Exploring some aspects of home to hospital transports

“What is your transport rate?” During interviews between a midwife and a potential client, this is a common question.  The straightforward interpretation is: ‘in your practice, how many women do you end up taking to the hospital during labor from their planned home birth?” 
 
This question is more complex than it would first seem and to tease apart the layers gives more insight than answering with a simple percentage.  To do that in any meaningful way, you need studies that can look at large numbers.  One of the more recent studies looked at planned, midwife attended home births between 2004 to 2009 and found that the overall transport rate during labor was 10.9 %. 
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However, this number may not accurately represent a midwife with a small home birth practice.  The frequency of transporting to the hospital for any individual midwife has more to do with the demographics of her practice.  If a midwife has a client base of mostly women for whom the pregnancy is not the first baby, then her transport rate is likely to be very low.  If a midwife has all first time mothers as clients, that will make for a high looking transport rate.  Age can also be a factor:  women who are in their upper 30s who are having a first baby have a higher rate of transport than women of the same age range having a consecutive baby. 
 
A midwife’s level of skill also plays a part.  It would be expected that a newly launched midwife, whose goal is to practice safely, would transport with a bit more frequency than someone who has had years of experience.  A seasoned midwife simply has more skills at her disposal with a more nuanced eye to evaluate what situation can be worked with at home and when it becomes necessary to go in.  
 
The legality of the practice of midwifery in one’s particular state will also affect the transport rate.  States in which the practice of midwifery is illegal or are hostile to midwife-attended home births create an environment in which midwives and their clients are fearful about transporting.  They may wait too long to go in resulting in a lowered number of transports but ones of a more serious nature. 
 
The safest home birth and midwifery practice environments are places where midwifery is legal, where midwives can consult and transport freely without fear of legal repercussion for simply seeking timely help.
 
Built into this question, I feel, is an underlying assumption that transporting to the hospital is a bad thing.  Of course, if someone is planning a home birth, we all want that to be successful with no need to go to the hospital.  However, there are times during the course of the labor when it becomes clear that a baby is simply not going to be born at home.  Most likely it is due to a stalled labor that needs some kind of assistance after everything has been tried at home to make that happen.  So, if that is the case, after a laboring woman and her team of supporters and care providers have tried everything and had a discussion of options, then going to the hospital is a prudent choice, a necessary choice, and even though can be a disappointing turn of events, it isn’t a “bad thing.”
 
There are a couple more points the question of transports bring.  What if, during your interview with a midwife, she relates that she never or rarely ever transports?  It’s possible that she is a very experienced midwife with a practice of women in their mid-twenties, none of whom is having a first baby.  Or perhaps she is simply telling you what she believes you want to hear?  It would be worth asking a few more questions to figure this out.  A woman seeking midwifery care should be looking for a reasonable and thoughtful approach to complicated labors that need to transport, not something sounds like an implied guarantee that births will always happen at home. 
 
If birth teaches us anything, it is that none of us are in the driver’s seat for this most common of miracles.  Other than the skills and knowledge that a midwife appropriately uses for an individually unfolding labor and birth, she ultimately has no control over how a labor will go.  Yes, there are some women who, statistically, have a higher chance of needing to transport, but no midwife carries a crystal ball in her birth bag, and the hopefulness of “defying the odds,” for an otherwise healthy, low-risk woman, deserves a real chance (called a ‘trial of labor’ in technical terms).  Midwives are sometimes surprised, in hindsight, of who ended up successfully birthing at home and who ended up needing to transport.  Statistics can tell some of the story but they can’t always tell your story. 
 
Even though the question of transporting can’t be answered in a meaningful way with a flat number, it still deserves to be discussed during an interview with a home birth midwife.  Better questions to ask are: What are some reasons women in labor transport? Who is more likely to need to transport and why?  What skills do you have to try to work with those situations so that a transport won’t be necessary? How do you know when it is time to transport?  How do you handle a transport? 
 
The best we can hope for and continue to work toward is for providers of all levels of care, from home birth midwife to high–risk obstetrician, to be able to communicate and collaborate so the most appropriate level of care is easily accessible for any pregnant woman at any stage of this journey.