Despite the fact that the United States spends more money on health care than any other country – and more on maternity care than any other type of hospital care – maternal mortality rates are actually increasing for U.S. women rather than decreasing. Maternal mortality rates have doubled since 1987, and the United States ranks 37th in the world in terms of maternal mortality (Amnesty International, 2010). These discrepancies in maternal health outcomes are paralleled with the rising rates of cesarean section, the decreased rates of vaginal birth after a previous cesarean section, and the increase in the amount of medical interventions in the “standard” hospital birth.
Where are the studies demonstrating institutionalized birth to be a safe place for a healthy mom and baby to birth?
Let’s be Clear
The National Center for Health Statistics reports that midwife-assisted deliveries are 19% lower in morbidity and mortality rates than physician-assisted deliveries.
Home births have a proven track record of safety for women, and few argue this point. Cesarean rates are lower, as well as infection, hemorrhage, preterm labor, and even maternal mortality. Satisfaction is also increased in those having birthed at home in comparison to those having birthed in the hospital. The controversy surrounds perinatal outcomes, meaning the literature seems to demonstrate that the unborn baby and the newly born baby have worse outcomes when birth is planned at home. The evidence demonstrates the issue is largely a matter of hiring a competent provider and having necessary supplies. Unfortunately the consumer has limited ability to assess the value of their midwifery care because there is no accreditation or regulation of home birth practices in our country.
Dr. Penny Lane CNM addresses these issue within her doctoral capstone project, Neonatal Resuscitation Training for Health Care Providers in the Home Birth and Birth Center Setting. Her practice model is one that works to improve neonatal outcomes in the home and birth center setting, and her career goal has been to establish an accreditation body for home birth practices in effort to set the standard for home birth.
The World Health Organization recognizes homebirth as a viable option for low risk women. From 2004-2009 there was a 29% increase in the U.S. homebirth rate, but the total percentage of births occurring in homes in 2009 was a mere 0.72% (CDC, 2012; NCHS, 2012). Only 1.7% (439) of Certified Nurse-Midwives (CNMs) attend homebirths (Declercq & Stotland, 2011; Fullerton, Schuiling & Sipe, 2010).
The home as a birthing environment is not a well supported choice in the current U.S. healthcare system. Quite frankly, the midwifery profession lacks support within the current U.S. healthcare system.
Can research end the home birth controversy?
Rixa Freeze PhD asks in her 2010 article published within Expert Reviews Obstetrics & Gynecology, “Could a series of large, well-designed studies finally heal the rift between advocates and opponents? In other words, is the real problem with home birth simply lack of sound research and evidence?” The answer Dr. Freeze concludes, “No. There is, in fact, already a large and growing body of research about the outcomes of home birth (p 8).”
The safety of home birth for healthy, low-risk women, when attended by skilled midwives and in a system that facilitates collaboration and timely transfer of care, is well supported by the evidence.
“The reaction from medical organizations to these recent studies – especially the studies affirming the safety of home birth for low-risk women – has been a nonreaction: no press releases, no commentaries or critiques and certainly no change in policy towards home birth. Attitudes towards home birth shape which studies a group privileges and which it ignores; additional studies are unlikely to convince an organization that is already ideologically opposed to home birth (Freeze, 2010, p 10).”
Approximately 83-85% of obstetrical clients are appropriate clients for midwifery-led care (WHO, 2005; WHO, 2010), which is best delivered by midwives in midwife-led facilities, including homes. However, 82.7% of U.S. births occur under the supervision of obstetricians within the hospital, and our elevated cesarean rate and increased mortality rates are the result.
It certainly is ironic that, while the gold standard of medical research is the randomized controlled trial, which generally looks at the risks and benefits of an intervention on a population level, it is individual women who have to make the decisions – and individual women may not always find these kind of data helpful. – Sara Wickham
Research & Publications
Dr. Lane’s doctoral project above offers an extensive literature matrix specific to homebirth and neonatal outcomes.
