Home births gone wrong

CBlover, BSN, RN · Feb 1, 2016

Thank you LibraSun for your educated post. I can see both sides a little more clearly now. I never necessarily frowned upon anyone who had a home birth, although I always thought it was risky and would kinda go, "What's the point?" I have heard how "beautiful" home birth can be. I still dont think I'll do it myself. I had a 3rd-nearly 4th degree tear recently and kinda glad there was some Fentanyl around... :)

MNNICU, RN · Feb 1, 2016

Ok here are some different links to studies since someone pointed out the other one wasn't a valid study. One is from the American Journal of Obstetrics and Gynecology and the Other is from Midwives Alliance of North America (MANA) which both state that infant mortality rates in planned home births are 1.26 (or 1.30 according to the MANA study) per 1000 births and hospital rate is 0.32 per 1000 live births. So the numbers really don't lie that is a 4 times higher death rate in home births. MANA tried to spin these numbers as extremely low but really they were still significantly higher than hospital deliveries.

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Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009 - Cheyney - 2014 - Journal of Midwifery & Women'

Now that said I also agree that the MANA study did show there was a much lower C section rate, lower hemorrhage rate in moms, lower anelgesia rates and higher breast feeding rates in home births. It just seems when things go wrong the baby pays for it. It just depends on what the mom is willing to risk. Babies have no reserve, they need help immediately if things go wrong whereas generally the moms have a little more time. My original post was definitely pointing to really poor choices that no sane midwife in her right mind should agree to. I think the main thing I am struggling with is in the USA there is not enough policing of midwives. Almost anyone can be a lay midwife with very little training and there are not enough laws in place to punish them for making mistakes or making reckless decisions. And really the parents should be held accountable as well. I know that in European countries home birth is the norm. England sees better outcomes in their home birth settings for low risk moms than hospital settings but they have the National Health System to report to which has strict guidelines they aren't allowed to go against without repercussions. The US home birth scene really is just not safe at this time and needs a major revamp. Do I think they could eventually become much safer? Sure. But currently it is not as safe as a hospital.

**LibraSunCNM, BSN, MSN, CNM** · Feb 1, 2016

This is a thread meant for nurses and NPs who work in the NICU and was about how to cope with home births that went badly. Of course our perspectives are skewed. We see home birth babies only when the birth went horribly wrong and usually have devestating outcomes.
I'm sure that there are wonderful midwives out there who assist with home births and recognize when things are going badly, when to transfer care, and how to appropriately resuscitate when needed. The ones in my area are terrible and I would deliver unassisted before I would let any of them touch me or my baby.
Personally, I don't believe that people who deliver at home are selfish, but I think some are misguided. Such as my previous example of the frank breech baby who died, that mom also stated that she would prefer her baby die than be born at a hospital. That's just plain wrong. I have also met families that intended to deliver at home but their plans were changed and they were very pleasant parents to work with and I would never describe them as selfish or uncaring about their baby.

I was just trying to present another perspective, the post showed up on my main page so I thought I'd offer my point of view. I in no way mean to suggest that you shouldn't be upset by what you've experienced. I do agree that some people who choose home birth (and some midwives who attend them) are misguided. I just wanted to offer that most of the time, this isn't the case. Again, I have the utmost respect for NICU staff.

