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?
I am all for tort reform, for one. I realize that yes, there are some cases when malpractice does exist, and cases when somebody truly acted negligently. It gets a bit ridiculous - "the doctor should have known the baby was bigger..."
What the heck?! It's one thing to estimate via Leopold or an u/s (which, in the 3rd trimester, is notorious for being WAAAAAY off), and quite another to be able to tell exactly. No freakin' way.
I'd be all for people taking responsibility for their decisions, especially when it comes to childbirth! And it seems that many do, but it seems there are also just enough people who want to sue over every little thing that goes wrong. Unfortunately, there are malpractice lawyers just waiting to pounce on that small percentage of the population.
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.
Licensed Midwives can get a Medi-Cal provider number and bill reimbursement if we have a physician (OB/GYN) on record and proof of Liability Insurance. Otherwise we bill PPO plans as out-of-network providers for professional service only, not for reimbursement of the facility ("home").
Specializes in L&D, postpartum, nursery, antepartum CLC.
The experiences I have had with midwives have been very poor. (I do know midwives about an hour away from my town that are excellent, but the ones in our area are horrendous) We have a few Lay midwives in the area that do home births. I have a few examples of the terrible things that have occured.
1) Lay midwife laboring a VBAC at home (we do VBAC's at our hospital). The woman was in labor for 48+ hours and not progressing past 5cm. She had particulate mec. staining the whole time (ROM was what started it all) At no point did the midwife access FHT the last 12 hours according to the mother. The mother said she had been begging for an epidural and to be taken to a hospital for the last 12 hours - she said the midwife refused to take her saying (according to the mother) "i can't do that, you don't want me getting in trouble, do you?" Finally the midwife decided to bring her in when the woman was complaining of constant pain in the lower abdomen for 2 hours. the lay midwife drove her to the ER and literally pushed her out onto the sidewalk in front of the ER and drove off. (we know this because they have cameras and thats how the ER staff knew she was there because she was not able to walk on her own.) We delivered her baby and it lived (was 10 lbs.) and she did ok and was very greatful(apgars 3,7,9). We later found out the reason she didn't come to us for a VBAC was that she said "I knew you wouldn't do it, because I had a uterine rupture with the last VBAC attempt" We also discovered that she had a history of gestational didabetes and was likely one again (infant was hypoglycemic and required IV glucose to maintain blood sugars for 3 days) except she was of course not screened. The OB attempted to track the midwife down to report her but she disappeared from the area.
2) 2 lay midwife patients were brought to the ER due to severe PPH. The 1st the husband said he left to pick up something at the grocery store after the delivery and returned 15 min later hearing a baby crying and found his wife unresponsive in a huge puddle of blood and no midwife in sight. The woman was clinically dead when the ambulance got there, but she was revived.
3) this one is a story from a co-worker who worked in a NICU. There was a woman that wanted a home water birth and wanted her DAUGHTER (20 years old) to deliver it, so the daughter took some online classes and ta-da was a Licensed midwife and attempted a water birth at home there was major shoulder dystocia and the the head was delivered - under water - for 20 min. prior to 911 being called. she was brought to the hospital and the baby was delivered and the mother demanded that the baby (who had apgars of 0,0,1) continue to be worked on - not because she was so concerned about the baby, but because the daughter would be charged with manslaughter if it died. the baby is now 3 and remains on life support til this day for the same reason.
I think Midwives should have to have training both didactic and hands-on and be monitored by a governing body. The first 2 examples all the women thought the midwives were licensed and credible and they weren't. I wish that there could be consistant requirements across the US for all midwives, because around here all you have to do is go online and read a few pages and take a test to qualify as a "licensed midwife".
I haven't had any bad experiences to speak of with midwifery births in my area. They must be going just fine! I think we've only had a couple of transfers in the 3 years I've been on my unit, don't remember what for but they were appropriate and ended up fine. I don't think we have a large volume of home births in my area, though (we are in a small town - maybe the per capita is the same but we also don't have any local mw's - girls have to use them from 1.5 hrs away). I have several friends who have had home birth, so I'm somewhat in that circle.
I think Midwives should have to have training both didactic and hands-on and be monitored by a governing body. The first 2 examples all the women thought the midwives were licensed and credible and they weren't. I wish that there could be consistant requirements across the US for all midwives, because around here all you have to do is go online and read a few pages and take a test to qualify as a "licensed midwife".
I am not sure about the individual states, but to NARM and ACNM both require far more than a few online classes to become a midwife. I believe most states use certification by NARM or ACNM (the CPM) as a prerequisite for licensure. Some states have optional licensure or midwifery is not technically "illegal" so perhaps those women claimed they were licensed or certified in one of those states and were not.
Let's not forget our physician friends who are not required to take board exams to become licensed.
I believe most states use certification by NARM or ACNM (the CPM) as a prerequisite for licensure.
