Home birth

Background
Home birth is childbirth that occurs outside a hospital or birthing center setting, usually in the home of the mother. Most home births are assisted by midwives, but some home births are physician assisted. Others have no medical assistance at all. This is known as unassisted childbirth or freebirth.

In most Western countries, home birth declined over the 20th century, although there was some revival of the practice in 1970s. In The Netherlands, about 30% of all births occur at home, but this number is falling. In countries where midwives are the main carers for pregnant women, home birth is more prevalent.

Assisted home birth
For low-risk pregnancies, a number of studies have shown that planned, assisted home births are at least as safe as hospital births. There are fewer medical interventions, such as cesarean sections, forceps or ventouse deliveries, episiotomies and administration of pain medication such as epidurals, all of which may pose some risk to the health of the mother and baby of which a homebirth can help minimise.

Unassisted home birth
Main article: Unassisted childbirth

There have been no formal studies on unassisted birth. A mother having an unassisted home birth can do so in the environment in which she feels most comfortable.

Many mothers choose a "couple's birth" where the birthing mother and her spouse or partner are the only ones present while she gives birth. Other children may be sleeping, or busy elsewhere in the house. Advocates of unassisted birth believe that couple's birth is an intimate extension of babymaking.

Differing opinions
Proponents of home birth prefer the atmosphere and safety of a home birth. The mother 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. The mother is often more comfortable in her own home and increased comfort contributes to shorter labor. Antibiotic resistant pathogens commonly found in hospitals, such as staph (methicillin-resistant Staphylococcus aureus and others), are less likely to be transferred to the mother or child when the birth takes place at home. However, in the case of emergencies such as cord prolapse, breathing problems with the infant, inverted uterus, or bleeding of the mother, there is less access to life-saving equipment. Properly trained midwives can manage such emergencies until the woman can be transferred to a hospital.

Conversely, some mothers are more comfortable in a hospital setting because they implicitly trust the medical system and because they prefer to be closer to an operating room should an emergency arise. Most hospitals have a policy of trying to deliver the baby within 30 minutes of determining a caesarean is required, however, owing to the theatre preparation time, this goal is only achieved 66% of the time. Despite this, there is no statistical increase in morbidity or mortality when it takes longer than 30 minutes. This generally fits with the view that very few obstetric emergencies require immediate action.

Safety
The safety of home birth has been questioned by some obstetricians and general practitioners, but designing randomized controlled trials to test the safety of home birth compared to hospital birth has significant ethical problems. Studies of safety have differing conclusions.

A recent study in the British Medical Journal, "Outcomes of planned home births with certified professional midwives: large prospective study in North America" (Johnson & Daviss, June 2005), concluded that outcomes were just as good and "medical intervention rates (such as epidural, episiotomy, forceps, ventouse, and caesarean section) were substantially lower than for low risk US women having hospital births." For example, amongst the home birth women, 3.7% ended up having a caesarean section compared to 19% for the US as a whole (for a similar risk profile) [2000 data]. The intrapartum and neonatal mortality was 1.7 deaths per 1000 low risk intended home births after planned breeches and twins (not considered low risk) were excluded.

The National Center for Health and Clinical Excellence, a healthcare watchdog organization in the UK, has recently performed a comprehensive review of homebirth literature and concluded that high-quality research is lacking, specifically with regard to the number of babies who die at home births versus hospital births, but feel that women should be given the choice of where to birth:

“The quality of evidence available is not as good as it should be for such an important healthcare issue and most studies do not report complete or consistent outcome data. Planning birth outside an obstetric unit seems to be associated with an increase in spontaneous vaginal births, an increase in women with an intact perineum and improved maternal satisfaction.

“Of particular concern is the lack of reliable data, relating to relatively rare but serious outcomes such as IPPM [intrapartum-related perinatal mortality] in all places of birth. Uncontrolled confounding and selection bias are particular methodological limitations of most studies. The GDG was unable to reassure itself that planning birth in a non-obstetric setting is as safe in this respect as birth in an obstetric unit.

“Women should be offered the choice of planning birth at home, in a midwifery unit or in an obstetric unit. Women should be reassured that intrapartum-related perinatal mortality is low in all settings. Before making their choice, women should be informed of the variable quality of the information comparing the potential risks and benefits of each birth setting.”

According to Enkin et al in the work A Guide To Effective Care in Pregnancy and Childbirth; "Women with low risk pregnancies considering out of hospital birth should not be discouraged."

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, Missouri, North Carolina, South Dakota and Wyoming. However, Certified Nurse Midwives can legally practice in these areas.

People wishing to have a midwife-assisted home birth in the United States should always research the applicable laws in their home state.

Legal situation in Australia
Whilst there is no restriction on having homebirths in Australia, it is illegal for midwives to practice in some Australian States and Territories, because they are unable to obtain professional indemnity insurance. Medical practitioners in some Australian jurisdictions must have insurance before they can practice. 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, many independently practicing midwives have elected to discontinue providing independent services, even though they are qualified health professionals and are allowed to practice within hospitals.

When several large insurance companies threatened to withdraw insurance for obstetricians in 2002, the Australian Government immediately responded and provided a A$600 million dollar (over 4 years) subsidy to the obstetricians to allow them to continue to practice legally.

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.

Additional reading

 * 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
 * The birthjunkie site has an unassisted childbirth forum where you can discuss unassisted and minimally assisted childbirth with others. You can also read birth stories from unassisted births, including an 11.25 pound (5.1 kg) baby born without tearing.
 * The MANA state-by-state chart shows midwife certification requirements in the USA and reimbursement by Medicaid. It is common for private insurance to reimburse according to the Medicaid rules.
 * Summary of Medical Studies on Homebirth
 * Home Midwifery Association Queensland
 * Joyous Birth forums