Homebirth: Safe & Sane

php81E69IPMMy parents were born at home in 1921, as were most in their generation and by the 1940s, when I was born, 44% of births still took place outside of the hospital. But, by the time I was ready to have babies myself, things had changed dramatically and few births took place outside of the home: less than 1.00% in 1969.

This percentage stayed pretty much the same through the 1980s. In 1989, the CDC began to collect data about home birth specifically, and to differentiate it from other births outside of the hospital. The CDC data shows that homebirth declined from 0,67% in 1990 to 0.56% in 2004.  But, in 2004 homebirths began to rise again and by 2009 were 0.72% of births.

While this increase in births at home from 2004 to 2009 is a 29% increase in percentage points, the rate of homebirth is the US still remains under 1%, as it has for the last 44 years. And, while the number of homebirths in 2009 is the highest level since the data first began to be collected in 1989, and was statistically significant in 31 states, it nevertheless represents a very small number of births: 29,650 in 2009.

THE HOMEBIRTH STATES

db84_fig3Montana has the highest percentage of homebirths: 2.55% in 2009. That’s 692 homebirths per year in Montana, which has a yearly birth rate of 12,594. 1.96% of births in Oregon (962) were homebirths and Vermont had 121 homebirths, 1.91% of all Vermont births. Five additional states (Idaho, Pennsylvania, Utah, Washington, and Wisconsin) had a percentage of home births of 1.50% or above (Figure 3).

In contrast, the percentage of homebirths was less than 0.50% for southeastern states from Texas to North Carolina, as well as for Connecticut, Delaware, the District of Columbia, Illinois, Massachusetts, Nebraska, New Jersey, Rhode Island, South Dakota, and West Virginia.

CRITICS OF HOMEBIRTH

Despite the increased popularity of homebirths and mothers’ preference for midwifery care—or perhaps because of it—the American College of Obstetricians and Gynecologists (ACOG) has increased its criticism of homebirth. While the ACOG Committee Opinion on Planned Homebirth gives lip service to informed choice, it warns that women who choose homebirth are endangering their child.

It is not surprising that ACOG, a trade organization representing direct competitors to midwives, should be critical of homebirths and of midwives. In 2010, they opposed the Midwifery Modernization Act after it passed the New York state legislature, despite its widespread support.

Midwives routinely have to claim their turf from doctors and sometimes even sue for restraint of trade. This happens often enough that the Academy of Certified Nurse Midwives (ACNM) has developed a resource packet on the subject for their members.

It is also not surprising that a recent study published in the American Journal of Obstetrics and Gynecology claims adverse effects from homebirth. The study flies in the face of existing scientific literature about homebirth safety and raises questions of conflict of interest.

THE SCIENTIFIC LITERATURE

iStock_000011980029SmallOne source that does not have a conflict of interest is the Cochrane Collaboration, internationally recognized as the highest standard in evidence-based healthcare reviews. When Cochrane compared the midwifery model of care to other models of maternity care, they concluded “that most women should be offered midwife-led continuity models of care…” Cochrane also says that there is no strong evidence to favor either planned homebirth or hospital birth.

Plenty of evidence does exist, however, to support the safety of planned home birth. In recent years, high-quality prospective controlled cohort studies and descriptive studies have established that planned home births achieve excellent perinatal outcomes.

Recent data from a large North American prospective study found that planned homebirth for low risk women was associated with lower rates of medical intervention but similar mortality to that of similar hospital births.

CURRENT STUDY CRITICIZED

In addition to the fact that the recent ACOG study is out of sync with other studies on the topic, it has also been criticized for its poor methodology. Midwife Wendy Gordon, critiques the study in a piece called, “Understanding Outliers in Home Birth Research.

In a letter to members, the American College of Nurse Midwives calls the study flawed and questions both how it was conducted and its interpretations.

SMOKESCREEN

iStock_000003581073SmallThe sensational press over this recent, flawed study distracts from the bigger picture of our declining maternity care in the US. Both infant and maternal mortality are on the rise and medical interventions during childbirth are at an all time high. The situation is so bad that Amnesty International warned in 2009 that women in the USA “have a greater lifetime risk of dying of pregnancy-related complications than women in 49 other countries.”

