Objective
More women are planning home birth in the United States, although safety remains unclear. We examined outcomes that were associated with planned home compared with hospital births.
Study Design
We conducted a retrospective cohort study of term singleton live births in 2008 in the United States. Deliveries were categorized by location: hospitals or intended home births. Neonatal outcomes were compared with the use of the χ2 test and multivariable logistic regression.
Results
There were 2,081,753 births that met the study criteria. Of these, 12,039 births (0.58%) were planned home births. More planned home births had 5-minute Apgar score <4 (0.37%) compared with hospital births (0.24%; adjusted odds ratio, 1.87; 95% confidence interval, 1.36–2.58) and neonatal seizure (0.06% vs 0.02%, respectively; adjusted odds ratio, 3.08; 95% confidence interval, 1.44–6.58). Women with planned home birth had fewer interventions, including operative vaginal delivery and labor induction/augmentation.
Conclusion
Planned home births were associated with increased neonatal complications but fewer obstetric interventions. The trade-off between maternal preferences and neonatal outcomes should be weighed thoughtfully.
Key words
The American Congress of Obstetricians and Gynecologists (ACOG) issued a Committee Opinion by the Committee on Obstetric Practice in 2011 that stated that “hospitals and birthing centers are the safest setting for birth, but it respects the right of a woman to make a medically informed decision about delivery.”
1
Most recently in 2013, the American Academy of Pediatrics (AAP) concurred with the ACOG and stated that “pediatricians should advise parents who are planning a home birth that AAP and ACOG recommend only midwives who are certified by the American Midwifery Certification Board.”1
, 2
The American College of Nurse-Midwives (ACNM) also maintains that “every family has a right to experience child birth in an environment where human dignity, self-determination, and the family's cultural context are respected and that every woman has a right to an informed choice regarding place of birth and access to safe home birth services.”3
, 4
Although informed decision-making necessitates accurate assessment of risks and benefits, to date few studies have examined perinatal outcomes of home birth in the United States. The safety of home birth specifically in the United States remains debatable.American College of Nurse-Midwives, Division of Standards and Practice. Position statement: home birth. Approved by the ACNM Board of Directors: May 2011. Available at: http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000251/Home%20Birth%20Aug%202011.pdf. Accessed Jan. 25, 2012.
Common challenges in the study of the relative risks/benefit of planned home birth include small sample sizes, the rare nature of severe maternal and neonatal morbidity/death, ascertainment that relies on self-reporting or voluntary submission, variable definitions that are used to quantify and qualify morbidity, and accuracy in discerning planned home vs hospital births.
1
To date, randomized controlled trials have not been conducted to examine planned home birth. Among the many barriers to the conduct of such a study is that women likely would be reluctant to be assigned randomly to home vs hospital deliveries.1
, 3
The current literature on the safety of home birth consists of large population-based studies mostly from outside the United States. Although some studies report no difference in perinatal outcomes in women who had planned home births compared with those who had hospital births,
5
, 6
, 7
, 8
other studies demonstrate worse neonatal outcomes in planned home birth, even in systems in which this birth option is integrated fully into the medical care system in countries such as Australia, The Netherlands, and the United Kingdom.9
, 10
, 11
A recent metaanalysis of 12 studies from North America, Australia, and Europe compared planned home births to planned hospital births and found that planned home birth was associated with fewer obstetric interventions, such as electronic fetal heart rate monitoring in labor, epidural anesthesia for pain control, and operative deliveries (including assisted vaginal deliveries with forceps or vacuums, and cesarean delivery). However, planned home birth was also associated with a 2- to 3-fold increase in the odds of neonatal death.12
Literature on the safety of planned home birth in the United States is also mixed, and controversy regarding the validity of these studies exists because of questions about data sources and analyses.
13
For example, analyses that used Washington state birth certificate data and Missouri vital records independently found that home birth is associated with a 2- to 10-fold increase in the risk of fetal/neonatal death, an Apgar score ≤3 at 5 minutes, and neonatal seizure.14
, 15
One study that examined birth certificate data from US births in 2006 also reported neonates who were delivered at home were more likely to have an Apgar score of <7 at 5 minutes16
; other studies report similar neonatal outcomes among planned home births that were attended by certified nurse-midwives and certified professional midwives compared with low-risk hospital births.17
, 18
Although the safety of planned home birth in the United States remains controversial, the proportion of women who choose to deliver outside of hospitals increased by 29% between 2004 and 2009, and this rising trend appears to be continuing.
19
In 2009, approximately 1 in 90 births to non-Hispanic white women occurred at home.20
In light of the unclear data and the increasing frequency of home births, our study objective was to compare neonatal outcomes in women who had a planned home birth with outcomes in women whose births occurred in hospitals.MacDorman MF, Mathews TJ, Declercq E. Home births in the United States, 1990-2009. NCHS Data Brief no 84. January 2012. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/nchs/data/databriefs/db84.htm. Accessed Feb. 2, 2012 .
