Ep 296: What Hospital Birth Can Learn from Home Birth

Nicole Rankins (00:00.194)

Today I'm talking about a topic I never really planned to cover much on this podcast and that is home birth. But this isn't about debating home versus hospital. It's about asking a better question. What actually works? Most women in this country, yourself included, will give birth in a hospital. And that's where I do my work. And if we want hospital birth to be safer,

more respectful and more empowering, we have got to be willing to look at what home birth gets right and bring that into the hospital.

Nicole Rankins (00:43.02)

Welcome to the birth with power podcast where knowledge is power and power transforms birth. I'm Dr. Nicole Callaway-Rankins, mom of two and practicing board certified OB-GYN with over 20 years of experience and nearly 2000 births attended. I've seen firsthand how the hospital system can leave women feeling unheard and uncertain, but that doesn't have to be your story.

Here, you'll get the knowledge, support, and strategies to take charge of your birth experience so you can walk into the hospital feeling calm, confident, and empowered. Note, this podcast is for educational purposes only and it's not a substitute for medical advice. See the full disclaimer at drnoklomerhankens.com forward slash disclaimer. Now let's get to it.

Hello there, welcome to another episode of the podcast. This is episode number 296, whether it is your first time being here or you've been here before, I'm so glad you're spending some time with me today. In this episode, we're talking about home birth. And if you've been listening to my podcast for a while, you might've heard me say before that I would never talk about home birth on my podcast.

And it's not because I am against home birth. I'm not. I actually work collaboratively with the home birth midwives in my community, but it's because I ain't never seen a home birth. Okay. And it didn't feel right to speak on something that I hadn't experienced myself. I don't know anything about the home birth experience. The truth is the work I do is and always will be rooted in hospital birth. That's where I've spent my entire career. And that's where the vast majority of women in this country, yourself included,

We'll give birth. So when I talk about improving maternity care, I am talking about improving hospital birth, which is exactly why I am now talking about home birth. Because if we're serious about improving outcomes and experiences in the hospital, we've got to look outside the hospital walls. We've got to get curious about what's working elsewhere, including in the home birth model. Again, this is not about debating hospital

Nicole Rankins (02:57.262)

versus home. is about learning about evolving, about making hospital birth, what it should be, what it must be safe, respectful, empowering, and centered around the woman giving birth. So in this episode, I'm going to break down for you why some women choose home birth, what the data says about safety. I'm all about data and evidence.

who home birth is for and who is not for. And then most importantly, what hospital birth can learn from the home birth model. And I'll close with some of my own personal reflections, both as a doctor and as a mother who wants better for every woman walking into a labor and delivery unit in a hospital. So let's do it. Now, before we dive in, I want to be clear on what we're actually talking about. When I say home birth, I mean a

planned home birth with a trained professional in attendance. Planned home birth is exactly what it sounds like. The decision is made ahead of time to give birth at home and it's attended by a skilled provider. In the U.S. that's most often a certified professional midwife, CPM, though sometimes it's a certified nurse midwife, C.

in him. Either way, the key is that it's intentional, prepared, and supported. I am not talking about free birth, also known as unassisted birth, where there is no trained provider present. And let me be absolutely clear, I am completely against free birth. It is dangerous and irresponsible. Historically, women have

almost always given birth with a skilled attendant present, whether a doctor, a midwife, a trained traditional birth worker in the community, the idea of giving birth completely alone is not something that aligns with a safe model of birth or centuries of human practice. So this episode is about planned home birth, not unassisted or emergency at home.

Nicole Rankins (05:18.702)

So let's get into why some women choose home birth. It usually comes down to one or more of these core reasons. One is to avoid unnecessary medical intervention. Birth is a normal physiologic process. It's not a disease. And while hospitals are great at managing emergencies, most births actually are not emergencies.

The hospital system is structured in a way that does increase the chances of interventions like inductions, pitocin, continuous monitoring, artificial rupture of membranes or breaking the water, epidurals, pesiotomies, forceps, vacuums, cesareans. And these interventions of course have their place and can be very helpful, but they're often overused, especially in low risk pregnancies. Another reason why people choose home birth is to maintain autonomy. In the home setting,

Women often feel more involved in their experience because they are, and not like things are being done to them. They can move around freely. They eat and drink when they want. They choose whatever positions they want to labor and birth in. They decide who's president for the birth. It's their space. It's their rhythm. It's very much so their birth. And that kind of agency is powerful.

