Embed Size (px)
Citation preview
United States Home Births Increase 20 Percentfrom 2004 to 2008
Marian F. MacDorman, PhD, Eugene Declercq, PhD, and T. J. Mathews, MS
ABSTRACT: Background: After a gradual decline from 1990 to 2004, the percentage ofbirths occurring at home increased from 2004 to 2008 in the United States. The objective of thisreport was to examine the recent increase in home births and the factors associated with thisincrease from 2004 to 2008. Methods: United States birth certificate data on home birthswere analyzed by maternal demographic and medical characteristics. Results: In 2008, therewere 28,357 home births in the United States. From 2004 to 2008, the percentage of birthsoccurring at home increased by 20 percent from 0.56 percent to 0.67 percent of United Statesbirths. This rise was largely driven by a 28 percent increase in the percentage of home birthsfor non-Hispanic white women, for whom more than 1 percent of births occur at home. At thesame time, the risk profile for home births has been lowered, with substantial drops in the per-centage of home births of infants who are born preterm or at low birthweight, and declines inthe percentage of home births that occur to teen and unmarried mothers. Twenty-seven stateshad statistically significant increases in the percentage of home births from 2004 to 2008; onlyfour states had declines. Conclusion: The 20 percent increase in United States home birthsfrom 2004 to 2008 is a notable development that will be of interest to practitioners and policy-makers. (BIRTH 38:3 September 2011)
Key words: birth certificate, home birth, out-of-hospital birth, race and ethnic differences
Major changes in United States childbearing patterns
have occurred over the past century. At the beginning of
the last century, almost all United States births took
place outside a hospital, the vast majority at home (1,2).
However, by 1940, only 44 percent of births occurred
outside a hospital, and by 1969 this percentage had
declined to about 1 percent, where it has remained rela-
tively stable for several decades (3,4).
Before 1989, place of birth was identified on the
birth certificate as simply in or out of a hospital (3,4).
A change in 1989 specifically identified ‘‘residential’’
out-of-hospital births, and since 2003 an increasing
number of states have added an item that identifies
planned versus unplanned home births (3–5). From
1989 to 2004, the percentage of home births remained
low (fewer than 1 in every 140 births) and declined
very slowly but regularly every year from 0.69
(27,748 births) in 1989 to 0.56 (23,150) of all births
in 2004 (3,6). However, in 2005 the United States rate
of home births increased notably for the first time
since 1989 to 0.59 percent, a figure that remained
steady in 2006 (6). A study of data generated by the
new item on planning status of home births available
for 19 states in 2006 found that approximately 83 per-
cent of home births that occur at home (exclusive of
hospital transfers) were planned (5). The purpose of
this report was to compare more recent data for 2008
(7) with data for 2004, and to examine the continued
increase in home births and the factors associated with
this increase.
Marian F. MacDorman and T. J. Mathews are Statisticians in theReproductive Statistics Branch, Division of Vital Statistics, NationalCenter for Health Statistics, Centers for Disease Control and Preven-tion, Hyattsville, Maryland; and Eugene Declercq is a Professor in theDepartment of Community Health Sciences, Boston University Schoolof Public Health, Boston, Massachusetts, United States of America.
Address correspondence to Marian F. MacDorman, PhD, Reproduc-tive Statistics Branch, Division of Vital Statistics, National Center for
Health Statistics, 3311 Toledo Road, Room 7318, Hyattsville, MD20782, USA.
Accepted March 8, 2011
� 2011, Copyright the AuthorsJournal compilation � 2011, Wiley Periodicals, Inc.
BIRTH 38:3 September 2011 185
Methods
The data in this study are based on birth certificates for
the approximately 4.2 million live births registered in
the United States in 2008, and equivalent data from
previous years (8). For home births, the birth certificate
is completed by the home birth practitioner or, in his
or her absence, by a family member. For hospital
births, the birth certificate is completed by the hospital
birth registrar. All birth certificates are filed in the state
vital statistics offices, and then transmitted to the
National Center for Health Statistics, where the data
are made into publicly available national data files (8).
Trends in home births are examined by maternal
race ⁄ ethnicity, maternal age, live birth order (number
of previous live births plus the index birth), marital sta-
tus, period of gestation, birthweight, plurality, attendant
at birth, and state.
Race and Hispanic origin data are reported indepen-
dently on the birth certificate, and are obtained from the
mother. Data for Hispanic persons are not further classi-
fied by race because most women of Hispanic origin are
reported as white (7). Non-Hispanic white, non-Hispanic
black, and Hispanic data shown in Fig. 2 exclude New
Hampshire in 1990 to 1992 and Oklahoma in 1990, as
these states did not report Hispanic origin on their birth
certificates for those years (7).
Gestational age was measured as the interval
between the first day of the mother’s last menstrual
period and the date of birth, except when inconsistent
with birthweight and plurality, in which case the obstet-
ric estimate of gestation was used (approximately 5%
of births). These methods are described in detail else-
where (7). Preterm births are those occurring before 37
completed weeks of gestation. Low-birthweight births
are those in which the infant’s birthweight is less than
2,500 g.
Variables included in this study are generally well
reported on birth certificates (9,10); not stated responses
(0.8% or less for all variables) were excluded before per-
centages were computed. All statements in the text, as
well as the trends in Tables 1 and S1, were tested for sta-
tistical significance using a two-proportion z test, and
any differences noted as higher or lower were statisti-
cally significant at the p < 0.05 level.
Results
In 2008, there were 28,357 home births in the United
States, or 0.67 percent of the approximately 4.2 million
births in the country in that year. After a gradual decline
from 1990 to 2004, the percentage of home births
increased by 20 percent from 0.56 percent of births in
2004 to 0.67 percent in 2008 (Fig. 1).
Table 1. Percent Distribution of Home Births by SelectedCharacteristics, United States, 2004 to 2008
Characteristics
Percent of Home Births*
2004(n = 23,150)
2008(n = 28,357)
Attendant at birth
Certified nurse-midwife ⁄certified midwife
15.8 19.2†
Other midwife 43.9 42.0†Physician 8.7 5.4†Other 31.7 33.4†
Maternal characteristics
Maternal age (yr)
<20 3.9 2.7†20–34 74.1 75.6†35+ 22.0 21.7
Live birth order
1 21.4 21.9
2–3 45.4 45.8
4+ 33.1 32.3
Marital status
Married 79.6 83.7†Unmarried 20.4 16.3†
Birth outcomes
Preterm birth 7.1 6.0†Low birthweight 5.3 4.4†Multiple birth 1.1 1.1
*Among all home births, the percent with the specified characteristic;†statistically significant change from 2004 to 2008 (p < 0.05).
0.0
0.2
0.4
0.6
0.8
1.0
1990 1992 1994 1996 1998 2000 2002 2004 2006 2008
Per
cent
Fig. 1. Percentage of births occurring at home, UnitedStates, 1990 to 2008. Note: Numbers of home births areshown within parentheses after percentages. Source:Birth certificate data from the National Vital StatisticsSystem.
186 BIRTH 38:3 September 2011
Trends by Race and Ethnicity
Large differences occurred in the percentage of
home births by maternal race and ethnicity, and these
differences widened over time (11) (Fig. 2). In 2008,
1.02 percent of births to non-Hispanic white women
were home births, representing a 28 percent increase
from 2004, when 0.80 percent of births to non-Hispanic
white women were home births. In contrast, the percent-
age of home births declined slightly for non-Hispanic
black women from 0.30 percent in 2004 to 0.28 percent
in 2008. In 2008, the percentage of home births was 0.20
for Hispanic women and 0.38 for American Indian
women, statistically unchanged from the 2004 figures.
In 2008, the percentage of home births was 0.27 for
Asian or Pacific Islander women, up from 0.24 percent
in 2004. Approximately 94 percent of the increase in the
overall percentage of home births from 2004 to 2008
was because of the increase for non-Hispanic white
women. In 2008, 83 percent of home births were to non-
Hispanic white women, compared with 54 percent of
hospital births.