The College specifically supports the provision of care by midwives who are certified by AMCB or whose education and licensure meet the ICM Global Standards. Because the ICM Standards are supportive of independent midwifery practice, this statement is a nice complement to the ACNM-ACOG Joint Statement and is evidence that ACOG has expressed support for autonomous midwifery practice multiple times.
The Federal Trade Commission offers a Staff Paper, “FTC Offers Strong Endorsement: Expanded APRN Scope of Practice is Good for Competition and Consumers, which argues that APRNs should work autonomously for better consumer outcomes.
The Lancet’s Series on Midwifery
This series contains four papers and was launched on Monday, June 23rd, 2014. According to The Lancet’s press release, “Midwifery has a crucial part to play in saving the lives of millions of women and children who die during and around the time of pregnancy. The Series, produced by an international group of academics, clinicians, professional midwives, policymakers and advocates for women and children, is the most critical, wide-reaching examination of midwifery ever conducted. It shows the scale of the positive impact that can be achieved when effective, high-quality midwifery is available to all women and their babies.”
To read the executive summary, the comments and the four papers in the Series, click here.
To read a two-page overview of the Series and what it means for US midwives, click here.
American College of Nurse-Midwives Position Statement
ACNM (2005) offers a position statement specific to homebirth and states, “High quality controlled trials and descriptive studies have established that planned home births achieve excellent perinatal outcomes. Home birth is also credited with the reduced use of medical interventions that are associated with perinatal morbidity.” Thirty-one references complete the bibliography.
American Academy of Pediatrics Committee Statement
The AAP (2013) states that homebirths should be attended by the certified nurse-midwife.
The methodological challenges of attempting to compare the safety of home and hospital birth in terms of the risk of perinatal death
Nove, A., Berrington, A., & Matthews, Z. (2012). Midwifery, 28, 619-626.
Authors offer ten methodological challenges of attempting to compare the safety of home and hospital birth in terms of the risk of perinatal death, and suggest how these can be overcome, and set out a number of ‘essentials’ which must be in place before firm conclusions can be drawn from a study of the safety of planned homebirth (p 620).
“There are several significant hurdles which must be overcome if a study is to make a useful contribution to the debate about whether perinatal death is more likely if a home birth is planned or if a hospital birth is planned, and few (if any) readily available data sources can overcome all of these hurdles. These deficiencies have in part led to the continuation of the debate over several decades, and it is unlikely to be brought to a satisfactory conclusion in the foreseeable future” (Nove, Berrington & Matthews, 2012, p 625).
Planned home compared with planned hospital birth in the Netherlands.
Van der Kooy J, Poeran J, de Graaf JP, et al. (2011). Obstet Gynecol 118, 1037-1046.
Study results provide evidence that mortality outcomes in planned home birth are not significantly different compared to planned hospital birth, among 693,592 women with singleton births in the Netherlands. This study also provides further evidence to support the safety of planned home birth.
An 18-Year Review of Advance Practice Nurse Outcomes
Newhouse et al. (2011). Advanced practice nurse outcomes 1990-2008: a systematic review. Nursing Economic$, 29, 230-251.
How do APRN (advance practice registered nurses) patient outcomes compare with outcomes of other providers? Nurse practitioners demonstrated with a high grade level of evidence, either equivalent or better in patient satisfaction, self-reported perceived health, functional status ADL/IADL, glucose control, lipid control, blood pressure control, ED or urgent care visits, hospitalization, and mortality. Thirdy-seven studies were included in this review, with 14 random control trials and 23 observational studies.
Nurse-midwives demonstrated with a high grade level of evidence a lower rate of cesarean sections, lower apgar scores, lower labor augmentation, lower episotomy rates, equivalent low birthrates, lower vaginal operative deliveries, less use of labor analgesia and epidurals, and lower rates of third-and fourth-degree perineal lacerations. Moderate grade evidence demonstrated an equivalent or lower rate of labor inductions, higher success with vaginal births after previous cesarean sections, lower rates of NICU admissions and higher rates of breastfeeding. Twenty-one studies, including two random controlled trials and nineteen observational studies, were used to compare nurse-midwifery outcomes to those by physicians.
