Category Archives: Home birth

Home birth geography quiz!

Quick! Name the country where:

  • Maternity care is provided in hospitals by obstetricians, and at home by medically-trained midwives and traditional midwives.
  • Obstetricians don’t trust midwives.
  • Midwifery groups don’t trust each other, and none of them trust obstetricians.
  • Midwives feel obstetricians are often insulting and disrespectful to them.
  • Obstetricians, in fact, are often insulting and disrespectful to midwives.
  • Timely transfer from home to hospital during labor is often hampered by delays in deciding to seek care, by slow transport to the hospital, and by delays in receiving care on arrival.
  • Women seeking home births are afraid of hospitals, which they see as cesarean mills.
  • Obstetricians are viewed primarily as surgeons, their motives mainly financial.
  • Economic and ethnic disparities are rife; those with money get care when and where they want it.
  • Despite years of progress, maternal mortality rates remain stubbornly high.

I know what you’re thinking: Hey! I live there, right?

Wrong. It’s Iran.

Specifically, it’s Zahedan, the capital of Sistan and Baluchestan province in eastern Iran, home to 600,000 people on the border with Pakistan.

A recent study of maternity care in Zahedan revealed a very fractured, and fractious, obstetrical world. What with battles over where and when midwives can legally practice, how best to deal with a flood of undocumented and uninsured immigrants, layers of professional suspicion, accusation, intrigue and infighting…you start to get the idea that maternity care is a mess the whole world ’round.

Granted, there are differences between Zahedan and the U.S. It’s unlikely, for example, that an American woman would have to have her eclamptic seizures exorcised by a faith healer before her family would allow her to go to the hospital (a not-uncommon practice in Zahedan). Too, an American family would probably not be required to drive their very angry midwife home before heading to the local maternity ward. And an Iranian midwife’s trump card–the threat to “go outside the home and shout and bring disgrace” on a woman and her family for seeking hospital care–probably doesn’t strike a lot of fear in American hearts.

Still…

Hospitals in Zahedan have begun a two-pronged outreach effort of sorts, aimed at convincing mothers and their relatives that a) traditional midwives may be lacking the kind of training needed in real emergencies, and b) hospitals aren’t simply scary cash-machines for doctors:

“Women who choose to give birth at home accept the risk that complications may arise. Training midwives and persuading mothers and significant others who make decisions about the value of referring women to hospitals at the onset of life-threatening complications are central factors to increasing the use of available hospitals. The hospitals must be safe, comfortable and attractive environments for parturition and should give appropriate consideration to the ethical and cultural concerns of the women.”

Maybe we have more in common with Iran than we thought…

 

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Home VBACs on the rise

The rise and fall of VBACs

A new study by Eugene DeClercq and Frances MacDorman–my favorite epidemiologists–looks at trends in home vaginal birth after cesarean (home VBAC) from 1990-2008. The results are interesting, if not surprising, given the trends in American maternity care as a whole.

Basically, Declercq et al found that home VBACs in the U.S., while still rare events, have been increasing–most recently from 664 in 2003 to 1000 in 2008. VBACs accounted for less than 1% of home births in 1996, but are now 4% of total home births. Meanwhile hospital VBACs have decreased from 3% of total hospital births in 1996 to 1% in 2008.

VBACs underwent a steep decline in the late 1990s after the American College of Obstetricians and Gynecologists came out strongly against VBACs being performed in hospitals that did not have 24/7 OB anesthesia services, in case of the need for an emergency c-section. For a small number of women–likely those with no local VBAC alternative–this simply drove VBACs out of the hospital and “underground” – ie, into the home setting.

The safety of home VBACs can (and will) be debated endlessly. The take-home point for me, though, is that this is one more reason to integrate home birth into the larger American maternity care system. Women can’t be forced to give birth in hospitals, and neither demonizing home birth  nor overstating the advantages of hospital birth is doing anyone any good. (For examples of some especially vocal opposition to home birth, see the replies to Dr. Alice Dreger’s article in The Atlantic I cited a few days ago.)

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“The Case for Hospital Births”

Best place to have a baby?

Here’s a kind of counterpoint article, also from The Atlantic,  to the one by Alice Dreger M.D. on low-intervention birth in my previous post. The author, Adam Wolfberg M.D., is an obstetrician at Tufts University who specializes in high risk pregnancies. Right from the article’s first sentence he’s pretty up front about where he thinks births should happen:

“I believe babies ought to be born in a hospital.”

