Running head: SAFETY OF HOME BIRTH 1

Safety of Home Birth

Claire Sandrock

MWDF 100

Instructor: Ruth Colby Martin

April 3, 2017
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Safety of Home Birth

The safety of birth is defined by outcomes for mothers and babies, including rates of

maternal and fetal morbidity and mortality. As mothers make choices about their labor and

delivery setting, they can evaluate the relative safety of hospital, birth center and home births.

For low-risk women, home is a safe birth setting and recent studies have demonstrated low rates

of maternal and fetal morbidity and mortality. Therefore, home birth is a safe choice for the

majority of women in the United States.

Safe for mothers

Birthing practices which lower maternal morbidity and mortality increase safety for

mothers. While women in the United States generally have access to modern medical care, the

rates of maternal mortality are higher than in many other countries. In the 2015, the maternal

mortality rate in the United States was 14 deaths/100,000 live births, which is higher than the

rates in Norway, Canada and the United Kingdom which are 5, 7, and 9/100,000 births,

respectively (World Health Organization, 2015a). In 2010, only 5 states met the Office of

Disease Prevention and Health Promotion goal of 4.3 deaths/100,000 births (Amnesty

International, 2010).

One reason for high mortality rates are increasing levels of medical interventions in the

birthing process, such as Cesarean sections (C-sections) and induction of labor (Amnesty

International, 2010), which increase a mothers risk of injury and death. The risk of death

following C-sections is more than three times as high as for vaginal births. C-sections have been

shown to increase a womans risk of infection, hysterectomy, and kidney failure, and have been

associated with a 52 percent increase in the risk of developing a life threatening blood clot

(pulmonary embolism) (p. 78). In the United States, the rate of C-sections was 32.2% in 2014
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(Centers for Disease Control and Prevention, 2017). This rate is among the highest of developing

countries. The World Health Organization (WHO) notes that at population level, caesarean

section rates higher than 10% are not associated with reductions in maternal and newborn

mortality rates (World Health Organization, 2015b). The Office of Disease Prevention and

Health Promotion has set a goal of reducing primary C-sections among low-risk women in the

United States from 26.5% (in 2007) to 23.9% (2017a) and reducing repeat C-sections from

90.8% (in 2007) to 81.7% by 2020 (2017b). In addition, the use of drugs to stimulate labor is

associated with an increased rate of C-sections and hemorrhage (Amnesty International, 2010).

In the United States, drugs were used to stimulate labor in 23% of cases (Amnesty International,

2010).

Women birthing at home have lower rates of medical interventions and studies

demonstrate that home birth is safe for mothers. In the United States, Cheyney, Bovbjerg,

Everson, Gordon, Hannibal, & Vedam (2014) collected data from 16,924 planned home births

from 2004 to 2009. The C-section rate was 5.2%, well below the national average and the WHO

target. Maternal mortality was approximately 6.25/100,000 births, with one maternal death at 3

days postpartum caused by a blood clot. Labor augmentation was utilized in 4.5% of births, also

lower than the national average.

In addition, 49.2% of women gave birth over an intact perineum. The rate of perineal

trauma was 50.8%, the majority of which (40.9% of the total) were first- or second-degree

perineal lacerations. For women in the United States that have a spontaneous vaginal delivery,

the rate of perineal trauma, including episiotomy and first through fourth degree lacerations, is

85% (Kettle & Tohill, 2008). Perineal trauma is associated with postpartum perineal pain,

discomfort during sexual intercourse, urinary and fecal incontinence, and psychological effects
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(Kettle & Tohill, 2008). Thus, home birth improves maternal physical and psychological

outcomes.

In a comparison of over 12,000 home and hospitals births attended by midwives in

Ontario, Hutton, Reitsma, & Kaufman (2009) noted no maternal deaths in either birth setting.

Women who gave birth at home had less intrapartum interventions, less perineal trauma and a

lower incidence of blood loss over 1000 mL. In a comparison of over 64,000 births in England,

there was no significant difference in maternal or neonatal outcomes for women who gave birth

at home, in a free standing birth center, alongside midwifery units, and obstetric units (Birthplace

in England Collaborative Group, 2011). There were fewer interventions for women who gave

birth at home and in midwifery units. These studies contribute to the understanding that home

birth is safe for mothers.

Safe for Babies

Hutton et al. (2009) evaluated the effect of home or hospital birth setting on fetal

outcomes. Since all women were attended by midwives, the study could determine the effect of

birth setting on these measures. The study only included low-risk mothers, excluding those with

multiple previous Caesarians, breech presentations, multiple pregnancies and preterm delivery

before 37 weeks gestation. Hutton et al. reported no difference in neonatal outcomes between

babies born in the two birth settings. There was no difference in birth weight, Apgars at 1 and 5

min, rates of infant resuscitation, number of still births, neonatal mortality and infant death at 28-

42 days of life.

The Birthplace in England Collaborative Group (2011) reported low rates of neonatal

mortality in home births and the rate of morbidity events (such as intrapartum stillbirths,

neonatal encephalopathy, meconium aspiration syndrome, fractures) was 4.3/1000 births. There
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was no difference in these figures for home births, free standing birth centers alongside

midwifery units or obstetric units. The incidence of 5-minute Apgar scores below 7 ranged from

0.75 to 0.98% of births across the various birth settings, with no significant difference between

birth settings.

In an evaluation of over 16,000 home births in the United States, Cheyney et al. (2012)

reported that 1.5% of babies had a 5-minute Apgar score below 7. When data from the

intrapartum transfers are removed (69 babies), this number drops to 1.0% of babies , similar to

the rates reported by Hutton et al, which were 0.7 and 0.9% from home and hospital births

respectively. Cheyney et al. (2012) also reported that, after excluding babies with congenital

abnormalities, the rates of intrapartum fetal death (after onset of labor, before birth), early

neonatal death (after birth, before 7 days of life) and late neonatal death (7-27 days of life) were

1.3/1000 births, 0.41/1000 births and 0.35/1000 births, respectively. These rates are lower than

the national average in 2013, in which neonatal mortality (under 28 days) 4.04/1000 births

(Mathews, MacDorman, & Thoma, 2015).

While C-sections may be performed to improve fetal outcomes, an analysis of C-sections

on women with no-indicated risk found the opposite effect. MacDorman, Declercg, Menacker,

& Malloy (2006) found higher neonatal mortality rate among infants of low intrapartum risk

women delivered by cesarean section when compared with similar low- risk women delivered

vaginally. The neonatal mortality rate for cesarean births was 1.77 deaths per 1,000 live births,

2.9 times the rate of 0.62 for vaginal births. Thus, practices which reduce C-sections in low-risk

women are also beneficial for babies.

Collectively, these studies demonstrate that home birth is safe for babies and mothers.

Maternal and fetal outcomes are similar across birth setting. In some cases, such as C-section
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rates and perineal lacerations, mothers who birth at home are less likely to experience morbidity.

As more women are informed of the results of these studies, they may make informed decisions

about their individual and family preference for birth setting.

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References

Birthplace in England Collaborative Group. (2011). Perinatal and maternal outcomes by planned

place of birth for healthy women with low risk pregnancies: the Birthplace in England

national prospective cohort study, British Medical Journal, 343, 1-13. doi:

10.1136/bmj.d7400

Amnesty International. (2010). Deadly delivery: The maternal health care crisis in the USA.

London. Retrieved from

http://www.amnestyusa.org/sites/default/files/pdfs/deadlydelivery.pdf

Centers for Disease Control and Prevention. (2017). Births Method of Delivery. Retrieved from

https://www.cdc.gov/nchs/fastats/delivery.htm

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. 2014.

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

alliance of North America statistic project, 2004 to 2009. Journal of Midwifery &

Womens Health, 59, 17-27. doi:10.1111/jmwh.12172

Hutton, E. K., Reitsma, A. H., & Kaufman, K. (2009). Outcomes associated with planned home

and planned hospital births in low-risk women attended by midwives in Ontario, Canada,

2003-2006: A retrospective cohort study. Birth, 36(4), 180-189.

Kettle, C. & Tohill, S. (2008) Perineal Care. BMJ Clinical Evidence, 9, 1401.

MacDorman, M. F., Declercq, E., Menacker, F., & Malloy, M. H. (2006). Infant and neonatal

mortality for primary cesarean and vaginal births to women with "no indicated risk,"

United States, 1998-2001 birth cohorts. Birth, 33(2), 175-82.

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Mathews, T. J., MacDorman, M. F., & Thoma, M. E. (2015). Infant mortality statistics from the

2013 period links birth/infant death data set. National Vital Statistics Reports, 64: 9.

Retrieved from https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_09.pdf

Office of Disease Prevention and Health Promotion. (2017a). Healthy people goals Morbidity

and mortality. Retrieved from https://www.healthypeople.gov/2020/topics-

objectives/objective/mich-72

Office of Disease Prevention and Health Promotion. (2017b). Healthy people goals Morbidity

and mortality. Retrieved from https://www.healthypeople.gov/2020/topics-

objectives/objective/mich-71

World Health Organization. (2015a). Trends in maternal mortality: 1990 to 2015: estimates by

WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population

Division. Retrieved from

http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-

2015/en/

World Health Organization. (2015b). WHO statement on Cesarean section rates. Retrieved from

http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/cs-

statement/en/