Should you have a home birth? (And what to look for in a midwife!)
Interested in home birth but concerned about the safety of giving birth at home?
Photo by Monet Moutrie
Let me start by saying I do not think home birth is right for every person and this decision hinges on the risk level of your pregnancy and your personal preference. A person should not make the decision to have a home birth out of fear of birthing at the hospital and I encourage you to explore that fear if that is true for you.
Fear of unnecessary interventions is a driving factor for many people in choosing home birth. While it is true that you are much less likely to experience unnecessary interventions in a home birth setting, I would also like to emphasize that hospitals in this area of the country are far less likely than some other areas to commit acts of obstetric violence and perform non-evidence-based care. In most cases, the options of intermittent fetal monitoring, upright birthing positions, and other factors that promote physiologic birth will be available in a hospital setting.
The cesarean rate of hospitals in Sonoma County all are around 22-25%. The United States by comparison has a c-section rate of 32%, with some states having rates over 40% and some under 20%. The World Health Organization states that a 10-15% cesarean section rate improves maternal and neonatal outcomes, but a rate beyond 19% does not. From this, we can conclude that about 20-40% of c-sections are unnecessary at our local facilities.
*San Francisco General Hospital has achieved the WHO’s goal and has a c-section rate of 17%.
If you decide to give birth at home, you should make the decision out of a desire for the intimacy of the home birth experience and the comforts of your familiar surroundings.
Perhaps you also desire the individualized care that you receive when you are being cared for by a home birth midwife.
An example situation: you are over 40 and would like to avoid an induction. Your doctor must recommend that you be induced at 39 weeks and will cite data from ACOG. Your midwife may let you know that there is slightly increased risk in your pregnancy and may suggest an extra ultrasound or biophysical profile as you approach your due date to ensure you and your baby’s safety. After reviewing this information, your midwife will present you with all of your options, including the risks and benefits of waiting for labor or induction. They will not pressure you to make a decision based on statistics about a population without accounting for your personal situation and health.
Let’s talk about the safety:
For low-risk pregnancies, midwife-attended home birth is increasingly recognized in many industrialized settings as a valid and safe option. Some research suggests that maternal and child health outcomes associated with planned home birth of low-risk pregnancies are equivalent or preferable to those in hospital settings in the United States and Canada. A meta-analysis including 14 studies found no statistical difference in perinatal or neonatal mortality between planned home birth and planned hospital birth for low-risk birthing people in well-resourced countries. Furthermore, home births in well-integrated settings appeared to lead to better perinatal outcomes in this meta-analysis.
However, this view contrasts with mainstream biomedical practice in the United States, where the American College of Obstetricians and Gynecologists (ACOG) believes that hospitals and accredited birth centers are the safest settings.
Some studies using less strict criteria for screening pregnancies or certification of attendants have reported an increased risk of neonatal mortality for home births. One study using US linked birth and infant death files from 2000-2004 found that home deliveries attended by CNMs and 'other midwives' were associated with higher risks for mortality than in-hospital deliveries by CNMs. The adjusted odds ratio for neonatal mortality for home CNM-attended deliveries versus in-hospital CNM-attended deliveries was 2.02.
Another study in Victoria, Australia, found that for low-risk birthing people, the rates of perinatal mortality were similar between planned home birth and planned hospital birth. However, for high-risk birthing people, planned home birth was associated with significantly higher rates of perinatal mortality.
It is important to note that the absolute risk of perinatal and neonatal mortality remains low in both home and hospital settings across studies. However, outcomes of planned home birth may be markedly poorer for offspring of birthing people with higher-risk pregnancies.
The safety of home birth is also complicated by the challenges of hospital transfers. While most transfers are not due to obstetric emergencies, smooth communication during emergency transfers is associated with lower mortality rates.
Risks:
Home birth is considered a safe option only for birthing people experiencing relatively low-risk pregnancies.
There is a potential increase in rare but severe outcomes for the neonate with planned home birth.
One study found planned home birth in Oregon to be associated with increased intrapartum mortality. Another large nationwide dataset in the US also found increased intrapartum mortality with planned home birth.
Deliveries at home attended by CNMs and 'other midwives' were associated with higher risks for mortalitycompared to in-hospital deliveries by CNMs in one US study.
For high-risk pregnancies, planned home birth in Victoria, Australia was associated with significantly higher rates of perinatal mortality.
The US currently lacks a formal set of guidelines for home-birth practitioners, which could impact safety.
The perception of home birth as risky within the biomedical community might lead to reluctance in transferring birthing people to hospitals when medically indicated, potentially increasing actual risk.
Hospital transfers themselves pose a risk, although most are not for emergencies. Delays in transfer or poor communication can negatively impact outcomes.
Benefits:
Some individuals choose home birth for reasons including their perception of greater safety, avoidance of unnecessary interventions common in hospital settings, previous negative experiences with hospital birth, greater control, a more comfortable environment, and trust in the birth process.
Planned home birth is strongly associated with spontaneous vaginal childbirth. Rates of emergency cesarean section are significantly lower for birthing people who begin labor with a midwife, including those planning home births, compared to those under physician care anticipating vaginal birth.
Individuals planning home birth report associations with empowerment, avoidance of obstetric interventions and interruptions, avoidance of disrespect from hospital-based providers, maintenance of a calm and peaceful environment, and connection to their bodies and those around them.
Planned home birth is associated with a substantial decrease in obstetric interventions and their associated risks. For example, rates of electronic fetal monitoring, labor augmentation, assisted vaginal delivery, cesarean delivery, and episiotomy are lower in planned home births.
