Where is best for birth: Hospital or home?

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.