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How Safe Are Home Births? What You Need to Know

First, having a baby at home was how everyone gave birth. Then it became a thing of the past and undeveloped countries. Then it was the domain of back-to-the-land types, followed by the celebrities who wanted to be back-to-the-land types. Today, spurred in part by reluctance to enter hospitals during the coronavirus pandemic, all kind of people are asking questions about home births.

“There’s a lot of people who specifically are coming because of COVID,” Tanya Wills, a licensed midwife and board-certified women’s healthcare nurse practitioner in New York City, told SheKnows. Her practice, Small Things Grow Midwifery, is getting inquiries from a broader range of potential clients. “They say, ‘I think the hospital’s great, and I think I definitely would have had the baby in the hospital, but now it just doesn’t seem like a very good place to go.”

But there’s a lot more to consider in this decision, for the sake of both baby and pregnant person. While we’ve all seen the photos and videos of candle-lit rooms and kiddie pools surrounded by supportive women, it’s not as simple as all that.

We hope the following information is a good place for you to start.

Why have a home birth?

Less than 1 percent percent of births in the United States take place at home, and 15 percent of those were unplanned home births (oops).

This is Wills’ profile of the typical home-birth parent: “When they think about the process of birthing, they think, ‘I want to do this on my own terms, and I want to do it safely. And they’re concerned that if they birth in the hospital, there’s going to be a lot of people telling them what to do and trying to manage the experience for them and intervening. … And what feels safe and right for them is to have a little bit more autonomy over their body.”

Beyond that desire for autonomy, pregnant people might also be considering the positive statistics about birthing at home: There is a significantly lower chance of needing interventions such as labor inductions, episiotomy, regional anesthesia, and C-sections. There’s also a lower risk of perineal tearing and of potentially deadly infections — and that’s according to the American College of Obstetricians and Gynecologists (ACOG), of all sources. (The caveat to these stats being that no one can really do a randomized trial of birth settings, and home-birth patients are already low risk.)

Other reasons to choose a home birth include wanting to have a larger support system of people at your birth, without being restricted by hospital visitation policies. You’re also getting one-on-one care from your midwife, rather than having to share their attention with other laboring parents in the hospital.

Who shouldn’t have a home birth?

Now we get to the tricky part, because while home birth might mean fewer complications like the above, there are many people for whom it is absolutely not recommended. On that point, midwives and doctors mostly agree.

Here are some factors that would likely rule out a home birth: diabetes, high blood pressure, having unchecked gestational diabetes, a previous history of complicated births, being pregnant with multiples, having the baby in breech position at the time of delivery, placenta previa, an abnormal anatomy scan, going into labor before 37 weeks, and going into labor after 42 weeks. Doctors and many midwives will also rule out anyone who has previously had a C-section, as VBACs (vaginal birth after C-section) carry a high risk for uterine rupture. Some midwives will attend VBAC home births, however. The ACOG says anyone over the age of 35 should not have a home birth, but midwives might not look at age as its own factor if there are no other indications of risk.

In her practice, Wills looks for some non-medical red flags in her screening process, too. She rules out couples where one person wants a home birth and the other doesn’t. She also isn’t keen on attending parents who aren’t prepared to go straight to the hospital if complications arise.

“If we’re in interview with somebody and they say, ‘I just don’t believe in hospitals under any circumstances,’ I don’t know that they’re going to be right for our practice,” Wills said, because even though only about 10 percent of her clients might end up having to transfer to the hospital, she wants them to be absolutely prepared to do so in an emergency.

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Image: Ken Tackett/Shutterstock. Design: Ashley Britton/SheKnows. Ken Tackett/Shutterstock. Design: Ashley Britton/SheKnows.

Even low-risk pregnancies can result in difficult births. According to the ACOG, low-risk home births result in higher instances of infant seizures, low Apgar scores, and deaths of the infant or the mother. Now there’s the risk of COVID-19 transmission, as well, especially if more people are present at the birth.

Midwives can provide some safeguards against emergencies, such as medications to stop hemorrhaging, oxygen, and training in neonatal resuscitation. But those may not be enough.

“[Doctors], paramedics and anyone in the hospital — we go through really rigorous neonatal resuscitation training on a regular basis, and if you don’t use that skill very frequently, especially in an externally stressful situation, there’s no expectation that you would be practiced enough to be able to do that,” Jessica Madden, MD,  a board-certified pediatrician, neonatologist and Aeroflow Breastpumps medical director, told SheKnows. “The first 5 to 10 minutes of a baby’s life are critical in terms of being properly resuscitated and getting oxygen. If something is going wrong, and you call 911, if they don’t get there for 10 or 15 minutes, it really could be past the point of your baby surviving.”

For this reason, your distance from the hospital should be part of your criteria for deciding on a home birth, too.

How can you have the safest home birth?

While we’ve all heard the stories about parents giving birth to healthy babies on their own in their bathtubs and cars, your first priority when you choose a home birth is to find a qualified professional. The requirements for midwives varies greatly from state to state — with some states certifying only professional nurse midwives (CNM) while others also certify midwives (CPM) who haven’t trained as nurses. Certification is important. It means that your practitioner has been trained in every possible safety procedure necessary. It also means that if something goes wrong, you want your midwife to be able to direct you to a hospital without hesitation — something you can’t necessarily expect from someone doing this on the DL.

To verify your midwife’s certification, you can look them up on this website from the American Midwifery Certification Board.

