Neonatal Mortality Rates Part 2: Who has the best/worst infant morality rates?

This is the second part of our series on understanding neonatal mortality rates, in which we try to answer two questions: “Which is riskier, hospital or home birth?” and "How does place of birth and birth attendant impact outcomes?"  This post will specifically address mortality rates based on data from Wisconsin’s WISH initiative.*

As out-of-hospital birth advocates are quick to point out when a baby dies on their watch, babies die in hospitals, too. This is true. But does this mean that hospitals are less safe? No! One important reason is that the patient populations for home births and hospital births are vastly different. A hospital takes mothers of every kind: healthy mothers, obese mothers, drug addicts, mothers pregnant with multiples, breech babies, preemies, mothers with heart conditions, mothers with high blood pressure, and mothers with every other kind of complication you can imagine. On the other hand, a midwife practicing outside of the hospital is supposed to take on only normal, low-risk pregnancies. Thus, if the safety of the care itself is the same in both places, we would naturally expect the hospital to have higher neonatal mortality rates, given the high-risk population it serves.

You might be surprised to know that is not the case - at least not in Wisconsin.

The data collected in the WISH database can be stratified in many ways.  For our purposes, we have stratified the data by the type of birth attendant. We’ll try to understand how the specific mortality rates for physicians working in a hospital setting (MDs, in this case) compare to direct entry midwives largely responsible for home birth (DEMs, otherwise known as CPMs). We’ll also consider CNMs and their role, since they deliver in both settings.     

The data collected in Wisconsin and presented in the chart below show that the mortality rate for home births attended by DEMs was 4-5 times higher on average during 2003-2008 despite the low-risk client population they serve! 

When you consider that these data include all comers, with high-risk moms tending to choose hospitals and home birth midwives only taking on low-risk pregnancies, things look pretty bad for the DEMs. There seems to be little doubt that care provided by DEMs is much riskier.  The CNM data, however, are more difficult to assess because CNMs can deliver babies in both settings -- hospital and home.  (Note: CPMs would be listed as DEMs in this data set because they are part of the home birth sub group statistics.) 

So let’s look more closely at the role of CNMs and their mortality rates.  The chart above shows that CNMs have mortality rates on par with or even better than MDs. How is this possible when we read that out-of-hospital birth is 3-4 times more risky? Or when the ACOG (American College of Obstetrics and Gynecology) states that perinatal mortality is higher in out-of-hospital births?

To better understand this seemingly conflicting evidence, we asked Deb O’Connell, CNM and home-birth midwife, to answer a few questions: 

Safer Midwifery: Deb, ACOG states that perinatal mortality rates are higher in out-of-hospital births. Is this true? 

Deb: Not exactly. When CNMs are managing out-of-hospital births we have the LOWEST perinatal mortality and morbidity rate in the country. That is actually true regardless of our practice setting, home or hospital.

Safer Midwifery: OK, but you have also said that home birth is not as safe for a baby as being born in a hospital. So I'm a little confused. Can you please explain? I think this can be misread as thinking midwife outcomes are the same or better, when there is so much more to be explained. 

Deb: Sure. The reason that out-of-hospital birth is not as safe for baby (and this not limited to home-birth -- it includes freestanding birth centers) is due to delayed response time for intubation if required.  A CNM who is practicing in an out-of-hospital setting and who is practicing within a strict set of protocols will have roughly the same perinatal outcomes as her counterparts practicing in a hospital setting, and if they are NOT the same or BETTER than she needs to revisit her risk-out criteria.

Safer Midwifery:  Okay, I think I am starting to get it. If I understand correctly, there are really two separate but related issues. For two identical pregnant moms, the risk for out-of-hospital birth will be higher than in the hospital. But high-risk births will tend to go to the hospital, so the patient pool for midwives will be mainly low-risk births. Thus, if we see that outcomes are worse for a midwife practice, we can infer that they are doing something very wrong: either they are delivering poor care to low-risk births, or they are taking on too many high-risk births. Is that right?

Deb: Yes!

