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Sep292009

Medscape Article - 9/29/09 - Slamming Homebirth -again-

Home Birth Gone Awry: Is This Typical?

Maria I. Rodriguez, MD

Case History

Often, it is an especially busy night in Labor and Delivery when a patient with a disastrous clinical circumstance presents to the service. One call night, during my internship year, proved to be no exception. Although the events that follow happened many years ago, the encounter is indelibly etched into my memory. Hazel and her partner were brought in by their midwife "for pain medication." (Identifying details of the patient and midwife have been changed to preserve confidentiality.) Hazel had broken her bag of water 7 days earlier but had not started to feel any contractions until 5 days ago. She had been evaluated by the midwife when her water broke. Once labor began, someone from the birth center remained with her. Three days later, 2 days prior to presentation to the hospital, she developed a fever, and the contractions became stronger.

The midwife was a direct-entry midwife who had apprenticed and then practiced at a popular birth center in town. [Note to reader: Discussion section that follows explains the different types of midwifery trainings.] She indicated to us that she was one of their most experienced midwives. The midwife and I had actually met the month before when another patient from her practice was brought in hemorrhaging. That patient had attempted a home birth after a prior cesarean section but instead wound up having a cesarean hysterectomy, 12 units of blood products, and a prolonged stay in the intensive care unit.)

The moment I heard we were expecting another transfer from this center, my adrenaline surged and we started preparing for the worst. The expected patient (namely, Hazel) had been seen at our hospital early in her pregnancy; while waiting for the transfer, I reviewed the available hospital records. She was of advanced maternal age and had undergone in vitro fertilization (IVF) to achieve this pregnancy. She had an early ultrasound that put her at 2 weeks overdue the night of the awaited transfer.

When Hazel arrived, the nurse took her vital signs while I listened to Hazel and the midwife relate the rest of the history, placed the fetal monitoring belts, and prepared to do a cervical exam. Hazel was incoherent from exhaustion and pain; most of the history came from the midwife, who explained that the patient's cervix had last been examined yesterday, it was a "dynamic 8," and the baby was in occiput posterior position. My pulse climbed even higher; this was sounding worse by the moment.

The patient had been asked to start pushing 9 hours ago because the midwife was concerned about fetal heart rate decelerations that she was auscultating intermittently with a fetoscope. I interrupted her elaborations on the various positions the patient had been pushing in to ask about the monitoring. I was nervous as I watched our nurses having a hard time getting the baby's heart rate on the monitor. The midwife explained they had been listening to heart tones using a fetoscope every hour for a minute and that the fetal heart rate had been around 100 to 120 beats per minute for the last 3 days. By report, the fetal heart rate had been 140 when labor had started. Hazel was herself tachycardic to the 120s with her fever of 39 degrees Celsius, and the nurse had quietly called my attention to purulent amniotic fluid she noted on the pad.

More people were called into the room and an intravenous line was placed, type and cross sent, antibiotics ordered, cervical examination performed, anesthesia and obstetrical attendings paged, and the ultrasound set up. The operating room was on stand-by. Hazel was working hard not to push with contractions, and her partner was engrossed in supporting her. I had barely been able to talk directly to her, other than to introduce myself. Her pain and fatigue made it difficult to establish any kind of rapport, and the midwife was standing between the 2 of us, repeating what I said to the patient. I tried to change positions so I could at least make eye contact with Hazel, and the midwife changed, as well. I knew she wanted to maintain a role in the process, but her desire to do so was obstructing my ability to connect with our patient, and I needed to do so immediately.

I finally just pushed past the midwife to sit down on the bed next to Hazel and told her what we had learned. She was only dilated to 4 cm. Her cervix was swollen, and she was bleeding briskly from a tear in her cervix. Her baby was in frank breech position, edematous, and molded in her pelvis. The umbilical cord had prolapsed past the breech and was palpable; there was no pulse. No cardiac activity could be seen on the monitor or the ultrasound. They had likely been listening to Hazel's heart rate for the last 3 days. "Hazel," I said as gently as possible, "I am so sorry, but your baby did not survive this labor." This was Hazel's first pregnancy.

