Planned home birth

INTRODUCTION — Pregnant people began planning to give birth in a hospital rather than at home as early as the 1700s and 1800s [1], but the majority of births in the United States did not occur in a hospital until 1939, corresponding to the rapid growth in hospital beds in the 1930s and 1940s [2].

The American College of Obstetricians and Gynecologists considers hospitals a safer location for birth than the home because of the availability of physicians, blood transfusions, antibiotics, anesthesia, and other resources for intensive/emergency maternal and newborn care, if needed [3]. However, the Society of Obstetricians and Gynaecologists of Canada describes a planned home birth with a registered midwife or appropriately trained physician in their integrated system as a reasonable choice for persons with a low degree of risk where the birth is anticipated to be uncomplicated and neither the birthing parent nor the neonate will require resources beyond the local capacity [4].

Some advocates of home birth see hospital birth as the medicalization of a natural process. They acknowledge that hospitals have resources that are important for saving lives in an emergency but point out that most births are uncomplicated. When these low-risk births occur in hospitals, the chances of loss of personal control over the birth process and unnecessary medical intervention, which can lead to poorer outcomes, are increased. In addition, they feel that the home is the more comfortable environment because of the familiar surroundings, relaxed environment, and greater intimacy with the partner and other family/friends. A majority of individuals choosing home birth are multiparous with a prior hospital birth, and in some cases, their plan for home birth is in response to a past negative experience [5].

This topic will discuss issues related to planned home birth in high-resource countries/regions where hospital birth is readily available and planned home birth is a choice rather than a necessity. Planned delivery at a birth center is reviewed separately. (See "Birth centers".)

PREVALENCE AND EPIDEMIOLOGY — The prevalence and epidemiology of home birth for many industrialized countries are not readily available, but some information is known:

●In the past decade, reported prevalence of home birth was 0.1 percent in Sweden, 0.4 percent in Australia, 1.1 percent in Japan, 1.2 percent in Canada, 2.1 percent in England, 3.3 percent in New Zealand, and 14 percent in the Netherlands [6]. Of note, the prevalence of home birth in the Netherlands has steadily declined by approximately 1 percent per year: from approximately 75 percent in 1953 to 14 percent in 2021. This reduction has been attributed to negative publicity about the safety of home delivery, a requirement that midwives counsel their patients about the high referral rates during labor, the high proportion of immigrants not familiar with home delivery, and the increasing demand for epidural anesthesia [7].

●A report from the National Center for Health Statistics noted that the proportion of home births in the United States in 2021 was the highest since home births were first recorded in 1990 [8]. A total of 1.41 percent of births (51,642) occurred at home in 2021 [9]. A total of 79 percent of these were planned (a slightly higher proportion than in past years), resulting in a planned home birth rate of 1.11 percent, the highest proportion since planning status has been included on the birth certificate. The 2021 increase was likely attributable, at least in part, to the COVID-19 (see 'COVID-19' below). The states in which the rate of planned home birth exceeded 2 percent were Idaho, Wisconsin, Utah, Vermont, Montana, Maine, Oregon, Washington, Hawaii, Pennsylvania, Alaska, and Wyoming [9].

Planned home births were far more common among non-Hispanic White peoples (1.76 percent) than among non-Hispanic Black (0.45 percent), non-Hispanic Asian (0.23 percent), or Hispanic (0.33 percent) people. Individuals who had a planned home birth were also more likely to be older, multiparous, born in the United States, have a body mass index in the normal range, and live in a nonmetropolitan county (table 1) [10,11].

Nationally, 70 percent of individuals who had a home birth reported paying out-of-pocket for the birth, and 2.6 percent did not report having had prenatal care [11-13]. Approximately 37 percent of individuals who had a planned home birth were college graduates.

WHY DO INDIVIDUALS CHOOSE HOME BIRTH? — There is little systematic research on the motivation of individuals in high-resource countries who plan home birth. Most studies report survey data from select groups of pregnant people who report being more self-reliant, more comfortable with their own intuition than with professional advice, adverse to medical intervention and technology, and confident about the normality of childbirth and their bodies' inherent ability to give birth without interference [5,14,15]. These individuals choose to give birth at home for many reasons, including [5,16-21]:

●A desire for a low-intervention birth, in particular avoidance of induction of labor, artificial rupture of membranes, oxytocin, continuous fetal monitoring, epidural analgesia, pharmacologic pain relief, prophylactic antibiotics, episiotomy, instrumental vaginal delivery, and cesarean birth. In some cases, patients with breech presentation or a previous cesarean birth who are good candidates for a trial of labor may not have convenient access to a hospital that offers a trial of labor in these higher-risk clinical scenarios, leaving such patients with a difficult choice between a higher-risk home birth versus an unnecessary cesarean birth [22].

●A concern about iatrogenic complications of hospital birth.

