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.)

Are freestanding birth centers "safer" than hospitals?

Expectant Mother: I've been hearing rumors of several infant deaths in your care over the past couple of years and a baby who is currently in the RNICU fighting for its life.  Should I be worried? 

Local Freestanding Birth Center: Here is an updated stat sheet (shows "data" through 2010, even though it's half-way through 2012).  Having your baby at our birth center is still safer than the hospital.  

Expectant Mother:  Really, safer than the hospital?  

Local Freestanding Birth Center: "Freestanding birth centers have demonstrated superior safety.  Safe and satisfying outcomes include significantly lower cesarean rates than the nation-wide average of 32%."  "Birth is as safe as life gets."  

I feel compelled to address some of the myths women are being told in our own community.  The first is noting that safety should be defined as much, much more than whether or not you have a cesarean.  The way your baby is born has nothing to do with whether the labor & delivery was "safe".  What matters most is whether you both come through the experience alive.  

Safety is defined by Merriam-Webster dictionary as, "the condition of being protected from, or unlikely to cause danger, risk, or injury."  Ignoring risk factors, inviting clients to opt out of assessments that would determine risk,  and pretending that risks don't exist during childbirth, is not what I would consider safe.  Implying that having a cesarean is the enemy, a danger to be avoided, or that having one is "un-safe" creates a fear in expectant mothers that shouldn't be perpetuated.  Consider for example a mother who ends up needing a cesarean for reasons that couldn't be avoided in order to keep her baby safe.  Her first thoughts would be about how dangerous it is for her and baby instead of understanding its necessity.  A planned, pre-term cesarean without medical conditions is one thing, a cesarean that saves lives is another.  Using statistics as scare tactics and without context is unethical.    

I would also note that having a "satisfying" birth has nothing to do with safety.  Approaching birth with the priority being about the "experience" instead of the safety of babies and mothers is absurd.  While I believe that everything should be done that possibly can be done to ensure the experience is positive, ultimately the safety of the baby matters more.  It is not acceptable to sacrifice safety for a satisfying experience, rather the two should work together with an understanding that sometimes safety takes the driver's seat.  The mother I mentioned in the previous paragraph who had to have a cesarean, deserves to know her baby was born just the way he or she needed to be and to be no less satisfied because of it.  When cesareans are made out to be the standard by which we measure safety, we have a real conflict of interest on our hands.   

While I appreciate that no major surgery, cesareans included, come without risks, there are many more immediately dangerous circumstances that can come during labor that could cost your baby his life, put him at risk, and place him in a situation that is ultimately not safe at all in a freestanding birth center setting. ACOG President Kenneth L. Noller, MD, MS, states, “Even a normal pregnancy can become high-risk with little or no warning, and serious, sometimes life-threatening complications may arise for the woman and her fetus.”  He noted that shoulder dystocia occurs in one in every 200 births and listed the frequency of other complications:

• prolapsed umbilical cord: 1 in every 200 births
• life-threatening maternal hemorrhage: 1 in 250
• eclamptic seizures: 1 in 500
• uterine inversion: 1 in 700
• Apgar score of 0–3 at 5 minutes: 1 in 100 to 200.

These situations should be considered far more dangerous for your baby than a cesarean, and furthermore should be the foundation for discussions about the safety of out-of-hospital birth and it's relative "safety".  Instead, the birth center in this example is referencing cesarean rates and not addressing the real complications mothers need to be aware of if they are going to be truly "informed" about the risks they are embarking upon by choosing a freestanding birth center.  Neglecting to share the real risks that would define measures by which safety could be adequately assessed is not informed consent, nor is it honest, nor is it honoring the rights of women to make choices for their own well being.  No one can argue that based on proximity alone and immediate access to medical technology, hospital birth has to be considered safer than having a baby farther away...even if it's "only 12 minutes from the hospital".     

I need to state the obvious, of course a freestanding birth center with no medical equipment or medical personnel, is going to have a lower cesarean rate when compared to a hospital.  They are comparing apples to oranges here.  A freestanding birth center doesn't do surgery and would have a cesarean rate of 0%.  A hospital, taking on all kinds of high risk births including breech and delivery of multiples, etc, would of course have a higher cesarean rate in comparison.  Does this mean they are somehow not as safe in overall practices?  The claim doesn't even make sense.  Nothing about the rate of cesarean in either birth center or hospital addresses why a birth center would be safer.  Wouldn't the outcome, a baby and mother who are alive, be a better determining factor of safety, regardless of how the baby is born?  The statement about cesarean rates is nothing more than a distraction, a way to avoid answering the question, a way to influence a woman's feelings about cesarean delivery in a subtle way. 

