Is home birth safe?

June 26, 2012 · 11 comments

a newborn after home birth a newborn after home birth

Yesterday Michelle Goldberg published a piece for Newsweek on home birth that appeared in The Daily Beast. She interviewed me as part of her research for it, and it talks about the darker side of home birth, which I have recently been exposed to.

It’s spawned even more home birth discussion, like this article in Jezebel, which sound jarring to those of us who are firmly in the home birth camp, but ends with a great question: “A call for more studies on home births does not equate to doubting the amazing capabilities of the female body. After all, what’s more empowering than being completely educated when making a choice?”

I am a home birth and midwife advocate, and I’m glad these articles are being published and these questions are being asked. Anyone who considers home birth should know all sides of it — the empowering side championed by Business of Being Born (and me!), and the devastating side of women who received sub-standard care from midwives they adored and trusted.

I strongly believe we should improve access to home birth and midwives, and by doing so we will provide more options for mothers to have a safe and satisfying birth. I also believe a lot can be done to learn about exactly how safe home birth in the U.S., as well as what can be done to make it safer.

Only 3 states of the 26 that currently license midwives collect and publicly release annual licensed midwife statistics: California, Colorado, and Wisconsin (a few other states provide midwifery and home birth statistics based on information from other vital records, but these are the only states that specifically gather information from their licensed midwives). Colorado hasn’t released their latest numbers from 2010, but so far the results from California and Wisconsin all show higher perinatal and neonatal mortality than the overall state numbers.

Because home birth should only be reserved for the lowest risk pregnancies, these numbers from California give me pause:

  • 16% of licensed midwives didn’t report their statistics
  • 18% of labors that began at home transferred to the hospital
  • The infant death rate after home birth is 7/1000 – higher than any measure California takes of fetal, infant, neonatal, or post-neonatal mortality.
  • 13 breech babies and 5 sets of twins were delivered at home — conditions which are supposed to be transferred to the care of an OB before labor begins

Now, I don’t think these statistics should be a rallying cry for those who say home birth is dangerous. Even though these statistics are higher than the rest of California, the death rate is close to the overall U.S. infant mortality rate and better than more than a third of individual states. Sadly, it does mean some babies whose lives could have been saved in different circumstances instead died.

More can be done

2010 was the first year California collected these comprehensive statistics, and it was the first year the state collected any statistics from midwives over the internet. I sat in a meeting of the California Midwifery Advisory Board where they discussed the challenges of collecting these statistics, and they knew they had many obstacles to overcome. Even details that seem simple, like ensuring an infant who dies in the hospital after an attempted home birth is only counted once as attributed to the attending midwife, require an extraordinary amount of coordination across agencies and personnel.

So perhaps it isn’t a surprise that 16% of licensed midwives didn’t report — there was a lot of confusion about how to ensure midwives who weren’t on the Web would be able to access the system, as well as making sure all midwives were notified in a timely manner about the new requirement. I hope 2011 is better, and provides even better information when it’s released in the next few months.

The next step

After consistently good data is collected (not necessarily positive or negative data, but data that accurately and consistently records information and trends), the challenge then becomes what to do with it.

Even after one year, critical questions should be asked:

  • Why are 18% of home births being transferred after labor is initiated (this is high!!)? Are there some midwives who have higher transfer rates than others? Can an opportunity for additional training in screening be offered, or does it show there is a lack of alternative care available in some areas?
  • Why is the infant death rate higher than would be expected for low-risk pregnancies and mothers? Are certain midwives taking on higher-risk patients, and if so, why? Is there a population of higher-risk patients that are choosing home birth because they aren’t satisfied with the hospital alternatives in their area? Is there a population of higher-risk patients choosing home birth because they don’t have the means to pay for other maternity care, or because of their belief system?
  • Why are breeches and twins being delivered at home, when midwives are at risk of losing their license? Are clients informed of the risk but choose to do it anyway? Are midwives not informing them of the risk? Are suitable alternatives for vaginal delivery of higher-risk pregnancies being prevented by malpractice insurance policies or other restrictive regulations?
  • What factors did “the system” play into any of these infant deaths? Could they have been prevented by expedited transfer of care between a midwife and hospital, or collaboration between midwife and OB during prenatal care? Were any of the deaths attributable to underlying conditions that were ignored by the midwife, or were some the result of a mother opting out of prenatal tests with informed consent?

