From the Editor

Transfer to the hospital for women planning a home birth: A high-risk obstetrics problem

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Do you have a written clinical guideline for pregnant women planning a home birth who are transferred to your hospital?


 

References

CASE: Febrile laboring mother transferred to hospital
You are in the hospital managing the induction of labor for one of your nulliparous patients who is postterm. You are hoping for a quiet and uneventful shift.

At midnight the nursing administrator pages you and asks if you would please provide care to a pregnant woman attempting a home birth who is in labor and is being transferred to your hospital.

The woman is a 41-year-old G2P1 with one prior cesarean delivery who has attempted a trial of labor at home. According to the nursing administrator the patient has a temperature of 100.4°F and the most recent cervical examination shows her to be fully dilated at +3/5 station in an occiput posterior position. She has been fully dilated for 5 hours. The fetal heart rate, assessed by Doppler monitor, is reported to be reassuring.

What is your clinical plan?

The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics recommend that pregnant women should deliver at certified birth centers or hospital-based obstetric units to optimize clinical outcomes for newborns and mothers.1,2 Both organizations also recognize a woman’s right to exercise her autonomy and choose a planned home birth.

In 2012, approximately 0.8% of pregnant women in the United States planned a home birth (31,500 home births and 3,999,386 total births).3 In 2009, three states had home birth rates above 1.9%, including Montana (2.6%), Oregon (1.96%), and Vermont (1.91%). Five states had home birth rates above 1.5%, including Idaho, Pennsylvania, Utah, Washington, and Wisconsin.4 Because planned home births may require transport to the hospital to complete the birth, all obstetric units should develop written plans for dealing with these high-risk patients.

Hospital transfer is common for women attempting a home birth
Many home birth experts regard the Netherlands as the country with the best organized and most successful home birth system that is fully integrated with hospital-based obstetric care. Approximately 23% of births in Holland occur at home supervised by a midwife. A key feature of the highly regulated Dutch system is that all pregnant women with a high-risk condition are required to give birth in a hospital and cannot have a home delivery. Consequently, only women with a low-risk pregnancy are permitted to attempt a home birth.

By contrast, in the United States, with a less well-regulated home birth system, women with high-risk conditions, such as one or more prior cesarean deliveries, may try to birth at home. In a Dutch study of 168,618 low-risk women attempting a home birth, 32% (N=53,809) were transferred to the hospital. Most of the transfers occurred during labor.5

In England about 2.8% of births occur at home. In a study of 16,840 planned home births in England, 21% (N=3,530) of the women were transferred to the hospital.6 Of the 3,530 transfers to the hospital, 70% were transferred before delivery and 30% after birth. In this study among 4,568 nulliparous women attempting home birth, 45% were transferred to the hospital. Among 12,272 multiparous women attempting home birth, 12% were transferred to the hospital.

Among the nulliparous women, but not among the multiparous women, there was a significantly increased risk of adverse newborn outcomes. Adverse newborn outcome was a composite measure that included perinatal death, stillbirth after the onset of labor, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, or fractured humerus or clavicle. The risk of an adverse newborn outcome among nulliparous women was 0.9% for those delivering at home and 0.5% for those delivering at the hospital.6

Your patient asks you, “Are home births safe for the baby?”
No large-scale randomized trials have compared home birth versus hospital birth.1 Consequently, the best evidence evaluating the risks and benefits of home birth is based on observational studies of large cohorts. Recent studies from the United States have reported that neonatal complications, including the risk of a low Apgar score and neonatal seizures, is significantly increased with planned home birth compared with birth at a hospital.2,3 In one study, the risk of a 5-minute Apgar score of zero was 1 in 615 home births and 1 in 6,493 hospital births.3 Studies from the Netherlands also have reported that planned home birth is associated with increased perinatal mortality and morbidity.4,5
Because planned home birth is associated with an increased risk of neonatal morbidity and mortality, some experts conclude that obstetricians have an ethical obligation to recommend against home birth and to respond to refusal of that recommendation with respectful persuasion.6

References
1. Olsen O, Clausen JA. Planned hospital birth versus planned home birth. Cochrane Database Syst Rev. 2012; (9):CD000352.
2. Grunebaum A, McCullough LB, Sapra KJ, et al. Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting. Am J Obstet Gynecol. 2013;209(4):323.e1–e6.
3. Cheng YW, Snowden JM, King TL, Caughey AB. Selected perinatal outcomes associated with planned home births in the United States. Am J Obstet Gynecol. 2013;209(4).325.e1–e8.
4. Evers AC, Brouwers HA, Hukkelhoven CW, et al. Perinatal mortality and severe morbidity in low and high risk term pregnancies in the Netherlands: Prospective cohort study. BMJ. 2010;341:c5639.
5. Arabin B, Visser GHA. Comparison of obstetric care in Germany and in the Netherlands. J Health Med Informat. 2013;S11:014.
6. Chervenak FA, McCullough LB, Arabin B. Obstetric ethics: An essential dimension of planned home birth. Obstet Gynecol. 2011;117(5):1183–1187.

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