The Coalition for Safer Home Birth

In response to the increased death rates at home birth and the lack of regulation and accountability of home birth midwives, an citizen-led organization called the Coalition for Safer Home Birth has formed. The Coalition is made up of home birth families, doctors, midwives, and advocates who wish to make home birth safer in America.

https://www.change.org/p/state-legislators-protect-mothers-babies-make-home-birth-safer

To draw our lawmakers' attention to the laws that would most improve the safety of home birth in the United States, the Coalition for Home Birth has started a petition on Change.org.

The petition endorses the following regulations for midwives:

1. Require a License
2. AMCB Certification
3. Malpractice Insurance
4. Low-risk Scope of Practice
5. Report Outcomes to the Public
6. Integrated System of Care

You can sign it here: Change.org: Protect Mothers & Babies - Make Home Birth Safer

We need to improve our home birth system! Please read and sign the petition, and use it as a guide for pushing for a better system in your state.

Home Birth After Cesarean (HBAC)


What is an HBAC?

A vaginal birth after a previous cesarean section is called a VBAC. A home VBAC is often called an HBAC - home birth after cesarean.

Are HBACs riskier than hospital VBACs?

HBACs have nearly four times the newborn death rate that hospital VBACs have. VBACs attempted in the hospital have a neonatal mortality rate of 1.3/1000; this means that one baby will die for about every 800 hospital VBACs attempted. VBACs attempted at home (HBACs) have a neonatal mortality rate of 4.75/1000; this means that one baby will die for about every 200 HBACs attempted.

Why are VBACs considered "high risk"?

In other countries where home births are well-integrated into the medical system and they have regulated risk assessment criteria, having a prior cesarean section means you will be "risked out" of having a home birth. Your pregnancy and labor are considered "high risk." Why is that?

Well, one of the biggest reasons having a prior cesarean section makes you high risk is the increased chance of uterine rupture. In the place where the uterus was cut during the prior cesarean delivery, a scar has formed. The stress of stretching out during pregnancy and then undergoing labor can cause the uterus to tear open at the scar. This is called uterine rupture, and it is a life-threatening event for both mother and baby.

For women who have never had a cesarean section, the uterine rupture rate is only 0.012%, or 1 in 8,434.  For women who have had a previous "classic" cesarean section (vertical cut on the uterus), the uterine rupture rate is 2-11%, or at least 1 in 50 (and possibly as high as 1 in 9). For women who have had a previous low transverse cesarean section (the most common kind of cesarean), the uterine rupture rate is 0.5-2%, or about 1 in 200 (but possibly as high as 1 in 50).

What are the signs of a uterine rupture?

Signs of a uterine rupture include abnormal patterns in the baby's heart rate, tachysystolic contractions (that means where the contractions are one right after the other), vaginal bleeding, shock, prolonged labor, and abdominal pain, but by far the most consistent sign of a uterine rupture is abnormal patterns in the baby's heart rate. The absolute best way to watch for this sign is with continuous electronic fetal monitoring, which can only be done in the hospital.

http://reference.medscape.com/article/275854-overview#a5

Some women have been told that even if they have an VBAC at home, they will definitely be able to tell if they have a uterine rupture because they will experience abdominal pain. But as you can see from the above chart and reference, only one out of every four women who have a uterine rupture experience abdominal pain. Abdominal pain is specifically pointed out as being "an unreliable and uncommon sign of uterine rupture."

Sometimes CPMs and other home birth midwives claim that they have "better training" than nurses or doctors to detect uterine ruptures. This is not true. It may be possible for a home birth midwife to detect a uterine rupture with a doppler if they are listening for longer intervals than normal and at the exact same time as the rupture, but it's highly unlikely they will catch the rupture right away. It's also a myth that being at home with a midwife will prevent a rupture. It will not. Uterine ruptures occur at the same rate in the hospital and out; it's just far more likely at home that the rupture will go undetected until it is too late for the baby.


If the uterus ruptures, how long do you have to save the baby?

When the uterus ruptures, the biggest risk to the baby is lack of oxygen. Essentially, the baby cannot breathe, and the placenta is no longer providing them with oxygen. They are suffocating. A cesarean section needs to be performed immediately to save the baby from brain damage or death. Several studies have shown that you have at most about 18 minutes to deliver the baby after uterine rupture before certain brain damage or death. You can see those studies here and here.

Many families planning home birth are comforted by the fact that "we live just five minutes from the hospital" in case anything goes wrong. But living five minutes from the hospital means you are at least thirty minutes from an emergency c-section, as this post explains: Five Minutes to the Hospital.

VBAC at the hospital vs. VBAC at home, a summary

At the hospital: A woman is attempting a VBAC with continuous electronic fetal monitoring, the best way to detect a uterine rupture. She does, indeed, rupture. The baby's distress is detected almost immediately and the doctors can act immediately to save the baby's life and brain function.

At home: A woman is attempting a VBAC and the baby's heart rate is being checked every fifteen minutes with a doppler. The midwife checks the baby's heart rate. It sounds good. A few minutes after she checks, a rupture occurs. Fifteen minutes later, she checks again. This time she can tell the baby's distressed. They call the ambulance, which takes a few minutes to arrive and another few minutes to get to the hospital. Some more time (we'll estimate 15 minutes) is spent getting the mom ready for an emergency c-section. By this time, the baby's been without oxygen for over 30 minutes and is most likely lost or at the very least severely brain damaged.


VBACs are classified as "high risk" for a reason. 

https://www.facebook.com/groups/birthaftercsectionfacts/

Five Minutes to the Hospital


Distance from an operating room during childbirth matters. If you give birth in a hospital, if there is an emergency you are literally down the hall from the operating room and can be having a stat c-section in minutes.

Families planning home births are often comforted by the fact "We live just five minutes from the hospital in case anything goes wrong!"

I want to ask you something - how long can you hold your breath? Can you hold it for five minutes? Try holding it for the next five minutes. Because every minute from the time something goes wrong at a home birth until you are at the hospital, in the operating room ready for an emergency c-section, your baby will be holding their breath. Do you think they can live through that? Do you think they can live through that without brain damage?

"Five minutes from the hospital" is not really five minutes from the hospital. Sure, on a normal day, once you are in your car you might be able to drive from your house to the hospital in five minutes. But this is not a normal day. You are in labor, in severe pain, and there is an emergency occurring. It could take five minutes - or more - just to get from whatever room you are in to the car. Then it could take another five minutes to drive to the hospital, if the traffic happens to be good and you don't hit any red lights. And even if you drive up to and park in front of the ER, it will probably take another couple minutes to make it out of the car, inside the ER, and explain the situation. They have to evaluate you themselves, and make the decision to do an emergency c-section. Then they have to prep your for surgery. All of that takes at least another twenty minutes. At this point, it's been at least forty minutes from the moment of decision to go to the hospital until you're going into surgery. Can you hold your breath for that long? Can your baby? Is that "five minutes away?"

And if you think this would all be significantly sped up if you call for an ambulance at the moment of decision - think again. First, the ambulance has to get to you. If you're lucky, it will be at your house in five minutes or less. They load you up - another five minutes. Drive to the hospital - another five minutes. Unloading you, hooking you up to monitors, getting the story and your history, checking the baby, prepping you for surgery - another twenty minutes. At the very best, from moment of decision to incision to save your baby is 35 minutes.

So remember, "living five minutes from the hospital" really means "living over thirty-five minutes away from an emergency c-section." And every minute counts when your baby is deprived of oxygen.

This is a good article from a nurse's points of view: When Minutes Matter in Nursing 
And this post is a good explanation of the same thing: Friday Fallacies - The Hospital is Just Minutes Away

Home Birth Death in Hawaii

A newborn died last Wednesday as the result of an attempted home birth in Hawaii. From the Hawaii Tribune Herald

"One obstetrician said that Wednesday’s death had taken a toll on hospital staff, especially because of the fact that it was another in a disturbing trend."

“'This is an ongoing problem here. … Within the last five years, I’ve seen at least three dead babies from home births, and just a week ago I took care of a patient who nearly bled to death after a home birth,' the doctor said. 'All of the obstetricians here have had similar experiences. And in all of these situations, the standard of care of obstetric practice was not followed by the practitioners. I believe that all of these bad outcomes could have been avoided if good practice patterns were actually followed.'”

