By John C. Hobbins, MD
Professor, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora
Dr. Hobbins reports no financial relationships relevant to this field of study.
SYNOPSIS: A new study of neonatal death rates over a four-year period in the United States has identified two new contraindications to home birth.
SOURCE: Grunebaum A, McCullough LB, Sapra KJ, et al. Planned home births: The need for additional contraindications. Am J Obstet Gynecol 2017;216:401.e1-401.e8.
Home birth has stimulated sometimes heated debate. Some consumers, citing a tendency for hospital-based deliveries to be associated with unnecessary interventions, coupled with their perceived inability to exercise autonomy, continue to deliver at home. However, some studies have shown an increase in neonatal death rates (NDR), low Apgar scores, and neonatal seizures with home birth. The American College of Obstetricians and Gynecologists (ACOG) even cited three absolute contraindications to proposed home birth: fetal malpresentation, multiple gestation, and a previous cesarean delivery.1
Using U.S. birth statistics from a study population of 12,953,671 deliveries between the years 2000 and 2013, Grunebaum et al searched for additional factors that might represent a higher risk of adverse outcomes. They excluded anomalous fetuses and multiple gestations and compared NDR in three groups: hospital births attended by certified nurse midwives (CNMs), hospital births attended by physicians, and planned home births. The investigators were interested in a variety of independent variables, which included parity, maternal age, and gestational age at delivery (< 37 weeks and > 40 weeks).
The NDR was significantly higher in home deliveries (12.1 per 10,000) vs. in-hospital deliveries by CNMs (3.08 per 10,000) and physician-attended deliveries (4.09 per 10,000). The highest home birth NDRs per 10,000 deliveries were in breech presentations (121.5 per 10,000) along with the other ACOG high-risk category of previous cesarean delivery (18.9). The investigators found two new categories also were associated with increased risk: primiparity (22.5) and post-term pregnancy (17.1). The authors concluded that these categories should be added to the list of contraindications to home birth.
COMMENTARY
Home births are quite common in some countries, such as the Netherlands, where they comprise 30% of all births, and have gained some momentum recently in the United States, rising from 0.79% in 2004 to 1.28% in 2012,2 with the highest rate occurring in Oregon (2.4%). A 2013 study using a one-year sampling of birth statistics in Oregon compared 75,923 in-hospital deliveries with 3,203 planned out-of-hospital deliveries (2,000 of which were at home) and found higher PDRs in the latter category (3.9 per 1,000) vs. 1.8 per 1,000 in the hospital.3 Not surprisingly, the cesarean delivery rate was substantially higher in the planned hospital deliveries (24.7%) vs. planned out-of-hospital births (5.3%). Interestingly, unlike the data above from deliveries across the United States, the NDRs in this study were not significantly different between groups.
The featured study highlighted two new variables of risk. Post-term pregnancy should not be a surprise, since these infants are more likely to need immediate neonatal expertise. However, the category of first-time pregnancies represents an interesting dilemma, since 40% of all deliveries in the United States are contributed by these patients. Theoretically, this contraindication alone would halve the home birth rate in the United States if it influenced all first-time patients to opt out. However, we have found that many women are so strongly committed to avoiding a cesarean delivery and/or fear a loss of autonomy in an institutional setting that they are willing to accept this increased risk.
We all have been asked the common question, “What would you do, doctor, if I were your family member?” In most cases, after providing the best objective risk/benefit information available, I often will roll out a stock phrase about why we avoid injecting our biases into their very personal decision-making. However, regarding home birth, my answer would have a more subjective spin if any of the above risk factors are put in play.
REFERENCES
- American College of Obstetricians and Gynecologists’ Committee Opinion No. 669: Planned Home Birth. Obstet Gynecol 2016;128: e26-31.
- Centers for Disease Control and Prevention. National Center for Health Statistics. Birth Data. Available at: https://www.cdc.gov/nchs/nvss/births.htm. Accessed April 26, 2017.
- Snowden JM, Caughey AB, Cheng YW. Planned out-of-hospital births and birth outcomes. N Engl J Med 2016;374:2190-2191.
A new study of neonatal death rates over a four-year period in the United States has identified two new contraindications to home birth.
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