a. Well-designed studies of home birth as practiced in other countries suggest that home birth can be as safe as hospital birth

Several large and well-designed studies of home birth come from developed countries outside the US, including two studies from Canada and a large study from England. This body of evidence supports the view that home birth can be as safe as hospital birth.

The first of the Canadian studies, from 2009, was a prospective cohort study, meaning that women were enrolled in the study before they gave birth and that a comparison group of women who gave birth in the hospital was included. Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee SK. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician, CMAJ 2009. DOI:10:1503/cmaj.081869. The researchers looked at outcomes for all women in British Columbia who planned home births with registered midwives over a 5-year period. (Registered midwives in Canada have training comparable to that of certified nurse-midwives here in the US.) The researchers compared those outcomes to outcomes for other women who were attended by the same group of midwives as the home birth group, and who would have been eligible for home birth but chose hospital birth instead. In addition, the researchers looked at outcomes for a sample of women who planned hospital births attended by doctors and who were matched for risk factors with the other two groups.

The researchers concluded:

Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.

So in this study, outcomes were equally good at home as in the hospital (and interventions were lower).

The second Canadian study, from 2015, was a retrospective cohort study, meaning that women were identified for the study after giving birth and that a comparison group of women who gave birth in the hospital was included. This study accessed the database of the provincial Ministry of Health to compare a group of nearly 11,500 Ontario women who were planning home births at the time their labors began to a matched group of nearly 11,500 women with comparably low-risk pregnancies who planned to birth in a hospital attended by a midwife. Hutton EK, Reitsma AH, Kaufman K. Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: a retrospective cohort study. Birth 2009;36:180–9.

Again, researchers found that outcomes were equally good at home as in the hospital:

The rate of perinatal and neonatal mortality was very low (1/1,000) for both groups, and no difference was shown between groups in perinatal and neonatal mortality or serious morbidity. . . . All measures of serious maternal morbidity were lower in the planned home birth group.

See also Hutton EK, Cappelletti A, Reitsma AH, et al. Outcomes associated with planned place of birth among women with low-risk pregnancies. CMAJ 2016; 188:E80. (Same data set: “Compared with planned hospital birth, planned home birth attended by midwives in a jurisdiction where home birth is well-integrated into the health care system was not associated with a difference in serious adverse neonatal outcomes but was associated with fewer intrapartum interventions.”)

These studies offer good evidence that home birth as it is practiced in Canada is as safe as hospital birth.

A study from England, referred to as the “Birthplace in England” study, was a prospective cohort study like the British Columbia study, meaning that women were enrolled in the study before they gave birth and that a comparison group of women who gave birth in the hospital was included. Brocklehurst P, Hardy P, Hollowell J, Linsell L, Macfarlane A, McCourt C, et al. Perinatal and maternal outcomes by planned place of birth for healthy women with low-risk pregnancies: the Birthplace in England national prospective cohort study. Birthplace in England Collaborative Group. BMJ 2011;343:d7400.

Over a two-year period, the researchers followed the pregnancies and births of nearly 80,000 women, including over 18,000 women planning home birth, over 29,000 women planning birth in midwife-led birth centers, and over 32,000 women planning birth in the hospital.

In this study, for those women who had given birth before, researchers found no difference in outcomes, whether they planned to give birth at home or in the hospital:

[M]ultiparous women [women who have already had a baby] planning birth at home experience fewer interventions than those planning birth in an obstetric unit with no impact on perinatal outcomes.

However, this study did find a difference for first-time mothers (termed nulliparous women) when looking at the combined risk of a variety of adverse outcomes—including admission to the Neonatal Intensive Care Unit, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, and fractured humerus or clavicle. The risk of having one or more of these adverse outcomes was higher for babies born at home to first-time mothers:

Adverse perinatal outcomes are uncommon in all settings, while interventions during labour and birth are much less common for births planned in non-obstetric unit settings. For nulliparous women, there is some evidence that planning birth at home is associated with a higher risk of an adverse perinatal outcome.

