Safety of Homebirth

Is homebirth safe?

What are the risks of birthing at home?

How do I choose a midwife?

First thing first- Birth is normal.

And when everything goes normal...

Then obviously a woman's body can birth safely on its own in her home, on her deck, in the woods, in a car, beneath a table, behind a bed, or anywhere else Dr.Seuss would list with rhyme and reason. 

So, that would mean undisturbed birth is safest, and home would be the most undisturbed place.

...but it is also normal to need some help. 

And so choosing a skilled midwife is important. 

This is very important, actually. 

You will be trusting us to guide you in decisions, monitor your wellbeing, and respond to emergencies.

So, safety is dictated by :

  • Your risk factors
  • Your progression
  • Your midwife's ability to pick up problems
  • Your midwife's skills
  • Your access to tertiary care

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Don't skip these important things...

Don't shop for midwives  to find that one that accepts your risk factors when others have declined you. Don't skip routine screening tests. Do the glucose screening- it's super important to not grow babies in high blood sugar! Exercise and eat well, because unhealthy placentas are not safe. That also means you high-stress mommas need to get your chill on, because cortisol is equally harmful to growing babies and placentas. Dont' skip the anatomy ultrasound, because babies with problems deserve extra help. And if you measure small or large, or go past 41 weeks, get that extra monitoring . BTW, have that baby before 42 weeks- accept our tricks to get that labor rolling, because risks due legitimately increase after 41 weeks, ok? It's not a myth, but we can certainly discuss that reasonably instead of scaring you. No dear, we will not just throw one study at you, but give you a large data of information, which includes legitimate points from all sides. 

Isn't that kinda a lot? Oh, but there is so much more.

Don't you think it'd be nice to be guided through this? 

Please don't "freebirth," okay? Thanks.

Research proves homebirth is safe

These articles describe the safety:

ps. I'm not a big data person so I'm sure there are more... my colleague Priscilla Hall CNM, PhD knows them all and I should have her update this section!

What about those things that say homebirth isn't safe? 

  1. Data from the United States is really crummy because we don't have a good system for integrating, regulating or screening for homebirth candidates. I agree that we have a lot of unsafe homebirthing happening in the US, much in part because of this system of exclusion from the medical system and lack of standards. So, is our data worse than european countries, yes, legitimately. We definitely have some bad stats and cases in GA because we have no regulation of homebirth or midwifery.
  2. Many of the reports are using data collected from birth certificates, which may have been unplanned home deliveries, or planned home deliveries that ended at hospitals. 
  3. Not everything is predictable, and therefore an event could occur outside the hospital that would have been better managed inside a hospital. This is a legit point, but most people writing these things have no experience in attending normal births in normal settings, and definitely, the hospital brings healthcare workers to operate from places of fear because of all those reasons Ricki Lake talked about in Business of Being Born. Random, unpredictable events that didn't have warning signs (that gave you time to transfer from home to hospital) just don't happen- they are rare- and "safety" is not determined as "no risk" but "safe despite rare risk." 
  4. Safety needs to be weighed comparatively. Which is safer, at this point- Midwife care? Medical care? Home? Hospital? Vaginal? Cesarean? 

More- Article  More-Interpreting research

Want to know more about safety standards?

Protocols
Complications, care, transfer

Safety of a mother and baby is the most important thing.

Homebirth and Midwife Model of Care aims to accomplish all of these levels. 

We aim for the top!

But we keep grounded in the bottom needs- Mother and Baby must be safe.

Is a CNM safer for homebirth?

