Thursday, August 28, 2014

Home Birth in the USA

There are some things you may not know about home birth in the USA. For example, if you were told that "home birth is as safe as hospital birth" then you need to know that is, in fact, not true... not in America... not even for low risk women. Here is some information regarding midwives, birth centers, home birth, studies, statistics, guidelines, and more, that you may find useful for learning more about home birth in our country. There is a lot to read here but it is important information in order for you to make a fully informed decision.

Let's start with an introduction for those who have never stopped by before. My name is Dani. I'm a birth doula and former home birth advocate. Here's my story:

One key issue with home birth here is the many different types of midwives we have in the USA: CNMs, CMs, CPMs, LMs, LDMs, lay midwives..... So many!! Each type has different standards for education and training (or no standards at all). Here is an easy-to-read series that touches on the three main types of midwives:

Most home births in the USA are attended by a Certified Professional Midwife (CPM) or Licensed Midwife (LM) (CPMs and LMs are very similar). It's important to know that CPMs and LMs would not be able to be licensed in any other first world country. The standards simply are not rigorous enough. They are only legal in 26 states, do NOT earn hospital privileges as a part of their training process nor do they have any higher level education requirements -- as opposed to American CNMs/CMs and midwives in countries like the Netherlands, Canada and the UK. Safer Midwifery for Michigan has an eye-opening post that explains how little it potentially takes to earn the title “Certified Professional Midwife”:

Here is a great series exploring what it takes to become a midwife in other countries: The Education of Midwives Around the World

Many home birth midwives do not carry malpractice insurance. Why is insurance important? Insurance protects you. It means that if something happens that causes death or injury, you are able to have recourse and accountability. It means that if your child suffers an injury during birth, you can have compensation to help pay for life long care that may be needed.

There is no transparency for home birth midwives. They do not have a publicly accessible board where any disciplinary measures would be listed. How do you know if your midwife has ever practiced negligently, resulting in the death or injury of a baby or mother? What is your midwife's real record? How can you verify it? How do you know for certain how many births she has attended? Far too many mothers have trusted their midwives, trusted the friendship they developed with their midwives, trusted their judgement and reputation, only to find out after a bad outcome that their midwife was less than forthcoming.

Is a freestanding birth center safer than a home birth? That depends. In many ways, a freestanding birth center birth is just a home birth in someone else's home. What equipment does your birth center offer that wouldn't be available at home? Is the distance to the hospital closer? What types of midwives are running the center and who will attend your birth? The 2013 Birth Center study shows that out-of-hospital birth can be a reasonably safe option. However, it's important to know that this study does NOT reflect all birth centers in the USA. It was a select group of birth centers, majority of which were run by CNMs. The birth centers met certain criteria and were CABC-accredited. Out of 248 freestanding birth centers in the USA, only 79 were included in the study. Read more about the Birth Center Study here:

Here are studies and statistics regarding home birth safety. It's important to look at studies done in the USA. Studies regarding home birth in other countries do not reflect home birth in America: different midwives, different health care systems. Outcomes will be better in countries where, for example, midwives have high standards for education and training and where the midwives have hospital privileges. These links are studies regarding home birth in America... and every single study shows a significant increase risk for babies born at home:

1. The 2014 MANA study, showing an increase risk of intrapartum and neonatal death of 3-5x for babies born to low risk women: Mortality rates from the new study by the Midwives Alliance of America 

2. Studies in the USA, current as of January 2014: Home birth studies 

3. 2013 studies (USA and internationally) and CDC data: 2013 Home birth studies and statistics 

Advocates of the home birth movement use infant mortality to try to scare women away from our hospitals / maternity care.

Infant mortality is not the correct mortality rate to use to gauge safety of obstetrics / maternity care. Infant mortality is live birth through the entire first year. It does not include stillborn babies. It includes any and all deaths like accidents, disease, SIDS, etc that may happen day 4, day 204 or day 364... death at any time, for any reason for the first full year of life. Perinatal mortality is a much more accurate measure for maternity care (even the World Health Organization acknowledges this). It includes prematurity, fetal mortality (death of baby in utero), intrapartum mortality (death of baby during labor and delivery) and neonatal mortality (death of baby during first 27 days of life).

So why don’t the leaders of the home birth movement discuss perinatal mortality? Because the United States does very well with perinatal mortality, tied with countries like France and Japan, and actually better than countries like the Netherlands and the UK.

When will they stop trying to scare women using the wrong mortality rate?

Home birth in our country is sadly built on a foundation of lies and misinformation. An example is the press release written by MANA for the new MANA study: it's lies, cherry-picked info and misinformation. I shared more about this in an interview with SteadyHealth (as well as thoughts on HBAC/VBAC). To touch on this issue of the MANA study, I tried to put things into perspective:

"A home birth mortality rate of 1.62/1000 [from the new MANA study] for babies born to low risk women might not mean much of anything without having something to compare it to. 1.62/1000 just sounds low. However, when you compare it to the 2013 Birth Center study, for example, which has a mortality rate of 0.87/1000 for babies born to comparable risk women, then it makes you wonder why is the MANA study mortality rate twice as high?

