Clinical Review

Does home birth empower women, or imperil them and their babies?

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  • certified nurse-midwife (CNM)
  • certified midwife (CM)
  • certified professional midwife (CPM).

The first two categories are certified by the American Midwifery Certification Board (AMCB). CNMs and CMs undergo rigorous training and examination, and this designation will require a graduate degree within the next few years. The CPM category, however, requires much less rigorous training. Its midwives are certified by the North American Registry of Midwives. The clinical requirements for certification as a CPM include:

  • attending a “minimum of 20 births”
  • managing at least 20 additional births, at least half of them in the home or another out-of-hospital setting
  • performing a small number of prenatal, newborn, and postpartum exams.28

A high school diploma is not required.

I suspect that concerns about this lax certification process contributed to ACOG’s decision to issue a statement from its executive board in 2006: “While ACOG supports women having a choice in determining their providers of care, ACOG does not support the provision of care by lay midwives or other midwives who are not certified by the American College of Nurse-Midwives (ACNM) or AMCB.”29

A number of midwifery advocates have made a legislative push to expand licensure for CPMs in this country, and the debate continues on a state-by-state basis.30

Economics and other variables affect delivery decision

Some advocates of home birth note that the “average uncomplicated vaginal birth costs 68% less in a home than in a hospital.”31 Others try to organize support for women who want to give birth at home, such as the Home Birth Hotline, a voluntary, UK-based organization.32

Some articles suggest that patient satisfaction is of significant importance in the decision about where to deliver. One noted that women who delivered where they had planned had higher overall satisfaction when that place was in the home (P<.01).33

A randomized, controlled trial (n=3,510) simulated home delivery in a hospital, with “home delivery” patients having midwifery care in a room “similar to one in one’s own home” and the others having “consultant-led care” in rooms in the delivery suite that contained equipment to resuscitate both mother and baby, as well as monitors and other technology.34 This study found no significant differences in measured outcomes, but “generally higher levels of satisfaction” among the women who had simulated home delivery.

A study from “remote and rural Scotland” found that most women “expressed a preference to give birth in hospital and have consultant-led care because they felt safer.”35

Does the rhetoric surrounding home birth “empower” women?

Another frequently overlooked issue is the passionate rhetoric used to describe home birth—and the effect of that passion on women whose birth plan doesn’t play out as expected. Words such as “choice” and “empowerment” are often used. Regrettably, there is considerable mistrust of the medical system.

One woman describes how her planned home delivery, “influenced by the feminist literature,” went awry.38 After a long labor, she wrote, she “just wanted the baby out, safe and healthy. It no longer mattered how it happened….I couldn’t get rid of the underlying feeling that I had ‘failed’ in some way….”38

Because of her strong desire for home delivery, this woman was deeply affected when the delivery became difficult: “I did not have the authority to proclaim whether or not various medical interventions were necessary, or whether my case actually did constitute a medical emergency….Faced with these ‘options’—safe birth or potential death—how could I be said to be making a ‘choice’?…The obstetrician has more power than the woman because s/he has more knowledge.”38

Despite having come to this realization, and delivering a healthy baby, she still experienced “a sense of disappointment and anger” and “traumatic flashbacks.”

I worry that patients may become so caught up in the rhetoric of their own power and choice that, when uncontrollable events occur, the happiness of a healthy delivery is overshadowed by deep disappointment.

Heated debate isn’t helpful

An unfortunate rift seems to have developed between some members of the midwifery community and some physicians. ACOG and the ACNM have a longstanding policy that: “In those circumstances in which obstetrician/gynecologists and certified nurse-midwives/certified midwives collaborate in the care of women, the quality of those practices is enhanced by a working relationship characterized by mutual respect and trust.”39

Whether individual physicians agree with the practice of planned home birth or not, the health and welfare of the patient must be paramount. The American Public Health Association and the ACNM support home birth.40,41

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