Prior to the 19th century, childbirth was conducted at home, with the aid of a midwife and attended by other female friends and family. As European hospitals began to establish obstetrics departments in the late 18th century, families with enough resources began turning to male surgeons—who claimed superiority over midwives—to oversee the trials of labor and delivery. Ever since, women in western developed nations have generally viewed physician-supervised hospital births as normal and home births as the exception. In the United States today, about 99% of all babies are delivered in hospitals—a rate that has remained steady for at least two decades.

Midwifery does still exist in the U.S., but it is primarily practiced in a hospital setting by midwives who are also certified nurses. In this setting, midwife attended childbirth has actually been on the rise—going from less than 1% in 1975 to over 8% in 2002. Home care with so-called “direct entry midwives”, on the other hand, remains uncommon and controversial. (Direct entry midwives vary greatly in their training, certification and methods; unlike nurse midwives, they are not registered nurses with bachelor degrees in nursing, nor do they undergo the same standard two year post-graduate program in midwifery.)

While some studies have suggested that home births are relatively safe, a few have shown they result in a higher number of newborn deaths. This latter finding has been well documented among women at high risk for complications of childbirth (i.e., women with health or obstetric problems that existed before or developed during pregnancy and were discovered before the onset of labor).

In light of the well-established risk for complications among high risk women, a new study published in the June 18, 2005 issue of the British Medical Journal focused solely on home birthing outcomes among low-risk women in North America. They found that for these women, medical intervention rates were substantially lower for home births than for hospital births, and that mortality rates were about the same in either location.

About the Study

The study collected information from 502 direct entry midwives certified with the North American Registry of Midwives. These midwives reported on the birthing outcomes of 5,418 women in 2000, 98% of whom resided in the US, the other 2% in Canada. The researchers only included information on the women who were at low risk for complications of delivery in their analysis. In addition, they also contacted over 500 (10%) of these women directly, to confirm details of their deliveries and ascertain their overall level of satisfaction with home birth.

The researchers compared the data for this low risk home birth cohort with data on all low risk hospital births in the US for the year 2000. They relied heavily on information listed on US birth certificates. To further strengthen their findings, they also compared their data to that of several other North American studies that had involved 500 births or more either at home or in hospitals.

The Findings

The researchers found that the home birth mothers were on average older, of lower socioeconomic status, of higher educational achievement, and less likely to be Hispanic or African-American than the hospital-going majority of Americans.

Twelve percent (655) of the home birth mothers were transferred to the hospital during or after delivery (mostly during). First time mothers were four times more likely to be transferred than women who had given birth before.

Medical interventions—such as epidural anesthesia , episiotomy , forceps or vacuum extraction, and cesarean section —occurred less than half as often in home births as they did in hospitals; for example, the cesarean rate for home births was 3.7% compared to 19% for the US as a whole.

No maternal deaths occurred among the home births. Fourteen babies died in the home births: three from fatal birth defects, five during delivery, and six as newborns. The overall death rate was 2 deaths per 1,000 intended home births; this rate was comparable to averages for hospital births in other studies.

Home birth mothers reported high satisfaction with care on 11 measures; 97% (of the 10% sample contacted directly) reported they were extremely or very stratified.

How Does This Affect You?

This study suggests that women at low risk for complications of labor and delivery might want to consider the option of home birthing more carefully. For many of these women, the convenience and comfort of home—coupled with the lower rate of medical interventions—may make home birthing an attractive option. Furthermore, midwives traditionally provide ongoing, personalized care throughout pregnancy and into the child’s infancy, which is an accommodation rarely available from busy obstetricians.

It seems clear that many pregnant women planning a hospital-based delivery could safely have their babies at home, with its many advantages. Before deciding on the home birth option, however, there are three criteria to consider. First, your pregnancy must be low risk. An obstetrician or obstetrical nurse practitioner would be in the best position to make this judgment. Second, the midwife who manages your home birth must be highly experienced and appropriately certified. And, third, there must be convenient and reliable hospital-based back-up services should something unexpectedly go wrong.