So, here are the top ten reasons that I'd never ever ever have a home birth.
1. Appalling rates of Death at home births
Study after study after study has shown that home birth in the United States has at least 3 times the neonatal death rate that hospital birth has. That means that at least three times as many babies die in labor or at birth at home than at the hospital.
- This study, published February 2014 and with a huge sample size of 10,453,778 births in the US, found that home birth has 4 times the death rate of hospital birth: Term neonatal deaths resulting from home births: an increasing trend, Neonatal Mortality Risk Increased for Home Midwife Births.
- This analysis from Arizona in 2013 found that home birth triples the risk of your baby dying: Outcomes of Home vs. Hospital Births Attended by Midwives: A Systematic Review and Meta-analysis.
- These CDC statistics from data collected in 2008, released in 2013, show that "the neonatal mortality rate for planned homebirth attended by a non-nurse midwifes (CPM, LM) is 3.5 times higher than comparable risk hospital birth attended by a CNM (certified nurse midwife).": CDC Wonder Database Homebirth Statistics.
- These statistics, gathered by the state of Oregon in 2012 and released in 2013, found home birth had a death rate of term babies 8 times higher than hospital birth: Intrapartum Fetal and Neonatal Deaths Associated with Planned Out-of-Hospital Births in Oregon (2012). Eight times! Judith Rooks, past president of the American College of Nurse-Midwives and the CNM in charge of collecting the data, said: "Many women have been told that out of hospital births are as safe or safer than births in hospitals…But out-of-hospital births are not as safe as births in hospitals in Oregon, where many of them are attended by birth attendants who have not completed an educational curriculum designed to provide all the knowledge, skills and judgment needed by midwives who practice in any setting."
- And this data, collected by the Midwives Alliance of North America themselves, found that babies born at home died 5.5 times more often than babies born at hospitals: MANA Home Birth Data 2004-2009. And if you looked at various subgroups - such as breech babies - the numbers were truly shocking. MANA reported, "Of 222 babies presenting in breech position, 5 died either during labor or the neonatal period." That's a rate of almost 22.5 deaths per 1000 babies born. Breech babies born in the hospital have a rate of 0.8/1000. So breech babies born at home died at a rate 28 times higher than those born in the hospital. That's HUGE.
Four times the death rate, three times the death rate, three and a half times the death rate, eight times the death rate, five and a half times the death rate - one thing that all these studies have in common is that they clearly show giving birth at home significantly increases the chance that your baby will die during birth.
Homebirth advocates like to say that "babies die in hospitals too," but the difference is that babies don't die preventable deaths at hospitals. At a homebirth, at least two out of every three babies that die die for causes that would not have killed them in a hospital.
2. Appalling rates of Brain Damage at home births
One study that came out this year, Home birth and risk of neonatal hypoxic ischemic encephalopathy, found that babies born at home birth have 17 times the amount of brain injuries that babies born at hospitals do. Seventeen times! These brain injuries are caused by lack of oxygen to the baby during labor and delivery. It's really not surprising that dramatically higher rates of brain injuries occur at home births, since the lack of electronic fetal monitoring equipment at home makes it almost impossible to tell if a baby is being deprived of oxygen during labor.
In the hospital, the nurses and doctors are continually monitoring your baby during labor and will act if your baby is in distress (meaning, if she's not getting enough oxygen). If needed, the doctor can give you a c-section, and that can save your baby's brain function. Thus, the rates of brain damage are much, much lower at the hospital. At home, midwives have only a doppler to listen to your baby's heartbeat, and that can't tell them the same information that electronic fetal monitoring can. So, your midwife misses the warning signs, and doesn't act. And even if she does realize the baby's not getting enough oxygen, what can your midwife do? At the hospital, doctors can perform an emergency c-section in minutes and save the baby's life and/or brain function. At home, midwives can...send you to the hospital. Or do nothing. And every minute the baby is deprived of oxygen, the brain damage worsens.
Correspondingly, another study published in 2012, Selected perinatal outcomes associated with planned home births in the United States, found that three times as many babies at home births have seizures than babies born in the hospital.