Home birth can be viewed as a model combining evidence-based practice with a humanized philosophy consistent with evolved human anatomy and physiology, emphasizing a supportive environment and maternal autonomy. This approach may lead to lower intervention rates and focus interventions on medically indicated cases.
Studies have shown that birthing people planning home birth are less likely to have adverse maternal outcomes like third- or fourth-degree perineal tears and postpartum hemorrhage compared to those planning midwife-attended hospital births.
Newborns in the home-birth group may be less likely to require resuscitation at birth or oxygen therapy beyond 24 hours compared to those in hospital births attended by midwives.
Context in the United States:
Home birth is relatively rare in the US, accounting for less than 1% of births.
The proportion of home births in the US increased slightly from 2009 to 2013.
The US lacks a formal set of guidelines for home-birth practitioners, unlike several other industrialized countries where home birth is more frequent.
Planned home birth is not well integrated into the mainstream US maternity health-care system, leading to discussions about the need for integration and the risks associated with the current system.
Risk and Integration:
The safety of home birth appears to be influenced by the level of integration of midwives into the broader health system. Studies from countries with well-integrated midwifery often show more comparable outcomes between planned home and hospital births for low-risk birthing people.
Choosing a home birth may represent a trade-off: a decrease in obstetric interventions versus a potential increase in rare but severe neonatal outcomes.
The bottom line: it is crucial for birthing people considering home birth to be appropriately selected for low-risk status, have access to a qualified birth attendant (such as a certified nurse-midwife or certified midwife), and have a well-defined plan for safe and communicative hospital transfer should the need arise.
Photo by Monet Moutrie
So, what does out-of-hospital midwifery care look like?
Usually, your midwife will meet with you at the same intervals as your hospital based midwife or physician: monthly through the first and second trimester, bi-weekly 28 weeks through 36 weeks gestation, and weekly thereafter. Your appointments will involve vital checks (blood pressure and pulse) and monitoring of your baby. They will use a fetoscope or hand-held doppler to listen to baby. They will measure the height of your fundus (the upper segment of your uterus) and make sure your fundal height is in line with expected growth of the baby. As you approach birth in the third trimester, they will also palpate your abdomen to assess the lie and position of your baby.* They will also provide nutritional and other health support to you during your pregnancy. Midwifery care is typically much more hands-on than OB care. Most appointments will last about an hour, allowing you to get all of the answers and information you need to prepare for your birth.
*One benefit of the palpation of your baby’s position throughout pregnancy is that you have more time to get your baby in the optimal position. Usually physicians only check the baby’s presentation at 36 weeks to ensure they are head down for delivery. This gives all of the Spinning Babies exercises and moxibustion for turning a breech baby limited time to work! Knowing your baby’s lie earlier in pregnancy will give you more time to move baby.
Your midwife or midwives will do a home visit around 36 to 37 to assess your home for safety and discuss the set-up for birth. They will perform your normal check-ups at this time.
In California, midwifery regulations allow for home birth between 37 weeks and 42 weeks of gestation. If you spontaneously go into labor during this time, your midwife will likely have phone calls with you in early labor and join you as things become more intense.
During labor, your midwife will check your baby’s heart rate with a doppler every 15-30 minutes. They will also monitor your vitals. This will include your temperature so that they are aware if you develop an infection (chorioamnionitis) during labor and can treat you appropriately.
As you get closer to pushing, your midwife may monitor the baby’s heart rate more frequently, sometimes every other contraction during the pushing stage.
Your midwife may perform cervical checks, but a wonderful benefit of home birth is that you don’t have to get any vaginal exams at all if you don’t want to!
Your midwife can catch your baby, or coach you or your partner through catching your baby.
After birth, your midwife will ensure that you have not experienced excessive blood loss and that your placenta is intact. Your midwife can also repair most tearing (1st and 2nd degree, more advanced tearing may require transfer). Midwives carry suture supplies for repairing tears. If you do experience excessive blood loss postpartum, or have difficulty delivering your placenta, your midwife is equipped with Pitocin (synthetic oxytocin) that can be delivered intramuscularly (in your thigh, typically). They may also administer herbs first for low-risk situations.
For more advanced bleeding, your midwife will likely initiate transfer protocol while administering other medications like methergine or tranexamic acid.
Your midwife will stay with you 2-6 hours after birth to help you establish breastfeeding, perform the newborn exam, administer newborn medications (if desired) and clean up!
Photo by Monet Moutrie
Your postpartum care with your midwife will extend to 6 weeks postpartum. During this time, you do not need to leave the house to see your OB or visit a pediatrician (unless indicated).
I hope that this has provided you with a framework of what you can expect from a planned home birth and the safety of choosing this type of birth for you and your family.
I recommend these midwives. They are all highly trained and competent individuals with the utmost dedication to your safety and satisfaction within your birth experience. They will inform you if at any time in your pregnancy there are any concerns that would warrant transfer of care and have established and well-maintained relationships with local hospitals.
They are all certified by the North American Registry of Midwives (NARM) and licensed by the Medical Board of California.
Audrey Rees, LM, CPM at Your Village Midwife
KathRyn Barry, LM, CPM and April Durham, LM, CPM Sonoma County Midwives
Morgan Conway O’Neill, LM, CPM and Brigette Barnato, LM, CPM Homebody Midwifery
Clover Brown, LM, CPM Earthling Midwifery *primarily providing lactation support at this time
