Home Births vs. Hospital Births

If you're weighing an at-home birth in the United States, several factors affect the safety of you and your baby. The American College of Obstetricians and Gynecologists reports that of the roughly 35,000 home births each year, nearly 25% are unplanned or unattended. Good information and planning lower that risk. Here's how home births and hospital births compare on benefits and risks.

Are Home Births Safe?

There's no single answer. Home births without a midwife or obstetrician present are far more likely to be unsafe. A 2020 study found planned home births were also less safe than hospital births even when attended by direct-entry or certified nurse midwives. That study put the infant death rate from 2010 to 2017 at four times higher for planned home births than hospital births.

Researchers note this safety gap did not appear in other developed nations, where more established midwifery systems integrate home birth into the wider health system. An earlier study found many planned U.S. home births involved women who wouldn't have qualified under the stricter home-birth guidelines used in those countries, with risk factors like obesity, age, and a prior cesarean section.

Why Choose a Home Birth?

For low-risk women, a planned home birth carries a lower chance of intervention such as a cesarean section. The challenge is identifying who actually qualifies. Low-risk women are much better candidates.

One study of birth outcomes found a 41% increase in home births from 2004 to 2010, with low-risk women showing higher rates of vaginal birth without intervention and no increase in adverse outcomes. The cesarean rate in that group was strikingly low at 5.2%, against a national average of 31%. Low-risk women include those who:

• Have no medical conditions that may affect the birth outcome
• Have no history of serious pregnancy complications
• Carry a single baby in the head-down position
• Go into labor spontaneously at term

Moderate- and high-risk women have better outcomes in a hospital. Low-risk women have adverse-outcome rates similar to hospital births.

Associated Risks

As planned home births rise, researchers keep weighing the risks and benefits. Less intervention can be a positive for low-risk women, but it isn't always clear when intervention is necessary to prevent a bad outcome. Some risks exist in either setting and can't be predicted.

Potential Risks of Home Births

Maternal blood transfusions. In a sample of nearly 79,730 women, Oregon Health and Science University found those who gave birth outside the hospital had a higher risk of postpartum transfusion, likely from postpartum hemorrhage. Transfusion risk was higher for women who gave birth outside a hospital, gave birth more than three hours before transferring, or had a cesarean section. A U.K. study using 1988-to-2000 data found the opposite, with hospital births carrying greater hemorrhage risk.

Low Apgar scores. Apgar scores measure an infant's heart rate, breathing, muscle tone, reflexes, and color at one and five minutes after birth. A low score signals the baby needs help maintaining heartbeat and breathing. Some studies found more low five-minute Apgar scores in home births, without accounting for the mother's risk factors.

Neonatal seizures. The neonatal period, especially the first week, is the most vulnerable. Neonatal seizures (abnormal, excessive electrical activity in the brain during the first 28 days) can result from low oxygen, intracranial hemorrhage or infection, metabolic disturbances, or drug withdrawal. Most home-versus-hospital research finds no difference in deaths, Apgar scores, or NICU admissions, though some found a higher rate of neonatal seizures without separating low- and high-risk women.

Potential Risks of Hospital Births

Hospital-acquired infections. The most common are skin infections caused by methicillin-sensitive or methicillin-resistant Staphylococcus aureus, appearing on the umbilical stump, nose, or groin, sometimes only after discharge. In the NICU, blood and urinary tract infections are most frequent and can threaten survival and development. Prevention is critical.

Perineal lacerations and vaginal tears. Severe third- or fourth-degree perineal lacerations can occur during hospital births when labor progresses too fast for the vagina to stretch. A third-degree tear involves the anal and rectal muscles; a fourth-degree tear can extend into the lining of the anus or rectum. Midwives can lower this risk with prebirth perineal massage, warm compresses during birth, and slow, controlled delivery of the baby's head.

Interventions. Hospital births involve optional interventions that disrupt normal physiology. Sometimes they prevent poor outcomes; sometimes providers use them to control the situation. They include bed rest during labor, frequent electronic fetal monitoring, limited oral intake, frequent vaginal exams, induction, intentionally breaking the water, and catheter insertion. These can lead to ineffective pushing, surgical cuts and tearing, instrumental delivery, and cesarean section.

Cesarean sections. Since 1990, the cesarean rate has tripled, from 6% to 21% in 2018, with cesareans now outnumbering vaginal deliveries in parts of southeast Europe, Latin America, and China. Cesareans raise the later-life risk of obesity and autoimmune disease. They can be lifesaving when medically necessary, but they carry higher maternal morbidity and mortality and links to uterine rupture, stillbirth, preterm birth, and ectopic pregnancy. Infants also face altered bacterial and hormonal exposures.

COVID-19's Effect on Home Births

The pandemic shifted the dynamics of home versus hospital birth. Changing policies, reduced staffing, delayed surgeries, and visitation bans raised concerns. At the height of the pandemic, birthing partners couldn't attend prenatal or ultrasound appointments, and only one person, including a doula, could be present at delivery. Shifting policy drove some to choose home birth in 2020. Sharing a hospital with sick patients also changed how some parents viewed safety. One economic analysis estimated that shifting 10% of hospital births to birthing centers or home could save the system $11 billion a year "without compromising safety."

Nurses and Birth Settings

In hospital births, labor and delivery nurses care for patients through labor, birth, and immediate postpartum, monitoring the patient's condition and providing emotional support. Nurses are not licensed to assist deliveries outside the hospital. Certified nurse midwives assess, diagnose, and treat patients toward a healthy delivery and can manage births at home, in a birthing center, or in a hospital.

Weigh the pros and cons as you plan. Recent research shows home births carry adverse-outcome rates similar to hospital births when the person is low risk. Before deciding, talk with your provider about your options and risks.

Frequently Asked Questions

Are hospital births safer than home births?

It depends on your risk factors, such as obesity, older age, and a prior cesarean section. Both settings carry risk. Base your decision on your risk level, access to an experienced midwife, and how quickly you can reach a hospital.

What are the advantages of a home birth?

People who give birth at home report greater comfort and satisfaction, plus a lower chance of interventions that may not be immediately necessary, such as induction, breaking the water, frequent fetal monitoring, and frequent vaginal exams. Home births also have a much lower cesarean rate.

What are the disadvantages of a home birth?

Higher risk of postpartum hemorrhage and blood transfusion. When maternal risk isn't adequately assessed, home birth can raise the risk of low Apgar scores, neonatal seizures, and neonatal mortality.

Can I have my baby at home without a midwife?

A certified nurse midwife has years of education to provide safe home-birth care. Birth is a natural process, but a midwife can quickly recognize when immediate medical help is needed.