"The obstetrician said that state law does not require licensing and oversight of midwives and other practitioners that aid in the home birthing of babies, which can lead to dangerous situations."

“'You need a license to be a plumber, you need a license to be a carpenter, you need a license to cut hair in the state of Hawaii. You do not need a license to deliver a baby,' the doctor said. 'I have had multiple occasions where babies died, and did not need to die, and there are no repercussions for the people who misled these patients.'”

Read the full article here: Hawaii Tribune Herald: Death of newborn rekindles home-birth debate

What do the studies say?



Every study done on planned, midwife-attended home birth in the United States has found significantly increased rates of babies dying at home birth. 

Term neonatal deaths resulting from home births: an increasing trend 
This study was published in 2014 by researchers from the Weill Cornell Medical Center. They analyzed over ten million births from 2007 to 2009, and found a death rate 4 times higher at home birth than hospital birth. 

Oregon Study 
These are the official homebirth death statistics from the State of Oregon in 2012. They found that homebirth had a death rate 8 times higher than hospital birth.

Infant outcomes of certified nurse midwife attended home births: United States 2000 to 2004 
This study from 2010 found that home birth with CNMs had 2 times more deaths as the hospital, and home birth with CPMs had 3.5 times more deaths than the hospital.

Home birth and risk of neonatal hypoxic ischemic encephalopathy 
Researchers from Weill Cornell Medical Center and Yale School of Medicine found that home birth babies suffer 17 times as many brain injuries as those born in the hospital.

Selected perinatal outcomes associated with planned home births in the United States 
This study, published in 2013, found that 3 times as many babies born at home have seizures.

Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting
This study was published in 2013. The researchers found that almost 4 times as many babies born at home have seizures, and 10 times as many babies born at home have a five minute Apgar score of 0.

Outcomes of Care for 16,924 Planned Home Births in the United States 
This study was released 2014 by the Midwives Alliance of North America. It has numerous weaknesses such as voluntary participation by midwives and self-reported numbers. With obvious personal interests in making the numbers look better, is is likely that many negative outcomes were not reported by midwives. As such, this study likely under-counts the death toll of homebirth, but even with those limitations it found a death rate 5.5 times higher at homebirth (for breech babies the death rate was 28 times higher).


The Business of Being Born

Many women first become interested in home birth after watching the movie "The Business of Being Born." Unfortunately, it's full of misinformation and misleading statements.

These posts do a good job of debunking the misinformation found in the film:

American Home Birth: The Business of Being Misled

and

Debunking the Business of Being Born: Part 1
Debunking the Business of Being Born: Part 2
Debunking the Business of Being Born: Part 3
Debunking the Business of Being Born: Part 4
Debunking the Business of Being Born: Part 5
Debunking the Business of Being Born: Part 6
Debunking the Business of Being Born: Part 7
Debunking the Business of Being Born: Part 8
Debunking the Business of Being Born: Part 9

Honest Midwife


Earlier this year, a former CPM midwife spoke out. She started a new blog called "Honest Midwife" to pull back the curtain and expose some of the unethical and illegal practices of the CPM world.

Her name is Leigh Fransen, and she attended a midwifery school accredited by the state of Florida. After graduating she moved to South Carolina and started a successful freestanding birth center in partnership with three other midwives. She left the practice in 2013. After she left, the birth center had three deaths within two years. She wrote of the experience:

"As I drove home, I gripped the steering wheel tightly, my heart racing in my chest. I GOT OUT. It was messy and confusing and ugly, but I was out of there for good. I was relieved, but I wasn’t ready to be honest with the world about why."

"That was January 2013. In April 2013, I heard the first rumors of a baby’s death soon after her birth at the center. In September 2013, news of a second death was splashed across local newspapers. And in January 2015, a third death was reported. My thoughts and emotions ran rampant. One moment, I would arrogantly congratulate myself: No deaths on my watch, and three on theirs, who’s the best midwife now? Another moment, I would wonder at my favored status in the universe, that God had spared me from all the horror, and just in time. And in my most honest moments, I knew the truth of it: I had gotten incredibly, ridiculously lucky. And those three mothers who sat at home with empty arms, they simply had not."

