Home births surged to their highest rate in over 30 years in 2021, the Centers for Disease Control and Prevention (CDC) found in a recently-released report.
There were over 50,000 home births in 2021, an increase of 12% from 2020. However, between 2019 and 2020, home births were also already on the rise, which the CDC attributed to the pandemic. Home birth numbers also differed by race, with Black women having the highest increase in the number of home births (21%), followed by Hispanic women (15%) and White women (10%).
Despite the fact that home births still account for just over 1% of births in the U.S., nurses working in obstetrics and newborn health as well as Certified Nurse Midwives (CNM) might wonder what this means for future nursing care.
Does the rise represent a trend that will see home births increase in the years to come? Could home births ever be safely integrated into the U.S. pregnancy care system? What should pregnant people be aware of? Alexandra Bratschie, a CNM with Corewell Health provided Nurse.org with some insight.
Why Home Births Increased During the Pandemic
Bratschie explains that some of the restrictive policies instituted during the pandemic contributed to the rise in home births. For instance, she notes that despite the fact that mask wearing can help prevent the spread of disease, wearing a mask during labor wasn’t always an easy decision to face for someone about to have a baby. “The idea of wearing a mask for potentially days or long hours while participating in a life-changing event that requires heavy breathing, moving, and that is very emotional and personal was very off-putting to many,” she explains.
Additionally, visitor policies were still being developed, in some cases, not clear, and pregnant people may have worried that they could not have their partner with them or were not allowed to have other members of their birth team with them, including a friend, parent, or doula.
And lastly, of course, parents-to-be were rightly concerned about what potential impact visiting a hospital during a pandemic might have. “With the unknown of the virus and its potential side effects, a lot of families were looking for a place with fewer people and less exposure,” she says.
For Black families, the disparity in healthcare also explains the significant rise in homebirths among Black women.
“Even before the pandemic, we know that black and brown women are more likely to die or have mortality-related events related to childbirth and the postpartum period in the conventional medical system compared to their white peers,” Bratschie says. “Members of the BIPOC community are more likely to be ignored, their pain not treated, and their symptoms overlooked within the medical system. With the inequity of deaths in the BIPOC community at the start of the pandemic along with the historic and current mistreatment or undertreatment of communities of color, it was not surprising that families of color were choosing their home or a smaller group of providers to support them at their birth.”
Are Home Births Safe?
As a birth professional, Bratschie says that out-of-hospital births can actually be a “safe and viable” option for people who are low-risk. In fact, she notes that those who meet certain criteria, even have a lower risk of medical intervention, including rates of Cesarean section. Criteria can vary, but in general, she says some of the requirements would include:
- only one baby in a head-down position
37 weeks gestation and greater (no preterm labor)
no serious medical conditions that require further monitoring for mom or baby during labor such as women with hypertension, diabetes, or a growth-restricted baby
However, she adds that just with all births, out-of-hospital home births do come with risks. For instance, because home birth is not a part of the U.S. birthing system, there is no standard for training or guidelines that regulate home births. Thus, many of the midwives that attend home births are not trained in the same ways or have access to resources that could be life-saving. Luckily, Bratschie adds that in the obstetric world true emergencies are rare and that most transfers from the out-of-hospital setting to a hospital are for non-emergent reasons such as a need for pain relief or failure for labor to progress.
But when true emergencies happen, having access to an operating room, more providers or emergent medicines can be life-saving for both mom and baby. “So, for those who birth at home and live farther away than 15-20 minutes from those emergency services, it can increase their risk of having higher mortality or morbidity that could otherwise be prevented,” she explains.
The American Academy of Pediatrics (AAP) does recognize parents’ rights to choose home birth, but stops short of recommending anyone—even those who are low-risk—choose to have a home birth. According to the AAP, home births are associated with a two to three-times increased risk of fetal death, along with a higher incidence of low Apgar scores and newborn seizures.
Nurses and Home Birth
In the U.S., the majority of Certified Nurse Midwives and obstetric nurses do care for pregnant people and their babies in a hospital environment, whether that’s a traditional labor and delivery unit or a birth center affiliated with a hospital. But the American College of Nurse-Midwives does stipulate that home births are under the scope of practices for CNMs. Their definition of care and scope of practice guidelines explain that CNMs’ “services are provided in partnership with individuals and families in diverse settings such as ambulatory care clinics, private offices, telehealth and other methods of remote care delivery, community and public health systems, homes, hospitals, and birth centers.”
And while Bratschie encourages anyone interested in a home birth to fully consider the scope of what a home birth actually entails–including the financial aspect, being responsible for the full clean-up after delivery, and what a hospital transfer might look like—she also points out that the rise in home births should be a signal to nursing professionals that people of reproductive age and their families have unmet needs in the current maternity care model.
“We live in a country where the maternal and infant mortality rates are higher than most industrialized countries and are increasing despite our country’s wealth and rate of medical interventions,” Bratschie explains. In addition to high maternal and infant mortality rates, the C-section rate in the U.S. is higher than what the CDC has set as a “healthy” level. “That tells us the current medical model we have does not work and it does not work particularly for the BIPOC community and other marginalized groups,” she adds.
“Due to all of this, I think birthing persons are looking for a space with more choice, more support, and less unnecessary intervention during the birth and postpartum process that is still safe for themselves and their babies,” says Bratschie. She believes that nurses and CNMs will see a continued increase in the number of out-of-hospital births and more midwifery-led care as well. So if you’re a nurse or a CNM or a student looking to get into maternity care, you can use these statistics as a good starting point to guide your own practice and profession—times may very well be changing for pregnancy care in the U.S. and that will inevitably start with nurses.