In defense of home birth
Almost a decade ago, I called my mother to tell her about the birth of my daughter — her first grandchild. Her first question was: "Where are you?"
I'd recently confessed that I was planning to have my baby at home. Mom's eyebrows raised, but after reminding her that we could see the hospital from our apartment, she didn't try to dissuade me. "Just don't tell your father," she half-joked.
I live in the U.K., where home birth is, at least on paper, a mainstream choice. It is offered as an option by the National Health Service and is recognized by our leading obstetric and midwifery bodies as being safe and suitable for many women. The National Institute for Health and Care Excellence even says home birth is safer than hospital birth for some women with uncomplicated pregnancies.
Yet, women who choose to have their babies at home are frequently ostracized for their decision. One good and timely example can be found in the reactions to the news that Meghan Markle was considering a home birth for her and Prince Harry's first child. Her decision was labeled "risky" and "dangerous" by the press, and even "laughable" by obstetricians. These stereotypes are outdated, inaccurate, unproductive, and dangerous. They need to change.
There are many reasons a woman might choose a home birth. She may have had a previously traumatic birth in hospital or want to minimize her chances of an unnecessary intervention that could leave her with physical or emotional scars. She might feel more able to advocate for herself in a home setting, or be keen to get to know the midwife who will care for her. Or she may just feel safer and more relaxed in her own home.
By far the most common criticism aimed at home birth is that it is not safe, or not as safe as giving birth in a hospital. But the research contradicts this claim. In a 2011 study, researchers from Oxford University examined more than 64,000 low-risk births (i.e. births in which there were no complications during the pregnancy or leading up to the delivery) and found that, for women having their second or subsequent child especially, hospital birth was not any safer for their babies than home birth. A secondary study of higher risk women showed similar outcomes for babies at home as in hospital, and a higher rate of admission to neonatal units for hospital-born babies.
So, when it comes to birth in the U.K., the hospital setting doesn't appear to be safer than the home setting. What the hospital does offer, according to the data, is an increased number of unplanned interventions, such as caesareans or the use of forceps during birth. Such interventions can be life-saving in some circumstances, but when they are unplanned and even unnecessary, they can be physically and emotionally traumatizing for women. Fifty-four percent of low-risk first-time mothers who planned a hospital birth had interventions compared with 31 percent who started at home. I say "started" at home because roughly 45 percent of first-time laborers transfer to the hospital during their home births, but this is usually for non-emergency reasons.
Of course, there is never a 100 percent risk-free option in childbirth, only a balancing of risks and benefits based on a pregnant person's health, history, and preferences. One study did find a small but statistically significant increase in poor outcomes among first babies born at home. In this group, the risk of a poor outcome (a category that included the rare tragedy of stillbirth alongside conditions that might leave no lasting damage) increased from 5.3 per 1000 births to 9.3 per 1000 births. This is something all women need to know when planning where to give birth, even if other studies have found no difference at all. The hospital setting also offers pain management, such as the epidural, which is no doubt an important consideration for many women.
For me, home birth was a pragmatic choice, rather than ideological one. As my pregnancy progressed, I became less keen on the idea of giving birth somewhere I always felt on the back foot. I often came home from appointments disoriented, as if I'd been put through a spin cycle and spat out on the other side. Key questions went unanswered, and I was unsure of why I'd had particular tests. I considered home birth because I wanted to play a real part in decision-making, to be treated respectfully, and to feel as in control of my childbirth as possible. This decision was instinctive for me, but it also has some interesting science to support it. Research shows that giving a woman choice and control with regard to her labor and birth is associated with positive birth experiences and can mitigate birth trauma. This is hugely important, especially when we consider that rates of traumatic birth and postnatal depression are rising, and that suicide remains a leading cause of maternal death.
My home birth went as planned. I walked the neighborhood with my husband and, between contractions, we bought a milkshake from a late-night shake shack. I labored in my roll-top bath with the lights low, refusing to move. I was frightened when my body started to push involuntarily but the midwives stepped in and told me what to do. My husband breathed with me until, just as day broke, our child emerged.
I hesitate before saying that my home birth was wonderful. I've learned that positive experiences can be triggering for the 25-35 percent of women who found their labors traumatic. I also know that, as all birth choices are judged and policed, sharing my personal story can feel like an attack to someone who chose differently. But let me be clear: I do not promote home birth above other kinds of birth. I support all birth choices, and I've campaigned hard for access to caesareans at maternal request. No one knows what decisions are best or safest for someone else.
But that I need this caveat at all is the very reason why we must make home birth part of the conversation. The hysteria and the refusal to listen to the evidence surrounding home birth demonstrates how suspicious we are of giving women reproductive control and freedom. For some women, this freedom means staying at home, and for others it means electing a c-section or choosing an epidural. Perhaps home birth and elective caesarean provoke the strongest reactions because they show women taking control of the birth process.
My home birth was easy to arrange, but I was lucky. Despite the support for home birth on paper, many women in the U.K. still face arbitrary barriers, such as staffing issues and a lack of investment in home birth services alongside the critiquing of their choices. Critics cite the low home birth rate — between 2 and 3 percent of all U.K. births happen at home — as evidence that women don't want this kind of birth. But in services where home birth was funded and enabled in the same way as other options, that number skyrocketed to 40 percent. Perhaps women do want the option of home birth, they just don't feel supported in their choice.
In the U.S., accessing home birth is complicated. The options for having an out-of-hospital birth in America vary wildly from state to state. Insurance issues, licensing, mandatory pelvic exams, a lack of certified midwives experienced in out-of-hospital birth, deliberate barriers to transferring into hospitals, court-forced caesareans, and the for-profit system can all play a part in making home birth in the U.S. feel more radical and harder to achieve.
There is limited data on the safety of home birth in the U.S. But what data there is suggests a lack of support for home birth might actually make the practice more dangerous. Thus, the narrative that hospital birth is best and home birth is reckless is perpetuated.
For me, home birth was a wonderful start to motherhood. I hope one day soon a woman simply choosing to have her baby in the place that feels safest to her will be met with a nod and a smile rather than a global temper tantrum.