Home Birth Consensus Summit, Part 2: Safety

STATEMENT 9 – Home Birth Consensus Summit Vision Statements

“We recognize and affirm the value of physiologic birth for women, babies, families and society and the value of appropriate interventions based on the best available evidence to achieve optimal outcomes for mothers and babies.”

My first exposure to home birth was in 1980, during my pediatric residency, when a paramedic burst through the NICU doors with a limp, blue baby in his arms–the product of a home birth gone very wrong. We cared for her as best we could, but she died a few hours later.

The baby’s young parents were devastated, of course. They had chosen to deliver their baby themselves at home rather than opt to give birth in the hospital. Though they had read volumes on normal birth, they’d given little thought to the possibility of complications–in this case shoulder dystocia and a tight nuchal cord–and by the time the paramedics were called it was simply too late.

That tragic experience shaped my opinion of home birth for the next twenty-five years: I concluded that having a baby at home was a risky, irresponsible thing to do. Not until long afterward did I stop to think that maybe the problem with this particular birth was not that it was a home birth per se, but that it had been poorly planned by inexperienced/overconfident parents with no midwife and no access to timely emergency aid.

Safe?

The big question here in 2011, then: Is home birth a safe alternative to hospital birth? What are the real risks?

Let’s take a quick look at the pros and cons in the medical literature. (A big thank you to Professor Saraswathi Vedam, Director of the Division of Midwifery at the University of British Columbia–and the driving force behind the Home Birth Consensus Summit–for her Annotated Guide to Home Birth Literature.)

Evidence supporting home birth as a safe alternative to hospital birth:

A number of studies in North America and particularly in Europe have demonstrated that planned, midwife-assisted home births within an organized system of care can be safe for low-risk mothers and their babies (more on my italicized qualifiers below), and in many cases results in fewer complication-prone interventions as well. Some highlights (more can be found in the Annotated Guide):

1) Maternal and infant mortality and morbidity (complications resulting from birth):

  • Janssen and colleagues (British Columbia, 2009): found no increase in risk of death or serious morbidity for either mother or baby from low-risk, registered midwife-attended home birth compared with hospital birth.
  • de Jonge, et al, (the Netherlands, 2009): studied 529,000 low-risk women; no increased risk of death or severe newborn morbidity in home birth vs. hospital.
  • Leslie and Romano (United Stated, 2007): low-risk out-of-hospital births had similar rates of neonatal mortality and  morbidity, including birth trauma and NICU admission, compared with hospital births.
  • Janssen, et al (British Columbia, 2002): found no difference between low-risk home and hospital birth in regard to serious neonatal complications requiring NICU care.

2) Obstetric interventions:

A number of studies cited in the Annotated Guide found that home birth is associated with a significant reduction in obstetric interventions, such as epidurals, induction or augmentation of labor, episiotomies, maternal fever, hemorrhage and severe tears or lacerations. Some of this has to do with the lack of certain technologies at a home birth (it’s darn hard to get an epidural at home, for one thing…), but regardless, there are clearly fewer interventions with home vs. hospital birth.

Evidence unfavorable to home birth:

1) Maternal and infant mortality and morbidity

  • Wax and colleagues (click on “Wax Maternal and Newborn outcomes” in link for article PDF) performed a meta-analysis of international studies related to home birth safety. They concluded that a baby was three times more likely to die in a home birth than in a hospital birth. This study was both widely publicized and heavily criticized for a number of significant flaws, which cast doubt on its findings. See Gyte’s critique here for much, much more detail.
  • Similarly, Chang and Macones (Missouri, 2011; to be published in the American Journal of Perinatology soon) concluded that home birth increases the risk of seizures and death for newborns. As with the Wax analysis, the authors have been criticized for irregularities in study design and execution, not the least of which were an unusually broad definition of  “low-risk” pregnancies (which included both some premature and nearly all post-mature pregnancies) and the inclusion of a class of midwives that did not exist in Missouri at the time of the study.

* * *

My opinion of home birth has changed considerably since 1980. Based on current research, planned, midwife-attended home birth for low-risk mothers in an integrated maternity care system does appear to be at least as safe for babies, and in some ways safer for mothers, as hospital birth.

Ah, but here’s the rub: What constitutes a “planned, low-risk” birth? What is an “integrated maternity care system”? And are safety studies from the Netherlands and British Columbia, where home birth midwives are an accepted part of the larger maternity care universe, applicable to the United States, where a tradition of acrimony and mutual suspicion in the childbirthing world has led to a badly fractured system of care?

Here’s just one example of that fracture: while home births are supported in states like Washington, hiring a home birth midwife, no matter how well-trained, is  illegal in 10 states including the three I lived in as a child (Iowa, Indiana and Illinois).

This is a set-up for bad outcomes.  A home birth midwife working under the radar in Indiana, say, might delay seeking consultation with an obstetrician or transferring a mother to a hospital for fear of prosecution, which in turn could lead to disaster. It’s not that my fellow Hoosiers are any less capable of giving birth safely at home. Poor communication between maternity caregivers increases the risk of delayed and uncoordinated care, making a home birth in Indiana theoretically riskier overall than a home birth in Washington.

An enormous amount of work will need to be done before home birth becomes a safe option for all low-risk women in the United States, regardless of location. But new research on the benefits of vaginal birth, particularly home birth, for the development of a child’s immune system makes it important that we get started on this critical work now.

And that’s why the vision statements from the Home Birth Consensus Summit are so important. They reflect a set of common agreements among very disparate groups–a big first step in what I hope will be an interesting, thoughtful process leading to healthy outcomes for mothers and babies.