(PAGE 2)

Discussion: Controversy of Home Births

Home birth is common throughout the developing world, where resources are scarce, and maternal and neonatal death rates are high. In certain developed countries, such as Great Britain, The Netherlands, and Switzerland, home births are a fairly well integrated option in their healthcare systems.[1] In the United States, however, home births are controversial, both medically and socially. For many women, choosing to give birth at home is an important personal and philosophical decision that reflects their unique values.[2,3] In addition, given that the United States is actively evaluating healthcare expenses and how best to curb them, the question of the legitimacy of home births may be raised from an economic perspective, as well. According to some sources, an uncomplicated vaginal birth in a US hospital costs, on average, 68% more than an uncomplicated vaginal home birth by a midwife.[1,4]

National census data show that approximately 1% of all births are home births, with rates highest in Oregon and Washington.[2] Research in this area is inherently challenging. A randomized controlled trial would not be ethical or feasible. Women who elect to have home births self select, and they tend to be white and better educated than average.[2,5,6] This introduces significant confounding and bias into the observational studies conducted to date. In addition, most states do not record place of birth on death certificates for neonates, which further limits the ability to compare home birth with hospital birth outcomes. California is an exception.[1]
Midwifery Training and Certification

The wide variation in midwifery training and local regulatory practices also makes rigorous evaluation of home birth in the United States difficult. Midwives may be trained as part of a certified nursing program (ie, nurse midwives) or as a direct-entry midwife through apprenticeship. Direct-entry midwives may come from any type of educational background and may or may not be certified through an organization such as the North American Registry of Midwives. The term "direct entry" refers to midwives who enter the profession of midwifery directly without earning a nursing degree. The North American Registry of Midwives was developed in 1987 as a way to certify and credential midwives involved in home births who are not nurse midwives.[1] Not all nonprofessional, direct-entry midwives in North America choose to participate in the Registry by becoming certified; those who do represent a subset of direct-entry midwives in North America. The certification process for nonnurse, direct-entry midwives is quite variable as well; there are 2 main processes -- certified professional midwives (CPMs) and certified midwives (CMs). CPMs are trained primarily through apprenticeship; CM training is much more extensive, involving 3 years of university-affiliated training, completing the same science requirements and certification exam as a nurse-midwife.[7]

As the American College of Obstetricians and Gynecologists (ACOG) explains, CPMs are the least qualified midwives because of their lack of training and lack of collaborative work with hospital-based providers.[7] There are options for use of midwives in a hospital setting, hospital-based birthing center, or properly accredited freestanding birthing center. ACOG warns against using midwives not certified by the American College of Nurse-Midwives or the American Midwifery Certification Board.
Evidence For and Against Home Births

Multiple observational studies conducted to date do not show an increased risk for adverse outcomes for home births compared with a low-risk hospital-based cohort.[1,2,8] Conversely, other studies, such as a retrospective analysis of all home births in Washington state, showed a statistically significant increased relative risk for [6]:

* Neonatal death;
* Depressed Apgar scores;
* Prolonged labor in nulliparous women; and
* Postpartum hemorrhage in nulliparous women.

Data for this trial came from the Washington State birth registry between 1989 and 1996. Uncomplicated singleton pregnancies of at least 35 weeks gestation delivered at home (N = 5854) or transferred to medical facilities after attempted home delivery (N = 279) were compared with hospital-born singletons (N = 10,593) during that time period. The same relationship of increased neonatal demise and depressed Apgar scores remained when the analysis was restricted to pregnancies of at least 37 weeks gestation. This study suggested that planned home births in Washington State during 1989-1996 had greater infant and maternal risks than did hospital births.

