The Delivery Revolution: The Rise of Home Births in the U.S.

“I wish somebody would have explained to me that there were different options before this happened to me. Sometimes that can save somebody from experiencing that same trauma.”

Samantha Jordan, a doula and birth photographer based in Northeastern Ohio, wishes she had been better informed about her options as she approached her first childbirth. After two largely negative experiences with hospital birth, Jordan chose home birth when she was pregnant with her third child. She resolved to take control of her own experience. Jordan is one of an increasing number of American women who made the choice to labor at home rather than in the hospital.

Since the mid-20th century, the hospital has been culturally accepted in the United States as the safest place for a pregnant individual to give birth. But an increasing percentage of American women are choosing to give birth outside of the hospital. Between 2019 and 2020, there was a 22% increase in home births. Another 12% increase occurred between 2020 and 2021. While home births still account for a relatively small percentage of total births in the United States—about 1.51%—the trend continues to rise.

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Jaimi Sauder, a 30 year-old stay at home mom, feared that if she gave birth in a hospital, her doctors would not listen to her preferences. Sauder knew exactly how she wanted her delivery experience to look. She was certain she wanted to have a natural birth free of pain-killing interventions like an epidural—and she was adamantly opposed to a Cesarean section.

While Sauder knew she had a right to refuse certain treatments and procedures, she feared doctors might overzealously engage in medically unnecessary interventions. “I’m not very confrontational. So, if I’m in labor, I can’t really advocate for myself. And my husband is not very confrontational either…that’s what led me to looking at other options,” Sauder said.

There is some evidence to support this worry. The hospital’s biomedical approach to childbirth can encourage medical intervention that may not occur in other settings. Professor Rebecca Tannenbaum, a senior lecturer in History at Yale who specializes in the history of women’s health, said, “[In the hospital] there are things like continuous fetal monitoring. A midwife might listen with the fetoscope once every couple of hours. [In the hospital], if there’s a small change, that might lead to some other intervention, which leads to another intervention, which leads to a cesarean.”

Sauder worried that under the duress and pain of labor, she would not be able to properly defend her choice to have an unmedicated, natural birth.

Jordan echoed Sauder’s claims about excessive medical interventions in hospitals. “All these interventions happen in a hospital. You get the Pitocin, the baby has a bad reaction to it. You get the epidural, the baby has a bad reaction to it. Now, your baby’s in distress and you need to have an emergency C-section,” Jordan said.

It is true that many women report negative experiences with hospital births. In 2023, the CDC analyzed a survey of 2,400 new mothers’ experiences with hospital childbirth. The survey included frequent accounts of mistreatment, such as ignored requests for help, being shouted at, threats to withhold treatment, and pressure to accept unwanted treatment.

These reports are a symptom of a larger conversation within the birth care community. Evidence does demonstrate that maternity care in the US is intervention-heavy. In other words, women giving birth may experience a range of interventions that are not medically necessary. For example, the majority of women giving birth in the U.S. experience electronic fetal monitoring, receive intravenous fluids, and face restrictions on eating and drinking during labor. All of these interventions are considered medically unnecessary for most low-risk pregnancies.

A substantial number of women also received more physically invasive interventions during their births, with 67% of women receiving epidurals, 31% receiving Pitocin to speed up delivery, 20% having their membranes artificially ruptured, and 31% undergoing cesarean sections. In other parts of the world, these numbers are lower. For example, in the Netherlands, which has a nationalized home birth program, the rate of Cesarean sections is under 17%. Notably, the U.S. also has the highest rate of both maternal and infant mortality rates compared to other high-income countries.

There is a legitimate concern amongst expectant mothers about being subjected to unnecessary medical interventions. Sauder pointed out that there is an inherent power dynamic between the physician and a laboring mother, which makes women vulnerable to interventions they may not want nor need. “[Doctors] are taught to intervene, and they just expect most women to do what they tell them to. When [a woman] questions something, or they want to try something different, [doctors] are taken aback by that, and they’re like ‘Well, I’m the doctor,’” Sauder said.

But this sentiment, while common in the natural birth community, is certainly not unanimous. Carol Glass, a registered nurse who worked in the Emergency Department for over 30 years, expressed more faith in doctors’ ability to respect the wishes of mothers pursuing natural childbirths. “Nowadays, patients have to give consent for anything that’s done [to them]. Hospitals are aware that women are wanting to have a natural birth, so they will try to accommodate them,” Glass said.

