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?
Let me clarify---I mean sources demonstrating safety of these practices AT HOME. I work in a facility where we do VBAC and lady partsl twins routinely. I am interested in your references demonstrating safety of home VBAC, twins, breech. Thanks.
Let me clarify---I mean sources demonstrating safety of these practices AT HOME. I work in a facility where we do VBAC and lady partsl twins routinely. I am interested in your references demonstrating safety of home VBAC, twins, breech. Thanks.
Sorry- I didn't mean necessarily safer at home- my point was that the evidence supports these practices but most hospital providers are not trained in them or choose not to perform them. So homebirth midwives are the only option- sometimes they are more skilled, I would trust Ina May Gaskin to deliver my breech before any MD. I don't necessarily agree with some things- I wouldn't personally have a home VBAC for instance. But if my only option was a repeat c or a homebirth I might consider it. There are very few facilities in my area doing VBAC and next to no options for lady partsl breech. Most twins are sectioned regardless of position. And sadly I live in a major metropolitan area where women should have choices.
I don't think there is any evidence out there to say if things are or aren't safer at home because there is very little data about homebirth in general. I just mean that evidence supports the practice in general and if the homebirth midwife is the only one with that skill to offer then the patients must make that choice. You can't get a Whopper at McDonald's even though they both sell hamburgers.
I had my first son by c/s almost 26 years ago. My next two sons were born by home VBAC, because 1. There was an excellent CNM group who did them backed up by an OB who had a home birth herself, and 2, I didn't think I had much chance of success with the hospital atmosphere. I can't believe that that we've gone backwards on this issue...
What's the rate of litigation on home births? Is there a higher rate of lawsuits from homebirths as compared to hospital births? Isn't that what scares everyone?
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
I am sad we have a culture in so many parts of the country that make would-be homebirthers and their attendants feel they must go underground, on the verge of criminal activity, to practice what they believe is the safest and most comfortable way to give birth. There are a lot of special interests riding on making it such. I read a great book about the granny midwives of the South and how their status as very knowledgeable and caring birth attendants was systematically stripped of them after the turn of the 20th century by, surprise, medical doctors!
Legal issues in the USA being what they are, however, I see both sides. I just wish EVERYONE understood in the USA, that with our RIGHTS come RESPONSIBILITIES and the two always must go hand in hand, in order not to lose the liberty of choice. If you make a choice, you should accept the consequences of such. (should!)
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
There are a lot of studies and literature about the safety of homebirth, but most of these exist in countries outside the USA. We are a bit unique in that the predominant thought is birth belongs in the realm of the hospital under the care of medical doctors, in every case, even low-risk ones.
Specializes in Pediatrics, Lactation, Women's Health, Obstetrics.
In CA there is licensure available for direct-entry midwives. Direct-entry midwives can become "Licensed Midwives" (LM) when they have achieved the required educational and clinical experience in midwifery through midwifery education (at specific designated midwifery schools). After passing the North American Registry of Midwives' (NARM) comprehensive examination the LM is also given the designation of "Certified Professional Midwife" (CPM). I believe that they can accept private insurance but not Medi-cal.
At our community hospital "birth center" in rural northern CA we have one LM who practices under an OBGYN. Most LM/CPMs work outside the hospital setting in this area. Our hospital is the only one in the area that has an LM with hospital privileges. The only difference between the LM and CNMs at our facility is the LM does not have prescriptive authority.
As for all the homebirth midwives in the area, which there are many, some are LM/CPMs and others have no formal certification (apprenticeship only). None of the homebirth midwives have physician back-up and many practice without malpractice insurance due to the outrageous costs. Our hospital gets most if not all of the home-to-hospital transfers due to the more accepting attitude/atmosphere on our unit. I would say we average only a few transfers from home a month (and we average 60 births a month at the birth center). Also, our birth center is known in the area for a more holistic/physiologic perspective and a non-interventionist approach to labor and birth- so, often we get people who would have opted for a homebirth if our birth center didn't exist. We are also the only facility within 300 miles that offers VBAC.
So far in a year of working at this hospital, I have only experienced "appropriate" transfers and haven't seen one "train wreck" yet (knock on wood). Usually the midwives arrive at the hospital with their laboring moms and stay on as doulas for the rest of the birth. I'm not sure how the MDs/CNMs feel about the transfers/midwives but most of the RNs get along just fine with the homebirth midwives. Maybe it is because most of the RNs have had homebirths themselves! I think that our hospital is pretty unique, so I wouldn't say that any of this is representative of the state of CA in general.
I want to say everything that Redwood said, but don't need to say it twice now do we? I did a lot of training at her hospital which is great. I love the fact that I live in an area that is so accepting to home birth; I know I will be having one.
