How safe is it in the United States to be born someplace other than a hospital? The question has long been the focus of emotional debate and conflicting information. Now, Oregon scientists and health workers who deliver babies have some research evidence that sheds a bit more light.
The study, which involved more than 75,000 low-risk births in the state in 2012 and 2013, found the risk of death for the baby appears to be twice as high when mothers planned to deliver at a birthing center or at home compared with when delivery was intended for a hospital. But in any location the overall risk to the child is very low, the study showed.
"The bottom line is, childbirth in the United States is very safe regardless of where you decide to do it," says Dr. Michael Greene, who directs obstetrics at the Massachusetts General Hospital in Boston. Greene co-authored an editorial accompanying the study in the New England Journal of Medicine but was not involved in the research.
Out of every 1,000 babies whose mothers planned to deliver at home or at a birthing center, 3.9 died just before, during or in the month after labor, the study found. In comparison, 1.8 out of every 1,000 babies died when the births were planned for a hospital, the study found.
Roughly 99 percent of American women give birth to their infants in a hospital. But the number of women delivering babies at home or in a birthing center has been increasing dramatically in recent years — up nearly 30 percent between 2004 and 2009, for example. So scientists at the Oregon Health and Science University decided to try to get a better idea of how risky that is.
The researchers took advantage of the fact that Oregon recently started requiring all birth certificates to list whether the mother had intended to give birth inside or outside a hospital. That designation helped researchers tease out births that were intended for home, but ended up in the hospital when something went awry. The study also excluded twins and other pregnancies designated as higher risk; hospital deliveries are more likely to be planned for pregnancies deemed higher risk.
"I think this is the best data we've had in our country on this question because where the woman intended to deliver really matters," says Dr. Aaron Caughey, who heads the university's department of obstetrics and gynecology.
While the study found the risk of death to the baby was higher when it was planned for outside the hospital, the study also found that there were benefits. Women who planned to deliver outside a hospital were much less likely to have their labor induced by drugs or have their babies delivered with forceps or through a cesarean surgical procedure, the researchers reported.
"It does support this idea that women are in some cases getting what they desire," Caughey says. "They're getting this lower intervention rate in the out-of-hospital birth setting."
The study also found that women who planned to give birth outside a hospital were less likely to experience lacerations to the vagina, but more likely to need blood transfusions. The researchers did not have sufficient data to examine other possible risks to the mothers.
Caughey tells Shots he hopes the new study will help each woman decide whether the slightly increased risk to her baby is worth the possible benefits.
Green agrees that the information should be very helpful. "That's the wonderful thing about having this data," he says. "It lets every woman decide what's most important to them. Is it most important to them to have, for example, a spontaneous vaginal delivery and avoid a cesarean section, or avoid an instrumented vaginal delivery? Or is it most important to them to have the least potential risk of coming away without a baby."
One group that represents midwives, The Big Push for Midwives, also welcomed the new findings.
"This study is consistent with other literature that shows the absolute risks are low," says Steff Hedenkamp, the group's spokesperson. She calls the findings "pretty remarkable, given that in the United States midwives — certified professional midwives — are not integrated into many of our states' health care systems."
Hedenkamp's group is urging more states to license midwives, in the hope that doing so will lead doctors and midwives to coordinate the care of their patients more closely, so that having a baby outside a hospital will become even safer.
ROBERT SIEGEL, HOST:
Here's a question that's been at the center of a long, emotional debate. How safe is it for a woman to give birth outside of a hospital? The New England Journal of Medicine is now reporting the results of a big, new study that has some answers to that question. Here's NPR's health correspondent Rob Stein.
ROB STEIN, BYLINE: Samanda Rossi gave birth to her third son just before Christmas, and like his two brothers, Tate was born at home.
SAMANDA ROSSI: He had a really, really peaceful, loving introduction into the world. And I was grateful for him that he had such a gentle journey.
STEIN: Most American women still have their babies in a hospital, but the number of women who are giving birth at home or in a birthing center has been increasing dramatically. Many, like Rossi, went to avoid getting a C-section or other medical procedures, but Aaron Caughey of the Oregon Health and Science University says there's been a big question about how safe that is.
AARON CAUGHEY: Tens of thousands of women are choosing to deliver out of hospital, so the fundamental question that we're trying to address was to identify the risks of attempting an out-of-hospital birth.
STEIN: So Caughey and his colleagues studied almost 80,000 low-risk pregnancies in Oregon in 2012 and 2013, and the results were clear.
CAUGHEY: For women who intend to deliver out-of-hospital, the risk was about four per thousand of the baby dying either before labor, during labor or in the first month of life. In women who chose to deliver in-hospital, that risk was about two per thousand, so about half.
STEIN: Now that might make giving birth anywhere but in a hospital seem pretty scary.
CAUGHEY: But in the grand scheme of things, there are definitely those individuals who consider that a relatively small risk.
STEIN: And the study also clearly shows there are some real benefits of trying not to give birth in a hospital. Those women were much less likely to get their labor induced with drugs or have their babies delivered with forceps or a C-section.
CAUGHEY: It does support this idea that women are in some cases getting what they desire.
STEIN: So Caughey hopes the new study will help each woman decide for herself whether that risk is worth the possible benefits. Other experts agree. Michael Greene heads obstetrics at the Massachusetts General Hospital in Boston. He says this is the best evidence yet about the risks of giving birth inside or outside a hospital.
MICHAEL GREENE: That's the wonderful about having this data. It lets every woman decide what is most important to them. Is it most important to them to have a - for example, a spontaneous vaginal delivery and avoid a cesarean section or avoid an instrumented vaginal delivery? Or is it most important to them to have the least potential risk of coming away without a baby?
STEIN: One group that is pushing for more states to legalize midwives welcome the new study. Steff Hedenkamp is the spokesperson for that group. It's called The Big Push for Midwives.
STEFF HEDENKAMP: This study is consistent with other literature that shows that the absolute risks are low. And this is pretty remarkable given that in the United States, midwives - certified professional midwives - are not integrated into many of our states' healthcare systems.
STEIN: For her part, Samanda Rossi, the mom we met at the beginning of the story, thinks any risk she faced by giving birth at home were outweighed by the benefits of staying away from a hospital.
ROSSI: There are certain risks that I would have going to the hospital, and there are certain risks that I may have an increased risk of at home, but I have to, as a mother, choose which risks I'm most comfortable with.
STEIN: But Rossi says Tate is probably going to be her last child, so she won't face that choice again. Rob Stein, NPR News. Transcript provided by NPR, Copyright NPR.