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Clinical Reviews

Does home birth empower women, or imperil them and their babies?

How safe is home birth? Do mistrust of the medical establishment, fear of cesarean, and other variables affect a woman’s decision about where to deliver her infant?

August 2009 · Vol. 21, No. 08


The author reports no financial relationships relevant to this article.

Few issues in obstetrics spark as much controversy as home birth—and where controversy rages, media attention follows.

Press reports of a 2008 policy statement on home birth issued by the American Medical Association (AMA) and the American College of Obstetricians and Gynecologists (ACOG) highlight the rift between the formal medical establishment and advocates of home birth. 1-3

On one side, the AMA and ACOG assert that the hospital or an accredited birthing center “is the safest setting for labor, delivery, and the immediate postpartum period.” 1 On the other side, advocates of home birth argue that having the option adds to women’s empowerment and choice.

Some people have accused the medical community of trying to corner the “baby birthing industry.” 4 The title of a recent Baltimore Sun article sums up this sentiment: “Home birth battle: Doctors strong-arm women away from healthy alternative to hospital care.” 5

Neither ACOG nor the AMA advocates criminalization of home deliveries, but their statements on home birth have generated considerable fear that they will.

This article explores the controversy, focusing on the literature on home birth, gaps in knowledge, the state of regulation, liaison with midwives, and other issues. It also offers suggestions on how to discuss labor and delivery with patients so that they clearly understand the risks involved and do not feel that they have “failed” at meaningful childbirth when they choose hospital delivery.

Did a rise in hospital births reduce maternal mortality?

Obstetric care changed dramatically in the mid-20th century. In 1940, 55.8% of deliveries occurred in the hospital, but that percentage rose to 99.4 by 1970 and hasn’t changed appreciably since. 6

Some proponents of hospital delivery note that, in 1940, when 44% of births occurred outside the hospital, the maternal mortality rate was 608 deaths for every 100,000 live births, compared with 37 deaths for every 100,000 live births in 1960, when fewer than 4% of deliveries occurred outside the hospital. 6 And in 2003, with only 1% of deliveries occurring in a home setting, the maternal mortality rate was even lower: 12 deaths for every 100,000 live births. 7

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Others argue that this sharp decrease in maternal mortality cannot be attributed solely to the change in location of the delivery (and subsequent availability of services and personnel), but reflects universal advancement in safe practices such as aseptic technique. 8

What do the data show? All studies of home birth have serious methodologic flaws, thanks largely to the nature of the subject matter. A recent Cochrane review observes that there is only one randomized, controlled trial—with a sample size of only 11 women—from which to draw conclusions. 9 The review concludes that “there is no strong evidence to favour either home or hospital birth for selected, low-risk pregnant women.” 10

Most data come from abroad

Much of the literature on home birth comes from international sites because of the higher prevalence of home delivery in other countries. These data reveal that:

  • Two percent of deliveries in the United Kingdom occur in the home. 11 The British National Institute for Health and Clinical Excellence recommended that all women be offered the option to have their baby at home or in the hospital, although, depending on the “trust” (a geographically based public-system cooperative that provides care), 8% to 76% of women weren’t given this choice formally. 12
  • One study conducted in Switzerland involved 489 women who opted for home birth and 385 who chose hospital birth. Of the former, 37 were referred to a specialist during pregnancy, and 70 were referred during labor. The groups had similar birth weights, gestational ages, and clinical conditions. 13
  • In the Netherlands, 30% of infants are born at home. 14 If a woman has an uncomplicated pregnancy, she remains under midwifery care and can decide where to deliver. A study of 280,000 “low-risk” women under primary midwifery care found that 68.1% completed childbirth under that care, 3.6% were referred urgently, and 28.3% were referred without urgency. 14 When referrals were considered as a whole, 11.2% involved urgency, primarily for fetal distress (50.2%) and postpartum hemorrhage (33%). Adverse neonatal outcomes were most common in urgently referred cases, followed by nonurgent referrals. The authors acknowledge the importance of transport time once a referral is initiated, stating that, “The Netherlands is a very densely populated country where the average distance to the hospital is relatively short.” (The same cannot be said of many parts of rural America.)
  • A study involving home deliveries in Australia from 1985 to 1990 identified 50 perinatal deaths out of 7,002 planned home births. 15 The perinatal death rate of infants weighing more than 2,500 g exceeded the national average (5.7 versus 3.6 for every 1,000 deliveries), with a relative risk (RR) of 1.6 (95% confidence interval [CI], 1.1–1.4). Intrapartum death not attributable to prematurity or fetal malformation was also higher (2.7 versus 0.9 for every 1,000 deliveries), with a RR of 3.0 (95% CI, 1.9–4.8). According to the authors, the main contributors to excess mortality were underestimation of the risks associated with post-term birth, twin pregnancy, and breech presentation, and a lack of response to fetal distress.

Is the evidence on water birth just too murky?

In the summer of 1999, a woman delivered a 7.7-lb infant after 42 weeks of gestation. The birth took place in the woman’s home in Japan, and the baby was delivered in a bathtub of warm water. The woman had had an uneventful pregnancy, and the baby appeared to be perfectly normal.

