Notes on home birth: Safety, interventionism and satisfaction

Background: Home birth is still considered an unusual situation on most developed countries, where it accounts between 0.2 and 25 percent of all births depending of the country. However, the safety of the process and whether it should be offered as a choice makes it a controversial topic with strong opinions on both sides. This review aims to describe the situation of home birth in several developed countries and debate its safety and mothers’ satisfaction, by reviewing studies that compare home vs. hospital births. Methods: A systematic research has been done using different search engines to nd publications that portray the current situation on this topic. Protocols and historical facts were selected using no lters, while publications reporting maternal and birth outcomes, as well as levels of satisfaction, were selected using lters that limited the search to articles that had been published in the last 10 years. A total of 45 articles were selected and reviewed. Results: Home birth in each country depends on many factors, including historical and cultural. Some countries have either developed good practice guidelines or included home birth on the already existing ones, while some other countries still do not recognize it as a safe option. While most studies do not show signicant differences on neonatal mortality APGAR score and intensive care admissions, they do describe slightly better maternal outcomes on home birth due to lower interventionism. Studies also show that between 13 and 29 percent of home births require transferring the woman or the fetus to the hospital. Satisfaction levels also appear to be higher in women who had a planned home birth. Conclusions: Home birth appears to be a safe choice for women with low risk pregnancies, due to a lower rate of interventionism. However, safety depends on many factors, from professional accreditation, to the presence of protocols and good practice guidelines. Satisfaction also appears to be higher on women who had a planned home birth, although it depends on personal considerations and circumstances.


Introduction
Almost since the beginning of the medical practice the patient has always played a secondary role in the decision-making process. However, this tendency is slowly changing due to the democratization of knowledge, mainly in uenced by the fast development of IT, freedom of speech and the achievement of basic rights on the second half of the XX century.
This tendency is even more evident in the eld of obstetrics, where women are demanding more than ever their right to take a part on deciding any affairs that have to do with their bodies.
Looking at this context it should not come as a surprise that women are demanding more control over pregnancy care and delivery. Today more than ever, a large number of women ask for a non-medicalized delivery at the hospital, and there is a raising amount of them that go further and demand a home birth, usually under the care of midwives. This tendency differs from one country to another, and even between regions of the same country.
It cannot be forgotten that although woman rights should never be ignored, on the medical practice this is an extremely political matter, and that controversial terms such as obstetric violence (1) have been established within the last twenty years pushed, amongst others, by political agendas. This review has several objectives. The rst objective is to review the situation of home birth in developed countries, specially focusing on those countries that have developed protocols including midwifery care and home birth within their health policies. Additionally, the social and historical context in which home birth is perceived depending on the country will also be reviewed. Outcomes data of both the newborn and the mother will also be reviewed to determine the safety of home birth and the pro le of women that might be eligible to choose it as an option. Last but not least, the satisfaction of women who gave birth both at home and the hospital will be reviewed.

Methods
The exploration taken in this work has been limited to several developed countries. We mainly chose studies published within the last 10 years, primarily with the purpose of exploring the current situation and therefore avoiding possible biases related to the changes that new technology and outdated guidelines might lead to. However, some older articles have been used, primarily to describe historical or governmental facts.
Additionally, there is literature that addresses the risks, outcomes and satisfaction on women that choose to give birth at childbirth centers and compares it with hospital childbirths. This will not be included, as the focus of this review is home birth compared to hospital for the place of birth. Nevertheless, references to birth centers might be found on some sections of this work, however, articles which main topic were birth centers have been excluded.

