The potential risks of home birth
So what makes home birth so controversial? After all, if the women I spoke with (all of whom were able to deliver healthy babies at home with no major health complications) are any indication, it seems like there are plenty of positives to successful home birth experiences. Proponents of home birth point not only to the improved experience for mothers, they also note the lower rates of episiotomies and vaginal tearing, as well as the reduced rate of interventions overall—and the cost savings that go along with it.
But when home births go wrong, there is a greater chance that they will go very wrong. While it can be hard to pin down data regarding the safety of home births (with both sides referencing studies that support their perspectives), it does seem clear that home births are, on average, riskier than hospital births. “The balance of data suggests that the risk of death for a full-term newborn is about two-fold higher,” says Dr. Kate Menard, Professor and Director of Maternal-Fetal Medicine and Vice Chair for Obstetrics at the University of North Carolina Chapel Hill’s Department of Obstetrics and Gynecology. “The other risk that’s documented is that when labor goes bad and there is oxygen deprivation, it can cause seizures and brain damage, and that risk is about two-fold higher, as well. All of that is rare in a term baby, but it’s more common with home birth.”
When it comes to both home births and birthing center deliveries, appropriate upfront risk-assessment plays a key role. “You need to have risk criteria for folks to deliver at home or a birth center, and they should be the same criteria,” Darcey says. “You should be no more than 30 minutes from ‘decision to incision,’ and you have to make decisions earlier if you live further. You shouldn’t be doing twins and breeches at home. If you really risk-screen your moms, there may be a small increase in admissions to NICUs, but home births can do just as well as the hospital.”
Even with proper risk assessment, however, low-risk births sometimes go awry, and in those cases speed of access to appropriate care is crucial. “‘Low risk’ can become ‘high risk’ with little warning,” notes Dr. Menard.
Obviously, proximity to the hospital in a true emergency may explain some of the differences in the documented risks. But another factor may have to do with the midwives themselves, who practice with widely varying levels of education and experience. There are two kinds of midwives: certified nurse midwives (CNMs) and certified professional midwives (CPMs). While CNMs have nursing degrees in addition to a standardized course of midwifery education, CPMs are far less uniform in terms of training. All CPMs receive certification through the North American Registry of Midwives (NARM), but there are several pathways to certification. Some CPMs attend midwifery schools, while others receive their CPM status without any formal education outside of an apprenticeship process (as well as the completion of a competency-based written exam administered by NARM).
For a number of reasons (including insurance coverage, state-specific laws requiring physician oversight, and liability concerns), nurse midwives are more likely to attend births in hospitals and birthing centers rather than in the home. So it is mostly CPMs who provide home birth services, and, since CNM-attended home births are illegal in a number of states, these services may be provided outside the law.
While many CPMs can and often do provide an excellent standard of care, at least one study indicates that CPM-lead home births are significantly riskier than CNM-lead home births in terms of infant mortality (both of which were found to be riskier than CNM-lead hospital births). Clearly, then, it is important for expecting mothers to be aware of the difference between CNMs and CPMs and to learn about a prospective midwife’s background and educational experience before making the decision to work with her, especially for a home birth.