A home birth in developed countries is an attended or an unattended childbirth in a non-clinical setting, typically using natural childbirth methods, that takes place in a residence rather than in a hospital or a birth centre, and usually attended by a midwife or lay attendant with expertise in managing home births.

Women with access to high-quality medical care may choose home birth because they prefer the intimacy of a home and family-centered experience or desire to avoid a medically-centered experience typical of a hospital or clinical setting. Professionals attending women in home births are usually trained to provide limited medical care, including administering oxygen and managing events like shoulder dystocia,postpartum hemorrhage, repairing perineal tears, and resuscitating infants. Home birth was until the advent of modern medicine the de facto method of delivery. In developing countries, where women may not be able to afford medical care or it may not be accessible to them, a home birth may be the only option available, and the woman may or may not be assisted by an attendant of any kind.

The safety of home birth has been a subject of some controversy, especially among professional physicians groups in the U.S. A number of studies have shown that the safety of an attended home birth for low-risk women is equal to the risks of giving birth in the hospital or a birthing center, though the quality and reliability of the available data has been called into question. The American Medical Association and the American College of Obstetricians and Gynecologists oppose home birth on the basis that a seemingly uncomplicated birth can still potentially become a medical emergency without warning, and they assert that home birth makes the birth experience a greater priority than safety.

Legal regulations in some Western nations, especially the United States, limit a woman's ability to choose an attended home birth. Attended home births are supported in much of Europe. The majority of all infants in developing countries are born at home with mothers attended by lay midwives, nurse/midwives, or family members but due to poor medical care and other cultural and socio-economic reasons, the risks of perinatal death or maternal death are very high.

Types of home births

Home births are either attended or unattended. Women are attended when they are assisted through labor and birth by a professional, usually a midwife, and rarely a general practitioner. Women who are unassisted or only attended by a lay person, perhaps their spouse, family, friend, or a non-professiona birth attendant, are sometimes called freebirths.

Factors in opting for a home birth

Many women choose home birth because delivering a baby in familiar surroundings is important to them. Others choose home birth because they dislike a hospital or birthing center environment, do not like a medically-centered birthing experience, are concerned about exposing the infant to hospital-borne pathogens, or dislike the presence of strangers at the birth. Others prefer home birth because they feel it is more natural and less stressful:8 In a study published in the Journal of Midwifery and Women's Health, women were asked, Why did you choose a home birth? The top five reasons given were safety, avoidance of unnecessary medical interventions common in hospital births, previous negative hospital experiences, more control, and a comfortable and familiar environment.

One study found that women experience pain inherent in birth differently, and less negatively, in a home setting.

Many midwives are prepared with oxygen, if needed, to assist the mother or newborn. Midwives are usually trained to provide neonatal resuscitation, start intravenous solutions, and can administer oxytocinand other medications as needed to halt postpartum hemorrhaging. They carry the supplies needed and are trained to suture. Births necessitating other interventions must be transferred to a hospital. Home births do not offer access to pharmaceutical pain relief or pharmaceutical labor induction. They do not provide ready access to the equipment and supplies required for emergency cesarean section. Most midwives develop working relationships with obstetricians and hospitals in case these options become necessary. Depending on the midwifery practice, transfer rates range from 5% to 40%, with most studies citing a transfer rate of about 16%.

Home birth trends

Home birth was until the advent of modern medicine the de facto method of delivery.

Developed countries

In many developed countries, home birth declined rapidly over the 20th century. In the United States home birth declined from 50% in 1938 to fewer than 1% in 1955; in the United Kingdom a similar but slower trend happened with approximately 80% of births occurring at home in the 1920s and only 1% in 1991. In Japan the change in birth location happened much later, but much faster: home birth was at 95% in 1950, but only 1.2% in 1975.

The decline was due in large part to the expansion of private insurance coverage in the US and taxpayer-funded medical care in Europe and Canada, changes which included policies about where birth should take place. In addition, there was a large population migration from rural to urban areas, an increased accessibility to hospitals, and unwillingness by doctors to attend to women in their homes.

One doctor described birth in a working class home in the 1920s:

You find a bed that has been slept on by the husband, wife and one or two children; it has frequently been soaked with urine, the sheets are dirty, and the patient's garments are soiled, she has not had a bath. Instead of sterile dressings you have a few old rags or the discharges are allowed to soak into a nightdress which is not changed for days.:p156

This experience is contrasted with a 1920s hospital birth by Adolf Weber:

The mother lies in a well-aired disinfected room, light and sunlight stream unhindered through a high window and you can make it light as day electrically too. She is well bathed and freshly clothed on linen sheets of blinding whitenes... You have a staff of assistants who respond to every signal... Only those who have to repair a perineum in a cottars's house in a cottar's bed with the poor light and help at hand can realize the joy.:157

Midwifery, the practice supporting a natural approach to birth, enjoyed a revival in the United States during the 1970s. However, although there was a steep increase in midwife-attended births between 1975 to 2002 (from less than 1.0% to 8.1%), most of these births occurred in the hospital and the US rate of out-of-hospital birth has remained steady at 1% of all births since 1989 with 27.3% of these in a free-standing birth center and 65.4% in a residence. Hence, the actual rate of home birth in the United States has remained remarkably low (0.65%) over the past twenty years.