Largest homebirth study conducted to date demonstrating homebirth as a safe option for appropriate candidates cared for by qualified midwives.
de Jonge, A., van der Goes, B.Y., Ravelli, ACJ., Amelink-Verburg, MP., Mol, BW., Nijhuis, JG., Gravenhorst, JB. & Buitendijk, SE. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG, 107.
“In this large cohort study, planned home birth in a low-risk population was not associated with higher perinatal mortality rates or an increased risk of admission to a NICU compared to planned hospital birth after controlling for maternal characteristics.”
“The sheer magnitude of numbers in de Jonge et al. – over half a million midwife-attended low-risk births, either at home or in the hospital – combined with a true comparison group (low-risk, women who chose hospital birth but could have chosen a home birth; both home and hospital groups, attended by the same group of midwives) makes this a valuable study (Freeze, 2010, p 8).”
“This study has some major strengths. As far as we know, this is the largest study into the safety of home birth. Its large sample size provided the power to detect differences in rare adverse outcomes. As it has been shown that conducting a randomised controlled trial is not possible, the best evidence about the safety of home birth can only come from good quality, routine registrations such as the one we used in our study. Furthermore, we were able to study a group of truly low-risk women.”
The authors stress however, that the safety of homebirth is dependent on maternity care systems that support this choice and attendance by well-trained midwives who assess the appropriateness of a home birth and through a rapid transportation and an integrated referral system.
Analyzing medical death rate data over an eight-year period, John Hopkins patient safety experts have calculated that more than 250,000 deaths per year are due to medical error in the United States. Their figure, surpasses the U.S. Centers for Disease Control and Prevention’s third leading cause of death – respiratory disease, which kills close to 150,000 people last year. This risk is overlooked when considering safe outcomes for birth based on birth site, which is an incredible oversight considering the U.S. Department of Health and Human Services’ has recently concluded that 9.5% of all deaths each year in the U.S. stems from a medical error. ~American Nurses Association
Boucher, D., Bennett, C., McFarlin, B., & Freeze, R. (2009). Staying home to give birth: why women in the United States choose home birth. Journal of Nurse Midwifery, 54(2), 121-126.
This study describes the reasons that women in the United States choose home birth. Women were asked, “Why did you choose home birth?” The most common reason given for wanting to birth at home was safety.
Outcomes of Planned Home Birth with Registered Midwife versus Planned Hospital Birth with Midwife or Physician
Janssen, Saxell, Page, Klein, Liston, & Lee. (2009). CMAJ, 181(6-7), 377-383.
The authors concluded that the decision to plan a birth attended by a registered midwife at home versus in the hospital was associated with very low and comparable rates of perinatal death. Women who planned a home birth were at reduced risk of all obstetric interventions assessed and were at similar or reduced risk of adverse maternal outcomes compared with women who planned to give birth in hospital accompanied by a midwife or physician. Newborns whose mothers planned a home birth were at similar or reduced risk of fetal and neonatal morbidity compared with newborns whose mothers planned a hospital birth, except for admission to hospital, which was more likely compared with newborns whose mothers were in the physician-attended cohort.
The strengths of this research article is that both home and hospital births were attended by the same cohort of midwives, offering a true comparison of planned place of birth uncompounded by type of caregiver. The study adds to the body of large cohort studies of planned home births that have reported on the relative safety of home versus hospital births.
This research should add confidence to the safety of home birth in a context such as Canada’s in which registered midwives have a baccalaureate degree or equivalent and are an integral part of the health care system. These findings do not extend to settings where midwives do not have extensive academic and clinical training.
