MANA Study: This study, which examines nearly 17,000 courses of midwife-led care, is the largest analysis of planned home birth in the U.S. ever published.

The results of this study, and those of its companion article about the development of the MANA Stats registry, confirm the safety and overwhelmingly positive health benefits for low-risk mothers and babies who choose to birth at home with a midwife. At every step of the way, midwives are providing excellent care. This study enables families, providers and policymakers to have a transparent look at the risks and benefits of planned home birth as well as the health benefits of normal physiologic birth.

Of particular note is a cesarean rate of 5.2%, a remarkably low rate when compared to the U.S. national average of 31% for full-term pregnancies. When we consider the well-known health consequences of a cesarean — not to mention the exponentially higher costs — this study brings a fresh reminder of the benefits of midwife-led care outside of our overburdened hospital system.

Home birth mothers had much lower rates of interventions in labor. While some interventions are necessary for the safety and health of the mother or baby, many are overused, are lacking scientific evidence of benefit, and even carry their own risks. Cautious and judicious use of intervention results in healthier outcomes and easier recovery, and this is an area in which midwives excel. Women who planned a home birth had fewer episiotomies, pitocin for labor augmentation, and epidurals.

Most importantly, their babies were born healthy and safe. Ninety-seven percent of babies were carried to full-term, they weighed an average of eight pounds at birth, and nearly 98% were being breastfed at the six-week postpartum visit with their midwife. Only 1% of babies required transfer to the hospital after birth, most for non-urgent conditions. Babies born to low-risk mothers had no higher risk of death in labor or the first few weeks of life than those in comparable studies of similarly low-risk pregnancies.


