by Kate Saumweber Hogan, CPM, LM

When we meet with families who are looking to choose a midwife, we are often asked about the statistics available for Twin Cities Midwifery’s home birth practice. While we do gather data, the small size of our 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, we often direct families to studies that look at a much larger pool of data than ours.

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 birthing people with a trained attendant, such as this one from Canada, this one from the Netherlands, this one from England, and this one from New Zealand. 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. In 2014, Cheyney released a study looking at outcomes of almost 17,000 planned home births in the United states. This study is a great reference for similar outcomes that we track in our practice, such as transfer rates, vaginal birth, assisted delivery, and cesarean birth rates for families planning a home birth.

Birth statistics are becoming more freely available

Over the past few years, hospitals and clinics have become more transparent in statistics around 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 are becoming easier and easier to find. Annually, this website is updated reflecting cesarean rates by state, and this one has VBAC rates by state. It is also possible to find rates by hospital in MN. Fees for hospital charges can be found here. 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.

Our state professional organization, MCCPM, also looks at data trends for out-of-hosptial births in Minnesota every few years.

Statistics are a mirror that help us see and improve practice

It has been amazing how Twin Cities Midwifery has grown and flourished over the past ten years. Each midwife in our practice limits their client load to about 2-5 due dates a month, and there are certain months when we plan ahead, not taking any due dates, allowing for a planned vacation, or a birth in our own families. This means that the pool of data is still small, but we need to start somewhere. We update the statistics annually to provide a level of transparency to families wanting to learn more about the practice.

We expect the numbers to ebb and flow. The Johnson and Daviss article gives good estimates of where our 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 clients who intended to deliver at home when labor began were transferred to hospital during labor or postpartum. First time parents had a 25.1% transfer rate and those having a second or subsequent baby had a 6.3% transfer rate.

Medical intervention rates included:

• Epidural: 4.7%
• Forceps: 1.0%
• Vacuum extraction: 0.6%
• Caesarean section: 3.7%

Another great place to look for statistics is Cheyney’s article, Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. Her study found that of the 16,924 pregnant people who planned homebirths at the onset of labor:

• 89.1% gave birth at home, meaning 10.9% were transferred to hospital during labor. Of first time people giving birth, 22.9% transferred during labor, while only 7.5% of non-first time birthing people transferred.
• There was a postpartum transfer rate of 1.5%
• There was a newborn transfer rate of 0.9%
• 93.6% gave birth vaginally

Medical intervention rates included:

• Epidural and/or oxytocin augmentation: 4.5%
• Assisted vaginal birth (forceps or vacuum extraction): 1.2%
• Caesarean birth: 5.2%

All obstetrical interventions have a place, and we are grateful to 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 receive 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 birthing people have cesareans or other interventions, but that so many have unnecessary cesareans or unnecessary interventions (which in turn carry risks and cause additional health problems for birthing people 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 32.2% is so high. According to the article, the optimal cesarean rate is 4-6% for a low-risk 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 close to that range. The Johnson and Daviss study found a 3.7% cesarean rate. The Cheyney study found a 5.7% cesarean rate.

So what are Twin Cities Midwifery’s stats over the past ten years? 

These statistics below encompass all 378 pregnancies which care was established for, starting from when Twin Cities Midwifery opened in December of 2010 with due dates through December of 2020. In this ten year period, 38.6% (146) were first-time pregnancies, and 61.4% (232) were subsequent pregnancies. Unfortunately, 6.1% (23) of the pregnancies ended in miscarriage. Another 12.5% (47) transferred out of our care during their pregnancy, 5.6% (21) were for non medical reasons (such as moving out of our service area, or changing their mind on place of birth or provider), and 6.9% (26) were transferred during pregnancy for medical reasons (such as preterm labor, preterm rupture of membranes, high blood pressure, non-reassuring fetal surveillance, cholestasis, or a fetal congenital anomaly that indicated a need for a hospital birth). All 24 of the clients who transferred prenatally for medical indications at their hospital births had the option of their TCM midwife joining them at the hospital, providing non-medical support (such as doula support), and accepting them back into care for postpartum and newborn follow up after hospital discharge. Out of all 378 pregnancies under the care of TCM, 9.3% (35) transferred to the hospital during labor.

This image shows what the journey looks like from establishing care to birth. You’ll see that most of our client’s births happen at home, as planned. However, some pregnancies end in miscarriage, and sometimes there are medical or non-medical reasons to transfer care during pregnancy.

In the last few years we also started tracking demographics of all previous and current TCM families. We’d love to see the diversity of our practice grow, and our whole homebirth community would like to see more kinds of families having more access to home birth. But to be able to see that grow, we need to be tracking to see where we are starting from. Of the 378 pregnancies we’ve cared for with due dates through 2020, 94.4% of our clients identified as white while 5.6% identified as American Indian, Asian, African American, or Other. Partners identified as white 89.4% of the time, while otherwise identifying as American Indian, Asian, African American, or Other. Clients identified as Hispanic 2.1% of the time, and partners 4.5% of the time. Clients identified as heterosexual 96.6% of the time, while 3.4% identified as bisexual, homosexual, or other.

Stats for full term pregnancies, starting labor as a planned home birth

Of the 308 pregnant people who were under our care when their labor started, 32.8% (101) were first time parents, and 67.2% (207) were experiencing their second, third, fourth, fifth, sixth, or seventh births.

The majority of those families, 89% (274), chose to have a water birth tub available to them in labor. Of those who had water immersion available, 87.6% (240) labored in water, and 56.9% (156) gave birth in water. The water birth rate for all 308 births was 50.6%.

