Home birth in the US is uniquely dangerous

[ttt]

Interesting. 


www.nytimes.com/2016/05/01/opinion/sunday/why-is-american-home-birth-so-dangerous.html

IS home birth safe? That depends on where you ask the question.

In much of the developed world, home birth is a fringe practice, at about 2 percent of births or less, for obvious reasons: Childbirth is inherently dangerous, and if an emergency occurs, the baby or even the mother may die. Indeed, in the United States, the switch from home birth to hospital birth over the 20th century was accompanied by a more than 90 percent decrease in neonatal mortality and nearly 99 percent decrease in maternal mortality. Antibiotics, blood banking, safe C-sections and neonatology have combined to change death in childbirth from common to rare.

But there are places in the world where home birth is relatively safe, like the Netherlands, where it is popular at 16 percent of births. And in Canada, where it appears safest of all, several studies have demonstrated that in carefully selected populations, there is no difference between the number of babies who die at home or in the hospital.

In contrast, home birth in the United States is dangerous. The best data on the practice comes from Oregon, which in 2012 started requiring that birth and death certificates include information on where the birth occurred and who attended it. The state’s figures show that that year, the death rate for babies in planned home births with a midwife was about seven times that of births at a hospital.

Many studies of American home birth show that planned home birth with a midwife has a perinatal death rate at least triple that of a comparable hospital birth. (The perinatal death rate refers to the death rate of babies in their last weeks in the womb and first week outside it.)

Could racial or economic differences, or poor prenatal care, explain this deadly difference between home births here and in Canada? No. The relevant statistic is again perinatal mortality, and on that measure, the countries are roughly equal.

The problem is that there are two types of midwives in the United States. The first, certified nurse midwives, called C.N.M.s, are perhaps the best-educated, best-trained midwives in the world, exceeding standards set by the International Confederation of Midwives. Their qualifications, similar to those of midwives in Canada, include a university degree in midwifery and extensive training in a hospital diagnosing and managing complications.

The other, certified professional midwives, or C.P.M.s, fall far short of international standards. One 2010 study of midwives published in The Journal of Perinatology found that home births attended by nurse midwives had double the neonatal mortality rate of hospital births attended by nurse midwives, while home births attended by C.P.M.s and other midwives had nearly four times that rate. 

This second class of poorly trained midwives attend the majority of American home births. And yet they are legal in only 28 states; in the rest of the country, many practice outside the law.

They used to be called “lay midwives” or “direct entry midwives,” in recognition of their lack of formal medical schooling. That didn’t sound very impressive. In a brilliant marketing ploy, they created a credential — the C.P.M. — and awarded it to themselves. Many receive their education through correspondence courses and their training through apprenticeships with another C.P.M., observing several dozen births and presiding at fewer. How woefully inadequate is this education? In 2012 the requirements were updated to require proof of a high school diploma.

They seem to believe they don’t need more training because they are “experts in normal birth.” As I often say, that makes as much sense as a meteorologist being an expert in sunny weather. Anyone from a taxi driver to a 12-year-old sibling can handle (and has handled) an uncomplicated birth. The only reason to have a trained attendant is to prevent, diagnose and manage complications, the very things that C.P.M.s never have to learn to do.


Another difference between the United States and Canada is that in Canada home birth is governed by strict eligibility requirements that exclude women at high risk of complications (no twins or breech births, for example). In contrast, the Midwives Alliance of North America, the organization that represents C.P.M.s, eschews such standards. Each C.P.M. is apparently charged with deciding for herself what is safe.

The organization’s statement of ethics in fact rejects “traditional codes of ethics that present a list of rules to be followed.” Instead, “a midwife must develop a moral compass to guide practice in diverse situations that arise from the uniqueness of pregnancy and birth as well as the relationship between midwives and birthing women,” it says. “This approach affirms the mystery and potential for transformation present in every experience.”

The American Congress of Obstetricians and Gynecologists has published 163 clinical bulletins to establish parameters for safe and effective practice for all obstetricians. The American College of Nurse Midwives has published 14 such bulletins. I know of none issued by the Midwives Alliance of North America.