It's something that too often is not present in the hospital. A third reason why women choose home birth is to create a calm and familiar environment. Home birth can feel more relaxed and intimate and emotionally safe. Being in your own space with your own bed, your bathroom, music, lighting, all of that can create an atmosphere that supports the flow.

of labor that's in contrast to the hospital, which can often have things like bright lights, people kind of in and out of the room. It's not a familiar environment to you. And then the final reason why a lot of women choose home birth is in response to past trauma. This is a big one. A lot of women turn to home birth after a bad hospital experience. I've heard this so many times. My first birth was traumatic. So this time I want something different.

Nicole Rankins (07:34.05)

they may have felt ignored, rushed, scared, pressured into decisions they didn't fully understand. But whatever the reason, for some women, home birth feels like a way to reclaim their power that was lost in a prior birth experience. So those are the main reasons why women choose home birth. And while this may surprise you, we're actually not talking about a huge number of births when we talk about

That number is growing. So let's look at the numbers. According to the CDC in 2021, there were about 52,000 births that occurred at home in the U.S. That's about 1.26 % of all U.S. births. So not a lot, but it is the highest rate since data collection began in 1989. And about 88 % of those home births were planned. So while home birth is still

pretty uncommon actually. It is becoming more frequent and also demographically, it's not evenly distributed. Women who choose home birth in the U.S. are more likely to be white, older, have had a baby before, have a normal BMI and live in a rural or non-metropolitan area. For example, in 2021, 1.7 % of births to white women occurred at home. And for black women, that number was around 0.5%, so a lot lower.

And then states with the highest home birth rates include Idaho, Wisconsin, and Pennsylvania. Pennsylvania is heavily influenced by a large Amish population that traditionally births at home. And so this isn't a widespread choice across all groups. There are actually differences in access and acceptance, even insurance coverage when it comes to home birth, depending on where you are. And choosing home birth can actually be a form of privilege because

since it's often not covered by insurance, it's available to people who can't afford it. All right, so let's get into the question that comes up the most around home birth. And that is, is home birth safe? Okay, is home birth safe? Now, safety isn't just one thing. When we talk about the safety of home birth, we're kind of looking at three main areas. One is the risk to the baby. One is the risk to the birthing person.

Nicole Rankins (09:58.068)

I should say two, risk to the birthing person. And then three, the risk of transfer to the hospital. Because I want this information to be as relevant as possible to you. We're going to focus on data from the United States, home birth in countries with integrated midwifery systems like the UK and the Netherlands and Canada. Although we're to talk a little bit about the Netherlands. That's a different conversation. In the U.S. we do not

have widespread integration that actually affects outcomes. Okay. So let's walk through a few key studies about home birth in the United States. The first is the MANA STATS study. happened between 2004, 2009. This study looked at over 17,000 planned home births attended by midwives in the U.S. It's one of the most well-known data sets on home birth that exists. And the women in this group were mostly low risk.

78 % had given birth before. Most were healthy, well-educated. They had above average income and intervention rates were low. This is something that we will see consistently across home birth studies that intervention rates are low. So episiotomy was 1.4%, cesarean 5.2%, vacuum or forceps 1.2%. As far as transfer rates, 11 % in this group were transferred during labor.

1.5 % transferred after birth. And then first time moms had a higher transfer rate at 23 % compared to those who'd given birth before. That was only 8%. There was one maternal death in these 17,000 women and that was a cardiac condition three days postpartum. Now, when we look at neonatal outcomes, the intrapartum fetal death rate was 1.3 per 1,000 births. The early neonatal death rate, that's

within the first seven days was 0.4 per 1,000 births. And then late neonatal death at seven to 27 days was 0.35 per 1,000 births. So the bottom line in this study for appropriately selected low risk women, outcomes were good, but the risk is not zero. The risk in any birth is not zero. So the risk in home birth is not zero either, all right?

Nicole Rankins (12:22.016)

Next study is the birth certificate data analysis from the Midwives Alliance of North America. This was a retrospective study that looked at about 3,200 out of hospital births, including both home and birth center births actually, and compared them to 75,000 planned home births. The perinatal mortality rate, that's death around the time of birth for out of hospital birth was 2.4 per 1,000.

compared to hospital, which was half of that at 1.2 per 1,000. And then neonatal mortality, that's death in the first 28 days for out of hospital was 1.6 per 1,000, whereas hospital was a lot lower, 0.6 per 1,000. So yes, that is about a two to three times higher risk for out of hospital births. But I want you to hear me very clearly when I say this.