Trends by State
In 2008, Montana had the highest percentage of home
births (2.18%), followed by Vermont (1.96%) and Ore-
gon (1.91%). Three other states (Alaska, Pennsylvania,
and Wisconsin) had a percentage of home births of 1.50
percent or above (Table S1 [available on Internet] and
Fig. 3). An additional 10 states had 1.00 to 1.49 percent
of home births. In contrast, 18 states had less than 0.50
percent of home births.
Twenty-seven states had statistically significant
increases in the percentage of home births from 2004 to
2008 (Fig. 4). Four states had statistically significant
declines, and 18 states and Washington, DC, had no sta-
tistically significant change. The percentage change
from 2004 to 2008 could not be computed for Ohio
because of a data-processing error in Ohio home birth
data in 2004 (6). However, a sensitivity analysis based
on estimates of what the correct number might have
0.0
0.2
0.4
0.6
0.8
1.0
1990 1992 1994 1996 1998 2000 2002 2004 2006 2008
Perc
ent
Year
Non-Hispanic white
Non-Hispanic black
Hispanic
American Indian
API
Fig. 2. Percentage of births occurring at home by raceand Hispanic origin of mother, United States, 1990 to2008. Notes: Non-Hispanic white, non-Hispanic black,and Hispanic data exclude New Hampshire in 1990 to1992 and Oklahoma in 1990, as these states did notreport Hispanic origin on their birth certificates forthose years. API denotes Asian or Pacific Islander.Source: Birth certificate data from the National VitalStatistics System.
MT
WY
ID
WA
OR
NV
UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL IN
KY
TN
MS AL GA
FL
SC
NC
VAWV
OH
MI
NY
PA
MD
DE
NJ
CT RI
MA
ME
VT
NH
AK
HI
<0.50%0.50-0.99%1.00-1.49%
DC
1.50-2.19%
Fig. 3. Percentage of home births by state of residence, 2008. Source: Birth certificate data from the National VitalStatistics System.
BIRTH 38:3 September 2011 187
been for Ohio in 2004 had minimal impact on the overall
results of the study.
Change in the Risk Profile of Home Birthsfrom 2004 to 2008
Of note is an improvement in the risk profile of home
births for some variables from 2004 to 2008. For exam-
ple, the home births of infants who were born preterm
declined by 16 percent, from 7.1 percent in 2004 to 6.0
percent in 2008 (Table 1). By comparison, the percent-
age of preterm infants for hospital births was 12.4 per-
cent in 2008 (8). The percentage of home births of
infants who were of low birthweight declined by 17, that
is, from 5.3 percent in 2004 to 4.4 percent in 2008. By
comparison, the percentage of low-birthweight infants
for hospital births was 8.2 in 2008. The percentage of
home births that were multiple births (1.1%) did not
change from 2004 to 2008, but was still lower than that
for hospital births (3.4% in 2008) (7).
Little absolute change occurred in the age distribution
of women who had home births between 2004 and 2008,
although a large relative decline was seen in home births
to teenagers, from 3.9 percent of all home births in 2004
to 2.7 percent in 2008 (Table 1). Little change occurred
from 2004 to 2008 in the distribution of home births by
live birth order; however, the percentage of home births
to unmarried women declined from 20.4 percent in 2004
to 16.3 percent in 2008.
When examined by attendant at birth, the percentage
of home births delivered by certified nurse-midwives or
certified midwives increased from 15.8 percent of home
births in 2004 to 19.2 percent of home births in
2008—an increase of 22 percent. The percentage of
home births delivered by other midwives was 42.0 in
2008 compared with 43.9 percent in 2004. Other mid-
wives include certified professional midwives, direct
entry midwives, and any other midwives not included in
the certified nurse-midwife ⁄ certified midwife category.
The percentage of home births delivered by physicians
dropped from 8.7 percent in 2004 to 5.4 percent in
2008—a decline of 38 percent. The decline in the per-
centage of home births delivered by physicians may be
an indication of an improved risk profile, as most physi-
cian-delivered home births are unplanned (5). As in the
past, for about one-third of home births the attendant is
identified as ‘‘other.’’ The ‘‘other’’ category refers to
any other person delivering the baby, such as a husband
or family member, emergency medical technician, or
taxi driver.
