Home births rise despite higher neonatal mortality rate
■ Although the vast majority of deliveries occur in hospitals, more women who want a less institutional experience are opting to give birth at home.
Women seeking to avoid medical interventions and gain control of the birth process are increasingly choosing to deliver their babies at home, but medical experts warn that the option is accompanied by elevated neonatal mortality, even in low-risk births.
The news came shortly after an Australian home-birth advocate died following the delivery of her child at home, shedding a grave light on women's choices about where to give birth.
Births taking place at home grew by 28% between 2004 and 2009, with nearly 30,000 home deliveries happening in 2009. Home births, which were 0.56% of all U.S. deliveries in 2004, accounted for 0.72% of all deliveries in 2009. That is the highest rate since at least 1990, when birth certificates were changed to allow additional detail about out-of-hospital births, said a data brief published in January by the National Center for Health Statistics.
Nearly 90% of home births are planned, while the remainder are emergency deliveries in which the woman could not make it to the hospital.
The growth in home births is being driven by white women, whose home-delivery rate has passed the 1% mark. Home births among white women grew by 36% between 2004 and 2009, the newly reported data show.
"Home birth provides increased access to authority for the client, and they can feel like they are the central point of interest during their labor and birth and that they have privacy," said Alice Bailes, former chair of the American College of Nurse-Midwives' home birth committee. She co-directs the BirthCare & Women's Health Certified Nurse-Midwives practice in Alexandria, Va.
When the practice began providing home-birth services more than two decades ago, it assisted about 10 deliveries monthly. Now it sees nearly 30 births a month, Bailes said.
"Women have, by definition, more authority in their own home than they do anywhere else," she said. "We feel -- through a process of good education about options in care -- that they can look at their options and make their own decisions about various approaches that are available and safe and evidence-based."
Higher death rate at home
News of the rising popularity of out-of-hospital births in the U.S. came just days after Australian Caroline Lovell died of cardiac arrest after giving birth to daughter Zahra in her Melbourne home. Lovell, 36, was taken to a local hospital for treatment but died the following day, according to the Australian newspaper the Herald Sun. Lovell had submitted testimony in favor of legislation to give public funding and legal indemnity to midwives who assist home births.
While Australian authorities are conducting an investigation to determine whether Lovell's choice to give birth outside of a hospital contributed to her death, the case highlighted the serious concern among medical experts that home deliveries raise the risk to mother and child.
However, the relative safety of planned home birth is heavily disputed. Good evidence is difficult to come by. Randomized controlled trials are virtually impossible, as that would involve telling women where to give birth. Observational studies are beset by problems such as a lack of data distinguishing planned home births and emergency home deliveries, as well as poor information about the relative risk profiles of the births studied.
Getting apples-to-apples comparisons is tough, experts added. Women at high risk for difficult pregnancies are likelier to give birth in the hospital, and women who struggle with at-home deliveries often transfer to the hospital to complete delivery.
Nonetheless, recent evidence suggests that while the absolute risk of planned home births is low, such births carry a neonatal death rate at least twice as high as that of planned hospital births. Neonatal death occurred less than once in 1,000 hospital births, compared with two in 1,000 home births, said an American Journal of Obstetrics & Gynecology meta-analysis published in September 2010. Women who planned to give birth at home were less likely to have an episiotomy or cesarean section, suffer lacerations or acquire infections. It was the higher rate of medical interventions that lowered the neonatal mortality rate in hospitals, the study said. There was no difference in the maternal death rate.
Midwifery organizations dispute the findings, arguing among other things that home delivery is poorly integrated into the U.S. health system, making it more difficult to secure urgent hospital care when needed.
Hospitals and affiliated birth centers "are the safest setting for birth," said an opinion issued in February 2011 by the American College of Obstetricians and Gynecologists' Committee on Obstetric Practice.
"When you're at home, you can't respond to a real emergency the way you could when you're in the hospital," said George Macones, MD, chair of the committee and chair of the Dept. of Obstetrics and Gynecology at Washington University School of Medicine in St. Louis. "Those super emergencies don't happen that often in obstetrics, but they do happen. That's why we see the death rate is higher when you deliver at home versus when you deliver in the hospital."
Midwifery training varies
ACOG said women have the right to choose home delivery but ought to know the risks involved. The organization added that it "does not support the provision of care by lay midwives or other midwives who are not certified by the American Midwifery Certification Board." Nearly 20% of home births are attended by certified nurse midwives or certified midwives who receive rigorous training to acquire that certification, according to the National Center for Health Statistics.
Nearly three-quarters of home births are assisted by others with lower levels of training, known variously as lay midwives, direct-entry midwives or certified professional midwives. Certified professional midwives can earn their credential by attending as few as 20 births. The typical ob-gyn resident could take part in that many births during just one week of training.
Retired ob-gyn Amy Tuteur, MD, has written extensively about the dangers of home births attended by poorly trained midwives at her blog, The Skeptical OB. She said women who consider giving birth at home deserve to know the risks involved.
"Every woman has a right to have a home birth, but the decision has to be informed," Dr. Tuteur said. "What really bothers me is how many women lose babies because they never understood that this was a real risk. There is this whole culture of home-birth advocacy that says obstetrics is lying to you -- only the OBs mess it up, and [medical] interventions kill babies. Interventions don't kill babies; they save them."
The American Medical Association has policy stating that the safest setting for labor, delivery and the immediate postpartum period is in the hospital, a birth center at a hospital complex that meets ACOG and American Academy of Pediatrics standards, or a freestanding birthing center accredited by the Joint Commission, the American Assn. of Birth Centers or the Accreditation Assn. for Ambulatory Health Care.
The AMA's policy "supports state legislation that helps ensure safe deliveries and healthy babies by acknowledging" these locations as the safest birth settings. The Association also has policy stating, "Obstetrical facilities and their staff should recognize the wishes of women and their families within the bounds of sound obstetrical practice and encourages public education concerning the risks and benefits of various birth alternatives." AMA policy supports "state legislation regarding appropriate physician and regulatory oversight of midwifery practice."