This mother labored in a tub of water, which proponents say makes labor easier.

A home birth in developed countries is an attended or an unattended childbirth in a non-clinical setting, typically using natural childbirth methods, that takes place in a residence rather than in a hospital or a birth centre, and usually attended by a midwife or lay attendant with expertise in managing home births.

Women with access to high-quality medical care may choose home birth because they prefer the intimacy of a home and family-centered experience or desire to avoid a medically-centered experience typical of a hospital or clinical setting. Professionals attending women in home births are usually trained to provide limited medical care, including administering oxygen and managing events like shoulder dystocia, postpartum hemorrhage, repairing perineal tears, and resuscitating infants. Home birth was until the advent of modern medicine the de facto method of delivery. In developing countries, where women may not be able to afford medical care or it may not be accessible to them, a home birth may be the only option available, and the woman may or may not be assisted by an attendant of any kind.

The safety of home birth has been a subject of some controversy, especially among professional physicians groups. A number of studies have shown that the safety of an attended home birth for low-risk women is equal to the risks of giving birth in the hospital or a birthing center, though the quality and reliability of the available data has been called into question.^[1][2] The American Medical Association and the American College of Obstetricians and Gynecologists oppose home birth on the basis that a seemingly uncomplicated birth can still potentially become a medical emergency without warning, and they assert that home birth makes the birth experience a greater priority than safety. ^[3][4]

Legal regulations in some Western nations, especially the United States, limit a woman's ability to choose an attended home birth. Attended home births are supported in much of Europe. The majority of all infants in developing countries are born at home with mothers attended by lay midwifes, nurse/midwives, or family members. Due to poor medical care and other cultural and socio-economic reasons, the risks of perinatal death or maternal death are very high.

[edit] Types of home births

Home births are either attended and unattended. Women are attended when they are assisted through labor and birth by a professional, usually a midwife, and rarely a general practitioner. Women who are unassisted or only attended by a lay person, perhaps their spouse, family, friend, or a non-professional birth attendant, are sometimes called freebirths.

[edit] Factors in opting for a home birth

Many women choose home birth because delivering a baby in familiar surroundings is important to them.^[5] Others choose home birth because they dislike a hospital or birthing center environment, do not like a medically-centered birthing experience, are concerned about exposing the infant to hospital-borne pathogens, or dislike the presence of strangers at the birth. Others prefer home birth because they feel it is more natural and less stressful.^[6]:8 In a study published in the Journal of Midwifery and Women's Health, women were asked, Why did you choose a home birth?^[5] The top five reasons given were safety, avoidance of unnecessary medical interventions common in hospital births, previous negative hospital experiences, more control, and a comfortable and familiar environment.

One study found that women experience pain inherent in birth differently, and less negatively, in a home setting.^[7]

Many midwives are prepared with oxygen, if needed, to assist the mother or newborn. Midwives are usually trained to provide neonatal resuscitation, start intravenous solutions, and can administer oxytocin and other medications as needed to halt postpartum hemorrhaging. They carry the supplies needed and are trained to suture. Births necessitating other interventions must be transferred to a hospital. Home births do not offer access to pharmaceutical pain relief or pharmaceutical labor induction. They do not provide ready access to the equipment and supplies required for emergency cesarean section. Most midwives develop working relationships with obstetricians and hospitals in case these options become necessary. Depending on the midwifery practice, transfer rates range from 5% to 40%, with most studies citing a transfer rate of about 16%.^[8]

[edit] Positions of International and Medical Organizations

The WHO has released a statement supporting the right of women to choose where they give birth. They state that women who have low-risk pregnancies and receive appropriate support and formulate contingency plans can give birth at home.^[9]

