What is Home Birth?

© 2012 by Rebecca Dekker, PhD, RN, APRN

Home birth is a common occurrence for women in some countries, such as the United Kingdom and the Netherlands. However, in the U.S., home births are rare and actively discouraged by many obstetricians, including the American Congress of Obstetricians and Gynecologists. In fact, before my husband and I began looking into home birth for our second child, we had never met anyone who had experienced a home birth (unless you count my aunts and uncles who were born at home in the 1920’s.) Although U.S. home births have increased by 30% in the past few years, less than 1% of American women give birth at home (MacDorman et al., 2012). This means that for every 100 of your friends and family members who get pregnant and have a baby, 99 of them will birth in the hospital.

For our second child, my husband and I—after much discussion and research—chose to have a home birth. To our surprise, we never received any negative or disparaging comments about our choice. Instead, we mostly met with genuine curiosity and interest from our family and friends, and even from our obstetrician and her office staff. They all wanted to know— “What is home birth? What is it like? Who cleans up the mess? What supplies do you have to have? How much does it cost? What if there is an emergency?” We even got questions like, “Does the midwife bring stirrups? Can you have an epidural at home? Do they do C-sections at home?” The stirrups question actually came from a PhD-prepared nursing professor, and the C-section question from a school teacher. So yeah, the average American has no idea what a home birth is all about. Hence, this article.

This is Part 1 of a 2 part series on Home birth. This article will cover the basics of home birth. A follow-up article (coming later this summer) will discuss the evidence for home birth.

What is home birth?

Home birth is defined as giving birth to a baby in your place of residence. Home birth can be planned (87% of U.S. home births) or unplanned (13%). It can be attended by a midwife (62% of U.S. home births), a physician (5%), or others, such as family members or emergency medical technicians (33%) (MacDorman et al., 2012). In this article I will be focusing on planned home birth with a midwife.

Who gives birth at home?

Women who give birth at home in the U.S. are more likely to be white, married, and have had previous children than women who give birth in the hospital. Women who give birth at home are also more likely to be lower-risk— they are less likely to be teenagers, deliver prematurely, have babies with low birth weight, or have multiples (MacDorman et al., 2012).

Who is a good candidate for a home birth?

There is a lot of controversy over who should be eligible to give birth at home. Many countries have standardized “lists” of what makes a woman a good candidate for a home birth, but the U.S. does not. The list below is taken from the criteria used in Janssen’s (2002; 2009) studies on home birth in Canada.

Women who are considered “low risk” and may be good candidates for home birth include the following (this should not be considered an exhaustive list):

• A woman who is pregnant with a single baby and has made an informed choice to birth at home
• Baby is head down at term
• Between 37 and 41-42 weeks pregnant (researchers differ on the 41-42 weeks)
• No serious medical conditions (heart disease, kidney disease, blood clotting disorders, type I diabetes, gestational diabetes managed with insulin, preeclampsia, or bleeding)
• No placenta previa at beginning of labor
• No active genital herpes
• No thick meconium
• *No prior C-section
• *Spontaneous labor

*Some research study guidelines also included women with one prior C-section (low transverse incision) and women who were induced on an outpatient basis (Janssen, 2009). However, because of the lack of data on safety, ACOG considers prior C-section to be an “absolute contraindication to planned home birth.” (ACOG, 2011)

What are some reasons women and families decide to have a home birth?

In a 2009 study, Boucher et al. interviewed 160 women who had a home birth in the U.S. and asked them why they chose a home birth. Reasons that the woman gave included:

• Belief that home birth is safer than the hospital*
• Desire to avoid unnecessary interventions*
• Previous negative or traumatic hospital birth experience*
• Control over birth decisions and choices (want to avoid strict hospital rules)*
• Dislike of hospitals, doctors, or medically managed birth*
• Desire for privacy and to avoid strangers
• Trust in birth as a normal, healthy process
• Lack of separation from baby, easier breastfeeding initiation
• Preference for midwives as caregivers
• Increased options such as delayed cord cutting or water birth
• Decreased risk of Cesarean birth
• Comfortable atmosphere
• Family involvement during the birth (children can be present)
• Decreased risk of infection
• History of fast (precipitous) labor where it is difficult to get to the hospital in time

* indicates one of the 5 most common reasons stated

Is home birth right for everyone?

No. Homebirth is not right for everyone. Parents who choose a home birth must engage in a much higher level of preparation, responsibility, and involvement in the birth. Many parents cannot or should not take on this responsibility. Women who choose a home birth must also be willing to labor without an epidural, although it is possible to change your mind during labor and transfer to the hospital for an epidural. 

How do you find a midwife?

There are 2 main types of midwives who attend home births in the U.S. A certified nurse midwife (CNM) has a nursing degree plus at least a master’s in midwifery, and is certified by the American College of Nurse Midwives. These midwives are legal in all 50 states and can deliver babies in hospitals, birthing centers, and homes. However, the majority of births attended by CNMs take place in hospitals.