Mothers also need to understand that a freestanding birth center in Michigan is not a licensed facility and does not report their outcomes to the state or anyone else.  There is no data to support the claim that giving birth outside the hospital is somehow safer than giving birth in the hospital. In fact, when babies who die are transferred to the hospital in an effort to save their lives, they are counted as the hospital's loss, as we learned from personal experience.  There is no body of oversight, no third party checking the "data" on the handouts a birth center distributes, and nothing that gives what is printed on that paper any kind of credibility.  There cannot be evidence to prove the birth center's safety if there is no reported data about outcomes that would directly demonstrate safety margins. 

Studies that have been done to compare safety and mortality rates of out-of-hospital birth to in-hospital birth, consistently show that out-of-hospital birth is 3-4 times more risky.  (See Wisconsin's WISH website)  Another interesting point to be made here is that MANA (Midwife Alliance of North America) did conduct their own study about mortality rates in home birth. When the study was completed, they decided to keep the results private, only issuing the release of their findings to researchers who sign a contract, agreeing to use the information to advance the cause of midwifery.  Hmmm, something to hide? 

A birth center's safety can only be considered "superior" when compared to free or unassisted birth.  You don't want to find yourself in a room with a care giver who views cesarean rates as the defining standard for safety assumptions.  Please make sure you have real conversations about risks and safety before choosing to have your baby outside of a hospital or hospital run birth center.  Are hospital's perfect?  No, but real risks, like your baby not surviving, are even higher when you choose to have your baby at a freestanding birth center.  Make sure you're in the hands of a care provider who is being honest with you about potential complications, risks, and all matters that would impact you or your baby's safety.  It is one thing to be honestly and accurately informed in making choices about where to have your baby, and quite another to make a choice without knowing the truth.        

Neonatal Mortality Part 1: "Babies Die in Hospitals Too!"

(This will be a two part post, the latter specifically focused on the populations served and what data says about the outcomes, as stratified by birth attendant for both hospital and out-of-hospital birth.)


Midwife (to a mother whose baby didn't survive out-of-hospital birth):  "I'm sorry your baby didn't make it.  Babies die in hospitals too.  You know, some babies just aren't meant to live.  You could always try again.  Come have another baby with us someday.  We did everything we could, there just wasn't anything we could have done differently."   

Yes, babies do die in hospitals, but there's a little more to it than the statement implies.  Sometimes everything possible was done to save a baby's life, and other times errors are made, regardless of place of birth.  The difference is that in one environment (hospitals) there are protocols, review processes, oversight, regulation, insurance, and the opportunity for accountability...and in the other (out-of-hospital birth) there is not.  The purpose of oversight, review processes, insurance, and regulation becomes abundantly clear.  I'd like to look more deeply at the context and implication of the statement, "Babies die in hospitals too," to gain a more complete perspective.

Let's focus first, on how hospitals are accredited and what precisely happens when a baby dies from complications at birth in a hospital setting.

Our focus is Sparrow Hospital in Lansing, MI, because that is the hospital we know best.  Sparrow is accredited by the Joint Commission, an organization that has accredited hospitals for more than 60 years and today it accredits approximately 4,168 hospitals nationwide. Approximately 82 percent of the nation's hospitals are currently accredited by The Joint Commission.  Listed on a document entitled, Facts about Hospital Accreditation, are statements explaining why hospitals seek Joint Commission accreditation.  Here are just a few:

• Helps organize and strengthen patient safety efforts.
• Improves risk management and risk reduction.
• May reduce liability insurance costs.
• Provides education on good practices to improve business operations.
• Provides professional advice and counsel, enhancing staff education.
• Provides a customized, intensive review.
• Provides a framework for organizational structure and management.
• May fulfill regulatory requirements in select states.

Sparrow also applies for and has achieved many other notable recognitions that can be found at http://www.sparrow.org/recognitions.  Not mentioned there, but relevant to our discussion specifically related to obstetrics, is the MHA Keystone OB study.