lavenderskies, BSN · Feb 1, 2016

OP, thank you for your perspective. I know it must be horrible to see babies have such terrible outcomes. I respect the work of NICU nurses enormously. The fact that you heard a midwife say "that baby wasn't meant to live" makes me sick.
However, I think two things seem to be happening in your case: you seem to be in an area with particularly dangerous, untrained midwives who are not practicing appropriately, and you are ONLY seeing the bad outcomes of home births, and not getting exposed to the vast majority of home births that have completely safe outcomes.
As a CNM, I got the privilege to do my final semester in the home birth setting with a CNM. There I learned how normal birth can be and how powerful women are. Right now I work as a CNM in a hospital, and while I still get to learn those things every day, I am planning a home birth for the birth of my first child.
Most people in this country have never been to a home birth and only know about it from some scary story of a bad outcome, and then can confidently brand women "selfish" for doing so. This saddens me. Most people also assume that all bad outcomes in the hospital are the result of the inherent danger in birth, that all interventions were used appropriately, and "Thank God we had all those doctors and equipment and access to an OR to save you and your baby!!!" In fact, I would venture to say MOST bad outcomes in the hospital are due to unnecessary intervention in the first place! Of course not ALL are, and thank God we have OBs and ORs and anesthesia and blood transfusions and antibiotics. But I can give you just as many stories about women's lives being irrevocably changed because of bad decisions made in the hospital.
I saw an 18 year old mother die in childbirth because a doctor ignored the midwife's concerns about the patient's bleeding during pushing, and then life-saving measures were taken far too late. I've seen a 23 year old woman lose her uterus because the incompetent doctor didn't know how to use a vacuum to deliver the baby (all that was needed was probably 1 pull), instead made excuses for why she needed a C/S, then nicked an artery in the surgery without knowing it, closed the patient, and one day later, the patient required a hysterectomy. I have seen countless women bullied, humiliated, and severely physically and emotionally traumatized from their hospital births. To say that the only outcome that matters in childbirth is a "healthy" baby is simply too myopic.
It is wonderful that in the OP's hospital, they have a lot of options for low-intervention birth. However, this is not the case for most women in the country. The choices are a high-intervention birth in a hospital with an OB, or home birth (some places don't even have access to home birth midwives, and some women opt for unassisted birth!). Women have to look at the risks of both settings, and make their own choices. Sometimes this results in a bad outcome, which is awful. But to completely malign home birth as dangerous and hospital birth as safe is just foolish.
Home birth with a CNM (in my area most home births are attended by licensed midwives, there are few CPMs) doesn't require eschewing any routine prenatal testing or standards of care. You have access to all of the normal blood work, screenings, ultrasounds, etc. Some people CHOOSE not to have an ultrasound, for example, so yes, you could have an accreta and not know about it and bleed out and die. But this is not BECAUSE they had a home birth, KWIM? If there are unlicensed midwives in your area practicing dangerously, they need to be reported and prosecuted.
At the end of the day, childbirth, while mostly normal and safe, does have risks, and will always have risks. Women and babies will sometimes die in the process. It is so terrible, but it's the truth. We cannot eliminate risk in OB. As such, women have the right to assess their options for birth in their area, weigh the risks and benefits of all birth settings, and make their own decisions.

Thank you for saying what needed to be said.

bebbercorn · Feb 1, 2016

A well trained provider with a low risk mother can make for a safe environment for a home birth. That being said, as with anything in life, things can take a turn for the worst, that is why there are generally considerations in place... how close are we to the hospital? what is the providers transfer rate? for what reasons has the provider transferred? how is their relationship with the transferring facility, do they work with any providers at the hospital with whom they can communicate in the event of an unplanned transfer?

Most people don't realize that midwives do carry emergency equipment with them and can resuscitate if need be. It is not as fast as being at a hospital, this is true. But as far as I understand it, many "emergency c's" that women have been on oxytocin and epidurals which may/may not have precipitated the need for the c. Undoubtedly, this won't be occurring at a home birth.

I've seen my share of home births (mom was a midwife), and as an ED nurse I've seen/heard of some that have gone wrong. But these have been: a woman who had a midwife refuse to deliver her at home because she was a first time breech... unassisted because of concerns because mom was on rx painkillers... meconium staining, family asked to transfer and the midwife brushed it off. All different problems. All could have had very different outcomes. We know that worldwide home births are working, right now we just don't have the kinks work out of the system to have the best of outcomes. We can and should do better. The c-section and induction rates in this country are atrocious.

24gaDalek · Feb 1, 2016

I am a NICU nurse and as part of my job I also work up in L&D as an NRP rapid response personnel. I attend all deliveries typically, but mainly the high risk ones, so I have seen a lot of births and resuscitated my share of infants. At my facility, Midwives typically deliver low risk infants and OB/GYN deliver high risk.

I respect someone's decision to have a baby at home as long as people are fully aware of the risks behind it and the willingness to accept the blame if there are complications due to their choices. Unfortunately, I have seen many infants that end up in the NICU due a mistrust of "medical establishment" and a fear that anything associated with a hospital means aggressive and unnecessary treatment for mom and baby. Sometimes this misinformation comes from misguided practitioners with their own agendas. Sometimes the misinformation is from countless hours of "research" by the parents from Dr. Google and/or countless blogs dedicated to using homebirth as a big middle finger to the "medical establishment." I would respect the decisions of these parents more if their information came from rational sources and sound consideration of both the pros and cons. Generally, this is not the case in my experience.

