The photographs were stunning: A mother and father cradling their newborn twins, born minutes earlier in a bathtub at home.
Published on BuzzFeed earlier this month, the pictures made the birthing process seem no more difficult or dangerous than taking a bath. The mother is smiling at the camera as one of the babies emerges.
But a new study published in the New England Journal of Medicine warns that home births, which are on the rise in the U.S., may pose danger for the mother and child. Babies whose parents planned a home birth are slightly more likely to die or suffer neonatal seizures than those whose parents planned hospital deliveries, the report said.
The research supports the position of the American College of Gynecologists and Obstetricians, and that of the American Academy of Pediatricians, and both say a hospital is the safest place to have a baby.
But research also offers support for advocates of home birth, like the California doula who took the photographs that went viral on BuzzFeed. It shows that, in Oregon at least, planned home deliveries have significantly less surgical intervention, including cesarean sections, and induced labor.
“Perception is a big part of why people are opposed to home birth. Most people in the United States believe that birth is inherently dangerous and should occur close to an OR (operating room) as possible. That’s a powerful lens,” said Melissa Cheyney, a certified professional midwife and professor in Oregon. “It is harder for people to see that giving birth in the hospital carries its own risks, especially related to maternal health.”
According to the Centers for Disease Control and Prevention, out-of-hospital births have been increasing since 2004. In 2012, there were 35,184 births in homes and 15,577 in birthing centers. Despite the uptick, out-of-hospital deliveries represent just slightly more than 1 percent of births in the U.S. This is, in part, because of parental fear, which, according to one Massachusetts doctor, is justified.
"So many people choose home birth without understanding what they're choosing," said Dr. Amy Tuteur, a Boston-area OB/GYN who runs a website called Hurt by Home Birth.
"There is a large and growing body of scientific evidence that home birth is deadly," Tuteur said. "The risk of death is not gigantic, but it's higher than deaths from not putting your baby in a car seat, and we think car seats are important."
Others say the difference is statistically insignificant, and that home births, when properly regulated and attended by well-trained assistants, are just as safe as hospital births. Each state set its standards, creating a patchwork system with disparate participation across the nation. Oregon, Montana and Alaska, for example, have home-birth rates that are more than twice the national average. Alabama, meanwhile, prohibits home birth with a midwife present.
"The U.S. is all over the map," said Dr. Michael Klein, neonatologist and professor emeritus of family practice and pediatrics at the University of British Columbia. "It's actually remarkable how good the outcomes are when the system is so chaotic."
Differences in midwives
Robin Baker, 39, is a professional birth photographer and a certified doula, trained to provide support to a pregnant woman before, during and after delivery. She's the photographer who took the viral BuzzFeed photos in February and also a mom whose first five babies were born in a hospital. Her last child, a daughter, was born at her home in Temecula, California.
"All of my births were low risk, fast and easy. My youngest boy's birth was very precipitous, and he was born 10 minutes after we arrived at the hospital. After that, I was terrified of having a side of the road birth, so we found a licensed midwife and planned our home birth. It was a great experience, and I would do it again in a heartbeat," she said.
A radically different picture is painted on the Hurt by Home Birth website run by Tuteur. There, women share their stories of babies who died or had serious health problems after being delivered at home or at birthing centers (clinics that try to bridge the gap between hospitals and homes) as well as women who had medical issues. They include a mother who suffered complications when a midwife couldn't get the placenta out, and a baby who died because of 40 minutes of oxygen deprivation.
Tuteur is a fierce crusader against home birth, and she believes it has been glorified by those who profit from it and by birthing assistants who she believes are not adequately trained.
In the U.S., there are three kinds of midwives: certified nurse-midwives, who hold nursing degrees; certified professional midwives, who meet standards set by the North American Registry of Midwives; and lay midwives, whose training typically consists of apprenticeship to another midwife and who possess no formal training or certification.
Studies have shown that complications are less likely to occur at home births attended by midwives who have more education, Tuteur said.
"Most women who have had disasters with home births didn't realize their midwife wasn't a real midwife," she said. "You can't call yourself a lay surgeon, and you shouldn't be able to call yourself a lay midwife."
Midwives, meanwhile, point to a 2014 study that analyzed nearly 17,000 planned home births in the U.S. between 2004 and 2009 and found an infant mortality rate (both fetal and neonatal) of less than two per 1,000.
Another study examined the credentials of professional certified midwives and found that 90 percent of midwives who responded to a survey had attended college and 47 percent had a bachelor’s degree or higher.
Cheyney, the lead author of both studies and an associate professor of medical anthropology and reproductive biology at Oregon State University, is also chair of the Midwives Alliance of North America’s Division of Research. She said there is still plenty of room for improvement in U.S. and acknowledged that nearly 40 percent of certified professional midwives who responded to the survey had less than the recommended three years of training.
“Is it perfect? Absolutely not. We’re working to improve it all the time. But the idea that CPMs as a whole are undertrained doesn’t seem to be supported by the evidence,” Cheyney said. “Poor outcomes are closely tied to the risk level of the mother and the planned location of the birth, not the credential of the provider.”
Questions parents should ask
Klein, the neonatologist who is senior scientist emeritus at the Child and Family Research Institute in Vancouver, said the U.S. should look to Canada, where 16 percent of women give birth at home and a cooperative system ensures that if something goes wrong, the woman and her child can get to a welcoming hospital quickly.
Three major Canadian studies have shown that the outcomes for home and hospital births are equivalent, Klein said, and Canada’s transfer rate — the number of women who begin giving birth at home but then go to the hospital — is about 20 percent. It's an integrated system where the government pays for both home and hospital births, and every province has a College of Midwives that sets standards on who qualifies for a home birth. (Women with hypertension or complications in a previous pregnancy, for example, wouldn't qualify.)
Klein said rather than discouraging home births, the American College of Obstetricians and Gynecologists should encourage the development of uniform standards that would improve the process for women who prefer to give birth at home. Absent that, he encourages American women to ask fundamental questions before choosing home birth.
"What's the back-up system for me? Who will back that midwife up if that midwife needs support? Do I live within 30 minutes of an operating room that is willing to support me?
"Twenty percent of the time, you're going to need help. If that system is not in place, home birth is not safe," Klein said.
Although she approaches the subject from a different perspective from Klein, Tuteur also encourages women to think about what might go wrong when making a decision.
"Nobody needs an expert in normal birth. That's like having a meteorologist who's an expert in good weather," Tuteur said.