Going right along both with the increased rates of brain damage at home birth and increased numbers of seizures at home births, researchers have found that having a baby at home instead of the hospital increases the risk of that baby having a five-minute Apgar score of 0 by over ten times.
Apgar scores are assigned to babies at 1 minute and 5 minutes after birth to assess how the baby is doing. They measure complexion (from blue or gray to pink), pulse, reflex (response to stimulation), activity, and respiratory effort (how well the baby is breathing). A score of 10 is perfect; a score of 0 means that there are no signs of life. And babies born at home have over ten times the risk of showing no signs of life five minutes after they are born compared to babies delivered by OBs in the hospital. Ten times the risk that your baby will have no signs of life after five whole minutes! Many of those babies are eventually resuscitated, but what kind of brain damage will there after going so long without any oxygen?
3. Lack of equipment at home
Both of these points - higher rates of death at home birth and higher rates of brain damage at home birth - bring me to my next point: your home does not have the same equipment a hospital does. And no matter how big the bag your midwife brings with her is, she will still not have the same equipment a hospital has.
***Thank you to everyone who contributed to this section.***
Stuff the hospital has that your midwife does not:
- Electronic Fetal Monitoring. Does your home have electronic fetal monitoring (the equipment, mentioned above, that will tell you if your baby is being deprived of oxygen)? No. Your midwife will have a doppler to listen to the baby's heart rate at intermittent time intervals. Does that seem good enough? It isn't. Here are two good articles about electronic fetal monitoring that explain why: Electronic fetal monitoring gives much more information and Electronic fetal monitoring halves early neonatal mortality.
- Electronic fetal monitoring gives much more information explains what EFM can tell you that a doppler can't. In a nutshell, by just listening to the baby's hear rate with a doppler you will miss patterns in the heart rate like decreased variability, absence of accelerations, and subtle late decelerations - all signs of a baby deprived of oxygen and in distress. An EFM tracing will show these things, the nurses and doctors will see and act on it, and your baby's life and brain function will stay intact. At home...nope. You cannot measure variability with a doppler and it's almost impossible to determine if there are no accelerations or if there are late decelerations. So, at home, you cannot tell if your baby is being deprived of oxygen during labor.
By the time your baby's heart rate shows brachycardia - a sustained abnormally low heart rate (something your midwife can detect) - it's almost certainly too late. So a baby can have a heart rate in the normal range the entire period of labor, and still drop mostly dead (and almost certainly brain damaged) into the midwife's hands. That wouldn't happen in a hospital, becausetheir distress would have been picked up on the monitors and interventions would have been performed to save them. Home birth advocates often complain about "unnecessary interventions" in the hospital, seemingly without realizing that these same interventions save lives and brain function. When you decrease interventions, you increase brain damage. When you decrease interventions, you increase deaths.
Electronic fetal monitoring halves early neonatal mortality explains about a study published in 2011, "Electronic fetal heart rate monitoring and its relationship to neonatal and infant mortality in the United State," published by the American Journal of Obstetrics and Gynecology in a "Report of Major Impact," that shows that electronic fetal monitoring cuts early neonatal death (from birth to 7 days) rates in half. I'll repeat that with less words - Electronic Fetal Monitoring cuts early neonatal death in half. EFM allows nurses and doctors to immediately see that a baby is in distress, and act in time to save them from death and brain damage. At home you do not have that.
- An operating room. This goes along with the EFM mentioned above. If it's discovered during labor that your baby is being deprived of oxygen, a c-section could save their life and their brain function. In the hospital, an emergency c-section can be performed in minutes. At home, you have to get to the hospital before a c-section can be performed. And as I explain below, from moment of the decision at home "This is an emergency, let's go to the hospital," to an emergency c-section at hospital, it will be at least over thirty minutes. And every minute matters during an emergency.