Thanks to Deb for helping us think that through! You can see now why things are so confusing. As parents, the number we really want to know when choosing between out-of-hospital and hospital birth is the first one: What's the difference in safety across the two settings for two identical, low-risk pregnant mom? The problem is that we don't see this comparison reflected in the Wisconsin dataset, or in any dataset for that matter. We only see final outcomes that reflect the two confounding effects: higher-risk practice versus lower-risk population.

It appears then that CNMs have comparable mortality rates to doctors when they function under a strict set of risking out criteria.  That being said, for two identical mothers, one giving birth at a hospital and one outside of the hospital, the risk is 3-4 times greater outside the hospital --  and even higher if your CNM is not adhering to  strict risking out criteria. Of course, with poorly trained DEMs or CPMs, the risk of out-of-hospital birth are also likely higher. 

Evaluating the efficiency and relative safety by place of birth & type of birth attendant in Michigan is nearly impossible.  You may have wondered why we used data from Wisconsin for this post.  We were not able to use data from Michigan because as a state we are lacking in our data collection efforts  and reporting outcomes as related to birth.  The type of birth attendant is not included on MI birth certificates, thereby making it impossible to adequately collect data stratified by place and care giver type.   In addition, when midwives aren't required to report their outcomes, data becomes even more vague and consequentially so does proper assessment of outcomes, measures of safety, and relative efficiency.  Michigan needs much revision when it comes to collecting data about birth in order to utilize that data to ultimately improve outcomes for mothers and babies.

*(Wisconsin's Department of Health offers a website/database which gives information about health indicators [measures of health] in Wisconsin. WISH allows policy makers, health professionals, and the public to submit questions [requests for data] and receive answers [tables] over the Internet.)

Lansing State Journal: "Homebirth movement raises questions of acceptable risk..."

The Lansing State Journal has spent 3 months researching birth in Michigan.  Reporter Louise Knott Ahern did countless hours of research and interviews to compile a comprehensive piece about midwifery in the state of Michigan.  The article considers everything from philosophy, to birth options, and safety.  

You can pick up a print copy of the Lansing State Journal today, Sunday, June 3rd, or you can find all the articles, videos, and more at:

"Lawsuit brings home birth movement into the spotlight"

"Home birth movement raises questions of acceptable risk" 

"Who cares how the baby gets here?" 

"How far is too far in a birth emergency?"  

"Where do hospitals fit in with 'normal and natural' birth?"

"Birth Center's practices under scrutiny since March lawsuit"  

"Read local birth stories and share your own" 

(Notes: Be sure to check out the links on the left and right of the article too for extensive resources, interviews, birth stories, and more.  If you start getting pop up boxes asking you for a subscription, just clear your browser's cache.)  

Dr. Amy weighs in on the subject too on the Skeptical OB Blog: 

"Brilliant series on the dangers of home birth"

A full article review by Safer Midwifery for Michigan will be posted tomorrow. 

The Roots of Dogma: Ina May's Religion & the Midwives Who Follow

dog·ma  n. 

1. A doctrine or a corpus of doctrines relating to matters such as morality and faith, set forth in an authoritative manner by a church.

2. An authoritative principle, belief, or statement of ideas or opinion, especially one considered to be absolutely true.

dog·mat·ic  adj.

1. Relating to, characteristic of, or resulting from dogma.

2. Characterized by an authoritative, arrogant assertion of unproved or unprovable principles

After reading the recent article in the New York Times about Ina May Gaskin and her battle for home birth, it all makes sense.  Now I know exactly where the dogma started.  

As I read the article, I learned more about who Ina May Gaskin is on a human level.  It seems to me that her perception of birth is much like a religion.  Her followers even reference her as a "saint" and feverishly distribute copies of "Spiritual Midwifery" to expectant mothers.  Apparently, being a saint these days means that you were involved in a four-person marriage, are proud of doing LSD and attending workshops to process your acid trip, and that you preach to the masses about just how safe birth really is without having any real education, medical training, or reported data to back it up.  The roots of Gaskin's movement are most clearly articulated with this sentence: "The participants in the caravan settled in Summertown, Tenn., in 1971. They took a vow of poverty and veganism and lived communally. Birth was a revered 'sacrament.'"  

