Where is best for birth: Hospital or home?

Jeffrey Ecker, MD
Jeffrey Ecker, MD, Contributing Editor

By the second half of the 20th century, hospital birth had become the norm in most Western countries. Hospital birth offers monitoring and interventions, many of which saved the lives of mothers and babies. At the same time, births became increasingly — and some would say unnecessarily — medicalized.

Many would also argue that the pendulum of intervention has swung too far. For example, from 1970 to 2010, the rate of U.S. cesarean delivery doubled — but (although both are low) the risk of a baby dying during the course of delivery remained unchanged, and the risk of a mother’s dying slightly rose. In an effort to avoid seemingly unnecessary intervention, and seeking an alternative to the environment of the hospital ward, it is not surprising that some women have turned again to home birth.

Is home birth safe?

We don’t have the best data to answer this question. The ideal way to answer would be a randomized controlled trial. But the randomized part (the place for delivery would essentially have to be decided by the flip of a coin) would be unacceptable to most women. So instead, women and their doctors have had to rely on after-the-fact analyses of large administrative data sets (e.g., information recorded on birth certificates).

There are a few problems with this type of analysis.

There may be differences between the women who give birth at home and those who deliver in the hospital that are not accounted for when drawing conclusions. For example, a woman might decide to give birth at home because she doesn’t have access to care, and so might be more likely to experience complications. On the flip side, perhaps the woman who chooses home birth emphasizes a lifestyle intended to avoid health problems and interventions in general (healthy diet, not smoking, etc.). So when evaluating the outcomes of home birth, it is possible that the results are due to factors about the woman herself as much as the place she has her baby. One of the things that make teasing out the data so difficult is that until recently, there was no way to distinguish between planned home births and unplanned home births. Unplanned home births may include factors that make home birth look riskier than it may actually be (for example, birth due to unexpected emergencies or among women who have not had access to regular prenatal care). On the other hand, counting complicated deliveries that start at home but can’t be completed there as “hospital births” might hide home birth risk.

Women, and those who care for and about their health, have been in desperate need of better data and analysis.

A unique data set offers some insight

A recent article in The New England Journal of Medicine describes a study in which researchers in Oregon were able to overcome some of these data problems. Oregon birth certificates now record whether a mother planned to give birth at home or in the hospital. The researchers also had access to information about a mother’s health conditions (e.g., diabetes or high blood pressure) that put her at higher risk for problems during labor and birth. For the study, the researchers excluded unplanned home births and included only what seemed to be healthy singleton deliveries (not twins or more).

In their analysis, the risk of a baby’s dying was low in each setting, but higher among the group that intended home delivery: 1.8 per 1,000 for planned in-hospital births as compared with 3.9 per 1,000 for planned out-of-hospital births. Planned out-of-hospital birth was also associated with lower Apgar scores as well as a greater likelihood of a baby having a seizure or needing a ventilator, and of a mother needing a blood transfusion. Yet, planning delivery at home was also associated with lower rates of a baby’s needing admission to an intensive care unit and a lower rate of obstetrical interventions, including the use of medicines or other means to start (induce) or strengthen (augment) labor, forceps or vacuum vaginal delivery, or cesarean delivery, and severe tears of the vagina.

What does this mean for women and their doctors?

These results are consistent with those from other studies and make sense to me, as they will to many obstetricians. Sometimes emergencies happen, and having the tools, medicines, and facilities to respond quickly can make a difference. But having all those things at hand means they will also be used in cases in which doing nothing would have been just fine.

It is important to recognize that while the risk for problems for babies was “higher” in the home birth group, it’s not “high” in either group. The difference judged in absolute terms was on the order of 0.5 to 2 newborn deaths per 1,000 births. This risk is similar to other accepted options in obstetrical care, such as a trial of labor after past cesarean delivery. The home birth group had lower rates of cesarean delivery and other complications that can affect a mother’s health.

