Running head: HOME BIRTH SAFETY 1

Home Birth Safety- Still a Power Struggle

Atoosa Benji

Midwifery College of Utah

HOME BIRTH SAFETY 2

Home birth is child abuse in its earliest form.

-Keith Russell, MD (Warrick, 1992, p. 2)

With statements such as this coming from a former president of the American College of

Obstetricians and Gynecologists, how could families even fathom of home birth as a safe option?

In reality, it is sentiments such as these, fueled by faulty and inadequate research that has elicited

panic in U.S obstetrics around home birth. While midwives have been under scrutiny in every

state for attending homebirths, the evidence shows that homebirth is still a safe option for both

mother and child, when certain parameters are met. The measure of safety is determined by rates

of both maternal and perinatal mortality and morbidity- which are lower at home than in hospital

births around the world. The Western, technocratic model of childbirth operates through the risk

management model, practicing from a prophylactic angle, rather than a holistic, evidence-based

angle. The gap between the scientific research in obstetrics and what happens at the clinical

level, continues to be detrimental to mothers and babies across the United States and many other

countries (Wagner, 2006). This paper will demonstrate that home birth continues to be a safe

option when the birth is a planned homebirth, attended by a qualified midwife, and the

pregnancy is low-risk for both mother and child.

The early studies on home birth did the world of childbirth a huge disservice. While it

was established firmly in the scientific community that a distinction must be made in any study

of homebirth between planned homebirth and unplanned homebirth, articles that did not abide by

those guidelines, were still published. (Wagner, 2006). In a study presented to ACOG by J.

Pang et al., favoring hospital birth, the researchers rely solely on date from birth certificates

which do not show the intended location of birth (Wagner, 2006). This is problematic. The

problem lies wherein births that may have been precipitous or premature and mothers for whom
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prenatal care was never provided are included in many homebirth safety studies, even though

they were not planned homebirths. This skews the numbers and causes inflated neonatal

mortality rates in the home birth group (Wagner, 2006 p.139). In one Australian study, the

higher risk of perinatal mortality was due to the fact that breech babies, twins and post-term birth

were included in the study (De Jonge, 2009). In determining the safety of homebirth, we must

produce research that compares apples to apples. For the most part, articles pointing to

homebirth as unsafe are failing deeply in their analyses. When birth is planned to be at home, a

midwife provides both prenatal care and continuity of care during the birth. This decreases the

risk of a bad outcome that may have occurred due to a lack of proper prenatal care and a birth

with no qualified professional in attendance. As Wagner points out, a trained midwife who is

providing one on one care is more likely to be able to anticipate, recognize and take action on a

labor complication than a nurse or doctor in a hospital where more than one patient is assigned to

the care of each provider (Wagner, 2006).

Midwives are trained to attend low-risk birth. The parameters of a low-risk mother,

according to the National Institute of Health are existing health conditions, mothers age,

lifestyle factors and conditions of pregnancy (National Institute of Health, 2016). When factors

such as advanced maternal age, fetal malpresentation and pre-eclampsia are present, care is

transferred to the care of an obstetrician. The safety of homebirth lies in this fact. The

midwifery model of care not only treats low-risk mothers, but provides care that inherently

reduces the risk of intervention. It is known that in labor, intervention begets intervention and

when intervention increases the likelihood of induction, operative vaginal birth or cesarean

section, the rate of both maternal and fetal perinatal morbidity and mortality increase (Jansen,

Gibson, Bowles, & Leach, 2013). In one Australian study comprised of women giving birth to a
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singleton baby in the period between 2000 and 2008, it was concluded that, for low-risk

women, care in a private hospital, which includes higher rates of intervention, appears to be

associated with higher rates of morbidity seen in the neonate and no evidence of a reduction in

perinatal mortality (Hannah et al., 2014, p.2). In a study of 1707 planned, midwife-attended

births in rural Tennessee at The Farm, 1.46% of deliveries were Cesarean section, compared to

16.46% in the physician attended hospital sample. Additionally, 2.11% of women required an

assisted vaginal delivery versus 26.6% in the hospital group (Durand, 1992). Durand concluded

that There is some evidence, however, that elective interventions, which are used more

frequently in hospitals, may increase the risk of various adverse outcomes in low risk women

(Durand, 1992 p. 452). Many have rebuked the Farm study claiming the sample size to be far

too small to have statistical influence. The issue of sample size was addressed in the following

Canadian study.

In this study, conducted from 2000-2004 by Janssen et al., three cohorts were studied;

planned homebirths attended by registered midwives, hospital-planned birth attended by the

same midwives with same eligibility requirement as the home birth group mothers, and physician

attended hospital births. The following results highlight the premise that planned homebirth

attended by a registered midwife had decreased risk of obstetric interventions, perinatal death,

and adverse perinatal outcomes, as compared to planned hospital birth attended by a physician or

a midwife (Janssen et al. (2009). Perinatal death in the planned homebirth group was 0.35%,

0.57% in the hospital birth midwives group and 0.64% in the physician-attended group.

Additionally, the rates of intervention, including electronic fetal monitoring, assisted vaginal

delivery, and poor maternal outcomes including postpartum hemorrhage, third and fourth-degree

vaginal lacerations were lower in the homebirth group than in the other two groups. Babies born
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at home were also less likely to experience meconium aspiration and less likely to be admitted to

the hospital (Janssen et al., 2009).

