Home Birth Data Trends 1990 – 2009 and a Midwife Who Lives the Trend

In January of 2012, Marian MacDorman and her colleagues compiled a data brief for the United States Department of Health & Human Services, Center for Disease Control and Prevention, National Center for Health Statistics. This brief, entitled Home Births in the United States, 1990- 2009, noted large changes in birthing patterns have occurred in the US over the past century. In 1900, most births occurred at home. By 1940, 44% of all births were at home, and by 1969, this dropped to 1%, and this rate held steady throughout the 1980’s.

The researchers state that homebirths have been increasing since the 1990’s through 2009. In 2004, homebirths accounted for .56% (23,150 births) and increased by 29% to .72% (29,650 births) in 2009. The composite demographic of a woman desiring a homebirth is non-Hispanic Caucasian, over 35 years old, with previous children. The homebirth demographic has a lower risk profile: fewer preterm, low birthweight, multiple births and fewer, teenaged and unmarried mothers. 1 in 90 births to non-Hispanic Caucasian women were homebirths.

Generally, there were more homebirths in rural areas than non-rural areas and more in northwestern states than the southeastern states. Montana, Oregon and Vermont had the highest percentage of homebirths followed by Idaho, Pennsylvania, Washington and Wisconsin. Some of the states with lowest homebirth rates are Texas, North Carolina, Connecticut, District of Columbia, New Jersey and West Virginia.

62% of these home births were attended by midwives: 19% by certified nurse-midwives (CNM) and 43% by other midwives (direct-entry or certified professional midwives).

An Interview with Homebirth Midwife, Angelita Nixon, CNM

Angelita Nixon, CNM, is one of those home birth midwives in West Virginia. I had the pleasure of speaking with Angy about her work last week. Her career parallels the changing trends in US birth care. She began her career in 1998 as a certified nurse-midwife in a hospital. In 2003, she began doing home births exclusively.

Angy says: “ I left the medical arena feeling burned out. My caseload was getting heavier and heavier. A full medical practice were my golden handcuffs. It was impossible to give the personal care I wanted to give to women, I was always rushing. Worse than rushing, I felt like I was witnessing crimes against women. And not only was I witnessing crimes against women, I felt I was a party to this. I saw many crimes against women: mistreatment, being disrespected, taking away personal power, denying a woman the ability to walk, not literally confining a woman, but discouraging her. I saw medical rape often, I did not perform this myself, but saw it happen. A woman would say, “I need to relax for a minute before you examine me” but she was ignored. I couldn’t do that work anymore, I knew there was a better way. You know, at first in my career, I distanced myself from homebirth, I thought those people were extremists. But, I began to have women ask me to attend home births and I liked the people and the work.”

Describing her practice: “I do about 3 births a month. I don’t like missing births and I won’t run the risk of being over-committed. I love it when people pop into my office, which is my home, as they need. I love being able to have long patient visits. Most importantly, I assess the person as a good fit for home birth. My patient population is low risk.”

She describes her work as modeled after the European midwifery: “In Europe, the system is completely different, it’s all midwife based. Doctors are the experts, the midwives are the generalists who deliver 80 – 90 % of births. The midwives listen to the women, to what’s going on in the family, assesses if she has had a traumatic experience in her life which might affect the birth. In this way, the midwives filter out the 10 -15% of the women who will need doctors. That is how I run my practice.”

“We have lost the generation where homebirth was the norm. Our maternity system would look different if its ultimate goal was health and not profit. The funny thing is, intensive midwifery care saves money, as it is less es pensive than traditional hospital care. The Washington Department of Health (2008) found that midwifery care would save Medicaid $500,000 biennially and if private insurance was included, $2.7 million. So sensitive midwifery care is less expensive and has better maternal-baby outcomes. Why do we wait? ”

She uses the following  comfort measures: hydrotherapy, freedom of movement, repositioning, massage, acupressure, efflureage, eating, drinking, hydrating, respectful treatment, continuous support, encouragement,, hot & cold therapies, and a lot of hands on comforting. Her homebirth statistics are impressive: because of careful pre-screening, she has had only one emergency transfer, her cesarean section rate is 7%, and she has done one episiotomy in 8 years.

Ms. Nixon says the system needs reform: “We need more midwives, as they provide the best outcome. I want to collaborate I want to be a medical provider. I do know my limits, I do know when to send a patient to the next level. But I find the hospitals shun this type of collaboration. This is a barrier for the women in my care. I have already triaged the patient, but then the patient is not directly admitted, but must get triaged again in the ER. They say there is a shortage of nurses. I know there is not a nursing shortage, but a shortage of people, nurses, who will work in our hospital’s conditions. Healthcare is in crisis, that’s why there are pressures for reform. We need more midwives, but the system needs reform.”

