Does home birth empower women, or imperil them and their babies?

The author reports no financial relationships relevant to this article.

Few issues in obstetrics spark as much controversy as home birth—and where controversy rages, media attention follows.

Press reports of a 2008 policy statement on home birth issued by the American Medical Association (AMA) and the American College of Obstetricians and Gynecologists (ACOG) highlight the rift between the formal medical establishment and advocates of home birth.^1-3

On one side, the AMA and ACOG assert that the hospital or an accredited birthing center “is the safest setting for labor, delivery, and the immediate postpartum period.”¹ On the other side, advocates of home birth argue that having the option adds to women’s empowerment and choice.

Some people have accused the medical community of trying to corner the “baby birthing industry.”⁴ The title of a recent Baltimore Sun article sums up this sentiment: “Home birth battle: Doctors strong-arm women away from healthy alternative to hospital care.”⁵

Neither ACOG nor the AMA advocates criminalization of home deliveries, but their statements on home birth have generated considerable fear that they will.

This article explores the controversy, focusing on the literature on home birth, gaps in knowledge, the state of regulation, liaison with midwives, and other issues. It also offers suggestions on how to discuss labor and delivery with patients so that they clearly understand the risks involved and do not feel that they have “failed” at meaningful childbirth when they choose hospital delivery.

Did a rise in hospital births reduce maternal mortality?

Obstetric care changed dramatically in the mid-20th century. In 1940, 55.8% of deliveries occurred in the hospital, but that percentage rose to 99.4 by 1970 and hasn’t changed appreciably since.⁶

Some proponents of hospital delivery note that, in 1940, when 44% of births occurred outside the hospital, the maternal mortality rate was 608 deaths for every 100,000 live births, compared with 37 deaths for every 100,000 live births in 1960, when fewer than 4% of deliveries occurred outside the hospital.⁶ And in 2003, with only 1% of deliveries occurring in a home setting, the maternal mortality rate was even lower: 12 deaths for every 100,000 live births.⁷

Others argue that this sharp decrease in maternal mortality cannot be attributed solely to the change in location of the delivery (and subsequent availability of services and personnel), but reflects universal advancement in safe practices such as aseptic technique.⁸

What do the data show? All studies of home birth have serious methodologic flaws, thanks largely to the nature of the subject matter. A recent Cochrane review observes that there is only one randomized, controlled trial—with a sample size of only 11 women—from which to draw conclusions.⁹ The review concludes that “there is no strong evidence to favour either home or hospital birth for selected, low-risk pregnant women.”¹⁰

Most data come from abroad

Much of the literature on home birth comes from international sites because of the higher prevalence of home delivery in other countries. These data reveal that:

• Two percent of deliveries in the United Kingdom occur in the home.¹¹ The British National Institute for Health and Clinical Excellence recommended that all women be offered the option to have their baby at home or in the hospital, although, depending on the “trust” (a geographically based public-system cooperative that provides care), 8% to 76% of women weren’t given this choice formally.¹²
• One study conducted in Switzerland involved 489 women who opted for home birth and 385 who chose hospital birth. Of the former, 37 were referred to a specialist during pregnancy, and 70 were referred during labor. The groups had similar birth weights, gestational ages, and clinical conditions.¹³
• In the Netherlands, 30% of infants are born at home.¹⁴ If a woman has an uncomplicated pregnancy, she remains under midwifery care and can decide where to deliver. A study of 280,000 “low-risk” women under primary midwifery care found that 68.1% completed childbirth under that care, 3.6% were referred urgently, and 28.3% were referred without urgency.¹⁴ When referrals were considered as a whole, 11.2% involved urgency, primarily for fetal distress (50.2%) and postpartum hemorrhage (33%). Adverse neonatal outcomes were most common in urgently referred cases, followed by nonurgent referrals. The authors acknowledge the importance of transport time once a referral is initiated, stating that, “The Netherlands is a very densely populated country where the average distance to the hospital is relatively short.” (The same cannot be said of many parts of rural America.)
• A study involving home deliveries in Australia from 1985 to 1990 identified 50 perinatal deaths out of 7,002 planned home births.¹⁵ The perinatal death rate of infants weighing more than 2,500 g exceeded the national average (5.7 versus 3.6 for every 1,000 deliveries), with a relative risk (RR) of 1.6 (95% confidence interval [CI], 1.1–1.4). Intrapartum death not attributable to prematurity or fetal malformation was also higher (2.7 versus 0.9 for every 1,000 deliveries), with a RR of 3.0 (95% CI, 1.9–4.8). According to the authors, the main contributors to excess mortality were underestimation of the risks associated with post-term birth, twin pregnancy, and breech presentation, and a lack of response to fetal distress.