Editor’s Note: Eugene Declercq is a professor and assistant dean at the Boston University School of Public Health. He is the founder of Birth by the Numbers, a website that provides information on childbirth practices and outcomes in the United States and abroad. The opinions expressed in this commentary are solely those of the author.
The rising interest in home births tells us a lot about the experiences of mothers in the U.S.
Eugene Declercq: Mothers turn away from hospital births because they feel poorly treated or pressured
Recent studies in the New England Journal of Medicine and the Canadian Medical Association Journal have examined the safety of home births. That they came to different conclusions isn’t as interesting as the fact that so much attention is being devoted to a phenomenon that accounts for less than 1% of U.S. births. So, why should we care?
Because the rising interest in home births tells us a lot about the experiences of mothers in the 3.9 million hospital births every year.
While the rate of home births has increased by 70% since 2004, the decision to seek a home birth in the United States still involves some daunting challenges. Oversight of midwives who attend planned home births (M.D.s attend less than 1% of planned home births) is done at the state level and involves a bewildering patchwork of laws and regulations that can make it difficult to find, let alone determine the qualifications of, a home birth provider.
Also, a majority of mothers in home births report having to foot the bill themselves, whereas almost all hospital births are covered by private insurance or Medicaid. If that weren’t enough, women have to deal with the stigma associated with a home birth. Women may be told by their obstetrician they’re risking their baby’s life if they choose a home birth, with some obstetricians arguing that doctors have an ethical obligation to oppose home births.
So what’s really going on? Is home birth safe or not?
The study published in the New England Journal of Medicine was based on data from Oregon, and unlike most U.S. studies, was able to identify births that were planned to be at home, but involved a transfer to the hospital. Researchers found higher rates of stillbirths and neonatal death in planned home births when compared to low-risk hospital births, with most of the difference occurring in the transfers. They also found the absolute differences in infant death rates between home and hospital was very small – on the order of about 1 in 1,000 or less.
The Canadian study came from Ontario, where midwives attend mothers both at home and in the hospital, and tracked the births attended by midwives in both settings. No differences were found in stillbirths and neonatal mortality rates. The Ontario findings parallel results from England and the Netherlands, where larger studies also found no overall differences in comparing planned home births, including transfers, with low-risk hospital births.
Why is the United States the exception to the rule?
The three countries with better outcomes all have integrated home births into their maternity care systems. Midwives attending home births in these countries typically have hospital privileges and transfers of care to hospitals don’t involve the turf disputes that often accompany home-to-hospital transfers in the United States.
Home birth mothers in the U.S. tend to be older, better educated, more likely to have given birth before and healthier than low-risk mothers in hospital births.
So, given all these barriers and potentially greater risk, why would these women plan a home birth?
There are multiple reasons, but a major impetus for the choice of a home birth is revealed in surveys of mothers who had hospital births in the United States. Mothers were asked in 2012 if, in a future birth, they would be interested in giving birth at home. Eleven percent said they would definitely want to have a future home birth and another 18% would consider the option. Notably, 64% of mothers were open to the option of giving birth in a birth center separate from a hospital.
What kind of care are mothers receiving in hospital births that results in so many considering alternative sites for their next birth?
The same survey found 20% of mothers reporting poor treatment during their hospital stay because of a difference of opinion with their caregiver about the right care for their baby, while 14% identified poor treatment because of their race, cultural background or language. Some mothers also felt pressured to have medical interventions such as an induction (15%) or a cesarean (13%).
Is it surprising that when so many women feel poorly treated, disrespected and pressured to have interventions they don’t want, that some would start to look elsewhere?
The differences in the Oregon and Ontario findings suggest a solution to the “problem” of home birth in the United States. Integrating home and birth center births into our maternity care system should improve outcomes in all out-of-hospital births.
Equally important will be the model they provide to hospital births of respecting mothers’ choices for less intervention unless medically necessary. The result will be a safer and more rewarding maternity experience for mothers and their babies in all settings.