Ms. Nixon became politically active in order to help change the political climate. She was on the board on the Midwives Alliance of North America (MANA). She is also on the board of the National Midwifery Organization and is President of her state’s chapter. She contributes to MANA’s data collection project. She asks that we spread the word that researchers are needed to interpret the prospective data that has been collected: over 25,000 courses of midwifery care is available for researchers to study. The data is from 2001 – 2011, every client enrolled in the study at beginning of pregnancy, not based on results, voluntary contribution , not restricted to any one type of credential (physicians, hospital based, majority of the data is from homebirth midwives). Qualified researchers can apply for access to the data, by application to the Division of Research of MANA, which is headed by Melissa Cheyney.

Angy ends our conversation with a smile: “Homebirth is the real world. Birth is in its natural habitat. “


Health Management Associates (2008). Midwifery licensure and discpiline program in Washington State:Ecxonomic Costs and Benefits


MacDorman, M.F., Mathews, M.S. & Declerq, E. (2012). US Department of Health & Human Services, Center for Disease Control and Prevention, National Center for Health Statistics. NCHS Data Brief # 84, Home births in the United States, 1990- 2009.

Angelita (Angy) Nixon, CNM, MSN

Having practiced full-scope midwifery in hospitals, clinics, and a freestanding birth center, Angy became a midwife business owner in 2003, provides mobile midwifery services and makes house calls. She participates in peer reviews and maintains a formal collaborative agreement with a physician, as well as collaborative relationships with multiple other physicians. In celebration of her first 7 years in private practice, Angy enjoyed a modified sabbatical, traveling and spending more time with her family. In June 2011, she attended her first ICM Congress in Durban, South Africa. Angy believes birth is a normal process and a healthy event.

Find her at her website.

Babies, Baby Friendly Initiative, Childbirth Education, Healthy Birth Practices, Home Birth, Lamaze Method, Midwifery, Uncategorized , , ,

  1. avatar
    | #1

    “…large changes in birthing patterns have occurred in the US over the past century. In 1990, most births occurred at home. By 1940, 44% of all births were at home…” I’m assuming that you mean that in 1900 most births occurred at home, not in 1990.

  2. | #2

    Kathy, thank you for this excellent article and interview with Angy! She is an amazing midwife and leader in the profession, and it saddens me to read that even *she* has to deal with hostility when she appropriately transfers a client to the hospital. As noted in the beginning of this article, more and more women are choosing to have their babies at home or in freestanding birth centers with midwives. It is critical for smooth inter-professional collaboration to occur so that mothers and babies receive competent care and continue to have excellent outcomes.

    In countries where midwives are well-integrated in the maternity care system, research has shown over and over again that there are good outcomes for mothers and babies, increased maternal satisfaction and lower costs. When hospital staff shuns a careful and thoughtful practitioner like Angy for appropriately transferring a client who needs what they have to offer, there is work to be done. I’m encouraged by the consensus statements from the Homebirth Summit (http://www.homebirthsummit.org) that address this issue specifically, stating that “all women and families planning a home or birth center birth have a right to respectful, safe and seamless consultation, referral, transport and transfer of care when necessary. When ongoing inter-professional dialogue and cooperation occur, everyone benefits.”

    Finally, I wanted to share a better link for the MANA Division of Research: http://mana.org/DOR Thanks for a great article!

  3. | #3

    What an interesting interview. I am a bit saddened by the fact that childbirth seems to have become such a polarized area of health care. I know some wonderful OB-GYNs, who are truly patient-centered and passionate about good care. I also know some wonderful midwives and nurse midwives, who are truly patient-centered and passionate about good care. I feel for the worried new moms, who may not feel as though they know the right way to turn when both “sides” have compelling arguments about why “their way” is the safe way. I appreciate this series because you appear to be working hard to present a diverse range of viewpoints in clear, easy to understand language.

  4. | #4

    This was an interesting read for sure. I agree with Ann that it is sad to have so much controversy over how childbirth happens in our country. I have a friend who had two successful, beautiful home births, but I also have a friend who desperately wanted a home birth but ended up with an emergency C-section because of complications the midwife could not handle in the home environment. She was happy with how the midwife did her job and felt she was referred to a higher level of medical care appropriately, but she felt a huge loss at not being able to have the home birth she wanted for her child. She is still mourning the loss of her desired birth experience several months later.

