How safe are home births? And what does “safe” mean?

The debate over the safety of giving birth at home, both for the mother and for the infant, has been debated for years. I’ve written about the issue myself. From time immemorial until about 75 years ago or so most babies were born at home. Now it’s around 1% in the USA, although it’s much higher than that in many Western European countries. The shift to hospital births paralleled the growth of hospitals, pediatrics, and obstetrics. With that shift there has been a perceived decrease in women’s autonomy over their healthcare decisions. There has also been an unsurprising jump in the proportion of caesarian section deliveries, an operative procedure, and various other medical interventions in labor and delivery, even though current data suggests the recent jump in caesarian delivery (now around 30%) has not added any benefits. The debate over whether the dominance of hospital births is a good thing or a bad thing (or neither) is much more than a medical debate; it is also a social and political one. It is also to some extent an issue of medical power, a struggle between physician obstetricians who deliver babies in the hospital and nurse midwives who often deliver babies at home. I’m very interested in the social and political aspects, but as a pediatrician I’m particularly concerned with the safety question: Is it more dangerous for your baby to be born at home?

One problem in answering this question is that most of the studies about the safety of home birth came from abroad. But now we have some data from the USA, published in a recent issue of the prestigious New England Journal of Medicine, entitled “Planned out of hospital births and birth outcomes.”

One big problem with evaluating previous data has been that vital statistics from birth certificates counted home births and hospital births, but did not identify as a separate category those women who planned to deliver at home, but then were admitted to a hospital to deliver there because of some issue with the labor. Such women were just counted as hospital births. Also, the recent growth of birthing centers has introduced a location kind of intermediate between home and hospital. A recent large study from Oregon using the years 2012 and 2013 gives some useful information.

The bottom line is that children born to women who intended to give birth at home had an infant mortality rate of 3.9 deaths per 1,000 deliveries. This was significantly higher than the death rate of infants born in a hospital, which was 1.8 deaths per 1,000 deliveries. Not surprisingly, women who delivered in the hospital had a far high rate of some kind of intervention, such as caesarian section.

What should we make of this? Thinking about risk can be difficult, and it is important to understand the difference between relative and absolute risk. (I’ve written about that, too.) Media reports often obscure this key point. For example, in this study the risk of infant mortality increased 100% with home birth. 100%!! But twice a very small number is still a very small number. The absolute risk of a baby dying in a home delivery is very small. Still, it is higher.

What this means is that a woman deciding to deliver at home should understand all the facts. Some will not want to accept this increased risk, however small it is in absolute terms. Some will accept it. The same issue of the Journal had a good editorial discussing how to think about the issue. It’s a very good summary of the fundamental question. It’s all about the issue of acceptable risk, and how that varies with the person. The conclusion:

Ultimately, women’s choices for place of delivery will be determined by the extent of their tolerance for risk and which risks they most want to avoid.


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