Discussion
After a decade and a half of decline, the number and pro-
portion of home births rose by 20 percent from 2004 to
2008 in the United States, to the point where it is at the
highest level since 1990. The overall increase in home
births was driven mostly by a 28 percent increase for
non-Hispanic white women, for whom more than 1 per-
cent of all births are now at home. For non-Hispanic
white women, the percentage of home births was three to
six times higher than for any other race or ethnic group.
MT
WY
ID
WA
OR
NV
UT
CA
AZ
ND
SD
NE
CO
NM
TX
OK
KS
AR
LA
MO
IA
MN
WI
IL IN
KY
TN
MS AL GA
FL
SC
NC
VAWV
MI
NY
PA
MD
DE
NJ
CT RI
MA
ME
VT
NH
AK
HISignificant decreaseNo significant change
DC
Significant increase
Data not available
OH
Fig. 4. States with statistically significant increase or decrease in the percentage of home births, 2004 to 2008. Note:Data are tabulated by mother’s state of residence. Source: Birth certificate data from the National Vital StatisticsSystem.
188 BIRTH 38:3 September 2011
In 2008, the percentage of home births was generally
higher in the western United States and lower in the
southeastern United States. The increase in the percent-
age of home births from 2004 to 2008 appeared to be
widespread, and involved selected states from every
region of the country. Overall, 27 states had statistically
significant increases in the percentage of home births
from 2004 to 2008; only four states had statistically sig-
nificant declines.
The data in this paper suggest a reduction in the
overall risk profile for home births from 2004 to 2008,
including a 30 percent decline in the proportion of
home births of infants born to teen mothers, and a 20
percent decline in home births for unmarried mothers.
Although national data on maternal education are not
currently available, a previous study using data from 19
states found that women with planned home births were
more likely to be college educated than those with hos-
pital births (5). The percentage of home births of infants
who were preterm and of low birthweight declined by
16 and 17 percent, respectively, from 2004 to 2008, and
in 2008 were at approximately one-half the level of
hospital births.
The percent of home births delivered by physicians
also declined by 38 percent from 2004 to 2008. Because
few physicians plan to deliver an infant at home (5), a
physician-attended home birth may be suggestive of an
emergency or unplanned home birth situation. This
overall improved risk profile for home births may indi-
cate an improvement in prenatal risk assessment to iden-
tify low-risk women as candidates for home birth.
An examination of trends in planning status of home
births is not possible because of changes in the states
reporting this variable from year to year (8). However,
among the 25 states (Colorado, Delaware, Florida,
Idaho, Indiana, Iowa, Kansas, Kentucky, Michigan,
Montana, Nebraska, New Hampshire, New Mexico,
New York, North Dakota, Ohio, Oregon, Pennsylvania,
South Carolina, South Dakota, Tennessee, Texas,
Vermont, Washington, and Wyoming), representing 48
percent of United States births, which reported this item
in 2008, 87 percent of births that occurred at home were
planned (no data are available on home births resulting
in hospital transfers) (8). However, this figure varied
substantially by maternal race and ethnicity, from a high
of 93 percent for non-Hispanic white women, to 59 per-
cent for Hispanic women, and to a low of 33 percent for
non-Hispanic black women. Almost all the home births
attended by certified nurse-midwives ⁄ certified midwives
(98%) or ‘‘other’’ midwives (99%) were planned, com-
pared with 70 percent for ‘‘other’’ attendants and 23 per-
cent for physicians (8).
The national home birth rate of less than 1 percent in
the United States is similar to that of most other industri-
alized countries. However, 30 percent of births in the
Netherlands occur at home (12,13), whereas in England,
the percentage of home births has nearly tripled, from
1.0 in 1983 to 2.9 in 2008 (14). New Zealand also had a
large increase in home births, to 2.5 percent of births in
2004 (15).
Interestingly, the recent increase in home births in the
United States began before the release of a series of doc-
umentaries and newspaper articles about home birth
(16). Such a development is not without precedent. In
the United Kingdom, a government-endorsed movement
called Changing Childbirth has been credited with lead-
ing to a growth in home births that has continued until
the present. However, the home birth rate in the United
Kingdom had already been increasing for five consecu-
tive years before Changing Childbirth came into being
(17). Women choosing home birth may be a harbinger,
as much as a result, of increased activism related to
childbirth (16).
It is also interesting that this increase in home births
in the United States occurred in the context of increas-
ingly public physician opposition to the practice. In
2007, the American College of Obstetricians and Gyne-
cologists (ACOG), citing concerns about the safety of
home births for mothers and infants, issued a policy
statement opposing home birth (18), a statement sup-
ported by a resolution passed at the 2008 American
Medical Association (AMA) annual meeting (19). A
recent update to the ACOG statement also appears to
discourage home birth (20). These attitudes may also be
reflected in the very low proportion of planned home
births attended by physicians (5). In contrast, the World
Health Organization, the American College of Nurse-
Midwives, the American Public Health Association, and
the National Perinatal Association all support home and
out-of-hospital birth options for low-risk women (21–
24). In addition to physician opposition, some home
birth practitioners have reportedly had difficulty obtain-
ing support for women who needed to be transferred to a
hospital for medical complications (25–27).
Despite these difficulties, an increasing number of
United States women are opting for a home birth.
Women may prefer a home over a hospital birth for
a variety of reasons, including a desire for a low-
intervention birth in a familiar environment, surrounded
by family and friends, and cultural or religious concerns
(28–31). Lack of transportation in rural areas and cost
factors may also play a role in the decision to have a
home birth, as total costs for home birth are about
one-third of those for a hospital birth (28–33).
Conclusion
Whereas home birth remains a rare event in the United
States, an increase of 20 percent in a national rate over
BIRTH 38:3 September 2011 189
4 years is a notable development that will be of interest
to practitioners and policymakers.
References
1. Wertz RW, Wertz DC. Lying-in: A History of Childbirth in
America. New York: Schocken Books, 1977.
2. Leavitt JW. Brought to Bed: Childbearing in America, 1750–
1950. New York: Oxford University Press, 1988.
3. Curtin SC, Park MM. Trends in the Attendant, Place and Timing
of Births, and in the Use of Obstetric Interventions: United States,
1989–97, National Vital Statistics Reports, Vol. 47, No 27.
Hyattsville, MD: National Center for Health Statistics, 1999.
4. National Center for Health Statistics. Vital Statistics of the United
States, 1993, Vol. 1, Natality. Hyattsville, MD: Author, 1999.
5. Declercq E, MacDorman MF, Menacker F, et al. Characteristics
of planned and unplanned home births in 19 states. Obstet
Gynecol 2010;116:93–99.
6. MacDorman M, Menacker F, Declercq E. Trends and Character-
istics of Home and Other Out-of-Hospital Births in the United
States, 1990–2006, National Vital Statistics Reports 2010, Vol.
58, No 11. Hyattsville, MD: National Center for Health Statistics,
2010.
7. Martin JA, Hamilton BE, Sutton PD, et al. Births, Final Data for
2008, National Vital Statistics Reports 2010, Vol. 59, No. 1.
Hyattsville, MD: National Center for Health Statistics, 2010.
8. National Center for Health Statistics. Vital Statistics Data Avail-
able Online: Birth Data Files. Accessed December 13, 2010.
Available at: http://www.cdc.gov/nchs/data_access/VitalStats
Online.htm.
9. DiGuiseppe DL, Aron DC, Ranbom L, et al. Reliability of birth
certificate data: A multi-hospital comparison to medical records
information. Matern Child Health J 2002;6:169–179.
10. Zollinger TW, Przybylski MJ, Gamache RE. Reliability of Indi-
ana birth certificate data compared to medical records. Ann
Epidemiol 2006;16:1–10.
11. MacDorman MF, Declercq E, Menacker F. Trends and character-
istics of home births in the United States by race and ethnicity,
1990–2006. Birth 2011;38:17–23.
12. DeVries R. A Pleasing Birth: Midwives and Maternity Care in
the Netherlands. Philadelphia, PA: Temple University Press,
2005.