Yes, bad outcomes can happen anywhere. I have witnessed semi-questionable actions by both midwives and OB/GYNs at deliveries (aggressively delayed cord clamping and placental birth resulting in severe maternal hemorrhage, TOLAC of 10.5 lb baby where the uterus ruptured). But none (yet) that have resulted in a preventable insult to the infant. And most of these choices by the practitioners were in deference to parental preference.

The sticking point for me is the preventable insult, whether at home or in the hospital. There seems to be this chain of responsibility that just goes absolutely haywire in these cases. SOMEONE at some point in this process should have been the emergency brake before the train went off the rails. It is the supervising practitioner's responsibility to present all of the pertinent information and sufficiently lay out the worst case scenarios. It is the parent's responsibility to put aside their own agenda and listen to all information presented and make the choice that is the best for the baby. Yes, your birth may end up less than your ideal if you have had complications. But I personally believe that a healthy baby and mom is the best outcome. I don't think that in birthing the journey is the end all, be all. All that matters is being able to take your little one home. The problem is that labor and delivery is so fraught with emotion that I think it is hard for both parties to see clearly.

I completely understand the frustration of the OP. We NICU RNs see so many messed up babies due to just sheer horrible luck (incompetent cervix, CMV exposure, genetic factors, etc.) that it boggles our minds that anyone would play roulette with a perfectly healthy baby.

I personally ended up with two c-sections and had both babies before being a NICU nurse. My first due to cpd and failure to progress. My son ended up being 9.2 pounds and having a nuchal x4. I boo-hooed the fact that I didn't have the natural labor that I originally wanted because then I don't think I really grasped what really was going on. Now I'm grateful that I kept an open mind to any outcome that resulted in my son being born alive and healthy. Today I get to come home after a sad night in the NICU and I get to hug and kiss both my babies before they head off to school. The trade-off of ideal birth vs. actual birth was worth it to me for that very reason.

I could blah blah about this all day but I won't.

lavenderskies, BSN · Feb 1, 2016

The OPs post and the example she gave specifically mentions that physicians warned the mother she needed a C-section due to a breech baby. Her point is that the home birth should not have taken place in this instance and you mention "anticipated complications like breech should be in a birth ctr or hospital." This is her point in the post. I did not take her post as some did that home birth should not be an option, but more that she's angered at the mothers who have complications like you mentioned and still pursue home births and have a not so happy ending. I agree women should have a choice myself. I don't agree that they should attempt a home birth if they knew they were at risk due to complications like you mentioned. Surely that's common sense?

Yes it is common sense, and it is a good midwife that refers to the OB/hospital setting for the situations and conditions referred by the OP and some others in this thread. It may or may not have been the intention of the OP but the overall theme of this thread quickly became home birth is irresponsible.

We cannot mitigate all risk no matter what setting we elect. I have been first witness to many situations where the interventions "offered" were supposed to decrease morbidity and mortality and yet were in themselves the cause of another entire set of complications. Medical professionals are all educated in how to present interventions in a manner that it is very difficult and in some cases nearly impossible to refuse.

Out of hospital birth is a huge multifaceted topic. Healthcare professionals throwing their opinions around in a way that serves only to support biased and often flawed opinions about intervention and restrict options for a healthy birth should have no place in healthcare.

Anyone that claims to know that hospital birth is always the safer option has not practiced in an average medical birth facility with standard orders and your typical informed consent and is denying the obvious inherent potential complications.

I'm not in any way dismissing the frustration any NICU nurse must experience when faced with the outcomes of malpractice. But I would suggest that improving options for appropriate care would be a better focus if we as a profession wanted to increase trust and ultimately improve outcomes and patient satisfaction.

24gaDalek · Feb 1, 2016

Just got out of the shower and had to get a few more points in, lol

We NICU personnel are the end of the line for the birth trauma/bad baby scenario. When the questioning begins from the parents it is typically, "Why can't you save my baby?" instead of, "Where did this all go wrong?" We are the bearers of bad news and wholly the advocate for the baby and the baby alone. We can look like the bad guys.