The midwifery model of care does not limit oral intake during a normal labor, nor does it

recommend routine amniotomy or continuous fetal monitoring. Continuous fetal monitoring

not only restricts a laboring patients movements but can also result in high rates of cesarean

surgeries and vacuum extractions among low-risk laboring women (Jansen et al., 2013 p. 84).

Midwives do not frequently check cervical dilation. Frequent position changes and walking

during labor are strongly promoted. Additionally, the familiar setting of home, with the freedom

to eat, drink and move freely contributes to a womans feelings of safety and confidence on her

ability to birth, versus feeling undermined in an unfamiliar hospital setting (Durand, 1992).

In a study conducted between 2004 and 2010, a sample of close to 17,000 planned

homebirths was studied. The rate of cesarean section was 5.2% while the rate of operative

vaginal birth was 1.2%. Of the hospital transfers during labor, the majority were for failure to

progress not due obstetrical emergencies. In the U.S, the rate of oxytocin for labor augmentation

and the use of epidural anesthesia are 26% and 67% respectively (Cheyney et al., 2014). In the

same study, only 4.5% of the MANA sample (planned homebirth group) required oxytocin

and/or epidural anesthesia. (Cheyney et al., 2014). Again, the study concluded that a planned

home birth attended by a midwife for a low-risk woman can result in positive outcomes for both

mother and baby (Cheyney et al., 2014).

Earlier, safety with regards to childbirth was defined as the low rate of maternal and fetal

morbidity and mortality during the perinatal period. As evidenced by the research discussed in

this paper, planned homebirth, attended by a qualified midwife is a safe option for a healthy, low

risk mother. When birth is planned to be at home, the pregnant woman is under the prenatal care
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of her midwife. At the onset of labor, the midwife arrives bringing with her expertise, skill and

needed medication and oxygen to intervene if necessary. It is imperative that any study of the

safety of homebirth includes, not only place of birth, but also intended place of birth and the

qualification of the care-giver in attendance. Too many studies have failed to do so and thus, the

numbers are grossly skewed against homebirth.

While maternal and fetal mortality and morbidity can occur for a variety of reasons,

bleeding, infection, and respiration issues are common reasons for poor outcomes. Research

confirms that higher rates of interventions lead to increased need for vaginal operative deliveries

which often end in emergency cesareans sections (Jansen et al. 2013). In the afore-mentioned

studies, the C-Section rate in all the home birth studies was below 10%. Currently, in the US,

our cesarean section rate is close to 32 %, a whopping 15-20% higher than the recommendation

of the World Health Organization for an industrialized country (Hamilton et al. 2015). Cesarean

sections are associated with higher rates of hemorrhage and uterine rupture as well as maternal

sepsis (Jansen et al., 2013). There are also risks for to the neonate born via cesarean section. In

one study, there was a 69% higher incidence of fetal death for C-section babies. Additionally,

babies are at risk for accidental lacerations during surgery, poor transitions, and respiratory issues

(Jansen et al., 2013).

By sheer virtue of the fact that midwives care for low-risk women at home, where

interventions are minimal, homebirth is a safe option for many women in the US, increasing

overall maternal-child health and reducing cost for an already strained medical system. It would

behoove the medical community to educate women on the risks and benefits of homebirths,

instead of operating from the angle of scare tactics and faulty research.
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References

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Saraswathi, V. (2014).

Outcomes of care for 16, 924 planned home births in the United States: The midwives alliance

of North America statistics project, 2004 to 2009. Journal of Midwifery & Womens Health,

59, 17-27. Doi: 10.1111/jmwh.12172

de Jonge, A., van der Goes, B.Y., Ravelli, A., Amelink-Verburg, M.P., Mol, B.W., Nijhuis, J.G.,

& Buitendijk, S.E. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529

688 low-risk planned home and hospital births. BJOG: An International Journal of Obstetrics

& Gynaecology, 116, 1177-1184. Doi:10.1111/j.1471-0528.2009.02175.x

Durand, A. M. (1992). The safety of home birth: the farm study. American Journal of Public

Health, 82, 450453.

Hamilton, B.E., Martin, J.A., Osterman, J.K, Curtin, S.C., & Mathews, T.J. (2015). Births: Final

data for 2014. National Vital Statistics Reports, 64, 1-64. Retrieved from

http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_12.pdf

Hannah, G.D., Tracy, S., Tracy, M., Bisits, A., Brown., & Thornton, C. (2014). Rates of obstetric

intervention and associated perinatal mortality and morbidity among low-risk women giving

birth in private and public hospitals in NSW (2000-2008): A linked data population-based

cohort study. BMJ Open, 4, 1-13. Doi: 10.1136/bmjopen-2013-004551

Jansen, L., Gibson, M., Bowles, B.C., & Leach, J., (2013). First do no harm: Interventions during
childbirth. The Journal of Perinatal Education, 22, 83-92. Doi: 10.1891/1058-1243.22.2.83

Janssen, P. A., Saxell, L., Page, L. A., Klein, M. C., Liston, R. M., & Lee, S. K. (2009). Outcomes
of planned home birth with registered midwife versus planned hospital birth with midwife or
physician. CMAJ: Canadian Medical Association Journal, 181, 377383.
http://doi.org/10.1503/cmaj.081869
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National Institute of Health (2016). https://www.nichd.nih.gov/health/topics/high-

risk/conditioninfo/pages/factors.aspx

Wagner, M. (2006). Born in the USA. Los Angeles, CA: University of California Press.