If you decide to give birth at home, you will be expected to sign an “informed consent” document for your midwife, stating that you understnad the benefits and risks of choosing a home birth. While current studies have shown home birth to be safe, it is important that you understand the specifics so you can make an informed decision about the best place for you to give birth. Most home birth midwives do not carry malpractice insurance, and for this reason as well as for your own growth as a parent, you must take full responsibility for how your health care is managed, as well as where and with whom you will give birth.
Most women will give birth to healthy babies in a “textbook” fashion. This means that if you are among the majority, there is unlikely to be any problem with your pregnancy or birthing experience, even unattended by any care provider, and your body would still function normally. Birth is not a medical condition, which is one reason why some women choose to give birth with a midwife at home. They recognize the safety of birth and trust their bodies to give birth without the help of an obstetrician.
With that said, there is a small chance that your birth could go horribly wrong. Babies die during birth, in the hospital and at home, and there are times when mothers and babies get hurt regardless of who manages their care. Sometimes it does benefit a woman and baby to give birth at the hospital, and doctors and cesareans can prevent the death or long term injury of either or both of them. This is why it is essential that you understand what the small percentage of injuries and deaths represent, and are prepared to transfer to the hospital if necessary.
The Johnson and Daviss study, Outcomes of planned home births with certified professional midwives, published in the British Medical Journal in 2005, showed that 12.1% of women transferred to the hospital during their planned home births. Only 3.4% of those were considered an emergency by the midwives, the others were due to maternal exhaustion, desire for pain relief, or other non-emergency situations. There were no maternal deaths. The initial report was that the perinatal death rate (babies dying in late pregnancy and up to a month after birth) was comparable to that of the hospital, but some suggest that this is where the numbers get murky. There is currently debate over whether home birth does result in a slightly higher rate of death among newborns. The Johnson and Daviss study showed a perinatal death rate of .17% for low risk women, but you will need to read the studies and arguments from both sides in order to decide what you believe is a good risk to take. Giving birth in the hospital increases your chance of having an unnecessary induction (2.1% vs. 21%), episiotomy (2.1% vs. 33%), cesarean section (3.7% vs. 19% in the above study), and a more painful and longer labor. On the other hand, being at home will put more distance between you and the operating room, should there be a true emergency.
ANd what are the possible emergencies? The most common complication of birth is fetal distress, which happens when the baby responds negatively to labor and the heart rate drops and meconium may be passed. If the baby does not respond to treatment at home (maternal position change, hydration, or oxygen by mask) transfer will be necessary. In the Johnson and Daviss study, .9% of mothers were transferred for fetal distress, .6% were considered “urgent”. If fetal distress is not recognized quickly enough, or you are too far from the hospital, brain damage or death of your baby could occur.
The second most common complication of birth is maternal hemorrhage. Excessive bleeding after birth is actually more likely to happen in the shospital due to induction of labor, forced pushing, and other reasons, but occurs in approximately .2-1% of births. Midwives usually carry pitocin, the first line of defense in the hospital, as well as herbal remedies for bleeding, but blood products are not available at home, and if this happens to you, the bleeding does not stop, and you are unable to get to the hospital quickly enough, it could mean long term health problems or even death.
The third most common complication of birth is when the baby does not breath after birth (often preceeded by fetal distress). It is not unusual for a baby born at home to begin breathing gradually, or not cry immediately, because midwives do not cut the umbilical cord as soon as the baby is born to ensure the baby receives a much oxygen as possible. However, in the Johnson and Daviss study, about 2.1% of babies needed supplemental oxygen or (less frequently) resuscitation in order to begin breathing. Only .6% of the babies needed to be transferred after birth for respitory complications. Most of the time babies will respond quickly to midwifery treatment, but rarely, treatment is needed that a midwife cannot offer, and brain damage or death is possible.
Other possible, rare, complications from birth at home, and reasons for transfer to the hospital, include but are not limited to: placental abruption, where the placenta separates from the uterine wall; chorionamnionitis, an infection caused by your water being broken too long; uncontrolled hypertension or preeclampsia; and retained placenta, where the placenta does not come out after birth on its own.
Midwives are trained to recognize symptoms of complications before they become emergencies, and if a complication occurs during your preganncy or birth, you are likely to be transferred to the hospital before injury or death is a possibility for you or your baby, but it is important that you speak to your midwife about her experience with complications and their outcomes, the equipment she has available and her experience in using them, and that you also speak up if you have any concerns about symptoms you are having. Make sure she is certified in CPR for adults and newborns, and in neonatal resuscitation or neonatal advanced life support.
Varney’s Midwifery, Fourth Edition, a major textbook for CPMs and CNMS, recommends adherence to the following four principles for a safe home birth:
- The woman must be committed to actively engage in health promotion
- The place of birth must be planned before the onset of labor
- The attendent must be skilled, able to screen appropriately, provide vigilant care, and manage emergency complications should they occur
- There is a system in place for access to medical consultation, hospitalization, and emergency transport
Home birth is very safe, birth can be trusted, and a trained midwife can help you to have a wonderful birth experience, but there are risks, however small they may be. In the end, you must be willing to take an honest look at the risks and benefits associated with both home and hospital birth, and decide which risks you are willing to take. Then, you are ready to sign an informed consent document for your care provider.
For your reference, here are some websites where you can find home birth studies, and read what care providers are saying about them. Be aware that each opinion is biased: