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Sep
01

“If I Were at Home,I Would Have Died.” The Trouble With Extrapolating Hospital Birth Events to Homebirth

Author // Erin Ellis, CPM, LM

A midwife in North Carolina was recently charged with practicing midwifery without a license because her state does not license Certified Professional Midwives (CPMs) and other direct-entry midwives. There was some local news coverage of the arrest and the ongoing efforts of North Carolina families to legalize CPMs. One of the local news stories included a mother’s birth story with a familiar perspective. “If I were at home,” she said, “I would have died.”

When I hear statements like this I cringe on the inside. Being a midwife, I hear it a lot. Women love to talk about their birth stories. In the park, at moms’ groups, among new friends, birth stories are being told. When I hear a story with the “I would have died at home” perspective, I nod in empathy and say mmm-hmm.

It’s a bit of a double bind. Midwives and doulas, you know what I’m talking about. In these moments, I strive to listen with deep gratitude, kindness and love. Every woman’s story is inherently valid and it is her story to tell, her journey. On the other hand, my inner advocate of truth and justice wants to illuminate the myths and realities of the hospital birth industry; very often the emergencies are caused by unnecessary interventions. The best I can do is to honor the mother’s feelings and experiences while side-stepping all the nuts and bolts of the “would have died” argument. That can get messy. But since it’s coming up again in the media and a larger audience of women is hearing such emotionally-charged statements about homebirth, it’s time to get messy.

Why do women in the U.S. die while giving birth? No one knows with certainty, because our reporting methods for maternal mortality are abysmal. We think, based on fractured U.S. statistics and older studies, that the primary causes of death to women during birth or shortly after are thromboembolism, preeclampsia/eclampsia, hemorrhage, infection and anesthesia deaths.


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Let’s look at hemorrhage, because it is the most likely of these unlikely complications to occur in low-risk women birthing at home.

Here are a few reasons why. Homebirth and hospital birth are supported by two divergent models of care. The homebirth model subscribes to the philosophy of Don’t fix what isn’t broken: Natural processes generally work best when they are not interfered with. The medical model subscribes to the (more profitable) philosophy of action: Pregnancy and birth are conditions that require fixing. All actions and interventions have consequences. Each and every one of the interventions in a typical hospital birth has the potential to cause complications, like hemorrhage. These interventions do not happen at home.

New research demonstrates that women whose labors are altered by prolonged exposure to Pitocin are more likely to hemorrhage after birth. This is because oxytocin, our body’s natural hormone that Pitocin was medically created to mimic, helps the uterus to contract after birth and minimize blood loss.


The United States ranks 41st in maternal mortality among nations. That means in 40 other countries, women are less likely to die from pregnancy and birth-related causes. The CDC also states that half of the reported deaths were preventable, and that death rates are underreported by almost a third.


Pitocin binds to oxytocin receptor sites, and over time the body becomes desensitized to it, preventing the uterus from contracting normally and leading to hemorrhage. Regrettably, we’ve gotten to a point now where most births in the U.S. are induced or augmented with the help of Pitocin. Homebirth midwives do not use Pitocin to start or speed up labor. In fact, using Pitocin for convenience without explicit medical cause has never been FDA-approved.

Immediate postpartum interventions can also lead to hemorrhage. The period just after birth is a unique and potent time biologically for the mother and baby. A natural flood of hormones connects mother and baby physically and emotionally, and helps the mother safely birth her placenta. The mother’s hormone levels will never be as high as in this hour after birth, and when this flow is disrupted, the mother is more likely to bleed excessively.

Interventions during this immediate postpartum time are routine in a hospital setting. They include failing to give the baby to the mother immediately, assessing the baby away from the mother, pulling on the umbilical cord, changing the mother’s position to suit the care provider, diverting the mother’s attention away from the baby, prematurely clamping and cutting the umbilical cord without good reason to do so, and more. Midwives honor the biological importance of the hormonal bubble after birth and do not intervene unless there is a medical risk that outweighs the risk of intervening.

When you hear someone say “I would have died if I’d had a homebirth,” or “My baby would have died,” please remember that these are very emotionally charged declarations. Yes, tragic outcomes do occur in any setting despite the best possible care. However, in many hospital births, it is unnecessary interventions that have caused the complications that women and babies suffer from.

