Is home birth safe?
According to the most recent and up-to-date research evidence, yes. On this page, I’ll share some of that with you. I also link to a number of articles and blog posts that I’ve written about this.
In 2019, a large systematic review and meta-analysis was published in The Lancet. It looked at 14 studies including data from around 500,000 intended home births. The authors found that, “The risk of perinatal or neonatal mortality was not different when birth was intended at home or in hospital.” (Hutton et al 2019).
This is just one of many studies that show the same thing. The Hutton et al (2019) study was remarkable because of its size. But, as the studies on this page show, it’s not a unique finding.
More on safety
If you’re the kind of person that likes the detail, here are the results of the Hutton et al (2019) study:
“Among nulliparous women intending a home birth in settings where midwives attending home birth are well-integrated in health services, the odds ratio (OR) of perinatal or neonatal mortality compared to those intending hospital birth was 1.07 (95% Confidence Interval [CI], 0.70 to 1.65); and in less integrated settings 3.17 (95% CI, 0.73 to 13.76). Among multiparous women intending a home birth in well-integrated settings, the estimated OR compared to those intending a hospital birth was 1.08 (95% CI, 0.84 to 1.38); and in less integrated settings was 1.58 (95% CI, 0.50 to 5.03).” (Hutton et al 2019).
Hutton et al (2019). Perinatal or neonatal mortality among women who intend at the onset of labour to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses. doi.org/10.1016/j.eclinm.2019.07.005
The findings of Hutton et al (2019) also confirmed those of the meta-analysis conducted by Scarf et al (2018). And both of these reviews are simply the latest in a long series of studies confirming home birth safety.
Here’s how I summarised the Scarf et al (2018) review:
“A systematic review and meta-analysis has further confirmed the safety of home birth for healthy women, even if they are having their first baby. After comparing data from births planned at home birth, in birth centres and in hospital, researchers found that high-quality studies found no statistically significant difference in infant mortality between the different settings, although women giving birth at home or in birth centres were more likely to have a normal vaginal birth. In fact, women planning home births were nearly three times more likely to have a normal (that is, non-instrumental) vaginal birth than women planning a hospital birth.”
The Scarf et al (2018) review was an important one because, as the authors explain in the background to their paper, there have been many debates on this area and there exist methodological challenges which have to be taken into account. Some of the so-called evidence that is cited on this topic is not of good quality. The review authors include some world experts on this topic, and in order to produce high-quality research they “reviewed original research from high-income countries (World Bank, 2016) using a birthplace-specific quality appraisal instrument (Vedam et al 2017a), and undertook meta-analysis of outcome data where possible.” (Scarf et al 2018).
In their summary of the findings and conclusions, the researchers noted that, “Meta-analysis indicated that women planning hospital births had statistically significantly lower odds of normal vaginal birth than in other planned settings. Women experienced severe perineal trauma or haemorrhage at a lower rate in planned home births than in obstetric units. There were no statistically significant differences in infant mortality by planned place of birth, although most studies had limited statistical power to detect differences for rare outcomes. Differences in location, context, quality and design of identified studies render results subject to variation. High-quality evidence about low-risk pregnancies indicates that place of birth had no statistically significant impact on infant mortality. The lower odds of maternal morbidity and obstetric intervention support the expansion of birth centre and home birth options for women with low-risk pregnancies.” (Scarf et al 2018).
Other benefits of homebirth
Studies also confirm other benefits of homebirth. For example, a study which looked at the experiences of more than 28,000 women in the UK and Ireland showed a significant association between home birth and breastfeeding (Quigley et al 2016).
And, when researchers asked fathers about their experiences of homebirth, they described it as magical.
Home birth isn’t just for those who manage to stay in the ‘low risk’ box either!
Research shows that home birth is also safer for women who are labelled as ‘high risk’. (Let’s acknowledge that this labelling is often inaccurate, unhelpful and offensive though.)
The research keeps coming
Many individual studies from around the world have evidenced the safety of homebirth, as well as the reviews. Here are a few of the most recent:
In Finland, researchers were concerned that, “compared to in-hospital births, the long-term outcome of children born out-of-hospital, planned or unplanned, is poorly studied.”
Researchers often use hospital birth as the standard by which the safety of home birth is measured. This is curious, because hospital birth is a relatively new intervention and it was introduced without evidence of safety compared to home birth. But that’s another post.
So they looked at the outcomes of 790,136 children born in Finland between 1996 and 2013. These included planned and unplanned out-of-hospital births. Usually, it’s better to separate the two as there can be quite a difference in outcomes.
The fact that planned AND unplanned out-of-hospital births were included make the results even more interesting.
They actually found that, although on the whole there is no difference in children’s health at the age of seven, “morbidity (illness) related to asthma or allergic diseases and infections by seven years of age appeared to be lower in children born out-of-hospital.”
In 2021, researchers published a descriptive study of planned homebirth in Catalonia (Spain).
“In Spain, official records show that 0.63% of births take place at home, but these records do not state the proportion of planned and unplanned home births. For this reason, official records do not enable the analysis of maternal and neonatal outcomes according to the place of birth; thus, the rate of adverse advents with respect to planned place of birth remains to be determined.”
“Catalonia is the region with the largest number of home births, and thanks to the data collected by CAHBM midwives, we know that most home births in Catalonia were planned.”
“The rates of maternal and neonatal morbidity show a high degree of safety during birthing and reflect the work of independent midwives in Catalonia. The variety of positions during the birth and the low percentages of high-grade perineal tears and episiotomies, as well as the high percentage of women who used water during birth and of babies who started feeding within an hour of birth, demonstrate that the care provided by the midwives in these planned home births in Catalonia is based on the scientific evidence and on a respect for physiology.”
