The Risks of a Postterm Pregnancy

Home birth midwives dismiss many risks in pregnancy as being "variations of normal." They use this term to ease the mind of concerned parents, acting as though simply because a complication occurs in nature, it is harmless.

Unfortunately, most of the complications that home birth midwives dismiss as "variations of normal" carry real risk that increase the chances of harm to the baby or mother. And ignoring the risk does not make it go away, as many home birth mothers have learned the hard way.

Some of the risks most commonly dismissed by home birth midwives are the risks associated with going past your due date. "Babies come when they're ready," they say. "Babies know when to be born."

But if this is true, why are any babies born prematurely? Prematurity can result in serious long-term complications for baby, months-long NICU stays, and death. If those babies didn't know when to be born, how can a home birth midwife be so sure that *your* baby knows when to be born? Just like preterm birth, postterm birth can result in serious complications and sometimes death.

Postterm Death Rates

The different "terms" of pregnancy are defined as: preterm (before 37 weeks), early term (from 37 weeks to 38 weeks and 6 days), full term (from 39 weeks to 40 weeks and 6 days), late term (from 41 weeks to 41 weeks and 6 days), and postterm (42 weeks and beyond):

"Definition of Term Pregnancy"

At the end of pregnancy, there is a balance between babies being born too early and babies being born too late. Too early, and their organs might not be ready yet. Too late, and the chances of stillbirths, cord accidents, shoulder dystocia, meconium aspiration, and placental failure increase.

The chart below shows what those risks look like balanced against each other.

The risk of babies dying after they're born birth is higher before 37 weeks, decreases and is it its lowest point between 39 and 40 weeks, and increases from then on. The risk of babies dying before they're born (being stillborn) increases from 37 weeks on, increasing exponentially after 40 weeks. The following chart shows those trends, with deaths of babies after birth in blue, stillborn deaths in red, and the combined risk of the two in yellow:

"Risk of Stillbirth and Infant Death Stratified by Gestational Age"

As you can see, the risk of death from both complications after birth and from stillbirth rises after 40 weeks and just keeps getting higher.

The study that this table is from, Risk of Stillbirth and Infant Death Stratified by Gestational Age, shows that the risk of stillbirth is more than twice as high at 42 weeks than 40 weeks, and only keeps increasing from there. Medscape summarizes the findings of multiple studies as "Perinatal mortality (defined as stillbirths plus early neonatal deaths) at 42 weeks of gestation is twice that at 40 weeks (4-7 vs 2-3 per 1,000 deliveries, respectively) and increases 4-fold at 43 weeks and 5- to 7-fold at 44 weeks."

What are the risks of going postterm?

So why does the risk of death begin to increase so much after the 40th week of pregnancy?

In a nutshell: Your baby's organs are 100% ripe and ready to go by 39-40 weeks. There is no physical benefit to your baby for waiting any longer; there is only more risk.

There are only two things that can happen post-dates, and both are potentially bad. Either the placenta stays strong, or it doesn't.

If the placenta stays fully adequate, the baby keeps getting bigger and bigger, which is going to be a problem when labor finally starts. Complications for the baby can include "prolonged labor, difficulty passing through the birth canal, and birth trauma (eg, fractured bones or nerve injury) related to difficulty in delivering the shoulders (shoulder dystocia)." Risks to the mother "are related to the larger size of postterm fetuses, and include difficulties during labor, an increase in injury to the perineum (including the vagina, labia, and rectum), and an increased rate of cesarean birth with its associated risks of bleeding, infection, and injury to surrounding organs."

If the placenta starts to fail, then the baby gets weaker and becomes more stressed the longer things go on. The chance of oligohydramnios (low amniotic fluid levels) increases, raising the risk of umbilical cord compression (which cuts of the baby's source of oxygen). Babies are also more likely to pass meconium (baby poo) in the womb and inhale it, which can cause serious breathing problems and death.

The risks of postterm pregnancy are real

Clara Edith

Heather O., the author of the blog The Destiny Manifest, has written a heartbreaking account of how her daughter Clara died from postterm pregnancy complications. In a post called She Was Still Born, Heather writes,

"I reached the 40 week mark on June 14th. I was thrilled to have made it to my due date, feeling a little arrogant about how the doctors had said I would “never carry a baby to full term”, but also feeling ready for our baby girl to make her appearance. We had read all of the research that shows that 40 weeks is just the average length of a normal pregnancy — anything from 38 to 42 weeks is considered in the normal range, and I know of several women who have had their babies at 43 and 44 weeks. We weren’t worried.

