Objective: To evaluate the safety of home births in North America involving direct entry midwives, in jurisdictions where the practice is not well integrated into the healthcare system.
Design: Prospective cohort study.
Setting: All home births involving certified professional midwives across the United States (98% of cohort) and Canada, 2000.
Participants: All 5418 women expecting to deliver in 2000 supported by midwives with a common certification and who planned to deliver at home when labour began.
Main outcome measures: Intrapartum and neonatal mortality, perinatal transfer to hospital care, medical intervention during labour, breast feeding, and maternal satisfaction.
Results: 655 (12.1%) women who intended to deliver at home when labour began were transferred to hospital. Medical intervention rates included epidural (4.7%), episiotomy (2.1%), forceps (1.0%), vacuum extraction (0.6%), and caesarean section (3.7%); these rates were substantially lower than for low risk US women having hospital births. The intrapartum and neonatal mortality among women considered at low risk at start of labour, excluding deaths concerning life threatening congenital anomalies, was 1.7 deaths per 1000 planned home births, similar to risks in other studies of low risk home and hospital births in North America. No mothers died. No discrepancies were found for perinatal outcomes independently validated.
Conclusions: Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.
Despite a wealth of evidence supporting planned home birth as a safe option for women with low risk pregnancies, the setting remains controversial in most high resource countries. Views are particularly polarised in the United States, with interventions and costs of hospital births escalating and midwives involved with home births being denied the ability to be lead professionals in hospital, with admitting and discharge privileges. Although several Canadian medical societies and the American Public Health Association have adopted policies promoting or acknowledging the viability of home births, the American College of Obstetricians and Gynecologists continues to oppose it. Studies on home birth have been criticised if they have been too small to accurately assess perinatal mortality, unable to distinguish planned from unplanned home births accurately, or retrospective with the potential of bias from selective reporting. To tackle these issues we carried out a large prospective study of planned home births. The North American Registry of Midwives provided a rare opportunity to study the practice of a defined population of direct entry midwives involved with home birth across the continent. We compared perinatal outcomes with those of studies of low risk hospital births in the United States.