Four days later, the infant developed fever and jaundice and was admitted to the hospital, where she was treated with phototherapy. She improved, but her symptoms recurred 3 days later, and she began to vomit. Eight days after birth, she suffered cardiopulmonary arrest and died. An autopsy revealed the cause of death to be legionellosis—infection with Legionella pneumonia. The most likely source was the bathtub in which she was born. 43

Other case reports describe similar tragedies associated with water birth (among them, drowning, infection, and a snapped umbilical cord), but no randomized, clinical trial has systematically compared delivery in water with conventional land-based birth.

The death, morbidity, and lack of data so troubled members of the American Academy of Pediatrics that the Committee on Fetus and Newborn issued an advisory in 2005:

  • The safety and efficacy of underwater birth for the newborn has not been established. There is no convincing evidence of benefit to the neonate but some concern for serious harm. Therefore, underwater birth should be considered an experimental procedure that should not be performed except within the context of an appropriately designed randomized clinical trial after informed parental consent. 44

This statement contrasts the conclusion of the most recent Cochrane review of the subject, which found that, “Immersion in water during the first stage of labour significantly reduces women’s perception of pain and use of epidural/spinal analgesia.” 45 The review also noted, however, that, “No trials could be located that assessed the immersion of women in water during the third stage of labour.” 45

No studies have explored immersion in water during the third stage of labor.

What’s in that water?

Amy Tuteur, MD, an ObGyn who publishes a popular blog (“The Skeptical OB”), focused on the topic of water birth earlier this year. “What’s in the water at waterbirth?” she asks. 46

To answer the question, Dr. Tuteur cites a 1999 study of 4,030 deliveries in water, which found that 35 infants suffered serious morbidity and three died—although it is unclear if any of the deaths were a direct result of water birth. “However, of the 32 survivors who were admitted to the NICU,” writes Dr. Tuteur, “13 had significant respiratory problems, including pneumonia, meconium aspiration, water aspiration, and drowning. Other complications attributable to water birth include five babies who had significant hemorrhage due to snapped umbilical cord. In all, 18 babies had serious complications directly attributable to waterbirth.” 47

Dr. Tuteur also points to the poor quality of the water in birthing pools, arguing that it is “essentially toilet water.” 46 “The water in a birth pool, conveniently heated to body temperature, the optimum temperature for bacterial growth, is a microbial paradise,” she writes. 46 She cites a study of 1,500 water births that included analysis of the water found in the birthing pools (before anyone entered the water) and identified:

  • coliforms in 21% of samples
  • enterococcus in 19% of samples
  • Escherichia coli in 10% of samples
  • Legionella pneumophila in 12% of samples
  • Pseudomonas aeruginosa in 11% of samples. 48

After a special water filter was installed, contamination diminished but did not disappear completely.

Pools in the home setting were not the only ones implicated in contamination; some hospital pools also were affected.

What’s the bottom line?

The American College of Obstetricians and Gynecologists has yet to weigh in on the matter. Until it does, ObGyns may be wise to heed the words of Ruth Gilbert, MD, of the Centre for Paediatric Epidemiology and Biostatistics at the Institute of Child Health in London.

“Can delivery in water cause serious adverse outcomes?” she asks, rhetorically, it turns out.

“Undoubtedly, the answer is ‘yes.’” 49 JANELLE YATES, SENIOR EDITOR

The data we do have are difficult to interpret

Among the limitations of studies of home birth are:

  • lack of follow-up after the delivery
  • varying definitions of perinatal mortality internationally
  • lack of clarity regarding the identity and education of delivering providers
  • the fact that there are often “too few neonatal deaths from which to extrapolate reliable rate calculations.” 16

One meta-analysis found a rate of intrapartum transfer ranging from 7.4% to 16.5%, and a rate of primary cesarean delivery of 1.4% to 17.7% (it was 13.8% to 28.25% in the “comparison group”). 16

A challenge inherent in many of these studies is identifying exactly what the comparison group is. In addition, some of the data are obtained from discharge summary records, which don’t always reflect the level of risk or acuity.

Oft-cited study has weaknesses

The study that many advocates of home birth cite was conducted in the United States and Canada and published in 2005. 17 It evaluated “all 5,418 women expecting to deliver in 2000 supported by midwives with a common certification [certified professional midwives] and who planned to deliver at home when labour began.” The hospital transfer rate was 12.1%, in line with other studies. The risk of adverse outcomes was lower in the group that planned to have home delivery, compared with a “relatively low-risk hospital group.”

The study focused on:

  • electronic fetal monitoring, used in 9.6% of deliveries in the home-birth group, versus 84.3% of the hospital group
  • episiotomy, performed in 2.1% of home deliveries, compared with 33% of hospital births
  • cesarean delivery, 3.7% of planned home deliveries, versus 19% of hospital births
  • vacuum-assisted vaginal delivery, performed in 0.6% of planned home deliveries, versus 5.5% of hospital births
  • neonatal death, at a rate of 2.0 deaths for every 1,000 intended home births. No comparison figure was cited.

One of the weaknesses of this study, as of others, was identification of a comparison group as a “low-risk” population without data to back up that designation. In addition, this study derived its data from birth certificates for 3,360,868 singleton, vertex births at 37 weeks or more of gestation. Data from birth certificates are limited as a basis for accurate risk assessment. Moreover, although the authors of this study asserted that they had no conflict of interest, the investigation was funded by The Foundation for the Advancement of Midwifery.

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