill out the Host application            
2. Purchase insurance for the machine (submit proof)            
3. Develop the policies and procedure for Coalition/EHDI approval. (Sample policy)

For more information about Newborn Hearing Screening for Midwives and to order free educational materials, call (517) 335-8955 or email Nan Asher at: AsherN@michigan.gov.

Resources:
Michigan's Newborn Hearing Screening Program English MDCH-0474
Midwife Flyer
Midwife reporting form