The American College of Gyneclogy and Obstetrics (ACOG) recognizes the right of women to make informed decisions and choose a place of birth, but does not support home birth programs or providers, citing the lack of scientifically rigorous studies and potential safety risks, explaining "lay or other midwives attending to home births are unable to perform live-saving emergency cesarean deliveries and other surgical and medical procedures that would best safeguard the mother and child." For women who choose to have a midwife, they strongly recommend choosing one certified by the American College of Nurse-Midwives or the American Midwifery Certification Board.^[4]

The American Medical Association also concludes that the "safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers." The AMA points out that emergencies such as maternal hemorrhage, shoulder dystocia, or eclampsia, which may require immediate emergency care as they are extremely time-sensitive, can quickly present themselves even in an apparently low-risk delivery. ^[3]

[edit] Home birth trends

Home birth was until the advent of modern medicine the de facto method of delivery.^[10]

[edit] Developed countries

In many developed countries, home birth declined rapidly over the 20th century. In the United States home birth declined from 50% in 1938 to fewer than 1% in 1955; in the United Kingdom a similar but slower trend happened with approximately 80% of births occurring at home in the 1920s and only 1% in 1991. In Japan the change in birth location happened much later, but much faster: home birth was at 95% in 1950, but only 1.2% in 1975^[11].

The decline was due in large part to the expansion of private insurance coverage in the US and taxpayer-funded medical care in Europe and Canada, changes which included policies about where birth should take place. In addition, there was a large population migration from rural to urban areas, an increased accessibility to hospitals, and unwillingness by doctors to attend to women in their homes.

One doctor described birth in a working class home in the 1920s:

You find a bed that has been slept on by the husband, wife and one or two children; it has frequently been soaked with urine, the sheets are dirty, and the patient's garments are soiled, she has not had a bath. Instead of sterile dressings you have a few old rags or the discharges are allowed to soak into a nightdress which is not changed for days.^[12]:p156

This experience is contrasted with a 1920s hospital birth by Adolf Weber:

The mother lies in a well-aired disinfected room, light and sunlight stream unhindered through a high window and you can make it light as day electrically too. She is well bathed and freshly clothed on linen sheets of blinding whitenes... You have a staff of assistants who respond to every signal... Only those who have to repair a perineum in a cottars's house in a cottar's bed with the poor light and help at hand can realize the joy.^[12]:157

Midwifery, the practice supporting a natural approach to birth, enjoyed a revival in the United States during the 1970s. However, although there was a steep increase in midwife-attended births between 1975 to 2002 (from less than 1.0% to 8.1%), most of these births occurred in the hospital and the US rate of out-of-hospital birth has remained steady at 1% of all births since 1989 with 27.3% of these in a free-standing birth center and 65.4% in a residence. Hence, the actual rate of home birth in the United States has remained remarkably low (0.65%) over the past twenty years.^[13]

Home birth in the United Kingdom has also received some press over the past few years as there has been a movement, most notably in Wales, to increase home birth rates to 10% by 2007. Between 2005 to 2006, there was an increase of 16% of home birth rates in Wales, but the total home birth rate is still 3% even in Wales (double the national rate) and in some other counties of Great Britain the home birth rate is still under 1%.^{[citation needed]} In Australia, birth at home has fallen steadily over the years and is currently 0.3%, ranging from nearly 1% in the Northern Territory to 0.1% in Queensland.^[14]:20 The New Zealand rate for births at home is nearly three times Australia's with a rate of 2.5% and increasing.^[15]:64

In the Netherlands, an opposite trend has taken place: in 1965, two-thirds of Dutch births took place at home, but that figure has dropped to less than a third'about 30%.^[16]

In Korea, well-known Actress Kim Se-ah-I made headlines in January 2010 when she delivered a baby girl at home. Less than one percent of Korean infants are born at home.^[17]

[edit] Developing countries

In developing countries, about 40 percent of births are attended by lay midwives, 30 percent by a nurse/midwife, followed by a family member or unattended at 17 percent. Only 13 percent were attended by a physician.^[18] The majority of births are at home.^[19] In many regions of Tajikistan in Central Asia, up to 70-80% of births take place at home.^[20] In Uganda, 60-70% of women give birth at home.^[21] In the Greater Republic of Congo, traditional birth attendants or lay midwives attend nearly 75 per cent of all births in the nation.^[18]