Search strategy
When exploring literature, we primarily focused on research studies, reviews, meta-analyses, and opinion papers, by searching electronic databases and reviewing reference lists. Search engines mainly included PubMed, Google Scholar and Cochrane Library. A literature and publications manager such as Mendeley were also utilized.
Due to the structure of this review, literature search has been split into different sections. Literature for each country has been separately searched, following common criteria but also, adapting the search to different country needs. To describe the situation as accurate as possible, protocol research has been limited to Western Europe countries and North America.
The nal list of selected countries has been made after researching a series of historical, cultural and sociological facts of each one of them. We also took into consideration the differences in their health systems and the literature available, with the aim to portrait a vision as wide as possible. This list includes the following countries: The Netherlands, United Kingdom and Spain from Western Europe, and the United States of America and Canada from North America.
For estimating the situation of each country, common search techniques were used. Search terms included "home" + "birth" + "name of the country" and "midwives" + "name of the country" using lters that adapted the search. The key words contained in either the title and/or the abstract. When searching for the United States and United Kingdom the terms "US" and "UK" were added to the search.
The electronic searches in the search engines listed above yielded a number of publications in PubMed and in Google Scholar for the Countries listed (Table 1). After reviewing the titles and the abstracts, a total of 42 publications, which followed the criteria and topic of this review, were selected and reviewed. There have been some exceptions on this search. When searching for Spain there were also included results in Spanish that were published by Spanish governmental institutions such as the Spanish Ministry of Health, the Spanish Statistical Institute and a Spanish professional association of midwifes. When searching for the UK, NICE guidelines were also included in this review.
When searching for the outcome's section, search terms included "home" + "birth" + "outcomes" and "homebirth" + "outcomes" with lters that limited the search for results that included the keywords in either the title and/or the abstract. In this case the search was extended to other developed countries outside of Europe and North America. This search yielded 53 results in PubMed, 49 results in Google Scholar and 56 results in Cochrane library. Search techniques for this section also included the terms "home" + "birth" or "homebirth" ltered to include these keywords in the title, throwing 450 results in PubMed and 598 results in Google Scholar. After reviewing the titles and the abstracts of these publications, 16 publications followed the criteria and were selected ( Table 2). When browsing for the satisfaction section, search terms included "home" + "birth" + "satisfaction" and "homebirth" + "satisfaction" with lters that also limited the search for results that include the keywords in either the title and/or the abstract. This search yielded 107 results in PubMed and 1 result in Google Scholar. After reviewing the titles and the abstracts, 9 publications followed the criteria and were selected ( Table 2). Together with the publications selected on Table 1, a total of 67 publications were selected and fully reviewed, and 45 of them have been referenced.

North America
United States of America Planned home birth in the United States (US), as it is in most of other developed countries, can be considered a rst-class health care. It is an expensive service and is almost never covered by any public funds, and as stated by The New York Times in 2012, it is becoming some sort of a "status symbol" (2). This is especially evident in the US if it is compared to other countries such as Canada or the Netherlands, where there is a public health care system that covers home birth expenses. In the US there is a high number of uninsured individuals and hence models that are observed in other countries cannot be assumed.
Although in the US the rate of home births rose 41% between the years 2004 to 2010 (3), it is still relatively low compared to other countries. According to a 2015 publication where national data between 2010 and 2012 was reviewed, home births only accounted for 0,71% of all births in the US (4)(5). However, the percentage of home births was signi cantly different among counties. Rural counties had a 74% higher home birth rate compared to non-rural counties (6). This fact is easily explained by logistical and infrastructural reasons, since over 80% of rural counties have no hospital providing obstetric services and 50% of rural counties have no actively practicing obstetricians. Also, rural women face higher challenges if they decide to choose a hospital to give birth, since less than 50% of rural US women live within a 30 minute ride to the nearest hospital offering obstetric services (6).
There is also a perception not only in the medical community, but also within the general public, that home birth is signi cantly riskier than a hospital based birth (5). And although there are many studies that show otherwise (4)(5)(6) it is true that in the hypothetical case that complications appear, the transferal to a hospital is challenging (5).
The US system also shows some problematics due to the particularly tense relationship between medical practitioners and midwives who work in home births (7). Obstetricians are trained medical doctors (MDs) and have the skills to provide care to both low and high-risk pregnancies.
US midwives, on the other hand, can be either Certi ed Nurse Midwives (CNMs), Certi ed Midwives (CMs), Certi ed Professional Midwives (CPMs) and lay midwives (5). The technical differences between them are essentially educational (8). CNMs and CMs have a Graduate Degree and are certi ed by the American College of Nurse Midwives (AMCB), whereas CPMs are only required to have a High School diploma or equivalent and are not certi ed by the AMCB, however they have to meet the standards of the North American Registry of Midwives (8). The factual difference between them is that CNMs and CMs can attend both hospital and home births whereas CPMs and lay midwives usually attend exclusively at extrahospitality settings. Nowadays only 10% of all births are attended by midwives (5) and that might be also explained by the absence of protocols or evidence-based guidelines that are meant to set standards in order to offer a safer, higher quality practice.
All of the above helps to explain why most births in the US nowadays take place in hospitals and rely on obstetricians rather than midwives.

