For Baby's Sake, Women Considering Home Birth Must Plan and Heed Health, Safety Issues

If you're a trend-watcher, there's an intriguing statistical uptick that's worth a second glance and it involves women, their health and where they're giving birth.
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If you're a trend-watcher, there's an intriguing statistical uptick that's worth a second glance and it involves women, their health and where they're giving birth.

Before I dive into this topic more fully, let's take a brief detour into history as to why human females need help birthing their babies. Let's go back a few million years to Lucy, the fossilized remains of the hominid representing our first human ancestor to walk on two feet. OK, to keep a long story short, when Lucy and her prehistoric peers stood up, evolution began the task of rearranging just about everything in the human body.

For women and their babies, upright posture meant an altered female pelvis and a narrower and more circuitous birth canal. Where once it was a roomy, straight shot from uterus to cervix, as it is still for our closest cousins, the apes, human birth evolved into a tight, carnival-like ride with the baby forced to twist and turn head and shoulders on the way out. Ape mothers can still reach down during delivery and pull their babies out. But if human beings try that, they risk injuring the infant.

This biological truth demanded that we evolve socially as well, into people that need each other from day one. Women need help giving birth. And for millennia, up until the last 100 years or so, we know that that help came to the mother's own bedside in the form of a person -- almost always a woman -- experienced in supporting, coaching and catching.

From Home to Hospital

In 1900, almost all babies in the U.S. were born at home. In 1940, 44 percent of births still took place at home, but by 1969, that figure was 1 percent. Physicians and hospitals had taken over the task of helping mothers give birth. That percentage slightly dipped through the 1980s, and home births are still rare, with less than 1 percent of babies born at home. But they've gone up between 2004 and 2009, from 0.56 percent to 0.72 percent. In real numbers, that means 29,650 of the 4,137,836 babies born in 2009 were born at home. While that's a small actual number, it represents a 29 percent increase in home births during that time.

For a national, expert perspective on this issue, I talked with my colleague, Sarah Kilpatrick, MD, the Helping Hand Chair of Obstetrics and Gynecology at Cedars-Sinai. "In the U.S.," she says, "the safest place to have your baby is in the hospital. But women can make informed decisions on their own." She adds this major caveat: "As long as they're knowledgeable about the risks of home birth." Her thoughts are in line with the American College of Obstetricians and Gynecologists' recommendations: True, it's each woman's individual choice. Also true, she should be well aware of all the risks.

What Are the Risks?

There are two sets of risks: to the baby and to the mother. The most serious risks fall to the infant. The ACOG's Committee on Obstetric Practice cites an analysis of studies comparing planned home births to hospital births. They found, most key, that planned home births carried two to three times the risk that the baby would die compared to planned hospital births. "What women sometimes forget is that even in the most low-risk circumstances, emergencies still happen. The baby can still get in trouble," says Kilpatrick.

The ACOG committee's research also found that first-time mothers were far more likely to need a last-minute transfer to a hospital -- 25 percent to 37 percent of them, compared to only 4 percent to 9 percent of home birthing women who had had at least one other child. The transfers resulted from lack of progress in labor, concerns about the fetus, a need for pain relief, hypertension, bleeding and a poorly positioned fetus.

Mothers themselves had fewer medical interventions like epidurals for pain or fetal monitoring in the home births. No maternal deaths at home were reported in the analysis. In fact, mothers did better with fewer medical procedures: they were less likely to suffer lacerations and infections. But, as noted, this decreased risk to the mothers comes with a greater risk to their newborns.

Planning Helps

When I talk about home birth, I mean a birth that is planned with all due cautions. Despite the best intentions, sometimes babies deliver in surprising fashion. Just last month, Christy Henry gave birth in a car on the I-5 as her husband sped to a hospital in San Diego. Neither hospital nor home, that counts as an unplanned birth location, and fortunately the 6-pound early arrival was fine, as was his mother.

Most, but not all, home births are planned. A study published last year looked at about half of all the home births in the U.S., or 11,787 home births recorded in 2006. Of those, 9,810 were planned. Those that were unplanned more likely involved mothers who were young, unmarried, foreign-born, smokers, lacked a college education who had received no prenatal care and were attended by people who were neither doctors nor midwives. Not surprisingly, unplanned home births had worse outcomes than planned home births.

