Other investigators in the midwifery literature have reported similar findings.8
But to extend these findings to higher-risk women…
Generally positive outcomes for home birth in carefully selected, low-risk women have emboldened some advocates to push the envelope. They have begun to encourage and attempt home birth for women who are not low-risk, including ones who have had prior cesarean delivery.
There are few data on the risks of home birth after C-section. Based on studies of a trial of labor after C-section in birth centers, however, it is very likely that this practice will significantly increase maternal and newborn morbidity. In one study9 of 1,913 women attempting vaginal birth after a cesarean delivery at a birth center,
- 0.4% of subjects ruptured their uterus
- 0.5% of pregnancies resulted in fetal or neonatal death.
Clearly, home birth after cesarean delivery is a high-risk practice that should be condemned. ACOG has done so: “Attempting a vaginal birth after cesarean at home is especially dangerous because if the uterus ruptures during labor, both the mother and baby face an emergency situation with potentially catastrophic consequences, including death.”
Yet advocates of home birth have not vocally opposed the practice of home birth after cesarean delivery.
Failed home birth means transfer to the hospital
Approximately 10% to 15% of planned home births do not succeed. Failure—most often, because of lack of progress in labor—means that the mother is transferred to a local hospital for birth. After successful home birth,
- about 1% of mothers are transferred to the hospital because of maternal hemorrhage or retained placenta
- about 1% of newborns are transferred to the hospital because of respiratory difficulty.10
Women who planned a home birth but then require transfer to a hospital because of failure are at increased risk of harm and death, as is the fetus or newborn.11
A tough spot for the OB
Transferring a woman to the hospital after failed home birth places the receiving OB in an awkward position. She (he) typically has had no role in antepartum or intrapartum management of the patient, but is expected to develop an emergent plan for resolving a high-risk pregnancy that best protects mother and fetus!
My impression is that OBs who are placed in this unfortunate situation at first 1) wish that the mother had not chosen a home birth plan and 2) feel moral outrage and anger about the decision she made to place herself and her offspring at increased risk of injury and death.
In most cases, these emotions evolve to reflective acceptance of the physician’s responsibility to provide care to a woman in need, regardless of her past decisions. And most women who have failed home birth are accepting of the recommendations of their new physician.
More home births to come?
My hope is that the rate of planned home births, now at about 0.6% of all births, will decrease—or, at least, not increase. But it’s troubling to see that, in a number of states, legislation is being vigorously argued that would, first, expand the scope of practice of minimally trained midwives and, second, more explicitly embrace the practice of home birth from the perspective of regulatory agencies and healthcare insurance companies.