- A resuscitation team that can do the specialized work required for a newborn. If your baby is born with breathing issues, or not breathing at all, hospitals have a resuscitation team who are well-practiced in advanced resuscitation skills and who immediately begin to work on your baby with equipment for suctioning, ventilation, oxygenation, intubation, central line IV access, administration of emergency drugs, monitoring, and lab value assessments. Home birth midwives often say that they are trained in NRP (Neonatal Resuscitation Program), and they indeed might have taken a class, but they cannot perform true NRP at home because they do not have the equipment, medications, or training necessary to do so. This article goes more into that: A neonatal resuscitation class does NOT mean that a midwife is actually qualified to resuscitate a baby. Additionally, hospitals have a team of professionals with the appropriate equipment to deal with a maternal resuscitation. What happens at home if the baby and mother need emergency attention at the same time?
- More staff. At a home birth, there are at most two midwives, and more usually one, dealing with the needs of two people. At a hospital, the staff is able to greatly outnumber you if it looks like it might be necessary. In the event of an emergency like a tight nuchal cord, shoulder dystocia or other problem, there will be many hands to immediately help. If your labor is prolonged, a change of shift means the staff will be adequately rested. At home births, there is no change of staff for your midwife, and there are no extra teams of people to help when needed.
- More practice. Homebirth midwives are considered "experienced" if they've attended more than a hundred births. OB residents get that much experience in their first few months. When the Labor & Delivery unit is quiet, the staff run drills on coping with things like shoulder dystocia.
- Supplies. Hospitals have the stuff they need to take care of you. They bought it in bulk. When appropriate, they have it wrapped up in sterile packaging. You are not responsible for making sure the hospital has enough chux pads, or suturing kits, or units of O-. There's a department of administrators that makes sure the hospital has the necessary supplies, and that they stored them correctly.
- IV drugs to stop a postpartum hemorrhage before it really gets off the ground. According to MANA's own data, 15% of home birth mothers suffered excessive blood loss. Some midwives carry pitocin that they can inject, but in cases of severe postpartum hemorrhage that is not enough to stop the bleeding. IV drugs are needed, and those can only be administered by a CNM or at the hospital. CPMs and other lay midwives will not have those drugs.
- A Blood Bank. In addition to strong medications that a midwife cannot legally have or administer, the hospital has a blood bank on site. If the worst happens and you hemorrhage uncontrollably, the hospital has blood products that can save your life should other measures to control hemorrhaging fail. If you lose too much blood, and if it's not replaced soon enough, you go into irreversible hypovolemic shock and die. The blood bank can supply red cells, plasma, clotting factors and platelets ... whatever is needed. And they can supply it quickly. If your baby needs transfusions, the blood bank will use blood from O-NEG donors that has been rigorously screened.
- Oversight, accountability and witnesses. If something goes wrong at a homebirth, it is incredibly easy for a midwife to get away with something they did wrong. Reporting them to NARM (if they are a CPM) does basically nothing, and they can continue to practice without disclosing their history of injuries or deaths to their future clients. At the hospital, nurses, doctors, and CNMs have people watching over them every single day. They are accountable for their actions. They have insurance. If they make a mistake, their insurance will pay for your medical bills. Almost no home birth midwives are insured. If they make a mistake and you have huge medical bills because of it (or life-long medical bills to pay in the case of a brain-damaged child), there is no safety net for you to fall back on.
Homebirth advocates like to say that complications are rare, and you likely won't need any of this stuff at your birth. So let me remind you - the death rate at home birth is at least 3 times higher than the death rate at the hospital. The rate of brain damage is 17 times higher. A lot of women and their babies did need all this stuff at home - and it wasn't there.
4. "Five minutes" from a hospital is too far from a hospital
The talk above of oxygen deprivation brings me to my next point - distance from the hospital. People planning home births often say something like, "We live just five minutes from the hospital in case anything goes wrong!"
I want to ask you something - how long can you hold your breath? Can you hold it for five minutes? Try holding it for the next five minutes. Because every minute from the time something goes wrong until you are at the hospital, in the operating room ready for an emergency c-section, your baby will be holding their breath. Do you think they can live through that? Do you think they can live through that without brain damage?
