4 questions to ask when planning a home birth

Where to deliver your baby is not a decision to take lightly. There are pros and cons to hospital birth and out-of-hospital birth – such as at home or in a birthing center. Ultimately, the goal is a healthy baby and a healthy mom.

As we discussed in the first half of this two-part series, a study published in December 2015 analyzed nearly 80,000 deliveries and found that planned out-of-hospital births carried double the risk of infant death. And while the actual number of deaths was small – 3.9 deaths per 1,000 planned home births versus 1.8 deaths per 1,000 in-hospital births – we take any infant death, or any increased risk of death, seriously.

If you are thinking about an out-of-hospital birth, consider these four questions before you make your decision.

1. What are your risk factors?

Out-of-hospital birth is not right for everyone. If there is such a thing as an “ideal” candidate for home birth, she would be a healthy woman who has not experienced complications during the pregnancy.

A few situations in which home birth may not be the best option are if you:

• Have diabetes, gestational diabetes, or high blood pressure
• Are having multiples
• Go into labor before 37 weeks
• Have a breech baby
• Have had a previous C-section

While a midwife may be able to handle some of these situations, we strongly recommend you give birth in a hospital where advanced medical attention can be given immediately if necessary.

2. What training and certification does your midwife have?

There are many types of midwives, each with different levels of training and certification based on the state in which they practice. A few types include:

• Certified nurse midwives: Highly trained with extensive medical backgrounds. You may find these midwives practicing in some hospitals.
• Certified midwives: Certified in midwifery with at least a bachelor’s degree.
• Lay midwives: Trained in childbirth, but not licensed or certified.

Knowing how much medical education and training your midwife has is crucial. Here are a few questions you should ask when interviewing a midwife:

• What is her training, and how many births has she attended (as a primary provider and as an assistant)?
• Which labor and delivery complications is she qualified to handle?
• What equipment will she bring?
• Can she start an IV or prescribe and administer medication for pain or postpartum bleeding if needed?
• Does she have an assistant to help during labor and after delivery when there will be two of you – mom and baby – who need attention?
• Will she provide postpartum care and for how long?
• What is her emergency plan? Does she have a relationship with a physician or hospital if labor doesn’t go as planned? If not, is she prepared to speak to the emergency room physician or obstetrician on call about your medical history and what has happened when you get to the hospital?

I once had a patient who chose to labor at home, with a prior cesarean section. After 24 hours in labor, and no progress in dilatation, her midwife dropped her off outside the emergency room but didn’t stay around to consult with the attending physician or comfort her patient – she didn’t even walk her inside. You want a midwife you feel comfortable with and can trust to do the right thing for you, even when the right thing might not be what you expected. You must be confident that your and your baby’s health are of their utmost concern and that they will do all they can to keep you safe.

3. How far are you from a hospital?

When my sister mentioned that she was considering a home birth, I cautioned her against it. One of the reasons was because of where she lived, which was an old section of the city that had narrow, cobblestone streets. It had limited access for an ambulance, and there were always traffic jams. I worried that even though she was healthy and at low risk for complications, if the unexpected happened, she would have trouble getting to a hospital in time.

There are many things that can go wrong during labor and delivery, and they can happen quickly. It’s important to be able to get to a hospital as soon as possible. I personally think if you’re not next door to an operating room in case of emergency, you’re too far away.

Talk with your midwife about which situations might prompt a transfer to the hospital, and when that call would be made. Complications may include:

• Labor not progressing
• Fetal distress
• Umbilical cord prolapse
• Heavy bleeding
• The placenta is not delivered intact

Make sure you have access to reliable transportation, or ask your midwife to make arrangements with a nearby hospital in case you need to be immediately transferred.

As for my sister, I suggested she deliver at the hospital with a certified nurse midwife. She had an easy pregnancy, and had a great delivery. You’d think she would have made an even better candidate for home birth the second time around, because everything went so well the first time. But the second delivery didn’t go as smoothly as expected. Her baby was nearly 11 pounds and had shoulder dystocia, in which the head of the baby is delivered but the shoulders are stuck. I was thankful she was in a hospital with a certified nurse midwife who had extensive medical training, because not all midwives would have been able to handle that situation. And while not needed, an anesthesiologist and an Ob/Gyn were at arm’s length.

4. Have you considered a birthing center?

A birthing center is a home-like facility in which midwives are the primary care providers. Often they are freestanding facilities, but sometimes they are attached to or even inside a hospital. Birthing center rooms don’t look like hospitals rooms. They are meant to make you feel like you’re in your bedroom at home.

Birthing centers often have a relationship with a physician or hospital. This relationship is important if you need to be transferred to the hospital because the midwife can quickly update the physician on your medical history, pregnancy, and labor.

When looking at birthing centers, ask the same questions you would ask a midwife.

Making a hospital birth feel more like home

If having a home-like environment and less medical intervention is important to you, talk with your physician about what can be done at the hospital to accomplish these goals. I have patients ask me, “Can I walk around? Can I use a birthing ball? Can my partner massage my back?” I answer, “Yes!”

There are plenty of home-like adjustments we can make if your labor and delivery are proceeding normally. I’ve had patients turn the lights down, play music and watch movies, and even have aromatherapy going!

If you want to walk around during labor, we may be able to use a wireless fetal heart rate monitor or monitor your baby’s heart rate intermittently. Though IV fluids may not be needed, we do want to have IV access in case of emergency.

We may not have room for your entire extended family to be present at the birth, but your partner, parents, and even a close friend or two would be welcome. If you want your other children in the room, ask beforehand about the hospital’s policy. For example, we ask that there be an adult present, not including the patient’s partner, to watch any young children in the room.

Talk to your physician about your birth preferences and how they can be accomplished at the hospital. Problems can come up suddenly during labor and delivery, and delaying care could put you and your baby’s life at risk. If you are set on an out-of-hospital birth, develop a relationship with a midwife who is well-trained and has emergency plans in place. We can’t predict every complication, even in a hospital, but it’s important to consider all the possibilities and plan accordingly to keep the risks as low as possible.