Home Births Are On the Rise — Are They Safe?

As home births rise in popularity, we explore the benefits and risks of giving birth at home versus in a hospital setting.

Melanie Musson was pregnant with her fourth child when she decided to have a home birth for the first time. The mother of six had her first child via C-section at a hospital and then the two following children at a standalone midwife-led birthing center.

“I almost didn’t make it to the birth center the second time,” Musson tells Wellnesspulse. “So I decided to try a home birth because I didn’t want the stress of trying to hold in a baby while driving down the highway.”

Musson is among many of the parents now choosing to deliver at home. From 2019 to 2020, the number of home births in the United States increased by 20.2%, followed by an additional increase of 12% from 2020 to 2021. By the end of 2021, approximately 1.41% of all U.S. births occurred at home.

“Nothing could have prepared me for how much I would love a home birth,” Musson says. “I was so relaxed and stress-free. My family was with me and could come and go as they wanted. Once I had one home birth, I said, ‘This is the only place I will have a baby.’”

Following the successful birth of her fourth child, Musson had her two remaining children via home birth.

However, not all home birth experiences are positive. In November, the Washington Post reported that an established midwife was under scrutiny after a baby died under her care, revealing that several other births facilitated by the same midwife had gone wrong.

Musson was aware of such situations occurring, so she made sure to do her due diligence.

“Before I ever decided on an out-of-hospital birth, I interviewed my midwife and asked how she assessed safety,” she says. “I had heard the horror stories.”

So how safe is a home birth, and how can the safety of the birthing parent and child be ensured?

Why choose a home birth?

Parents may choose home birth for a variety of reasons, according to Tania Lopez, CNM, a certified nurse midwife at Pediatrix Medical Group. These include feeling safer, trying to avoid acquiring infections from a hospital setting, and the overall comfort of delivering at home, which Lopez says can actually help labor and birth progress naturally.

“Home is a known, comfortable environment where the woman may feel more calm and less restricted,” Lopez tells Wellnesspulse. “In light of higher-than-expected maternal mortality rates, many women feel that exposing themselves to the hospital setting or medical establishments may actually increase their risk for adverse outcomes.”

Many hospitals also won't allow women to labor or deliver in birthing tubs, so Lopez says many will choose a home birth for this reason.

Some pregnant people meanwhile wish to have very few medical interventions, such as an IV or fetal heart rate monitoring, adds Kelli Daugherty, APRN, a certified nurse midwife at OSF HealthCare.

“The benefits to a home birth are that the person can better control their birth process and interventions,” Daugherty says.

Birthing at home can also be much less expensive than in a hospital. Granted, it can also be more expensive, as many insurance companies — including Musson’s — don’t cover home births.

The rise in home births has come as many have lost trust in the medical system as a result of negative experiences.

Faith Ohuoba, MD, MPH, FACOG, an OB-GYN at Memorial Hermann Northeast, says she encounters many patients who mistrust the medical system due to poor patient-doctor communication.

“There is a growing desire for more autonomy over birthing experiences, which is sometimes due to prior traumatic experiences, but also because of the desire to complete their preferred birthing plan,” Ohuoba says. “If someone previously had a traumatic hospital birthing experience, they can sometimes prefer a different environment where they believe it will be less stressful or dangerous.”

The risks of a home birth

While a home birth does offer a number of benefits, it is not without risk, and it can become dangerous if any complications develop.

“Home birth itself is not inherently dangerous,” Lopez notes. “Birth has been happening without medical intervention from before historical accounts of pregnancy and delivery are recorded.”

However, if the birthing parent develops complications such as preeclampsia/eclampsia, hemorrhage, or infection, Lopez says both the parent and the baby are better cared for in the hospital setting.

Sometimes, these conditions are predictable, and women can plan a hospital delivery in early pregnancy, she says. However, complications can also happen unexpectedly at any time, and time is lost while being transported to the hospital for a higher level of care.

Indeed, the risk of delayed care is one of the greatest dangers of home birth, according to Ohuoba. The risk of needing transport to a hospital is 23-37% for first-time moms and 4-9% for moms who have previously given birth, she says.

Birthing parents also cannot access epidural anesthesia for labor pain relief at home, Lopez adds, which is a major reason many women choose to deliver in a hospital.

Other methods of pain relief are available at home births, however, such as water immersion and freedom of movement, among others.

“Home births could be even more safe if there were improved communications between home-birth midwives and hospital systems,” Daugherty notes. “If guidelines existed to determine which risk factors might determine a woman is better attended in a hospital delivery vs. which women are considered low-risk and might safely birth in their home, providers and women could collaborate to help make the safest choice for their pregnancy and birth.”

Who makes a good candidate — and who doesn’t

Daugherty says a home birth can be a good choice for someone who has a low-risk pregnancy without any medical complications, who is pregnant with only one baby, whose baby is in a head-down position, and who has never had a prior Cesarean.

There are some home birth providers who will accept clients with a previous Cesarean — like in Musson’s case — but for many, this is a high enough risk to warrant a hospital birth.

Someone with any higher-risk medical issues, however, such as high blood pressure or diabetes, would likely be better off delivering at a hospital.

As a board-certified OB-GYN, Ohuoba does not provide planned home birth services. Whenever her patients bring up the topic, she provides them with the current recommendations from The American College of Obstetricians and Gynecologists (ACOG).

ACOG has set criteria for those planning at-home births, including ensuring that safety protocols are in place in case a patient must be transferred to a hospital or medical facility for emergencies.

“It is very important for patients to know that if their baby is breech, if they are having twins, or if they have had a prior C-section, the hospital is the better, safer option for both mom and baby,” Ohuoba says.

During Musson’s first pregnancy, her baby was breech — meaning in a legs-first position rather than head-first — which is why she ended up delivering via C-section in a hospital.

“The breech presentation made me too high of a risk for my midwife out-of-hospital,” she recounts.

Making your decision

To ensure a home birth is as safe as possible, Daugherty recommends making sure to seek out a qualified home birth midwife and receive regular prenatal care.

She also recommends having at least one qualified nurse or other trained person present who is responsible for the baby's care and making sure to have a plan in place in the event that a transfer to the hospital becomes necessary.

“In medicine, nothing is ever guaranteed,” Ohuoba says. “However, a patient can work closely with their care team towards a safe delivery for both mom and baby. It is important for the mom to understand her own medical history.”

Some questions Ohuoba recommends asking and understanding when making a decision:

• Am I high or low risk?
• Do I meet the ACOG criteria for at-home births?
• Do I understand who is on my care team and their qualifications?
• Do I understand the existing arrangement for my transfer to a hospital, if needed?

“Asking these questions will become imperative as mom makes her final decision for her birthing experience,” she says.

Musson says she had many thorough conversations with her midwife about all the possible scenarios before giving birth, and she made sure to learn exactly how her midwife would determine when a delivery might be deemed too dangerous to continue at home.

Her midwife explained that as birth progresses, she analyzes whether it is in the green, yellow, or red zone, with green meaning all clear, yellow meaning some risk, and red meaning dangerous. The only way she allows the delivery to continue out of the hospital is if it’s in the green zone, and anything outside of that range means transferring to the hospital.

“She wasn’t into heroics,” Musson says. “It’s in her best interest to catch healthy babies and care for healthy moms. Anything outside of that should be in a hospital.”

Her midwife also had medications to stop hemorrhaging, was trained in neonatal resuscitation, and carried oxygen.

“I was very reassured after hearing that,” Musson says. “If you want to make sure your home birth is as safe as possible, choose a midwife who is experienced and equipped to recognize abnormalities, recommend hospital transfers if needed, and deal with emergencies.”