Description: This report describes 14 years of homebirth statistics done by CHOICE midwives. These statistics are for all births attended by the CHOICE midwives in 1976-1979, 1983 and 1992-1996 (1980-1982 and 1984-1991 have not been tabulated at this time.). These statistics chart the outcome of 479 planned homebirths, including statistics concerning birth complications dealt with at home, transfers from home to hospital, episiotomies, cesarean sections, birth weight, and mother’s education. Until today, this information was compiled annually by the midwives for their own review and record-keeping, and to share with clients considering homebirth. (Note: The 1996 data covers only births and six-week postpartum visits completed by December 4, 1996.)
Summary of Data: The statistics show very favorable birth outcomes in most categories studied.
Birth Weight: 79.7 percent of the babies weighed over 6 pounds.
Cesarean Sections: The Cesarean Section rate for planned home births was 4.4 percent.
Episiotomy: 74.2 percent of the women gave birth without an episiotomy or tear. 18.4 percent of the women had only a first degree lacerations. Only 8.6 percent of the women required repair. It is important to note that midwives are traditionally hard on themselves and report even the tiniest split in the skin as a 1st degree tear, even though most, if not all of these tears would not be repaired in any setting.
Blood Loss/Hemorrhage: Blood loss over 500 ml (2 ¼ cups) was reported in 20.3 percent of the births. Excessive blood loss can lead to shock and maternal death. Although this rate of excessive blood loss seems high, only 6.5 percent of the women required Pitocin to halt the bleeding suggesting both that the majority of women were in no danger from a true hemorrhage and that the midwives were perhaps overestimating blood loss due to the importance of a timely hospital transfer in this event. The majority of cases were controlled with nipple stimulation, fundal massage or herbal treatments. It is worth noting that routine hospital procedure is to prevent excessive blood loss by administering Pitocin in the IV to most maternity patients (nearly 100 percent as compared to the 6.5 percent receiving Pitocin in this sample). Prior to 1988, blood loss was simply recorded as 0-2 cups, 2-4 cups and greater than 4 cups. Starting in 1988, blood loss was recorded as less than 500 ml (2 ¼ cups) or greater than 500 ml (considered a hemorrhage). Thus, for this study, we suspect that many women from the early years whose blood loss was 2-4 cups, but did not hemorrhage, were entered into the statistics as having lost more than 500 ml.— even though their blood loss was not considered a hemorrhage. This is evidenced by the low percentage of Pitocin given, leading one to believe their were actually fewer hemorrhages than the statistics indicate.
Cord Problems: Since about 25 percent of babies are born with a cord around the neck, a direct-entry midwife must be ready to handle cord problems. Indeed, in this group, 20.3 percent had cord problems. The midwives were able to remove the cord without clamping and cutting the cord in 100 percent of the cases. There were no transfers due to cord problems.
Placenta Previa/Abruptio: The percentage of clients with placenta previa/abruptio diagnosed here during labor is 0.2 percent. This low percentage probably does not reflect the actual number of women with placental problems, but rather that placental problems and risk factors leading to placental problems have caused these women to be screened out as too high risk for home birth early in pregnancy and referred to physician care and hospital birth.
Infant Deaths: There was only one intrapartum/neonatal death in this sample. This death occurred at 57 hours after birth. This infant was transferred to the hospital 12 hours following the birth when respiratory difficulty developed and was diagnosed with hypoplastic left heart syndrome, an inoperable heart defect.
Maternal Deaths: There were no maternal deaths.
Discussion: It is important to remember that without carefully matching comparable populations of women, midwife-attended births will always have significantly better outcomes than physician-attended hospital births. This is true whether the birth is at a birth center or home, and whether the midwife is a nurse-midwife or a direct-entry midwife. This is chiefly because midwives attend only the low-risk population. The practice of midwives under examination here, for example, will only attend women who go into labor at full-term (at least 37 weeks gestation). Women with preterm labor are transferred to the hospital. In addition, the care of women with obvious high-risk health factors, like diabetes and hypertension, or high-risk life-style factors, like drug use, are transferred to the care of a physician. Women pregnant with twins or whose babies are breech are evaluated on a case-by-case basis. A breech birth with a primipara, for instance, would not be attempted at home. Several studies have compared the outcome of a group of planned home births with a similar, low-risk population of women giving birth in the hospital. The National Birth Center Study published in the New England Journal of Medicine 321:1804-1811 (December 28), 1989 prospectively matched 11,814 women planning birth center births with nurse-midwives with the same number of women planning hospital births.(1) That study found that “birth centers offer a safe and acceptable alternative to hospital confinement for selected pregnant women…” Similar studies, on a smaller scale, have been designed to study home birth. According to recently published studies(2) direct entry midwife-attended home births were accomplished with safety comparable to that of conventional hospital births. In fact, physician-attended hospital birth has never been shown to be safer than midwife-attended home birth for women with normal pregnancies. In a 1977 study(3) Lewis Mehl reported a perinatal mortality rate in elective home births of 9.5/1000 compared to 20.3/1000 for the control group. Burnett(4) reports, in the Journal of the American Medical Association, a neonatal mortality rate of 4/1000 in planned home births (768) attended by a midwife compared to 12/1000 in hospital births (242,245). Murphy reported in the British Medical Journal(5) a neonatal mortality rate of 3.2/1000 among 315 planned home births compared to 10.7/1000 in the control group (44,521 hospital births). A 1996 study(6) published in the British Medical Journal concluded, “The perinatal hazard associated with planned home birth in the few women who exercised this option (<1%) was low and mostly unavoidable. Health authorities purchasing maternity care need to address the much greater hazard associated with unplanned delivery outside hospital.” Another 1996 study(7) comparing outcomes of planned home and hospital births in low risk pregnancies concluded there was “no relation between the planned place of birth and perinatal outcome in primiparous women when controlling for a favourable or less favourable background. In multiparous women, perinatal outcome was significantly better for planned home births than for planned hospital births, with or without control for background variables.” These findings have uniformly demonstrated that home birth with a trained, experienced midwife has outcomes comparable or better than that of a low-risk hospital birth. An exception to this rule may be the midwife who attends a population that refuses physician care regardless of the presence of high-risk factors. Rural Amish and Mennonite women, for instance, have a strong preference for home birth with a midwife regardless of the likelihood of a complicated birth or a poor outcome. (An Amish or Mennonite woman in preterm labor may resist transferring to the hospital despite her knowledge that a premature baby is unlikely to survive without special care.) Statistics gathered from a midwife who attends such populations will be noticeably poorer. This situation is of particular relevance to Ohio, a state with a large Amish/Mennonite population traditionally attended by direct-entry midwives. Midwives attending Amish/Mennonite women are usually “English” (i.e. not Amish or Mennonite). Some midwives see both Amish and non-Amish women in their practice. No effort has been made here to compare these 479 births to a comparable population of low-risk hospital births. However, a comparison of these statistics to those published in the sources cited below demonstrate that for this population, giving birth at home was as safe or safer, than giving birth in the hospital in terms of serious complications, infant mortality/morbidity, and maternal mortality/morbidity. In addition, the Cesarean Section rate was much lower.