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home birth safety

Women Are Choosing Home Birth: The Infant-Maternal Health Care System in the U.S. Owes Them A Safe Option

Posted by Midwives Alliance on May 3rd, 2016

Women Are Choosing Home Birth

In the face of increasing home birth rates and declining maternal health outcomes in hospitals, society owes it to families to ensure safe birth options, regardless of the setting.

A small but growing number of families are opting out of a maternal health care system that is falling short. According to the Lancet, the U.S. is only one of eight countries in the world where the maternal death rate is increasing. In some states, such as California, rates of maternal and newborn mortality in hospitals have risen substantially – notably and alarmingly for women of color. 

Families choose home birth for many reasons. Some opt to avoid the often unnecessary interventions associated with hospital birth (including inductions, high cesarean section rates, and NICU stays). Others do not want to leave their communities or their families and have a tradition of birthing at home for personal, religious or cultural reasons. Some families cannot afford to pay the cost of a hospital or, for those who can afford to be more discriminating in their healthcare choices, feel as if their beliefs and preferences will not be honored. An integrated health care system for families that choose home birth and the midwives who serve them is the safest option.

The debate around U.S. home birth statistics as it is currently framed is only serving to confuse stakeholders in this debate. Critics of home birth cite flawed birth certificate studies and highlight relative instead of absolute risk. The State of Oregon has recently made an important leap forward by creating a birth certificate that captures the intended place of birth as well as provider type. Early data is being collected and research completed, which provides consumers and providers with the kind of data that can be used to inform practice and decision making.

The U.S maternal health care system has an obligation to support the conditions that increase safety for home births, including access to consultation, smooth transfers of care and transport to hospital when necessary. The Home Birth Summit, which brings together obstetricians, midwives, consumers, hospital administrators and others in maternal-health care, has published Guidelines for smooth transports crafted by a multidisciplinary Collaboration Task Force, as well as Transport Forms and Scripts to ease communications.

As the professional association for home birth midwives, MANA firmly supports the rights of families to birth outside of a hospital setting, with the providers who are trained in home birth specifically and within a system that supports midwives in all settings.   

The CPM, issued by the North American Registry of Midwives (NARM), is accredited by the National Commission for Certifying Agencies (NCCA), the accrediting body of the Institute for Credentialing Excellence (ICE, formerly NOCA). The mission of ICE is to promote excellence in credentialing for practitioners in all occupations and professions. The NCCA accredits many healthcare credentials, including nurse-midwives, nurse anesthetists, nurse practitioners, and critical care nurses. The CPM credential requires extensive training and the passage of exams that assure competency and focuses exclusively on the safe provision of out of hospital birth. 

Midwifery organizations and coalitions around the country are working to secure licensure for home birth midwives in all 50 states. Licensure gives families the reassurance that their provider is competent and does not have to work under the radar. Currently, misinformation, fractured interprofessional relationships (learn more here and here) and medical monopolies prevent this safe choice for mothers and babies.

Families deserve the support of a provider that meets international standards. The International Confederation of Midwives, with input from over 100 countries’ midwifery associations including those from the United States, have created standards that are increasing safety for families globally. The International Confederation of Midwives supports the “recognition that midwifery is a profession that is autonomous, separate and distinct from nursing and medicine.” and does not expect, nor recommend, that midwives be nurses first. MANA, among other midwifery organizations, is working on continuing to meet and even exceed the recommendations of the ICM. 

Families deserve the right to make choices with high quality evidence informing their decisions. A growing body of literature (including in the United States, Canada, and ) suggests that home birth is safe for women and babies when the birthing parent is healthy, the midwife is trained and medical-back-up is available should a complication arise. One of the hallmarks of home birth midwives’ care is their commitment to providing evidence based information so that clients can make truly informed decisions regarding their care during pregnancy and birth. In a system that supports the autonomy of the family, decisions can be made based on evidence, not fear.

When the maternal health system of the U.S. can have a balanced discussion on how to fully incorporate non-nurse midwives into our system, regardless of place of birth, our families will have better access to the care providers of their choice, fewer interventions including surgical birth, and better outcomes. 


About the Author

Marinah FarrellMarinah Valenzuela Farrell, LM, CPM Politics and traditional medicine are what led Marinah to midwifery, and she has a firm commitment to both political activism and birth work. Marinah has worked in waterbirth centers and medical facilities for international NGOs, in free­standing birth centers in the U.S., and is the owner of a long standing homebirth practice in Phoenix, Arizona. In addition, Marinah is known for her grassroots activism at the community level. Marinah is currently a founding board member and the Director of Maternal Health for Phoenix Allies for Community Health (PACH) a community, not federally, funded free clinic in downtown Phoenix, and the President of the Midwives Alliance of North America (MANA). Marinah is focused on the issue of lack of access to midwives and the profession of midwifery in communities where health disparities are overwhelming, trainings in cultural safety and is active in numerous grassroots political collaboratives. Marinah continues to work with traditional midwives outside of the U.S and bridges professional midwifery with community traditions.

New and Sometimes Conflicting Research on Out-of-Hospital Birth

Posted by Midwives Alliance on January 7th, 2016

In the past month, two new studies have been released - one in the New England Journal of Medicine (NEJM), the other in the Canadian Medical Association Journal (CMAJ) - examining out-of-hospital birth outcomes. The CMAJ study examined 2006-09 provincial health records while the NEJM study analyzed two years of Oregon vital statistics data. What makes the NEJM study unique is that the Oregon birth certificate now allows researchers and others to track the intended place of birth, providing for more accurate categorization of the outcome of transfers.

The two studies both found that families that choose out-of-hospital birth experience fewer interventions, including labor augmentation, assisted vaginal births, cesarean births, and episiotomies.

Both studies also found that the absolute risk of adverse neonatal outcomes is small regardless of setting. However, the CMAJ study found equivalent risk between home and hospital settings, while the NEJM study found that planned out-of-hospital births were associated with an excess of less than 1 fetal death per 1000 deliveries -- a small but statistically significant difference. 


Media coverage. MANA has compiled resources for midwives reviewing the outcomes and providing guidance for interpretation for families. 

First, here's a piece in Forbes that provides balanced coverage (note the article - like many - refers to "home birth" while the study combined birth center and home birth data together). 

MANA provided expert commentary to a number of the recent news articles, including The New York Times and The Washington Post.

Expanded coverage at Science and Sensibility. The official blog of Lamaze International has provided balanced coverage of the New England Journal of Medicine research. In this post, Henci Goer compares and contrasts this newest study with other recent home birth analyses. Missy Cheyney, Chair of the Midwives Alliance Division of Research, provides guidance for families interpreting the new research in this post.

Model transfer guidelines. The authors of the NEJM article call for increased collaboration and integration of out-of-hospital providers into the maternal health care system. The Best Practice Guidelines: Transfer from Planned Home Birth to Hospital, developed by the collaboration committee of the Home Birth Summit, are an important and practical tool to increase integration.

The guidelines were designed to facilitate the safe and mutually respectful transfer of care of a woman and her family from a planned home birth to the hospital. The model blueprint was created as the result of a unique collaboration among physicians, midwives, nurses and consumers.

To learn more or endorse the guidelines, visit here.

Home Birth Research Q & A

Posted by MANA Community Manager on February 7th, 2014

We’ve had lots of questions from families, midwives, and others about the recent release of two articles that were based on the Midwives Alliance of North America dataset (MANA Stats). Here are answers to some common questions, along with a roundup of some of the coverage.

Numbers are useful, but only if they can be compared to something. What outcomes can we compare to the Cheyney article’s findings?

In the study, the authors compare the findings to the best available observational studies of planned home births and birth center births. For low-risk women, the authors find similar rates of both positive and negative outcomes for mothers and babies as nearly every other large, well-designed study.

