Attitudes Towards Home Birth In The USA

283
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Perspective
10.1586/EOG.10.22
Home birth attracts controversy and polarization.
A small but vibrant movement, home birth went
mainstream after Ricki Lake and Abby Epstein’s
2008 documentary The Business of Being Born and
follow-up book Your Best Birth [1,201]. Advocates
share stories ofpeaceful,ecstaticandevenorgasmic
births. Opponents compare home birth to Russian
Roulette and drug abuse. News magazines employ
sensational headlines such as “Extreme Births”
and “Doctors Versus Midwives”. This polariza-
tion extends deep into the world of maternity
care. Most medical organizations strongly oppose
giving birth at home, while almost every other
maternity-related organization, from nursing to
public health to childbirth education, supports
home birth as a safe, reasonable choice for healthy,
‘low-risk’ pregnant women. There is a large body
of literature on the outcomes of home birth,
yet attitudes towards home birth remain highly
divided and fractured. After reviewing current
attitudes towards and research regarding home
birth, this article makes sense of the wildly differ-
ent perspectives towards home birth and proposes
some strategies for overcoming this divide.
A selish, dangerous fad?
Opposing organizations
Oficial medical positions on home birth emerged
in the 1970s, in response to the American renais-
sanceofmidwiferyandhomebirth.TheAmerican
Congress of Obstetricians and Gynecologists
(ACOG) and the American Academy of Ped-
iatrics (AAP) have oficially opposed home birth
since the mid-1970s. With only minor variations
in wording, ACOG and AAP have argued that
because even healthy pregnancies and labors can
suddenly develop complications without warn-
ing, a hospital “provides the safest setting for
labor, delivery, and the postpartum period” [2–10].
ACOG’s most recent statement in 2008 on home
birth was notable for several signiicant deviations
from previous statements [11]. ACOG portrayed
home birth as a fad: “Childbirth decisions should
not be dictated or inluenced by what’s fashion-
able, trendy, or the latest cause célèbre.” ACOG
also accused home birth parents of selishness:
“The main goal should be a healthy and safe
outcome for both mother and baby. Choosing to
deliver a baby at home, however, is to place the
process of giving birth over the goal of having a
healthy baby.” A mother choosing a vaginal birth
after cesarean (VBAC) at home (also known as
home birth after cesarean) is particularly fool-
hardy, according to ACOG: “She puts herself and
her baby’s health and life at unnecessary risk.” On
the other hand, the 2008 statement contained
a dramatic reversal of ACOG’s historic opposi-
tion to out-of-hospital birth in general. While
its 2006 statement on “Out-of-Hospital Births
in the United States” approved only of hospital
Rixa Ann
Spencer Freeze
415 W. Main St., Crawfordsville,
IN 47933, USA
Tel.: +1 765 225 1489
rixa.freeze@gmail.com
Home birth is highly controversial and divisive. Medical organizations oppose the practice, while
other maternity-related organizations (nursing, midwifery, public health, consumer advocacy,
doula and childbirth education) uphold home birth as a safe, reasonable choice for healthy
pregnant women. Individual physicians and midwives have more complex perspectives on home
birth than their professional organizations. Women choose home birth primarily for safety. In
addition, they also have had negative hospital experiences, desire low intervention rates, trust
birth and want a familiar, safe environment. Public opinion centers on four main issues: safety,
choice, women’s experiences and critiques of maternity care. Ironically, medical opposition to
home birth compromises safety. After reviewing current attitudes towards and research about
home birth, this article discusses how discarding the status quo of hostility and mutual distrust
in favor of a pragmatic, autonomy-based approach that fosters communication and respect
would make home birth a safer choice.
KEYWORDS: home birth • midwifery • patient transfer • pregnancy • safety • United States
Attitudes towards home birth
in the USA
Expert Rev. Obstet. Gynecol. 5(3), 283–299 (2010)
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birth, ACOG’s 2008 statement endorsed accredited freestanding
birth centers for the irst time. The 2008 statement acknowledged,
also for the irst time, concern over the rising cesarean rate, but
challenged the idea of a maximum target number.
The American Medical Association (AMA) has published
two position statements concerning birth location: “Obstetrical
Delivery in the Home or Outpatient Facility” [202] and the more
recent “Home Deliveries” [203]. The older statement asserted that
“obstetrical deliveries should be performed in properly licensed,
accredited, equipped and staffed obstetrical units.” The newer
statement endorsed freestanding birth centers for the irst time,
probably because ACOG introduced the resolution that led to the
AMA’s statement on home deliveries [204]. An emphasis on emer-
gencies and sudden complications was still present: “An appar-
ently uncomplicated pregnancy or delivery can quickly become
very complicated.” This resolution likewise mentioned celebri-
ties: “There has been much attention in the media by celebrities
having home deliveries,” including Ricki Lake. The AMA’s newer
statement also recommended developing legislation afirming
that the safest place for childbirth is in a hospital or approved
birth center.
The American Academy of Family Physicians (AAFP) and
American Society of Anesthesiologists (ASA) have remained silent
on the issue of home birth. A search through their websites and
phone calls to headquarters yielded no oficial position statements.
A safe & reasonable choice? Supportive organizations
In contrast to medical opposition to home birth, almost all other
maternity-related organizations (including nursing, midwifery,
public health, doulas, consumer advocacy and childbirth educa-
tion) support the choice to give birth at home. While medical
organizations have adopted a narrow argument against home
birth based on safety concerns, organizations supportive of home
birth emphasize the following themes:
Table 1. Nursing, midwifery, public health, consumer advocacy, childbirth education and doula positions
on home birth.
Responses Frequency Nursing Midwifery Public health
ANN
AWHONN
NANN
ACNM
MANA
NARM
APHA
No response 2
No position 2 × ×
Unoficial position 2
Home birth is a safe choice 15 × × × ×
Evidence 13 × × ×
Collaboration and transfer 5 × × ×
Opposition harms safety 4 × ×
Skilled birth attendant 11 × × ×
Risks of hospital birth 7 ×
Beneits of home birth 6 × ×
Autonomy 15 × × ×
Informed choice 10 × × ×
Physiological event 6 × × ×
Legal/insurance issues 3 × ×
Emergency role 2 ×
Cost 6 ×
Ref. [15,206] [207] [218] [219] [208]
ACEO: American College of Evidence-Based Obstetrics; ACNM: American College of Nurse-Midwives; ANN: Association of Neonatal Nurses; APHA: American
Public Health Association; AWHONN: Association of Women’s Health, Obstetric and Neonatal Nurses; CAPPA: Childbirth and Postpartum Professional Association;
CIMS: Coalition for Improving Maternity Services; ICAN: International Cesarean Awareness Network; ICEA: International Childbirth Education Association;
MANA: Midwives Alliance of North America; NANN: National Association of Neonatal Nurses; NARM: North American Registry of Midwives.
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www.expert-reviews.com 285
Perspective
Table 1. Nursing, midwifery, public health, consumer advocacy, childbirth education and doula positions
on home birth (cont.).
