Home birth

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home birth

A home birth

Home birth occurs when a woman labors and births a child at home, rather than the labor and delivery ward of a hospital or birthing center. Home births are generally attended by a midwife, but are sometimes attended by general practitioners, other medical professionals or doulas. Some mothers choose to give birth without any medical professional present – this is generally known as an "unassisted home birth" or "freebirth."

In choosing home birth, the mother generally has more control over her surroundings, and can eat and move around, sleep and do anything she pleases - activities which may be discouraged in a hospital setting. Midwives generally view birth as a natural process, and therefore keep their intervention and any other sort of medical intervention to a minimum.

During a homebirth there is no access to pharmaceutical pain relief or pharmaceutical labor induction, nor equipment for emergency delivery (such as forceps, vacuum extraction, or surgery). Births necessitating these interventions would require transfer to a hospital. Depending on the midwifery practice, transfer rates can range anywhere from 5% to 40%, but most studies cite a transfer rate of about 16%.

In many Western countries, home birth declined over the 20th century due to migration to urban centers and increased accessibility of hospitals. The WHO has released a statement supporting the right of women to choose where they give birth. In the case of low-risk pregnancies, with appropriate support and contingency plans women can give birth at home.

International Home Birth Rates

There was a revival of midwifery, the practice supporting a natural approach to birth, in the United States in the 1970s. However, although there was a steep increase in midwife-attended births between 1975 to 2002 (from less than 1.0% to 8.1%), most of these births occurred in the hospital and the US rate of out-of-hospital birth has remained steady at 1% of all births since 1989 with 27.3% of these in a free-standing birth center and 65.4% in a residence. Hence, the actual rate of home birth in the United States has remained remarkably low (0.65%) over the past twenty years.

Home birth in the United Kingdom has also received some press over the past few years as there has been a movement, most notably in Wales, to increase home birth rates to 10% by 2007. Between 2005 to 2006, there was an increase of 16% of home birth rates in Wales, but the total home birth rate is still 3% even in Wales (double the national rate) and in some other counties of Great Britain the home birth rate is still under 1%.

In the Netherlands, an opposite trend has taken place: in the 1965, two-thirds of Dutch births took place at home, but currently, that figure has dropped to less than a third – about 30%.

Research on Safety

In 2009, a study of 529,688 low-risk planned home and hospital births, reported in the British Journal of Obstetrics and Gynaecology, concluded:

A home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low risk women, provided the maternity care system facilitiates this choice through the availability of well-trained midwives and through a good transportation and referral system.

Further, the study noted there was evidence that low risk women with a planned home birth are less likely to experience referral to secondary care and subsequent obstetric interventions than those with a planned hospital birth.

In 2007, after a comprehensive review of the literature, the UK’s National Institute for Health and Clinical Excellence (NICE) released the following recommendations concerning the location of birth:

With relation to women’s and babies’ outcomes for home births, there is a lack of good quality evidence. The evidence in relation to perinatal mortality is not strong enough to support past or current policies of increasing or decreasing current provision outside consultant units. Women should be offered the choice of planning birth at home, in a midwifery-led unit, or a consultant-led unit [hospital]. Before making their choice, women should be informed of the potential risks and benefits of each birth setting.

"As a minimum," the NICE report continues to state, such information should include the following:

• Planning birth at home: increases the likelihood of normal vaginal birth and satisfaction in women who are committed to giving birth in this setting, compared with planning birth in a hospital
• Planning birth in a consultant-led unit: increases the likelihood of pharmacological analgesia, interventions and an instrumental birth, and decreases satisfaction, compared with planning birth in other birth settings. There may be a lower risk of perinatal mortality when care is delivered in a consultant-led unit."

Study Design

The research concerning the safety of home birth is few and far between, and much of it is of questionable methodology . In fact, there are no randomized controlled trials for home birth, possibly because maternal choice is such a major aspect of home birth and thus, few mothers would be willing to be randomly assigned to either the home birth or the hospital birth. The studies that do exist tend to be matched cohort studies conducted either retrospectively (by selecting hospital records that match the characteristics of the home birth records), by matched pairs (by pairing study participants based on their background characteristics), or by using multivariate analysis to control for background variables.

