Planned home birth: benefits, risks, and opportunities

Figures & data

Table 1 Comparison of home birth rates by country

Country	Year/s	Rate
England and Wales^Citation1	2012	2.3%
Sweden^Citation5	1992–2001	0.1%
US^Citation2	2012	0.89%
Japan^Citation6	2010	1.1%
Finland^Citation7	2012	0.6%
the Netherlands^Citation4	2013	20%
Canada^Citation8	2008	1.2%
Australia^Citation9	2011	0.4%
New Zealand^Citation3	2011	3.3%
Norway^Citation10	1990–2007	0.8%

Table 2 Maternal and neonatal outcomes associated with home birth

Author and year	Study design	Population and sample size	Outcome measures	Results
Australia
Kennare et al^Citation23 2010	Retrospective population-based study of all births and perinatal deaths	1,141 planned home births (any birth that was intended to occur at home at the time of antenatal booking), 297,192 hospital births	Perinatal death, IP death, IP asphyxia, Apgar <7 at 5 minutes, use of PICU or NICU	Transfer rate: 30.6% Neonatal outcomes: Perinatal mortality rates similar (7.9 vs 8.2/1,000) IP fetal death higher in home birth group (1.8 vs 0.8/1,000) Apgar <7: 1.1% planned home births, 1.4% hospital births (NS) Admit to NICU 7.7% for home vs 15.0% for hospital (NS) Maternal outcomes: C/S rate 9.2% vs 27.1% Episiotomy rate 21.7% vs 3.6% PPH 5.5% vs 4.4% (NS)
Catling-Paul et al^Citation24 2013	Descriptive retrospective cohort study	12 publicly funded home birth programs 1,807, 97% of all home births	Place and mode of birth, perineal trauma, PPH, neonatal mortality, 5-minute Apgar score, birth weight, breastfeeding, admit to SCU	Transfer rate: 17% Neonatal outcomes: Mortality 1.7/1,000, 2.7% admit to SCN 96.8% breastfeeding initiation 69% breastfeeding at 6 weeks Maternal outcomes: 5.4% C/S rate 3.8% instrumental birth rate 56% intact perineum 2.6% episiotomy rate 1.8% PPH rate
Homer et al^Citation25 2014	Retrospective analysis of public birth data	258,161, 0.3% planning a home birth	Place and mode of birth Composite measure of neonatal mortality/morbidity Stillbirth	Transfer rate: 29% Neonatal outcomes: Stillbirth 1.44/1,000 home vs 1.05/1,000 hospital Composite outcome 7.1/1,000 home vs 5.8/1,000 hospital (NS) Maternal outcomes: 3.3% C/S rate for planned home birth 10.6% C/S rate for planned hospital birth 4% instrumental birth for planned home 15.5% instrumental birth for planned hospital
Canada
Hutton et al^Citation26 2009	Retrospective 3-year cohort study	All women planning home birth (at time of labor onset) n=6,692 were matched n=6,692 with comparable low-risk women. Matched for parity and previous LTCS	Composite measure of perinatal and neonatal mortality/morbidity (death before 28 days, Apgar <4 at 5 minutes, resuscitation, admit to NICU or PICU, <2,500 g) Maternal mortality, morbidity (PPH, infection, third or fourth degree laceration, IP interventions, breastfeeding)	Neonatal outcomes: Perinatal/neonatal mortality 1/1,000 both groups Composite perinatal neonatal morbidity/mortality 2.4% for home vs 2.8% for hospital (NS) Maternal outcomes: PPH 0.8% home vs 1.2% hospital (P=0.026) Lacerations 54% home vs 61% hospital (P<0.000) C/S 5.2% home vs 8.1% hospital (P<0.000) Breastfeeding 6 weeks 87.5% home vs 76.8% hospital (P<0.000)