Consumer advocacy Childbirth, education and doulas
ACEO
Big
Push
for
Midwives
Childbirth
connection
Citizens
for
Midwifery
CIMS
ICAN
National
Peri
natal
Advocates
Birthing
From
Within
Birth
Works
Bradley
Hypnobirthing
CAPPA
DONA
International
Hypnobabies
ICEA
Lamaze
× ×
× ×
× × × × × × × × × × ×
× × × × × × × × × ×
× ×
× ×
× × × × × × × ×
× × × × × ×
× × × ×
× × × × × × × × × × × ×
× × × × × × ×
× × ×
×
×
× × × × ×
[209] [220] [216] [11,210–213,221] [12] [222] [223] [Tuschoff
K, Bobro V
(2009); Pers.
Comm.]
[Daub
C,
Pers.
Comm.]
[217] [214] [Tuschoff
K, Bobro V
(2009); Pers.
Comm.]
[13] [14,215]
ACEO: American College of Evidence-Based Obstetrics; ACNM: American College of Nurse-Midwives; ANN: Association of Neonatal Nurses; APHA: American
Public Health Association; AWHONN: Association of Women’s Health, Obstetric and Neonatal Nurses; CAPPA: Childbirth and Postpartum Professional Association;
CIMS: Coalition for Improving Maternity Services; ICAN: International Cesarean Awareness Network; ICEA: International Childbirth Education Association;
MANA: Midwives Alliance of North America; NANN: National Association of Neonatal Nurses; NARM: North American Registry of Midwives.
• The documented safety of home birth for healthy, low-risk women
• Women’s autonomy and informed consent in making healthcare
decisions
• The advantages of home birth for both childbearing women
and birth attendants
• Disadvantages of the hospital setting for healthy women
• The need for better access to medical collaboration and
consultation
TABLE 1 summarizes the key perspectives on home birth from
23 maternity-related organizations [12–15,205–223]. A total of 19 of
these organizations had formal position statements on home birth.
Two organizations – the Association of Neonatal Nurses (ANN)
and the National Association of Neonatal Nurses (NANN) – had
no oficial position on home birth. Phonecalls to Hypnobabies
founder Kerry Tuschoff and Virginia Bobro, Managing Director
of Birthing From Within (BFW), revealed that they are unof-
icially supportive of home birth [Tuschoff K, Bobro V (2009); Pers.
Comm.]. Bradley and Hypnobirthing did not respond to requests
for position statements.
Seven of the main perspectives on home birth from these organ-
izations revolve around safety. A total of 15 out of the 21 organiza-
tions with either oficial or unoficial position statements asserted
that home birth is a safe, reasonable choice for healthy, low-risk
pregnant women. From the American Public Health Association
(APHA): “births to healthy mothers, who are not considered at
medical risk after comprehensive screening by trained profession-
als, can occur safely in various settings, including out-of-hospi-
tal birth centers and homes” [208]. From Lamaze International
(Washington DC, USA): “Home births with a qualiied attendant
have been shown to be safe for healthy women” [14,215]. A total of
13 organizations presented evidence for the safety of home birth.
Attitudes towards home birth in the USA

286
Perspective
For example, the American College of Nurse-Midwives (ACNM)
referenced 31 studies, almost all of which addressed safety and
outcomes [207]. Five organizations mentioned the need for medi-
cal collaboration and smooth home-to-hospital transfers. The
Association of Women’s Health, Obstetric and Neonatal Nurses
(AWHONN) noted:
“Effective communication between all types of healthcare profes-
sionals is essential to provide safe and effective care of women and
newborns, and is especially critical when the patient’s care occurs
in more than one care setting … Because women may choose
different settings for birth (hospital, free-standing birth center or
home) it is important to develop policies and procedures that will
ensure a smooth, eficient transition of the patient from one setting
to another if the woman’s clinical presentation requires a different
type of care” [206].
The ACNM stated that:
“The evidence indicates that appropriate client selection, attend-
ance by a qualiied provider, sound clinical judgment, and transfer
to a receptive environment when necessary, promote safe outcomes
… [The ACNM] urges all healthcare providers and institutions to
collaborate in the creation of seamless systems of care when transfer
is needed from the home to the hospital setting” [207].
Four organizations stated that medical opposition to home birth
compromises the safety of home birth. For example, the Childbirth
Connection argued that ACOG’s opposition “ostensibly issued out
of concern for the safety of mothers and babies … will endanger
mothers and babies in two important ways” [216]. First, ACOG’s
policy “could jeopardize appropriate physician back-up for the
considerable number of women who will continue to desire and
choose out-of-hospital births … Obstruction of such professional
collaboration is of grave concern.” Second, medical policies against
home birth may harm mothers and babies by “enforcing current
questionable hospital standards on all mothers,” such as high rates
of cesarean section and episiotomy, or bans on VBAC.
Three other factors related to safety were the availability of
skilled birth attendants, the risks of unnecessary intervention in
the hospital setting, and the advantages of home birth. A total of
11 organizations noted the importance of a skilled, qualiied birth
attendant for optimal outcomes. Seven organizations argued that
common hospital practices can disturb the birth process and harm
mothers and babies. By contrast, home birth confers several ben-
eits, as six different organizations noted. Lamaze International
succinctly articulated most of these points:
“The medical attitude of expecting trouble during birth, and the
hospital policies that support this attitude, prevent women from
giving birth easily and safely in the typical hospital. Routine medi-
cal interventions used at hospitals interfere with the natural process
of birth and present unnecessary risks that can harm you and your
baby. Home is where most women feel safest and comfortable.
At home, there are no routine restrictions placed on a laboring
woman, which make labor and birth more dificult. At home, you
can choose your own caregivers, family and friends to support you,
wear your own clothes, sleep in your own bed and eat your own
food. In addition, at home, there are no hospital-borne germs to
endanger the health of you and your baby” [215].
A second main theme emerging from these 21 organizations
focused on two inter-related issues: autonomy and informed
choice. A total of 15 organizations supported women’s autonomy
in healthcare decisions and women’s right to choose their provider
and place of birth. Ten organizations mentioned the importance
of informed choice for the birth setting. The Childbirth and
Postpartum Professional Association’s (CAPPA’s) position on
home birth captures these two inter-related themes:
“Women have the right to choose where they give birth, whether
at home, at a birthing center or in the hospital, and we should
uphold their right to do so. Every place of birth has its own risks
and beneits and we should not discourage a mother from birthing
wherever and with whomever she feels safest” [217].
The other key themes addressed a range of miscellaneous issues
related to home birth. Six organizations characterized birth as a
normal, physiological life event – at wide variance with ACOG’s
focus on the potential for pathology. The ACNM argued that
home birth can serve as a valuable teaching tool about normal,
physiological birth:
“The home birth setting provides an unparalleled opportunity
to study and learn from normal, undisturbed birth. Medical
and midwifery students who understand the characteristics of
normality are better equipped to recognize deviations from
normal” [206].
Three organizations addressed the need for insurance reimburse-
ment, malpractice insurance and legal recognition for home birth
providers. The ACNM and The Big Push for Midwives also argued
that access to home birth is particularly important during natural
disasters or pandemics, when hospitals may be inaccessible or exces-
sively dangerous for laboring women. Finally, six organizations
noted that home birth leads to substantial cost savings.
