Home Births: Responding to a Cultural Shift in Medicine
We can no longer dismiss the dissatisfaction many women feel with the medicalization of the birthing experience.
Are your pregnant patients thinking about having a home birth? You bet they are!
So many women now opt to deliver their babies at home that in August of this year the American College of Obstetrics and Gynecology (ACOG) revised their Committee Opinion on home births. ACOG stated that “Hospitals and accredited birth centers are the safest setting for births,” but added that “each woman has the right to make a medically informed decision about delivery.”
What does this mean? According to ACOG, women need to know the risks and benefits of home vs. hospital deliveries based on evidence. “The home birth is associated with fewer maternal interventions, but also a more than 2-fold increased risk of perinatal death (1-2 in 1000) and a 3-fold increased risk of neonatal seizures or serious neurologic dysfunction.” There also has been a slight shift in how physicians view home births. We can no longer ignore that this is happening. We can no longer dismiss the dissatisfaction many women feel with the medicalization of the birthing experience.
Hospital birth by a physician gained momentum in the late 19th century when this country experienced an increase in urbanization and growth of hospitals. In 1938, approximately 50% of US births took place in a hospital. By 1955, the rate had risen to 99%.
At first, patients were brought to hospitals because of labor complications. Modern obstetrics, including the use of antibiotics and safe cesarean delivery, decreased the mortality rate significantly. Previously, maternal morbidity and mortality was high, primarily due to infection, obstetric hemorrhage and obstructed labor. The advent of special hospitals for women, new obstetrical skills and anesthesia all helped make birth safer. And state and federal financing and oversight of maternal and fetal care meant that more women began to receive prenatal attention.
As the field of obstetrics developed, cesarean delivery rates rose from 5.5% in 1970 to 31.8% in 2007 (ACOG, 2009). But while infant mortality rates declined, maternal mortality rates increased — likely the result of too many cesarean sections being performed. Not surprisingly, the call for natural childbirth, home births and vaginal birth after cesarean (VBACs) is a backlash.
These trends are not insignificant. In 2014, there were 59,674 out-of-hospital births in the US, 18,219 of which were at birth centers and 38,094 were home births, 88% of them planned. The number of out-of-hospital births increased from 0.87% in 2004 to 1.5% in 2014 (MacDorman, 2016).
Who delivers at home? Statistics show that compared with mothers who had in-hospital births, out-of-hospital birth mothers had lower rates of pre-pregnancy obesity (12.5% vs. 25%) and tobacco use (2.8% vs. 8.5%), and higher rates of having a college graduation (39.3% vs. 30%) and breastfeeding (94.3% vs. 80.8%) (MacDorman, 2016). Maternal risk factors also declined among women who opted for home births over the years studied, resulting in fewer high-risk pregnancies being delivered at home. Low-risk patients who choose home birth are more likely to have good outcomes, while patients with gestational diabetes, multiple pregnancies, preeclampsia, prior cesarean section and other complications should not elect to deliver at home.
Home birthing can save individuals and society money, especially if for those who are not insured. Depending on the area of the country, hospital birth costs from $2000 to $12,000 (Health Affairs, 2011). A home birth costs much less ($1500 to $5000), as only the birth attendant and doula get paid. Home births are more likely to be self-financed (67.1%), as compared to delivering at a birth center or hospital. Financial ability still affects a woman's choice of where to deliver. Medicaid does not pay for home births and few Medicaid-insured women deliver at home.