Episode 163 - Is homebirth a good choice for you?
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host,
[0:03] Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD. And each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey. Welcome to today's episode of the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson and today we're talking about home birth and if it's a good option for you. As many of you already know, I myself am a private midwife here in Australia. I'm an endorsed midwife and I've been working in this way for 17 years. I still attend home births. I'm a clinical midwife and a large part of my academic career has been spent researching birth at home and researching the maternity care system. So today I'm doing a broad sweep of some of the research papers around home birth outcomes and I'm going to focus on the bigger ones but there are over 40 references listed on the resource folder for this episode of the podcast.
[1:15] This is an area that I've researched over many years so I was able to draw on lots of the research. Obviously we can't cover it all today but I'm going to cover some of the bigger research papers that look at physical outcomes. Of course, there are also the social, emotional, cultural and mental outcomes
[1:33] as well as physical outcomes when it comes to birth. And we know that emotionally, socially, psychologically, culturally, home birth offers an incredible amount of safety. And we can talk about that in another episode today. I'm focusing on physical outcomes because that's what everybody's wondering about. Now my PhD research was called Birthing Outside the System and in writing that and in writing the other research papers that stem from that over the last 10 years I've become very familiar with home birth culture practices, the industry and the academic literature. So today I'll not only be drawing on my clinical experience but also from the academic literature as we look into the topic of home birth.
[2:21] Now, I'll start with some definitions and explanations of what home birth is, and then I'll look at some of the home birth literature and research to help you decide if home birth is a good option for you and your baby. Today, I'll be looking at the research on women who are considered low risk and planning a home birth. And in another episode, I'm going to cover what happens when you choose to give birth at home if your pregnancy is complicated by some risk factors or some complicating factors. I did think ambitiously that I would be able to discuss low risk and high risk home birth in the same episode. I don't know why I thought that, but that was my intention.
[3:02] As I was writing this, it became very obvious that it needs to be done in two parts. So the second part on more complex home birth will be coming in later episodes. Now for too long, research findings have focused on the outcomes of the babies. So I'm really going to highlight the difference between outcomes for both women, for the baby's mamas, and the babies. And medical people for too long have prioritized the outcomes of the baby over the woman. And more and more in maternity care, we are witnessing the disregard of women's experiences in childbirth. So the research about the safety of home birth often reports only on the baby's outcomes, and it seems to put them as more important, higher priority than the experience and outcome for the woman. And that's why people say that home birth is considered as safe, if not safer than giving birth in hospital.
[3:59] However, that statement only applies if you're looking at newborn outcomes.
[4:06] If we want to describe the outcomes for women themselves, the results are very different. And I'm going to be so bold to say straight off the bat that I believe, based on my collective knowledge, research, and experience, that home birth outcomes for women across all parameters of safety and experience are way better for women who give birth at home compared to those who give birth in hospital. And that's not to say that hospital birth is not safe. I'm saying that overall, on a statistical level, women come out in much better condition from home-based care with a midwife if we compare that to hospital-based care. Now, of course, and I'll go through the research on this, this is not a baseless statement.
[5:02] And what I'm also not saying is that home birth is appropriate for every woman. But in this episode and in following episodes, I'll share what I know from my experience and from the evidence to help you determine what might be the best for your circumstances. And social messaging around birth is that the mother should sacrifice herself for the good of her baby. But what if there was a way for both the mother and the baby to come out of birth well, where no one had to compromise their body, safety, or experience. So we'll talk about that more as I explore the question, is home birth a good option? And as usual, if you are keen to read the research papers for yourself, you have access to the podcast resource folder if you're on the mailing list. So the details are in the show notes. If you haven't already put yourself on the mailing list, you can get access to that through the link in the show notes.
[5:57] Okay, let's answer the question. Is home birth a good idea? And here's where I make a broad sweeping statement and then spend the next little bit of the podcast justifying it. But from what I can see in the research and in clinical practice in almost all birth scenarios, excepting a few higher risk scenarios, the women who choose to give birth at home are by far better off physically, emotionally, socially, mentally, spiritually than women who give birth in hospital when you compare maternal outcomes across the whole spectrum. There is not a shadow of doubt in my mind that for most women, home is far better for their well-being and safety than going to hospital. And I'm speaking from the perspective of research in high-income countries where women have access to medical care and where there's not issues of malnutrition and poor access to health care. Of course, there are some pathological reasons that cause women to become sick during labour and birth and in these scenarios women would be better at hospital. But.
[7:04] There's no doubt at all from the research that women do much better themselves having been cared for by a midwife in their home. Even if they were planning a home birth and end up transferring to hospital, their outcomes are still undoubtedly on the whole, statistically speaking, better than if they were planning to give birth in hospital. And I know some women are saying, I could never have given birth at home. I would have died if I had given birth at home. I had to give birth in a hospital. Well, that's good. That's where you should have given birth. But the majority of women don't need that. The majority of women don't have complications that are life-threatening but medicalized people will tell you that medical management of birth is the only safe and appropriate option but that's because their ideology and perspective and their experience in highly medicalized settings where things go wrong more often than they go wrong at home that's what is informing that opinion. It's not because they've read and understood the research because if they had, they would have a different opinion.
[8:06] But before we look at specific research articles, I want to quickly justify the research methods that are used to explore home birth outcomes and why it's important to sort of understand this when comparing home to hospital birth.
[8:22] So if you've been a long-term listener of the podcast, you will have heard me talk about the Cochrane Database of Systematic Reviews, which is quite an authoritative publication that usually compares collections of randomized controlled trials on particular topics and they pull that information. So certainly when you look at interventions and medications, randomized controlled trials are a good option because they typically have a control group. So they work out what happens when you give nothing or a placebo compared to providing an intervention and they control for confounding factors and often they're blinded to prevent bias from the research team and the participants and they're considered a very rigorous way of researching a very narrow and focused topic area.
[9:12] Now, the Cochrane Database of Systematic Reviews recently broke with their tradition of using randomized controlled trials to write their papers. They usually only use randomized controlled trials as the sources of their systematic reviews. The reason they broke with tradition was in order to discuss the topic of home birth for low-risk women. Cochrane is considered an authoritative publisher of high-quality and accessible research, and their publications are considered by academics as quite high quality and rigorous. So let's have a look at what they said about home birth for women at low risk of complications in their pregnancy and birth. So instead of using randomized control trials, of which there are none of high quality, there's a few of them, but they're tiny, the reason there's not many randomized control trials is because it's unreasonable to force women into a birth location over another for the purpose of research. So when you do a randomised control trial, the participants don't get to choose where they would go. They would have to be randomised to home or hospital. And it's considered unacceptable to women. So it would never work as a study design. And so the Cochrane database proposed that observational studies.
[10:30] So where you just look at what happens in a home birth versus a hospital birth, observational studies are the best way to review home birth outcomes. And what that means is that the best quality evidence we can hope to use when assessing home birth is to use studies that basically watch and record what happens to women and their babies when they choose home birth and then report on the outcomes.
[10:56] So to begin their paper that the Cochrane Database wrote, well, the authors wrote it. It's obviously it's published on the Cochrane Database, but it's called Planned Hospital Birth Compared to Planned Home Birth for Pregnant Women of Low Risk of Publications. And it was published in 2023. You can get the full text in the resource folder.
[11:17] And they said, observational studies of increasingly better quality and in different settings suggests that planned hospital birth in many places does not reduce mortality and morbidity but increases the frequency of interventions and complications.
[11:35] Europeristat, which is part of the European Union's health monitoring program, has raised concerns about the iatrogenic effects of obstetric interventions. Now, what that means, an iatrogenic effect is a medically caused effect. So they've raised concerns about iatrogenic effects of obstetric interventions. And the World Health Organization has raised concern that the increasing medicalization of childbirth tends to undermine women's own capability to give birth, and then it negatively impacts on their childbirth experience. So in their paper, they first identified an issue that seems to be that the hospital as a place of birth is not having the desired or advertised effect to reduce mortality or death or morbidity. So morbidity is an illness or injury, but it's actually having the opposite effect where we're now seeing an increase in the use of interventions and also complications as a result of medically induced, it's a medically induced situation.
[12:50] So knowing this, Cochrane set out to write a paper that would help understand the impact of hospital birth in comparison to home birth and wrote as part of their conclusion to that, that the International Federation of Gynecology and Obstetrics and the International Confederation of Midwives collaboratively conclude that there is strong evidence that out-of-hospital birth supported by registered midwife is safe. Given the weight of the research, randomized control trials may now thus be considered unethical or hardly feasible and frankly unnecessary given the quality of the observational research. What they're saying is that the International Federation of Gynecology and Obstetrics and the International Confederation of Midwives have collaboratively agreed that there's strong enough evidence for home birth with registered midwives as being safe and that we don't need to focus on a randomized control trial to get any more information because there's a number of quality observational studies.
[13:59] Not only that, this Cochrane article states that it is of historical interest to note that the transfer of low-risk births from home to Hospital in the 1960s, despite the lack of high-quality evidence, was one of the pivotal issues when Archie Cochran laid out the ideological ground for the Cochran collaboration.
[14:22] Cochran awarded the wooden spoon to obstetrics because, and I quote.
[14:30] The specialty missed its first opportunity in the 60s when it failed to randomise the confinement of low-risk women at home or in hospital. Then, having filled the empty beds by getting nearly all pregnant women into hospital, the obstetricians started to introduce a whole series of expensive innovations into the routines of pre- and post-adal care and birth without any rigorous evaluation. The list is long, but the most important were induction, ultrasound, fetal monitoring, and placental function tests. What they're saying is, is that in the 1960s, when hospital birth became the more popular choice for a historical range of reasons, that obstetrics had an opportunity to study who would be better off at home and who would be better off in hospital. And they missed that opportunity and simultaneously they introduced a list of unqualified, untested interventions into the care of these women. So the relationship between hospitalisation, childbirth and intervention is still an important issue and I'm quoting here.
[15:46] There is a concern about the iatrogenic effects of obstetric intervention in women who do not have a clinical need for it, and this has put the restoration of normal birth firmly on the agenda for the 21st century.
[16:01] And those are the words from the Cochrane database. The World Health Organization now explicitly expresses concern that there has been a substantial increase over the last two decades in the application of a range of labour practices to initiate, accelerate, terminate, regulate or monitor the physiological process of labour and birth.
[16:24] So if hospital is not where it's at and there are growing concerns in the funneling of every pregnant and birthing woman into hospitals we have to explore alternative options and that's what we're doing today we are looking at home birth so let's get started what is home birth, Well, a home birth is a planned birth at home or just outside of a formal birthing institution like a hospital or birth centre. And there's a plan to have a qualified healthcare provider present whose job it is to provide clinical care and midwifery care to the woman and her baby. Now, home birth around the world can look different. Here in Australia, midwifery is regulated. So you will be attended by a university trained and registered midwife with a set of standardized skills and the midwife is capable of managing a range of emergencies. However, in other places in the world, you might be attended by a traditional birth attendant with midwifery skills and they might be the main care providers at home, particularly in lower income countries.
[17:34] And in the USA, midwifery is not heavily regulated and the rules and laws and training differ from state to state. So it's harder for women to know the skill and scope of their midwife and the midwives will vary in their level of access to medical equipment and clinical skills. So while in some countries home birth is facilitated through the mainstream maternity care like a lot of places in Europe and the UK and the Nordic countries, it is integrated into the public health service, in other countries, it's a fringe decision that requires women to pay out of pocket for a private midwife or some places it's illegal to plan a home birth with a care provider.
[18:19] So here in Australia, and it might be different wherever you're listening from, there are two ways to access home birth. It can either be through a publicly funded program where you can apply to be on the home birth program at your local hospital. There are not many publicly funded programs. So only around 15 to 20, the number fluctuates. That's over the whole country and they have a very strict acceptance criteria. So if you develop complications that don't align with the program, then you might not be allowed to stay on the program and be planning a home birth. So while this option is free to you financially, there's still some uncertainties and they are very difficult to access, particularly if you have complex health needs or you live in an area that doesn't have a publicly funded home birth service. So if you can get on a publicly funded home birth service, it means that you get cared for by a team of midwives who you'll meet over the course of your pregnancy and then they come to your home for the birth postnatal care.
