The rate of perinatal death in Oregon was more than twice as high among pregnant women who gave birth outside of a hospital, concludes an analysis published Wednesday in the New England Journal of Medicine.
The study further found that women who gave birth in nonhospital settings and were less likely to be assisted by a physician, certified nurse or midwife faced higher odds for neonatal seizure. While these findings are consistent with previous studies that suggest out-of-hospital births are riskier for mom and baby, the topic remains one of controversy.
The study authors point out that in other countries, where midwifery has been more strategically integrated into the healthcare system, there are fewer out-of-hospital complications. Furthermore, U.S. hospital policies that limit a woman's ability to give birth vaginally after a previous C-section may be driving expectant mothers to deliver at home with the assistance of people who have no hospital privileges.
In commentary accompanying the NEJM study, clinicians weighed in on both sides of the issue.
Many physicians would support a woman's attempt to deliver vaginally after a prior cesarean section, argued Dr. Sarah Little, a maternal-fetal medicine specialist at Brigham and Women's Hospital in Boston. And that additional support “may help us move forward toward determining how we can create more coordinated-care systems to make home birth safer for women in the United States,” Little said.
On the other hand, while women do not imagine becoming one of the 1.6 per 1,000 women whose baby will die during a home birth, “the reality is that it will happen to someone,” countered Dr. Linda Szymanski, medical director of labor and delivery and inpatient obstetric services at Johns Hopkins Hospital in Baltimore.
Ultimately, the choice should be left up to the mother-to-be. “The question is, what level of risk is she willing to take,” Szymanski said.
To compare the perinatal risks of planned out-of-hospital versus in-hospital births, researchers looked at more than 79,000 births in Oregon, using state birth, infant death and fetal death certificates from Jan. 1, 2012, through Dec. 31, 2013.
Oregon is one of six U.S. states with exceptionally high rates of births that occur outside of a hospital, ">according to estimates
Researchers began comparing the two types of births in Oregon after the state updated data used on its birth certificates to include information about the planned place of delivery. However, the data did not identify whether out-of-hospital births were in a home or a birth center. At 3.9 deaths per 1,000 deliveries, the mortality rate for births that were planned for locations outside of hospital was more than twice as high. The rate was 1.8 deaths per 1,000 deliveries for planned hospital settings.
The analysis was conducted by researchers from the Oregon Health and Science University in Portland, the University of California at Davis, and the California Pacific Medical Center in San Francisco.
Approximately 25,000 U.S. births occur outside of the hospital each year, and about one-fourth are unplanned or are not attended by a professional. That puts women at high risk of perinatal and neonatal mortality, according to the American Congress of Obstetricians and Gynecologists. While ACOG believes hospitals and birthing centers are the safest option, the group says woman should be medically informed about the risks and benefits of all options.
Women should be informed of the availability of a certified nurse or midwife, or physician practicing within an integrated and regulated health system and the assurance of safe and timely transport to nearby hospitals, according to the study.
Authors of the NEJM study say the extent to which midwifery is integrated into a healthcare system probably explains some of the differences in practice and outcomes reported in U.S. and European studies.
For example they note that adverse outcomes are rare in the Dutch home-birth system, which includes formal collaborative agreements between out-of-hospital and in-hospital providers, and protocols for the transfer of care.
In a Canadian jurisdiction where planned home births attended by midwives were well-integrated into the healthcare system, there was no difference in serious adverse neonatal outcomes when compared to in-hospital deliveries, and there were fewer intrapartum interventions needed, ">found a 2015 study in the Canadian Medical Association Journal.
