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

Home Birth Guidelines for Safety

photo courtesy of debit72

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!