Homebirth Safety in Colorado
Article 12-37-105(12) of the Colorado Revised Statutes requires Colorado Registered Midwives to report, at the time of renewal, the following information:
• The number of women to whom care was provided
• The number of deliveries performed
• The Apgar scores of delivered infants
• The number of prenatal transfers
• The number of transfers during labor, delivery and immediately following birth
• Any perinatal deaths (and beginning in 2011, the cause of death and a brief description of the circumstances)
The Colorado Department of Regulatory Agencies (DORA) Office of Direct-Entry Midwifery Registration collects this information via a survey administered each year to midwives seeking renewal. Through 2005, Midwives Registration reported 3 or fewer perinatal deaths associated with homebirth per year. In 2006, the survey reported 5 perinatal deaths; in 2007 it reported 5; in 2008 it reported 7; and in 2009 it reported 9. Over the last 6 years, Colorado has averaged between 40 and 60 Direct-Entry Midwives attending between 500 and 700 homebirths per year.
Much about the numbers collected by DORA over the years is unreliable. The surveys did not ask when in the pregnancy, birth or postpartum the demise took place. The term “perinatal” was not defined. The survey didn’t ask where the actual birth took place, who was managing the birth, or the reason for the demise. Because the information collected by DORA has never been refined to be used as statistical data, statistical inferences cannot be made from it.
Indeed, the Midwives Sunset Review written in 2000 recommended the Colorado General Assembly should eliminate the reporting requirements contained in §12-37-105(12), C.R.S. That review noted “the data collected by the program on renewal notices has been found to be inaccurate, and not useful in analyzing the program” and concluded, “the usefulness of the information is questionable.”
For the 2009 renewal period, Colorado Registered Midwives gave care to 936 women and attended 637 homebirths. They reported 9 perinatal demises for that year. The Colorado Midwives Association collected brief stories about the situations surrounding the demises and they are summarized below:
Two babies were born premature; one stillborn a week after transfer of care to a physician due to maternal hypertension, and the other died at 24 weeks in the hospital after preterm labor.
Serious Anomaly Deaths at Term:
Three babies had serious anomalies incompatible with life. One died in-utero at 32 weeks and was stillborn at the hospital. Two were born in hospital weeks after transfer of care following discovery of the anomalies during routine ultrasound.
Other Deaths at Term:
Three babies developed nonreassuring heart tones during labor and all were transferred to hospital. Two died before birth; pathology noted an infection in the placenta of one of those babies. One died within hours after birth with an enlarged heart noted on the autopsy.
The final baby was born precipitously at home in a rural part of the state before the midwife arrived, although she was in contact with the parents during the birth. The baby wasn’t doing well, an ambulance was called and arrived but the baby could not be resuscitated and the parents requested no autopsy be performed.
In summary, setting aside the babies that had malformations incompatible with life or were born prematurely (since Colorado statute rules out premature babies for home birth) the non-malformation deaths at term comprised:
- One stillbirth with infection present but no autopsy was done.
- One stillbirth with no identified cause and autopsy refused.
- One neonatal death where autopsy revealed an enlarged heart.
- One neonatal death after precipitous birth, with no identified cause but no autopsy.
Based on the information provided, these data suggest that planning a home birth can be ruled out as a causative factor in the death in all but one stillbirth during labor, although even with this one it is not clear whether intervention such as a Cesarean section would have saved the baby, a fact which the refused autopsy may or may not have revealed. The baby born with an infection in the placenta did not receive intervention that changed the outcome even though born in hospital. The baby with the enlarged heart was also born in hospital and this apparent cause of death was not able to be treated there. The neonatal death without explanation (also with autopsy refused) was precipitous and occurred in a rural area; this baby would have likely been born out of hospital, and suffered the same fate even if a hospital birth had been planned.
Based on numerous studies already published comparing home and hospital births, it’s clear that two deaths in 600 or 700 births are not outside expected outcomes for planned homebirth of healthy low-risk women and babies attended by trained direct-entry midwives.
The mission of the Colorado Midwives Association is to support and promote the option of homebirth for childbearing families in the state of Colorado. The Colorado Midwives Association declares and affirms that homebirth continues to be a safe and viable choice for women with healthy, low-risk pregnancies when attended by a Colorado Registered Midwife.