Materials and Methods
This is a retrospective cohort study of low-risk women at term with singleton vertex live births who were delivered in 2008 in the United States with data from the Vital Statistics Natality Data provided by the Centers for Disease Control and Prevention. The 2008 birth data were compiled with the use of either the 2003 revision or the 1989 revision of the US Standard Certificate of Live Birth. The 2003 revision delineates the location of birth as hospital, freestanding birthing center, or home and is further specified as accidental, intended, or unknown if intended. We included only births in the 27 states that used the 2003 revision of the birth certificate. These states represent 65% of all 2008 US births and include California, Colorado, Delaware, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Michigan, Montana, Nebraska, New Hampshire, New Mexico, New York, North Dakota, Ohio, Oregon, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Vermont, Washington, and Wyoming.
21
Center for Disease Control and Prevention. User guide to the 2008 natality public use file. Available at: http://www.cdc.gov/nchs/nvss.htm. Accessed July 10, 2010.
We compared outcomes of neonates whose mothers had planned home births to those who delivered in hospitals. We did not have information to differentiate different types of hospitals (such as academic, community, or military). We included term, singleton, vertex live births. We also included women with previous cesarean delivery in the analysis because some women chose to have home vaginal birth after previous cesarean delivery in the United States and increasingly so; home vaginal birth after previous cesarean delivery increased from 1% in 1996 to 4% in 2008.
22
Exclusion criteria were breech deliveries, multifetal gestations, deliveries at <37 weeks of gestational age or at ≥43 weeks' gestational age. We also excluded women who delivered in freestanding birthing centers, those who did not intend to deliver at home but did (ie, accidental home births), and home deliveries for which planned birth location was unclear. For this study, gestational age was based on the obstetric/clinical dating because studies have shown that such estimates provide the best approximation for dates.23
, 24
Institutional Review Board approval was obtained from the Committee on Human Research at the University of California, San Francisco, and the institutional review board at Oregon Health & Science University.We examined the risk of a 5-minute Apgar score <4 as a primary outcome,because an Apgar score of 0-3 at 5 minutes has been shown to be a valid predictor of neonatal death
25
and is associated with an increased risk of cerebral palsy.26
An Apgar score of 0-3 at >5 minutes is recommended by the ACOG and the AAP as one criterion for the diagnosis of an intrapartum asphyxial insult.27
Other secondary outcomes included 5-minute Apgar score <7, assisted ventilation for >6 hours, neonatal seizure, and admission to a neonatal intensive care unit (NICU). Additionally, we examined the following maternal obstetric interventions: operative vaginal delivery (forceps or vacuum-assisted), induction of labor, augmentation of labor, and maternal antibiotic use in labor. The definition and diagnostic criteria for outcomes in the birth data were based on definitions compiled by a committee of federal and state health statistics.28
, National Center for Health Statistics. Guide to completing the facility worksheets for the Certificate of Live Birth and Report of Fetal Death (2003 revision). Hyattsville, Maryland: National Center for Health Statistics. Available at: http://www.cdc.gov/nchs/data/dvs/GuidetoCompleteFacilityWks.pdf. Accessed March 30, 2012.
29
We compared the absolute risk (expressed as frequency) of neonatal/obstetric outcomes among planned home births with births that occurred in hospitals. We also performed a stratified analysis to examine perinatal outcomes that were associated with location of birth in nulliparous women separately from multiparous women. Multivariable logistic regression models were used to control for potential confounders, which included parity, maternal age, race/ethnicity (self-reported), educational attainment, marital status, gestational age at delivery, cigarette use during pregnancy, prenatal visits, and medical conditions (prepregnancy hypertension, gestational hypertension and/or preeclampsia, eclampsia, prepregnancy diabetes mellitus, gestational diabetes mellitus). Further, we examined perinatal outcomes that were associated with birth attendants (recorded as Doctor of Medicine, Doctor of Osteopathy, Certified Nurse-Midwife [CNM], other midwife, others, unknown/not stated). Of note, certified professional midwives were categorized as CNMs in the 2003 Revision of Birth Certificate. More specifically, we compared hospital births to planned home births that were attended by CNMs and planned home births attended by other midwives. In this stratification, we excluded home births that were attended by persons other than midwives and those with unknown attendants. Statistical analysis was performed with the use of STATA software (version 11.0; StataCorp, College Station, TX). Statistical significance was indicated using a probability value of < .05 and 95% confidence interval (CI).
