Written by Heather Siebert
Overwhelming support for the safety of home birth with a midwife has recently been reported in two major studies, one conducted in the UK and another in Canada. In fact, these paradigm-shifting publications provide robust evidence that home births are as safe as, if not safer than, births in a traditional hospital setting. Another, much smaller, US study that was not specific to midwives was also recently published and while it showed an increased risk in perinatal mortality in out-of-hospital births, it emphasized that absolute risks in both settings are very low.
United Kingdom’s NICE demonstrates home birth safety
The idea that the hospital is the best location for birth is examined in a landmark press release published by the National Institute for Health and Care Excellence (NICE), an advisory entity for the United Kingdom’s National Health System.
The NICE publication makes two primary claims based upon evidence from 17,000 home births included in the UK’s population health data conducted by Birthplace:
What is a straightforward pregnancy?
A “straightforward” pregnancy is one in which there are no complications such as high blood pressure or gestational diabetes; the mother is considered low-risk for complications. While some may be surprised to learn this, in fact most women fall into this category. Dr. Baker, NICE’s clinical practice director is quoted as saying, “Most women are healthy and have straightforward pregnancies and births.”
What safety issues are avoided by giving birth at home?
Dr. Neel Shah, assistant professor of Obstetrics, Gynecology, and Reproductive Health at Harvard Medical School, examined the NICE recommendations, recognizing differences in treatment intensity between traditional hospital treatment and midwifery care. His response was published in June 2015 by the New England Journal of Medicine. Shah explained that obstetricians are trained as surgeons and are surrounded by operating rooms. Read his description of hospital birth:
Nearly all Americans are currently born in settings that are essentially intensive care units (ICUs): labor floors have multipaneled telemetry monitors, medications that require minute-by-minute titration, and some of the highest staffing ratios in the hospital. Most labor floors are actually more intensive than other ICUs in that they contain their own operating rooms.
There are dangers to over-intervention. Greene and Ecker write in a December 2015 editorial published in the New England Journal of Medicine that interventions have not demonstrated their worth; for example, the cesarean rate has doubled since the 1970s but the fetal death rate has not changed. Because of this, “…It is easy to see them [interventions] as unnecessary, meddlesome, and unacceptable.” Obstetricians are much more likely than midwives to routinely intervene with the birth process through inducing labor, electronic fetal monitoring, episiotomy, and cesarean birth, causing greater and perhaps unnecessary discomfort for women and increasing the risk of further interventions. Additionally, the risk for hospital-acquired infection increases. To top it off, Dr. Shah from the Harvard Medical School admits that birth interventions are rarely helpful to the newborn baby.
To put it simply: birthing with a midwife gives mothers peace of mind that their safety will not be compromised though routine, unnecessary intervention. Their uncomplicated pregnancies do not require ICU attention.
The UK’s NICE recommends mothers should have the option to birth with a midwife, whether at home or in a midwife-led unit. Healthcare providers should respect a mother’s choice if she decides to birth under the care of a midwife. Here in the United States, NICE recommendations are initiating important conversations about medicalized birth and treatment intensity in the US, reports Wang in a September 2015 Wall Street Journal article.
McMaster University researchers find home birth as safe as hospital birth
The Canadian Medical Association Journal published an article on December 22, 2015 comparing 11,493 planned home births to 11,493 planned hospital births. The study was conducted by researchers from McMaster University (Ontario); it found that home births, under the care of a midwife, showed no increased risk of harm to the baby compared to hospital births.
The McMaster University researchers included both first-time mothers and women who had previously given birth in their study. All women had low-risk pregnancies.
Eileen Hutton, a professor of Obstetrics and Gynecology at McMaster’s School of Medicine, is quoted as saying, “Among women who intended to birth at home with midwives, the risk of stillbirth, neonatal death or serious neonatal morbidity was low and did not differ from midwifery clients who chose hospital birth.”
As illustrated in the NICE publication, this study showed that women who gave birth at home were less likely to have interventions such as induction or labor augmentation, assisted vaginal birth, or cesarean delivery. The home birth mothers were also more likely to be exclusively breastfeeding at 3 and 10 days after delivery.