Canada
Contrary to what happened in many other countries like the Netherlands, midwives were not allowed to practice in Canada until 1993 (9,10). Therefore, births took place in the hospital and the primary care provider during pregnancy and post-partum care was the doctor, either a primary care doctor or an obstetrician.
Since then, registered midwives have increased their presence in eight out of ten provinces and one out of three territories. However, the number of active midwives is still small, accounting a total of 943 midwives in 2010 for the whole country, and they attend around 5% to 10% of all births, depending on the region (11).
Currently, pregnant women in Canada can choose who will be their primary care provider during pregnancy.
They can, hence, choose between a primary care doctor, an obstetrician or a midwife (9). Historically, obstetricians usually only provided consulting services and would deliver at the hospital, and although this last fact has not changed, they do now provide primary care and follow up services, all of them integrated, however, at the hospital. Midwives on the other hand, are usually more versatile since they provide their services either at home, birth centers or hospitals. In some areas, midwives are actually required to attend a minimum number of cases in each setting to maintain their status (12).
Although birth at home only represents 2% of the total births in Canada (9) it scores up to 30% of midwives attending births, depending on the region (11,12). Whereas it is still a small movement, general practitioners and obstetricians still have a negative perception of this practice (9).
Europe Spain Planned home birth in Spain is considered to be a choice that is taken by a minor group of women. There are very few sources that offer statistics and information about this topic in Spain, however in 2013 a home birth association published that around 800 women had chosen a home birth that year. This is the equivalent to 0.2% of all births in Spain (13). This is probably due to the fact that the Spanish National Health Service (SNS) only offers the opportunity to give birth at the hospital (13,14). Consequently, the SNS does not offer any alternative to those women who do not want to give birth at the hospital. Even so, in the public recommendations that the SNS has published it is stated that birth at home does not have enough evidence to be introduced in such guidelines (17). Overall, the primary care and labor assistance offered by the SNS is considered to be based on a interventionist-institutionalized model (17).
Women that actually decide to plan a birth at home have to do it with a private midwife and cover all the costs related to the procedure. Nonetheless, Catalonia, a region of Spain, is currently a leader in the home birth tendency. In 2016, according to the National Statistics Institute (NSI) there were 67,909 births in the region (18), and a total number of 373 of them were at home (19), what makes a 0.54% of all births in this region, which doubles the national average. As a result, the o cial college of nurses of Catalonia has developed a guideline to help midwives assist births at home "Guideline of home birth delivery" (13,19) and also determine which women are eligible to have a birth at home, according to the established criteria.

United Kingdom
In 2014 the British National Institute for Health and Care Excellence (NICE) updated their guidelines for "Intrapartum care for healthy women and babies" in which they stated that women with low risk pregnancies should be able to choose freely the place they want to give birth on. More exactly it was speci ed that low risk multiparous women had no additional risk and therefore should be free to choose the birth setting. Meanwhile low risk nulliparous women should acknowledge that if a home birth is chosen, there is a small increase in the risk of an adverse outcome for the baby (20).
This happened following a series of health policies adopted in the late 2000's that focused on prioritizing the right of the mother to choose over the birth setting if, once ensured the safety, it is more comfortable and satisfying for the woman (21). Not only the government but the Royal College of Obstetricians and Gynecologists (RCOG) along with the Royal College of Midwives (RCM) stated in 2007 that they institutionally supported home birth for low risk pregnancies (21).
Currently in the United Kingdom, women with low risk pregnancies are offered to choose between four different settings to give birth: A obstetric unit; a midwifery unit that is commonly located also in the hospital or health center next to the obstetric unit; a freestanding midwifery unit, located afar from the obstetric unit; or at home, with the services of a midwife (22).
In terms of popularity, the number of women that chose to have a birth at home varies signi cantly from one region to another. The average home birth rate form England and Wales was the 2.5% of all births.
Regional ranges varied widely: from only 1.2% in the North East of England, to 3.3% in East of England and up to 7.6% in one Welsh region (21). In Northern Ireland, the amount reported was of only the 0.3%, this is consistent with the rate that can be found in the Republic of Ireland, which is about the 0.2% of maternities (23).
In England the average transfer rate to the closest hospital in a home birth is 20.8%, being up to four times more common in nulliparous women than in multiparous women. The most common problem that requires a transfer is the failure of progress in either the rst or the second stage of birth. However, almost half of the transfers take place after the birth for different reasons that can actually be considered a hazard for either the woman's or the baby's health (22).