●Fear of and dissatisfaction with hospital care from previous negative hospital experiences [23].

●Cultural or religious concerns (eg, Amish population or member of a religion that proscribes male birth attendants).

●A desire for freedom and personal control in the birth process.

●A desire to give birth in a comfortable, familiar environment surrounded by family and friends.

●A desire to avoid maternal and infant separation and exposure to practices that undermine the initiation and success of lactation (eg, encouragement of supplementation with formula and use of pacifiers).

For some individuals, however, home birth is not their preference but becomes a default option because of lack of access to transportation, a local maternity facility, or insurance/financial resources.

COVID-19 AND HOME BIRTH — In the 15 months before the COVID-19 pandemic (ie, 2019 and the first quarter of 2020), the proportion of planned home births was 0.80 percent, but increased to 1.08 percent in the last nine months of 2020 and all of 2021, an increase of 35 percent during the pandemic. While there were multiple reports in the popular press documenting pregnant individuals' concerns about giving birth in hospitals struggling to care for COVID-19 patients, limited systematic research is available on the relationship between COVID-19 and home birth decisions in the US. Two studies found marked increases in the number of Google searches for home birth after the beginning of the pandemic [24,25]. In one, the proportion of such searches increased by 239 percent after the beginning of the pandemic [24].

IS HOME BIRTH A SAFE OPTION? — There is no completely risk-free site for giving birth [26]. The safety of planned home birth depends on the selection of appropriate candidates (low-risk pregnancies in multiparous individuals) and the quality of the home birth program, including the training/credentials of home birth providers, access to supplies and equipment, a reliable transportation system for transfer to hospital, good communication/relationship between home and hospital clinical providers, and a clearly defined system for care after transfer [27]. (See 'Program organization' below.)

Home birth is well integrated into the health care system in England, Iceland, the Netherlands, New Zealand, parts of Canada, and, to a lesser extent, Washington state (United States). Cohort studies from such regions have generally found that, compared with planned hospital birth, planned home birth is associated with reduced rates of cesarean birth and medical interventions and similar rates of morbidity and mortality except for higher neonatal mortality in births to primiparous individuals [28-42]. In a report by the United States National Academies of Sciences, Engineering, and Medicine, compared with low-risk individuals choosing hospital birth, low-risk individuals choosing home birth had lower rates of intrapartum intervention and lower rates of intervention-related maternal morbidity [26]. The risk of neonatal death, while low in absolute terms, was significantly higher in home births as compared with low-risk hospital births with midwives. In Washington state, where midwifery practice in out-of-hospital settings is integrated into the overall maternity system, maternal and neonatal birth outcomes were similar for births planned at home or at a state-licensed, freestanding birth center [43]. (See 'Evidence' below.)

However, there are significant limitations to the quality of data available for analysis and, in some cases, on the methodological quality of the studies themselves [44]. For example, studies that report outcomes of individuals who actually birthed at home rather than those who planned home births (which includes hospital transfers of complicated births) favorably bias the outcome of the home birth group. Similarly, studies that do not appropriately match the planned home birth group to the planned hospital birth group in terms of medical/obstetric risk and parity are also biased if the home birth group is dominated by low-risk, multiparous individuals while the hospital group has a high proportion of high-risk, nulliparous individuals [14]. Ideally, studies should ascertain and describe provider training/credentialing, whether fetal demise occurred antepartum versus intrapartum, the definition of planned status, how planned home births delivered in hospital after intrapartum transfer were tracked, and serious neonatal outcomes other than death (eg, neurodevelopmental impairment).

Evidence — Representative examples of studies reporting outcomes of planned home birth are described below. These examples provide data on absolute and relative risks and provide insight about differences in study design.

●Meta-analyses

(1) In a 2019 meta-analysis of 14 cohort studies comparing the perinatal outcomes of approximately 500,000 planned home births among low-risk individuals in well-resourced countries with those of similarly low-risk individuals with planned hospital births [45], perinatal outcomes were similar in both groups:

•Perinatal or neonatal mortality in nulliparous individuals:

-Home-birth settings where midwives are well integrated into health services: odds ratio (OR) 1.07 (95% CI 0.70-1.65)

-Home-birth settings where midwives are less integrated into health services: OR 3.17 (95% CI 0.73-13.76)

•Perinatal or neonatal mortality in multiparous individuals:

-Home-birth settings where midwives are well integrated into health services: OR 1.08 (95% CI 0.84-1.38)

-Home-birth settings where midwives are less integrated into health services: OR 1.58 (95% CI 0.50-5.03)

•Odds of neonatal intensive care unit admission, Apgar scores, and need for resuscitation were also similar.