A large, well-designed North American prospective cohort study examined 5418 women who had planned home births in Canada and the United States.[1] Outcomes studied included:

* Medical intervention rates;
* Patient satisfaction; and
* Maternal and infant mortality rates.

The study population was women who sought the services of a midwife certified via the North American Registry in Canada or the United States for a birth with an expected delivery date in 2000. In the fall of 1999, the Registry provided the research team with an electronic database of 534 certified midwives whose credentials were current; and the North American Registry of Midwives made study participation a mandatory criterion for recertification.

Compared with low-risk women delivering in hospitals, the cohort had a markedly low rate of medical interventions (such as epidural, cesarean, or assisted delivery), no maternal deaths, and a comparable neonatal death rate -- namely, 2.0 deaths per 1000 intended home births and 1.7 deaths per 1000 low-risk intended home births after planned breeches and twins were excluded. Of note, 80 breech deliveries occurred at home with 2 intrapartum deaths. Cesarean section for breech presentation is the standard of care in the United States. No separate analysis of outcomes for breech infants was done. A comparison of neonatal death for this subcohort with hospital-delivered breech would be of interest.
Where Do Professional Organizations in America Stand on Home Births?

Regardless of the paucity of data, as well as their conflicts and limitations, and despite ACOG's stated opposition to the practice of home births,[9] a few women will continue to choose this mode of delivery. Of note, not all professional organizations in the United States agree; the American Public Health Association passed a resolution in 2001 to increase access to out-of-hospital maternity care services.[1,10] The American Medical Association (AMA), however, supports ACOG in its resolution that "the safest setting for labor, delivery, and the immediate postpartum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers."[11] ACOG and AMA share this position because "an apparently uncomplicated pregnancy or delivery can quickly become very complicated in the setting of maternal hemorrhage, shoulder dystocia, eclampsia, or other obstetric emergencies, necessitating the need for rigorous standards, appropriate oversight of obstetric providers, and the availability of emergency care, for the health of both the mother and the baby during a delivery."[11] ACOG explains that "while childbirth is a normal physiologic process that most women experience without problems, monitoring of both the woman and the fetus during labor and delivery in a hospital or accredited birthing center is essential because complications can arise with little or no warning even among women with low-risk pregnancies."[9] They go on to explain that the fact that home births in other developed countries, particularly in Europe, seem relatively safe does not pertain to the United States.[7] The Netherlands, for example, is geographically small and densely populated; therefore, everyone lives within 20 minutes of a hospital.
Guiding Our Patients: Why Do Women Choose Home Births?

Our responsibility as clinicians is to ensure that our patients are well informed and to advocate for the best possible outcome for both mother and child. Understanding the reasons why women choose to give birth at home is one opportunity we have to address their concerns, reassure them about the hospital birth experience, and help them make a well-informed decision.

In a qualitative study of US women exploring reasons they chose to deliver at home, common themes included[2]:

* Safety -- patients expressed the belief that home was the safest place for birth and would result in the best health outcomes;
* Fear of medical interventions;
* Previous negative hospital experience; and
* Desire for more control and comfort that they anticipated at home.

Narrative surrounding these fears is available from a descriptive study of women having home births in Sweden.[8] Women cited a desire to know the people caring for them and their newborn and feared a loss of control in the birth process if labor and delivery were to take place in the hospital. Understanding the reasons why some women choose home birth can also help facilitate change in hospital settings to better address patient concerns. ACOG cites women's desire for vaginal birth after cesarean or VBAC as another potential reason for seeking home birth delivery.[7,9] But attempted VBAC is all the more reason to deliver one's baby in the hospital; if the uterus ruptures during labor, this is an emergent and potentially fatal situation for both mother and baby.

The vast majority of physician encounters with home birth patients comes during a transfer for a problem or complications being experienced at home. In the prospective study by Johnson and colleagues[1] discussed earlier, 12.1% of intended home births were transferred for hospital delivery. The 3 most common reasons for intrapartum transfer were failure to progress in the first stage of pregnancy, pain relief, and maternal exhaustion. The time of transfer is a stressful and difficult situation for all parties involved. The woman does not want to be there and may be in medical distress. The midwife may be anxious or defensive. The accepting practitioner has the responsibility, both medically and legally, of caring for a patient whom they have never met before and who has now developed a potential complication.

