Friday, July 19, 2013

Considering Home Birth?

Our country affords many freedoms, among them the right to birth where and with whom we choose.  In a state like Michigan where there are currently no regulations or laws surrounding midwifery, that freedom is widely interpreted.  But what about the rights of consumers to be "fully informed", and what exactly does that mean?  It seems that many home birth advocates tell mothers to "educate themselves", and defend their cause when things go awry with reprimands about the mother's responsibility to make an educated choice.  

In a state with no defined scope of practice or licensing measures for out-of-hospital midwives, it's extremely difficult for consumers to access information that would allow them to fully educate or inform themselves before making the choice to have a home birth or birth center birth.  Being fully informed means families are told about the good, the bad, and the ugly as they pertain to home birth.  It means a woman is told by her care provider directly & honestly the benefits of home birth, and the inherent risks that come along with it. 

All too often I meet mothers, usually those whose birth stories don't have happy endings, who were only told about the benefits of home birth.  They feel duped, embarrassed, like they somehow were fooled by an illusion of promises that turned out to be anything but empowering.   These mothers have not been informed, they have been misled. 

There will also forever and always be those mothers who choose home birth despite the risks that come with it, and fully knowing what they are risking.  And there are mothers who do not fully understand the choices, and more importantly the consequences that can be associated with making the home birth choice.  I fully accept a woman's right to choose home birth, but the one caveat is that she deserves to know a few key facts.  Then, if knowing these facts, she still makes the choice for home birth, then the choice and responsibility can truly be her own.  The problem comes when mothers choose home birth with their heads full of misguided information and misleading propaganda...blinded by the woo as some might say.  

And so with these mothers in mind, those who weren't fully informed about the important factors to consider before choosing home birth, here is a list of things to consider...

Facts You Should Know When Considering Home Birth
  1. "Planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth." ~ ACOG Statement on Planned Homebirth
  2. Requirements for licensing vary widely by state.  This includes minimum standards for education, scope of practice, collaborative agreements, and insurance requirements.  Some states have NO regulations, others some, and still others more thorough guidelines.  Know your state laws well, and consider heavily the impact they have on safety in practice.  (MI is a state that has no regulation what so ever.) 
  3. Credentials and educational training vary greatly too.  Look for a midwife who is certified by the American Midwifery Certification Board The only type of midwives who are AMCB certified are Certified Nurse Midwives and Certified Midwives.  CPMs, DEMs, or lay midwives do not typically meet the educational standards for this important certification. There are exceptions for CPMs in states like NY where state law has required CPMs to further their education and pass the AMCB exam to earn a license to practice.  In other states CPMs are licensed without the added educational requirements.  Certification by AMCB demonstrates a high degree of competency, and is a more reliable hallmark of educational training than licensing alone. 
  4. Outcomes for home birth are greatly impacted by several factors.  Among the most critical are a high degree of education and training (In the US that means an AMCB certified midwife), working within a fully integrated health system, and practices regarding consultation, referral, and transfer of care.
  5. Not all women are good candidates for home birth.  Risk factors matter a great deal when considering where to have your baby, and they matter even more if you're considering an out-of-hospital birth. Research has shown time and time again that home birth is intended for LOW RISK pregnancies...yet somehow story after story of baby deaths and injuries are surfacing, revealing they were high risk to begin with according to modern medical standards. 
  6. Assessments matter in order to ensure your pregnancy is and stays low-risk.  If your midwife disregards important assessments, she is "trusting birth" more than she is assessing and monitoring your risk factors.  A good midwife will value assessments so she can be informed, and she can keep you informed about whether or not your pregnancy becomes high risk at any point.  She should have very clear guidelines for what defines high risk, and what situations "risk out".
  7. Not all "birth centers" are safe.  Looking for a birth center?  Look for one that is affiliated with a hospital with licensed, insured midwives providing the care.  At the very least, choose a birth center that is accredited by AABC. 
  8. Most midwives practicing outside of a hospital DO NOT carry malpractice insurance.  Midwives like to claim that they can't afford it.  Insurance protects both the consumer and the midwife.  The former by providing specific safety guidelines for practice, and protecting those who are victims of negligence.  The latter from lawsuits that could be life altering. 
  9. Just because a midwife is covered by Medicaid, does not mean she is a safe care provider. 
  10. Just because a midwife tells you home birth is safe, and that she has never been responsible for a baby or mother's death, doesn't mean it is true.  When there is no oversight and no public track record, there is no way to actually know the truth.  You have to decide whether or not to take your chances. 

What Factors Contribute to the Best Outcomes for Out-of-Hospital Birth?
  1. An educated, licensed midwife 
  2. A low-risk pregnancy and health status of mother and baby 
  3. A professional, collaborative relationship between the midwife and local physicians and medical providers 
  4. Routine prenatal care and testing in accordance with professional medical guidelines 
  5. Informed consent leading to a clear knowledge that certain conditions are more dangerous in out-of-hospital settings - and not indoctrination into 'trusting birth' at all costs. A provider should be honest and open about what cannot be handled in an out-of-hospital setting. If the client is led to believe that all complications are handled better at home with a midwife, or if those 'scary' complications only happen in hospitals, then they are being misled.

Other Important Thoughts
  1. Cesareans are not the worst outcome.  A baby who is injured or does not survive birth is the absolute worst outcome, especially when that death or injury was fully preventable. 
  2. Collaborative Care Models are on the rise.  Want a natural childbirth?  You have options, many of them.  Look for a collaborative care model where midwives work as part of the fully integrated health care system.   This means the midwife delivers in a hospital or in a hospital-affiliated birth center.  (Not to be confused with a freestanding birth center.)  Many collaborative care midwife groups have their own practices.  You'll have the most highly educated midwives in the country, with emergency care seconds away should you need it.  You'll have licensed, insured care providers working within a defined scope of practice.   

Any mother planning a home birth who goes around touting that it is safe or as safe as a hospital birth does not have, or fails to acknowledge the facts.  A mother who claims her unlicensed midwife is safe, cannot really know without the data on her outcomes to back it up.  A  mother who tells you she is educating herself and choosing not to do any of the prenatal assessments because they are unnecessary or harmful has fallen hard for the fallacy of trusting birth.  Whatever your choices may be surrounding birth, take time to understand the benefits, the risks, and their subsequent consequences before making the decision to have your baby at home. 


  1. Comparison chart of midwives in the United States health care system is available here. Note the many differences midst each state, for Medicaid, by location (whether home or hospital training and experience), and scope/range of practice.

  2. This article describes the differences in Neonatal care for hospitals. Levels of hospitals are discussed and Level l (no NICU), Level ll (Special Care Nursery), and Level lll (NICU) are described with reference to neonatal-infant care. Free-standing birth centers, Out of Hospital Birth locations, or Homebirth locations are not discussed. Most would or should have identical or similar equipment as available at Level I hospitals in Michigan and other states as well. The other main differences would be in personnel. (i.e. pediatricians or specialty physicians) I believe that CPMs are required to be trained in Neonatal Resuscitation...which is the gold standard for nurses in hospitals.
    The chart is a bit easier to understand. Great article because it talks about standardizing care due to better outcomes and lower mortality rates for neonates at various levels of hospitals.