1. Capitulo', Kathleen Leask PhD, RN, FAAN, FACCE
  2. Olafsdottir, Olof Asta PhD, RN, RM
  3. Huang, Zhaoxia BSN, RN

Article Content


The local healthcare system, organization of home birth, protocols for identifying women at low risk for complications, transfer systems, conditions in place of birth, care philosophy, and culture are all factors in the safety of home birth. In the western world there are ongoing, sometimes heated, debates on the safety of home birth, contrasting medical management of birth with physiological birth based on a midwifery approach. Planned home births in organized healthcare systems that accept low-risk women, support transfers from home to hospital during labor, and provide care by experienced midwifes, have outcomes comparable to planned hospital births, with lower cesarean rates and medical intervention rates, and increased exclusive breast feeding (Blix, Kumle, Kjaergaard, Oian, & Lindgren, 2014). When planned home births in the United States were attended by experienced midwives, women had lower rates of medical interventions without any adverse outcomes (Cheyney et al., 2014).


Identifying low-risk women is important in home birth. Low-risk criteria include a single fetus, cephalic presentation, and no complex medical conditions that could have a negative impact on outcomes, for example, cardiac disease. Home births should be attended by experienced midwives practicing under established guidelines and protocols (Cook, Avery, & Frisvold, 2014). Safety requires a plan for transfer to a hospital should a complication arise. The most frequent reasons for transfer from home to hospital during home birth are dystocia (5.1-9.8%), fetal distress (1-3.6%), postpartum hemorrhage (0-0.2%), neonatal respiratory distress (0.3-1.4%), and emergencies (0-5.4%) (Blix et al., 2014). Emergencies are rare and include placenta abruption, cord prolapse, and shoulder dystocia (Olsen & Clausen, 2012).


Synthesis of evidence about home birth practice and care suggests planning home birth with a qualified careprovider is a safe choice for healthy women in pregnancy at low risk for complications (Olsen & Clausen, 2012). Research in the United States and Europe suggests home birth outcomes are as good or better than hospital births for low-risk pregnancies, with less medical intervention and morbidity (de Jonge et al., 2013; Olsen & Clausen, 2012).


Since the mid-20th century, birth in the western world has been medicalized. With few organized systems for home birth care, most western babies are born in medically led hospital obstetric units. The Netherlands is an exception, where about 30% of births occur at home (Olsen & Clausen, 2012) and women and their families, based on available information on benefits and risks, can use their right to make informed choice to give birth safely at home (de Jonge et al, 2013).


Home birth with a qualified midwife or other professional health carer should be a part of comprehensive maternity care when the right facilities are in place for transfer to higher levels of maternity care. Based on research findings, home birth enhances emotional and medical safety and can be looked at as prevention for unnecessary medical interventions, which can cause complications for mother and baby and put them at risk in following pregnancies or later in life.


In home birth, salutogenesis and physiology rather than risk and pathology are the drivers of care, all having a positive effect on health, satisfaction, and outcomes. Women who give birth at home reported greater satisfaction with their experience. A Cochrane Review of planned home births found that "there is no strong evidence to favour either planned hospital or planned home birth for selected, low-risk pregnant women" (Olsen & Clausen, 2012, p. 15). Therefore, in my opinion, home births based on clinical guidelines are safe, and should be part of comprehensive maternity services for low-risk women, promoting a positive experience for the woman and the new family.



Blix E., Kumle M., Kjaergaard H., Oian P., Lindgren H. E. (2014). Transfer to hospital in planned home births: A systematic review. BioMed Central Pregnancy and Childbirth, 14, 179. doi:10.1186/1471-2393-14-179 [Context Link]


Cheyney M., Bovbjerg M., Everson C., Gordon W., Hannibal D., Vedam S. (2014). Outcomes of care for 16,924 planned home births in the United States: The Midwives Alliance of North America statistics project, 2004 to 2009. Journal of Midwifery and Women's Health, 59(1), 17-27. doi:10.1111/jmwh.12172 [Context Link]


Cook E., Avery M., Frisvold M. (2014). Formulating evidence-based guidelines for certified nurse-midwives and certified midwives attending home births. Journal of Midwifery and Women's Health, 59(2), 153-159. doi:10.1111/jmwh.12142 [Context Link]


de Jonge A., Mesman J. A., Mannien J., Zwart J. J., van Dillen J., van Roosmalen J. (2013). Severe adverse maternal outcomes among low risk women with planned home versus hospital births in the Netherlands: Nationwide cohort study. BMJ: British Medical Journal, 346, f3263. doi:10.1136/bmj.f3263 [Context Link]