[19:26] However, because they are employed by the hospital, they are required to adhere to workplace policies and guidelines. So the rates of transfer in a public home birth program are possibly higher than a private home birth model because the midwives are bound by the requirements of their workplace. So in a public home birth model, there would be two midwives at your birth, which is the same if you hire a private midwife. You'll have two midwives at your birth and that's a requirement here in Australia. It could differ where you are.
[20:03] Now, there is some research about the publicly funded home birth programs here in Australia and the outcomes of these services. And this particular paper that I'm looking at is called Insights from a Publicly Funded Home Birth Program. And it was published this year in 2025 by Cheryl Sidery and her team, which you may have heard on the podcast before. And it's available in full text in the resource folder. If you want to have a look at that one, you can get access to the resource folder through the show notes. So the Royal Hospital for Women in Sydney, here in Australia, pioneered a new home birth service within their facility, and they reported on the first 100 births through that service. So although it was only 100 women, the researchers matched the 100 women who birthed at home with 100 women that had similar characteristics and demographics who birthed in the same hospital as where the home birth program was hosted. But even more interestingly, this study is the first of its kind because it compared the hospital outcomes to the outcomes of women who birthed at home. But in both groups, the women were cared for through the same midwifery group practice. So same care providers, thus different location, same type of women.
[21:24] So the same midwifery group practice was responsible for the care of all the women in the study but some women chose to give birth at home and some chose to give birth in hospital so this is unique because there is a comparison of women who are matched to be the same the same as possible have the same care providers from the same group practice and the same collaborating obstetrician so they're controlling for the influence of the care provider because we know that care providers influence the outcomes of birth. That's one of the big elements, the care provider and the location. So they've managed to control for the care provider influence. And that means we're more likely to be able to measure the impact of what just changing the location, just giving birth at home, can do to difference in outcomes compared to hospital because the main differing factor between the two groups was the location. So then they reviewed the data and they were particularly interested in eight things. Normal birth rates, caesarean births, instrumental births, postpartum hemorrhage over a thousand mils, APGAR scores.
[22:37] Birth weight, any major perineal tears, so third or fourth degree tears to the perineum, and episiotomy. And these things happen frequently enough to be suitable for a small study size of 100. But this study was not powered enough in the numbers to capture rarer occurrences like the death of a baby or the death of a mother. These are considered rare circumstances. You would need hundreds and thousands of participants to be able to accurately calculate maternal and newborn deaths and injuries. So these weren't measured in this study, but there are studies that have done that and we will do that later.
[23:18] So what did they find? What difference did it make for women who planned a home birth compared to women who planned a hospital birth? Remembering they were matched and they had similar risk factors and levels of complications. These were low risk women and they were all cared for by continuity of care midwives the only difference was the birth location and obviously they were only included in the study if their labor started on its own otherwise they wouldn't be at home if they were being induced so let's have a look at how the women and the babies did just by changing their birth location but being cared for by the same midwifery group practice. So the birth and neonatal outcomes. In home birth, the normal birth rate, so zero interventions, was 88%. Low-risk women cared by midwives at home. Now the rate of normal birth for women who were low-risk cared by midwives in hospital was 73%. So that's 88% compared to 73%. That difference you're seeing relates to the location of birth.
[24:27] The number of women who needed an assisted birth, an assisted birth means those who required a vacuum or forcep extraction, 7.7% if you were planning a home birth, 16% if you were having a hospital birth. So that's double just by being in hospital.
[24:50] Episiotomy rate, so where they cut your perineum at the time of birth, 6.8% if you were planning a home birth, 18% if you gave birth in hospital with the same midwives, with the same risk profile.
[25:06] Caesarean section, so this is in labour, caesarean section, 4.2% if you were planning on giving birth at home, 10.9% if you planned to have a hospital birth. APGAR score, so an APGAR score is a score we give the babies about their condition at birth. Anything over than seven is considered all good, no drama. Less than seven is where the research starts to consider if the baby's compromised. So 100% of babies born at home had an APGAR above seven in this group and 1%. So six babies also had an APGAR below seven if they were born in hospital. Let's look at postpartum hemorrhage. And this is a hemorrhage blood loss over 1,000 mils. If you're at home, 2.54%. In hospital, 5.66%. So that's about double, again, risk of over 1,000 mil blood loss if you give birth in hospital compared to home. Now, let's look at intact perineum. So did not tear at all. 23% of women who gave birth at home did not tear at all. If you gave birth in hospital, the number of women who did not tear was 9.4%. So again, double, more than double the chance of having an intact perineum for the women who gave birth at home.
[26:34] Major perineal trauma, so third or fourth degree tears. At home, it was 2.6%, which is pretty consistent with the usual third and fourth degree tear rates. At hospital, 4%. Again, an increased risk. So this study, although it only had 100 women, showed what larger international and local studies have shown. And the authors suggest that women are more likely to have a normal physiological birth without interventions if they birth at home, along with improved outcomes that they experience for themselves as a result of less intervention. And this just shows the safety of giving birth at home for women, but also for the babies. good outcomes all round and better outcomes for the women who gave birth at home than in hospital. Remember, they're all low risk and they all had the same maternity care providers. So the difference is demonstrated in the location.
[27:32] So yes, a smaller study but unique in its design and it found the same as larger studies. So, but we're not going to stop there because there are much larger studies we can refer to when we're asking questions about the outcomes for women and babies. Another interesting thing about that study is that this publicly funded home birth program was unique in that the midwife who mentored these midwives into home birth practice was an experienced private home birth midwife herself. So the hospital midwives were able to learn from a private midwife as they were mentored into caring for women outside of hospital because a lot of midwives have not got experience in caring for women at home. And this was unique because this group of midwives were mentored by a private midwife, an experienced one. I wonder if that made difference to the outcomes. But this paper attributes this type of mentorship to the success of the program. And the authors are keen to explore how impactful the expert mentorship is on the home birth outcomes. Now, another study done here in Australia with reference to publicly funded home birth programs, and this was done when the publicly funded home birth programs were more in their infancy.