In my opinion, recording home birth statistics and interpreting them tells us much, much more than just the safety of home birth in a particular state or area.  Women choose home birth. It’s not the default option for most families because it’s often outside of health insurance coverage and even with growing popularity still a small fraction of all births.

Even if the statistics show a not-so-rosy picture, we need to know, and we need to be able to explore all the reasons why.

If we use the statistics to argue about who dies where and which method is better and who really takes care of women, we miss an important opportunity to identify how to make our system better for women and babies. And ultimately, that’s what any maternity care system should be about.

If you’re considering home birth, please read my article about how to assess your own home birth risk and how to make an informed decision about the best place for your baby to be born.

 Photo credit: eyeliam on Flickr

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{ 11 comments… read them below or add one }

1 areawoman June 26, 2012

You raise some really great questions, and I appreciate your perspective on this issue. As you know, I disagree that an 18% transfer rate is high, but I totally agree that better data needs to be collected. Great post!

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2 Suchada @ Mama Eve June 26, 2012

As I learn more, I’m questioning my previous thoughts about the 18% transfer rate. It was a belief I held from my anecdotal knowledge of home birth, and now it’s something I want to learn more about. If a higher transfer rate is something that saves lives, then there should absolutely be a higher transfer rate. I think the only way to answer that question is to ask more questions, which I sincerely hope CA and other states that license midwives will do.

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3 Abigail July 3, 2012

I had my prenatal care with a midwife and a home birth in British Columbia, Canada where it is completely covered and supported by the government medical system. They’re having great outcomes here because of the major checks and balances that go on with the midwives working within the system. Mine had full hospital privilages and works in collaboration with the local OB’s and nurses. Although I am a home birth convert I doubt I would risk it in the USA because all of the scary stats and horror stories I’ve heard seem to be coming from there. I totally agree with you that the more research the better and women need more safe choices where you are.

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4 Suchada @ Mama Eve July 4, 2012

I was looking forward to hearing from home birthers in other parts of the world! I absolutely agree the more comprehensive systems in other countries where midwives have hospital privileges and work collaboratively with OBs is the safest system for home birth. There are definitely areas in the U.S. and midwives who operate in a similar manner, and in those cases I think the safety is comparable — which is why I’m choosing to birth at home again with a CPM licensed in CA. I hope it’s something that every person considering home birth talks over with their prospective midwives so they understand the pros and cons of their individual situation.

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5 Diane Dawson July 5, 2012

An excellent article. And you really have hit all the issues surrounding the CA statistics. I think all the points you addressed affected the statistics. Each situation is so unique, it is really hard to generalize. So yes – some midwives take on higher risk clients, hopefully with informed consent. Some clients refuse prenatal testing, so you might find a baby with an undiagnosed anomaly. There were also some errors in the reporting. For instance, 1 midwife who reported a death was not even working in California and yet reported her statistics. 2 others made an error in their reports. The statistics were later adjusted to reflect these errors… but the Medical Board chose to meet their publishing deadline and only corrected the errors after the original results were made public. The original form also had some glitches. For instance, if a baby died after transfer to a hospital, it was still recorded as a home birth related death. It may have been. Or not. You can’t really interpret this from statistics.

The statistics are important – but more important is an individual analysis of each tragic outcome.