Do women have a right to choose any religion they please?  Sure they do.  Do they also have a right to know whom they are following?  Absolutely. But (and this is a big "but") when a mom hires a CPM or a lay midwife to attend her birth, does she fully understand the dogma at the root of that woman's practice?  I don't think so. And this is the big problem that I see.

When a woman seeks the care of a midwife, someone who is posing as a professional caregiver, the expectation is that they operate under certain professional parameters, religion aside.  I have to believe that most women do not understand the dynamics of who it is they are hiring or how the the extremist nature of the "root" philosophy will impact the care she receives.  I know I didn't.  I was looking for a more personal model of care and thought birth to be an intimate experience.  I liked knowing exactly who would attend our birth and that our midwife would be present for the duration.  I thought midwives to be a safe, reliable, professional option...part of our health care system (as some are).  Surely it must be safe if they are running freestanding birth centers in the middle of reputable suburbs.

So what went wrong?  How did we end up in the hands of midwives who were so far from the professionals, the people we thought them to be?  What I didn't understand is the vast spectrum in philosophy that resides within the practice called "midwifery."  I wasn't looking for religion and I didn't knowingly volunteer my baby for sacrifice at the altar to advance anyone's cause, yet somehow that's exactly what happened.  Blind religious faith masked as natural childbirth and sold on a communal platter.  Some might call it a cult as in this post from 10 cm, The Cult of Natural Childbirth.  I must admit, in retrospect, much of this parallel seems eerily familiar.  Especially after reading about where the dogma started and after personally experiencing the backlash from the NCB community after speaking out about our experiences.           

What bothers me most is that the "Big Push" for midwives is aimed at the general population. Women are brought into the care of extremist midwives with specific selling points and marketing tactics that make birth sound alluring and empowering. There is no honest discussion of the real risks involved.  Ina May is a good saleswoman - she has already successfully marketed her cause across the country, with 27 states now licensing CPMs (who are directly trained and credentialed from Ina May's organizations, MANA and NARM).

How is this happening when most don't fully realize just how extreme the founder's roots really are?  How can someone earn a license to attend life and potentially deadly events without an education?   How are these women earning the privilege of attending our births with no oversight or accountability whatsoever?  Dogma cannot be allowed to influence maternity care.  Best practices must be defined, standards of care established, reporting outcomes required.  I hope we can reach women in MI and help them understand the complexity of this issue before Michigan makes the same detrimental mistake. Please visit:  Top 10 Reasons Why HB5070 Would do More Harm Than Good.

Every woman has the right to know exactly where this movement is coming from and what it's all about. They also have the right to know how many families it has adversely affected through infant loss and injury, BUT unfortunately, without regulation to require reporting outcomes, we don't have that data. We just have small voices fighting to be heard.  To read more about some of those small voices, visit: Hurt by Homebirth

Click here for Another reader's review of the NYT article .

To read more about dogma in midwifery visit: 

N.A.R.M ~ No Accountability, Renegade Midwifery

The "Whistleblower Midwife" & More

Midwife Masquerade: What Does Your Midwife Believe? 

Midwife Masquerade: Denial

Should my midwife be my friend?

When Our Baby Died

Freestanding Birth Centers ~ Common Myths Revealed 
The Hypocrisy of Midwifery

The Hypocrisy of Midwifery

I'm growing weary of the hypocrisy that permeates much of midwifery and the accompanying NCB (Natural Child Birth) advocates that can't see the forest through the trees, despite their own great experiences. Those who "sell" natural childbirth say that it is safe and put it on a pedestal. But when a baby dies, they quickly change their tune and say that it was the parents "choice."  Never mind that the risks were never part of the conversation from the start, at least not in an honest way.

How is it that midwives can claim that home birth is safe - as safe as life gets, safer than the hospital - BUT the minute a baby dies the mantra shifts dramatically to place responsibility on the parents as having made the "choice?"  

Dear midwife, ...Wait a minute, I thought you said it was safe?  Isn't that the "choice" I made, choosing something safe, the educated choice that was better for me, for my baby?  I don't remember making a choice to put my baby's life at greater risk?  Did we talk about risks?  I don't remember talking about them, but I do remember talking about how close the hospital was, how sure you were that you could spot trouble with plenty of time, how we are born to do this and babies know how to be born, how you've been delivering babies for 30 years with a spotless record.  I remember choosing you because you told me this was safer for me and for my baby.  I remember all the awful things you taught me about what the hospital and doctors would do to me if we went there.  

