In general, doctors aren’t thrilled with the idea of home birth. And while less than 1% of U.S. babies are ushered into the world at home, the American Academy of Pediatrics (AAP) decided to collaborate on guidelines they say should govern home births, which are attended mostly by midwives.
Many of the recommendations, published in the academy’s journal, Pediatrics, are fairly straightforward: at least one person at the birth should be responsible for tending to the newborn infant; that person should also be trained in infant CPR. Medical equipment should be tested before the delivery. A phone line should be available; while you’re at it, check the weather forecast too, in case complications arise and a trip to the hospital is necessary. In case of emergency, have a plan to transfer the laboring mom to a hospital. And do all the stuff that nurses do in the hospital to brand-new babies: monitor their temperature and heart rates, keep them warm and cozy, administer vitamin K and heel-prick newborn screening tests that are sent to outside labs for processing, among other things. “No matter where a baby is born, they deserve the same standard of care,” says Dr. Kristi Watterberg, a neonatologist and professor of pediatrics at the University of New Mexico who is the lead author of the AAP’s home birth guidelines.
More controversial is the academy’s advice that pediatricians endorse only midwives who are trained and cleared by the American Midwifery Certification Board. Midwives accredited by this board typically attend deliveries at hospitals and birthing centers. That position has upset certified professional midwives, who deliver the majority of babies born at home in this country but are accredited by a different body — the North American Registry of Midwives (NARM).
“The assumption is that one type of midwife is better than the other,” says Melissa Cheyney, an associate professor of medical anthropology at Oregon State University and a practicing certified professional midwife who oversees the research division for the Midwives Alliance of North America, or MANA, which represents certified professional midwives.
That might be because the category of certified professional midwives has existed for just 20 years. Yet Cheyney notes that both the midwifery certification board endorsed by the AAP and the registry of midwives are accredited by the same body, the National Commission for Certifying Agencies. The AAP checklist for home birth is consistent with the standard of care upheld by the registry, says Cheyney.
Watterberg says that the AAP is simply echoing a similar recommendation from the American College of Obstetricians and Gynecologists regarding which midwives should attend home births. “It’s inappropriate for us as pediatricians to get in the middle of that,” she says. “We don’t hold ourselves out to be experts on midwifery.”
But even experts can be confused by the various categories of midwives. As I wrote in a previous story about an increase in the use of midwives in the U.S.:
… some of the obstacles to expectant moms embracing midwives may stem from the confusion around their qualifications. An obstetrician is an obstetrician, but there are three categories of midwives: certified nurse midwives (CNM) are registered nurses who’ve studied an additional two years to get a degree in midwifery. Certified midwives are a small group who undergo training but come to midwifery from a background other than nursing. Certified professional midwives follow a different track altogether and attend mostly home births.
Is one training system better than the other? The AAP guidelines cite data that show home births are slightly less safe, with an increased risk of infant death of one per 1,000 babies born. But certified professional midwives take issue with those numbers, citing other studies that show home birth is just as safe as hospital birth. And Watterberg points out that in British Columbia, where midwives routinely offer either home or hospital delivery, studies have revealed no difference in infant mortality. “Neonatal death is a rare event regardless of whether babies are born at home or in a hospital,” says Watterberg.
For now, Watterberg says that certified professional midwives should focus on defining their standards more clearly, which could help to quantify their success and complication rates. “I understand they are working very hard to do that,” she says. “It’s our best shot for the best outcomes for babies and moms.”
And that, of course, is the goal for anyone delivering babies.