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.
Chaim
Finally, a logical article
As a Hatzalah member, we’ve unfortunately been called to way too many home births that have gone wrong, threatening both the mother and child’s life.
Don’t try home births.
And if you do and something goes wrong:
Play stupid games: win stupid prizes. Only it’s potentially fatal prize(s)
Pearl
Chaim, that kind of language is exactly why mothers in these situations hesitate to call Harzalah. As an EMT, your role is to provide care without judgment. Anecdotes don’t equal data—planned, low-risk home births with qualified midwives have low absolute risk. Respectful, timely response and good integration save lives; stigma and hostility delay care and make outcomes worse.
Pearl
With respect, this overstates the data. ACOG cites ~1–2 per 1,000 vs ~0.5 per 1,000—higher, but still very low absolute risk. U.S. studies often don’t separate planned vs unplanned births or account for provider type, and reflect poor integration. In systems with low-risk selection, CNMs, and seamless transfer, outcomes are comparable with fewer interventions.
Rdz
The reason some people don’t call hatzalah are due to fear mongers that scare them. We should listen the Rebbe who said many times to ask a rofe ya did. I understand that to be your own personal doctor. Not the person that will tell me what I want to hear.
Pearl does not like that the date does support her narrative. She wants to spin things.
Listen to the Rebbe
Rdz
Typo. Data does not support pearl at all. I forgot the word not
Pearl
First learn English. Reading your incoherent comment is enough suffering, let alone to merit a proper reply. Your points are self contradictory and make no sense.
Concerned
What is considered low risk?
Many people don’t understand what is considered low risk.
Nulliparous (first babies) according to data is actually high risk due to being an untried pelvis.
Some people think I’ve had ten easy labor this one will be a breeze. Each baby increases the risk of hemorrhage as the uterus get stretched out and has a harder time contracting after birth.
Pearl
Low-risk has a clear medical definition—healthy mother, term, singleton, head-down, no major conditions. First-time moms aren’t “high risk,” just slightly higher intervention/transfer rates, which is why screening and planning matter. And yes, risk isn’t zero—but that’s true in hospitals too. The question is proper selection and management, not pretending only one setting has risk.
America vs europe
The home birth practice in america is completely separate from the medical community in america. This leaves no oversight on which pts they deem low risk. In Europe there is incredible oversight and therefore home birth is safe there. It is not the same in america at this time.
Pearl
Thank you. This is exactly the problem. If the “medical community” in the USA would cooperate like in Europe, instead of constantly trying to detail, outcomes would be better.
That is, if they’d really care about saving lives Vs. ulterior motives.
It’s very simple, in countries where they cooperate and are integrated, outcomes are fairly similar. Yes, the DATA says so!
Pearl
Typo: deRail, (not deTail).
Financial incentive
There is also a financial incentive . As per my midwife friend, home birth midwives can walk away w 20k after a birth. Bc they bill as the hospital, baby nurse, etc… as opposed to the MD practice who usually gets paid 2-4 k / birth which covers all your visits as well.
So it is not in a midwives best interest to turn down pts and I repeat there is no oversight.
Pearl
So you want to go down that lane? Not a great idea.
People in glass houses…
Go back to simpler time
Many people saying having homeboy goes back to simpler time. In the 1800s mortality for mother at home birth was 1-1.5% for each birth. That means 1/100 women died in childbirth. If someone had ten drliveries her lifetime risk of dying during childbirth was 10%.
Rdz
There is a very scary and dangerous anti medicine/doctor perspective that I feel this is based on. Medicine and doctors are not perfect, but they do the best they can to help people and save lives. Sadly, some people do not trust doctors and feel they know better. You may see a few cases where the non-traditional approach works, but in the long run, with many more people, the doctors are correc
A chosid
One can tell them selves what ever they would like to justify actions (risks!) they take, whoever a home birth is in fact a risk! and anyone who attempts to say otherwise is either outright lying or delusional…..
Pearl
Everything you do in life has risks, nothing is risk free. You take many risks on a daily basis that are much riskier than a planned low risk home birth with a reputable CNM. But TBH I detect from your tone that there’s nobody home to rationalize with so “anyone who attempts to say otherwise is either outright lying or delusional…..”