What is a woman really asking when she asks her midwife what the midwife's transfer rate is? Women often interview several private midwives when they are choosing the right midwife for their needs. Women will ask many questions of their prospective midwife, and one of the more common questions is, "What is your transfer rate?" meaning, "what percentage of the women who book with you for homebirth, end up transferring to hospital?"
On the surface, this seems like a fair question. But what is the woman really asking? I consider that the woman is really asking, "If I book with you, what's my chance of being transferred?" and when women ask the same question of several midwives, they are most reassured by the midwife with the lowest transfer rate because they perceive that they have the lowest chance of transferring if they go with the midwife with the lowest transfer rate.
Is it a fair assumption to make, that the midwife's transfer rate, representing her previous client's outcomes, are a valid guage for the current woman's likelihood of transfer? Often I find that transfers can't be predicted at the time a woman books-in for care. If we could predict it, we'd recommend a planned hospital birth. Considering transfer rates from this perspective, a midwife's transfer rate has no bearing on the current woman sitting with her. As well as this, some transfers occur because the woman has requested it - eg a request for transfer for an epidural, but not on the advice of the midwife as the labour is actually progressing very normally. The other situation that can arise is that the midwife forsees problems occurring and makes some recommendations to avert those problems, but the woman considers the recommendations and declines to follow them. In these cases, again, the midwife's transfer rate has no bearing on each new client who interviews a midwife.
What's a "good" homebirth transfer rate?
Well, many might argue that the lowest transfer rate is the best transfer rate. You're setting out for a homebirth, right? So why go to the midwife with a "high" transfer rate?
I did some scouting around on the internet and found that transfer rates range from 10% through to 50%. The Netherlands has a transfer rate of 52%! This surprised me. In the Netherlands, 86% women start in "primary" care (midwifery care), 28% are transferred in pregnancy and 17% are transferred in labour, leaving 41% women birthing with midwifery care. Of this 41%, 30% occurred at home and 11% occurred in hospital.
The St George hospital homebirth program reported a transfer rate of 37% for its first 100 births and this was in a low-risk clientele (at the start of pregnancy). Their outcomes were excellent, however and the satisfaction of the women and midwives using / working in the service was very high.
Private midwives' transfer rates vary - anywhere from 10% to 40% in some States of Australia as well as overseas. So there's a wide fluctuation. What can we deduce from these transfer rates?
Well, with the exception of the Netherlands - which has large numbers - we can't really deduce very much at all. You never can when you're dealing with small numbers. Private midwives in Australia typically don't attend more than 25-30 births a year, and some as few as 5 births a year. One transfer in 5 births is 20%, whereas if that same midwife had attended more births without complication, perhaps the transfer rate would have only been 10%.
There are a couple of things to consider with high and low transfer rates: 1. The risk status of the women at booking 2. The midwife's adherence to safety and risk management guidelines and her outcomes.
The midwife with the lowest transfer rate might simply have a low transfer rate because she only attends very low risk women: women who have birthed without complication before, who have no health history and who have no problems in their current pregnancy.
The midwife with the high transfer rate might not be transferring willy-nilly, she might just be taking on a higher risk group of women and adopting a wait and see approach - eg, "yes, you have a family history of high blood pressure and you've had it with every pregnancy thus far, but let's try some preventative measures and see what happens this time", and continue with homebirth plans. If this woman's blood pressure went up, she would have been transferred, contributing to the midwife's "high" transfer rate. The low risk / low transfer rate midwife might not have accepted this woman for homebirth at all, hence the difference in transfer rates.
The other thing to consider with transfer rates is the midwife's commitment to safety and risk management. Some midwives may have low transfer rates because the decision to transfer is prolonged, or because risk factors are denied. Is it good to have a low transfer rate if women or babies have been compromised?
But getting back to the question, "If I book with you, what's my chance of being transferred?", this question is impossible to answer. 1. We can't tell the future. Family history and health history might shine some light on possible issues for the pregnancy, but not necessarily. We can't predict all the paths a pregnancy can follow. 2. A woman's determination to move towards - and remain in - a state of health and wellness is a life-long journey that pre-dates the pregnancy. 3. Although midwives will make recommendations with the aim of homebirth in mind, it is the woman's right to consider the advice and decline it. Declining a midwife's advice may well mean that a transfer will become necessary. 4. Midwives' statistics are only relevant to her past clients, not the client sitting with her currently. 5. For many midwives, the goal is really safety: safety for woman and baby. We strive to achieve the safest birth in the setting that can best meet the needs of our client.
Melissa Maimann is an eligible midwife in private practice in Sydney. One of the first eligible midwives in Australia, Melissa offers a range of care options for women. Visit Melissa's website to learn more about her services.