The safety of home birth has been a long debated topic. Because of the controversy, the safety of home birth has been studied extensively. The midwives’ model of care contributes to the safety of homebirth, which includes continuity of care and less intervention. Outcomes of planned home births with qualified midwives are comparable or better than outcomes of hospital births, and have lower rates of medical interventions.
U.S. Studies
Several studies regarding the safety of home birth have taken place over the last 30 years in the United States. Early studies regarding home birth in the United States were performed by Mehl (1977 and 1978). The 1977 Mehl study gives data showing the safety of home birth attended by direct-entry midwives following 1,146 cases. The 1978 Mehl study shows better outcomes for planned home births compared to planned hospital births following 2,092 matched pairs. Several others studies were performed in the United States showing the safety of direct-entry ‘lay’ midwives in North Carolina (Burnett, Jones, Rooks, Tyler, & Miller, 1980), Arizona (Weitz, R., & Sullivan, D. (1984). Weitz, R.,& Sullivan, D. (1984).Weitz & Sullivan, 1984), Kentucky (Hinds, Bergeisen, & Allen, 1985), the Farm in Tennessee (Durand, 1992), and Washington State (Janssen, Holt, & Myers, 1994).
One of the larger home birth study that is frequently sited was performed by Johnson and Daviss (2005) covering 5,000 home births attended mostly Certified Professional Midwives (CPMs) in the United States and showed that CPM attended planned home births had comparable mortality rates during labor and delivery to rates found in most studies of low risk hospital births. A conflicting study was issued in American Journal of Obstetrics & Gynecology (AJOG), (Wax et al., 2010) showing a higher neonatal mortality rate for planned home births verses hospital births. However, many have since determined that the design of the study was flawed for several reasons, one reason being that it included unplanned and planned home births (Michel, Janssen, Vedam, Hutton, & de Jonge, 2011).
The most recent study is the largest analysis of planned home birth in the U.S. ever published which examines nearly 17,000 courses of midwife-led care (Cheyney et al., 2014). This study was issued in peer-reviewed Journal of Midwifery & Women’s Health, and confirms that among low-risk women, planned home births result in low rates of interventions without an increase in adverse outcomes for mothers and babies.
Studies Around the World
Study after study performed all over the world have also shown home birth outcomes to be comparable or better than hospital outcomes in terms of perinatal and maternal mortality, with substantially less interventions. The largest study to date looked at more than 500,000 births to healthy women in the Netherlands and found perinatal mortality to be similar between planned home birth and planned hospital birth (de Jonge et al., 2009). In Canada, a 2009 study showed that planned home births attended by a registered midwife resulted in low and similar rates of perinatal death, less intervention and less other adverse outcomes compared with planned hospital birth attended by a midwife or physician (Janssen et al., 2009).
Factors Contributing to Home Birth Safety
Several factors contribute to the safety of home birth, such as continuity of care, individualized care, less intervention, well screened clientele, and more in-depth postpartum care. Being in the mother’s own home exposes her to less risk of infection by being around familiar germs. Additionally, the mother is more comfortable in a familiar environment which is supportive of physiological birth.
Women who birth at home with a midwife receive continuity of care where they are supported throughout their entire pregnancy with a caregiver whom she has had the opportunity to form a deep and trusting relationship. During labor and delivery, the mother is given continuous hands-on assistance with this same caregiver. This continuity of care allows for the midwife to see the ‘whole’ picture regarding this mother and her pregnancy, making it easier to identify when things might no longer be ‘normal’ for this particular mother. Large obstetrical practices may have as many as eight or nine rotating physicians seeing the mother during her pregnancy, which makes continuity of care impossible. Continuity of care during hospital birth is further diminished when the laboring mother arrives at the hospital to be supported by a nurse they have never met, and will be given a new nurse as shifts change. Enkin et al. (2000) mentions a Canadian study that found that women giving birth in a hospital encountered an average of six unfamiliar professionals during labor, with some women reporting up to 14 attendants (p. 249). Additionally, several studies have shown that on average less than 10% of the labor nurse’s time was spent in supportive activities (Enkin et al., 2000, p. 249).
