Is it more dangerous for your baby to be born at home?

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. So the debate over whether this 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?

There have been many studies that attempt to answer that question. Many, even most, of them come from outside the USA. The results are mixed. Some say hospital birth is safest (this one, for example), others that there is no difference (this one, for example). One U.S. study that found home delivery to be riskier has had its methodology heavily criticized. What we need are some well designed, large cohort studies from the USA, especially since healthcare systems differ substantially from country to country. I think a recent study from the American Journal of Obstetrics and Gynecology is very useful in that regard.

The main question the authors tried to answer was how the babies did. The measure they looked at was to analyze the frequency of two well-accepted markers of infant distress, things that correlate with trouble later in development. Bear in mind that there can be many reasons for these bad things to happen — some avoidable, some not. The notion is that if one can study a large enough group, then particular circumstances for individual births will wash out in the totals.

The potentially bad things that the authors chose were easy things to count and document. The first was a low Apgar score at 5 minutes after birth. The Apgar score, scaled 0 to 10 and recorded at 1 and 5 minutes after birth, has been a standard, well validated measure of infant distress for many decades. A value of less than 4 is potentially very bad for the baby. The other measure the authors chose was seizures, convulsions, immediately after birth. These can be caused by many things, but most of them are bad.

The study group consisted of over 2 million infants born in 2008. Of these only 12,000 were planned home births (0.6%). This shows how uniform hospital birth has become in the USA, but 12,000 is still a very large group of babies. They excluded babies born unexpectedly outside the hospital.

The results showed that babies born in the hospital, as you would expect, had a very much larger percentage of obstetrical interventions of various sorts associated with their birth. Regarding the distress measures, 0.24% of hospital-born babies had Apgars of less than 4 at 5 minutes; this compared with a rate of 0.37% for babies delivered at home — 1.5 fold higher. This difference was statistically significant. Also significantly different was the rate of seizures: for hospital-born babies it was 0.02% and for home-birth babies it was 0.06%, or 3-fold higher.

So what does this mean? First, the incidences of both of these bad things, although statistically higher in the home-birth group, were still very low. That is encouraging. But to understand things better you need to dig deeper into the data and see who attended at these deliveries. In the hospital it was presumably a physician, but what about at home? After all, “home delivery” can mean many things.

In this study, 26% of the home birth attendants were certified nurse-midwives, 51% were other midwives, and the remainder something else. A key finding to me is that the outcomes for babies delivered at home by certified nurse-midwives were no different than for those born in the hospital. So proper training matters — a lot. One key thing a trained midwife should offer is the knowledge of which pregnancies are higher risk and unsafe to deliver outside a hospital.

Both the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists have issued policy statements about planned home births. The bottom line to me is that, while neither society is thrilled with the practice, both say properly selected (and they give lists of what that means, which is itself a bit controversial, such as if previous Caesarian section should be a disqualifier), low risk pregnancies can be safely delivered at home. As a pediatrician, I should point out that if you chose that there are some routine things that need to be done for your baby in the first days of life, such as a hearing screen. So you should bring your infant to the doctor promptly for a newborn evaluation.

Christopher Johnson is a pediatric intensive care physician and author of Keeping Your Kids Out of the Emergency Room: A Guide to Childhood Injuries and IllnessesYour Critically Ill Child: Life and Death Choices Parents Must FaceHow to Talk to Your Child’s Doctor: A Handbook for Parents, and How Your Child Heals: An Inside Look At Common Childhood Ailments.  He blogs at his self-titled site, Christopher Johnson, MD.

Comments are moderated before they are published. Please read the comment policy.

  • doc99

    Listing any previous uterine surgery which increases the risk of uterine rupture as a disqualification for home birth can hardly be called controversial by anyone other than a home birth true believer.

    Of course that’s just my opinion. I could be wrong.

    • http://www.chrisjohnsonmd.com/ Chris Johnson

      I was surprised myself by that, but I’m not an OB doc.

    • JR DNR

      The reason people who’ve had c-sections previously choose to birth at home is because it’s the only way they can even attempt a VBAC… many hospitals follow the “once a c-section, always a c-section” rule (which was first published almost 100 years ago!).

      • exit 7

        I think that philosophy has evolved over the last several years such that VBAC is no longer the controversy it used to be,

        • http://www.chrisjohnsonmd.com/ Chris Johnson

          That’s my understanding, but maybe an OB doc will stop by and tell us the current thinking.

