According to the American College of Obstetricians and Gynecologists (ACOG), roughly 35,000 births per year in the United States happen at home (1). With the rise in popularity of home births, we are going to dig into families’ motivations for choosing a home birth and how they compare to hospital births in terms of safety.
Why do women choose home births?
Some common reasons women choose to have home births include:
- More flexibility in labor positions and movement during labor
- More flexibility in eating and drinking during labor
- The familiarity or comfort of the home setting during labor and delivery
- The company of friends and family during labor and delivery
- The ability to avoid medical interventions such as labor induction, pain medication, fetal heart rate monitoring, and others (2, 3).
What does a home birth look like?
While many aspects of a home birth are personalized to the mother (such as linens, music, aromas, and other comforts), most certified midwives have standard medical equipment that they will bring with them to home births (3). Tools for home birthing include:
- Medications to slow or stop hemorrhage
- Suturing tools
- Ultrasonic stethoscopes or fetoscopes
- Oxygen for the baby
- IV’s for the mother if needed
The midwife present will likely periodically monitor the baby’s heart rate, as well as the mother’s blood pressure, pulse, and temperature.
What does a hospital births look like?
Hospital births involve the following (4):
- A nurse present to monitor the labor process
- Monitors in place to continuously monitor the baby’s heartbeat with a fetal heart rate monitor
- A close proximity to the operating room for a planned or emergency cesarean delivery
- Access to pain relief
- Physicians in house
- Pediatricians in house and a nearby Neonatal Intensive Care Unit (NICU) in case neonatal emergencies occur
What care is needed when fetal distress occurs?
If a baby starts to suffer from a lack of oxygen to the brain, this will show up as a non-reassuring heart tracing on the monitor, called fetal distress. Hospital deliveries offer quick access to medical professionals and the tools necessary to address fetal distress and other complications properly and immediately. When a baby is in distress, delivery should occur immediately, in most cases. If a baby cannot be safely and quickly delivered by a vaginal delivery, a c-section should be performed to get the baby out of the oxygen-depriving conditions and allow physicians to help if needed. Failure to quickly deliver a baby experiencing a lack of oxygen to the brain can cause a permanent brain injury called hypoxic-ischemic encephalopathy (HIE), which often leads to cerebral palsy and other conditions.
When would a home birth become a hospital birth?
Complications can arise during home births that require hospital care immediately. For this reason, one of the most important parts of a home birth is making sure you have easy and fast access to transportation to the hospital (3). Most midwives would advise transporting the mother to a hospital for a hospital birth in the following cases:
- The mother is experiencing abnormal bleeding
- Labor has stalled
- Signs of fetal distress are present
- The mother needs pain relief
- The baby presents in a position other than head first
- The mother gets high blood pressure
Are home births safe?
While both the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists believe that hospitals and accredited birth centers are the safest places to give birth, they know that women have the right to make informed decisions about where they choose to deliver (5).
The American Public Health Association (APHA) and the American College of Nurse Midwives (ACNM) have endorsed the safety of home births under the following circumstances:
- The candidate is low-risk
- The provider is certified
- High-quality intrapartum fetal monitoring takes place
- Higher levels of care can be easily accessed
What factors could prevent a woman from having a home birth?
The Committee on Obstetric Practice strictly advises against planned home birth in the cases of multiple gestation, fetal malpresentation, or prior cesarean delivery (1). A doctor or midwife may additionally recommend against a home birth in the case of other high-risk pregnancy conditions, such as gestational diabetes, placental abnormalities, and others.
These qualifications are in place because of the several neonatal risk factors associated with home births in the United States. In a 2012 study of births in Oregon, the death rate for infants in planned home births was 7 times the death rate for infants born in hospitals (5).
What are the risks of a home birth?
We know a few facts about the risks associated with home births (1):
- Home births are associated with a threefold increased risk of neonatal seizures or severe neurologic dysfunction.
- Home births are associated with a more than twofold increased risk of perinatal death.
- Home births are associated with a higher risk of 5-minute Apgar scores less than 7, less than 4, and 0.
Home births are, by nature, outside of an institution with the capacity to quickly perform a C-section delivery if necessary. This greatly increases the baby’s risk of suffering permanent brain damage, birth injuries, hypoxic-ischemic encephalopathy (HIE), cerebral palsy, and seizures.
