WebMD Medical News
Brenda Goodman, MA
Laura J. Martin, MD
May 20, 2011 -- The number of women in the U.S. who gave birth at home rose 20% between 2004 and 2008, a new study shows.
Although home births represent only a fraction of the millions of babies delivered in the U.S. each year, researchers say the bump is significant because it follows a steady, 15-year decline in the practice and comes at a time of intense debate over the safety of home births.
A review paper published in 2010, for example, found the risk of newborn death was two to three times higher for babies born during planned home births compared to planned hospital births.
The review generated so much criticism that the journal that published it, The American Journal of Obstetrics and Gynecology, took the unusual step of having independent experts revisit its methods and conclusions.
In the end, the journal published a fuller explanation of the findings, but the paper was not retracted.
In January, citing the evidence from the much scrutinized review, the American College of Obstetrics and Gynecologists issued an opinion discouraging home births.
The World Health Organization, the American College of Nurse Midwives, the American Public Health Association, and the National Perinatal Association all support home and out-of-hospital births for low-risk women.
The current study will likely further fuel the discussion, since it found that home births appear to be getting safer.
From 2004 to 2008, rates of preterm births and low birth weights had dropped slightly among infants born at home, by 16% and 17% respectively.
The study found that college-educated white women in their 30s and 40s who have already had at least one child are the most likely to opt for home birth.
The rate of home births rose 28% among non-Hispanic white women from 2004 to 2008, a greater increase than was seen in any other racial or ethnic group. There was also a slight rise, 0.03%, among Asian mothers.
Rates of home births declined slightly among African-American women over that time period and held steady for American Indians and Hispanics.
Overall, there were 28,357 home births in the U.S. in 2008, representing 0.67% of all the babies born that year. In 2004, home births accounted for 0.56% of the total.
Researchers who have watched the trend believe it may signal a growing desire among expectant mothers to have more control over the kinds of procedures that are used to deliver the baby, particularly cesarean sections.
"Our study is based on birth certificates, so I don't have direct data on why, but certainly we've seen a lot of discussion and interest recently in the birthing process," says study researcher Marian F. MacDorman, PhD, a statistician in reproductive health at the National Center for Health Statistics in Hyattsville, Md.
"For example, a lot of concern about the rising C-section rate, rising medical interventions, induction of labor, episiotomy, and so forth," MacDorman tells WebMD.
"I think there's a certain group of women who maybe feel nervous about going to the hospital and maybe having a C-section they didn't want or something like that," she says.
Other experts say that rings true.
"They are people who have had control over their lives, so they want control over this," says Annette E. Fineberg, MD, an obstetrician-gynecologist in the department of women's health at the Sutter West Medical Group, in Davis, Calif.
Feinberg recently wrote a commentary for Obstetrics & Gynecology on the rise in home births, but she was not involved in the study.
She says many of her patients have voiced concerns about a hospital birth experience, hoping they'll have a better chance of delivering a baby vaginally if they give birth at home.
Sometimes, they're right, she says.
"There is currently a cesarean epidemic in the United States," says Aaron Caughey, MD, PhD, chair of the department of obstetrics and gynecology and director of the center for women's health at Oregon Health and Science University, in Portland.
Caughey is researching home births but was not involved in the current study.
He points to the numbers: In 1996, 21% of births were C-sections, but by 2009, that number was 32%, a 50% increase, "making cesarean delivery the most common surgery that a woman under the age of 50 will have."
Fear of lawsuits has driven some doctors to order C-sections instead of waiting for labor to progress.
"The saying in the profession is that 'nobody is ever sued for the cesarean delivery they did too soon,'" Caughey says.
And many hospitals refuse to let women who've had one C-section deliver their next baby vaginally, even though most can do so safely, a policy that sends some women looking for other options.
At the same time, he says, it's clear that doing more cesareans hasn't improved the health of mothers or infants.
"There wasn't then a dramatic decline in birth injury. It's not like we somehow improved outcomes with that cesarean delivery," he says.
Most mothers and infants recover well after C-sections, but the procedures require a longer healing time than vaginal deliveries, up to four to six weeks, and there are additional risks of bleeding, infection, or reactions to anesthesia.
In addition, the March of Dimes says babies born by C-section are more likely to have breathing problems than babies that are delivered vaginally. And though it's not clear why, moms who have C-sections are less likely to breastfeed.
C-sections may also cost more than vaginal births.
The majority of babies that are born at home, about 60%, are delivered by midwives, the study found.
And midwives say they've noticed an increase in demand.
"We started out our practice doing eight to 12 births per month and now we're doing twice that number," says Alice Bailes, a certified nurse midwife who has a practice in Alexandria, Va., with Marsha Jackson, who is also a certified nurse midwife.
The women who come to them, they say, are well informed, and are looking to avoid invasive births and procedures they may not want. They also may have been born at home themselves and want to continue the tradition.
"Women are having fewer babies and they do a lot of research. The Internet is available," Jackson says. "They do a lot of research to look at all the different options to be sure that the practitioner that they work with is going to help them have the type of birth that they desire."
Even in normal pregnancies that have progressed without a hitch, Caughey says things that happen during labor and delivery can make the birth risky to mother or baby.
"I think that the evidence would suggest that if you have a birth far away from the ability to do an emergency cesarean delivery, complications could occur that could lead to morbidity and mortality in the babies," Caughey says.
"What is that number? It's maybe one per thousand or two per thousand," babies that will run into trouble, he says. "It's not a big number. It's not a dramatic number."
"That needs to be played off a person's preferences, what a person wants, and what risks they want to take."
For healthy, normal pregnancies, Fineberg thinks home births are a reasonable option.
But she worries that some women who are opting for birth at home, particularly mothers who are over age 40, may not realize the increased risks they face.
"Statistically, they have a much higher chance of having interventions in labor, that's been shown in quite a few studies," she says.
From a midwife's perspective, women with pre-existing medical conditions should probably avoid home birth.
"If you have heart conditions, high blood pressure, gestational diabetes, multiple births, or breech births, those aren't the people we feel are appropriate candidates for home birth," Jackson says.
SOURCES:MacDorman, M. Birth, online May 20, 2011.Fineberg A. Obstetrics & Gynecology, May 2011.Obstetrics & Gynecology, February 2011.Hayden E. Nature News, online, March 18, 2011.Marian F. MacDorman, PhD, statistician in reproductive health, National Center for Health Statistics, CDC, Hyattsville, Md.Annette E. Fineberg, MD, ob-gyn, department of women's health, Sutter West Medical Group, Davis, Calif.Aaron Caughey, MD, PhD, ob-gyn, Oregon Health and Science University.Alice Bailes, certified nurse midwife, Alexandria, Va.Marsha Jackson, certified nurse midwife, Alexandria, Va.
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