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:

What Drew Me to Home Birth and What Turned Me Away

* MIDWIVES *
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:

American Midwives series

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”:

CPM education: The bar is too low

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.


* BIRTH CENTERS *
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:

5 Things to Know about the Birth Center Study

* HOME BIRTH STUDIES AND STATISTICS *
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 

4. The latest study on home birth in the USA (Feb 2014): New Cornell study shows home birth has 4x higher death rate than comparable risk hospital birth 

5. Risk of brain injury and home birth: Risk of anoxic brain injury is more than 18 times higher at home birth

* INFANT MORTALITY *
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?


* THE LIES AND MISINFORMATION *
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:

The Business of Being Misled

* GUIDELINES, EQUIPMENT & WHAT TO ASK YOUR MIDWIFE *
What makes home birth a reasonably safe option? Here are some guidelines:

Home Birth Guidelines for Safety

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:
https://www.facebook.com/douladanielle/posts/646718472063552

7 Home Birth Myths: No For Real This Time

photo courtesy of Edward Willett

I recently read a little article about myths about home birth. It was funny. Not so much like funny haha but funny in that full-of-misleading-information type of way.

So I thought I'd take this opportunity to tell 7 actual myths about home birth. The legitimate and dangerous myths, the myths that many home birth moms and advocates (and their family/friends) believe. Because I've been there. If you'd like to read more about my journey and why I am a former home birth advocate, click here to read for the full story. If you have any doubts on how well I researched home birth, that should clear it up for you.

Let's start with the biggest myth of them all.....

Myth #1: Home birth is as safe as hospital birth

While that may be true in countries like Canada or Netherlands or UK, it is actually NOT TRUE here in the USA. Not true at all. Not a single peer review study regarding home birth in the USA supports that idea that "home birth is as safe as hospital birth" -- they each, in fact, show an incredible increase risk for babies born at home versus in a hospital. (Click here for the studies) (and Click here for the *new* MANA study which yet again shows increase risk to babies born at home)

Under certain conditions - similar to the the way home birth is typically practiced in other first world countries (click here) - home birth may be as safe as hospital birth. But that's not how it typically goes here in the US. The US stands alone in our home birth practices -- which is why all studies point toward increase risk at home versus hospital. Even when you take things like rare hospital-acquired infections into account, the risk is still greater at home.

Myth #2: Home birth midwives are experts in normal birth

If you are seeing a Certified Nurse Midwife (CNM) or Certified Midwife (CM) that has current hospital privileges, then yes, you are seeing an "expert in normal birth." Mass majority of home births in the US are attended by a Certified Professional Midwife (CPM), Licensed Midwife (LM) or lay midwife -- these midwives would not be able to practice as a midwife in any other first world country because the requirements for becoming a CPM or LM are incredibly lacking compared to midwives in other first world countries (and especially compared to our American midwives that go through ACNM). And obviously, if you are seeing a lay midwife, who knows what training she has under her belt or what her real track record is.

If you feel like you are the exception and that your home birth midwife is incredibly well-trained and incredibly ethical and would never take chances (especially without you knowing), then you might want to read up on these midwives. Sadly, there is no guarantee and no way to know for certain what your midwife's training consisted of, what her real track record is and whether or not her own birth philosophy will trump what is ethical.

Myth #3: Home birth midwives carry with them everything needed, in case of an emergency

There is a huge difference in what you will find at a home birth versus a hospital birth. To some, this may sound obvious. But to others it might help to see it laid out, the difference what you would find at a home birth and a hospital birth. It's one thing to hear your midwife say "here's what I will bring -- it's everything you need in an emergency," and another to actually see equipment home versus hospital, and even ambulance. So click here to see the full lists and compare. Perhaps the biggest difference is the team you will find at a hospital that you won't have at home - especially if your midwife works alone. If both mother and baby are in need of immediate medical attention after birth, you have many hands and minds - not to mention equipment - to help them both at the same time. When will minutes matter? Read these stories and you'll get an idea of how low risk can turn into emergency in a matter of seconds.

Myth #4: If complications come up, home birth midwives will be able to identify and transfer before it becomes an emergency

There are circumstances when minutes can really be the difference in life or death (or serious neurological and/or physical injury). Shoulder dystocia, cord prolapse, placenta abruption to name a few... how will your midwife handle these situations at home? Ask her. What if what she tries doesn't work, then what? The reality is, those complications can be and have been deadly at home birth. If what she tries does not work, you will be transferring to a hospital and minutes. will. matter. I, unfortunately, know of 3 home births in just the past year that resulted in shoulder dystocias that were not resolved in time and the babies did not survive.

Myth #5: Home birth midwives give better care than OBs

Home birth midwives are afforded a little luxury that OBs are not. The luxury is called: no accountability. OBs must always err on the side of safety. If they do not, they have the hospital, their medical board and lawyers (lawsuits) expecting answers if something goes wrong. If their actions prove they were negligent and/or unethical, they are in big, big trouble.... like Dr. Fischbein or Dr. Biter. Home birth midwives, however, are able to push the envelope when it comes to potential disasters. Why? Because they aren't required to carry insurance and NARM (North American Registry of Midwives -- their governing body) is nothing short of a joke as a whole but especially in the accountability department. Here is one (of too many) home birth loss mom's story of seeking accountability after her midwives were incredibly negligent in the care they gave (which, tragically, ended in the death of their child). What an incredibly sad and frustrating ordeal it becomes for parents who expect accountability. Even if your child requires lifelong medical care after a home birth injury (which means medical bills for the rest of his or her life), without insurance, you won't get a dime from your midwives -- no matter how lacking their care was.

Myth #6: Home birth is more affordable

If you go bare bones home birth - meaning no "extras" - with a midwife who charges a pretty low fee and you do not need a hospital transfer, then yes, it might be more affordable. But if you start adding in some of the typical "extras" recommended by home birth midwives: herbs, supplements, chiropractic care, acupuncture, doula, etc then it can add up and fast. Not to mention if you transfer! Then you pay for a home birth and a hospital birth and maybe even an ambulance, too! And because certain conditions can worsen en route to the hospital, it may be a more complicated delivery, which means higher hospital bill (such as a postpartum hemorrhage that requires a blood transfusion because of all the excess blood lost during the transfer).

Myth #7: Home birth means no interventions

Nothing shocks me anymore in the world of home birth midwifery. Interventions, especially. From home birth midwives (illegally) using vacuums for delivery and Cytotec for induction, to more "natural" interventions like castor oil or black and blue cohosh or breaking the mom's water to home birth midwives even suggesting alcohol during labor (yikes!).... truth is, interventions exist at home births, too. And they can be offered (or sometimes they'll just be done without consent) at home and at hospital. They may seem more "natural" if it's an herb in a bottle versus a hormone in an IV but interventions are interventions. If you can't ask "why is this needed" or say "I'd rather not" at a hospital, what makes you think you'll be able to do so at home with your midwife?

And because it was too hard to stop with just seven:

Myth #8: Home birth means evidence based care

From lack of monitoring during second stage (meaning anything less than checking fetal heart rate every 5 minutes while the mother is pushing) to treating GBS with garlic and/or Hibiclens to VBACs without continuous EFM to breech and twins delivered outside of a hospital, there is a long list of common home birth practices that are not supported by any evidence at all. Click here for a longer list, which still does not include everything.

So there ya go. Those are the real myths about home birth in the USA.