Results
In 2008, there were 2,081,753 women who gave birth in the United States and who met the study criteria. Among them, 12,039 women (0.58%) had planned home births, and 2,069,714 women delivered in hospitals. Compared with women who delivered in hospitals, women who had planned home births were more likely to be multiparous, ≥35 years old, non-Hispanic white ethnicity/background, and married (P < .001 for all; Table 1). Women who had planned home births were also more likely to have college and postgraduate education than those who delivered in hospitals (P < .001). Further, women who had planned home births were more likely to have late initiation of prenatal care (≥4 months) compared with women who had hospital births (50.7% vs 26.5%; P < .001). They were also more likely to deliver at a gestational age of >40 weeks (P < .001).
Table 1Study cohort characteristics of US pregnancies in 2008
| Characteristics | Planned home birth, n (%) | Hospital birth, n (%) | P value |
|---|---|---|---|
| Parity | < .001 | ||
| Nulliparous | 2532 (21.0) | 843,602 (40.7) | |
| Multiparous | 9507 (79.0) | 1,226,652 (59.3) | |
| Age, y | < .001 | ||
| ≤19 | 118 (1.0) | 215,676 (10.4) | |
| 20-34 | 9269 (77.0) | 1,572,867 (76.0) | |
| ≥35 | 2652 (22.0) | 281,171 (13.6) | |
| Race/ethnicity | < .001 | ||
| Non-Hispanic white | 11,122 (93.3) | 1,136,536 (54.9) | |
| Non-Hispanic black | 242 (2.0) | 265,428 (12.8) | |
| Latina/Hispanic | 413 (3.4) | 503,643 (24.3) | |
| Asian | 138 (1.2) | 130,423 (6.3) | |
| Other | 124 (1.0) | 33,688 (1.6) | |
| Marital status | < .001 | ||
| Not married | 925 (7.7) | 833,160 (40.3) | |
| Married | 11,114 (92.3) | 1,236,554 (59.7) | |
| Education, y | < .001 | ||
| 0-12 | 5250 (44.2) | 952,453 (48.2) | |
| 13-16 | 5426 (45.7) | 857,046 (43.4) | |
| >16 | 1201 (10.1) | 166,069 (8.4) | |
| Initiation of prenatal care, mo | < .001 | ||
| 1-3 | 5849 (49.3) | 1,452,864 (73.5) | |
| ≥4 | 6028 (50.7) | 522,704 (26.5) | |
| Gestational age at birth, wk | < .001 | ||
| 37 | 526 (4.4) | 198,635 (10.0) | |
| 38 | 1391 (11.7) | 429,287 (21.7) | |
| 39 | 2881 (24.2) | 625,679 (31.7) | |
| 40 | 3887 (32.7) | 455,450 (23.1) | |
| 41 | 2368 (19.9) | 201,904 (10.2) | |
| 42 | 824 (6.9) | 64,613 (3.3) |
Cheng. Planned home births and perinatal outcomes. Am J Obstet Gynecol 2013.
a N = 12,039 births
b N = 2,069,714 births. From: Natality Public Use File, National Center for Health Statistics, Centers for Disease Control and Prevention (2008).
21
Center for Disease Control and Prevention. User guide to the 2008 natality public use file. Available at: http://www.cdc.gov/nchs/nvss.htm. Accessed July 10, 2010.
Infants of women who had planned home births were more likely than infants born in hospitals to have a 5-minute Apgar score of <4 (0.37% vs 0.24%; P = .009), with a nearly 2-fold increase in the adjusted odds of a 5-minute Apgar <4 (adjusted odds ratio [aOR], 1.87; 95% CI, 1.36–2.58; Table 2). Similarly, the odds of having a 5-minute Apgar <7 were higher among those who had planned home births compared with hospital births. Although there was no difference in assisted ventilator support for >6 hours for neonates of planned home births vs hospital births, infants who were born to women who had planned home births were more likely to have a neonatal seizure than infants who were born in a hospital (0.06% vs 0.02%; P < .001). When this association was examined with multivariable logistic regression models to control for confounding, infants of planned home births had a >3-fold increase in the adjusted odds of seizure (aOR, 3.08; 95% CI, 1.44–6.58) compared with infants who were born in a hospital. Conversely, NICU admission was lower among infants who had planned home births (aOR, 0.23; 95% CI, 0.18–0.30) compared with hospital births.
