How Common Are Home Births In The United States?
With an increasing number of women opting for home births in the United States, they still only constitute a small fraction of total deliveries. Recent trends indicate a significant rise, particularly in the during and post COVID-19 pandemic.
The Rise of Home Births in the U.S.
Historical Trends and Recent Increases
Home births have been a relatively uncommon practice in the United States for several decades. Historically, the vast majority of births took place in hospitals, with home births constituting a small fraction of total deliveries. From 1990 to 2019, home births consistently accounted for about 1% of all births in the country. However, this trend began to shift markedly in the wake of the COVID-19 pandemic.
According to the National Vital Statistics Reports by the CDC, the percentage of home births in the U.S. rose from 1.26% in 2020 to 1.41% in 2021, a 12% increase that marked the highest level in 30 years. This rise followed an even more substantial increase from 2019 to 2020, where home births jumped by 22% from 1.03% to 1.26%.
Factors Driving the Increase in Home Births
The COVID-19 pandemic played a important role in the surge of home births. The fear of contracting the virus in hospitals, combined with strict hospital policies limiting the presence of support persons during labor, drove many expectant mothers to consider alternative birthing options. Home births offered a way to avoid potential exposure to COVID-19 and maintain a sense of control and comfort during childbirth.
Personal experiences, such as that of Patricia Lee -Anne Schusterman, illustrate the individual motivations behind this shift. Schusterman's first childbirth in a hospital was a traumatic experience, leading to an unwanted cesarean section due to the breech position of her baby. Determined to have a vaginal birth after cesarean (VBAC) for her second child, she faced challenges finding a hospital that would accommodate her wishes. After numerous rejections, she eventually found a midwife willing to assist with her home birth. Her successful and peaceful home birth in 2022 starkly contrasted with her previous hospital experience, highlighting the personal and emotional factors driving many women to choose home births.
Judy Ribner, a New York -based certified nurse-midwife at Holistic Midwifery New York and Birthing Center NYC, encapsulated the sentiment of many mothers opting for home births during this period.. "Many women feel safer at home where they have more control over their birthing experience and can avoid unnecessary interventions," she said. This perspective underscores the desire for autonomy and personalized natural care that home births can provide, which became even more appealing during the uncertainties of the pandemic.
Demographics and Statistics
Demographic Breakdown
Home births in the United States are characterized by notable variations across different demographic groups. Statistics from recent years highlight significant increases in home births among non-Hispanic White, Black, and Hispanic women. For instance, in 2021, home births accounted for 1.41% of all births, with non-Hispanic White women showing the highest percentage. Black and Hispanic women, while still representing a smaller proportion of home births overall, experienced some of the most considerable increases.
Geographically, home birth rates also vary widely by state. States like Idaho, Pennsylvania, and Washington have reported some of the highest rates of home births. In contrast, states with more urban populations and stricter regulations, such as New York and California, tend to have lower home birth rates. This variation often reflects differences in state policies, availability of midwives, and cultural attitudes towards home births.
High-Risk Home Births
Alongside the overall rise in home births, there has been a notable increase in high-risk home births. These include vaginal births after cesarean (VBACs), breech births, and twin deliveries. For example, from 2016 to 2022, the number of home births involving a previous cesarean rose by 63%, breech births more than doubled, and twin deliveries increased by 68%.
High-risk home births carry significant risks, including the potential for uterine rupture during VBACs, complications from breech presentations, and the added challenges of managing twin births. Despite these risks, many women opt for home births to avoid unnecessary medical interventions and to maintain a sense of control over their birthing experience.
Home Birth Settings and Midwifery
The Role of Midwives
Midwives play a crucial role with home births in the United States. There are three main types of midwives involved in home births: Certified Nurse Midwives (CNMs), Certified Midwives (CMs), and Certified Professional Midwives (CPMs).