The planned site of delivery was based on the individual's plan at the onset of labor; those who planned a home birth but had antepartum complications necessitating delivery in a hospital or who changed their mind before the onset of labor were not included in the planned home-birth cohort. Strengths of this analysis were that the highest-quality studies came from large registries in places where midwives providing home birth care were well integrated into the health care system, appropriate control groups were used (low-risk hospital births from the same region and time frame as the home births), results were stratified by parity, and planned home births that transferred to the hospital in labor were included in the analysis of the planned-home-birth group.

(2) In a 2018 meta-analysis of outcomes by planned place of birth in low-risk pregnancies in high-income countries, individuals planning a home birth had statistically significant higher odds of a normal vaginal birth, intact perineum, nonsevere perineal trauma, and avoiding severe (≥1000 mL) postpartum hemorrhage compared with those planning a hospital birth [46].

(3) In a 2010 meta-analysis of 12 studies from Western countries evaluating outcomes associated with over 342,000 planned home births and over 207,000 planned hospital births, home birth was associated with lower rates of interventions, reductions in morbidity to the birthing individual, and comparable levels of perinatal deaths, but a higher rate of neonatal mortality [47]. A large proportion of the cases came from a Dutch study that examined only perinatal mortality [32]. When the authors of the Dutch study reanalyzed their data to include neonatal mortality (>466,000 home births), they reported similar neonatal mortality up to 28 days after birth for planned home births and planned hospital births (nulliparous individuals: OR 0.97, 95% CI 0.70-1.34; multiparous individuals: OR 1.07, 95% CI 0.70-1.62) [48]. This study had a large impact on the two more recent meta-analyses reported above.

●Home birth in the United States

(1) The largest prospective study of home birth in the United States (excluded from the 2019 meta-analysis above) included nearly 17,000 low-risk individuals who delivered between 2004 and 2009, utilized a midwife as their primary caregiver, and planned to deliver at home [49]. These individuals were healthy, mostly multiparous (78 percent), of above-average education and income, and averse to intervention. Data for the analysis were obtained from a database that included almost 200 variables recorded by professional midwives. Data from hospital births were not available for comparison. Major findings were:

•Rates of medical intervention for home births were consistently low: episiotomy rate 1.4 percent, assisted vaginal birth 1.2 percent, and cesarean birth rate 5.2 percent (based on the cases transferred to the hospital).

•Approximately 11 percent of patients were transferred to a hospital intrapartum, and an additional 1.5 percent were transferred postpartum. Primiparous individuals were more likely than multiparous individuals to experience an intrapartum transfer (23 versus 8 percent).

•One postpartum death from an intracardiac thrombus occurred three days after the birth of a healthy infant.

•The rate of intrapartum fetal death was 1.3 per 1000 births, the rate of early neonatal mortality (after exclusion of life-threatening congenital anomalies) was 0.41 per 1000 live births less than seven days of age, and the rate of late neonatal death was 0.35 per 1000 live births at 7 to 27 days of age. The risk for poor neonatal outcome was higher in births to primiparous individuals compared with multiparous individuals, in breech births compared with vertex presentations, and in births to individuals with a prior cesarean birth.

(2) A well-designed retrospective study from the United States (excluded from the 2019 meta-analysis above) used revised birth certificate data to compare outcomes of out-of-hospital births (both home and birth center births) with hospital births [41]. It included 3203 individuals who planned and completed an out-of-hospital birth (1968 at home and 1235 at a birth center), 601 individuals who planned an out-of-hospital birth but delivered in the hospital after intrapartum transfer, and 75,923 individuals with full-term planned hospital births irrespective of risk factors for pregnancy complications. Compared with planned hospital birth, planned out-of-hospital birth was associated with:

•Increased risks of fetal and neonatal death (fetal death: 2.4 versus 1.2 per 1000 births, adjusted OR 2.30, 95% CI 1.13-4.69; neonatal death: 1.6 versus 0.6 per 1000 births, adjusted OR 2.87, 95% CI 1.10-7.47). After multivariate regression, the absolute difference in risk between the groups was extremely small: 0.093 and 0.063 percentage points, respectively.

•Increased risks of neonatal seizures (1.3 versus 0.4 per 1000 births; adjusted OR 3.60, 95% CI 1.36-9.50) and ventilator support (3.8 versus 3.3 per 1000 births; adjusted OR 1.36, 95% CI 1.14-1.62). After multivariate regression, the absolute difference in risk between groups was extremely small: 0.06 and 0.97 percentage points, respectively.

•Major reductions in obstetric interventions (eg, augmentation of labor: adjusted OR 0.21, 95% CI 0.19-0.24; cesarean birth: adjusted OR 0.18, 95% CI 0.16-0.22). After multivariate regression, the absolute differences in risk between groups were large: 28 and 21 percentage points, respectively.

Planned out-of-hospital births involved a transfer to hospital in 16.5 percent of cases. Transferred patients were more likely to be nulliparous (67 percent) than either those who planned and successfully birthed out of hospital (35 percent) or planned an in-hospital birth (41 percent).

