Homebirth Safety Data
Compared to the number of hospital births in the United States, home births are still relatively low. Still, over the past seven years the rate of planned home births has increased by 60% to nearly 2% of all births. The number of home births reached 46,918 in 2023, the highest in three decades and up from 29,592 in 2016, according to a recent analysis published in the Journal of Perinatal Medicine.
What studies have been done on homebirth and midwifery care?
​Cheyney, M et al, 30 January 2014. “Outcomes of care for 16,924 planned home births in the United States: the midwives alliance of North America statistics project 2004-2009. Journal of Midwifery and Women’s Health, vol 59. https://doi.org/10.1371/journal.pone.0192523
"The Lancet Series on Midwifery (2014) concluded that “national investment in midwives and in their work environment, education, regulation, and management … is crucial to the achievement of national and international goals and targets in reproductive, maternal, newborn, and child health” [1]. In countries where midwives are integrated into the health care system, the benefits of midwifery care are well-documented [2]. Global health experts recommend scaling up midwifery to improve maternal and newborn outcomes, reduce rates of unnecessary interventions, and realize cost savings [3,4]."
Daviss and Johnson, 18 June 2005. “Outcomes of planned home births with certified professional midwives: large prospective study in North America.” BMJ 330(7505). doi: 10.1136/bmj.330.7505.1416
"Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States."
Declercq, E.R. et al, 26 August 2019. “Intrapartum Care and Experiences of Women with Midwives versus with Obstetricians in the Listening to Mothers in California Survey. Journal of Midwifery and Women’s Health vol 65(1). https://doi.org/10.1111/jmwh.13027
"Bivariate analyses found significant socioeconomic differences by type of intrapartum care provider, with women in California attended by midwives more likely to be well educated and privately insured than women attended by obstetricians. Women with midwife birth attendants were less likely to report experiencing various intrapartum medical interventions, less likely to experience pressure to have epidural analgesia, and more likely to report that staff encouraged the woman's decision making. Adjusted odds ratios found that women with midwives were less likely to experience medical interventions, including attempted labor induction; labor augmentation; and use of pain medications, epidural analgesia, and intravenous fluids; and less likely to report pressure to have labor induction or epidural analgesia. Women cared for by midwives were more likely to experience any nonpharmacologic pain relief measures and nitrous oxide and to agree that hospital staff encouraged their decision making."
Hutton, E. K. et al, July 25, 2019. “Perinatal or neonatal mortality among women who intend at the onset of labour to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: a systematic review and meta-ananalyses.” the Lancet E Clinical Medicine. https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(19)30119-1/fulltext
"We identified 14 studies eligible for meta-analysis including ~500,000 intended home births. Among nulliparous women intending a home birth in settings where midwives attending home birth are well-integrated in health services, the odds ratio (OR) of perinatal or neonatal mortality compared to those intending hospital birth was 1.07 (95% Confidence Interval [CI], 0.70 to 1.65); and in less integrated settings 3.17 (95% CI, 0.73 to 13.76). Among multiparous women intending a home birth in well-integrated settings, the estimated OR compared to those intending a hospital birth was 1.08 (95% CI, 0.84 to 1.38); and in less integrated settings was 1.58 (95% CI, 0.50 to 5.03)...The risk of perinatal or neonatal mortality was not different when birth was intended at home or in hospital."
Stapleton, E.R. et al, 30 January 2013. “Outcomes of care in birth centers: Demonstration of a durable model of care.” Journal of Midwifery and Women’s Health, vol 58 (1). https://doi.org/10.1111/jmwh.12003
"Of 15,574 women who planned and were eligible for birth center birth at the onset of labor, 84% gave birth at the birth center. Four percent were transferred to a hospital prior to birth center admission, and 12% were transferred in labor after admission. Regardless of where they gave birth, 93% of women had a spontaneous vaginal birth, 1% an assisted vaginal birth, and 6% a cesarean birth. Of women giving birth in the birth center, 2.4% required transfer postpartum, whereas 2.6% of newborns were transferred after birth. Most transfers were nonemergent, with 1.9% of mothers or newborns requiring emergent transfer during labor or after birth. There were no maternal deaths. The intrapartum fetal mortality rate for women admitted to the birth center in labor was 0.47/1000. The neonatal mortality rate was 0.40/1000 excluding anomalies."
