By Kathryn Doyle
(Reuters Health) - Giving birth outside of a hospital has become more common in the U.S., especially for white women, with almost 60,000 out-of-hospital births in 2014, according to a new study.
"I think it speaks to some women's growing discomfort with the standard hospital-based system of childbirth in the U.S," said lead author Marian F. MacDorman of the Maryland Population Research Center at the University of Maryland in College Park.
"Currently, it seems difficult for women wanting a natural birth to be assured of having that experience in the hospital, where one out of every three U.S. births are delivered by cesarean section, and where induction rates and other interventions are very common," MacDorman told Reuters Health by email.
She and her coauthor Eugene Declercq used data from 47 states and the District of Columbia, from 2004 to 2014, to compare in hospital and out-of-hospital births.
During that period, out-of-hospital births rose from less than 1% to 1.5% of U.S. births.
Of the nearly 60,000 out-of-hospital births in 2014, 38,000 were home births and 18,000 took place at birth centers. Almost 90% of the home births were planned.
That year, one in every 44 births to a non-Hispanic white woman in the U.S. took place outside a hospital.
Only 13% of mothers who gave birth out-of-hospital were obese, compared to 25% of those in hospital. Mother who gave birth out-of-hospital were also less likely to smoke and more likely to have graduated from college.
Two-thirds of planned home births were self-paid, that is, the mother paid out of pocket for pregnancy and delivery care, compared to less than half of those in birth centers and less than 5% of those in hospitals, as reported in the journal Birth, March 16.
Home birth can be very safe if the healthcare system at large supports it and integrates it with other options, MacDorman said.
"The finding that more women are able to choose to have the type of birth experience that they want to have seems positive to me," she said. "I think it is of concern that so many doctors seem to be so opposed to out-of-hospital birth that they won't examine ways to make the home to hospital transfer a smoother and safer process."
The current study did not include data on mortality. According to MacDorman, something goes seriously wrong only very rarely, in less than 1% of births in or out of the hospital. Most high quality international studies have found that the risk of stillbirth and early infant death is not higher for out-of-hospital than for hospital births, she said.
"Overall the numbers are still very small and it will be interesting to see where it goes in the next few years but I believe it will never be a large percentage of women who opt for out-of-hospital birth," said Ruth E. Zielinski, a midwife at the University of Michigan School of Nursing who was not part of the new study.
Out-of-hospital births tend to involve less intervention, like cesarean section, and have higher patient satisfaction, MacDorman said. "Midwives that attend out-of-hospital births generally screen clients, so that only low-risk women attempt an out-of-hospital birth."
High-risk women should give birth in a hospital, MacDorman said.
"Other factors that improve patient safety are having an experienced and properly trained midwife who has an existing relationship with an obstetrician or hospital in case a patient develops complications," MacDorman said.
Certified professional midwives who do many out-of-hospital births are only licensed in about half of U.S. states, she said. Another barrier to giving birth at home may be insurance coverage, as most women with planned home births had to pay out of pocket for the costs of their pregnancy and delivery care, she said.
"If both private insurance companies and Medicaid would cover the costs of pregnancy and delivery care for out-of-hospital births, this could substantially improve access to this birthing option, now clearly of interest to an increasing number of women," MacDorman said.