We tend to medicalize some human activity, we have advice on diet and exercise, but home birth, under the watchful eye of mid-wives, is still looked at askance. Are home births as safe as hospital births for both mother and baby? A meta-analysis looks for answers to two related questions, do women who intend to give birth at home experience higher or lower fetal or neonatal loss than women who intend to give birth in hospitals. In one case, the criteria is explicitly low obstetrical risk, in the second, local criteria, which implicitly includes these women. Outpatient birthing centers were not considered.
Beginning with roughly 4500 studies, they narrowed their scope to 14 observational studies further noting which were well-integrated programs, and those that were not. [1] Overall, the studies looked at 500,000 home births.
- When pooled, there was no difference in neonatal or fetal deaths between home and hospital births.
- This did not change with parity, that is, first-time mothers and children fared as well at home as in hospital as did multiparous mothers.
- There were no higher incidences of admission to the Neonatal Intensive Care Unit (NICU) for either group.
The researchers concluded:
“We challenge readers to interpret the safety of home birth within a greater societal context and consider the integration of home birth practices within health care systems.”
All studies have limitations; in this instance, the better quality evidence came from well-integrated programs where risk was assessed, and patients at higher risk funneled towards more medicalized settings. Less integrated programs were often excluded from consideration reducing the power of the study and perhaps shifting the consequences. But what does seem reasonably certain, home births, for a select population, are as safe as hospital births, with one more caveat. The one American study could not be included in the meta-analysis, because of data unavailability, but it showed a significant increase in perinatal and neonatal mortality with intended birth.
The real challenges
There is no wholly accepted definition of low-risk, beyond the absence of significant medical problems for the mother or soon to be born child, a singlet birth in the vertex position, and a supportive environment. Not only is the definition ambiguous, but it also fails to identify low-risk to whom, mother or child, and to what specific harm. The study did not consider maternal adversity or the need for emergent intervention; it simply spoke to the issue of neonatal death. Moreover, birth is deeply woven into our culture – the US is more risk-averse than other cultures, and while home birth was the rule rather than the exception in 1940, those numbers have reversed since then; childbirth may not have changed, but our cultural assumptions and desires certainly have.
From a pragmatic point of view, we need to consider how a patient could be quickly and safely transferred into a more medical environment. After all, birth and its risks are dynamic, dynamic enough to require minutes not hours. To develop these systems in the US will require collaboration between midwives, laborists, obstetricians, transport, and hospitals. That is a big undertaking, and to be honest, it is one we have not done well with for even slower problems, like chronic disease. Does the concept work? I think the answer is yes. But can it be easily transported into our culture and healthcare system, here I believe the response is less favorable and will require significant efforts and expenditures.
Perhaps, we might consider a hybrid model, where childbirth is returned to mothers and midwives, with close collaboration and proximity, i.e. “down the hall” to all the health services we can bring to bear.
[1] A well-integrated home birth program are “where home birth practitioners: are recognised by statute within their jurisdiction; have received formal training; can provide or arrange care in hospital; have access to a well-established emergency transport system; and carry emergency equipment and supplies.”
Source: Perinatal or neonatal mortality among women who intend at the onset of labor to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analysis EClinicalMedicine DOI: 10.1016/j.eclinm.2019.07.005