Her full account is breathtaking, and I encourage you to read it in its entirety.

In her account, she describes finally "doing her research" after years of telling parents that home birth was safe.

"I began in familiar territory, the website of the Midwives Alliance of North America (MANA.org). On this site there is a button titled “Research,” and it leads to an extensive collection of the studies that MANA has determined builds the case that nonhospital birth with a midwife is safe...I spent the next several hours using my university library (and helpful librarians) to track down every one of these 24 studies and print them out, filling a large 3-ring binder with my efforts."

"Shades of guilt danced in the back of my head: shouldn’t I have done this years ago? Perhaps before I decided to actually give birth to my own child in a bathtub in a residential neighborhood in Miami? Possibly during my years as a student of midwifery? Maybe before I had assured scores of women that “research showed” giving birth at my birth center was as safe as any hospital? I cleared my head to focus on the task at hand. The research was all here in front of me now. I sat down with my giant binder of studies, a cup of coffee, and a handful of pens and highlighters. I had a long day ahead of me. I began at the beginning of MANA’s list."

She writes about reading each study, one by one, and again, I highly encourage you to read her analysis.  What did she find?

"The hours I had spent combing over all of MANA’s best evidence led me to this conclusion: nonhospital birth might be as safe as hospital birth, but likely only in health systems in which midwives are hospital-trained and well-integrated, and where exclusion criteria are strictly observed to permit only the lowest risk women to proceed. Nonhospital birth in the United States as currently practiced is responsible for lower numbers of interventions (such as cesarean section and medical pain relief) but a substantially higher risk of death or injury to the baby."

"Unbelievably, our 'own' evidence, upon close inspection, was almost unanimously against us."

As damning as this is, it is not the worst thing that Leigh Fransen reveals in her account of CPM midwives. The most stunning indictment of CPMs comes as Leigh describes her first-hand experiences at her midwifery school and in the field as a fully-practicing CPM:

"When, as a student midwife, I first participated in nonhospital births, I witnessed some things that made me uncomfortable. At my school, the head midwife would sometimes do illegal vacuum-assisted deliveries. The first time I saw one done I didn’t realize it was illegal, but when I started talking about it freely, I was quickly quieted by the more senior students. “We call it ‘the fruit,’” they said, a reference to the vacuum’s brand name, Kiwi. I rationalized that these other students and midwives would not be using “the fruit” if it was really harmful, so the law must be an unnecessary one. Soon, I was recruited to help usher family members out of the room “so the mother can rest,” as a cover for the vacuum use; I would then lock the door and stand guard. If I was instructed to cover the mother’s face with a cold washcloth “to help her relax,” I made sure her eyes were covered so not even she could see the vacuum being applied. I rationalized that surely she would have given us permission to do this to help her get her baby out without transporting, but that it wasn’t smart to ask permission to perform an illegal procedure. Toward the end of my apprenticeship, I was the one holding the vacuum, applying it to the baby’s head, exerting the carefully angled pressure to help pull the baby down. I rationalized that now I would know how to get a baby out, if I were ever in a situation where there were no available hospitals."

"I did not originally plan to attend a school where I would learn to perform dangerous, illegal procedures; I became complicit through a chain reaction of participation and justification. "The fruit" was only one of many "exceptions" I learned to make; many of these exceptions I carried with me to my later practice. Illicit use of medications, cavalier usage of toxic herbs, induction techniques, pretending not to see a cesarean scar, fudging dates, doctoring charts, “accidental” breech deliveries, cheating blood pressure readings, lying to doctors, ignoring borderline test results, pretending to know answers while furtively Googling, waiting just a little bit longer for baby’s heart tones to improve, purposely underestimating the staining of amniotic fluid, misrepresenting our personal statistics and the statistical realities of our “profession”… all of these practices are endemic to direct-entry midwifery in the United States. I know because I did most of them. I was present (and silent) as others did them. I heard the stories in “peer review.” Not every midwife does all of them; very, very few, if any, do none. It all starts with one small step, and we justify along the way, until we are lost in the woods with no moral compass left to guide us."

To read Leigh Fransen's full account, click here: High Risk: Truth, Lies, and Birth
To read Leigh's account in blog form, click here: Honest Midwife 
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