I believe that having a good birth experience is and should be a factor in women’s decision-making about where to give birth. But I don’t believe it should be the primary factor, and don’t believe it is for most women, including those who chose homebirth. There is no doubt that for a women who wishes to avoid medical intervention as much as possible, the experience will almost always be better in her own home where she can feel more in control of what is done to her and it is easier to relax. However, some women (myself included) would be willing to give up these advantages to themselves if it equated to better outcomes for the baby.

So, the question is, how does homebirth affect babies? Does being born at home harm them, have no effect, or help them? Theoretically, homebirth is a “more peaceful transition” and the baby “benefits from the mother’s lack of trauma,” but is there anything clinically measureable? What follows is my attempt to answer these questions with research. I have included citations and links to all the studies I cited so you can look at them yourself and make your own judgments about them. What I have linked to is what I read–in some cases full studies, and in others an abstract or the results cited in another article.

Clinical benefits of homebirth for the baby:

First of all, and most importantly, the outcomes that have the highest significance are perinatal mortality and morbidity, because all mothers want a living baby who is not permanently disabled. Research indicates that babies of low risk women who plan homebirths under a supportive system with a qualified attendant are statistically no more likely to die or have serious injuries than babies of similar women who choose hospital birth (1, 2, 3, 4, 5, 6). Babies of mothers who plan homebirths also:

• are less likely to require resuscitation at birth (2, 3, 4)
• are less likely to take longer than 1 minute to establish respiration (4)
• may have higher 5 minute APGAR scores (4, 6)
• are less likely to need oxygen therapy beyond 24 hours (2)
• are less likely to experience meconium aspiration (2)
• may be less likely to be admitted to the NICU (1, 3) though in one study (1) this difference disappeared when the data was controlled for risk factors
• are less likely to be born by cesarean, forceps or vacuum extraction (4, 5)
• are less likely to have birth trauma (2)

Why the differences?

Some possible explanations for the differences in neonatal outcomes:

• Women who plan homebirths are less likely to have obstetric interventions, including electronic fetal monitoring, augmentation of labor, assisted vaginal delivery, cesarean section, and episiotomy (2).
• Women who give birth at home feel more free to move and be upright during labor, which can promote progress without the use of oxytocin augmentation (7), thereby avoiding pitocin’s potential side effects on the baby.
• Women who give birth at home are not under any pressure (direct or subliminal) to push in a bed. Studies show that upright birth results in a shorter pushing phase (8), higher APGAR scores, and lower arterial pCO2 with unchanged pO2, which indicates less transient cord compression (9).
• Women who give birth at home are not given any pain medications that have effects on the newborn’s breathing or that increase the need for assisted delivery (10, 11). The vacuum extractor, the most common method of assisted delivery used today, is associated with slightly higher rates of neonatal cephalhaematomata and retinal haemorrhages (12)
• Babies born at home do not have their cords cut immediately. Academic OB/GYN has covered the research about cord clamping timing–see this post and these videos. In my experience, delaying cord clamping in most hospitals is much easier said than done, though hopefully this is changing.
• Babies born at home are almost never separated from their mothers. Most hospitals fail to implement immediate skin-to-skin contact as standard practice, despite the well-documented benefits for the newborn, including a positive impact on breastfeeding rates, breastfeeding duration, temperature regulation, cardio-respiratory stability, and infant crying (13).

It could be questioned whether the good outcomes were more related to midwifery practices than the place of birth. Some argue that midwives working in hospitals where there is immediate access to emergency care could get better results than they get at home. One study (2) found better outcomes for homebirths when comparing between home and hospital births with the same cohort of midwives. The difference could be attributed to different patient preferences in the two groups, such as a desire for pain medication in the hospital group. However, as I learned in my first birth, sometimes women who desire low-intervention births find that the hospital environment and protocols make this more difficult. Hospital policies often require providers to intervene in certain situations, such as slow or stalled labor, prolonged rupture of membranes, or a certain amount of time passing between full dilation and birth of the baby. Homebirth protocols are usually less restrictive, allowing more women to birth without intervention (without compromising results, if the protocols they are using are appropriate). Theoretically, women who birth at home will need intervention less often because being in a low-stress environment with minimal disturbance will promote optimal labor hormone release, resulting in less protracted labor and better natural pain control. And the research I’ve cited here indicates that when birth can safely occur with less intervention, better outcomes for babies result.

 

Some Caveats

Of course, it is important to recognize that we are talking about low risk birth here. Some higher risk women probably are taking an increased risk to their baby by choosing homebirth. I don’t think all of them are necessarily “all about the experience” either. Most of them, I believe, are in a situation where they are certain or nearly certain to have a cesarean if they birth in a hospital, and they believe that the risks of surgery do not outweigh those of vaginal birth with their increased risk situation. However, these higher risk births would be much safer if they had immediate access to emergency care while still being able to give birth vaginally. While I am saddened by the lack of options for these women, homebirth is not meant to be a last resort for those in unusual circumstances that cause them to feel that the safest birth for them (vaginal birth in a hospital) is not an option.