The risks to consider for each option are very different, but this data can help women make choices based on what they value most.

Finally, roughly 15% of women planning home birth will require transfer to the hospital. Keep in mind that right now, there are no U.S. national standards for integrating home birth into a continuum of care. There are no agreed-upon criteria to help identify good candidates for home birth, nor are there standards to ensure adequate training of those attending home births. We need those systems and criteria before the U.S. should consider matching the recent call in Britain to encourage and support home birth.

Related Information: Harvard Women’s Health Watch

Comments:

  1. Cesar Blakley

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  2. monica wood

    Hi every one…

    This seems to be a great article!
    I want to share my experience of home birth here.
    It is so amazing when another phase of life begins to breathe. The moment we see another life on earth, the place where a new child is born is a great experience.
    The hospital is a place where financial issues trouble you. Midwives offer you place where ideal care promises great competency.
    Midwives always perceive and integrate proper assessment, heartily diagnosis, good planning, right implementation. Midwife are qualified enough to handle all types of low risk pregnancies.

    The midwives play a great mother like role in the delivery.
    Midwives aim to deliver the paramount understanding about rules and regulation during deliveries which are necessary to carry during birth. These midwives can stay with you even after your delivery and can look after your newly born for 28 days. The midwives understand the emotional and social state of the pregnant lady.
    These midwives spend quality time with their patients unlike the physicians. These midwives update the patient and their significant others the situation the patient is undergoing, the needs they can give, the emotional and spiritual support and other necessary information that are essential and desirable.
    These midwives are a great friend and a guide at the same time. The pregnant lady can lie in her favorite position while the delivery.

  3. Jeff Ecker

    You are correct: there is much data speaking to the safety of delivery in birth centers (I’m a give fan of the AHRQ funded San Diego Birth Center Study). In the case of the this current study, the way the data was collected by the State of Oregon did not permit separation and separate analysis. The authors recognized this limitation: “… a major limitation is the inability in the case of planned home births to distinguish between transfers from birth centers and transfers from home. Although there are important differences between these two settings, most state offices of vital statistics do not as yet distinguish between them in the case of transfers.”

  4. Fran Schwartz

    Why is the out of hospital data only related to home birth? There is no discussion or even mention of birthing centers as a safer choice for women choosing out of hospital. Birthing centers, licensed and accredited, are a recognized basic level of maternity care. Yet, the data lumps together all out of hospital births. There are studies that demonstrate that there is a difference in better outcomes at a birth center than home birth. While absent in home birth, there is definitive criteria in an accredited birthing center to help identify good candidates and standards to ensure adequate training of those attending birth centers. Included in the NEJM were 11 birth centers in the state of Oregon, but only 2 are accredited. It is unfortunate that the study does not differentiate between out of hospital births at home or at an accredited birth center.

  5. Linda Davis

    I find it puzzling and concerning that the study you reference did not report the differences between home birth and birth center births. They lumped them together. They data on this third option, birth center, was available. Accredited birth centers, who are required to have adequate transfer protocols, may be the “just right” in-between option for low risk moms.

  6. Marcia Weinstein

    Of course, midwives deliver babies without anesthesiologists. Are you sure that obstetricians still recommend prepared childbirth to their patients?

  7. Marcia Weinstein

    I’m concerned about the current lack of dialogue about prepared childbirth, that was so popular in USA during late 20th century. This seemed to fill the demand for at-home-style births within hospital settings, considered by many to be the best of both worlds. Classes that included Lamaze techniques, as well as other information useful for those about to start a family, were ubiquitous and recommended by obstetricians for first time mothers and fathers. Nowadays, they are too few and far between.

    • Anon

      That dialogue still very much exists. When I gave birth last year, I did so in a hospital setting with a midwife. She suggested a variety of childbirth preparation and newborn care classes. There’s no shortage of classes or birthing options (at home, childbirth center or hospital) available to women today.