The safety of home birth in developing countries is constrained by a number of socio-economic factors, including lack of health care services and poor nutrition, Women die as a result of infection and of hemorrhage.^[22] Some have obstructed labor and cannot get a Cesarean section. Others die of preventable complications. In a study published in early 2010, it was noted that world-wide about seven million infants "die in the womb or soon after birth," with 98 percent of these perinatal deaths taking place in developing countries.^[22]

In the developing world, the risk of death from complications relating to pregnancy and childbirth over the course of a woman's lifetime is one in 76, compared with one in 8,000 in the industrialized world. Nearly 99 percent of maternal deaths related to pregnancy and labor take place in the under-developed nations, with the greatest concentration in sub-Saharan Africa and Southern Asia. That means only 1% of the world's maternal deaths occur in the United States, Canada, Europe and Australia combined.^[23]

[edit] Research on safety

Cherie LaVergarray delivers her child unassisted in a home birth.

The data available on the safety of home birth in developed countries is limited and difficult to interpret due to issues such as studies being too small in scope, retrospective in their design, and difficult to compare with other studies because of varying definitions of perinatal mortality.^[1] It is difficult to compare home and hospital births because only healthy, low-risk women tend to give birth at home.^[24] An additional problem is that transportation time is a significant factor in safety, and data comes from many different countries, which have different population density levels and therefore different average hospital distances.^[2]

In 2007, after a comprehensive review of the literature, the UK's National Institute for Health and Clinical Excellence (NICE) expressed concern for the lack of quality evidence comparing the potential risks and benefits of home and hospital birthing environments. Their report also noted that intrapartum-related perinatal mortality was low in all settings. In conclusion, the report recommended that women should be offered the choice of planning birth at home, in a midwifery unit or in an obstetric unit, and informed of the potential risks and benefits of each birth setting.

The uncertain evidence suggests intrapartum-related perinatal mortality (IPPM) for booked home births, regardless of their eventual place of birth, is the same as, or higher than for birth booked in obstetric units. If IPPM is higher, this is likely to be in the group of women in whom intrapartum complications develop and who require transfer into the obstetric unit.

When unanticipated obstetric complications arise, either in the mother or baby, during labour at home, the outcome of serious complications is likely to be less favourable than when the same complications arise in an obstetric unit.^[25]

The NICE report concluded that women who give birth at home are more likely to deliver vaginally and to have greater satisfaction from the experience when compared with women who plan to give birth in a hospital. The report compared women's home birth experience to birth in a consultant-led unit. It concluded that the consultant-led setting increased the likelihood that the woman would receive analgesia, obstetrical intervention and a delivery using instruments, and decreased the woman's satisfaction with the experience. It reported that women who give birth at home may experience an equal or lower risk of perinatal mortality equal when they receive care in a consultant-led unit.^[1]

Since the 2007 review, a study of 529,688 low-risk planned home and hospital births was reported in the British Journal of Obstetrics and Gynaecology in 2009. The study concluded:

A home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low risk women, provided the maternity care system facilitiates this choice through the availability of well-trained midwives and through a good transportation and referral system.^[26]

Further, the study noted there was evidence that "low risk women with a planned home birth are less likely to experience referral to secondary care and subsequent obstetric interventions than those with a planned hospital birth."^[26]:9 The study has been criticised on several grounds, including that some data might be missing and that the findings may not be representative of other populations.^[27]

In North America, a 2005 study found "similar mortality rates for low-risk hospital births and planned home births." The study found that mothers who gave birth at home were less likely to require medical interventions like a caesarean section or forceps delivery. About 12 percent of women intending to give birth at home needed to be transferred to the hospital for reasons such as a difficult labor or pain relief.^[19] However, women in the study were more likely to already had a child, tended to be older, of lower socioeconomic classes, better educated, and less likely to be African-American or Hispanic.^[19]

A 2010 metastudy of studies which specifically compared only planned home births with planned hospital births among healthy, low-risk mothers in industrialized countries found no difference in the home and hospital rates of perinatal death, but also found that planned home birth holds more than twice the risk for death from the ages of 1 week to 1 month (commonly called the neonatal period). The authors wrote that they found this increase "striking" since women planning home births generally had fewer risk factors than those planning hospital births ' lower rates of obesity, fewer prior Caesarean sections, and fewer previous pregnancy complications.^[28]

[edit] Study design

This section's citation style may be unclear. The references used may be made clearer with a different or consistent style of citation, footnoting, or external linking. (March 2010)

Randomized controlled trials are the "gold standard" of research methodology with respect to applying findings to populations; however, such a study design is not feasible or ethical for location of birth. The studies that do exist, therefore, tend to be cohort studies conducted either retrospectively (by selecting hospital records that match the characteristics of the home birth records),^[29] by matched pairs (by pairing study participants based on their background characteristics),^[30][31] or by using multivariate analysis to control for background variables.^[32] The Midwives Alliance of North America is collecting prospective data from out of hospital births for future research.^[33]

There are many differences between women who choose to give birth at home versus in hospital. There are unquantifiable differences in home birth patients, such as maternal attitudes towards medical involvement in birth^[29], and demographically, home birth patients tend towards being more multiparous, less ethnic minorities, attend more prenatal visits, be slightly taller and lighter, of better educational background, and have fewer previous obstetric complications, including cesarean sections.^[32] None of the studies conducted were able to study a large enough group of matched births to make definitive statements concerning perinatal mortality and other rare complications.^{[citation needed]}

The Cochrane database, first published in 1998, is a study of Home versus hospital birth, Systematically reviewed in May 2010, it "found only one small trial, which provided no strong evidence to favour either planned hospital birth or planned home birth for low-risk pregnant women."^[34]

However, in a study of over four hundred Cochrane entries, C. H. Hofmeyr reported that, "The relative benefits and risks of different settings are difficult to quantify. For a woman and her baby with no complications, the risk of an unexpected adverse event during a home birth may be smaller than risks specific to hospitalization, such as hospital-acquired infections." ^[35]

Olsen and Jewell (2000), the authors of the systematic review also state: "In countries where it is possible to establish a home birth service backed up by a modern hospital system, all low-risk women should be offered the possibility of considering a planned home birth...." (Olsen & Jewell: 2000 (CD000352) in Buckley:2005:230).

[edit] Maternal safety

Evaluations of maternal safety are based on studies of developed countries where professionals are available to attend to women giving birth at home. Women who do not receive prenatal care and give birth unattended have a much higher risk for maternal deaths and perinatal mortality.

All medical interventions were substantially decreased in the home birth sample, including the use of any pain medication or analgesics including epidurals, forceps or vacuum extraction, episiotomy and cesarean sections. Accordingly, the likelihood of normal vaginal birth was also greatly increased in the home birth sample. The studies were able to establish that there was no difference between the home birth and the hospital birth groups in the incidence of pre-eclampsia, premature rupture of membranes, or premature birth. Except in the 1989-1992 Zurich study.^[30] the length of labor tended to be longer during home birth, which is unsurprising given the fivefold lower incidence of labor induction in the home birth populations.

In terms of maternal outcome, no study found any statistically significant difference between the number of women that had third-degree perineal lacerations or postpartum hemorrhage. However, the 1998-1999 British Columbia study did find a three- to fourfold less likelihood of infection for both the infant and the mother,^[32] and all studies reported a substantially higher likelihood of an intact perineum in the home birth sample.

