Is a Homebirth for You?

So you’ve read the blogs, you talked to your friends, you saw all the chatter about switching to a homebirth early in the pandemic. Maybe you’ve seen the popular birth documentary like The Business of Being Born? You’re pregnant and you have come to the conclusion you want to give birth at home. Or maybe you’re pregnant and you have no idea where you want to give birth. Maybe you assume you’ll go to the hospital like most everyone else you know. But you keep hearing these stories of friends who had C-sections, who had to lie down for most of the birth, who couldn’t hold their babies right after giving birth and you wonder if there’s an alternative option. What about giving birth right in the comfort of your own home?

Here we want to shed some light on the advantages and things to consider with a homebirth. Is homebirth an option for you? Is it safe for you? 

What are some of the advantages of giving birth at home?

• You get to birth in place without a lot of travel and distraction. You don’t have to get dressed, walk out your door, take a bumpy  car ride with a stranger or have a frazzled partner drive you, talk to lots of medical staff, wait in a waiting room, or listen to other people who are in labor.
• You get to hand select who will attend your birth. Do you want 10 of your closest friends and family there to support you? Great. Do you want just your partner and your midwife and doula? Fine. You dictate who is with you and who is not. No unknown care providers, students, nurses, or visitors.
• You have your bed, your shower, your stuff, your blankets, your…you get the idea. You are in your home where you feel safe and comfortable. A non-clinical environment in which you will have the ability to do whatever you need to do to get the baby out, whether that’s walking around, squatting on the floor, being on all fours in the birth tub.
• You have true freedom of movement. Studies show that restricting movement lessens the effectiveness of contractions, lengthens labor and makes Pitocin use more likely.  People who are allowed to move around as they wish during labor, are able to manage their labors much better than people who are forced to lie on their backs as many hospitals still require. Their babies also move more easily into the proper position through the birthing person selecting their own positions. 
• Handheld Monitoring. The midwife will use a handheld Doppler to monitor your baby’s heart rate. This means no wires and machines to hook up to, which means more Freedom of Movement. 
• You can usually have your prenatal clinical visits at home! Most often, all of your pregnancy visits are at home and they are often close to an hour!! This can’t be emphasized enough. When you are pregnant there is nothing more delightful than having your midwife come to you for a long visit. (Do check this point: some homebirth midwives have you visit them at their office for most of the visits. We would still say this is fine, as your appointments will be long and focused on your needs). With the average OB pregnancy appointment topping out at 6 minutes in the US, this is a huge point. 
• Homebirth midwives believe that birth is a normal process. They are patient. They know birth can take a long time and in many positions. They only intervene when medically necessary. Want to lower your chances of needing an IV, a cesarean, episiotomy, forceps or vacuum suction, or a cesarean? Hire a homebirth midwife. If you end up needing any of this medical support, you will know it was medically necessary. 
• Unrestricted time to bond with your baby after birth and to recuperate undisturbed. No need to figure out how to transport your baby home from the hospital. No medical staff trying to take your baby away from you. No one waking you up all night. No roommate and their whole family to contend with.
• Significantly lower likelihood of medical intervention. People who give birth at home have a lowered chance of cesarean birth, forceps, vacuum, episiotomy, pain medication. Yes, these things can still occur during childbirth, even when planned at home, because birthing parents will be transferred to the hospital when medical intervention is necessary. 

Ok, so you love the advantages of giving birth at home. But is it really safe? 

Ultimately, this is a personal choice and the risks to giving birth in a hospital are different than the risks to giving birth at home. You’ll need to read the studies, read the position papers, talk to midwives, talk to people who have given birth at home, and check in with yourself to make the best decision for you and your family. Choosing homebirth means accepting all that comes with this choice in the same way that choosing a hospital birth means accepting the potential risks from that choice. Birthing at home is not considered safe if you are deemed high-risk and birthing in a hospital will be recommended to you. As ACOG points out below homebirth is associated with a more than twofold increased risk of perinatal death (1–2 in 1,000) and a threefold increased risk of neonatal seizures or serious neurologic dysfunction (0.4–0.6 in 1,000) although it must be 

Both the ACNM (the American College of Nurse Midwives) and ACOG (the American College of Obstetrics and Gynecology) have statements on the safety of homebirth. They also came together to make a joint statement that supports midwives and OBs working together to make birth safest. It is also enlightening to look at the recent statement below by the NYC homebirth midwives early in the pandemic. 