These numbers all seem low, though. But it’s important to remember how many babies are born every year in the USA, specifically how many are born in an out-of-hospital setting. According to the CDC Wonder Database, in 2012 there were 38,997 midwife-attended out-of-hospital births - some in birth centers, some at home. So just for the sake of illustrating a point here, let’s round up to 40,000 births and let’s pretend they are all low risk women. According to the MANA study mortality rate of 1.62/1000, approximately 65 babies would die out of 40,000. According to the Birth Center study mortality rate of 0.87/1000, approximately 35 babies would die. According to the hospital mortality rate of 0.38-0.58/1000, approximately 15-23 babies would die. That’s a huge difference in the number of babies born at home that would not survive either childbirth or the first month of life. Now those mortality rates don’t seem so small.

What is home birth in America doing so wrong that their mortality rates are so much worse than hospitals and (certain) CABC-accredited birth centers? 1.62/1000 is the mortality rate for babies born to low risk women. This is not acceptable. Instead of addressing this issue and figuring out ways to make home birth better, safer they instead are spending their time trying to pull the wool over everyone’s eyes. They want people to think that 1.62/1000 is good. But it isn’t."

Read more here: SteadyHealth Interview

Another big source of misinformation is the popular film “The Business of Being Born.” Here is my critique of the film, which hits on misleading information that is widely shared, not just in this movie:

What makes home birth a reasonably safe option? Here are some guidelines:
What equipment is available at home versus in a hospital?
Home vs Hospital: The Equipment
What questions should you ask your midwife?
Considering Out-of-Hospital Birth?

Have questions or more suggested reading material? Share in the comments below or here on Facebook:


  1. link # 4 is described mistakenly. the cornell study did not include intrapartum death rate, only neonatal death rate which ends up as a different number. regarding the johnson study, you only linked to a piece by amy tuteur and not to the actual missing mortality 2000 data that johnson and mason allegedly excluded deliberately. do you have a link or a direct citation? thank you.

    1. I already replied to you on this issue. Here is what I said:

      You can't link directly to the information, you have to do a search through the CDC wonder data base. Do you know how to do that? I can tell you if you don't.

      Here's another read you might enjoy:

      Link #4 does not describe the link incorrectly.

    2. If you'd like intrapartum mortality rate info, read here:

  2. link doesn't have anything about the data related to the jackson and study, if i missed it can you quote it here? sorry for the bother.

    1. excuse me once more, i'm mixing up my replies again. this was regarding the post on the jackson study.

  3. None of your links are working, I'd love to read them though.

    1. Sorry about that! They should all be working now. Let me know if you have any problems and thanks for alerting me to the issue!

  4. Why don't you do your next bashing blog on the maternal statistics of hospital. How the C-section rate in the US is 3 times higher than the WHO recommends. How you are more likely to die from placenta implantation problems caused from multiple C-sections than you are to die from uterine rupture yet very few places allow women to attempt a VBAC. How infants are more likely to have respiratory problems and now coming to light, immune system problems causes from all of the C-sections.....I could go on and on. I am just giving you a few subjects for your next blog. Maybe the women of the United States should just stop having children since it isn't safe no matter where you go.

    1. Wow... you seem really upset by my post here. I think no matter where a woman chooses to give birth, she deserves informed consent. Home or hospital.

      As far as maternal statistics... Unfortunately, the real issue in our country is health of pregnant women. Maternal death is very rare (which is why it's measured per 100,000). And it's even more rare for healthy, low risk women.

      Our number one pregnancy-related killer for women in the USA is cardiovascular disease. Followed by non-cardiovascular diseases.

      Some important information to read/consider:

      "In the U.S., deaths from hemorrhage, sepsis (infection) and abortion (the medical definition of which includes ectopic pregnancy, miscarriage and induced abortion) are on the decline.... But deaths from medical complications that were either exacerbated by pregnancy or started during pregnancy -- things like congenital heart disease, diabetes, obesity and kidney problems, are on the rise." ( << this link includes a recent study on maternal mortality around the globe)

      In other words, mass majority of the women dying due to pregnancy-related issues in the USA have chronic health issues and need more intervention, not less.

      Chronic health issues also affect the cesarean section rate... a high risk mother is more likely to need a cesarean section.

      But yes, our cesarean section is likely too high. The WHO admitted their cesarean rate goal range is not based on evidence and seeings how the Netherlands is over 15% and has a female population that is *significantly* lower risk than the female population in the USA, I highly doubt that even if we never had another unnecessary cesarean section that our rate would be between 10-15%. I'm glad that ACOG is pushing for a reduction in the primary cesarean section rate -- it's needed. Cesarean sections are major surgeries.

      I'm not on board with VBAC bans. So I share your concern with that.

      Just because I want women to have information about home births that brings to light certain issues with face in our home birth system here... information that clearly upsets you.... doesn't mean I think hospitals are infallible. We have work to do on both sides. That doesn't change the fact that a baby is more likely to not survive at a planned, midwife attended home birth than in a hospital. And women deserve to know that.

  5. Just wanted to say that your post has helped me so much. You have done an amazing job of staying respectful and unbiased but still giving facts. This mama appreciates the honesty. I have been struggling with this very issue since finding out I am pregnant with our second

    1. Thank you, Megan! I appreciate your comment very much. And congratulations on your pregnancy :)

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