According to the Centers for Disease and Prevention ( CDC ) US infant and maternal mortality failed to improve between 2000 to 2005. This plateau represents the first time since the 1950s that infant mortality has seen no improvement. The US spends more than any other country in the world on health care and yet is only 33rd in the world in infant mortality. A baby born in Cuba, Slovenia, the Czech Republic or South Korea has a greater chance of living for the first year than a baby born in the US. In fact, a baby born in Singapore has twice the survival rate of a US baby.

WOMEN PREFER MIDWIVES

Is it any wonder then, in the context of such poor maternal and newborn outcomes, that women who want to actively participate in their births prefer to be attended by midwives during birth and consider giving birth at home.

The families who choose homebirth are not reckless. They want their choice to be supported by scientific evidence and it is. The Midwives Alliance of North America (MANA) offers a comprehensive annotated guide to the literature on homebirth safety. And, here are a number of links to studies on homebirth safety that I’ve compiled.

What the studies show is that birth is safe in any setting.

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Peggy HeadshotPeggy O’Mara is the CEO of peggyomara.com. She was the editor and publisher of Mothering from1980 to 2011. The author of Having a Baby Naturally; Natural Family Living; The Way Back Home; and A Quiet Place, Peggy has conducted workshops at Omega Institute, Esalen, La Leche League, and Bioneers. She is the mother of four and grandmother of two.

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About Peggy O'Mara

Editor and Publisher of peggyomara.com. Longtime natural living advocate, award winning writer, and independent thinker.

7 thoughts on “Homebirth: Safe & Sane

  1. Doula Dani

    Why the lies? If home birth is so safe, why the misleading information and lies?

    Infant mortality is the wrong rate to consider for safety of obstetrics in a country. The correct rate to look at is PERINATAL MORTALITY RATE. Perinatal mortality refers to death around the time of delivery and includes both fetal deaths (of at least 20 weeks of gestation) and neonatal deaths (death during the first 28 days after live birth – neonatal deaths obviously then determines the neonatal mortality rate)

    The US has one of the lowest perinatal mortality rates in the world!! Lower than the Netherlands and the UK, countries where home birth is much more popular.

    Studies trying to show the safety of home birth that have been conducted in other countries are not useful for women in the US. Other countries have different systems and DIFFERENT MIDWIVES…. midwives with more training, education, etc than the typical american home birth midwife. Those midwives in other countries have hospital privileges. Ours do not.

    This is a ridiculous article just full of lies. This is what I don’t understand…. just tell the truth! If you believe at home birth at all costs, then so be it. But not all women feel that way. If you want to empower when, tell them the truth and let them make fully informed decisions! S

    Reply
    • Peggy O'MaraPeggy O'Mara Post author

      The Perinatal Mortality rates I’m finding are as bad as our infant and maternal mortality rates. I’d love to see the source for your perinatal mortality rate comment as I only want to publish factual information.

      The “typical American homebirth midwife” is no longer a lay midwife. Rather she must sit a rigorous written and practical exam to be licensed by a state or to receive the Certified Professional Midwife (CPM) credential from the North American Registry of Midwives (NARM).

      I live in New Mexico where homebirth midwives have been licensed since 1978 and their statistics are exemplary. New Mexico is a rural state so midwifery is vital and Medicaid reimburses for homebirths here.

      Regarding US studies of midwives and homebirth, a 2005 British Medical Journal study of 5418 women, “Outcomes of planned home births with certified professional midwives: large prospective study in North America” concluded, “Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.”

      I certainly don’t believe in homebirths at all cost, but I do believe that midwifery-attended homebirth is safe and that the scientific evidence supports its safety. That being said, I hope that women will choose birth in whatever setting they are comfortable with as all birth settings are safe.

      Reply
      • Doula Dani

        Perinatal mortality rates listed by country:

        http://webcache.googleusercontent.com/search?q=cache:http://whqlibdoc.who.int/publications/2006/9241563206_eng.pdf

        Where have you found your perinatal mortality rates that are “just as bad”?

