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Should American Women Learn to Give Birth at Home?

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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