Another factor contributing to the safety of home birth is the holistic and individualized care the mother receives. Midwives focus on the mother as a whole; including the physical, psychological, and social well-being. A typical prenatal exam with a midwife may be 45 minutes to an hour long. During these longer prenatal exams, the midwife develops a close relationship with the mother, and is able to assess not only the mother’s physical well being, but psychological and social well-being as well. This is extremely important as the psychological and social well being of the mother has a direct impact on the physical well being of the mother, which significantly impacts the health of the pregnancy and the baby. This intimate relationship that is formed contributes to the overall safety of the birth, as the midwife is given more opportunities to identify potential issues or red flags that may need to be discussed or addressed. It also gives the midwife more opportunity to rely on her intuition regarding a situation. These longer prenatal appointments foster the opportunity to develop individualized care. Each mother’s pregnancy is treated as a unique situation where education, counseling, care, and support can be tailored specifically to meet that mother’s needs. For instance, a thorough discussion on nutrition, which significantly impacts the health of the pregnancy, can be made where the mother is educated and encouraged on wise choices.
A significant factor contributing to the safety of home birth is the lower use of interventions. Midwives believe that childbirth is a natural physiological process that is typically safest when left alone. Just as a cat or any other mammal seeks a dark, quiet, and safe place to birth; human birth thrives under those same conditions. A mother is more comfortable in her familiar environment at home which supports physiological birth. Midwives understand that many of the interventions that are routinely performed in the hospital contribute to complications for mothers and babies by not allowing the natural process of birth to take place.
Research by Johnson and Daviss (2005) shows rates of medical interventions were much lower for planned home births attended by CPMs than for low risk hospital births, and showed comparable mortality rates during labor and delivery. Additionally, a higher degree of maternal satisfaction was reported. Midwives also have much lower cesarean rates, 3-4% for out of hospital midwives compared to 32.8% for national average (Citizens for Midwifery, 2006) and (CDC, 2011). This dramatic difference in cesarean births has significant impact on outcomes for mothers and babies as maternal and neonatal mortality is tripled for cesarean births (Deneux-Tharaux, et al., 2006) and (MacDorman, et al., 2006).
Because of the medically minded nature of the culture in the United States, along with the fear of birth from media portrayal, many erroneously assume that home birth is not safe. However, research from the United States and all over the world show that outcomes of planned home births with qualified midwives are comparable or better than outcomes of hospital births.
Increasing the number of midwife attended home births in the United States would provide safe birth options with less interventions and better outcomes for mothers and babies.
By Shannon Greika, CPM
References
Burnett, C., Jones, J., Rooks, J., Tyler, C., & Miller, A. (1980). Home delivery and neonatal mortality in North Carolina. Journal of American Medical Association, 244(24), 2742- 2745.
Citizen for Midwifery. (2006). Out-of-hospital midwifery care: Much lower rates of cesarean sections for low-risk women. Retrieved from http://www.cfmidwifery.org/pdf/cesarean2x.pdf
Cheyney, 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 & Women's Health. Vol 59(1). pp. 17-27.
de Jonge, A., van der Goes, B.Y., Ravelli, A. C., Amelink-Verburg, M. P., Mol, B. W., Nijhuis,
J. G., Bennebroek Gravenhorst, J., & Buitendijk, S. E. (2009). Perinatal mortality and
morbidity in a nationwide cohort of 529,688 low- risk planned home and hospital births.
BJOG, 116(9), 1177-84. doi: 10.1111/j.1471-0528.2009.02175.x
Deneux-Tharaux, C., Carmona, E., Bouvier-Colle, M.H., & Breart, G. (2006). Postpartum maternal mortality and cesarean delivery. Obstetrical Gynecology, 108(3 Pt 1), 541-8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16946213
Durand, M. (1992). The safety of homebirth: The farm study. Journal of American Public Health Association, 82, 450-452.
Enkin, M. W., Keirse, M. J., Neilson, J. P., Crowther, C. A., Duley, L., Hodnett, E. D., &
Hofmeyr, G. J. (2000). A guide to effective care in pregnancy and childbirth. New York, NY: Oxford University Press
Hamilton, B. E., Martin, J. A, & Ventura, S. J. (2010). Births: Preliminary data for 2010. Center for Disease Control: National Vital Statistics Reports. 60(2).
