Home births rise amid Utah's complex midwifery laws

By the numbers: About 1,400 of Utah's live births in 2023 took place at home. That's more than 3%, the sixth-highest of any state, and more than double the national rate of 1.5%.

• That rate also reflects a sharp increase from 2017, when about 2% of Utah babies were born at home.

Between the lines: That doesn't count hundreds of midwife-attended births at free-standing birth centers, which pushed Utah's share of intended out-of-hospital births above 4% as of 2022, the latest year for which state data was available.

State of play: The U.S. maternal death rate tops that of any high-income nation.

• Those figures — along with the medical system's not-so-ancient history of racial discrimination and overlooking women — scare some pregnant patients away from giving birth in a typical hospital setting.

What we're hearing: "In general, patients have distrust of the established medical system — especially Black patients," says Veronica Gillispie-Bell, a representative of the American College of Obstetricians and Gynecologists. "In the 17 years I've been in practice, there's definitely been a shift."

The other side: A review of Utah births from 2016 to 2021 showed the rate of neonatal deaths was "significantly" higher for births that were planned outside of hospitals.

Reality check: Comprehensive data on out-of-hospital births is difficult to collect, ACOG notes.

• Caveat: Utah's birth certificates asked where patients planned to deliver. That let researchers "ask providers and facilities more explicit questions" about hospital transfers amid complications, "greatly" increasing accuracy.

Between the lines: Midwife licensure is voluntary in Utah, meaning it's up to the patient to vet their provider's credentials.

• That can range from certified nurse midwives (CNMs), who complete post-graduate coursework, to lay midwives with no formal training.
• Between those are "direct-entry midwives" or "certified professional midwives" (CPMs) who are licensed with a high school diploma and professional training.

The fine print: Nothing in the licensure law "abridges, limits, or changes in any way the right of parents to deliver their baby where, when, how, and with whom they choose," Utah law states.

Yes, but: CNMs and CPMs could lose their licenses if they attend high-risk births outside hospitals.

• That may include certain patients with prior C-sections, multiples (twins, triplets, etc.), diabetes, high blood pressure, fetuses in breech and other dangerous medical conditions.

That means home births for the riskiest patients are often left to unlicensed lay midwives.

Flashback: In 2012, a Moab infant died after a high-risk home birth attended by Valerie El Halta, a longtime lay midwife nationally revered by "natural" birth advocates despite earlier criminal charges in California and a $1 million judgment after a death in Michigan.

• A professional group had revoked El Halta's certification, but that didn't legally preclude her from accepting a Moab client who wanted a vaginal delivery after three C-sections. The baby died from oxygen deprivation, and the mother nearly bled to death, prosecutors alleged.
• El Halta pleaded no contest to negligent homicide and other charges after investigators said she'd illegally used a prescription drug to induce labor and injured the mother with a vacuum extractor.

The bottom line: If you only consider low-risk patients who are attended to by qualified providers and have clear hospital transfer plans in case of emergency, births at home have comparable outcomes to those in birth centers, per a national study in 2024.

What we're watching: As Medicaid cuts and the government shutdown lead to the overburdening and closures of more hospitals in rural and underserved areas, pregnant patients may face more obstacles to getting personalized care, regardless of where they plan to deliver.