by Kate Saumweber Hogan, CPM, LM, owner of Twin Cities Midwifery, LLC
When I meet with families who are looking to choose a midwife, I am often asked about the statistics available for my home birth practice. While I do gather data, the small size of my practice brings the usefulness of these particular rates into question. With such a small pool of data, how statistically significant would these numbers be? Thus, I often direct families to studies that look at a much larger pool of data than mine.
Home birth studies shed light on safety and other key indicators
A number of studies demonstrate the safety of planned home birth for healthy, low-risk women with a trained attendant, such as this one from Canada, or this one from the Netherlands. An article by Johnson and Daviss, “Outcomes of planned home births with certified professional midwives: large prospective study in North America,” is especially important in that it uses data from planned home births in the U.S., and it not only addresses safety but also looks at hospital transport rates, cesarean rates, and other statistics that families commonly ask about.
Birth statistics are becoming more freely available
Over the past few years, I have noticed that hospitals and clinics are becoming more transparent in the care they provide. There is still a long road ahead of them, but due to the demand from informed consumers (pregnant people and families!), data on interventions like cesarean sections is becoming easier and easier to find. Annually, a report comes to my email discussing the cesarean rates by Minnesota hospital and Wisconsin hospital, and this report details rates by clinic (starting on page 192). I think it is fantastic that families have this information accessible to them as they choose a provider and consider who will walk with them on their journey of pregnancy, birth, and postpartum care.
I’m also inspired by our very own, local Childbirth Collective, which requires members to participate in a data-gathering project to learn more about the births its doula members attend. I always look forward to seeing what is included in their data report!
Statistics are a mirror that help us see and improve practice
I have been amazed by how Twin Cities Midwifery has grown and flourished over the past four years. I still limit my practice to about 3-5 due dates a month, and there are certain months when I plan ahead, not taking any due dates, allowing for a planned vacation, or a birth in my own family. This means that the pool of data is still small, but I need to start somewhere. I intend to update my statistics annually to provide a level of transparency to families wanting to learn more about my practice.
I know that the numbers will ebb and flow. I think that the Johnson and Daviss article gives good estimates of where my statistics will eventually hover around. For example, when they looked at all home births attended by certified professional midwives in the U.S. and Canada in 2000, they found:
- 12.1% of women who intended to deliver at home when labor began were transferred to hospital.
Medical intervention rates included:
- Epidural: 4.7%
- Forceps: 1.0%
- Vacuum extraction: 0.6%
- Caesarean section: 3.7%
All obstetrical interventions have a place, and I’m glad that I practice in an area where we have access to wonderful hospital care when it is needed. Being able to transport when we need to and receiving appropriate care in the hospital is what makes planning a home birth so safe; when we need extra help, we get it.
The problem we have in our country is not that women have cesareans or other interventions, but that so many have unnecessary cesareans or unnecessary interventions (which in turn cause additional health problems for moms and babies). Just like all obstetrical interventions, when overused, they can cause more harm than good. The Childbirth Connection has a useful article about why our national cesarean rate of 32.8% is so high. According to the article, the optimal cesarean rate is 5%-10% for the general population. Since home birth midwives work with an exceptionally healthy and low-risk population, it would make sense for the rate in this population to be lower. The Johnson and Daviss study found a 3.7% cesarean rate.
So what are Twin Cities Midwifery’s stats over the past four years?
These statistics below encompass all 105 women who established care for their pregnancies from when I started Twin Cities Midwifery in December of 2010 with due dates through December, 2014. In this four year period, 43.8% (46) of my clients were first-time moms, and 56.2% (59) were experiencing a subsequent pregnancy. Unfortunately, 5.7% (6) of the pregnancies ended in miscarriage. Another 13.3% (14) transferred out of my care during their pregnancy (for reasons such as preterm rupture of membranes, preterm labor, signs of pre-eclampsia, or moving out of the area). Out of all of these families, 6.7% (7) transferred to the hospital during labor.