I remember you telling me that a breech baby is just a variation of normal, that they tend to fall out.  I remember you telling me that you were confident in delivering him, that we didn't need another, more experienced midwife to be here.  I remember you telling me that recent research supports vaginal breech delivery and that we were good candidates for said delivery.  I remember you telling me you watched a video once on breech birth, was it Ina May's from 1980?  I remember you teaching me to trust birth, and building a relationship in which I would trust you, and I did.  Turns out that trust is exactly what blurred my rational thought.  Our baby never came home.   I trusted you to know what you were doing and to tell me the truth about risks involved so I could make a "choice".  

Instead, the choice people speak of was taken from me, by intentionally manipulating information and conveniently avoiding conversations about real risks involved.  Perhaps I should coin the phrase "choice rape" here. 

Things get even uglier when NCB advocates start defending negligent midwives by saying, "Don't take my choice away just because things went wrong for you.  Maybe you should  have done more research and picked a better midwife."  Why is it that in the Natural Child Birth movement, women are continually exhorted to "educate yourself, mama!" and "take responsibility" for your birth? We don't do that with any other aspect of medical care -- we don't tell women take responsibility for their own breast cancer treatment! Plus, to what degree can a person truly educate themselves when their main tool is the trust they have with their care provider (one who claims to be a professional), and frankly, Google?  I am not a researcher, nor am I a physician.  I am a mother who trusted her care givers to be professionally competent & honest in an area that they posed as an expert.

Dear midwife, . . . Why is sharing the truth about adverse care so viciously attacked?  Why does your good experience with a midwife mean you were smarter than me or did better research?  Why does your good experience mean we should excuse situations that weren't handled properly?  Do you not care about the fact that negligence is happening and being brushed under the rug?  Why should we not hold midwives professionally accountable?  Why should they fly under the radar without reporting outcomes, getting a degree, or carrying insurance?  Why is this about hoping you get lucky in whom you choose to attend your birth and not about consistently reliable standards of care & ethical practice? Why does asking for midwifery to improve its practice, be accountable, and function in a way that is professionally safe, somehow threatening to a woman's choice?  Holding midwives accountable is about doing the right thing, about making negligence known, and ensuring bad things don't happen to other families, not about taking away anyone's choice!   Why wouldn't we aim to improve midwifery if it really has something to offer?   

The hypocrisy has to stop.  Either out-of-hospital birth is safe, or it's not.   
A midwife is either ethical and responsible 100% of the time, or she's not.  Women are being educated about real risks or they are not.  
We're either making a truly informed "choice" or we're not.  
Midwifery is a profession of highly educated professionals, functioning on behalf of the safety and a well-being of mothers and babies...or it's not.     

Related Posts:

Ask an OB: "Risk Out" Criteria

Midwife Masquerade: Denial

The Importance of Defining Risk

Considering Out-Of-Hospital Birth?  Questions to ask your midwife.

What We're Seeking: Defining "Birth Center"

"What We're Seeking" is a bi-weekly series that expands upon Safer Midwifery for Michigan's statement of purpose.  This week's post examines more closely, the current state of "birth centers" in Michigan and further indicates improvements Michigan families deserve.

Freestanding birth centers are not currently regulated in any way in the state of Michigan.  I could literally wake up tomorrow, call myself a midwife, and open a "freestanding birth center" in my garage according to current MI laws.  "There are 215 freestanding birth centers in the United States, with more in development. The number of birth centers has increased more than 20% over the past 5 years; they are regulated in 41 states." (American Association of Birth Centers.  http://www.birthcenters.org.  Accessed March 30, 2012)  

What is a birth center?  

The term "birth center" refers to a facility that specifically is designed around birth.  Birth centers are generally more in tune with supporting and nurturing a woman in labor.  In Michigan, we have birth centers that are attached to or affiliated with hospitals.  We also have "freestanding birth centers," which is an entirely different model and a body of absent regulations.

 

What is a" freestanding" birth center?

 A freestanding birth center is one that is not affiliated with a hospital or a physician.  The birth center may have a consulting physician, but this relationship is as your midwife determines a consultation is necessary.  It is not in a capacity of oversight.  Freestanding birth centers are not required by MI law to be licensed as a facility or insured, nor are there any regulations that specify when you should consult a physician.    

How is a birth center different from a hospital?  

A birth center's mission is to support and perceive birth as natural and normal first.  The staff is trained to support women and create an environment that embodies this mission.  You may find options in a birth center that more traditional hospitals don't offer, such as birthing balls, water birth, birthing stools, etc.  A freestanding birth center goes further to offer things like homeopathy, placenta encapsulation, and the freedom to birth without any rules or regulations in place.

Freestanding birth centers do not have emergency medical equipment beyond oxygen.  They cannot intubate or give medications that would be used in a resuscitation circumstance. They do not use Electronic Fetal Heart Monitoring, instead using intermittent Doppler assessments.  Midwives working at a freestanding birth center may or may not be licensed as individual, may or may not carry insurance, and may or may not be trained in NRP (Neonatal Resuscitation Program).  The bottom line is that in the event of an emergency, they are under equipped for life saving measures. 

     

Who works in a birth center?

In a hospital affiliated birth center, you care is primarily with a licensed, nurse midwife.  If at any time during your pregnancy or labor complications arise, your care would shift to that of an obstetrician at the same birth center or hospital.  

In a freestanding birth center, midwives, doulas and other staff run the facility.  Some may be licensed nurse midwives, others certified professional midwives (no license), and other apprentices or lay midwives (also not licensed).  Often times midwives in a freestanding birth center have a physician they will work with to refer clients they determine to have complications.  (Bear in mind that this determination of need is solely at their discretion as there are no regulations.) 

Are birth centers safe?    

This is subject to opinion and definition of "safety".  It is our belief that a birth center affiliated with a hospital is the safest alternative to a hospital birth.  Medical technology and staff are immediately available and they have high standards for education, scope of practice, and review of outcomes.  It seems to be the best collaboration at present, between out of hospital birth and traditional maternity care.  As you will read in many of our other posts, without defined regulations, standards for education, defined scope of practice, and without reporting outcomes, freestanding birth centers vary widely in ethical practices.  This poses great risk in terms of safety.  It's difficult to determine what you're really getting into. 

Are birth centers licensed, insured?

Hospital and physician affiliated birth centers are licensed and insured, as are the nurse midwives who work in these facilities.

Freestanding birth centers may be insured, but many are not as it is not required by law.  Freestanding birth centers are not licensed through the state of Michigan as facilities.  Some of its employees may be licensed as individual professionals if they hold the appropriate credential (CNM), while other employees are not.  There is no requirement for any midwife at a birth center to have a license.

Are birth centers "accredited"?

Some freestanding birth centers are "accredited" by a national third party who supports regulation.  To find out if your birth center is accredited, please visit this link. Click on the "parents" tab and search by zip code.  If the birth center is accredited, it will say so in parenthesis next to the name of the birth center.  (Note: The Greenhouse Birth Center in Okemos is NOT accredited.  In fact there is not an accredited, freestanding birth center anywhere in MI.)   

What actions would improve freestanding birth centers? 

A freestanding birth center is essentially electing home birth in another house with no regulations, no insurance, and no reporting of outcomes.  In order for birth centers to be considered safe, they must be licensed as facilities & individuals, insured, and required to report all out comes. They should also have a board and policies established to review practices regularly, including insight from outside their own practice.  Even if these practices were in place, proximity alone makes them a greater risk to get the help you need in the event of an emergency.  

Ask a Midwife: "Risk Out" Criteria

What are some "risk out" criteria for home birth? In other words, what are some things that might make a woman (and her midwife) change her mind about pursuing an out-of-hospital birth? -- Grand Rapids mom

As a provider (nurse-midwife) attending home births, one of the biggest challenges I am presented with is informing a woman that she is not (or is no longer) a candidate for a home birth. Why is this a challenge? Because it will disappoint her. One of the “myths” surrounding the natural childbirth community is the idea that having a labor/birth at home is a choice for all healthy women. However, there is often a difference between being “healthy” and meeting a medical criteria for a home birth that will optimize outcome for both mom and fetus/ baby.