At 41 weeks, I was still 4cm and baby girl was at 0 station. We discussed induction but decided against it. I wanted a vaginal birth after cesarean very badly, and pitocin is generally contraindicated in a VBAC, particularly when the mom has a “special scar” like I have.

By this point I was very uncomfortable and ready to not be pregnant...David and I had a long soul-searching conversation over the course of a couple days and decided that, since baby girl was still fine, with a great heart rate and passing every kick count, we’d give it until 42 weeks and then reconsider the hospital induction. We felt very good about this decision, having weighed all of our options.

On the afternoon of Thursday, June 28th, the day that I hit 42 weeks, we made the decision that if I was not in “real labor” by the next night...we would go into the hospital for a medical induction. We didn’t make this decision based on any worry about the baby’s health, as she was still kicking quite exuberantly in her very tight living quarters. We made the decision because I was uncomfortable and oh-so-ready to meet our baby.

I woke up on Friday morning to contractions, but this time they felt different...I told David that I was pretty sure these weren’t going to stop. They felt more real than any of the other times...The contractions slowed down that night but never stopped completely. The next day was much like the one before, painful contractions but nothing I couldn’t handle.

I woke up on Sunday in real pain. It didn’t feel like the labor I’d been having, and it didn’t feel like the way countless books and birth stories and friends have described labor. It was pain and it was harsh...I told David that something felt wrong, that it hurt too much and I needed to go to the hospital NOW.

The doctor came in and began the ultrasound. After a couple more minutes, David and I looked at each other and the realization that there was a problem began to dawn. I said, “Can you not find her heartbeat?” and the doctor said “No, here is her rib cage and there is no heartbeat there.”

Time seemed to slow to a crawl. I felt cold, lost in some surreal nightmare. David ran to the bathroom and collapsed to the floor, sobbing. The nurses and tech disappeared from our room. The doctor said “I’m so sorry.” David asked if he could possibly be wrong, that maybe he made a mistake. The doctor said that there are no guarantees in life and that there was a chance he was wrong. I asked “how quickly can you get her out?” and he answered “with a cesarean, we can get her out right now.” I said, “then do it, get her out now.”

Over the next 15 minutes, I signed a consent form, was shaved and prepped for surgery, and had my blood typed...I was crying, but still believed absolutely that they were wrong. I would hear her cries any minute. She might need some help, maybe she’d need to go to the NICU, but she would be fine.

The smell of infection filled the room when our doctor opened my uterus. David stood and watched as the doctor pulled our daughter from my body...My husband looked down at me and shook his head slowly. I began to sob in earnest and the anesthesiologist, with tears running down his own face, gave me “something for anxiety.” The nurse called David over and handed him our beautiful daughter, Clara Edith. He brought her to me and I touched her cheek, still warm from my body. I wanted to hold her so badly, and I was assured that they would take pictures of her right then and bring her to me as soon as I got out of surgery.

It took almost an hour and a half after Clara was born before the doctors were done cleaning out all of the infection in my uterus...I was taken back down the hall of crying and healthy babies to a room at the end, where my husband and I waited for our lifeless daughter to be brought to us. An hour after the surgery, a nurse brought in a cart with a white basket draped in a hospital blanket. She asked if I wanted to hold her and I said that I did. She laid my baby girl in my arms and told us to take as long as we needed.

...What if we had decided to medically induce at 40 weeks? What if we had decided 41 weeks was our limit? What if we had gone on to the hospital as soon as those contractions started on the Friday before she was born?

The doctor said she had been gone between 1 and 3 days...She died sometime between Friday evening and Saturday afternoon. The doctor’s theory is that my amniotic fluid level dropped drastically and she passed and ingested meconium, which poisoned her and ended her life."

I encourage you to read Heather's full account; there's a lot that I couldn't include here.


Daxton Green is a baby who died shortly after being born at the Carolina Community Maternity Center (a freestanding birth center) on January 20, 2015.

In an inquest following his death, his death was ruled a homicide.

The Charlotte Observer explains:

"The jury had four options in ruling the manner of death – undetermined, natural, homicide and accidental."

"Homicide in this particular case is not a legal definition; it’s a description of the manner of death,” Gast said after Thursday’s verdict. "[The jury decided] there was enough information in the testimony today and the documents provided to them that...there was a responsible party for the death of Daxton.”

Daxton's mother's pregnancy was being overseen by midwives at the birth center, who, as she got closer to her due date, moved her due date so that she could still deliver at the birth center instead of a hospital.

Daxton's father testified that he and his wife "had no issues during prenatal care, but they started getting worried about risking out due to approaching 42 weeks gestation. Christine [the midwife] told them they could switch to using the ultrasound due date instead of the date established by “last menstrual period” to get an extra week. She did not discuss any risk factors of approaching 42 weeks gestation, only that the rules stipulated that it wasn’t allowed to go beyond that point. Thus, M.G.’s due date was moved from January 5th to January 12th."

So what happened on January 20th?

At the inquest,

"The midwives all told the same story: the baby’s heartbeat was always just fine, and they put the mother on oxygen only to treat her lightheadedness and help her collect herself. The amniotic fluid was clear until the baby’s head was born and shoulders released, at which point heavily meconium-stained fluid was revealed. They attempted to resuscitate him and called 911. The baby was declared dead shortly after arriving at the hospital."

"The medical witnesses (specifically the maternal-fetal medicine specialist, the pathologist, and the perinatologist) were all very clear that the midwives’ story did not make sense to them. They testified, based on their examination or on the records that they reviewed, that Daxton was completely overwhelmed by meconium, completely, inside and out. No one thought it was feasible that the midwives could have seen clear fluid. They indicated that the midwife should not have moved the due date, did not adequately monitor the baby during labor, and did not do a proper resuscitation. They indicated that oxygen should never be used for the purpose that the midwives stated, but that it could be used during repeated deep decelerations that should cause great concern for the baby’s wellbeing. The perinatologist made it clear, as the director of neonatal care at a well-known local children’s hospital, babies do not die like this in the hospital. This death would have been prevented in a hospital setting."

Gavin Michael

Gavin Michael's full story is already here on this blog. You can read it here: Gavin Michael.

Gavin Michael's mother Danielle was planning to have a home birth with the certified professional midwife Christy Collins. At 42 weeks, Danielle had a biophysical profile to check on the baby. The test showed that she had no amniotic fluid. Instead of telling her to go immediately to the hospital, her midwife told her that the baby "looked terrific and everything was fine," and to go home and drink water.

After she told them to go home, Danielle's midwife crowd-sourced for information from other midwives on Facebook. Shockingly, the other home birth midwives seemed as relaxed about the risks as she was.

After the baby was found to have a low heart rate the next day, Danielle and her husband went to the hospital and Gavin Michael was delivered by cesarean section, but it was too late. Since he had no amniotic fluid, Gavin had nothing to swallow or breathe but meconium, and it killed him. The doctors tried incredibly hard to revive him and worked on him for 47 minutes after he was born, but it was just too late.

Unbelievably, the midwife responsible for Gavin Michael's death posted this poem on her facebook page just four days after he died from post-dates complications:

The full poem reads:

I repeat - Gavin Michael died directly as a result of post-dates pregnancy complications. He died because the pregnancy went too long. And just 4 days after he died, his midwife posted this poem on her facebook page.

The risks of postterm pregnancy are real, and should not be dismissed by home birth midwives.

MANA's "Best Evidence" Shows Homebirth is Unsafe

Families thinking about home birth are often told, either by their midwives or by the blogs and websites that advocate for home birth, that "Birth at home is as safe or safer than the hospital." It is not. Every study on American home birth has shown it to have a significantly higher death rate than the hospital.

"But what about the studies on MANA's website?" some ask. That's a good question. On their website, the Midwives Alliance of North America has a section called "Research" in which they have six subsections (A-F) of studies which they say prove the safety of home birth.

Leigh Fransen, former CPM, LM, and part-owner of a birth center and author of the blog Honest Midwife, has gone through and helpfully summarized all of these studies.

After she finally read all of these studies after years of practicing as a midwife, what the data showed shocked her and eventually led her to leave the profession:

"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."

You can read Leigh's summaries of all of the studies from the MANA website here:

Doing My Research
Section I: Meta-analyses and Systematic Reviews
Section II: RCTs and Section III: Cohort and Population Based Studies
Section III: Cohort/Population Studies Continued
Section III: Cohort/Population Studies (Re-Continued)
Section IV: International Observational Studies
Section V: Descriptive Studies
The MANA Study
The Other Side
My Days as a Midwife Close

In her post The Best Evidence MANA Does Not Want You To See, she writes:

"In my paper High Risk, I reviewed all the literature that the Midwives Alliance of North America (MANA) claims forms the “best evidence” for the safety of home birth. I found that most of the studies were either not applicable to the United States, did not address issues of safety, or actually demonstrated the opposite of what MANA claimed.