[edit] Infant safety

Perinatal outcome is more complicated to assess due to the low incidence of mortality and the subjectivity of Apgar scoring. Most studies found a slight, but statistically significant, difference in Apgar score for infants at five minutes. However, the 1994 UK National Birthday Trust study found a slight advantage for home birthed infants at one minute and no difference at five minutes.^[31] No cohort study has conducted long-term follow up on the infants. The perinatal mortality figure still remains controversial. The Zurich study^[30] showed an equal perinatal death rate between the home birth group and the hospital birth group (2.3 / 1000), and the Birthday Trust study found a slightly higher perinatal death rate in the hospital birth group (1 / 1000 vs. 0.8/1000).^[31] However, two other studies^[29][32] found a slightly higher perinatal mortality in the home birth group as compared to the hospital birth group. None of these results were seen to be statistically significant, since the actual mortality rate and the sample sizes were both so low, these figures have been the subject of much debate regarding the relative safety of home birth compared to hospital birth.^[32][36]

[edit] Legal situation

While a woman in developed countries may choose to deliver her child at home, in a birthing center, or at hospital, legal issues influence her options.

[edit] Australia

In April 2007, the Western Australian Government expanded coverage for birth at home across the State.^[37] Other state governments in Australia, including the Northern Territory, New South Wales and South Australia, also provide government funding for independent, private home birth.

The 2009 Federal Budget provided additional funds to Medicare to allow more midwives to work as private practitioners, allow midwives to prescribe medication under the Medicare Benefits Schedule, and assist them with medical indemnity insurance.^[38] However, this plan only covers hospital births. There are no current plans to extend Medicare and PBS funding to home birth services in Australia.

As of July 2010, all health professionals must show proof of liability insurance. Midwives who attend home births will be excluded from the indemnity requirement for two years while the government seeks to make affordable insurance available.^[39]

[edit] Canada

Public health coverage of home birth services varies from province to province as does the availability of doctors and midwives providing home birth services. The Provinces of Ontario, British Columbia, Saskatchewan, Alberta, and Quebec currently cover home birth services.^[40][41]

A comprehensive four-year study of all home births attended by midwives in British Columbia, published in August 2009, found "Planned home birth attended by a registered midwife was associated with 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."^[42]

[edit] United Kingdom

The are few legal issues with a home birth in the UK. There is no way a woman can be forced to go to hospital^[43], if she does not want to. Both the RCM (Royal College of Midwives) and the RCOG (Royal College of Obstetricians and Gynaecologists) support home births where there are no expected complications.^[44]. The support of the various Health Authorities of the National Health Service may vary, but in general the Government is pro home birth - the Parliamentary Under-Secretary of State for Health, Lord Hunt of King's Heath has stated

I turn to the issue of home births. The noble Lord, Lord Mancroft, made some helpful remarks. As I understand it, although the NHS has a legal duty to provide a maternity service, there is not a similar legal duty to provide a home birth service to every woman who requests one. However, I certainly hope that when a woman wants a home birth, and it is clinically appropriate, the NHS will do all it can to support that woman in her choice of a home birth."^[45]

and

My Lords, I have had two babies at home. I should say that my wife had the babies but I was an enthusiastic spectator. The Government want to ensure that, where it is clinically appropriate, if a woman wishes to have a home birth she should receive the appropriate support from the health service. At the end of the day, it must be the woman's choice."^[46]

[edit] United States

Practicing as a direct-entry midwife is illegal in states shown here in red

In 27 states it is legal to hire a direct-entry midwife, or certified professional midwife (CPM).^[47] It is legal in all 50 states to hire a certified nurse midwive, or CNM, who are trained nurses, though this practice is rare as most CNMs work in hospitals.^[47] Some CPMs continue to attend mothers in the 23 states where it is illegal, and can be arrested and prosecuted, while efforts are underway to change the law.^[47]

Practicing as a direct-entry midwife is still (as of May 2006) illegal under certain circumstances in Washington, D.C. and the following states: Alabama, Georgia, Hawaii, Illinois, Indiana, Iowa, Kentucky, Maryland, North Carolina, South Dakota and Wyoming.^[48] However, Certified Nurse Midwives can legally practice in these areas.