The ACNM’s position statement on planned home birth includes:

• Home birth is best accomplished in an integrated, supportive system of safe, seamless care with respectful collaboration among all health care providers and institutions if a transfer of care from home to hospital becomes necessary.
• Planned home birth refers to care by qualified providers of well [people] experiencing a healthy maternity cycle within a system that provides for hospitalization if necessary. Large observational studies have demonstrated excellent perinatal outcomes for planned home births
• Planned home birth is also credited with reduced use of medical interventions that are associated with perinatal morbidity for both women and their infants. 
• The safety of home birth is optimized by assessing appropriateness of the [person] and family for planned home birth, attendance by a qualified maternity care provider, and integrated systems that support collaborative care.
• For the essentially well [person] experiencing a healthy pregnancy, intrapartum, postpartum, and newborn course, childbirth with qualified providers can be accomplished safely in all birth settings, including home, birth center, and hospital

The NYC Homebirth midwives statement on homebirth during the pandemic in 2020 includes (all direct quotes):

• For low risk individuals, birth at home is the safest option. This is not simply a philosophical attachment to the idea of "natural" birth. The evidence associated with planned homebirth with a licensed provider demonstrates a reduction in medical or procedural intervention while maintaining excellent outcomes for infants and birthing parents. (Cheney, 2014; Scarf 201). 
• Physiologic birth has been repeatedly shown to carry benefits including but not limited reduced morbidity for both parent and infant; (Buckley, 2015).
• planning is in fact a significant factor in the safety of homebirth. The careful screening of clients before and during their care, as well as the developing of a relationship of trust over time, helps ensure the best outcomes for parent and baby. This not only involves medical screening in order to make sure the birthing person remains low risk throughout their pregnancy. It not only involves partnering with the birthing person to promote well being through nutrition and lifestyle. It also, importantly, involves facilitating emotional preparedness. Throughout pregnancy, we process fears and anxieties about giving birth. We develop strategies for coping with the intensity of labor and birth without analgesic medication. Clients are advised to take childbirth education classes to fully understand the physiology of normal birth. Many secure a doula. All of this work and emotional preparation make homebirth safe. 
• Birth is a physiologic process that is greatly impacted by one’s environment and one’s emotional state. For most people, the two are inextricably linked. Homebirth with a client who does not fundamentally trust their location of birth place is unsafe for both client and midwife.
• It does not serve birthing people to birth in a place they do not trust is safe

ACOG’s position statement includes:

• The belief that hospitals and accredited birth centers are the safest settings for birth, but that each person has the right to make a medically informed decision about delivery.
• Homebirth is associated with a more than twofold increased risk of perinatal death (1–2 in 1,000) and a threefold increased risk of neonatal seizures or serious neurologic dysfunction (0.4–0.6 in 1,000).
• People birthing at home must be appropriately screened to see if they are optimal candidates
• People birthing at home must be working with a midwife whose education and licensure meet International Confederation of Midwives’ Global Standards for Midwifery Education or a physician practicing obstetrics within an integrated and regulated health system
• People must have access to safe and timely transport to nearby hospitals.
• The following are contraindicated for homebirth: fetal malpresentation, more than one baby, or prior cesarean delivery 

What will happen if something goes wrong during labor?

A person needing any medical support will be transferred to the hospital during labor, often to a physician or hospital the midwife has a relationship with in case the home birth doesn't go as planned. Here are some common reasons a parenting birthing at home might need to go to the hospital:

• Birthing parent wants an epidural or other pain medication not available at home
• Baby begins showing signs of fetal distress 
• Labor isn’t progressing
• Blood pressure begins to rise above or near what is considered safe
• Significant vaginal bleeding
• Breech presentation or other improper fetal position becomes 

To give birth at home you should:

1. Be low-risk. (A midwife will assess whether you are a candidate for birthing at home)
2. Find the right midwife in your area who offers homebirth services.
3. Desire to give birth with as little medical intervention as possible, including without pharmacological pain medications like epidurals.
4. Believe that home is the safest and best place of birth for you and believe that the risks of birthing in a hospital are higher than the risks of birthing at home.
5. Understand that many people including your family and friends may not support you or understand your choice
6. Be comfortable with that fact that in order to keep your birth as safe as possible, the hospital may become the safest place for you to give birth and your midwife will determine if that becomes necessary during pregnancy or during labor. 
7. Be aware that some or all of their prenatal lab work and ultrasounds you might choose to do may be done through a labor or doctor's office at the midwife’s recommendation

Having a homebirth can be a rewarding and amazing choice if it is right for your family and you baby. Like any place of delivery, the outcomes and safety considerations are extremely important to consider. Hiring a midwife you trust, who has the education and training needed to keep birth safe, plus has a clinical backup plan in case of transfer will increase your wellbeing and confidence throughout your experience. Where and with whom you give birth are highly personal and important decisions. We hope this post will help you as you work to make an informed decision about the best place of birth for you.