According to statistics drawn from Oregon—where home birth is popular and birth and death certificates include information about the location of birth and who attended—the infant mortality rate for home births attended by a midwife was seven times that of hospital births, making home birth in America much more dangerous than it is in Canada and Europe.

The New York Times reports:

Many studies of American home birth show that planned home birth with a midwife has a perinatal death rate at least triple that of a comparable hospital birth. (The perinatal death rate refers to the death rate of babies in their last weeks in the womb and first week outside it.)

So, what’s causing the high infant mortality rate among home births in the United States? It’s clear from the number of safe home births performed in Canada, the Netherlands, as well as other European countries that home birth itself isn’t inherently dangerous. In fact, home birth in Canada is just as safe as hospital birth. Rather, the Times notes, it’s the unregulated practices surrounding home birth in the United States that drives the infant mortality rate up.

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The Times reports that there are two kinds of midwives practicing in the United States. The first group, certified nurse midwives (C.N.M.s) are highly skilled and educated:

“[C.N.M.s exceed] standards set by the International Confederation of Midwives. Their qualifications, similar to those of midwives in Canada, include a university degree in midwifery and extensive training in a hospital diagnosing and managing complications.”

In addition to the qualified and knowledgeable C.N.M.s, there’s another group, the far more common certified professional midwives [C.P.M.s], who often “fall short of international standards.” Unlike C.N.M.s, C.P.M.s receive far less training; their certification is often from correspondence classes, and C.P.M.s only oversee a handful of live births (learning from C.P.M.s) before practicing independently.

Since there is no central agency that oversees the certification of midwives, training and best practices are largely left to the individual midwife. That loose system can have catastrophic results, the Times reports:

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One 2010 study of midwives published in The Journal of Perinatology found that home births attended by nurse midwives had double the neonatal mortality rate of hospital births attended by nurse midwives, while home births attended by C.P.M.s and other midwives had nearly four times that rate.”

The practice of home birth is regulated from state to state, meaning that there is no federal oversight about who may oversee births; there are also no federal guidelines for choosing a home birth. In Canada, however, there’s much more oversight, as a result of qualified midwives and home births being fully integrated into the national health care system.

“[...] In Canada home birth is governed by strict eligibility requirements that exclude women at high risk of complications (no twins or breech births, for example). In contrast, the Midwives Alliance of North America, the organization that represents C.P.M.s, eschews such standards. Each C.P.M. is apparently charged with deciding for herself what is safe.

The organization’s statement of ethics in fact rejects “traditional codes of ethics that present a list of rules to be followed.” Instead, “a midwife must develop a moral compass to guide practice in diverse situations that arise from the uniqueness of pregnancy and birth as well as the relationship between midwives and birthing women,” it says. “This approach affirms the mystery and potential for transformation present in every experience.”

Canada’s national health also treats their highly trained midwives (all the equivalent of C.N.M.s) as integral health care providers. Unlike the United States, Canadian midwives have admitting privileges and are allowed to continue to care for their patient once admitted. Canada is invested in the expertise of midwives, in other words, and it’s no surprise that mortality rates in the country are significantly lower.

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So, how does the United States address the problem? The Times suggests that first, pregnant women should be educated about the differences between the different kinds of midwives available to them, making clear the difference in their qualifications. Secondly, the piece suggests abolishing the C.P.M. altogether in favor of clear training guidelines governed by professionally mandated best practices. It’s an interesting debate, and one that strikes as particularly American, in some respects, showing our aversion to the government playing a role in health and childbirth, in a debate that’s far from settled.

Image via Getty.