Home births—Where are we heading?

In developing countries, efforts are being made to get women to a hospital or health care facility in time for giving birth. However, several developed countries are currently experiencing a significant increase in home births including the United Kingdom, the United States, Canada, and Denmark, among others. The Netherlands is the only European country where home births have been common for a long period. Here, the rate of home births has dropped from around 25% in 2005 to 13% in 2015, and women with uncomplicated pregnancies who choose to give birth in a hospital pay a fee of around 300 Euros. In Denmark, homebirths increased from approximately 1% to 3% between 2012 and 2016, and among nulliparous women around one third of planned home births end up in a hospital with varying levels of urgency. Approximately 8% of multiparous women are transferred to a hospital. The reasons behind the rise in home births internationally are unknown. Cultural beliefs, norms and practices certainly play a role when deciding where and how to give birth, and these can vary greatly, even within a region. A study from the Netherlands exploring ethnic differences for preferences of birth centre care showed that non-Dutch women preferred to give birth in centres with access to comprehensive care compared to Dutch women.1 A study from Spain showed that the use of intrapartum epidural analgesia in vaginal deliveries varied according to the geographic origin of women and was lower for all ethnic minority groups compared to the Spanish reference population.2 Another important factor is distance to the nearest hospital. Women living far from a hospital, who have previously experienced a very fast birth, could find it stressful having to reach the hospital in due time. Other women could find it distressing to plan for a home birth knowing that the hospital is far away in case a transfer becomes necessary. Some studies point toward the comfort of having a known midwife present during the entire course of birth, of giving birth in a “homely” environment, and having more control and decision-making power throughout the process3 as important to many women. The positive effect of continuous care has previously been well established in the scientific literature, showing that women who had continuous support during childbirth were more likely to have a spontaneous vaginal birth and shorter labour, and less likely to have intrapartum analgesia, cesarean section and instrumental vaginal birth.4 The increasing popularity of home births could possibly also be attributed to negative media attention toward busy hospitals with full maternity wards and staff under time pressure. Hospitals worldwide have been blamed by the World Health Organization for intervening unnecessarily in naturally progressing births, and the WHO has called for less unnecessary medical intervention for healthy pregnant women.5 Hence, the rise in home births could in some contexts perhaps be seen as a response to some health systems being under financial pressure and as a calm alternative to busy hospitals, where you have the midwife for yourself during the entire birth process. This could lead one to think of equality issues, since only healthy women with uncomplicated pregnancies are recommended to give birth at home, and the midwives undertaking home births are usually some of the most experienced, leaving the less experienced staff to deal with the more complicated deliveries. In line with this, the use of private doulas has risen both in Denmark and in the UK during recent years.6, 7 Both countries are experiencing financial cuts in the public health sector. A doula is a non-medical “birth-coach” who follows a woman's pregnancy, provides ante- and postnatal conversations and is present during birth alongside with a midwife to support the woman and try to give her the individual birth experience she wishes. In both countries, a doula costs up to around 2000 Euros. Solid evidence on the safety of home births is scarce and much debated. Some argue that hospital births lower the risk of neonatal mortality.8 Other studies show no significant differences in risk for healthy women giving birth in non-obstetric unit settings compared to obstetric units.9 Finally, other studies have shown that planned home births are associated with fewer intrapartum medical interventions.10 It is unfeasible to carry out a randomized controlled trial to study the safety of homebirths. Partly due to the high number of low-risk participants needed to observe a difference, since the serious adverse outcomes fortunately are rare, but also because of ethical issues in recruitment. However, several observational studies of varying quality have been carried out in different countries.11 The observational studies available are characterised by methodological challenges in obtaining adequate sample sizes, difficulties in defining a relevant reference group, and non-distinction between planned and actual place of birth. Furthermore, international studies are often not directly comparable as health care systems, midwifery training and the roles of midwives and obstetricians during childbirth are organised differently from country to country. In Denmark, midwives lead hospital births, and obstetricians or anaesthesiologists only intervene if needed. In Portugal, there is always an obstetrician present during a hospital birth, and the role of the midwife or nurse is auxiliary to the obstetrician. Discrepancies in data collection methods and the registration of reasons for transfers from home to hospital are other challenges. In some countries and studies, a planned home birth that is transferred to the hospital is registered as a hospital birth. In contrast, an unplanned home birth where the woman does not reach the hospital in time is registered as a home birth. This may lead to misleading data and conclusions, since it does not account for the planned setting of the birth. Finally, some authors argue that conclusions from the international literature on home births are influenced by the professional background of the authors,12, 13 and that obstetricians are generally less favourable toward home births than midwives. Typically, midwives highlight that giving birth is a natural process, and for women with uncomplicated pregnancies the risk of complications is not higher at home. Obstetricians seem to stand on the hospital side receiving the few cases that are transferred acutely and argue that it is an unnecessarily risky procedure. A Canadian study exploring maternity care providers’ attitudes on planned home births showed that the amount of exposure to home births during educational training was significantly associated with favourability. The study concluded that increasing knowledge and experience in handling a home birth during educational training might increase favourability.12 It is problematic to have two professional groups working side by side disagreeing on the safety of a procedure carried out on a daily basis. It is also unacceptable if the professional background of the authors might bias scientific literature. In a publicly financed health care system it should not be necessary for women to purchase private support in order to have a positive birth experience. If the choice of place of birth is legally up to the woman, the health care system should have the resources to accommodate this wish. Evidence-informed guidelines, high quality studies and standardised data collection methods are needed in the area of home births both in terms of safety and also regarding reasons behind the trends and women's needs, motivations and attitudes toward birthplace. Both women and health care providers deserve that.

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