However, even in cohort studies, there are many differences between women who choose to give birth at home versus in hospital. There are unquantifiable differences in home birth patients, such as maternal attitudes towards medical involvement in birth, and demographically, home birth patients tend towards being more multiparous, less ethnic minorities, attend more prenatal visits, be slightly taller and lighter, of better educational background, and have fewer previous obstetric complications, including cesarean sections. Thus, none of the studies conducted were able to study a large enough group of matched births to make any definitive statements concerning perinatal mortality, and other rare complications.

The most recent research contained in the Cochrane systematic review of the literature, (published on the Cochrane database; the source from which hospital policies are usually created), states that there is not enough evidence to decide one way or another, whether home or hospital birth is safer (Olsen & Jewell: 2000 (CD000352) in Hofmeyr et al:2008:252). However, Hofmeyr goes on to say, on behalf of the Cochrane database; "The relative benefits and risks of different settings are difficult to quantify. For a woman and her baby with no complications, the risk of an unexpected adverse event during a home birth may be smaller than risks specific to hospitalization, such as hospital-acquired infections" (Hofmeyr et al:2008). Olsen and Jewell (2000), the authors of the systematic review also state: "In countries where it is possible to establish a home birth service backed up by a modern hospital system, all low-risk women should be offered the possiblity of considering a planned home birth...." (Olsen & Jewell: 2000 (CD000352) in Buckley:2005:230).

Maternal safety

All medical interventions were substantially decreased in the home birth sample, including the use of any pain medication or analgesics including epidurals, forceps or vacuum extraction, episiotomy and cesarean sections. Accordingly, the likelihood of normal vaginal birth was also greatly increased in the home birth sample. The studies were able to establish that there was no difference between the home birth and the hospital birth groups in the incidence of pre-eclampsia, premature rupture of membranes, or premature birth. Except in the 1989-1992 Zurich study , the length of labor tended to be longer during home birth, which is unsurprising given the five-fold lower incidence of induction of labor in the home birth populations.

In terms of maternal outcome, no study found any statistically significant difference between the number of women that had third-degree perineal lacerations or postpartum hemorrhage. However, the 1998-1999 British Columbia study did find a three- to four-fold less likelihood of infection for both the infant and the mother, and all studies reported a substantially higher likelihood of an intact perineum in the home birth sample.

Infant Safety

Perinatal outcome is more complicated to assess due to the low incidence of mortality and the subjectivity of Apgar scoring. Most studies found a slight, but statistically significant, difference in Apgar score for infants at five minutes. However, the 1994 UK National Birthday Trust study found a slight advantage for home birthed infants at one minute and no difference at five minutes . No cohort study has conducted long-term follow up on the infants. The perinatal mortality figure still remains controversial. The Zurich study showed an equal perinatal death rate between the home birth group and the hospital birth group (2.3 / 1000), and the Birthday Trust study found a slightly higher perinatal death rate in the hospital birth group (1 / 1000 vs. 0.8/1000) . However, two other studies did find a slightly higher perinatal mortality in the home birth group as compared to the hospital birth group. None of these results were seen to be statistically significant, since the actual mortality rate and the sample sizes were both so low, these figures have been the subject of much debate regarding the relative safety of home birth compared to hospital birth.

Legal situation in the United States

Practicing as a direct-entry midwife is illegal in states shown here in red

No state prosecutes mothers for giving birth outside of a hospital. However, midwives who assist at such births may be prosecuted in some areas.

In the early and mid 1900s, physicians pushed to have midwifery banned throughout the United States. In 37 states it is once again legal to acquire the services of a midwife. Many midwives continue to attend mothers in states where it is illegal, while efforts are underway to change the law.

