Having Your Baby at Home, or Thinking about It?

Home birth is increasing in popularity in the United States, although it still accounts for a  small percentage of births overall – less than 1%.  If you are thinking about a home birth, you need to ask yourself a lot of questions, do some research, find out if there is a home-birth provider (usually a midwife) that you feel you can trust and work closely with, discuss it with your partner and family, and consider the decision carefully.   If you and home birth are meant for one another, it can be a powerful, astounding, and lasting experience. On the other hand, if you are making this choice for the wrong reasons, you are more likely to experience it with ambivalence, disappointment, or worse.  The information in this article is here to help you get started on your quest to see if having your baby at home is the right decision for you.

According to Wikipedia, “a home birth in developed countries is an attended or an unattended childbirth in a non-clinical setting, usually a residence, rather than in a hospital or a birth center.” Home births are usually attended by midwives or other attendants with expertise in managing home births, although they may be unattended or attended only by family members or friends.

Home birth appeals to women who want the familiarity, intimacy, freedom, and control that being in their own home provides; who believe that birth is a natural process and want to minimize the risk of unnecessary and routine interventions that commonly occur in many hospitals.  Women who seek a home birth are screened carefully to assure that they are appropriate candidates – that is, they are healthy, at low risk for complications during pregnancy and birth; they are motivated to prepare for the experience, to eat a healthy diet, etc.; and they are not choosing home birth for the wrong reasons (e.g., they can’t afford a hospital birth, they are afraid of hospitals).

Until early in the 20th C, most people were born at home.  In fact, the first edition of Williams Obstetrics, published in 1904, assumes that the physician will be attending the laboring woman at home, and advises him on the necessary contents of the “obstetrical bag” to take to the home at the time of “confinement.”  “The obstetrical valise should contain a pelvimeter, a pair of nail clippers and a nail cleaner, chloroform, permanganate of potash, oxalic acid, green soap, and a nail brush, 1 ounce of ergotol or fluid extract of ergot, tablets of sodium chloride for preparing normal salt solution, and a hypodermic syringe with the usual tablets.”  Well, this is all fascinating and I could go on, since the obstetric valise contained other things as well.  The midwife or other home birth attendant today also carries a bag with necessary equipment, which varies considerably from that obstetric bag of a century ago.  The 23rd edition of Williams Obstetrics frowns on home birth, and assumes that birth will take place in the hospital.  In developing countries, where women may not be able to afford medical care or it may not be accessible to them, a home birth may be the only option available, and the woman may or may not be assisted by a professional attendant of any kind.

In most developed countries, midwives who meet the standard definition from the International Confederation of Midwives are educated to practice midwifery in the hospital, in a birth center, or in a home, and have a mechanism for consultation and referral during pregnancy, labor, birth, and postpartum for women who experience difficulty.  This is the ideal situation, providing continuity of care for women laboring at home in the event that they require transfer to the hospital, and for the midwives attending them, so that they can continue to care for them in the hospital setting, to the extent that their scope of practice allows and in collaboration with other providers.  This model is the norm in the Netherlands, in the U.K., in Scandinavian countries, and in Canada.

History of Home Birth in the U.S.

The practice of midwifery was reborn in the 1960s-70s in the United States in two separate forms.  Nurse-midwifery grew of out public health nursing, and nurse-midwives attended women who could not get care from physicians.  They organized as the American College of Nurse-Midwives in 1955.  At first, these women were attended in their homes, but as the mainstream medical profession began to accept nurse-midwives in hospitals, the care moved to that setting.  For the low socio-economic, sometimes medically high-risk women followed by nurse-midwives, the hospital seemed to be a better setting, particularly since the homes of many of these women were unsuitable for an event that required cleanliness, proper supplies, privacy, and calm.  Nurse-midwives gradually became almost exclusively hospital providers, although a small number continued to attend home births.

On the other hand, home birth was part of a greater grass roots movement away from the social constraints of the 1950s, and the majority of midwives who attended women in their homes were, at first, self-taught.  As they gained experience, they took apprentices, and taught other women the knowledge and skills that they had learned on their own.  Home-birth midwives were only loosely organized until the late 1980s and the founding of the Midwives Alliance of North America (MANA).  Although this organization was open to nurse-midwives as well, it became an organizational home for  “direct-entry,” “lay,” or “home-birth” midwives, and eventually led to separate but affiliated organizations to educate, certify and regulate midwives as CPMs (North American Registry of Midwives, NARM) and to accredit direct-entry midwifery training and educational programs (Midwifery Education and Accreditation Council, MEAC).  However, although CNMs are licensed and regulated in all 50 states, home-birth midwives may or may not be CPMs and/or be licensed, depending on the state in which they practice.  While clinical training for CNM students occurs almost exclusively in hospitals, education and clinical training for CPMs focuses specifically on out-of-hospital birth.

