Planned Home Birth
/What is the history of home birth?
Until recent history, the home was the place for birth! In fact, the term was not coined until the 19th century because until then, birth usually occurred at home and not in a birthing center or hospital.
In the United States, in 1900, close to 100% of births were at home
In 1938, rates had fallen to 50%, and then fewer than 1% in 1955
In other countries like the UK, the trend to non-home births was slower, but still occurred; IN the UK, 80% of births occurred at home in the 1920s, and only 1% in 1991
In Japan, this happened much later: In 1950, 95% of births occurred at home, but only 1.2% in 1975
However, recently between 2004-2009, the number of home births in the US increased by 41%
Where in the world are there still home births?
Many countries!
So why did home births decrease over the years?
Hard to know exactly why
There is some increased medicalization of birth
In the hospital, there was the promise of anesthesia – ie. you could get an epidural
At the same time, there was a trend of decrease maternal mortality and morbidity as well as decreased infant morbidity
Why is there an increased movement to home birth?
One note
We want to discuss planned home births, not unplanned ones!
Lots of reasons
Some birthing people like the familiar environment of their home, and do not like the medically centered birth experience
Some people feel it is more relaxing at home
In one study published in the Journal of Midwifery and Women’s Health the top five reasons were:
Safety
Avoidance of unnecessary medical interventions
Previous negative hospital experiences
More control
Comfortable and familiar environments
One other study found that women experienced pain differentially and less negatively in the home setting
This speaks to some of the things that we in hospitals or even birth centers can do to make patients feel safer and more comfortable!
Clearly, some patients do not feel safe in the hospital setting, even though as doctors, we would argue that the hospital is the “safest” place to deliver a baby because of quick access to resources (ie. blood banks, ORs, NICUs)
So I think this study gives us a good way to figure out what we can do in the hospital to make patients feel more comfortable
See our episode on limiting interventions in birth!
What about now? Where in the US is there increases in home birth?
Top five in 2020:
Idaho (3.2%)
Vermont (3%)
Wisconsin (2.8%)
Montana (2.6%)
Utah (2.6%)
So, now that we know there is increased desire for home birth, what is the evidence for or against home birth?
A word on the evidence
Our gold standard is of course to have a randomized controlled trial, but you really can’t do that ethically for home birth!
So most data is from observational studies, but they are often limited by methodological problems, including small sample size, lack of appropriate control group, reliance on birth certificate data, reliance on voluntary submission of data or self-reporting, limited ability to distinguish accurately between planned and unplanned home births, and variations in skill, training, and certification of birth attendants etc.
The data for home birth for moms
Patients don’t want unnecessary interventions — and look at all the interventions we do!
Even in TOLACers it seems that we do a lot – maybe it’s safe to TOLAC at home
In England, women planning a home trial of labor after cesarean exhibited fewer obstetric risk factors, more likely to deliver vaginally, and had similar maternal and perinatal outcomes compared with those planning hospital TOLAC
The data against home birth for moms
Most research about home birth cohorts recently have strict selection criteria for appropriate candidates
So remember: these studies usually select so that there is absence of preexisting maternal disease, absence of significant disease arising in pregnancy (so think of all your GDMs! Your hypertensives!), singleton fetus, cephalic presentation, gestational age >36 or 37 weeks and less than 41-42, labor is spontaneous
Finally, while in many other countries they may have safe methods of identifying risk and reasons to get moms to the hospital, most places in the US do not have this
The relatively low rates of morbidity and mortality reported for planned home births from Ontario, British Columbia, and the NEtherlands were from highly integrated health care systems with established criteria and provisions for emergency intrapartum transport
In the US, however, the home birth attendant (midwife, etc) do not always have hospital privileges or are not connected to a doctor that has hospital privileges
There is not a safe and timely way to transfer the patient intrapartum to the hospital if needed
There is also a reported risk of needing intrapartum transport to hospital of 23-37% for nulliparous women and 4-10% for multiparous women
Reasons for transport: lack of labor progress, nonreassuring fetal status, need for pain relief, hypertension, bleeding, and fetal malposition
Conclusion: It does appear that home births can be safe for mom, but only in a selected populations. We would recommend that if someone desires to have a home birth, that they have a birth attendant that is a certified nurse midwife (CNM) or a physician who practices obstetrics within an integrated and regulated health system. They should also have a plan about when and how to come into the hospital if there are complications.
They should also be a specifically selected population:
Absence of preexisting maternal disease
Absence of significant disease during pregnancy
Singleton fetus
Cephalic presentation
Term gestation, and not post dates
Spontaneous labor
No uterine scars (ie. no TOLAC)
That data for home births for babies
While we can see that in previous data, there was some increased risk of neonatal morbidity and mortality, there was a recent big paper that looked at 10,609 births that came out in the Green Journal in November 2021, published by midwives in Washington state
Basically, they compared planned home births (40.9% of the population they studied) vs. planned birth center births (59.1%)
Their results were really great! Not only did they have a C/S rate of 11.4% for the nulliparous women and 0.87% for the multiparous women, the perinatal mortality rate after onset of labor was 0.57/1000 (super low, compared even to older data)
Compared to planned birth center births, planned home births had similar risks in crude and adjusted analyses
Overall, numbers were low anyway for
The data against home births for babies
That’s all well and good for Washington
But let’s not forget that these women were carefully selected for a planned home birth
They followed ACOG’s guidelines
If we look at the demographics, most of these women were <35 (only 21% were 35 or older)
These women were thin (63% had normal BMIs, and only 14% had BMIs >30)
Most of them were white (83.8%)
They likely were of higher social class (62% had commercial insurance)
Most of them were multiparous (63.9%, and 8.4% had >4 prior births)
Only 3.2% had gestational diabetes
Basically, very healthy population that not all people fit the mold for
There is a lot more increased perinatal morbidity for babies in other data! And mortality!
Basically: there is about a 2.43x risk of perinatal mortality if we look at all data and a 3x increase risk of neonatal seizures or serious neurological dysfunction
Overall, yes these numbers are small (death is 1-2/1000 and seizures/neurological dysfunction is 0.4-0.6/1000)
Even in this study from Washington state, nulliparous women had a 1.04/1000 birth perinatal mortality rate
Conclusions: Again everyone has the right to choose what type of birth they have. However, if we look at data as a whole, neonatal outcomes are overall worse with planned home births overall compared to in hospital births. While these outcomes are overall low, patients should still be counseled the risk of perinatal death is approximately 2x higher in planned home birth and neonatal seizures/neurological dysfunction is about 3x higher. It’s likely that these outcomes can be mitigated in the right population with a good plan to transfer patients/babies to a hospital and with the right birth attendant.
However, the fact remains that there is not always infrastructure in place to make sure that all of these things can happen.
Therefore, it’s important to discuss these studies with your patients and especially review with them if they are a good candidate or not. Remember they should also be a specifically selected population:
Absence of preexisting maternal disease
Absence of significant disease during pregnancy
Singleton fetus
Cephalic presentation
Term gestation, and not post dates
Spontaneous labor
No uterine scars (ie. no TOLAC)