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Saturday, Sep. 04, 2010
Should American Women Learn to Give Birth at Home?
By Catherine Elton
When Hillary McLaughlin found out she was pregnant, she was unable to
legally obtain the service she needed. So she looked for an underground
contact. She got a woman's name--just a first name--and a phone number from
a friend who advised her to destroy the evidence as soon as she made the
call. When McLaughlin reached the woman, however, the woman told her she no
longer "did that" and that she wasn't willing to risk going to jail for it
anymore. Turned off by all the "whisper, whisper, cloak-and-dagger stuff,"
McLaughlin decided to "jump state lines" from Illinois to Missouri to find a
legal provider.
Forty years ago, you might have assumed McLaughlin was looking for an
unlawful abortion. Rather, what the small-business owner, 33, sought was a
certified midwife who could deliver her baby at home in Edwardsville, Ill.
"It's completely ridiculous that I had to do all this because midwives
aren't licensed to practice here," says McLaughlin, who delivered her son in
April at her parents' home in St. Louis. "I wanted a home birth, but I
wanted to do it legally, because I wanted some assurance that the midwife I
chose knew what she was doing."
Each year, some 25,000 American women like McLaughlin opt to deliver their
babies at home. Although that accounts for fewer than 1% of all births in
the U.S., the figure is probably on the rise. From 2004 to 2006, the most
recent year for which estimates are available, home birthing in the U.S.
increased 5% after having gradually declined since 1990, according the
Centers for Disease Control and Prevention. While the recent uptick is not
conclusive proof of a trend, home-birth advocates say anecdotal evidence and
informal surveys from the field also point to growing demand.
Why? Largely because women wish to avoid what they deem overmedicalized
childbirth. Compared with hospital deliveries, 32% of which end in cesarean
section, those taking place at home involve far fewer medical interventions
and complications. Some women, like McLaughlin, who have had cesareans in
the past, elect to have a home birth because they want to attempt vaginal
delivery--what is known as vaginal birth after cesarean, or VBAC, a
procedure that most obstetricians and hospitals have banned to avoid
liability lawsuits.
But midwife-assisted home births are not always easily or legally arranged.
Today, just 27 states license or regulate so-called direct-entry
midwives--or certified professional midwives (CPMs)--whose level of training
has met national standards for attending planned home births. In the 23
states that lack licensing laws, midwife-attended births are illegal, and
midwives may be arrested and prosecuted on charges of practicing medicine or
nursing without a license. (Unlike CPMs, certified nurse midwives, or CNMs,
who are trained nurses, may legally assist home births in any state. But in
practice, they rarely do, since most of them work in hospitals.)
Putting aside the fact that the threat of arrest makes for a stressful work
environment, midwives say it also increases risks for the mother and child.
In the worst case, it could dissuade or delay a midwife from transferring a
patient in medical need to a hospital. (Doing so might expose the midwife to
the attention of law enforcement.) But now a campaign is under way to expand
state licensing of CPMs, which would not only grant mothers increased access
to home births, midwives say, but also make them safer.
Momentum appears to be growing. Of the 27 midwife-friendly states, eight
began licensing midwives only in the past decade. And legislatures in 10
other states are now considering bills to institute licensing of CPMs--a
fact that has not gone unnoticed by the medical establishment.
The Battle over Birth
The turf war between midwifery and medicine has been long-running. Both the
American Medical Association (AMA) and the American Congress of
Obstetricians and Gynecologists (ACOG)--the professional groups that write
official medical and obstetrics guidelines in the U.S.--oppose home birthing
on grounds of safety. In 2007 ACOG stated that the "safest setting for
labor, delivery and the immediate postpartum period is in the hospital or a
birthing center within a hospital ... or in a freestanding birthing center."
The statement was supported in a resolution passed by the AMA in 2008.
Choosing to deliver a baby at home, ACOG said, is to give preference to the
process of giving birth over the goal of having a healthy baby.
Midwives counter that for low-risk mothers, planned home births are no less
safe than hospital births. A study published in the BMJ in 2005 found that
among 5,418 mothers in the U.S. and Canada who planned home births, the rate
of neonatal or intrapartum death was 1.7 per 1,000 births--similar to the
rate of neonatal deaths (those occurring within the first 28 days) in
hospital births found in other studies. And home birth can be a favorable
experience for both mother and child, midwives say. Women who give birth at
home not only recover faster after delivery but also are more likely to
breast-feed and avoid postpartum depression, according to home-birth
advocates.
The political debate ratcheted up on July 1, when the American Journal of
Obstetrics & Gynecology published online a controversial new meta-analysis
of the safety of planned home births. The authors of the paper, which
consists of a review of 12 previous studies, acknowledged significant
benefits associated with home birth: fewer maternal interventions, including
epidurals, episiotomies and C-sections; and fewer cases of premature birth
and low birth weight.
But the finding that made headlines was that planned home births led to a
two-to-three-times higher risk of neonatal death than planned hospital
deliveries among healthy, low-risk women. The result was especially
striking, the authors wrote, because women planning home births generally
had fewer obstetric risk factors than those who chose hospital births: they
were less likely to be obese and had fewer previous C-sections or pregnancy
complications.
Lead author Dr. Joseph Wax cautions against alarm, noting that the absolute
risk of neonatal death is still extremely small in any birthing environment
in the U.S. According to the review, the rate of neonatal death was 2 to 3
for every 1,000 home births. The rate among hospital births was 1 for every
1,000 births. "Home birth is quite safe for the baby," says Wax, a
maternal-and-fetal-medicine specialist at Maine Medical Center. "But not as
safe as a hospital birth."
All the more reason for women to eschew home birth, say obstetricians. Wax's
study found that the increase in neonatal death could be attributed in part
to babies' breathing difficulties and failed resuscitation--factors
associated with inadequate midwife training and lack of access to hospital
equipment. The obvious solution: give birth in a hospital. "During the labor
process, emergencies can arise that we cannot predict. In some of those
cases, you only have moments to intervene successfully," says Dr. Erin
Tracy, an ob-gyn at Massachusetts General Hospital and an outspoken
detractor of home birthing. "It's a tragedy in those rare instances [of
infant death] where medical intervention could have saved the life of the
baby."
Informing the Patients
In terms of scientific evidence, meta-analysis sets a high bar. Because it
aggregates data from multiple studies, a meta-analysis is useful for
revealing medical trends that cannot be picked up by individual studies.
Perhaps more important, the results of meta-analyses hold great sway in
doctors' offices. They are kind of like medical Cliffs Notes: doctors often
prefer to read a single review paper rather than 20-odd original studies to
make a judgment about a particular treatment or intervention.
It would seem that the editors of the American Journal of Obstetrics &
Gynecology, who highlighted Wax's paper as an Editor's Choice, hoped the
study would inform patient decisions. The 12 studies analyzed were from
seven countries (two from the U.S.; the rest from Australia, Britain, Canada
and Western Europe) and compared data on maternal and infant outcomes in a
total of 342,056 planned home births and 207,551 planned hospital births.
But two independent experts in meta-analysis who reviewed the paper for TIME
concluded that it was weak and methodologically flawed. Other critics say
some of the studies included are outdated or misleading, thus limiting the
conclusions of the review.
One such study, published in the journal Obstetrics & Gynecology in 2002,
compared the outcomes of 6,133 home births and 10,593 hospital births in the
state of Washington from 1989 to 1996. But the paper did not make clear
whether any of the babies who died had birth defects that would have
resulted in death regardless of where they were born. The study also could
not determine in every case where exactly the birth had been intended to
occur; the authors relied on birth-certificate data, which indicated whether
a baby was delivered at home but not whether the home birth was accidental.
There is a big difference, of course, between having a baby in a planned
home birth with a midwife who has cared for the mother throughout pregnancy
and giving birth on the bathroom floor with a frantic spouse following
instructions from a 911 dispatcher. Births that happen at home unexpectedly
also tend to happen very precipitously, which is itself a risk factor for
the baby.