If MANA’s cherry-picked data paints a not-so-happy picture, wait until you check out what happens when you look outside of what MANA wants you to see. The literature on nonhospital birth in the United States is downright frightening. Despite what many midwives claim, these studies look at midwife-attended births, not accidental or unattended home births.

If you have had a nonhospital birth like I have, it is natural and normal to feel defensive about the safety of it. After all, to accept that you put your child at a substantial and unnecessary risk doesn’t feel good, even if you know that you made your decision out of love and a genuine desire to make a gentle, safe choice for yourself and your child. Sometimes knowing the truth hurts. I have accepted that my baby was one of the many lucky ones; I invite you to consider joining me in that realization."

Gavin Michael

In February 2014, a woman named Danielle was nine months pregnant with her son Gavin Michael and planning a home birth.

Her midwife was Christy Collins, a CPM (Certified Professional Midwife). Danielle explains, "The midwife I chose was different. She had an education and seemed very clean. She didn't just start doing home births but was trained to be a midwife. I really actually thought she was a nurse midwife but honestly didn't know there was so many different kinds of midwives. She had a list of types of births she would not take on as her clients and did testing to make sure both baby and mother were doing good which there is a lot of midwives that don't do either. I thought she was perfect and was so relieved to have found her. I could focus on my pregnancy and baby with her making sure we were alright."

At 42 weeks gestation Danielle had a biophysical profile to check on the baby, and it was found that she had zero amniotic fluid. Having no fluid in the womb is an incredibly dangerous, life-threatening situation for the baby. But instead of telling Danielle to go to the hospital immediately, her midwife told her to go home and drink water. She told them that Gavin "looked terrific and everything was fine."

Danielle explains about that day: "We did a BPP and found out that the results came back that there was 0 fluid in with my baby. I did not understand that and my midwife seemed like she didn't either. She told me to drink more water and sent me back hours later for another BPP. She did not want to see me because she had other clients...I had no idea the urgency of our situation. We went for another BPP and it came back the same. We saw her after and she sent me home with herbs."

That same day, Danielle's midwife Christy wrote to Jan Tritten, the founder and editor-in-chief of Midwifery Today. Instead of telling Christy to get Danielle to the hospital immediately, Jan Tritten copied and posted Christy's message on her Facebook page, crowd-sourcing for opinions on what to do from other midwives. The "advice" given by the other midwives was shocking and appalling. Danielle's midwife read her these responses the next day in an attempt to persuade her to continue with a home birth instead of going to the hospital.

Danielle explains that the day after the first two BPP tests (and Facebook crowd-sourcing by her midwife), "She wanted me to take castor oil but I refused. It started a fight so we went back in for another BPP. This time she went to the appointment with us. The results were the same. Afterwards, we talked about what to do. My husband and I decided we wanted to go into a hospital to be induced or c section or whatever was needed to be sure our baby was ok. She told me I was scared and that she wanted me to go home again to think about this decision because it was a big one. She told us that she contacted a few of her mentors and colleagues to ask what they thought about our situation. She read off a few responses and all seemed like everything was fine so to continue my home birth."

"Before we went to leave, we asked to check our baby's heart rate and his heart rate had gone down."

When the low heart rate was discovered, Danielle's midwife "called Dr. X (he provides backup for many homebirth midwives their city) and told him the biophysical profile was normal, but heart tones were 'variable.' He told her to immediately come in. She didn’t share with Dr. X that they were at at an ultrasound office attached to Hospital Y. They left that hospital and the midwife got in the car with the clients, put oxygen on the mother and drove 30 minutes to Hospital Z where Dr. X was located. They were immediately taken for a cesarean. They worked on baby for 47 minutes before they stopped.”

Gavin Michael was pronounced dead on Thursday, February 20th.

In response to his death, Jan Tritten updated the thread on Facebook with a message that said "It is always so sad when a baby doesn't make it." 

Meanwhile Christy Collin's, Danielle's midwife, wrote and posted on Facebook a long, gas-lighting, victim-blaming letter in which she clearly insinuates that it is Danielle's fault, and Danielle's fault alone, that Gavin Michael died.