Table 2Neonatal outcomes, planned home births vs hospital births
| Neonatal outcome | Frequency, n (%) | Adjusted OR (95% CI) a Multivariable logistic regression controlled for parity, maternal age, race/ethnicity, education, gestational age at delivery, number of prenatal care visits, cigarette smoking during pregnancy, medical/obstetric conditions; referent comparison group: deliveries that occurred in hospitals. From: National Center for Health Statistics (2008).21 |
|---|---|---|
| 5-minute Apgar score <4 | ||
| Hospital births | 5028 (0.24) | Referent |
| Planned home births | 42 (0.37) | 1.87 (1.36–2.58) |
| 5-minute Apgar score <7 | ||
| Hospital births | 24,145 (1.17) | Referent |
| Planned home births | 278 (2.42) | 2.42 (2.13–2.74) |
| Ventilator support >6 hours | ||
| Hospital births | 5531 (0.27) | Referent |
| Planned home births | 26 (0.22) | 0.97 (0.66–1.44) |
| Neonatal seizures | ||
| Hospital births | 447 (0.02) | Referent |
| Planned home births | 7 (0.06) | 3.08 (1.44–6.58) |
| Neonatal intensive care unit admissions | ||
| Hospital births | 62,218 (3.03) | Referent |
| Planned home births | 68 (0.57) | 0.23 (0.18–0.30) |
CI, confidence interval; OR, odds ratio.
Cheng. Planned home births and perinatal outcomes. Am J Obstet Gynecol 2013.
a Multivariable logistic regression controlled for parity, maternal age, race/ethnicity, education, gestational age at delivery, number of prenatal care visits, cigarette smoking during pregnancy, medical/obstetric conditions; referent comparison group: deliveries that occurred in hospitals. From: National Center for Health Statistics (2008).
21
Center for Disease Control and Prevention. User guide to the 2008 natality public use file. Available at: http://www.cdc.gov/nchs/nvss.htm. Accessed July 10, 2010.
When we examined the occurrence of obstetric interventions (such as operative vaginal delivery, induction of labor, augmentation of labor, and maternal antibiotic use), women who had planned home births were much less likely to experience these obstetric treatments/interventions than women who gave birth in a hospital (Table 3).
Table 3Obstetrics interventions, planned home births vs hospital births
| Obstetric intervention | Frequency, n (%) | Adjusted OR (95% CI) |
|---|---|---|
| Operative vaginal delivery | ||
| Hospital births | 90,880 (6.2) | Referent |
| Planned home births | 10 (0.1) | 0.12 (0.08–0.17) |
| Induction of labor | ||
| Hospital births | 530,940 (25.7) | Referent |
| Planned home births | 170 (1.4) | 0.19 (0.18–0.22) |
| Augmentation of labor | ||
| Hospital births | 476,653 (22.2) | Referent |
| Planned home births | 253 (2.1) | 0.29 (0.27–0.31) |
| Antibiotic use in labor | ||
| Hospital births | 313,329 (15.2) | Referent |
| Planned home births | 308 (2.6) | 0.40 (0.37–0.42) |
CI, confidence interval; OR, odds ratio.
Cheng. Planned home births and perinatal outcomes. Am J Obstet Gynecol 2013.
a Multivariable logistic regression controlled for parity, maternal age, race/ethnicity, education, gestational age at delivery, number of prenatal care visits, cigarette smoking during pregnancy, medical/obstetric conditions; referent comparison group: deliveries that occurred in hospitals
b Antibiotics received by mother during labor, either for prophylaxis or treatment. From: National Center for Health Statistics (2008).
21
Center for Disease Control and Prevention. User guide to the 2008 natality public use file. Available at: http://www.cdc.gov/nchs/nvss.htm. Accessed July 10, 2010.
In addition to planned location, we explored whether type of birth attendant was associated with neonatal outcomes. Of the 11,906 women who had planned home births (excluding 133 births by medical doctors and doctors of osteopathy), 26% of the infants were delivered by certified nurse-midwives (n = 3258); 51% of the infants were delivered by other midwives (n = 6277), and the remaining 23% of the infants were delivered by others (n = 2311) or unknown birth attendants (n = 60). Compared with births that occurred in hospitals, infant outcomes after planned home births that were attended by certified nurse-midwives did not differ significantly, except that infants who were born in a hospital were more likely to experience NICU admissions (Table 4). However, neonates of women who had planned home births and were delivered by other midwives had an increase in the risk of 5-minute Apgar scores <4 (aOR, 1.62; 95% CI, 1.01–1.83) and increased risk of seizure (aOR, 3.29; 95% CI, 1.22–8.87) compared with neonates born in a hospital.