The Washington study found a twofold increase in infant mortality associated
with home birth compared with hospital birth. Given that it was one of only
seven studies out of the 12 included in Wax's meta-analysis that assessed
infant mortality in the first 28 days of life, the Washington study
accounted for nearly 40% of all such data and contributed heavily to the
final conclusions of Wax's meta-analysis.
Wax defends the inclusion of the Washington study, noting that its authors
used various methods to exclude any home birth that was likely to have been
unplanned. Moreover, he says, neonatal mortality rates were "fairly
consistent across the included studies" in his review. Indeed, Wax and his
colleagues think the conclusions of their analysis tend to underrate the
risks of home birth. "The lower obstetric risk characterizing women
self-selecting home birth likely underestimates the risk and overestimates
the benefit of this delivery choice," the authors write.
Making Home Birth Safer
Understanding the relative risks of home birth has always been tricky, in
large part because the subject is impossible to examine in a randomized
controlled trial; few women would agree to let a study investigator randomly
determine their birth plans. Meanwhile, broad reviews like Wax's of the
existing research can be limited by the quality or relevance of the original
data.
Some observers, including Wax, further suggest that American women should
draw only limited conclusions about the safety of home birth from studies
conducted in other countries. The experience of home birth in the
Netherlands, for instance, where 1 out of 4 mothers delivers at home, bears
little resemblance to the process most American women endure.
Two key factors contribute to a successful home birth: a mother who is at
low obstetric risk and the possibility of a seamless transfer to the
hospital in case of medical necessity. Because of eligibility requirements
for home birth in the Netherlands, Dutch mothers who choose that route tend
to be at lower risk from the start than their American counterparts. Dutch
women who have had C-sections, for example, are not candidates for home
birth, while in the U.S., previous C-sections are a major reason women
choose to labor at home. Yet according to ACOG's 2008 statement, attempting
VBAC at home is especially dangerous, because it puts the woman at risk of
uterine rupture during labor, with no immediate access to necessary medical
equipment or expertise.
In the Netherlands, moreover, midwives are fully integrated into the health
care system and obstetrics practices, making transfers to hospitals routine.
In the U.S., where 1 out of 200 women gives birth at home, midwives can be
and have been arrested for bringing their patients to hospitals in states
that do not license CPMs.
So it is no surprise that a large 2009 Dutch study showed home birth to be
safe. What that means for women elsewhere is less clear, however, and
results of various U.S.-based studies tend to conflict. "Research in this
area is desperately needed, particularly for women in the United States,"
says Wax.
The lack of definitive data guarantees that the birth wars won't soon end.
But many obstetricians and midwives can at least agree on one thing: easy
and immediate access to hospitals can improve birth outcomes and increase
home-birth safety overall. Which is precisely why midwives say they are
pushing to expand state licensing of CPMs. In states where licensing already
exists, home-birth advocates say, there is, on the whole, good cooperation
between midwives and hospitals.
A midwife's working relationship with a hospital aside, what really matters
is her competence. The reality is that licensed or not, midwives are already
practicing in every state, many in the shadows and many lacking any
certification whatsoever. Certification is granted on the basis of a
candidate's attainment of obstetric knowledge--acquired at midwifery school,
through distance learning or in an apprenticeship--along with her experience
attending births. A midwife must assist 20 births and serve as the primary
midwife on at least another 20 to become certified, a process that typically
takes three to five years.
In states without licensing programs, the danger is that women seeking a
home birth will not know whether the women delivering their babies are CPMs.
Many don't even think to question whether certified and uncertified midwives
have different training. That's why in two states where legislators have
recently considered licensing CPMs--Wisconsin, where a law was passed, and
Massachusetts, where the matter is still pending--the bills were championed
by unexpected proponents: women whose babies died during home birth. Their
babies didn't die because the women chose to give birth at home, they said,
but because the midwives who attended their births had not been certified as
competent. In the absence of a state licensing system, women can be none the
wiser.
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