Certified Nurse Midwives (CNMs)
CNMs are advanced practice registered nurses with additional midwifery training. They are educated in both nursing and midwifery and can provide a wide range of healthcare services, including prenatal, birth, and postpartum care. CNMs are licensed to practice in all 50 states and often work in hospitals, birth centers, and home birth settings.
Certified Midwives (CMs)
CMs have similar training and certification to CNMs but do not have a nursing background. They are licensed in fewer states but provide comprehensive maternity care like CNMs, focusing on low-intervention and personalized birth experiences.
Certified Professional Midwives (CPMs)
CPMs specialize in out-of-hospital births, including home births and births in freestanding birth centers. Their training focuses extensively on providing care in these settings, and they are certified through the North American Registry of Midwives (NARM). CPMs are licensed in 33 states and emphasize the midwifery model of care, which prioritizes natural childbirth and minimizes medical interventions.
The practice of midwifery is governed by state regulations, which can significantly impact the availability and scope of services that midwives can provide. These regulations vary widely, with some states offering full practice authority to CNMs and CMs, while others require varying levels of physician oversight. For CPMs, state licensure and regulatory environments also dictate their ability to carry and administer medications, order and interpret diagnostic tests, and practice independently.
Birth Settings and Services
Home births, freestanding birth centers, and hospital births each offer distinct resources, services, and care models. Here is a breakdown of what each one offers:
Home Births
Home births provide a highly personalized care experience, often characterized by a strong emphasis on the midwifery model. This model supports natural childbirth, continuous one-on-one care, and minimal medical intervention. Women who choose home births typically value the comfort and familiarity of their home environment, and the ability to have more control over their birthing experience.
Freestanding Birth Centers
These centers are designed to offer a home-like environment with the added benefits of certain medical facilities. They are often staffed by midwives and provide services like prenatal care, labor and delivery support, and postpartum care. Birth centers emphasize low-intervention births but have protocols in place for transferring to hospitals if complications arise.
Hospital Births
Hospitals provide the most comprehensive medical resources and services, including access to specialists like obstetricians, anesthesiologists, and neonatologists. Hospitals are equipped to handle high-risk pregnancies and emergencies with facilities for cesarean sections, epidural analgesia, and neonatal intensive care. The care model in hospitals is more medicalized, with a higher likelihood of interventions like inductions and continuous fetal monitoring.
Home birth settings are uniquely tailored to provide a more intimate and individualized birthing experience. Midwives attending home births offer continuous, personalized care and are trained to manage first-line complications. They bring necessary medical supplies, such as resuscitation equipment and medications, to ensure safety. The emphasis on the midwifery model in home births allows for a focus on the mother’s and baby’s well-being, supporting a natural birthing process and fostering a calming environment.
While each birth setting has its strengths and limitations, the choice often reflects the mother's preference for the type of care and level of intervention she desires, with home births and birth centers offering a more personalized and less medicalized experience compared to hospital births.
Policy, Financing, and Access
State Regulations and Licensing
The licensing and scope of practice for midwives vary significantly from state to state, impacting the choices available to expectant mothers.
Certified Nurse Midwives (CNMs) are licensed in all 50 states and the District of Columbia, allowing them to practice independently in some states while requiring physician supervision or collaborative agreements in others. Certified Midwives (CMs) are licensed in only a few states, including Delaware, Maine, and New York, and their ability to practice is often more restricted compared to CNMs. Certified Professional Midwives (CPMs), who specialize in out-of-hospital births, face even more variation in state regulations. They are licensed in 33 states, but in many areas, their practice is restricted or not recognized, limiting their ability to provide care.
These variations create disparities in access to midwifery care and home birth options. For instance, states with more supportive regulations, such as those allowing full practice authority for midwives, tend to have higher rates of home births and better integration of midwifery care into the healthcare system. Conversely, states with restrictive regulations may force women to travel long distances to find a midwife or choose between an unassisted home birth and a hospital birth that may not align with their preferences for low-intervention care.
Insurance Coverage and Costs
Insurance coverage and costs are significant factors influencing the accessibility of home birth options. Different insurance mechanisms, including private insurance and Medicaid, vary in their coverage of home births and midwifery services.