    In my case, I did give birth in the hospital and had to make some decisions that did not fit what perhaps was my ideal picture of childbirth, but I felt completely respected by my physician and the nurses at the hospital, and I felt empowered to make informed decisions. I thought the overall experience was great.

    I know a lot of new moms and moms-to-be, so this discussion is interesting! Thank you for presenting this point of view.

  5. avatar
    | #5

    There’s a confusing typo in the first paragraph, and I think the year should be 1890. The sentence is “In 1990, most births occurred at home.” Since the next line is about births over the course of a century, 1990 can’t possibly be the correct year.

  6. avatar
    | #6

    I had the privilege of having Angie for a home birth midwife. After having my previous birth (4th of 5 children) in the hospital, I refused to ever go back again. They threatened me with Child Protective Services before the baby was born, because I hadn’t decided on whether or not I would choose to have the vitamin K shot or the ointment in the eyes, they ran over my decision not to have pitocin and then had three people come and tell me that I needed to cut on my child’s face “for her good”. I never did have her tongue clipped and there are no traces of any problems, but the badgering I received in the hospital set me to tears, and I vowed I’d never go back. Thanks to Angie I was able to have the home birth that I wanted!

  7. | #7

    It will be interesting to see how changes in the US health care and insurance industry alter any collaboration that does occur between hospitals, mid-wives, & OB-GYNs. It would also be interesting to learn why some states have hire usage of midwives.

    Thanks for providing such an informative series, Kathy.

  8. | #8

    This is very useful information about home birth. It does seem that childbirth has been “medicalized” in the US. The numbers about the potential for savings in medical costs are impressive. For women to feel comfortable and respected and save society money–what’s not to like?

  9. | #9

    Although unassisted home birth is not part of the data (I think, but I am not sure) I wonder how this trend is going.The term medical rape used in the beginning of the article seems totally appropriate in what I saw in American hospitals and even more appropriate in the Brazilian city where I have a tiny sprouting HB practice. I also work as a hospital doula when women do approach me for that reason. We have a 99% rate of c/s in the private sector divided in about 3 facilities of the Natal Area. if a woman wants to birth vaginally, she’d better stay home… if not, she probably wont have any room when she comes to thee maternity and will end under the knife. The maternity has all of the apartments booked in advance for c/s. If women do not undergo c/s, they are driven to have a spinal, with no continuous monitoring, plus fundal pressure done by the anestesiologist, and a large episiotomy in order to have the baby as fast as possible. I have not seen a second stage longer than 30 min, and many c/s are performed at this stage with Diagnosis of arrest of descent Vs Obstetrician impatience..

    I am not even going to the public hospital issue where the violence is endemic and accepted as normal routine.

    Several NGO’s are working hard but there is so much work to do… Seems impossible to change the docs mentality..

    Thank you Regine

  10. | #10

    Thanks for the correction!

  11. | #11

    Hi Wendy – I truly appreciate your input! Thanks for the links and info! Angy was truly inspiring to speak with. My talk with her definetly refueled my passion to support the midwifery model of birth, as practiced in Europe. This model seems so common sense, generating real emotional care and truly family-centered. And makes economic sense too! Duh, so now why is this not being adopted here????

  12. | #12

    @Ann Becker-Schutte, Ph.D.
    Hi Ann – I empathize with what you are saying. It is confusing to the consumer. It is difficult to know what to believe. There are many caring ob/gyns. I dont see it as either/or, but as a different model of birth, which is not implemented in the US. Midwifery care for the majority and obs as specialists for those who need the care. It’s less expensive and is family friendly.

  13. | #13

    Great interview with a fabulous midwife. Thank you!

  14. | #14

    @Rachelle Norman
    Hi Rachelle – thanks for your comments. I think your points are important. Women just feel so much pressure to do things “right,” and it really is individualized. If there are complications, thank goodness we have the medical technology to help those people. I think any medical procedure, even if necessary, has some emotional content to process. Birth is (of course) loaded with personal meaning. We can only support those who need it and help them not to feel shame.

  15. | #15

    I made a typo! Corrected! thanks for your sharp eyes!

  16. | #16

    Hi Jamie – Your experiences in the hospital sound horrifying. There are so many good doctors and nurses around, I sure don’t want to do any bashing. I hear good stories and I also hear some really appalling things about healthcare today. Glad you found Angy!

  17. | #17

    @JoAnn Jordan
    Hi JoAnn – It sure will be interesting to see how this all plays out in healthcare. I hope it’s not biz as usual, with the richest lobbyists unduly influencing the outcome.