Outcomes of Planned Home Birth: An Integrative Review
Fullerton, J.T., Navarro, A.M. & Young, S.H. (2007). Journal of Midwifery & Women’s Health
Policy makers should consider the models of homebirth services available in that some homebirth practices have established a “first-level” of care similar to birth center and remote facility resources (and others have failed to offer a safe infrastructure of care or a skilled attendant). In “first-level” of care scenarios, results of maternal and neonatal outcomes are generally favorable and in keeping with the fundamental right of women to have a choice in childbirth.
Murphy PA, Fullerton J. (1998). Obstet Gynecol, 92(3): 461-70.
Conclusion: Home birth can be accomplished with good outcomes under the care of qualified practitioners and within a system that facilitates transfer to hospital care when necessary. Intrapartal mortality during intended home birth is concentrated in postdates pregnancies with evidence of meconium passage.
Outcomes of 11,788 planned home births attended by certified nurse-midwives: a retrospective descriptive study
Anderson, R.E. & Murphy, P.A. (1995). Journal of Nurse-Midwifery, 40(6), 483-492.
This retrospective study is unique in its description of more than 11,000 home births attended by certified nurse-midwives. In this study, the intrapartum/neonatal mortality was 2/1,000 (0.9/1,000 excluding congenital anomalies). This rate is similar to the National Birth Center Study and to the low-risk hospital births used as a comparison group in the same study of 1.3/1,000 (0.7/1,000 excluding anomalies).
“A major concern that was identified in this study was that emergency situations may occur and the provider may not have appropriate resources for dealing with them. Should unexpected emergencies occur, the equipment or personnel needed in critical situations may not be available” (Anderson & Murphy, 1995, p 490). Only seventy percent of respondents were currently certified in neonatal resuscitation. Ten percent failed to carry neonatal resuscitation bags, and only half carried laryngoscopes and endotrachial tubes.
This exact point is the focus of Penny’s doctoral work, as she too is concerned about the level of care provided neonates in the out-of-hospital setting. Our practice does carry all necessary resuscitative equipment and we lead the industry (both hospital and homebirth) in providing three-to-one staffing ratios. Penny is an instructor for the Neonatal Resuscitation program for the American Academy of Pediatrics and the American Heart Association.
Attitudes towards home birth in the USA
Freeze, R.A.S. (2010). Expert Rev. Obstet. Gynecol
After reviewing current attitudes towards and research regarding home birth, this article makes sense of the wildly different perspectives towards home birth and proposes some strategies for overcoming this divide.
The American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have officially opposed homebirth since the mid-1970’s. In the 2008 statement, ACOG portrayed home birth as a fad and accused home birth parents of selfishness. However, the same statement endorsed accredited freestanding birth centers for the first time. The American Academy of Family Physicians and the American Society of Anesthesiologists have remained quite on the issue of home birth (Freeze, 2010).
“In contrast to medical opposition to home birth, almost all other maternity-related organizations (including nursing, midwifery, public health, doulas, consumer advocacy and childbirth education) support the choice to give birth at home” (Freeze, 2010, p 2-3).
Severe Maternal Morbidity Among Delivery and Postpartum Hospitalizations in the United States
Callaghan, W.M., Creanga, A.A., & Kuklina, E.V. (2012). Obstetrics & Gynecology, 120(5).
Authors discovered “increasing rates for blood transfusion, acute renal failure, shock, acute myocardial infarction, respiratory distress syndrome, aneurysms, and cardiac surgery during delivery hospitalizations.” Since 1998-1999, severe maternal morbidity has increased by 75% related to delivery and 114% for postpartum events and “based on current trends, this burden is expected to increase.”
U.S. Newborn Death Rate Increasing
“Babies in the United States have a higher risk of dying during their first month of life than do babies born in 40 other countries, according to a new report. Some of the countries that outrank the United States in terms of newborn death risk are South Korea, Cuba, Malaysia, Lithuania, Poland and Israel, according to the study” (Rettner, 2011).
Yes, you read that correctly. It is safer to have your baby in Malaysia or Cuba, or even Lithuania, than it is in a hospital right here in the good old United States of America.
