Atoosa Benji
With statements such as this coming from a former president of the American College of
Obstetricians and Gynecologists, how could families even fathom of home birth as a safe option?
In reality, it is sentiments such as these, fueled by faulty and inadequate research that has elicited
panic in U.S obstetrics around home birth. While midwives have been under scrutiny in every
state for attending homebirths, the evidence shows that homebirth is still a safe option for both
mother and child, when certain parameters are met. The measure of safety is determined by rates
of both maternal and perinatal mortality and morbidity- which are lower at home than in hospital
births around the world. The Western, technocratic model of childbirth operates through the risk
management model, practicing from a prophylactic angle, rather than a holistic, evidence-based
angle. The gap between the scientific research in obstetrics and what happens at the clinical
level, continues to be detrimental to mothers and babies across the United States and many other
countries (Wagner, 2006). This paper will demonstrate that home birth continues to be a safe
option when the birth is a planned homebirth, attended by a qualified midwife, and the
The early studies on home birth did the world of childbirth a huge disservice. While it
was established firmly in the scientific community that a distinction must be made in any study
of homebirth between planned homebirth and unplanned homebirth, articles that did not abide by
those guidelines, were still published. (Wagner, 2006). In a study presented to ACOG by J.
Pang et al., favoring hospital birth, the researchers rely solely on date from birth certificates
which do not show the intended location of birth (Wagner, 2006). This is problematic. The
problem lies wherein births that may have been precipitous or premature and mothers for whom
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prenatal care was never provided are included in many homebirth safety studies, even though
they were not planned homebirths. This skews the numbers and causes inflated neonatal
mortality rates in the home birth group (Wagner, 2006 p.139). In one Australian study, the
higher risk of perinatal mortality was due to the fact that breech babies, twins and post-term birth
were included in the study (De Jonge, 2009). In determining the safety of homebirth, we must
produce research that compares apples to apples. For the most part, articles pointing to
homebirth as unsafe are failing deeply in their analyses. When birth is planned to be at home, a
midwife provides both prenatal care and continuity of care during the birth. This decreases the
risk of a bad outcome that may have occurred due to a lack of proper prenatal care and a birth
with no qualified professional in attendance. As Wagner points out, a trained midwife who is
providing one on one care is more likely to be able to anticipate, recognize and take action on a
labor complication than a nurse or doctor in a hospital where more than one patient is assigned to
Midwives are trained to attend low-risk birth. The parameters of a low-risk mother,
according to the National Institute of Health are existing health conditions, mothers age,
lifestyle factors and conditions of pregnancy (National Institute of Health, 2016). When factors
such as advanced maternal age, fetal malpresentation and pre-eclampsia are present, care is
transferred to the care of an obstetrician. The safety of homebirth lies in this fact. The
midwifery model of care not only treats low-risk mothers, but provides care that inherently
reduces the risk of intervention. It is known that in labor, intervention begets intervention and
when intervention increases the likelihood of induction, operative vaginal birth or cesarean
section, the rate of both maternal and fetal perinatal morbidity and mortality increase (Jansen,
Gibson, Bowles, & Leach, 2013). In one Australian study comprised of women giving birth to a
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singleton baby in the period between 2000 and 2008, it was concluded that, for low-risk
women, care in a private hospital, which includes higher rates of intervention, appears to be
associated with higher rates of morbidity seen in the neonate and no evidence of a reduction in
perinatal mortality (Hannah et al., 2014, p.2). In a study of 1707 planned, midwife-attended
births in rural Tennessee at The Farm, 1.46% of deliveries were Cesarean section, compared to
16.46% in the physician attended hospital sample. Additionally, 2.11% of women required an
assisted vaginal delivery versus 26.6% in the hospital group (Durand, 1992). Durand concluded
that There is some evidence, however, that elective interventions, which are used more
frequently in hospitals, may increase the risk of various adverse outcomes in low risk women
(Durand, 1992 p. 452). Many have rebuked the Farm study claiming the sample size to be far
too small to have statistical influence. The issue of sample size was addressed in the following
Canadian study.
In this study, conducted from 2000-2004 by Janssen et al., three cohorts were studied;
same midwives with same eligibility requirement as the home birth group mothers, and physician
attended hospital births. The following results highlight the premise that planned homebirth
attended by a registered midwife had decreased risk of obstetric interventions, perinatal death,
and adverse perinatal outcomes, as compared to planned hospital birth attended by a physician or
a midwife (Janssen et al. (2009). Perinatal death in the planned homebirth group was 0.35%,
0.57% in the hospital birth midwives group and 0.64% in the physician-attended group.
Additionally, the rates of intervention, including electronic fetal monitoring, assisted vaginal
delivery, and poor maternal outcomes including postpartum hemorrhage, third and fourth-degree
vaginal lacerations were lower in the homebirth group than in the other two groups. Babies born
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at home were also less likely to experience meconium aspiration and less likely to be admitted to
The midwifery model of care does not limit oral intake during a normal labor, nor does it
not only restricts a laboring patients movements but can also result in high rates of cesarean
surgeries and vacuum extractions among low-risk laboring women (Jansen et al., 2013 p. 84).