It is hard not to get angry when parents who choose to forgo a hospital birth because of the big, bad medical establishment suddenly want us to do "everything medically possible to save my baby" regardless of how detrimental it is to the infant and in some cases completely futile. The hospital is spending millions of dollars to put their baby on ECMO and body cooling for a baby that is, without a doubt, going to be dinged (a NICU term) and possibly unsaveable when perhaps a few quiet conversations and some different choices could have resulted in a 2-3 day hospital stay and a healthy infant. We get frustrated because we see what could have been and are only left picking up the pieces of what is.

**LibraSunCNM, BSN, MSN, CNM** · Feb 1, 2016

Just got out of the shower and had to get a few more points in, lol
We NICU personnel are the end of the line for the birth trauma/bad baby scenario. When the questioning begins from the parents it is typically, "Why can't you save my baby?" instead of, "Where did this all go wrong?" We are the bearers of bad news and wholly the advocate for the baby and the baby alone. We can look like the bad guys.
It is hard not to get angry when parents who choose to forgo a hospital birth because of the big, bad medical establishment suddenly want us to do "everything medically possible to save my baby" regardless of how detrimental it is to the infant and in some cases completely futile. The hospital is spending millions of dollars to put their baby on ECMO and body cooling for a baby that is, without a doubt, going to be dinged (a NICU term) and possibly unsaveable when perhaps a few quiet conversations and some different choices could have resulted in a 2-3 day hospital stay and a healthy infant. We get frustrated because we see what could have been and are only left picking up the pieces of what is.

I can't imagine how sad and frustrating that must be. I really do see what you're saying and feel for you. Again, however, I offer another perspective---I get frustrated almost every day seeing birth outcomes that "could have been" different were the patient not subjected to unnecessary interventions in the hospital. Dismissing women's concerns about interventions in their birth by saying "a healthy mom and healthy baby is all that matters" doesn't prevent women from lifelong emotional scarring from their births.

We need a better plan for integrating home birth into our health system. We need standardized guidelines for what is and isn't appropriate at home. We need better informed consent in ALL birth settings so that patients truly understand their choices. We need to radically change the way obstetrics is practiced in the hospital. We need way, way more licensed midwives so that they can be the standard of care for healthy, low-risk women in this country, to promote a much more judicious use of interventions in obstetrics. And we need to recognize that sometimes interventions are absolutely warranted and we need to be grateful that we have them.

kktegan · Feb 1, 2016

Is this the same study that included all births outside the hospital even if they weren't planned? If so, of course it is going to show a higher mortality rate. You're comparing apple to oranges.

rnkaytee · Feb 1, 2016

No, the MANA study was based on planned place of birth.

At a home birth, you're relying on one person's opinion who sees things through one set of eyes. At a hospital, you can rely on many different people not only in an emergency but hopefully to prevent one. Like 24gaDalek, I keep coming back to this thread because it touches a very real nerve with me. I've met many CNMs who are great but that's not who is doing the home births (at least in my area).

24gaDalek · Feb 2, 2016

We need a better plan for integrating home birth into our health system. We need standardized guidelines for what is and isn't appropriate at home. We need better informed consent in ALL birth settings so that patients truly understand their choices. We need to radically change the way obstetrics is practiced in the hospital. We need way, way more licensed midwives so that they can be the standard of care for healthy, low-risk women in this country, to promote a much more judicious use of interventions in obstetrics. And we need to recognize that sometimes interventions are absolutely warranted and we need to be grateful that we have them.[/QUOTE]
I agree completely. Especially with the bolded statements.
In addition, I would like to add that many of today's common comorbidities are changing the face of L&D as we know it. Increasingly obese and unhealthy moms are having larger, unhealthier babies. It is common for me to see a mom with a BMI >50 at least once per week when 10 years ago that was a once a year or once every five years type of thing. Gestational Diabetes causes many issues with infants, not just increased size (cardiac anomalies to name a few). Many of these cases are poorly controlled.
I would say infant hypoglycemia after gestational diabetes went untreated is one of our top term infant admissions.
I also just read a CDC report that incidences of gastroschesis are on the rise and we have no idea why.
I would like to give people the BOD when it comes to putting their infant at unnecessary risk by making responsible choices.
Unfortunately, many times that is not the case. But, as previously stated, in the NICU we see the 1% that need help, not the 99% that don't.