Like the two Canadian studies, the Birthplace in England study provides good evidence that, for experienced mothers at least, home birth is as safe as birth in the hospital. For first-time mothers, the policy in England is to offer home birth but to counsel mothers on the higher risk.

As you consider this evidence, you need to keep in mind that these studies come from health systems where home birth is well integrated. Home birth midwives in these systems have uniform and recognized credentials. The criteria to decide whether a woman is eligible for home birth are established and applied consistently. Obstetricians and midwives collaborate to care for women who develop complications. Transport from home to hospital is planned for and well coordinated.

The picture is different here in the United States.

b. The special challenges of studying home birth in the US

Each state regulates home birth separately. This means that home birth midwives do not have uniform licensing credentials across the US, and there is no single agreed-upon set of criteria to decide whether a woman is eligible for home birth.

In addition, home birth is much less well integrated in the US system of maternity care than in the UK, Ontario, or British Columbia (as examples). This means that home birth midwives and doctors in the hospital may not collaborate well if transport from home to hospital becomes necessary. All of these factors are likely to affect the safety of home birth. Researchers are challenged to analyze data sets that include births attended by providers with different credentials, to women with different risk profiles, who had different options for transport and back-up care.

Another challenge to studying home birth in the US (and elsewhere) is that a well-designed study will compare groups of women who intended to birth at home (even if they ended up transporting to the hospital in labor) with groups of women who intended to birth in the hospital. In many of the US studies, that data was unavailable, so the researchers instead compare women who actually gave birth at home (whether they planned to or not) to women who actually gave birth in the hospital (even if they had planned a home birth).

Finally, many of the US studies rely on data from birth certificates. The birth certificate form was revised in 2003 to distinguish between planned and unplanned home births, which has improved the usefulness of birth certificate data for home birth studies. However, there are still many limitations and inaccuracies in birth certificate data. See for instance,  Martin JA, Wilson EC, Osterman MJ, Saadi EW, Sutton SR, Hamilton BE. Assessing the quality of medical and health data from the 2003 birth certificate revision: results from two states. Natl Vital Stat Rep. 2013 Jul 22;62(2):1-19.

For these reasons, every study of home birth in the US has methodological flaws. (Here are links to two academic articles explaining this further: Nove A, Berrington A, Matthews Z. The methodological challenges of attempting to compare the safety of home and hospital birth in terms of the risk of perinatal death. Midwifery.2012;28(5):619‐626. doi: 10.1016/j.midw.2012.07.009; DOI:10.1111/jjns.121116; Elder HR, Alio AP, Fisher SG. Investigating the debate of home birth safety: A critical review of cohort studies focusing on selected infant outcomes. Japan Journal of Nursing Science. Volume 13: 3 July 2016 297-308.)

And because every US study has flaws, opponents of home birth tend to discount the studies that show equally good outcomes at home, while home birth advocates tend to discount the studies that show worse outcomes at home. 

c. The evidence about the safety of home birth in the US

Studies showing similar outcomes for home and hospital birth

2021: A 2021 study looked at outcomes for over 10,000 planned out-of-hospital births in Washington state, where out-of-hospital birth is more integrated into the medical system than it is in most of the US. Strict risk selection criteria were applied. The researchers did not compare outcomes to those for hospital birth, but found perinatal mortality rates (0.57 per 1000 births) comparable to those in the Canadian and British studies discussed above, where out-of-hospital and hospital outcomes were equally good. Nethery E, Schummers L, Levine A, et al. Birth Outcomes for Planned Home and Licensed Freestanding Birth Center Births in Washington State. Obstet Gynecol 2021; 138:693.