Some of these well-designed studies are able to compare to hospital rates (which is difficult to do in the U.S.). For example, the Hutton et al (2009) study found no difference in risks to babies between home and hospital in Ontario, Canada. While it is reassuring that the Hutton study had comparable rates of mortality at home as the Cheyney study and it found no difference in risk between home and hospital, more research will be needed to compare U.S. home birth and hospital birth rates.

Why doesn’t the Cheyney study compare home birth to hospital birth mortality rates?

It makes sense to want to draw these comparisons. However, hospital rates in the U.S. are derived from vital statistics data (birth certificates and/or death certificates). A number of organizations, including the American College of Nurse Midwives and Citizens for Midwifery have spelled out the limitations, which include a failure to capture the intended place of birth and inaccurate reporting of some outcomes.

Also, the MANA Stats data captures three kinds of mortality outcomes:
Intrapartum = a baby that was alive at the onset of labor, but died prior to birth
Early neonatal = a baby that was born alive, but died during the first week of life
Late neonatal = a baby that was born alive, but died between 7 and 28 days of life

Vital Statistics data report only two: early and late neonatal deaths. You may have participated in discussions that attempt to make these comparisons. Many have confused the combined rate (intrapartum+early+late neonatal) with rates that include only one or two of these outcomes. When attempting to compare rates, we encourage you to ask whether the rate is for intrapartum, early, or late neonatal, and to ask for the source of their data.

How could the findings of this research be so different from findings that suggest home birth has a greater risk than hospital births?

Those studies primarily rely on Vital Statistics data. For a helpful fact sheet on how to assess the quality of articles based on medical records - the “gold standard” for research and the basis of MANA Stats - against those based on Vital Statistics, see this in-depth look at Citizens for Midwifery.

I’m looking for unbiased analyses of this article and home birth evidence to share with families, policy makers, and others.

Here’s a few we’ve found:
Evidence-Based Birth summary on Facebook. Rebecca Dekker is known for her thoughtful and unbiased approaches to the literature.
Judith Lothian’s review at Science and Sensibility.
ACNM’s preliminary review of the Chervenak/Grunebaum findings. This includes a comment on MANA Stats.
Citizens For Midwifery's summary of the findings.


The Daily Beast’s look at how “alarmist studies . . . from data pulled from vital-statistics data” are getting in the way of ensuring safety for mothers and babies, from the Daily Beast. 

Hutton EK, Reitsma AH, Kaufman K. (2009). Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: a retrospective cohort study. Birth 36(3):180-9.


The only comments that have not been published have been because the author did not leave a first and last name. Please check our community guidelines if you have any questions.

New Studies Confirm Safety of Home Birth With Midwives in the U.S.

Posted by Midwives Alliance on January 30th, 2014

by Geradine Simkins, CNM, MSN, Executive Director, Midwives Alliance of North America

In today’s peer-reviewed Journal of Midwifery & Women’s Health (JMWH), a landmark study** confirms that among low-risk women, planned home births result in low rates of interventions without an increase in adverse outcomes for mothers and babies.

This study, which examines nearly 17,000 courses of midwife-led care, is the largest analysis of planned home birth in the U.S. ever published.

The results of this study, and those of its companion article about the development of the MANA Stats registry, confirm the safety and overwhelmingly positive health benefits for low-risk mothers and babies who choose to birth at home with a midwife. At every step of the way, midwives are providing excellent care. This study enables families, providers and policymakers to have a transparent look at the risks and benefits of planned home birth as well as the health benefits of normal physiologic birth.

Of particular note is a cesarean rate of 5.2%, a remarkably low rate when compared to the U.S. national average of 31% for full-term pregnancies. When we consider the well-known health consequences of a cesarean -- not to mention the exponentially higher costs -- this study brings a fresh reminder of the benefits of midwife-led care outside of our overburdened hospital system.

