A home birth is a birth that takes place in a residence rather than in a
hospital or a
birthing center. They may be attended by a
midwife
A midwife is a health professional who cares for mothers and newborns around childbirth, a specialization known as midwifery.
The education and training for a midwife concentrates extensively on the care of women throughout their lifespan; co ...
, or lay attendant with experience in managing home births. Home birth was, until the advent of modern medicine, the de facto method of delivery. The term was coined in the middle of the 19th century as births began to take place in hospitals.
Multiple studies have been performed concerning the safety of home births for both the child and the mother. Standard practices, licensing requirements and access to emergency hospital care differ between regions making it difficult to compare studies across national borders. A 2014 US survey of medical studies found that perinatal mortality rates were triple that of hospital births, and a US nationwide study over 13 million births on a 3-year span (2007–2010) found that births at home were roughly 10 times as likely to be stillborn (14 times in first-born babies) and almost four times as likely to have neonatal seizures or serious neurological dysfunction when compared to babies born in hospitals, while a 2007 UK survey found that perinatal mortality rates were only slightly higher in that country than planned hospital births for low-risk pregnancies. Higher maternal and infant mortality rates are associated with the inability to offer timely assistance to mothers with emergency procedures in case of complications during labour, as well as with widely varying licensing and training standards for birth attendants between different states and countries.
Etymology
The word combination "home birth" arose some time in the middle of the 19th century and coincided with the rise of births that took place in lying-in hospitals. Since women around the world left homes to give birth in clinics and hospitals as the 20th century progressed, the term "home birth" came to refer to giving birth, intentionally or otherwise, in a residence as opposed to a hospital.
History and philosophy
Although the fact humans give birth is universal, the social nature of birth is not. Where, with whom, how, and when someone gives birth is socially and culturally determined. Historically, birth has been a social event. For the most of humankind history of birth is equivalent to history of home birth. The hypothesis exists that birth was transformed from a solitary to social event early in human evolution. Traditionally and historically, other women assisted women in childbirth. A special term evolved in the English language around 1300 to name women who made assistance in childbirth their vocation – ''
midwife
A midwife is a health professional who cares for mothers and newborns around childbirth, a specialization known as midwifery.
The education and training for a midwife concentrates extensively on the care of women throughout their lifespan; co ...
'', literally meaning "with woman". However, midwife was a description of a social role of a woman who was "with woman" in childbirth to mediate social arrangements for woman's bodily experience of birth.
Birthing on country
Birthing on country is a traditional birthing practice that constitutes giving birth on the land where the mother was born as well as her ancestors.
It is a culturally appropriate practice that coincides with spiritual tradition. It offers support to women and their families by continuing the birthing process in the community among the women and children. It is largely practiced by aboriginal women, in countries such as Australia, Canada, New Zealand and the United States. The belief is that if a child is not born on country they lose their connection to the land and their community.
Birthing on country can happen in rural areas as well as birthing in cities.
In Australia
In the Northern Territory of Australia, the prescribed steps advocated by the government is that, in rural areas, a woman at 37 weeks gestation must leave "country" and fly to the nearest city. If an adult, she flies alone with no family members. She will wait in accommodations until she goes into labour. After birth she and the baby are flown back to "country".
Types
Home births are either attended or unattended, planned or unplanned. Women are attended when they are assisted through labor and birth by a professional, usually a
midwife
A midwife is a health professional who cares for mothers and newborns around childbirth, a specialization known as midwifery.
The education and training for a midwife concentrates extensively on the care of women throughout their lifespan; co ...
, and rarely a
general practitioner. Women who are unassisted or only attended by a lay person, perhaps a
doula
A doula () is a trained professional who provides expert guidance for the service of others and who supports another person (the doula's client) through a significant health-related experience, such as childbirth, miscarriage, induced abortion or ...
, their spouse, family, friend, or a non-professional
birth attendant A birth attendant, also known as skilled birth attendant, is a health professional who provides basic and emergency care to women and their newborns during pregnancy, childbirth and the postpartum period. A birth attendant, who may be a midwife, phy ...
, are sometimes called
freebirth
Unassisted childbirth (UC) refers to the process of intentionally giving birth without the assistance of a medical birth attendant. It may also be known as freebirth, DIY (do-it-yourself) birth, unhindered birth, and unassisted home birth. Unassis ...
s. A "planned" home birth is a birth that occurs at home by intention. An "unplanned" home birth is one that occurs at home by necessity but not with intention. Reasons for unplanned home births include inability to travel to the hospital or birthing center due to conditions outside the control of the mother such as weather or road blockages or speed of birth progression.