“We know that solutions as simple as keeping newborns warm, clean and properly breast-fed can keep them alive,” said study researcher Joy Lawn of the Save the Children Foundation, which worked with the WHO on the report. “It isn’t that you have to build invasive care units to halve your neonatal mortality.”
Amen! Is it really safe for women to birth vulnerable babies in an environment surrounded by illness, disease and death?
“More healthcare workers, including midwives, are needed to teach and implement these lifesaving practices,” Lawn states.
The Institute of Medicine (IOM) report titled, To Err is Human
In 2000, the IOM published their report summarizing information regarding errors made in health care and offered recommendations for improving quality of care. It was found that “preventable adverse events are a leading cause of death in the United States” (Kohn, Corrigan, & Donaldson, 2000, p26). Out of over 33.6 million admissions to U.S. hospitals in 1997, 44,000 to 98,000 people died as a result of medical-related erros (American Hospital Association, 1999). It was estimated that deaths in hospitals by preventable adverse events exceed the amount attributable to the eight leading cause of death in American (CDC, 1999b) and even exceed the number of deaths cause by automobile accidents (43,458), breast cancer (42,297) or AIDS (16,516) (CDC, 1999a).
Revised guidelines on when and how to induce labor in pregnant women were issued recently by The American College of Obstetricians and Gynecologists (ACOG). The guidelines provide physicians with guidance regarding which induction methods may be most appropriate under particular circumstances, as well as the safety requirements, and risks and benefits of the different methods. Most importantly, ACOG states induction should not occur prior to 39 weeks or verification of fetal lung maturity, which differs from its previous recommendation of 37 weeks. Midwives are once again proven to have a safer standard of care!
The maternal health care crisis in the United States by the Amnesty International. Health is a human right.
Safety of Alternative Approaches to Childbirth
Summary of critical points by Peter F. Schlenzka
Doctoral thesis comparing safety and costs of natural out-of-hospital birth with in-hospital obstetric births. He finds out-of-hospital births to be slightly safer and significantly superior in terms of economic costs ($13 billion annually) and social costs (reduced incidence of birth trauma and bonding disorders).
Judity A Lothian, PhD, Rn, LCCE, FACCE
In spite of technology and medical science’s ability to manage complex health problems, the current maternity care environment has increased risks for healthy women and their babies. It comes as a surprise to most women that standard maternity care does not reflect best scientific evidence. In this article, evidence-based maternity care practices are discussed with an emphasis on the practices that increase safety for mother and baby, and what pregnant women need to know in order to have safe, healthy births is described.
Patient Safety by Gluck, P. (2012). Journal of Obstetrics & Gynecology
Less than one percent of women who have had a previous cesarean section rupture their uterus in a subsequent trial of labor. Ironically, the above study demonstrated that 3.7% of hospitalized patients sustain an injury caused by medical treatment; 69% of these injuries were preventable and 14% of these errors contributed to the death of the patient. An estimated 98,000 deaths occur annually as a result of preventable medical errors. Take a guess at how many U.S. women have died from uterine rupture following a previous cesarean? Zero.
Vacuum and Jaundice
“All infants exposed to vacuum assisted delivery devices will have a caput succedaneum” – FDA 1998.
“Cephalohematoma or significant bruising” is a ‘major risk factor’ for hyperbilirubinemia and kernicterus” – AAP 2004.
Suprainfection results from the emergence of drug resistance and is identified when a new infection appears while being treated for a primary infection. These new infections present when antibiotics have wiped out the normal flora that was otherwise competing with the super bug for nutrients. Eliminating the competition allows the super bug to flourish, and therefore, establish the superinfection. These scenarios are rampant within the hospital, even within labor and delivery units, and newborn nurseries.
Nosocomial infections are those infections acquired within the hospital. Because hospitals are sites of intensive antibiotic use, resistent organisms can be extremely drug resistant and among the most difficult infections to treat. According to the Centers for Disease Control and Prevention (CDC), about 1.7 million patients acquire an infection while hospitalized each year, and 99,000 die – making nosocomial infections the sixth leading cause of death in the United States.