  • The CNM midwife chose the highest level of education offered, is licensed by the state and has to adhere to standards of practice set by her national certification body is going to naturally be inclined to be focused on safety as equal to or more important than client autonomy.  She is the caregiver for two persons, one of whom cannot make decisions. Therefore, her outcomes should be safe and better than midwives who do not adhere to guidelines about risks or are inadequately trained or equipped to deal with the common complications of birth.
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  • In the state of GA, the only licensed midwife is the CNM- Certified Nurse Midwife.  
  • The Certified Nurse Midwife is licensed as an Advanced Practice Registered Nurse (APRN), holding a Masters Degree in Nursing.  (link to state code)
    • Scope and Standards of Practice for the Certified Nurse-Midwife.
      (a)The certified nurse-midwife (CNM) provides independent management of women's health care, focusing particularly on pregnancy, childbirth, the postpartum period, care of the newborn, and the family planning and gynecological needs of women. The certified nurse-midwife practices within a health care system that provides for consultation, collaborative management, or referral as indicated by the health status of the client. The certified nurse-midwife must practice in accordance with the Board-approved American College of Nurse-Midwives' current Standards for the Practice of Nurse-Midwifery.
  • If a CNM is not practicing safely, she can be easily reported to the Board of Nursing, who regulates her practice. 
  • However, no other midwife can be reported for review , discipline or regulation in the state of GA because there is no Midwifery board. This has led to our state being very unregulated and a breeding ground for "birthkeepers" and people calling themselves "midwives" without any standards. It is easy to get online training these days. It is easy to hang out a shingle. It is easy to convince women that you'll be their support for the birth they want. It is not easy, however, to manage mother and baby complications outside the hospital without a skilled team, equipment and meds, and years of experience. 
  • Personally, it infuriates me to hear cases of babies not receiving the support they needed to be born safely, for a resuscitation and infant transfer to not be supported with CPAP or a skilled provider accompanying that baby on the EMS (because EMS is not equipped for newborn or birth complications... they are like 19yr olds on there... and they don't even have neonatal pulse ox machines). 
  • Birth complications happen. I wouldn't attend homebirth if I didn't feel safety is possible with vigilence and skills and smooth transfer support options. I can provide the smoothest process as a CNM because of my license, because of the respect I get when I command an EMS team to what is needed in the transfer, when I can report directly to the hospital team who is coming in and why. I cannot control all unforseen complications, but we really do, as CNMs, have the best route in GA to being integrated into care. 
  • We are also the only homebirth midwives who can order perinatal consults for you. I am appreciative to Emory MFM for the collaborative care they provide so there is no gap in evaluations and consults needed for  many of my homebirth clients. Although we do have to practice independently within our midwifery scope  as homebirth midwives, we are not isolated from the consultations needed on a peer and referral level.  Many of my clients enroll in hybrid care with the wonderful midwifery hospital services offered by OB2Me and have been very well supported for peaceful transitions of care when it was needed. 

  • Is a CPM also a safe midwife option for homebirth?

  • Yes, I  believe so. 
  • Their training is very specific to homebirth and very thorough, with years of apprenticing. They have limitations because GA won't establish a midwifery board and recognize their national certification with GA licensure. However, there is a very strong group of CPMs practicing in GA. The ones active in GMA (Georgia Midwifery Association)  keep to practice safe protocols, engage in continued skills training and lots of educational workshop. Peer review is important for the CPM certification. However, I know there are some CPMs who hesitate at transfer because of the lack of licensure. I know of one who has terrible outcomes (Cindy Morrow Johnson) that we don't want any of you to use. But in summary, yes I will refer clients I can't serve to CPMs and would use them myself.


  • Is a Community Midwife also a safe midwife option for homebirth?

  • Yes, I  believe they can be. 
  • Without  a certification or licensure though, it's just harder to know who has what training and what practice guidelines. I believe the community would hold the information about this midwife, and that years of apprenticeship, practice, her methods of collaboration and supporting during transfer may all be adequate to provide birth options that are safer than the care women may experience in hospitals sometimes, especially BIPOC women who are in a state with poor maternal and neonatal outcomes. They have tried to get a midwifery board on the state level to facilate their standards and licensure, but currently it will just be up to women to determine who fits her as a midwife. 
  • From my understanding, Community Midwife is the current respectable title for what used to be Grand Midwives or Traditional Midwives. It is not synonymous with the newer rogue midwife that is using Birthkeeper as her model. 

  • Is a Birthkeeper Midwife also a safe midwife option for homebirth?