Factors
Many women choose home birth because delivering a baby in familiar surroundings is important to them.
[ 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
In biology, a pathogen ( el, πάθος, "suffering", "passion" and , "producer of") in the oldest and broadest sense, is any organism or agent that can produce disease. A pathogen may also be referred to as an infectious agent, or simply a ger ...
, or dislike the presence of strangers at the birth. Others prefer home birth because they feel it is more natural and less stressful. In a study published in the ''Journal of Midwifery and Women's Health'', women were asked why they chose a home birth; 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.
Cost is also a factor. The estimated average cost of a home birth in the United States in 2021 was $4,650, compared with $13,562 for a vaginal hospital birth. In developing countries
A developing country is a sovereign state with a lesser developed industrial base and a lower Human Development Index (HDI) relative to other countries. However, this definition is not universally agreed upon. There is also no clear agreem ...
, 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 a professional attendant of any kind.
Some women may not be able to have a safe birth at home, even with highly trained midwives. There are some medical conditions that can prevent a woman from qualifying for a home birth. These often include heart disease, renal disease, diabetes, preeclampsia, placenta previa, placenta abruption, antepartum hemorrhage after 20 weeks gestation, and active genital herpes. Prior cesarean deliveries can sometimes prevent a woman from qualifying for a home birth, though not always. It is important that a woman and her health care provider discuss the individual health risks prior to planning a home birth.
Trends
Home birth was, until the advent of modern medicine, the ''de facto'' method of delivery. In many developed countries, home birth declined rapidly over the 20th century. In the United States there was a large shift towards hospital births beginning around 1900, when close to 100% of births were at home. Rates of home births fell to 50% in 1938 and to fewer than 1% in 1955. However, between 2004 and 2009, the number of home births in the United States rose by 41%. 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. In countries such as the Netherlands, where home births have been a regular part of the maternity system, the rate for home births is 20% in 2014. Over a similar time period, maternal mortality during childbirth fell during 1900 to 1997 from 6–9 deaths per thousand to 0.077 deaths per thousand, while the infant mortality rate dropped between 1915 and 1997 from around 100 deaths per thousand births to 7.2 deaths per thousand.
One doctor described birth in a working-class home in the 1920s:
This experience is contrasted with a 1920s hospital birth by Adolf Weber:
Midwifery
Midwifery is the health science and health profession that deals with pregnancy, childbirth, and the postpartum period (including care of the newborn), in addition to the sexual and reproductive health of women throughout their lives. In many ...
, the practice supporting a natural approach to birth, enjoyed a revival in the United States during the 1970s. Ina May Gaskin
Ina May Gaskin (born March 8, 1940) is an American midwife who has been described as "the mother of authentic midwifery."Granju, K.A. (1999"The Midwife of Modern Midwifery"Salon.com, Brilliant Careers. She helped found the self-sustaining communi ...
, for example, sometimes called "the mother of authentic midwifery" helped open The Farm Midwifery Center in Summertown, Tennessee, in 1971, which is still in operation. A movement termed 'pushing for midwives' intensified during the 1990s and early 2000s in the United States, when the public organized to request legislation that would formally legalize midwifery a consumable service. However, although there was a steep increase in midwife-attended births between 1975 and 2002 (from less than 1.0% to 8.1%), most of these births occurred in the hospital. The US rate of out-of-hospital birth has remained steady at 1% of all births since 1989, with data from 2007 showing that 27.3% of the home births since 1989 took place in a free-standing birth center
A birthing center is a healthcare facility, staffed by nurse midwives, midwives and/or obstetricians, for mothers in labor, who may be assisted by doulas and coaches. The midwives monitor the labor, and well-being of the mother and the baby durin ...
and 65.4% in a residence. Hence, the actual rate of home birth in the United States remained low (0.65%) over the twenty years prior to 2007.