Don’t be afraid to ask your prospective midwife questions about what their safety precautions are, what equipment they use, and even this uncomfortable question Wills says she gets sometimes: “Have you ever had a patient die on you?” (The answer for Wills, by the way, is no.) Their ease with answering these questions will give you an idea of whether they’re someone you want with you during this very important endeavor.

Here are the safeguards Wills has in place: an assistant with her at all times, masks and other PPE for herself and the assistant for to protect from COVID-19, Pitocin (for hemorrhaging, not for inducing labor), oxygen, and a fetal heart-rate monitor. And while she’ll let laboring go on for as long as it has to (her record is five days), she has a low threshold for transferring to the hospital when there are signs of trouble.

“My job is not to make sure they have a home birth,” she told us. “My job is to make sure that if they can have a home birth, they want to have a home birth, and it’s safe, we can get them at home. And my job is that if it’s not safe for them to be at home, to know 100 percent how to make that call and be able to bring them into a terrific hospital setting, where they’re going to be comfortable.”

What does home birth really look like?

We’ve seen them depicted in movies and uploaded onto YouTube, but here’s a basic recap of the setting:

You’ll be in charge of getting your bed ready with a layer of regular sheets, a rubber sheet, and then some sheets you don’t mind throwing out later for the top. You can add anything else you want to make your setting comfortable, too (cue those candles!). Your midwife might ask you to order other supplies like rubber gloves, pads, and any other disposable items. She’ll usually bring the inflatable birthing pool, an IV, a blood pressure cuff, sterile tools, and the other safety equipment listed above.

“The tub is one of the main things that we use for pain relief in labor,” Wills explained, though it’s not necessarily where the parent will give birth.

Just a reminder: Midwives do not provide epidurals for pain relief, so if the pain is too much, you’ll have to transfer to the hospital. Wills has seen some parents do this because they’re too exhausted after days of laboring, but only once has it happened just because of pain.

As with a hospital birth, the pregnant person might be laboring on their own for a while before it’s time for the midwife to come. The good thing is, unlike with hospital births, no one is going to rush to end things by a certain time (unless there is a danger to the parent or baby).

Wills never really plans for where in the home the birth will happen. Because the person can be moving around to relieve pain, they could be anywhere when it’s go time.

“Maybe they’ll be on their hands and knees, maybe they’ll be leaning over their kitchen counter — wherever they are when they start pushing and it becomes clear to us that the baby is going to come, they’re probably not moving from there,” Wills said. “Toilet births are fun. … The blood and the poop and everything just kind of goes down, which is great. They’ll sit there and they push, and I can see that they’re nervous that the baby’s going to be born in the toilet. So I always tell people, ‘Listen, right when you feel the burning right before the baby comes out when the head is coming out, you’re going to stand up.'”

Amazingly, they really are able to do that instinctively, before plopping back down on the seat and receiving the baby into their arms. That first moment of skin to skin is the vision everyone has of home birth — an intimate moment in the setting of their choice rather than the hospital.

And no worries about the mess, that’s the midwife’s job to clean up.

Last but not least, if necessary, Wills also has lidocaine and stitches for any perineal tearing, but she said that only happens about a quarter of the time. One of the benefits of an unmedicated birth is that the laboring parent feels when the pushing is too much.

What about birthing centers?

We’d be remiss if we didn’t mention that there is something of a happy medium available between home births and hospital births: The free-standing birth center staffed by midwives, who can do all the necessary prenatal and postnatal care, in addition to labor and delivery, on site. This is not just a hospital under a different name.

“It’s time-intensive care,” said American Association of Birth Centers President Amy Johnson-Grass, a naturopathic doctor and CMP who runs Health Foundations Family Health & Birth Center in St. Paul, Minn. “We spend 30 to 60 minutes at prenatal visits, where of course, we’re checking in on mama and baby, but we’re doing lots of education as well.”

Like with home births, birthing centers are for parents who want a natural, unmedicated labor and delivery — though Johnson-Grass said they do sometimes give the birthing parent nitrous oxide for pain relief — without the so-called “intervention cascade” to make labor go faster. This is one explanation for the fact that women who receive their care at birth centers have a lower rate of c-sections than those who go to directly to hospitals.

“We don’t have a time limit at our birth center; we say as long as moms are doing good and babies are doing good, it’s okay to be at the birth center,” Johnson-Grass said.

But like home births, and unlike hospitals, birthing centers are right only for very low-risk pregnancies. The criteria Johnson-Grass listed sounded just like Wills’.

Some parents might choose a birthing center because they prefer a professional setting over their home. It is also sometimes easier to get insurance coverage at a birthing center — though that depends on your state and insurance carrier, as Wills assured us that she is able to accept insurance.

Like with a home birth scenario, birth centers have a strict protocol for when to decide that it’s time to transfer to a hospital. The midwives at Johnson-Grass’ center have admitting privileges at the nearby hospital, so they’re able to accompany their patients during the transfer and help them there.

What if home birth or natural birth doesn’t happen for you?

It is wonderful to live in an age where we have all these different options for birth settings and care. But if your birth doesn’t go according to plan, please do not feel like you somehow failed your child.

While delivering in a hospital and recovering from a C-section aren’t exactly fun and beautiful, chances are the outcome will be the same as your home-birth dream: that beautiful, brand-new baby in your arms.

Here are some very real, very beautiful photos to show you what childbirth looks like.

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