Although the two paths in midwifery led to very different ways of learning, practice sites, characteristics of clientele, regulatory mechanisms, methods of payment, etc., all midwives shared and continue to share one central philosophy or belief – that is,  childbirth is a normal, natural, physiologic process, not a disease or an abnormality. The response to this philosophy was the Midwifery Model of Care, espoused by all midwives.   In the 1950s and 1960s, hospital-based birth didn’t look like a natural process – it looked like a surgical procedure.  Women were treated badly by hospital staff, drugged with “maternity cocktails” to the point where they were essentially absent from the birth of their own babies, who were assisted into the world not by the mother’s pushing efforts but by routinely applied forceps.  Fathers and family members were forbidden in the delivery room, and babies were whisked away to a “sterile” nursery as soon as they were born and given a bottle of formula. Babies born outside the delivery room or the hospital were taken to the “contaminated” nursery so they wouldn’t endanger the other babies with their germs.

Women began to revolt against this inhumane attitude toward them and their births and looked elsewhere for something better.  They found midwives, childbirth educators, and a few physicians, mostly in France, who were also in revolt against the extremes to which medicalization had taken childbirth.  In 1964, Marjorie Karmel’s best-selling “Thank You, Dr Lamaze” introduced Fernand Lamaze’s method, consisting of childbirth education classes, relaxation, breathing techniques and continuous emotional support from the father and a specially trained nurse, to women in the U.S.  Some women worked to make hospital birth more mother-friendly, but others weren’t satisfied with this compromise and looked outside the hospital for alternatives.  They found home birth. In 1971, Ina May Gaskin and her husband Stephen founded The Farm, a commune in Tennessee, and Gaskin started attending births for the other women there.  Gaskin was self-taught in midwifery, but she was an intelligent and educated woman and quickly became an auto-didact in obstetrics.  In 1977,

her book “Spiritual Midwifery” was published and became a sensation.  According to Carol Lorente, “Considered a seminal work, (Spiritual Midwifery) presented pregnancy, childbirth and breastfeeding from a fresh, natural and spiritual perspective, rather than the standard clinical viewpoint. In home birth and midwifery circles, it made her a household name, and a widely respected teacher and writer.”

Up until 2004, the rate of home birth in the U.S stayed around 0.5%.  However, the rate has been increasing in the U.S. since then; in 2009 it was up to 0.72%, still a small overall percentage but a significant increase in absolute numbers, to 29,650.  That year, Montana was the state with the highest percentage of home births (2.55%) followed by Oregon (1.96%) and  Vermont (1.91%).

In 2009, 62% of home births were attended by midwives: 19% by certified nurse midwives and 43% by other midwives (such as certified professional midwives or direct-entry midwives).  Only 5% of home births were attended by physicians, and a previous study suggested that many of these were unplanned home births (possibly involving emergency situations). See MacDorman et al for more statistics about recent home birth trends in the U.S.

Safety of Home Birth

In the United States, there is ongoing controversy about the safety of home birth. The American College of Obstetricians is at best equivocal about home birth, stating in a position paper that “although the Committee on Obstetric Practice believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery. Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence.”  The American College of Nurse-Midwives takes the position that “every family has a right to experience childbirth in an environment where human dignity,self-determination, and the family’s cultural context are respected.  Every woman has a right to an informed choice regarding place of birth and access to safe home birth services.” The Midwives Alliance of North America’s homebirth position paper states that “homebirth is an expression of a woman’s autonomy and a process in which her autonomy and privacy are assured. A woman has the right and responsibility to choose the place and care provider for pregnancy, birth, and postpartum and to make decisions based on her knowledge, intuition, experiences, values, and beliefs.”  Clearly, these are differences in opinion that reflect the beliefs, values, and practice of each professional organization.  They are based somewhat on professional bias, and clearly not solely on evidence from research studies.

Until recently, home birth had not been researched for its safety. Quality research on home birth vs birth center or hospital birth is difficult; large studies are expensive, they can be difficult to carry out.  Women will make choices based on their own biases and on the biases of those who influence them.  The best that researchers can hope for is to design a study that compares outcomes in similar groups that give birth in different settings. That being said, several important studies on outcomes of home birth compared to hospital birth have been published in the last few years.  A few of the major studies are described below. (This section does not include studies on birth-center birth – they are on the birth-center page.)

Johnson and Daviss, working with MANA, conducted a large prospective study on the outcomes of home birth in low-risk women in the United States and Canada in 2004.  The authors looked at intrapartum and neonatal mortality, perinatal transfer to hospital care, medical intervention during labor, breast feeding, and maternal satisfaction for 5418 births undertaken by 409 certified professional midwives (CPMs) in the year 2000.  They concluded that “planned home birth for low-risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.”

In the Johnson and Daviss study, there were 80 planned breeches at home with two deaths and 13 sets of twins with no deaths.  As the authors note, “breech and multiple births at home are controversial among home birth practitioners.”  (In fact, these births do increase the risk of adverse outcomes and many midwives exclude them from consideration for home birth for this reason.)  In the 694 births (12.8%) in which the baby was born under water, there was one intrapartum death (birth at 41 weeks, five days) and one fatal birth defect death.