"Five minutes from the hospital" is not really five minutes from the hospital. Sure, on a normal day, once you are in your car you might be able to drive from your house to the hospital in five minutes. But this is not a normal day. You are in labor, in severe pain, and there is an emergency occurring. It could take five minutes - or more - just to get from whatever room you are in to the car. Then it could take another five minutes to drive to the hospital, if the traffic happens to be good and you don't hit any red lights. And even if you drive up to and park in front of the ER, it will probably take another couple minutes to make it out of the car, inside the ER, and explain the situation. They have to evaluate you themselves, and make the decision to do an emergency c-section. Then they have to prep your for surgery. All of that takes at least another twenty minutes. At this point, it's been at least forty minutes from the moment of decision to go to the hospital until you're going into surgery. Can you hold your breath for that long? Can your baby? Is that "five minutes away?"
And if you think this would all be significantly sped up if you call for an ambulance at the moment of decision - think again. First, the ambulance has to get to you. If you're lucky, it will be at your house in five minutes or less. They load you up - another five minutes. Drive to the hospital - another five minutes. Unloading you, hooking you up to monitors, getting the story and your history, checking the baby, prepping you for surgery - another twenty minutes. At the very best, from moment of decision to incision to save your baby is 35 minutes.
So remember, "living five minutes from the hospital" really means "living over thirty-five minutes away from an emergency c-section." And every minute counts when your baby is deprived of oxygen.
5. Home birth midwives are shockingly uneducated and unregulated.
In trying to understand why home birth is so dangerous, it's important to understand the "qualifications" of home birth midwives.
You know how when you go to the doctor's office, the doctor who sees you has to have gone to medical school and have a medical degree, and currently be licensed? Or when you go to the hospital, and a nurse attends you, she has to have gone to nursing school and have a nursing degree? Or if you see a Physician Assistant, they had to have gone to PA school and have a PA degree? Or even when you go to the dentist, the dentist had to go to dental school and get a dental degree and be licensed to practice? In short, when you see any medical professional they had to attend a regulated, certified school, obtain a degree, obtain a license, and pass tests and regulations that prove they are qualified to attend you?
Home birth midwives don't have to do that.
In other countries, they do. In the UK, in the Netherlands, in Canada - in every other first world country - they have to have degrees and licensure to prove that they know what they're doing. There are regulations and people closely watching over them to hold them accountable for their actions. In the US - nope. Regulations vary widely by state and in many states literally anyone can call themselves a "midwife" and immediately start practicing. Many are "certified" as "Certified Professional Midwives" by the North American Registry of Midwives, but the certification requirements are weak. In 2012, the requirements were "strengthened" to include a high school degree.
Here are a couple charts that explain the difference between the midwives who work at doctors offices and in hospitals (CNMs) and home birth midwives (CPMs, LMs, lay midwives, etc.):
Even in countries idealized by home birth advocates, where home birth is integrated into the medical system and homebirth midwives have far more education and standards than they do in the US, it is still more dangerous to have a homebirth with a midwife than a hospital birth with an OB. In fact, in the Netherlands it's more dangerous to be a low-risk woman giving birth with a midwife than a high-risk woman giving birth with an OB. This study from the Netherlands found that "Delivery related perinatal death was significantly higher among low risk pregnancies in midwife supervised primary care than among high risk pregnancies in obstetrician supervised secondary care." More babies died from low-risk pregnancies under the care of midwives than from high-risk pregnancies under the care of OBs!
And this holds true both in the hospital and out! In this last study from the Netherlands, both hospital births and home births with midwives had higher neonatal death rates than hospital births with OBs.
Now, if you think you'll be safe at home birth if you choose a CNM instead of a CPM, think again. Researchers in 2009 found that home birth with a CNM had twice as many babies die than hospital birth with a CNM. Even if your midwife is a CNM instead of a CPM, you still won't be able to tell at home if your baby is being deprived of oxygen, you won't have an operating room if it becomes urgently needed, and you won't have a neonatal resuscitation team with all of the equipment that might be needed to save your baby.
The hypothetical situations you can imagine when you think about home birth midwives' lack of education and regulation - like, "If my labor suddenly goes from low-risk to high-risk at home, will my midwife know what to do? Will she have the skills and training to save my baby?" - clearly actually happen at home, as we can see from the numbers. With home birth midwives, three times as many babies die. With home birth midwives, seventeen times as many babies have brain injuries. These are the numbers that result from the faulty regulation and pitiful education requirements required of US home birth midwives.
