With Home Birth, Preparation Is Key

While less than 1 percent of people give birth at home in the United States, more than a quarter of those home births are unplanned. Emergency home births are extremely rare, but being prepared is wise for any pregnant person. Here's what you should know about home births.

Who should have a home birth (and who shouldn't)

The American College of Obstetricians and Gynecologists (ACOG) advises against having a home birth if you're expecting multiple babies, your baby isn't in a head-first position or you've had a previous C-section.

For those giving birth to a second, third or fourth baby, a planned home birth is as safe for the baby as birth in hospital obstetric units, stated Ayanthi Gunasekera, M.B.B.S., medical information lead at London Gynaecology.

"Home births are safest for those without any medical diseases or past pregnancy complications," said Caitlin Goodwin, a certified nurse-midwife (CNM) in Florida. "There are conditions that add risk to any out-of-hospital birth. For instance, fibroids will increase the risk of postpartum hemorrhage."

The benefits of home birth

A 2020 meta-analysis of 500,000 intended home births published in eClinicalMedicine, part of The Lancet medical journal, found that women who intended to give birth at home and were "in settings where home birth care is a well-integrated service within the health system" were approximately:

• 40 percent less likely to require a cesarean
• 50 percent less likely to have an instrumental birth
• 55 percent less likely to have an episiotomy
• 40 percent less likely to have a third- or fourth-degree perineal tearing
• 70 percent less likely to have an epidural
• 30 percent less likely to hemorrhage

The authors of the meta-analysis also stated that "risk of stillbirth, neonatal mortality or morbidity is not different whether birth is intended at home or hospital."

There are many advantages to giving birth at home. It's more comfortable than a hospital, there's customized care and there's unrestricted skin-to-skin contact with the infant. "People choose to have a home birth because they want to give birth in a familiar setting and desire freedom over the birthing process," Gunasekera said.

"Home births have lower rates of maternal morbidity," Goodwin added.

Some people want to give birth without medical interventions, including pain medication, labor augmentation and labor induction. "Home births reduce the use of clinical interventions during childbirth, including episiotomy, forceps/vacuum and cesarean birth," said Jada Shapiro, a certified lactation counselor, and a birth and postpartum doula in New York.

The risks of home birth

While experts say planned home births are safe for most women and their babies, there are certain risks to keep in mind.

Home births have a greater risk of neonatal mortality and seizures than hospital births. "The overall risk of neonatal seizures is small (0.02 percent to 0.06 percent in planned home births)," Goodwin said. "Meaning, 2 in 10,000 babies experience a seizure in the general population versus 6 neonatal seizures in 10,000 babies in the planned home birth population."

The disadvantages of home births include the need to be transferred to a hospital if there is an emergency and the risk to mother and baby if there's a delay in transfer time. "With home birth, there's no operating room or medical team nearby," Goodwin said.

What to expect during a home birth

Communication is key to a safe planned home birth. "Discuss your wishes with your midwife and obstetrician," Gunasekera advised. "Understand any health conditions you have that would impact your ability to deliver at home. Have a birth plan detailing your methods for pain relief, preferences for cord clamping, and breastfeeding. Prepare protective coverings for your floor and mattress."

Typically, a midwife will come to your home and make an assessment when you're around 37 weeks pregnant. During home birth, your midwife will listen to the baby's heart tones regularly and may occasionally do a vaginal exam to decide the labor process. They'll also check your temperature, pulse and blood pressure.

How to prepare for an emergency home birth

Out of 35,000 annual home births in the United States, 8,750 are unexpected. Many emergency home births occur without medical support, which is known as a "free birth." During an unexpected home birth, it's important to remain calm as best you can and concentrate on your breathing.

Emergency home births are also referred to as "born before arrival" (BBA). To be ready for an unexpected home birth, Goodwin suggests having warm blankets and towels at the ready. "Dry the baby and place them on the birthing person's chest, covering them both with a blanket," she advised. "People worry about clamping and cutting the umbilical cord, but that isn't a priority."

Costs and insurance coverage of home births

Home birth is less expensive than hospital birth (which often costs at least five figures in the United States). "Home birth costs vary from an average of $3K to $9K as a flat fee, which includes all prenatal visits, birth care, delivery and a postpartum visit," Shapiro said.

Insurance may cover at-home deliveries in New Hampshire, New Mexico, New York and Vermont. "Most home birth midwives are out-of-network providers," Shapiro said. "Some insurances will cover home birth partially and others will cover the fee in full."

Call your insurance company to find out what is covered and if your healthcare provider can be used in case of emergency hospital transfer. Goodwin suggests asking about response time for emergency services, who and where the collaborating physician is, and how quickly an emergency surgery can be performed.