It is also important to note the qualifiers “under a supportive system” and “with a qualified attendant.” I believe it is very important to have a well-trained person you can trust to help you determine when intervention is truly necessary for the safety of you or your baby. The majority of homebirth research I have cited here is international. Many other countries have different requirements for midwife training than what we have in the U.S. In most of the countries where large-scale homebirth research has been done, homebirth midwifery is integrated into the maternity care system, allowing for smooth transfer in the event of an emergency. In the U.S., it is very important to ask questions about your midwife’s qualifications, and be familiar your state’s laws about direct entry midwifery (see Citizens for Midwifery) and requirements for licensure. Twenty-two states currently do not license direct entry midwifes. If your state is one of these, The Big Push for Midwives, is a resource that may help you get involved if you are interested. The requirements for the national direct-entry midwifery credential (Certified Professional Midwife or CPM) have been criticized for not being extensive enough, and are currently going through a revision process. It is also important to take into account the attitudes towards homebirth in hospitals in your area, as many in the U.S. are not supportive, which may interfere with transfer and care after transfer, should it become necessary.

Please review the the studies below, and, as always, consult with a qualified medical provider to help you make decisions about your care.

References:

• Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births
• Outcomes of planned home birth with registered midwife vs. planned hospital birth with midwife or physician
• 3. Ontario study, outcomes cited in this article
• 4. A matched cohort study of planned home and hospital births in Western Australia 1981–1987
• 5. The Farm Study
• 6. Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome
• 7. Ambulation vs. oxytocin in protracted labor: a pilot study
• 8. The Squatting Position for the Second Stage of Labor: Effects on labor and on Maternal and Fetal Well-being
• 9. A comaparision of fetal outcome in birth chair and delivery table births
• 10. Epidural vs Parenteral Opiod Anestheia on the Progress of Labor
• 11. Rates of caesarean section and instrumental vaginal delivery in nulliparous women after low concentration epidural infusions or opioid anesthesia: systematic review
• 12. Vacuum extraction versus forceps for assisted vaginal delivery (Cochrane Review)
• 13. Early skin-to-skin contact for mothers and their healthy newborn infants

This wonderful blog post was borrowed from http://birthunplugged.blogspot.com/

1. Get good information: Go to a breastfeeding class and bring your partner, family members and other care givers. It’s important they learn the basics so they can help you and won’t unintentionally sabotage your efforts. Read a breastfeeding book like “Breastfeeding Made Simple” or “The Womanly Art of Breastfeeding”. Check out www.breastfeeding.com for great articles and advice.
2. Connect with nursing moms: Spend time and befriend women who successfully breastfed. Don’t take advice from people who didn’t. (I know it sounds obvious, but I made that mistake!)  Look for a mother to mother support group or La Leche League meeting.  Make these connections before you have your baby.
3. Choose your birth location carefully: Deliver at a “Baby Friendly” hospital, birthing center or at home. Ask the hospital if they have lactation consultants to help you. Some staff nurses don’t have much lactation training and/or have never breastfed themselves. We were told by a mom recently that when she asked for help  at an Anchorage hospital they gave her a bottle instead. Not good.  And don’t keep any formula samples you get in the mail or from the hospital.  It’s too tempting to have it in the house.
4. Plan a drug free, normal birth: IVs, epidurals, c-sections and narcotic drugs in labor all make breastfeeding harder. The more drugs, fluids and painful incisions you have, the harder it will be for the baby to latch on and the longer it will take for you to produce milk. Choose midwife or obstetrician that supports natural birth. Learn about and practice mental and spiritual techniques like non-focused awareness, prayer, hypnobirthing, and visualization.  Take a childbirth education class that focuses on natural birth. Find out if you will have access to a birthing tub, shower, birthing ball, food during labor, etc.  Hire a doula.  If you do need pain medications, ask for the lowest dosage.
5. If you have concerns, get professional lactation support immediately: WIC offers free breastfeeding support for their clients. Some pediatric offices have lactation consultants on staff . You can call the hospital where you delivered and get phone help. Most home birth and birthing center midwives will visit you in your home. ANMC has a program where they will come to your house and help you as well. LLL leaders and members are another great resource. Don’t wait to get help if things aren’t going well. Pick up the phone instead of a bottle.
6. Pediatrician or nurse practitioner: Find a provider that not only supports breastfeeding but that can give you specific help and advice. Some medical schools offer ZERO lactation education. Other pediatricians have done extensive training and have breastfed their own children. Ask about their training, experience and philosophy.  Consider using a nurse practicioner or naturopathic physician.
7. Plan for pumping at work: Delay returning to work as long as possible.  Try to arrange for job sharing, part-time, work from home or creative scheduling.  Nurse your baby at night to make up for lost nursing and cuddle time. Make sure to find a place to pump before you take maternity leave. We know women who have left their jobs to go to others that were more breastfeeding friendly.
   Going back to work and maintaining milk supply is a major challenge for women.  Remember that even a little breastmilk is valuable and better than none at all.  With enough support, you can do it!