Hinds, M., Bergeisen, G., & Allen, D. (1985). Neonatal outcomes of planned vs. unplanned out- of-hospital births in Kentucky. Journal of America Medical Association, 253(11), 1578- 1582.
Janssen, P. A., Holt, V. L., & Myers, S. J. (1994). Licensed midwife-attended, out-of-hospital births in Washington state: are they safe? Birth, 21(3), 141-8.
Janssen, P.A., Saxell, L., Page, L. A., Klein, M. C., Liston, R. M., & Lee, S. K. (2009). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ, 181(9), 617.
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.
doi: 10.1136/bmj.330.7505.1416
MacDorman, M. F., Declercq, E., Menacker, F., & Malloy, M. H. (2006). Infant and neonatal mortality for primary cesarean and vaginal births to women with "no indicated risk," United States, 1998-2001 birth cohorts. Birth. 33(2), 175-82. Retrieved from
http://128.193.4.112/cla/anthropology/reproductive_lab/sites/default/files/MacDorman_2 006.pdf
Mehl, L. (1977). Outcomes of elective home births: A series of 1146 cases. Journal of Reproductive Medicine, 19, 281-290.
Mehl, L. (1978). Scientific research on childbirth alternatives & what it tells us about hospital practice. 21st Century Obstetrics, 1, 171-207.
Michal, C. A., Janssen, P. A., Vedam, S., Hutton, E. K., & de Jonge, A. (April 1, 2011). Planned home vs. hospital birth: A meta-analysis gone wrong. Medscape Ob/Gyn. Retrived from http://www.medscape.com/viewarticle/739987
Wagner, M. (2006). Born in the USA: How a broken maternity system must be fixed to put women and children first. Berkley, CA: University of California Press.
Wax, J. R., Lucas, F. L., Lamont, M., Pinette, M. G., Cartin, A., & Blackstone, J. (2010). Maternal and newborn outcomes in planned home birth vs. planned hospital births: a metaanalysis. American Journal of Obstetrics & Gynecology. 203(3), 243.
Weitz, R., & Sullivan, D. (1984). Licensed lay midwives in Arizona. Journal of Nurse- Midwifery, 29(1), 21-28.
World Health Organization. (2008). Maternal Mortality Ratio [Data file]. Retrieved from
http://apps.who.int/ghodata/
U.S. Studies
Several studies regarding the safety of home birth have taken place over the last 30 years in the United States. Early studies regarding home birth in the United States were performed by Mehl (1977 and 1978). The 1977 Mehl study gives data showing the safety of home birth attended by direct-entry midwives following 1,146 cases. The 1978 Mehl study shows better outcomes for planned home births compared to planned hospital births following 2,092 matched pairs. Several others studies were performed in the United States showing the safety of direct-entry ‘lay’ midwives in North Carolina (Burnett, Jones, Rooks, Tyler, & Miller, 1980), Arizona (Weitz, R., & Sullivan, D. (1984). Weitz, R.,& Sullivan, D. (1984).Weitz & Sullivan, 1984), Kentucky (Hinds, Bergeisen, & Allen, 1985), the Farm in Tennessee (Durand, 1992), and Washington State (Janssen, Holt, & Myers, 1994).
One of the larger home birth study that is frequently sited was performed by Johnson and Daviss (2005) covering 5,000 home births attended mostly Certified Professional Midwives (CPMs) in the United States and showed that CPM attended planned home births had comparable mortality rates during labor and delivery to rates found in most studies of low risk hospital births. A conflicting study was issued in American Journal of Obstetrics & Gynecology (AJOG), (Wax et al., 2010) showing a higher neonatal mortality rate for planned home births verses hospital births. However, many have since determined that the design of the study was flawed for several reasons, one reason being that it included unplanned and planned home births (Michel, Janssen, Vedam, Hutton, & de Jonge, 2011).
The most recent study is the largest analysis of planned home birth in the U.S. ever published which examines nearly 17,000 courses of midwife-led care (Cheyney et al., 2014). This study was issued in peer-reviewed Journal of Midwifery & Women’s Health, and confirms that among low-risk women, planned home births result in low rates of interventions without an increase in adverse outcomes for mothers and babies.
