This information is taken from my practice ICD document.

Every choice that is made regarding our health care and that of our family should be made based on; an understanding of precisely what the condition is, what treatment alternatives are available, the risks of each alternative and the benefits of each alternative. There are many such questions that families face in the course of their lives, the answers to these questions will be different for each person and each circumstance.

The most important decision a woman makes about her pregnancy and birth experience is the decision regarding place of birth. This single decision will have more impact than any other decision the birthing family must make. It will effect; the quality and quantity of care she receives, the decision-making power she has, and the physical and emotional experience of pregnancy and birth for her and her infant.

Most major healthcare sources (American Public Health Association, World Health Organization, American Pediatric Society, British Medical Association, and the Centers For Disease Control) agrees that homebirth with a midwife is at least as safe as a hospital birth and may be a healthier option for birthing women and babies.

What follows are two sub-sections. The first section (a) contains research on the safety of homebirth. The second section (b) contains a list of risks, limitations and issues that must be considered before deciding on a homebirth.

So far, the largest and most complete study on the safety of CPMs and homebirth was conducted in 2000 by independent researchers in America & Canada, and reported on in medical journals world wide. It was shown once again that homebirth with a CPM is safe and healthy for normal mothers and babies. In addition many advantages for mothers and babies were demonstrated such as:

• Greater maternal comfort and satisfaction
• Fewer birth injuries
• The use of fewer unnecessary, painful & harmful interventions or procedures.
• Babies protected from dangerous exposure to institutional infection

A very thorough study on the comparison of hospital-birth outcomes to that of homebirth outcomes was done by Dr. Lewis Mehl and associates in 1976. In the study, 1046 homebirths were compared with 1046 hospital-births of equivalent populations in the United States. For each home-birth patient, a hospital-birth patient was matched for age, length of gestation, parity (number of pregnancies), risk factor score, education and socio-economic status, race, presentation of the baby and individual major risk factors. The homebirth population also had trained attendants and prenatal care.

The results of this study showed a three times greater likelihood of cesarean operation if a woman gave birth in a hospital instead of at home with the hospital standing by.

The hospital population revealed twenty times more use of forceps, twice as much use of oxytocin to accelerate or induce labor, greater incidence of episiotomy (while at the same time having more severe tears in need of major repair).

The hospital group showed six times more infant distress in labor, five times more cases of maternal high blood pressure, and three times greater incidence of postpartum hemorrhage.

There was four times more infection among the newborn; three times more babies that needed help to begin breathing.

While the hospital group had thirty cases of birth injuries, including skull fractures, facial nerve palsies, brachial nerve injuries and severe cephalohematomas, there were no such injuries at home.

The infant death rate of the study was low in both cases and essentially the same. There were no maternal deaths for either home or hospital.

The main differences were in the significant improvement of the mother's and baby's health if the couple planned a homebirth, and this was true despite the fact that the homebirth statistics of the study included those who began labor at home but ultimately needed to be transferred to the hospital. 25

"No study of planned home births of a screened population of women with a trained attendant taking proper precautions has shown excess risk." 14

"A six-year study done by the Texas Department of Health for the years 1983-1989 revealed that the infant mortality rate for non-nurse midwives attending homebirths was 1.9 per 1,000 compared with the doctors' rate of 5.7 per 1,000." 28

"In the U.S. the national infant mortality rate was 8.9 deaths per 1,000 live births [in 1991]. The worst state was Delaware at 11.8, with the District of Columbia even worse at 21.0. The best state was Vermont, with only 5.8. Vermont also has one of the highest rates of home-birth in the country as well as a larger portion of midwife-attended births than most states. . .

"The international standing of the U.S. [in terms of infant mortality rates] did not really begin to fall until the mid-1950s. This correlates perfectly with the founding of the American College of Obstetricians and Gynecologist (ACOG) in 1951. ACOG is a trade union representing the financial and professional interests of obstetricians which has sought to secure a monopoly in pregnancy and childbirth services. Prior to ACOG, the U.S. always ranked in 10th place or better. Since the mid-1950s the U.S. has consistently ranked below 12th place and hasn't been above 16th place since 1975. The relative standing of the U.S. continues to decline even to the present." 27

Note: "It is important to clarify that safety is measured by death (mortality) or illness (morbidity) during the labor and birth process and shortly thereafter. The United States has consistently high maternal and perinatal mortality and morbidity rates compared to other industrialized countries. In 2005 the United States was ranked forty-second by the Population Reference Bureau, which publishes the mortality and morbidity statistics. This means that there are forty-one other countries where it is safer for women to give birth than in the United States." [Barbara Harper, R.N. Gentle Birth Choices. Rochester, Vermont: Healing Arts Press, 1994. Page 52.]

What is most interesting about this fact is that most of the countries on the top of the list, where it is safer for women to give birth, have ONE thing in common… a comprehensive network of midwives providing ALL of the care for low-risk women, with obstetricians seeing ONLY high-risk women.

