In contrast, the demographics of women choosing planned home birth in the United States favor those who are white, nonsmoking, self-pay, college-educated, and multiparous (MacDorman, 2016). As perceived beneits, planned delivery at home for those with low-risk pregnancies results in fewer medical interventions that include labor augmentation, episiotomy, operative vaginal delivery, and cesarean delivery (Bolten, 2016; Cheyney, 2014). Regarding the safety of planned home birth, data from randomized trial are lacking, and large observational studies derive from heterogeneous care systems, whose results may not be generalizable. For example, several developed countries deliver at home a large volume of carefully screened women, delivered by midwives with substantial training and in a setting closely integrated with the local health-care system (Birthplace in England Collaborative Group, 2011; de Jonge, 2015; Hutton, 2016). The level of such coordination in the United States is less uniform.
Overall, risks of home births in the United States are small but greater than those of hospital delivery. Midwife-attended home births carry a neonatal mortality risk of 1.3 per 1000 births. This is a nearly fourfold greater rate compared with midwife-attended hospital births. The most common underlying causes of death are those attributed to labor and delivery events, to congenital anomalies, and to infection. Of neonatal injuries, rates of neonatal seizure and serious neurological dysfunction are similarly elevated in home-birth groups (Grunebaum, 2013, 2014, 2017; Snowden, 2015; Wasden, 2016). Importantly, substantial risks attend home birth for those with prior cesarean delivery, with breech presentation, and with multifetal gestation (Cheyney, 2014; Cox, 2015). The American College of Obstetricians and Gynecologists (2017b) considers these to be absolute contraindications. Further, the College considers accredited hospitals and birthing centers to be the safest site for birth but recognizes the autonomy of the well-counseled patient.
As one option for pain relief, some women choose to spend part of first-stage labor in a large water tub. With this practice, one Cochrane review found lower rates of anesthesia block use and no greater adverse neonatal or maternal efects compared with traditional labor (Cluett, 2009).
For delivery, however, water birth carries greater concern for neonatal harm and without proven benefits. Case reports describe aspiration leading to fresh-water drowning (Pinette, 2004). The risk of cord avulsion during water birth approximates 3 per 1000 births, and stems primary from abruptly bringing the newborn out of the water (Schafer, 2014). Last, case reports also enumerate serious infections, which emphasize the need for rigorous sanitizing protocols. hat said, in most large studies comparing land and water births, overall maternal or neonatal infection rates are not increased (Bovbjerg, 2016; Burns, 2012; Thoeni, 2005). In sum, several reviews comment on study shortcomings and isolated complications but do not identiy definitive evidence for overall greater rates of neonatal harm from water birth in low-risk populations (Davies, 2015; Taylor, 2016). However, given the paucity of robust data and potential for serious complications, the American College of Obstetricians and Gynecologists (2016a) currently recommend that "birth occur on land, not in water."