Studies Around the World
Study after study performed all over the world have also shown home birth outcomes to be comparable or better than hospital outcomes in terms of perinatal and maternal mortality, with substantially less interventions. The largest study to date looked at more than 500,000 births to healthy women in the Netherlands and found perinatal mortality to be similar between planned home birth and planned hospital birth (de Jonge et al., 2009). In Canada, a 2009 study showed that planned home births attended by a registered midwife resulted in low and similar rates of perinatal death, less intervention and less other adverse outcomes compared with planned hospital birth attended by a midwife or physician (Janssen et al., 2009).
Factors Contributing to Home Birth Safety
Several factors contribute to the safety of home birth, such as continuity of care, individualized care, less intervention, well screened clientele, and more in-depth postpartum care. Being in the mother’s own home exposes her to less risk of infection by being around familiar germs. Additionally, the mother is more comfortable in a familiar environment which is supportive of physiological birth.
Women who birth at home with a midwife receive continuity of care where they are supported throughout their entire pregnancy with a caregiver whom she has had the opportunity to form a deep and trusting relationship. During labor and delivery, the mother is given continuous hands-on assistance with this same caregiver. This continuity of care allows for the midwife to see the ‘whole’ picture regarding this mother and her pregnancy, making it easier to identify when things might no longer be ‘normal’ for this particular mother. Large obstetrical practices may have as many as eight or nine rotating physicians seeing the mother during her pregnancy, which makes continuity of care impossible. Continuity of care during hospital birth is further diminished when the laboring mother arrives at the hospital to be supported by a nurse they have never met, and will be given a new nurse as shifts change. Enkin et al. (2000) mentions a Canadian study that found that women giving birth in a hospital encountered an average of six unfamiliar professionals during labor, with some women reporting up to 14 attendants (p. 249). Additionally, several studies have shown that on average less than 10% of the labor nurse’s time was spent in supportive activities (Enkin et al., 2000, p. 249).
Another factor contributing to the safety of home birth is the holistic and individualized care the mother receives. Midwives focus on the mother as a whole; including the physical, psychological, and social well-being. A typical prenatal exam with a midwife may be 45 minutes to an hour long. During these longer prenatal exams, the midwife develops a close relationship with the mother, and is able to assess not only the mother’s physical well being, but psychological and social well-being as well. This is extremely important as the psychological and social well being of the mother has a direct impact on the physical well being of the mother, which significantly impacts the health of the pregnancy and the baby. This intimate relationship that is formed contributes to the overall safety of the birth, as the midwife is given more opportunities to identify potential issues or red flags that may need to be discussed or addressed. It also gives the midwife more opportunity to rely on her intuition regarding a situation. These longer prenatal appointments foster the opportunity to develop individualized care. Each mother’s pregnancy is treated as a unique situation where education, counseling, care, and support can be tailored specifically to meet that mother’s needs. For instance, a thorough discussion on nutrition, which significantly impacts the health of the pregnancy, can be made where the mother is educated and encouraged on wise choices.
A significant factor contributing to the safety of home birth is the lower use of interventions. Midwives believe that childbirth is a natural physiological process that is typically safest when left alone. Just as a cat or any other mammal seeks a dark, quiet, and safe place to birth; human birth thrives under those same conditions. A mother is more comfortable in her familiar environment at home which supports physiological birth. Midwives understand that many of the interventions that are routinely performed in the hospital contribute to complications for mothers and babies by not allowing the natural process of birth to take place.
Research by Johnson and Daviss (2005) shows rates of medical interventions were much lower for planned home births attended by CPMs than for low risk hospital births, and showed comparable mortality rates during labor and delivery. Additionally, a higher degree of maternal satisfaction was reported. Midwives also have much lower cesarean rates, 3-4% for out of hospital midwives compared to 32.8% for national average (Citizens for Midwifery, 2006) and (CDC, 2011). This dramatic difference in cesarean births has significant impact on outcomes for mothers and babies as maternal and neonatal mortality is tripled for cesarean births (Deneux-Tharaux, et al., 2006) and (MacDorman, et al., 2006).
Because of the medically minded nature of the culture in the United States, along with the fear of birth from media portrayal, many erroneously assume that home birth is not safe. However, research from the United States and all over the world show that outcomes of planned home births with qualified midwives are comparable or better than outcomes of hospital births.
