U.S. home births hit 30-year high

When Kindrea Hines gave birth to her son in 2008, her husband, then in his medical residency, assisted with the delivery. After the birth, Kindrea began learning about midwifery from a certified nurse-midwife while the couple prepared to go onto the mission field. “I had someone from my church who had home births and I thought it was very interesting,” she said.

The Hines worked as missionaries with a church plant in the Democratic Republic of the Congo from 2014 to 2016 and used their medical training to help families they met there. “The Lord opened up a lot of opportunities for the gospel through medical needs,” Kindrea said. “One of those was actually with a Congolese family that we helped to deliver their child.”

Kindrea is now a registered nurse in Ohio, and her husband, Dr. Ethan Hines, is a family medicine physician. Ethan has since helped deliver all six of their daughters at home, and the couple works as a team to help women have home births. Despite some of the risks associated with giving birth outside the hospital, Kindrea Hines said many U.S. women still feel safer and more in control delivering at home. Women who choose to deliver at home say big factors are avoiding medical interventions, staying in a familiar space, and working through labor at their own pace, Kindrea said.

“A lot of people are looking for that relationship aspect of birth where they want to be able to ask questions,” she said. “They want to know that they have more than one option.”

In recent years, the number of women choosing to give birth outside of a traditional hospital has increased to the highest rate in three decades, according to the Centers for Disease Control and Prevention. Between 1990 and 2022, the percentage of births that occurred at home—whether planned or not—more than doubled from 0.6 percent to 1.47 percent. In 2020, the COVID-19 pandemic amplified the trend as more families decided to avoid often crowded hospitals to deliver their babies, according to the Pew Research Center.

While the number of babies born at home still represents a small fraction of total births, some physicians and midwives are calling for better regulations to oversee the practice. Across the country, each state has its own laws that dictate who can attend and assist with births outside of a hospital. And not all states recognize midwifery licenses and certifications by national organizations.

Meredith Bowden began training to become a midwife 18 years ago after having a home birth of her own. Because she already had a bachelor’s degree in biology and environmental science, she decided to complete a four-year apprenticeship and training program through the North American Registry of Midwives to become a certified professional midwife. She now serves on the board of the National Association of Certified Professional Midwives.

Despite her training, Bowden is taking a risk by practicing midwifery in her state. “In North Carolina I am practicing without a license,” she said. “So I could face judicial consequences if someone chose to press charges around that.”

Like many states, North Carolina only licenses certified nurse-midwives to perform home births. Those individuals are registered nurses who have graduated from a nurse-midwifery program accredited by the Accreditation Commission for Midwifery Education. In October, a new state law took effect that removed the requirement for certified nurse-midwives to be supervised by a physician when performing home births. Certified professional midwives (CPMs) like Bowden are still barred from practicing.

“Wilmington is only 45 miles from South Carolina, where I could open a birth center and practice [while] licensed and integrated into the system,” Bowden said. South Carolina and 35 other states currently have a pathway for CPMs to become licensed, according to the National Association of Certified Professional Midwives. In June, Iowa lawmakers approved a bill to license CPMs. Other states, including Georgia, West Virginia, and Nevada, are considering similar legislation.

Because she cannot be licensed, Bowden said she cannot bill insurance for her services and her patients have to pay out of pocket. While some insurance plans do cover midwives and home births, many state Medicaid plans only reimburse services provided by CNMs who are licensed by the state, according to the National Academy for State Health Policy.

The lack of regulations also leaves women without a state mechanism to submit grievances or complaints, though Bowden does inform her patients that they can file complaints with the North American Registry of Midwives.

“People are not going to stop having their babies at home,” Bowden said. She added that the lack of licensing pathways makes the practice less safe by reducing access to trained, experienced, and credentialed providers.

Dr. Sudheer Jayaprabhu, an OB-GYN in Texarkana, Texas, said hospitals are still the safest place to deliver. Delivery or birth complications for women and babies during hospital births have declined dramatically since the 1930s and 1940s due to the widespread use of antibiotics, monitoring technology, and blood transfusions, he said.

Jayaprabhu expressed concern about births attended by what are called lay or direct-entry midwives, who learn through apprenticeships instead of a formal education program. When women receive care from a board-certified OB-GYN, they know their training and knowledge level, he said, but the experiences and practices of midwives can vary significantly.

The American College of Obstetricians and Gynecologists recommends hospitals or accredited birth centers as the safest option. Infant mortality rates for babies born at home are twice as high as those for babies born at a hospital, according to ACOG, and mothers are at a higher risk of excessive bleeding or hemorrhage. While emergency situations during labor are rare, Jayaprabhu said it is critical for women to have access to medical care if they need it. “Ninety percent of the time you probably don’t need an obstetrician-gynecologist around to do deliveries,” he said. “It’s the 10 percent that goes bad that you need them, and you can’t predict which 10 percent.”

Months before her first child was due in 2011, Shannon Musselman began looking for a midwife near her home in Ohio. Growing up in Africa, she didn’t mind eschewing medical practices considered standard in America and decided that giving birth at home would be more comfortable for her.

Since midwives typically only accept a few patients per month, Musselman had to make arrangements for her second-choice midwife to attend her labor. Musselman and her husband also made plans to labor at her parents’ home near a hospital where an OB-GYN had agreed to be her backup delivery option if the home birth didn’t go as planned.

After Musselman labored for hours at home and struggled to progress even after her water broke, her midwife called in the first-choice midwife for assistance. “I was running out of energy and the contractions were slowing down,” Musselman said. “My body was starting to quit, although all along we were monitoring my son and he was fine.”

They went to the hospital, where a doctor determined that her labor had slowed because she wasn’t able to empty her bladder properly. He inserted a catheter, a procedure that midwives were not legally allowed to do outside medical facilities at that time. After getting some rest and receiving Pitocin to restart her contractions, Musselman delivered her son vaginally more than 48 hours after labor began.

For her second and third pregnancies, Musselman and her husband asked the Hines to deliver her babies. When women are searching for a midwife, it is critical that she knows what each provider’s plan is in case of an emergency and how they are equipped to handle complications, said Kindrea Hines.

As physicians do in traditional medical settings, responsible midwives should look at a woman’s full medical history to determine whether home birth is right for her or not, Ethan Hines said. Some risk factors, like high blood pressure, a history of hemorrhaging, developmental issues with the baby, and being pregnant with multiple babies may lead some midwives to recommend a woman have a hospital birth, he said.

The Hines are hesitant to recommend some midwives in their region if they are not sure that they know how to perform vital checks, have access to fluids and medications, and have established emergency plans if a woman needs to be transferred to the hospital.

The emergency move to a hospital frustrated Musselman, she said. “It was disappointing because I really wanted a home birth. But then my other two were a lot easier. We had them at home, close to a hospital,” Musselman said. With the births of her daughters in 2012 and 2017, she said being able to deliver at home made her feel more safe and comfortable than at a hospital. “My favorite part is [that], after the baby is born, if baby is fine, everybody [assisting in the delivery] goes home and I can sleep in my bed,” she said. “The recovery is better and nursing is better.”