Home Births Associated With More Seizures, Lower Apgar Scores

Nancy A. Melville

February 14, 2012

February 14, 2012 (Dallas, Texas) — Women who have home births or plan to deliver at home have lower rates of cesarean delivery; however, their babies are more likely to have neonatal seizures and lower Apgar scores if a certified midwife is not in attendance, according to research presented here at the Society for Maternal-Fetal Medicine 32nd Annual Meeting.

A research team, led by Yvonne W. Cheng, MD, from the University of California, San Francisco, conducted a retrospective study to examine how or if neonatal outcomes differ depending on where the birth took place (at a hospital, at a birthing center, or at home).

"About 1% of births in the United States occur outside of the hospital, and this appears to be an increasing trend," Dr. Cheng told Medscape Medical News. However, "the safety of planned home births remains unclear." Data emerging from in and outside of the United States are conflicting, she explained.

The team evaluated nearly 2.3 million live singleton births in the United States in 2008 for which they had specific birthing-facility information.

Of the live births, 10,726 (0.47%) were at birthing centers and 12,433 (0.54%) were intended home births; the rest took place in hospitals.

Rates of cesarean delivery were substantially lower for women who delivered or intended to deliver outside of hospitals, compared with in-hospital deliveries (0.02%; 4% vs 24%; < .001).

The rate of having a child with a 5-minute Apgar score below 7 were about twice as high with intended home births as with hospital births (2.51% vs 1.23%); the rate at birthing centers was no higher than at hospitals (0.99%).

The risk of having a neonatal seizure was higher at birthing centers (0.04%) and with intended home births (0.08%) than at hospitals (0.03%).

Interestingly, the risk for lower Apgar scores was only seen in home births at which a certified nurse-midwife was not present. However, these represented the majority of home births.

"We did not observe a statistically significant difference in neonatal outcome in certified nurse-midwife-attended home births, compared with hospital births," Dr. Cheng said. "According to our analysis, the majority of the planned home births were not attended by certified nurse-midwives."

"It appears that while location of delivery is important, equally important are the birth attendants who assist the births."

With so many home births apparently taking place without skilled attendants, the risk is something that clinicians should be aware of, Dr. Cheng noted.

"We hypothesized that home births would not be associated with an increased risk of neonatal morbidity, and we were surprised to find a positive association," she said.

"As clinicians who take care of women transported to the hospital after failed planned home births, we might have a skewed viewpoint regarding the safety of planned home births because we do not see the approximately 90% of successful home births," she said.

In a committee opinion published in February 2011 (Obstet Gynecol. 2011;117[2 Pt 1]:425-428), the American Congress of Obstetricians and Gynecologists (ACOG) explained that although recent research has shown that planned home births, particularly in low-risk women, have a low absolute risk, they nevertheless carry a 2- to 3-fold greater risk for newborn death, compared with planned hospital births.

"As physicians, we have an obligation to provide families with information about the risks, benefits, limitations, and advantages concerning the different maternity-care providers and birth settings," said ACOG president Richard N. Waldman, MD, from Fayetteville, New York, in a statement.

"It's important to remember that home births don't always go well, and the risk is higher if they are attended by inadequately trained attendants or in poorly selected patients with serious high-risk medical conditions, such as hypertension, breech presentation, or prior cesarean deliveries," he noted.

The ACOG considers that "hospitals and birthing centers are the safest place for labor and delivery."

However, the findings do underscore the relative safety of home birth when appropriately trained attendants are present, said Saraswathi Vedam, RM, SciD(hc), director of the division of midwifery at the University of British Columbia in Vancouver.

"There are high-quality international data that support the defense that there are no appreciable differences between birth outcomes when you have a low-risk population, qualified attendants, and access to hospitalization when necessary," she told Medscape Medical News.

"When those factors are all in place, it appears not only that outcomes are good, but there is also a significant reduction in obstetric intervention outside of the hospital. Interventions, of course, are associated with their own risk."

Dr. Vedam noted the importance of weighing those factors before prejudging mothers wanting a home delivery.

"It's a complex issue. Obviously no one wants a poor outcome for mothers or babies in any setting," she said. "But it's unfair to women to suggest they're being selfish in choosing their outcomes over their babies' outcomes. That's what's been suggested before, and it's not a correct interpretation."

The authors and Dr. Vedam have disclosed no relevant financial relationships.

Society for Maternal-Fetal Medicine (SMFM) 32nd Annual Meeting: Abstract 65. Presented February 10, 2012.

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