Janssen et al^Citation27 2009	Prospective 5-year cohort study	Low-risk women Planned home birth n=2,889 Matched cohort attended by same midwives n=4,752 Attended by physicians n=5,331	Perinatal death – stillbirth after 20 weeks or death in first 7 days of life Obstetric interventions Adverse neonatal outcomes Adverse maternal outcomes	Neonatal outcomes: Perinatal mortality 0.35/1,000 in home birth group 0.57/1,000 in hospital midwife group 0.64/1,000 in hospital physician group (NS) Apgar <7 at 5 minutes RR 0.76 home vs 0.74 hospital midwife (NS) Maternal outcomes: C/S rate 7.2% home birth vs 10.5% hospital Operative vaginal birth 3.0% home vs 7.2% hospital midwife Intact perineum rate 54.4% home vs 46.1% hospital midwife PPH rate 3.8% home vs 6.0% hospital midwife
Japan
Kataoka et al^Citation6 2013	Descriptive, retrospective	5,477 women attended by midwives, 83.9% in birth centers and 16.1% at home	Neonatal mortality, Apgar <7, length of labor, EBL, perineal laceration	Neonatal outcomes: No neonatal mortality in either group No difference in Apgar scores Maternal outcomes: PPH rate for primiparous women 17.6% in home vs 27.2% in birth center No difference in perineal outcomes
Hirazumi and Suzuki^Citation28 2013	Retrospective cohort (midwife- led home and midwife-led hospital)	291 women in midwifery-led care: 168 women chose home delivery	Transfer of care Perinatal outcomes: length of labor, augmentation, delivery mode, laceration, PPH, Apgar <7	Transfer rate: 21% Neonatal outcomes: Apgar <7 1.6% for home, 1.8% for hospital Maternal outcomes: Labor >24 hours 2% for both groups; C/S 2.4% for home, 2.5% for hospital; PPH 5.7% for home, 6% for hospital No difference between groups
the Netherlands
De Jong et al^Citation29 2009	Nationwide retrospective cohort study	529,688 low-risk women Midwife-led care at labor onset 321,307 planned home, 163,261 hospital, 45,120 unknown	Groups controlled for parity, gestational age, maternal age, ethnic background, SES IP and neonatal death, admit to NICU	Neonatal outcomes: IP or neonatal death 0.06% home vs 0.07% hospital Admit to NICU 0.17% home vs 0.20% hospital
van der Kooy et al^Citation30 2011	Retrospective analysis of population data. Two analyses used: natural prospective (intention to treat) and perfect guideline approach	679,952 low-risk women, 602,331 using perfect guideline approach	IP and neonatal death <7 days Congenital anomalies Preterm, IUGR, Apgar scores	Neonatal outcomes: IP and neonatal death <7 days 0.15% planned home vs 0.18% planned hospital 4 risk factors were present in 85% of deaths: congenital anomaly, preterm, IUGR, or low Apgar score
de Jonge^Citation31 2013	Retrospective analysis of national perinatal register data and maternal morbidity data	Low-risk women with term singleton pregnancy: 146,752, 92,333 planned home birth, 54,419 planned hospital birth	Severe acute maternal morbidity (admit to ICU, uterine rupture, HELLP syndrome, major PPH, or other) PPH	Maternal outcomes: Severe maternal morbidity 1.5/1,000 home vs 2.7/1,000 hospital (NS) PPH rate 29.2/1,000 home vs 39.9/1,000 hospital (NS)
de Jonge et al^Citation4 2014	Retrospective nationwide cohort study utilizing 3 databases	Women in low-risk midwife-led care: 466,112 planned home birth, 276,958 planned hospital birth	IP or neonatal mortality Apgar scores Admit to NICU	Neonatal outcomes: IP or neonatal deaths nulliparous 1.02/1,000 home vs 1.09/1,000 hospital parous 0.59/1,000 home vs 0.58/1,000 hospital (NS) 5-minute Apgar scores <7 Primiparous 7.9/1,000 home vs 8.85/1,000 hospital Parous 3.2/1,000 home vs 4.57/1,000 hospital (NS) Admit to NICU Nulliparous 3.41/1,000 home vs 3.61/1,000 hospital Parous 1.36/1,000 home vs 1.95/1,000 hospital (NS)
