With a growing number of American women choosing to give birth at home or in birthing centers, debate is intensifying over an important question: How safe is it to have a baby outside a hospital?
The study analyzed nearly 80,000 pregnancies in Oregon, and found that when women had planned out-of-hospital deliveries, the probability of the baby dying during the birth process or in the first month after — though slight — was 2.4 times as likely as women who had planned hospital deliveries.
On the other hand, out-of-hospital births were far less likely to involve cesarean sections — 5.3 percent compared with 24.7 percent in a hospital. They also involved fewer interventions to augment labor, and mothers had fewer lacerations.
In the often polarized debate over home birth, the study has been embraced by advocates on all sides.
Mary Lawlor, the executive director of the National Association of Certified Professional Midwives, who has criticized research that reached similar conclusions, called the new study “very well done” and said “the overall statistics are pretty darn good. But, of course, when the lives of babies are at stake, we need to do everything we can to constantly learn from the data.”
Dr. Joseph Wax, the vice chairman of the American College of Obstetricians and Gynecologists’ committee on obstetric practice, said the study showed “there’s clearly pros and cons to the different available birth settings, both with benefits and risks to moms and babies.”
A tiny fraction of United States births occur outside hospitals, but they have been increasing, partly because some women want to avoid interventions like induced labor or cesarean sections. In 2012, according to federal data, births at home and birth centers amounted to 1.28 percent of all American births, up from 0.79 percent in 2004.
The study was strengthened by key information recently added to Oregon birth certificates: where women planned to give birth, not just where they ended up delivering. That disclosure allowed researchers to separate out births that started at home or birthing centers but had to be transferred to hospitals.
The study team, based at Oregon Health and Science University and including two obstetricians, a nurse, an epidemiologist and a certified nurse midwife, also adjusted for women’s race, age, and pregnancy risks like diabetes or hypertension, so those factors could be ruled out as explanations for delivery problems.
Jonathan Snowden, an epidemiologist who was the lead author, and his colleagues analyzed 79,727 births in 2012 and 2013 in Oregon, which, with Vermont, has the country’s highest home birthrate. They excluded births involving twins, birth defects, breech or premature delivery. Of those, 75,923 women delivered in a hospital as planned; 3,203 delivered outside a hospital as planned, including almost 2,000 at home; and 601 women planned out-of-hospital births but were transferred to hospitals.
Severe complications were rare in all locations, but in planned out-of-hospital births, 3.9 out of 1,000 cases resulted in a baby’s death during the birth process or within four weeks afterward, compared with 1.8 deaths out of 1,000 in planned hospital births. There were 15 deaths among the planned out-of-hospital births and 137 deaths among the planned hospital births.
“The question is what is most important to you and what risks are you willing to accept,” said Dr. Michael Greene, the chief of obstetrics at Massachusetts General Hospital and an associate editor of The New England Journal of Medicine. He added, “We’re not going to pat women on the head and tell them what to do.”
Ellen Tilden, a certified nurse midwife practicing in a hospital who was an author of the study, said she hoped the results “will be used to think about decreasing risk in all birth settings.”
Erin Dietrich would welcome that. Ms. Dietrich, 35, had her first child in 2011 at a midwife’s house in isolated Otis, Ore. She said she loved the “hippy kind of alternative birth thing,” but suffered a “pretty bad tear” that the midwife did not treat. “I was in a lot of pain for a long time until I finally saw a regular doctor.”
For her second child, she chose a big Portland hospital with a bathtub-equipped birthing suite and a nurse midwife. But when she arrived, she had to wait for a room and received notably less individual attention, she said.
Still, when she had a tear, “they stitched me right up and I healed so quickly and I felt great,” Ms. Dietrich said. “I was shocked: This is what actual care can do.”
Anna Hope-Melnick, 32, is a labor and delivery nurse at a hospital in Hillsboro, Ore., but wanted a home birth in 2012 because in the hospital “it’s not just about the one-on-one needs of the family; it’s about the whole overarching system.”
But after her water broke and she labored for 40 hours at home and developed a fever, her midwife told her to go to a Portland hospital. That “was absolutely the right choice,” she said and she gladly accepted the drug Pitocin, to jump-start labor, and an epidural to help her relax. Even so, she said hospital staff members overreacted to some symptoms.
“They kind of assumed that we were idiots, and why would you stay home for 40 hours?” she said. When her daughter was born, “she was showing no signs of distress, but they went full-court press with breathing tubes, suctioning” and neonatal intensive care, she said.
For the second child, Ms. Hope-Melnick, who said she hoped to become a midwife, delivered at home without much difficulty.
Dr. Aaron Caughey, a co-author who heads the university’s obstetrics department, said the researchers consciously adopted a nonjudgmental tone so critics would not say that the in-hospital providers were demonizing out-of-hospital births.
“We’re never going to make it equally safe, because there’s always emergencies that can occur,” he said. “The biggest thing is going to be improving the trust between hospital providers and out-of-hospital providers.”
Melissa Cheyney, a certified professional midwife in Oregon who also heads the Midwives Alliance of North America’s research division, said she appreciated the study’s results and its tone.
“As long as we have divisive debate, I’m not sure how much progress we’re going to make in making it possible for women who are going to choose home birth anyway to have a safe outcome,” she said.
Ms. Cheyney said hospitals could become less interventionist to “remove some of the desire that women have to go outside the hospital,” and at the same time, “We should turn the lens on ourselves and ask how can we provide better care.”