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.
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."
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
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.
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.)
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.
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
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.
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
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.
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.
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."
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
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.
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.
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.
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.
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.
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
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
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
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.
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.
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.
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.
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
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.