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