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Sauder’s lack of faith in the possibility of a positive and autonomous birth experience in a hospital is what pushed her to look for alternative options. For her first birth in 2021, Sauder decided on a birthing center run by midwives.

“From my research, [it would] be harder to have a natural birth at a hospital than it would at a birth center, because a birth center is more natural-minded. They have birth tubs, a natural form of reducing pain, and they have nitrous oxide,” Sauder said.

Sauder emphasized taking a holistic and natural approach to her first birth. She self-induced using castor oil as she embarked on what was ultimately a 38-hour labor. While Sauder was pleased she was able to deliver her first baby naturally at the birthing center, she didn’t like every aspect of her birth experience.

“For [my] birthing center, they have eight different midwives, so you could have any of them. I don’t know if I really like that model of care, because you don’t really have continuous support, because you don’t know who’s going to be there at the time [of your labor]. So I ended up having someone that I didn’t even like—I had never met her before,” Sauder said. While this is not reflective of how all birthing centers operate, this was a central aspect of Sauder’s birthing experience.

When Sauder became pregnant for the second time, she decided to give birth at home instead. Home birth allows women an even higher degree of control over their birth experience. They can determine precisely who is in the room with them, how the room is organized, and the position they give birth in.

Jordan, who had three vastly different birth experiences herself—one emergency Cesarean section, one vaginal birth in the hospital, and one home birth—said that home birth was the only setting that provided her with a birth experience she looked back on fondly. “When I decided to have a home birth, I knew that I wasn’t going to have people in my space telling me that I can’t when I know that I could. I was left to just labor in my own house, alone, as exactly how I needed. [My] labor was pretty intense, but it still was nothing compared to what I experienced at the hospital,” Jordan said.

For both Sauder and Jordan, laboring at home allowed for a more comfortable and flexible birth process. Giving birth at home means that women dictate the rules of their own experiences.

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Notably, major concerns persist about the safety of home births. While home birth was able to provide individuals like Sauder and Jordan with a positive birth experience, legitimate concerns remain regarding the relationship between home birth, infant, and maternal mortality.

According to a study published in the American Journal of Obstetrics and Gynecology in 2020, the infant mortality rate for in-hospital midwife-attended births in the United States was 3.27 per 10,000 live births, while the infant mortality rate for planned home births was 13.66 per 10,000 live births. The gap in outcomes is central to other, more critical perspectives on home birth. Many view the choice to give birth at home as irresponsible.

Glass maintained that the hospital remains the safest place to give birth. “Birthing is natural, and usually there is no problem, but if there is a problem, it happens fast. It’s good to know that there’s the needed interventions there to help you through your problems,” Glass said, “If you’re farther than 15 minutes away from a hospital, you probably should think again before you attempt a home birth…Having seen firsthand how things can go bad quickly, I like the idea that there’s emergency care available to the mom and baby. I can’t foresee the same thing happening if [an emergency] would happen at home. How could you get the help you needed quick enough?”

Even advocates for home birth acknowledge that the hospital may be safer for those giving birth, especially those who have “high-risk” pregnancies. A high-risk pregnancy occurs when the pregnant individual has certain health conditions, and involves increased health risks for the pregnant individual, the fetus, or sometimes both. Conditions that make pregnancy high risk include autoimmune diseases, high blood pressure, diabetes, polycystic ovary syndrome (PCOS), preeclampsia, and multiple gestation, amongst others. Approximately 30,000 to 50,000 Americans have high-risk pregnancies each year.

Although Jordan is a doula who advocates strongly for home birth as an available and accessible option, she recognized that the home may not always be the safest setting for childbirth. “True emergencies do happen, and there are high-risk people who should be in a hospital setting. There are also people who are perfectly low risk, but they feel better in a hospital setting,” Jordan said.

It’s important to note that while there may be disparities in neonatal mortality rates based on birth setting within the U.S., there seems to be less of a gap when looking at high-income countries generally. A study published in the journal Midwifery did not find significant differences in neonatal mortality rates between planned home births and hospital births. This study also showed that those with planned hospital births had lower odds of normal vaginal birth as compared to other planned births in different settings. The higher safety observed in home births in other high-income countries suggests that factors such as healthcare infrastructure and accessibility to trained midwives may play a critical role in minimizing risks.

