Did you know that in 1940, 44% of births were home births? In 1969 (my birth year), the percent of home births was just 1% and has remained that low until recently. The trend of out-of-hospital birth (one that happens either at home or in a free-standing birthing center) has increased by 3% since 2004 (up until 2006-which is the latest data they have). In 2006, 61% of home births were delivered by midwives—16% by certified nurse midwives (CNMs), and 45% by other midwives.

Women living in rural areas were much more likely to have home births, and women who birthed in free-standing birthing centers were more likely to do so if there was such a center in their area. (DUH- don’t ya just love statistics?)

One interesting trend was that physician attended home birth declined from nearly 22% to 7% from 1990 to 2006. I’m guessing this is due to the pressure (and professional stance) of the AMA to demonize home birth. Yet all in all, after perusing the report, nothing else startling jumped out at me, except perhaps the lack of data from many states and the lack of standardization in birth reporting. It makes statistical reporting very difficult.

The report just solidifies my stance that midwives of all types are important assets to every community and we need to continue our grassroots movement to educate women about midwifery as a desirable and viable option for healthy, low-risk pregnancies. Home birth and midwife assisted birth is enjoying a bit of a uptick and I’m hoping that this is just the beginning of a trend.

Recently, women are choosing or are interested in home births at a greater rate than in the past several decades. The paper discusses ‘planned home birth’, which refers “to the care of selected pregnant women by qualified practitioners within a system that provides for hospitalization when necessary.”

Historically, the safety of home birth has always been the issue cited in articles, studies and professional stances against the option of home birth. The Medscape article explains how many of the recommendations and “strong” policy statements from the AMA, ACOG, the American Association of Pediatrics and others are based on flawed or not properly controlled studies. These professional medical organizations say they have attempted to design randomized controlled studies, but can’t find enough women who would consent to be randomly assigned to a birth site. (Yeah, I would think that would be difficult.)

A whole slew of other professional organizations who support midwives, or who represent obstetricians not based in the US, or who support and promote public health, have conducted studies that have findings based on ‘observational cohort studies’ (studies of birthing women within the birth setting the women have chosen.) These studies have been used to make policy statements that support out of hospital birth because of their findings: reduced interventions, increased satisfaction of the mother, safety, and informed choice.

Up until 2009 this is where it stood. Different approaches to studies, flawed studies, different interpretations.

In 2009, three new well-respected, credible reports came out that concluded “that planned home birth in a low-risk population is not associated with higher perinatal mortality rates or an increased risk for admission to a NICU compared with planned hospital birth.” The other two studies concluded that not only was home birth as safe, but resulted in fewer interventions, c-sections, and better outcomes for both mom and baby. Interestingly, one of the studies found that no matter where the birth actually took place, the experience the mother had was consistent with where she PLANNED to give birth. (Less interventions and better outcomes even if she was a home birth transfer.)

Each research team concluded that maternal satisfaction with the experience of (or desire for) home birth lead to happier birth experiences all around and changed the “provider-patient power dynamic” which lead to a sense of safety and increased decision-making about their birth experience. I doubt this is news to anyone who might read this blog.

This is where the article gets interesting. Let’s go back to “planned home birth” which assumes that there will be a team of qualified professionals available to back up a home birth practitioner should a ‘normal birth’ develop into something less than normal. This requires a midwife to be “fully integrated into a network of maternity care services at all levels.”

A fully integrated network assumes that the place of birth is a reasonable distance from more emergent maternity care services, that there is willing and able MD back-up, and that a continuity of care would be able to still exist with the mother’s care provider, and that the woman, and her practitioner, would be received into a supportive and caring environment. The medical culture in this country does everything in their power to block any kind of integration, and in fact goes out of its way to create barriers for women and their midwives.

The article cites many reasons for home birth discrimination, including cultural beliefs -which of course is somewhat true. But social and cultural beliefs can be, and often are changed by laws against discrimination or marginalizing any one group. (Think of how far we’ve come in our thinking about women, african-americans and gays. These beliefs are changing because laws were enacted that criminalized discrimination and changed beliefs.) Think about how home birth used to be normal before the AMA stepped in a systematically squashed midwifery citing witchcraft and inducing fear etc.

As the article states, “Many jurisdictions have significant regulatory, logistic, financial, and legislative barriers to provision of home-birth services. Attitudes and beliefs that are particular to the professional culture may be partly responsible for these restrictions.”
It is true that malpractice also plays a role, as does regional, (particularly rural) access to a fully integrated network of care but “interprofessional conflict” is definitely the crux of the matter. In the face of mounting evidence against their ‘position’ regarding the safety of home birth, professional groups that represent doctors are still on mission against home births and the midwives who perform them.

The best argument I ever heard against home birth midwifery was that ‘they aren’t required to get malpractice insurance and I am. So when the poop hits the fan, and they have to transfer, I am in a position of caring for a patient who I do not know, who is possibly in a dire situation, and if things go wrong, I am the one who will be sued.” This argument is however, an issue of perspective. If doctors weren’t hell bent on burning bridges instead of building them, they would see that a change in attitude would serve them well. A wise woman once said to me “people don’t sue you if they like you.” Not to mention that under current laws, most midwives can’t get malpractice insurance even if they wanted to.