Olsen O., Clausen J. A. (2012). Planned hospital birth versus planned home birth. The Cochrane Database of Systematic Reviews, 9, CD000352. doi:10.1002/14651858.CD000352.pub2 [Context Link]



Home birth refers to childbirth in a residence rather than in a hospital, usually in the context of a natural childbirth with less medical interventions. Planned home births are attended by professionals, including certified midwives. Many women and their families favor planned home births because they dislike the atmosphere of hospitals and prefer a family-friendly environment where the mother feels more comfortable, less stressed, more in control of the process, and is able to avoid unnecessary interventions and costs. However, in many developing countries, an unplanned home birth may be the only choice a poor woman has because of her inability to pay or lack of access to medical care.


Despite positive attributes of home birth, intrapartum, neonatal, and maternal complications should not be ignored. The professional obstetrical community and childbearing families should both be concerned about the safety of home births. Infant and mother mortality rates have decreased considerably since the beginning of the 20th century. Many researchers believe this decline is related to the drastically decreased home birth rate. Though higher in developing countries, the home birth rate has fallen to less than 1% in most developed countries (American College of Obstetricians and Gynecologists [ACOG], 2011; MacDorman, Mathews, & Declercq, 2012).


Although planned home births may be relatively safe for the mother, there are significant risks for morbidity, disability, and mortality to the baby. Risk of perinatal and neonatal death is the first concern. According to a meta-analysis of observational studies in 2010 (Wax et al., 2010), although perinatal mortality rates were similar among planned home births and planned hospital births, the risk of neonatal death in planned home births was twice as high than in the hospital. And when limited to only nonanomalous newborns, the risk was almost triple. Some studies found babies born at home had a higher risk of low Apgar scores, as well as delays in diagnosing hypoxia, acidosis, and asphyxia. Although other studies showed planned home births were comparably safe, the conditions of pregnant women were strictly restricted. Pregnant women with one or more of the following conditions may be considered not safe enough to have a home birth: more than one fetus, other than a cephalic presentation, history of a previous cesarean birth, pregnancy less than 36 weeks or more than 41 weeks, any preexisting maternal disease, or any pregnancy-related disease (Hutton, Reitsma, & Kaufman, 2009). Lack of an organized transportation for timely transfer to hospital for a woman laboring at home who develops complications is a contraindication for home birth. Any delay in intrapartum transfer can increase rates of intrapartum and neonatal death and serious disability. Anoxia, inadequate neonatal resuscitation, and lack of access to technology all pose serious risks for permanent and severe disability (de Crespigny & Savulescu, 2014).


Most planned home births are attended by midwives. However, worldwide only about 25% of midwives are certified. The remaining 75% are usually laypersons (ACOG, 2011). For those women who are unattended, or attended by nonprofessional birth attendants, higher rates of perinatal mortality are reported. According to ACOG, (2011) hospitals and birthing centers are the safest setting for birth. Given the significant risks to the baby, in my opinion, planned home birth should, instead, be planned birth in a family-friendly hospital. Many hospitals have birth centers in their facilities, bringing the best of both worlds: a home-like family-friendly environment and the availability of emergency staff, equipment, and immediate intervention, should it be necessary. Why risk a baby's life or future?



American College of Obstetricians and Gynecologists. (2011). ACOG Committee Opinion No. 476: Planned home birth. Obstetrics and Gynecology, 117(2 Pt 1), 425-428. doi:10.1097/AOG.0b013e31820eee20 [Context Link]


de Crespigny L., Savulescu J. (2014). Homebirth and the future child. Journal of Medical Ethics, 1-5. doi:10.1136/medethics-2012-101258 [Context Link]


Hutton E. K., Reitsma A. H., Kaufman K. (2009). Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: A retrospective cohort study. Birth, 36(3), 180-189. [Context Link]


MacDorman M. F., Mathews T. J., Declercq E. (2012). Home births in the United States, 1990-2009 (NCHS Data Brief No. 84), 1-8. Hyattsville, MD: National Center for Health Statistics.[Context Link]


Wax J. R., Lucas F. L., Lamont M., Pinette M. G., Cartin A., Blackstone J. (2010). Maternal and newborn outcomes in planned home birth vs planned hospital births: A metaanalysis. American Journal of Obstetrics and Gynecology, 203(3), 243.-.e8. doi:10.1016/j.ajog.2010.05.028 [Context Link]