     
     "MHA Keystone: OB focuses on eliminating preventable harm to mothers giving birth  
      and their newborn babies in Michigan hospitals. The collaborative integrates    
      evidence-based clinical and science-of-safety interventions that, together, support a 
      culture of safety to prevent harmful outcomes. Strategies are incorporated to prevent
      fetal and maternal harm due to complications of labor induction and management of the 
      second stage of labor. The collaborative aims to reduce the number of birth injuries from 
      the current estimate of three injuries for every 1,000 births in the United States, and  
      aligns with Gov. Rick Snyder’s “dashboard” priority to reduce infant mortality."

Sparrow was one of the 8 hospitals chosen to participate in the MHA Keystone OB pilot study in 2008, and then continued in the large prospective trial that started in 2010 and is ongoing.  When asked about this initiative, the chief obstetrician at Sparrow, Dr. Molly Guerin says, "Data is starting to come in and looks excellent.  The commitment to avoiding preventable harm is job number one at Sparrow.  We are not perfect but we strive for perfection at all times."  I then asked Dr. Guerin a series of follow up questions.  Here is our dialogue: 

Me: What happens when a baby does die in a hospital? 

Dr. Guerin: "At Sparrow Hospital, specific review processes and protocols are in place for any death, including babies.  Nationwide the Joint Commission on Accreditations of Hospitals mandates reporting of and investigation of "sentinel events", which are events that result in harm or risk of harm to hospitalized patients, including moms and babies. (See their website http://www.jointcommission.org/sentinel_event.aspx)

When we have a sentinel event we do a Root Cause Analysis, which is a specific framework for identifying systems and individual causes of these harms, and make appropriate changes if issues are identified.  Sparrow is fully JACOH accredited, is randomly inspected, and has passed all inspections in full." 

Me: Does Sparrow Hospital report doctors whom they suspect have acted negligently?

Dr. Guerin: "We have taken action against individual physicians in the 22 years I have been here, and those physicians are no longer on our staff. Because these issues are part of Peer Review they are confidential. Certain changes in status of hospital privileges are reported to the State of Michigan and also to the National Practitioner Data Bank." 

Me: Dr. Guerin, am I right in pointing out that what you have stated are the steps Sparrow takes upon themselves to report questionable circumstances?  What can the patients do in terms of reporting questionable care?  

Dr. Guerin:  "Patients can report complaints to the Risk Management Department directly at Sparrow.  These complaints are taken very seriously.  The can also report adverse care, and negligence to Licensing and Regulatory Affairs to request a state investigation.  Patients can  file a lawsuit if they feel negligent circumstances have occurred that have not been resolved by other means."  

Conversely, let's briefly look at what happens when a baby dies in home birth or at a freestanding birth center.  You could report you concerns to NARM, but their process for "complaints" is a peer review, essentially group therapy for when you have had a bad outcome among your colleagues.  Nothing gets submitted to NARM from those peer reviews and none of the "recommendations" are required changes in practice.  I've heard it described as, "Fight Club with all the oaths of silence."  When MANA and NARM were approached about how many midwives in MI have had disciplinary action taken or credentials revoked, they would not disclose the information.  In fact, they couldn't even tell us how many CPMs were certified and working in MI.  I guess it's true that midwives do police midwives, just not very safely, effectively, transparently, or responsibly.  

Some wonder if doctors & nurses are held accountable at all?  While I recognize this isn't a perfect system, doctors and licensed midwives are more likely to be held accountable than unlicensed midwives with NO system of accountability and NO insurance.  There is good reason for oversight and dangerous consequences without it.  For disciplinary actions taking place over the past 7 years against licensed individuals in MI, visit this link: 

Disciplinary Action Reports (Licensing & Regulatory Affairs for the State of MI)

Negligence is negligence no matter where it happens, in a home or hospital.  The point is that there must be mechanisms in place to hold responsible parties accountable, to consistently review & improve practices taking place.  Babies do die in hospitals, true, but at least there is an immediate system of review, mandated reporting of outcomes, and malpractice insurance as a means of recourse.  In addition, hospitals are licensed facilities, full of licensed professionals, both of which have oversight and opportunity for reporting negligent circumstances. 