Home birth in the United Kingdom has also received some press since 2000. There was a movement, most notably in Wales, to increase home birth rates to 10% by 2007. Between 2005 and 2006, there was an increase of 16% of home birth rates in Wales, but by 2007 the total home birth rate was still 3% even in Wales (double the national rate). A 2001 report noted that there was a wide range of home birth rates in the UK, with some regions around 1% and others over 20%. In Australia, birth at home has fallen steadily over the years and was 0.3% as of 2008, ranging from nearly 1% in the Northern Territory
The Northern Territory (commonly abbreviated as NT; formally the Northern Territory of Australia) is an Australian territory in the central and central northern regions of Australia. The Northern Territory shares its borders with Western Aust ...
to 0.1% in Queensland
)
, nickname = Sunshine State
, image_map = Queensland in Australia.svg
, map_caption = Location of Queensland in Australia
, subdivision_type = Country
, subdivision_name = Australia
, established_title = Before federation
, establishe ...
. In 2004, the New Zealand
New Zealand ( mi, Aotearoa ) is an island country in the southwestern Pacific Ocean. It consists of two main landmasses—the North Island () and the South Island ()—and over 700 smaller islands. It is the sixth-largest island count ...
rate for births at home was nearly three times Australia's with a rate of 2.5% and increasing.
In the Netherlands, the trend has been somewhat different from other industrialized countries: while in 1965, two-thirds of Dutch births took place at home, that figure has dropped to about 20% in 2013, which is still more than in other industrialized countries. Less than 1% of South Korean infants are born at home.
Research on safety
In 2019, a meta-analysis examined perinatal and neonatal mortality of planned home birth among low-risk women in well-resourced countries, with research eligible for inclusion encompassing approximately 500,000 intended home births. The study concluded that the risk of perinatal or neonatal mortality was not different when birth was intended at home or in hospital.
In 2014, a comprehensive review in the ''Journal of Medical Ethics
The ''Journal of Medical Ethics'' is a monthly peer-reviewed academic journal covering the field of bioethics that was established in 1975. According to the ''Journal Citation Reports'', the journal has a 2019 impact factor of 2.021, ranking it fou ...
'' of 12 previously published studies encompassing 500,000 planned home births in low-risk women found that neonatal mortality rates for home births were triple those of hospital births. This finding echoes that of the American College of Obstetricians and Gynecologists
The American College of Obstetricians and Gynecologists (ACOG) is a professional association of physicians specializing in obstetrics and gynecology in the United States. Several Latin American countries are also represented within Districts of ...
. Due to a greater risk of perinatal death, the college advises women who are postterm (greater than 42 weeks gestation), carrying twins, or have a breech presentation not to attempt home birth. The ''Journal of Medical Ethics'' review additionally found that several studies concluded that home births had a higher risk of failing Apgar scores in newborns, as well as a delay in diagnosing hypoxia, acidosis
Acidosis is a process causing increased acidity in the blood and other body tissues (i.e., an increase in hydrogen ion concentration). If not further qualified, it usually refers to acidity of the blood plasma.
The term ''acidemia'' describes ...
and asphyxia
Asphyxia or asphyxiation is a condition of deficient supply of oxygen to the body which arises from abnormal breathing. Asphyxia causes generalized hypoxia, which affects primarily the tissues and organs. There are many circumstances that ca ...
. This contradicts a 2007 UK review study by the National Institute for Health and Clinical Excellence
The National Institute for Health and Care Excellence (NICE) is an executive non-departmental public body of the Department of Health and Social Care in England that publishes guidelines in four areas:
* the use of health technologies withi ...
(NICE), a British governmental organization devoted to creating guidelines for coverage throughout the UK, which expressed concern for the lack of quality evidence in studies comparing the potential risks and benefits of home and hospital birthing environments in the UK. Their report noted that intrapartum-related perinatal mortality was low in all settings in the UK, but that in cases of unanticipated obstetric complications, the mortality rate was higher for home births due to the time needed to transfer the mother to an obstetric unit.
A 2002 study of planned home births in the state of Washington found that home births had shorter labors than hospital births. In North America, a 2005 study found that 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. A 2014 survey of American home births between 2004 and 2010 found the percent of women transferred to a hospital from a planned home birth after beginning labor to be 10.9%.
Both the ''Journal of Medical Ethics'' and NICE report noted that usage of caesarean sections were lower for women who give birth at home, and both noted a prior study that determined that women who had a planned home birth had greater satisfaction from the experience when compared with women who had a planned birth in a hospital.
In 2009 a study of 500,000 low-risk planned home and hospital births in the Netherlands, where midwives have a strong licensing requirement, was reported in the ''British Journal of Obstetrics and Gynaecology''. The study concluded that for low-risk women there was no increase in perinatal mortality, provided that the midwives were well-trained and there was easy and quick access to hospitals. 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." 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.
