Most U.S. Planned Home Births Are Not Low-Risk
(Reuters Health) – Experts recommend that home birth only be considered for low-risk pregnancies, but that’s often not what happens in the U.S., where no formal guidelines exist, researchers say.
U.S. data on intended home births from 2016 through 2018 show that more than 60% of the pregnancies had risk factors that could lead to complications and possibly maternal or infant death, they reported in the American Journal of Obstetrics & Gynecology, online November 9.
These risk factors, such as high maternal age or previous cesarean delivery, would trigger automatic advice against planning a home delivery in many other countries, the authors note.
“Every baby that dies unnecessarily is unacceptable. We should not accept a baby’s loss that could have been saved,” said co-author Dr. Amos Grunebaum of the Zucker School of Medicine at Hofstra/Northwell Health in Hempstead, New York.
About 1%-2% of U.S. births are planned home births, a rate that has leveled off after rising over the past five years, he said. About 10 times more newborns die with a planned home birth than a hospital birth, Grunebaum added.
“I have personally met many women who have lost their babies at planned home births,” he told Reuters Health by email. “Each time I talk to one, it’s personally devastating.”
The study team analyzed National Center for Health Statistics data on 88,000 planned home births in 2016-2018 to identify risks known to increase consequences for both the mother and infant.
They found that about 4% of births followed prior cesarean deliveries. About 23% of the mothers were 35 or older, and nearly 5% were 40 or older. About 1 in 5 pregnancies were beyond the recommended full term of 41 weeks, and nearly 4% were beyond 42 weeks.
The research team also calculated that 17% were first-time births and 7.5% were “grand multipara,” meaning it would be the mother’s fifth or higher delivery. About 13% involved mothers with obesity.
Many advocates for planned home births say it is typically chosen by women with low-risk pregnancies, but the results show this isn’t true, the study team writes.
“U.S. home birth supporters say that low-risk home births are safe, but our study shows that U.S. home births are not low-risk and consequently are not safe,” Grunebaum said. “You cannot use other countries’ data to say planned home births are safe because they have very clear guidelines to ‘risk out’ deliveries.”
Midwives in other countries, such as the Netherlands and Germany, don’t allow high-risk patients to deliver at home, he said. Guidelines in the U.S. should establish who should deliver at home, including no prior cesareans, no obesity, no twins, no first-time babies, no breech and no older women, he added.
Grunebaum created the babyMed.com website to provide information about fertility and pregnancy. It includes information about home birth, explaining risk factors and outcomes, and features a quiz to test knowledge about home birth (here: https://bit.ly/2OB0Hiq).
“It is well known that maternal and fetal morbidity and mortality have reduced over the years thanks to hospitalization. To deliver at home means going back to 50-60 years ago,” said Dr. Cristina Rossi of Ospedale della Murgia in Bari, Italy, who wasn’t involved in the study.
Overall in cases of complications, hospital births are more likely to receive medical interventions, fetal monitoring and prompt delivery, she said. A complication such as placental abruption, for instance, must be solved within 10 minutes after diagnosis, she noted. Transportation time from home to the hospital could cause a problem, and the risk of infection and neonatal sepsis is lower at hospitals, too, Rossi added.
“There is no need to deliver at home,” Rossi told Reuters Health by email. “Even in cases of extremely low risk, hospital management is surely more appropriate than management at home.”
Am J Obstet Gynecol 2019.