Individuals’ perspectives on home birth
Physicians
While medical organizations emphasize safety as the only perti-
nent issue regarding home birth, physicians as individuals have
more complex, nuanced perspectives. The only published research
about American physicians’ attitudes towards home birth comes
from Oregon State University Professor and practicing certiied
professional midwife (CPM) Melissa Cheyney. She and gradu-
ate student Courtney Everson conducted open-ended interviews
and attended focus group discussions with hospital-based provid-
ers and home birth midwives [16]. They found a deep divide in
how these two groups deined risk. Hospital providers held the
following key beliefs:
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“(1) The belief that home delivery is substantially more
dangerous than current studies indicate; (2) fear and frustra-
tion generated when physicians are forced to assume the risk
of caring for another provider’s patient; and (3) the belief
that midwives make high-risk situations more dangerous by
being dificult to work with due to poor charting and defensive
personalities” [16].
By contrast, home birth midwives articulated a different set of
key concerns:
“(1) The defense of more holistic and co-negotiated constructs of
risk in midwifery models of care; (2) accusations that physicians
tend to judge them by the exception, rather than the rule; and (3)
the failure of physicians to take responsibility for their roles in poor
state and national-level maternal-child health outcomes” [16].
In addition, providers on both sides of the home/hospital divide
often engaged in ‘birth story telephone’ – passing on second-
hand stories that become more exaggerated with each telling.
When home birth midwives transported a laboring client to a
hospital, the providers’ divergent world views and mutual distrust
tended to clash, leading to interactions that were “more fractured
than smooth.”
Anthropologist Robbie Davis-Floyd has also remarked on the
skewed perceptions of home birth from hospital-based providers:
“To hospital-based practitioners, the choice for home birth appears
to be a choice for danger, pain, and random chaos in contrast to
order and control. Most hospital-based practitioners have never seen
a home birth and know little about the knowledge base of home birth
midwives, in part because of a near-total lack of contact” [17].
Mutual hostility and mistrust between hospital- and home-based
providers is often the result. Hospital-based providers talk about
“botched home births”. Home birth midwives respond by accus-
ing them of “botched hospital births”. Davis-Floyd commented:
“This trading of insults is an in-group phenomenon: hospi-
tal practitioners complain to other hospital practitioners about
home birth and midwives; midwives complain to other midwives
about hospital practitioners. Dialogue between these groups is
rare. Mostly, their members inhabit separate worlds that only
intersect when a home birth goes awry and a transport is the
necessary result” [17].
Cheyney and Everson argued that cooperation, communication
and mutual respect between hospital- and home-based providers
would enhance the safety of home birth [17]. Cheyney and her
back-up obstetrician have created a protocol – the irst of its kind
– for facilitating constructive interactions between home birth
midwives and hospital providers [224].
The sharp divide between home birth supporters and opponents
continues to this day. For example, in August 2009 ACOG began
collecting anecdotal accounts of “Complications Related to Home
Delivery” [225]. Concerned that the recent rise in home birth “will
result in an increased complication and morbidity rate,” ACOG
created a survey “to determine the extent of the problem.” The sur-
vey invited physicians to submit information about all home birth
transfers they encountered, “even if there was no adverse outcome.”
Consumer outcry was so strong and swift [226] – a Hufington Post
blog warned “ACOG Up To Dirty Tricks” [227], and home birth
parents began looding the survey with successful results of their
births [228] – that ACOG made the survey accessible to members
only within a few days.
To discover additional physician perspectives on home birth,
we read through discussions over 5 years (January 2005–October
2009) about home birth in the OB–GYN–L archives, a list serve
for obstetricians, gynecologists and maternal–fetal medicine
specialists, and the occasional family physician or midwife [229].
Although this discussion group is not a representative sample
of obstetricians, the themes serve as a starting point for future
research about physicians’ attitudes towards home birth.
First, legal and political constraints played a signiicant role
on limiting physician involvement with home birth, either direct
(attending home births) or indirect (providing collaboration,
consultation, or backup to home birth families and midwives).
Several physicians wanted to provide backup and/or collaboration
with home birth midwives, but their hospitals or malpractice car-
riers speciically forbade these actions. In addition, many physi-
cians on this list could not move beyond an adversarial view of all
patients as potential litigants. Besides having to protect themselves
against (real or potential) lawsuits, physicians dealing with home
birth transfers often faced the brunt of the families’ anger, disap-
pointment and hostility. They did not enjoy being seen as the ‘bad
guy’ in situations they sometimes described as “train wrecks”. In
addition, since home birth midwives often do not carry malprac-
tice insurance, physicians are more likely to be sued for a nega-
tive outcome in a home birth transfer. In sum, physicians often
characterized themselves as victims of out-of-control legal and
bureaucratic systems, forced to adhere to regulations that beneit
hospital administrators and trial lawyers at the expense of patients’
wellbeing. In addition, some obstetricians on this discussion list
suggested that the ACOG’s and AMA’s disavowal of home birth
was motivated less by safety concerns and more by licensure and
professional recognition issues.
Second, physicians held a wide range of opinions regarding
the safety of home birth. Some physicians adhered strongly to
the ACOG position that birth outside of a hospital setting can
never be as safe owing to the unpredictable nature of birth com-
plications, and the access to monitoring and emergency treat-
ments that a hospital can offer. Some characterized home birth
as an inherently risky and selish behavior, on par with smoking,
drug abuse or other dangerous lifestyle choices. Other physicians
questioned these deinitions of safety, turning instead to research
on home birth, and discussing the strengths and weaknesses of
various studies. Other list members suggested that physicians
could beneit from interacting with home birth midwives, who
consistently achieve high rates of spontaneous, unmedicated
vaginal births. They also noted that improved communication

288
Perspective
between physicians and home birth midwives would make home
birth safer. Others proposed revising certain hospital practices
that currently drive some women towards out-of-hospital births.
Midwives
A national organization’s position on home birth does not always
mirror its members’ individual attitudes. Some obstetricians sup-
port home birth despite ACOG’s opposition. On the other hand,
some nurse-midwives feel that a hospital is the only safe setting
for childbirth, even though their professional organization sup-
ports home birth. A survey of certiied nurse-midwives’ (CNMs)
perceptions of home birth – the irst of its kind – found that
nurse-midwives are, as a group, “moderately favorable toward
planned home birth” [18]. Vedam et al. sent a survey measuring
Provider Attitudes Towards Planned Home Birth (PAPHB) to
all ACNM members and received 1893 completed surveys [18].
The authors found:
“The average PAPHB scale score for nurse-midwives was 78.77,
with 60 points indicating a neutral attitude toward planned home
birth. Most study participants agreed that good scientiic evidence
exists demonstrating the safety of planned home birth (82%) and
that the home setting facilitates mother–baby bonding (83%).
Most also agreed that it is easier to preserve cultural congruence
(70%) and an empowering experience (79%) for the woman at
home than in the hospital. Seventy-nine percent believed that
women who give birth in the hospital are more likely to experience
morbidity associated with interventions” [18].