2015: A 2015 study by Snowden at al. used revised birth certificate data to compare outcomes of both home and birth center births with outcomes of hospital births in Oregon. Snowden JM, Tilden EL, Snyder J, Quigley B, Caughey AB, Cheng YW. Planned out-of-hospital birth and birth outcomes. N Engl J Med 2015;373:2642–53.) The researchers analyzed outcomes from 3600 planned out-of-hospital births (including 600 who transferred to the hospital during labor) with outcomes from 76,000 planned hospital births to both high-and low-risk mothers. They found increased risks of fetal death and neonatal death in the planned out-of-hospital birth group compared to the planned in-hospital birth group (fetal death 2.4 vs 1.2 per 1000 births; neonatal death 1.6 vs 0.6 per 1000 births). However, after multivariate regression, the absolute difference in risk between the groups was extremely small (fetal death varied by 0.093 percentage points; neonatal death varied 0.063 percentage points). 

2014: The largest prospective study of home birth safety in the US was published in 2014 and analyzed data for 17,000 low-risk births recorded in the Midwives Alliance of North America database. The researchers reported an intrapartum fetal death rate of 1.3 per 1000 births. Cheyney M, Bovbjerg M, Everson C, et al. Outcomes of care for 16,924 planned home births in the United States: the Midwives Alliance of North America Statistics Project, 2004 to 2009. J Midwifery Womens Health 2014; 59:17. While the researchers did not compare their outcomes to outcomes in the hospital, the reported intrapartum fetal death rate is comparable to rates reported elsewhere for hospital birth, but note that those hospital outcomes were for populations including both low- and high-risk pregnancies. The researchers found higher rates of poor neonatal outcomes for home birth among first-time mothers, those with breech presentations and those giving birth after a prior c-section.

2010: There’s an earlier study by Wax et al. that is often cited as showing that home birth is unsafe. Wax JR, Lucas FL, Lamont M, Pinette MG, Cartin A, Blackstone J. Maternal and newborn outcomes in planned home birth vs planned hospital births: a meta-analysis. Am J Obstet Gynecol 2010;203:243.e1–8. In this 2010 study, researchers pooled and analyzed data from seven earlier studies of home birth safety. (This pooling of data is called a meta-analysis.) Only two of these seven studies were from the US, and the numbers of US women included in the pooled data were small overall. The Wax study is therefore not primarily a study of home birth in the US, and it should be considered in the context of the other international studies discussed above.

In any case, the Wax study reported a higher neonatal mortality rate for out-of-hospital birth when all types of attendants were included. But when the researchers analyzed the data for studies that included only births attended by certified midwives and certified nurse-midwives, they found that the difference in neonatal death rates [babies dying in the month after birth] for out-of-hospital birth was not statistically significant:

The analysis excluding studies that included home births attended by other than certified or certified nurse midwives had findings similar to the original study, except that the [odds ratios] for neonatal deaths among all (OR, 1.57; 95% CI, 0.62–3.98) and nonanomalous (OR, 3.00; 95% CI, 0.61–14.88) newborns were not statistically significant.

In other words, when the researchers looked only at data for women attended by CNMs (or CMs, their international equivalent), there was no statistically significant difference in safety outcomes between the home and hospital birth groups. 

Studies showing better outcomes for hospital than for home birth

There are two large US studies that analyzed linked birth and death certificate data and found better outcomes for midwife-attended births in the hospital than for midwife-attended births at home.

In a study published in 2010 by Malloy et al., researchers examined data from linked birth and death certificates for over 1.3 million low-risk births attended by midwives in a five-year period (2000–2004). Malloy MH. Infant outcomes of certified nurse midwife attended home births: United States 2000 to 2004. J Perinatol. 2010 Sep;30(9):622-7. doi: 10.1038/jp.2010.12. Epub 2010 Feb 25. Of those 1.3 million births, over 1.2 million were midwife-attended hospital births and 13,500 were midwife-attended home births. The researchers found a lower risk of neonatal mortality for midwife-attended births in the hospital compared to midwife-attended births at home (5 per 10,000 compared to 10 per 10,000).

A similar study published in 2017 by Grünebaum et al. examined data from linked birth and death certificates for 97,000 planned home births attended by midwives and compared outcomes to those for hospital births attended by midwives. After accounting for maternal age, numbers of prior births and prematurity, the researchers found a lower risk of neonatal mortality for midwife-attended births in the hospital compared to midwife-attended births at home (1.2 vs 0.3 deaths per 1000). Grünebaum A, McCullough LB, Sapra KJ, et al. Planned home births: the need for additional contraindications. Am J Obstet Gynecol 2017; 216:401.e1.

