In this post, I will go over the pros and cons of home birth, “is home birth safe?,” “are home births dangerous?,” who is present at a home birth, and “why home birth is safer than the hospital.”
Is Home Birth Safe?
One study looked at home births in 2016 to 2018 and found that most intended home births in the united states are not generally considered “low risk” [17]. Some of the conditions commonly noted as “high-risk” (although there may be debate around some of these and how they can be handled) include gestational diabetes, hypertension, a breech baby, a higher BMI, twins, vaginal birth after a cesarean, and even obstetrics considering pregnancy at 35 years and older as high-risk (cue my palm to my forehead).
A few studies looking at home birth compared to hospital birth have found no difference in maternal or neonatal mortality or morbidity [3, 5, 9]. In the largest planned home birth analysis that looked at outcomes of care for 16,924 planned, midwife-led home births in the U.S. found, the intrapartum, early neonatal, and late neonatal mortality rates were 1.30, 0.41, and 0.35 per 1,000, respectively [5].
Another study looked at 814,979 women, 466,112 had a planned home birth and 276,958 had a planned hospital birth [12].
The combined intrapartum and neonatal death rates up to 28 days after birth, including cases with discrepancies in the registration of the moment of death.
- For women who have never given birth, the intrapartum and neonatal death rate was 1.02% for planned home births versus 1.09% for planned hospital births.
- For women who have given birth before, the intrapartum and neonatal death rate was 0.59% for planned home births versus 0.58% for hospital births.
- Further, among the women who have given birth before, the rates of APGAR scores below 7 and NICU admissions were significantly lower at 1.36% for planned home birth compared to 1.95% for planned hospital birth.
What Does the Other Side of Research Look Like?
I want to make it clear that the studies that did find an increased rate of mortality in home births when compared to hospital births were of similar quality of evidence as the studies that did not find a difference.
However, the studies that did not find a difference in outcomes from home birth compared to hospital had much more impressive numbers of participants which certainly adds credibility.
The study that the American College of Obstetrics and Gynecology (ACOG) lists on their website says, “the relative risk to the infant may be two-fold, with absolute risks of about 1.2/1,000 versus 0.6/1,000 for home and hospital, respectively. The literature is not conclusive as to the magnitude of these rates because the available data make it difficult to distinguish between planned and unplanned or accidental home births, attended and intentionally unassisted births (also called “freebirths”), and provider type, if present” [18].
Who is Present at a Home Birth?
If you are planning a home birth, you should definitely have a trained and certified midwife. Certified Professional Midwives (CPMs) are the most common practitioners for home birth who have years of experience and education in the home birth setting.
Certified Nurse Midwives (CNMs) may also practice home birth, however, if they are a newer CNM practicing home birth, it is good to keep in mind that all of their training and education took place in the hospital setting which is very different than how prenatal care, births, and postpartum care is at home.
Learn more about the education and training different midwives have.
Your home birth midwife may have another midwife as a partner who attends your birth. And/or your midwife may have a student midwife or two, which add hands for neonatal resuscitation if needed and help with charting so you can have more time with your midwife if desired.
Furthermore, you may hire a doula to be present at your birth! Even with a home birth midwife, I highly recommend a doula. Check out 7 Reasons You Need to Hire a Birth Doula to learn more!
Why Home Birth is Safer Than the Hospital?
Many hospital birth experiences consist of doctors and hospital midwives making the decisions for the mother. Like in my labor and birth story when a physician and nurse came in, did an exam, and broke my waters without a word to me about it.
And in some cases, they do ask but did they really give you all of the benefits, risks, and alternatives and time to make an informed decision?
Some people like the medicalized birth experience and not making many decisions, however “every pregnant woman also needs to know that the standard maternity care is not evidence-based and, therefore, the healthcare provider and place of birth will influence the care that she receives in powerful ways” [1].