In 2012, Oregon performed a study of all births in the state during the year as a part of discussing a bill regarding licensing requirements for midwives in the state. They found that the rate of intrapartum infant mortality was 0.6 deaths per thousand births for planned hospital births, and 4.8 deaths per thousand for planned home births. They further found that the death rate for planned home births attended by direct-entry midwives was 5.6 per thousand. The study noted that the statistics for Oregon were different for other areas, such as British Columbia, which had different licensing requirements. Oregon was noted by the Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention (CDC) is the national public health agency of the United States. It is a United States federal agency, under the Department of Health and Human Services, and is headquartered in Atlanta, Georgi ...
as having the second-highest rate of home births in the nation in 2009, at 1.96% compared to the national average of 0.72%. A 2014 survey of nearly 17,000 voluntarily reported home births in the United States between 2004 and 2010 found an intrapartum infant mortality rate of 1.30 per thousand; early neonatal and late neonatal mortality rates were a further 0.41 and 0.35 per thousand. The survey excluded congenital anomaly-related deaths, as well as births where the mother was transferred to a hospital prior to beginning labor.
In October 2013 the largest study of this kind was published in the American Journal of Obstetrics and Gynecology
The ''American Journal of Obstetrics and Gynecology'' (AJOG) is a peer reviewed journal of obstetrics and gynecology. It is popularly called the "Gray Journal". Since 1920, AJOG has continued the American Journal of Obstetrics and Diseases of Wom ...
and included data on more than 13 million births in the United States, assessing deliveries by physicians and midwives in and out of the hospital from 2007 to 2010. The study indicated that babies born at home are roughly 10 times as likely to have an Apgar score of 0 after 5 minutes and almost four times as likely to have neonatal seizures or serious neurological dysfunction when compared to babies born in hospitals. The study findings showed that the risk of Apgar scores of 0 is even greater in first-born babies—14 times the risk of hospital births. The study results were confirmed by analyzing birth certificate files from the U.S. Centers for Disease Control and Prevention (CDC) and the National Center for Health Statistics. Given the study's findings, Dr. Amos Grunebaum
Amos Grunebaum (born January 27, 1950) is an American obstetrician and gynecologist. He serves as Professor of Obstetrics and Gynecology at the Zucker School of Medicine, as Professor Emeritus at the medical school Weill Cornell Medicine, and as ...
, professor of clinical obstetrics and gynecology at Weill Cornell Medical College
The Joan & Sanford I. Weill Medical College of Cornell University is Cornell University's biomedical research unit and medical school located in Upper East Side, Manhattan, New York City, New York.
Weill Cornell Medicine is affiliated with N ...
and lead author of the study, stated that the magnitude of risk associated with home delivery is so alarming that necessitates the need for the parents-to-be to know the risk factors. Another author, Dr. Frank Chervenak, added that the study underplayed the risks of home births, as the data used counted home births where the mother was transferred to a hospital during labor as a hospital birth.
A 2022 study, which examined the introduction of maternity wards in Sweden, found that the wards substantially reduced home deliveries and early neonatal mortality, as well as positive long-term effects on labour income, unemployment, health-related disability and schooling for individuals born in maternity wards.
Study design
Randomized controlled trials
Clinical trials are prospective biomedical or behavioral research studies on human participants designed to answer specific questions about biomedical or behavioral interventions, including new treatments (such as novel vaccines, drugs, dieta ...
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, are cohort studies
A cohort study is a particular form of longitudinal study that samples a cohort (a group of people who share a defining characteristic, typically those who experienced a common event in a selected period, such as birth or graduation), performing ...
conducted retrospectively by selecting hospital records and midwife records. by matched pairs (by pairing study participants based on their background characteristics), In February 2011 the American Congress of Obstetricians and Gynecologists identified several factors that make quality research on home birth difficult. These include "lack of randomization; reliance on birth certificate data with inherent ascertainment problems; ascertainment of relying on voluntary submission of data or self-reporting; a limited ability to distinguish between planned and unplanned birth; variation in the skill, training, and certification of the birth attendant; and an inability to account for and accurately attribute adverse outcomes associated with transfers". Quality studies, therefore, need to take steps in their design to mitigate these problems in order to produce meaningful results.
The data available on the safety of home birth in developed countries is often difficult to interpret due to issues such as differing home-birth standards between different countries, and difficult to compare with other studies because of varying definitions of perinatal mortality. Additionally, it is difficult to compare home and hospital births because only the risk profiles are different between the two groups, according to the CDC: people who choose to give birth at home are more likely to be healthy and at low risk for complications. There are also unquantifiable differences in home birth patients, such as maternal attitudes towards medical involvement in birth.