[28:53] And it's called Publicly Funded Home Birth in Australia, a review of maternal and neonatal outcomes over six years. And it was done in 2013. So about 15 years ago. And this was the first national evaluation of a significant portion of women who were choosing publicly funded home birth in Australia. And nine of the publicly funded home birth programs in Australia provided data.
[29:20] And they collected 1,807 women's information. These are the women who intended to give birth at home at the onset of labour. Now, 84% of women in the study who planned to give birth at home did give birth at home. So there was a 17% transfer rate to hospital during labour or within a week of giving birth. So things can happen in the week after that maybe require some medical attention. Obviously, there was over a thousand babies in here. So we could make a few conclusions about the possible stillbirth or early neonatal death rate.
[29:59] So the rate of stillbirth or early neonatal death, so within the first seven days of birth, was 3.3 per thousand births. But when they excluded the expected fetal anomalies, so there were some babies who had anomalies where they weren't expected to survive birth, when they excluded those, the stillbirth and early death rate was 1.7 per thousand. And the rate of normal birth was 90%. 90% of the women had a normal vaginal birth without interventions. Now, for comparison, I did have a look at the Australian Institute of Health and Welfare Statistics on Stillbirth. And this is the Australian Mothers and Babies Report. And I brought that up for 2013 to check what the usual stillbirth and neonatal death rate might be.
[30:54] And in 2013, at the time this paper was released, the stillbirth rate in Australia was 7.1 per thousand. So that's just for reference. Of course, this included babies with deformities and prematurity, but it gives some comparison. So just saying that the 3.3 in 1,000 stillbirth and early neonatal death rate is somewhat equivocal. It's not a higher than expected rate. So that's some of the research on the publicly funded home births here in Australia.
[31:27] And in countries like the UK, where midwives are more able to facilitate planned home birth as part of a public maternity care system and where the population is larger, they're able to do more extensive study. And that included huge numbers of women. So let's have a look at the Birthplace in England study. That's the common name for the study but if you're interested in having a look at this one yourself it's in the podcast resource folder as a full text paper and it's called perinatal and maternal outcomes by planned place of birth for healthy women with low-risk pregnancies the birthplace in england national prospective cohort study so this one is cool because it compares outcomes across three locations, home, birth centers, and hospital births. And it also breaks the birth centers up into a detached birth center that's away from a hospital or an attached birth center that's either attached or very close to the hospital, affiliated with the hospital.
[32:31] They only looked at low-risk women. And it was also helpful though that they commented on the outcomes for women who are having their first baby compared to subsequent babies to see if there was a difference. Now, we know that there is often a difference between the first birth, it can be a lot harder, than subsequent births. So, this study broke up the findings between first babies and subsequent babies. Now, this study was a prospective cohort study, which means the study participants were tracked over a period of time, and women were included in.
[33:09] The study group, depending on where they planned to give birth at the start of their care. So regardless of whether they were transferred during labor or not, or immediately after birth, they were still included in the home birth group, which is a good, for those out there, that's a good way of looking at outcomes.
[33:27] The authors also compared each of these groups, birth center, home birth, and hospital birth. They compared those to an obstetric group of the same type of women, low risk, that were cared for in hospitals in an obstetric unit where it's more doctor-led care. And they wanted to establish whether the outcomes differed for women who were receiving midwifery care compared to obstetric care, even though they were all low risk. The outcomes that they were looking for were grouped together when they examined the findings. So we call this a composite outcome. So there's some really, again, rare occurrences that happen in birth and that includes things like stillbirth, death after the baby is born, certain complications are a lot more rare and so in order to study them effectively or to not need millions of people in a study you can group them together and when you do your report you report on how many of those instances happened collectively. So the first thing they were looking for what we call the primary outcome, if you're reading along on the paper, the primary outcome they were looking at was.
[34:40] Specific to perinatal mortality, which was a combination of any death of a baby relating to stillbirth after 28 weeks of pregnancy and spanning all the way to a death of the baby within the first seven days of life. And they also included in this composite counting, less serious outcomes within the same group. So these were relating to things like injuries or illness of the baby once it was out and it included neonatal encephalopathy, meconium aspiration syndrome.
[35:13] Brachial prexis injuries which sometimes happen with the shoulder dystocia, fractured humerus, same thing if there's a difficult extraction, fractured clavicle of the baby, again, usually relating to shoulder dystocia. So they included in this one group anything from death at 28 weeks of pregnancy, which is obviously very serious. And that was major outcomes all the way down to a fractured clavicle. So these were all counted in the same composite group because of how rarely they occurred.
[35:49] Now, the secondary outcomes, so kind of the other stuff they were looking for, were other various combinations of neonatal and maternal morbidities and interventions. So they counted the mode of birth. So did the baby come out of the vagina or cesarean or episiotomy, forceps, vacuum? I won't list them all out. We've got a lot of studies to get through, but you can see in the full article resource folder if you're on the podcast mailing list, all the details. So the researchers on this particular study, the Birthplace in England study, collected data on nearly 80,000 eligible women of who about 65,000 were low risk and they were from 142 of the 147 birthing services in England. So they captured 97% of the services in England. They captured 95% of freestanding maternity units, 84% of midwifery units that were alongside a hospital, and they had a sample of 36 obstetric units. So there was a lot of birthing services and sites included in this study, and that's how they could collect data on so many women's births. So let's have a look at what they found. Okay.
[37:06] They reported on outcomes for all the women, whether they were considered high risk or low risk, and then they isolated the findings for the women who were considered uncomplicated so that we could get an idea of the outcomes for low risk women,
[37:21] but also all women, regardless of their risk factors. And in our next episode, where I talk about more complex home births, we can draw on the data that they gathered for higher risk pregnancies from this birthplace in England study. So we'll look at that later, but we're going to look at the low-risk outcomes first. So let's have a look at how women went. And this can be measured by the number of women who experienced what the study called a normal birth. So they defined a normal birth as a birth without induction, epidural, forceps, vacuum, cesarean section, or episiotomy. So the baby came out under the woman's own power, no cuts, no surgery, no instruments, no medication.
