Background
Planned home births have leveled off in the United States in recent years after a
significant rise starting in the mid-2000s. Planned home births in the United States
are associated with increased patient-risk profiles. Multiple studies concluded that,
compared with hospital births, absolute and relative risks of perinatal mortality
and morbidity in US planned home births are significantly increased.
Objective
To explore the safety of birth in the United States by comparing the neonatal mortality
outcomes of 2 locations, hospital birth and home birth, by 4 types of attendants:
hospital midwife; certified nurse-midwife at home; direct-entry (“other”) midwife
at home; and attendant at home not identified, using the most recent US Centers for
Disease Control and Prevention natality data on neonatal mortality for planned home
births in the United States. Outcomes are presented as absolute risks (neonatal mortality
per 10,000 live births) and as relative risks of neonatal mortality (hospital-certified
nurse-midwife odds ratio, 1) overall, and for recognized risk factors.
Study Design
We used the most current US Centers for Disease and Prevention Control Linked Birth
and Infant Death Records for 2010–2017 to assess neonatal mortality (neonatal death
days 0–27 after birth) for single, term (37+ weeks), normal-weight ( >2499 g) infants
for planned home births and hospital births by birth attendants: hospital-certified
nurse-midwives, home-certified nurse-midwives, home other midwives (eg, lay or direct-entry
midwives), and other home birth attendant not identified.
Results
The neonatal mortality for US hospital midwife-attended births was 3.27 per 10,000
live births, 13.66 per 10,000 live births for all planned home births, and 27.98 per
10,000 live births for unintended/unplanned home births. Planned home births attended
by direct-entry midwives and by certified nurse-midwives had a significantly elevated
absolute and relative neonatal mortality risk compared with certified nurse-midwife–attended
hospital births (hospital-certified nurse-midwife: 3.27/10,000 live births odds ratio,
1; home birth direct-entry midwives: neonatal mortality 12.44/10,000 live births,
odds ratio, 3.81, 95% confidence interval, 3.12–4.65, P<.0001; home birth–certified nurse-midwife: neonatal mortality 9.48/10,000 live births,
odds ratio, 2.90, 95% confidence interval, 2.90; P<.0001). These differences increased further when patients were stratified for recognized
risk factors.
Conclusion
The safety of birth in the United States varies by location and attendant. Compared
with US hospital births attended by a certified nurse-midwife, planned US home births
for all types of attendants are a less safe setting of birth, especially when recognized
risk factors are taken into account. The type of midwife attending US planned home
birth appears to have no differential effect on decreasing the absolute and relative
risk of neonatal mortality of planned home birth, because the difference in outcomes
of US planned home births attended by direct-entry midwives or by certified nurse-midwives
is not statistically significant.
Key words
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Article info
Publication history
Published online: February 07, 2020
Accepted:
January 24,
2020
Received in revised form:
January 23,
2020
Received:
December 29,
2019
Footnotes
The authors report no conflict of interest.
Cite this article as: Grünebaum A, McCullough LB, Orosz B, et al. Neonatal mortality in the United States is related to location of birth (hospital versus home) rather than the type of birth attendant. Am J Obstet Gynecol 2020;223:254.e1-8.
Identification
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© 2020 Elsevier Inc. All rights reserved.
