Your Pregnancy Matters

Examining the risks and outcomes of home birth

Your Pregnancy Matters

Not all out-of-hospital births are equal, and you have to understand the statistics behind each study as well as how different countries license midwives and monitor home births.

The number of births that occur outside of a hospital – at home or in a birthing center – is growing every year, and Texas is no exception. Out-of-hospital births in Texas increased to 1.16 percent in 2012 from 0.72 percent in 2004, according to the Centers for Disease Control. These percentages put Texas just below the national average for out-of-hospital births (1.36 percent in 2012, and 0.87 percent in 2004).

While out-of-hospital births represent a very small number of the children born in the United States, the growing trend has led us to take a closer look at its safety. Unfortunately, the data available is not always accurate, and while the United States is often compared to other countries, it’s not always apples to apples.

In the first of this two-part series, we’ll look at out-of-hospital births in the U.S. In part two, we we’ll discuss what you should consider if you’re thinking about out-of-hospital birth.

How home birth in other countries compares to the U.S.

I have a friend whose company transferred her to England for a year, just as she was about to give birth to her third child. She was excited to learn that she qualified for home birth under England’s National Health Service (NHS) guidelines. The key word here is qualified – unlike in the U.S., not just anyone in England can opt for home birth under NHS guidelines. This friend was considered a perfect candidate: a young, healthy, non-smoker with normal blood pressure who had had two other normal, uncomplicated vaginal deliveries – basically, no major risk factors.

When her water broke, she called the midwife for instructions. She told the midwife that her water had broken, but since she was not contracting, the midwife sent her to the hospital. By the time she got to the hospital, she was already in labor, and she delivered in about an hour with no problems.

While she likely could have delivered at home and everything would have been fine, the NHS in England follows strict criteria to allow at-home delivery. Even the seemingly small fact that my friend’s water broke without contractions made her ineligible.

Midwives in England are required to obtain an approved midwifery degree, register with the Nursing and Midwifery Council, and go through revalidation every three years. They are required to follow the NHS guidelines, including stated protocol for transferring a patient to a hospital when required. These formalities are not the case in the U.S.

In the U.S., we take a more piecemeal approach. Our criteria to perform out-of-hospital births is not set up in a way that reduces risks. For example, midwife licensing differs from state to state, and there are many types of midwives, including:

  • Certified nurse midwives: Highly trained with extensive medical backgrounds. CNMs also can prescribe and administer pain medication if needed.
  • Certified midwives: Certified in midwifery with at least a bachelor’s degree. They cannot administer medication.
  • Lay midwives: Trained in childbirth, but not licensed or certified. They cannot administer medication.

Until we have a national, uniform standard to train and license midwives, it’s almost impossible to accurately compare the practice and outcomes of out-of-hospital births in the U.S. with other countries.

Home birth studies: Things to consider

Not only does the U.S. not have uniform guidelines for performing out-of-hospital deliveries, but we also do not have a consistent method for tracking them.

In most states, if you planned for a home birth but encountered a complication during labor or delivery that required you to go to the hospital and deliver there, it would be classified as a hospital birth. This limits researchers’ ability to assess the outcomes and risks of planned out-of-hospital births.

Thanks to a change in Oregon birth certificates that documented the intended place of delivery, a 2015 study in that state has given us our clearest data so far. Oregon has one of the highest rates of out-of-hospital births in the country, with 2.4 percent of births taking place at home and 1.6 percent in a birthing center in 2012.

The study analyzed nearly 80,000 deliveries and found that planned out-of-hospital births carried double the risk of perinatal death. While the actual number of deaths was small – 3.9 deaths per 1,000 births out-of-hospital versus 1.8 deaths per 1,000 in the hospital – any increase in risk of infant death concerns me. Higher rates of neonatal seizures and lower 5-minute Apgar scores also were reported in the out-of-hospital births.

It’s important to note that this study only looked at singleton, non-breech babies delivered after 37 weeks. Even in these lower-risk deliveries, researchers found that 16 percent of women who planned an out-of-hospital birth had to be transferred to a hospital for a higher level of care.

Like previous studies, the Oregon analysis revealed a higher rate of vaginal delivery and lower rate of medical intervention for at-home births. This is to be expected because of the nature of the study: To be a good candidate for home birth, ideally, you should have no pregnancy complications that would put you at higher risk of a delivery complication. If you are experiencing problems during the pregnancy or know your baby will need immediate medical attention at birth, you likely will plan a hospital birth.

And of course there are fewer interventions in an out-of-hospital birth. A key philosophy of midwifery is to let Mother Nature take control, which is a good philosophy for childbirth in general. However, when looking at these statistics, it’s important to remember that a midwife can’t perform a C-section at home, and not all midwives can induce labor or prescribe pain control medications. If interventions are needed, the woman would need to be transferred to a hospital.

Should I have an out-of-hospital birth?

Women cite many reasons for planning an out-of-hospital birth: wanting more control over their environment, wanting to include more family members in the birth, preferring a more natural birth experience.

I understand these desires, and I explain to my patients that we can accomplish many of these goals in the hospital. A majority of out-of-hospital births result in a healthy baby and mother. But I’ve seen what can go wrong during labor and delivery, and I strongly encourage you to give out-of-hospital birth a lot of thought and weigh the risks for you and your baby.

If you are trying to decide if an out-of-hospital birth is right for you, there are important factors to consider and decisions to make. In part two of this series, we look at what questions to ask yourself and your midwife, and how to make a hospital birth feel a little more like home.