Home birth remains a controversial topic. The American College of Obstetrics and Gynecology (ACOG) advises against it, citing a large multi-study analysis that concludes the risks to mother and baby are higher in home births.
But just across the border in Canada, a study of home births in Ontario found that low-risk mothers who began birthing at home did not increase risk for themselves or their infants.
The study compared low-risk women who intended to give birth at home under the care of a midwife to those who gave birth in a hospital birthing center, also under the care of a midwife.
The women who chose home birth, including those who eventually went to the hospital because the labor became too painful or complicated, did not have higher complication rates.
“This suggests to me that in appropriate patients in an appropriate system, there does not seem to be a significant difference in home birth and hospital birth,” said Dr. Jeffrey Ecker, the chair of ACOG’s Committee on Obstetric Practice who practices at Massachusetts General Hospital.
The women who gave birth in a birthing center instead of at home were more likely to undergo medical interventions, the study also found.
Eileen Hutton, Ph.D., a professor of Obstetrics and Gynecology at McMaster University, who was the lead author of the paper, thought that finding was likely about readily-available access.
If a woman at home is having trouble managing pain, she might at some level want an epidural anesthetic. However, before getting one she would have to relocate to the hospital, which may not seem worth it.
“If you’re in hospital and there’s an OB right down the hall, accessing an epidural is a more likely eventuality,” Hutton said.
It could also be that women who prefer to give birth at home “are more intervention averse,” she added. Women who had previously experienced a miscarriage or abortion were excluded from the study.
Ecker mused that patients with slightly higher risk may choose not to have birth under a midwife’s care. For instance, cesarean sections were only rarely performed on the study participants, he said.
The findings give medical practitioners more information to share with women to help them make informed decisions about how and where they want to give birth.
“One of the things women want to know about is safety, and safety is a hard thing to define, but we can certainly provide women with the information that in a situation where you have a skilled care provider, the outcomes for low-risk healthy women are the same,” she said.
Differences in Healthcare Systems
So how can research in Canada show no difference in safety while U.S. research finds differences great enough that obstetricians are advised to tell patients precisely the opposite of what Hutton advises in Canada?
It’s in part a question of emphasis. ACOG cites evidence that risks are three times greater at home, but the risk is still quite small in absolute terms.
The difference in risk can likely be accounted for by the differences between the nations’ healthcare systems, Hutton and Ecker both said.
The Canadian study notes that it measured home births within a system where communication between doctors and midwives, and between at-home births and hospital staff, are quite good.
“That is not a reality anywhere that I’m aware of in the United States,” Ecker said.
Within a single-payer system like Canada’s, it’s also possible to set universal standards that determine who is and who is not a good candidate for home birthing. It can also ensure that all midwives receive standard training.
The difference in health care systems also means that American women sometimes choose a home birth because it’s cheaper. At the same time, poverty and lack of regular health care would both make these home-birth candidates higher risk.
“With poverty, we know that there’s a lot of maternal and perinatal outcomes that are influenced by that, so it may be that there are a lot of other provisos that need to be built in in the U.S. context,” Hutton said.
The Canadian findings that home birth is safe support other recent data from the United Kingdom and the Netherlands. This research could eventually push the U.S. system to look for better ways to offer institutional support for the practice.
“It makes an argument for examining what system would be needed,” Ecker said. “But there are lots of practical challenges.”