The full study can be read at https://www.sciencedirect.com/science/article/pii/S0266613821000565
In 2020, a Norwegian study by Skrondal et al (2020) which is freely available here provided more evidence of homebirth safety.
“Planned home birth may be experienced as a very positive occurrence for nulliparous women, and the care those women in this study received contained several elements that can help to promote normal labour and birth at a time in which reducing interventions in maternity care is of importance. Their positive birth experiences gave the women confidence both in their transition to motherhood as well as in other aspects of life.” (Skrondal et al 2020).
One older but important study is de Jonge et al’s (2013) study, Severe adverse maternal outcomes among low risk women with planned home versus hospital births in the Netherlands: nationwide cohort study.
The authors of this research looked at the experiences of 146,752 low-risk women, of whom 92,333 (62.9%) had a planned home birth and 54,419 (37.1%) had a planned hospital birth. Upon analysing the outcomes, they discovered that, although the absolute risks were small in both groups, low risk women who planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital birth. These differences were statistically significant for women who had had given birth before.
The take-home message, although worded in the negative as is often the case with such studies, is that: There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system (de Jonge et al 2013).
Another useful study is Publicly funded homebirth in Australia: a review of maternal and neonatal outcomes over 6 years.
This comprises the first national evaluation of 97% of the women who chose publicly funded homebirth between 2005 and 2010. While 97% is a significant proportion of the available sample, however, the rarity of poor outcomes means that the sample size isn’t big enough to be conclusive about safety. What the evaluation shows is that 84% of the women who planned to give birth at home actually did so, and 90% of the women (which will include a few of those who transferred to hospital) had a normal vaginal birth.
Other positive outcomes included that intervention rates among these women were low. Women choosing homebirth had low rates of postpartum haemorrhage (which is particularly significant given that around three quarters of the women had physiological placental births) and third degree perineal tears and stillbirth and early neonatal death rates were also low. In other good news, 69% of the women were breastfeeding at 6 weeks postpartum. Transfer rates were high though and, although this is consistent with some other studies, it warrants further exploration.
In a related editorial, Professor Marc Kierse addresses those who may question the need for publicly funded homebirth programs, especially as only around half a per cent of Australian women currently choose homebirth, noting that, “It is a woman’s prerogative and her fundamental human right to determine her reproductive behaviour, and this includes how and where to give birth.” (Kierse 2013: 575).
What about freebirth?
Several studies also look at how, when home birth isn’t made available by the maternity services, some women will decide to freebirth instead. This highlights how important it is that homebirth is offered. It’s important to know that the studies cited on this page showing that homebirth is safe are looking at planned home births attended by midwives.
But I know that people are also interested in freebirth, so here are some recent papers.
An Australian study is beautifully described by its title. Birthing outside the system: the motivation behind the choice to freebirth or have a homebirth with risk factors in Australia (Jackson et al 2020, also freely available).
“The core category was ‘wanting the best and safest,’ which describes what motivated the women to birth outside the system. The basic social process, which explains the journey women took as they pursued the best and safest, was ‘finding a better way’. Women who gave birth outside the system in Australia had the countercultural belief that their knowledge about what was best and safest had greater authority than the socially accepted experts in maternity care. The women did not believe the rhetoric about the safety of hospitals and considered a biomedical approach towards birth to be the riskier birth option compared to giving birth outside the system. Previous birth experiences taught the women that hospital care was emotionally unsafe and that there was a possibility of further trauma if they returned to hospital. Giving birth outside the system presented the women with what they believed to be the opportunity to experience the best and safest circumstances for themselves and their babies.” (Jackson et al 2020)
Another Australian survey of why women choose homebirth showed that, “if a midwife was not available, half of the respondents indicated they would give birth without a registered midwife (freebirth) or find an unregistered birthworker.” (Sassine et al 2020). Unfortunately, this paper isn’t freely available, but you can see the abstract here.
Homebirth and cost
There are lots of reasons to opt for a home birth. We know from research studies that home birth is both safe and satisfying, that it leads to fewer interventions, a higher chance of breastfeeding success, and helps to make confident parents.
A 2021 study from the USA also showed that it is also far more cost effective than hospital birth.
Anderson and Gilkison (2021) set out to estimate the cost of home birth in the USA and found that: “On the basis of a nationwide study, we estimate that the average cost of a home birth in the United States is USD 4650, which is significantly below existing cost estimates for an uncomplicated birth center or hospital birth.” “Further, we find that each shift of one percent of births from hospitals to homes would represent an annual cost savings to society of at least USD 321 million.”
No, it’s not just about money.
But it makes you think.
Anderson, D.A.; Gilkison, G.M. The Cost of Home Birth in the United States. Int. J. Environ. Res. Public Health 2021, 18, 10361. https://doi.org/10.3390/ijerph181910361 The paper is freely available at https://www.mdpi.com/1660-4601/18/19/10361
How to find out more
A year or so ago, I helped a colleague with putting the evidence on safety together for a book. Homebirth: Safe & Sacred.
It was written by American homebirth midwife Kim Osterholzer. The book’s aim is to get information out to those who have questions in an affordable, readable format. It is written for a US audience, so some of the information about midwifery care is US-specific. But the stories and the evidence transcend national borders. You can find out more about the book here.
This site also contains other articles that might interest you if you’re looking for information on home birth.
If you’d like to know more about your options, or explore tools for decision making, I can help!
My book What’s Right For Me? has been written to help women and families make the decisions that are right for them.
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