A strength of this study, in contrast to a previous larger study by this group [50], is that the analysis was based on intended rather than actual site of delivery.

(3) In the largest retrospective study (excluded from the 2019 meta-analysis above), which included 97,000 planned home births of singleton, nonanomalous, term infants ≥2500 grams, the risk of neonatal death was fourfold higher for planned home births who delivered at home than for hospital births by a midwife (1.2 versus 0.3 deaths per 1000 births; standardized mortality ratio [SMR] 4.13, 95% CI 3.38-4.88 after accounting for maternal age, parity, and gestational age) [51]. A limitation of these data is that individuals who developed complications and were transferred to the hospital for delivery were not included in the home birth cohort, thus favorably biasing the outcome of this group; therefore, these increased adverse outcomes may be an underestimate. (Note: SMR is the ratio of observed number of deaths in the study population to the number of deaths that would be expected).

(4) In Washington state, researchers studied midwifery in home and freestanding birth centers that utilized strict risk selection and was integrated into the overall maternity care system [43]. Analyzing data from 2015 to 2020 (10,609 births; 41 percent planned home and 59 percent planned birth center), with an intent to treat model that included hospital transfers, the perinatal mortality rate after the onset of birth was 0.57 per 1000 births (1.0 in nulliparous; 0.3 in parous patients), rates comparable to other industrialized countries with integrated systems. Intrapartum transfers were more common among nulliparous patients (31 percent) than parous patients (4 percent). The cesarean birth rate was 11 percent for nulliparous and 1 percent for parous patients. Physiologic birth (spontaneous labor; no epidural or pain medication or augmentation with oxytocin) occurred in 85 percent of births.

●Home birth in Canada – The largest prospective study of home birth in Canada compared nearly 11,500 individuals who planned home birth with a midwife with a matched cohort of individuals with low-risk pregnancies who planned hospital birth with the same group of midwives [42]. Compared with planned hospital birth, planned home birth was associated with:

•Statistically significant lower rates of labor augmentation (31 versus 39 percent, risk ratio [RR] 0.79, 95% CI 0.76-0.82), pharmaceutical pain relief (16 versus 42 percent, RR 0.39, 95% CI 0.37-0.41), third- and fourth-degree perineal lacerations (1.3 versus 2.3 percent, RR 0.57, 95% CI 0.47-0.69), episiotomy (4 versus 6 percent, RR 0.68, 95% CI 0.61-0.77), postpartum hemorrhage (2.5 versus 3 percent, RR 0.82, 95% CI 0.70-0.96), assisted vaginal birth (3 versus 5 percent, RR 0.61, 95% CI 0.54-0.70), and cesarean birth (6 versus 8 percent, RR 0.74, 95% CI 0.67-0.82). While the differences were statistically significant, the absolute rates and differences in rates in this low-risk population were generally low.

•No statistically significant difference in the primary outcome of stillbirth, neonatal death <28 days, or serious neonatal morbidity (0.4 percent in both groups, RR 1.03, 95% CI 0.68-1.55).

●Home birth in England – The largest prospective study of home birth in England ("Birthplace in England") compared the outcomes of low-risk individuals planning to deliver at an alternative birth site (home, freestanding midwifery units, midwifery-run units within hospitals) with those of a comparable population planning to deliver in hospital obstetric units throughout England [52-54]. The final sample consisted of 64,538 individuals with singleton, term births from 2008 to 2010. Major findings were:

•The primary composite outcome consisted of stillbirth after the start of labor, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, and fractured humerus or clavicle. There were only 250 primary adverse outcome events, giving an overall weighted incidence of 4.3 per 1000 births.

•The odds (adjusted) of the primary composite outcome were similar for the alternative birth settings (home, freestanding midwifery units, midwifery-run units within hospitals) and the hospital obstetric units.

•Primiparous individuals planning to deliver at an alternative birth setting were more likely to experience transfer to hospital than multiparous individuals (44 versus 9.2 percent) and had a higher occurrence of the primary composite outcome than primiparous patients planning to deliver in a hospital obstetric unit (0.93 versus 0.53 percent), even after adjustment for confounding variables.

•In multiparous individuals, the primary composite outcome was similar for those in the planned alternative birth setting and planned hospital obstetric unit groups.

•Planned alternative setting births had lower rates of augmentation of labor, epidural anesthesia, and cesarean birth compared with births planned for obstetric units: intrapartum cesarean birth (2.8 versus 11.1 percent), augmentation (5.4 versus 23.5 percent), and epidural anesthesia (8.3 versus 30.7 percent).