Midwives do not frequently check cervical dilation. Frequent position changes and walking
during labor are strongly promoted. Additionally, the familiar setting of home, with the freedom
to eat, drink and move freely contributes to a womans feelings of safety and confidence on her
ability to birth, versus feeling undermined in an unfamiliar hospital setting (Durand, 1992).
In a study conducted between 2004 and 2010, a sample of close to 17,000 planned
homebirths was studied. The rate of cesarean section was 5.2% while the rate of operative
vaginal birth was 1.2%. Of the hospital transfers during labor, the majority were for failure to
progress not due obstetrical emergencies. In the U.S, the rate of oxytocin for labor augmentation
and the use of epidural anesthesia are 26% and 67% respectively (Cheyney et al., 2014). In the
same study, only 4.5% of the MANA sample (planned homebirth group) required oxytocin
and/or epidural anesthesia. (Cheyney et al., 2014). Again, the study concluded that a planned
home birth attended by a midwife for a low-risk woman can result in positive outcomes for both
Earlier, safety with regards to childbirth was defined as the low rate of maternal and fetal
morbidity and mortality during the perinatal period. As evidenced by the research discussed in
this paper, planned homebirth, attended by a qualified midwife is a safe option for a healthy, low
risk mother. When birth is planned to be at home, the pregnant woman is under the prenatal care
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of her midwife. At the onset of labor, the midwife arrives bringing with her expertise, skill and
needed medication and oxygen to intervene if necessary. It is imperative that any study of the
safety of homebirth includes, not only place of birth, but also intended place of birth and the
qualification of the care-giver in attendance. Too many studies have failed to do so and thus, the
While maternal and fetal mortality and morbidity can occur for a variety of reasons,
bleeding, infection, and respiration issues are common reasons for poor outcomes. Research
confirms that higher rates of interventions lead to increased need for vaginal operative deliveries
which often end in emergency cesareans sections (Jansen et al. 2013). In the afore-mentioned
studies, the C-Section rate in all the home birth studies was below 10%. Currently, in the US,
our cesarean section rate is close to 32 %, a whopping 15-20% higher than the recommendation
of the World Health Organization for an industrialized country (Hamilton et al. 2015). Cesarean
sections are associated with higher rates of hemorrhage and uterine rupture as well as maternal
sepsis (Jansen et al., 2013). There are also risks for to the neonate born via cesarean section. In
one study, there was a 69% higher incidence of fetal death for C-section babies. Additionally,
babies are at risk for accidental lacerations during surgery, poor transitions, and respiratory issues
By sheer virtue of the fact that midwives care for low-risk women at home, where
interventions are minimal, homebirth is a safe option for many women in the US, increasing
overall maternal-child health and reducing cost for an already strained medical system. It would
behoove the medical community to educate women on the risks and benefits of homebirths,
instead of operating from the angle of scare tactics and faulty research.
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References
Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Saraswathi, V. (2014).
Outcomes of care for 16, 924 planned home births in the United States: The midwives alliance
of North America statistics project, 2004 to 2009. Journal of Midwifery & Womens Health,
de Jonge, A., van der Goes, B.Y., Ravelli, A., Amelink-Verburg, M.P., Mol, B.W., Nijhuis, J.G.,
& Buitendijk, S.E. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529
688 low-risk planned home and hospital births. BJOG: An International Journal of Obstetrics
Durand, A. M. (1992). The safety of home birth: the farm study. American Journal of Public
Hamilton, B.E., Martin, J.A., Osterman, J.K, Curtin, S.C., & Mathews, T.J. (2015). Births: Final
data for 2014. National Vital Statistics Reports, 64, 1-64. Retrieved from
http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_12.pdf
Hannah, G.D., Tracy, S., Tracy, M., Bisits, A., Brown., & Thornton, C. (2014). Rates of obstetric
intervention and associated perinatal mortality and morbidity among low-risk women giving
birth in private and public hospitals in NSW (2000-2008): A linked data population-based
Jansen, L., Gibson, M., Bowles, B.C., & Leach, J., (2013). First do no harm: Interventions during
childbirth. The Journal of Perinatal Education, 22, 83-92. Doi: 10.1891/1058-1243.22.2.83
Janssen, P. A., Saxell, L., Page, L. A., Klein, M. C., Liston, R. M., & Lee, S. K. (2009). Outcomes
of planned home birth with registered midwife versus planned hospital birth with midwife or
physician. CMAJ: Canadian Medical Association Journal, 181, 377383.
http://doi.org/10.1503/cmaj.081869
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Wagner, M. (2006). Born in the USA. Los Angeles, CA: University of California Press.