What’s in it for the midwife?

You’re thinking about homebirth and you are interviewing the midwife. Or perhaps you’ve already decide on a homebirth, but you have developed a complication and you need to decided whether to deliver in a hospital instead. Maybe you’ve decided on a homebirth, but you haven’t decided whether to have the tests routinely included in MD supervised prenatal care.

You’ve asked the midwife for her opinion, but before you decided to accept it, you need to ask yourself a critical question: What’s in it for the midwife?

For better or for worse, most obstetricians have no vested interest in how you end up with a healthy baby. Most obstetricians make no extra money for a C-section, and they certainly don’t profit from fetal monitoring, routine prenatal tests, ultrasound, induction, just about any intervention you can think of. Homebirth and NCB advocates routinely deride “defensive medicine” but even that it about giving you a healthy baby. They order tests and recommend interventions because they think it will increase the chances of an excellent outcome, not because it will line their pockets.

The situation is entirely different for a homebirth midwife. She stands to make money if she can convince you that you need nothing more than what she knows how to provide. She stands to lose money if she can’t provide what you need. Therefore, it is important to understand that an inherent financial conflict of interest exists for a homebirth midwife at every juncture requiring a decision.

Are you a good candidate for homebirth?

For homebirth midwives, this is the threshold financial issue. Unless they can convince you that it is safe for you to give birth at home, they can’t make any money from you. Therefore, they have a tremendous financial incentive to minimize any and all risk factors. Previous C-section? Previous shoulder dystocia? High risk condition in pregnancy? In any of these cases, you are not a good candidate for homebirth. If your homebirth midwife tells you that you are, ask yourself: what’s in it for her?

Following her financial interest will lead her to tell you that you are a good candidate even when you are not. A midwife who is not distracted by her own financial concerns will tell you honestly that you are at greater risk of a poor outcome. She may offer to attend you anyway, to facilitate whatever choice you make, but if she denies you are at increased risk, you should be asking yourself whether she is worried about her wallet instead of being appropriately concerned about you.

Should you be tested for gestational diabetes?

This one is a no brainer. The primary treatment for gestational diabetes is diet. Any pregnant woman contemplating homebirth is almost certainly very careful about her diet, eating only what she believes is best for her baby. Learning that she needs to cut down on sugar to keep her baby safe is valuable information and it is easy to act on it.

There may be a downside for a homebirth midwife, though. She may not have access to the equipment needed for the screening test or the follow up test if the screening test shows a problem. Or a diagnosis of moderate to severe gestational diabetes might risk you out of a homebirth, depriving her of income. There’s a lot of potential downside to a homebirth midwife in following the recommendation to screen for gestational diabetes. Therefore, if your midwife tells you it’s okay to skip the test, consider that it benefits her, but it does not benefit you and it certainly does not benefit your baby who may be exposed to excess blood sugar for weeks or even months.

You are measuring unusually large or small for dates. Should you have an ultrasound?

If the issue turns out to be as simple as an error in your due date, both you and the midwife will benefit from having the information. However, if there is a problem like intra-uterine growth retardation or if it turns out you are carrying twins, you are no longer a good candidate for homebirth. If your midwife tells you that it’s not an issue if you are consistently measuring smaller or larger than dates, she is thinking of herself, not of you. If you have the information an ultrasound will provide, you might decide to change your provider. That’s a financial loss for her.

Should you be tested for group B strep?

Group B strep is the leading infectious threat to newborn babies. Since routine screening and IV antibiotics in labor for women who are found to be GBS has been instituted, the neonatal death rate from GBS has dropped 70%.

For most homebirth midwives, though, GBS testing is all downside. They may not have access to the screening test. They may not have access to IV antibiotics. They may not know how to put in an IV. It is ever so much more covenient for a homebirth midwife to ignore GBS than to acknowledge the danger. If a homebirth midwife recommends not testing for GBS or if she recommends something other than IV antiobitics for treatment, she is making a decision that benefits her and puts your baby at risk. It is not in her interest to be honest about GBS, so you have to think long and hard about whether to take her recommendation to avoid screening and/or conventional treatment.

You are 41 weeks. Should you have a non-stress test and a biophysical profile (ultrasound)?

Does your midwife have easy access to that technology? If not, and she tells you that you don’t need to check the well being of your postdates baby, you need to ask yourself why. Is it truly because the tests are unnecessary, or is it because she can’t arrange them for you or she doesn’t want to have you risked out of her care if the NST or biophysical profile are abnormal?

You are 42 weeks? Should you have an induction?

Whether you decide to have an induction or not, you should know that going beyond 42 weeks doubles your baby’s risk of death (and that’s in the hospital; it’s almost certainly much higher at home). Your midwife cannot perform an induction and thereby loses control of your care. She has financial and personal benefits to denying the increased risk of postdates and denying the benefit of induction. If she tells you to avoid induction for postdates, you need to ask yourself whether she’s doing so because of what’s in it for her, or because it is truly the best course for you.

Should you transfer in labor?

There’s thick meconium. Or there’s an unusual amount of bleeding. Of labor is going far more slowly than normal. Should you transfer to the hospital? You’ve probably paid the midwife by now, so there’s no financial incentive for her but there is an even more powerful motivation at work. If you transfer to the hospital, she may end up in legal trouble. It is far better for her to convince you to stay home than to let you transfer to a hospital. When she begs you to trust birth, ask yourself: is that for your benefit and the safey of your baby or is it to protect herself?

The financial incentives for homebirth midwives are almost always in opposition to what is safest for you and your baby. For a homebirth midwife, ignorance is bliss (and cash). It is better for her not to know about complications, better for her not to test for high risk conditions, better for her not to treat problems that she doesn’t have the equipment or experience to treat and better for her not to transfer to the hospital. But all too often, it is not beneficial or even safe for you and your baby.

Homebirth midwives want to convince you that you never need more than what they can provide. They have a vested interest in denying the validity of tests they cannot order, monitoring they cannot offer, and treatments they cannot access. The next time your homebirth midwife recommends ignoring conventional medical practice, ask yourself: what’s in it for her?