[38:08] And the normal birth rates are an indication that the women also did better emotionally as well as generally because women who have fewer interventions and interruptions in their labor are less likely to interpret their birth as traumatic. That's not just me making it up. There's research papers that correlate to the number of interventions that you have and the amount of childbirth trauma that you have. So the less interruptions, the less interventions means less likelihood, theoretically, and as we've seen in the studies, literally, of having a traumatic birth experience, but also experiencing fewer complications because lower intervention births don't have that iatrogenic gathering of risk and complications. applications.
[39:03] So let's see the normal birth rates by location. So for low-risk women, if you give birth in an obstetric unit, based on this study in the UK, there's a 62% chance of a normal birth. If you're the same type of woman cared for by midwives at home, 89% chance. So 62 versus 89. Now, the closer you get to a hospital, so in a birth center, the lower your rate of normal birth gets. So a freestanding birth center or a freestanding midwifery unit is an 84% normal birth rate.
[39:47] And if you go to a unit that is alongside a midwifery unit, so alongside a hospital, it's 77. So the lowest chance of a normal birth, if you have a low-risk pregnancy, based on this study, is with an obstetrician in hospital, 62%. If you move a bit further outside of the hospital to an attached birth center, 77%. If you move further away from the hospital to a freestanding midwifery unit, it's 84%. Further again into your own home is the highest chance of a normal birth at 89%. Now let's break this down a little bit further. So if you want to just look at spontaneous vaginal head down birth, there may have been some interventions in there, for example, like an epidural.
[40:38] If you go to an obstetric unit, 73% chance of a head down normal birth. At home, 92%. Freestanding birth unit, 90%. Alongside birth unit, 85%. Again, these mimic the same idea that the further away you get from hospital, the more likely your chance of a spontaneous vaginal birth without intervention. Let's look at breech births. If you give birth at home, 0.4% vaginal breech birth. If you give birth in a freestanding midwifery unit, same, 0.4%.
[41:18] If you give birth in a midwifery unit that's attached to a hospital, you half your chance rate of a vaginal breech birth, 0.2%. And that's the same as if you give birth in an obstetric unit, 0.2%. So more chance of a vaginal breach birth if we give birth at a hospital. Let's look at vacuum birth.
[41:43] And again, we'll start in hospital with an obstetrician as a low-risk woman, 8.1%. Low-risk women, 8.1% cared for by an obstetrician would have a vacuum. If you are in a birth unit that's alongside a hospital, that's around half, 4.8%. If you move further out of a hospital to a freestanding maternity unit, 2.7%. And again, the least chance of a vacuum is if you plan to give birth at home. Obviously, we don't do vacuums at home. You would be transferred into hospital. The vacuum would happen there. But they counted the stats based on where you planned to give birth. So even though they gave birth in hospital, they still had a reduced chance if they planned a home birth. Let's look at four steps. Hospital, 6.8. Birth unit attached to a hospital, 4.7. Detached birth center, 2.9. And 2.1 if you gave birth at home. Same stats, the same thing is true. If you give birth in hospital, it's the most likely chance of intervention. And it gets less and less and less the further that you get away. Now, cesarean section during labour. So this is not one that you needed beforehand. This is during labour. If you're at hospital, 11.1%. A birth centre attached to the hospital, 4.4%. A birth centre away from the hospital, 3.5%. And at home, 2.8%.
[43:09] The story is the same for third and fourth degree tears, most likely in hospital, least likely at home and a sliding scale. Blood transfusion we give blood transfusions if you've lost a lot of blood the most chance of you needing a blood transfusion due to profuse blood loss is in a hospital, and your least chance is if you're in a freestanding birth center it's ever so slightly better than home 0.5 versus 0.6 but you're twice as likely to need a blood transfusion if you give birth in an obstetric unit as a low-risk woman. At home, the blood transfusion rates were 0.6%, needed a blood transfusion. If you go to hospital, it's 1.2%, so double that. You know, hospitals often are touted as the place to keep safe if you have blood loss, but what this is showing is that you may be more likely to have excessive blood loss if you give birth in hospital. And home is protective, or being away from the hospital is protective from excessive blood loss and that's mimicked in other studies that I will talk about later.
[44:20] And here's where it also gets interesting. So augmentation with artificial oxytocin. So this is where you're already in labor, but because your labor's not going fast enough, and I'm using inverted commas, fast enough, there's something slowing it down. If you're in hospital, they quite readily and quite excitedly offer you some IV, artificial oxytocin to help speed it up. So, look, these findings mimic that cultural aspect of maternity care in hospital. So, if you're at home, the likelihood of needing artificial oxytocin to speed up your labor is 5.4%. If you go to a birth center, 7.1%. If you go to a birth center that's attached to a hospital, 10.3%. If you give birth in an obstetric unit as a low-risk woman under the care of an obstetrician, the chances of having artificial oxytocin to speed up your labor are 23 percent that's compared to 5.4 percent if you give birth at home i mean it is what it is uh that those are the stats that's what they found and it's the same story for epidural use so if you're at home 8.3 percent of those women ended up transferring in for an epidural birth center 10.6 and alongside you know attached to the hospital birth center was 15.3.
[45:46] And 30% of women, low-risk women who gave birth in hospital had an epidural.
[45:52] Now here's another little interesting tidbit. Maybe I'm the only one that finds it interesting. But in hospitals, they manage the birth of the placenta usually actively where you give an injection of oxytocin and you pull the placenta out. And they do this because they believe that it's going to reduce the amount of blood loss that the woman would have.
[46:15] The thing is, is that in this study, they found that you're twice as likely to need a blood transfusion and therefore have had a lot of blood loss if you give birth in an obstetric unit. And here, what we can see in these stats is that only 6.1% of women who gave birth in an obstetric unit had not had the active management, did not have the injection to give birth to the placenta. So, around 94% of women were given the injection and had their placenta removed from them, hoping that it would prevent blood loss. But, in fact, they experienced double the amount of blood transfusions that were required.
