There are few things that seem to polarize people more quickly than home births. That's the topic of this week's Healthcare Triage.

(Intro)

Many medical students are taught this adage: when you hear hoof beats, think of horses, not zebras. It means that we as physicians need to remember that common things are common, and that we shouldn't immediately focus on the rare or esoteric. As a pediatrician, I have to remind myself constantly that the vast, vast majority of children are healthy. Just 'cause I encounter mostly sick kids in clinic doesn't mean otherwise. I see a skewed population.

Recently, a new study comparing the safety of home or birth centre deliveries with hospital deliveries lead to headlines proclaiming that babies not born in hospitals were significantly more likely to die. I have no trouble believing that's the case. That's the zebra though. There are a number of people in the United States who would rather have their baby at home. I'm gonna lay all my cards and biases here on the table: I recoil at this thought. Why? Because pretty much the worst things I saw on residency occurred after home births. I can't help myself; I hear home birth and I think of zebras. I and my wife Amy feared the deaths of our babies during delivery so much that we chose in-hospital births. Our zeal to minimize that specific risk outweighed any other considerations. If faced with the decision again, I don't doubt we'd choose the same. But that doesn't mean that everyone prioritizes risks the same way.

Women should also know that if they're in the hospital, they're more likely to get an induction, augmentation, or other labor-related procedure. They're more likely to get a Cesarean section, their children are more likely to be admitted to the intensive care unit and spend time separated from them after birth. It's perfectly rational for parents to accept a statistically significant but relatively rare higher risk of one bad outcome to avoid another.

Home births are gaining in popularity. In Britain, about 10% of births don't happen in the hospital. In The Netherlands, it's much higher. The Centres for Disease Control and Prevention estimated that in 2012 more than 53,000 births took place out of the hospital in the United States. More than 35,000 of them took place at home. The rest at dedicated birth centres. Out of hospital births are a small percentage of overall deliveries here, about 1.36%, but the rate's been increasing since 2004, when they were about .8%. In some states like Alaska (6%), Montana (3.9%), and Oregon (3.8%), out of hospital births are even more common.

In Oregon, data's recorded on birth certificates that allows researchers to know which births were planned at home and which were planned for the hospital. They can then compare outcomes. In 2012 and 2013, researchers found that the rate of perinatal death was significantly higher for births planned at home; 3.9 versus 1.8 per 1,000 births. That would be an additional death for each 500 births at home. At-home births were also associated with an increased risk of neonatal seizures. However the risk of admission to an intensive care unit was significantly lower for those born at home. I recently wrote an editorial in JAMA Pediatrics discussing how increased neonatal intensive care use is a possible example of supply-induced care. In other words, those facilities might sometimes be used because they exist and need to be filled, not because infants need them.

In a hospital you're also more likely to get a procedure. More than 30% of women with planned in-hospital births had labor induced, versus 1.5% of those with planned at home births. Almost 25% of those who planned to deliver in the hospital has a C-section, versus 5.3% of those who planned to deliver at home. It's important to remember that the rates of severe morbidity and death in women are 27 per 1,000 for planned or low-risk C-section deliveries, versus nine per 1,000 for planned vaginal deliveries. C-sections are probably more common in the United States than they need to be and being in the hospital increases your chance of getting one, and the risks that come with it. Unfortunately, the choice of birth location has become a charged debate in this country. In Britain on the other hand, the medical system seems to have been adopting a more holistic view.

The National Institute for Healthcare Excellence or NICE released guidelines just over a year ago that recommended that healthcare providers explain to women at low risk of complications that home birth is a safe and acceptable option. In fact, for British women who have given birth before and were at low risk, NICE recommends that providers explain that birth out of the hospital carries no differences in risk and is associated with higher rates of normal vaginal deliveries and lower rates of intervention. In addition, there are protocols and mechanisms in place to coordinate care between home births and the hospital. An editorial in the New England Journal of Medicine last year noted that almost half of first time mothers in Britain who intend to give birth outside the hospital wind up doing so in the hospital, and that this might be looked at as a sign of systemic success, not failure. If things don't go well at home, everyone's prepared and ready to make the transfer, because home and hospital delivery systems work closely together. The British safety net works.

The medical profession has a case that in-hospital births carry a lower risk of death, but many women still might be better off delivering elsewhere. A system can be created in which parents' values and priorities are recognized while also ensuring that more intensive care is available when it's needed. Just because zebras exist doesn't mean that horses can't.

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