Home birth

Home birth is childbirth that occurs outside a hospital or birthing center setting, usually in the home of the mother. Most home births are assisted by midwives, but some home births are physician assisted. Others have no medical assistance at all. This is known as free-birth or unassisted home birth.

In most Western countries, home birth declined over the 20th century, although there was some revival of the practice in 1970s. In The Netherlands, about 30% of all births occur at home, but this number is falling. In countries where midwives are the main carers for pregnant women, home birth is more prevalent.

Assisted home birth
For low-risk pregnancies, a number of studies have shown that planned, assisted homebirths are at least as safe as hospital births. There are fewer medical interventions, such as cesarean sections, forceps deliveries, episiotomies and administration of pain medication such as epidurals, all of which pose some risk to the lives and health of the mother and baby. Antibiotic resistant pathogens commonly found in hospitals, such as staph (methicillin-resistant Staphylococcus aureus and others), are less likely to be transferred to the mother or child when the birth takes place at home. However, in the case of emergencies such as cord prolapse, breathing problems with the infant, inverted uterus, or bleeding of the mother, there is less access to life-saving equipment, although properly trained midwives can manage such emergencies until the woman can be transferred to a hospital.

Unassisted home birth
There have been no formal studies on unassisted birth. A mother having an unassisted home birth can do so in the environment in which she feels most comfortable.

Many mothers choose a "couple's birth" where the birthing mother and her spouse or partner are the only ones present while she gives birth. Other children may be sleeping, or busy elsewhere in the house. Advocates of unassisted birth believe that couple's birth is an intimate extension of babymaking.

Differing opinions
Proponents of home birth prefer the atmosphere and safety of a home birth. The mother has more control over her surroundings, and can eat and move around, sleep and do anything she pleases – activities which may be discouraged in a hospital setting. The mother is often more comfortable in her own home and increased comfort contributes to shorter labor. The germs that are present are the normal germs of that family's home, to which the baby has immunity acquired from the mother. Hospitals are a common source of infection for mothers and babies by antibiotic resistant bacteria.

Conversely, some mothers are more comfortable in a hospital setting because they implicitly trust the medical system and because they prefer to be closer to an operating room should an emergency arise. It usually takes a minimum of 30 minutes to prepare an operating theatre for surgery and so for women within easy travelling distance of a hospital, this is less important.

Safety
Over the years the safety of home birth has been questioned and designing randomized controlled trials to test the safety of home birth compared to hospital birth has significant ethical problems. Studies of safety have generally found home birth (for healthy women with normal pregnancies) to be at least as safe as hospital birth. A recent study in the British Medical Journal Outcomes of planned home births with certified professional midwives: large prospective study in North America (Johnson & Daviss, June 2005), concluded that outcomes were just as good and "medical intervention rates (such as epidural, episiotomy, forceps, ventouse, and caesarean section) were substantially lower than for low risk US women having hospital births.'" For example, amongst the home birth women, 3.7% ended up having a caesarean section compared to 19% for the US as a whole (for a similar risk profile) [2000 data]. According to Enkin et al in the work A Guide To Effective Care in Pregnancy and Childbirth; "Women with low risk pregnancies considering out of hospital birth should not be discouraged."

According to the World Health Organization, the primary causes of maternal death throughout the world are obstetrical hemorrhage (25%), infection (13%), eclampsia (12%), obstructed labor (8%), complications of abortion (13%), other direct causes (8%), and indirect causes (20%). "Indirect causes" include common diseases, such as malaria and diabetes, that are often treatable in the prenatal period. Many of these problems occur in countries where there is no prenatal care or a trained birth attendant available during labor, birth and the first few hours after the birth when the mother (and the baby) is at greatest risk. A trained midwife can most often identify signs of hemorrhaging, eclampsia, fetal distress and obstructed labor in time to transport the woman to a hospital or call an ambulance. Thus basic prenatal healthcare, proximity to a hospital, and a trained midwife can provide nearly all the safeguards offered by a hospital birth.

Legal Situation in the United States


No state prosecutes mothers for giving birth outside of a hospital. However, midwives who assist at such births may be prosecuted in some areas.

In the early and mid 1900s, physicians pushed to have midwifery banned throughout the United States. Childbirth became very clinical and controlling, with the mother generally subdued with leather straps and ether. In 37 states it is once again legal to acquire the services of a midwife. Many midwives continue to attend mothers in states where it is illegal, while efforts are underway to change the law.

Practicing as a midwife is still (as of May 2006) illegal under certain circumstances in Washington, D.C. and the following states: Alabama, Georgia, Hawaii, Illinois, Indiana, Iowa, Kentucky, Maryland, Missouri, North Carolina, South Dakota and Wyoming.

People wishing to have a midwife-assisted home birth in the United States should always research the applicable laws in their home state.

Though it may be illegal for a midwife to attend a homebirth due to the constraints of the law, it is absolutely legal for a woman to give birth at home, regardless of the statutes that apply in any given state.

Legal Situation in Australia
Whilst there is no restriction on having homebirths in Australia, it is illegal for midwives to practice in some Australian States and Territories, because they are unable to obtain professional indemnity insurance. Medical practitioners in some Australian jurisdictions must have insurance before they can practice. After 9/11 and the collapse of the large Australian insurer HIH, the remaining Australian insurance companies ceased offering insurance to home birth midwives, as they claimed that the pool of midwives requiring insurance was too small to make it commercially viable. Without insurance, it is illegal for home birth midwives to practice, even though they are qualified health professionals and are allowed to practice within hospitals.

When several large insurance companies threatened to withdraw insurance for obstetricians in 2002, the Australian Government immediately responded and provided a A$600 million dollar (over 4 years) subsidy to the obstetricians to allow them to continue to practice legally.

Some State Governments have now introduced government funded home birth services, including the Northern Territory, Western Australia and New South Wales.

Additional Reading

 * A Good Birth, A Safe Birth : Choosing and Having the Childbirth Experience You Want. (1992), Korte, Diana, Boston, MA: USA, The Harvard Common Press.
 * Birthing From Within: An Extra-Ordinary Guide to Childbirth Preparation. (1998), England, Horowitz NM: USA, Partera Press.
 * A Wise Birth. Bringing together the best of natural childbirth with modern medicine, Armstrong C & Feldman S, 1990
 * Having a Great Birth in Australia Ed David Vernon, Australian College of Midwives, Canberra, 2005 ISBN 0-9751674-3-X
 * The Thinking Woman's Guide to a Better Birth, by Henci Goer
 * Lamaze Institute for Normal Birth
 * The American Way of Birth, Jessica Mitford
 * The birthjunkie site has an unassisted childbirth forum where you can discuss unassisted and minimally assisted childbirth with others. You can also read birth stories from unassisted births, including an 11.25 pound (5.1 kg) baby born without tearing.
 * The MANA state-by-state chart shows midwife certification requirements in the USA and reimbursement by Medicaid. It is common for private insurance to reimburse according to the Medicaid rules.
 * Summary of Medical Studies on Homebirth