Planned birth in an out- of -hospital setting, such as the home, has been shown to be safe for low-risk mothers in several studies, and yet still continues to be debated. Low-risk, or normal birth, has been defined by the World Health Organization as spontaneous labor that begins between 37 and 42 weeks gestation, with one fetus in a head down presentation, following an uncomplicated pregnancy (7). Many pregnancies in the United States certainly meet this definition, but are still attended by obstetricians trained primarily in high-risk care. Data from birth certificates show that one out of 85 babies was born out-of-hospital in the United States in 2010, with two-thirds of these births occurring at home. This was only 1.18% of all total U.S. births (6). Out-of-hospital births increased by more than 40% between 2004 and 2010 (6).
In this age of information, more women are seeking evidence-based care from midwives. By adhering to the Midwives’ Model of Care, home birth midwives provide unique factors that contribute to the safety of childbirth. This has been proven with better outcomes and increased satisfaction of mothers (5). Based on the belief that pregnancy and birth are normal life processes, routine interventions are reduced in a planned home birth setting (3). The continuous presence of the caregiver, reduced interventions, and collaboration across birth settings are all aspects of a safe birth experience (4).
With more women choosing home birth attended by a Certified Professional Midwife (CPM), the Midwives Alliance of North America (MANA) was able to put together a landmark study of 16,924 women birthing at home with midwives. Cheney, et al. (2014) discovered that 89.1% of these mothers went on to birth at home, and the remaining transferred care. Of these, 93.6% achieved a spontaneous vaginal birth, an astounding feat in a culture with a 33% cesarean section rate(1). Only 5.2% of this home birth group underwent cesarean section surgery. The majority of hospital transfers were for failure to progress. Just 10% of transfers in the Cheney, et al. (2010) study were for fetal distress or meconium. Almost half delivered with their perineum intact, and routine interventions were much reduced compared to typical hospital rates (2). At first glance, the rate for fetal demise seemed a little high, but it must be understood that the study included what are typically considered higher-risk profile pregnancies: breech, vaginal birth after cesarean, gestational diabetes, and pre-eclampsia mothers. With these risk factors removed, the intrapartum neonatal death rate was .85 per 1,000 (2).
A second large study of importance in regard to the proven safety of home birth is the Johnson and Daviss (2010) study of 5,418 women planning home birth in the United States and Canada. From this group of women, 12.1% transferred to the hospital to give birth and the intervention rates were as follows: epidural (4.7%), episiotomy (2.1%), and instrumental delivery with forceps (1.0%). There were no maternal losses, and the intrapartum and neonatal mortality rate was 1.7 per 1000. The hospital rates for episiotomy was 33% versus the home birth group’s rate of 2.1% (5). The home birth group in the Johnson and Daviss (2010) study challenged the hospital cesarean section rate of 19% with only 3.7% of women receiving cesarean section. The most common reasons for transfer to the hospital was hemorrhage (.6% of total births), retained placenta (.5% of total births) and newborn respiratory problems (.6% of total births). Happily, 98.3% of newborns were well at six weeks postpartum, and 97% of moms stated that they were “extremely satisfied” with the outcome of their births (5). With healthy babies, satisfied moms, and reduced interventions, money is saved and health is increased.
Johnson and Daviss (2010) noted the importance of the normalcy of birth in a safe outcome by stating, “women choosing homebirth may have an advantageous enhanced belief in their ability to give birth safely with little medical intervention.” Another study also noted the parallel between good outcomes and a belief in birth as a normal physiological process. A small study out of Southeastern Pennsylvania of planned home births attended by CNMs from 1983 through 2008 found that the normalization of birth in the community “maximized the safety of home birth for this group of women” (3). When mothers were transferred to the hospital (5.6% of this group transferred), the midwives were able to accompany the women because of favorable relationships with hospital staff and ambulance personnel (3). This continuity of care and trust in the care provider influenced good outcomes. There were only seven early neonatal deaths and all were due to congenital anomalies that are common among people in this region (3).
One study, heralded by the American College of Obstetrics and Gynecology as the definitive ruling that home birth is not safe, measured maternal and newborn outcomes and found that infants had three times higher risk for neonatal death in the planned home birth group versus the hospital birth group (9). The most glaring problem with this meta-analysis is that it included studies that were over 20 years old. Second, this meta-analysis included unplanned home birth as well as unassisted home birth, meaning that no trained care provider was present. On page 242.e3, there was a correction to only include home births attended by trained care providers and this indicated that the neonatal death rate was comparable to the hospital group.