Increasing the number of midwife attended home births in the United States would provide safe birth options with less interventions and better outcomes for mothers and babies.
By Shannon Greika, CPM
References
Burnett, C., Jones, J., Rooks, J., Tyler, C., & Miller, A. (1980). Home delivery and neonatal mortality in North Carolina. Journal of American Medical Association, 244(24), 2742- 2745.
Citizen for Midwifery. (2006). Out-of-hospital midwifery care: Much lower rates of cesarean sections for low-risk women. Retrieved from http://www.cfmidwifery.org/pdf/cesarean2x.pdf
Cheyney, 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 & Women's Health. Vol 59(1). pp. 17-27.
de Jonge, A., van der Goes, B.Y., Ravelli, A. C., Amelink-Verburg, M. P., Mol, B. W., Nijhuis,
J. G., Bennebroek Gravenhorst, J., & Buitendijk, S. E. (2009). Perinatal mortality and
morbidity in a nationwide cohort of 529,688 low- risk planned home and hospital births.
BJOG, 116(9), 1177-84. doi: 10.1111/j.1471-0528.2009.02175.x
Deneux-Tharaux, C., Carmona, E., Bouvier-Colle, M.H., & Breart, G. (2006). Postpartum maternal mortality and cesarean delivery. Obstetrical Gynecology, 108(3 Pt 1), 541-8. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16946213
Durand, M. (1992). The safety of homebirth: The farm study. Journal of American Public Health Association, 82, 450-452.
Enkin, M. W., Keirse, M. J., Neilson, J. P., Crowther, C. A., Duley, L., Hodnett, E. D., &
Hofmeyr, G. J. (2000). A guide to effective care in pregnancy and childbirth. New York, NY: Oxford University Press
Hamilton, B. E., Martin, J. A, & Ventura, S. J. (2010). Births: Preliminary data for 2010. Center for Disease Control: National Vital Statistics Reports. 60(2).
Hinds, M., Bergeisen, G., & Allen, D. (1985). Neonatal outcomes of planned vs. unplanned out- of-hospital births in Kentucky. Journal of America Medical Association, 253(11), 1578- 1582.
Janssen, P. A., Holt, V. L., & Myers, S. J. (1994). Licensed midwife-attended, out-of-hospital births in Washington state: are they safe? Birth, 21(3), 141-8.
Janssen, P.A., Saxell, L., Page, L. A., Klein, M. C., Liston, R. M., & Lee, S. K. (2009). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ, 181(9), 617.
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.
doi: 10.1136/bmj.330.7505.1416
MacDorman, M. F., Declercq, E., Menacker, F., & Malloy, M. H. (2006). Infant and neonatal mortality for primary cesarean and vaginal births to women with "no indicated risk," United States, 1998-2001 birth cohorts. Birth. 33(2), 175-82. Retrieved from
http://128.193.4.112/cla/anthropology/reproductive_lab/sites/default/files/MacDorman_2 006.pdf
Mehl, L. (1977). Outcomes of elective home births: A series of 1146 cases. Journal of Reproductive Medicine, 19, 281-290.
Mehl, L. (1978). Scientific research on childbirth alternatives & what it tells us about hospital practice. 21st Century Obstetrics, 1, 171-207.
Michal, C. A., Janssen, P. A., Vedam, S., Hutton, E. K., & de Jonge, A. (April 1, 2011). Planned home vs. hospital birth: A meta-analysis gone wrong. Medscape Ob/Gyn. Retrived from http://www.medscape.com/viewarticle/739987
Wagner, M. (2006). Born in the USA: How a broken maternity system must be fixed to put women and children first. Berkley, CA: University of California Press.
Wax, J. R., Lucas, F. L., Lamont, M., Pinette, M. G., Cartin, A., & Blackstone, J. (2010). Maternal and newborn outcomes in planned home birth vs. planned hospital births: a metaanalysis. American Journal of Obstetrics & Gynecology. 203(3), 243.
Weitz, R., & Sullivan, D. (1984). Licensed lay midwives in Arizona. Journal of Nurse- Midwifery, 29(1), 21-28.
World Health Organization. (2008). Maternal Mortality Ratio [Data file]. Retrieved from
http://apps.who.int/ghodata/
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