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As home births rise, pediatricians group sets new guidelines

Jennifer Margulis (shown with Leone, 17 months; Etani, age 6; Hesperus, 10; and Athena, 8) delivered her oldest child in a hospital and the other three at home.
Jennifer Margulis (shown with Leone, 17 months; Etani, age 6; Hesperus, 10; and Athena, 8) delivered her oldest child in a hospital and the other three at home.Courtesy Christopher Briscoe

Back in 2001, when Jennifer Margulis decided to give birth to her second baby in the comfort of her own home, most doctors were stridently opposed to any deliveries outside the hospital. They’d wag their fingers and lecture women on the dangers of home birth, often implying that anyone who refused to give birth in a hospital was a bad mother.

But that stance seems to have softened – at least a little bit - in the intervening decade. In a 2011 position statement, the American College of Obstetricians and Gynecologists said that while it still views the hospital as the safest place to deliver, it “respects the right of a woman to make a medically informed decision about delivery.”

In response to that statement - and the growing number of home births in the U.S.- the American Academy of Pediatrics released a set of guidelines Monday for the care of infants born at home. The guidelines were published in the AAP’s journal, Pediatrics.

“We felt that it needed to be stated that no matter where a baby was born, the care needs to adhere to the same standards,” said the guideline’s lead author Dr. Kristi Watterberg, a professor of pediatrics and a neonatologist at the University of New Mexico. “One thing we feel very strongly about is that there needs to be one person present at the birth whose primary responsibility is care of the baby. While it’s uncommon for both the mom and the baby to get into trouble, it does happen.”

The guidelines detail the care and monitoring an infant should receive in the first hours and days after delivery. For example, babies born larger or smaller than expected should be tested for high blood sugar; caregivers should make sure breastfeeding is going without a hitch; blood should be drawn and screened for genetic abnormalities like cystic fibrosis.

The fact that the AAP has issued guidelines doesn’t mean the group supports home births, Watterberg said. “We concur with ACOG that hospitals and birthing centers appear to be the safest settings for birth in the U.S., but respect the right of women to make their own decisions about delivery,” she added.

Simply telling pregnant women not to choose a home birth “doesn’t work and isn’t helpful or constructive.” she said.

When it comes to care of the infant after delivery, the guidelines closely follow what is done in the hospital. Watterberg and her colleagues hope they will help standardize the care babies born at home get, whether that care is provided by a pediatrician, a family practitioner, or a midwife.

“I suppose we as a society are moving towards a spirit of tolerance,” said Dr. Dennis Woo, an associate clinical professor at the David Geffen School of Medicine at the University of California, Los Angeles, and former chief of pediatrics at the UCLA Medical Center, Santa Monica.

If new parents are going to opt for a home birth, there are some things they need to consider, he said. “The article makes the point that the pregnancy should be low risk, that there should be an experienced, certified midwife in attendance, and there should be a Plan B ready as a back-up.”

Though still relatively uncommon, home births have been on the rise. Between 2004 and 2009, home births rose by 29 percent, according to the National Center for Health Statistics. The increase was driven mostly by a 36 percent increase for non-Hispanic white women. Among this group of women, one out of every 90, about 1.1 percent, will choose to have her baby at home.

Many doctors argue that moms who choose to give birth at home are putting themselves and their babies at risk. If labor becomes obstructed, both the mother and the baby can be at risk. And though it is rare, a woman can hemorrhage and, in some cases, lose blood so quickly that in minutes she can go into shock and suffer organ failure, said Dr. Sindhu Srinivas, director of obstetrical services at the Hospital of the University of Pennsylvania and a professor of maternal-fetal medicine at the Perelman School of Medicine at the University of Pennsylvania.

At least one midwife group, the Midwives Alliance of North America, welcomed the new guidelines.

“We are very happy to see that these new guidelines overlap completely with the standard of care that is expected of certified professional midwives,” said Melissa Cheyney, chair of the division of research at  MANA and an associate professor at Oregon State University as well as a practicing midwife. “It’s clear that [AAP] supports birth centers and hospitals, but they also acknowledge that home birth is on the rise and they state that if a woman chooses homebirth, this is the standard of care she should expect.”

Cheyney agreed that a woman should expect two midwives to attend the birth, one to focus on the mom and one to focus on the baby. “Having two at the birth is essential,” she said. “The mother may need something at the same time as the baby. If the baby needs to be resuscitated, that requires two individuals.”

Margulis said that when she had her first baby in a hospital, she felt the experience was impersonal and insensitive. “There was a labor and delivery nurse who was physically rough with me,” said the 43-year-old Ashland, Ore., mother of four. “I was in labor for over 22 hours and she made us feel so rushed and stressed – and then we were left to sort of fend for ourselves. It was a joyless situation.”

After her health baby girl, Hesperus, was born, she was whisked away from her parents. “The staff insisted on taking the baby away from me and my husband,” Margulis said. “They took her to the nursery to wash her off and locked my husband out. But he saw how they were handling the babies – like they were little footballs.”

She was sure there had to be a better way. “The thing I wanted was for my babies to experience love and gentleness in the moments after they were born,” said Margulis, a senior fellow at the Schuster Institute at Brandeis University and author of “The Business of Baby.”  

Margulis has had three babies at home and feels she made the exact right choice in all three cases. “At home I felt totally at ease and comfortable,” she said. “No one was telling me what to do and I could just listen to my body and move around freely.” 

Shayna Marie Perkinson echoes those sentiments. The 27-year-old Ashland, Ore., mom, who gave birth at home to her son Milo 4 months ago, said “I felt like being at home I would be able to just allow the experience rather than being told what to do.”

One thing that made Perkinson comfortable with home birth was the family’s proximity to medical care: there is a hospital just five minutes away. The situation might be different if the hospital was a lot further away, she said, adding “I know families [who decided on home birth] who have come to stay with friends when the time was close so they’d be near the hospital.”

Watterberg and other doctors can understand how moms get turned off.

“Hospitals are where the vast majority of women give birth,” Watterberg said. “We need to continue to work on our hospitals to make the experience more gentle.”

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