Home Birth culture in your Area

[mamafeliz]

I am writing to get a better sense of home birth culture across the US and how home birth and hospital birth cultures blend, dovetail, or clash in your experience. I live in a state where licensure for direct entry midwives (DEM) is voluntary, meaning anyone can legally deliver a baby. Some DEMs opt for licensure so they can bill some insurances and medicaid. I am delving a bit deeper into what is involved for licensure for DEM, primarily because of a recent disastrous transport to my unit. It turns out that within the standards of practice for LICENSED DEMs, breech, VBAC and multiple deliveries are allowed. It all makes my head spin. This is a huge concern, especially in light of some tragic losses in the past few years. As the 7 member board has 4 DEMs, there has been resistance to changing the standards of practice, resistance to moving to mandatory licensure, and seemingly little repercussion for complaints that have been made to the board.

Let me make it clear: I am a home birth advocate. I had two home births, and believe in the midwifery model for low risk, healthy term mamas and babes. I just don't understand why DEMs here and across the country would resist mandatory licensure which would legitimize and regulate their practice, and why there would not be support for safe standards of practice. Help me out here!

The general feeling in the hospital when we get transports is one of exasperation and frustration, because of the lack of accountability on the part of the DEMs and us being left to clean up a train wreck because of unsafe management. It is my observation that the majority of transports to our unit ARE appropriate--but the births gone bad are what eclipse everyone's perception.

Is there licensure for DEMs in your state? What is the relationship between DEMs and your hospital? Do you get many transports? Had any bad outcomes?

Do tell! And thanks.

[BabyLady, BSN, RN]

Rare....very rare.

[imenid37]

Only for the Amish here.

[CEG]

In my state legislation to legalize DEMs is pending. The reason an otherwise qualified DEM would choose not to be licensed is that with licensure comes restriction (at least in most states, I am guessing you are in Oregon and I am not that familiar with their laws). Truthfully, the evidence supports VBAC, lady partsl frank/complete breech and lady partsl twins. Few conventional providers are trained to do those things or are not offering those services due to insurance restrictions so actually in many cases DEMs ARE the experts in those things -i.e. very few new docs know how to deliver a lady partsl breech but many unlicensed DEMs have years of experience with it.

Most transfers would be bad outcomes to varying degrees since otherwise they would not be transferring. Births go bad in hospitals too- that's why we have the stat c-section and one of the worst perinatal mortality rates in the developed world.

I am also an OB RN and also a homebirther. I had two wonderful hospital births and moved to a new area of the country. A homebirth was the only option for me here if I did not want an intervention-laden race with the clock. I chose a homebirth with a CNM but if there weren't any CNMS I might have chosen a DEM or even an unassisted birth rather than put myself at risk in the hospital. The hospital where I used to work was a prime example of bad practice and iatrogenic complications.

[tryingtohaveitall]

I bet there are more home births out there than people realize. Unless something goes awry and mom or baby come in to the hospital, or unless you're aware of a case personally, it's hard to know how many are out there giving birth at home. I suppose birth registries would have that info?

I have one friend who homebirths, but I'd bet in our large homeschooling group there are many more give birth to their many children at home.

[GilaRRT]

I bet there are more home births out there than people realize. Unless something goes awry and mom or baby come in to the hospital, or unless you're aware of a case personally, it's hard to know how many are out there giving birth at home. I suppose birth registries would have that info?

I have one friend who homebirths, but I'd bet in our large homeschooling group there are many more give birth to their many children at home.

Agreed. There are actually a relatively large number of people who opt for home birth for a variety of reasons.

[CEG]

I bet there are more home births out there than people realize. Unless something goes awry and mom or baby come in to the hospital, or unless you're aware of a case personally, it's hard to know how many are out there giving birth at home. I suppose birth registries would have that info?

I also agree!

[shortstuff31117]

The LMs in my area are very busy with home births. However none of the OBs here in town will support them so they have a back up doc that is 40 min north of us. So of course in an emergency or just a situation where they dont want or need to travel that far, they come to one of the hospitals in town. The general feeling for these poor women is total disdain, like they did something horrible.

I am a big supporter of home birth, I had a vbac at home. I wish the docs around here would be more supportive.

[Elvish, BSN, DNP, RN, NP]

We don't have a homebirth supportive culture in my state. There is push in current legislation to legalize CPM/DEMs to deliver homebirths but as yet is nowhere close to becoming law.

That said, I know of at least one practicing CPM in my area, because she delivered a friend's 2 kids at home. I am going to scope her out when we start thinking about our 2nd. I'm sure she's not the only one.

There is no MD backup, and the CNM at my Ob/Gyn's office is actually pretty neutral about it, though she won't do homebirths herself. I say if you legalize CPMs, everybody benefits because they are regulated, out of the shadows, and doctors get to swoop in and save the day on bad cases. (oops, then their m/m statistics might be off....darn.)

[nkochrn, RN]

I don't know of any DEM's or CPM's in my area, but I'm in rural Kansas. It may be more common in other areas.

There is a group of Apostolic Christians nearby and I just recently learned that most of their births are at home. I believe it's just their family that assists with the birth. I actually work with a couple of them, I'll have to ask. We did just have one deliver at our hospital. She did not have a sono per her own preference. The Doc said that I believe AWHONN says a sono is not necessarily indicated if there are no complications with pregnancy. This lady was induced at 41 weeks and her family was unsupportive of the induction.

[CEG]

I don't know of any DEM's or CPM's in my area, but I'm in rural Kansas. It may be more common in other areas.

There is a group of Apostolic Christians nearby and I just recently learned that most of their births are at home. I believe it's just their family that assists with the birth. I actually work with a couple of them, I'll have to ask. We did just have one deliver at our hospital. She did not have a sono per her own preference. The Doc said that I believe AWHONN says a sono is not necessarily indicated if there are no complications with pregnancy. This lady was induced at 41 weeks and her family was unsupportive of the induction.

The NIH does not recommend routine ultrasound in pregnancy. Remember that ultrasound does not improve outcomes. It does sometimes give us advance warning of problems but it doesn't change things.

[mamafeliz]

Truthfully, the evidence supports VBAC, lady partsl frank/complete breech and lady partsl twins.

Do you have sources to back this? I ask respectfully, not to challenge your statement. As I often act as buffer in my hospital between home birthers and L&D staff, I would love to have research that supports this statement. This is the one area I currently have difficulty advocating/supporting at home. The home birth disasters I have seen almost always relate to attempted breech, VBAC, twins. I have not been able to find sound evidence supporting these practices. I would appreciate any sources you could give!