In the absence of safety standards, C.P.M.s have been known to attend births of women with serious medical conditions at home. In Oregon, midwives are protesting the state Medicaid program’s decision to stop covering high-risk home birth, and in Arizona, where midwives cannot legally attend certain kinds of high-risk births, they have been lobbying to have the law changed.

Finally, home birth in Canada is integrated into the obstetric system. Nearly 25 percent of women (including 45 percent of first-time mothers) are transferred to a hospital during labor if there is even a hint that a life-threatening complication might develop. In contrast, I have known C.P.M.s to boast of transfer rates of 10 percent or lower, either because they don’t recognize impending complications or they believe they can manage them at home.

One reason transfers are routine in Canada is that Canadian midwives have hospital privileges, meaning they can continue to care for their patients in the hospital. If American C.P.M.s transfer a patient, they lose control of her.

These midwives might also put off transferring a patient because, if they are operating illegally and a baby is injured or dies, they could face criminal charges.

Personally, I would always opt for a hospital birth. But many women want to give birth at home, and Canada shows us that it is possible for them to do so safely. What can we do to make that true in the United States as well?

It is very hard to crack down on midwives operating illegally. Instead, we should focus on informing pregnant women about the risks and the fact that C.P.M.s would not even qualify as midwives in other developed countries. If women knew, most would not hire them.

But we need to do more. We must abolish the C.P.M. and demand that all American midwives meet international standards; keep women at increased risk of complications from giving birth at home; insist on transfer to a hospital at the first hint of potential problems; and require that midwives have hospital privileges.


Medicine is not regulated by the federal government, so these changes would need to be made on the state level. Home birth midwives will lobby against them, fiercely, while the women who have suffered from home births gone wrong are often ashamed and less willing to speak up. But as long as we allow poorly trained laypeople with watered down credentials to perform home births, we are risking the health of mothers, and the lives of babies.

[karinothing]

Agreed. I have said frequently on here that home birth shold be attended by CNMs.

[NewOrleans]

Remember. You KNOW what's going to happen in here. DO NOT ENGAGE when it starts. Do not empower through questions or arguments. Be like the phalanx in The 300.

[Miss Phryne Fisher]

Does anyone know if there are criminal charges in any states when women go unassisted (planned)? What is to stop these "midwives" from being a "friend" at an unassisted birth?

[mrsdewinter]

Yep. CPMs either need to completely overhaul their standards WRT education and clinical practice, or the credential should be abolished.

That said, CNMs (or physicians) aren't that much better if they are not following proper standards in terms of risking mothers out or transferring when necessary. That's why I think the aspect she mentions about home birth providers also having hospital privileges is important.

[gpw]

You're just begging here. It's shameless, really, ttt .  

[karinothing]

May 1, 2016 12:42:33 GMT -5 mrsdewinter said:

Yep. CPMs either need to completely overhaul their standards WRT education and clinical practice, or the credential should be abolished.

That said, CNMs (or physicians) aren't that much better if they are not following proper standards in terms of risking mothers out or transferring when necessary. That's why I think the aspect she mentions about home birth providers also having hospital privileges is important.

Well I think CNMs could lose their licence if they didn't follow proper standards. My CNMS do not have hospital privledges, but they do work with an OB. they also carry malpractice insurance.

[AJL]

Yep. Home birth is very dangerous in its current state. I dare say that it will not be much less dangerous just because attendants at CNMs.

And for any and all the women who have had a home birth with non-lethal outcomes and want to contradict this fact, your experience does not make it a safe practice.

[mrsdewinter]

May 1, 2016 12:51:18 GMT -5 karinothing said:

May 1, 2016 12:42:33 GMT -5 mrsdewinter said:

Yep. CPMs either need to completely overhaul their standards WRT education and clinical practice, or the credential should be abolished.

That said, CNMs (or physicians) aren't that much better if they are not following proper standards in terms of risking mothers out or transferring when necessary. That's why I think the aspect she mentions about home birth providers also having hospital privileges is important.

Well I think CNMs could lose their licence if they didn't follow proper standards. My CNMS do not have hospital privledges, but they do work with an OB. they also carry malpractice insurance.