PROGRAM ORGANIZATION — International studies have found that home births in low-risk pregnancies are safest when all of the following are present [26]:

●They are part of an integrated, regulated system

●Multiple provider options across the continuum of care are covered

●Providers are well qualified and have the knowledge and training to manage first-line complications

●Transfer is seamless across settings

●Appropriate risk assessment and risk selection occur across settings and throughout pregnancy

An integrated plan for care of the individuals planning a home birth is essential for a successful program. If integration is inadequate, the potential for maternal and newborn morbidity/mortality is increased during emergencies when rapid access to the hospital's resources is essential.

The components described above are not universally present in the United States. The Dutch system is probably the best model of planned home birth for a resource-abundant country, given the high rate of successful home births in the Netherlands. The Netherlands is unique among such countries in its strong reliance on independent direct-entry midwives, a widespread view among families that birth is a natural process, a generalized questioning of the use of technological interventions in medicine, a view of obstetricians as specialists in high-risk births only, and a pride in the uniqueness of their status as the center for planned home birth among resource-abundant countries [55,56].

Key features — Key features of the Dutch-home-birth program include:

●A highly organized system of midwifery care. Dutch midwives are trained in a four-year program that prepares them to practice in the hospital or in the home and to recognize and manage some pregnancy complications. Early pregnancy care is primarily delivered by independently practicing midwives. If complications occur or threaten to occur, the midwife refers the patient to an obstetrician at the secondary or tertiary care level. At that point, the patient is no longer eligible for home birth.

●Formal agreements for collaboration between professional groups (home and hospital midwives, obstetricians, pediatric providers, hospital labor and delivery units) potentially involved in home births. These agreements are clearly described in the Verloskundig Vademecum (Obstetric Manual) and provide the foundation for good communication and relationships among these stakeholders.

●Formal, mutually agreed upon stratification of risk. The Verloskundig Vademecum (Obstetric Manual) provides a clear distinction between individuals at low risk and those at high risk of problems during pregnancy, labor, and delivery. It also includes a list of obstetric indications for referral from primary to secondary care, based on best evidence or consensus. In this system, midwives are trained to identify escalation of birthing risk when it occurs; families, midwives, and secondary providers are receptive to timely transfer to secondary care when the need arises; and the secondary team is able to respond rapidly when the patient arrives at the hospital.

●Formal protocols for home-to-hospital transfer and a timely transfer system where the average distance to the hospital is relatively short. In Amsterdam, 85 percent of urgent obstetric referrals arrived in the hospital within half an hour. In addition, the midwife is able to provide some interventions herself in the patient's home, such as the administration of an intravenous infusion and provision of basic life support. The midwife for the home delivery may stay with her patient in the hospital for support but is no longer the primary provider. (See 'Hospital transfer' below.)

●A philosophy in favor of lack of intervention. For example, pharmacologic methods of pain relief are not offered to individuals laboring at home. Periodic measurement of temperature, pulse, blood pressure, and fetal heart rate is part of the ongoing assessment of labor, not interventions, and should be performed [57].

●Availability of appropriate equipment, including a clean delivery kit and sterile instruments for contact with vaginal epithelium or non-intact skin, or penetration of the skin or vaginal epithelium. In the Netherlands, six weeks before the due date, health insurers commonly send pregnant individuals a maternity box, which contains bed protectors, maternity pads, gauze, sterilizing alcohol, and other necessities for delivery and postpartum. The midwife brings the supplies that they need, including medications and a neonatal resuscitation set with oxygen.

Hospital transfer — The rate of hospital transfer varies from 7 to 33 percent and depends on the individual's parity and birth country [31,41,43,49,52,58]. Most transfers are not urgent and reflect a low threshold of assessment of increased intrapartum risk [58]. (See 'Labor management' below.)

●In a Dutch study of 168,618 low-risk individuals attempting home birth, 32 percent were transferred to the hospital [38].

●In a study of 16,840 planned home births in England, 21 percent were transferred to the hospital (70 percent prior to delivery and 30 percent after birth) [52]. Among nulliparous individuals, 45 percent were transferred to the hospital.

●In three studies of planned home birth after a previous cesarean birth including a total of nearly 2700 patients, 30 to 38 percent underwent intrapartum transfer to a hospital [59-61].

In the United Kingdom, one-third of transfers from freestanding midwifery units occurred because of a delay in labor progress; less common reasons for transfer included meconium staining (12 percent), abnormal fetal heart rate (10 percent), retained placenta (8 percent), repair of deep lacerations (8 percent), request for neuraxial anesthesia (6 percent), intrapartum or postpartum hemorrhage (6 percent), hypertension (3 percent), neonatal concerns (3 percent), and other [62].