A woman can be “healthy” (or have a self-perception of health) and still have a medical/ emotional diagnosis that risks her out of having a home birth. An example would be a woman with a history of seizures, even if the history were a remote one. She would still risk out of having a home birth. Another example would be a mom with a history of having insulin-dependant gestational diabetes with her previous pregnancy. She may be “diabetes-free” currently but her HISTORY of having the insulin-dependent GDM risks her out. Other factors are fetal-related as opposed to maternal-related issues. Malpresentation is the most common fetal related risk factor for a home birth, with breech presentation being the most prevalent at a rate of 2-3% of pregnancies. 

The following is a list of common risk factors that "risk out" a woman from having a home birth in a responsible home birth practice. It is not an exhaustive list but includes many of the issues we have come across while interviewing clients and managing pregnancies within our practice. Many times we will co-manage gals that “risk out” of a home birth with their physician(s) and will provide continuity of care for them in the postpartum period as well as be present for them during the hospital labor/birth. Here is the list:

1	Noncompliance with visits, scheduled screenings, testing during pregnancy
2	History of previous cesarean section
3	Current/History of seizure disorder
4	Current diabetes (and history of Insulin Dependent Gestational Diabetes)
5	Current fetal malpresentation (breech, transverse lie)
6	Placenta Previa or Marginal Previa
7	Current drug and tobacco use
8	Current alcohol dependence
9	Current mental illness that involves thoughts of harming self or others
10	Home that is greater than 30 minutes from a hospital or paramedic station
11	Home that does not have running water, heat and electricity
12	Pre-eclampsia during pregnancy
13	Insulin-Dependent diabetes during pregnancy
14	Fetal anomaly detected during pregnancy that may compromise neonate if born at home (cardiac anomaly, cleft palate, gastroschisis, ect).
15	Pregnancy before 37 weeks
16	Pregnancy after 43 weeks (we require antenatal testing at 41 weeks weekly and if, at 42 weeks, mom wishes to continue plans for a homebirth, she is counseled on increased risk of meconium and the fact that we will no longer manage birth at home once meconium in noted.)
17	Poor support system in place for days after the birth
18	History of postpartum psychosis
19	Multiple gestations (twins, etc.)
20	Fetal demise during pregnancy

The article links below are pertinent to this topic. Please keep in mind that the Committee Opinion from ACOG (American Congress of Obstetricians and Gynecologists) does not reflect the difference between planned home births attended by CNMs and “other midwives”. Unfortunately we are all lumped in together, which is very disappointing since it is clear that Certified Nurse Midwives (CNMs) have the LOWEST neonatal mortality and morbidity rates of ALL providers both in the planned home birth and planned hospital birth settings.

Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ (Canadian Medical Association Journal) September 15, 2009 vol. 181 no. 6-7.  

Planned home birth. Committee Opinion No. 476. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:425–8 

"Ask a midwife" is a write-in series here on the blog. If you have a question for our Certified Nurse Midwife, please share it with us here.

Free standing Birth Centers: Common Myths Revealed

The quotations below are taken from the website of Greenhouse Birth Center, a free standing birth center in Okemos, MI. Many of these statements - or versions of them - inform the philosophies and practices of birth attendants nationwide. They are reassuring and empowering. They are also woefully incomplete and oversimplified.  As with many things, birth cannot (and should not) be summed up in one sentence, one phrase or one mantra. For mothers considering out-of-hospital birth, it is essential to be able to think critically about statements like these. After all, birth is complex and our understanding of it should be equally complex. To that end, we've taken these statements of belief and fleshed them out a bit to paint a more realistic picture of birth and maternal care.

• "Birth works."  Birth often works, but not always.  Sometimes women and babies need help. 

• "Just as our bodies know how to grow and nurture our babies, they know how to give birth and how to feed them."  Our bodies are beautifully designed, but they don't magically know how to give birth or how to breastfeed successfully all of the time.  They are not perfect in function.  We have intuition, but we also have experts to help guide us when our bodies need help.  Birth and breastfeeding come with great challenges for most of us.  Many women and many babies have died during childbirth. 

