In January of 2012, Marian MacDorman and her colleagues compiled a data brief for the United States Department of Health & Human Services, Center for Disease Control and Prevention, National Center for Health Statistics. This brief, entitled Home Births in the United States, 1990- 2009, noted large changes in birthing patterns have occurred in the US over the past century. In 1900, most births occurred at home. By 1940, 44% of all births were at home, and by 1969, this dropped to 1%, and this rate held steady throughout the 1980's.

The researchers state that homebirths have been increasing since the 1990's through 2009. In 2004, homebirths accounted for .56% (23,150 births) and increased by 29% to .72% (29,650 births) in 2009. The composite demographic of a woman desiring a homebirth is non-Hispanic Caucasian, over 35 years old, with previous children. The homebirth demographic has a lower risk profile: fewer preterm, low birthweight, multiple births and fewer, teenaged and unmarried mothers. 1 in 90 births to non-Hispanic Caucasian women were homebirths.

Generally, there were more homebirths in rural areas than non-rural areas and more in northwestern states than the southeastern states. Montana, Oregon and Vermont had the highest percentage of homebirths followed by Idaho, Pennsylvania, Washington and Wisconsin. Some of the states with lowest homebirth rates are Texas, North Carolina, Connecticut, District of Columbia, New Jersey and West Virginia.

62% of these home births were attended by midwives: 19% by certified nurse-midwives (CNM) and 43% by other midwives (direct-entry or certified professional midwives).

An Interview with Homebirth Midwife, Angelita Nixon, CNM

Angelita Nixon, CNM, is one of those home birth midwives in West Virginia. I had the pleasure of speaking with Angy about her work last week. Her career parallels the changing trends in US birth care. She began her career in 1998 as a certified nurse-midwife in a hospital. In 2003, she began doing home births exclusively.

Angy says: ' I left the medical arena feeling burned out. My caseload was getting heavier and heavier. A full medical practice were my golden handcuffs. It was impossible to give the personal care I wanted to give to women, I was always rushing. Worse than rushing, I felt like I was witnessing crimes against women. And not only was I witnessing crimes against women, I felt I was a party to this. I saw many crimes against women: mistreatment, being disrespected, taking away personal power, denying a woman the ability to walk, not literally confining a woman, but discouraging her. I saw medical rape often, I did not perform this myself, but saw it happen. A woman would say, 'I need to relax for a minute before you examine me' but she was ignored. I couldn't do that work anymore, I knew there was a better way. You know, at first in my career, I distanced myself from homebirth, I thought those people were extremists. But, I began to have women ask me to attend home births and I liked the people and the work.'

Describing her practice: 'I do about 3 births a month. I don't like missing births and I won't run the risk of being over-committed. I love it when people pop into my office, which is my home, as they need. I love being able to have long patient visits. Most importantly, I assess the person as a good fit for home birth. My patient population is low risk.'

She describes her work as modeled after the European midwifery: 'In Europe, the system is completely different, it's all midwife based. Doctors are the experts, the midwives are the generalists who deliver 80 -90 % of births. The midwives listen to the women, to what's going on in the family, assesses if she has had a traumatic experience in her life which might affect the birth. In this way, the midwives filter out the 10 -15% of the women who will need doctors. That is how I run my practice.'

'We have lost the generation where homebirth was the norm. Our maternity system would look different if its ultimate goal was health and not profit. The funny thing is, intensive midwifery care saves money, as it is less es pensive than traditional hospital care. The Washington Department of Health (2008) found that midwifery care would save Medicaid $500,000 biennially and if private insurance was included, $2.7 million. So sensitive midwifery care is less expensive and has better maternal-baby outcomes. Why do we wait? '

She uses the following comfort measures: hydrotherapy, freedom of movement, repositioning, massage, acupressure, efflureage, eating, drinking, hydrating, respectful treatment, continuous support, encouragement,, hot & cold therapies, and a lot of hands on comforting. Her homebirth statistics are impressive: because of careful pre-screening, she has had only one emergency transfer, her cesarean section rate is 7%, and she has done one episiotomy in 8 years.

Ms. Nixon says the system needs reform: 'We need more midwives, as they provide the best outcome. I want to collaborate I want to be a medical provider. I do know my limits, I do know when to send a patient to the next level. But I find the hospitals shun this type of collaboration. This is a barrier for the women in my care. I have already triaged the patient, but then the patient is not directly admitted, but must get triaged again in the ER. They say there is a shortage of nurses. I know there is not a nursing shortage, but a shortage of people, nurses, who will work in our hospital's conditions. Healthcare is in crisis, that's why there are pressures for reform. We need more midwives, but the system needs reform.'

Ms. Nixon became politically active in order to help change the political climate. She was on the board on the Midwives Alliance of North America (MANA). She is also on the board of the National Midwifery Organization and is President of her state's chapter. She contributes to MANA's data collection project. She asks that we spread the word that researchers are needed to interpret the prospective data that has been collected: over 25,000 courses of midwifery care is available for researchers to study. The data is from 2001 - 2011, every client enrolled in the study at beginning of pregnancy, not based on results, voluntary contribution , not restricted to any one type of credential (physicians, hospital based, majority of the data is from homebirth midwives). Qualified researchers can apply for access to the data, by application to the Division of Research of MANA, which is headed by Melissa Cheyney.

Angy ends our conversation with a smile: 'Homebirth is the real world. Birth is in its natural habitat. '

References:

Health Management Associates (2008). Midwifery licensure and discpiline program in Washington State:Ecxonomic Costs and Benefits

MacDorman, M.F., Mathews, M.S. & Declerq, E. (2012). US Department of Health & Human Services, Center for Disease Control and Prevention, National Center for Health Statistics. NCHS Data Brief # 84, Home births in the United States, 1990- 2009.

Angelita (Angy) Nixon, CNM, MSN

Having practiced full-scope midwifery in hospitals, clinics, and a freestanding birth center, Angy became a midwife business owner in 2003, provides mobile midwifery services and makes house calls. She participates in peer reviews and maintains a formal collaborative agreement with a physician, as well as collaborative relationships with multiple other physicians. In celebration of her first 7 years in private practice, Angy enjoyed a modified sabbatical, traveling and spending more time with her family. In June 2011, she attended her first ICM Congress in Durban, South Africa. Angy believes birth is a normal process and a healthy event.

Find her at her website.

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