When Is Homebirth Not A Good Choice?
CW: mention of sexual assault, rape, body dysmorphia, and eating disorders
One of the most common questions I get from prospective clients and from friends asking more about what I do is: "What kinds of complications or circumstances make having a homebirth not a good idea or causes someone to be risked out of your practice?"
There are a lot of medical conditions that rule out homebirth entirely and then there medical conditions that with a solid plan, co-care, and extra monitoring homebirth can be kept on the table of options. It is the responsibility of midwife, client, and additional care providers to be in communication and always reassessing risks and benefits of all available options.
Because every midwife is unique in their experience, comfort level, and training, some conditions and complications that occur might leave no room for discussion and immediately mean that a client is risked out from having a homebirth with a particular midwife. It is a good idea to discuss what the most common circumstances would be for this kind of risking out before contracting with your midwife.
Let's explore some of the more common circumstances when homebirth might not be the best choice (at all or in context).
1) Gestating More Than One Baby
Carrying twins or more is a common reason for homebirth plans to go out the window. One of the most common reasons for this is that it is quite common for multiples to be born premature/preterm and need assistance with breathing, keeping warm, low-blood sugar, and in very premature multiples they can have underdeveloped organs and not be able to nurse successfully. There are other risks to consider, but these are the biggies and they increase with each baby in a pregnancy beyond twins.
Personally, I have experience, training, and comfort with twins and when people ask me if I attend twin births at home, I respond with, "Yes, I do attend *some* twin births at home." There are some twin births that I do not attend, namely a first-timer with Baby A in a posterior breech position. None of those factors alone would cause me to immediately risk myself out of a client's homebirth plans, but each one of those factors adds additional risks. Other factors that are part of any multiple gestation would be: type of twins (di/di, mono/di, or mono/mono), previous successful vaginal birth, previous successful vaginal birth of multiples, position of babies (especially Baby A) when labour begins, weeks gestation when labour begins, distance from a NICU, and so on.
2) Breech Position At Beginning of Labour
Having a baby in a breech position is another common reason for not only having homebirth plans cancelled, but also having plans for a vaginal birth cancelled. Unfortunately, not only are very few OBs being taught breech birth skills, very few midwives are learning the skills either or they live in states where legislation has been laid out that forbids them from attending known breeches and requires them to transport in or call for EMS as soon as it is discovered that a baby is breech during labour. This is a true tragedy and causing many, many cesareans, mostly primary cesareans. I am truly thankful for my experiences with and training in attending breech births.
Again, it is a good plan to talk with your midwife (before hiring them) about what their protocol is for breech birth. Equally important is to talk to your co-care provider or your midwife's back up physician about their breech protocol. This will help eliminate the potential for miscommunication and a lack of informed consent.
3) Hypertension (High Blood Pressure)
Hypertension is a condition that can develop because of pregnancy or it can be a preexisting health condition. In either case, changes in eating and activity can help quite a bit, but in most cases medication will be prescribed for management of hypertension. If hypertension is controlled and blood pressure levels remain at or below levels agreed upon by your midwife and co-care physician, a homebirth can still be possible. However, hypertension that is not controlled in some way can cause additional complications and is linked to Pre-Eclampsia, Eclampsia, and HELLP Syndrome, all of which pose serious risks for both pregnant person and baby.
Whether we are talking about Type 1, Type 2, or Gestational Diabetes, in most cases the safest place to give birth is at the hospital. One of the major risks of a pregnancy with diabetes complicating it is stillbirth. Other common risks are having a baby born with Hypoglycemia (low-blood sugar) or Macrosomia (large for dates), which can lead to Shoulder Dystocia and its resulting complications. While homebirth *is* possible with many, many specifically tailored plans, it is not advisable.
These are some of the top ones. While other complications and conditions like placenta previa, some clotting disorders, uterine windows, history of multiple cesareans, significantly decreased foetal movement (or lack of movement), and more can be reasons for risking out of homebirth, I want to go over a few less talked about reasons why homebirth might not be the best decision.
