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Considering a home birth?

May 01, 2013

The published a new policy statement this week that addresses the controversial and often polarizing topic of home births. The AAP stands in agreement with the American College of Obstetricians and Gynecologists (ACOG), stating that “hospitals and birthing centers are the safest settings for birth in the United States.” Both physician groups, however, also advocate for respecting the rights of a woman to make a medically informed decision about her delivery.

Planning a home birth is attractive to women for a variety of reasons. Some women desire a more comfortable, less clinical environment to experience such intimate moments. Others desire less medical intervention, and prefer to retain more control over their birthing experience. Many feel that a birth at home is a more natural and holistic way to experience the miracle of life. For these and other reasons, the number of home births has risen dramatically in the United States. Although home births still account for less than 1% of births in this country, there was a 29% increase in planned home deliveries between 2004 and 2009.

What’s the risk?

Newborn deaths are two to three times more likely to occur in planned home births in the U.S. than in planned hospital births. This doesn’t appear to be true in some other countries (one study conducted in British Columbia, Canada showed similar outcomes for newborns with home births compared to hospital births). The reason for this difference isn’t known but may be attributed to the lack of appropriately trained healthcare providers, lack of support and coordination within the healthcare system, or prolonged travel times to hospitals in case of emergencies.

Although hospitals and birthing centers are the safest place for delivery, the medical community acknowledges the rights and desires of those who choose to deliver at home. Because of the potential for considerable risk to the newborn, the AAP has established recommendations for families to consider that will help provide for the health and safety of their newborn if they choose a home birth.

Women who are appropriate candidates for a home delivery:

  • Do not have any preexisting diseases
  • Have not developed any diseases during pregnancy
  • Carry a single fetus which is the appropriate size for its gestational age
  • Carry a fetus with cephalic presentation (the head is positioned to enter the  pelvis first, as opposed to breech or shoulder positions).
  • Completed 37 weeks to less than 41 weeks of gestation
  • Experience spontaneous labor or labor induced as an outpatient
  • Have not been referred from another hospital

Necessary support systems for a planned home birth:

  • The delivery should be attended by a certified nurse midwife, certified midwife or physician
  • Each delivery should be attended by two individuals, with one person whose primary responsibility is care of the newborn. This person should be appropriately trained and capable of performing a full resuscitation of the infant if necessary
  • Access to communication (i.e. a working telephone) for medical consultation if needed
  • Access to reliable and timely transportation to a hospital in case of emergency. A planned arrangement with a medical facility should be established prior to delivery. Travel times greater than 20 minutes to a hospital facility are associated with greater risk of harm and death of the newborn.

How do I determine whether my midwife is appropriately trained?

When planning a birth at home, one of the difficulties families often face in following these recommendations is determining whether the midwife they’ve chosen is in fact certified and appropriately trained according to the standards of the AAP and ACOG.

There is more than one governing body that provides accreditation for practicing midwives, but both physician groups advocate utilizing only midwives who have been certified by the American Midwifery Certification Board. Those who have been accredited by this group are known either as certified nurse midwives or certified midwives. Those midwives accredited by other groups are identified as certified professional midwives, and they are not endorsed by the AAP or ACOG.

If you’d like to find out whether the midwife you’re considering is accredited by the American Midwifery Certification Board, you can verify the licensure of your healthcare provider here:

American Midwifery Certification Board Instant Verification

Caring for your newborn immediately after birth

Immediately after birth, your healthcare provider should provide the infant with transitional care for the first 4-8 hours after birth. This includes warmth (often through skin-to-skin contact with the mother), a detailed physical exam including Apgar scores and ongoing monitoring. If the baby requires help breathing for more than 30-60 seconds or is less than 37 weeks gestation, he should be transferred to a hospital for monitoring.

Other aspects of care that should take place within the first hours after birth are:

  • Monitoring for group B streptococcal disease
  • Glucose screening
  • Eye prophylaxis (antibiotics given to prevent eye infections)
  • Vitamin K injection
  • Hepatitis B vaccination
  • Assessment of breastfeeding
  • Screening for hyperbilirubinemia
  • Universal newborn screening
  • Hearing screening
Keep in mind that as a new parent, it may not be practical to address each of these issues within the hours after birth. If you choose to have a home birth, discuss this list of care provisions with your midwife and your pediatrician before delivery to ensure that your baby gets all of the necessary care. And be sure to follow up with your pediatrician (and bring all of the records from your delivery) within 24 hours of the baby’s birth.

Would you choose to have a home birth? Why or why not?