A freestanding birth center has no such oversight, as they are not a licensed facility.  A CPM or DEM?  No such regulation exists in MI.  They are not licensed or insured, and they are not mandated to report outcomes.  When a baby dies at a freestanding birth center or at home, it's as if it never happened and there's not a damn thing you can do about it.  There isn't any opportunity for recourse in any way.  While no system is perfect, something is better than nothing.   

                      
10 cm blog ~ "Babies Die in Hospitals Too"

The real reason I chose a birth center

I'd like to welcome a guest post today by a Lansing area mom. Do you have an idea for a post topic? Are you interested in sharing your story? We would love to hear from you. Please get in touch with us here. 

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It took me a year, but I think I am finally able to be honest with myself about why I wanted to have my baby at a birth center.  I didn't chose a birth center because I thought it was safer. Or because I was scared of the hospital. Or because I think natural birth is better than medicated birth. I went to a birth center because I was lonely and I wanted to meet people.  That's the truth. Let me explain.

My husband and I moved to Lansing a little over a year ago from another town in Michigan. We got pregnant and had our first trimester of care out of state. When we came home I felt anxious to start building my social "nest" - surrounding myself with people that would support me through the rest of my pregnancy and into parenthood. With all of my friends and family out of town (and out of state) and no local network of colleagues or acquaintances since I work from home, I felt terribly isolated. The way I saw it, I had about twenty weeks to build a social hub for myself and my baby. How could I do it?

Then I landed on the perfect answer: I could have my baby at the local birth center - Greenhouse Birth Center! Plugging into that community of midwives and families seemed to be the fastest and easiest way to gather support for my motherhood journey. I felt that if I had a hospital birth, I would miss out on a one-time chance to forge meaningful, long-lasting friendships . . . the kind of relationships that build up around powerful, shared life events (like birth). Have you ever heard a woman talk about her hospital "community?" Me neither.

Through our pre-natal care, I did feel that I was building close relationships with the midwives. We talked for hours over the course of our pre-natal visits. They asked me about my Thanksgiving dinner. They met my mom when she was in town. They gave me hugs. We laughed, we cried . . . I figured we were well on our way to being buddies. I didn't have as much interaction with other moms as I had hoped (our birth class was really small) but I figured that would come after our son was born with Mommy & Me classes, breastfeeding support, etc. All in all, I felt very comfortable and welcome at the birth center and that was just what I needed . . . a place to go where everybody knew my name. As my due date approached I felt very confident. Not only was I healthy but I trusted that the close relationships I had been forging with my caregivers over the last 20 weeks would come in super handy during labor. I imagined that the midwives would know exactly what to do and say to help me. I also felt certain that they would support me if and when I needed additional help or asked to go to the hospital. Through all of this, it never occurred to me that we would have anything less than a stellar labor/delivery at Greenhouse Birth Center. After all, I had only ever heard positive things!

Unfortunately, I did not end up having a great experience. I had a frustrating labor and a sloppy hospital transfer. I asked questions during labor and got blank looks. The midwives told me I was completely dilated and encouraged me to push when it was too early. They stalled when I asked to go to the hospital after pushing for three hours then told me that, if I went, I would probably have an emergency c-section (which I didn't). We arrived at the hospital and spent the next 30 minutes answering basic health questions and filling out insurance forms, since we weren't pre-registered. Our midwife came with us but did nothing to assist in the transfer of care. We felt like people off the street. All in all, the midwives were passive and at times downright unprofessional during the time when I most needed guidance and support.  Happily, our care at the hospital was excellent and our son was born healthy. But my carefully laid plans for having the birth center as my social hub post-partem had gone right out the window.

I didn't feel like continuing relationships with the people who had disappointed me. I also felt embarrassed about "failing" and going to the hospital - how could I face other birth center moms with my story? I felt confused and insecure. Those feelings all persist but now, more than anything else, I feel angry at myself for making such an important decision based on my emotional needs. By placing such high value on my social "birth experience" as a woman and a mom, I actually jeopardized what was really important: the health and wellness of our baby. I will always regret that.

I wanted to write this post because I don't think my mindset in choosing an out-of-hospital birth was unique. After all, it seems that most couples these days are raising children far away from their support network of parents, siblings, relatives and friends. Unfortunately, the people that matter most to us - the people we want around during challenging times - are often scattered far and wide. For women, I think this distance is especially difficult during the childbearing year. I know it was for me. But I learned that no matter how lonesome you feel and no matter how much you crave a place to belong, it isn't appropriate to make important decisions about health care based on emotions. I won't be making that mistake twice.