Ideally, the backup hospital should provide 24-hour obstetric care and should be within 15 minutes of the home, but this may not be possible, especially in some geographic areas where home birth is more common precisely because of the lack of nearby hospitals. In such settings, home birth providers should have a lower threshold for transferring patients to the hospital and must consider the transfer time when caring for patients in labor. For example, mild/borderline abnormalities in the fetal heart rate pattern or borderline hypertension might warrant transfer rather than observation for progression if transit time is anticipated to be significantly longer than 15 minutes. Ideally, such decisions are made in collaboration with the hospital team via telephone consultation. Individuals delivering in homes that are remote from a hospital should be informed by their home birth provider during prenatal care that, in the case of an unforeseen catastrophic complication (eg, abruption, cord prolapse), they may not be able to be transferred to the hospital in time to avoid maternal or neonatal injury or death.

An optimum outcome is facilitated when hospital providers, including nurses, clinicians, and hospital-based midwives, communicate in a respectful manner with home birth providers and their clients during the transfer process and vice versa. Home birth providers and their clients sometimes report that they are treated "punitively" or disrespectfully by hospital staff when a transfer occurs [16,63]. This perception may lead to a delay in a needed transfer, thereby increasing the risks of morbidity to mother and baby. Perceived antagonism from hospital staff may also lead to the patient's refusal and resultant delay of recommended medical interventions [63,64].

Hospital staff should be aware that most home birth providers keep detailed antenatal and intrapartum records, and such information may be crucial for patient care after hospital transfer. Good communication between home birth providers and hospital staff will allow conveyance of this information and a smoother transition for the patient.

Providers should also be aware that individuals transferred to the hospital after an attempted home birth may be very disappointed and/or fearful of hospital transfer; putting such patients at ease may facilitate patient care. The use of the expression "failed home birth" is discouraged, as it is unnecessarily negative, as opposed to a neutral expression such as "home birth transfer."

APPROACH TO INDIVIDUALS WHO WANT TO PLAN A HOME BIRTH — Home birth can be a reasonable option for carefully screened individuals at low risk of obstetric or medical complications if home birth is supported by appropriate resources and a backup plan to facilitate transfer to the hospital is in place, if needed. While some countries, such as the Netherlands, have developed such integrated plans for care [27], few such examples exist in the United States.

Position statements from selected groups

●In the Netherlands, pregnant people without medical complications are routinely asked to choose where they want to give birth: at home or in a short-stay hospital setting [65].

●In the United States, the American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice states that hospitals and accredited birthing centers are the safest setting for birth, but they respect the right of individuals to make medically-informed decisions about their delivery site [3]. The American Academy of Pediatrics (AAP) has taken a similar position [66]. The American College of Nurse Midwives (ACNM) [67] and the American Public Health Association (APHA) [68] have policy statements supporting the practice of planned out-of-hospital birth in select populations of individuals.

●In the United Kingdom, the National Institute for Health Care Excellence (NICE) issued guidelines concerning intrapartum care that included the following recommendation concerning place of birth: "Explain to both multiparous and nulliparous individuals that they may choose any birth setting (home, freestanding midwifery unit, alongside midwifery unit, or obstetric unit), and support them in their choice of setting wherever they choose to give birth" [69].

COVID-19 — Although many patients are concerned about leaving their home because of the COVID-19 pandemic, ACOG continues to recommend following existing evidence-based guidance regarding home birth, as described above [70].

Prenatal provider obligations — The provider's ethical obligations in discussing home birth with patients have been the subject of several commentaries [71-73]. If a provider does not agree with an individual's plan to have a home birth, they could offer to continue to provide ongoing, parallel prenatal care, including diagnostic tests and ultrasounds as needed, despite disagreement with the individual's birth plan [66]. Some obstetric providers are uncomfortable providing parallel prenatal care for patients considering home birth due to concern about the possibility of their own medicolegal liability in the event of a poor home birth-related outcome. These providers should refer the patient to another provider who is more accepting of the plan.

Counseling — Low-risk individuals considering planned home birth should be informed of its risks and benefits based on data from their locale since the infrastructure for home birth varies. For individuals in most of the United States, planned home birth is associated with fewer maternal interventions compared with planned hospital birth but also appears to be associated with a higher risk of perinatal death (approximately 1 to 2 additional fetal and neonatal deaths per 1000 births in one study [41]) and a higher risk of neonatal seizures (approximately 1 additional neonatal seizure per 1000 births in one study [41]) [41,49,51]. (See 'Evidence' above.)

Suggested discussion points for counseling an individual who is considering a home birth include:

●What are your reasons for considering a home birth?

●Are there specific aspects of hospital birth that concern you, and are there ways we can reduce those concerns? It may be helpful to provide information about the planned birth hospital's policies on fetal monitoring, amniotomy, ambulation, food and drink during labor, options for pain relief and support during labor, episiotomy, family/friends in the birthing room, newborn care, breastfeeding support, rooming in, etc. For multiparous patients with a prior unsatisfactory hospital birth, discuss the prior experience and identify areas where the patient's concerns can be addressed.

●What research have you done to find a home-birth provider, and what are their credentials?