1) You (or your partner, if applicable) Do NOT Want A Homebirth
I realise that this might seem obvious upon first glance, but after 20 years of birthwork, I have been to many planned homebirths where either the pregnant person or their partner did not want to have a homebirth. I am not talking about pregnant folks who choose homebirth under duress because they can't find a birth centre or hospital provider that will honour their informed choices, but rather people who do NOT want to be giving birth at home. Many of them will start care out with a midwife, planning a homebirth, because they were pressured to do so by their partner, friend, or family member. Sadly, some will sign on because it is the trendy thing to do and they want to get their "crunchy parent" points. Frequently, these folks will end up transporting in labour for a myriad of reasons and almost none of them will be satisfied with their birthing experience no matter what their providers do or where they end up giving birth.
As for reluctant partners: I always say that the pregnant person gets the last word on where they give birth, how they give birth, and who they have attend (or not attend) their birth. Only a pregnant person knows if a disagreement about the place of birth is worth stressing or ending a relationship over.
While it is absolutely true that homebirth can be cathartic and very empowering for pregnant people with a history of sexual abuse, assault, or rape, it can also be terrifyingly triggering despite all best intentions and preparations. Unfortunately, this is an area that is not talked about often enough in general and it is sometimes hard to predict how intensely a person will react to labour or birth until they are in the middle of it. While this is not always the case, many people find that pregnancy alone is very triggering and they might need medications that would require a birth to occur in hospital for the newborn's safety.
Even if you have had previous pregnancy and birthing experiences without past trauma being a negative factor, please find a way to disclose that you have a history of trauma to your provider so that they can prepare themselves to better support you if you end up being triggered during pregnancy, labour, or the moments of birth.
Experiencing intense social or body dysphoria during pregnancy can be a reason for or against having a homebirth. For transgender, nonbinary, and gender non-conforming (TNBGNC) people pregnancy can be a difficult time because of changes in their body that can accentuate certain parts; how much focus and attention will be given to their bodies by others; the often inappropriate questions from strangers, especially if the pregnant person presents masculine or androgynous; the cis-het, woman centred nature and culture of birth, birth education, and providers; and the fear that they will not be respected by their care providers when it comes to their name, pronouns, and gender identification. Some TNBGNC people end up having wonderful, supportive, and affirming care and birthing experiences at home, while others have better luck finding the kind of compassionate and competent care they need in hospital. In either case, a doula who is competent in providing support for TNBGNC pregnant people will be an invaluable member of the birth team.
Another population of pregnant people who can experience body dysphoria are those with current eating disorders or a history of eating disorders (ED). The sometimes drastic changes in the pregnant body along with the focus and attention others will give their bodies, can cause anxiety, stress, and unhealthy eating habits. The heavy focus on food and nutrition during pregnancy can also cause a lot of anxiety, stress, and push a pregnant person towards unhealthy eating habits. ED is not an immediate risk out for homebirth and current standard of practice suggests that pregnant people who have group and or therapy support and in some cases, medication for anxiety, and who are eating a healthy diet can safely plan a homebirth. For many folks with ED, pregnancy can actually be a time of great empowerment and marveling at what their bodies can do.
4) History of Homebirth to Hospital Transports
Having a history of planned homebirths that ended up as transports to the hospital either before or immediately after birth alone is not cause to rule out planning a homebirth. However, it is our opinion that if a person has had two or more subsequent planned homebirths end up in a transport to the hospital, it may be time to really assess these past experiences with a fine tooth comb, assess current health concerns, and highly consider having co-care with a physician to ensure that as many potential roadblocks as possible can be addressed to avoid having another homebirth to hospital transport situation.
I hope this helps clarify some complications and circumstances when homebirth might not be the best decision for a pregnant person to make.
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