For many women, a home birth seems like the most natural way to have a baby, but new research published in the October issue of the American Journal of Obstetrics and Gynecology suggests it can be a risky proposition.
In the largest study of its kind, investigators at New York-Presbyterian/Weill Cornell Medical Center in New York City reviewed data from a sampling of 13 million of the nearly 17 million singleton full-term births in the United States between 2004-2007. These included births to parents of all races, ethnic groups and income levels.
Among their findings: Babies born at home were nearly 10 times more likely to be stillborn, and the risk of stillbirth increased to 14 times for firstborns. Babies born at home were also almost four times more likely to experience neonatal seizures or serious neurologic dysfunction compared with babies born in hospitals.
The study's results were confirmed by analyzing birth certificate files from the National Center for Health Statistics to evaluate deliveries by physicians and midwives in the hospital and at home from 2007 to 2010. The researchers looked at Apgars, scores that assess the health of an infant one minute and five minutes after birth. A five-minute Apgar score of zero is considered a stillbirth. About 10 percent of these babies survive, though often with major health problems.
"Childbirth is one of the most wonderful moments in humanity, and people deserve the best of all circumstances, including enhancing the experience and reducing unnecessary interventions," said Dr. Amos Grunebaum, chief of labor and delivery at New York-Presbyterian/Weill Cornell Medical Center, and the study's lead author. "Having said that, it's not only about experience. It's also about making sure the baby is born safely."
Grunebaum said that the study associated risk with the location of a planned birth, rather than the credentials of the person delivering the baby. When a child is born at home, typically there is only the midwife or doctor to address any unpredictable circumstances that arise, but in the hospital, a team of specialists can be mobilized in seconds if needed, he said.
He also said that the study probably underestimated the dangers of home births because the data didn't account for babies transferred to the hospital when difficulties arose during at-home labor.
"For transfer cases, the birth certificate is attributed as a hospital birth," he explained.
Wendy Gordon, a member of the Midwife Alliance of North America's research committee, vehemently disagreed with the study's conclusions. She called them misleading and said they didn't accurately represent what epidemiologists and birth certificate scholars have found within an enormous body of research over the past several decades.
"Birth certificates are good at capturing common outcomes of birth but not rare outcomes, like seizures and deaths, which are extremely rare," she said.
Gordon also said that birth certificates couldn't properly reflect the safety of birth location because they revealed only where a baby was born, not its intended birthplace.
"If you make the assumption that any birth that happened at home was planned, you lump in all the unplanned home births and the ones that happen on the side of the road," Gordon said. "We know that births without a skilled attendant present have worse outcomes."
But Grunebaum said the data excluded all so-called "taxi cab" births that were unattended by a labor specialist, such as a doctor or midwife, as well as premature and multiple births. It did not compare insured versus uninsured families to analyze whether uninsured mothers sometimes choose a home birth because of its lower cost. Nor did it look at access to prenatal care. Grunebaum, however, said he did not believe these factors influenced the outcome of the study. He noted, too, that midwives did not typically take on high-risk cases.
In 1900, virtually all births occurred outside the hospital, according to the Centers for Disease Control and Prevention. By 1969, less than 1 percent of births took place outside the hospital, and that rate held steady until recently. Although the number of home births remains less than 1 percent of all births, between 2004 and 2009, home births increased overall by nearly 30 percent. Home births by white women, who now make up the vast majority of home births, increased by a rate of more than 35 percent during that same time period.