Home birth mothers had much lower rates of interventions in labor. While some interventions are necessary for the safety and health of the mother or baby, many are overused, are lacking scientific evidence of benefit, and even carry their own risks. Cautious and judicious use of intervention results in healthier outcomes and easier recovery, and this is an area in which midwives excel. Women who planned a home birth had fewer episiotomies, pitocin for labor augmentation, and epidurals.

Most importantly, their babies were born healthy and safe. Ninety-seven percent of babies were carried to full-term, they weighed an average of eight pounds at birth, and nearly 98% were being breastfed at the six-week postpartum visit with their midwife. Only 1% of babies required transfer to the hospital after birth, most for non-urgent conditions. Babies born to low-risk mothers had no higher risk of death in labor or the first few weeks of life than those in comparable studies of similarly low-risk pregnancies. 

Importantly, this study also sheds light on factors that may increase risk. These findings are consistent with other research on pregnancy complications, but the numbers of these pregnancies were low in the MANA Stats dataset, making it impossible to make clear recommendations. This article from Citizens for Midwifery contains important information to share with families who are contemplating their birth options and weighing their individual risks and benefits.

This study is critically important at a time when many deeply-flawed and misleading studies about home birth have been receiving media attention. Previous studies have relied on birth certificate data, which only capture the final place of birth (regardless of where a woman intended to give birth). The MANA Stats dataset is based on the gold standard -- the medical record. As a result, this study provides a much-needed look at the outcomes of women who intended to give birth at home (regardless of whether they ultimately transferred to hospital care). The MANA Stats data reflects not only the outcomes of mothers and babies who birthed at home, but also includes those who transferred to the hospital during a planned home birth, resolving a common concern about home birth data.

This study adds to the large and growing body of research that has found that planned home birth with a midwife is not only safe for babies and mothers with low-risk pregnancies, but results in health and cost benefits that reach far beyond one pregnancy. We invite you to share this news in your communities, and join the conversation on our Facebook page, Twitter, and Pinterest

We are grateful to the ongoing support of the Foundation for the Advancement of Midwifery, which has been a major funder of the MANA Statistics Project.

** Note added 12:33 EST when the issue was published:

MANA Statistics Project Update

Posted by MANA Community Manager on January 24th, 2014

We’re incredibly excited to tell you that on January 30th, next Thursday, the much-anticipated outcomes from our MANA Stats 2004-2009 dataset will be publicly released.  

Two articles will be published in the upcoming Journal of Midwifery & Women’s Health: one describes the MANA Stats system and how it works, and the other describes the outcomes of planned home births with midwives between 2004 and 2009.  

The Midwives Alliance is proud of our Division of Research and the amazing MANA Stats system. This is the largest registry of planned home births in the U.S. and one of only two large datasets where normal physiologic birth can be studied, and we thank all of the contributor midwives who have made this possible. We also thank the members of the MANA Division of Research who created the system, continually improved it over the years, and have put quality assurance processes in place to make sure the data are sound.  And finally, we thank the researchers who shepherded these articles down the long road to publication.  We’re looking forward to the important conversations that these articles will generate!

For an in-depth look at what to expect from the articles, check out the post Understanding MANA Stats here.

Watch here for an update next Thursday, when we’ll share with you a summary of the findings, links to the research, and materials to share with women, families and others interested in learning more about home birth.

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Guest Post at Science & Sensibility on Home Birth Safety Research

Posted by MANA Community Manager on September 26th, 2013

Have you been following the debate about the recent press release by the authors of a new study, suggesting that babies born at home had a 10-fold higher death rate than babies born in the hospital?

We hope you'll check out today's Science and Sensibility post, where Wendy Gordon shares with Lamaze's readers "why the recent home birth research using 5 minute Apgar scores does not produce reliable data that consumers can use to make a decision on where they would like to give birth."

To read Wendy's earlier piece here on the MANA blog about the limitations of using birth certificate data for this kind of research, click here.

To read today's guest post, click here. We hope you'll join the discussion over at Science and Sensibility!

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