17 states where direct-entry midwifery is legal and regulated use the NARM examination to gain licensing: AL, CA, AZ, CA, CO, FL, LA, LA, MN, MT, NH, NM, OR, SC, TN, TX, VT, WA.
25 of 50 states regulate direct-entry midwifery and either license, register, document, permit, or certify them.
Some states have optional licensure...
UT and OR only.
or midwifery is not technically "illegal" so perhaps those women claimed they were licensed or certified in one of those states and were not.
If licensing/registration/documention/permits/certifications aren't available the state is considered unregulated.
CT, NE, OH, WV are the only places where there is nothing on the books defining direct-entry midwifery so it's neither permitted nor forbidden
AL, DC, IL, IN, IA, KY, MD, NC, PA, SD, WY expressly prohibit direct-entry midwives from practicing. I.e., it is illegal to be anything other than a Certified Nurse-Midwife (although a precedent may have been recently set in PA to nullify that fact.)
GA and HI say it's legal by statute but they don't have a licensing mechanism
KS, ME, MA, MI, MS, MO, NV, ND, OK say it's legal by inference of the statute but there isn't a licensing mechanism.
It would be nice for there to be a national standard for direct-entry midwives who attend OOH birth just as there is for CNMs to do the same plus hospital birth. I bet nurses who SUPPORT that idea would see less "trainwrecks" in the hospital in the long run than they would if they continue (as they have) to oppose direct-entry midwifery laws with the physician lobbies.
I am not a home birth supporter, as I've seen many bad outcomes in the hospital, and can't imagine a timely rescue for mom or baby, if a home birth had been in progress. I suppose the uninsured have financial reasons for not going
to a hospital...... I wonder if they realize how much greater the cost would be, of treating complications later, rather than preventing them from getting out of control, in a hospital?
40 years ago, home births were favored by counter culture [arents, who didn't want birth certificates done for their sons, due to conscription possibility later.
They thought that 18 years later, if their sons went to war involuntarily, the risk of them dying then would be greater than the risk of death at birth at home. That was the Viet Nam era, and desperate anti war folks made their statement known. No sonograms existed then, so they didn't know the sex of their baby before birth.
What reasons do expectant parents give for home births, other than "it's more natural", now?
I am not a home birth supporter, as I've seen many bad outcomes in the hospital, and can't imagine a timely rescue for mom or baby, if a home birth had been in progress. I suppose the uninsured have financial reasons for not going
to a hospital...... I wonder if they realize how much greater the cost would be, of treating complications later, rather than preventing them from getting out of control, in a hospital?
40 years ago, home births were favored by counter culture [arents, who didn't want birth certificates done for their sons, due to conscription possibility later.
They thought that 18 years later, if their sons went to war involuntarily, the risk of them dying then would be greater than the risk of death at birth at home. That was the Viet Nam era, and desperate anti war folks made their statement known. No sonograms existed then, so they didn't know the sex of their baby before birth.
What reasons do expectant parents give for home births, other than "it's more natural", now?
People who chose homebirth tend to be older, more educated, higher socioeconomic status. Research shows that homebirth is as safe or safer than hospital birth for low risk women and babies. Just because you feel that it isn't safe does not make it a fact that it isn't safe. The likelihood of complications, iatrogenic and otherwise, is higher in the hospital.
I chose homebirth because I didn't want continuous fetal monitoring, an i.v., pitocin, AROM, baby sent to nursery, pressure for hep B vaccine, pressure for an epidural, pressure for GBS prophylaxis, etc all of which are par for the course in my area.
I was also an L & D nurse at the time. I worked in a community hospital. We did not have in-house OB and anesthesia. If I was in that hospital and had a cord prolapse or abruption it would take about 1 hour to assemble the surgical team. The fastest I ever saw it done at night was 2 hours for an urgent case, so I am estimating 1 hour for a true emergency. One of the doctors lived an hour and fifteen minutes away- glad we never had an emergency on his call. (By the way that same hospital still does routine episiotomies). I was more than willing to take my chances with a lower risk of complications anyway and transferring to a larger hospital. Being in the hospital does not make you safe.
Elvish, BSN, DNP, RN, NP
4 Articles; 5,259 Posts
I am all for tort reform, for one. I realize that yes, there are some cases when malpractice does exist, and cases when somebody truly acted negligently. It gets a bit ridiculous - "the doctor should have known the baby was bigger..."
What the heck?! It's one thing to estimate via Leopold or an u/s (which, in the 3rd trimester, is notorious for being WAAAAAY off), and quite another to be able to tell exactly. No freakin' way.
I'd be all for people taking responsibility for their decisions, especially when it comes to childbirth! And it seems that many do, but it seems there are also just enough people who want to sue over every little thing that goes wrong. Unfortunately, there are malpractice lawyers just waiting to pounce on that small percentage of the population.