New Zealand
Davis et al^Citation32 2011	Population-based retrospective cohort study	Low-risk women (no previous C/S, stillbirth, PPH, or medical or pregnancy-related conditions: gestation between 36 and 42 weeks) n=16,453 Planned place of birth: home, primary unit, secondary and tertiary hospital	Mode of delivery Active management third stage labor Postpartum hemorrhage	Maternal outcomes: 1% PPH rate (>1,000 mL) despite lowest rates of active management of third stage 1% C/S rate, 2.6% home, 32% primary unit, 8.5% secondary hospital, 14.9% tertiary hospital (P<0.0005)
Norway
Blix et al^Citation10 2012	Retrospective cohort	Planned home births with midwife (1,631) and low-risk comparison group (16,310)	Perinatal mortality Neonatal mortality Mode of delivery Epidural Episiotomy PPH	Neonatal outcomes: Perinatal mortality rate 0.6/1,000 home and hospital Neonatal mortality rate 0.6/1,000 home and 0.9/1,000 hospital (NS) No difference in Apgar scores Maternal outcomes: Instrumental birth: primiparas 5.7% home vs 14.8% hospital, multiparas 0.6% home vs 1.8% hospital Episiotomy: primiparas 13.3% home vs 16.7% hospital, multiparas 1.7% home vs 3.7% hospital PPH: primiparas 7.1% home vs 10.7% hospital, multiparas 1.9% home vs 6.6% hospital
Sweden
Lindgren et al^Citation5 2008	Retrospective analysis of Swedish Medical Birth Register	All planned home births (regardless of actual place of birth). Twins, preterm, and postterm were included in home birth group but not the hospital group. 897 planned home births, 11,341 planned hospital births	Neonatal mortality (28 days or less) Apgar scores Mode of birth Episiotomy Perineal lacerations	Neonatal outcomes Neonatal mortality 2.2/1,000 home vs 0.7/1,000 hospital (NS) No difference in Apgar scores Maternal outcomes: Spontaneous vaginal birth 95% home vs 84% hospital (P=0.002) Vacuum 2% home vs 10% hospital (P<0.001) Episiotomy 1% home vs 7% hospital (P<0.001) Perineal lacerations 18% home vs 31% hospital
UK
Birthplace in England Collaborative Group^Citation20 2011	Prospective cohort study Compared home, birth center, midwifery, and obstetric units	64,538 low-risk women at term	Composite index combining stillbirth, early neonatal death, encephalopathy, meconium aspiration, birth-related injuries Interventions	Neonatal outcomes: Composite outcome measure was low for the entire sample and no different between groups When sample was split, the adverse outcomes were slightly higher in nulliparous at home (9.3/1,000) than in hospital (5.3/1,000) Odds of Pitocin, epidural, C/S, vacuum forceps higher in obstetric unit vs home
Nove et al^Citation33 2012	Observational, secondary analysis of maternity records	Low risk 5,998 planned home 267,874 planned hospital	Postpartum hemorrhage (>1,000 ml)	PPH rate was 0.38% at home vs 1.04% hospital (P=0.000)
US
Johnson and Daviss^Citation34 2005	Retrospective descriptive study (98% in US and 2% in Canada)	5,418 planned home birth with CPMs	Transfers IP and neonatal mortality Interventions: epidural, episiotomy, C/S	Transfer rates: 12.1% Neonatal outcomes: IP and neonatal deaths 1.7/1,000 (excluding breeches and twins) Maternal outcomes: Epidural 4.7% Episiotomy 2.1% C/S 3.7%