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9 Comments

Filed under Home birth, Natural childbirth

9 responses to “Home Birth Consensus Summit, Part 2: Safety

  1. Thanks for this great overview Mark. I am one of the Janssen and colleague authors living and practicing in Vancouver, Canada. Home birth is an option under a woman’s health insurance (no cost to her) and the registered midwife attending her birth must have hospital privileges in case of transfer to hospital. The hospital is notified that there is a home birth in progress in the community and also notified that it has been successfully completed.
    On another note, we have been exceptionally fortunate to have Saraswathi Vedam, an American midwife, join us here in Canada as the director of our 4 year degree midwifery program!

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  2. I agree that homebirth cam be practiced safely, but in the US it won’t be safe until midwives are required to at least meet the standards required to be a midwife in Canada, the Netherlands, the UK, Australia, and all the other developed nations that allow midwives to practice. Zero required didactic education and a few years apprenticing to a midwife who barely attends enough births to keep her own skills sharp, as currently required by the CPM certification, is a joke.

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    • Hi Heather,
      Thanks for your comment. I agree completely. Don’t know if you’ve already seen this, but see Statement 4 of the Common Grounds Statement from the Home Birth Consensus Summit (October 2011). A lot of discussion centered on this issue, and the consensus was that education, training and licensure are key to promting home birth in the U.S.
      Take care – Mark

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      • Rain

        Do you believe the current requirements set forth by NARM and the current oversight of MANA meet this goal?

        “It is our goal that all health professionals who provide maternity care in home and birth center settings have a license that is based on national certification that includes defined competencies and standards for education and practice.”

        I personally do not think they do. I am not opposed to midwives who specifically train to attend home births, but I do not think NARM and MANA in their current form are adequate to develop a safe, national home birth system. Also, I think you will run up against an entire group of midwives who refuse to support licensing requirements at all. This is because they would be forced by these requirements to turn high risk pregnancies over to CNMs or OBs in hospitals or birth centers. They do not want to do this because they refuse to acknowledge any pregnancy may be high risk.

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  3. Jeremy Galvan

    It is very important to understand what we are talking about when we start suggesting that Midwives go thru certain educational requirements. In the world of Paramedics you have a variety of ways to certify. You can go get a 4 year degree, a 2 year degree, or take a fire department sponsored class which is no college credits. All three are legit ways to sit for a national test and then license in your state.
    If you are having a medical emergency are you going to call 911 and ask specifically for a 4 year degree medic to ensure your safety?
    Certified Professional Midwives have 2 ways to learn their skills. Either thru a 3-5 year intership with a already certified Midwife or thru a MEAC accredited class. Either way lets them sit for the National Test and then license in their state if its legal.
    Dont be fooled into thinking that one must be a Nurse in order to function as a Midwife. Nursing Boards fought hard to keep Paramedics from existing because they thought (as many still do) that Paramedics should have to go to nursing school before they go to Paramedic school.

    Having licensure is very important to establishing a standard and a means of maintaining skills and retraining. Home Birth families need to have access to Midwives in order to ensure that if anything happens in a Home Birth that should be handled by an OB… they know that it would be a good idea to go to the hospital. When they get there they should be able to transfer care in the same way paramedics transfer care to ER doctors.

    Hopefully we will see the other half of the country take a step in the right direction by licensing CPM’s in their state.

    Jeremy Galvan
    Maryland Families for Safe Birth

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  4. Charity

    Um.

    “… home births are supported in states like Washington” – Home births are not regulated in states like Washington. Does that mean supported? Like, “turning a blind eye” supported?

    “An enormous amount of work will need to be done before home birth becomes a safe option for all low-risk women in the United States, regardless of location. But new research on the benefits of vaginal birth, particularly home birth, for the development of a child’s immune system makes it important that we get started on this critical work now.”

    It’s not the new research on the benefits of home birth for the development of a child’s immune system (really???) that should make it important, it’s the preventable deaths and maternal injuries that home births are causing. *token maternal morbidity statistic (hysterectomy and major pelvic reconstruction, Nov. 2011) waves hand*

    That last comment and this: “are key to promting home birth in the U.S.” (I assume you meant to say “promoting”) makes me say: “Methinks someone doesn’t have his priorities straight.”

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    • Charity,
      I don’t have a personal interest in whether there are more home births in the future than there are now. When I say that home birth should be promoted, I mean that there will always be women who choose to give birth at home, and we need to make home birth as safe as possible for them and their babies. We can’t force women to give birth in the hospital. The injuries that you describe are likely the result of a system that functions poorly at present (ie, home birth as practiced in the U.S., versus Canada and elsewhere), not the result of home birth itself.

      I do see the health benefits of home and other non-hospital birth for babies as significant. The bacteria Clostridium difficile, acquired in hospitals, is increasingly being linked to asthma, diabetes, obesity and a host of other chronic illnesses. Children born at home have the lowest risk of picking up this germ, and hence have significantly lower risk of the diseases mentioned.

      My priorities are healthy women and healthy babies. Home birth will always be a tiny but important part of the larger maternal-child health picture, and should be treated as such.
      Thanks for taking the time to write,
      Mark Sloan

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  5. I’ve read your article with great interest, and agree with you in working towards making childbirth safe for mothers and babies, whatever their choice of care path. Quoting Mary Cronk, who before retiring supported both home births and physiological breech births. She said of women who didn’t get the home birth or breech birth they wanted, who required interventions to birth their babies “they have not failed, they just needed a little help”. That included if they needed a c-section. As midwives we support normal birth when all is normal, we detect what is not normal and advise and act upon thus, weather that is needing midwife intervention or obstetric intervention.

    Also, thank you for signposting Gyte’s critique of the Wax and colleagues research! I will continue to read your very sensibly blog, both past blogs and future ones!

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