Like so many controversial parenting topics, discussing home births brings out dynamic opinions. These controversial topics unfortunately often tear us apart from one another. This week, the American Academy of Pediatrics (AAP) issued a policy statement on home births that will hopefully help inform. In general, the policy statement identified data confirming it’s safer to have birth in a hospital, but outlined ways to decrease risks for moms and families, midwives, and doulas that want to partner with moms to have their babies at home, as safely as possible.
- Home births only occur in about 1% of births here in the United States although interest in increasing. Distance from the hospital matters~ if it takes more than 20 minutes to get into a hospital from home, risk of complications including infant mortality are higher. Data shows that home births carry at 2-3 fold higher risk for infant death when compared to hospital births.
- The AAP states home births should only be considered if no maternal health problems, if it’s a term baby (after 37 weeks and before 41 weeks gestation), labor started at home spontaneously or as an outpatient, and it’s a single pregnancy that isn’t breech. Having had a previous C-section makes a home birth a no-no in their mind.
- The AAP recommends having at least 2 people attending the birth with at least one person at the birth who’s sole job is to care for and tend to the baby after the birth. They outline that the baby’s caregiver needs to know how and why to resuscitate a newborn. The team caring for mom and baby need access to consultation with obstetricians and pediatricians and a well-planned way to access the hospital or medical team easily if needed.
- The AAP says, “Every newborn infant deserves health care that adheres to the standards highlighted in this statement.” Care described includes warming the baby and initial transitions, glucose monitoring, infection monitoring, feeding assessment, jaundice checks, vitamin K shot, Hepatitis B shot, eye infection prevention, hearing screen, newborn blood screen, and follow-up care plans.
I believe we each have the right to make health care decisions that are best for our families. We also must have access to un-biased information on safety. Every single health decision we make is a process where we weigh risks against benefits. Home birth versus hospital birth is no exception.
My disclaimers: I had 2 hospital births which required all sorts of intervention and intensive care—2 C-sections, a bedside resuscitation for my newborn, and a short NICU stay for one of my sons. I would never have wanted to have a home birth after my training in pediatrics. That being said, there were aspects of the hospital care that really upset me. I didn’t have a birth plan, per se. I wanted this: a healthy baby and to survive the delivery without complication. I got both, thank goodness, but it wasn’t perfect. The beginning of motherhood was a challenge for me both times around and in part, I’ve always looked back feeling I should have been a stronger mom in the hospital…
For example, after my second son was born, the nurse practitioner told me on day-of-life #2 that they had forgotten to give him vitamin K. I was stunned into silence. When I then asked to see documentation for the rest of the interventions that occurred while I was away from him in the NICU, I noticed he hadn’t yet gotten his Hep B shot. When I advocated for him to get it before discharge, they reflected inconvenience. I had to ask multiple times. Further, when I came up to breastfeed my sweet little boy in the NICU, I got into an argument with the nurse about the pacifier. I asked her not to use it. I remember realizing she didn’t know I was a pediatrician (she shouldn’t have had to). She seemed to tease me during the conversation and used a patronizing tone when she something like, “Why, do you think it will impair breastfeeding?” She explained that to keep the NICU quiet, she would need to use it. I remember crying into my pillow thinking that already on day-of-life #2 I was failing him. It’s amazing how emotional we get when control is taken away.
I still wouldn’t want a home birth. Aside from my emotional responses to the hospital at the time of my sons’ births I also had the privilege to train as a pediatrician. The statement didn’t change my opinion, my experiences have. The 2-3 fold increase risk of death for a newborn is too big for me to recommend the choice. During the time we attended deliveries at the university during residency, we accepted high-risk deliveries that transferred late from home with midwives. I have also cared for babies who have suffered neurologic tragedies in the home birth setting because of delayed resuscitation and in one case, I helped care for a newborn with a delayed diagnosis of congenital heart disease that may have been picked up if a pediatrician was present at the delivery. Like many pediatricians, I am terrified of home births but also lack expertise and education on their safety and ways to mitigate risk. Those scary experiences in residency compounded my views just as much as witnessing the incredible resuscitations I saw and participated in. I’ve also had the fortune of caring for dozens of babies who were born at home and who have done wonderfully. Yet I still like the safety net a hospital provides for a delivery.
That being said, there are many ways to have a baby…
The American Academy of Pediatrics statement really helped begin the education for me on home births. But it’s certainly clear that differing opinions continue.
Incidentally on Twitter when I saw the policy I asked this question while going through the security line at O’Hare airport.
A HUGE conversation ensued including dozens and dozens of responses. Some pediatricians spoke out, some ethicists weighed in, and many parents provided opinions about their experiences and deliveries. It’s meaty. I really encourage you read the entire conversation here on Storify. Please share your thoughts.
I delivered my baby in Denmark. The most common procedure there (which I followed) is to deliver the baby in a hospital’s maternity ward with the assistance of a midwife. Because I had no complications and no need of an epidural (baby was coming too fast), I saw not one doctor, although doctors were of course nearby if needed. The hospital delivery rooms weren’t “homey,” but they were equipped with birthing tubs if one wanted a water birth, and exercise balls, if those will help with the delivery posture. Afterwards, my baby and I (and my husband!) stayed 5 days in the “patient hotel” while I learned to nurse (with 24-hr midwife assistance). I found this arrangement to be ideal, and would do it exactly the same way in the future.