Danielle has started a Facebook page, In Light of Gavin Michael, in memory of her son and to share her experience with home birth and home birth midwives

Some of the posts (click on the dates to read the full posts) that she has shared on her page read:

February 13, 2015 -

"Today is exactly one week away from the day I lost Gavin last year. It's amazing to look at where I was then til now. I really didn't know anything about home birth or midwives. The only info I could find was all positive so I believed home birth to be an amazing experience. There was no real sites out there explaining how home birth actually works in the US and the truth about what can and does happen.

Let me share some things that I've learned that many people don't know."

This post is so full of good information that I want to copy and paste the whole thing. Instead, I'll just strongly recommend that you read it in its entirety.

March 16, 2015 -

"While searching online, I came across this article about parents being blamed for their midwives mistakes. I cannot stress enough how a mother is blamed if things go wrong with a home birth.

People will accuse the parents of not doing enough research and believe they got the only 'bad' midwife out there.

The facts are that in the US, home birth midwives are not educated enough nor trained enough to know when things have become dangerous and actually don't know how to handle those kinds of situations. On top of that, they are not equipped with any tools to make sure mother and baby are safe but even if they had them, they aren't educated enough to use them."
June 4, 2015 -

"How much do you really know about home birth? Can you tell the difference between the midwives? Do you know the risks of having a baby at home?

I know from experience that when it came to home birth I didn't know anything. I believed what I was told but I wasn't being told any facts. There are many people just like me that have thought the same things.

We thought it was safe. We thought we were giving our baby the best chances of a calm and comfortable birth. We thought the midwives we hired were educated and had our safety as the one number priority. But we thought wrong.

All the things we heard weren't factual and for many of us, we found out the worst way possible.

When I discuss home birth with people, I notice that most of them believed the same things as me. Home birth midwives are assumed to be educated like doctors or nurses. That goes for anyone that adds the title "midwife" to themselves but that isn't true.

How safe is home birth really? When you research home birth, what do you find? I found lots of awesome stories about these amazing home births but that's all I could find. I didn't see anything negative and actually believed that was because hospitals had bad outcomes for not letting mothers be natural and free of interventions. I actually believed babies and mothers never die or become harmed in any way at home.

The reality is nothing like that. Babies and mothers die at home all the time. Many are injured and some just get lucky. But why aren't we hearing about it?!

The reality is because home birth is a business and the general rules do not apply to home birth. Medical professionals never hide numbers of deaths or injuries at hospitals but at home no one is watching so the numbers aren't revealed. Babies are literally dying and being completely covered up like they never existed.

I know we would have been covered up in the same way but the person I hired liked the spotlight on her so she went public with our info before my son's death. People were watching that aren't part of that natural community so things were exposed for what really happened and couldn't be covered up. And trust me, they have tried to cover and shut us up.

Since the midwives that do home birth cover things up, what does that say about home birth and the risks? It means people are not being told the truth so they honestly do not know the risks. There is no informed consent. People are choosing home birth while only being given bits and pieces of what's going on.

People's rights are being violated because of the lies being told and the lack of information to make the decision of choosing home birth. Do you know your state's statistics on how many babies have died during a home birth compared to how many in a hospital?"

July 14, 2015 -

"Let me explain the worst decision I've ever made in my life. It was made when I was pregnant and excited so I tried to research what the best of everything would be for my baby.

 I did get lots of references for doctors and offices so I picked a lady that I thought might be good. We went to her office to meet her for the first time...I left thinking about the rest of my pregnancy with this lady and decided she was not right for me. Then I was really confused on who to choose. Friends that kept asking me about my birth plan told me they had home births and it was the best thing they ever did.

So I looked into home birth and midwives. I found nothing but beautiful pictures and empowering stories.

Then my friends told me to meet their midwife so I gave it a shot too. But I thought it was all too hippie style for me and I didn't fit in with that midwife or her followers. I looked into other midwives which lead me to the midwife I ended up choosing.

The midwife I chose was different. She had an education and seemed very clean. She didn't just start doing home births but was trained to be a midwife. I really actually thought she was a nurse midwife but honestly didn't know there was so many different kinds of midwives. She had a list of types of births she would not take on as her clients and did testing to make sure both baby and mother were doing good which there is a lot of midwives that don't do either.

I thought she was perfect and was so relieved to have found her. I could focus on my pregnancy and baby with her making sure we were alright. But everything I thought wasn't true.

Everything that should have been amazing turned into a nightmare that I never thought were ever possible. The person I hired turned out to not know what she was actually doing and instead of having me go see an actual medical professional, she turned to the internet and other midwives that have no clue what they are doing.