Ask an OB: Hospital worries

Thank you for your questions! Dr. Molly will answer them as they come in and we'll post a couple to share here on the blog every Monday. Here are two to start us off . . . 

What are three common misconceptions that the NCB (Natural Child Birth) culture promotes about hospitals that you would like to dispel? - Mom of three

1. “You will be strapped into bed flat on your back the whole time you are there”. 

Actually . . . .we don’t want you flat on your back! Please walk, go in the shower, crouch on your haunches, rock on all 4s, roll on our birthing ball, etc.

2.  “The chance for a c section is 40 – 50%”.

Actually . . .  the chance for a c section in a mom who is term, low-risk, and in spontaneous labor is about 15 – 20%. Most of these are done because either the baby won’t fit, or the baby’s heart rate doesn’t tolerate the strong contractions in late labor.

3. “Your baby will be taken away from you and given meds, formula, pacifiers, sugar water and vaccines you don’t want it to have”.

Actually . . .your baby will be plopped right up on your chest at birth, left there till you want him weighed, allowed to nurse as soon as she wants to, room in 24 hours a day, and go home whenever you are both ready to go.

What is the No. 1 fear that women come to the hospital with that they really DON'T need to worry about? -Mom of three

For some reason some women worry they will be a bystander to their labor and delivery – that all decisions will be made without their knowledge or consent, that nurses and doctors have an agenda that they don’t share, and that what the parents want will be disregarded. This is absolutely not true! Please talk with your provider about your hopes and dreams for your labor and delivery – it is our strongest desire to make you happy. If there is a mismatch between what you want and what we think is safe – we WILL discuss this in as much detail as you need.

You can read more about Dr. Maude "Molly" Guerin, MD, FACOG, right here.

Considering Out-of-Hospital Birth? Questions to Ask Your Midwife

Note: "Out of Hospital" birth is defined as home birth or birth at a freestanding birth center, one that is not within the walls of a hospital.)  

A note about pointed questions: If you are embarrassed to ask the questions lest you offend the midwife, don’t be. Any midwife who bristles about these questions needs to be left in the dust. She should have complete composure, no defensiveness and be clear and truthful in her answers. If she can’t act professional with you, how will she act with a doctor in front of her if you transport? It’s a midwife’s job to answer these questions; it’s your right to know the answers.

Are you licensed?  What are your credentials and experience?

Being licensed, regardless of state is critical.  Do not hire a midwife practicing without a license.  Know the laws in your state.  In all states CNMs have a license, but CPMs are licensed in some states, not in others, and illegal completely to practice in yet others.  Even if you find a CPM who is licensed, please thoroughly understand their credential because it is far less education, clinical practice, and experience than a CNM.  The philosophy of their credential is also something to be concerned about. 

How long have you been practicing as a primary midwife for out of hospital birth?  How many births have you attended as a doula? As an apprentice? A midwifery assistant? How many births have you been the primary midwife with supervision and then without supervision at a homebirth for? How many births did you experience in the hospital setting?  

I can’t stress this enough, asking the midwife more pointed questions will give the woman more information than just, “How many births have you been to?”  But, what should the answers be? Because there is no standardization in midwifery education or skills training, the answer depends a lot on the woman.  It’s difficult to evaluate philosophy and character, indicators for how this person would handle your care in the event of impending danger or crisis.  The more specific questions you ask, the more information you have.  At a minimum, you’re looking for someone who has experienced hospital births, complications, transfers as the primary caregiver, and doesn’t hesitate to describe circumstances that were out of her scope of practice whereby care was transferred.  

Do you carry malpractice/liability insurance? 

If your midwife does not carry malpractice insurance, find another care provider.  This is an enormous red flag as it says a great deal about the philosophy under which that midwife is practicing.  Malpractice insurance protects them as much as it protects you.  It establishes a consistent set of guidelines for scope of practice, safety measures, and professional development for the caregiver you are hiring.  Without this is place, they can function in whatever way they please…and if they do act negligently you have NO recourse.  Insurance is a mechanism to ensure your safety and to help families who suffer negligent circumstances like preventable birth injuries and preventable deaths.  Don’t hire a midwife who isn’t responsible enough to carry insurance.  

