Category Archives: Home birth

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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Who knew?

Ron Paul, obstetrician and long-shot presidential candidate, is a home birth proponent.

(Still, I ain’t voting for the guy…)

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Making sense of ‘Birthplace in England’

Many of you are no doubt aware of the study released last week by the Birthplace in England Collaborative Group. The purpose of the study was to take a detailed look at the risks associated with different settings where women with low-risk pregnancies plan to give birth: hospital OB units, midwifery-run birth centers within or close to hospitals, freestanding birth centers, and at home.

The study ran from  April 2008 to April 2010. The measured outcome was a composite of things that can go wrong for babies at birth: death at or just after birth, and injuries that may occur during birth such as broken bones, traumatic nerve injury, brain injury and a type of respiratory distress called meconium aspiration syndrome .

The findings: overall, birth for low-risk women was equally safe in all four settings. In other words, low-risk births anywhere in England tended to have low rates of bad outcomes.

When the data was carved up a bit more, one difference popped up: women having their first babies at home were 2 to 3 times more likely to have bad outcomes than those giving birth in any of the other settings. The risks were still quite low, but the increase was statistically significant.

The British press jumped all over that statistic. Many were quick to condemn all home birth as dangerous and not all the reporting was accurate. (See the Daily Mail story here, which exaggerates the risk of death or brain damage.)

Cooler heads are still trying to have themselves heard over the tabloid din. Britain’s National Health Service, which directs midwifery care in England, has an excellent review of the study’s findings and the risks of home birth (which includes the definition of a low-risk pregnancy, too). It’s well worth the read.

What seems to have been somewhat overlooked in all hubbub about risks to first-time mothers is what the study found about women having second or later babies. There was no safety difference for these mothers  in any of the birth settings – birth at home was as safe as anywhere else. Fortunately, some reporters picked up on that part of the story.

So what’s the Birthplace in England study’s bottom line? That low-risk births generally go well, regardless of where they happen. A first-time mother planning a home birth needs to be aware of the small but significantly increased risk her choice entails, and second-time moms should be fine regardless of birth setting.  

Ah, but that’s in England, where home birth is integrated into the larger maternity care system. The U.S. is a whole different story. And there’s more to assessing risk of place of birth than focusing on immediate outcomes. More on that soon.

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Congresswoman Roybal-Allard praises the Home Birth Consensus Summit

Congresswoman Roybal-Allard

Here’s a YouTube link to Congresswoman Lucille Roybal-Allard (D-CA) speaking in the House of Representatives yesterday about the Home Birth Consensus Summit. She does a great job of summing up why the Summit was so important. I’ll be adding another post soon about the “next steps” based on the Summit’s nine vision statements.

 

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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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