Types of midwives in the United States

Practice in hospitals, homes or birth centers

Certified nurse-midwife: nurse who completes graduate-level midwifery education

Certified midwife: educated in the discipline of midwifery and completes a graduate level of midwifery education in a program accredited by the American Midwifery Certification Board

Practice only in homes or birth centers

Certified professional midwife: national licensure recognized in 27 states, including Oregon; may attend school accredited by the Midwifery Education Accreditation Council or prepare an educational portfolio documenting ability using apprenticeship and self-study; certification established by North American Registry of Midwives

Direct-entry midwife: licensure varies by state; educated through self-study, apprenticeship, midwifery school, college or university

Oregon women who plan to give birth outside of a hospital face double odds that their fetus or newborn will die, though the risk of death to a baby in any setting remains low, according to an Oregon Health & Science University study published today in the New England Journal of Medicine.

Looking at vital statistics data from 2012 and 2013, the OHSU team found 3.9 deaths per 1,000 deliveries for cases in which the mother intended to give birth at home or at an independent birth center, versus 1.8 deaths per 1,000 deliveries in which the mother planned to be at the hospital all along.

The researchers also found significantly greater odds of delivery via cesarean section among births planned in the hospital.

The subject of home birth is polarizing, said co-author Ellen Tilden, a certified nurse-midwife and assistant professor of nursing at OHSU, but the findings aren’t conclusive enough to point women away from it.

“People are going to come with very different eyes to the same numbers,” Tilden said.

Some women will find the increased odds of perinatal death unacceptable, she said, while others will consider that the rate is still extremely small: 0.04 percent. (The perinatal death rate is a category that includes both fetuses and newborns in the first 28 days of life.)

Oregon has one of the highest rates in the nation of women giving birth at home or in independent birth centers. In 2012, the home-birth rate in Oregon was 2.4 percent, the highest of any state, and another 1.6 percent of women delivered at birth centers, according to the study.

Judith Rooks, a retired nurse-midwife and epidemiologist who lives in Portland, was one of the first in Oregon to analyze the new vital-statistics data. She used it to lobby for midwifery licensing requirements, which took effect in 2015. Before this year, Oregon was one of two states that didn’t require midwives to be licensed.

Rooks said she is in favor of home birth, but she’s concerned because the United States lacks uniform education requirements for midwives. For women considering delivering outside of a hospital, she said, “You need to be with a well-educated midwife. And you need to be close enough to the hospital.”

Jesica Dolin, a midwife and spokeswoman for the Oregon Midwifery Council, declined to comment.

The OHSU team, as well as authors of an editorial appearing in the same edition of the prestigious medical journal, didn’t fixate on midwives’ education but said the study points to the need for better maternity care across settings.

Countries like the Netherlands and United Kingdom, where home birth is common and birth outcomes are better than in the United States, have high standards for midwives’ education, guidelines for which women are suitable for home birth and systems that encourage timely transfer to a hospital, Tilden said.

“I think it highlights opportunities to improve care both in and out of the hospital,” Tilden said of the study.

In addition to leading the country in out-of-hospital births, Oregon was the first to begin keeping vital statistics on a woman’s intended place of birth along with the actual birth setting. Starting in 2012, women were asked, “Did you go into labor planning to deliver at home or at a freestanding birth center?”

The new data allowed researchers to disentangle cases in which a woman was transferred to a hospital during labor. They found the reclassification affected fetal and neonatal death rates previously attributed to hospitals.

The overall number of births in Oregon is low, which means the study lacked the statistical power to generalize the results to other states, the authors noted. It was also impossible for them to analyze the results according to the type of health care provider women used.

Of the 3,203 completed home births, about 57 percent were assisted by licensed direct-entry midwives, who must complete an apprenticeship but may or may not have a formal midwifery education. Women also gave birth outside hospitals with naturopathic doctors, certified nurse-midwives and unlicensed midwives.

The study excluded high-risk cases such as multiple and breech babies in all settings for a total sample of 79,272 deliveries over two years. The vast majority of those — 95.2 percent — were planned and completed in a hospital.

Four percent of women chose and completed an out-of-hospital birth, while 0.8 percent planned that but ended up delivering at a hospital.

The OHSU team also looked at the rate of C-section deliveries, which was just under 25 percent for births planned in a hospital and 5.3 percent for planned out-of-hospital births.

Tilden noted that C-section rates across the United States have risen over the past two decades without a corresponding improvement to mothers’ and babies’ health. In addition to the short-term risk of surgical infection, women who have C-sections face the risk in future pregnancies of uterine rupture or placenta problems and hemorrhaging.

Women choosing home and birth-center births were mostly white, educated beyond high school and covered by private insurance or paying out of pocket. A larger portion of those women were also age 35 or older.

Rooks said those women might be choosing home birth because they know that a C-section is more likely if they start out labor in a hospital. “They don’t want to go into a hospital that has a 50 percent cesarean rate. They also don’t want to have dead babies and damaged babies.”

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