Non-evidence-based practices used are often to control pregnancy, labor, and birth and consist of interfering with the natural course of birth through unnecessary interventions.
“The routine use of intravenous fluids, restrictions on eating and drinking, continuous electronic fetal monitoring, epidural analgesia, and augmentation of labor characterize most U.S. births. The use of episiotomy is far from restrictive. These interventions disturb the normal physiology of labor and birth and restrict women’s ability to cope with labor. The result is a cascade of interventions that increase risk, including the risk of cesarean surgery, for women and babies”
Lothian, 2009
More women in America are moving away from continuing to accept this type of care. Especially after learning more about birth physiology and what true informed consent is and looks like! Unfortunately, a lot of this information had to come from outside of their OB-GYN’s office that almost all of us grew up going to.
The Increasing Risk of Cesareans from Hospital Births
In 2021 our overall cesarean rate was 32.1%. The report notes that most cesareans every year (roughly 3 out of 5) are primary cesareans, and that 4 out of 5 women who have had a primary cesarean delivery will go on to have another cesarean for subsequent births.
True indications for a cesarean section include:
- Umbilical cord prolapse with a cephalic (head down) baby
- Placenta previa
- Placental abruption
- Persistent transverse lie of fetus
- Obstruction (a large uterine fibroid, a pelvic fracture)
- Genital herpes at the time of birth
However, each of these conditions occurs in considerably fewer than 1% of births.
In contrast, the two most common reasons for cesarean section in America today are fetal distress and “failure to progress”. Further, the vast majority of these occurrences are iatrogenic: meaning, the issue was caused by medical treatment. Which we know most of the time is unnecessary and is pressured or manipulated onto mothers to make them think these things are necessary.
Hello to CEFM which over 5 decades of use, despite evidence showing “it is ineffectual, prone to interpretive errors, has a 99% false-positive prediction of fetal distress, has increased the incidence of cesarean delivery, has not reduced the rate of cerebral palsy (CP), and has not produced better perinatal outcomes. With CEFM, OBs and labor and delivery nurses can simultaneously sit and watch multiple monitors. CEFM doesn’t seem to be going anywhere anytime soon in American hospitals” [13].
However, naturally, there’s an abundance of reasons a birth is likely to go well: 99% of the time there is only one fetus in the womb, 97% of infants are born head first, and 97% of fetuses have no major structural or genetic abnormalities.
The Most Significant Danger of Cesarean Births
The biggest issue with our unnecessarily high cesarean rates, which OB-GYNs and midwives are seeing more and more of, is called placenta accreta.
Placenta accreta is a condition in which the placenta grows into the uterine wall and will not release after birth, often because it has grown into the scar from a previous cesarean.
In the 1950s, accretas occurred in fewer than 1 in 30,000 births; and by 1980 the rates were 1 in 2,500. Today, 1 in 533 births has an accreta – a 55-fold increase in 60 years [14].
Furthermore, a study published in 2022 found, “according to current estimation, the incidence rate of placenta accreta spectrum may increase to 1 in 200 women undergoing cesarean delivery by 2025″ [15].
What’s worse, the maternal mortality rate in the face of accreta is as high as 7 percent. One obstetrician, in connecting a cesarean section today “the complications [of] tomorrow,” described a mother who had given birth at his hospital and died shortly after due to postpartum hemorrhage caused by placenta accreta: “72 units of blood, the entire hospital stopped [16].”
So, when you hear about postpartum hemorrhage being the leading cause of maternal death, I feel like so many of us have been sold this idea that it is these normal, healthy vaginal births where this just happens and that is much less common than these iatrogenic situations we have discussed.
We have such high rates of postpartum hemorrhage that has increased because of over-medicalization of birth regarding cesarean sections, inductions, and augmentations of labor with Pitocin.
Is Home Birth Safe? Our Bodies Are Smart
A significant difference between the true midwifery model of care and the obstetric model is that midwives know and believe that so much more often than not, the womb is safest place for baby to be.
At one home birth this woman was having contractions 5-7 minutes apart, but she was also acting as if she was going to have her baby very soon and usually contractions 5-7 minutes apart would be early labor which can last several hours or more and when a mother is going to give birth very soon her contractions are only 60-90 seconds apart.
She went on to birth her baby and her placenta and the umbilical cord were bad, not in good shape. And her body accounted for its current state of physiologic functioning and baby and mama were perfectly fine. But what could have happened in this case if she transferred to the hospital? They would likely give her Pitocin and her body and baby likely wouldn’t have coped well considering the placentas condition.
This would very likely have led to a cesarean and then the hospital professionals looking at this placenta and feeling pride in what they did and taking credit for a cesarean saving a baby’s life. But instead, this woman and her midwives were able to awe at the beauty and intelligence of life and our bodies.
The Pros and Cons of Home Birth:
There are pros to a planned hospital birth and pros to a planned home birth or birth center birth. (The cons of home birth are the pros of hospital birth and vice-versa).
The Benefits of a Planned Hospital Birth:
- If you desire a medicalized birth for predictability of timing labor and birth
- If you desire a medicalized birth for the feeling of it being safer to increase your satisfaction regardless of potential treatment or outcomes
- You can have an epidural or opioid pain medications, which are not available at home births or birth centers
- Quicker access to the NICU if needed
- Quicker access to the operating room if you need a surgery for a cesarean of postpartum hemorrhage
Is Home Birth Safe?
The Cochrane collaboration is a research database filled with only systematic reviews which are the highest quality level of evidence available. With this, no research confirms that hospital birth is the safest place to give birth.
The Cochrane Collaboration has this to say on the subject: “There is no strong evidence from randomised trials to favour either planned hospital birth or planned home birth for low-risk pregnant women. However, the trials show that women living in areas where they are not well informed about home birth may welcome ethically well-designed trials that would ensure an informed choice. As the quality of evidence in favour of home birth from observational studies seems to be steadily increasing…”
olsen et al., 2012
The Benefits of Home Birth:
Evidence-based benefits of home birth include:
- A reduced risk of postpartum hemorrhage
- Fewer assisted vaginal births, meaning the need for vacuum or forceps to help baby out [3, 11]
- Fewer cesareans [3,4, 5, 11]
- Less likely to experience severe perineal trauma and have higher perineal integrity rates, meaning there was no tearing [3-5].
- Higher spontaneous vaginal birth rates, meaning no induction or sped up labor [4, 5]
- Increased birth satisfaction [4]
- Higher rates of breastfeeding [5]
- Increased rates of successful vaginal breech births
- Reduced risk of an episiotomy [5, 11]
- Adequate postpartum care. Home birth midwives offer around 6 postpartum visits or more. Additionally, some or all of the visits are made to your house instead of you needing to travel with a newborn. The U.S. medical system only providing one 6 week postpartum visit as this is the only one they can bill insurance companies for.
- Increased rates of mother and baby bonding; more skin-to-skin and breastfeeding
- It costs less
- More partner involvement
- You can rest in your own bed after birth instead of where sick people congregate
- In-home prenatal and postpartum care for at least some of the appointments
- Increased chances of receiving evidence-based care and proper information (benefits, risks, and alternatives) to make informed choices
- Increased bodily autonomy
- Avoiding iatrogenic events (events caused by medical treatment)
- Less pressure to perform under non-evidence-based time constraints. One of the leading causes of cesarean is called “failure to progress” which is actually just “failure to wait“
- No strangers are involved
- Reduced rates of postpartum mood and anxiety disorders such as postpartum depression, postpartum anxiety, postpartum post-traumatic stress disorder, and more due to a reduced risk of birth trauma
- Your environment, including the people present is much more in your control
- Your kids can be involved in your birth experience
Questions or Comments on “Is Home Birth Safe?”
