Out-of-Hospital Births at Highest Level Since 1975

Troy Brown, RN

March 05, 2014

Out-of-hospital births are at their highest level since 1975, according to a federal report of births from 1990 to 2012. Still relatively rare, they have been steadily increasing since 2004, according to a March 4 report published in the NCHS Data Brief.

"If this increase continues, it has the potential to affect patterns of facility usage, clinician training, and resource allocation, as well as health care costs," Marian F. MacDorman, PhD, from the Centers for Disease Control and Prevention, National Center for Health Statistics, and colleagues write.

Out-of-hospital births gradually declined from 1990 to 2004 and have been rising since then. In 2004, 0.87% of US births occurred outside a hospital. That percentage increased to 1.26% in 2011 and 1.36% in 2012, the highest level since 1975.

"In 2012, two-thirds (66%) of out-of-hospital births occurred at home, and another 29% occurred in a freestanding birthing center. (The remaining 5% of out-of-hospital births occurred in a clinic or doctor’s office or other location.)," according to the report.

"Women who are healthy and have no identified risk factors can deliver in an out-of-hospital setting," James Byrne, MD, chair, Department of Ob/Gyn, Santa Clara Valley Medical Center, San Jose, and affiliated clinical professor, Stanford University School of Medicine, California, told Medscape Medical News.

Highest Among Non-Hispanic White Women

The percentage of out-of-hospital births increased for all racial and ethnic groups from 2004 to 2012, but the increase in non-Hispanic white women was responsible for most of the total increase. By 2012, 1 in 49 births to non-Hispanic white women (2.05%) took place outside a hospital. That year, the percentage was 2 to 4 times higher for non-Hispanic white women than for any other racial or ethnic group.

The increase in the percentage of out-of-hospital births from 2011 to 2012 was significant for non-Hispanic white (from 1.89% to 2.05%), Hispanic (from 0.44% to 0.46%), and Asian or Pacific Islander (from 0.49% to 0.54%) women. Increases were not statistically significant for non-Hispanic black and American Indian women.

Highest in Northwestern States

In 2012, the highest rates (3% - 6%) of out-of-hospital births occurred in Alaska (6.0%), Montana (3.9%), Oregon (3.8%), Washington (3.4%), Idaho (3.4%), and Pennsylvania (3.1%).

The next-highest rates (2% - 3%) occurred in Utah, Vermont, Indiana, Wisconsin, and Delaware.

The lowest rates (<1%) occurred in southeastern states from Louisiana to Georgia, as well as for a few other states throughout the United States.

Safe for Low-Risk Women

The risk profile of out-of-hospital births declined from 2004 to 2012. Home and birthing center births tended to have lower risk profiles compared with hospital births, with fewer births to teenage mothers and fewer preterm, low-birthweight, and multiple births.

"The women who were delivering out of the hospital were lower risk, so there was a more appropriately cautious assessment to identify women with risk factors and refer them to hospitals, and those women who were free of risk factors were safer...and allowed to deliver in an out-of-the-hospital setting," Dr. Byrne explained.

It is hard to make an across-the-board statement regarding whether out-of-hospital births are safer than hospital births, M. Christina Johnson, CNM, MS, director, Professional Practice & Health Policy, American College of Nurse-Midwives, told Medscape Medical News.

"If you've got a set of low-risk factors going into your delivery, and you're also working with a provider who has the highest level of training and education and experience with home birth, and you're getting continuous assessment of your baby and your own risk as you go through the labor, then it's certainly a safe option for many women," Johnson said.

Planning, Coordination of Care Key

Most (88%) of home births in a 36-state reporting area (71% of births in the United States) were planned in 2012. Unexpected home births are more likely than planned home births to be born preterm and at low birthweight, the report notes.

Dr. Byrne serves on the Midwifery Advisory Council for the Medical Board of California. "We're putting things into place to help make coordination of care safer for women who choose an out-of-hospital birth. A big part of that is closer working relationships between those women's care providers and the doctors and midwives who practice in hospitals," Dr. Byrne said.

Johnson and Dr. Byrne have disclosed no relevant financial relationships.

"Trends in Out-of-Hospital Births in the United States, 1990-2012." NCHS. Full text

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