Although most CNMs practice in a hospital setting [19], 32.5%
of CNMs with children chose home birth for one or more of
their children. Vedam et al. also noted that the more exposure
to home birth (personal, clinical or educational), the more likely
a nurse-midwife was to support home birth [18]. On the other
hand, several external factors were associated with less favora-
ble attitudes towards home birth, including “inancial and time
constraints, inability to access medical consultation, and fear of
peer censure” [18].
In 1996, the Midwifery Task Force, composed of representa-
tives from the Midwives Alliance of North America (MANA), the
North American Registry of Midwives (NARM), the Midwifery
Education Accreditation Council (MEAC) and Citizens for
Midwifery (CfM), outlined the basic features of the “Midwives
Model of Care” [230]. This model, which can include both hospi-
tal- and home-based midwifery, is “based on the fact that preg-
nancy are normal life processes.” The midwifery model takes a
more holistic approach to childbirth, monitoring the “psycho-
logical and social well-being of the mother” as well as her physi-
cal condition. The primary goal of midwifery is a “good birth”.
Safety is an important concern, but the midwifery model of care
recognizes that other factors can contribute to better outcomes
for both mother and child [20,21]. Midwives tend to see a woman’s
emotional needs as inseparable from her physical needs. Thus
placing a woman in a setting in which she feels safe, comfortable
and loved can have a direct, positive impact on her labor [22,23].
What about home birth midwives’ perspectives on home birth?
Given the wide body of writing by American home birth mid-
wives – memoirs, textbooks, advice books, blogs, websites and
articles – there is relatively little scholarly analysis or synthesis
of their views on home birth. A study of shared responsibility
in home birth concluded that the close relationships formed
between home birth midwives and their clients “provide structure
for safe, effective clinical practice in planned home birth when
practice boundaries are not deined by institutional walls” [24].
Carol Sakala conducted interviews with home birth midwives to
investigate how they attained consistently low cesarean rates [25].
The midwives held “strikingly” different perspectives about valid
indications for cesarean section, feeling that “many women receive
cesareans due to pseudo-problems, to problems that might easily
be prevented, or to problems that might be addressed through
less drastic measures.” Home birth midwives also employ a lex-
ible, innovative and individualized approach to helping a woman
through the pain of labor [26].
More recently, Davis-Floyd summarized common beliefs
among American home birth midwives:
“All home birth midwives in the United States are inspired by a
transnational ideology of home birth and ‘sisterhood’in midwifery.
All home birth midwives critique the failures and limitations of
biomedicine and have a strong sense of mission about preserv-
ing home birth in the face of biomedical hegemony. They believe
in women’s ability to give birth with little intervention most
of the time, in the superiority of homes and birth centers as the
sites of birth, and in the eficacy of their own knowledge systems
and skills” [27].
She has also written a book about contemporary American
midwives’ struggles with legalization, professionalization and
regulation: Mainstreaming Midwives: The Politics of Change [27].
Anne Frye’s textbook series Holistic Midwifery provides a window
into contemporary American home birth midwives’ attitudes and
beliefs [28,29].
American home birth midwives, most of whom are direct entry
or ‘lay’ midwives, hold conlicted attitudes towards the legalization
and regulation of direct entry midwifery (CNMs can attend home
births in almost every state, but the vast majority of CNMs work
in hospital settings). Midwives living in illegal or alegal states –
where direct entry midwifery is either expressly forbidden, or where
no laws protecting or deining midwifery exist – face arrest and
prosecution for attending births. At the same time, legalization of
direct entry midwifery has been a double-edged sword. Midwifery
legislation may limit midwives’ scope of practice and actually make
midwives more susceptible to prosecution than before. For exam-
ple, when direct entry midwifery was legalized in New York State
(USA), nine midwives were arrested in the same year because they
didn’t meet the legal requirements passed by the law [30].
No study about labor and delivery or postpartum nurses’ atti-
tudes towards home birth exists; this would be a valuable addi-
tion to the small body of research on physicians’ and midwives’
perspectives.
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Perspective
Women who choose home birth
Now that we have discussed attitudes towards home birth from
a range of maternity-related organizations and care providers,
we will examine the experiences and motivations of women
who give birth at home. Women’s experiences of and attitudes
towards home birth have been studied in Australia [31–40],
Canada [41–43], Finland [44,45], France [46], Italy [47,48], Holland
and Belgium [49–57], New Zealand [58,59], Sweden [60–62], and the
UK [63–70]. Although the American home birth movement has
been active since the 1970s, research on American home birth-
ers is relatively modest. A 1979 article argued that women who
choose home birth “are responding in a normal, healthy manner
to threats imposed by present maternity care” and called for more
open communication between these women and healthcare pro-
fessionals [69]. Women rate giving birth in hospitals as signiicantly
more painful that giving birth at home [70]. Women having home
births often face hostility from health professionals that may place
them “at unnecessary risk” [71]. As healthcare consumers, women
perceive medical risk differently from obstetric deinitions. They
also choose birth location based on “evaluations of social as well
as medical risks and beneits connected with place of birth” [72].
Women in New Jersey (USA) chose out-of-hospital birth because
they wanted “to be attended by a midwife, to have the family
present, to be part of the decision-making process.” They also
saw birth as a natural process to be trusted [73]. A 1993 article
summarized the philosophy of the home birth movement – one
applicable to home birth midwives as well as mothers – as an
alternative model that “stresses normalcy and non-intervention
and is informed by an ideology that promotes individual author-
ity and responsibility for health and healthcare … Differences
of opinion with the conventional medical model of childbirth
do not spring from misunderstanding of this model, but from
disagreement with it” [74]. There are also several academic works
investigating various facets of the home birth experience, includ-
ing religion [75], belief systems about birth [76], autonomy [77] and
planned unassisted birth [78].
Box 1. Categories of public opinion on home birth.
Safety
• Home birth is a safe option
• Home birth is too risky
• Home birth is safe with a skilled attendant and a good transfer system
• Home birth mothers are selish, putting their needs above their child’s safety. Women who choose hospital births care more
about safety
• Bad things also happen in hospitals
• Home birth statistics can be manipulated either way
• We should trust the birth process
• We should not trust birth – it’s too risky
Choice
• Consumers are uninformed about birth
• Cesarean section rates are too high, and elective, nonmedically indicated cesarean sections should not be allowed
• Women should be able to choose elective cesarean sections
• Women should be able to choose where and how they give birth
• Women shouldn’t judge other women’s choices
Care providers and maternity care systems
• Home birth isn’t a new fad – hospital birth is
• The midwifery model of care is best for most women
• Care providers need to be more compassionate – this is hard to ind in a hospital setting
• Obstetricians use fear and manipulation to control patients
• Medical opposition to home birth is motivated by inancial concerns, not safety
• Our current healthcare system in general, and obstetric care speciically, need a major overhaul
• It’s nearly impossible to have an undisturbed birth in a hospital; there are too many interventions and complications with hospital care.
• We lack a system for transferring care from home to hospital
The ‘experience’
• The experience of birth matters
• All that matters is a healthy baby
• I had a terrible experience giving birth in a hospital; I wish I had done a home birth
• I had a great experience giving birth in a hospital
• I had a bad home birth experience
• Giving birth is easier at home
• Home birth is better for babies and more empowering

290
Perspective
Recent research has shed more light on why American women
choose home birth. From essay-response surveys completed by
160 women who had given birth at home at least once, safety
was their primary motivation, followed closely by a desire to
avoid unnecessary medical interventions; previous negative hos-
pital experiences; the comfort, control and familiar environment
of a home setting; and trust in the birth process. Some of the
least commonly mentioned motivations for choosing home birth
were history of fast labors, fear of a hospital-acquired infection
and cost [79]. In-depth ethnographic interviews at the homes of
20 home birth families yielded similar conclusions [80]:
“All of the women described themselves as ‘mainstream’. They all
wanted a natural birth. All the women came to believe that ‘inter-
vention intensive’ maternity care increased risk for them and their
babies. They valued the personal relationship with their midwife
and believed that this relationship increased safety. They believed
they could manage the work of labor more easily and more safely in
their own homes. They all expressed conidence that a hospital and
skilled physician care were available if needed. ‘Being safe’ emerged
as the theme that captured the essence of women’s decision to plan a
home birth” [231].
Public opinion
The only study of public perceptions of home birth is a 1983
survey that asked Massachusetts (USA) residents if they sup-
ported CNM-attended home birth versus physician-attended
home birth [81] – a question that is hardly relevant today, since
home birth is now almost exclusively the domain of midwives. To
gain a preliminary understanding of the range of public opinion
about home birth, we surveyed the main text and comments
sections of three recent news and blog articles about home birth
[232–234]. The comments likely over-represent those who feel
strongly about the issue, but they are still a fascinating starting
point for understanding the wide range of public opinions about
home birth. BOX 1 highlights the four main themes articulated in
both the articles and comments: safety, choice, laws with the
current maternity care system, and whether the ‘experience’ of
birth matters.
Expert commentary
Can research end the home birth controversy?
One might ask if all of the controversy over home birth could
be put to rest with good scientiic research. Could a series of
large, well-designed studies inally heal the rift between advo-
cates and opponents? In other words, is the real problem with
home birth simply a lack of sound research and evidence? The
answer to both of these questions is no. There is, in fact, already
a large and growing body of research about the outcomes of
home birth. See, for example, ACNM’s position statement [206]
and the bibliography of home birth studies provided by CfM
[235]. The past 5 years have been particularly fruitful for home
birth research. Several studies are of particular note [82–93]; see
TABLE 2 for highlights from selected studies. An integrative review
on home birth outcomes has also been published recently [94].
The primary focus of this article is not on home birth research;
consult Romano and Goer’s forthcoming book for an in-depth
examination and discussion of home birth research [Goer H,
Romano A, Pers. Comm.].
In 2005, the British Medical Journal published the results of
all CPM-attended births in North America in 2000 [82]. While
Johnson and Daviss’ study had the advantages of a large sample
size and prospective design, there was no good matched con-
trol group [82]. Instead, the authors compared their indings to
several different studies of low-risk hospital birth, some dating
back several decades. In 2007, Fullteron et al conducted an inte-
grated review of home birth research [94]. They concluded that
these studies “demonstrate a remarkable consistency in the gen-
erally favorable results of maternal and neonatal outcomes, both
over time and among diverse population groups … [and] when
viewed in comparison to various reference groups (birth center
births, planned hospital births and vital statistics).” They argued
in favor of policies supporting planned home birth and home
birth infrastructure.
Three 2009 studies addressed several weaknesses of existing
home birth research [86–88]. The sheer magnitude of numbers
in de Jonge et al. – over half a million midwife-attended low-
risk births, either at home or in hospital – combined with a true
comparison group (low-risk women who chose hospital birth but
could have chosen a home birth; both home and hospital groups,
attended by the same group of midwives) make this a valuable
study [86]. The authors found no signiicant differences in rates
of intrapartum and neonatal death or neonatal intensive care unit
admission between the two groups. The authors commented:
“The Netherlands is the only Western country that can provide
a large enough data set to show potential differences in severe out-
comes between planned home and planned hospital births among
low-risk women. Homebirth is still very common and compre-
hensive data are available in The Netherlands Perinatal Register.
Moreover, low-risk women in primary care at the onset of labour
can easily be identiied and compared, based on their intended
place of birth” [86].
Two other studies – Janssen et al. [87] and Hutton et al. [88] – were
also notable for their strong comparison groups. Women planning
midwife-attended home births were compared with women plan-
ning hospital births with the same midwives. Janssen et al. also
included another comparison group: a matched sample of low-risk
women planning physician-attended hospital births [87]. Janssen
et al. found that rates of perinatal death were comparable among
all three groups[87]. However, compared with both planned hos-
pital groups, planned home births had lower rates of obstetric
interventions and fewer adverse maternal outcomes. Newborns
in the planned home birth group required less resuscitation at
birth and had lower rates of oxygen therapy [87]. Hutton et al.’s
indings were similar. There were no signiicant differences in
perinatal or neonatal mortality between the two groups. Serious
maternal morbidity and rates for all interventions were lower in
the planned home birth group[89].
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Perspective
Table 2. Recent (2005–2009) selected studies on home birth outcomes.
Auhor (year) and
study type
Study population Sample size and control/
comparison groups
Key indings Ref.
Johnson et al. (2005)
Prospective
All North American women
planning CPM-attended home
births in 2000
5418 planned CPM-attended
home births at onset of labor
Planned home birth for low-risk women in North America using CPMs
was associated with lower rates of medical intervention but similar
intrapartum and neonatal mortality to that of low-risk hospital births in
the USA
[82]
Lindgren et al. (2008)
Population-based register
All home births in Sweden from
1992 to 2004
897 PHBs (at onset of labor)
11,341 randomly selected
hospital births
Intrapartum and neonatal mortality was higher (although not statistically
signiicant) in PHB group. PHB group had higher rates of sponteanous
births, less medical intervention, and fewer pelvic loor injuries
[84]
Mori et al. (2008)
Population-based
cross-sectional
All births in England and Wales,
including home births (intended
or unintended) between 1994
and 2003
6,314,315 total births, of those
130,700 were PHB (at time of irst
antenatal booking, not necessarily
at onset of labor)
Completed planned home births have low IPPM rates. Home birth
transfers (including prenatal transfers as well as in-labor transfers) have
a higher risk of IPPM
[85]
de Jonge et al. (2009)
Nationwide cohort
All low-risk women (529,688) in
Holland who gave birth
between 2000 and 2006, and
who were in primary MW-led
care at the onset of labor
321,307 planned MW home
births
163,261 planned MW hospital
births
45,120 MW births, intended place
of birth unknown
Planning a home birth does not increase the risks of perinatal mortality
and severe perinatal morbidity among low-risk women, provided the
maternity care system facilitates this choice through the availability
of well-trained MWs and through a good transportation and
referral system
[86]
Janssen et al. (2009)
Retrospective cohort
All PHBs attended by registered
MWs in BC (Canada) from 2000
to 2004
2889 planned home births
4752 planned hospital births with
the same MWs
5331 matched physician-attended
planned hospital births
Planned home birth attended by a registered MW was associated with
very low and comparable rates of perinatal death, and reduced rates of
obstetric interventions and other adverse perinatal outcomes compared
with planned hospital birth attended by a MW or physician
[87]
Hutton et al. (2009)
All MW-attended births in ON
(Canada) from 2003 to 2006
(both planned home and
hospital births)
6692 planned home births
13,384 planned hospital births
with the same MWs
Midwives who were integrated into the healthcare system with good
access to emergency services, consultation and transfer of care
provided care resulting in favorable outcomes for women planning
both home or hospital births
[88]
Symon et al. (2009)
Births from IMA database
matched with comparable
Scottish NHS records
1462 IMA births (66% occurred
at home)
7214 NHS births (0.4% occurred
at home)
IMA births (66% occurred at home) had higher rates of spontaneous
vertex deliveries, spontaneous labor and breastfeeding, lower rates of
pharmacologic analgesia, and higher rates of pre-existing medical
conditions, previous obstetric complications and twin pregnancies.
