Examining the risks and outcomes of home birth

March 14, 2023

Robyn Horsager-Boehrer, M.D. Obstetrics and Gynecology

With out-of-hospital births on the rise, it's important to understand potential risks and the different levels of midwife certifications.

The number of births that occur at home or in a birthing center is growing every year. From 2020 to 2021, out-of-hospital births increased 13% nationally and 22% in Texas, according to the Centers for Disease Control and Prevention (CDC), reaching the highest level since 1990.

The COVID-19 pandemic accelerated the rise in home births, particularly during the months when transmission rates were high and vaccinations were not available or widely used, according to the Associated Press. The trend also cuts across racial and ethnic lines: home birth rates increased 21% among Black patients and 15% among Hispanic patients, compared with a 10% increase for White patients.

While out-of-hospital births represent a very small number of the children born in the U.S. – 1.41%, according to the CDC – the growing trend has led us to take a closer look at its safety. Unfortunately, the data available are not always accurate, and while the U.S. is often compared to other countries, it’s not always apples to apples.

How home birth in the U.S. compares to other countries

In the U.S., we take something of a piecemeal approach to home births. They are legal, but criteria to perform out-of-hospital births are not set up in a way that reduces risks. For example, midwife licensing differs from state to state, and there are many types of midwives, including:

Certified nurse midwives: Highly trained with extensive medical backgrounds, CNMs also can prescribe and administer pain medication if needed. This is a graduate degree-level of midwifery.
Certified midwives: Certified in midwifery with at least a graduate degree, they cannot administer medication.
Certified professional midwives: This role requires at least a high school diploma and often requires specific science and math courses, childbirth education, or doula certification for non-medical childbirth support. They cannot administer medication.
Lay midwives: Trained in childbirth, but not licensed or certified, they cannot administer medication.

By contrast, the National Health Service (NHS) in England follows strict safety criteria for at-home delivery.

Midwives in England are required to obtain an approved midwifery degree, register with the Nursing and Midwifery Council, and go through revalidation every three years. They are required to follow the NHS guidelines, including stated protocol for transferring a patient to a hospital when required.

Until we have a national, uniform standard to train and license midwives in the U.S., it’s almost impossible to accurately compare the practice and outcomes of out-of-hospital births in the U.S. with other countries.

Home birth research: Data to consider

Not only does the U.S. not have uniform guidelines for performing out-of-hospital deliveries, but we also do not have a consistent method for tracking them.

In most states, if you planned for a home birth but encountered a complication during labor or delivery that required you to go to the hospital and deliver there, it would be classified as a hospital birth. This limits researchers’ ability to assess the outcomes and risks of planned out-of-hospital births.

At UT Southwestern, we work with our patients to accommodate their birth plans.

Thanks to a change in Oregon birth certificates that documented the intended place of delivery, a 2015 study in that state has given us our clearest data so far. Oregon has one of the highest rates of out-of-hospital births in the country, with 2.4 percent of births taking place at home and 1.6 percent in a birthing center in 2012.

The study analyzed nearly 80,000 deliveries and found that planned out-of-hospital births carried double the risk of perinatal death. The actual number of deaths was small – 3.9 deaths per 1,000 births out-of-hospital versus 1.8 deaths per 1,000 in the hospital – but any increase in risk of infant death should be concerning. Higher rates of neonatal seizures and lower 5-minute Apgar scores also were reported in the out-of-hospital births.

It’s important to note that this study only looked at single, non-breech babies delivered after 37 weeks. Even in these lower-risk deliveries, researchers found that 16% of women who planned an out-of-hospital birth had to be transferred to a hospital for a higher level of care.

Like previous studies, the Oregon analysis revealed a higher rate of vaginal delivery and lower rate of medical intervention for at-home births. This is to be expected because of the nature of the study: To be a good candidate for home birth, ideally, you should have no pregnancy complications that would put you at higher risk of a delivery complication.

The American College of Obstetricians and Gynecologists (ACOG) notes that about 1 in 4 home births are unplanned or unattended. If you are experiencing problems during the pregnancy or know your baby will need immediate medical attention at birth, we agree with ACOG that planning a hospital birth is the safest choice.

Fewer interventions are available in an out-of-hospital birth. A key philosophy of midwifery is to let Mother Nature take control, which is a good philosophy for childbirth in general. However, a midwife can’t perform a C-section at home, and not all midwives can induce labor or prescribe pain medications. If interventions are needed, the laboring patient would need to be transferred to a hospital.

Should I give birth at home?

Women cite many reasons for planning an out-of-hospital birth: wanting more control over their environment, wanting to include more family members in the birth, and preferring a more natural birth experience, just to name a few.

These reasons are understandable, but we can accomplish many of these goals in the hospital. UT Southwestern Ob/Gyns and CNMs are happy to accommodate your birth plan and preferences, with your safety as the priority.

The hospital is the safest place to deliver for patients with complex pregnancies, such as having twins or more, underlying health problems, or a history of delivery complications.

If you have a non-complex pregnancy and are trying to decide if an out-of-hospital birth is right for you, there are several important factors to consider, such as: