Until the mid-1920s, most births in the US occurred at home. By the mid-1950s, it was standard to deliver at the hospital. The rate of homebirths in the US remained exceedingly small until recently, when home births began to increase again. Those in favor of homebirth argue that it is a more natural experience, involves fewer medical interventions, and provides a woman more control over her delivery. Those opposed to homebirth argue that it is associated with increased risk of morbidity and mortality for both mom and baby.
As an obstetrician working in the US, I have seen patients who were planning on delivering at home and ended up delivering in the hospital, for a variety of reasons. The outcomes have ranged from good (healthy mom, healthy baby, vaginal delivery, relatively little morbidity) to poor (suboptimal neonatal outcomes, labor dystocia, infection, hemorrhage, and even neonatal death). Frankly, this range of experiences leaves me uneasy with homebirths, but I acknowledge that my view is skewed. I don’t oversee planned homebirths, so I do not have personal experience with women who delivered at home and did well. I only see the women who planned to deliver at home, but required transfer to the hospital. The fact that these women required transfer makes them different. Something wasn’t going as planned, and many of these women ended up undergoing interventions at my hands (e.g., vacuum or forceps deliveries, C-sections, antibiotics, ICU admissions, prolonged hospitalizations). Most of the data currently available on US homebirths are biased in a similar manner, only including those intended homebirths that went on to become hospital births.
This week, NEJM published a large retrospective cohort study that provides data on planned homebirths, regardless of actual location of delivery. Oregon is one of the areas in the US with a relatively high rate of homebirths, and that state recently began collecting data on where patients planned to deliver. These data are not routinely collected in other states. The Oregon data show that, as compared with planned hospital birth, planned out of hospital birth was associated with an increased rate of perinatal death (3.9 vs 1.8 per 1000, p=0.003). But, planned out of hospital births was also associated with a higher rate of unassisted vaginal delivery (93.8% vs 71.9%, p<0.001).
These data are likely to be interpreted differently by different people. To some, the data will make homebirth seem an appealing option, given the less meddlesome activity by obstetricians and the very low rates of neonatal mortality in both groups. To others, the doubling in risk of neonatal mortality with planned out of hospital birth will be a substantial concern, and they will consider more intervention by obstetricians an acceptable tradeoff to lower that risk. Ultimately, each woman must make her own choice. As an obstetrician working within our current system, and a woman expecting her first child, I have a strong personal preference for hospital birth. But, plenty of reasonable people will disagree with me. What do you think? Please consider sharing your comments here or follow the link to our Clinical Decisions on this topic, where you can read expert views, comment, and vote in a poll.