NHS cohort had higher rates of prematurity, low birth weight and
NICU admissions. IMA cohort had higher rates of stillbirth or neonatal
death; this difference disappeared when high-risk cases were excluded
from both cohorts
[92]
Kennare et al. (2010)
Retrospective
population based
Data from South Australian
perinatal statistics from 1991
to 2006
297,192 planned hospital births
1141 planned home births (at
time of antenatal booking, not
necessarily at onset of labor;
69.4% occurred at home)
Compared with planned hospital births, PHBs had a similar overall
perinatal mortality rate but higher rates of intrapartum death and
death from intrapartum asphyxia. The three PHB deaths (out of nine
total) possibly attributable to place of birth were associated with twins,
post-date pregnancies and inadequate fetal surveillance
[93]
CPM: Certiied professional midwife; IMA: Independent Midwives Association; IPPM: Intrapartum-related perinatal mortality; MW: Midwife; NHS: National Health Service; NICU: Neonatal intensive care unit;
PHB: Planned home birth.
Attitudes
towards
home
birth
in
the
USA

292
Perspective
The safety of home birth for healthy, low-risk women, when
attended by skilled midwives and in a system that facilitates col-
laboration and timely transfer of care, is well supported by the
evidence. The safety of home birth is much less clear for cer-
tain situations, such as post-term pregnancies, breech birth or
twins. Kennare et al.’s study of planned home births in South
Australia found that the three home birth deaths in which place
of birth was a likely factor were associated with post-term preg-
nancy, twins or inadequate fetal surveillance [93]. Symon et al.’s
investigation of planned home births attended by independent
midwives in England and Wales found a higher rate of stillbirth
and neonatal death among ‘high-risk’ planned home births [92].
However, stillbirths and neonatal deaths were similar among the
low-risk home and hospital groups. Mori et al. examined all births
in England and Wales, including home births, between 1994
and 2003 [85]. They found that completed home birth transfers
(both prenatal and in-labor) were associated with a higher risk of
intrapartum-related perinatal mortality[85]. The reverse was true
for completed planned home births. Both Kennare et al.[93] and
Mori et al. [85] classiied planned home births according to their
booking at the irst prenatal visit; thus, women who intended to
give birth at home at their irst prenatal visit, but later changed
their plans during pregnancy, would still have been considered
planned home births [85].
The reaction from medical organizations to these recent stud-
ies – especially the studies afirming the safety of home birth
for low-risk women – has been a nonreaction: no press releases,
no commentaries or critiques and certainly no change in pol-
icy towards home birth. Attitudes towards home birth shape
which studies a group privileges and which it ignores; additional
studies are unlikely to convince an organization that is already
ideologically opposed to home birth.
Meanings of safety
The ACOG, AMA and AAP policies on home birth contain no
cited evidence for their conclusions; rather, they rely on con-
sensus opinion and obstetrical beliefs about safety. By contrast,
most organizations supportive of home birth supply citations to
support their assertion that planned, midwife-attended home
birth is a safe, reasonable choice. Groups supportive of home
birth would argue that this is simply because the evidence is
clearly on their side. However, there is a more complex explana-
tion behind this disparity in the use of evidence. Medical organ-
izations are in a relative position of power. Their guidelines are
the basis for hospital and insurance policies, and shape clinical
practice. The vast majority of pregnant women still see obstetri-
cians for maternity care. In that sense, medical organizations
are under less pressure to justify their policies than are other
maternity-related organizations, such as midwifery or consumer
advocacy groups, which are still struggling for legitimacy and
public recognition.
In addition, the controversy over home birth will never be
resolved with medical studies because the very meaning of safety
is open for debate. Obstetrics tends to adopt a narrow deini-
tion of safety, focusing solely on mortality and short-term, major
morbidity. Concern over the fetus/baby tends to trump women’s
physical or emotional experiences. Women who choose home
birth, midwives who attend home births and organizations that
support home birth take a wider approach to safety. A healthy
mother and baby are still primary goals, but other factors are also
important. Goer and Romano explain:
“Although physical safety, e.g., avoidance of death or disabil-
ity, is part of women’s risk calculus, women who choose home
birth describe a broader concept of safety that incorporates the
long-term physical and emotional wellbeing of both them and
their infants and places a high value on practices that ease and
facilitate labor, prevent complications, protect breastfeeding and
foster early mother–infant attachment. They believe that planned
home birth offers a safety advantage over hospital birth because it
allows relationships with care providers that are based on trust,
active participation in decision making, and minimal exposure to
potentially harmful interventions” [Goer H, Romano A, Pers. Comm.].
These are all safety issues – not frivolous emotional concerns
– to home birthers [78,82]. British sociologist Ann Oakley called
these differences “conlicts between two opposing ‘frames of ref-
erence’, each of which is internally consistent, accepted within
the relevant peer group” [95]. The obstetrical frame of reference
understands the hospital as the safest location for birth owing to
the potential for sudden complications. Home birth supporters
feel that the home environment enhances safety because it enables
labor and birth to unfold uninterrupted, and without routine and
potentially dangerous interventions.
Paternalism vs maternal autonomy
So how else can we make sense of the widely varying attitudes
towards home birth in the USA? Behind the rhetoric about safety
is a fundamental struggle between two competing ideologies:
paternalism and maternal autonomy. A paternalistic approach to
maternity care allows women to make some choices (e.g., epidural
anesthesia on demand [236], elective induction for logistic or psycho-
social reasons [96], and elective cesarean section [97]) because they
are seen as safe and reasonable, but not others (e.g., VBAC [98],
home birth, and employing direct entry or lay midwives [237]), pre-
sumably because they are too risky. Even when women insist they
are fully informed of the risks and beneits of various options, pater-
nalism overrides informed consent. For example, ACOG upholds
women’s right to choose their caregiver – with several limitations
[11]. The birth cannot not take place at home or at a nonaccredited
birth center, and can be attended only by a physician or approved
midwife (most of whom practice in a hospital setting):
“ACOG acknowledges a woman’s right to make informed deci-
sions regarding her delivery and to have a choice in choosing her
healthcare provider, but ACOG does not support programs that
advocate for, or individuals who provide, home births. Nor does
ACOG support the provision of care by midwives who are not
certiied by the American College of Nurse-Midwives (ACNM) or
the American Midwifery Certiication Board (AMCB)” [11].