Maybe they would lose their licenses.  But I think for home birth providers who don't have hospital privileges, they have incentive to take on higher risk clients or delay transfer, because a hospital birth means they lose their client.  (Not to say that all midwives will do this, but some do).  Whereas if a CNM knows she can still keep that client for a hospital birth, there is less incentive to avoid a hospital birth when it becomes advisable.  That prevents unsafe practice from occurring in the first place, whereas disciplinary action and losing your license is a response to unsafe practice that has already occurred (and may have already resulted in a dead or brain damaged baby).  

Anecdotally speaking, in my experience home birth providers who have hospital privileges seem to have safer practices with clearer risk out criteria.  Also speaking just about my own experience here, I had a homebirth with a physician.  He didn't risk me out properly and regularly took on high risk home births.  He also didn't follow the standard of care with regard to important things like GD testing, or antibiotics for GBS+ mothers.  He was even investigated for several home birth deaths.  Yet he still has his license and is still actively delivering babies at home births.  But he did lose his hospital privileges many years ago.  So if hospital privileges were a requirement for home births, perhaps he would have been shut down years ago.  Unfortunately, unsafe providers don't always lose their licenses or hospital privileges, but requiring both would provide another level of safety checks.

It's a good sign that your CNMs have an OB back up and carry malpractice insurance.  I also think those should both be required for home birth midwives.

[AJL]

Unfortunately, there will be people who'll read this article and completely dismiss it because it is written by Amy Tuteur.

[bears]

May 1, 2016 13:13:45 GMT -5 AJL said:

Unfortunately, there will be people who'll read this article and completely dismiss it because it is written by Amy Tuteur.

Really? I think she's softening her stance. She typically is anti home birth...this very much seems like she is moving to properly regulate it.

[MrsAxilla]

I'm honestly flabbergasted that the majority of women having home births are using a CPN. I mean, not to generalize, but don't most pregnant women pour over car seat reviews and interview periatricians and "research" the safety of vaccinations? Or is that just women on the bump? How do you not know or understand the education and experience of the person delivering your baby?!? Just....wow.

[ttt]

May 1, 2016 14:17:25 GMT -5 MrsAxilla said:

I'm honestly flabbergasted that the majority of women having home births are using a CPN. I mean, not to generalize, but don't most pregnant women pour over car seat reviews and interview periatricians and "research" the safety of vaccinations? Or is that just women on the bump? How do you not know or understand the education and experience of the person delivering your baby?!? Just....wow.

Well, some people, who may or may not frequent this board on occasion, believe that a midwife's education isn't important and that you can't learn about delivering babies from books anyway. 

[MrsAxilla]

May 1, 2016 14:19:10 GMT -5 ttt said:

May 1, 2016 14:17:25 GMT -5 MrsAxilla said:

I'm honestly flabbergasted that the majority of women having home births are using a CPN. I mean, not to generalize, but don't most pregnant women pour over car seat reviews and interview periatricians and "research" the safety of vaccinations? Or is that just women on the bump? How do you not know or understand the education and experience of the person delivering your baby?!? Just....wow.

Well, some people, who may or may not frequent this board on occasion, believe that a midwife's education isn't important and that you can't learn about delivering babies from books anyway. 

Well of course.  But the MAJORITY?  That's crazy!  

[karinothing]

May 1, 2016 13:13:45 GMT -5 AJL said:

Unfortunately, there will be people who'll read this article and completely dismiss it because it is written by Amy Tuteur.

Well hot damn. I have never agreed with anything she has ever wrote and I agree with the majority of this. I think her sayin anything nice about homebirth is huge.

MrsAxilla I think a lot of states ban CNMS from attending home births so many women do not have the option

[karinothing]

May 1, 2016 13:12:17 GMT -5 mrsdewinter said:

May 1, 2016 12:51:18 GMT -5 karinothing said:

Well I think CNMs could lose their licence if they didn't follow proper standards. My CNMS do not have hospital privledges, but they do work with an OB. they also carry malpractice insurance.

Maybe they would lose their licenses.  But I think for home birth providers who don't have hospital privileges, they have incentive to take on higher risk clients or delay transfer, because a hospital birth means they lose their client.  (Not to say that all midwives will do this, but some do).  Whereas if a CNM knows she can still keep that client for a hospital birth, there is less incentive to avoid a hospital birth when it becomes advisable.  That prevents unsafe practice from occurring in the first place, whereas disciplinary action and losing your license is a response to unsafe practice that has already occurred (and may have already resulted in a dead or brain damaged baby).  

