By Sandra Londino, MS, CNM, LM
Home birth is common among women in many countries, but in the US it's rare and poorly understood. This wasn't always the case. During colonial times, women gave birth in their homes, attended by women, with male physicians allowed into the birthing room only when labor deviated from the norm.
During the second half of the eighteenth century, male physicians began taking a more prominent role in childbirth, especially for members of the upper and middle class, who saw being attended by physicians as a status symbol. Commonly held sexist beliefs about the intellectual and emotional inferiority of women contributed to this shift. By the turn of the century, doctors were attending half of all births, though midwives still served the poor and rural folks.
In the early 1900s, medical leaders began calling for the abolition of midwifery entirely. Prominent obstetricians of the time believed that pregnancy and childbirth were dangerous, pathological conditions that could be best managed in hospitals with drugs, specialized procedures, and surgery. Thus, women began to believe that hospitals offered them the safest and most satisfying birthing experience. This happened in spite of the favorable outcomes that midwives experienced, such as lower rates of maternal death and neonatal injury and death, and more comprehensive postpartum care. By the early twentieth century, thousands of American women still died from postpartum infection every year. Serious perineal lacerations, head injuries to the fetus, and breathing disorders resulted because of inappropriate and careless use of forceps and chloroform. As midwifery declined during the first half of the century, maternal and infant mortality rates steadily increased. By 1935, the percentage of births attended by midwives in the US had decreased to 12.5 percent.
Fast-forward to the present day: According to World Health Organization, the US now ranks 58th in the world for maternal mortality (meaning 57 countries are better at keeping new mothers alive after birth). Our infant mortality rate is 34th in the world (meaning 33 countries are better at keeping infants alive). This despite the fact that, globally, the US spends the most money on maternity care, close to $100 billion annually.
Currently, midwives attend about 11 percent of all American births; about 2 percent of women give birth at home. This actually represents an increase, as out-of-hospital birth went up by 41 percent between 2004 and 2010, with 10 percent of that rise occurring within the past year. Clearly, women are starting to realize that the modern maternity health care system doesn't serve their needs.
Home birth with midwives has a very high level of proven safety. Studies show that low-risk women who plan a home birth have significantly fewer interventions and complications than low-risk women birthing in hospitals. Out-of-hospital births have similar perinatal outcomes to hospital births with the added benefit of fewer interventions. No statistical difference in mortality exists between planned home birth and planned hospital birth, while the rates of medical interventions, severe lacerations, operative births, and low Apgar scores are significantly lower in home births (this from a meta-analysis of several studies). Rates of certain complications and interventions are significantly higher in hospital births.
There are many reasons why women choose home birth, among them desire to avoid unnecessary interventions (especially cesarean birth); previous negative or traumatic hospital birth experience; control over birth decisions and choices; trust in birth as a normal, healthy process; no separation from baby; easier breastfeeding initiation; increased options (delayed cord cutting, water birth); and history of fast labor, making it difficult to get to the hospital in time.
Home birth midwives believe that birth is a natural physiological process, and that pregnancy and childbirth are best supported with good nutrition, personal responsibility of the mother for her pregnancy, and attentive clinical management. They educate clients and consult with them on clinical care decisions, allowing for truly informed choice. Before she accepts a client, a midwife will determine whether she's a good candidate for home birth: i.e., she will accept responsibility for self-care, has adequate family and/or social support, has a positive attitude about and strong desire for natural birth, and has no medical or obstetric complications requiring hospitalization during labor and birth. Extended prenatal visits provide a thorough health history and a relaxed opportunity for questions and just getting to know each other.
The importance of physical, emotional, and spiritual well-being are all considered in the birth plan. Women are encouraged to be active participants in their births as they choose their surroundings, support team, and comfort measures. It's important for home birth parents to plan for the possibility of a transfer to the hospital. A transfer rate of about 10 to 12 percent is common for most home birth midwives, though urgent transfers are rare.
Care during labor and birth includes attendance by the midwife and her birth assistant, often a registered nurse. The mother and baby are monitored during labor and the laboring woman is offered natural pain relief including position changes, massage, hydrotherapy, aromatherapy, acupressure, herbal and homeopathic remedies, and continuous loving support. The midwife monitors mother and baby throughout labor and after the birth. She provides breastfeeding support and postpartum care immediately after the birth and even helps with clean-up before leaving several hours later. Home birth midwives provide frequent and loving support and monitoring in the early post-partum period, with breastfeeding encouraged and supported. Following several home visits, a six-week postpartum visit to wrap up perinatal care usually takes place in the midwife's office.
Most home birth midwives also offer gynecological services such as preconception counseling, fertility counseling, family planning, well-woman exams, pap smears, and breast exams.
Two main types of midwives attend home births in the US. Certified nurse midwives (CNM) have a nursing degree plus at least a master's in midwifery. These midwives are legal in all 50 states and can deliver babies in hospitals, birthing centers, and homes. However, the majority of births attended by CNM's take place in hospitals.
The majority of home births in the US are attended by direct-entry midwives —midwives directly trained in midwifery who don't have a nursing degree. A common type of direct-entry midwife in the US is a certified professional midwife (CPM). The CPM certification offers legal status in 26 states. New York State is the first state in which CNM's and CPM's are regulated by the same legislation and the same board using the same designation — Licensed Midwife (LM). LM's have the authority, as necessary, to prescribe and administer drugs, immunizing agents, and diagnostic tests and devices, and to order laboratory tests. New York State LM's, considered licensed independent practitioners (LIP's), are not required to practice under the supervision of a physician.
The cost of home birth can vary considerably. Home birth may or may not be covered by health insurance. In central New York, home birth generally costs around $3,000 to $4,000, usually including all prenatal visits and several postpartum visits.
Midwives have varying styles and levels of expertise. It's important to choose a midwife you feel compatible with, who inspires confidence. Determine whether the midwife's answers to the following questions agree with your desires. If your heart trusts her, you've found your midwife.
• What training and licensure does she have?
• What is her basic philosophy of childbirth?
• How many births has she attended as the primary midwife?
• Does she handle higher risk situations, such as twins or breeches?
• What kinds of services are included in prenatal care? What kind of postpartum care does she provide?
• What does she do if two of her clients are in labor or birth at the same time? Is she easily reached by pager or cell phone allowing 24-hour access?
• How does she handle problems or complications that develop during labor?
• Is she affiliated with a physician who can answer questions about unusual developments during the pregnancy or birthing?
• What is her policy for transporting to a hospital?
• What medical facility would she use? Has she developed a good working rapport with them?
Home birth midwifery services are a valuable addition to the health care options of any community. Women, children, and families have healthier lives because of the work that midwives do. Midwifery focuses on the normalcy of women's life events, and therefore empowers women to make choices that promote health: healthy mamas bringing healthy babies into healthy families.
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