Feature

More risk factors boost mortality in home births


 

AT THE PREGNANCY MEETING

– Analysis of nearly 13 million U.S. deliveries during 2009-2013 identified two new, significant dangers posed to neonates delivered by planned home births: nulliparous pregnancies and deliveries at 41 weeks gestational age or older.

Both conditions linked with a substantially increased risk for neonatal mortality, compared with babies delivered at a hospital, either by a nurse midwife or a physician, said Amos Grünebaum, MD, at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

Dr. Amos Grünebaum Mitchel L. Zoler/Frontline Medical News

Dr. Amos Grünebaum

“We should inform women considering a planned home birth about the increased risks and contraindications for home births,” said Dr. Grünebaum, an ob.gyn. and director of clinical maternal-fetal medicine at Weill Cornell Medical Center in New York. “Hospitals should limit interventions and provide options for women desiring fewer interventions and more home birth–like settings.”

The critical difference between a home birth–like setting at a hospital and home birth in the field is distance from a hospital when emergency care is needed, he said.

“Women want less intervention during delivery and should get less intervention,” but a midwife run, home birth–like clinic should operate adjacent to a hospital able to handle obstetrical and neonatal emergencies, Dr. Grünebaum said in an interview. “Women need to understand the risks of home births.”

He and his associates used data collected by the Centers for Disease Control and Prevention on 12,953,671 U.S. deliveries during 2009-2013 for singleton, nonanomalous neonates with at least 37 weeks gestation at birth and weighing at least 2,500 grams. The total included 91% hospital deliveries by a physician, 8% hospital deliveries by a nurse-midwife, and 96,815 home births or 0.75% of U.S. deliveries during this period. Despite that low percentage, the number of U.S. home births nearly tripled from 2007 to 2015, he noted.

The rate of neonatal deaths for each 10,000 live births was 3 among infants delivered by nurse midwives at hospitals, 5 for infants delivered by physicians at hospitals, and 12 for infants delivered by home births. The standard mortality ratio was 66% higher for physicians at hospitals, compared with nurse-midwives at hospitals, because physicians handle higher-risk deliveries, and more than fourfold higher for home births, compared with hospital deliveries by nurse-midwives, Dr. Grünebaum reported.

Further analysis showed that the death rate per 10,000 neonates for pregnancies that continued to a gestational age of 41 weeks or more was 17.2, and for deliveries among nulliparous women, neonatal mortality was 22.5 deaths per 10,000 births. These rates were in the same ballpark as three conditions cited by an ACOG committee in a 2016 report as contraindications for home birth: prior cesarean delivery, which had home birth mortality of 18.9 per 10,000 neonates in the current study, multiple gestations, and breach presentation, with home birth mortality in the current study of 127.5 per 10,000.Maternal age of 35 years or greater at the time of delivery linked with a death rate of 13.6 per 10,000 births, a rate that Dr. Grünebaum did not consider high enough to specifically label it a contraindication to home birth. But Dr. Grünebaum took a dim view of home births in general. For any type of pregnancy, a birth center not adjacent to a hospital is “unprofessional,” he declared.

A journal article with this report also appeared online (Am J Ob Gyn. 2017 Jan 29. doi: 10.1016/j.ajog.2017.01.012).

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