Vedam, S et al, February 21, 2018. “Mapping integration of midwives across the United States: Impact on access, equity, and outcomes.” PLOS One. https://doi.org/10.1371/journal.pone.0192523
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"MISS scores ranged from lowest at 17 (North Carolina) to highest at 61 (Washington), out of 100 points. Higher MISS scores were associated with significantly higher rates of spontaneous vaginal delivery, vaginal birth after cesarean, and breastfeeding, and significantly lower rates of cesarean, preterm birth, low birth weight infants, and neonatal death. MISS scores also correlated with density of midwives and access to care across birth settings. Significant differences in newborn outcomes accounted for by MISS scores persisted after controlling for proportion of African American births in each state."
Iowa's MISS score was 25 out of 100 points.
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"Outcomes of trial of labor after cesarean birth by provider type in low-risk women" Matthew S. Fore MD, Amanda A. Allshouse MS, Nicole S. Carlson CNM, PhD, K. Joseph Hurt MD, PhD, 10 December 2019 https://doi.org/10.1111/birt.12474
"Overall VBAC success was 88% for 502 included patients. Postpartum hemorrhage and composite maternal morbidity were increased with unplanned cesarean, but there was no difference in neonatal outcome by mode of delivery or provider type. Obstetricians had slightly higher composite adverse maternal outcomes. Nomogram-predicted VBAC success but not provider type was associated with unplanned cesarean. Unplanned cesarean was similar for patients attempting labor after cesarean managed by midwives or obstetricians. Increasing the number of CNMs who manage TOLAC may help decrease the high rate of cesareans."
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The vaginal birth rate was 91.3% (n = 63): 77.3% for primips and functional primips (no previous vaginal births) and 97.9% for multips. Six mothers (8.7%) had in-labor cesareans (1 multip and 5 primips). A community birth can lead to high rates of vaginal birth and good outcomes for both mothers and babies in properly selected twin pregnancies. Community twin birth with midwifery style care under specific protocol guidelines and with a skilled practitioner may be a reasonable choice for women wishing to avoid a cesarean section-especially when there is no option of a hospital vaginal birth. Training all practitioners in vaginal twin and breech birth skills remains an imperative.
Why does the American College of Obstetrics and Gynecology (ACOG) & American Academy of Pediatrics (AAP) have position papers against homebirth?
Over the last decade or so as home births rise, more studies, opinion papers and meta-analysis have come out supporting and cautioning against homebirth.​ Each professional organization has representatives that review the literature, decide which literature to accept and then make recommendations based off that literature to it's members. ACOG specifically has used the notorious Wax, et al paper. To which many subsequent analyses of the Wax paper have discredited its legitimacy, read here.
"this faulty study now forms the evidentiary basis for an American College of Obstetricians and Gynecologists Committee Opinion,[7] meaning that its results are being presented to expectant parents as the state-of-the-art in home birth safety research."
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Other references that have been used are either strong opinion pieces by members or those with a flawed collection of data, read more here. For instance some have collected birth certificate data for 'planned homebirth' vs 'unplanned hombirth'. All this does is confirm the family wanted a homebirth but doesn't address if they had a Midwife, or if they did what kind of Midwife they had. Unfortunately, it has not stopped organizations like the AAP from supporting the ACOG position paper and coming out with their own. As you can see in the aforementioned list, there are many studies showing the safety of homebirth, what increases safety at a homebirth and birth center birth, however they have not been chosen as references for these organizations.
What do studies & health organizations suggest do help make homebirth safer?
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A physician or a midwife certified by the American Midwifery Certification Board (or its predecessor organizations) or whose education and licensure meet the International Confederation of Midwives (ICM) Global Standards for Midwifery Education practicing within an integrated and regulated health system. (such as a Certified Nurse Midwife or Certified Professional Midwife)
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Adopting Best Practice Guidelines for Transfer from Planned Home Birth to Hospital
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Clear practice guidelines for assessment and treatment of risk factors prior to delivery.
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Having an emergency care plan for urgent transport.
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Ready access to medical consultation when needed.
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Attendance by at least 2 care providers, one of whom is an appropriately trained individual whose primary responsibility is the care of the newborn infant
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Availability of appropriate equipment for neonatal resuscitation
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​​Access to safe and timely transport to a nearby hospital (ideally) with a preexisting arrangement
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Providers attend ongoing continuing education
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Providers practice regular drills with simulated patients
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RESOURCES:
Providing Care for Infants Born at Home - American Academy of Pediatrics
Best Practice Guidelines for Transfer from Planned Home Birth to Hospital - Home Birth Summit
​Professional Standards & Competencies - National Association of Certified Professional Midwives (NACPM)
Essential Competencies for Midwifery Practice - International Confederation of Midwives (ICM)