The Netherlands
In the Netherlands, in the 1990s, nearly one-third of births used to happen at home (24) however, and although this is a tendency that is slowly declining, a review of the current literature shows that the number is closer to one-fourth of births (25). The Netherlands is a special case because it features a collection of circumstances that make home birth a service offered by the government and included it in the public health system.
On the rst place, Dutch midwives are considered amongst the best educated in the world, and because of that they have an increased level of autonomy compared to their fellows of other western countries. This situation, on top of the historic importance of midwifery in the country has contributed to the development of a system where midwives take care of nearly 50% of births (24).
In the Netherlands there are protocols that regulate and strictly limit the choices of women when it comes to choose the place and method of delivery. Usually when women suspect they are pregnant they consult with their primary care doctor, and in this rst visit, based on Dutch guidelines, they are categorized according to the risk. High risk pregnancies are referred to the gynecologist, who will be in charge of both the pregnancy follow up and the intrapartum care. Medium risk pregnancies must go to the hospital for the delivery, but they can be supervised by an experienced community midwife. Finally, women with low risk pregnancies can actually decide whether they want to deliver at home or at the closest hospital or health center, where the pregnancy would be managed by a community midwife (26).
There are several other factors that contributed to the development of this system. Aside from the midwives' care quality and autonomy, the Netherlands' topography and infrastructural features allow a fast and e cient transfer of the woman if any complications are encountered (24).
Although the Netherlands have one of the highest perinatal mortality rates in Europe, it has been shown that it is not directly linked to home birth (27).
Most publications give results that stay in an equivalent range, although when studying neonatal and perinatal mortality, the balance is tilted to favor home birth or hospital birth depending on the country. As it is shown in Table 3, most publications described a slightly increased neonatal mortality rate in planned home births compared to planned hospital births, however the results are usually not considered to be statistically relevant, except for Grünebaum et al (8) who evidenced a signi cantly lower rate of neonatal mortality in births at the hospital compared to home births when both are managed by a CNM. This article also describes that having a home birth that is attended by an uncerti ed midwife notably increases the rate of neonatal mortality. Only one publication compared not only planned home births against planned hospital births but it also included categories for women according to the risk of the delivery (29). For low risk women the results do not really vary much from what is exposed above, but for high risk women the results con rm that planned hospital births offer a superior safety since high risk women having a planned home birth had a 7.16% more risk to present neonatal death.
De Jonge et al (34) described in a Dutch nationwide cohort study that the differences in intra-partum and neonatal mortality between a planned home birth and a planned hospital birth were not relevant, even comparing the groups of nulliparous and multiparous women. When analyzing the APGAR score at 5 minutes, only De Jonge et al (34) described differences between planned home birth and planned hospital birth, especially notable in the nulliparous women group (the percent of low APGAR scores was 7.92% home vs. 18.85% hospital). In this study, multiparous women also showed an inferior rate of low APGAR scores at 5 minutes when having birth at home, but the difference is not as notable (3.2% home vs. 4.57 hospital).
The rest of studies that used this variable (28,29,35,37) did not show any clear superiority in either groups, only M. Davies-Tuck et al. described an slightly inferior rate of births that scored an Apgar <7 at ve minutes in the high risk women that gave birth at an hospital facility (2.4% home vs. 1.8% hospital).
common at the hospital in both groups (1.5% home vs. 5.8% hospital in low risk women and 3.2% home vs. 6.6% hospital for high risk women).
Overall if we resort to a Cochrane Library meta-analysis published in 2013 (38) it con rms what is described above, that there is no strong evidence to favor either planned hospital or planned home births on low-risk pregnancies.