If you have any questions or comments, please leave them below👇🏻
Talk soon, mama!
– Katelyn Lauren
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References:
[1] Lothian J. A. (2009). Safe, healthy birth: what every pregnant woman needs to know. The Journal of perinatal education, 18(3), 48–54. https://doi.org/10.1624/105812409X461225
[2] Olsen, O., & Clausen, J. A. (2012). Planned hospital birth versus planned home birth. The Cochrane database of systematic reviews, 9(9), CD000352. https://doi.org/10.1002/14651858.CD000352.pub2
[3] Hutton, E. K., Cappelletti, A., Reitsma, A. H., Simioni, J., Horne, J., McGregor, C., & Ahmed, R. J. (2016). Outcomes associated with planned place of birth among women with low-risk pregnancies. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 188(5), E80–E90. https://doi.org/10.1503/cmaj.150564
[4] Alliman, J., & Phillippi, J. C. (2016). Maternal Outcomes in Birth Centers: An Integrative Review of the Literature. Journal of midwifery & women’s health, 61(1), 21–51. https://doi.org/10.1111/jmwh.12356
[5] Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. (2014). Outcomes of care for 16,924 planned home births in the United States: the Midwives Alliance of North America Statistics Project, 2004 to 2009. Journal of midwifery & women’s health, 59(1), 17–27. https://doi.org/10.1111/jmwh.12172
[6] Janssen, P. A., Lee, S. K., Ryan, E. M., Etches, D. J., Farquharson, D. F., Peacock, D., & Klein, M. C. (2002). Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 166(3), 315–323.
More references
[7] American Association of Birth Centers. What is a birth center? Accessed January 21, 2013. Available at: https://www.birthcenters.org/what-is-a-bc
[8] HealthyPeople.gov. Healthy people 2020: Maternal, infant and child health. Accessed January 21, 2013.
[9] Rooks JP, Weatherby NL, Ernst EK, et al. Outcomes of care in birth centers. The national birth center study. The New England Journal of Medicine. 1989;321:1804-1811. Available at: http://www.ncbi.nlm.nih.gov/pubmed/2687692.
[10] Brocklehurst P, Hardy P, Hollowell J, et al. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: The birthplace in England national prospective cohort study. British Medical Journal. 2011;343:d7400. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22117057.
[11] Johnson, K. C., & Daviss, B. A. (2005). Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ (Clinical research ed.), 330(7505), 1416. https://doi.org/10.1136/bmj.330.7505.1416
[12] Jonge, A., Verhoeven, C., & Thornton, J. (2016). Re: Perinatal mortality and morbidity up to 28 days after birth among 743 070 low‐risk planned home and hospital births: A cohort study based on three merged national perinatal databases. BJOG: An International Journal of Obstetrics & Gynaecology, 123(7), 1235–1236. https://doi.org/10.1111/1471-0528.13935
[13] Sartwelle T. P. (2012). Electronic Fetal Monitoring: A Defense Lawyer’s View. Reviews in obstetrics & gynecology, 5(3-4), e121–e125.
[14] Cesarean Section: An American History of Risk, Technology, and Consequence. By Jacqueline H. Wolf. Link here.
More references:
[15] Han X, Guo Z, Yang X, Yang H, Ma J. Association of Placenta Previa With Severe Maternal Morbidity Among Patients With Placenta Accreta Spectrum Disorder. JAMA Netw Open. 2022;5(8):e2228002. doi:10.1001/jamanetworkopen.2022.28002
[16] “Management of Placenta Accreta”; interview of retired obstetrician by author, Chicago physician interview 8, October 5, 2012, Chicago IL, transcribed from digital recording.
[17] Grünebaum, A., McCullough, L. B., & Chervenak, F. A. (2020). Most intended home births in the United States are not low risk: 2016−2018. American Journal of Obstetrics and Gynecology, 222(4), 384–385. https://doi.org/10.1016/j.ajog.2019.11.1245
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