[46:56] Now, at home, 31% of women had no active management, so they just gave birth to their placenta under their own power without any medication. Yet at home, they managed to half the number of women who needed a blood transfusion. And we've spoken about this on the podcast before, about how physiologically managed placental birth can actually prevent excessive blood loss, and perhaps that's what they're seeing here. Now, this is a more interesting one, too, is episiotomies. If as a low-risk woman you give birth in hospital with an obstetrician, according to this study, you'll get an episiotomy 19% of the time. If you give birth at home, 5% of the time.
[47:38] I still think that's too much. But anyway, the stats are clear. You're about four times more likely to get an episiotomy as a low-risk woman in hospital compared to if you stay at home. Now, let's have a quick look at transfers. So how many women require transfer from out of hospital to in hospital? And again, transfer doesn't mean failure. It doesn't mean there's something wrong. Some transfers are precautionary. Some are for pain relief. There are a huge number of reasons. So don't just think that this is how many transfers means how often there's emergency or how often things go wrong. We do transfer for emergencies, yes, but not all transfers are an emergency.
[48:22] So I had a look at the sub data for the study, which is in a different paper, by the way, which is also in the resource folder. And the main reasons for transfer was slow progress in labor, not an emergency. Meconium in the fluids, not an emergency. Requests for an epidural, not an emergency. Repair for a tear, which sometimes they bleed, but generally not an emergency. And those were the main reasons that made up the bulk of transfers. So all of these could be transferred in a car and not require an ambulance unless, of course, there was excessive blood loss. So the transfers weren't all necessarily emergency transfers. The bulk were for non-emergency situations. I mean, as suspected, the likelihood of needing transfer is more so in your first if you're a first-time mum having your baby at home. The transfer rates were around 30% compared to if you were having a second baby, which was around 5%. So if you're planning a home birth and you're having your first baby, there is...
[49:27] More likelihood that you'll transfer to hospital than if you're having your second. But I think don't let that deter you from planning a home birth because there's still 70% chance that you'll stay at home based on this study. Not all studies have that transfer rate. Just remembering too that in the UK, a lot of the home births are embedded in the National Health Service. And so still these transfers might be occurring due to systematic pressures or based on policy, not necessarily because there's an emergency or a necessity to do that.
[49:59] So home birth was able to significantly reduce the interventions, but did that translate into worse outcomes for the home birth women? So let's talk about the outcomes for the primary outcome, which I'll remind you were about perinatal mortality, so deaths, and intrapartum-related neonatal morbidity. So this included stillbirth, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury and fractures to the humerus and clavicle. So the primary outcomes for babies of healthy, low risk women. Let's have a look. and I'm going to warn you here that it does look as though if you're having your first baby at home that your outcomes are going to be poorer than if you give birth in hospital. But I'll tell you the stats because this is a decision for you to make not for me to make. The risk of something is interpreted by the person who is going to be exposed to the risk not to anybody else.
[51:05] So that primary outcome which included stillbirth and a range of other morbidities and injuries. Of the 4,488 women who gave birth at home, 39 of their babies had an event included in that composite group and that translated to 9.3%. For the women who gave birth in an obstetric unit, there was 52 babies of 10,500 which translated to 5.3%. The best outcomes for babies were experienced in the birth centers, which were the lowest rate of stillbirth, injuries. So from this study, think of how does it feel to hear, if you're a first-time mom, having your baby at home, you're going to be exposed to a whole lot less intervention, a whole lot less medication, tools, cuts, surgery, all that kind of stuff. Okay.
[52:06] And this study is saying that there is an increased chance of your baby having a poorer outcome at home at a rate of about 39 babies to 4,488. So that's the information from this paper. I know there's a lot of numbers, a lot of numbers in this research paper. So if you need to see these graphs yourself, they are in the research paper, easy to read. Now, this risk is mitigated if you've had a baby before. That's typical second births and subsequent births are a lot less complicated so your outcomes actually improve for babies if you're having your second baby at home but this study is one of the reasons why some obstetricians will say have your first baby in hospital because there seems to be increased rate of poor outcomes if you're having your first baby at home however that is not a decision for us to make if that risk feels too high. That's a decision for you to make. So the findings of this study, the Birthplace in England study, demonstrated that transfer rates.
[53:14] To hospital from home were much higher if you're having your first baby. It ranged from about 35 to 45 percent than if you're having a second baby, which ranged from 9 to 13 percent. And the incidence of adverse perinatal outcomes was low in all settings, all very safe statistically. However, there was an increase in perinatal morbidity for women having their first baby who gave birth at home. And any woman planning to give birth at home was significantly less likely to have an instrumental or operative birth or to receive any medical interventions. So this study showed that the further away from hospital you give birth, the more detached from the mainstream maternity services you are, the more likely you are as a woman to have less complications, less interventions, you're more likely to have a normal birth. But if you're having your first baby, if you're a first-time mum, this correlates with a slight increase, but still a relatively small number overall of an adverse outcome for your baby.
[54:17] On top of, you know, if you're having a subsequent baby, that risk is gone. So the authors concluded that their results support a policy of offering healthy first-time mums and subsequent mums, so primips and multips.
[54:33] With low-risk pregnancies, a choice of birth setting, and that adverse outcomes are uncommon in all settings. So while interventions during labour and birth are much less common for births planned in a non-obstetric unit, so at home and birth centres, for primates, first-time mums, there is some evidence that planning a birth at home is associated with a higher risk of an adverse perinatal outcome, but that women's choices should nonetheless be supported if they choose to give birth at home. So this, the authors still concluded that it's still very, very safe comparatively to give birth at home if you're having your first baby. Obviously for women having their second, it was a definite, you can definitely say that. But the adverse outcomes were limited, but obviously more so if you're having your first baby at home. Now, unfortunately, the study was unable to determine the reasons for the poor outcomes for mothers who are having their first baby. But nonetheless, the authors suggested that first-time mums should still be offered the opportunity to give birth at home if they're well-informed.
[55:39] And this is where we allow women to make their own choices after receiving all of the information. And certainly, women themselves experience better outcomes at home. So now it's up to you to do the risk assessment on that one. Is balancing the risk to yourself in hospital versus the risk, the potential increased risk for if you're having your first-time baby at home.