Anecdotally speaking, in my experience home birth providers who have hospital privileges seem to have safer practices with clearer risk out criteria.  Also speaking just about my own experience here, I had a homebirth with a physician.  He didn't risk me out properly and regularly took on high risk home births.  He also didn't follow the standard of care with regard to important things like GD testing, or antibiotics for GBS+ mothers.  He was even investigated for several home birth deaths.  Yet he still has his license and is still actively delivering babies at home births.  But he did lose his hospital privileges many years ago.  So if hospital privileges were a requirement for home births, perhaps he would have been shut down years ago.  Unfortunately, unsafe providers don't always lose their licenses or hospital privileges, but requiring both would provide another level of safety checks.

It's a good sign that your CNMs have an OB back up and carry malpractice insurance.  I also think those should both be required for home birth midwives.

See my midwives malpractice insurance prevents them from taking high risk births or deviating from the standard of care. So I think requiring malpractice insurance could serve much of the same purposes.

[AJL]

May 1, 2016 13:38:08 GMT -5 bears said:

May 1, 2016 13:13:45 GMT -5 AJL said:

Unfortunately, there will be people who'll read this article and completely dismiss it because it is written by Amy Tuteur.

Really? I think she's softening her stance. She typically is anti home birth...this very much seems like she is moving to properly regulate it.

I agree with you. I'm a totally Dr. Amy fan. I just know that there are people who see her name and dismiss her outright.

[AJL]

May 1, 2016 14:17:25 GMT -5 MrsAxilla said:

I'm honestly flabbergasted that the majority of women having home births are using a CPN. I mean, not to generalize, but don't most pregnant women pour over car seat reviews and interview periatricians and "research" the safety of vaccinations? Or is that just women on the bump? How do you not know or understand the education and experience of the person delivering your baby?!? Just....wow.

I'm not at all and that's because in many states CNMs are not allowed to attend home births. What choice does that woman have if her state won't legally allow a more qualified medical professional attend her birth at home?

[WanderingWinoZ]

I'm sure the CNM vs CPM are a big part of the problem, but I also wonder about the type of person that chooses to have a home birth & especially one that uses a CPM. Are they part of the group that doesn't trust the medical establishment, gets subpar prenatal care anyways, and is generally an anti-vax type of person? Maybe the take more risks in general and/or are less likely to follow common sense (or empirical medical) evidence about when a PG is high risk or showing complications???

[WanderingWinoZ]

yea, dito PP on the US having some fucked up laws regarding midwives too... I'm not certain about who/which type is allowed, but I think the doc's have fought pretty hard against midwives in general- which sucks!

I delivered with midwives at a hospital & loved my experience.

[karinothing]

May 1, 2016 15:57:48 GMT -5 WanderingWinoZ said:

I'm sure the CNM vs CPM are a big part of the problem, but I also wonder about the type of person that chooses to have a home birth & especially one that uses a CPM. Are they part of the group that doesn't trust the medical establishment, gets subpar prenatal care anyways, and is generally an anti-vax type of person? Maybe the take more risks in general and/or are less likely to follow common sense (or empirical medical) evidence about when a PG is high risk or showing complications???

The people I know that delivered with CPMs are normal.folks it was just their only option .

[imobviouslystaying]

May 1, 2016 12:36:03 GMT -5 @domerjen said:

Women will continue to have home births, the same way people did back alley abortions when they weren't legal (and probably are starting again in this climate). Give women a safe option (CNM) and they will use it. Most states currently do not allow it, which is a damned shame.

What?

No seriously, I need clarification. 

Because women do have a safe, accessible, low cost options for birthing their children so it's not at all comparable to choosing a back alley abortion because abortions are difficult to access and afford.

ETA: In fact, choosing and unlicensed or undertrained midwife to deliver your baby at home would be more like having access to a safe, regulated, affordable abortion at a clinic and choosing to have an under assisted at home abortion anyway.

[imobviouslystaying]

May 1, 2016 14:17:25 GMT -5 MrsAxilla said:

I'm honestly flabbergasted that the majority of women having home births are using a CPN. I mean, not to generalize, but don't most pregnant women pour over car seat reviews and interview periatricians and "research" the safety of vaccinations? Or is that just women on the bump? How do you not know or understand the education and experience of the person delivering your baby?!? Just....wow.

