Continuing from the blog piece entitled “Your Home Birth is Not a Feminist Statement” by a research scientist “named” Isis, she makes this comment:
“Even more interesting, up to 37% of home births result in emergency transport to a hospital.”
“Having delivered a lot of babies myself and having seen normal low-risk deliveries turn to disaster in a heartbeat, I would never have considered having my own babies at home, and I would personally be very frightened to attend a home birth, especially if there was a 37% chance of it ending with a nerve-wracking rush to the hospital. I would rather see babies born within easy reach of a C-section and other lifesaving interventions.”
To clarify what the Wax Study says:
“However, such investigations likely underestimate the risks associated with planned home birth, as up to 9% of parous (women with one previous delivery [presuming vaginal] and 37% of nulliparous (women who’ve never had a baby [presuming vaginal]) women intending home birth require intrapartum transfer to hospital.”
Homebirth midwives move women to the hospital two ways: via transfer and via transport. I’ve been very careful to make the distinction and if the writers above would have, it would make things clearer for their readers. The Wax Study doesn’t clarify which transfers are emergency and which are not, but they should have.
My definition of transfer is it’s a get-in-the-car-and-head-to-the-hospital type of trip, whereas a transport is a call-the-ambulance,-it’s-an-emergency (and not even necessarily a life and death emergency!) experience. Note the huge difference between the two? Life and death emergencies are rare even when transports might not be. I cannot imagine there being a 37% transport rate anywhere in the US.
To point out once again, if the Wax Study were exactly correct (and that’s highly debatable, but not for me to do so as I am not a statistician), “up to 9%” of women who’ve had a baby before and “(up to) 37%... require intrapartum transfer to hospital.” Looking at most bloggers and reporters around the Net, one would think the entirety of homebirthers in “first world” countries have a 37% emergency transport rate. Not true!
Even I, with a higher transfer/transport (combined) rate than many midwives (who report about a 10% transfer rate, with a 1% emergency transport rate) did not have “emergency transport(s) to a hospital” at 37%. I will acknowledge, however, that my combined transfers and transports fell in almost exact line with what the Wax Study; about 10% for multips and about 40% for primips. I can hear homebirth advocates gasping, but I feel vindicated by the statistics stated in the study/studies. Remember, some definitions of “intrapartum” include from one to four hours postpartum; the Wax Study does not state their definition of intrapartum, but seems to include several postpartum (post-placental delivery) indications for transfer/transport.
Before reviewing my own stats several months after closing my homebirth practice January 1 of this year, I felt that people’s shock at the 37% was unwarranted. I would never have guessed my own rates would be that high, but thought, instead of being horrified by the number, midwives should be applauded for seeing the changes from low-risk to higher/high-risk in labor and immediately postpartum. Isn’t that what a midwife is for? To assess the risk and move the woman to the hospital? Personally, I would love to believe there was a nearly 40% recognition of a woman’s need to be in the hospital. That way, the hospital is not receiving what they so frequently call “train wrecks,” but are seeing the women long before an absolute crisis occurs.
The 37% number is bandied about like it’s a demonstration that that percentage of women should have been risked out of a home in the first place, but I see it as an acknowledgement that 37% of all women who start out low-risk might be transported during labor or the birth. I do not believe just because a woman moves to the hospital she automatically shifts to high risk. It merely says she has moved out of the realm of a straightforward homebirth. Hospitals are places for far more than emergencies.
(Some) Reasons women might transfer (in a car, unless mom requests ambulance) from home to hospital during labor (the types of situations the Wax Study would include… from my memory, then checked with my Standards of Care):
- Continuous vomiting
- Fever or even just the mom’s temp increasing over time
- Prolonged rupture of membranes
- Abnormal bleeding
- Active HSV genital lesion
- Fear (of home/situation/gut instinct)
- Increasing blood pressure
- Prolonged labor
- Prolonged pushing
- Mal-position of the baby
- Thick meconium upon rupture of membranes
(Some) Reasons women might transport (in an emergency, via ambulance) from home to hospital (again, the types of transports the Wax Study would include):
(From the Medical Board of California’s Standards of Care -)
- “Prolapsed umbilical cord
- Uncontrolled hemorrhage
- Preeclampsia or eclampsia
- Severe abdominal pain inconsistent with normal labor
- Ominous fetal heart rate pattern or other manifestation of fetal distress
- Seizures or unconsciousness in mother
- Evidence of maternal shock
- Presentation not compatible with spontaneous vaginal delivery
- Any other condition or symptom which could threaten the life of the mother, fetus or neonate as assessed by the licensed midwife exercising ordinary skill or knowledge.”
- Retained placenta or placental fragments
Two questionable intrapartum reasons from the Standards’ list are “laceration requiring repair outside the scope of practice or practice policies of the individual midwife” and “neonate with unstable vital signs.” I say questionable because they could be considered postpartum reasons versus intrapartum reasons, depending on whose definition you’re using.
Can I tell you how many times I (and others) have transferred for something that resolved mid-trip and the thought, “We could have stayed home after all!”? My mantra for transferring/transporting to the hospital is: I’d rather be told “You didn’t need to come in,” than “Why the hell didn’t you come in sooner?” While moving into the hospital can create hardship for the families, most specifically, financially, I hope they would rather be there and not need to be than staying at home and needing to be in the hospital. It’s totally a judgment call… one that takes a great deal of experience to tell the difference. Even with experience, I know I erred on the side of caution. Too many midwives become complacent, thinking they know better than the law and don’t transfer or transport for reasons they would expect another midwife to transfer/transport for. Yet, when someone has a bad outcome, interestingly, rates of getting a mom or baby to the hospital go up. What made the difference? Complacency went down.
One of the most common questions a midwife is asked during an interview is how often she transports. Instead of looking for a midwife who transports only a very few women a year, women must take her years of experience into consideration. I’d even go so far as to say the newer the midwife, the higher her transport rate should be. Unless she is meticulously within the understood limitations in most midwifery communities: no breeches, twins, older moms, VBACs, etc., her rate will be higher than a more seasoned midwife. Sure, the limitations are controversial, but they are there for a reason; they increase a woman’s risk of moving out of the realm of normal, whether during pregnancy or the birth. With experience, the midwife might expand her competency in variations of such pregnancies. This, of course, begs the question: “Where will she get the experience if she’s not doing them?” The answer is: “By attending births with midwives who have more experience,” or even by being in the hospital where the safety net is standing by. On-the-job training is unacceptable for midwives.
And who wants to be the practice client for an inexperienced midwife, especially with a complicated pregnancy or with the upcoming birth? If you say, “Me,” I worry about your motivations for a homebirth. If you say, “Not me!” I applaud you. I know I wouldn’t let someone practice on my body or baby… without the supervision of a very experienced midwife.
Instead of being ashamed of higher rates of transfers and transports, I hope midwives will now be proud of their statistics because they can accurately demonstrate her appreciation for mid-labor, birth and postpartum movement from low-risk to higher-risk. Isn’t that what we hire her for in the first place?