Home birth in the United Kingdom has also received some press over the past few years as there has been a movement, most notably in Wales, to increase home birth rates to 10% by 2007. Between 2005 to 2006, there was an increase of 16% of home birth rates in Wales, but the total home birth rate is still 3% even in Wales (double the national rate) and in some other counties of Great Britain the home birth rate is still under 1%. In Australia, birth at home has fallen steadily over the years and is currently 0.3%, ranging from nearly 1% in the Northern Territory to 0.1% in Queensland.:20 The New Zealand rate for births at home is nearly three times Australia's with a rate of 2.5% and increasing.:64

In the Netherlands, an opposite trend has taken place: in 1965, two-thirds of Dutch births took place at home, but that figure has dropped to less than a third—about 30%.

In Korea, well-known Actress Kim Se-ah-I made headlines in January 2010 when she delivered a baby girl at home. Less than one percent of Korean infants are born at home.

Research on safety

Lisa J. Patton delivers her newborn LaVergerray unassisted in a home birth.

The data available on the safety of home birth in developed countries is limited and difficult to interpret due to issues such as studies being too small in scope, retrospective in their design, and difficult to compare with other studies because of varying definitions of perinatal mortality. It is difficult to compare home and hospital births because only healthy, low-risk women tend to give birth at home. An additional problem is that transportation time is a significant factor in safety, and data comes from many different countries, which have different population density levels and therefore different average hospital distances.

In 2007, after a comprehensive review of the literature, theUK's National Institute for Health and Clinical Excellence(NICE) expressed concern for the lack of quality evidence comparing the potential risks and benefits of home and hospital birthing environments. Their report also noted that intrapartum-related perinatal mortality was low in all settings. In conclusion, the report recommended that women should be offered the choice of planning birth at home, in a midwifery unit or in an obstetric unit, and informed of the potential risks and benefits of each birth setting.

The uncertain evidence suggests intrapartum-related perinatal mortality (IPPM) for booked home births, regardless of their eventual place of birth, is the same as, or higher than for birth booked in obstetric units. If IPPM is higher, this is likely to be in the group of women in whom intrapartum complications develop and who require transfer into the obstetric unit.

When unanticipated obstetric complications arise, either in the mother or baby, during labour at home, the outcome of serious complications is likely to be less favourable than when the same complications arise in an obstetric unit.

The NICE report concluded that women who give birth at home are more likely to deliver vaginally and to have greater satisfaction from the experience when compared with women who plan to give birth in a hospital. The report compared women's home birth experience to birth in a consultant-led unit. It concluded that the consultant-led setting increased the likelihood that the woman would receive analgesia, obstetrical intervention and a delivery using instruments, and decreased the woman's satisfaction with the experience. It reported that women who give birth at home may experience an equal or lower risk of perinatal mortality equal when they receive care in a consultant-led unit.

Since the 2007 review, a study of 529,688 low-risk planned home and hospital births was reported in theBritish Journal of Obstetrics and Gynaecology in 2009. The study concluded:

A home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low risk women, provided the maternity care system facilitiates this choice through the availability of well-trained midwives and through a good transportation and referral system.

Further, the study noted there was evidence that "low risk women with a planned home birth are less likely to experience referral to secondary care and subsequent obstetric interventions than those with a planned hospital birth.":9 The study has been criticised on several grounds, including that some data might be missing and that the findings may not be representative of other populations.

In North America, a 2005 study found "similar mortality rates for low-risk hospital births and planned home births." The study found that mothers who gave birth at home were less likely to require medical interventions like a caesarean section or forceps delivery. About 12 percent of women intending to give birth at home needed to be transferred to the hospital for reasons such as a difficult labor or pain relief. However, women in the study were more likely to already have had a child, tended to be older, of lower socioeconomic classes, better educated, and less likely to be African-American or Hispanic.

A 2010 meta-analysis of studies which compared home births with planned hospital births among healthy, low-risk mothers in industrialized countries found no difference in the home and hospital rates of perinatal death, but also found that "planned home birth is associated with a tripling of the neonatal mortality rate." The authors wrote that they found this increase "striking" since women planning home births generally had fewer risk factors than those planning hospital births — lower rates of obesity, fewer prior Caesarean sections, and fewer previous pregnancy complications. This study was controversial for many reasons, most notably that it included a large U.S. study that contained both planned and unplanned home births, the latter of which are known to have much higher rates of perinatal mortality.