For what it’s worth, I think an average transport rate of 18% is about right. Some will be higher, some will be lower. The transport rate will vary according to the experience of the midwife, the tenacity of the clients to their original plan, the geography and logistics of getting to a (hopefully) supportive hospital, the parity of the client base (a newer midwifery practice will probably have more first time mothers – and probably longer labors).

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6 Abigail July 9, 2012

Interestingly, when I was deciding on home birth with my midwife she told me that the vast majority of hospital transfers that happen in her clinic is from mothers who change their mind and decide to go to a hospital instead (usually because they want an epidural which is fair enough!). She explained that the rules here are clear that if a mother decides she wants to be moved to a hospital for whatever reason and it’s safe to do so, then the midwife will take her without argument and stay with her through the whole thing. I even had to sign something that said if I asked to be transfered that I would be taken and I couldn’t blame her later for that. It felt really good to know that I had the option of saying, “nope I’m done! I want hard core pain meds NOW!” and she would pack me up and we’d go by car or ambulance without judgement. It really made me able to do a home birth without fear. She also monitored the baby and kept telling me that everything was going normally and that if it wasn’t at any time she was all over it and the docs would be waiting for us at the hospital.

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7 Rachel July 13, 2012

I had no idea that breech babes and twins are required to be transferred per California law… my Oregon midwife has done both, numerous times, and I see no reason why she shouldn’t, if mother and baby (or babies) are healthy, given her experience. Also, there might not be statistics required by the state, but that doesn’t mean that midwives aren’t reporting… a lot of them do (my midwife does) and they report them at the national level. If the states don’t report them, we should blame the states, not the midwives, right?

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8 Sarah @ BecomingSarah.com August 7, 2012

A friend of mine delivered twins in 2011 at home with a midwife – because nobody caught them before labor began. The doppler only ever picked up momma’s heartbeat and one other, the mother turned down ultrasound, and the mother was sick the entire pregnancy so she gained weight at a pretty normal rate and thought she just had an extra-active bugger in there.

Everyone was shocked, but sometimes surprises happen…even in the hospital. I’m not a home birth advocate myself, but I did want to point out that I would expect that some of the conditions which are suppoesd to be transferred in California might not happen simply because they are not detected. My midwife has a transfer rate to the hospital during labor of around 20% with first-time mothers and around 8% with subsequent pregnancies.

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9 nancy geregl August 19, 2012

i would like to be part of the team.

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10 Siri Dennis September 15, 2012

I had 3 hospital births (the first one was a forceps delivery), then a lovely homebirth attended by two experienced, mature community midwives and two of my friends, who were (as I was) second year student midwives. I felt 100% safe and cared for. My last baby was going to be born at home, but after nine hours of labour I lost my nerve and became frightened, and so we transferred to the consultant unit where a fantastic staff midwife emptied my bladder of a litre of urine, allowing my baby space to be born within a couple of minutes. The UK system is very safe and family-friendly; problems arise when women hire independent midwives who are all talk (you can have a lovely homebirth regardless of previous history) and no expertise (you may retain a big piece of placenta and bleed to death in the comfort of your own home). Lots of hospital midwives give holistic care and act as women’s advocates, and all community midwives are required to update their skills by doing shifts in hospital.

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11 Erin O'Brien September 28, 2013

Thank you for your intelligent and measured response. I live in Colorado, planned a home birth, and am in week 41. I know several
Midwives, did my homework, and had every test under the sun done at the local hospital along with my prenatal.

Why? Because I care and wanted to give the best to my baby. I know 3 disaster stories involving OBGYN’s too, and what those cases have in common match what the stories Ms.Goldberg gave have in common as well- utter carelessness on the part of te practitioner and blind faith on the part of the mother. No matter from whom I get my care, you better bet I’m going to be researching it on my own and getting a second opinion if it doesn’t feel right.

There is a 1% difference in infant mortality in this state. I feel, as you do, that individual choice on the part of the mother has a lot to do with that. Unfortunately, those statistics aren’t neatly grouped together for public view.

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