6. The United States has one of the lowest perinatal rates in the world (which tells you they have some of the best obstetric care and practices in the world)
Home birth advocates love to say that OBs are incompetent and the US medical system is weak, because "the US infant mortality rate is one of the worst in the world's developed countries."
The problem with this claim? Infant mortality is the wrong statistic to use. "Infant mortality" records the deaths of all babies who die in the first whole year of life. It is a measure of pediatric care, not obstetric care.
"According to the World Health Organization, the best measure of obstetric care is perinatal mortality, usually defined as deaths from 28 weeks of pregnancy (stillbirths) through 28 days of life. And according to the World Health Organization, the United States has one of the lowest perinatal mortality rates in the world, lower than Denmark, the UK and the Netherlands." You can see those numbers here: World Health Organization, Neonatal and Perinatal Mortality or read another article about it here: Infant vs. Perinatal Mortality.
Now, in the pro-homebirth movie "The Business of Being Born," they repeat multiple times that the US has a poor infant mortality rate (a caption even references it as the "newborn death rate," but they are talking about infant mortality rate, and the two are not the same thing!), while implying this means hospitals are dangerous and doctors don't know what they're doing. But infant mortality is the wrong statistic to measure obstetric safety! Which tells us one of two things: Either the people who made this movie about obstetric safety don't understand how obstetric safety is measured, or else they are deliberately trying to mislead their audience. If you've watched "The Business of Being Born" and have any questions about the statistics it talks about in that movie, a doula at the blog What Ifs and Fears Are Welcome breaks down the movie in a great post, The Business of Being Misled. She also talks about it in her personal story, What Drew Me to Home Birth and What Turned Me Away.
The US has some of the best obstetric care and practices in the world, and it's proved by the US's low perinatal mortality rate. I want to take advantage of that great obstetric care by giving birth in a hospital.
7. OBs give personalized care; home birth midwives give "one size fits all care."
In deciding to give birth at a hospital or at home, women will often hear things from home birth advocates like "homebirth midwives give so much more personalized care than OBs! They really know who you are and tailor their care to you!" This is, in fact, the opposite of the truth. OBs give personalized care; midwives give "one size fits all" care.
OBs will take everything about you into account when recommending a course of action - your age, weight, pre-exisiting conditions, medical history, previous complications, previous shoulder dystocias or c-sections or postpartum hemorrhages, if you have gestational diabetes or group B strep, if the baby is breech or very large or very small or twins - everything. They take everything into account and help you have a safe pregnancy and delivery. They make different recommendations to each person based on that person's medical history and current health.
Midwives, on the other hand? Sure, a midwife will chat with you and know all of your childrens' names and what your husband does for a living, but what about your medical care? Will she base her recommendations on all of your medical history and current risk factors, or will she tell you that you, regardless of your risk factors, can manage a home birth? That you can have an unmedicated vaginal delivery? Of course she'll tell you that. Because if she tells you anything otherwise, she will lose you as a client. Midwives will tell you platitudes like "Your body is made for this." "Trust birth." "Women have been doing this for thousands of years." If they tell you that because of your blood pressure, or because your baby is breech, or because you had a previous cesarean, or because you are now past 40 weeks pregnant, or because it's your first baby, or because your pelvis is a different shape, or because you are group B step positive, that your baby's risk of death or injury is substantially higher in a home birth, they know they will lose you as a client. So, they don't tell you that. Another author sums it up better than I could about the lack of individualized care that comes from homebirth midwives:
"Personal characteristics are irrelevant. Advanced maternal age, maternal obesity, pre-existing maternal disease? It doesn’t matter because the counseling and treatment plan are always the same: you can and should have an unmedicated vaginal birth at home.
Medical history is irrelevant. Had a previous shoulder dystocia, C-section, postpartum hemorrhage? Who cares? You can and should have an unmedicated vaginal birth at home.
