Standards? Oregon homebirth midwives don’t need no stinking standards!

Standards stamp with binder in the office

You might think that Oregon homebirth midwives would be shocked into action by their hideous death rates.

You would be wrong.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Who cares about dead babies? Not Oregon homebirth midwives.[/pullquote]

In August 2010, Melissa Cheyney, then Director of Research for the Midwives Alliance of North America (MANA) and also the head of the Oregon Board of Direct Entry Midwifery, rejected a call by the state for access to the MANA homebirth death rates for Oregon. As a result, the State decided to collect the statistics themselves. They turned to Judith Rooks, a certified nurse midwife and midwifery researcher who was known to be a supporter of direct entry midwifery, to analyze the Oregon homebirth statistics for 2012.

In March 2013 presented the data using this chart:


Rooks regretfully acknowledged:

Note that the total mortality rate for births planned to be attended by direct-entry midwives is 6-8 times higher than the rate for births planned to be attended in hospitals. The data for hospitals does not exclude deaths caused by congenital abnormalities.

Many women have been told that OOH births are as safe or safer than births in hospitals …

Who cares about dead babies? Not Oregon homebirth midwives.

Since then, as far as I can determine, no similar analysis of homebirth safety has been undertaken and homebirth midwives have dragged their feat in implementing higher standards.

Finally, the Oregon Board of Direct Entry Midwifery has proposed new standards to enhance safety and Oregon homebirth midwives are incensed. They have directed their clients and supporters to bombard the Board with a form letter that summarizes their objections. Thus far 86 people have sent the form letter as originally written, and additional people have submitted it with modifications.

Here are the objections as stated in the letters:

The proposed rules that I do not agree with are:

  • Requiring midwife to terminate midwifery care when an indication to transfer presents
  • Requiring midwife to immediately transfer care to the hospita] when a transfer of care indication arises in labor.
  • Transferring care in labor for two blood pressures over 140/90
  • Transferring care in labor for inability to hear fetal heart tones
  • Transferring care in labor for outbreak of genital herpes
  • Transferring care in labor for thick meconium-stained amniotic fluid when birth is not imminent
  • Transferring care postpartum for retained placenta
  • Transferring care postpartum for a client with postpartum depression or mood disorders with suspicion or possible endangerment of self or others
  • Transferring care postpartum for high blood pressure
  • Transferring care for the newborn with high respirations
  • Transferring care for the newborn with temperature below 97 degrees
  • Having to consult in pregnancy for someone taking any medication
  • Having to consult in pregnancy for all VBAC clients
  • Having to consult in labor for someone who has one high blood pressure (140/90)
  • Having to consult in labor for a surprise breech
  • Having to consult in the postpartum period about any evident or suspected infection
  • Requirement that each time fetal heart tones are taken they be assessed continuously during and after contractions
  • Removing twin home births from LDMs scope of practice.

These higher standards are in no way unusual. Nearly all the proposed changes reflect compliance with standards in countries like the UK, Canada and the Netherlands, where homebirth is much more highly regulated and, in consequence, much safer than in Oregon.

Who cares about international standards? Not Oregon homebirth midwives.

Every single one of these situations is a risk factor for death of the baby, the mother or both. It is only reasonable that homebirth midwives should do everything in their power to prevent dead babies and dead mothers.

But there’s an additional risk; its a risk to the midwives themselves. It’s the risk of losing money. That risk to their wallets is apparently more important to Oregon homebirth midwives than the risk that babies or mothers might die preventable deaths.

Of course, there’s yet another possible reason for midwives to oppose these standards and it’s even more appalling than the financial conflict of interest. Homebirth midwives are so poorly educated and so poorly trained that many may not understand the significance of these risk factors. Indeed they might not recognize them as risk factors at all, euphemizing them as “variations of normal.”

Here’s a tip for them: if it substantially increases the risks of death, it’s not a variation of normal.

For example, the Oregon Health Evidence Review Commission informed the Board:

We have highlighted two key areas in which the proposed rules conflict with the updated evidence review related to recent evidence of infant harms…

• Vaginal Birth After Cesarean (VBAC) -up to 4 prior cesarean sections, or 3 without a previous successful vaginal delivery
• Breech presentation

… A 2014 study by Cheyney included in the 2015 Coverage Guidance found that breech position increased the intrapartum fetal death rate by 13.51/1000 v. 1.09/1000 vertex (p<0.01) – a 12-fold increase in death rate. This study included 16,924 planned home births with 222 breech presentations and 5 perinatal deaths…

VBAC updated evidence

The updated HERC evidence review found 2 new comparative U.S. studies that provide additional information about the harms to neonates in women with prior cesarean planning an out-of-hospital birth.

Who cares about scientific evidence? Not Oregon homebirth midwives.

Standards? Oregon homebirth midwives don’t need no stinking standards!