In Out-of-Hospital Birth
Woman laboring at home

A large Washington State study affirms that planning birth in a free-standing birth center or at home (community birth) can be as safe as planned hospital birth provided:

  • Women are at low-risk for complications.
  • Births are attended by a professional midwife.
  • Midwives are integrated into the medical system, that is, they can readily consult and collaborate with hospital-based practitioners and transfer to a higher level care.

In fact, women and their babies may be better off.

The investigators analyzed data from the Washington State Obstetrical Care Outcomes Assessment Program data set. Their analysis included 10,609 births planned at freestanding birth centers and at home by women who were eligible for planned community birth at the onset of labor. Exclusion factors were health or obstetric complications such as high blood pressure or pre-existing diabetes, gestations less than 37 weeks or reaching 42 weeks or more, twins, breech presentation, or prior cesarean. All labors were attended by professional midwives (direct-entry Licensed Midwives or Certified Nurse-Midwives).

Babies fared as well as babies of low-risk mothers planning hospital birth. The preeminent outcome of concern with community birth is the perinatal mortality rate (deaths during labor or within 7 days after birth). This was 6 per 10,000 births, identical to the rate in low-risk women planning hospital birth, and the standard set for community birth by the American College of Obstetricians & Gynecologists (ACOG 2017). Other adverse outcome rates were also reassuringly low. Only 2% of babies were admitted to intensive care nurseries, and only 4 per 1000 babies experienced a severe adverse outcome (seizures, meconium aspiration syndrome, systemic infection requiring hospital admission, perinatal death).

Women fared better than similar women planning hospital birth. In particular, the cesarean rate among first-time mothers was 11%. Obstetricians are increasingly recommending routine labor induction at 39 weeks because a large obstetric trial found that 19% of low-risk first-time mothers allocated to induction at 39 weeks had cesareans compared with 23% allocated to planned expectant management. If those same women had planned community birth, 8 to 12 fewer women per 100 would have had cesareans, thereby sparing them, their babies, and the babies of future pregnancies the hazards of surgical delivery. In addition, in the population overall, less than 1% had instrumental vaginal deliveries or episiotomies (a cut to widen the vaginal opening for birth), and 1% had a tear involving the anal sphincter, all very low rates.

The study also investigated whether adverse outcome rates differed between home births and birth center births and found that they did not.

Discussion

U.S. obstetric authorities continue to oppose out-of-hospital birth in general and home birth in particular on the grounds that they pose excess risks to babies, and they have a long history of publishing flawed studies in support of their argument. In recent years, those studies have been a series of analyses of U.S. birth and death certificate data by Grunebaum and colleagues concluding that home birth increases neonatal mortality compared with nurse-midwife attended births in hospitals. Unlike Nethery’s study, however, Grunebaum’s analyses:

  • Include births attended by non-professional midwives.
  • Include births with risk factors (prior cesarean, breech, pregnancies exceeding 42 weeks).
  • Use a data source that isn’t designed to assess community birth risks and benefits.
  • Use a data source that is highly likely to underreport the neonatal mortality rate for hospital-based midwives because if care was transferred to a physician during labor, the physician, not the midwife, may be listed as the birth attendant.

These differences would tend to increase mortality rates at planned community births compared with planned midwife-attended hospital births. No one, though, is arguing that home birth is as safe as hospital birth under any circumstances. The question is whether it confers excess risk in women at low risk of complications attended by qualified home birth providers. Grunebaum’s analyses (and those of his predecessors) don’t answer that question. Nethery’s analysis does.

Furthermore, while warning about the perceived risks of community birth, obstetricians shirk their responsibility to mitigate them. Birth center and home birth regulatory agencies and midwife professional organizations are doing their part to ensure that birth attendants have the requisite competencies and to set eligibility criteria for community birth. Integrating community birth attendants into the maternity care system, however, a factor acknowledged to impact safety by ACOG itself (ACOG 2017), depends on the obstetric community for implementation. The best ACOG can muster on this point is an anemic admonition that in cases of transfer of care, “The receiving health care provider should maintain a nonjudgmental demeanor with regard to the woman and those individuals accompanying her to a hospital” (ACOG 2017). That is very different from mandating that hospital staff meet their obligation to consult and collaborate with community-based midwives and to facilitate transfer of care.

Finally, omitted from the equation are the benefits of planned community birth. Every study of community birth, as does this one, has found that women are less likely to undergo cesarean delivery or have other medical interventions compared with similar women planning birth in the hospital and therefore, less likely to be exposed to their attendant potential harms. The benefits of avoiding unnecessary use of these interventions should be included in any calculation of the harms versus benefits of planned community versus planned hospital birth.

Nethery’s study joins other studies coming to the same conclusion: planned community birth is often as reasonable an option as planned hospital birth and may be the superior choice.

The Take-Away

So, where does this leave you? If you are thinking about community birth, you will want to:

  • Consider what factors make you an optimal or less than optimal candidate for community birth and make your decision accordingly. This isn’t as straightforward a decision as it should be. For example, if you are wanting a vaginal birth after cesarean, you have a higher risk of an emergent event in labor that might be better handled by the resources of a hospital, but you also have much better odds of birthing vaginally by planning community birth than by planning birth with a typical obstetrician in a typical hospital—if VBAC is even an option at all.
  • Choose a professional midwife. This is someone with the credentials CPM, CNM, CM, or LM after their name. This ensures that the midwife has demonstrated their knowledge and skills to the satisfaction of a regulatory body.
  • Find out what arrangement your midwife has with your local hospital and how difficult it is to access higher levels of care. Treatment delay due to antipathy to planned community birth could affect your and your baby’s safety and wellbeing, as, for example, when staff won’t listen to the midwife’s report and insist on starting your intake process from scratch. Some women also report unkind and disrespectful treatment from disapproving staff.

References

ACOG Committee on Obstetric Practice. Committee Opinion No. 697: Planned Home Birth. Obstet Gynecol 2017;129(4):e117-e22.

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