How do you evaluate risk? 

This is another critical aspect of your conversation.  How much is too much risk and how will it be determined?  I don’t know precisely the exact answer, but your potential midwife should be able to explain exactly what she monitors, looks for, when she might be concerned, when she would transfer your care. 

What defines your scope of practice?

In other words, what types of births do you take on and which would you consider too risky?  Who regulates or determines your scope of practice?  If a midwife is running the show by her own rules, there is a problem.  Ask for a copy of her scope of practice from whomever has issued her credentials…it could be a state board via public health code or ACNM, a national credentialing body for Nurse Midwives.  What are they permitted to take on in an out of hospital setting? 

How do you define “high-risk”? 

Some midwives don’t think anything is too high risk for them to handle.  Many claim to take on only low risk, normal pregnancies, but somehow end up delivering breech babies, twins, women with gestational diabetes, women with high blood pressure…and on and on.  Even low risk, normal pregnancies can go wrong in seconds, but at the very least, establish a boundary of low and high risk in your own mind and with your midwife.  Consult an OB and ask this question too. 

Do you think a hospital is ever necessary and under what circumstances?

Your midwife should be specific about this.   A general “of course they are” isn’t going to cut it.  This question will help you get a sense for her attitude toward hospitals.  Does it sound like a working relationship?  Her answer shouldn’t be about mothers who aren’t strong enough or who fatigue, they should be about specific concerns for the labor and delivery of your baby…prolonged labor (more than 3 hours of pushing with little to no progress), too much pain, meconium present, size of the baby as determined with ultrasound before labor, baby’s position, multiples, high blood pressure, VBAC, gestational diabetes, group B strep...etc.    

What is your relationship with the local hospital?  What privileges or practicing rights do you have at the local hospital?  Does the nearest hospital have a Neonatal Intensive Care Team/Unit? 

Only hire a midwife who has a good standing with your local hospital.  Don’t just take her word for it, ask the manager of the Neonatal Care Unit, Nurses, Doctors, local paramedics.  Ideally, hire a midwife who has practicing rights or privileges to work and transfer along side you as part of your continued care in the event of transfer.  If your nearest hospital doesn’t have a Neonatal Intensive Care Unit or staff, out of hospital birth is not for you. 

What hospital do you transfer to?  What records & personnel transfer with me?  What would happen in the event of transfer?

You need to know where the nearest hospital is that includes a neonatal unit.  It doesn’t really matter how many minutes away the hospital is if your midwife doesn’t catch danger signs soon enough or her fear/ego gets in the way of transferring you in the first place.  A hospital 10 minutes away won’t matter once the crisis has hit.  The key is someone skilled, equipped, and responsible enough to catch it before it gets to that point. 

Midwives are also notorious for taking less than detailed records or sending no records at all during transfer.  You need to know what they note during labor, how that compares to an OB or L&D nurse, and what a transfer would be like.  (See post about what transferring is like.) 

Who determines/decides when to transfer?  What would you say to a mom who asks to transfer during labor?  What complications warrant transfer?  What is your rate of transfer? 

You are hiring a midwife to attend your birth as a professional, a so-called expert on birth.  They need to be clear that they will tell you when you are in danger and be a leader in deciding to transfer.  The decision should never fall on you during labor, nor should you ever be pressured to stay.  If your midwife starts to tell you about how long it will take for transfer to take place, that you’re so close…just a little longer, or if it seems like your midwife is avoiding transfer, indecisive, or stalling, get to the hospital!  .  

The list of transportable reasons is endless and it’s the midwife’s professional responsibility to know what they are. The midwife will surely say something like, “Breeches, twins, high blood pressure, a fever, baby’s heart tones are questionable.” They are hired to know when to transfer (non-emergency) and transport (emergency), but sometimes egos, fear, and mantra get in the way.   

Some states now have an exhaustive list of complications during pregnancy and mandate which of those requires a consultation with an OB and which requires transfer altogether.  If your state does not have these guidelines in place, you are subject to the will of the midwife, making out of hospital birth far more subjective, dangerous, and unregulated.  (Essentially a midwife can do whatever she wants…low risk, high risk…etc.)  If during labor, you or your partner is questioning the situation at all, please be a self advocate and transfer.  