The majority of home births in the U.S. are attended by direct-entry midwives—these are midwives who are directly trained in midwifery and did not go through a nursing training program. A common type of direct-entry midwife in the U.S. is a certified professional midwife (CPM).  CPMs are educated through class and clinical experience. The clinical component consists of an apprenticeship under the supervision of one or more preceptors.  The average apprenticeship lasts 3-5 years. The CPM certification is offered by the North American Registry of Midwives. CPMs have legal status in 26 states and attend births in hospitals, birthing centers, and homes.

There are several other types of midwives, including certified midwives (CM), direct-entry midwives, and lay midwives. You can read definitions of these types of midwives here.

Since my husband and I live in a state that does not legally recognize CPM’s, it was difficult for us to find home birth midwives. We finally found several midwives through word-of-mouth. We interviewed them by phone and in person, and we completed an extensive reference check (4 client references and 2 midwife references) before hiring our midwife. I will say this—if we had not found a care provider who practiced safely and who we trusted, then we would not have chosen a home birth.

So what questions did we ask the midwives during our interviews? Well, there are several good resources on line for interview questions. Prep for Birth has a thorough list of questions here.

And the Navelgazing midwife has an interesting series on how to interview a home birth midwife here.

What kind of prenatal care do you receive when you plan for a home birth?

Women who plan a home birth with a midwife generally receive care that is based on the midwifery model of care. The midwifery model of care sees pregnancy and birth as normal life events. Midwives who practice using this model monitor a woman’s physical, psychological, and social well-being. They provide individualized education, counseling, prenatal care, hands-on assistance during labor and delivery, and postpartum support. When you receive care based on the midwifery model of care, you are less likely to experience unnecessary medical intervention or Cesarean birth, and you are more likely to feel in control during birth and to initiate breastfeeding. Midwives are trained to identify and refer women who experience pregnancy or birth-related complications. (Wiysonge, 2009).

In addition to receiving prenatal care from a midwife, women who choose home birth in the U.S. often receive collaborative care from a physician. This may range from a single visit for an acute need, to a back-up arrangement for hospital transfer, to full collaborative care—in which the mother receives duplicative care from a physician and a midwife. For example, I received full collaborative care, so I had twice the prenatal care. For each visit with my home birth midwife, I had a duplicate visit with my obstetrician. This was the only way my OB would agree to serve as my back-up in case of a hospital transfer.

How much does it cost?

The cost of home birth can vary considerably depending on your geographic location. Home birth may or may not be covered by health insurance. In my area (Southeastern U.S.), home birth can cost anywhere from $2,000 to 2,500. This cost usually includes all prenatal visits, birthing tub rental, midwife’s fee for the birth, any medical supplies or medications used during the birth, an assistant for the midwife, and several postpartum visits. My home birth and prenatal care with my midwife was not covered by insurance, but my duplicative care with my obstetrician was covered.

What kind of supplies do you have to have on hand?

Supplies that the mother and her partner need to gather beforehand include clean towels, washcloths, 1 set of bed sheets that can get messy, a waterproof cover for the bed mattress, food and drinks for yourself and the midwives, and more. Click here for a google document that lists the supplies we collected for our home birth.

What does the midwife bring to the home birth?

The midwife brings an assistant—often a student midwife, doula, or someone who has experience being present at births. The supplies that a midwife brings varies from midwife to midwife, but the basics may include: emergency medications such as Pitocin (for post-partum bleeding), handheld Doppler and fetoscope to monitor baby, sterile instruments for cutting the cord, Vitamin K and eye ointment for the infant, suction device to remove mucous from the infant’s nose or mouth, 2 oxygen tanks, and adult and infant resuscitation equipment.  You can view a picture of the contents of a midwife’s birth kit here.

Contrary to popular belief, a midwife does not bring stirrups to the birth. Giving birth in bed with stirrups is an invention of hospitals and—aside from standing on your head—it is the worst possible pushing position for mom and baby! Midwives respect women’s ability to push and give birth in whatever position a woman chooses as long as mom and baby are okay—upright, in a birthing tub, side-lying, squatting, hands-and-knees, leaning on a birthing ball, or sitting on the toilet. You name it; a home birth midwife has probably helped a woman push that way—except for maybe standing on her head or in stirrups.

What interventions can a midwife do at a home birth?

To answer my friends’ questions—no, a midwife cannot do an epidural or a C-section at home.

However, midwives do have a host of other clinical skills that they can use, depending on their scope of practice, training, and licensure. In general, home birth midwives can do the following:

• Intermittently monitor baby’s heart rate with a handheld Doppler and/or fetoscope
• Monitor the woman’s progress of labor
• Perform cervical exams as requested by the mother
• Provide physical and emotional support during labor
• Perform a newborn exam
• Suture any tears after birth
• Recognize complications and transfer a patient to the hospital (most of the time complications are recognized and women are transferred before the situation becomes an emergency)
• Administer oxygen and emergency medications
• Perform adult and neonatal resuscitation
• Start IV’s and administer IV fluids (some midwives)

What are the reasons that a mother might need to transfer to the hospital?