Private insurance policies often have limited coverage for home births, and when they do provide coverage, it may be subject to high out-of-pocket costs. Some insurers do not cover home births at all, while others may cover only a portion of the costs, requiring families to pay for midwifery services out of pocket. Medicaid, which covers a substantial portion of births in the United States, has inconsistent coverage for home births across states. Some states cover home births under Medicaid, while others do not, creating financial barriers for low-income families seeking home birth options.
The costs associated with home births are generally lower than those for hospital births. A national analysis revealed that total payments for hospital births, including both vaginal and cesarean deliveries, are significantly higher than for home births. For example, payments for privately insured vaginal births in hospitals averaged $18,329, while Medicaid payments averaged $9,131. In contrast, the costs for home births and births at freestanding birth centers are considerably lower, with substantial savings for Medicaid and other payers.
Despite the lower costs, financial barriers remain for many families due to the limited insurance coverage for home births. This disparity in coverage contributes to unequal access to home birth options, with those who can afford out-of-pocket expenses having more freedom to choose their preferred birth setting.
Outcomes and Quality of Care
Health Outcomes for Home Births
Health outcomes for home births compared to hospital births are a critical consideration for expectant parents and healthcare providers. Data on these outcomes reveal both benefits and risks associated with home births.
Studies have shown that planned home births for low-risk pregnancies are generally associated with high rates of positive outcomes and lower rates of medical interventions, such as cesarean sections and inductions. However, the safety and risks of home births can vary depending on the presence of trained midwives and the availability of transfer protocols for emergencies. For example, a study highlighted that for every 1,000 planned home births, 4.75 fetal deaths occur, compared to 0.13 per 1,000 in hospital births. This indicates an increased risk that requires careful consideration and planning.
Improving Home Birth Safety
Improving the safety of home births is a priority for healthcare providers and policymakers. Initiatives and guidelines aimed at enhancing safety focus on better integration of home birth services within the broader healthcare system and establishing clear transfer protocols.
One key initiative is the development of standardized guidelines for midwives and home birth attendants to follow, ensuring they are equipped to manage first-line complications and coordinate timely transfers to hospitals if needed. Collaborative relationships between home birth providers and hospitals are essential for seamless transfers and to avoid delays in emergency situations.
Additionally, efforts to improve midwifery education and certification standards, along with state-level regulatory support, can enhance the quality of care provided during home births. These measures help ensure that midwives are well-prepared to handle various birth scenarios and provide safe, high-quality care.
By addressing these aspects, the overall safety and outcomes of home births can be significantly improved, offering women more viable and safe options for their childbirth experiences.
Resources
American College of Obstetricians and Gynecologists. "Planned Home Birth." ACOG Committee Opinion, no. 697, Apr. 2017, www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/04/planned-home-birth. Accessed 23 July 2024.
Centers for Disease Control and Prevention. "Home Births in the United States Reach Highest Level in 30 Years." CDC Press Release, 17 Nov. 2022, www.cdc.gov/nchs/pressroom/nchs_press_releases/2022/20221117.htm. Accessed 23 July 2024.
Centers for Disease Control and Prevention. "Births: Final Data for 2021." National Vital Statistics Reports, vol. 71, no. 8, 2022, www.cdc.gov/nchs/data/nvsr/nvsr71/nvsr71-08.pdf. Accessed 23 July 2024.
Cohen, Elizabeth. "As Midwife-Assisted Home Births Rise, So Too Do High-Risk Births Outside Hospitals." STAT, 23 Feb. 2024, www.statnews.com/2024/02/23/midwife-assisted-home-births-rise-high-risk-births/. Accessed 23 July 2024.
"Maternal and Newborn Care in the United States." Birth Settings in America: Outcomes, Quality, Access, and Choice, National Academies Press, 2020, www.ncbi.nlm.nih.gov/books/NBK555484/. Accessed 23 July 2024.