Of all of the 85 women who were under my care when their labor started, 41.2% (35) were first time moms, and 58.8% (50) were experiencing their second, third, fourth, or sixth labors.
The majority of those families, 84.7% (72), choose to have a water birth tub available to them in labor. Of those women who had water immersion available, 88.9% (64) labored in water, and 58.3% (42) gave birth in water. Not all of the women who had water available planned or wanted to birth in the water. There were 8 women who planned to labor in the water but did not. They were not able to utilize the tub in labor either because their labor was so fast that there was no time to set up the tub, once the tub was set up they were already pushing and did not want to move to get in the water, or because they transferred to the hospital prior to active labor.
Of the babies I helped to welcome in the world, 44.7% (38) were girls, and 55.3% (47) were boys.
A doula was present at 58.8% (50) of these labors; 60% (21) of first-time moms had a doula, while 58% (29) of mothers of two or more had a doula with them.
Of these 85 women who intended to deliver at home when labor began, 91.8% (78) gave birth at home, meaning that we transferred 8.2% (7) of these labors to the hospital. All of the hospital transfers were for first-time moms and were non-urgent; one transfer was due to signs of infection during labor, and the others were due to very long labors with a labor progression that slowed or had stopped.
Due to transfers to the hospital during labor, my practice has an epidural rate of 7.1% (6) and a pitocin augmentation rate of 7.1% (6). All but one of the women who transferred gave birth vaginally; 1.2% (1) were assisted by vacuum, and 1.2% (1) were assisted by forceps. Twin Cities Midwifery’s cesarean rate is 1.2% (1).
We have had a 2.4% (2) postpartum transfer rate (going to the hospital for extra care for mom after baby arrives) and a 3.5% (3) newborn transfer rate. Of the total 26 transfers (prenatally, during labor, postpartum, and newborn), only 7.7% (2) were considered urgent. Most transfers, 92.3% (24) were not urgent.
As I was calculating statistics this year, I decided to start tracking rates of intact perineums and perineal tears. I have recently heard people say things such as “all first time moms tear,” “most women need stitches,” or “it just doesn’t matter what we do, you will tear.” I’ve been shocked when I hear these statements, because they don’t resonate as true in my experience, however I hadn’t calculated my practice’s statistics, so I wondered if I just had a very optimistic viewpoint. From now on, I will be able to easily calculate this statistic in my practice’s stats.
I was pleased to discover that 72.9% (62) of women who started labor under my care had no or minimal tearing (34.1% (29) had an intact perineum, 8.2% (7) had minor skids, 30.6 (26) had a 1st degree tear). There were 24.7% (21) women who experienced a 2nd degree tear, 1.2% (1) who had a 3rd degree tear, no 4th degree tears, and 1.2% (1) who required an episiotomy. Not all tears require suturing, therefore 24.7% (21) of the women who started labor in my care needed sutures to repair their tear.
I also separated this data by first time mom and non-first time mom. I found that in my practice, it is true that first time moms are more likely to tear, however I would not agree that most first time moms tear. Of the 35 first time moms who started labor under my care, less than half, 42.9% (15) required a repair. There were 22.9% (8) of first time moms who had a perfectly intact perineum, 33.4 (11) who had a skid or 1st degree tear, and 45.7% (16) who had a 2nd or 3rd degree tear. Looking at perineal outcomes for the 50 multiparous women (women who have previously given birth), only 12% (6) required a repair. There were 42% (21) who had an intact perineum, 44% (22) who had a skid or 1st degree tear, and only 14% (7) who experienced a 2nd degree tear.
Toward healthier, safer births for moms and babies in Minnesota
I am honored to have attended each and every one of these births and am so grateful for the opportunity to be with families during this incredibly special time. I look forward to our regular TCM events so that I get to watch these babies grow! With this midwifery model of care, Twin Cities Midwifery is helping to improve our state’s maternal and newborn outcomes in a healthy and safe way, one birth at a time.