These studies suggest that neonatal mortality rates are higher for midwife-attended home birth compared to midwife-attended hospital birth.

d. The absolute risk that your baby will die or be seriously injured is very small, whether you choose home or hospital birth

Of course you want to know whether home birth and hospital birth are comparably safe. Unfortunately, while there is certainly good evidence to support the safety of home birth, there is also evidence that suggests that home birth is less safe than hospital birth.

But it’s also important to keep in mind that the absolute risk to your baby is very low, whether you choose hospital or home birth. Based on the study by Grünebaum et al., if you choose hospital birth with a midwife, the likelihood that you will lose your baby  is 0.3 per 1,000, and if you choose home birth with a midwife, the likelihood that you will lose your baby is 1.2 in 1,000. You can say, “The likelihood that my baby will die is four times as high if I have a home birth.” Or you can say, “The likelihood that my baby will die at home and wouldn’t have died in the hospital is 0.9 in 1,000, which is less than 0.1%.” Both statements are supported by evidence, but they may feel very different to you.

e. You have control over some of the factors that affect home birth safety

The recent licensing of Certified Professional Midwives in Illinois is an important step towards integrating home birth into the Illinois maternity care system the way it is in Ontario, British Columbia, and the UK. However, you can’t count on home birth being as safe here as it is in those systems. But you can create for yourself at least some of the conditions that make home birth safe in those countries:

• You can find out whether you have any of the risk factors that are likely to make home birth less safe. (See Am I High Risk?)
• You can choose an attendant who has credentials comparable to those of the international midwives who have such good outcomes. 
• You can check that your provider has a relationship with a back-up obstetrician, or you can line up someone for yourself.
• You can ensure that transport is readily available and you can be open to the need to transfer. (Research the hospitals in your area that are in easy reach. In the Chicago area, you are likely to have several choices. Find one that you’ll be comfortable going to if you need to transport in labor.)

Every study of home birth to date, worldwide, reports lower rates of medical intervention (including cesarean birth, induction, Pitocin augmentation, episiotomy, epidural analgesia, forceps or vacuum extractor use, antibiotic use, etc.) for low-risk women who plan to deliver at home as compared to low-risk women who plan to deliver in the hospital. This is true even when you include outcomes for women who planned a home birth but ended up transferring to the hospital.

In the US, one exception is the 2015 study by Snowden et al. (a study which included births attended by midwives who were not CNMs). This study found a higher rate of maternal blood transfusion in the planned home birth group as compared to the planned hospital birth group. But all other types of interventions were lower. Snowden JM, Tilden EL, Snyder J, Quigley B, Caughey AB, Cheng YW. Planned out-of-hospital birth and birth outcomes. N Engl J Med 2015;373:2642–53.

Taken as a whole, the research pretty clearly shows that women who birth at home have lower rates of interventions.

It is certainly reasonable to weigh this difference when you consider whether to have your baby at home or in the hospital.

None of the studies examining CNM-attended home births in the US included transfer rates. The largest prospective study of US home birth (mostly non-CNM-attended births) found that about 11% of women planning home births transferred to the hospital during labor. Cheyney M, Bovbjerg M, Everson C, Gordon W, Hannibal D, Vedam S. Outcomes of care for 16,924 planned home births in the United States: the Midwives Alliance of North America Statistics Project, 2004 to 2009. J Midwifery Womens Health 2014;59:17–27.

A subsequent study reported a 16.5% transfer rate. Snowden JM, Tilden EL, Snyder J, Quigley B, Caughey AB, Cheng YW. Planned out-of-hospital birth and birth outcomes. N Engl J Med 2015;373:2642–53. Only about 4% of these transfers are considered emergencies (so less than 1% overall).  Your likelihood of needing to transfer is higher if this is your first baby and lower if you’ve given birth before.