No state prosecutes mothers for giving birth outside of a hospital.

[edit] Additional reading

[edit] Material supporting home birth choice

• Harper, Barbara (2005). Gentle Birth Choices: Making Informed Decisions. Rochester, VT: Healing Arts Press. ISBN 1594770670. 
• Gaskin, Ina May (1977). Spiritual Midwifery (first ed.). The Book Publishing Company. ISBN 1-57067-104-4. 
• Korte, Diana (1992). A Good Birth, A Safe Birth: Choosing and Having the Childbirth Experience You Want. Boston, MA: USA: The Harvard Common Press. ISBN 1558320415. 
• England, Pam (1998). Birthing From Within: An Extra-Ordinary Guide to Childbirth Preparation. England: Partera Press. ISBN 0965987302. 
• Armstrong, Penny (1990). A Wise Birth. Bringing together the best of natural childbirth with modern medicine (Pinter & Martin 2007 ed.). ISBN 978-1-905177-03-5. 
• Vernon, David (2005). Having a Great Birth in Australia. Canberra: Australian College of Midwives. ISBN 0-9751674-3-X. 
• Vernon, David (2006). Men at Birth. Canberra,: Australian College of Midwives. ISBN 0-9751674-4-8. 
• Wesson, Nicky (2006). Home Birth: A Practical Guide. Pinter & Martin. ISBN 978-1-905177-06-6. 
• Goer, Henci (1999). The Thinking Woman's Guide to a Better Birth. Perigee Books. ISBN 0399525173. 
• Abby Esptein. (2007). The Business of Being Born. New Line Home Video. 
• Hazard, Leah (2008, reprint edition 2010). The Father's Home Birth Handbook. Pinter & Martin. ISBN 978-1-905177-50-9. 

[edit] Material regarding safety and risk relating to birth

• Obstetric Myths versus Research Realities - a guide to the medical literature, Henci Goer, Bergin & Gavey, 1998
• The Thinking Woman's Guide to a Better Birth, Henci Goer
• Pursuing the Birth Machine - the search for appropriate birth technology, Marsden Wagner, Ace Graphics, 1988

[edit] Material against home birth choice

[edit] Material regarding birth culture

• Mitford, Jessica (August 1999). The American Way of Birth. ISBN 0788163450. 
• Wolf, Naomi (February 4, 2003). Misconceptions: Truth, Lies and the Unexpected in the Journey to Motherhood. Anchor. pp. 352. ISBN 0385497458. 

[edit] See also

• Childbirth
• Midwifery
• Doula
• Natural childbirth
• Nursing
• Pregnancy

[edit] References

[edit] External links

• International Models of Maternity Care Report on maternity care released in Scotland, 2002, includes summary of how maternity care is dealt with in other countries besides the UK. Expert Group on Acute Maternity Services: Reference Report
• Intrapartum Care Guidelines (2007) National Center for Health and Clinical Excellence, an independent health care monitoring organization in the UK, reviewing the home birth literature.
• Home Birth Reference Site, Index of Research on Home Birth
• Home Birth American Pregnancy Association, brief article outlining the pros and cons of home birth
• General Aspects of Labor World Health Organization, Care in Normal Birth: A practical guide, Chapter 2, 1997.
• ACOG Statement on Home Birth American College of Obstetricians and Gynecologists Reiterates its long-standing opposition to home births (Feb 8, 2008)
• Canadian Medical Association Journal, Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician'Jansen et al., 10.1503/cmaj.081869, August 2009. This was a 4-year study of all home births with midwives in British Columbia. Conclusion: Planned home birth attended by a registered midwife was associated with 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.
• Profile of home birth pioneer Ina May Gaskin, The Guardian, September 2009