Can you safely give birth at home?
- Evidence is clear — home births are as safe for low-risk pregnancies as giving birth in the hospital; they may even be safer
- Women giving birth in a hospital have a higher chance of being given drugs to speed labor or having a cesarean section, both of which impact the health of mother and baby
- Risks associated with a cesarean section include infection, hemorrhage and adhesions. Infants may arrive early, have breathing difficulties and not benefit from exposure to the birth canal to seed their gut microbiome
- Some conditions are best addressed at a hospital, including those raising the risk of a pregnancy such as the mother's age and health conditions such as diabetes, PCOS, high blood pressure and obesity
The question of where and how to give birth is a relatively new one for women. Up until the early 20th century, fewer than 5% of women gave birth in a hospital. In the 1950s the birth of a baby, an event that had once been a family affair and attended by a midwife, became more medicalized.1
Pregnancy and birth were seen more as a sickness than a natural part of life. One mom described the birth of her first child in the 1960s as occurring without pain medication, with minimal interaction from medical staff and a forced two-week hospital stay.2
Dads began attending births in the 1970s and by the 1990s childbirth was swinging back toward being a natural part of life. More women are now offered choices that are respectful of their wishes, without repeating the horror stories of past generations. This is an important factor in the future health of mother, child and family as recognized by the World Health Organization.3
The outcome not only affects the mother but may also be important in the development of the mother’s and child's relationship and mom’s future childbearing experiences. Researchers have found that a woman's positive and negative perceptions of birth are related more to her ability to control the situation and have a choice in her options, than specific details.
Low-Risk Home Birth as Safe as Hospital Birth
Evidence doesn’t back the long-held belief that low-risk deliveries are better served in the hospital where medical intervention may be used to speed delivery.
The safety debate surrounding home births is not a new one. Nearly 11 years ago data showed when a home birth was planned by a woman with a low-risk pregnancy and attended by a midwife, there were:4
" … very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician."
In 2008 the American College of Obstetricians and Gynecologists (ACOG) published a statement in opposition to home births, writing that “Choosing to deliver a baby at home, however, is to place the process of giving birth over the goal of having a healthy baby.”5
Despite evidence to the contrary, their statement published nearly 10 years later did not change: In 2017 they recommended women be informed of the risks, specifically that there are a lower number of risks to the woman but a higher rate of perinatal deaths.6
In another study of 530,000 births in the Netherlands,7 researchers found no differences in the rate of death in mother or baby between those born at home or in a hospital. The study was sparked by the suggestion that the high rate of infant mortality may be due to the high number of home births. The review of medical records did not bear out the hypothesis. Professor Simone Buitendijk commented to the BBC:8
"We found that for low-risk mothers at the start of their labour it is just as safe to deliver at home with a midwife as it is in hospital with a midwife. These results should strengthen policies that encourage low-risk women at the onset of labour to choose their own place of birth."
Safety Data Positive With Well-Educated Midwives
It should be noted data were published long before the 2017 policy statement from ACOG mentioned above. In 2014, a review of 16,924 home births recorded between 2004 and 2009 were examined. Researchers noted the rise of home births by 41% from 2004 to 2010, writing there is a9 “need for accurate assessment of the safety of planned home birth.”
The scientists found that of the participants who planned a home birth, 89.1% did in fact do so. Most of the transfers to the hospital during labor were for failure to progress. However, 93.6% went on to have a spontaneous vaginal delivery, and 86% of infants were breastfeeding exclusively by 6 weeks of age. The overwhelming majority — 87% — of 1,054 who attempted a vaginal delivery after cesarean section at home were successful.
Researchers recently conducted an international meta-analysis to evaluate the safety of home and hospital births with the primary outcome measurement of any perinatal or neonatal death. They chose 14 studies including approximately 500,000 intended home births attended by a midwife.10
The information was pulled from outcomes from eight Western countries, including the U.S., in studies published since 1990.11 What they found fit many of the previous studies:12 "The risk of perinatal or neonatal mortality was not different when birth was intended at home or in hospital." Eileen Hutton from McMaster University, one of the researchers, commented:13
"More women in well-resourced countries are choosing birth at home, but concerns have persisted about their safety. This research clearly demonstrates the risk is no different when the birth is intended to be at home or in hospital."