She didn't know what to do with the warning signs that she was given. She went with her opinion that everything was fine instead of doing the right thing by talking to someone with more knowledge than herself for a second opinion. Then later lied to everyone saying I refused to go to the hospital when in reality, she told me to go home and I did what she told be to do because I trusted the provider that I hired for situations like this.

My son died from a mistake that should have never been made and if I had just chose a doctor instead of a home birth midwife, he would be alive today. I have to live with the choice that I have made. I have to live with the lies and deceit with no kind of justice for my son's death. I have to live with the midwives that blame me to cover up the truth about how CPMs are not educated enough to handle birth. I have to live with my childless life while this midwife like so many other midwives go on with their lives like we never existed."

February 4, 2015 -

"Last year, today was my due date. I wish I had Gavin on this date or around it so I wouldn't have to go through what I have. He would be here and I'd spend my time raising him instead of sharing my story to help educate people.

Honestly, I didn't know anything compared to what I do now. I didn't know the risks and dangers of home birth. I didn't know people pretended to be more educated than they actually are. I didn't know there is no system set up for accountability. I didn't know babies were becoming injured or dying from home birth.

There is so many things I really did not know. I only was told the positive stuff but never the other side of things. I didn't know that when home birth goes bad, it goes insanely bad in ways that I couldn't imagine.

I've gone through many what ifs and thought about what I could have changed to have my son here alive today. The only way would have been if I had an OB. They would have explained risks to me truthfully. They wouldn't let me go so far over due. They would have been paying attention to the fluid levels.

So I could have picked any OB out there and my son would be alive. I wouldn't have cared if their bedside manner wasn't very good or if they didn't spend that much time with me for appointments. Being nice doesn't mean a baby is going to be ok.

I picked a home birth with a CPM because I believed it was safe and the midwife would know if something was wrong to protect us. To take care of us. To be there for everything.

I was wrong."

Malpractice Insurance

When looking for a safe care provider for your birth, it is very important to find one that carries malpractice insurance.

Many home birth midwives do not carry malpractice insurance, reassuring their clients that they don't need it because "malpractice insurance only protects doctors so that they can keep practicing when they do something wrong."

In truth, malpractice insurance does not protect health care providers who make mistakes. It protects the families who the health care provider injures. Birth injuries in particular can be very costly and require expensive life-long care. If a family chooses a health care provider who carries malpractice insurance, and something goes wrong because of the health care provider, malpractice insurance will allow the family to be able to get the money they need to take care of the injury. If it's a hospital-based doctor or midwife who made the mistake, malpractice insurance will not protect them from the professional repercussions of their actions. Hospital-based care providers are overseen by boards of professionals who thoroughly review their actions; malpractice insurance doesn't protect them in any way from losing their hospital privileges or their license.

On the other hand, if a family chooses a birth center or home birth midwife who does not carry malpractice insurance, and something goes wrong that the midwife should have prevented, the family will have no venues for financial compensation. They will have to pay for the (potentially life-long) costs of the injury themselves. And the home birth midwife will have no professional repercussions, as she has nothing to stop her from taking on new clients without telling them of her past negative outcomes.

Many home birth midwives without malpractice insurance cannot be sued if they have a negative outcome, because very few lawyers will take on a lawsuit against them if they don't carry malpractice insurance. There just isn't enough money in the midwife's bank account to make the lawsuit worth it to the lawyer. And if a lawsuit is successfully brought and won against them, they can just declare bankruptcy, use a new name and continue practicing. One birth center in Michigan did just that.

In a report comparing different state midwifery laws, "Do State Midwifery Laws Matter?", the data shows that requiring midwives to carry malpractice insurance cut the rate of newborn deaths in half. Women and children benefit from midwives carrying malpractice insurance - and they benefit a lot.

If your midwife does not carry insurance because the cost will cut into her profits, she has weighed the pros and cons of not carrying malpractice insurance, and decided that the benefits to her outweigh the risks to you.

Babies Die in Hospitals Too

Yes, they do.

Most babies that die at hospitals cannot be saved despite all of equipment there just for them, and the training and skill of the teams working so hard to save them.

Some babies die at hospitals because of mistakes or negligence.


Whatever the reasons babies die at the hospital, *more* babies die at home. Every study on US home birth has found significantly increased rates of death for babies born at planned, midwife-attended home births than those born at the hospital.

When understanding this point, it's very important to look at the rate. Some people only look at the absolute numbers, and are confused. "But 1,000 babies died at US hospitals last year, and only 100 died in home birth, so doesn't that mean home birth is safer?"

