Prior to the birth of baby Archie to the Duchess of Sussex Meghan and her husband Prince Harry, there was much media speculation that they were opting for a home birth instead of a hospital one. Whether that, in fact, was ever up for serious discussion is unknown. As news is slowly being disclosed about the circumstances surrounding his delivery, the latest revelation released today puts those rumors to rest. Alas, childbirth occurred at a private hospital in London.
Putting into context why home versus hospital birth matters
When it comes to childbirth, fortunately most result in a healthy mother and healthy baby. But, when things do go awry in this arena they tend to do so precipitously.
In these scenarios, any delays or lack of expertise can lead to profound short- and long-term disability, even death. Having every piece of equipment at the ready at the hands of experienced and seasoned health professionals to rescue a distressed mother or infant by emergent c-section, for example, changes the game entirely.
For instance, every second counts when considering an infant brain's ability to endure oxygen deprivation. Waiting for a hospital transfer without necessary interventions instantly available can literally change the course of lives. Not monitoring vital signs of mom and baby in real time during the perinatal period can miss any number of opportunities to capture an evolving issue that when caught early is reversible. But, when unnoticed potentially catastrophic (and at that point irreversible).
The stakes are too high to add a risk factor or hurdle to childbirth.
What the latest research shows
A new study by co-author Eyal Sheiner, MD, PhD, chair of the Obstetrics and Gynecology Department at Soroka University Medical Center, Be'er-Sheva, Israel presented at the recent Society for Maternal-Fetal Medicine's 39th Annual Pregnancy Meeting in Las Vegas, Nevada determined babies born outside of the hospital are three times more likely to die than those born in one. This work builds upon what we already know, that the hospital is the safest environment to reduce the potential for short- or long-term disability and death.
The American College of Obstetricians and Gynecologists (ACOG) reports the number of home births in the United States to be about 35,000 (0.9%) births per year, with roughly a quarter of those unplanned or unattended. They note
“Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although planned home birth is associated with fewer maternal interventions than planned hospital birth, it also is associated with a more than twofold increased risk of perinatal death (1-2 in 1000) and a threefold increased risk of neonatal seizures or serious neurologic dysfunction (0.4-0.6 in 1000).”
ACOG’s committee position statement details the limited high quality evidence available regarding planned home births and the various challenges to obtaining such data. But, they amplify their message that
“Although the American College of Obstetricians and Gynecologists believes that hospitals and accredited birth centers are the safest settings for birth, each woman has the right to make a medically informed decision about delivery. Importantly, women should be informed that several factors are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes.
These factors include the appropriate selection of candidates for home birth; the availability of a certified nurse–midwife, certified midwife or midwife whose education and licensure meet International Confederation of Midwives’ Global Standards for Midwifery Education, or physician practicing obstetrics within an integrated and regulated health system; ready access to consultation; and access to safe and timely transport to nearby hospitals. The Committee on Obstetric Practice considers fetal malpresentation, multiple gestation, or prior cesarean delivery to be an absolute contraindication to planned home birth.”
The good, bad and indifferent reality of medical progress
It is a double-edged sword to be alive now. We have witnessed incredible modern medical advances and benefited from them. While, simultaneously, this progress has led to societal amnesia surrounding how it wasn’t that long ago rates were considerably higher in terms of maternal and infant mortality.
As per ACOG, it is clear that there will always be those who want to deliver at home and it is their right to do so. Taking actionable precautions to lower risk in planned home birth through optimizing candidate selection, hospital transfer speed and ease of access to specialty care, insisting on attended birth by trained staff and so on are worthwhile recommendations. If this is the step a family takes, then being fully informed about the endeavor is essential for true consent - and reducing harm whenever possible is better than not doing anything.
The key component is fully informed consent.
Many believe today that the most natural experience there is, childbirth, has become too medicalized. This is a valid point. The good news is there are options. There are birthing centers within hospitals that offer an alternative for those at low risk with uneventful pregnancies. Though no birth is entirely without risk, should an issue arise at least there is immediate well-informed and well-equipped help right there to respond without delay.
The bad news is for this segment of the population this is manifesting in home births and water births (1), for example, along with ill-conceived notions of delaying labor as long as possible and against medical advice (read here about those pushing “overdue” birth). And for those most adamant about avoiding the hospital or any intervention, “free birth,” “unhindered birth” and “unassisted birth” go a step further to exclude a trained professional from being present at all during delivery (read here).
Debunking the many false perceptions that abound on these subjects is crucial to promoting the overall safest paths. A healthy mom and healthy baby should be the goal of any delivery.
To read more about the nuances involved in the timing of delivery, review this piece:
To read more comprehensive pieces on the dangers of water birth, review these articles: