Planned Home Birth - Marty Makary’s Blind Spot

Marty Makary's book "Blind Spots" seems to be popular among Sensible Medicine readers. Dr. Joseph Rall found one part that he didn't think adequately represented current practice. Here he discusses the most recent data regarding the safety of planned home birth in selected women.

---

In his recent book, "Blind Spots," Dr. Marty Makary details several instances in which the medical establishment has clung to medical dogma, to the detriment of patients’ health. One chapter examines the medicalization of childbirth, including the overuse of C-sections. Dr. Makary closes this chapter by characterizing home birth as an overcorrection that “triple(s) the risk of infant mortality.”

Is that true? As a family physician with personal and professional experience in childbirth — two of my children were delivered at home — I knew there was more to the story. In this article, I address Dr. Makary’s “blind spot” on planned home birth.

Examining the Available Evidence

Home birth is a complex topic to study. Randomized controlled trials could be done, but it would be difficult to find patients willing to be randomized to planned home vs. hospital delivery. The alternative — observational studies and subsequent meta-analysis — face significant limitations. Even with meta-analysis, sample sizes may be too small to detect rare outcomes. Critically, studies need to distinguish planned home births from unplanned ones.

Dr. Makary’s claim that home birth triples the risk of infant mortality is drawn from a 2010 meta-analysis by Wax et al. However, researchers have widely criticized this paper for its methodological flaws and newer data has superseded Wax’s conclusions. The 2010 meta-analysis relied heavily on a large retrospective Dutch study by de Jonge et al., which accounted for 95% of the included births. While this study found no difference in perinatal mortality (death within the first seven days of life), it did not examine neonatal mortality (death from 8–28 days) and was therefore excluded by Wax et al. As a result, the conclusion that home birth triples the risk of neonatal death was drawn from the remaining 5% of births from other studies. Without de Jonge’s paper, Wax’s analysis relied on old and flawed data. A notable example was a paper by Pang et al. that failed to differentiate between planned and unplanned home births. Unplanned home births will obviously have worse outcomes than either hospital births or planned home births.

A 2014 follow-up study by de Jonge analyzed 743,070 low-risk planned home and hospital births and found no significant difference in perinatal or neonatal mortality. Additionally, three meta-analyses published in the past decade on this topic also demonstrate the safety of home birth. A 2019 study by Hutton et al., analyzing about 500,000 planned low-risk home births in well-resourced countries, found no difference in perinatal or neonatal outcomes compared to planned hospital births. Similarly, a 2018 meta-analysis by Scarf et al., with comparable sample sizes, reported no statistically significant differences in infant mortality based on the planned place of birth. Finally, a smaller 2018 meta-analysis by Rossi et al. found no significant differences in neonatal morbidity and mortality between hospital and home deliveries.

One recent observational study based in the US did demonstrate an increased risk of perinatal or neonatal mortality. This study by Snowden et al. examined 79,000 births, including approximately 3,000 home births, and found that planned out-of-hospital births were associated with a higher relative risk of perinatal mortality (OR 2.43, 95% CI 1.37–4.30). However, the authors found that this increased risk was no longer statistically significant when analyzing subgroups of multiparous women and those younger than 35 years old. This is important information to guide expectant mothers who desire home births but also want to avoid any increased risk. Importantly, the absolute risk of complication in this study remained low, with less than one additional death per 1,000 deliveries. By comparison, a 2010 study by Guise et al. found that, when compared to scheduled repeat C-sections, vaginal birth after cesarean (VBAC), a procedure with broader acceptance than home birth, is associated with 0.8 additional deaths per 1,000 deliveries. Similarly, a 2017 study by Grunebaum et al. found a slightly increased neonatal mortality risk for home births — approximately 0.5 additional deaths per 1,000 deliveries. However, as with the Snowden study, when known risk factors were excluded (nulliparity, age >35, post-term, previous cesarean, breech presentation), Grunebaum et al. found no significant difference in outcomes between hospital physician-attended births and home births.

An International Perspective

ACOG’s practice guideline states that every woman has the right to make a medically informed decision about delivery location but discourages out-of-hospital delivery. The guideline reads,

"although planned home birth is associated with fewer maternal interventions than planned hospital birth, it also is associated with a more than twofold increased risk of perinatal death."

This recommendation differs from several other developed countries. For example, in the UK, the Netherlands, and Canada, home birth is an integral part of obstetric care for low-risk pregnancies. The UK’s National Institute for Health and Care Excellence (NICE) guidelines encourage home births for low-risk multiparous women, stating that outcomes for the baby are comparable to those in obstetric units, with fewer interventions. For nulliparous women, they acknowledge a small increase in neonatal risk but still support home birth as an option. In the Netherlands, where 16% of women deliver at home, midwives formally collaborate with obstetricians and hospitals under clearly defined protocols. Transport times are typically under 20 minutes, a key factor in better outcomes. In Canada, professional guidelines similarly affirm the safety of home birth for low-risk women under the care of trained midwives. These examples demonstrate that when home birth is properly integrated into the healthcare system, it can be a safe and viable option for women.

A Path Forward

Home births are growing in popularity, especially since the Covid-19 pandemic, reaching 1.51% of all U.S. births in 2022, the highest since records began in 1990. Women are increasingly drawn to home birth for its well-documented lower rates of intervention including fewer C-sections, intact perineums, and reduced postpartum hemorrhage. Current evidence suggests that for well-selected candidates (multiparous women under age 35 with term, singleton, cephalic pregnancies and no prior C-sections), planned home birth is a safe option. Yet, ACOG continues to discourage home birth. By maintaining this stance, ACOG further fragments the U.S. obstetric care system and legitimizes the overmedicalization of birth, driving the majority of low-risk women into hospitals, where the C-section rate exceeds 30% — a level well above international norms.

Rather than demonizing home birth, we should focus on improving its safety through randomized trials, integration, and collaboration. Obstetric care in the U.S. could benefit from adopting elements of international models, such as formalized transfer agreements and standardized protocols. Home birth isn’t inherently dangerous, but its success depends on proper candidate selection, supportive healthcare systems, and collaborative care. By addressing these factors, we can respect women’s autonomy while promoting the safest outcomes for mothers and babies alike. Home birth is not an overcorrection, as Dr. Makary suggests, but a needed corrective to the medicalization of childbirth and a legitimate option for women.

Joseph Rall, DO is a third-year FM resident from Cleveland with interests in value-based care, evidence-based medicine, and medical ethics. He will begin work as a primary care physician for ChenMed this August.

Photo Credit: Luma Pimentel