No. Here's why:

Let's say 100 million people go to the library this year, and 14 die while they're there. And 20 people hike Mt. Everest, but only 1 of them dies.

If you're just looking at absolute numbers, you would conclude that going to the library is more dangerous than hiking Mt. Everest, because 14 people died instead of 1.

Now, if you're looking at rate, you'll see that going to the library has a death rate of 0.00000014, while hiking Mt. Everest has a death rate of 0.05. That means hiking Mt. Everest is 357,143 times more dangerous than going to the library. And you understand that by looking at the rate.

According to one of the latest, best studies on US homebirth, the rate of death for newborns born at US hospitals with midwives is 3.1 deaths per 10,000 births. That same study found that the rate of death for newborns born at planned, midwife-attended home births is 13.1 deaths per 10,000 births. So, the rate of death is four times higher at home birth - meaning that home birth is four times more dangerous than hospital birth.

Babies die in hospitals, too. But they die four times more often at home birth.

Freestanding Birth Centers

When I was pregnant with my first and reading "What to Expect When You're Expecting" about hospitals, birth centers, and home births, I thought that a birth center was a kind of nice middle ground between hospitals and home births. I thought it was some kind of detached labor and delivery ward, like what you'd have at a hospital, just not attached to a hospital.

It is not.

First of all, and this is very important to understand, there are two kinds of birth centers. The first type is the kind that I originally thought they all were: they are attached to hospitals, and are staffed with licensed, nurse midwives. As this post explains, "If at any time during your pregnancy or labor complications arise, your care would shift to that of an obstetrician at the same birth center or hospital." Medical technology is available, everyone has insurance, and there are regulations and oversight.

The other type of birth center is a freestanding birth center, which is not directly overseen by a hospital. Choosing to give birth at a freestanding birth center is, in the words of Sara, whose son Magnus died at a birth center, choosing "a home birth in someone else's 'home.'" Freestanding birth centers are not some kind of detached labor and delivery wing. They do not have doctors. They do not have the equipment you would have at a hospital. They have the same midwives that deliver babies at home births.

The excellent website Safer Midwifery for Michigan has a good post about birth centers called What We're Seeking: Defining "Birth Center." In it, they explain: "Freestanding birth centers do not have emergency medical equipment beyond oxygen.  They cannot intubate or give medications that would be used in a resuscitation circumstance. They do not use Electronic Fetal Heart Monitoring, instead using intermittent Doppler assessments. Midwives working at a freestanding birth center may or may not be licensed as individual, may or may not carry insurance, and may or may not be trained in NRP (Neonatal Resuscitation Program). There is no requirement for any midwife at a birth center to have a license. The bottom line is that in the event of an emergency, they are under-equipped for life saving measures."

Babies born at freestanding birth centers are more than three times more likely to have a 5-minute Apgar score of 0 (no signs of life) than those born at a hospital. They are almost twice as likely to have seizures than those born at the hospital. And worst of all, babies born at freestanding birth centers are twice as likely to die than those at the hospital. 

The Qualifications of US Home Birth Midwives

In trying to understand why the risks of home birth are so elevated compared to hospital birth, it's important to understand the "qualifications" of home birth midwives.

There are several different types of midwives in the United States and if you're not familiar with all of them their titles can sound similar and confusing. CNM, CPM, CM, DEM, LM...what's the difference? As Danielle Repp explains in her series "American Midwives": 

"There are two midwifery certifying bodies in the USA: American Midwifery Certification Board (AMCB) and North American Registry of Midwives (NARM). The AMCB is considered the Gold Standard for midwifery certification and is the certifying body for Certified Nurse Midwives (CNMs) and Certified Midwives (CMs); NARM is the certifying body for Certified Professional Midwives (CPMs). Licensed Midwives (LMs) also fall under NARM as it is the NARM entrance exam they take. Specific requirements for LMs may vary by state in order to take the exam."

"So in short, midwives in the USA basically fall into one of these three categories:
1. AMCB certified
2. NARM certified
3. Uncertified"

She continues:
"1. Certified Nurse Midwife (CNM)"

"Certified Nurse Midwives (CNMs) are some of the most highly skilled and educated midwives in the world. The Certified Nurse Midwife is one of the only types of midwives in the world that requires a nursing degree. The CNM also holds a master’s degree as the minimum level of educational requirement (some have doctoral degrees). CNMs must complete their education through an ACME-accredited midwifery program (ACME = Accreditation Commission for Midwifery Education). Once completed, they can apply to take the AMCB certification exam."