  18. | #18

    @Carolyn Stone
    Hi Carolyn – I know, as I read more and more about the midwifery model, I thought the same thing. “Whats not to like?”

  19. | #19

    @Regine Marton MS CNM
    Hi Regine – Goodness, your description of Brazilian healthcare sounds anti-health. It must be difficult for you to work in such an atmosphere. good luck to you, Kathy

  20. | #20

    thanks Melissa!

  21. | #21

    I have been teaching childbirth education in Los Angeles, CA for 12 years. When I start thinking that I have seen everything, I am quickly humbled, (usually at the next birth that I attend), so I now acknowledge that I just know what I have seen. I used to think that women choosing to birth at home were being irresponsible. That was partly due to my ignorance at the time and mostly due to the fact that 75% of the attorneys in CA are in Los Angeles which makes for a litigious mindset. Today, however, if I was to find out I was pregnant, (and 20 years younger), I would be having my baby at home, in a birthing pool – and if my midwife did not arrive in time for the birth, I would be confident that I had two perfectly good hands to receive my child. That is how much I trust nature and a woman’s capability to birth naturally. With that said, the reality is that nature and common sense don’t carry a lot of weight in most cultures. I just came from Suzanne Arms roundtable in Brazil in March where I was horrified to learn that C-section rates are actually worse in countries outside the US. Private hospitals in Venezuela also have a 100% C-section rate. The way one obstetrician deals with it is by choosing to work only in a private clinic where she is able to practice with the midwifery model. Another obstetrician says the only way he can get around it is by having a doula with the mother until it is determined that she is at least 7cm dilated at which point she goes to the hospital and it is too late for surgery so the mother is able to have her natural birth. In Europe, midwives are honored while in CA everything is being done to put them out of business. There are many great OB’s here but there are many more of the not so great ones. But let’s put things in perspective. I had a “high risk” obstetrician take my childbirth course and he sat there in awe as I taught about the normalcy of birth. I was initially intimidated to even have him in my class but he ended up being a great asset. Every time a couple asked if what I was saying was true, he would just nod his head and say “Yes. This is incredible. It makes so much sense but they sure don’t teach you this in medical school.” What I am suggesting is that a lot of the horrifying things we see going on is not necessarily intentional but just carrying on the same routines and protocols that have been passed down from one generation of doctors training the next simply because that is the way it has always been done. Now add to that the fact that 70% of hospital profits, (at least here in LA) are generated from the labor/delivery ward and there is not much hope that change is going to occur at the hospital or doctor level. But the accountant side of me knows that even the business of giving birth, like any other business, is consumer driven so that is where I believe we can effect the quickest change. So we thank people like Angy that do such important research that we can take to our consumers. We educate our parents that giving birth in a hospital is merely the bed they have chosen go give birth in and need not be anything more. They can say no to interventions and inductions that are not medically indicated. Just because something has always been done that way does not mean that it is the only way and certainly doesn’t mean it is the best way. We can refer to those great OB’s and midwives that are out there and congratulate parents that take responsibility for their own births, being especially supportive when they choose to use a birth center or have a home birth because they will definitely need additional support (at least here). We continue to write our books and teach our programs on the normalcy of birth. It may be the slow road to change but by empowering parents to make good choices for their baby which includes finding caregivers that want to support their choices, the flow of patients, (or customers) will shift from caregivers with old ways of thinking to those with hopefully older ways of thinking when it was believed that when it comes to childbirth, “less really is more.)

  22. | #22

    This is such an interesting article. It is unfortunate that when a midwife refers to a hospital that they do not trust her judgement and collaborate in a way that is best for the patient. It should be that prenatal care includes matching the right approach to the right patient and not taking a one size fits all approach. Low risk pregnant women would benefit so much from understanding what a midwife birth means. I am so glad you are writing this and spreading the word. Best, Allison

  23. | #23

    Hi Allison – I had fun interviewing Angy and she made the midwifery model of care so accessible and easy to understand!

  24. | #24

    @Teresa Van-Zeller
    Hi Teresa – Thanks for your positive comments! I learned alot from Angy – it was empowering to hear her talk abt her journey from thinking homebirth people were extremists to where she is today.

  25. | #25

    @Regine Marton MS CNM

    I wish there were a less laden term than “rape” to describe what happens with this particular kind of loss of control and subtle abuse of power, particularly in cases in which it is unintentional, even well-meaning.

  26. | #26

    Hi Angy – thanks for checking in…rape sure is a loaded term. It’s odd though that anyone couldn’t wait for a woman to catch her breath before going ahead with an examination. You dont sound like an extremist to me.

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