Conditions Best Addressed at the Hospital
Of course, there are high risk pregnancies better served inside a hospital environment. According to the U.S. Department of Health and Human Services, factors that potentially create a high-risk pregnancy include existing health conditions and lifestyle choices. While this list is not all-inclusive, these are factors your midwife or doctor will consider as you discuss your birth plan. Some include:14
High blood pressure — If this is the only risk factor and blood pressure is only slightly elevated, it may not be enough to stop a home delivery plan. However, uncontrolled blood pressure is dangerous to mother and baby.
Polycystic ovary syndrome (PCOS) — PCOS can increase the risk of gestational diabetes, cesarean section, preeclampsia and pregnancy loss before 20 weeks.
Diabetes — Moms who have diabetes are more likely to have babies that are larger than most; their babies may also have low blood sugar after being born.
Kidney disease — Depending upon the extent of the disease, it may impact fertility and the ability to carry a pregnancy to term. Nearly 20% of women with preeclampsia during pregnancy go on to be diagnosed with kidney disease.
Autoimmune disease — Medications used to treat autoimmune diseases may be harmful to the baby; such conditions also increase risks of pregnancy and delivery.
Thyroid disease — Uncontrolled disease may increase stress on the baby and cause poor weight gain, heart failure or problems with brain development.
Obesity — Obesity before becoming pregnant is associated with high risk and poor outcomes, including large for gestational age babies, difficult birth and a risk for heart defects.
Age — Teens and first-time moms over 35 fall into high-risk categories.
Lifestyle factors — Alcohol, tobacco and drug use increase the risks to mom and baby during the pregnancy and delivery.
Pregnancy conditions — Women carrying multiples, who have had a previous premature birth or who have gestational diabetes, preeclampsia or eclampsia are at high risk.
Comparing the Risks of Home and Hospital Births
The decision to give birth at home or in a hospital is a personal one. While ACOG claims the hospital is the safest place, research evidence shows low-risk pregnancies delivered at home or in a hospital with a qualified midwife have the same risks and outcome potential. Just as important are the risks for low-risk women who give birth inside a hospital setting.
For instance, while a home birth rarely if ever includes the use of drugs or interventions to speed delivery, many women who are hospitalized may receive Pitocin, a synthetic form of oxytocin. The drug is used to induce labor or start contractions and it may be used to intensify labor contractions to speed the process.
However, the use of the medication must be balanced against outcomes, such as a higher rate of analgesia and cesarean section,15 both of which affect mother and baby. In any pregnancy, oxytocin may also increase the risk of fever in the woman, low pH values in the umbilical cord and a shorter first stage of labor.16
Data from the CDC show the rate of cesarean sections in 2018 were 31.9% of all births.17 However, this includes a number of cesarean sections considered medically unnecessary. The rate for Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean Birth Rate is 25.9%.18
This means that of all the women who had a cesarean section, 25.9% were having their first baby, beyond 39 weeks gestation and carrying one child who presented normally, in the vertex position with the head down.19
Having had a first cesarean section nearly guarantees the following births will also be a cesarean section as the repeat rate is 86.7%.20 As explained by the American Pregnancy Association, cesarean section introduces multiple risks for mother and baby. For the mother, these include infection, hemorrhaging, injuries, lengthy stays in the hospital and emotional reactions as well as those related to medicine.
Moms can also have adhesions, or scar tissue that causes a blockage in the stomach area. Babies can have a low birth weight, a low APGAR score, breathing difficulties and even injuries.21
Type of Birth Influences Future Health
As you likely know, the gut microbiome is an intricate living foundation for your immune system that plays a role in your risk of chronic disease, weight management and how well your body absorbs nutrition. As you may imagine, during a vaginal birth a baby's microbiome is first “seeded” and developed.
During the process a baby is passed the mother's microbiome, which is why it's so important for the woman to have a healthy gut before, during and after pregnancy. The makeup of the mother's gut will influence how the baby's microbiome grows.
A cesarean section bypasses this important step, which may be compounded by bottle feeding, a lifetime of processed foods and an overuse of antibiotics. These factors all have led to a steep loss of biodiversity in the human gut making many vulnerable to disease. Skin-to-skin contact after birth and breastfeeding are two ways to pass along a healthy microbiome if you've had a cesarean section.
For more information about how to more effectively help seed your baby's gut microbiome see "How the Method of Birth Can Influence Lifelong Health."
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