There is no one right option for the best, safest place to give birth. While people may fall at each end of a spectrum, in reality, there is no birth completely free of risk—which means that the choice between hospital and home birth ultimately depends on individual circumstances, preferences, and access to resources.

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The drive for American women to reclaim autonomy over their birth experience is far from new. The modern home birth movement calls for a shift back to a much older model of labor—one that once defined childbirth in America. In the 19th century, nearly all births in the U.S. occurred in the home, led by women midwives. However, by the early 20th century, male physicians framed midwife-attended home birth as dangerous. Instead, physicians encouraged women to give birth in hospitals. By the 1960s, 99% of births occurred in the hospital.

According to Tannenbaum, the modern shift back toward natural home birth began around 50 years ago. “This modern shift back to home birth starts in the 60s and 70s with second-wave feminism and the American leftist counterculture,” Tannenbaum said, “There was also the Women’s Health Movement which encourages women to know and understand their own bodies and to take control away from doctors.”

These movements in the mid- to late-19th century re-emphasized birth as a natural process, one overly-pathologized by the medical community. The shift back towards home birth, as well as the popularization of a natural form of birth preparation called lamaze, reflected a dissatisfaction with the medical establishment of the time. Counterculture and feminist movements struck a chord with women, and left many looking to reclaim power over their own reproductive experiences.

The home birth movement was not restricted to leftist or women’s liberation groups. Rather, these groups found an unlikely ally in the Christian fundamentalist movement.

Both the feminist movement and Christian fundamentalists share a distrust of medical institutions. Feminists emphasized that childbirth has historically been attended by female midwives. In the 19th century, women had their authority in the delivery room taken from them by male physicians. Feminists of the 1970s called for a return to this traditional model of birth, wherein women delivered their babies in the home, surrounded by other women.

Christian movements’ calls for a return to traditional birthing methods advocate for a similar outcome, but with vastly different motivations. “A lot of fundamentalist Christian families do home birth because they don’t trust large institutions. But also because [childbirth] is something that’s within the family, that’s within the household—part of the patriarchal family. The father should be there and supervise the birth,” Tannenbaum said.

Christian rhetoric is imbued throughout many popular home birth blogs. These blogs tend to reflect the idea that God designed the body for childbirth, while also emphasizing that the father of the child should be present to support in prayer. These blogs also recommend trusting in God’s plan to provide safety and health during birth, rather than relying on medical institutions.

Both movements emphasize the fact that childbirth is ultimately a natural human process which does not necessarily require intervention by medical practitioners.

“[One] thing that the two movements have in common is that Christian home birthers often say, ‘God designed my body to give birth,’” Tannenbaum said, “And you see that in second-wave feminist writings about childbirth: your body is designed by nature to give birth, and we shouldn’t define this as pathological. And [pathologizing childbirth] gives men control over our bodies, which we don’t want.”

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The trend of home births in the United States seems unlikely to abate anytime soon. Many advocates argue, then, the next step is to make home births safer and more accessible.

“The thing that could improve outcomes for women is to have [home birth] be more accepted by the medical profession. It would be great if we had a system that does exist in some European countries, for instance, where nurse midwives will do home births and that’s kind of the norm, unless you are a high risk birth,” Tannenbaum said.

Glass holds a slightly different vision for what the future of birth could look like in the U.S.. She maintained that hospitals should play the defining role in childbirth. Glass said hospitals are adapting to changing desires related to childbirth experiences and can continue doing so.

“Hospitals are aware that women are wanting to have a natural birth, so some are trying to accommodate this by having areas within their maternity section that replicate a home birth as close as possible, with water tubs, allowing all the family in a room, a queen size bed, and nurses that understand that this mother wants to have a natural birth. More hospitals can adopt this model,” Glass said.

As the popularity of home births increases, the demand for birthing options that balance autonomy with medical support grows. The ultimate goal should be to create a medical system wherein all women can have a birthing experience that not only ensures health for the mother and child but also honors their autonomy. This system need not choose between hospital and home birth, but rather create opportunities for women to be safe and healthy in whatever birth setting they choose.