Monday, October 8, 2007

Home Births in the US

There are many studies looking at the results of home birth versus hospital delivery. When using an intent to treat analysis (as a good study should - if the home baby dies when it gets to the hospital - it should not be placed in the 'hospital delivery' group) the home group always has higher mortality - presumably in the delay of getting care to critically ill mothers and infants.

Below are abstracts from 2 articles from a respected journal - looking at large numbers of patients. As seen below there are a high number of women that are transferred to the hospital - before, during, or after birth. It is also important to note that the 'hospital' group includes all the women with high risk pregnancies, that are known to have worse outcomes (pre-ecalmpsia, women with large babies, preterm labor, breech, Vaginal Birth After Cesarean, etc.).

Outcomes of Planned Home Births in Washington State: 1989–1996

Jenny W. Y. Pang, MD, MPH, James D. Heffelfinger, MD, MPH, Greg J. Huang, DMD, MPH, Thomas J. Benedetti, MD, MHA and Noel S. Weiss, MD, DrPH

From the Department of Epidemiology, University of Washington School of Public Health and Community Medicine; Department of Obstetrics and Gynecology, University of Washington School of Medicine; Department of Pediatrics, Children’s Hospital and Regional Medical Center, Seattle, Washington; and Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia.

Address reprint requests to: Jenny Pang, MD, MPH, University of Washington School of Public Health, Department of Epidemiology, Box 357236, Seattle, Washington 98195; E-mail:

OBJECTIVE: To determine whether there was a difference between planned home births and planned hospital births in Washington State with regard to certain adverse infant outcomes (neonatal death, low Apgar score, need for ventilator support) and maternal outcomes (prolonged labor, postpartum bleeding).

METHODS: We examined birth registry information from Washington State during 1989–1996 on uncomplicated singleton pregnancies of at least 34 weeks’ gestation that either were delivered at home by a health professional (N = 5854) or were transferred to medical facilities after attempted delivery at home (N = 279). These intended home births were compared with births of singletons planned to be born in hospitals (N = 10,593) during the same years.

RESULTS: Infants of planned home deliveries were at increased risk of neonatal death (adjusted relative risk [RR] 1.99, 95% confidence interval [CI] 1.06, 3.73), and Apgar score no higher than 3 at 5 minutes (RR 2.31, 95% CI 1.29, 4.16). These same relationships remained when the analysis was restricted to pregnancies of at least 37 weeks’ gestation. Among nulliparous women only, these deliveries also were associated with an increased risk of prolonged labor (RR 1.73, 95% CI 1.28, 2.34) and postpartum bleeding (RR 2.76, 95% CI 1.74, 4.36).

CONCLUSION: This study suggests that planned home births in Washington State during 1989–1996 had greater infant and maternal risks than did hospital births.

Outcomes of intended home births in nurse-midwifery practice: a prospective descriptive study

PA Murphy and J Fullerton

OBJECTIVE: To describe the outcomes of intended home birth in the practices of certified nurse-midwives. METHODS: Twenty-nine US nurse-midwifery practices were recruited for the study in 1994. Women presenting for intended home birth in these practices were enrolled in the study from late 1994 to late 1995. Outcomes for all enrolled women were ascertained. Validity and reliability of submitted data were established. RESULTS: Of 1404 enrolled women intending home births, 6% miscarried, terminated the pregnancy or changed plans. Another 7.4% became ineligible for home birth prior to the onset of labor at term due to the development of perinatal problems and were referred for planned hospital birth. Of those women beginning labor with the intention of delivering at home, 102 (8.3%) were transferred to the hospital during labor. Ten mothers (0.8%) were transferred to the hospital after delivery, and 14 infants (1.1%) were transferred after birth. Overall intrapartal fetal and neonatal mortality for women beginning labor with the intention of delivering at home was 2.5 per 1000. For women actually delivering at home, intrapartal fetal and neonatal mortality was 1.8 per 1000. CONCLUSION: Home birth can be accomplished with good outcomes under the care of qualified practitioners and within a system that facilitates transfer to hospital care when necessary. Intrapartal mortality during intended home birth is concentrated in postdates pregnancies with evidence of meconium passage.

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