Complications are irrelevant. Baby is breech, have gestational diabetes, colonized by group B strep? Who cares? You can and should have an unmedicated vaginal birth at home.
Labor complications are irrelevant. Dysfunctional labor, prolonged rupture of membranes, pushing for 4 hours? Who cares? You should still stay home because you can and should have an unmedicated vaginal birth at home."
8. Our bodies are not perfect
Home birth advocates often say things like, "Your body is made for this," "Women have been doing this for thousands of years," and "Trust birth."
Our bodies were made for eating. Does that mean no one chokes? It doesn't really matter what our bodies are "made to do" - things can still go wrong, and people can be seriously injured or die. Human bodies are not perfect, and we cannot always predict what they are going to do.
And there is no shame in having an imperfect body. There is no shame in having complications in labor. We all have imperfect bodies. It's not something we can control. You didn't "fail," you aren't "broken" - you are human.
Just because birth is "natural," just because birth is "normal," does not mean that birth is safe.
An important end note about birth centers: When I was pregnant with my first and reading "What to Expect What Your Expecting" about hospitals, birth centers, and home births, I thought that a birth center was a kind of nice middle ground between hospitals and home births. I thought it was some kind of detached labor and delivery ward, like what you'd have at a hospital, just not attached to a hospital.
It is not.
First of all, and this is very important to understand, there are two kinds of birth centers. The first type is the kind that I originally thought they all were: they are attached to hospitals, and are staffed with licensed, nurse midwives. As this post explains, "If at any time during your pregnancy or labor complications arise, your care would shift to that of an obstetrician at the same birth center or hospital." Medical technology is available, everyone has insurance, and there are regulations and oversight.
The other type of birth center is a freestanding birth center, which is not directly overseen by a hospital. Choosing to give birth at a freestanding birth center is, in the words of Sara, whose son Magnus died at a birth center, choosing "a home birth in someone else's 'home.'" Freestanding birth centers are not some kind of detached labor and delivery wing. They do not have doctors. They do not have the equipment you would have at a hospital. They have the same midwives, with the same lack of education and regulation, that deliver babies at home births. Babies born at freestanding birth centers are more than three times more likely to have a 5-minute Apgar score of 0 (no signs of life) than those born at a hospital. Babies born at freestanding birth centers are almost twice as likely to have seizures than those born at the hospital. Babies born at freestanding birth centers are twice as likely to die than those at the hospital.
The excellent website "Safer Midwifery for Michigan" has a good post about birth centers called What We're Seeking: Defining "Birth Center". In it, they explain: "Freestanding birth centers do not have emergency medical equipment beyond oxygen. They cannot intubate or give medications that would be used in a resuscitation circumstance. They do not use Electronic Fetal Heart Monitoring, instead using intermittent Doppler assessments. Midwives working at a freestanding birth center may or may not be licensed as individual, may or may not carry insurance, and may or may not be trained in NRP (Neonatal Resuscitation Program). There is no requirement for any midwife at a birth center to have a license. The bottom line is that in the event of an emergency, they are under equipped for life saving measures."
And finally, the 10th reason I would never have a home birth:
10. I know their names.
I've read Aquila's story. And Mary Beth's. And Wren's. And Sam's. And Thomas's. And Zen's. And Grant's. And Angela's. And Sheppard's. And Magnus's. And Shridam's. And Silas's. And Michael's. And Aminah's. And Vylette's. And Brody's. And Sarai's. And Miranda's. And Gavin Michael's. And every one of these babies.
As the author of the blog in that last link says,
"These are 40 deaths that I wrote about in the past 2 years. And only the American homebirth deaths. And only the deaths that I heard about.
Homebirth represents approximately 1% of US births. When you look at term births of normal sized babies to white women, homebirth represents approximately 1.4% births. So if you are planning to tell me that “babies die in the hospital, too,” ask yourself if you’ve heard of nearly 3000 deaths of term babies in the hospital in the past 2 years.
Homebirth kills babies (and mothers) and the only people who appear to be unaware of that fact are homebirth advocates.
Thinking about homebirth? Maybe you should think about these babies (and their mothers), and think again."