[56:04] Now that's what I'm going to say about the safety of publicly funded home birth programs that are well integrated into maternity care services. That's obviously not all the research. There's heaps more and a lot of it has a similar correlation. That's all I can cover today. But go to the resource folder for more extensive list of papers that you can have a look at. But they largely all say a very similar thing. And that is that home birth is on the whole just as safe as hospital birth for babies. And safer for women who are cared for by skilled midwives and where there's access to medical care and transfer if needed.
[56:43] Now, if you don't have access to a publicly funded home birth option, the other option is to hire a private midwife, which means that you personally select the midwife and that is different in the publicly funded home birth programs is often you're just allocated a midwife, you don't get to choose. So with a private home birth midwife, that means you personally select the midwife that you want for yourself, but you also pay them yourself. So private midwives are self-employed. They're not staff members of our hospital. Therefore, you pay out of pocket for their services. So you hire them as your personal midwife and you can claim a small portion back on Medicare for antenatal, postnatal care if you're here in Australia. There is no current financial rebate for birth care at this time if you're planning a home birth, but But that appears to be coming sometime soon, hopefully.
[57:36] So hiring a private midwife in Australia costs somewhere between $6,000 and $9,000, depending on the midwife and your arrangement. Private midwives set their own fees, and then you'll get around $1,500 of that back through Medicare. Now, the issues with private midwifery are similar to that of a public home birth program in that there is high demand for them, but there are only about 250 midwives in all of Australia who provide private home birth services. So not only can not all women afford a private midwife, but finding one that you like can be difficult because there are so few around. So on the plus side though, private midwives have a wider scope of practice. So they're capable of a lot more things often and they have a higher tolerance for risk when caring for women who have complicating factors. So often women who are risked out of a publicly funded home birth program will seek out a private midwife because they know that those midwives have fewer restrictions on who they can care for.
[58:44] So if we want to look at the outcomes for home birth where the majority of women give birth with a private midwife we've got the birthplace in Australia study which was done in a very similar study style to the birthplace in England study however in Australia at the time of the study there were not a large number of publicly funded home birth services so the majority of the home births that were included in this study were women who were cared for by private midwives. So let's have a look at this study because this pulled the data from eight Australian states and territories.
[59:22] And it included women with uncomplicated pregnancies who gave birth between 2000 and 2012 to a single baby that was head down at full term, and it included 1,250,000 births. Now, of the number of women that they had in the study, 8,212 gave birth at home. So this study also divides the statistics between first and first time babies, first time mums and women having subsequent babies. And they were looking at the mode of birth. Did the baby come out by cesarean, vacuum forceps or a spontaneous birth? Whether or not the women had normal labor in birth, any interventions, whether there were any maternal complications and if the baby needed or the mother needed admission into higher, into like intensive care. And they also looked at stillbirth and neonatal death.
[1:00:21] Now, when they compared the home birth stats with hospital births, the odds of normal labor and birth were over twice as high in a planned birth center birth and nearly six times as high in a planned home birth. And there were no statistically significant differences in the proportion of stillbirths, early deaths after birth.
[1:00:47] Between the three planned places of birth. What these authors concluded is that birth in Australia is quite and very safe regardless of where you choose to give birth at home, birth centre or hospital. However, in hospital they need to do a lot more interventions in order to keep birth safe compared to home and birth centre. So the authors concluded that this is the first Australia-wide study to examine outcomes by planned place of birth. For healthy women in Australia having an uncomplicated pregnancy, planned births in birth centres or at home are associated with positive maternal outcomes. Although, you know, there was somewhat 8,000 or so home births, it was a smaller study. They suggested that there are no significant differences in the perinatal mortality rate. Although the absolute numbers of deaths were very small and therefore firm conclusions cannot be drawn about specific perinatal mortality outcomes and that's because they only had around 8,000 home births. So they weren't, you know, that's not big enough. You know, baby dying at birth is a very rare occurrence and so 8,000 still doesn't seem like enough to be able to get an accurate statistic if that's more likely to happen at home or at hospital. Which is good news.
[1:02:13] Now, I could go through all of the stats in this Birthplace in Australia study, just like I did for the Birthplace in England study, but they are very, very similar and mimic the same sentiment. So the authors of this paper said that this is the first in Australia to examine maternal and perinatal outcomes by planned place of birth, and this study demonstrated results consistent with several other international studies of planned place of birth. Normal births were more likely for women who planned a birth in birth centers or at home when compared to hospital. Remembering they were all low risk. Some people say well of course you're going to have more interventions in hospitals because women who are who have complications are more likely to go to hospital. Well the fact is is that if you put a low risk woman in hospital what all of these studies have showed is that they're going to get more intervention because that's just how hospitals work. It's not because they have more complex needs because then if you put that woman at home, she's six times more likely to get a normal vaginal birth.
[1:03:20] Now, this study also did a similar thing with breaking up the stats between primips, so first-time mums, and multiples. Now, the perinatal mortality ratio for planned hospital births was 0.8 per 1,000 live births compared to 0.4 in planned birth center births. So, again, babies did better in birth centers. And it was 1.1 in planned home births. So, okay.
[1:03:45] 0.8 compared to 1.1 in planned home births. So although the absolute risk was very, very small with very low numbers of deaths overall, that is a differing statistic, 0.8 in hospital for perinatal mortality, 1.1 for planned home birth. So these differences by place of birth were actually not considered statistically significant overall for all women. However, when they broke it up into first-time and second-time mums, this is where the differences showed. So if you were a primip in hospital, it was 0.8 per 1,000. If you were having your baby at home, it was 1.7 per 1,000. And then in multiples very very similar no difference but given the small number of deaths in the planned home birth group so there was nine over 13 years out of around 8,000 births.
[1:04:49] That was that those are the types of numbers you're dealing with so if you're thinking okay what are the chances of my baby dying at a home birth if that's your main concern and a lot of people do think about that and that's okay because you're the one making decisions about your birth In this study, in Australia, over around 8,000 births, nine babies died. And obviously, some of those would have also happened in hospital at a rate of 0.8 per 1,000 live births.