"Certified Nurse Midwives are licensed and have prescriptive authority in all 50 states (and other territories of the USA). The educational and clinical skills training of the CNM not only includes pregnancy and birth care but also primary care for women throughout life, reproduction, infertility, newborn care, andent of sexually transmitted diseases."

"2. Certified Midwife (CM)"

"The Certified Midwife (CM) credential has existed since 1994. The CM is the direct-entry version of the CNM. While CMs do not need to have a nursing degree, they must take all of the nursing school pre-requisites (such as anatomy, physiology, microbiology, etc) and must receive a bachelor’s degree and master’s degree. The CM’s educational and clinical skills training is similar to the CNMs, as it again not only includes pregnancy and birth care but also primary care for women throughout life, reproduction, infertility, newborn care, and management of sexually transmitted diseases."

"3. Certified Professional Midwife (CPM)"

"The Certified Professional Midwife credential ... was developed as a direct-entry route to become an out-of-hospital midwife. CPMs are not authorized to work in a hospital setting."

"Certified Professional Midwives do not have any degree requirements. The only educational requirement is to have a high school diploma, which was not a requirement until September 1, 2012."

"The Portfolio Evaluation Process (PEP) is a popular route to become a CPM. It is an apprenticeship where the student midwife follows and learns from a preceptor midwife. After attending 40 births (and the prenatal exams leading up to it), the student midwife can qualify to take the NARM exam. Anyone with a desire to become a midwife can seek out a preceptor. Half of CPMs have earned their credential through the PEP route."

"Another route to become a CPM is to graduate from a Midwifery Education Accreditation Council (MEAC) school. There are nine MEAC schools in the USA, some of which award certifications, some diplomas and some degrees."

"CPMs not have prescriptive authority in any states (in certain states, CPMs are able to obtain certain medications, such as Pitocin, Cytotec, antibiotics, etc but CPMs cannot write prescriptions). CPMs also would not qualify to practice midwifery in other developed countries due to the lack of formal education requirements; the CPM requirements also do not meet the International Confederation of Midwives (ICM) standards."

The above was all from Danielle Repp's series American Midwives, part 1, part 2, and part 3; emphasis mine.

Due to the variation in types of training accepted to become a CPM, some CPMs might have enough education to meet the ICM minimum standards. However, the CPM credential itself does not require it, and ACOG estimates that "possibly as many as two-thirds of CPMs do not meet the ICM standards."

I want to repeat - Certified Professional Midwives - the kind of midwives that attend the majority of the home births in the United States - do not have any educational requirements other than a high school degree. And if they became a CPM before 2012, they don't even need that. They don't need to take anatomy, or physiology, or immunology, or even basic college biology.

And do you know what's even worse? In some states, midwives do not have to have any qualifications at all to practice. None. The state where I spent my college years - Utah - has voluntary licensure, which means that if a midwife simply decides that she'd rather not be licensed by the state, she has no educational requirements, no limits on her scope of practice, and no accountability for her actions. This satirical website points out the weaknesses in such a system.

Here are a couple charts that explain the difference between the midwives who work at doctors offices and in hospitals (CNMs) and the majority of home birth midwives (CPMs, LMs, lay midwives, etc.):


Now, if you think you'll be safe at home birth if you choose a CNM instead of a CPM, think again. Researchers in 2009 found that home birth with a CNM had twice as many babies die than hospital birth with a CNM. An even more recent study published in 2016 found that babies born to CNMs and CPMs at home birth died three to four times more often than babies born at the hospital, with no statistically significant difference between home births with CNMs or CPMs. Even if your midwife is a CNM instead of a CPM, you still won't be able to tell at home if your baby is being deprived of oxygen, you won't have an operating room if it becomes urgently needed, and you won't have a neonatal resuscitation team with all of the equipment that might be needed to save your baby.

More excellent articles that explain the disparity between US home birth midwives and US hospital midwives and the home birth midwives in other countries can be found here:

The hypothetical situations you can imagine when you think about home birth midwives' lack of education and regulation - like, "If I have an emergency during labor at home, will my midwife know what to do? Will she have the skills and training to save my baby?" - clearly actually happen at home, as we can see from the numbers. With home birth midwives, three times as many babies die. With home birth midwives, seventeen times as many babies have brain injuries. These are the numbers that result from the faulty regulation and extremely low educational requirements required of US home birth midwives.