The absolute risk, the actual number is still very low in both groups. That's an important point to remember. So when we look at mortality for out of hospital birth and it's 1.6 per 1,000, that's still a very low number, even though it is higher than the 0.6 per 1,000 for hospital birth. So yes, the risk is higher, but the absolute number is very low. This study also found that

rates of neonatal seizures and need for ventilator support happened in home births. Also, as most studies show, there were significantly fewer interventions in hospital births in terms of things like inductions or cesareans. And in this study, the transfer to hospital happened in about 16 % of home or birth center births, and it was mostly among first-time moms.

And then the final study I want to talk about is a study in 2016 that was a retrospective study of 97,000 planned home births. And this study focused on full term, singleton babies, plan to be born at home, so low risk. The neonatal death rate in this group was 1.2 per 1000 for home birth. For hospital birth with a midwife, it was 0.3 per 1000.

Nicole Rankins (14:43.79)

That is a four times higher risk at home, but again, the absolute number is still very low in both groups. Now this particular study highlighted increased risk for some specific groups. For first time moms over age 35, the risk went up to 5.2 per 1,000, a 5.2, excuse me, neonatal deaths per 1,000. For first time moms beyond 41 weeks, that was four per 1,000.

from women with a prior cesarean, there was an 8.3 times higher risk in a breech birth at home, 8.1 times higher risk of neonatal death. So the takeaway in this study is that even among low risk women, there is a statistically higher risk to baby with planned home birth. That is what we see across most studies, but the absolute numbers are low.

And then for women with some complicating factors like breach presentation prior cesarean or being past 41 weeks, the risk climbs significantly. It's still a low number, but it is a lot higher than if you don't have those things. Now, do you want to touch upon there is a large global study that can be talked about sometimes that looked at over 500,000 home births. This was an international study.

that looked at several high income countries in home birth. And that study actually found no significant difference in perinatal outcomes between home and hospital births. So things were the same, but there is a huge, huge point, okay, in this study. That study only included births in countries where home birth midwives are fully integrated into the healthcare system. Meaning,

There's easy access to hospitals. are established transfer protocols. There's mutual respect between physicians and midwives. There's shared medical records. That is absolutely not the case in most of the United States. In fact, disjointed systems are more common in the United States. That lack of integration certainly impacts outcomes.

Nicole Rankins (16:59.506)

So the final say on is home birth safe? Well, here's the truth for carefully selected women with low risk, low risk pregnancies. So no heart disease, no hypertension, no diabetes, no complications. So low risk planned home birth attended by a qualified provider is very reasonably safe, especially if it's your second or third baby and you live close to a hospital. the risk to baby

is going to be consistently higher than a hospital birth. That's especially for first time moms, those with a history of cesarean, breech babies or pregnancies that go past 41 weeks. Also, the risks are going to be consistently lower for mom. So a lower risk of interventions for mom. So, home birth has in general higher risk for baby.

lower risk for mom. And the safety of home birth depends very heavily on the skill and training of the home birth midwife provider access to emergency equipment like oxygen, medications, neonatal resuscitation abilities, the distance and ease of transfer to a hospital. And then having that respectful collaboration between home and hospital providers is absolutely

Key, that last piece, collaboration, is where things really, really, really fall apart in the United States. We do not have a system that supports seamless, respectful transfer. In fact, too often, transfers are done too late. There's an adversarial nature where hospital doctors and nurses judge the folks coming from home birth, and that really puts everyone...

at greater risk, most especially, of course, the person giving birth and her baby. Okay. So that's a problem in the U S. Now, if the data shows that there's a slightly higher risk for babies born at home, then why do so many women say home birth feels safer? Well, that is because safety isn't just about equipment or access to an operating room and medical things. Safety,

Nicole Rankins (19:19.54)

is also about trust. It's about respect. It's about being seen, heard and supported. And for a lot of women, that is what they don't feel in the hospital. I've heard from women time and again, who've thought about or who have chosen home birth, I've felt rushed and ignored at the hospital. No one is explaining what happened. No one explained what happened to me.

I didn't feel like I had any say in what was happening in my care, or they treated me like a problem and not a person having a baby. That emotional fallout is real. And that is often what pushes people to seek care outside of the traditional hospital system. The home birth model tends to offer more continuity of care. You know your doctor, they know, I'm sorry, you know your midwife, they know you, you've built trust long before labor starts.

