As Homebirths Continue to Rise, Experts Weigh Benefits and Risks

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Beth Weisberger delivered her first child on the kitchen floor in a warm, converted barn in the middle of a Maine winter. She planned it that way.

Weisberger, 35, said she pushed for two and a half hours under the care of a midwife before delivering her daughter at 9lb 2oz – a normal birth with no pain medication.

“Birth hurts. The pain is just a normal part of it,” the small business owner said matter-of-factly. “And being at home felt natural to me. I took comfort in the fact that people have been having babies like this for a long time.”

Home births are commonplace in many countries. The Netherlands has one of the highest rates of home birth at around 30 percent, according to the National Institute for Public Health.

“The Dutch attitude is that pregnancy is not an illness, that home births are the norm,” a reporter wrote for Expatica, a European online news source. According to the article, the Dutch health ministry has historically encouraged home birth on the theory that “what can be kept out of the hospital should be kept out.”

In the U.S., home birth rates are rising. The American College of Obstetricians and Gynecologists (ACOG) reported this month that home births have risen 40 percent over the last five years, though they still comprise only about one percent of all live births.

Home birth is associated with polarizing viewpoints in the U.S. 

Last month, comedian Amy Schumer collaborated on a video parody, making light of natural birth supporters.

“I just don’t trust Western medicine at this point,” a pregnant Schumer jokes in the video, her friends nodding in agreement. “That’s why I’m having my baby on the highest mountaintop in Tibet. As far from real medical help as is humanly possible.”

But women are avoiding hospitals for many reasons. One home-birther told us she wasn’t comfortable “bringing life into a bed where someone may have died the day before.”

Many others, like Weisberger, choose to give birth outside the hospital to avoid medical interventions, namely cesarean sections, which can sometimes cause added complications and generally increase recovery times after delivery.

“I just had heard so much about that loop,” Weisberger said. “You go in and you’re not progressing, so they offer you pain medication. But that makes your labor slow down. And then often you end up with a c-section because you’re just not getting there fast enough." 

U.S. cesarean section rates averaged about 32 percent in 2015, according to preliminary data from the Centers for Disease Control and Prevention. In some zip codes around major cities like Miami, Los Angeles, and San Diego, rates exceeded 70 percent, according to an analysis done by health data firm Amino.

Not surprisingly, birth data from the CDC show lower rates of cesarean section procedures in states with higher out-of-hospital births. The data also show several other encouraging safety metrics for births outside the hospital. Rates of low birth weight and preterm birth were lower in states with more births outside the hospital, while rates of vaginal birth after cesarean section (VBAC) were higher.

Mixed results of a recent December study examining planned births outside the hospital published in the New England Journal of Medicine (NEJM) highlight both sides of the debate.    

The study found significantly less obstetrical procedures, including induction and augmentation of labor, among women who delivered outside the hospital. Further, cesarean section rates for planned hospital births were nearly five times greater than for patients who had planned to deliver at home (just under one percent of patients were transferred to a hospital during labor).

But despite lower rates of interventions at home, the study also saw a two-fold increase in perinatal death (shortly before and after birth) and a three-fold increase in neonatal seizures among out-of-hospital births. Absolute numbers for major adverse events were low, however, with perinatal deaths totaling 3.9 for planned home birth versus 1.8 for planned hospital birth per 1,000 deliveries. 

“Rates of obstetrical intervention are high in U.S. hospitals,” the study concludes. “In contrast, serious adverse fetal and neonatal outcomes are infrequent in all birth settings we assessed.”

Amy Judy, MD PhH, a maternal fetal medicine fellow at Lucille Packard Children’s Hospital at Stanford, said any additional risk for a “potentially catastrophic outcome” should not be overlooked.

“We are talking about…death and permanent brain damage,” she said. “From a medical perspective, even a small risk…has to be taken very seriously.”

Still, recent studies like this one and the growing popularity of birth out of the hospital setting have led to an updated publication by ACOG profiling the benefits and risks of planned home birth in an effort to educate patients and caregivers alike.

Kathleen Belzer, CNM, NP, who has practiced as a midwife in the hospital setting across the Bay Area for over twenty years, said the topic of home birth is being heavily discussed within both the obstetric and midwifery communities because of its growing prevalence.

