The American Experience of Giving Birth at Home
All people are born, but how mothers give birth and where varies quite a bit from culture to culture and across time.
Current American preferences heavily favor giving birth in the hospital, about 99% of all births in the US occur in a hospital. Those that occur out of the hospital include births planned to deliver in the hospital but didn't make it in time, and deliveries that were planned to occur in the home of the mother.
In 2012, about 0.9% of all deliveries took place in the US, by plan, at home.
In the Netherlands, also in 2012, about 16% of all deliveries took place, by plan, at home.
And even in the US, the rate varies. The state with the highest rate of home births is Oregon, where in 2012 and 2013, about 4% of women gave birth at home.
American Infrastructure for Home Birth
One reason home birth is less frequent in the US than the Netherlands is a vast difference in how babies are delivered at home in the Netherlands. There, the person delivering the baby is a fully certified, highly trained professional, whose actions in delivering at a home are openly and highly coordinated with local medical centers. The delivering professional is part of the community health professional structures.
This means that the professional delivering a baby at a Dutch home has highly developed and open contingency plans for the first sign of trouble. The same approach takes place in Canada. These plans strictly deny the option of a home birth to mothers who have complicated pregnancies (e.g., twins, breech presentation). In Canada, about 25% of mothers attempting to deliver at home are easily transferred to a obstetric division in a hospital if any danger seems to be developing to mother or baby. That number is 45% for first time mothers.
The delivering medical professional in Canada and the Netherlands has hospital privileges, and so can continue to care for mother if she delivers in the hospital.
The US is dramatically different. Home births are frowned upon in the US. Very few, if any, licensed obstetricians will support midwives delivering at home. Very few certified nurse midwives who have hospital privileges, will deliver at home. Home deliveries in the US take place nearly in secret, certainly without coordination with hospital systems. The delivering professional is typically a certified professional midwife (CPM), which used to be called a lay midwife. CPM's are only given legal permission to deliver in 28 states. Many achieve CPM certification via correspondence courses and receive training by other CPM's. In 2012, requirements were updated to require a high school diploma. In contrast, the certified nurse midwife (CNM) is an advanced degree nurse who can legally deliver babies in all 50 states, has to achieve graduate school level schooling, with rigorous clinical training, and often must practice in collaboration with an obstetrician.
The real difference in the US comes down to this: in Canada and Netherlands the midwife who delivers at home is fully integrated in the official medical system, can also deliver their patient in the hospital, and has a seamless connection to it. In the US the midwife who delivers at home does so essentially separate from the medical system, unable to deliver the mother in the hospital, with no well-established two-way systems (hospital and midwife working together) in place to rapidly respond to a problem.
Many of these issues are clearly presented in this NY Times article:
Safety of Home Birth in the US
In the last issue of 2105, the world's leading medical journal, The New England Journal of Medicine, published as study of all births in the state of Oregon in 2012 and 2013, and asked, how did mothers and babies do if they planned to deliver at home v. planned to deliver in the hospital.
They compared groups' plans, because if you just look at those who actually delivered at home, you artificially exclude those who were going to deliver at home, but had to go to the hospital due to problems.
Now, it is important to note that there is a rate of death in the newborn period no matter where you deliver, in the very best of worlds, some tragic death still takes place.
With that in mind, here are the numbers:
From 1970 through to today, despite the increased use of induction and C-section, the chance of a baby not living much past delivery has remained steady at 1 in a thousand (1:1000) births.
In 2012 and 2013, in Oregon, if you planned to deliver in a hospital, the chance of the baby not living to a week of age was 1.8:1000 (as time goes on, this number goes up, as we know, after 120 years it goes to 1000:1000).
In 2012 and 2013, in Oregon, if you planned to deliver at home or at a birthing center out of a hospital, the chance of the baby not living to a week of age was 3.9:1000.
Births following the plan to deliver out of hospital births also carried higher risks of the baby suffering certain troubles, including need for a ventilator, blood transfusion, seizures.
At the same time, women planning to deliver out of the hospital experienced far fewer C-sections, induced labors, and episiotomies.
In this same issue of the Journal, a commentary by Dr. Michael Greene, Chief of Obstetrics, Massachusetts General Hospital, who I have known a long time, gives the above information is a very balanced and measured approach. His last line is: "Ultimately, women's choices for place of delivery will be determined by the extent of their tolerance for risk and which risks they want to avoid."
He is referring to the risk of the baby coming to some harm versus the risk of the mother experiencing obstetric procedures.
1. Home birth in the US would benefit tremendously from full integration with the medical system. This would allow fully trained midwives to participate with full backing of obstetricians, and the development of full communications with hospitals to make transfer to the medical setting far easier and more integrated. In countries where this is the reality, no difference in newborn survival at home v. hospital is seen.
2. Until that happens, giving birth at home does more than double the chance of a baby not living to a week of age.
3. It is also true that planning to give birth at home sharply reduces the chance the mother will have a C-section, induced labor, or episiotomy.
4. Wherever one delivers, the baby needs a shot of Vitamin K soon after birth. About 1:1000 babies who do not receive this very helpful aide will actually experience serious bleeding in their brain. The Vitamin K shot provides the needed substance to help the baby make normal clotting factors.
Very importantly, we at Advanced Pediatrics are very happy to work with all parents, whatever their plans, to discuss what is an important, and often complex, decision.
To your health,
Dr. Arthur Lavin
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