Home birth tragedy highlights importance of choosing the right midwife

Considering a midwife to deliver your baby? There are three different kinds of midwives, and it's important to know how their roles vary.

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/ Source: TODAY
By Meghan Holohan

When medics arrived at the Noe household on June 15, they found mom Emily Noe, 25, had partially delivered her daughter, Vera, but the infant was stuck in the breech position, according to a report from the Omaha Police Department, verified by NBC News.

According to the report, her midwife, Angela Hock, 36, had attempted the high-risk home birth, but was not successful. Doctors at the Unversity of Nebraska Medical Center told police that baby Vera was deprived of oxygen for 10 minutes, which caused her brain to swell.

After Vera's death on June 17, authorities arrested Hock, 36. A spokesperson for the Nebraska Department of Health and Human Services told NBC News that Hock does not have the certification needed by the state to practice as a midwife.

The Noe family did not respond to a TODAY request for comment.

While it's unknown if the family or the midwife knew if the baby was breech, the American College of Gynecologists and Obstetricians (ACOG) and professional midwife organizations stress that home births are not appropriate for the safety of the mom and baby when the baby is breech.

What people need to know about midwives

It's all too easy for some to become confused when seeking a midwife. Laws about where they can practice vary by state and there are three types of midwives that undergo different training and provide varied services.

“When women are making decisions about seeking midwifery care, they don’t ask the questions about what type of midwife you are, what are your credentials and how have you been certified,” said Erin McMahon, faculty practice director and assistant professor of nurse-midwifery and women’s health at Yale University School of Nursing in New Haven, Connecticut. “All women should be curious and ask questions about a midwife’s training and their level of experience.”

Direct entry midwife or certified professional midwife

Direct entry or certified professional midwives (CPMs) are a more community-based approach to midwifery, where people attend some classes, but learn by shadowing and apprenticing with other midwives. Most CPMs focus exclusively on prenatal and postnatal care.

“It is like an apprenticeship model. A student would work with another midwife often in the home and sometimes in a birth center. They develop their skills with education and by working with their preceptors,” McMahon explained.

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CPMs are not recognized in all 50 states, but 31 states do recognize them, according to the American College of Nurse Midwives (ACNM). A CPM is an independent midwifery practitioner who has met the standards for certification set by the North American Registry of Midwives.

CPMs are more likely to attend home births and often do not have privileges in hospitals. While they can't prescribe medication, they frequently work closely with physicians. That's how they obtain pregnancy-related medication, such as pitocin (used to induce labor).

While midwives are often allowed to stay and help the mom if she's transferred to the hospital, not all doctors welcome CPMs.

“I am no longer their healthcare provider, but I am giving all the information the doctors want and I stay until the baby comes,” Houston-based CPM Afua Hassan told TODAY.

Certified nurse midwife

A certified nurse midwife (CNM) has a bachelor's degree in nursing and master’s degree in nursing midwifery. CNMs can practice in all 50 states and they can prescribe medicine, according to ACNM. While CNMs deliver babies, they also provide care to women throughout their lives.

“We are lifetime healthcare providers. We provide contraception, gynecological services,” Shadman Habibi, director of the nurse-midwives program at UCLA Medical Center, Santa Monica, told TODAY. "We can administer routine care."

CNMs most often practice in hospitals or birth centers, though some participate in the 1% of home births that take place in the U.S.

“The majority of births in the U.S. are in hospitals and that is where you will find the majority of CNMs,” said McMahon.

Certified midwife

A certified midwife (CM) has a graduate degree in midwifery from a program certified by the Accreditation Commission of Midwifery Education, but does not have a bachelor's degree in nursing.

Like CMNs, CMs practice in hospitals and birth centers but can only prescribe medication in certain states. Normally, CMs have close relationships with physicians who can prescribe drugs needed for their patients.

The ACNM includes CMNs and CMs in its ranks. The American College of Obstetricians and Gynecologists (ACOG) works closely with CMNs and CMs. According to a policy statement, ACOG and ACNM recognize the importance of collaboration:

“Shortages and maldistribution of maternity care clinicians cause serious public health concerns for women, children, and families … ACOG and ACNM recommend increasing the number of OB-GYNs and CNMs/CMs, utilizing inter-professional education to promote collaboration and team-based care."

Emergency care across settings

According to the CDC, the overwhelming majority of births in the U.S., 99%, occur within hospitals or birth centers. Birth centers can be affiliated with hospitals or universities or they can be community-based.

The Commission for the Accreditation of Birth Centers provides accreditation for birth centers that adhere to their standards. Regulations on setting up a birth center vary from state to state.

While birth is normally uneventful, emergencies can occur in any setting. Hospitals use standardized practices to handle emergencies.

“We have protocols in California,” Habibi, who works at the UCLA Medical Center, said. “Everyone knows the steps. We talk about it. We have drills for obstetric emergencies.”

Birth centers and CPMs also have plans for emergencies or transfers to a hospital. Hassan has a 7% transfer rate and she knows exactly what to do if a mom needs to go to the hospital.

“I am five minutes away from the largest medical center,” she said. “Either we get in the car or we can take the ambulance depending on the situation. I have the patient’s records. I explain what is going on.”