In fact, the United States ranks 41st in maternal mortality among nations. That means in 40 other countries, women are less likely to die from pregnancy and birth-related causes. The CDC also states that half of the reported deaths are preventable, and that death rates are underreported by almost one third.

You cannot simply cut and paste all the circumstances surrounding a given hospital birth, superimpose them on a homebirth setting, and predict the same outcome—or vice versa. The models of care are too divergent. Women can die from birth complications in any setting, and in the United States our hospital death rate from birth-related causes is indefensibly high. We know that low-risk women are as safe, if not safer, birthing at home.

Authors Note: Due to the nature of the comments I received on this article’s original posting at erinmidwife.com, I would like to clarify this instance of the article by saying that I do NOT believe homebirths are categorically—in all instances—safer than a hospital births, nor am I saying that one is superior to the other. My intention here is to question the common premise that we can extrapolate outcomes from one setting to another.


Nonprofits for the Midwives Model of Care

American Association of Birth Centers. AABC was founded by Childbirth Connection and has has been the nation's most comprehensive resource on birth centers for more than 25 years. Birthcenters.org

Birthing the Future. The mission of Birthing the Future is to gather, synthesize, and disseminate the finest world wisdom about birthing and the care of mothers and babies from pre-conception to the first birthday. Birthingthefuture.org

Citizens for Midwifery. The goal of Citizens for Midwifery is to see that the Midwives Model of Care is available to all childbearing women and universally recognized as the best kind of care for pregnancy and birth. Citizens for Midwifery also endorses the Mother Friendly Childbirth Initiative. Cfmidwifery.org

Coalition for Improving Maternity Services. The Coalition for Improv-ing Maternity Services (CIMS) is a coalition of individuals and national organizations with concern for the care and well-being of mothers, babies and families. Our mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs. This evidence-based mother-, baby- and family-friendly model focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis, and treatment programs. Motherfriendly.org

Foundation for the Advancement of Midwifery. FAM is dedicated to increasing access to midwifery in North America through education, research and public policy. FAM receives its support from foundations and individuals who embrace the Midwives Model of Care. Foundationformidwifery.org

International Cesarean Awareness Network. The International Cesarean Awareness Network (ICAN) was formed more than 25 years ago in order to support women in their journey towards understanding the risks of cesarean section and with the purpose of helping them have healthy births and healthy lives after undergoing the surgery that changed them. Childbirth.org

Lamaze promotes a natural, healthy and safe approach to pregnancy, childbirth and early parenting. Knowing that pregnancy and childbirth can be demanding on a woman’s body and mind, Lamaze serves as a resource for information about what to expect and what choices are available during the childbearing years. Lamaze.org

Midwives and Mothers in Action. The MAMA campaign is a collaborative effort by the National Association of Certified Professional Midwives (NACPM), Midwives Alliance of North America (MANA), Citizens for Midwifery (CfM), International Center for Traditional Childbearing (ICTC), North American Registry of Midwives (NARM), and the Midwifery Education Accreditation Council (MEAC). This partnership is now at work to gain federal recognition of Certified Professional Midwives so that women and families will have increased access to quality, affordable maternity care in the settings of their choice. Mamacampaign.org

Midwives Alliance of North America. MANA’s goal is to unify and strengthen the profession of midwifery, thereby improving the quality of health care for women, babies and communities. MANA also welcomes student and midwifery advocate members as another valuable part of the organization. Mana.org

National Association of Certified Professional Midwives. NACPM is a professional association committed to significantly increasing women’s access to quality maternity care by supporting the work and practice of Certified Professional Midwives. Nacpm.org


The Midwives Model of Care™

The Midwives Model of Care is based on the fact that pregnancy and birth are normal life processes.

The Midwives Model of Care includes:

  • Monitoring the physical, psychological and social well-being of the mother throughout the childbearing cycle;

  • Providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support;

  • Minimizing technological interventions; and

  • Identifying and referring women who require obstetrical attention. The application of this woman-centered model of care has been proven to reduce the incidence of birth injury, trauma, and cesarean section.


Pathways Issue 31 CoverThis article appeared in Pathways to Family Wellness magazine, Issue #31.

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