As we continue to await news of the royal baby, the speculation over Meghan Markle's birth plan is rampant. And as rumors swirl that she and Prince Harry may be planning a home birth, that practice has come under increased scrutiny. The rumors have spurred a conversation about the risks of home births, and the importance of carefully planning them.
The argument over the safety of home births is nothing new. Women who choose home births have been called "crazy" or "irresponsible," and blamed for subjecting their babies to "child abuse."
In the United States, home deliveries make up less than 1 percent of all births, or approximately 35,000 per year. Home births are associated with a higher total neonatal mortality risk, a higher risk of a five-minute Apgar score of zero (meaning no heart beat), increased risk for neonatal seizures, and serious neurological dysfunction compared with hospital births, according to the American Journal of Obstetrics and Gynecology. Twenty-five percent of those births were not planned to take place at home, which may partially explain the poor statistical outcomes.
Conversely, in England, where the Duchess of Sussex will give birth, the most recent studies have shown no significant differences in safety between obstetric units and non-obstetric units for low-risk women. Additionally, for women who have given birth before, planned home births resulted in fewer interventions such as the use of forceps or a vacuum, induced labor, or antibiotics for the mother, with no impact to the baby's health. Similar findings were present in Canada and Denmark, where midwife and doula care are highly integrated into the obstetrics medical system.
"The USA does not have the same system as, say, Denmark, which is often referenced for low incidence of problems with home births by midwives," Mark Zakowski, anesthesiologist and president of the Society for Obstetric Anesthesia and Perinatology in Los Angeles, said in an email. "Denmark has integrated care and strict criteria for who may have home birth versus hospital birth."
The lack of rigorous guidelines for identifying low-risk women is a major contributing factor to poor home birth outcomes in the United States. "The number of low-risk women is far below what many think to be the case," Felice Gersh, an obstetrician and gynecologist and founder of the Integrative Medical Group of Irvine, California, says. "Many women are having their first baby at what is labeled an advanced age. Many women are overweight or obese. Many have underlying medical conditions."
All of these are considered risk factors. Additionally, breech presentation, multiples, prior C-sections, prior birth complications, gestational diabetes and other factors can play critical roles in determining the risk for mothers and babies.
"The bottom line is that if one is truly a low-risk pregnancy, absent of any current complications or the significant probability of complications, has a normal maternal weight and baby weight estimated, has a talented and readily available physician backup on standby, and is also situated near a quality hospital .... if all those prerequisites are met, then a home birth is truly the safest and nicest labor site option," Gersh says.
The Duchess of Sussex is 37 years old, which is considered advanced maternal age. If this is her only risk factor, according to midwifery standards in Britain, she appears to be a good candidate for a home birth. She and Prince Harry live near the Mulberry Birth Center at the Frimley Park Hospital in Surrey. It's a 15-mile journey, or a 23-minute ride in no traffic, from their Frogmore Cottage home at Windsor Castle. The couple also has the Lindo wing at St. Mary's Hospital as an option, which is where the Duchess of Cambridge and Princess Diana both gave birth. It's a little farther away but still a possibility.
Nichole Joy, a mother of three and a doula practicing in Tampa, believes expectant mothers should consider what conditions will make them feel the most supported and the most calm.
"When a laboring mother is relaxed and supported, it's easier for her body to go through the physiological birth process," she says. "And relaxation conditions may look different for each woman — and each pregnancy. For some, an assisted home birth or birth center with physician transfer backup feels the most supportive. And for others, the hospital provides that feeling."
She echoes Gersh's statement that assisted home births are very safe for mothers with no complications.
The American College of Obstetricians and Gynecologists doesn't agree, and recommends hospitals and accredited birth centers as the safest option. Even so, the ACOG says, "each woman has the right to make a medically informed decision about delivery."
Mimi Niles, a midwife and PhD candidate at the NYU Rory Meyers College of Nursing, says that a mother's whole well-being is being overlooked in the home birth conversation.
"If we continue to unilaterally focus on safety and risk management, we fail to see the deeper personal, moral and ethical choices that are often at the center of a person choosing to labor outside of a historically restrictive and paternalistic medical system," she says.
She points out that many women choose home birth as a way to preserve their control and agency. Black women especially, who face an increased maternal mortality rate, report feeling terrified and ignored in hospital settings.
"Safety is more than just leaving the hospital with an infant in arms," Niles says. "It is also about the mental, emotional and spiritual safety that a new parent needs to transition into the heavy lift of parenting."