occurs when a woman labors and delivers
a child at home, rather than the labor and delivery ward of a hospital
or birthing center
. Home births are generally attended by a midwife
, but are sometimes attended by general practitioners
or other medical professionals. Some mothers choose to give birth without any medical professional present – this is generally known as an "unassisted home birth
In choosing home birth, the mother generally has more control over her surroundings, and can eat and move around, sleep and do anything she pleases - activities which may be discouraged in a hospital setting. Midwives generally view birth as a natural process, and therefore keep their intervention and any other sort of medical intervention to a minimum. Thus, the mother is often more satisfied with the overall experience, and less likely to be exposed to the foreign pathogens in a hospital.
During a homebirth there is no access to pharmaceutical pain relief or pharmaceutical labor induction, nor equipment for emergency delivery (such as forceps, vacuum extraction, or surgery). Mothers necessitating these interventions would require transfer to a hospital. Depending on the midwifery practice, transfer rates can range anywhere from 5% to 40%, but most studies cite a transfer rate of about 16%.
In many Western countries, home birth declined over the 20th century due to migration to urban centers and increased accessibility of hospitals. However, the World Health Organization has released statements urging the use of more naturalistic, small-scale methods of childbirth, rather than the large-scale units now prevalent in developed countries.
International Home Birth Rates
There was a revival of midwifery
, the practice supporting a natural approach to birth, in the United States in 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.
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%.
In the Netherlands, an opposite trend has taken place: in the 1965, two-thirds of Dutch births took place at home, but currently, that figure has dropped to less than a third – about 30%.
Research on Safety
In 2007, after a comprehensive review of the literature, the UK
’s National Institute for Health and Clinical Excellence
(NICE) released the following recommendations concerning the location of birth:
With relation to women’s and babies’ outcomes for home births, there is a lack of good quality evidence. The evidence in relation to perinatal mortality is not strong enough to support past or current policies of increasing or decreasing current provision outside consultant units. Women should be offered the choice of planning birth at home, in a midwifery-led unit, or a consultant-led unit [hospital]. Before making their choice, women should be informed of the potential risks and benefits of each birth setting.
"As a minimum," the NICE report continues to state, such information should include the following:
- Planning birth at home: increases the likelihood of normal vaginal birth and satisfaction in women who are committed to giving birth in this setting, compared with planning birth in a hospital
- Planning birth in a consultant-led unit: increases the likelihood of pharmacological analgesia, interventions and an instrumental birth, and decreases satisfaction, compared with planning birth in other birth settings. There may be a lower risk of perinatal mortality when care is delivered in a consultant-led unit."
The research concerning the safety of home birth is few and far between, and much of it is of questionable methodology. In fact, there are no randomized controlled trials for home birth, possibly because maternal choice is such a major aspect of home birth and thus, few mothers would be willing to be randomly assigned to either the home birth or the hospital birth. The studies that do exist tend to be matched cohort studies
conducted either retrospectively (by selecting hospital records that match the characteristics of the home birth records), by matched pairs (by pairing study participants based on their background characteristics), or by using multivariate analysis to control for background variables.
However, even in cohort studies, 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, 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. Thus, none of the studies conducted were able to study a large enough group of matched births to make any definitive statements concerning perinatal mortality, and other rare complications.
All medical interventions were substantially decreased in the home birth sample, including the use of any pain medication or analgesics
or vacuum extraction
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 , the length of labor tended to be longer during home birth, which is unsurprising given the five-fold lower incidence of induction of labor
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 four-fold less likelihood of infection for both the infant and the mother, and all studies reported a substantially higher likelihood of an intact perineum in the home birth sample.
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 . No cohort study has conducted long-term follow up on the infants. The perinatal mortality figure still remains controversial. The Zurich study 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) . However, two other studies did find 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.
Legal situation in the United States
No state prosecutes mothers for giving birth outside of a hospital. However, midwives who assist at such births may be prosecuted in some areas.
In the early and mid 1900s, physicians pushed to have midwifery banned throughout the United States. Childbirth became very clinical with the mother generally subdued with leather straps and ether. In 37 states it is once again legal to acquire the services of a midwife. Many midwives continue to attend mothers in states where it is illegal, while efforts are underway to change the law.
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. However, Certified Nurse Midwives can legally practice in these areas.
Legal situation in Australia
There is no restriction on having homebirths in Australia. Midwives in some Australian States and Territories are unable to obtain professional indemnity insurance, but this does not affect a woman's right to hire an independent midwife to attend her birth. After the collapse of the large Australian insurer HIH
, the remaining Australian insurance companies ceased offering insurance to home birth midwives, as they claimed that the pool of midwives requiring insurance was too small to make it commercially viable. Without insurance, some independently practicing midwives have elected to discontinue providing independent services, even though they are qualified health professionals and are allowed to practice within hospitals.
Some State Governments have now introduced government funded home birth services, including the Northern Territory, Western Australia, New South Wales and South Australia. In April 2007, the Western Australian Government announced that it would be expanding birth at home across the State. A review indicating a relatively higher neonatal mortality rate of babies born at term to mothers who had chosen a home birth in has led to a currently ongoing government review of home births.
Famous homebirthersPamela Anderson
- Spiritual Midwifery Ina May Gaskin(The Book Publishing Company) ISBN 1-57067-104-4 (1st edition 1977)
- A Good Birth, A Safe Birth: Choosing and Having the Childbirth Experience You Want. (1992), Korte, Diana, Boston, MA: USA, The Harvard Common Press.
- Birthing From Within: An Extra-Ordinary Guide to Childbirth Preparation. (1998), England, Horowitz NM: USA, Partera Press.
- A Wise Birth. Bringing together the best of natural childbirth with modern medicine, Armstrong P & Feldman S, 1990, reissued 2007, Pinter & Martin, ISBN 978-1-905177-03-5
- Having a Great Birth in Australia Ed David Vernon, Australian College of Midwives, Canberra, 2005 ISBN 0-9751674-3-X
- Men at Birth Ed David Vernon, Australian College of Midwives, Canberra, 2006, ISBN 0-9751674-4-8
- Home Birth: A Practical Guide, Wesson, Nicky, 2006, Pinter & Martin, ISBN 978-1-905177-06-6
- The Thinking Woman's Guide to a Better Birth, by Henci Goer
- Lamaze Institute for Normal Birth
- The American Way of Birth, Jessica Mitford
- Expert Group on Acute Maternity Services: Reference Report 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.
- 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
- American Pregnancy Association, Home Birth, brief article outlining the pros and cons of home birth
- World Health Organization, Care in Normal Birth: A practical guide, Chapter 2: General Aspects of Labor, 1997.
- ACOG Statement on Home Birth, American College of Obstetricians and Gynecologists reiterates its long-standing opposition to home births (Feb 8, 2008)
- The Business of Being Born website on Ricki Lake's documentary on the American birth industry, contrasting it to her and other women's experiences with home birth, released at the 2007 Tribeca Film Festival
- Homebirth Network of South Australia Community group providing information and support for those interested in home birth. Birth stories, birth photos, birth information, midwives and doulas listing, further internet resources and recommended reading.
- Homebirth Access Sydney Information and resources for people in Sydney, Australia including a directory of local midwives.