Jennifer Gillian says
I feel very luck to live in a place where I could have two hospital deliveries with a midwife group. For me, it was the perfect balance of achieving the care that I wanted as a women/ mother-to-be while still having the safety net of a hospital. I was able to have two vaginal births with no interventions. I felt like my voice was listened to and respected both times. (I think that many women want a home birth because they fear their voice will not be heard/listened to in a hospital.) And when I felt out of control during my second labor (number two came VERY fast and furious) I knew I was in a place that would take care for me and my baby. I knew the risk of no NICU on site, but I also knew the plan for what would happen if an emergency were to arise and my baby needed transport. (Thankfully no emergency care was needed, but my son was a big baby and so extra precautions were taken to monitor his blood sugar) While I do believe that the act of childbirth has been over-medicalized in today’s world, I also believe that in case of an emergency I’d want to have access to the top care for both myself and my child. Giving birth is like fight club: “The rules are…there are no rules.” You never know what is going to happen.
Thanks for sharing. I had three hospital births. the first was almost and emergency c-section. My second was a very quick emergency c-section. the third was planned c-section based on how the other two handled labor. If it weren’t for my doc and being in the hospital both I and my son could have died. My sister in law just had her second home birth of a healthy baby girl. We could not be on further ends of the spectrum when it comes to this issue. I had to remind them several times during her first pregnancy and the spouting of how horrible hospitals are that their nephew is here because of a hospital and great docs. Scary as they were I wouldn’t change anything. Healthy baby, healthy mom is all that really matters. I am glad to see more recommendations put out their for home births. In the right situation they have their place. Its just not a chance I am willing to take.
As a Doula, I do support home births. That being said, women need to be educated on the risks to birthing at home. (And honestly even birthing at a birth center). If you have an uncomplicated pregnancy and everything is within the norm maybe trying a home birth is for you. I feel setting up guildlines and making them clear are very important. Such as when would a hospital transfer be necessary for moms sake or babies sake. For me personally I’ve had 2 hospital births, and come August I’ll be having another. I am so thankful for the monitoring, and care I’ve recieved there. Most likely during my the last birth the babies life was saved from the use of monitors and quick thinking of the nurses. As a parent you are your babies advocate and you have to stand up for what you feel and believe is right. The truth is sometimes those situations are tough in a hospital because things run a certain way, there are protocols and charts and a chain of command to answer to. I agree it is so difficult when we feel out of control and the whole process is so different for each individual. I’m so glad you are writing on this issue!!
I have a friend that even though she is a carrier for hemophilia and has two kids with the disease still insists on having home births. It completely scares me to even consider a home birth without having a situation like that. She will not be convinced that having babies in the hospital is safer and has been lucky that all her children have been born without complications. My experience with giving birth in a hospital was not great but it was not bad either. My son was born without any problems and is very healthy. I did feel like I was not listened to by the doctors and most of the nurses though. Because it was my first child they treated me like I couldn’t possibly know what was going on with my body. They sent me home twice because they said I wasn’t in active labor. If it hadn’t been for one nurse who refused to send me home the 3rd time I would have had home birth. Maybe with #2 they will listen to me. Maybe.
I think what needs to be added to this conversation is the additional risks that come with hospital births. We should also be talking about the medical interventions that snowball into other interventions leaving us with a much higher rate of c-sections in the U.S. than other industrialized countries. Why is there not more talk about the risks that come with interventions like epidurals and the major abdominal surgery that is a caesarean section.
While I completely agree that hospitals are the best places for high-risk moms and babies to get the emergency care they might need, I am alarmed by the number of low risk women ending up a variety of unnecessary medical interventions that can in themselves put mom and baby at additional risks.
Jessica Miller says
I completely agree with Jamie. The hospital is a risky place to give birth! Home birth has its risks as well, of course, but I have to call you (Dr. Swanson) out on “Data shows that home births carry at 2-3 fold higher risk for infant death when compared to hospital births.” I take it that this statement originates from “Outcomes of planned home births in Washington State: 1989-1996” by Pang et al and Wax’s meta-analysis “Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis”. The Pang study has serious methodologic issues, particularly that (contrary to the title of their study) they were unable to separate unplanned out-of-hospital births (e.g., giving birth to a premature infant in a car en route to the hospital) from truly planned home births. For an excellent critique of Pang’s study, see “Home birth versus hospital birth: questioning the quality of the evidence on safety” by Saraswathi Vedam (https://www.ncbi.nlm.nih.gov/pubmed/12581041). The Wax study was *staggeringly* flawed (https://www.medscape.com/viewarticle/739987).
Better-conducted studies have consistently showed that the safety of planned out-of-hospital birth in low-risk women is no different than that of planned hospital birth for low-risk women. The safety for babies is the same; for mothers it may well be safer! The Farm, Ina May Gaskin’s commune in Tennessee, has some incredible statistics on maternal and neonatal safety with out-of-hospital birth, with a c-section rate less than 4% . . . and they include VBACs, twins and other factors that would be risked out of home birth in a lot of places.
The AAP’s statement that hospitals or birthing centers are the safest location for birth in the U.S. is also illogical. The title “birth center” or “birthing center” could be attached to many different types of facilities, including the wing of the hospital maternity ward for low-risk deliveries. But it most commonly refers to freestanding birth centers staffed by midwives, and these facilities typically do not have the ability to do anything different or beyond what could be done at home. They may be a particularly good choice for someone who lives a long distance from a hospital, where the birth center would represent a shorter transfer, but beyond that there is nothing inherently safer about delivering at a freestanding birth center than at home.
It is well-documented that the maternal mortality rate in the U.S. is going UP. Maternity care in the U.S. is unacceptably flawed. I am all for delivering in a hospital if that is necessary or the family’s choice (I had my first baby in a hospital). But unnecessarily scaring women who are interested in home birth, and are good candidates, is only counterproductive to improving perinatal outcomes.