Which states are CNMs permitted to do homebirths?

Red Kryptonite · May 2, 2015

But I was asking specifically about the claim that VBAC and other higher risk births are safer at home.

I made no assertion about any other type of higher risk birth other than VBAC.

Unfortunately home VBAC is not a well-studied topic. I'll see if I can find some European resources where they undoubtedly have more experience and better collaboration between midwives and OBs instead of the adversarial relationship that exists here in the US.

Frankly, I think most of the risk in VBAC comes from the hospital environment. My second birth, had I had the sense to stay home instead of going to the hospital, would not have been a failed VBAC.

Anyway, here's an excellent, well-cited article to start with: Homebirth after Cesarean: The Myth and the Reality - by Amy V. Haas

klone, MSN, RN · May 2, 2015

I will say that my second child, who was born at home with two CPMs, I KNOW would have been a C/S if she had been born in the hospital.

queenanneslace, ADN, MSN, APRN, CNM · May 2, 2015

I made no assertion about any other type of higher risk birth other than VBAC.
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"Planned home birth with a trained attendant is as safe or safer than hospital birth. Even safer for VBACs I'd contend, due to hospitals' refusal to stop using pitocin and even misoprostol on women with uterine scars."

VBAC is safer in an out of hospital setting? Any evidence that this is true? What are the other higher risk births that increase risk in out-of-hospital settings?

The BMJ birth center study shows nulliparity to be a risk factor that increases rate of perinatal injury and death.

queenanneslace, ADN, MSN, APRN, CNM · May 2, 2015

Midwifery Today? Really?

There is really nothing academic, rigorous or evidence-based that comes from Midwifery Today.

The author's description of how to assess maternal/fetal well being in labor is frightening and the concept of "teaching women to stay low-risk" is pure ignorance.

I'm guessing the author, as a childbirth educator, has never actually been responsible for the life, health, and well-being of a woman and baby during labor.

klone, MSN, RN · May 2, 2015

I interpreted "I contend" to mean that was her opinion, not that she necessarily knew of any evidence to support it.

klone, MSN, RN · May 2, 2015

Yaeko, K., Hiromi, E., & Mariko, I. (2013). Outcomes of independent midwifery attended births in birth centres and home births: A retrospective cohort study in Japan. Midwifery, 29(8), 965-972. doi:10.1016/j.midw.2012.12.020

Dixon, L., Prileszky, G., Guillilan, K., Miller, S., & Anderson, J. (2014). Place of birth and outcomes for a cohort of low risk women in New Zealand: A comparison with Birthplace England. New Zealand College Of Midwives Journal, (50), 11-18. doi:10.12784/nzcomjn150.2014.2.11-1

(this next one is old, but it was a pretty groundbreaking study done at The Farm, so I would be remiss to not include it)

Durand, A. M. (1992). The Safety of Home Birth: The Farm Study. American Journal Of Public Health, 82(3), 450-453.

Cox, K. J., Schlegel, R., Payne, P., Teaf, D., & Albers, L. (2013). Outcomes of Planned Home Births Attended by Certified Nurse-Midwives in Southeastern Pennsylvania, 1983-2008. Journal Of Midwifery & Women's Health, 58(2), 145-149. doi:10.1111/j.1542-2011.2012.00217.x

Remez, L. (1997). Planned home birth can be as safe as hospital delivery for women with low-risk pregnancies. Family Planning Perspectives, 29(3), 141-143.

Fullerton, J., Navarro, A., & Young, S. (2007). Outcomes of planned home birth: an integrative review. Journal Of Midwifery & Women's Health, 52(4), 323-333.

Nove, A., Berrington, A., & Matthews, Z. (2012). Comparing the odds of postpartum haemorrhage in planned home birth against planned hospital birth: results of an observational study of over 500,000 maternities in the UK. BMC Pregnancy And Childbirth, 12130. doi:10.1186/1471-2393-12-130

Red Kryptonite · May 2, 2015

Midwifery Today? Really?

Did you actually go to the article and look at any of the peer-reviewed studies she cited? Or did you dismiss it based on the source and not even look? I'm betting it's the second......

AspiringNurseMW · May 3, 2015

Ditto for VBAC at home here too. I knew that VBAC would be a safer option for me, especially because I desire more children in the future. I knew even before I got pregnant I would NOT VBAC in a hospital. Never ever. I would have tried to VBAC at the birth center I worked at but at the time did not allow VBAC's there. So homebirth it was, especially because I didnt see anything my two CNM's could do or had access to that was different than the birth center. And unless I experience something that would make me high risk, future children will be at home too. But alas, that just my opinion.

Right now I really think its a matter of opinion and extrapolation for different studies. I have not found a comprehensive study that studied VBAC vs HBAC and taken into consideration things like planned vs unplanned HBAC, distance from hospital, type of provider, etc.

In PA CNM's can attend homebirths, but the problem is that they are not independent, they must have a collaborative relationship with an MD. As a result, the only CNMs I know that attend homebirth are tied to a birth center that deliver at home, the center, or at a hospital. CPM's are alegal, they attend all the homebirths in NEPA along with some lay midwives.

queenanneslace, ADN, MSN, APRN, CNM · May 7, 2015

I interpreted "I contend" to mean that was her opinion, not that she necessarily knew of any evidence to support it.

Well then I misunderstood that the statement that VBAC was safer at home than in a hospital was just an unfounded opinion. By all means, everyone is entitled to their opinion. Lets just make sure we're representing our biases as such, and not fact.

queenanneslace, ADN, MSN, APRN, CNM · May 7, 2015

Did you actually go to the article and look at any of the peer-reviewed studies she cited? Or did you dismiss it based on the source and not even look? I'm betting it's the second......

Oh my, the article was... amusing... to put it mildly.

Let's see - she trots out the statement that "homebirths are as safe as, if not safer than hospitals," which has no evidence to support it. Not even her studies. No, there is no study that shows this. I've been waiting for this study; it doesn't exist.

She quotes a VETERINARIAN who says that if you suture a certain way, uterine rupture after surgery is nonexistent.

What? A VETERINARIAN. Hello. Really?

She talks about "emotional dystocia" being caused by the hospital setting, yet there is no definition of it, or no way to measure 'emotional dystocia.'

I found it amusing that she cites the Lieberman birth center study published in the Green Journal in 2004 - where the authors' conclusion was that VBAC in an OOH birth center was too risky. The author also criticizes the Lieberman study as only looking at certain outcomes, namely: MATERNAL AND PERINATAL DEATH, HYSTERECTOMY, 5 MINUTE APGAR less than 7, and UTERINE RUPTURE.

I'm confused about the criticism of these variables - these are horrible things. These are severe complications. What other variables could offset these outcomes? Her baby lost half of his blood volume and suffered a brain injury, but she got her HBAC? The midwife held her hand all the way to the hospital while diffusing essential oils, she lost my baby and her uterus, but the midwife was nice and the woman didn't suffer any emotional dystocia?

She reviews intermittent monitoring at home and states that intermittent auscultation intervals of 15-30 minutes is appropriate for monitoring a laboring woman attempting a VBAC at home.

She also talks about how a midwife at home can "truly assess" a woman in labor due to her continuous presence. What is "truly assessing" when it comes to midwifery? Is that a thing? Sounds like magical thinking to me.

She includes statistics about neonatal mortality rates at home are 0.5%-3.5%. She uses this statistic to say that there is no difference in home birth and hospital birth neonatal deaths.

3.5% !!!! Are you kidding me! That is a horrifically high number. Actually, 0.5% is, too. I am not soothed by either of those numbers. Are you?

The author also talks about 'teaching women to stay low-risk' through some practice of magical thinking as far as I can tell. That level of ignorance is something I have no time for. Risk factors exist regardless of how much positive thinking, deep breathing and chiropractic adjustments you have.

Now, if we're presenting opinion - by all means, have your opinions - but be sure to represent them as opinions. If you want to discuss evidence, then we need to discuss evidence. And there needs to be data - measurable data - to support that evidence.

I've been steeped in the 'homebirth is safer than hospital birth' myth for years. I was present at the MANA conference when Ken Johnson and Betty Anne Daviss revealed their data from the CPM 2000 study prior to publication. They stood up in front of the crowd and told us all in gleeful voices that the CPM study showed 'equivalent outcomes' to hospital births.... my first thought was: Wait, I thought hospital birth was SO DANGEROUS that it would take very little to improve on our deplorable hospital birth outcomes. Aren't we hearing about how the US statistics are terrible for women and babies compared to other developed countries? And that these outcomes are due to dangerous hospital practices? Hasn't anyone else heard this? So naturally, taking birth out of the hospital HAS TO improve outcomes. But it doesn't. (And, a side note, there are some problems with the comparison data used in the CPM study. But that's another issue.)

That was over 10 years ago - and that is when this myth of 'home birth with a midwife is safer than hospital birth' started unraveling for me. STARTED.

There are a rare few studies that demonstrate nearly equivalent outcomes in out-of-hospital settings. The studies with the best outcomes have very conservative risk-out criteria. They also have midwives who are formally trained, licensed and integrated into the existing healthcare system.

Midwives who attend home births in the US, generally speaking, are not following these conservative risk-out guidelines, nor are they integrated into the healthcare system. But they want to claim equivalency in outcomes. Can't have it both ways.