The Netherlands has a system of pregnancy and birth care that is unique in the Western world. The majority of Dutch midwives work independently from obstetricians, are the sole care providers for low risk women and are primarily responsible for the system of risk selection. Almost 30% of women choose to give birth at home.  In their study of this system, De Jonge et al, showed no differences in perinatal mortality between planned home and hospital births among 529,688 low risk women in a nationwide cohort study.  To read more about the unique features of the Dutch system, the main findings of the recent home birth study, and the possible implications for the birth care system in the US, read the online article cited below.
In Canada, midwives are educated in a 4-year baccalaureate program with clinical training in home birth, birth center, and hospital sites, and midwives practice in all of those settings.  Janssen et al compared the outcome of 2889 home births for low-risk women in British Columbia from 2000-2004 with 4752 low-risk births conducted by the same midwives in hospital and also with 5331low-risk births conducted in hospital by physicians.  The authors found that the rate of perinatal death per 1000 births (intrapartum + neonatal deaths) was lowest (0.35}in the group of planned home births; the rate in the group of hospital births with a midwife was 0.57 and in the group with a physician the rate was 0.64. Women in the planned home-birth group were significantly less likely to have obstetric interventions, e.g., electronic fetal monitoring, assisted vaginal delivery, or adverse maternal outcomes (e.g., third- or fourth-degree perineal tear or postpartum hemorrhage) than women in either of the hospital groups.  Newborns in the home-birth group were less likely than those in either hospital-birth group to require resuscitation at birth or oxygen therapy beyond 24 hours.  In addition, newborns in the home-birth group were less likely to have meconium aspiration and more likely to be admitted to hospital or readmitted if born in hospital.
Hutton et al. studied home birth compared to hospital birth for low-risk women in Ontario, also in 2009.  They found that “the rate of perinatal and neonatal mortality was very low (1/1,000) for both groups, and no difference was shown between groups in perinatal and neonatal mortality or serious morbidity (2.4% vs 2.8%. No maternal deaths were reported. All measures of serious maternal morbidity were lower in the planned home birth group as were rates for all interventions including cesarean section (5.2% vs 8.1%). Nulliparas were less likely to deliver at home, and had higher rates of ambulance transport from home to hospital than multiparas planning home birth and had rates of intervention and outcomes similar to, or lower than, nulliparas planning hospital births.”  The authors concluded that “midwives who were integrated into the health care system with good access to emergency services, consultation, and transfer of care provided care resulting in favorable outcomes for women planning both home or hospital births.”

References

American College of Nurse-Midwives, Division of Standards and Practice: Clinical Standards and Documents Section and Homebirth Section, December 2005, Revised: May 2011, Approved by the ACNM Board of Directors: May 2011, Reviewed August 2011.
American College of Obstetricians and Gynecologists, Committee on Obstetric Practice Opinion on Planned Home Birth, Number 476, February 2011, (Reaffirmed 2013). http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Planned_Home_Birth
De Jonge A, Goes B, Ravelli A, Mol B, Nijhuis J, Buitendijk S. No differences in perinatal mortality between planned home and hospital births among 529,688 low risk women in a nationwide cohort study in the Netherlands. BJOG. 2009; published online April 15th 2009.
Hutton EK, Reitsma AH, Kaufman K (2009)  Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: a retrospective cohort study.  Birth 36(3):180-9. doi: 10.1111/j.1523-536X.2009.00322.x.
Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee SK.  Outcomes of planned home birthwith registered midwife versus planned hosital birth with midwife or physician.
CMAJ. 2009 Sep 15;181(6-7):377-83. doi: 10.1503/cmaj.081869. Epub 2009 Aug 31.

Johnson KC, Davis BA (2005). Outcomes of planned home births with certified professional midwives: large prospective study in North America. British Medical Journal; 330:1416. doi: http://dx.doi.org/10.1136/bmj.330.7505.1416

Lorente C (1995). Mother of Midwifery: Ina May Gaskin Hopes to Birth a Local Movement of Midwives. Vegetarian Times, Special Women’s Health Issue, July 1995.

Karmel, Marjorie (1959).  Thank You, Dr Lamaze.

Midwives Alliance of North America, Homebirth Position Paper as Adopted by the Midwives Alliance Board and Membership September, 2012

MacDorman MF, Mathews TJ, Declercq E.  Home birth in the United States, 1990-2009.  NCHS data brief, no 84.  Hyattsville MD: National Center for Health Statistics, 2012.

Rooks J. The Midwifery Model of Care. Journal of Nurse-Midwifery, 44(4):370–374, July-August 1999

Williams JW (1904).  Obstetrics: A Textbook for the Use of Students and Practitioners.  New York and London: D. Appleton and Co.