Feelings about homebirth vary quite a bit.
Whether you’re personally comfortable with homebirth or not, there is plenty of evidence to support homebirth as a safe option for low risk women.
Homebirth is safe for healthy mothers who are pregnant with healthy babies, and who have a skilled birth attendant for their planned homebirth.
Having said that, we haven’t always had evidence to support homebirth as an option for women who fall outside of the ‘textbook perfect' pregnancy that labels them low risk. After all, for women who deviate slightly from absolute low risk, it has to be safer to be in the hospital, right?
Homebirth: Fewer Interventions And Comparable Outcomes For Babies
The recent study from Iceland was a retrospective study that included 307 planned homebirths and 921 planned hospital births that took place in Iceland between 2005 and 2009.
The study compared rates of intervention, including oxytocin augmentation (to hurry labour along), epidural analgesia and surgical birth. It also looked at neonatal outcomes, such as APGAR score and Neonatal Intensive Care Unit (NICU) admissions.
What researchers found was that women who planned a homebirth had an increased likelihood of a straightforward vaginal birth, void of interventions (e.g. epidural, artificial oxytocin augmentation). Babies born outside the hospital environment had a 5 minute APGAR score comparable with that of babies born in hospital. However, the study found an increased risk of NICU admission among babies born after a planned homebirth.
The study from the UK was a secondary analysis of a larger study – the Birthplace study – which looked at the outcomes of “higher risk” women (women who have an increased risk of complications). This study found that “The babies of ‘higher risk’ women who plan birth in an OU (obstetrical unit) appear more likely to be admitted to neonatal care than those whose mothers plan birth at home, but it is unclear if this reflects a real difference in morbidity.”
What do these studies actually mean?
After all, the NICU admissions varied from one study to the other. One thing was clear: having a homebirth is associated with fewer interventions and a higher chance of a straightforward vaginal delivery. The NICU outcomes suggest the need for more research, as well as an understanding that the rate of admission doesn’t necessarily mean a difference in morbidity (or baby’s health) but could be reflective of how healthcare providers manage the care of neonates in different settings.
Why “High Risk” Is A Confusing Term
The term high risk, or higher risk, can be confusing, especially when reading a study. Certainly a mother who is extremely high risk for birth complications needs to be in a hospital, with her care overseen by an obstetrician. However, given the vast number of reasons why a woman might be labelled high risk (and the lack of evidence in some conditions being labelled high risk), these recent studies show that being higher risk doesn’t necessarily mean a hospital birth is safer and could lead to a high-intervention birth.
A woman might be labelled high risk because of hypertension. In her situation, access to medication and interventions will be vital if her blood pressure cannot be controlled. In this case, it certainly makes sense that she is labelled high risk and monitored accordingly.
Sometimes a woman is labelled high risk earlier in her pregnancy, because of fluid level concerns, risk of preterm birth, or other conditions which might not have an impact on her labour and her baby’s health should the pregnancy reach full term.
Women who have experienced pregnancy complications might not, in fact, be at risk for birth complications. However, because they have been labelled high risk, their care might continue to reflect that label. They will often be managed in the same way, and be at risk of the same interventions, as mothers who are genuinely at risk for labour and birth complications.
The Conflicting NICU Admissions Might Not Be Reflective Of Actual Neonatal Outcomes
One study found women who gave birth out of the hospital had babies that were more likely to be admitted to the NICU, while another study found the exact opposite to be true. Neither study showed a statistically significant difference in the actual health outcomes, or morbidity, of the babies.
If a mother planning a hospital birth is more likely to receive interventions during birth, it makes sense that her baby is also likely to receive more interventions and observations, simply given the type of care expected in a hospital environment. In the same way, a mother who has a baby at home might find her baby admitted to the NICU for minor concerns, “just in case”, because the she laboured and/or gave birth at home.
Basically, more research is needed but overall there doesn’t seem to be a correlation between a planned homebirth for a higher risk mother, and a higher risk of adverse neonatal outcomes for her baby.
I’m Higher Risk, Should I Have A Homebirth?
Evidence, statistics and studies have a place in helping someone make an informed decision regarding birth. Ultimately, however, it’s important to remember that every mother, baby and birth is unique. If you are higher risk and the thought of a homebirth – provided it’s safe – is appealing, then speak with a few homebirth midwives as well as your current provider, who is familiar with your health history. They can assess your high risk status, explain their experience and background, and let you know how “risking out” of care is handled (e.g. if, prior to labour, your risk level increases and homebirth isn’t an option, or if your labour becomes high risk).
Where you give birth is your choice. It’s important to make a fully informed choice, to be aware of your options and to understand that situations during pregnancy and birth can change quickly. Having a high risk pregnancy doesn’t always translate to having a high risk birth, in the same way that being low risk doesn’t guarantee how your birth will unfold.
What these studies do tell us is that women giving birth out of the hospital, with the care of a skilled birth attendant, have fewer interventions and comparable neonatal outcomes. Overall, in fact, homebirth is a safe option for low risk women and now we see it is also a safe option for some higher risk women. Although in some cases, a higher risk woman might genuinely be safer giving birth in a hospital.