The United States ranks below 41 other countries in infant mortality (8). Hospital-based obstetricians comprise the bulk of maternity care providers, and the culture does not view birth as a safe and normal process. We can clearly see that this is hurting mothers and babies when we consider that all countries with lower infant mortality rates use midwives as principle birth attendants (8). Our cesarean section rate is hovering around 33% (1) when common sense dictates that the idea of one-third of all women being unable to give birth without surgical help is ludicrous. Obviously our current system is broken. Home birth takes this normal life process out of the hands of trained surgeons, overburdened with too many patients, and places it back into the hands of the mother, who has the safety of her baby and herself in the forefront of her mind. With the recognition of the trained midwife as an appropriate attendant for normal birth in the home, the goal of reduced interventions in all birth settings, and a return to the cultural message that childbirth is a normal life event; we can see better, safer outcomes for mothers and babies.
Understanding the Risks
There are three components to a safe birth; the well being of mother, the wellbeing of the baby, and progress of labor. They are all interdependent.
One can tell if labor is beginning normally as part of the prenatal care your midwives offer: one baby, head down, good position in the pelvis, and healthy signs in both the mother and the baby. From here, birth follows a normal process of the body. If a problem begins to develop, some part of the process would reveal this- in the progress of labor or the baby’s heartbeat, for example.
Like other body processes, labor does not have to follow strict, invariable steps. There is leeway for variation, a range of normal, just as the number of breaths taken per minute can vary within certain limits, yet the body’s need for oxygen is met.
In most cases, problems also have their range. They develop over time and can be detected before they reach their limit. Lack of progress, for instance, can occur for some time before a well-nourished mother or baby would be adversely affected. This allows for transfer time to the hospital, if extra assistance is needed.
Very rarely do problems arise immediately and unexpectedly. A baby who tolerates early labor usually has no difficulty with active labor. The heartbeat is monitored throughout labor to evaluate how the baby is doing. Difficulty for the baby is evidenced by heartbeat patterns and rates that deviate from normal ranges. This develops over time and can usually be detected before the baby has reached its limit.
The unexpected may occur during delivery, when the baby is traveling out and its oxygen supply may be interfered with. At this point, though, delivery can be hastened and resuscitation can be provided. Midwives are trained in neonatal resuscitation and carry the equipment necessary to help babies breathe if needed. Well-nourished babies have special resources, which allow them to tolerate low oxygen levels for some time before danger of damage, especially if they are not compromised by drugs.
With the mother, the unexpected may be hemorrhage. Again, there are ways to work with this to encourage uterine contractions, which will help to stop the bleeding. Midwives are trained to respond to this emergency quickly. It is important to note that the mother has resources to sustain her, such as an expanded blood volume, approximately 60% greater than the non-pregnant woman.
Emergency care can usually be provided in the home to resolve these problems or maintain the client during transfer to the hospital. The rare risk of loss in birth, as in life in general, cannot be completely controlled or eliminated.
Unexpected emergencies are more likely to occur if the process of labor is interfered with, stressing the resources, creating too extreme a situation for the baby to cope with, disrupting the balance of the body, or too quickly exceeding the limits. An example is when a baby goes into distress due to the snow ball effect of obstetrical interventions: fetal monitors/I.V. use leads to immobilization which can lead to stress which can lead to lack of progress which leads to oxytocin which leads to pain which leads to medication which can lead to distress.
Midwives are present during your labor and make observations with continuity, so they can detect problems at subtle levels or early in their development. Hospital staffs, with their intermittent observation, shift changes, and use of medical intervention, have more of an impression that the unexpected in labor can occur suddenly, and that emergencies are to be feared.
1-Centers for Disease Control. (2015). Fast stats. Births: Method of delivery. Retrieved from: http://www.cdc.gov/nchs/fastats/delivery.htm.
2-Cheney, 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 and Women’s Health, 59(1), 17-27
3-Cox, K., Schlegel, R., Payne, P., Teaf, D., Albers, L. (2013) Outcomes of planned home births attended by certified nurse-midwives in southeastern Pennsylvania, 1983-2008. Journal of Midwifery and Women’s Health, 58(2), 145-149.
4-Halfdansdottir, B., Smarason, A., Olafsdottir, O., Hildingsson, I., Sveinsdottir, H. (2015) Outcome of planned home and hospital births among low-risk women in Iceland in 2005-2009: A retrospective cohort study. Birth, 42(1), 16-26.
5-Johnson, K. C. & Daviss. B. A. (2005) Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ (330),1416.
6-Macdorman, M., Ceclercq, E., Mathews, T. (2013) Recent trends in out-of-hospital births in the United States. Journal of Midwifery and Women’s Health 58(5), 494-501.
7-Technical Working Group, World Health Organization. (1997) Care in normal birth: A practical guide. Birth 24(2), 121-123.
8-Wagner, M. (2006). Born in the USA: How a broken maternity system must be fixed to put women and children first. England: University of California Press.
9-Wax, J., Lucas, F., Lamont, M., Pinette M., Cartin, A., Blackstone, J. (2010) Maternal and newborn outcomes in planned home birth vs planned hospital births: A metaanalysis. American Journal of Obstetrics and Gynecology 203(3), 243.e1-8. doi:10.1016/j.ajog.2010.05.028.