Maternal outcomes
Similar to what happened with neonatal outcomes, in the study of maternal outcomes a wide setting of variables is available to measure and describe the morbidity of the birth process. However, there are certain factors that are more common than others. Postpartum hemorrhage (PPH) is probably the most common variable used by publications (28,29,31,32,35,37), followed by the rate of instrumental birth in both women who gave birth at home and women who planned a hospital birth (28,30,31,33,35), the caesarean section (C/S) rate (28,30,31,37), the health of the perineum after birth (28)(29)(30)32), and the episiotomy rate (30,31,35).
When studying the interventional rate three main variables are used: C/S rate, the instrumental birth rate and the episiotomy rate. Overall, as most publications describe, and as R. Zielinsky et al. already stated in a similar but older study (39), women who have a planned home birth are less likely to experience interventions such as operative vaginal delivery and induction of labor. Most studies show a signi cant difference when comparing the two groups. P. Janssen et al. showed that this difference is not only signi cant between low risk women who plan a birth at home compared to those who plan a hospital birth with a midwife (3% vs. 7.2% of interventions), but also between women who had a planned hospital birth attended by a midwife or a physician (7.2% vs. 13.8%). Homer et al. (30) also described signi cant differences in this topic between women who had a planned home birth and those who had a planned hospital birth (4% vs. 15.5%). However, in this case, it is not explicitly stated that all women in the sample were classi ed as low risk pregnancies. In the Netherlands, Van der Kooy et al. (33) reported more subtle differences in interventional rates: 10.9% in planned home birth vs. 13.7% in planned hospital birth. This is somehow predictable, since home birth in the Netherlands is highly protocolled and midwives are very well trained. Blix et al. (35) stated in 2012 that these differences should mainly come from women who were having their rst baby since the rate of interventional births is of a 5.7% for home births and a 14.8% for hospital ones. However, when comparing multiparous women, the rates were not only lower, but also closer: 0.6% for home births and 1.8% for hospital births.
This should not be a surprise, since women who have a planned home birth not only should be classi ed with a lower risk than those who plan a hospital birth, but also most of these interventions are not eligible to be performed at home. Only studies performed in the Netherlands, where midwives are highly trained the results obtained were similar.
Across all studies reviewed, women intending to have a birth at home are less likely to have other obstetric interventions such as C/S or episiotomy performed on them. This is somehow, something to be expected since women who choose to give birth at home not only should be considered low risk, but also most obstetric interventions require an operation room and quali ed professionals to be performed. When studying the C/S rate between these two groups only Hiraizumi et al. (37) described similar rates in a study performed in Japan: 2.4% for home birth and 2.5% for hospital birth. All other studies show important differences between the two groups. P. Janssen et al. (28) described a difference (7.2% C/S rate at home vs. 10.5% at the hospital) lower than Homer et al. (30) (3.3% C/S rate at home vs. 10.6% at the hospital). Similar outcomes are observed when studying the episiotomy rate: Homer et al. (30) presented major differences between the two groups in Australia. Only 3.9% of women who had a planned home birth had episiotomy performed, against 18.7% of women who planned a hospital birth. Similar results were described by Catling-Paull et al. (31) whereby only a 2.6% of a single group of women who gave birth at home had an episiotomy performed. Blix et al. (35) also showed that multiparous women are less likely to have a episiotomy performed despite the place they choose to give birth on. The episiotomy rate in rst time mothers was lower at home compared to the hospital (13.3% vs. 16.7%), but generally much higher than multiparous women (1.7% at home vs. 3.7% at the hospital).
The morbidity of the process can be described using many variables and typical complications. However, because of their severity, PPH, and perineal laceration are usually the most commonly used to evidence the morbidity of eutectic deliveries.
In a similar way as women who had a home birth are less likely to have an instrumental birth, this group is less likely to develop complications as PPH as well. Many studies con rm this difference, showing substantial difference between groups. P. Janssen et al (28) published in 2009 that women who had their midwife-attended birth at home had almost 50% probability to lower the risk of developing PPH (3.8% home birth vs. 6% hospital midwife attended). Yaeko Katakoa et al. (32) described an important difference between groups as well. Despite both groups presenting high PPH rates, women who gave birth at a birth center with a midwife has a higher risk (17.6% home birth vs. 27.2% birth center). Other studies such as the one published by Hiraizumi et al. (37) presented a more balanced rate, where the difference was not as substantial (5.7% home birth vs. 6% hospital birth). M. Davies-Tuck et al. (29) described in a recent study that even women classi ed as high risk presented a lower rate of PPH at home (14.5% home birth vs. 19.6% hospital) despite requiring higher necessities of blood transfusion. PPH rates were also lower in multiparous women despite the place where the procedure took part (35).
Studies also indicate that women who plan their birth at home are less likely to end up with any type of perineal issues. P. Janssen et al (28) described that the group who planned their birth at home had a slight higher rate of intact perineum (54.4% home birth vs. 46.1% hospital birth). Following this idea M. Davies-Tuck et al (29) showed that although infrequent, women who had their birth at home had a lower rate of In addition, M. Davies-Tuck et al (29) described a series of maternal outcomes that are not mentioned in the rest of the articles that have been used to write this work. Similar to what happens with the morbidity variables described above, women who give birth at home are also less likely to be transferred to the Intensive Care Unit (0.2% of women who gave birth at home vs. 0.6% at the hospital) and to have their placentas removed manually (0.9% of women giving birth at home vs. 2.5% at the hospital).

Transferal rates
Another way to measure maternal outcomes in a more general way is studying the percentage of women that needed to be transferred to the hospital during a birth at home. Homer et al (30), Catling-Paull et al (31) and Hiraizumi et al (37) give simpli ed transferal rates: 29%, 17% and 21% respectively.
However an international prospective study was performed to 3068 women in Norway, Sweden, Denmark and Iceland by Blix et al (40)

Women's motivations and satisfaction
In western countries like Spain, medical access is relatively easy. However, as it has been stated before, a small group of women make the choice to take a step outside the system and give birth at home. This study could not reach de nitive conclusions without detailing the motivations of these women and their satisfaction with the whole process. Across the publications that were selected to formulate this work, three main topics were found consistently in almost all of them: Control and autonomy (41)(42)(43), relationship with the medical system, and perception of safety at home.
After researching for women's motivations, it becomes clear that the fear of losing autonomy if choosing a hospital setting is present in a large proportion of these women. Autonomy can be understood as a physical feature, but in this case also means the ability to make decisions about the process. B. Murray et al (42) proved that up to an 85.9% of their sample wanted to be able to move freely during labor. And over 90% of the women agreed that they wanted to be able to eat and drink during labor and be able to take part in the decision-making process.
Women's relations with the hospital environment are considered to be an important factor of the choice as well for both groups. Women who decide to have a home birth usually have the perception that home might be safer than the hospital. As B. Murray et al (42) described in their paper, this is related to the fact that 79.5% of women that decided to give birth at home wanted to avoid interventions. H. Lindgren et al (43) and M. Hollander et al (41) also expressed that some of these women believed that medical interventions are based on fear, and therefore unnecessary, since giving birth is a natural process.
On the other hand, 64% of women that decided to give birth at the hospital wanted to get an epidural, so interventionism can also be a decisive factor for women to lean towards the decision of giving birth at the hospital.
The perception of safety depending of the environment can also be considered as a determinant factor to women. B. Murray et al (42) also described that 96.1% of women who chose to give birth at home believed that home was a safer environment. This is signi cant, because it comes from a group that also scored high when they were asked about the importance of having the power to control surroundings. 45.5% of these women also stated that they had the feeling that recovery would be easier if they stayed at home.
However, the cohort of women that decided to have a hospital birth stated very different opinions towards the home environment. 78.7% of these women felt safer at the hospital, but other reasons were considered. For example, 60% wanted to avoid the "mess" of a home birth, and 53% of them found the idea of giving birth at home stressful.
When it comes to the actual satisfaction of the process it becomes clear that it relies not only on the chosen setting, but also in the expectations that the women may have developed towards the process. However, S. Fleming et al (44) did nd that satisfaction was higher for women who had both planned to deliver in a home or a birth center, and who had actually delivered in a home or a birth center. These ndings were assessed using both the Birth satisfaction scale (BSS) and a shorter version on it, the Birth satisfaction scale revised (BSS-R). No differences in satisfaction were found between giving birth at home or at a birth center, since both settings had a similar score (133 points in BSS and 33 in BSS-R) for home birth and (104 in BSS and 24 in BSS-R) for hospital birth with a wider standard deviation.
As we have stated before, expectations play an important role on the overall satisfaction, since women who planned to give birth at home or a birth center but ended up in the hospital tended to score lower on satisfaction tests (44). Studies developed in Belgium and Sweden also showed that women who needed to be transferred to a hospital tended to describe negatively the overall experience and emotional aspects of it (45).

