Why home birth is different in the United States compared to Canada

newborn baby
CC BY 2.0 Alper Tecer

The lack of standardized training and credentials among American midwives has created a patchwork system. It's time for the U.S. to catch up to Canada in this area of healthcare.

When I tell people that all three of my children were born outside a hospital – two at home, one in a Toronto midwifery clinic – reactions are mixed. Most people here in Ontario are supportive, since home births are becoming increasingly common. Americans, on the other hand, are usually surprised and often horrified. At first this reaction confused me, but since learning more about the difference between midwifery care in the United States and Canada, I now get why most Americans would object to the idea of home births. Even I would not have felt comfortable with a home birth in the United States.

The mortality rate for infants born at home in Oregon is seven times higher than in hospital. This is the best data for the U.S., according to obstetrician Amy Tuteur, since Oregon started requiring in 2012 that birth certificates state where a birth occurred and who attended it. By contrast, several years of studies have shown that home births in Canada are no more dangerous than hospital births for low-risk women.

Tuteur’s opinion piece for the New York Times titled “Why Is American Home Birth So Dangerous?” will no doubt generate serious controversy. Tuteur, who is also known as "The Skeptical OB," blames the problem on the two kinds of midwives allowed to operate within the United States, which is misleading and dangerous for women and newborns who assume the profession is more highly trained and regulated, like it is in Canada.

First there are Certified Nurse Midwives (CNMs), whom Tuteur describes as “perhaps the best-educated, best-trained midwives in the world, exceeding 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.”

Then there are Certified Professional Midwives (C.P.M.s), who do not meet international standards and are legal in only 28 states, yet attend the majority of home births in the U.S. They are often taught through correspondence courses or by shadowing other C.P.M.s. They created their own credentials, although these were updated in 2012 to require, at the very least, a high school diploma.

Tuteur has nothing but scorn for C.P.M.s, whom she believes can endanger the lives of women and newborns through their lack of training and the way in which they portray themselves as capable when they really do not possess the knowledge they should, by law, possess. Although they defend themselves as “experts in normal birth,” Tuteur points out that:

“[it] makes as much sense as a meteorologist being an expert in sunny weather. Anyone from a taxi driver to a 12-year-old sibling can handle (and has handled) an uncomplicated birth. The only reason to have a trained attendant is to prevent, diagnose and manage complications, the very things that C.P.M.s never have to learn to do.”

American C.P.M.s are also unable to transfer patients smoothly to hospitals, which is something that Canadian midwives do on a regular basis – some 25 percent of home births (and 45 percent of first-time mothers, says Tuteur) are transferred to hospital in Canada, compared to 10 percent of C.P.M.-assisted births. Canadian midwives are so well-integrated into the hospital and obstetric system that they continue caring for patients even when location has changed, whereas C.P.M.s are often reluctant to transfer because they have to hand over control to other caregivers and can face criminal charges for operating illegally.

The Cut cites Tuteur's new book, Push Back: Guilt in the Age of Natural Parenting: "Even the Midwives Alliance of North America self-report that 'planned home birth has a death rate 450 times higher than comparable risk hospital birth'."

One Canadian midwife I spoke to last year described the home birth situation in the U.S. as a “patchwork” of regulations with “very little physical autonomy for women.”

It will be difficult for the United States to regulate midwifery, but it needs to happen. Perhaps at the same time hospitals can partially de-medicalize their approach to childbirth – or perhaps focus on personalizing or humanizing the experience – in order to make women feel a bit more heard and understood. While Tuteur points out out that neonatal mortality has decreased 90 percent and maternal mortality 99 percent over the past century of improved medical care, that still doesn’t mean that the hospitals have everything figured out; otherwise all of these women would not be seeking alternatives.

A better balance needs to be struck between the contrasting approaches of hospital versus home birth, and looking to Canada as an example would be a good first step.

Why home birth is different in the United States compared to Canada
The lack of standardized training and credentials among American midwives has created a patchwork system. It's time for the U.S. to catch up to Canada in this area of healthcare.

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