Table 4Neonatal outcome stratified by birth location and attendant
| Neonatal outcome | Frequency, n (%) | Adjusted OR (95% CI) a Multivariable logistic regression controlled for parity, maternal age, race/ethnicity, education, gestational age at delivery, number of prenatal care visits, cigarette smoking during pregnancy, medical/obstetric conditions; referent comparison group: deliveries that occurred in hospitals. From: National Center for Health Statistics (2008).21 |
|---|---|---|
| 5-minute Apgar score <4 | ||
| Hospital births | 5028 (0.24) | Referent |
| Planned home births by certified nurse-midwives | 6 (0.19) | 0.69 (0.26–1.83) |
| Planned home births by other midwives | 17 (0.27) | 1.62 (1.01–1.83) |
| 5-minute Apgar score <7 | ||
| Hospital births | 24145 (1.17) | Referent |
| Planned home births by certified nurse-midwives | 34 (1.06) | 0.77 (0.52–1.16) |
| Planned home births by other midwives | 165 (2.63) | 2.92 (2.49–3.42) |
| Ventilator support >6 h | ||
| Hospital births | 5531 (0.27) | Referent |
| Planned home births by certified nurse-midwives | 6 (0.18) | 0.73 (0.33–1.63) |
| Planned home births by other midwives | 20 (0.23) | 0.91 (0.53–1.54) |
| Neonatal seizures | ||
| Hospital births | 447 (0.02) | Referent |
| Planned home births by certified nurse-midwives | 1 (0.03) | 1.59 (0.22–11.4) |
| Planned home births by other midwives | 4 (0.06) | 3.29 (1.22–8.87) |
| Neonatal intensive care unit admissions | ||
| Hospital births | 62218 (3.03) | Referent |
| Planned home births by certified nurse-midwives | 12 (0.37) | 0.13 (0.07–0.23) |
| Planned home births by other midwives | 40 (0.64) | 0.24 (0.18–0.34) |
CI, confidence interval; OR, odds ratio.
Cheng. Planned home births and perinatal outcomes. Am J Obstet Gynecol 2013.
a Multivariable logistic regression controlled for parity, maternal age, race/ethnicity, education, gestational age at delivery, number of prenatal care visits, cigarette smoking during pregnancy, medical/obstetric conditions; referent comparison group: deliveries that occurred in hospitals. From: National Center for Health Statistics (2008).
21
Center for Disease Control and Prevention. User guide to the 2008 natality public use file. Available at: http://www.cdc.gov/nchs/nvss.htm. Accessed July 10, 2010.
Because multiparous women are less likely to have labor dystocia, we stratified the cohort by parity to examine whether the risk of neonatal morbidity would be present mostly for nulliparous women or whether neonates of multiparous women were equally at risk. We observed that neonates of multiparous women who had planned home births that were attended by other midwives were more likely to have a 5-minute Apgar score <4 compared with neonates born in hospitals (0.25% vs 0.18% respectively; aOR, 1.84; 95% CI, 1.04–3.26). A similar association was observed for a 5-minute Apgar <7 (Table 5). For nulliparous women, the aOR for 5-minute Apgar <4 did not reach statistical significance in planned home birth compared with hospital births, but the aOR of 5-minute Apgar <7, need for ventilator support for >6 hours, and neonatal seizure was higher for neonates of planned home births that were attended by other midwives compared with hospital births (Table 5). The odds of NICU admissions remained lower for planned home births that were attended by either CNMs or other midwives than for hospital births for neonates of either nulliparous or multiparous women.
Table 5Neonatal outcome stratified by birthplace, attendant, and parity
| Neonatal outcome | Multiparous women (n = 1,227,272) | Nulliparous women (n = 840,641) | ||
|---|---|---|---|---|
| Frequency, n (%) | Adjusted OR(95% CI) a Multivariable logistic regression controlled for parity, maternal age, race/ethnicity, education, gestational age at delivery, number of prenatal care visits, cigarette smoking during pregnancy, medical/obstetric conditions; referent comparison group: deliveries that occurred in hospitals. From: National Center for Health Statistics (2008). | Frequency, n (%) | Adjusted OR (95% CI) a Multivariable logistic regression controlled for parity, maternal age, race/ethnicity, education, gestational age at delivery, number of prenatal care visits, cigarette smoking during pregnancy, medical/obstetric conditions; referent comparison group: deliveries that occurred in hospitals. From: National Center for Health Statistics (2008). | |
| 5-Minute Apgar score <4 | ||||
| Hospital births | 2185 (0.18) | Referent | 2843 (0.34) | Referent |
| Planned home births by certified nurse-midwife | 3 (0.12) | 0.83 (0.27–2.60) | 3 (0.42) | 0.47 (0.07–3.38) |
| Planned home birth by other midwives | 12 (0.25) | 1.84 (1.04–3.26) | 5 (0.37) | 1.34 (0.55–3.22) |
| 5-minute Apgar score <7 | ||||
| Hospital births | 10,452 (0.86) | Referent | 13,693 (1.63) | Referent |
| Planned home births by certified nurse-midwife | 25 (0.99) | 0.84 (0.52–1.36) | 10 (1.36) | 0.64 (0.30–1.35) |
| Planned home birth by other midwives | 119 (2.43) | 3.30 (2.74–3.97) | 46 (3.36) | 2.26 (1.67–3.07) |
| Ventilator support >6 hours | ||||
| Hospital births | 2980 (0.16) | Referent | 2551 (0.30) | Referent |