There is no reason why midwives can’t be looked at as part of a team much like family practice doctors, obstetricians and anesthesiologists, anesthetists and pediatricians are often a team. There is no reason why midwives should be looked upon with distain for having to transfer. If anything it’s a responsible thing to do. Any delay or hostility surrounding home birth transfers is very bad medical practice.

Women are demanding more choice in birth. Women are consumers of health care. They are demanding better treatment and autonomy, and turning to midwifery as the answer. The marketplace may help slowly shift current trends, thoughts and ‘policy’, but I hope that doctors take a long hard look at the evidence and change their attitudes and position statements and start viewing home birth as another viable option for birthing women-one that they can work in tandem with.

A Virginia attorney, Andrew Emrich who moved to Wyoming was dismayed not to have the option of a home birth midwife when his wife became pregnant with their fifth child back in 2005. It was then he learned that ‘midwifery is illegal in Wyoming’.

Certified Nurse-Midwives are licensed in the state of Wyoming, but Certified Professional Midwives (CPM’s), the ones who typically help with the bulk of home births throughout the country, are not. In May of 2007, in fact, one Wyoming midwife was charged with manslaughter and the practice of medicine without a license when a newborn died under her care. (This happens in hospitals and no one is charged.)

Mr. Emrich is working with a Wyoming House of Representatives Congresswoman to change the law. “The Senate on Thursday gave initial approval to a revised bill… to require training for midwives and set up a board to govern the profession.” The bill was introduced but died in committee just last year. One major difference this year, aside from the support of the congresswoman and a strong grass roots movement lead by Mr. Emrich, is that the “Wyoming Medical Society has removed its opposition as the result of a series of amendments to the bill and compromises.”

The bill is now set to go before a board of seven members including one physician.

This could be a great advancement for birthing women in this very sparsely populated, rural state- and according to the article, CPM’s are already lined up to move to Wyoming should the bill become law.

This excerpt from the report:

Australian College of Midwives president Jenny Gamble told protesters an amendment to the Medicare for Midwives Bill will give doctors the choice about how women give birth.

“They want to be able to control midwifery care. They want us as handmaidens. They want us under their direction,” she said.

UGH!

And this happened on the heals of another Australian law adopted in September that prohibits home birth midwives from receiving ‘registration’ (privileges)  because they do not have  malpractice insurance, but the government has no intention of providing that insurance.

It is rebuttal directed at the recent ‘story’ aired on the Today show called “The Perils of Home Birth” (which was originally going to be titled “The Perils of Midwifery”.)

Although much of their commentary has been said before and cited in statistics from all over, they did make one key point that I thought was worth highlighting.

“While midwives and obstetricians will continue to debate the safety and appropriateness of home birth, less controversial is the fact that some women seek to give birth in alternative settings because they do not see hospitals as meeting their needs. This should be cause for reflection and action by hospital leaders, and result in measures to make hospitals safer for women to birth. Changing childbirth practices in hospitals will make them a welcoming place for families and will likely result in better care for all.”

It’s a great point.  Basically many doctors and the media are pointing fingers at midwives, citing women who choose home birth as reckless and irresponsible, and sensationalizing the rare cases of home birth gone bad, but no one is talking about WHY women choose home birth and how bad hospital birth really has become.

Women are consumers of health care and don’t want to subject themselves to unnecessary interventions and a one in three chance of having a c-section.  If faced with this as their only alternative, they often choose home birth. Seems logical to me.  (I will note that if a mom chooses to have a hospital birth with a certified nurse midwife, her chances of undergoing interventions or c-section decrease dramatically.)

Why are doctors and hospitals not trying to change hospital experiences to meet the desires of women?  I think it ultimately comes down to philosophy.  Most obstetricians look at pregnancy as an illness or condition to be ‘fixed’, not an natural event to be gently managed.  Hospitals (theoretically) are places that sick people go to get better.  Perhaps the better question to be asking then is “Why are healthy women who are predicted to have normal pregnancies sent to hospitals to give birth?”

In July, the ACNM submitted a letter to members of congress opposing Federal Recognition of CPM’s for serving Medicaid and Medicare recipients.  At first glance this might seem like a cat-fight, so I thought I would highlight the issues.

First some definitions:

CNM, Certified Nurse Midwife: A person who holds a nursing degree, and a masters degree in Nurse Midwifery from an institution recognized by the Accreditation Commission for Midwifery Education (ACME) who answers to the US Dept of Education. To become a CNM, one must sit for the national certification exam put on by the American Midwifery Certification Board, Inc. (AMCB)  CNM’s practice in collaboration and consultation with other health care professionals, providing primary, gynecological and maternity care to women in the context of the larger health care system.

CM,  Certified Midwife: A person who has done post-baccalaureate training, but does not have a nursing degree.  The post-baccalaureate degree must be from an ACME accredited institution as well.  To become a CM, one must sit for the same national certification exam as a CNM. CMs practice in collaboration and consultation with other health care professionals, providing primary, gynecological and maternity care to women in the context of the larger health care system.

CPM, Certified Professional Midwife: A person educated and certified by an institution accredited by  the North American Registry of Midwives (NARM) or the Midwifery Education Accreditation Council. CPM’s are licensed to provide out-of-hospital births after passage of the NARM exam.

As many of you know, the profession of midwifery still has a long way to go toward mainstream recognition and is often misunderstood and misrepresented in the media.

The ACNM decision to take a stand again CPM’s was in step with their position statements on midwifery certification and on midwifery licensure and regulation.  They feel that federal recognition of a group of midwives in the United States that lack a standardized, formal approach to education— something that all other health professionals with similar responsibilities in the US have— could undermine progress towards mainstream recognition of the midwifery profession and full partnership in the US health care system.  It would also be a move that diverges dramatically from the successful models of midwifery care in all other developed countries.

I get this.  It makes sense.

However, the organizations who support and educate CPM’s have some good points as well.  They only deal in home births.  The fear is, if ACNM creates a standard that eventually pushes out CPM’s (which is very viable argument) it could lead to a significant decrease in home births which could seriously limit access for the thousands of women who have home births each year.  This might particularly affect rural and poor women who have little or no access to the US Health Care System.  Typically, CPM’s charge less, and their education costs less than post-baccalaureate programs which is why they are found in larger concentrations than nurse midwives or CM’s in less urban and economically challenged areas.  For CPM’s the issue is not only Medicaid reimbursement.  If ACNM secures the role of THE professional organization that deals with midwifery legislation (and licensure ) it’s the CPM’s very existence that is at stake.

Advocates for CPM’s second argument states (correctly) that there is no evidence that a post-baccalaureate degree results in better midwifery practice or better outcomes.  For an industry who still must prove their value and worth against MD’s by talking about outcomes, CPM’s feel that this is a slap in the face.

I feel that this argument, although true, is not a strong enough one to avoid standardization in the long term because standards exist in nearly all mainstream industries.   Ultimately, to gain the credibility that midwives want and deserve, there is going to have to be a standard, and probably just one- that all midwives must meet and achieve.  We want midwives to continue to do home births, we want them to serve in rural and poor markets.  ACNM and all midwives as a COLLECTIVE industry have to look long and hard at our main objective- to provide ACCESS to midwifery for birthing women.

My concern is that with standardization, people and places get priced out of the market.   Everyone who wants to be a midwife can’t always afford a post-baccalaureate degree.  Those midwives who do go for that degree might be forced to work in more urban markets to pay back loans. Future midwives won’t be able to be trained by experienced midwives in their own communities-leaving, even for a few years, could create a cultural disconnect that’s irreparable.   And the rural and underserved population will continue to be underserved.

Of course I know I’m jumping the gun here, and it’s probable that the abolition of CPM’s won’t ever happen as they are so important to the communities they serve, but there are large issues here that need to be addressed.

In an ideal world we would create a midwifery education and credentialing system that is standard, affordable and accessible to most wanna-be midwives.  Ideally, their education should primarily take place in their own communities if they so desire. (With hopes that they stay there.)

I agree that the move ACNM made was good for possibly helping to bring midwifery into the main stream through their willingness to push standardization, BUT we can’t forget our roots- which did not always involve post-baccalaureate degrees.  There are real reasons why CPM’s exist.  They meet a need.

So let’s stop whining and come to the table and figure it out.

Even though the ‘special investigation’ concluded what many studies have shown….that home birth or birth with a midwife is as safe, or safer than hospital birth, the slant of the story was hideously skewed and the main interviewees were a grieving family who lost their daughter to cord compression after a particularly arduous labor.  My favorite line of the whole ‘report’: “Homebirth had become almost the equivalent of a spa treatment for women, that it was this sort of hedonistic concept of birthing.”

Now, granted…..if I were the practitioner, I think I would have gone to the hospital before day 4 of labor, but……do they do segments on each doctor who makes a poor medical decision that results in death?  They would need their own network running 24/7. And how, pray tell, does one or two highlighted cases make for a fair story against home birth to spite studies and statistics that say otherwise?

This video is simply appalling and a prime example of irresponsible journalism.

Interpretation: Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.

: )

The mortality rate per 1,000 births was 0.35 in the home birth group, 0.57 in hospital births attended by midwives, and 0.64 among those attended by physicians, according to the study. Women who gave birth at home were less likely to need interventions or to have problems such as vaginal tearing or hemorrhaging and the babies were also less likely to need oxygen therapy or resuscitation.

The one issue that can, and does admittedly skew the results is that women who elect home birth are usually in better health and more fit than those who choose hospital birth…SO, if your fit and healthy, have a midwife assisted birth!  Higher quality birth experience (practically) guaranteed.