That belief seems to be based on personal experience (I say “seems,” because the only case presented is of a couple who wanted a home birth, ran into trouble that led to transfer, and then were “annoyed” to have had a healthy baby in the hospital) and backed up by a reference to the study by J.R. Wax that purported to show a three-fold increase in infant mortality for babies born at home.

This essay actually offers unintended support to Dr. Dreger’s claim that physicians sometimes confuse science with technology. The Wax study has been heavily criticized for presenting a distorted picture of home birth safety  (details here). Dr. Wolfberg ignores much research to the contrary in picking that particular study as evidence of the dangers of out-of-hospital birth, and his use of a badly flawed study to support hospital birth for all women is exactly the kind of thing Dr. Dreger decries.

As I said in my last post, I’ve been on both sides of this debate. Childbirth is sometimes a scary thing, and it doesn’t always end happily. I’ve seen the kind of birth disasters that make an aggressive approach to childbirth so attractive to physicians, and I’ve also taken care of babies harmed by that style of practice.

The trick is to find a safe balance of nature and technology for each mother and baby. That’s an elusive goal in the increasingly polarized world of American maternity care.

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More on home birth risks

From the recent comments file:

While I abhor the tone taken by many comments on the blog I’m asking you to look at, this doctor has some disturbing statistics on neonatal mortality at homebirths. Could you please discuss your thoughts on this post?http://skepticalob.blogspot.com/2012/01/curious-silence-on-rising-rate-of.html
Thank you! Catherine Taylor

Catherine – thanks for your comment! I appreciate it.

Home birth neonatal mortality, by provider type

The chart (left) from the blog you referenced says more about the way home births are handled in the U.S. than it does about home birth itself. As I’ve mentioned before, the Birthplace in England study, as well safety data from Canada and Europe, show that in selected circumstances home birth can be as safe as hospital birth in terms of maternal or neonatal deaths–if home birth is integrated into the larger maternity care system, which in the U.S. it is most definitely not.

Here in America we have a patchwork of state laws that in many cases increase the risk of home birth for mother and child. We also lack the kind of nationally recognized licensure and regulation of home birth midwives that most other western countries have, which can lead to women being cared for by poorly qualified, “underground”  birth attendants and to the kind of tragic outomes that the chart highlights.

The first step in addressing these issues can be found in the Home Birth Consensus Summit’s Common Ground Statements:

“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.

We believe that guidelines should:

  • allow for independent practice
  • facilitate communication between providers and across care settings
  • encourage professional responsibility and accountability, and
  • include mechanisms for risk assessment.”

With few exceptions the regulatory, institutional, and medical systems in the U.S. don’t support home birth. Yet women are increasingly seeking home births, and no matter what the blogging doctor Catherine cited might fervently prefer, they can’t be forced to do otherwise. Speaking as a physician, unless you’re part of the effort to make home birth a safer alternative for those women who want one (and their babies), you’re part of the reason for those bad statistics.

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New CDC report on U.S. home birth

Heading out the door to my office, but wanted to post this for perusing…

Home births are on the rise in the U.S., according to a new report from the Centers for Disease Control and Prevention. Home births accounted for 0.72% of all U.S. births (29,650 births in all) in 2009. The rise is disproportionately among non-Hispanic white women 35 and older (a 36% increase from 2004-2009).

There’s interesting data galore: about 67% of the births were attended by midwives (mostly) or physicians (less often), while 33% of the home births were attended by “others”–which could be anyone from a relative to a paramedic. It’s the latter category that tends to include unplanned home births (eg, babies born in toilets to very surprised mothers, etc.) and most of the “disaster stories” that plague home birth’s reputation. Reporting is getting better now, less “lump-em-all-together,” which should give a more accurate picture of the risks of well-planned, well-attended home birth in the U.S.

I’ll have more to say on this report later today and tomorrow.

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A comment on comments, Part 2

What's best?

I’ve decided to close out the comments related to my recent home birth posts. I’ve received quite a few of them in the last couple of weeks, the large majority of which are attacks on one category of midwives or another, are often personal in nature, and contribute little if anything to the discussion of home birth’s role in American maternity care. As promised, I didn’t publish them. There are obviously deep divisions among midwives (at least among many of those who wrote in) and  a blog shootout isn’t going to accomplish anything.