Well to be fair, if we're talking about the same sort of people, they aren't exactly deciding on vaccines or carseats based on science and real live research.

Too many people are relying on confirmation bias and calling it self education.

[imobviouslystaying]

May 1, 2016 14:19:10 GMT -5 ttt said:

May 1, 2016 14:17:25 GMT -5 MrsAxilla said:

I'm honestly flabbergasted that the majority of women having home births are using a CPN. I mean, not to generalize, but don't most pregnant women pour over car seat reviews and interview periatricians and "research" the safety of vaccinations? Or is that just women on the bump? How do you not know or understand the education and experience of the person delivering your baby?!? Just....wow.

Well, some people, who may or may not frequent this board on occasion, believe that a midwife's education isn't important and that you can't learn about delivering babies from books anyway. 

And some believe that risks and dangers are either overinflated or caused by hospitals and doctors. I often hear these people say that pregnancy is not a medical condition and doesn't need intervention and that we shouldn't treat pregnant women like they are sick, whatever that means.

There's a whole lot of talk about giving birth being something that ever woman's body knows how to do. So of course they don't even believe that medical training of some sort is necessary or relevant, unless you are one of the absolute few according to them, who might run into an issue.

[UMaineTeach]

So someone help me out with this new law legislature.maine.gov/legis/bills/getPDF.asp?paper=SP0248&item=5&snum=127

The governor's veto was overridden Friday, so Maine is going to oversee midwives. But I can't tell if this is just a way to keep tabs on CPMs and has no effect on them getting proper education or if this will actually help women. They seem to talk about CPMs and CNMs as if they are the same and both have prestigious credential granting boards.

[karinothing]

May 1, 2016 18:52:09 GMT -5 imobviouslystaying said:

May 1, 2016 12:36:03 GMT -5 @domerjen said:

Women will continue to have home births, the same way people did back alley abortions when they weren't legal (and probably are starting again in this climate). Give women a safe option (CNM) and they will use it. Most states currently do not allow it, which is a damned shame.

What?

No seriously, I need clarification. 

Because women do have a safe, accessible, low cost options for birthing their children so it's not at all comparable to choosing a back alley abortion because abortions are difficult to access and afford.

ETA: In fact, choosing and unlicensed or undertrained midwife to deliver your baby at home would be more like having access to a safe, regulated, affordable abortion at a clinic and choosing to have an under assisted at home abortion anyway.

I think she is saying women will have home births no matter what so by outlawing medical professionals from attending home birth you are giving them only dangerous options. When if you permitted CNMs with established OB partnerships you would have safer situations.

The abortion comparison being that woman have abortions no matter what even if they are dangerous. So we pass laws to make them safe and legal. Women will have home births no matter what, even if they are dangerous so we should pass laws which make them as safe as can be.

[imobviouslystaying]

May 1, 2016 20:14:25 GMT -5 karinothing said:

May 1, 2016 18:52:09 GMT -5 imobviouslystaying said:

What?

No seriously, I need clarification. 

Because women do have a safe, accessible, low cost options for birthing their children so it's not at all comparable to choosing a back alley abortion because abortions are difficult to access and afford.

ETA: In fact, choosing and unlicensed or undertrained midwife to deliver your baby at home would be more like having access to a safe, regulated, affordable abortion at a clinic and choosing to have an under assisted at home abortion anyway.

I think she is saying women will have home births no matter what so by outlawing medical professionals from attending home birth you are giving them only dangerous options. When if you permitted CNMs with established OB partnerships you would have safer situations.

The abortion comparison being that woman have abortions no matter what even if they are dangerous. So we pass laws to make them safe and legal. Women will have home births no matter what, even if they are dangerous so we should pass laws which make them as safe as can be.

Yeah, I think I explained above why both trains of thought are patently stupid but I'll repeat it again. Only dangerous options is a lie. There are plenty of safe, affordable and accessible options for childbirth. Women aren't choosing dangerous options because they aren't safe ones.