  • No, I  believe the freedom to call yourself a midwife has gotten out of hand and you need to know we hear a lot of very sad stories about "midwives" who feel called to just support a mother's autonomy. 
  • The calling upon a midwife is very high. We are not doulas, supporting the experience of a mother. We are the caregivers who navigate a mother and baby through an intense emotional and physical experience of birthing. Nowhere in this work is the freedom to let down our guard and not take action when action is needed. 
  • Somehow "freebirth doulas" are becoming "midwives" through Indiebirth and whatever routes they use to feel empowered to call themselves a midwife. They would never be considered to be Midwives by the definition of the International Congress of Midwives. The world have moved forward in maternal safety in so many parts of the world, yet we are moving back in the US by dropping our standards by not having government regulation. 

  • It is legal in GA for anyone to call themselves a 'Midwife', FYI. This was enforced by a civil lawsuit not long ago.  Only 'Certified Nurse Midwife' is a regulated professional title. 
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What are a few questions you can ask midwives to understand if they are equipped to support you and your baby during birth complications?

  1. How would you support me if my water was broken for over 12 hours?
  2. How would you support me if I my labor was not progressing?
  3. How would you monitor my baby's wellbeing through my labor and when would you feel it was unsafe to stay at home for my baby's birth?
  4. How many cases of shoulder dystocia and infant resuscitation and support have you managed?
  5. I know that 10% of babies do need respiratory support, even at homebirth, so what equipment do you have if my baby is grunty and struggling? Can you give oxygen and CPAP?
  6. If I was bleeding heavy after birth, what does your management look like? 
  7. Would you support me or my baby during an EMS transfer to the hospital by riding with me and continuing providing care if we were not stable?
  8. Will you give my records and report to the hospital team? (tip- calling report, not going, is standard)
  9. Have you ever not had a birth assistant with you? Do you use students or is this a consistent support person you work with?
  10. What is your backup support from other midwives if you need extra help or are exhausted? 

Each birth is unique and managed per so many factors! Therefore, try to not to quiz midwives on numbers, parameters, other people's cases, etc. Try to see her confidence in her care, examples of how she's managed complicated cases, her collaboration and smooth transport process, and her birth team strengths. We also need to feel your trust as you consult with as, because we want to feel safe ourselves at your birth. We each set our parameters for what clients we take based on our comfort and safety. I like to say it's like online dating... some people look good but they're not a match! The first date (the consult call) should be comfortable and relaxed because you feel the trust and agreement on parameters. 


I 100% believe that myself, or CNMs in general, are not the right midwife for many, and that another midwife is a better fit. Some families are afraid CNMs will have too many rules. Maybe :-). Just remember that the homebirth CNMs have said "goodbye" to their ability to work at hospitals because of their drive to support undisturbed physiologic birth. We are very protective of our hard work to get our APRN license though and don't want to get disciplined by the state board while we are in this gray are of independent midwifery practice! There are so many factors we look at in trying to fill our schedule with birth clients... way more factors than you should take personally if you are declined. It's a whole life thing to be on call 24/7 and responsible for what we are responsible for at birth. Some midwives attend VBAC, breech or twins. I prefer not to. Some gray areas I am okay walking in with shared decision making. Some I am not because I know I'd be responsible for the baby in such and such situation and that's beyond the  support level I'm comfortable and experienced providing independently. Some gray areas I've walked through so many times (big babies, meconium when water breaks, prolonged retained placentas, surprise breech) that I'm comfortable staying at home with you if you want. In a positive midwife-client relationship we can dance and flow together through what comes, and I will consult my peer midwives when I am questioning how far we go and when to draw the line. I am clear in my articulation of the situation and recommended plan and facilitate all steps to the next plan. The art of midwifery that I love is the flowing from relaxed woo woo support to mama bear protection mode. My amazing team is key to this working well, and I charge higher prices because I want to keep my team compensated for being a part of this work, and because a safe birth team is not exhausted (ps.... also why I think doulas are super important). 


Welcome to the world of midwife-momma matchmaking. I just hope that you do find the right midwife fit and that you and your baby are safe and held in love for this amazing process of welcoming babies earthside. 


xoxo Midwife Crystal

Learn about how birthing at home can be not only a Safe, but the safest option.