[1:05:18] That was over a 13-year period.
[1:05:22] Okay, that answers our questions about the risk to the baby and the outcomes for the mummers. Now, we have heard that mums do way, way, way better when they don't give birth in hospital. We know that. We can say that from this research. But a lot of people wonder about blood loss at home and what happens if I bleed. And now, let me talk to you about that briefly. I know this has been a long episode, but we're going to briefly talk about postpartum hemorrhage at home with the literature. Now, I will say as a private midwife, I know that private midwives are highly skilled and capable of managing postpartum hemorrhage in the same way with the same medications as what would be delivered in a hospital birth. It's not a complex task to treat a postpartum hemorrhage. Obviously, at home, it's a little bit more complex because you have less people and the transfer time to hospital is longer. However, medications and treatments are quite effective in the majority of postpartum hemorrhages. So I've got two studies here which talk about postpartum hemorrhage outcomes for women who give birth at home.
[1:06:36] And these ones focus specifically on postpartum hemorrhage. So a study by Nov et al, 2012, they did a study that compared the odds of postpartum hemorrhage at home compared to hospital. So what's the likelihood of you actually bleeding at home if you plan a home birth? And again, they included only low-risk women having home births. They excluded preterm births. Obviously, they excluded elective caesarean sections and inductions. Now there were a total of 274,000 pregnancies over 15 hospitals that were included in the analysis and they used the classification of a hemorrhage of blood loss that was over a thousand mils. Now some literature suggests that 500 mils is a postpartum hemorrhage. I think that it's better to class it as a thousand mil loss because that's more of a severe hemorrhage. women can cope quite well with just a 500 mil loss. So putting the benchmark there is a little bit too low, I think. So this study looked at women who had more than a thousand mil blood loss. This is more likely when women would get compromised. So of all of those research numbers, 6,000 women plan to have a home birth when they commence labor. Now of all the women who gave birth, There were 2,800 postpartum hemorrhages of the 280,000 participants.
[1:08:02] And 1.4% of women who gave birth in hospital had a blood loss of over 1,000 mils, so 1.04%. And if you gave birth at home as a low-risk woman, then you had a 0.38% chance. So about three times less chance of bleeding for the women who gave birth at home. So given these findings, the authors raised questions about the safety of hospital birth for mothers and suggested there is a statistical correlation between place of birth and postpartum hemorrhage. Now, while they could not explain why this was the case, they concluded that women should be informed that the risk of postpartum hemorrhage is higher in hospital when compared to giving birth at home.
[1:08:52] Now, similarly, in a study done in 2013 that was done in the Netherlands by De Jong and his team, they tested a hypothesis that low-risk women at the onset of labour who were having a planned home birth would have a higher rate of severe acute maternal morbidity than women that were having a planned hospital birth. So this study also compared the rate of postpartum hemorrhage and also manual removal of the placenta. So that's where women get what's called retained placenta and you have to literally insert your hand into the uterus to extract the placenta. So they looked at postpartum hemorrhage but also rates of manual removal of the placenta.
[1:09:38] So they performed a study that used data from 146,000 women, 92,000 were planning a home birth, and 54,000 were planning a hospital birth. So these are huge numbers, 92,000 women planning a home birth, 54,000 planning a hospital birth. Again, they were all low risk. Now, the overall rate of severe acute maternal morbidity, so severe blood loss or consequences, was 2 in every 1,000 births. And in this study, what they found was for women having their first baby at home, the postpartum hemorrhage rate was 43.1 per 1,000 if you were giving birth at home and 43.3 per 1,000 if you were having your baby in hospital. Manual removal of the placenta was 29 per 1,000 versus 29.8 per 1,000 if you're having your first baby at home. So similar statistics, remembering though that more women who give birth at home would have a physiological placental birth versus an active placental birth where they use medication.
[1:10:53] And if you are having your second baby at home or subsequent baby, here's where you see the big differences. If you are having your second or subsequent baby at home, the chances of a postpartum hemorrhage was 19.6 per 1,000 if you're at home and it was 37.6 per 1,000 if you were in hospital.
[1:11:18] Similarly, manual removal of the placenta was 8.5 per 1,000 if you were giving birth at home as a woman who's had babies before, 8.5 or 19.6 per 1,000. So the authors concluded that low-risk women planning home births had lower rates of severe acute maternal morbidity and that the differences between home and hospital were statistically significant, particularly for women who'd had babies before.
[1:11:47] Now this large study shows that there is no evidence that planned home birth for low-risk women leads to severe adverse maternal outcomes and that the maternity care system should support home birth and that's where you will see the greater outcomes. So from this literature we can conclude that the evidence supports planned midwife attended home births as being equally safe as hospital births for low-risk women and indeed safer in terms of rates for obstetric intervention and postpartum hemorrhage. However, primips, so women having their first baby planning a home birth may not expect neonatal outcomes as positive as those experienced by multiples, women having subsequent babies, but still the risk of poor outcomes is very low. So the research indicates that first-time mothers can and still should consider giving birth at home as safe enough to keep it on the table as an option, especially if they value their own well-being equal to that of their babies.
[1:12:52] So although women having their first babies at home are more likely to transfer, I would encourage you not that to discourage you from planning home birth just because there's a higher rate of transfer. I know this has been a lot of information. There is so much more that we could add. As I said, this has been my research focus for a lot of my academic career. So there's so much to talk about and I'm going to continue discussing the research on home birth in subsequent episodes where I'm keen to present the research on higher risk home birth scenarios. And everything that I covered today was for women having uncomplicated pregnancies. But there is a huge body of literature that explores what happens when risk factors meet a plan to have a home birth and we'll explore that soon. But for now, thank you for listening. If you want to see the other resources that I wasn't able to talk about today, jump onto the mailing list and get access to the resource folder and you can read the research that I discussed and also that I didn't discuss. I will see you in the next episode of the Great Birth Rebellion podcast and today we spoke about if home birth is a good option for you.
[1:14:01] To get access to the resources for each podcast episode join the mailing list at melanithemidwife.com And to support the work of this podcast, wear The Rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
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