To improve access to safe birth at home, nationwide standards are necessary.
Dr. McLean is a board-certified obstetrician-gynecologist at the University of Washington in Seattle.
July 31, 2019
Jen Carnig holds her son, Wiley Lavoie, immediately after his birth at home in Brooklyn, N.Y., as her husband Dan Lavoie, daughter Olive and best friend Lisa Johnson look on.CreditCreditAlice Proujansky
Earlier this month, a Nebraska midwife, Angela Hock, was charged with negligent child abuse when a newborn died after complications from a breech birth at home. It’s worth noting that before this delivery, Ms. Hock, the proprietor of a business called Nebraska Birth Keeper, had performed 50 births at home without incident. Nonetheless, Ms. Hock was not certified to practice as a midwife.
It’s unfortunate that these are the stories about home birth that make headlines, because they give the practice a bad name, and contribute to a sense that home births are irresponsible, a danger to the mother and baby. Home births can be safe — as long as they occur within a system of standards and regulations of the very sort that were missing in Nebraska. When home birth is practiced in the shadows because of fear of recrimination, patients are worse off. We can change this by acknowledging that home birth is a reasonable medical choice, and by licensing midwives for home birth in all 50 states.
I have practiced as an obstetrician in Washington State since 2006. I attend births only in the hospital, but I frequently take care of patients who intended to give birth at home and ended up transferring to me when their labor didn’t progress normally. The American College of Obstetricians and Gynecologists (ACOG) had long opposed home birth, but in 2017 issued a committee opinion acknowledging that while “hospitals and accredited birth centers are the safest settings for birth, each woman has the right to make a medically informed decision about delivery.” By contrast, the Royal College of Obstetricians and Gynaecologists in the United Kingdom encourages home birth for women with uncomplicated pregnancies.
The source of this discrepancy, as well as a great deal of controversy, is that studies on newborn outcomes have come to conflicting conclusions. Data collected by researchers in California and Oregon suggest there may be an increased risk of death in babies born at home, while research in the Netherlands found no significant difference between the risks associated with planned home and planned hospital births. There is no high-quality data from randomized controlled trials because none have been conducted. This is in part because of ethical challenges and because very large numbers of patients would be needed to definitively detect differences.
What does seem clear, however, is that women undergo fewer interventions when delivering at home. A meta-analysis of more than 24,000 births in multiple countries found lower rates of severe laceration, episiotomy and cesarean section with planned home births compared to planned hospital births. Maternal outcomes are likely better at home because the possibility of unnecessary interventions is removed, although those interventions can still be obtained efficiently through transfer to a hospital. There is also evidence from Britain that there are fewer maternal complications, like postpartum hemorrhage, when women give birth at home. Cochrane, a trusted global network of health researchers, distilled these factors to what is most important: the overall safety of home birth is comparable to that of hospital birth for healthy patients assisted by experienced midwives.
Unfortunately, giving birth at a hospital isn’t universally safe. NPR reported that the United States is the only developed nation with an increasing rate of maternal death, which has more than doubledfrom 1987 to 2015. According to the Institute for Health Metrics and Evaluation, it is now nearly twice as dangerous to give birth here as it is in Britain, France or Germany, despite the fact that the United States spends more on health care per capita than these countries. ACOG notes that the statistics are even more dire among minorities, with black women being three to four times more likely to die than white women.
No one is immune to this risk. In 2017, Serena Williams almost died of a pulmonary embolism after delivering her daughter when her complaints of shortness of breath weren’t taken seriously at a Florida hospital. Researchers in Alabama and Georgia found that half of maternal deaths are caused by medically preventable complications like embolism, while the other half, including those linked to rising obesity rates and poor access to health care, cannot be blamed entirely on hospitals. Nevertheless, it remains understandable that pregnant women have started to lose trust in the medical establishment.
Marginalizing home birth only endangers patients. There is a better way to handle this, starting with formal accreditation. According to ACOG, approximately 35,000 births occur at home in the United States each year. State governments regulate the education and experience needed to qualify as a birth professional through licensure. Certified Professional Midwives are the only providers required to have training in home birth, but just 33 stateslicense CPMs to practice.
Nebraska is not one of those states — only Certified Nurse Midwives who also hold a nursing degree are licensed, and they are prohibited from attending births at home. This means that there are no birth professionals in Nebraska who are “properly certified” for home birth, making it difficult for patients who want a home birth to figure out who is qualified and how to access services.
A recent study published in PLOS One showed that in states where midwives are regulated and integrated into the health care system, rates of neonatal mortality, cesarean section and preterm birth are all lower, regardless of birth setting.
Washington State has the highest level of midwife integration in the country, and our group obstetric practice at the University of Washington’s Northwest Hospital routinely works hand in hand with community midwives to ensure patients are provided with the information and services they need.
The women of America deserve access to the best medical care possible. They deserve access to safe home birth, with a licensed midwife, in all states.