July 10, 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. 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.
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.
What kind of interview questions can you ask a home birth midwife? 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.
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.
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.
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?
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%).
Do the parents have to clean up the mess?
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.
- “ACOG Committee Opinion No. 476: Planned home birth.” (2011). Obstetrics and gynecology 117(2 Pt 1): 425-428.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.