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A paternal approach simply outlines acceptable choices and
restricts the others. Obstetrician Lauren Plante commented that
physicians’ support of autonomy is only as strong as their position
of power relative to the patient:
“Autonomy stops at the door of the labor room. Women are
implicitly allowed, or encouraged, to make only those choices that
increase the power of the physician and that decrease their own …
The American College of Obstetricians and Gynecologists calumni-
ates not only women who want a home birth but anyone who advo-
cates leaving that option open. At the hospital, women who might
like to exercise their right to self-determination by choosing vaginal
birth after cesarean, or vaginal breech delivery, will have a hard
time of it. Is it not the opposite of autonomy to support only those
choices that increase the woman’s reliance upon the physician?” [99].
By contrast, an approach founded on maternal autonomy strives
to understand the reasons for women’s choices, to provide accurate
information about the risks and beneits of all choices, and to
make all choices as safe as possible. The woman, rather than her
care providers or their professional associations, has the ultimate
responsibility of deciding what birth location and providers are
best for her individual situation. Canadian physician Andrew
J Kotaska, Clinical Director of Obstetrics and Gynecology at
Stanton Territorial Hospital (Canada), wrote in response to
ACOG’s 2008 statement on home birth:
“Modern ethics does not equivocate: maternal autonomy takes
precedence over medical recommendations based on beneicence,
whether such recommendations are founded on sound scientiic evi-
dence or the pre-historic musings of dinosaurs. In the modern age,
the locus of control has, appropriately, shifted to the patient/client
in all areas of medicine, it seems, except obstetrics. We do not force
patients to have life-saving operations, to receive blood transfu-
sions, or to undergo chemotherapy against their will, even to avoid
potential risks a hundred fold higher than any associated with home
birth. In obstetrics, however, we routinely coerce women into inter-
vention against their will by not ‘offering’ VBAC, vaginal breech
birth, or homebirth. Informed choice is the gold standard in deci-
sion making, and it trumps even the largest, cleanest, [randomized
controlled trial]. Science supports homebirth as a reasonably safe
option. Even if it didn’t, it still would be a woman’s choice” [238].
Supporting maternal autonomy means making choices available
to women. It is not really a choice when the nearest hospital allowing
a VBAC is 500 miles away [239], or when having a home birth means
driving across two state lines in labor [240,241] – both real situations
that happened to American women in 2009. Unless options are
available and accessible within their local communities, pregnant
women cannot truly make informed decisions about their care.
Towards a pragmatic approach to home birth policies
There is a way out of the divisive controversy over home birth. It
involves a series of paradigmatic shifts. First, we need to move away
from the ideological rigidity and universality so often present in
debates about home birth, to an approach based on pragmatism.
The ACOG, AMA and AAP positions on home birth state that
women should not choose home birth at all, because it is too dan-
gerous. This position does not take into account women’s indi-
vidual needs and experiences, nor does it offer a solution to the
reality that home birth is here to stay, or to the women who feel
traumatized or violated by their hospital births. The numbers are
still relatively small, but home birth has persisted despite decades of
obstetric opposition. In fact, the most recent National Vital Statistics
Reports found that home births increased slightly in 2005 after a
15-year decline [242]. A pragmatic approach would accept the reality
of home birth as a choice that some women will always make and
seek ways to make that choice safer. As several recent studies on
home birth have concluded, home birth is safe when healthy preg-
nant women are attended by well-trained midwives, when the mid-
wives are integrated into the healthcare system, and when midwives
have access to consultation, referral and a smooth transfer of care.
American obstetrical opposition has, ironically, negatively affected
those key elements that contribute to safety. Direct entry midwives
still cannot practice openly in many states; this poses obstacles to
training and education, as well as to forming collaborative relation-
ships with physicians. When women transfer to a hospital during
labor in illegal/alegal states, their midwives may abandon them
at the hospital doors for fear of arrest and prosecution. State and
national medical associations consistently oppose legislation that
would license or regulate direct entry midwifery, further contribut-
ing to the problem. And medical opposition inluences malpractice
insurance policies and hospital regulations, creating a system hostile
to, rather than supportive of, home birth. Lowe has argued:
“What is most risky about home birth in the United States is
that for most women who desire it there is a scarcity of qualiied
providers of home birth services. There is no system of care that pro-
vides the needed safety net if transfer to a different type of care is
required during labor … It is our system that is not serving moth-
ers and babies well. There is not some inherent danger lurking for
healthy American women who desire to give birth at home. The
primary danger is that the ‘system’ does not support this choice” [15].
The irst step in helping the ‘system’ support the choice of
home birth is to reverse oficial medical and obstetrical opposi-
tion to home birth. Policy statements from the ACOG, AAP or
AMA are not just academic exercises; they directly affect hospi-
tal policies, malpractice and health insurance regulations, and
clinical practice. Obstetrical attitudes and policies also inluence
whether midwives can become legal, regulated and licensed in
individual states.
Practical suggestions for positive change
So what are the irst steps to a pragmatic, autonomy-based
approach to home birth? Home birth midwives would have the
responsibility to keep their skills and education up-to-date and to
stay abreast of current research. Midwives would carefully counsel
women about the risks and beneits of home birth for their indi-
vidual situations. The literature is clear about the safety of home

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Perspective
birth for low-risk women, but there appear to be increased risks
when certain higher risk groups give birth at home (although we
do not know how much of that risk comes from the home setting
versus the risk factor itself, independent of place of birth). If higher
risk women still wish to move forward with their home birth plans,
and if the midwives are comfortable attending, both parties should
remain watchful for indications for hospital transfer, and should
actively seek collaboration and/or consultation as needed.
Moving the CPM certiication into the university system as a
4-year undergraduate degree in midwifery is another strategy that
could improve midwifery skills and training. Curricula could be
modeled after the direct entry midwifery programs in Canada,
Europe or the UK. Perhaps more importantly, upgrading the CPM
credential would also increase the legitimacy and medical accept-
ance of direct entry midwifery. NARM is likely to resist requiring
university-based midwifery education, as it strongly values the
apprenticeship model that has been the most common educational
route for American direct entry midwives [243]. However, for home
birth midwifery to be accepted by medical organizations and to
become integrated into the American healthcare system, it needs
the increased legitimacy that would come from a university degree.
Hospital-based providers – obstetricians in particular – would
actively work to ensure that home birth midwives can collaborate,
refer and consult freely with physicians. This means, in part,
demanding that malpractice insurance carriers no longer forbid
such interactions. In the event of in-labor transfers, physicians
would remove barriers to transferring (such as the midwife’s fear
of being arrested if she transfers a client, or a woman’s fear of
harsh treatment at the hospital), see that lines of communication
remain open between the woman’s midwife and hospital staff, and
ensure that the staff treat the woman with respect and dignity, no
matter how they might feel about her choice to give birth at home.