| Planned home births by certified nurse-midwife | 4 (0.15) | 0.72 (0.23–1.65) | 2 (0.27) | 0.95 (0.23–3.80) |
| Planned home birth by other midwives | 7 (0.14) | 0.51 (0.23–1.15) | 8 (0.57) | 2.08 (1.04–4.18) |
| Neonatal seizures | ||||
| Hospital births | 199 (0.02) | Referent | 248 (0.03) | Referent |
| Planned home births by certified nurse-midwife | 1 (0.04) | 2.39 (0.33–17.2) | 0 | — |
| Planned home birth by other midwives | 2 (0.04) | 2.55 (0.63–10.3) | 2 (0.14) | 4.95 (1.22–20.0) |
| Neonatal intensive care unit admissions | ||||
| Hospital births | 30,988 (2.54) | Referent | 31,230 (3.73) | Referent |
| Planned home births by certified nurse-midwife | 9 (0.35) | 0.14 (0.07–0.28) | 5 (0.68) | 0.17 (0.06–0.45) |
| Planned home birth by other midwives | 20 (0.40) | 0.17 (0.11–0.28) | 19 (1.36) | 0.42 (0.27–0.67) |
CI, confidence interval; OR, odds ratio.
Cheng. Planned home births and perinatal outcomes. Am J Obstet Gynecol 2013.
a Multivariable logistic regression controlled for parity, maternal age, race/ethnicity, education, gestational age at delivery, number of prenatal care visits, cigarette smoking during pregnancy, medical/obstetric conditions; referent comparison group: deliveries that occurred in hospitals. From: National Center for Health Statistics (2008).
Comment
In this large cohort of low-risk women with term, singleton, vertex pregnancies, we observed that women who were multiparous, ≥35 years old, non-Hispanic white ethnicity/background, and married and who had college or higher education were more likely to have planned home births. This finding was consistent with that reported by MacDorman and Singh.
18
Women who had planned home births had lower rates of obstetric intervention compared with women whose births occurred in hospitals. However, neonates of planned home births were more likely to have critically low 5-minute Apgar scores (<4) and seizure activity, both of which are known prognosticators of neonatal death and poor neurologic outcomes such as cerebral palsy and long-term developmental impairment.25
, 26
, 27
The observed association between planned home birth and an increased risk of a low 5-minute Apgar score was similar to a recent study that examined home births in the United States.16
However, that study did not find home births to be associated with an increased risk for neonatal seizures; this lack of association might be due to insufficient statistical power because there were only 2 infants with seizure among the home birth group.16
Although we did not have data on neonatal deaths, a recent metaanalysis reported that planned home birth is associated with increased risk of neonatal death compared with hospital births.12
Given these findings, we report that, although women who choose to have home birth often achieve their goals of having a nonmedicalized birthing experience, it seems that they do this bearing a small but significant risk of neonatal seizure. We note that neonates who were born in hospitals were more likely to be admitted to the NICU. However, we did not have information on indications of NICU admission. It could be that the threshold for NICU admission was lower for hospital than for home births or that acuity was higher for hospital births.Some studies have demonstrated that planned home birth can be safe, particularly in countries where the majority of the home births are attended by certified nurse-midwives or registered midwives within an integrated referral system.
7
, 10
, 11
, 30
For example, in The Netherlands, where approximately 1 in 4 women have planned home births, there are clear guidelines for risk stratification and a high proportion of referral from midwives or general practitioners to obstetricians-gynecologists such that women who have home births were truly low risk. Similar practice guideline and integration of health system exists for the United Kingdom, Canada, and Australia.7
, 9
, 10
, 11
In the United States, we report that home birth is associated with an increase in neonatal morbidity. The risk difference in perinatal morbidity that is associated with home vs hospital births may be due to less rigid guidelines. Despite that the fact that ACOG, ACNM, and AAP all advocate appropriate selection of low-risk pregnancies, qualified clinicians, sound clinical judgment, and prompt transfer to a receptive environment as imperative to ensure lower risk in planned home births,1
, 2
, 3
more women than ever before in the United States are attempting vaginal birth after cesarean delivery at home.22
Besides appropriate selection of candidates, the liaison between home-birth providers and in-hospital physicians may not be as well-defined in the United States. Further, women who attempt home births that require transfer of care to hospitals can be ostracized as “failed home births,” which may lead to decreased willingness to seek consultation and potentially the loss of critical time when complications arise.Multiparous women, in general, are less likely to have labor dystocia, to require medical interventions, and they have lower neonatal morbidity compared with nulliparous women.
