Alternative Birth: Homebirth, Waterbirth, and Maternal Positions in Labor

by B.M. Petrikovsky, MD, PhD, D. Alyeshmerni

Childbirth practices have evolved dramatically over the last century, shaped by medical advancements, shifting social norms, and growing access to hospital-based care. While modern obstetrics has greatly improved maternal and neonatal outcomes through skilled providers, pain management, and emergency interventions, alternative birthing, such as homebirth, waterbirth, etc., have gained renewed popularity. Many families seek these options for greater comfort, autonomy, and a more natural birth experience. However, these practices raise important questions regarding safety, access to emergency care when needed, and outcomes for both mother and newborn.

This editorial explores the benefits and risks associated with homebirth, water immersion during labor, and alternative maternal positions.

Homebirth

Until relatively recently, homebirth was the only way women delivered.

Once advancements were made, like professionalization of obstetrics, policy/insurance, advancements in pain management, and availability of experienced doctors in cases of emergency, it took just 35 years for urban births in hospitals to jump from 5% to over 75%.

Some women still choose to give birth at home to have more autonomy, privacy, avoiding what they see as unnecessary interventions, negative past hospital experiences, or wanting family involved in a home setting.

Because of the unexpected complications that can arise during labor and delivery, a low-risk pregnancy in the hospital can quickly become a high-risk one at home. In the United States, about one-third of births are performed by cesarean section. Limited access to emergency obstetric care increases maternal and newborn morbidity.

The biggest risk occurs when homebirth is attempted in high-risk situations (breech, twins, VBAC) or when transfer is delayed. Some patients have complained that their midwives discouraged them from going to the hospital, either because they overestimated their ability to treat complications at home or feared that hospital staff would stigmatize the patient or take invasive measures. The resulting delays can put women at risk during their most vulnerable moments in childbirth, in some cases turning a complicated delivery into a life-threatening one.

Hospitals can be hesitant to accept homebirth patients for several reasons. Some doctors worry that they could be held legally responsible for a problem that arose at home. It can also be challenging to properly treat patients without having observed the full course of their labor.

National summaries report neonatal mortality rates of approximately 0.5 per 1,000 for hospital births versus 1–2 per 1,000 for homebirths involving low-risk patients. Similarly, analyses of nearly 14 million U.S. births from 2007–2010 found intrapartum and early neonatal mortality of 1 per 1,000 for homebirths compared with 0.32 per 1,000 for hospital births, attended by certified nurse-midwives (a threefold higher risk).

Risk differences tend to be greater for nulliparous women and have shown low APGAR scores and neurologic complications in homebirths compared with hospital births.

Waterbirth

Water immersion during labor and birth has become increasingly popular in the last several decades. The idea is that immersion in water during the first stage of labor will help the mother achieve pain relief, relaxation, a shortened labor, and decreased use of analgesia. A 2022 review found water immersion in the first stage to significantly reduce the use of epidurals, opioids, and episiotomies, as well as increase maternal satisfaction.

There is much debate around the risks and safety of water immersion during the second stage of labor and delivery. Possible neonatal risks of delivery underwater include infection, respiratory distress, hyponatremia, seizures, and cord avulsion, among other negative outcomes.

Alternate Maternal Positions

While the supine position provides healthcare providers with easy access to monitor the fetus, alternative maternal positions (side-lying, hands-and-knees, or standing) may help improve comfort for the mother.

Upright positions (standing, squatting, or kneeling) shorten the second stage by 6 minutes on average in women without an epidural. MRI pelvimetry studies show that these postures in labor can increase the pelvic outlet and midpelvic diameters. Some positions may be tiring for individual patients, and clinicians may adjust for fetal monitoring needs. Major guidelines encourage free movement and upright/non-supine pushing unless there is a medical reason not to do so.

Conclusions

While alternative birthing practices may offer increased comfort, autonomy, and satisfaction for women, they carry important safety considerations. Evidence suggests that homebirths are associated with higher neonatal and maternal risks.

As an obstetrician with 50 years of experience, I cannot support the practice of homebirthing, even for low-risk women. The problem is that risk factors for rare but life-threatening complications of pregnancy are poorly calculated.

Often, a 45-year-old obese diabetic woman with a history of severe hemorrhages will undergo an uneventful delivery, while a young and healthy woman will develop fetal distress (when the baby does not tolerate labor) and will end up with a handicapped child because of delayed cesarean section due to transport delay.

I have a clear recollection of several hysterectomies in patients with postdelivery hemorrhages at home, which would have been likely avoided if delivery had taken place in the hospital. In all those cases of maternal transfers, multiple blood transfusions and hysterectomies were life-saving procedures.

Homebirth attendants usually monitor fetal heart rate by intermittent auscultation. However, this practice is mostly useless because in cases of severe fetal compromise, help (cesarean section) is not readily available. Conservative measures (oxygen, changing maternal positions, etc.) are not helpful in cases of real emergency. Therefore, homebirth today is like Russian roulette with one bullet in a revolver.

For those who are passionate about homebirth, I would suggest a birthing center attached or in very close proximity to the maternity hospital, a recommendation I am hesitant to give!

One can argue that pregnancy, labor, and delivery are natural events, and I would agree. So is a tsunami. It’s not for nothing that textbooks on possible obstetrical complications of pregnancy and birth are thicker than the Talmud, and it takes many years of training to become a competent obstetrician, over 15, to be exact.

The only exception to the rule occurred in Vienna, Austria, with Dr. Semmelweis. He noticed that maternal mortality in the doctors’ service was three times that of the mortality in the midwives’ service. In 1847, he proposed handwashing with a chlorinated solution between cases. As a result, maternal mortality dropped drastically, and he reported his findings in his 1861 book entitled Etiology, Concept and Prophylaxis of Childbed Fever. This was the only time when home birth was safer for both mother and child.