So naturally, for women considering home birth, what's the evidence that matters? It's that women should plan and ensure there's a qualified attending at the birth.

Who Is Planning a Home Birth

According to national health statistics, home births are half as likely to be preterm births or result in low birth-weight babies, and less than 1 percent of home births are for twins. That lower risk profile most likely results from women and their attendants deciding that it's best for a hospital obstetrics unit to deal with the higher risks associated with premature birth, the birth of twins or multiples or births where it's known the baby is small for its gestational age. We know that healthy women with uncomplicated pregnancies are the best candidates for a home birth and they seem to be the ones considering such deliveries.

Most home births are to older, white, married women who already have one or more children. They are more common in rural counties, and in rural states. The states with the highest home birth rates are Vermont, Oregon and Montana, each with about 2 percent of deliveries at home. The rate in California of 0.40 percent is lower than the national average. When looked at by age, few teens plan home births, and the rate goes up with age. Women, older than 45, have the highest percentage of home births at 1.4 percent. Ironically, risks to both mother and baby also go up with the mother's age. "They have a higher rate of medical problems, and higher rates of C-section," Kilpatrick says of mothers over 35. But again, while the percentage of home birth goes up for older women, the actual numbers are exceedingly low. New mothers older than 45 are a tiny group regardless of where they give birth; only about 7,000 babies a year are born to mothers that age, and, according to 2006 national data, 98 of them were born at home.

With Risks in Mind, Who Is a Good Candidate?

Women who consider home birth have a strong sense that they want to be in familiar surroundings with family and friends around when they deliver. Some may have equally strong religious or cultural leanings toward home birth. All those feelings deserve respect. "My personal bias is that women who decide to deliver at home really believe they can control their delivery and are nervous about going into a hospital where that control is taken away," says Kilpatrick, chair of Cedars-Sinai's Department of Obstetrics-Gynecology. "But they also have the expectation that every baby born is going to be perfect." And that, sadly, is beyond anyone's control.

Women planning a home birth need to know that while it's still overwhelmingly likely that they and their babies will be fine, their infants have a statistically greater chance of dying if delivery occurs at home. If unexpected breathing or heart problems appear, for example, it's unlikely any home attendant would be equipped and prepared for the life-threatening emergency.

Women should understand that good candidates are healthy women having a normal, healthy pregnancy with no known increased risks; they'll likely do better if they've had at least one baby before; they should be attended by a certified midwife, certified nurse midwife or physician (fewer than 8 percent of home births were attended by a physician in 2006, down from about 22 percent in 1990.)

It's important, Kilpatrick says, to pick the right person for a home birth, and that is someone approved and certified by the American Midwifery Certification Board. In 2006, about 45 percent of home births were attended by uncertified midwives, and another 30 percent were attended by a category called "other," that includes family members, emergency medical technicians and unlucky taxi drivers.

Whoever attends the birth should be backed up by consultation with an obstetrician who is affiliated with a nearby, well-equipped hospital. And it's crucial that there's a transportation plan to get the mother and baby to a hospital, pronto, if the need arises.

A Word About What Hospitals Have Learned

The desire to give birth at home stems at least in part from women's fears of hospitals. They've heard stories. They're afraid they'll lose all control over the kind of birth they want.

Hospitals have listened and tried to respond. "Over the years, more and more hospitals have midwives," says Kilpatrick. "We have one midwife here with a private practice, and about eight midwives employed by Cedars who don't have their own practice, but help care for patients, many with a collaborative practice with physicians."

Hospitals offer Lamaze classes to help women cope with pain, and staff work with women to help coordinate a plan for the kind of birth each woman wants. For pain control, the pendulum has swung in sync with women's desires. Forty years ago, women often were over-sedated to the point they weren't even aware of the birth. Then, things swung to natural birth with no pain control. Now, epidurals have been refined to the point where many women can be awake, aware and have good pain control.

Hospitals are imperfect, but they are far and away the safest places to be for a baby's delivery. For an unfortunate few, the slight increase in risk of a home birth can result in a lifetime of regret. "When babies don't do well, it's because things can go bad very quickly in labor," says Kilpatrick. "If a woman has a home birth and has a bad outcome, she has to live with that decision for the rest of her life. Things like that can happen even to women who believe they're healthy."

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