Home birth

INTRODUCTION

Home birth is a subject of ongoing controversy. The American College of Obstetricians and Gynecologists' (ACOG) position statement contends that birth should only take place in the hospital setting [1], a statement supported by a resolution passed at the 2008 American Medical Association meeting [2], whereas other health authorities, such as the American College of Nurse Midwives [3], and the American Public Health Association [4], have policy statements supporting the practice of out-of-hospital birth in select populations of women. Out-of-hospital births may be planned to take place at a home or a free-standing birth facility that provides exclusively low-technology care, usually by midwives, and is not attached to a hospital.

PREVALENCE

The United States National Center for Health Statistics reports birth rates based on state vital statistics records, which are determined from the Standard Certificate of a Live Birth (ie, birth certificate). Prior to 1989, births were identified as either occurring in or out of a hospital (eg, home, car, office). Since 1989, a specific category for home births was included on the Standard Certificate. Since 2003, birth certificates in some states have been changed to identify planned versus unplanned home births, although these results have not been reported nationally.

In 2006, there were 38,568 out-of-hospital births in the US: 24,970 were home births and 10,781 occurred in free standing birthing centers [5]. From 1989 to 2003 the rate of home births in the United States declined from 0.69 to 0.57 percent of births, or by an average of 0.01 percent annually. The 2006 figures represent a very slight increase in both absolute numbers and rate, reaching 0.59 percent of all births [5]. This rate is comparable to that in other industrialized countries with two exceptions: England has experienced a slight rise in its home birth rate from 1.0 percent in 1989 to 2.7 percent in 2006 [6], while the Netherlands has maintained rates of home birth of approximately 30 percent [7].

In the United States, 9 states had home birth rates at least double the US national average, including: Vermont (2.4 percent), Montana (2.3 percent), Alaska (1.9 percent), Idaho (1.5 percent), and Utah (1.3 percent). These states are predominantly rural states; however, some nonrural states also have relatively high rates: Oregon (1.6 percent), Pennsylvania (1.6 percent), Wisconsin (1.4 percent) and Washington (1.4 percent). In Wisconsin, the home births were disproportionately located in rural counties [8]. In Pennsylvania, a large Amish population, which has traditionally relied on home birth, accounted for some of the high rate of home births; Lancaster County had the highest home birth rate (14.0 percent) of any county in the US.

DEMOGRAPHICS

The table shows characteristics and behaviors of mothers who give birth at home (table 1) [8]. Mothers who had a home birth were predominantly white non-Hispanic, older, multiparous, native born, living in a nonmetropolitan county, and nonsmokers. They were much more likely to report not having had prenatal care. Such women could include unplanned, emergency home births, as well as mothers who wished to avoid traditional prenatal care. Educational levels were comparable between women delivering at home and in the hospital. A higher proportion of home births was full term.