“I can’t tell you how huge of a step this is,” she said in reference to ACOG’s new publication. “The conversation has now shifted to the acceptance that home birth exists and how we can make it safer for everyone.”

Compounding analysis on the subject of home birth is a lack of controlled data.

The NEJM study lists many possible limitations to its findings, including the inability to distinguish between transfers from birth centers and transfers from home; differences in demographics between women who choose a hospital versus those who chose a home birth; and the fact the just one geography – women in Oregon – were studied (to name a few).

Judy said a significant confounding factor could lie in health differences between women on each side.

“From a medical perspective, it may be…that the population that’s delivering at home are those less likely to have complications, regardless of where they deliver,” she said.

Judy said a randomized trial, which would assign women to one group or another, would help to control for population differences. Unfortunately, no such study exists because strong individual preferences on both sides mean few women want to participate.

Judy also pointed to differences in care providers across settings, given that midwives, rather than doctors, tend to attend home births. Midwives tend to advocate for more natural delivery methods, she said.

Treesa McLean, LM, CPM, a bay area midwife who practices out of the hospital setting, attributed positive home birth outcomes in part to her practice’s intensive screening process. 

McLean said most licensed midwives screen patients initially and at each subsequent prenatal visit. Certain risk factors, such as elevated blood pressure, prior cesarean sections, or carrying twins (or more), may be gating factors to delivery out of the hospital setting, she said.

Weisberger said her midwife consistently monitored her blood pressure, which rose toward the end of her pregnancy, to ensure she continued to be a candidate for a normal, safe delivery at home.

“There’s this idea out there that midwives try to be heroic and have all babies at home,” she said. “But they’re interviewing you as much as you’re interviewing them. They’re not there to take any risks for you or your baby.”

Weisberger lived in New York City when she first got pregnant and said Manhattan’s crowded hospitals made the prospect of personal attention in a quiet home that much more compelling. She worried doctors’ decisions in the hospital may be influenced by a surplus of patients and limited time. 

“I feel like most people do what they think is right,” she said. “I don’t think the doctors that are giving c-sections are doing something wrong. It’s just the system.”

Belzer said in the hospital setting many patients deliver with the support of a doula. She said around 20% of full-term patients came into Labor and Delivery accompanied by doulas during her time at UCSF Medical Center. 

“A doula can help with coping mechanisms for pain relief,” she said. “The doula is hired to support a woman through her labor and delivery and should stay by her side at all times.” 

Both midwives and doctors often attend to multiple patients at once in the hospital, while a homebirth affords a patient the exclusive attention of her care provider, Belzer said. 

“In my opinion, the important thing you will gain in a homebirth is that one-on-one time with a midwife,” Belzer said. “Still, your care is as good as the person attending you. That person can be skilled and experienced but there is less of a safety net around you.”

Belzer herself had a high-risk pregnancy precluding a homebirth, though she did deliver one of her three children in an out-of-hospital birth center. Belzer advises patients who deliver outside the hospital to work with their midwife to establish a plan for a transfer of care in the event of an emergency.

“There are different risks involved with a hospital birth versus a home birth,” Belzer said. “Whoever your provider is, be sure that you have an open and trusting relationship, and that you are comfortable with his or her training and experience.”

Another important factor to consider, of course, may be cost. On average, home births cost the U.S. healthcare system (and the patient, depending on insurance) much less, according to an analysis done by the National Partnership of Women and Families, a non-profit organization that advocates for public policies for women at home and in the workplace.

In 2010, average facility labor and delivery charges for a normal birth in a birth center totaled around $2,277 according to data compiled from the U.S. Department of Health and Human Services and the American Association of Birth Centers. The same delivery in a hospital cost on average $10,166, and up to $23,111 for a cesarean delivery with complications, the data showed. 

Belzer said the most important thing a woman can do when evaluating birth choices is her own research.

“There can be a lot of misconceptions about birth, so women need to be informed,” Belzer said. “It is a natural process…but it’s not always going to go as intended. Just like so many things in life, birth rarely does.”


For more information on home births and birth metrics, check out our data visualization for a state-by-state analysis.


 TILDEN | Home Births Map

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