Methods of scientific inquiry
Modern scientific inquiry into home birth takes place in the fields of anthropology
Anthropology is the scientific study of humanity, concerned with human behavior, human biology, cultures, societies, and linguistics, in both the present and past, including past human species. Social anthropology studies patterns of be ...
, epistemology
Epistemology (; ), or the theory of knowledge, is the branch of philosophy concerned with knowledge. Epistemology is considered a major subfield of philosophy, along with other major subfields such as ethics, logic, and metaphysics.
Epis ...
, ethnology
Ethnology (from the grc-gre, ἔθνος, meaning 'nation') is an academic field that compares and analyzes the characteristics of different peoples and the relationships between them (compare cultural, social, or sociocultural anthropology). ...
, history, jurisprudence
Jurisprudence, or legal theory, is the theoretical study of the propriety of law. Scholars of jurisprudence seek to explain the nature of law in its most general form and they also seek to achieve a deeper understanding of legal reasoning a ...
, medicine
Medicine is the science and practice of caring for a patient, managing the diagnosis, prognosis, prevention, treatment, palliation of their injury or disease, and promoting their health. Medicine encompasses a variety of health care pr ...
, midwifery
Midwifery is the health science and health profession that deals with pregnancy, childbirth, and the postpartum period (including care of the newborn), in addition to the sexual and reproductive health of women throughout their lives. In many ...
, public health
Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals". Analyzing the det ...
, sociology
Sociology is a social science that focuses on society, human social behavior, patterns of social relationships, social interaction, and aspects of culture associated with everyday life. It uses various methods of empirical investigation an ...
, and women's studies
Women's studies is an academic field that draws on feminist and interdisciplinary methods to place women's lives and experiences at the center of study, while examining social and cultural constructs of gender; systems of privilege and oppress ...
. Research of home birth is complicated by ancient and modern biases about the nature of women and birth, manifested in the language and ideas that are used to refer to women, women's bodies, and what women do. It has been demonstrated that reports of research of physiological phenomena, such as conception, transmit deep-seated biased cultural notions of women and women's bodies. Most 20th- and 21st-century researchers of home birth view the phenomenon through two broad perspectives that are closely tied to the ideas and perceptions of birth itself – social and biomedical.
Insurance and licensing issues
While a woman in developed countries may choose to deliver her child at home, in a birthing center, or at hospital, health coverage and legal issues influence available options.
Australia
In April 2007, the Western Australian Government expanded coverage for birth at home across the State. 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. However, this plan only covers hospital births. There are no current plans to extend Medicare and PBS funding to home birth services in Australia.
, all health professionals must show proof of liability insurance.
In March 2016, the Coroners Court of Victoria found against midwife Gaye Demanuel in the case of the death of Caroline Lovell. "Coroner White also called for a review of the regulation of midwives caring for women during home births, and for the government and health authorities to consider an offence banning unregistered health practitioners from taking money for attending home births."
Canada
Public health coverage of home birth services varies in Canada from province to province, as does the availability of doctors and midwives providing home birth services. The Provinces of Ontario, British Columbia, Saskatchewan, Manitoba, Alberta, and Quebec currently cover home birth services.
United Kingdom
There are few legal issues with a home birth in the UK. Woman cannot be forced to go to a hospital. The support of the various Health Authorities of the National Health Service
The National Health Service (NHS) is the umbrella term for the publicly funded healthcare systems of the United Kingdom (UK). Since 1948, they have been funded out of general taxation. There are three systems which are referred to using the " ...
may vary, but in general the NHS will cover home births – the Parliamentary Under-Secretary of State for Health, Lord Hunt of King's Heath has stated that "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."
United States
27 states license or regulate in some manner direct-entry midwife, or certified professional midwife (CPM).[ In the other 23 states there are no licensing laws, and practicing midwives can be arrested for practicing medicine without a license. It is legal in all 50 states to hire a certified nurse midwife, or CNM, who are trained nurses, though most CNMs work in hospitals.]
References
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.
World Health Organization, ''Care in Normal Birth: A practical guide'', Chapter 2, 1997.
American College of Obstetricians and Gynecologists Statement on Home Birth
{{DEFAULTSORT:Home Birth
Midwifery
Natural childbirth
Maternal health
Women's health