There's shared decision-making. You're part of the conversation. You're not just a passive recipient of care. There's freedom of movement. You're not confined to a bed. You're not strapped to monitors if you don't need to be. And there's autonomy. You choose who's in the room, how the lights are, what music is playing, what positions you birth in. All of those things happen in home birth. And those elements create a sense of emotional and psychological security that many hospital births are not.

offering, we're getting better, but still too many don't offer that. And that type of emotional and psychological security matters. It is not extra. It is not indulgent. It actually directly impacts your stress hormones, which can affect how your labor progresses. And it can affect your memory of your birth experience, which can affect your postpartum recovery. It can affect how you bond with your baby, how you breastfeed, how you heal.

So this isn't woo woo. This is actually physiology and it's about basic human dignity. And here's the thing, emotional safety is something that hospital birth can, should, and must provide. I am proud to work in an environment where I believe that we do this well and there are other hospitals out there that do, but not enough. And women shouldn't have to choose between clinical safety and feeling respected. You absolutely

Nicole Rankins (21:45.038)

deserve both. Now I want to touch upon for a minute what home birth looks like when the system actually supports it and it's integrated into the system. So I'm going to tell you a bit about what happens in the Netherlands. In the Netherlands, about 10 to 15 % of births still happen at home. And it's because the whole system is built to support that choice safely.

So there midwives and OBs are integrated. Midwives manage healthy low risk pregnancies. OBs step in when complications arise. There's very clear collaboration, not competition. I will say in the United States, it will never be the case or not anytime soon where only midwives manage low risk pregnancies. There's not enough midwives to do that. But I certainly know that OBs can learn how to.

appropriately manage low risk pregnancies and learn from the midwifery model for sure. I certainly have. And then also in the Netherlands, there are defined protocols and risk criteria. Everyone, doctors, midwives, patients, hospitals know when it's time to escalate and go from home to hospital. There's no guesswork. It's not like a power struggle or waiting. And then those transfers are seamless. When someone needs to go, it's not chaos. The hospital's notified. OR is ready.

Records are shared, there's real time coordination, which creates real safety. And then also home birth midwives are actually well equipped. They carry resuscitation equipment, oxygen, medications, families even receive a maternity box with supplies because home birth is actually planned for. Now compare that to what we have in the US for the most part and integration is the exception, it's not the norm.

In many places, home birth midwives aren't even legally recognized or they're not reimbursed by insurance. And then hospitals don't have transfer protocols or any sort of relationships with community midwives. And that can cause delays in transfer because they're like, don't want to go to the hospital. There's judgment, there's resistance. And this lack of connection does not just cause tension. It actually causes harm. It can cause harm for mothers. It can cause harm for

Nicole Rankins (24:05.428)

Again, I'm proud to say that where I work, we collaborate with home birth midwives. They just call, they fax the records, the patients come in, it's not a big deal. No one really bats an eye at a home birth transfer, so things happen pretty seamlessly, but that is the exception rather than the rule. And we're not going to copy the Dutch system, I think, anytime soon, but we can certainly take those lessons seriously because when midwives and OBs work together, instead of working in silos, again,

Everyone wins. It's safer. Transfers are smoother. Women feel more supported and outcomes are better. They're better. So to bring this on home, let's talk about why we're really here. And that is to learn what hospitals can pick up from home birth.

So I'm not trying to glorify home birth. I'm not trying to say yes or no home birth or scare you out of the hospital. I am asking the better question of what can hospital birth learn from home birth? We're not trying to get everyone to birth at home because it's not realistic, right? Most women in the U S will give birth in the hospital period. All right. And that's because there are not enough home birth midwives. Not everybody wants to give birth at home or not everybody is an appropriate candidate.

for birth at home. So most women in the US will still give birth in the hospital. But instead of getting defensive or dismissive about home birth, we need to ask again, what does that home birth model get right that we can and must bring into the hospital? And I want to give you four things that hospital birth should be learning and adopting from the home birth model. One is building human connection.

In home birth, the CPM usually knows the birthing person well. That midwife has built trust over time and in hospitals, that kind of continuity just isn't necessarily the norm. You may get whoever is on call for your birth. You may get me like a hospitalist we may have never met before. But here's what is possible. And that is intentional human connection in the moment.