I’ll write more on the subject of home and other out-of-hospital birth in future posts, in particular about how place of birth increasingly appears to impact a baby’s long-term health, but for now it’s time to give it a rest.

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Home birth’s crazy-quilt legal status: Part 2

Laws, laws, and more laws...

If you were to spend a leisurely vacation driving the length of the Atlantic coast from Florida to Maine in search of a good place to have a home birth, you would encounter:

  • 3 states in which home birth attendees must be licensed Certified Professional Midwives* (CPMs)–(New Jersey, Virginia and South Carolina)
  • 2 states that allow Certified Midwives** to attend home births, but only those who have taken a specific test from the American Midwifery Certification Board (New York, Rhode Island)
  • 1 state which allows midwives to get a license if they pass a different exam than the one given in New York and Rhode Island.  (Florida)
  • 1 state which allows CPMs, but not CMs, to practice with a state-issued certificate (New Hampshire)
  • 1 state which allows CPMs, but not CMs, to practice with a state-issued permit (Delaware)
  • 2 states in which “direct-entry” midwives are flatly prohibited (North Carolina, Maryland)

…and 4 states inhabiting a kind of legal alternate-universe:

  • 2 states in which direct-entry midwives are legal “by judicial interpretation or statutory inference” (Maine, Massachussetts). “Inferred legality”! What a concept!
  • A Zen-like state (Connecticut) in which home birth attendance is neither legal nor illegal.
  • And the grand prize winner (Georgia), where home birth attendance by direct-entry midwives is legal…but you can’t get a license!

(Source: Midwives Alliance of North America.)

The crazy-quilt pattern of home birth regulations around the country (the rest of the states are as scrambled as the Atlantic coast) and the varying education and training requirements for the different classes of home birth midwives are major stumbling blocks to integrating home birth into the larger maternity care community. The Consensus Agreements that came out of the Home Birth Consensus Conference in Airlie, Virginia, this past October reflect this.

Take Statement 4:

“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.

We believe that guidelines should:

  • allow for independent practice
  • facilitate communication between providers and across care settings
  • encourage professional responsibility and accountability, and
  • include mechanisms for risk assessment ”

A national certification process for all midwives (similar to the process that already exists for physicians), acceptable to all the organizations involved in maternity care in the U.S., would go a long way toward resolving home birth’s legal limbo.

Ah, but there’s the rub in the factionalized world in which we live. Getting organizations with long histories of animosity to give up a bit of control in order to advance the greater good may strike some as a tilting-at-windmills exercise. But the Home Birth Consensus Summit, where representatives from major medical, midwifery, hospital, and insurance organizations reached agreement on some thorny issues, showed that it’s possible to move ahead.

The devil (probably a whole army of them) will be in the details. I’ll keep reporting on progress, or lack thereof, in future posts.

* * * *

* “A Certified Professional Midwife (CPM) is a knowledgeable, skilled and professional independent midwifery practitioner who has met the standards for certification set by the North American Registry of Midwives (NARM) and is qualified to provide the midwifery model of care. The CPM is the only international credential that requires knowledge about and experience in out-of-hospital settings.”

** “A Certified Midwife (CM) is an individual educated in the discipline of midwifery, who possesses evidence of certification according to the requirements of the American College of Nurse-Midwives.”

(Source: Midwives Alliance of North America)

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Home birth’s crazy-quilt legal status: Part 1

What a difference a few miles makes...

Okay, so I was a wee bit wrong about North Carolina. (Thanks to Russ Fawcett, Deb O’Connell, and Ida Darragh for their clarifying comments.)

Home birth is technically legal in the Tar Heel State. I say “technically,” because by state law the people who would be attending most of the home births in North Carolina—direct-entry midwives*—are legally barred from doing so. This sounds like a bit of a legal end-run, kind of like saying acupuncture is a legal activity… as long as nobody with needles is allowed in the room.

According to the Charlotte Observer report, home birth attendance in North Carolina is limited to registered nurses operating under the direct supervision of a physician. Due at least in part to that requirement for physician supervision, only about a half dozen of the 300 certified nurse midwives in North Carolina attend home births. So, yes, home births are legal, but if you’re looking for a qualified home birth midwife, in most of the state you’re on your own.

My legal fuzziness about the situation in North Carolina is understandable (at least to me). The laws governing home birth in the U.S. vary dramatically from state to state and are often quite byzantine.

Nowhere is this more obvious than in Charlotte. I’ve never been there, but from the look of things on the map, if you were to walk to the south side of town and take a long leap you’d land in South Carolina—where home births and the midwives who attend them are completely legal, and midwives are even paid by Medicaid for their services.

But just meander up and down the Atlantic coast a bit and things change, and change again. More on that in my next post.

* * * * *

* “A Direct-Entry Midwife is an independent practitioner educated in the discipline of midwifery through self-study, apprenticeship, a midwifery school, or a college- or university-based program distinct from the discipline of nursing. A direct-entry midwife is trained to provide the Midwives Model of Care to healthy women and newborns throughout the childbearing cycle primarily in out-of-hospital settings.” (Source: Midwives Alliance of North America.)

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Illegal home birth and bad outcomes: A self-fulfilling prophecy?

Kind of like home birth. Sort of.

Thinking a bit more about the North Carolina tragedy

The bad outcomes that happen in states where home birth is illegal (or poorly supported) strike me as classic self-fulfilling prophecies… kind of  like the outcome of the U.S.’s 50+ year economic embargo of Cuba. That may sound like a stretch (sorry, I just love analogies), but bear with me.

When Castro took over Cuba and embraced communism in the early 1960s, U.S. officials predicted that the Castro government would soon fail, as socialism/communism was an infinitely inferior economic system compared to capitalism. And, lo and behold, here in 2011 Cuba is one of the poorest nations in the western hemisphere. So the prediction of economic failure was accurate from the start…right?

Well, not entirely. The U.S.-versus-Cuba struggle has never been been a fair, level-playing-field test of economic philosophies. The U.S. government made sure of that in 1960 when it imposed a total economic embargo on Cuba. A classic self-fulfilling prophecy ensued: barred from trading with the world’s largest consumer nation (us), Cuba’s economy predictably floundered.

Back to North Carolina and home birth. In a state where home birth is illegal or poorly supported, bad things will inevitably happen as a result of poor communication and collaboration in times of emergency. And when those bad things happen, critics will inevitably point to home birth itself as the problem, rather than the many hurdles to success thrown in its path. This in turn leads to calls for ever-more draconian laws and restrictions, which in turn leads to potentially more bad outcomes. (Actually, that sounds like a combination of a self-fulfilling prophecy and a vicious circle…)

Home birth can only thrive in a system in which it is integrated with the larger OB community, so that all providers are well-educated and trained, and emergency care–especially transfer from home to hospital–is quick and seamless. Anything less simply invites more tragedy.

So judging home birth per se to be unsafe based on outcomes arising from a system stacked against it is a bit like our history with Cuba: when you work really hard to make something fail, it likely will.

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Home birth tragedy in North Carolina

When home birth is outlawed...

The recent death of a newborn baby girl during an attempted home birth in Charlotte, North Carolina, highlights just about everything that’s wrong with home birth as it is currently practiced in the U.S.

Though details are still somewhat sketchy, the situation seems to have been one of unlicensed midwives attending an illegal (in North Carolina) home birth. Complications arose, emergency care was delayed (possibly due to fear of prosecution) and a baby died.

The response from those already opposed to home birth has been swift and predictable. In the article, Dr. Amy Tuteur, a non-practicing OB and blogger in Boston who can be counted on to provide the ‘anti’ view on just about any subject related to natural childbirth, predictably blames home birth per se as the culprit.

But what about a legal system that forces a woman seeking a home birth underground and into the hands of questionably competent midwives who practice with little supervision and no link to the larger obstetric community? There are multiple levels of failure in this case, and there’s plenty of blame to spread around.

Home birth is easy to outlaw but impossible to eliminate. There will always be women who will insist on having their babies at home (and as I’ve written previously, there are some sound medical reasons for doing so), and fear of legal consequences isn’t likely to deter them.

So do we work to make home birth in the U.S. as safe as it is in much of Europe and Canada, or do we adopt a “tough luck–you got what you asked for” attitude when a baby dies? I’m a strong proponent of the former

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