Clearly there are issues in the home birth midwifery here in the States, as the numbers continue to show us the increase risk for babies born at home (you can read the studies by clicking here). In my opinion, based on what I have seen, it is because too many risks are taken -- risks that pregnant women may or may not be aware they are taking. What makes home birth safe? Here are my thoughts on the matter. My stipulations are based on the standards set by other countries where home birth has shown to be a safe option.
1. The mother is low risk and takes the proper screening measures to ensure that she remains low risk through the pregnancy and through labor/delivery -- otherwise care is transferred to an OB (or hospital, if during labor/delivery).
2. The birth attendant is a trained and certified midwife with current hospital privileges and OB back-up (which basically means your midwife is either a Certified Nurse Midwife or a Certified Midwife). I think it is important for a mother to meet with the back-up OB at least once during pregnancy. That way, if any complications develop later in pregnancy and she needs to transfer care, she can transfer to someone she has already met and to someone she knows her midwives trust.
3. A second attendant or midwife is present for labor/delivery -- someone that is trained to assist in birth (certified in CPR and neonatal resuscitation). In case mother and baby both need assistance after the birth there is one trained professional for each.
4. Close proximity to a hospital where the mother is preregistered in the event of a transfer (10 miles max -- even that seems too far, in my opinion)
5. Monitoring every 15-30 minutes during first stage of labor; monitoring every 5 minutes in second stage of labor. Anything less than that is falling outside the guidelines of evidence based care.
6. The midwife should have current insurance. This is to protect the family and the midwife in case something goes wrong. I know you can't imagine suing your home birth midwife if something went wrong. However, for example, if a birth injury occurs and the child needs lifelong medical assistance because of it, then you are certainly entitled to compensation to help pay for those medical bills.
7. The mother is not a first time mom. Home birth for a first time mother carries a higher risk for the baby.
Those are my suggestions. If you cannot check off all of these items for your home birth (or birth center birth), then it is not something I could get behind and call "safe." With the ever increasing interest in mothers wanting a home birth, I can only hope more midwives take reasonable measures like these to ensure only the safest options for their clients. I know there are home birth midwives that stick to these guidelines and that is wonderful!
I would also want references to patients that were transferred to the hospital. I would want to know how the midwife behaved when faced with that decision -- how much hemming and hawing was involved, whether there was an argument over the decision, etc.
ReplyDeleteJust seeing how the midwife reacts to being backgrounded also would give me some clues as to her fitness to be trusted with my baby's health. I'd think a professional would be totally accommodating and encourage any investigation the parents take on.
That's true! That's a really good idea. I will add that when I get a moment.
DeleteThat isn't an easy requirement with the HIPAA requirements. But a woman could talk to the nurse manager at the transferring hospital to discuss general transfer experiences. Unfortunately, the hostility some midwives face in transfer can make the transition from home to hospital less safe. The midwife is responsible for her part in making the assessment and recommendation to transfer and to facilitate the timely transfer. The EMS is responsible for their response and the receiving hospital is then responsible for how they receive the woman or infant. I have seen a transition in hospitals over the years as they have improved how they respond to a transfer, thus improving health outcomes for families. This is not the case in all parts of the country. Just as a hospital staff member is not responsible for the decisions a midwife made in a complication, a midwife is also not responsible for the lack of response by a doctor or nurse when she transfers. As a student years ago I watched helplessly while an EMS member delayed transfer for a NB because he wanted to put an IV in the baby, something he was never able to do. I've heard of doctors not believing a midwife's report of a prolapsed cord because they didn't feel it. None of this is good for care. Collaboration is a necessary piece of the safety plan for all birthing women.
DeleteWhat about an attendant trained in neonatal resc. and all the equipment for the baby? I know when I had my son all eyes were on him and none on me when he was born and needed worked on. The midwife didn't even know how much I bled... she guessed for the records. There needs to be a professional for mama and for baby.
ReplyDeleteYes, completely agree. If a CNM or CM has current hospital privileges then they should be up to date on all of their training certifications, like neonatal resuscitation. And I also think there should be at least two professionals: one for mother and one for baby. I put that as #3. I wrote another post about equipment that should be minimal at a home birth, I should add a link to it. Thank you for the idea!
ReplyDeleteBy the way, I've read your blog before and thank you for being so brave and sharing your story. I have other comments I want to respond to that you have posted here on my blog but it's been a busy couple days with visitors in town. I will get to it! Just wanted to say thanks for reading, commenting and sharing your story as well :)
Oops, I see it now! Although, homebirth is still so risky even it intubation equipment... but it'd make it a little less so with your #3! I just laid flat my views last night on my blog (you and a friend inspired me). A little nerve-wracking. I referred them to your blog on it. :)
DeleteI'm glad that here in BC, Canada, all of the above are part of our healthcare laws governing homebirth. Thanks for sharing!
ReplyDeleteYes and that is fantastic!! :) :)
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