Practicing as a direct-entry midwife is still (as of May 2006) illegal under certain circumstances in Washington, D.C. and the following states: Alabama, Georgia, Hawaii, Illinois, Indiana, Iowa, Kentucky, Maryland, North Carolina, South Dakota and Wyoming. However, Certified Nurse Midwives can legally practice in these areas.

Legal situation in Australia

Although some State Governments have now introduced government funded home birth services, including the Northern Territory, Western Australia, New South Wales and South Australia, homebirthing in Australia may be illegal by July 2010 by default. This is due to legislation pending at that time, introducing compulsory registration of all health professionals, and requiring that all health professionals carry professional indemnity insurance. Midwives in most Australian States and Territories are unable to obtain professional indemnity insurance, and hence by default will be unable to register as health professionals.

After the collapse of the large Australian insurer HIH, the remaining Australian insurance companies ceased offering insurance to home birth midwives, as they claimed that the pool of midwives requiring insurance was too small to make it commercially viable. Without insurance, some independently practicing midwives have elected to discontinue providing independent services, even though they are qualified health professionals and are allowed to practice within hospitals.

Midwives current inability to carry professional indemnity insurance does not currently affect a woman's right to hire an independent midwife to attend her birth. Midwives and people who wish homebirth to remain as a choice for Australian women are currently lobbying to protect the profession. In April 2007, the Western Australian Government announced that it would be expanding birth at home across the State.

Legal situation in Canada

Legality of homebirth currently is not the real issue. Coverage by Provinces public health service varies. Availability of doctors and midwives providing homebirth services also varies. Some Provinces appear to actively discourage homebirth. While other provinces are the opposite. Currently the Province of Ontario covers homebirth services as does British Columbia.

Famous homebirthers

Pamela Anderson

Charlotte Church

Cindy Crawford

Ricki Lake

Demi Moore

Thandie Newton

Kelly Preston

Meryl Streep

Davina McCall

Additional reading

• Spiritual Midwifery Ina May Gaskin(The Book Publishing Company) ISBN 1-57067-104-4 (1st edition 1977)
• A Good Birth, A Safe Birth: Choosing and Having the Childbirth Experience You Want. (1992), Korte, Diana, Boston, MA: USA, The Harvard Common Press.
• Birthing From Within: An Extra-Ordinary Guide to Childbirth Preparation. (1998), England, Horowitz NM: USA, Partera Press.
• A Wise Birth. Bringing together the best of natural childbirth with modern medicine, Armstrong P & Feldman S, 1990, reissued 2007, Pinter & Martin, ISBN 978-1-905177-03-5
• Having a Great Birth in Australia Ed David Vernon, Australian College of Midwives, Canberra, 2005 ISBN 0-9751674-3-X
• Men at Birth Ed David Vernon, Australian College of Midwives, Canberra, 2006, ISBN 0-9751674-4-8
• Home Birth: A Practical Guide, Wesson, Nicky, 2006, Pinter & Martin, ISBN 978-1-905177-06-6
• The Thinking Woman's Guide to a Better Birth, by Henci Goer
• Lamaze Institute for Normal Birth
• The American Way of Birth, Jessica Mitford

See also

• Childbirth
• Midwifery
• Doula
• Natural childbirth
• Nursing
• Pregnancy

External links

• Expert Group on Acute Maternity Services: Reference Report International Models of Maternity Care Report on maternity care released in Scotland, 2002, includes summary of how maternity care is dealt with in other countries besides the UK.
• Intrapartum Care Guidelines (2007) National Center for Health and Clinical Excellence, an independent health care monitoring organization in the UK, reviewing the home birth literature.
• Home Birth Reference Site, Index of Research on Home Birth
• American Pregnancy Association, Home Birth, brief article outlining the pros and cons of home birth
• World Health Organization, Care in Normal Birth: A practical guide, Chapter 2: General Aspects of Labor, 1997.
• ACOG Statement on Home Birth, American College of Obstetricians and Gynecologists reiterates its long-standing opposition to home births (Feb 8, 2008)