Birthing at home essentially eliminates this risk. Hospitals are not sterile environments. In fact, they are among the most deadly.
“Even though the United States has the most intense and widespread medical management of birth-99% of women give birth in a hospital-we rank near the bottom among industrialized countries in maternal and infant mortality. In spite of our vigilance, preterm births are on the rise, cerebral palsy-thought to be caused by fetal distress-rates have remained stagnant, and in 2002, infant mortality rose for the first time since 1958. According to the World Health Organization, we rank second to last among 33 industrialized countries in this regard and 30th for maternal mortality. Although we are superior in saving the lives of infants born severely premature, women are 70% more likely to die in childbirth in the United States than in Europe. Black women are four times more likely to die than white women (Block, 2007).”
“In the countries with the best maternal and infant outcomes- the Netherlands, Sweden, and Denmark-women and babies benefit from lifelong universal healthcare, but that care is markedly different: obstetricians attend only high-risk pregnancies. The vast majority of laboring women get individual support from a midwife, are free to move about and birth in whatever position feels best, and are rarely induced, anesthetized, or cut. These countries have between a 14% and an 18% cesarean rate, and in the Netherlands some 20% to 30% of births happen at home with virtually no medical intervention at all. Their approach, opposite to that of the United States, is to support physiological birth, allowing labor to begin and progress in its own time, and intervening only when necessary” (Block, 2007)”
“Are U.S. women less capable of giving birth than their Scandinavian sisters? Is technology being overused at the expense of women and babies? (Block, 2007)”
Pushed: The Painful Truth About Childbirth And Modern Maternity Care by Jennifer Block. (2007).
Facts & Figures
In 2006, there were 38,568 out-of-hospital births in the United States, including 24,970 home births and 10,781 births occurring in a freestanding birthing center. In 2006, out-of-hospital births represented 0.90% of the 4,265,555 births in the United States. After a gradual decline from 1990 to 2004, the percentage of out-of-hospital births increased by 3% from 0.87% in 2004 to 0.90% in 2005 and 2006.
In 2006, 61% of home births throughout the country were delivered by midwives – 16% by certified nurse midwives, and 45% by other midwives. Indiana does not make the distinction regarding the credentialing of the midwife in attendance; therefore, we have no knowledge of numbers or outcomes related to this variable in our state.
In 2006, only 7.6% of home births were delivered by physicians, a sharp decline from 1990, when 21.6% of home births were delivered by physicians.
In 2006, 99.9% of physician deliveries occurred in a hospital, 0.02% in a birthing center, and 0.05% in a home. For CNMs, 96.7% of deliveries occurred in a hospital, 2.0% in a birthing center, and 1.2% in a home.
The 2003 Revision of the U.S. Standard Certificate of Live Birth added an item which asks, for home births, whether the home birth was planned or unplanned. Indiana is currently following this recommendation. Of states differentiating planned verses unplanned homebirths, 83% were planned. Of home births delivered by medical doctors, only 31% were planned to deliver at home. In contrast, for homebirths delivered by doctors of osteopathy, 79% were planned home births. For certified nurse midwives and other midwives, nearly all, 98% and 99%, respectively, of home births were planned home births, whereas almost two-thirds (65%) of home births attended by “other” attendants were reported as planned. (These “other” attendants refer to any other person who delivered the baby -such as family members, emergency medical technician, or taxi drivers.) Unplanned home births are likely emergencies involving precipitous labor or other complications that might result in poorer-than-average outcomes when occurring in a setting unprepared for this type of delivery. Unfortunately, a number of research articles that failed to make this distinctive are used by ACOG to oppose home birth as a safe option.
National Vital Statistics Reports. (2010). Trends and characteristics of home and other out-of-hospital births in the United States, 1990-2006.NVSS, 58(11), 1-16.