Hearts Wide Open and Redwood, you are indeed lucky! I work in a similar hospital setting here in Oregon: waterbirth, low epidural rate, nurses skilled in low intervention labor support, etc. all rolled into the midst of a high risk setting where we take care also of the sickest of our state. We are looking at how to better bridge with our DEM community. Most of the home birth transports we receive are appropriate. The problem is that we do receive "train wrecks"---3 in the past 4 months. These transports, in my assessment, are a result of vague and wide open standards of practice that guide the Licensed Direct Midwives (state licensed midwives, able to get medicaid reimbursement.) As I originally said, they continue to be able to deliver breech, multiples, VBAC. They have no guidelines for length of ROM, second stage, frequency of auscultation of FHR. Relations will continue to be fractured between home and hospital until LDMs adopt safer standards of practice. Not all DEMs appear to have the same common sense, and will have bad outcomes with such undefined guidelines, reflecting poorly on the whole community.
We have communicated our concerns directly to their Board of Licensure, and met more informally with community LDMs. We have strong hopes they will evolve their practice.
Specializes in Pediatrics, Lactation, Women's Health, Obstetrics.
Hearts Wide Open and Redwood, you are indeed lucky! I work in a similar hospital setting here in Oregon: waterbirth, low epidural rate, nurses skilled in low intervention labor support, etc. all rolled into the midst of a high risk setting where we take care also of the sickest of our state. We are looking at how to better bridge with our DEM community. Most of the home birth transports we receive are appropriate. The problem is that we do receive "train wrecks"---3 in the past 4 months. These transports, in my assessment, are a result of vague and wide open standards of practice that guide the Licensed Direct Midwives (state licensed midwives, able to get medicaid reimbursement.) As I originally said, they continue to be able to deliver breech, multiples, VBAC. They have no guidelines for length of ROM, second stage, frequency of auscultation of FHR. Relations will continue to be fractured between home and hospital until LDMs adopt safer standards of practice. Not all DEMs appear to have the same common sense, and will have bad outcomes with such undefined guidelines, reflecting poorly on the whole community.
We have communicated our concerns directly to their Board of Licensure, and met more informally with community LDMs. We have strong hopes they will evolve their practice.
First off, I want to say that I completely agree that it would best serve all parties involved if there was a standardization of evidence based care throughout all birthing scenarios. And you are right that not all DEMs have the same common sense and/or defined guidelines for transfer to a higher level of care. That is definitely a problem and I really do understand your frustrations.
But, one could say the same thing for providers that work in the hospital system. I don't think that 30% c/section rates (national average) is good common sense, and neither does the WHO. We all know that the alarmingly high rates of surgical birth are hugely influenced by the provider's fears of litigation ("when in doubt- cut it out"). Same with continuous fetal monitoring - the research shows that this does not improve outcomes for low-risk moms or babies and only contributes to a higher c/section rate - yet, many many hospitals have everyone strapped to a bed with continuous EFM from the time they walk in the door. Don't even get me started on all the inductions of labor prior to 41 weeks gestation for non-medical reasons. These are only a few examples of things that we do routinely in the hospitals that are not evidence based and ultimately put moms and babes at risk- there are many more! Care that is based on fear of litigation or saving money by having less nurses (centralized monitoring) is not good common sense at all.
There needs to be more balance. We need to fix our maternity system so that it puts women and children first before all else. The "vague and wide open standards of practice that guide the Licensed Direct Midwives" that you speak of is likely a backlash from the over-medicalization of birth. Our patients are "consumers" (now more than ever before) and they are going to go where they need to go to get what they want. Women are seeking autonomy in the childbirth process. And if the hospitals are unwilling to deliver breech, VBAC, and twins in any other way besides major abdominal surgery- then folks are going to do it on their own terms. In my humble opinion, the big elephant in the room here is our broken maternity system that pushes women to the two extremes A) having an over-medicalized traumatic birth in a hospital or B) delivering their babies alone or without a skilled practioner at home.
What gives me hope is that a middle ground between those extremes does exist in the US- at birth centers like the one I work at, and also at home with skilled midwives who are following evidence-based guidelines. Just my .
I am saying the following with only a bit of my tongue in cheek:
Doctors/hositals/OB's/nurses: need to prominently display a notice saying
We don't carry insurance. We will give you proper care. If you make a decision that goes against our advice, the outcome lies with you. Deal? Then welcome.
Until docs don't have to pay out $100K+ in insurance premiums, the problem will continue. You can hardly blame them.
I've been deposed twice on cases that had less than optimum outcomes, but one was because the patient delayed her c/section because she wanted an epidural, not general anesthesia, thus delaying the birth even more, and one because a G10/P9 had a shoulder dystocia and the "doc should have known the baby was too big." (This was in the late '70's and this woman had 9 other kids, some born at home."
Both cases were settled out of court and the doc's insurance paid---but in my opinion, and I was there both times, the docs were not to blame, in any way.
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mamafeliz
56 Posts
Let me clarify---I mean sources demonstrating safety of these practices AT HOME. I work in a facility where we do VBAC and lady partsl twins routinely. I am interested in your references demonstrating safety of home VBAC, twins, breech. Thanks.