Regarding what the hospital transport rate is, this can be taken any number of ways. Low transfer rate? She only takes very low-risk women, maybe none who’re having their first baby. Or, maybe she stays home hoping complications will resolve or she’s afraid to transport…which directly puts you and your baby in danger.  (See this website if you question whether this happens and how often.) Maybe she has a lot of experience and takes appropriately low-risk women. How are you to know why she has a high or low rate of transfer? You can’t; it’s all in how she sells herself. 

Do you work in conjunction with an OB?  May I have a few visits to get to know him/her?  Under what circumstances might I consult with your OB?

A midwife should always have a working relationship with an OB.  Before hiring any midwife to attend your birth, schedule an appointment to interview the OB as well.  Meet with the OB at the beginning and at the end of your pregnancy (before labor) at minimum.  Talk with them about your plan for out of hospital birth and whether you are a good candidate for this kind of delivery.  Share with them who you have chosen as your midwife.  If there is no relationship with an OB or the two are not mutually agreeing on your plan of care, out of hospital birth should be reconsidered.  

Who is your midwife back-up? 

Some midwives take on more than 3 or 4 clients a month. Be sure to interview the back-up midwives, too, asking these same pointed questions.

How often will I see you during my pregnancy? How long will prenatal visits last?

I’ve never known a midwife to see clients on anything different than the standard monthly until 28 weeks, bi-weekly until 36-37 weeks and weekly until the birth. Plus, appointments are almost always 45-60 minutes long, most of the time being spent on social interaction… getting-to-know-you aspects. The actual medical/technical part lasts less than 15 minutes. When going to an OB, the social aspects are what is often what mothers see as missing. (Please see an important post about emotional attachment and personal relationships, the way they can adversely affect sound decision making and leave you vulnerable to manipulation.) 

What is your philosophy about prenatal testing (Gestational Diabetes, Ultrasound, Group B Strep)?

If your midwife tells you any of the listed tests are dangerous or that they are unnecessary, keep looking.  They do them for good reasons.  If you’re considering more advanced testing, please consult an OB. 

What (emergency) equipment do you use/carry?

The answer should be: Doppler (preferably waterproof) with extra batteries, blood pressure cuff (two sizes), thermometer, glucometer with in-date supplies, lancets, IV equipment with in-date fluids (Lactated Ringers, Sodium Chloride, Dextrose 5% Lactated Ringers are the most common types of fluids needed in birth), in-date Pitocin (which is supposed to be kept cool), Methergine (IM and tabs), Cytotec (for postpartum hemorrhage), in-date lidocaine, in-date sutures of at least two sizes (one smaller one for the labia), in-date Erythromycin eye ointment and Vitamin K for the baby, in-date antibiotics for GBS+ women, scissors, needle holders, forceps (not the kind that pull babies out), oxygen (I always carried two tanks… one for mom, one for baby), a bag and mask with new masks for each baby (they are marketed as disposable; most midwives I knew re-used the masks [after cleaning]), in-date blood draw supplies, in-date catheters, and a Sharps container.

It can be hard to know what answers you’re looking for when you ask a midwife about various complications.  The above list is a minimum and is no guarantee that they will have what they need when an emergency arises.  When emergencies come along they do so quickly, sometimes w/o warning on low-risk, normal pregnancies.  The best place to handle complications is in the hospital.  More important than any equipment is a midwife who appreciates and is skilled enough to spot trouble before it’s too late and has the respect for birth to get  you the help you need.  

If your midwife starts to use fear tactics, telling you the horrors of cesareans, that epidurals will lead your child to be a drug addict, that fetal heart monitoring is only so insurance companies can make a profit, or showing you disturbing videos about circumcision, find another care provider.

Please see our FAQ Page for more information.

Find your state’s public health code and determine what regulations there are for midwives in your state.  If there are none, that is a red flag.  

Nurse Midwives in MI are currently defined under "Nursing".  You will find next to no rules even for nurse midwives in our state.  CPMs, lay midwives, & birth centers are not regulated at all.  There are no safety guidelines for out of hospital birth in the state of Michigan, making standards of education, care, and practice inconsistent and making accountability nearly impossible.  Out of hospital birth in Michigan is an unregulated practice at present. Please see Michigan's Public Health Code  for more information. 

Written by Barbara E. Herrera, LM, CPM (aka Navelgazing Midwife) and augmented by Sara Snyder