• "The very things that help you go throughout pregnancy safely and well are the things that will help you give birth safely and well - health, confidence, support, privacy, and tender loving care."  What's missing from this list of what will "help you get thorough birth safely" is careful monitoring by educated, skilled professionals who can and will recognize signs of danger, acting appropriately to keep you and your baby safe.  Another  key factor in determining "safety" is the availability of emergency technology, equipment, medications, and medical personnel.  It's irresponsible and crazy to think if you're confident enough, trust birth enough, and are supported with love that things will turn out fine.  I used to think that, and it cost my baby his life. Safety means you and your baby go home alive, anything less is unsafe. 

• "The best way to care for a pregnant woman is to educate her, support her, nurture her, and help her watch for problems so that she can avoid them or correct them when possible."  All true statements.  You have to first accept that problems exist in order to appropriately address them.  Then you have to have the skills and knowledge to recognize them when they do appear.  I would add that appropriate transfer of care when the "problems" detected are outside one's scope of practice is critical. "Education" does not mean indoctrination and manipulation of research, data, and truth. 

• "That if a problem should arise with mother or baby, consultation and collaboration with appropriate health care professionals provides safety and smooth transition of care when needed." Also true statements, but without guidelines this determination of when the transition of care is needed, is very subjective.  There are no rules to follow, and nothing that defines what is high versus low risk.  To many home birth midwives, high risk is "just a variation of normal".

• "That the presence and assistance of experienced women -the midwives- are useful guides to mothers in their journey of pregnancy, birth, and parenting."  The ideal is there, and likely the intention, but for many of us we felt like we were "unassisted", left to follow our intuition, with no real guidance at all during labor.  "The presence and assistance of experienced women" is great as long as the relationship stays professional in making clinical decisions as oppose to influencing clients with personal agendas.  

• "That a safe, comfortable space, designed for gentle birth and individualized care is the ideal way to provide our services to the women in our community who want alternatives to the medical model of care but are not comfortable with a home birth."  I think this statement bothers me most.  The insinuated "safety" of a freestanding birth center is such an illusion!  There is nothing safer about giving birth in a different building than your own home when that building (aka freestanding birth center) adheres to no regulation, has no medical equipment for emergencies, has no insurance, has no guidelines for scope of practice, and doesn't report its outcomes.  To insinuate otherwise is fraudulent.  And, I would further add that sometimes birth is rather violent, even in a comfortable space.   

Please visit the Reformed CPM's post entitled, "Just Believing Does Not Make it So" for more on this subject. 

Ask a Midwife: How do I pick a good midwife?

"What should I be looking for in good midwife?" -- A mom considering home birth

Parents who choose to have their birth at home should be sure their midwife . . .

1. Is a Certified Nurse Midwife with experience managing both low and high risk pregnancies.

2. Is licensed to practice in her state.

3. Carries malpractice insurance.

4. Has a professional relationship with an OB/GYN team for collaboration, consultation, 

referral and transfer if needed.

5. Has a well organized transport system for her clients.

6. Is wiling to share her "risk-out" criteria, her protocols and her stats with you.

7. Asks you how far your home is from the hospital that has an OB Unit. Ideally, you should live no further than 15 minutes from your nearest hospital if you are attempting home birth.

8. Has another CNM or RN that attends EACH and EVERY birth with her AND they are both currently in their BCLS (basic cardiac life support) and NRP (neonatal resusitation program) certifications and have also had experience managing both low and high risk pregnancies.

9. Does not attend high risk deliveries at home including breeches, twins or VBACs.

Other points to consider . . .

• Home birth is not safe for everyone.

• Birth is not to be trusted - it is to be RESPECTED.

• Home birth is not as safe for baby as being born in a hospital. The NCB (Natural Child Birth) community can state that it is - and in the past I have stated it as well - but research has shown differently. Parents need to be aware that if the midwife they choose does not know how to recognize / anticipate when normal is turning into abnormal VERY QUICKLY , the results can be deadly for mom and baby.

• Women do not have the right to make choices for their baby. Your birth experience does not trump the safety of your baby. 

"Ask a midwife" is a write-in series here on the blog. If you have a question for our Certified Nurse Midwife, please share it with us here.