Both common sense and research in this area suggest that facilitation of the transfer process is a critical way providers can improve outcomes for women.[3,12] Protocols mandating hospital transfer have been used with success in areas where midwifery is regulated. In The Netherlands, which has a high rate of home birth, midwives undergo 3 years of professional training and screen patients for high-risk conditions that merit referral to the hospital.[13] Central to their system's success in providing the best care for each individual's needs is close collaboration and communication between midwives and physicians.[13]

Clear communication is essential but is challenging due to the urgency, tension, and differing perspectives of the home birth proponents from the hospital team, particularly at the time of the transfer. Developing strategies to respectfully, efficiently, and safely care for the woman who desired to deliver her baby at home, in the hospital is critical. Dialogue is essential to developing relationships that will enable this. Improving relationships between the hospital and midwives that attend home births by inviting midwives to attend group debriefings following stressful deliveries or hospital educational conferences might facilitate future transfers.

(page 3)

Case Outcome

Hazel received an epidural for pain management and, with oxytocin administration, went on to have a vaginal delivery of a beautiful, lifeless boy. Her midwife had left shortly after the ultrasound, but the doula, her nurse, and I stayed with her through the night. The tragedy was heartbreaking.

Hazel haunted the halls of the hospital that summer. I saw her regularly, crying outside of the nursery, and when I stopped to talk with her, all she could say between sobs was, "Owen didn't make it." Our social worker and counselor worked with her, and I saw her in clinic, as well.

We all make choices in life, some of which have consequences we never anticipated. A minority of women in the United States will continue to choose home birth as a reflection of their personal values. Our responsibility as medical clinicians is to educate communities and to strive to provide care that balances respect for an individual's autonomy with the need for safe, efficient quality healthcare. Maintaining open, respectful dialogue with women and midwives that attend home births is essential in facilitating timely and safe hospital transfers. This includes providing balanced information for women interested in home birth and encouraging midwives to consult for help sooner rather than later.

Reader Comments (16)

Yikes, I don't even know where to start. Yikes.

September 29, 2009 | Unregistered CommenterStassja

Ug. While a couple worthy points were made I do wonder if the average lay person notices the obvious lack of statistics concerning the results of Hospital births! *sigh*. Very nice horror story bookending the two research articles.

September 30, 2009 | Unregistered Commentersarah vine

I appreciate this doctor's perspective. Doctors do not get to witness or be a part of successful homebirths. They only get to participate when something has gone wrong. It is also a fact that there are birthing professionals (doctors, midwives and nurses) who should never be allowed near a patient, due to either their lack of bedside manners, training. I've heard horror stories about hospital and homebirths and I agree that the only way to prevent birth trauma is to have well trained midwives attending most births while working in partnership with ob's.

Just for background, I've had a hospital birth attended by midwives (CNMs) (wonderful) , a homebirth with twins attended by 4 midwives (both CNMs and Direct Entry, also wonderful) and I'm planning on becoming an OB and working with midwives.

September 30, 2009 | Unregistered CommenterNatana Gill

I was just reading this (and shaking my head). Was going to email it to you, but I guess you saw it!

Towards the end, they grazed the issue of better communication between in hospital and at home practitioners, and I think this is a much bigger issue than the article made it out to be.

September 30, 2009 | Unregistered Commenterlpnmon

Interesting article. I wonder how the statistics compare between homebirths attended by CM/CNMs vs CPM/ direct entry midwives? I myself am attending a birthing center and want to have a waterbirth. My midwives are all CNMs. I feel very confident in their judgements because I'm a labor and delivery nurse and I just feel like the experience of working as an L/D nurse hones skills and makes for a more in depth knowledge base.

September 30, 2009 | Unregistered Commentercyan77

This part:

"Central to their system's success in providing the best care for each individual's needs is close collaboration and communication between midwives and physicians."

Really got me. Well, YEAH! I don't know what goes on everywhere, but I know in my community the midwives have worked so hard with so little gain to create that collaboration and communication. They have organized event after event to come together as professionals with the obstetricians only to have the token couple show up and the vast majority refuse to even bother. I suppose we may have to look more closely at the way it works in those countries. Is it enforced cooperation built into the system? Perhaps we have to institutionalize that collaboration in order for it to exist. But geez, it's hard to imagine that more protocol and bureaucracy is the answer.

September 30, 2009 | Unregistered CommenterTatiana

I guess the answer to the question posed by the MD in her title would be 'NO'! It is not typical. Just surveying her studies, you can see that. Like others, I've heard my fair share of horror stories about doctors making disastrous mistakes with horrific outcomes - in hospital settings at that. Here in North Carolina, one nearby hospital has a caesarean rate of about 25% and an epidural rate of about 98%. I'd be curious as to whether having a caesarean counted as an 'adverse' outcome in the Washington State retrospective. All that to say, if you have a predetermined outcome in mind, you can make the numbers say what you want.

September 30, 2009 | Unregistered Commenterandrew bruch

So, post dates, prolonged rupture of membranes, mec stained amniotic fluid. maternal fever, mistaking the maternal heartbeat for the fetal heartbeat, breech AND a prolapsed cord? (Not to mention the swollen cervix with the tear, advanced maternal age, IVF and the labor dystocia of 5 days). Isn't that laying it on a bit thick?

How many red flags do they think these midwives would ignore? s this a real story?


Do they really think

September 30, 2009 | Unregistered CommenterMomTFH

When hospitals start telling the truth about how many women and babies die in pregnancy, childbirth and postpartum(ad hat procedures were used beforehand) then I'll start listening to all the hyped up concern about "uneducated midwives"!

October 1, 2009 | Unregistered CommenterColleen G.

to answer maria's question, i'll say "no, this is not typical"
...."would you like to talk about some 'typical' things that happen in hospitals?"

October 1, 2009 | Unregistered Commentertori

What we have here, folks, is a CODE MEC! CODE MEC!

October 1, 2009 | Unregistered CommenterDou-la-la

This is why I really hope when I become a doctor (hopefully an OB!) I will be able to work with midwives and be a good advocate for them in the health system. I hope there are more people like myself entering the medical field as OB/GYNs who feel the same way so things can start to change!

October 4, 2009 | Unregistered CommenterLisa

But they never want to mention the horror hospital stories, it's like they think it never happens there. This seems like the result of having a bad midwife that may have missed signs of trouble for quite some time. Does it sound weird to anyone else that her cervix swelled form 8 to 4 and was torn and bleeding, but they had her deliver vaginally? I'm no expert, but that seems like something they'd operated for. And when can someone just wander the halls in a maternity ward? Seems fishy.

November 12, 2009 | Unregistered CommenterRenee

In labor for 5 days? Pushed for 9 hours? Well of course her fake baby died. AND they quoted the flawed Washington study. :facepalm:

November 15, 2009 | Unregistered CommenterJill

Wow. Yikes. No WONDER you and Tracey want states to certify midwives.....Very eye opening. very sad story.

July 13, 2010 | Unregistered CommenterStephanie Thiess

Like Jill and Renee, and Mom TFH, I have my doubts about the truth of this story.
It sounds as if the doctor put ALL the things he could think of which could go wrong into one story.
And as Renee said, the woman would not be allowed to wander the halls of the maternity unit! Hospitals are extremely on guard about babies being stolen!

Not that nothing can go wrong, not that there has never been a case when a homebirth midwife missed something, but just that this particular story is just too much.
Susan Peterson

August 14, 2010 | Unregistered CommenterSusan Peterson

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