“We recognize and affirm the value of physiologic birth for women, babies, families and society and the value of appropriate interventions based on the best available evidence to achieve optimal outcomes for mothers and babies.”
My first exposure to home birth was in 1980, during my pediatric residency, when a paramedic burst through the NICU doors with a limp, blue baby in his arms–the product of a home birth gone very wrong. We cared for her as best we could, but she died a few hours later.
The baby’s young parents were devastated, of course. They had chosen to deliver their baby themselves at home rather than opt to give birth in the hospital. Though they had read volumes on normal birth, they’d given little thought to the possibility of complications–in this case shoulder dystocia and a tight nuchal cord–and by the time the paramedics were called it was simply too late.
That tragic experience shaped my opinion of home birth for the next twenty-five years: I concluded that having a baby at home was a risky, irresponsible thing to do. Not until long afterward did I stop to think that maybe the problem with this particular birth was not that it was a home birth per se, but that it had been poorly planned by inexperienced/overconfident parents with no midwife and no access to timely emergency aid.
The big question here in 2011, then: Is home birth a safe alternative to hospital birth? What are the real risks?
Let’s take a quick look at the pros and cons in the medical literature. (A big thank you to Professor Saraswathi Vedam, Director of the Division of Midwifery at the University of British Columbia–and the driving force behind the Home Birth Consensus Summit–for her Annotated Guide to Home Birth Literature.)
Evidence supporting home birth as a safe alternative to hospital birth:
A number of studies in North America and particularly in Europe have demonstrated that planned, midwife-assisted home births within an organized system of care can be safe for low-risk mothers and their babies (more on my italicized qualifiers below), and in many cases results in fewer complication-prone interventions as well. Some highlights (more can be found in the Annotated Guide):
1) Maternal and infant mortality and morbidity (complications resulting from birth):
- Janssen and colleagues (British Columbia, 2009): found no increase in risk of death or serious morbidity for either mother or baby from low-risk, registered midwife-attended home birth compared with hospital birth.
- de Jonge, et al, (the Netherlands, 2009): studied 529,000 low-risk women; no increased risk of death or severe newborn morbidity in home birth vs. hospital.
- Leslie and Romano (United Stated, 2007): low-risk out-of-hospital births had similar rates of neonatal mortality and morbidity, including birth trauma and NICU admission, compared with hospital births.
- Janssen, et al (British Columbia, 2002): found no difference between low-risk home and hospital birth in regard to serious neonatal complications requiring NICU care.
2) Obstetric interventions:
A number of studies cited in the Annotated Guide found that home birth is associated with a significant reduction in obstetric interventions, such as epidurals, induction or augmentation of labor, episiotomies, maternal fever, hemorrhage and severe tears or lacerations. Some of this has to do with the lack of certain technologies at a home birth (it’s darn hard to get an epidural at home, for one thing…), but regardless, there are clearly fewer interventions with home vs. hospital birth.
Evidence unfavorable to home birth:
1) Maternal and infant mortality and morbidity
- Wax and colleagues (click on “Wax Maternal and Newborn outcomes” in link for article PDF) performed a meta-analysis of international studies related to home birth safety. They concluded that a baby was three times more likely to die in a home birth than in a hospital birth. This study was both widely publicized and heavily criticized for a number of significant flaws, which cast doubt on its findings. See Gyte’s critique here for much, much more detail.
- Similarly, Chang and Macones (Missouri, 2011; to be published in the American Journal of Perinatology soon) concluded that home birth increases the risk of seizures and death for newborns. As with the Wax analysis, the authors have been criticized for irregularities in study design and execution, not the least of which were an unusually broad definition of “low-risk” pregnancies (which included both some premature and nearly all post-mature pregnancies) and the inclusion of a class of midwives that did not exist in Missouri at the time of the study.
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My opinion of home birth has changed considerably since 1980. Based on current research, planned, midwife-attended home birth for low-risk mothers in an integrated maternity care system does appear to be at least as safe for babies, and in some ways safer for mothers, as hospital birth.
Ah, but here’s the rub: What constitutes a “planned, low-risk” birth? What is an “integrated maternity care system”? And are safety studies from the Netherlands and British Columbia, where home birth midwives are an accepted part of the larger maternity care universe, applicable to the United States, where a tradition of acrimony and mutual suspicion in the childbirthing world has led to a badly fractured system of care?
Here’s just one example of that fracture: while home births are supported in states like Washington, hiring a home birth midwife, no matter how well-trained, is illegal in 10 states including the three I lived in as a child (Iowa, Indiana and Illinois).
This is a set-up for bad outcomes. A home birth midwife working under the radar in Indiana, say, might delay seeking consultation with an obstetrician or transferring a mother to a hospital for fear of prosecution, which in turn could lead to disaster. It’s not that my fellow Hoosiers are any less capable of giving birth safely at home. Poor communication between maternity caregivers increases the risk of delayed and uncoordinated care, making a home birth in Indiana theoretically riskier overall than a home birth in Washington.
An enormous amount of work will need to be done before home birth becomes a safe option for all low-risk women in the United States, regardless of location. But new research on the benefits of vaginal birth, particularly home birth, for the development of a child’s immune system makes it important that we get started on this critical work now.
And that’s why the vision statements from the Home Birth Consensus Summit are so important. They reflect a set of common agreements among very disparate groups–a big first step in what I hope will be an interesting, thoughtful process leading to healthy outcomes for mothers and babies.