Home births and hypoxic-ischemic encephalopathy (HIE)
Home birth is associated with an increased risk of hypoxic-ischemic encephalopathy (HIE). A 2007-2011 study in a New York City hospital found that newborns with HIE had a 44.0-fold odds of being delivered outside of the hospital (5).
Why are home births risky?
According to a New York Times piece by Amy Tuteur, the risks associated with home births have to do with the people performing them (5). There are two types of midwives in America, certified nurse midwives (CNMs) and certified professional midwives (CPMs). The former are a highly-trained group, complying with standards set by the International Confederation of Midwives, while the latter do not receive the same education and training.
CNMs achieve a university degree in midwifery. Additionally, they complete extensive training in a hospital, where they diagnose and manage birth complications. CPMs, on the other hand, do not receive such training, and in fact, only legally practice in 28 states. The success rate of CPMs is worrisome: home births attended by CNMs had double the neonatal mortality rate of hospital births attended by CNMS in 2010; home births attended by CPMs had nearly four times that rate in the same year. Yet CPMs attend the majority of home births in America.
In some countries, home births have much higher success rates, probably because eligibility requirements are stricter. In the US, however, the CPMs make their own rules about what is safe and pursue home births even when a woman is considered high risk.
It’s no surprise, then, that ACOG advises those women that choose to pursue a home birth to select “a certified nurse midwife, certified midwife, or midwife whose education and licensure meet International Confederation of Midwives’ Global Standards for Midwifery Education” (1). They recommend this choice as an addition to the woman having access to safe and fast transportation to a hospital and access to consultation from a physician.
Making a hospital birth more comfortable
There are many ways to combine the comfort of your home with the safety of a hospital birth (6). Here are a few things mothers have done to make hospital births feel more comfortable:
- Hire a midwife for your hospital birth: Many CNMs deliver at hospitals as well as at home births. These trained professionals can help to provide the same level of comfort you could have had at home in the hospital setting. Call your hospital to find out which CNMs deliver there.
- Hire a doula: Doulas offer natural pain remedies, gentle comforts, and have been known to improve birth outcomes and help women maintain their birth plans.
- Choose a birth center: Many hospitals have birth centers, which offer in-house natural birth experiences that are almost identical to home births.
- Ask about comforts: Some hospitals have items available, such as birthing balls, water therapy, ice packs, and other tools. Patients may also be able to walk around during labor and explore different parts of the building. It’s a great idea to call ahead and ask about these options.
- Pack comforts: A great way to make a hospital room feel more homey is by bringing your favorite comfort items with you. Ask hospital staff what you’re allowed to bring before you come, and pack accordingly. Even just your choice of music, scented lotions, or a body pillow can make a huge difference.
If you are considering a home birth, it’s important to weigh the pros and cons of this decision. A hospital room can offer many of the comforts of home, while also providing safety and emergency medical care when necessary.
- Women’s Health Care Physicians. (n.d.). Retrieved September 29, 2018, from https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Planned-Home-Birth
- Home birth: Know the pros and cons. (2017, July 07). Retrieved September 30, 2018, from https://www.mayoclinic.org/healthy-lifestyle/labor-and-delivery/in-depth/home-birth/art-20046878
- Home Birth: Benefits and Tips. (2017, July 19). Retrieved September 29, 2018, from http://americanpregnancy.org/labor-and-birth/home-birth/
- WhattoExpect. (2014, December 23). Delivering in a Hospital: What All Moms Need to Know. Retrieved October 1, 2018, from https://www.whattoexpect.com/pregnancy/hospital-birth/1
- Wasden, S. W., Chasen, S. T., Perlman, J. M., Illuzzi, J. L., Chervenak, F. A., Grunebaum, A., & Lipkind, H. S. (2017). Planned home birth and the association with neonatal hypoxic ischemic encephalopathy. Journal of Perinatal Medicine,45(9). doi:10.1515/jpm-2016-0292
- Tuteur, A. (2016, April 30). Why Is American Home Birth So Dangerous? Retrieved September 29, 2018, from https://www.nytimes.com/2016/05/01/opinion/sunday/why-is-american-home-birth-so-dangerous.html
- Faulkner, J., & R. (2017, April 03). Are Hospital Births Becoming More Home-Like? Retrieved September 30, 2018, from https://www.fitpregnancy.com/pregnancy/labor-delivery/ask-labor-nurse/are-hospital-births-becoming-more-home