Nicole Rankins (26:16.168)

Even if it's the first time you're meeting someone in labor, we need to still show up and actually care. So simple questions like, is there anything important to you you want me to know about you or your birth plan? Or what are you hoping for in your birth experience? Or how can we best support you through your birth? Those few minutes of conversation can completely shift the energy. I'm a big believer in the energy surrounding the birth.

environment and what that does to impact how labor unfolds. And when you shift that energy by asking these connecting questions, that turns a transactional moment into a collaborative one. And it tells the woman in front of me, you matter, your voice matters and your experience matters. And that's really important. We all need to do that in the hospital. Okay. Number two is respect the physiology of birth.

You'll hear OB say like roll their eyes and what do people even mean when they say physiologic birth? Well, home birth trust the body's process. It doesn't rush or interfere unless there's a reason. And that is wise. Okay. In hospitals, we're often managing labor. All right. And we're managing to a clock. Is it too slow? Not progressing. Do we need Pitocin? Do we need to break the water? And don't get me wrong. Sometimes those things are necessary and actually helpful, but sometimes a lot of times

They're not necessary at all. Okay. We need to learn how to support physiologic labor. That means patience is the biggest thing. I work at a hospital where the C-section rate is about 20, I think it's 20 and a half percent overall. And that's in a higher level hospital with a high risk population. And that's because we are patient with labor. We also do things like position changes, provide emotional support.

giving time before jumping to Pitocin or breaking someone's water, just kind of letting, letting labor unfold instead of forcing it into a schedule. All of those things are important and we need to bring that into the hospital consistently. Number three, let women control their environment. I say birth is unpredictable. cannot be controlled, but this aspect can be controlled. Okay.

Nicole Rankins (28:40.758)

In homework, the space is familiar. The lights are dim. The noise is low. You can move about as you want, eat when you're hungry, labor and water. In hospitals, that's often not the case. There may be bright lights flipped on, beeping machines, no food, limited mobility, folks in and out of the room without any warning. But listen, we can change that. And you should change that. You paying for that room? You and the insurance company so you can get what you want in the room. Turn down the lights.

Play your playlist, eat if it's appropriate, move, birth in the position that feels best. None of these things compromise safety and they can massively impact the birth experience. So let women control their birth environment. And then number four, create collaboration between OBs and midwives in places.

where OBs and mobiles work together, like where I work respectfully and without ego, outcomes improve. That is shown with data time and time and time and time again. That's not opinion, that's data. But too often in hospitals, there's like power dynamics or there may be tension or people are kind of like anti midwife or there's no trust or you know, people poo poo doctor. There's just not a collaborative relationship. And in the end that ultimately hurts.

Patients, need shared care models, open communication. Midwives are experts in normal births. OBs are specialists in complications who I will add need to learn how to also be experts in normal birth. When we work together instead of working in silos, everyone wins and most especially the woman giving birth. right. And please understand that these changes are not about copying home birth.

because we actually cannot create the same home birth experience in the hospital. So I'm not going into this saying that, we can create the same thing in the hospital because we can't, they're just different environments, but we can do better, a lot better. There's a lot of room to improve inside hospitals because again, women, you should not have to trade clinical safety for emotional safety. You shouldn't have to leave our hospital system in order to feel seen, heard,

Nicole Rankins (31:04.076)

or respected hospital birth has to be better. And it can be better. We can get there. We can get there. So just to recap, here's where I land. Again, not trying to convince you to have a home birth or scare you from the hospital. I'm asking better questions. What actually makes birth safer? Not just medically, but also emotionally. What kind of care do you deserve no matter where you give birth and how

How do we build a system where those things are the norm, not the exception? The reality is that most women in this country, you included, are going to give birth in the hospital, but too often we are falling short. We can do better. And if we're serious about changing that and making that better model more available or available to everyone,

then we got to put down our defenses, stop brushing off what home birth gets right. Start listening with curiosity and humility to what you are asking for. And that is to feel seen, heard, have your choices respected, move through labor with support. And you want to welcome your baby in a space that honors your power. That's not a radical idea. That should be standard hospital care.

And again, I believe we can get there. It's possible to build that hospital birth system that's just as empowering as it is safe. And it is going to take some change. We're making progress, but we have work to do. It's going to take all of us demanding more. I'm here for that. I hope you're here for that too. Okay. So that's it for this episode. If you found it helpful, share it with a friend. Every pregnant woman and person deserves to feel informed and empowered.

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Nicole Rankins (33:19.144)

myth-busting facts, real tools to help you take charge of your hospital birth. It's quick, powerful, made just for you. Hop onto the list at drnicholerinkins.com forward slash email. And then of course, do me one more favor and come on back next week and remember to trust your power and take charge of your birth.