Safety

BirthWise Maternity Care, LC

Gentle Births Happen at Home

Midwives and Out-of-Hospital Birth Are Safe

To many Americans, the idea of home birth, the use of a “direct-entry midwife,” or both, seems archaic. If you are like most people, whose birth experience is limited to the hospital births of your own children and what you have seen on TV, common sense would seem to indicate that a physician-attended hospital birth would be the safest option—and what could be more important than safety?

The truth of the matter is that hospitals have never been shown to be the safest place for mothers to give birth, or physicians the safest providers. Dozens of studies show that out-of-hospital birth attended by midwives is at least as safe as hospital birth for normal women, even in hostile environments and under less than ideal circumstances.^10,¹⁵ Evidence to the contrary is noticeably lacking.

It is important to note that it is the presence of a competent care provider, such as a midwife, that makes homebirth so safe.¹^,³ When planning an out-of-hospital birth, prenatal care is important so that if problems exist or develop during pregnancy they can be identified and referred before labor starts. Much of a midwife’s training focuses on screening for and identifying problems. Even during labor and birth the number of complications that cannot be predicted are very small and can be effectively managed at home or stabilized until medical help can be obtained.

Perinatal mortality (fetus or newborn dying after 20 weeks of pregnancy through 28 days after birth) rates typically range from 2-4 deaths per 1000 live births for all low-risk mothers regardless of where they plan to give birth, or which type of attendant they choose.²^,⁴^,⁵^,⁶^,⁷ ^,^8,⁹^,^10,¹¹^,¹²^,¹³^,¹⁴^,¹⁵ About ½ of the deaths are due to congenital defects and not considered preventable under any circumstances. Good studies comparing midwife-attended home births—including the outcomes of the women and babies who were transferred to the hospital due to problems—have been conducted all over the world including: the United States,¹²^,^13,¹⁵ Canada,¹¹^,¹⁴ New Zealand,⁹ Australia,⁷^,⁸ Great Britain,²^,⁴ Switzerland,⁵ and the Netherlands.⁶ They have consistently shown perinatal and maternal mortality (death) rates equal to low-risk hospital births.

So—does this mean that hospital births and homebirths have equivalent outcomes? As far as the chance of mother or baby dying—yes, but if any other measure of outcome is considered—cesarean section rates, forceps or vacuum deliveries, induction and augmentation rates, need for pain medication, episiotomy rates, infection rates, or birth injury rates—midwife-attended homebirths are far superior.^{2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15} The Midwives’ Model of Care specifically identifies “minimizing technological interventions” as a goal maternity care providers should have. Extensive research by the World Health Organization,¹⁸ the Pew Health Professions Commission,¹⁶ the American Public Health Association¹⁹ and the authors of A Guide to Effective Care in Pregnancy and Childbirth ¹⁷(the definitive medical reference of evidence-based care) come to the same conclusion. Why? Because interventions have consequences. The authors of a Swiss study noted, “The lower rate of interventions in the home birth group meant a lower risk of subsequent complications for the mother.”⁵

United States intervention rates are again at new highs. Cesarean sections are back up to 24.4% for 2001,²² forceps/vacuum deliveries at 12%²¹ and induction/stimulation rates at 34%.²¹ These high rates, with their attendant complications, are not justified by lower perinatal and maternal death rates. According to the Centers for Disease Control and Prevention

“Instead, over this 40-year period [1950-1990], the ranking of the United States’ perinatal mortality rate deteriorated because the decline in rate in the Unites States has not kept pace with the decline in other countries. The perinatal rate for the United States in the 1950’s was roughly 20% greater than that for the country with the best rate; by the 1980’s, the U.S. rate was close to 60% greater than that for the country with the lowest rate.”²⁰

The U.S. now ranks 28^th in world infant mortality rates.²³ Midwives are the sole attendants at more than 70% of the births in the 5 western countries with the lowest death rates—all substantially lower than the U.S. Home-based midwives typically have cesarean section rates of 5% or less, forceps/vacuum rates of 1-2% and induction/stimulation rates under 10%.²^,⁴^,⁵^,⁶^,⁷^,⁸^,⁹^,¹⁰^,¹¹^,¹²^,¹³^,¹⁴^,¹⁵

There is ample evidence that homebirth and midwifery care result in good outcomes for women with low-risk pregnancies. Alive or dead is not the only consideration when choosing maternity care. The likelihood of interventions and their consequences must also be taken into account. No one solution is best for all women. Everyone must make their own choices based on the available evidence and taking into consideration their own situation and preferences.