Readers React: Letters on home birth

Home birth: not all midwives are the same

I am a certified nurse midwife, certified by the American College of Nurse Midwives (ACNM) and now the American Midwifery Certification Board (AMCB). The recent article by Frank A. Chevrenak, MD, and Amos Grünebaum, MD, [Home birth: the obstetrician’s ethical response, May 2015 Contemporary OB/GYN] gives outcomes of planned home birth based on a generic "midwife" group. In their article they state that 2 of the 3 midwives attending planned home births were not in fact certified by the AMCB. This indicates that the "midwives" they grouped together included those with less education and fewer credentials than a CNM, MSN.

Although my midwifery career has been primarily in a hospital practice, I have delivered in 2 birth center settings and one home birth practice. The first birth center practice was truly a low-risk population and was directly across the street from a hospital for those sometimes-needed transfers. The second birth center practice (which was also the home birth practice) with which I had experience was not adhering to a truly low-risk population and increased risk clearly was being tolerated, which is why I left that practice after only 4 months. Interestingly both of these practices employed CNMs. The first birth center was well established and had more than 6 midwives on staff at that time, as well as many RNs and a board that regulated the practice. The second practice was owned and operated by one midwife and had no board or regulating entity.

I guess my point here is that if these folks who did the study on home birth were to weed out the kooks, and look at the outcomes of CNMs only (even though there would still be the outliers like the one I briefly worked for), the stats would look quite different. Just my observation.

Marilyn R. Smith, CNM, ARNP, MSN

Thank you for your letter.

You describe 2 practices of out-of-hospital births with different approaches, one more safe and the other less safe. Both have CNMs attending the births, so it’s unclear why you believe that CNM-attended home births are safer than those of other midwives and why CNMs should automatically have better outcomes. 

There are essentially 2 different attendants at homebirths in the United States, both calling themselves “midwives” but with very different educational models. CNMs have a strict academic education and are certified by the AMCB. In contrast, non-AMCB-certified midwives call themselves “certified professional midwives (CPM)" and are not required to have an academic education. Usually eligibility to become a CPM requires just a high school degree.  

The organization representing AMCB-certified CNMs is ACNM, which works closely with the 2 organizations representing non-AMCB-certified midwives, the National Association of Certified Professional Midwives (NACPM) and the Midwives Alliance of North America (MANA). These 3 organizations have published joint consensus statements (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3647729/), making it difficult for the public to differentiate between AMCB-certified and non-AMCB-certified midwives. The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have established home birth guidelines. The 3 midwifery organizations refuse to set standards for home births.

In our study of home births risks we showed that both AMCB and non-AMCB midwives practice home deliveries in patients with significant risks such as vaginal births after cesareans, postdates, twins, and breech presentations. None of these would be permissible in Dutch, British, or Canadian homebirths. 

Although CNMs may have apparently better training than non-AMCB-certified midwives, delivering high-risk patients at home is not the only major determinant in outcome. It is the birth location itself that increases neonatal mortality and morbidity. Everybody who has ever worked on a labor and delivery floor can attest that complications can occur unexpectedly. Even in so called “low-risk” patients, damage can occur within minutes. Interventions such as cesarean deliveries and electronic fetal heart rate (FHR) monitoring, none of which are available at home births, are sometimes indicated within minutes and can save lives in potentially catastrophic events such as cord prolapse, abruptio placentae, and cord compression. 

It is not necessarily the attendant’s experience or education level but the location of the home birth itself that makes a home birth delivery less safe.

Amos Grünebaum, MD

Frank A. Chervenak, MD

Reader: hospitals should be made safer

Drs. Chervenak and Grünebaumuse impressive, multisyllabic words to chastise the 1%–2% of women who choose home birth. Why not turn their concern for professional ethics to the fact that obstetric care in US hospitals has resulted in an increase in maternal deaths? Surely they know that unbiased data collection shows we now rank 60th in the world for maternal mortality, one of only 8 countries whose statistics have worsened rather than improved in the past decade. The way obstetrics is practiced across the United States in hospitals [. . .] has resulted in a 25% induction rate, Cesarean rates of 38%–42%, increasing "near misses," and actual deaths.

Women who seek my help for out-of-hospital birth reference real risks-not having a say in their care and unnecessary interventions they cannot refuse, which all too often lead to cesarean sections. Why not take on protocols we know are unscientific-continuous FHR monitoring, inductions at 40–41 weeks, IVs, and denying laboring women food and drink or any meaningful input in their care? The true "beneficence-based obligation" is to make hospitals safe for women!

Katharine Morrison, MD, FACOG

NEXT: The authors respond  >>

Thank you for your letter.

We provided strong evidence of the significantly increased neonatal morbidity and mortality related to home births when compared to hospital births. We also provided a strong ethical argument that this information should be shared with all women considering delivery outside the hospital. Dr. Morrison does not challenge either and it is unfortunate that home birth advocates often do not inform women of this crucial information.

Dr. Morrison does not provide evidence that the relative increased maternal mortality in the United States as compared to some other countries is causally related to the care pregnant women receive in US hospitals.

We have repeatedly emphasized that obstetricians have the professional responsibility to avoid unnecessary interventions and to provide caring, evidence-based hospital environments. They also have the professional responsibility to recommend against planned home births in a clear and compassionate manner.

Amos Grünebaum, MD

Frank A. Chervenak, MD