Not all of the clients who had water available planned or wanted to birth in the water. There were 35 clients who planned to labor in the water but did not, 12.7% of those who chose to have a tub. 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, because they transferred to the hospital prior to active labor, or one time it was due to a medical situation which risked them out of using the tub.

Of the babies TCM helped to welcome into the world, 49% (152) were girls, and 51% (156) were boys. The smallest baby was 5 pounds 13 ounces, the heaviest was 11 pounds 5 ounces, and the average was 8 pounds 0.5 ounces.

A doula was present at 49.7% (153) of these labors; 53.5% (54) of first-time parents had a doula, while 47.8% (99) of parents of two or more had a doula with them.

Of these 308 clients who intended to deliver at home when labor began, 88.6% (273) gave birth at home, meaning that we transferred 11.4% (35) of these labors to the hospital. All of the hospital transfers during labor were non-urgent, 27 were first time labors, and 3 were VBAC labors. Three transfers were due to thick meconium stained amniotic fluid, two were due to abnormal heart tones, two were due to client request for pain medication, one was due to signs of infection during labor, one was due to decreased fetal movement, one was due to elevated blood pressure (hypertension), one was due to signs of placental abruption, one was due to non-cephalic presentation, and the other twenty three were due to very long labors with a labor progression that slowed or had stopped. Of our 35 intrapartum transfers, we were able to transfer to Certified Nurse Midwives 60% (21) of the time, Family Practice Medical Doctors 5.7% (2) of the time, and Obstetricians 34.3% (12) of the time. 

Due to transfers to the hospital during labor, Twin Cities Midwifery has an epidural rate of 8.1% (25) and a pitocin augmentation rate of 7.5% (23). All but fifteen clients who transferred gave birth vaginally (13 primary cesareans, 2 repeat cesarean; 9 due to limited progression of labor, 5 due to non-reassuring fetal heart tones, 1 due to breech presentation); 1% (3) were assisted by vacuum, and 0.3% (1) were assisted by forceps. Twin Cities Midwifery’s cesarean rate is 4.8% (15), with a primary cesarean rate of 4.4%  and successful VBAC rate of 83.3%.

We have had a 4.5% (14) postpartum transfer rate (two for retained placenta, one for signs of infection, one for hemorrhage, ten for significant laceration repair) and a 3.6% (11) newborn transfer rate (nine for signs of respiratory distress, one for intestinal blockage, one for a congenital anomaly). Of the total 108 transfers (prenatally, during labor, postpartum, and newborn), only 5.5% (6) were considered urgent. Most transfers, 94.4% (102) were not urgent.

We also track rates of intact perineums and perineal tears. We have heard people say things such as “all first time moms tear,” “most people need stitches after giving birth,” or “it just doesn’t matter what we do, you will tear.” It can feel shocking to hear these statements, because they don’t resonate as true in our experience.

Over the past ten years, 67.8% (209) of clients who started labor under our care had no or minimal tearing (34.4% (106) had an intact perineum, 6.8% (21) had minor skids, 26.6% (82) had a 1st degree tear). There were 30.5% (94) clients who experienced a 2nd degree tear, 1% (3) who had a 3rd degree tear, 0.3% (1) 4th degree tears, and 0.3% (1) who had an episiotomy. Not all tears require suturing, only 27.9% (86) of the people who started labor in our care needed sutures to repair their tear.

We also separated this data by clients giving birth for the first time and non-first time parents. I found that in my practice, it is true that first time parents are more likely to tear, however I would not agree that most first time parents tear. Of the 101 first time birthing people who started labor under TCM care, less than half, 44.6% (45) required a repair. There were 27.7% (28) of first time parents who had an intact perineum, 29.7% (30) who had a skid or 1st degree tear, 39.6% (40) who had a 2nd degree tear, 2% (2) who had a 3rd degree tear, and 1% (1) who had an episiotomy. Looking at perineal outcomes for the 207 multiparous clients (those who have previously given birth), only 19.8% (41) required a repair. There were 37.7% (78) who had an intact perineum, 35.2% (73) who had a skid or 1st degree tear, 26.1% (54) who experienced a 2nd degree tear, and only 1% (2) who had a 3rd or 4th degree tear.

In 2015, we also started tracking insurance reimbursement rates. State funded Medical Assistance (MA) or MN Care plans do not cover services provided by Twin Cities Midwifery, however, private insurance plans often do cover our midwifery care. Out of all of our clients who birthed in 2015-2020 with private insurance, 24.2% had 100% coverage after meeting their deductible. Since deductible levels varied, we also looked at specific dollar amounts families were reimbursed. Of those who birthed in 2015-2020 with private insurance, 56% were reimbursed at least $1,000, 35.3% were reimbursed over $2,000, and 27.1% received more than $3,000 back from their insurance plan to pay for their care. Families received at least $4000 in reimbursement 13% of the time. For more information on insurance coverage of home birth services, check out our Insurance Benefits blog post.

Toward healthier, safer births for birthing parents and babies in Minnesota

TCM midwives are honored to have attended each and every one of these births and are so grateful for the opportunity to be with families during this incredibly special time. We look forward to our regular TCM events so that we 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.

A huge shout out and thank you to Brandi Olson of Brandi Olson Consulting for dreaming up and creating these gorgeous infographics! Brandi builds the capacity of mission-driven business to deepen their impact through agile strategic planning, evaluation, and data storytelling.