31
When attempting home births, parous women are also less likely to require transfer to hospitals.7
, 32
Thus, they are often considered ideal candidates for planned home birth. Yet, we observed that neonates of multiparous women who were born at home were equally at increased risk of perinatal morbidity as were the neonates who were delivered to nulliparous women undergoing their first birth. This association between planned home birth and adverse neonatal outcome in multiparous women was contrary to outcomes of home birth in England.11
Although we do not know reasons for the observed differences in findings, it is likely that variations in study population, management of home birth, and integration of home-to-hospital care are different in the United States than in other countries. We speculate that birth attendants may have a higher threshold for referring and transporting multiparous women to hospitals, which can lead to the potential loss of critical time and an increased risk of adverse outcomes in the United States. It is important to recognize that rare but serious complications of labor and delivery (such as umbilical cord prolapse, shoulder dystocia, or severe placental abruption) can occur unpredictably, regardless of parity. In this cohort, there were 489 multiparous women with previous cesarean delivery who had planned home birth. Even when we excluded these women with a previous cesarean delivery and women with existing medical/obstetric conditions from the study cohort to derive a low-risk population, neonates of multiparous women who had a planned home birth remained at higher risk of seizure and low Apgar score at 5 minutes. Thus, aberrations of normal labor and birth should warrant equal concern in women who attempt a home birth, regardless of parity.We explored whether the increased risk of neonatal morbidity that is associated with home birth may be modified by birth attendants and observed that planned home births that were attended by certified nurse-midwives resulted in neonatal complication rates that were not significantly increased when compared with hospital births. There was, however, an elevated risk of neonatal seizures and low Apgar scores in planned home births that were attended by other midwives compared with hospital births. This association was similarly observed in the analysis of US birth certificate data from 2000-2004 by Malloy.
33
Yet, in the United States, we observed that only approximately one-quarter of planned home births were attended by certified nurse-midwives in 2008. Although the precise reason for this association between other midwife–attended home births and adverse neonatal outcomes is unclear, certified nurse-midwives have formal accredited education and training with national certification34
and are therefore more homogeneous in credentials compared with other birth attendants, whose experience and qualifications may vary widely.American Midwife Certification Board. Certificate Maintenance Program Requirements. Available at: http://www.amcbmidwife.org/certificate-maintenance-program/objectives. Accessed Jan. 28, 2012.
32
, 34
Certified nurse-midwives may be more likely to have established relationships with obstetricians and/or pediatricians and protocols for accessing hospital care if needed. Although certified nurse-midwives can practice both in hospitals and out of hospital settings, other types of birth attendants are unlikely to be able to obtain hospital privileges. Thus, they may be less familiar with the hospital environment and have a greater reluctance to transfer patients to a hospital. Additionally, women who choose planned home birth may decline transfer to physician-led or hospital-based care either prenatally or intrapartum, which contributes to a higher risk of complications.American Midwife Certification Board. Certificate Maintenance Program Requirements. Available at: http://www.amcbmidwife.org/certificate-maintenance-program/objectives. Accessed Jan. 28, 2012.
35
There are some limitations to our study. First, as a retrospective cohort study, confounding or missing data could potentially bias our findings. We used multivariable logistic regression analyses to control for bias in the effect estimation because of confounding; however, there may be residual confounding from unobserved or uncontrolled covariates that cannot be accounted for by statistical models. For example, women who chose home birth may be inherently different from women who desired hospital births, and such underlying difference may not be accounted for by characteristics such as age, education, marital status, or race/ethnicity alone. However, the usual bias in selecting home birth would be towards a lower-risk population, which would have biased our findings towards lower risk in home births. Further, because adverse neonatal outcomes such as seizures or death are rare events and randomization of birth location is of low feasibility, we propose that a large, population-based observational study design is the best option available to date to examine the safety of planned home birth in the United States. Although we aimed to examine planned home birth in the United States, we were able to analyze births in the 27 states that had adopted the 2003 Revision in 2008 because the transition from the 1989 Revision to the 2003 Revision of the US Standard Certificate of Life Birth was gradual. We chose to examine only births for which the 2003 Revision was used because it is important to delineate whether births that occurred at home were planned or accidental. We acknowledge that births in 27 states may not be representative of all births in the United States. Eventually, all states will report birth information using the 2003 Revision, and we plan to reexamine this topic in the near future. Further, we recognize that administrative data (such as birth certificate data) may contain inaccurate information, particularly because it has been noted that deliveries by certified nurse midwives may be under reported, particularly in the hospital, where some births were attended by >1 attendant.