          • JR DNR

            How about some actual data?

            http://www.cesareanrates.com/texas/

            One of the 10 hospitals in Texas with the HIGHEST number of VBAC has a rate of.. of…

            5%??

          • querywoman

            I’m not sure how to read these stats. Public hospitals do top the list, and medical students and residents do need Cesareans for training purposes.
            As for Parkland Hospital, I’ll make a general comment. Former CEO Ron Anderson used to brag that Parkland delivers more babies than any other hospital in the country.
            He liked having a nursing and obstetrical department for government money and training purposes.
            Babies are born closer to their parental homes in other large urban areas, and they should be in Dallas county.

          • JR DNR

            I picked Texas just because it’s one of the most recent posted articles – not any other reason. If you go through the site you can find a lot of data on C-sections, VBAC, etc.

            I’m not sure what a safe VBAC rate is, but many women are told that hospital policy is no-VBAC. I was using these numbers to show that VBAC is not a common practice.

            This page is probably better:
            http://www.cesareanrates.com/vbac-rates-by-state/

            It seem in the US, once you’ve had a cesarean, your chance of having a vaginal birth afterwards is about 10%.

          • querywoman

            Since Texas is a huge state, it’s good to choose for these purposes.
            I think hospitals love the money from C-sections and hysterectomies, even as doctors are told not to do so many.
            With a perpetual supply of laboring women, it’s a good procedure to exploit for more costly procedures.

          • Hexanchus

            So you’re saying that women should be arbitrarily subjected to potentially unnecessary major surgical procedures with all the inherent risks for the sake of training medical students and residents?

            Unbelievable!

          • querywoman

            Duh? I am just pointing out how they use pregnant and laboring women for their own purposes.
            The status quo is always easiest to maintain. The hospitals will take money anywhere they can get it, like the government. And if it helps them staff and build units to turnover money and to train students, they don’t want to leg go of it.

          • Hexanchus

            Thanks for the clarification – the way your original post was worded could be taken as implying that you condoned such behavior – my apologies.

            I agree with your observations on the financially driven greed of the medical industry. The question becomes “How do we change it?”.

            For some reason, pregnancy and childbirth in the US have somehow evolved into being treated like a disease. When challenged, the system hides behind their so-called “standard of care”, which the patient has every legal right to refuse all or part of if they so choose.

            Instead of being told “what’s good for them”, women need to be provided with the information to make their own informed decisions and choices and have those decisions respected and supported.

          • querywoman

            With the Texas public hospitals so high at the top of the list and the staggering number of babies they yank out of moms, it’s hard to determine how many of these are done to train doctors.
            The public hospitals also host more dangerous deliveries, like druggies and drunks.
            Of course, it’s supposed to be better to have a board-certified surgeon but with OB/gyns, even the good ones, I have to assume they did a lot of unnecessary surgery to get there.

          • JR DNR

            Here’s some data from Missisippi – the rate of VBAC dropped form 1999 to 2009.

            http://www.cesareanrates.com/mississippi/

            It is true that VBAC is perfectly acceptable in many cases, and some organizations are starting to champion it, but it will take a long time before it becomes common place.

    • buzzkillerjsmith

      You’re not wrong.

  • Lisa

    I had my son at home after working in labor and delivery as a nursing student (I decided I didn’t want to be a nurse, so quit after my first clinical year). Anyway, I felt like I had a much better chance to avoid any unnecessary intervention if I had a home birth. All went well and I am still happy with that choice.

    I used a lay midwife, with a doctor back-up, because their weren’t any certified nurse midwives. Interestingly enough, it cost us more to have my son at home than in the hospital as my insurance didn’t cover my midwife.

  • JR DNR

    Some are Hospital Policies, some are OB/GYN specific.

  • Sandra Wright

    Attendant matters. I have to assume that the rigorously educated and trained Nurse Practitioner Midwives I know must be insulted to be lumped in with some quack waving crystals over the bellies of pregnant women and telling them to drink raw milk. Anecdote, so as useful as most anecdotes are: My second son was born at a birth center. It was a homelike environment, but just under the surface it was equipped as a medical facility. It was also staffed like a medical facility. All mothers were attended by a Nurse Practitioner Midwife, and a fully trained and qualified nursing staff. They had science based practice protocols, and the training and knowledge to know what they could and could not handle. When there were signs I was bleeding after the delivery of my son, I was very closely and constantly monitored, and while it turned out to be a false alarm, they were about two minutes from calling an ambulance and having me transferred to a very nearby hospital where they had arrangements with the obstetric staff to handle transfers.