Physicians and midwives also have the shared responsibility to
work towards a model of cooperation, communication and mutual
respect, rather than one of competition, mistrust and hostility.
Because exposure to home birth increases favorable attitudes, physi-
cians and nurses would beneit from opportunities to observe home
births. Vedam and her coauthors suggested the following strategy:
“Findings from this research suggest that the formal inclusion
of the theory and practice of home birth as core requirements for
medical and midwifery students could increase overall favorabil-
ity toward planned home birth. Interdisciplinary education about
planned home birth could lead to ‘best practice’ guidelines around
collaboration in maternity care and remove signiicant external
barriers to practice. Students may beneit from mandatory require-
ments for planned home birth clinical experiences, and out-of-
hospital management and skills competency assessment, similar
to those that exist in other nations” [18].
The reverse situation – giving home birth midwives opportuni-
ties to observe and learn from hospital-based practitioners – would
likely be beneicial, as well in improving trust in and knowledge
about the medical system. These opportunities cannot happen
without several initial changes:
• Reversal of the AMA and ACOG positions against home birth;
• Reversal of malpractice insurance policies forbidding interaction
with home birth providers;
• Legalization of direct entry midwifery in all 50 states, most
likely via the CPM credential. Midwives will not be willing to
interact with medical professionals if they risk being arrested.
Five-year view
There are three possible scenarios for the future of home birth
in the USA. The irst possible scenario is a change in home birth
policy based on a new feminist movement centered on two key
issues: maternal autonomy and informed consent. This movement
will ensure a full spectrum of choices for childbearing women,
from what has traditionally been termed ‘reproductive rights’
(access to contraception, family planning and abortion services)
to the new arena of ‘childbearing rights’. Plante has described what
a full spectrum of birth choices would look like: “Women can
give birth at home unaided; at home with family or with trained
assistance; in a birth center, either freestanding or hospital-based;
in the hospital delivery room with trained assistance; or in the
operating room where they are acted upon” [99]. However, this
scenario is unlikely to occur in the next 5 years, since feminist
groups have largely been silent on issues related to pregnancy and
birth, except for occasional interest in teen pregnancy.
A second possible scenario is a widespread change in attitude
towards home birth based upon research evidence. Although this
is unlikely to occur in the USA in the next 5 years, it is not
impossible. Canada underwent such a change in the mid-1990s.
Formerly opposed to home birth, the Society of Obstetricians
and Gynecologists of Canada now considers planned, midwife-
attended home birth to be safe for low-risk women and recognizes
women’s desire to choose their place of birth. Direct entry mid-
wives are integrated into Canada’s educational and healthcare
systems [100,244]. Medical and midwifery associations in the UK
have also based their home birth positions on the research about
the safety of home birth and about women’s experiences. From
the joint statement of the Royal College of Obstetricians and
Gynaecologists and the Royal College of Midwives:
“The review of the diverse evidence available on home
birth practice and service provision demonstrates that home
birth is a safe option for many women. However, this is not
to deine safety in its narrow interpretation as physical safety
only but also to acknowledge and encompass issues surround-
ing emotional and psychological wellbeing … Furthermore,
the studies into women’s descriptions of home birth experiences
have produced qualitative data on increased sense of control,
empowerment and self esteem, and an overwhelming preference
for home birth” [101].
The third and most likely 5-year scenario is a grassroots,
consumer-driven movement spurring changes both inside and
outside the hospital system. Fearing a loss of business owing to
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Key issues
• Since the 1970s, the American Congress of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the American
Medical Association have oficially opposed home birth on safety grounds. Individual physicians hold much more complex, nuanced
views on home birth than their professional organizations. Legal, political and insurance constraints limit physicians’ ability to provide
collaboration, consultation or back-up care.
• Favorable attitudes toward home birth are directly related to a healthcare provider’s exposure to home birth. For example, although
most certiied nurse-midwives (CNMs) attend births in hospitals, they have a high level of exposure to home birth and generally hold a
favorable view of home birth. A signiicant minority of CNMs have given birth at home.
• With the exception of medical associations, almost all maternity-related organizations (nursing, midwifery, public health, consumer
advocacy, doula and childbirth education) support home birth as a safe, reasonable choice for low-risk women. They refer to an
extensive body of evidence about the safety and beneits of home birth, note the disadvantages of a hospital setting for healthy
women, support maternal autonomy and informed consent in choosing a care provider and place of birth, call for increased
collaboration and cooperation between home birth midwives and physicians, and stress the importance of skilled birth attendants.
• Home birth midwives and women who choose home birth view home birth as a safe, natural and empowering choice. They value the
natural process of birth, want to avoid routine medical interventions, object to common hospital practices, and perceive the home
environment as a safe, private and comfortable space.
• Public opinion about home birth is sharply divided. Issues of safety, choice, women’s experiences and maternity care systems are key
concerns in public discussions about home birth.
• Research evidence has played only a small role in shaping attitudes towards home birth. Despite the growing body of well-designed
studies showing that home birth for low-risk women is a safe choice with beneits for both mother and baby, medical opposition to
home birth has remained unchanged. The debate over home birth is less about the evidence for or against its safety, and more about
underlying issues such as the meaning of safety itself and the struggle between paternalism and maternal autonomy.
• Home birth appears to be safest when healthy, low-risk women are attended by skilled practitioners who are integrated into a
healthcare system that facilitates collaboration, consultation and transfer of care when needed. In the USA, all of these elements need
improvement. Ironically, medical opposition to home birth remains the largest obstacle to achieving these key elements of safety.
Abandoning the current model of competition, hostility and mutual distrust, and implementing an approach based on collaboration,
cooperation and mutual respect between hospital-based practitioners and home birth midwives (and their clients) would make home
birth safer – an indisputable goal.
References
Papers of special note have been highlighted as:
• of interest
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consumer demand for a wide range of birth alternatives, hospitals
administrators and physicians will (perhaps somewhat reluctantly)
change their policies and practices. These changes may include
system-wide support for home birth, the reversal of hospital
VBAC bans, encouragement of maternal mobility during labor
and choice of birthing position, birth pools for labor and/or birth,
and increased access to hospital-based CNMs. There is some
evidence that this movement has begun, although widespread
changes are unlikely to be completed within the next 5 years.
The immediate future will likely witness further entrenchment
from the medical community, including continued efforts to out-
law home birth midwifery and restrict women’s ability to choose
their location of birth. Medical organizations have not reversed
their opposition to home birth for several decades, despite the
growing body of research demonstrating its good outcomes for
both mother and baby. Simultaneously, a small but growing move-
ment led by a coalition of consumers, doulas, childbirth educators,
and supportive healthcare providers will continue to advocate for
upholding childbearing women’s autonomy in general and home
birth speciically.
Financial & competing interests disclosure
The author has no relevant afiliations or inancial involvement with any
organization or entity with a inancial interest in or inancial conlict with
the subject matter or materials discussed in the manuscript. This includes
employment, consultancies, honoraria, stock ownership or options, expert
testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.

296
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