Guest Post: How to Choose a Safer Homebirth Midwife — A CNM’s Perspective

Please welcome today’s guest blogger, Deb O’Connell CNM, MS. Deb has a private homebirth and well-woman gynecology practice in Carrboro, NC. She has been a midwife for 11 years and has attended over 800 births. Deb has experience teaching at the university level while managing low and high risk pregnancies, community hospital midwifery, gynecological clinics and homebirth.

While writing this for 10Centimeters, I am reminded of the intense debate that surrounds midwifery care for homebirth here in our country. While this is not an exhaustive list by any means, it is meant to give families an idea of some of the important questions to ask while interviewing a midwife for their homebirth.

I am a Certified Nurse Midwife and I personally feel that CNMs with experience managing high and low risk pregnancies are best equipped to attend a laboring woman who plans a homebirth. Why? CNMs are the only credentialed midwife legal in all 50 states. CNMs have been trained and have worked within the hospital setting – exposing them to both high/low risk pregnancies. Most hospital trained CNMs in practice will “catch” anywhere between 50-150 babies a year depending on the size/volume of their practice. CNMs have a master’s level education. CNMs have the lowest neonatal mortality rate of any other provider documented by the Center for Disease Control. Most CNMs are registered nurses that have then decided to move forward with their midwifery education. RNs have a vast knowledge of assessment skills, clinical skills and documented excellence of care. RNs are also licensed in all 50 states and a consumer can go to their state board of nursing to view complaints/grievances filed against their licensed CNM/RN. Finally, CNMs are credentialed to provide full scope midwifery which includes well woman care beyond pregnancy as well as contraception management and menopausal management.

However women will choose whom they want to attend them at birth – regardless of the midwives’ education level, training, experience, credential (or lack thereof) or even licensure.

Let the buyer beware.

Homebirth is not safe for every woman and any midwife who tells you that is grossly misinformed. Birth is not to be trusted – it is to be RESPECTED.

Homebirth is not as safe for baby as being born in a hospital – the NCB community can state it is (and in the past I have stated it as well) – however research has proven differently and parents need to be made aware that if the midwife they choose does not know how to recognize / anticipate when normal is turning into abnormal during the labor or birth, the results can be disasterous for mother and baby. A mother’s birth experience does not trump the safety of her fetus/newborn .

Parents who choose to have their birth at home should be sure their midwife has the following:

  1. Has experience in managing both low and high risk pregnancies.
  2. Licensed and credentialed to practice in your state.
  3. Carries malpractice insurance.
  4. Has a professional relationship with an OB/GYN or Maternal Fetal Medicine team for collaboration, consultation, referral, transfer and transport if needed.
  5. Has a well- organized transport system for her clients and reviews this with you during the pregnancy.
  6. Is willing to share her risk- out criteria, her practice guidelines, her stats and her professional license numbers with you (This should actually be a printed disclosure statement that accompanies the informed consent she has you sign).
  7. Asks you about the distance your home is from the hospital that has an OB Unit – ideally you should live no further than 30 minutes from your nearest hospital.
  8. Has another midwife or RN that attends each and every birth with her and they are both current in their BCLS and NRP certifications and have also had experience managing both low and high risk pregnancies.
  9. Follows you through your pregnancy to six weeks after birth.

10 thoughts on “Guest Post: How to Choose a Safer Homebirth Midwife — A CNM’s Perspective

  1. “Homebirth is not safe for every woman and any midwife who tells you that is grossly misinformed. Birth is not to be trusted – it is to be RESPECTED.”

    BRAVA! This is exactly the attitude that we should have towards birth. I do indeed respect the process, but I will never again “trust” it.

  2. Thank you for this. This is really just excellent.

    Yes, homebirth will never be as safe as hospital birth. We should all get that. If we are going to have homebirths we should make them as safe as possible.

    I also really like the idea that having managed high-risk births (as CNMs do during their training) makes for a better homebirth provider. This is so true. When I think of poor Aquila Papperella…..in that case the homebirth midwife was poorly trained and failed to recognize the very clear signs of abruption….probably because she simply had never seen it. Can’t emphasize enough that you won’t know when normal has crossed into abnormal if you haven’t seen abnormal.

  3. I want to add- don’t just ask this stuff, make sure it’s true. Don’t take their word for it, talk to their back up docs, check their license and the any registry, Google them, talk to patients, both satisfied and unsatisfied. Too often a mom was told they had a back up hospital or doc, only to find out later that the doc has never talked to them, and the hospital is used only as a dumping ground for tragedies.

    I cannot support HB at all. I agree that Mom has a right to it, but I will not say it’s a good choice, especially in the US.

    • This is so true. Especially I would recommend not just talking with the backup but even scheduling an appointment or two, so you know each other. If the midwife balks at that idea, there’s your red flag.

  4. Thank you, a well written piece. And thank you for not following suit with previous posts here that only add to the hatred and fear by inflaming, criticizing and shaming.

  5. In my area (Wichita, KS), I have found that there is one CNM who practices in hospital, several CPMs and a few lay midwives who attend homebirths. Is it common for CNMs to attend homebirths? All that I have known had only hospital based practices. Is this more common in other areas?

  6. “Yes, homebirth will never be as safe as hospital birth. We should all get that. If we are going to have homebirths we should make them as safe as possible.”

    For high risk births, there is no arguing this point.

    For low risk births, I think there’s a huge question mark. From a strictly scientific point of view, it’s a difficult question to answer because there is an impossibility of a “control” birth. In other words, I cannot simultaneously give birth at home and in the hospital and compare outcomes. Babies die at home from improper care, but they *also* die in hospitals for the exact same reasons. It is not always easy to tell the effect of environment in a complex situation on outcome.

    Homebirth practices and homebirth statistics are rightly highly scrutinized because it’s out of the mainstream.

    However, comparable hospital practices and statistics are almost never given the same scrutiny. Thanks to the attitude above, it’s just a “given” if a baby dies or a women experiences infections or complications in a hospital, it was all in pursuit of “safety” and unavoidable. I think there are good reasons to avoid that assumption as it’s clear to me (anyway) that many hospital procedures are setup for the convenience of the staff, rather than what’s best for both mother and child.

    If homebirth is to come under a microscopic lens, then I believe that all hospital practices and stats should be subject to that same microscope. Let’s hear about infection from unnecessary C-sections in otherwise low risk patients, rates of possibly unnecessary inventions (leading to C-sections), and of course, actual death rates, maternal and infant and ask the question “Did giving birth in a hospital help create these situations?” (the natural question people ask during homebirth) and work endlessly to improve if the answer is “yes”.

    Especially on the point of C-sections, every surgeon worth anything will tell you that all surgery has risks. There is a reason why the medical community prefers women to give birth vaginally when possible. Is is by all measures safer except in high risk pregnancies. The US has one of the highest rates of C-section in the world – a good 20-25% of births. Working to bring that rate down would be a start at improving hospital birth safety.

    For the record, if you made it this far, I’m hoping for a 3rd successful homebirth, but if my CNM midwife says we need to go the hospital, I’m there in a New York Minute. I am profoundly grateful for modern medical technology, even if I recognize it’s shortcomings and prefer to avoid a hospital if it can be safely done. I also respect both birth and women who choose to give birth in a hospital. Good mothers are those who make a judgement for themselves about what is best for them and their family. The ultimate feminism is for a woman to feel that she can safely give birth in the place of her choosing without guilt from other people’s agendas and opinions (including mine.) 🙂

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