And the abortion comparison is a false one for the same exact reasons. Women choose dangerous abortions because there are few safe, accesible, affordable options, in many cases none at all. In the case of childbirth, some women simply do not like the options offered them, and choose a more dangerous route.

Because some women are willfully choosing a decidedly less safe option I am not on board with the idea that they wouldn't do it if they didn't have to. Plenty of them will still choose more dangerous way simply because they want the illusion of choice and self control.

[lolo]

I'm curious about the transfer rate comments and wish those had been fleshed out a bit more. For emergency transfers, the midwives I know still accompany you even though they don't have privileges. At least some contracts I've seen require payment in full in that situation. In fact, some require payment by 36w, so there's no economic incentive not to transfer.

I'm not sure about transfers earlier in pregnancy, but neither CNM in my area will birth twins or breach babies (except in an emergency where, for example, they arrive and mom is pushing with breach baby and ambulance hasn't arrived).

[debatethis]

May 1, 2016 20:25:19 GMT -5 imobviouslystaying said:

May 1, 2016 20:14:25 GMT -5 karinothing said:

I think she is saying women will have home births no matter what so by outlawing medical professionals from attending home birth you are giving them only dangerous options. When if you permitted CNMs with established OB partnerships you would have safer situations.

The abortion comparison being that woman have abortions no matter what even if they are dangerous. So we pass laws to make them safe and legal. Women will have home births no matter what, even if they are dangerous so we should pass laws which make them as safe as can be.

Yeah, I think I explained above why both trains of thought are patently stupid but I'll repeat it again. Only dangerous options is a lie. There are plenty of safe, affordable and accessible options for childbirth. Women aren't choosing dangerous options because they aren't safe ones.

And the abortion comparison is a false one for the same exact reasons. Women choose dangerous abortions because there are few safe, accesible, affordable options, in many cases none at all. In the case of childbirth, some women simply do not like the options offered them, and choose a more dangerous route.

Because some women are willfully choosing a decidedly less safe option I am not on board with the idea that they wouldn't do it if they didn't have to. Plenty of them will still choose more dangerous way simply because they want the illusion of choice and self control.

Well...er, no. That's not always true. Have you been out west? It's often several hours away to see an MD/OB to deliver your baby. That area is rural and remote and a ton of hospitals don't even have obstetric facilities. Many women in more remote areas choose CPMs over having to either travel quite a ways to a doctor/hospital or be med-evac'ed in labor. There is also a growing lack of physicians in the US and OB's are one of the hardest hit practices, especially in rural/remote areas (a piece from the Atlantic last year estimated that we'll be short 9,000 OBs by 2030). 

So when you're in a rural area and faced with rock and hard place, sometimes you don't have options.

[lurkingaw]

May 2, 2016 9:00:41 GMT -5 debatethis said:

May 1, 2016 20:25:19 GMT -5 imobviouslystaying said:

Yeah, I think I explained above why both trains of thought are patently stupid but I'll repeat it again. Only dangerous options is a lie. There are plenty of safe, affordable and accessible options for childbirth. Women aren't choosing dangerous options because they aren't safe ones.

And the abortion comparison is a false one for the same exact reasons. Women choose dangerous abortions because there are few safe, accesible, affordable options, in many cases none at all. In the case of childbirth, some women simply do not like the options offered them, and choose a more dangerous route.

Because some women are willfully choosing a decidedly less safe option I am not on board with the idea that they wouldn't do it if they didn't have to. Plenty of them will still choose more dangerous way simply because they want the illusion of choice and self control.

Well...er, no. That's not always true. Have you been out west? It's often several hours away to see an MD/OB to deliver your baby. That area is rural and remote and a ton of hospitals don't even have obstetric facilities. Many women in more remote areas choose CPMs over having to either travel quite a ways to a doctor/hospital or be med-evac'ed in labor. There is also a growing lack of physicians in the US and OB's are one of the hardest hit practices, especially in rural/remote areas (a piece from the Atlantic last year estimated that we'll be short 9,000 OBs by 2030). 

So when you're in a rural area and faced with rock and hard place, sometimes you don't have options.

And don't forget the financial aspect. I know women who have chosen homebirths simply because they cannit afford a hospital birth, even with insurance. With high deductable plans you can end up spending thousands more for a hospital birth. Some women can't afford that and homebirth becomes their only affordable option.