#MidwiferyDataMatters: Examining the rise in out-of-hospital birth during the COVID-19 pandemic

The increase in demand for home births during the COVID-19 pandemic has been reported anecdotally, but is this trend evident in the available midwifery data? To answer this question, the AOM looked to midwifery data collected through BORN Ontario, the Ontario perinatal database. The data on actual place of birth in Ontario (depicted in Figure 1 below) demonstrates a clear jump in midwife-attended home births from April to July of 2020, peaking at 16.6% in May, followed by a second peak in February 2021 with 15.5% of all midwifery births occurring at home. The dotted line stretching across the graph indicates a slight overall increase in the percentage of home births from April of 2018 to March of 2021.
 

The two home birth peaks in May 2020 and February 2021 mirror a similar pattern of confirmed COVID-19 cases recorded in Ontario, with the first wave of cases peaking in April of 2020 and the second wave peaking in January of 2021 (see Figure 2 below).
 

It is unclear exactly why home births tended to peak one month after the spikes in case counts were recorded. The lag may be due, at least in part, to birthplace planning; clients who are deciding where to give birth during the peak of a pandemic wave, stay-at-home order, increased COVID-19 hospitalizations[ii] and decreased hospital capacity may be inclined to plan for a home birth.

Interestingly, a similar demand for out-of-hospital births was identified in the United States during 2020. Research from MacDorman and colleagues in 2022 shows an increase in community births by 19.5% from 2019 to 2020: planned home births increased by 23.3%, while birth center births increased by 13.2%.[iii] BORN’s month-by-month data in Figure 1 mimics the pattern seen from the United States in Figure 3, with the same peak in out-of-hospital births occurring in May of 2020.
 

This data is an excellent reminder of why #MidwiferyDataMatters, providing an opportunity to visualize trends amongst midwifery clients. Through six waves of the COVID-19 pandemic, midwives have drawn on their clinical skills and judgement to keep birth safe for their clients and themselves in every setting. Midwives continue to apply appropriate risk screening and infection prevention and control principles all the while taking local context, resources, and rapidly evolving circumstances into account, including access to PPE and the capacity/availability of EMS. Maintaining the jump in the home birth rate since 2020 is valuable to demonstrate to midwifery stakeholders and the community at large that midwives continue to offer safe, client-centered and culturally sensitive home birth care while supporting the local health-care infrastructure.

Sustaining the Home Birth Rate

In Ontario, home birth rates have been steadily declining over time from 24.7% (2003-2004) to 11.65% (2019-2020) (see Figure 4). However, the recent increase in home births in 2020-2021 brought rates back up to 14.14%. Birth rates at the Toronto and Ottawa birth centres appeared to have remained stable through 2019 to 2021.
 

It's possible that this recent increase in home birth will be sustained. BORN data has consistently demonstrated that multiparous clients are more likely to give birth at home than those who are giving birth for the first time. Clients who opted for a home birth during the pandemic may now be more likely to attempt a home birth again in a subsequent pregnancy. Indeed, choosing a home birth has several benefits, which have been identified in research with Ontario midwifery clients, including increased client comfort, involvement of family, unmedicated labour and reduced interventions during labour and birth, increased time for skin-to-skin bonding, and increased client involvement in decision-making and communication about care.[iv] Furthermore, more home births create more opportunities for discussion about birthing at home and its many benefits, potentially reducing skepticism in the community and encouraging others to consider this option for their births. [v]

Informed choice and choice of birthplace are fundamental principles of midwifery care. In exploring this choice, midwives aim to develop an understanding of each client’s social circumstances and housing situation, as well as the options and specific resources available locally. To sustain the increase in home birth rates across Ontario, clients should be reassured in the proven safety of home births and should be reminded that midwives are skilled to manage any emergency that may arise. The AOM’s Birthplace Options web portal is a useful interactive resource that allows clients to explore their options, watch engaging videos on firsthand experiences and find answers to frequently asked questions.

Midwives can use the following resources with clients to discuss choice of birthplace:

• Choice of Birthplace Guideline (PDF, 450 KB)

• Choice of Birthplace Pictograms (PDF, 1705 KB)

• Customizable Birthplace Options Chart for MPGs

• Birthplace Options AOM Web Portal

• Home Birth During the COVID-19 Pandemic Guidance (PDF, 612 KB)