It is important for home birth parents to plan for the possibility of a transfer to the hospital. A study of 5,418 U.S. women who gave birth at home under the care of CPMs found that 12% of women had to transfer to the hospital during labor or after birth (Johnson et al., 2005). About 9% or three-fourths of these transfers were considered non-urgent. The most common non-urgent reasons for transfer were for  failure to progress (5.7% of all home births), need for pain relief (2.2%), and maternal exhaustion (2.1%).

Approximately 3% of women experienced an urgent transfer to the hospital. The most common reasons for urgent transfer were sustained fetal distress (0.6% of all births), baby’s head not presenting in an optimal position (0.4%), and maternal bleeding after birth (0.4%). Women who were having their first baby were four times more likely to need a transfer to the hospital then women who had previous children (25% vs. 6%) and two times more likely to have a transfer for an urgent reason (5% vs. 3%).

What is a home birth like?

Each home birth is unique. I can’t speak for every woman who has had a home birth, but I can speak for myself and my husband. During our home birth we received evidence-based, woman-centered and baby-friendly care, and I had very few interventions per our request (not even a single cervical check!). We trusted our care provider and felt safe from beginning to the end.

For a short video of a home birth (not my own!), you can watch this clip below—I feel that it does a good job of describing the aspects of home birth that I have covered in this article. And don’t worry– this video is PG rated!!

Do you have to clean up the mess?

This was one of the most common questions we received from curious friends and relatives who had given birth in hospitals. The answer is no, we did not have to clean up the mess! The midwives do much of the work ahead of time by protecting your floors and furniture with waterproof drop cloths and with the same blue “chux” pads that are used in hospitals. After mom and baby are settled in bed to recover after the birth, the midwives clean any mess that remains. Hydrogen peroxide can be used to clean up any spills. Your birth partner may need to empty the water from a birthing pool (our midwife lent us a sump pump to pump the dirty water out through a window into our side yard). Most midwives will start a load of laundry before they leave.

What was the recovery like?

I have consistently read that one of women’s favorite memories of home birth is being tucked into their own bed after giving birth. I would have to agree with that statement. After our son was born, my whole family (husband, myself, big sister, and new baby brother) ate dinner in bed together. We went to sleep in our own bed. Nobody woke us up for routine vital signs; nobody took our baby away to the nursery for testing or examinations.  It was quiet and restful. We planned ahead of time for people to bring us meals, and we also had meals ready to go in the freezer. We also planned for someone to come over and help with our older child for the next few days so that we could nap as much as possible.  

Our midwife made 4 post-partum visits at 3 days, 1 week, 3 weeks, and 6 weeks. During those visits she checked on me and provided well baby care (such as weight checks and assistance with breastfeeding). We also scheduled an initial visit with the pediatrician at 2 weeks. At that visit the pediatrician performed the mandatory state testing.

Finally, we had to go to the public health department and apply for a birth certificate. Our midwife gave us the paperwork to fill out ahead of time. Our baby’s birth certificate and social security card arrived in the mail a few weeks later.

Now it’s your turn to talk. Have you ever seen a home birth in person? What questions do you have about the basics of home birth?

Disclaimer: I do not believe that home birth is right for everyone. I do believe in a woman’s right to choose her place of birth. The purpose of this article is only to provide information about home birth. If you leave a comment, please choose your words carefully and show respect for each other’s viewpoints. Any comments that are not respectful towards others will be deleted.

References

1. “ACOG Committee Opinion No. 476: Planned home birth.” (2011). Obstetrics and gynecology 117(2 Pt 1): 425-428.
2. Boucher, D., C. Bennett, et al. (2009). “Staying home to give birth: why women in the United States choose home birth.” J Midwifery Womens Health 54(2): 119-126.
3. Janssen, P. A., S. K. Lee, et al. (2002). “An evaluation of process and protocols for planned home birth attended by regulated midwives in British Columbia.” J Midwifery Womens Health 48(2): 138-145.
4. Janssen, P. A., L. Saxell, et al. (2009). “Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician.” CMAJ 181(6-7): 377-383.
5. Johnson, K. C. and B. A. Daviss (2005). “Outcomes of planned home births with certified professional midwives: large prospective study in North America.” Bmj 330(7505): 1416.
6. MacDorman, M. F., T. J. Mathews, et al. (2012). “Home births in the United States, 1990-2009.” NCHS Data Brief, no 84. . U. S. D. o. H. a. H. Services. Hyattsville, MD, National Center for Health Statistics.
7. Wiysonge, C. S. (2009). “Midwife-led versus other models of care for childbearing women: RHL commentary.” The WHO Reproductive Health Library; Geneva: World Health Organization.