●What is the home-birth provider's backup hospital, and are there plans for what to do if complications arise during prenatal care, labor, birth, or postpartum?

Development of a patient-centered tool could assist with shared decision-making regarding place of birth [74].

While home-birth providers typically also provide prenatal care to their patients, they may not have access to the full range of routine and selectively indicated medical tests and procedures, so collaboration between hospital and home birth providers may be necessary to provide comprehensive care. For this reason, and because individuals may be undecided about their preferred place of birth at the start of their pregnancy, hospital-based obstetric providers may see patients who are planning or considering a home birth.

Finding a home-birth provider — Almost all planned home births are attended by midwives (table 2), but rarely, a physician is willing to attend these births (table 3) [75]. A study of state laws and regulations concerning midwives found improved outcomes in states in which midwives were integrated into the health care system [76].

Individuals may find assistance in seeking a qualified provider by contacting one of the following organizations:

●American College of Nurse-Midwives

●Midwives Alliance of North America

●North American Registry of Midwives

●Childbirth Connection

●DONA International

Optimal candidates — There is considerable controversy over the specific patient characteristics that might compromise the safety of out-of-hospital birth. Many medical organizations have established lists describing the characteristics of good candidates for home birth based on expert panel recommendations as well as local and international outcomes data [77-82].

While determining the appropriate birth setting ultimately falls upon the individual and their birth provider, individuals who may be good candidates for an out-of-hospital birth include the following (this should not be considered a complete list):

●Preference for home birth after informed consent of risks, benefits, and alternatives.

●Singleton cephalic fetus at 37+0 to 41+0 weeks of gestation with estimated weight that is appropriate for gestational age.

●Absence of preexisting serious medical conditions (eg, cardiovascular, pulmonary, neurologic, or renal disease; severe anemia; coagulopathy; diabetes mellitus managed with insulin; severe obesity).

●Absence of serious obstetric conditions (eg, prolonged prelabor rupture of membranes, preeclampsia, antepartum bleeding, intrauterine growth restriction, macrosomia, fetal anomaly, past history of postpartum hemorrhage).

●Absence of contraindications to vaginal birth (eg, placenta previa or accreta, active genital herpes, previous hysterotomy in the upper uterine segment).

●Spontaneous labor.

●No prior cesarean births.

●Prior vaginal birth.

●Plan to deliver at a home or other site in the vicinity of the backup hospital.

These characteristics are not accepted universally. For example, Canadian guidelines include individuals with one prior low transverse cesarean birth as acceptable candidates for planned home birth, but ACOG guidelines consider a prior cesarean birth an absolute contraindication [36,79].

In the retrospective United States cohort study of nearly 97,000 planned home births of singleton, nonanomalous, term infants ≥2500 grams (see 'Evidence' above), characteristics associated with the highest increased individual risk for neonatal death at planned home birth were, in decreasing order of frequency, as follows [51]:

●Breech presentation (127.52 neonatal deaths/10,000 births or 1 in 78 breech births)

●Nulliparity (22.5 neonatal deaths/10,000 births or 1 in 444 first-time births)

●Previous cesarean birth (18.91 neonatal deaths/10,000 births or 1 in 529 births)

●Pregnancy ≥41 weeks of gestation (17.17 neonatal deaths/10,000 births or 1 in 582 births with a gestational age ≥41 weeks)

●Birthing parent age ≥35 years old (13.61 neonatal deaths/10,000 births or 1 in 735 births among birthing parents ≥35 years of age)

When combinations of characteristics were considered, the births at highest risk for neonatal death were those in nulliparous individuals age ≥35 years (5.2 deaths per 1000 births) and nulliparous individuals ≥41 weeks of gestation (4 deaths per 1000 births). Importantly, when compared with a similar low-risk population cared for by midwives in a hospital setting, the risk of neonatal death in a planned home birth was 8.3 times higher for individuals with a prior cesarean birth, 8.1 times higher for individuals with breech presentation, and six times higher for nulliparous individuals. These findings suggest that parity and maternal age, as well as prior cesarean birth, should be considered when counseling individuals about risk of planned home birth.

No system of patient selection can avoid all risks of intrapartum complications since unanticipated problems can arise in any pregnancy. The Dutch system of continuous risk assessment and categorization of risk has been considered a model approach for pregnancy and delivery care. However, a 2010 analysis of two years of aggregated data from the catchment area of a single large medical center in the Netherlands found that infants of low-risk pregnant individuals whose labor started under the supervision of a midwife had a higher risk of delivery-related perinatal death and the same risk of admission to the neonatal intensive care unit compared with infants of high-risk pregnant individuals whose labor started under the supervision of an obstetrician at the medical center (perinatal death: 1.4 versus 0.6 per 1000 term nonanomalous births) [83]. Interpretation of these data is limited by inability to adjust for confounders, and the findings conflict with other national Dutch studies based on much larger populations [32,48] but provide support for Dutch obstetricians who argue that the Dutch system of risk selection may not be as effective in minimizing perinatal risk as previously believed [7].

Labor management — The general approach to labor management in home births is to allow the physiologic labor and birth process to progress spontaneously and avoid medical intervention. Fetal monitoring is typically performed by intermittent auscultation with a handheld Doppler device. Pharmacologic analgesia/anesthesia is not used; instead, nonpharmacologic methods (eg, massage, acupressure, showers/baths, ambulation) are used to ameliorate discomfort and support the normal progress of labor. Laboring individuals are encouraged to eat and drink as they like.

Indications for hospital transfer — Home birth providers have different thresholds for transferring patients to the hospital based on a myriad of factors including patient preference, distance to the hospital, and comfort level managing more complex labors.

Indications for intrapartum transfer include, but are not limited to, the following:

●Need for pain medication (most common reason for transfer and primarily in nulliparous patients)

●Persistent abnormal fetal heart rate

●Active phase arrest/arrest of descent not responding to nonpharmacologic interventions

●Fever or other evidence of intra-amniotic infection

●Meconium staining

●Hypertension/preeclampsia

●Bleeding (beyond normal "bloody show")

●An unanticipated indication for cesarean birth or hospital birth (eg, fetus "flips" from cephalic to breech presentation)

Common indications for postpartum transfer include:

●Postpartum hemorrhage

●Complex perineal lacerations (eg, third- or fourth-degree)

●Postpartum fever

●Postpartum hypertensive condition

●Abnormal neonatal assessment

SPECIAL ISSUES

●Group B streptococcus (GBS) colonization – GBS screening and intrapartum antibiotic prophylaxis for individuals planning home birth is controversial. In the United States, based on their training, certification, and local regulations, some home birth providers are able to administer intravenous antibiotics when indicated according to the Centers for Disease Control and Prevention guidelines for GBS-positive pregnant individuals. When intrapartum intravenous antibiotic prophylaxis is not technically possible, home birth providers have proposed a variety of alternatives; however, the effectiveness of these approaches is unproven [84,85]. (See "Prevention of early-onset group B streptococcal disease in neonates".)

●Newborn care – Standards for newborn care in the home-birth setting should be consistent with state and federal regulations and consistent with standards for infants born in a medical care facility [66]. For example, administration of vitamin K and eye prophylaxis and newborn screening should be explained and offered, but parents have a right to sign a waiver. In the United States, the American Academy of Pediatrics recommends that at least two individuals attend all deliveries: one who has primary responsibility for the mother and one who has primary responsibility for the infant. (See "Overview of the routine management of the healthy newborn infant".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Labor".)

SUMMARY AND RECOMMENDATIONS

●Prevalence – Planned home birth is uncommon in the United States (approximately 1 percent of births). The Netherlands has the highest rate of planned home birth (13 percent of births) among industrialized countries. (See 'Prevalence and epidemiology' above.)

●Reasons for choosing planned home birth – Individuals who choose home birth do so for many reasons, including:

•A desire for a low-intervention birth and personal control of the birth environment and process

•Fear of and dissatisfaction with hospital care

•Cultural or religious concerns

For some individuals, home birth is not their preference but becomes a default option because of lack of access to transportation, a local maternity facility, or insurance/financial resources. (See 'Why do individuals choose home birth?' above.)

●Candidates – Individuals who may be good candidates for an out-of-hospital birth include the following (this should not be considered a complete list) (see 'Optimal candidates' above):

•Preference for home birth after informed consent of risks, benefits, and alternatives

•Singleton cephalic fetus at 37+0 to 41+0 weeks of gestation with estimated weight that is appropriate for gestational age

•Absence of preexisting serious medical conditions

•Absence of serious obstetric conditions

•Absence of contraindications to vaginal birth

•Spontaneous labor

•No prior cesarean births

•Prior vaginal birth

•Plan to deliver at a home or other site in the vicinity of the backup hospital

●Safety – The safety of planned home birth depends on the selection of appropriate candidates (eg, low-risk, multiparous individuals with repeated risk assessment throughout pregnancy) and the quality of the home birth program, including the training/credentials of home birth providers, access to supplies and equipment, a system for transfer to hospital, communication/relationship between home and hospital clinical providers, and care after transfer. An integrated plan for care of the individual planning a home birth is essential for a successful program. Seven to 33 percent of mothers/newborns are transferred to the hospital intrapartum or postpartum. (See 'Is home birth a safe option?' above and 'Program organization' above.)

●Outcome – In systematic reviews of observational studies, compared with planned hospital delivery, planned home birth was generally associated with the following (see 'Is home birth a safe option?' above):

•Reductions in intrapartum interventions

•Reductions in morbidity to the birthing individual, including third-degree lacerations

•Similar or slightly higher neonatal mortality