Grünebaum et al^Citation35 2013	Retrospective cohort study of live birth certificate data in the US from 2007 to 2010	13,891,244 Four groups: Hospital physician Hospital midwife Freestanding birth center midwife Home midwife Multiple births, before 37 weeks, and <2,500 g infants were excluded	Apgar score of 0 at 5 minutes Seizures, neurologic dysfunction	Neonatal outcomes: Home births were more likely to have Apgar of 0 at 5 minutes (RR 10.55), seizures, and serious neurologic dysfunction (RR 3.80) Maternal outcomes: Women attended at home were more likely to be multiparous, non-Hispanic white, to deliver beyond 41 weeks, and to have macrosomic infants
Cheng et al^Citation36 2013	Retrospective cohort study of birth certificate data	Planned hospital birth compared with planned home births Low-risk women (including women with previous C/S) singleton, vertex, term 12,039 planned home births 2,069,714 planned hospital	5-minute Apgar score <4, 5-minute Apgar <7, seizures, admit to NICU, operative vaginal delivery, IOL	Neonatal outcomes: 5-minute Apgar score <4 0.37% home vs 0.24% hospital (P=0.009) 5-minute Apgar score <7 2.42% home vs 1.17% hospital NICU admission 0.57% home vs 3.03% hospital Higher rates of intervention in hospital births
Cox et al^Citation37 2013	Southeastern Pennsylvania, US Retrospective, descriptive analysis	Women cared for by CNMs who planned a home birth (mainly Amish), N=1,836	Demographic characteristics Reasons for transfer Maternal and neonatal complications	Transfer rates: 1,733 of births occurred at home (94.5%) Reasons for transfer were ROM at term, failure to progress, choice, C/S, breech, FHR abnormalities, hypertension, twins, maternal fever, IUFD Neonatal outcomes: 0.4% neonatal hospital admission 0.4% neonatal death (all with anomalies) Maternal outcomes: 5.5% PPH 14% perineal laceration rate 2.2% maternal postpartum complication rate
Grünebaum et al^Citation38 2014	Retrospective analysis of a CDC birth certificate-linked data set 2007–2010	Women attended by midwives at home N=61,993 vs those attended by hospital midwives in the US N=1,096,555 Also included data from hospital physician and freestanding BC midwife and home – other	Total neonatal mortality Subanalysis for nulliparas and gestation ≥41 weeks	Neonatal mortality: Midwife home births =1.26/1,000 Midwife hospital births =0.32/1,000 Neonatal mortality of women with a first birth Midwife home births =2.19/1,000 Midwife hospital births =0.33/1,000 Neonatal mortality of women with gestation ≥41 weeks Midwife home births =1.84/1,000 Midwife hospital births =0.27/1,000
Grünebaum et al^Citation39 2014	As above	As above	5-minute Apgar scores of 0 Neonatal seizures or serious neurologic dysfunction	Neonatal outcomes: 5-minute Apgar Hospital doctor RR =1.00 Hospital midwife RR =0.51 Home midwife RR =10.55 Neonatal seizures or neurologic dysfunction Hospital doctor RR =1.00 Hospital midwife RR =0.74 Home midwife RR =3.8
Cheyney et al^Citation40 2014	Retrospective, descriptive	Midwives Alliance of North America Statistics Project data registry 16,924 women	Actual place of birth Mode of birth 5-minute Apgar score <7 Transfers Breastfeeding	Transfer rates: Birthed at home 89.1% Neonatal outcomes: 5-minute Apgar score <7 1.5% IP or neonatal deaths 2.06/1,000 Maternal outcomes: Augmentation and/or epidural 4.5% Spontaneous vaginal birth 93.6%

