Original Research
Obstetrics
Planned home births: the need for additional contraindications

To be presented at the 2017 SMFM yearly meeting in Las Vegas.
https://doi.org/10.1016/j.ajog.2017.01.012Get rights and content

Background

Planned home births in the United States are associated with fewer interventions but with increased adverse neonatal outcomes such as perinatal and neonatal deaths, neonatal seizures or serious neurologic dysfunction, and low 5-minute Apgar scores. The American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice states that, to reduce perinatal death and to improve outcomes at planned home births, strict criteria are necessary to guide the selection of appropriate candidates for planned home birth. The committee lists 3 absolute contraindications for a planned home birth: fetal malpresentation, multiple gestations, and a history of cesarean delivery.

Objective

The aim of this study was to evaluate whether there are risk factors that should be considered contraindications to planned home births in addition to the 3 that are listed by the American College of Obstetricians and Gynecologists.

Study Design

We conducted a population-based, retrospective cohort study of all term (≥37 weeks gestation), normal weight (≥2500 grams), singleton, nonanomalous births from 2009–2013 using the Centers for Disease Control and Prevention’s period-linked birth-infant death files that allowed for identification of intended and unintended home births. We examined neonatal deaths (days 0–27 after birth) across 3 groups (hospital-attended births by certified nurse midwives, hospital-attended births by physicians, and planned home births) for 5 risk factors: 2 of the 3 absolute contraindications to home birth listed by the American College of Obstetricians and Gynecologists (breech presentation and previous cesarean delivery) and 3 additional risk factors (parity [nulliparous and multiparous], maternal age [women <35 and ≥35 years old], and gestational age at delivery [37–40 and ≥41 weeks]).

Results

The overall risk of neonatal death was significantly higher in planned home births (12.1 neonatal death/10,000 deliveries; P<.001) compared with hospital births by certified nurse midwives (3.08 neonatal death/10,000 deliveries) or physicians (5.09 neonatal death/10,000 deliveries). Neonatal mortality rates were increased significantly at planned home births, with the following individual risk factors: breech presentation (neonatal mortality rate, 127.52/10.000 births), nulliparous pregnant women (neonatal mortality rate, 22.5/10,000), previous cesarean delivery (18.91/10,000 births), and a gestational age ≥41 weeks (neonatal mortality rate, 17.17/10,000 births). Planned home births with ≥1 of the 5 risk factors had significantly higher neonatal death risks compared with deliveries with none of the risks. Neonatal death risk was further increased when a woman's age of ≥35 years was combined with either a first-time birth or a gestational age of ≥41 weeks.

Conclusions

In this study, we show 2 risk factors with significantly increased neonatal mortality rates at planned home births in addition to the 3 factors that are listed by the American College of Obstetricians and Gynecologists. These additional risks factors have neonatal mortality rates that are approaching or exceeding those for planned home birth after cesarean delivery: first-time births and a gestational age of ≥ 41 weeks. Therefore, 2 additional risk factors (first-time births and a gestational age of ≥41 weeks) should be added to the 3 absolute contraindications of planned home births that are listed by the American College of Obstetricians and Gynecologists (previous cesarean delivery, malpresentation, multiple gestations) for a total of 5 contraindications for planned home births.

Section snippets

Study population

This is a population-based, retrospective cohort study of all term (≥37 weeks gestation), normal weight (≥2500 g), singleton, nonanomalous births from 2009–2013, the last 5 years of the available data, in states that used the 2003 revised birth certificate and the Centers for Disease Control and Prevention’s period-linked birth-infant deaths files that allowed for identification of intended and unintended home births. We excluded births if they met any of the following criteria: birthplace

Characteristics

The study population included a total of 12,953,671 singleton, nonanomalous, term (≥37 weeks) deliveries with infants who weighed ≥2500 g who delivered in states that used the 2003 revised birth certificate from 2009–2013 in a hospital or were intended (or planned) home births. Of the whole group, 11,779,659 deliveries (90.9%) were hospital deliveries by physicians; 1,077,197 deliveries (8.3%) were hospital deliveries by certified nurse midwives, and 96,815 deliveries (0.7%) were intended

Comment

The results of our study confirm the findings of other studies that show an increased risk of neonatal death in planned home births.2, 4, 5 We have demonstrated that 2 risk factors, namely first-time and postterm (≥41 weeks) pregnancies, significantly had increased neonatal mortality rates, approaching or exceeding those for planned home birth after cesarean delivery, 1 of the 3 ACOG absolute contraindications for planned home birth.5 Therefore, 2 risk factors (first-time births and births at

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    • Critical appraisal of the proposed defenses for planned home birth

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      Midwives with less training have worse outcomes.22 In addition, planned home births continue to include patients at significantly increased risks;23 anesthesia and surgery are not available at planned home births, and access to them requires time-consuming transport that does not exist in the hospital setting. We have identified at least 8 valid clinical analogies to other very low-absolute-risk clinical situations and their implications that defenses of planned birth have not identified These highly clinically relevant analogies concern the application of the commitment to patient safety at the population level to situations in which absolute mortality risks are far lower than the absolute risk of neonatal death of planned home births but are nonetheless considered unacceptable because reducing variation results in improved outcomes.

    • Effect of Maternal and Pregnancy Risk Factors on Early Neonatal Death in Planned Home Births Delivering at Home

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      Citation Excerpt :

      Previous studies consisting of comparisons among home birth patients similarly noted elevated early neonatal death in breech deliveries, but neonatal death risk estimates failed to reach statistical significance for post-date pregnancies, twin gestations, nulliparous birth, and births of women who had a prior CS.11,12 A recent U.S. study examined risk factors for neonatal death in planned home births versus hospital births.9 Similar to our study, these investigators found that nulliparity and GA ≥41 weeks were associated with increased neonatal death in home births compared with hospital births.

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    The authors report no conflict of interest.

    Cite this article as: Grünebaum A, McCullough LB, Sapra KJ, et al. Planned home births: the need for additional contraindications. Am J Obstet Gynecol 2017;216:401.e1-8.

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