How To Choose A Homebirth Midwife

Parenting is all about choices and challenges, and difficult questions begin to pop up as soon as we discover we are pregnant. Choosing a healthcare provider to watch over the pregnancy is one of the most important things a pregnant woman does.

Expectant moms who are enjoying a healthy, low-risk pregnancy may decide to see a homebirth midwife for their prenatal care needs, and they may later decide to give birth with that same midwife by their side. How do you pick the right midwife, though?

Why choose homebirth?

Only one percent of moms chooses to give birth at home in the US at the moment, though giving birth in the comfort of your own home is becoming more popular in recent years. Hospitals have never been as well equipped, and science has never been as advanced as it is now. Why would anyone still choose homebirth?

That one percent may be statistically insignificant, but it is still a fairly large group of women. In short, there are many, many different reasons to choose to give birth at home, and they are as varied as the women who make this choice. The most common reasons to opt for a homebirth include: 

• Personal preference

• Seeing homebirth as the default choice for a healthy, normal pregnancy

• Desiring a family-centered labor and birth

• Fear of hospitals or doctors

• Seeing labor and birth as normal, rather than pathological and inherently dangerous

• Being refused a Vaginal Birth After Cesarean at local hospitals and hoping to avoid a c-section this time around

• Hoping to avoid medical interventions such as labor induction and epidural anesthesia

• A natural parenting/living philosophy

• For financial or insurance reasons

• A history of fast labors; thinking that you may not be able to make it to the hospital in time

Is homebirth safe? A meta-analysis of 11 studies, the Wax meta-analysis shook the homebirth "community" when it showed that homebirth was associated with a lower rate of maternal complications, but that it tripled neonatal mortality. Who wouldn't be scared by that? Well, the Wax meta-analysis has its problems, as do most homebirth studies. The Wax meta-analysis should have compared low risk homebirths to low risk hospital births, and the circumstances should have been similar. Instead, the study included homebirth studies from the 1970s and 1980s, as well as homebirths that were unplanned and where it was not even clear if they were attended by any midwife at all. Various countries were included in the meta-analysis.

Is homebirth safe? Not according to the dubious Wax meta-analysis. Yes, if you have a low-risk pregnancy, a good midwife, and good transfer possibilities, says a Dutch study from 2009. Which study is most convincing? Homebirth studies are generally carried out using small samples, given that not many women choose to give birth at home, and the outcomes cannot possibly be transferred from one country to the next, as healthcare systems, midwifery care, and other factors will be completely different.

This is not an anti-homebirth article — the author has done it herself. Weighing the risks and benefits is an individual process, the outcome of which will be different for every family (no matter what statistics say). You'll have to factor in your own health, any complications you may encounter during your pregnancy, the quality of your local hospitals, and of course the quality of homebirth midwives near you. That's what we are going to take a look at now — how to select the best midwife for you and your baby.

Types Of Midwives In The United States

If you are in the United States and looking into a homebirth midwife, you'll first have to know a bit about the various types of midwives that operate in the US. We've categorized midwives into three types. The last type, lay midwife, may operate under different names depending on the state she is in.

Certfied Nurse Midwives

Certified Nurse Midwives (CNMs) work in all states, in hospitals and sometimes in independent birth centers and at home. A Certified Nurse Midwife has the most extensive formal education of all the types of midwife active in the United States; they have a four-year nursing degree with additional midwifery training of two years, and have been licensed by the American College of Nurse Midwives. 

The greatest advantage of choosing a CNM is that this type of midwife will have seen many, many labors and births including all kinds of complications that can occur, and will be trained in how to deal with every possible eventuality. Around two percent of all Certified Nurse Midwifes provide homebirth services; those that do are most likely to have a good relationship with a hospital, facilitating an easier transfer should that prove to be necessary.  

One disadvantage that some women see in a CNM is that they are perceived to be more medically minded. The “natural birth community” sometimes jokingly refers to these midwives as “medwives”.

Certified Professional Midwives 

Certified Professional Midwives do not have to be trained nurses (though a few are, coincidentally), and they only practice at birth centers and preside over homebirths. Before being licensed, these midwives have to meet the requirements of NARM, the North American Registry of Midwives — an organization founded by the National Alliance of North America (MANA).

Recently, possessing a High School Diploma was added to the requirements. Self-study and attending a small number of births under the apprenticeship are other requirements. To get their CPM license, these midwives have to answer 350 multiple-choice questions.

Certified Professional Midwives have a serious sounding title, but let's make no mistake — they would not be allowed to practice in any other first-world countries in which homebirth midwives operate, including Canada, the Netherlands, and the United Kingdom. Why? Because they have no medical training, and often no experience. Some CPMs are great midwives, but their credential alone is not enough to prove that.

Lay Midwives

Lay midwives or direct-entry midwives may have apprenticed with other lay midwives, and may have engaged in self-study. They are not held accountable by a professional (or even a semi-professional) organization and carry no liability insurance. Some lay midwives may have a great deal of experience, but do you really want to take their word for it? 

Homebirth midwives in other countries 

What kind of midwives operate in other countries, where homebirth is more popular than it is in the US? In the United Kingdom, Australia and Canada, midwives go to university and take part in clinical practice before being qualified. Shorter options are usually available for those people who want to become midwives and already have a nursing degree. In the Netherlands, midwives go through a four-year midwifery school. Training is spread equally between hands-on practical training and theory.

Interviewing A Midwife

Before choosing a midwife, it is always wise to explore all the prenatal and birth care options in your area — including obstetricians/gynecologists and in some cases family doctors. Always interview more than one midwife where possible, and better yet speak to all the midwives who are available in your area. Now for the list of questions that can help you decide. 

Midwifery training questions 

• What midwifery credentials do you possess?

• Can I see your license?

• How many labors and births did you witness before being qualified? How many did you preside over?

• How many births have you attended since becoming a midwife?

• How long have you been practicing?

• Why did you become a midwife? 

Questions about experience 

• Has a baby ever died during a birth you attended? (If so, what happened?)

• Has a mom ever died during a birth you attended? (If so, what happened?)

• Where can I obtain reliable information about the track records of midwives like yourself?

• What complications of pregnancy would disqualify a mother from homebirth, in your opinion?

• Which complications on birth have you personally dealt with, and what was the outcome?

• (To make it more specific) Do you think it is possible to handle a shoulder dystocia, breech birth, twin delivery, placental abruption, or a cord prolapse at home? (In most cases, the answer should be an absolute no!)

• What situations require transfer to a hospital? How often do you transfer your patients to hospital? (You want to see a decent rate here. Complications do happen, after all.)

Questions about “birth philosophy” 

• How can your role in the birth process best be described?

• What do you do at a typical birth?

• What interventions (episiotomy, coached pushing, etc) do you typically engage in?

• Do you support the practice of water birth?

• Do you monitor a pregnant woman's GBS status?

• Who takes the lead during a birth; the mother or the midwife?

• Do you use medications? Herbs?

• How does homebirth differ from hospital birth?

Transfer and backup questions 

• Do you have privileges at any of the local hospitals (only for CNMs)?

• Have you transferred clients to a local hospital before? What is the procedure and what is your experience?

• Do you have a backup midwife? (In which case, great — also interview her!)

• Are you caring for other mothers with similar due dates?

• Do you always answer your cellphone?

• What happens if both you and the backup are unavailable? 

Insurance and payment questions 

• Do you take insurance? If so, which?

• What is the cost of prenatal care and birth services?

• Will I have access to ultrasound, blood tests, and other diagnostic tools through you?