Abbreviations: IP, intrapartum; PICU, pediatric intensive care unit; NICU, neonatal intensive care nursery; NS, nonsignificant; C/S, cesarean section; PPH, postpartum hemorrhage; SCN, special care nursery; LTCS, low transverse cesarean section; RR, relative risk; EBL, estimation of blood loss; SES, socioeconomic status; IUGR, intrauterine growth restriction; HELLP, hemolysis, elevated liver enzymes, and low platelet count; CPM, certified professional midwife; IOL, induction of labor; CNM, certified nurse midwife; ROM, rupture of membranes; FHR, fetal heart rate; IUFD, intrauterine fetal death; CDC, Centers for Disease Control and Prevention; BC, British Columbia; SCU, special care unit; ICU, intensive care unit.

Table 3 Maternal experience and satisfaction with home birth

Author and year	Place of study	Design	Sample size and age	Outcome measures	Findings
Bernhard et al^Citation49 2014	US	Qualitative descriptive	n=20 24–42 years (mean =33.1)	Women’s experiences who chose a home birth	• Choices and empowerment • Interventions and interruptions • Disrespect and dismissal • Birth space • Connection
Boucher et al^Citation50 2009	US	Qualitative descriptive (secondary data analysis)	n=160 20–65 years (mean=35)	Reasons why women choose home birth	• Safety and better outcomes • Intervention free • Negative previous hospital experience • Control • Comfortable environment • Trust in birth
Catling et al^Citation51 2014	Australia	Constructivist grounded theory	n=17 21–40 years (mean=31.5)	Processes/influences on choosing a publicly funded home birth	• Feeling independent, strong, and confident • Doing it my way • Protection from hospital-related activities • Having a safety net • Selective listening and telling • Engaging support
Farrish and Von Robertson^Citation52 2012	US	Qualitative	n=22 20 to ≥60 years (no mean reported)	Factors that influenced African American women to seek a home birth	• Desire for control • Avoiding pharmacological pain relief • Dissatisfaction with the medical aspects of intrapartum care
Hildingsson et al^Citation53 2010	Sweden	Descriptive and comparative study – questionnaires from women who had a planned home birth and women who had a planned cesarean section	Home birth n=671 Planned cesarean section n=126 Ages of women in home birth: <25–60 years 25–35=395 >35=215	Compare women who chose a cesarean section vs a planned home birth and birth experience	Compared with women who chose cesarean section planned home birth women in demographics:  • they were more educated  • had lower body mass index  • less likely to smoke When adjusted for background variables, women with a home birth felt:  • less threat to the baby’s life,  • more satisfied with their participation in decision making and support from midwife  • more in control  • a more positive birth experience  • more satisfied with intrapartum care  • the intensity of pain more strongly, but had more positive experience of the pain
Jouhki^Citation54 2012	Finland	Qualitative descriptive	n=10 29–39 years (mean=37.9)	Factors that affected the decision and actual birth experience	• Reasons for home birth • Seeking information before choosing home birth • Factors supporting and inhibiting home birth • Most important reason for giving birth at home • Home birth experience and women’s desire for alternative maternity care
Lindgren and Erlandsson^Citation55 2010	Sweden	Quantitative descriptive. Survey included an open-ended question. Each participant received a survey for each birth (1,038)	n=722 (1,025 birth totals) <20 years =88 20–25 years =257 26–35 years =606 >35 years =73 (no mean reported)	Factors that were experienced as empowering during a planned home birth	• Finding rest in acceptance of the process  • Emotional sensations  • Environmental sensations • Guidance  • Verbal guidance  • Nonverbal guidance • Tacit support  • Physical factors  • Mental factors • Overcoming disempowering conditions  • Emotions  • Actions
Lindgren et al^Citation56 2006	Sweden	Phenomenological	n=5 25–48 years (no mean reported)	How couples consider risks before making a decision about where to give birth	• Trust in the woman’s ability to give birth • Confidence in the midwife • Confidence in the relationship • Physical and intellectual preparation
Merg and Carmoney^Citation57 2012	US	Phenomenology	n=11 30–51 years (90% in 30s)	Experiences of home birth vs hospital birth	• Respect/autonomy vs disrespect/coercion • Trust vs distrust • Accomplishment vs failure • Empowerment vs power struggle/powerless • Allies vs adversaries • Satisfaction vs dissatisfaction • Avoiding probable interventions • Healing vs broken
Murray-Davis et al^Citation58 2012	Canada	Grounded theory	n=34 25–40 years (no mean reported)	Why women choose to give birth at home	• Wanting: the internal motivation for home birth • Informing: learning and unlearning about birth
Sjöblom et al^Citation59 2006	Sweden	Phenomenological, hermeneutical	n=12 28–43 years (no mean reported)	Women’s experiences of giving birth at home	• Choosing home: taking ownership for the decision • Having faith in one’s own competence • Choosing support on one’s own terms

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