Small US study is not specific to midwives
On December 31, 2015, The New England Journal of Medicine published a study comparing outcomes for low-risk mothers in Oregon who planned to give birth in the hospital (75,923) with low-risk mothers who planned to give birth out-of-hospital (3,203) in the years 2012 and 2013. This study agreed with the other studies in finding that those giving birth out-of-hospital experienced much lower intervention rates including induction and cesarean section as well as lower admissions to NICU units. The study also showed that those planning out-of-hospital births were more likely to give birth at full term. Unlike the larger Canadian and UK studies, this study was not specific to licensed midwives – 90% of the births were with licensed providers (Naturopathic Doctor 13%, Certified Nurse Midwife 20%, Licensed Direct-Entry Midwife 57%); 10% of the births were with unlicensed providers (unlicensed midwives 8% and other person, such as a relative 2%). The Oregon study showed a higher risk of perinatal mortality for planned out-of-hospital births, although the authors emphasized that the absolute risk for both groups was still very low.
Home birth is a good option for low-risk women
While there are no risk-free locations to have a baby, these studies show that for low-risk women, there are many benefits to choosing an out-of-hospital birth with a skilled midwife. The lower intervention rates and higher breastfeeding rates experienced by those families planning out-of-hospital births, not only save them money but may help them maintain lower risks in subsequent births.
Could the slightly higher perinatal mortality rates experienced by out-of-hospital births in Oregon be attributed to a lack of established transfer protocols and respect and cooperation between hospital staff and home birth providers? We need to continue to explore how birth can be improved for all families in all locations.
Improving South Dakota outcomes
Our current policy in South Dakota of prohibiting our families from accessing Certified Professional Midwives, the only US healthcare provider that has required training in out-of-hospital maternity care, is leaving dangerous gaps in care in many parts of the state. Home birth friendly countries like Canada and the UK and home birth friendly states like Alaska, Montana and Oregon have better perinatal outcomes than South Dakota. It is time we join the 30 other states who safeguard the practice of these highly skilled midwives for their citizens.
As we prepare to celebrate the birth of Christ, I’m wondering what it was like for Mary being so far away from home for the birth of her child. Did she have the help of a local midwife or did she and Joseph birth “unassisted” by other humans? Like Mary, many women in South Dakota today do not have the option to have their baby in the safety of their own home with a trusted midwife. Although Certified Nurse Midwives are allowed by law to assist at home births, very few choose to do so and most practice only near Sioux Falls and Rapid City, leaving the families in the rest of the state on their own.
The evidence continues to mount that our cultural norm of high-tech birth practices is not beneficial to most babies and moms. Interventions like fetal monitoring, induction and cesareans that were developed for high-risk births are now being used on many women with healthy pregnancies. As rates of cesareans and inductions have risen, so has the number of babies that are being born premature. And although our high-tech health care system heroically intervenes to save younger and younger babies, it seems a more effective solution would be to prevent the problem in the first place.
We are incredibly grateful that, at the encouragement of our South Dakota Department of Health, every hospital with maternity services in our state has agreed to a policy of no elective inductions before 39 weeks. This seems like such a common sense policy, but I have heard grumblings from some parents who don’t understand why they can no longer schedule their baby’s birth. We need to keep educating parents about the benefits of this policy.
When procedures are done for convenience rather than medical necessity, we end up with higher rates of injury and death to babies and their moms. The Midwives Model of Care has been proven to reduce the incidence of birth injury, trauma, and cesarean section. That is why South Dakota Birth Matters is so passionate about increasing the number of skilled midwives practicing in South Dakota.
This year we will be bringing 2 bills to the South Dakota State Legislature that would give South Dakota families access to Certified Professional Midwives (CPMs), the experts in out-of-hospital birth. Plan A is a licensure bill that will take a 2/3 vote to pass. Plan B decriminalizes the practice of midwifery for Certified Professional Midwives licensed in other states and student midwives under the supervision of an approved preceptor. You can read more about these bills at SDBirthMatters.org. Our goal is to increase the safety for those families in our state who choose to have their babies at home by giving them access to licensed professionals who are held to evidence-based practice standards. Plan A holds those midwives accountable to a board within our state. Plan B does not.
We will not be able to get one of these bills passed without your help. We have a dedicated leadership team who is working to get you the resources you need to network with all your acquaintances and make a huge impact on the legislators. Here are 4 easy steps you can take right now to make a difference:
None of us can do it all, but all of us can do something. Working together we are making a difference. Thank you in advance for the steps you are taking to help provide better birth options for South Dakota families!
May you and your family have a very Merry Christmas!
|Your help is needed to make our 2016 Legislative Advocacy Day the best ever. South Dakota Birth Matters will have a display set up in the Capitol Rotunda all day and serve lunch to the legislators there from 11 am to 1 pm. There will be time for you to visit with legislators, attend committee hearings and watch both the House and Senate while in floor session. (We will post more details as we get closer.)You can sign up to:
at our online volunteer site. You can also let us know if you need childcare, which will be available from 9 am to 3:30 pm in the Visitors Center (right next to the Capitol) for a free will offering. Please post on our Facebook Event if you are interested in ride shares from your area or staying with a host family in Pierre.
If you can’t come, but still want to help, we need your financial support to pay for things like facility rental, bottled water, juice, and paper products. Any amount is greatly appreciated! You can donate to our Paypal Account on the home page of our website or send a check to :
South Dakota Birth Matters
Julie Pease, Treasurer
1200 N Advantage
Sioux Falls, SD 57103
South Dakota Birth Matters is working on two bills for the 2016 legislative session to give South Dakota families access to Certified Professional Midwives
This bill sets up an advisory committee under the Board of Nursing to license and regulate Certified Professional Midwives. It is modeled after the statute that regulates Certified Nurse Midwives (SDCL 36-9A) and contains the language regarding educational requirements from the historic US MERA agreement.
What is US MERA?
Last year, all of the major US midwifery education and credentialing bodies got together and agreed upon language for Certified Professional Midwife licensure. This language sets standards for education that meet the criteria set by the International Confederation of Midwives (ICM).
Why does that matter?
It matters because the national office of the American College of Obstetricians and Gynecologists now officially support the ICM education and training standards. The language in our new bill meets those standards.
“The American College of Obstetricians and Gynecologists (ACOG) endorses the ICM education and training standards and strongly advocates the ICM criteria as a baseline for midwife licensure in the United States, through legislation and regulation. Women in every state should be guaranteed care that meets these important minimum standards…All midwives – whatever their title or professional designation and regardless of where they practice – should meet the ICM standards, to ensure access to safe, qualified, highly skilled midwives in all settings including birth centers.”
Companion document to the ACOG Policy Statement on Midwifery Education and Certification and the Obstetric Care Consensus document, Levels of Maternal Care, developed jointly by ACOG and the Society for Maternal-Fetal Medicine, April 20, 2015 Link to ACOG Statement
Some may argue that we do not have enough Certified Professional Midwives currently practicing or willing to practice in our state to warrant passing a licensure bill. This decriminalization bill would create a bridge to licensure by doing 3 things:
Section 1 allows Certified Professional Midwives who are licensed in other states, and student midwives under the direct supervision of an approved preceptor to practice in South Dakota. This is accomplished by adding them to the exemptions listed in the nurse midwife practice act (36-9A-3).
Section 2 of the bill calls for the repeal of Section 1 on July 1, 2020.
Section 3 establishes the Midwife Regulation Fund where voluntary contributions can be collected and used for initial costs of setting up a regulatory board or advisory committee to regulate Certified Professional Midwives.
We will updating here during the 2016 SD Legislative Session. To ensure you never miss an update, please fill out our Contact Form to get on our email list!
Why does birth matter?
Grand Prize – Abbie Paulson, Aberdeen, SD
Youth Award – Emma Pease, Centerville, SD
You Tube Award – Brayla Miller, Chadron, NE
Audience Favorite Award- George Dennert, Columbia, SD