"At the present time, 43% of all births [in Holland] remain under midwives' care: 44% of these are delivered in the hospital and 56% at home (Tew and Damstra-Wijmenga 1991:56). Perinatal mortality for these Dutch midwife-assisted births is the lowest in the world, approximately 2/1000 (Kitzinger 1988/236)." 26

"There is no evidence to support the claim that the safest policy is for all women to give birth in the hospital...There is some evidence ...that morbidity is higher amongst mothers and babies delivered and cared for in institutional facilities in general and ... obstetric units in particular. -- Campbell and Macfarlane 1986

"Excellent outcomes with much lower intervention rates are achieved at home births. This may be because the overuse of interventions in hospital births introduces risks or the home environment promotes problem-free labors." 14

"Because unexpected problems arise even within a screened population, those planning home birth should have appropriate backup arrangements with an obstetrician and a hospital. Home birth attendants should have the skills to monitor the labor and the baby and the skills, equipment, and medication to manage or stabilize emergencies such as a baby who does not breathe spontaneously or a mother who hemorrhages after birth." 14

"Raw data, such as birth certificates, give an inaccurate picture of the risks of home birth because they include a large proportion of unplanned home births and births without a trained attendant, both situations carrying extremely high risk." 14

"Home birth becomes dangerous only when doctors and hospitals fail to provide backup services." 14

The quotations and citations referenced above are just a sample of the information available on the safety of homebirth. You must decide for yourself, of course, if homebirth is for you. If you would like to research the subject for yourself, there are additional resources included in the Recommended Reading Section of this document.

Based on countless studies and evidence from around the world, midwives and mothers have concluded that homebirth should not be restricted but should be available to parents and babies. In a normal, healthy woman and baby, a homebirth attended by a trained midwife is healthier than a hospital birth. Or, to quote David Stewart, PhD:

"Every study published shows midwives to be safer than doctors. Every study. No exceptions. If your physician disagrees with this, challenge him or her to produce the data that supports otherwise. They won't be able to do it. Such data does not and never did exist. In a nutshell, that is the strength of the case for midwifery. It is unanimous . . .[O]ver and over again, throughout history, the data shows that when doctors displace midwives, outcomes get worse." [David Stewart, PhD. (Editor), The Five Standards of Safe Childbearing. Marble Hill, MO: NAPSAC Reproductions, 1982, 1997.]

There are few risks inherent in birthing at home. The most often cited risk for birth at home is that it is a setting with "low technology". This is actually a benefit if mother and baby are healthy and normal, however it becomes a risk when certain conditions arise. Should any condition arise that introduces risk, the birth team will reevaluate the safest place & care provider for the mother & baby, and possibly transfer care and/or transport to the hospital. Below are a few situations that should be considered. Many are often described as "risky" but most can be dealt with safely at home by a midwife. A few pose serious risks to the mother or baby outside of an acute care facility.

A long labor with slow dilatation of the cervix. A long labor is tiring, but unless other problems develop, is not in itself dangerous. There are numerous precautions taken to ensure the mother does not become clinically exhausted. If the mother does become exhausted a transport may become necessary.

Prolapsed cord. This is a rare complication and the possibility of a prolapsed cord is continually evaluated in late prenatal care, midwives are trained to manage a prolapsed cord safely and a surprise prolapsed cord in labor would necessitate a transfer to the hospital.

Cephalopelvic disproportion. Cephalopelvic disproportion (CPD), where the baby's head is too big to pass through the mother's pelvis, is often misdiagnosed simply because labor is long, and a cesarean section is performed for that reason. When it is obvious that a baby cannot pass through the mother's pelvis she should go to the hospital. This is not a sudden emergency. It is a decision made after much discussion when it is clear that no progress is being made.

Shoulder dystocia. The maneuvers and technology used in a high-tech environment like the hospital are also available at home, although most midwives are trained in additional maneuvers that are used first and cause fewer traumas to the baby and mother.

Fetal Distress. Midwives are trained to monitor the baby in labor and carry the necessary equipment to do so. There are several natural techniques for correcting a slow fetal heart rate. If these fail, an emergency or a non-emergency transport to the hospital would become necessary.

A cord around the baby's neck. This is not an emergency. With the birth of the head, the cord is simply slipped over the baby's shoulder as the baby's body is born through the cord, or the cord is carefully clamped and cut to allow the birth of the body. A "nuchal cord" occurs in about 25% of all births and is easy for the midwife to handle at home. [Barbara Harper, R.N. Gentle Birth Choices. Rochester, Vermont: Healing Arts Press, 1994..]

Breathing difficulties at birth. Babies are most likely to have breathing difficulties when their mothers have had pain-killing drugs in labor. Midwives receive the same (and additional) training to resuscitate babies that hospital staff receive. Your midwife is trained in AAP/AHA Neonatal Resuscitation as well as Neonatal Resuscitation for Midwives. Oxygen and suction equipment is available if needed.

Postpartum Hemorrhage. Postpartum hemorrhage is most likely to occur when there has been obstetric intervention in birth or attempts have been made to pull the placenta out before it has completely separated from the uterine wall. If there is excessive bleeding, treatment at home is available.

Certain conditions are necessary to ensure that homebirth is a safe choice. These conditions require cooperation and participation from everyone involved in the birth team.

• Attendance by a trained healthcare professional, your midwife.
• Thorough prenatal care with screening and transfer criteria.
• Immediately available transport system.
• Hospital accessibility within 30 minutes of home.
• Parental responsibility for preparation and participation.