Discussion
While some studies suggest that planned home birth is associated with a small increase in neonatal death rates (BB) and adverse neonatal outcomes, the results were not conclusive. Moreover, literature also describes that planned home birth is associated with a lower rate of adverse maternal outcomes and a lower rate of interventionism. Satisfaction is also higher in women who planned a home birth. However, some of these results have to be put into perspective. This is because although evidence leans towards the superiority of home birth when maternal outcomes and satisfaction are considered, there might be certain factors conditioning these results.
First, women who decide to give birth at home are fully executing the autonomy principle stepping outside the system, therefore only this very act, if it is consonant with the values and ethics of the patient, is considered a small victory by the patient. This is also related to the expectations that the mother might have about the act of giving birth, the relationship of the mother with the health care system, and the fact that the patient is in charge of the surroundings. Because of all of these statements, and because satisfaction is a highly subjective matter to review and analyze, results should be carefully interpreted. Despite good home birth's satisfaction results, it has been proven that the overall satisfaction of women who plan to give birth at the hospital is more than satisfactory.
Lower rates of interventionism and adverse maternal outcomes are also to be expected on women who plan a home birth, since most interventions require an operation room and the intervention of quali ed physicians. In addition, it has been evidenced that the overall safety of planned home births depends on many factors, including the quali cation and experience of the responsible midwife. However, carefully determining the eligibility for planning a home birth is considered the most important safety factor for both the woman and the fetus. Most publications agree with the fact that home births can only be a safe choice if the woman's pregnancy is classi ed as low risk and preferably if she is multiparous. This seems to limit the option of planning a home birth to a very speci c type of women.
Moreover, this is a complex subject since this topic is surrounded by a high dose of debate and controversy, with strong opinions on both sides. It has even trespassed the purely scienti c barriers, becoming an issue that has been discussed on mainstream media, with arguments linking it with a deeper discussion of patient's rights and women's rights. On the other side there are health care providers warning of the dangers of home birth if the patient is not eligible for the service or a careless choice is made. These differences frame the debate of home birth within the context of what should prevail as a primary focus: the principle of autonomy of the mother or the principle of fetus's bene t.
This social discussion has led to some countries like the UK to include the option of home birth in their national guidelines. In other countries like the Netherlands, guidelines were not modi ed to include home birth, since social and cultural heritage had made a standard out of it. While criteria to classify a pregnancy as low risk may differ from one country to another, most publications agree with the fact that including it on national guidelines acts as a security enhancer of the process. Countries like Spain have not recognized home birth as an option on its national guidelines, although one midwife's association has published its own (19).

Conclusions
Although studies con rm that home birth might be a safe choice to both women and the fetus, it is vital to individualize each case to evaluate their eligibility. It is fundamental to keep in mind that only women with low risk pregnancies should be offered this option and that a close follow up is mandatory in order to reevaluate the case days prior to the due delivery date. Safety depends on many factors, the preparation and experience of the midwife is fundamental, that is why only certi ed midwifes should attend these childbirths. Further studies should be done about cost-effectiveness of the procedure and further debates should be implemented about whether or not it should be publicly funded. Home birth rates on selected regions of Spain and the UK.