        Yes, CPMs must sit for ONE exam. That’s it. Until 2012 they didn’t even need a high school diploma. Majority of CPMs (and LMs) go through the PEP process….. it is a direct-entry program which can basically be completed after attending only 40 births – most attend more than 40 births but the fact remains only 40 are needed. CPMs and LMs do not have hospital privileges. The reason why home birth works so well in countries like the Netherlands is b/c the midwives are a part of the health care system. They have earned hospital privileges. They have been through a 4 year university program. High risk women are transferred to the care of an OB. CPMs and LMs are not comparable to midwives in other first world countries. There is no denying this.

        The 2005 BMJ study you are referring to has major flaws. I’m looking at the study right now. They compared intervention rates for home births in the year 2000 with hospital births in the year 2000. Fair enough. As expected intervention rates at home births are lower.

        BUT when they compared the 5418 home births in 2000 to hospital births, didn’t compare using hospital births in 2000. They used papers dating back to 1969. It’s taking me some time to pull the rates from 2000 (and I was busy yesterday with my children and Halloween) but so far from what I’ve seen, it looks to be almost double the risk….. that’s not comparable. I will get back to you with exact numbers. I don’t know why they didn’t do this themselves. Why didn’t they use hospital data from 2000? B/c if they did, it would show a higher risk at home birth.

        However, another important thing to note from this study is that 18 midwives have births unaccounted for. Why?? In Autumn of 1999, NARM contacted all registered CPMs regarding this study. Not everyone could be contacted, not everyone planned to re-certify, not everyone was still practicing. So they were left with 409 midwives. All 409 midwives AGREED to take part in this study. Yet, 18 midwives ended up not having their births used in the study… those 18 midwives also did not re-certify (this does not mean they are not still practicing, though). Where is the data on those 18 midwives and their births? Why did they AGREE initially to take part? What if they each had an infant die under their care and that’s why they did not complete the process? This is a major loop hole. If the midwives agreed initially to take part, the outcomes of each of their births should be a part of this study, regardless of whether or not they want the data to be used. This essentially means midwives who had bad outcomes could bow out after the fact and those outcomes wouldn’t be a part of the study.

        I will get back to you with hospital numbers for 2000. Please share your sources for the perinatal mortality rates you have seen. Regardless, what you have written is incorrect. Infant mortality is not a reflection of safety of obstetrics. Perinatal mortality is.

        Reply
  2. Peggy O'MaraPeggy O'Mara Post author

    I found a few interesting resources.

    Here is the Child Health USA 2013 Perinatal Health Status Indicators.
    http://mchb.hrsa.gov/chusa13/perinatal-health-status-indicators/perinatal-health-status-indicators.html

    Infant Morbidity from the report, which I assume is what you are interested in. As you know, this stat is mainly about preterm birth.. http://mchb.hrsa.gov/chusa13/perinatal-health-status-indicators/p/infant-morbidity.html

    CNN Article on the report says while rates of preterm births are decreasing, the US gets a C in preterm births.
    http://www.cnn.com/2013/11/01/health/preterm-births/index.html?hpt=he_c2&utm_source=buffer&utm_campaign=Buffer&utm_content=buffer8357f&utm_medium=twitter

    US Health and Human Services on Infant Mortality.http://mchb.hrsa.gov/infantmortality/index.html

    Reply
    • Doula Dani

      I left a comment earlier but it is missing. I’ll try again. I can’t remember exactly what I wrote but the jist of it….

      I looked at the links you provided but again they are for infant mortality, not perinatal mortality. And infant mortality is pediatrics, not obstetrics.

      And I am not surprised at all to know that the US has a high rate of preterm births. We also have a very high population of women that are obese, diabetic, etc we also have a lot of teen pregnancies and pregnancies over 35 (and, especially over 40)… all factors which increase the chances of preterm birth. The women of the US do not stack up very well compared to women of other first world countries in terms of health. If only low risk, healthy women became pregnant in the US (like the mass majority of those that seek home birth midwives) then our stats would be much better and our rate of preterm births would be much lower. But that is not the reality of the situation.

      Reply
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