13. EURO-PERISTAT Project, with SCPE, EUROCAT, EURONEO-
STAT. European Perinatal Health Report—Data from 2004,
2008. Accessed September 14, 2009. Available at: http://www.
europeristat.com.
14. Office for National Statistics. Birth Statistics 2008, Series FM1
No. 37, February 2010. Accessed May 10, 2010. Available at:
http://www.statistics.gov.uk/downloads/theme_population/FM1-37/
FM1_37_2008.pdf.
15. New Zealand Health Information Service. Report on Maternity:
Maternal and Newborn Information. Wellington, New Zealand:
New Zealand Ministry of Health, 2007.
16. Armstrong E, Declercq ER. Is it time to push yet? In: Hoffman B,
Tomes N, Schlesinger M, Grob R, eds. Impatient Voices: Patients
and Policy Actors. New Brunswick, NJ: Rutgers University Press,
in press.
17. Declercq ER. Changing childbirth in England: Lessons for US
health reform. J Health Polit Policy Law 1998;23(5):833–859.
18. American College of Obstetricians and Gynecologists. ACOG
Statement of Policy as issued by the ACOG Executive Board.
Home Births in the United States. Washington, DC: Author, 2007.
19. American Medical Association House of Delegates. Resolution:
205 (A-08). Home Deliveries, April 28, 2008.
20. American College of Obstetricians and Gynecologists. Planned
Home Birth, ACOG Committee Opinion No. 476. Washington,
DC: Author, 2011.
21. World Health Organization. Care in Normal Birth: A Practical
Guide. Geneva, Switzerland: Department of Reproductive Health
and Research, World Health Organization, 1996. Accessed Sep-
tember 14, 2009. Available at: http://whqlibdoc.who.int/hq/1996/
WHO_FRH_MSM_96.24.pdf.
22. American College of Nurse-Midwives. Position Statement on
Home Birth. Washington, DC: Author, 2005.
23. American Public Health Association. Increasing Access to Out-of-
Hospital Maternity Care Services through State-regulated and
Nationally-certified Direct-entry Midwives, Policy Statement
#20013. Washington, DC: Author, 2001.
24. National Perinatal Association. Choice of Birth Setting, Position
Paper. Binghampton, NY: Author, 2008. Accessed December 8,
2010. Available at: http://nationalperinatal.org/advocacy/pdf/
Choice-of-Birth-Setting.pdf.
25. Cheyney M. Born at Home: The Biological, Cultural and Political
Dimensions of Maternity Care in the United States. Belmont, CA:
Wadsworth Cengage Learning, 2011.
26. Davis-Floyd R. Home-birth emergencies in the US and Mexico:
The trouble with transport. Soc Sci Med 2003;56:1911–1931.
27. Cheyney M, Everson C. Narratives of risk: Speaking across the
hospital ⁄ homebirth divide. Anthropol Newsl 2009;50(3):7–8.
28. Boucher D, Bennett C, McFarlin B, Freeze R. Staying home to
give birth: Why women in the United States choose home birth.
J Midwifery Womens Health 2009;54:119–126.
29. Wesson N. Home Birth: A Practical Guide. London: Pinter and
Martin, 2006.
30. Declercq ER, Stotland N. Home birth. In: Rose BD, ed. UpTo-
Date. Waltham, MA, 2009. Accessed December 8, 2010. Avail-
able at: http://www.uptodate.com.
31. Showalter A. Birthing among the Amish. Int J Childbirth Educ
2000;15(4):10–11.
32. Health Management Associates. Midwifery Licensure and Disci-
pline Program in Washington State: Economic Costs and Benefits.
Olympia, WA: Washington State Department of Health, 2007.
33. Anderson RE, Anderson DA. The cost-effectiveness of home
birth. J Nurse Midwifery 1999;44:30–35.
Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Table S1. Percentage of all births that occur at home
by state, 2004 to 2008
Please note: Wiley-Blackwell is not responsible for
the content or functionality of any supporting materials
supplied by the authors. Any queries (other than missing
material) should be directed to the corresponding author
for the article.
190 BIRTH 38:3 September 2011