21
The National Center for Health Statistics regulates the birth certificate information and checks the information for completeness, validity, and consistency between items. The data collection and coding process are reviewed on an ongoing basis for quality control.Center for Disease Control and Prevention. User guide to the 2008 natality public use file. Available at: http://www.cdc.gov/nchs/nvss.htm. Accessed July 10, 2010.
21
If an irregularity is identified, steps are taken to resolve it. Additionally, the definitions and diagnostic criteria of conditions and outcomes reported on birth certificates were based on definitions that had been compiled by a committee of federal and state health statistics officials for the Association of Vital Record and Health Statistics.Center for Disease Control and Prevention. User guide to the 2008 natality public use file. Available at: http://www.cdc.gov/nchs/nvss.htm. Accessed July 10, 2010.
21
It is reassuring that the magnitude of association between low 5-minute Apgar scores in planned home births compared with hospital births that were observed in this analysis was similar to that reported for home births in Washington state, despite differences in study population and study period.Center for Disease Control and Prevention. User guide to the 2008 natality public use file. Available at: http://www.cdc.gov/nchs/nvss.htm. Accessed July 10, 2010.
14
In this study, we were able to identify women who had planned a home birth and delivered at home, but we could not identify those women who planned home births but who were transferred to hospitals, which accounts for approximately 10-15% women who plan home births.
5
, 8
, 32
Some suggest that the actual transfer of planned home birth to hospital care may be higher than 10-15%, particularly in populations with a higher proportion of nulliparous women who attempt home birth.11
This likely resulted in misclassification bias because women who planned home births could deliver in the hospital; women who started labor in hospitals were not discharged to deliver at home. Such differential misclassification likely underestimates the difference between the risk of adverse neonatal outcomes that are associated with a hospital and hospital births, because the women and infants who have complications before or during labor or birth at home who were transported to hospitals were analyzed as hospital births. Further, we were able to examine short-term neonatal outcomes but do not have long-term data or information on neonatal and infant death. Currently, the National Center for Health Statistics provides the linked birth/infant death dataset for public use up to birth year 200536
; thus, in the near future, we will be able to examine neonatal/infant death as an outcome measure.Centers for Disease Control and Prevention. Public use data file documentation: 2005 linked birth/infant death birth cohort data set. Available at: http://www.cdc.gov/nchs/nvss.htm. Accessed June 18, 2010.
In summary, this large US population-based study showed that, although women who choose home birth have fewer obstetric interventions, their newborn infants have an elevated risk of having neonatal seizures and low Apgar scores. Although outcomes of planned home births that are attended by certified nurse-midwives were similar to those of hospital births, the risk of adverse neonatal outcomes was higher in planned home births that were attended by other midwives compared with hospital births. Because of the complex tradeoff between maternal benefit and neonatal risk, women who contemplate location of birth should be informed fully about both to enable an informed decision.
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Article info
Publication history
Published online: June 20, 2013
Accepted:
June 12,
2013
Received in revised form:
May 15,
2013
Received:
February 28,
2013
Footnotes
Supported in part by the University of California, San Francisco, Women's Reproductive Health Research Career Development Award, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (K12 HD001262; Y.W.C.).
The authors report no conflict of interest.
Reprints not available from the authors.
Cite this article as: Cheng YW, Snowden JM, King TL, et al. Selected perinatal outcomes associated with planned home births in the United States. Am J Obstet Gynecol 2013;209:325.e1-8.
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Copyright
© 2013 Mosby, Inc. Published by Elsevier Inc. All rights reserved.
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- Interventions at home birthsAmerican Journal of Obstetrics & GynecologyVol. 210Issue 5
- PreviewWe congratulate the authors of the publication on selected perinatal outcomes associated with planned home births in the United States1 that agree with our findings2 that home births are associated with increased adverse neonatal outcomes. In addition to neonatal outcomes, the authors also examined the following maternal obstetric interventions: operative vaginal delivery (forceps or vacuum-assisted), induction of labor, augmentation of labor, and maternal antibiotic use in labor and showed the differences of these interventions in Table 3 of that article.
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- Planned home or hospital delivery: what outcomes provide valid comparisons?American Journal of Obstetrics & GynecologyVol. 210Issue 5
- PreviewCheng et al1 analyzed planned home birth and hospital outcomes (notably 5 minute Apgar, neonatal seizures) using national birth certificate data for 2008. Readers should consider several issues when weighing the validity of these findings. First, although the 2003 revision of the standard certificate of live birth classification2 differentiates planned from unplanned home birth, only 27 states adopted it by 2008, and several states had very limited experience with it. Although large, the final sample reported by Cheng et al1 after exclusions for missing data actually constitutes less than 50% (2,081,753 of 4,247,694) of all 2008 US births3 and excludes several large states (eg, Illinois, New York, and North Carolina).
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