Making Out-of-Hospital Birth Safer Requires Systems Change

Ellen L. Tilden, PhD, CNM; Jonathan M Snowden, PhD; Aaron B Caughey, MD, PhD; Melissa J. Cheyney, PhD, CPM, LDM


May 18, 2016

Birth is as safe as life gets. - Harriette Hartigan, direct-entry midwife

What one deems "safe" is inherently subjective, involving a series of judgments and a relative weighing of multiple (and sometimes conflicting) factors. Safety definitions are also culturally shaped; hospitals may be perceived as the safest place to deliver if childbirth is regarded as potentially pathologic [1] and capacity to quickly address emergent complications is most highly valued. Recent evidence indicating that the risk for perinatal mortality is increased among women intending out-of-hospital birth supports this perspective.[2] Alternatively, the home or birth center may be perceived as safest if childbirth is regarded as a normal physiologic event[3] potentially harmed by routine obstetric intervention.[1] Recent evidence also found that women intending out-of-hospital birth as compared with those delivering in-hospital were at significantly lower risk (5.3% vs 24.7%, P < .001) for cesarean delivery,[2] a surgery associated with higher rates of maternal mortality.[4] In the United States, these perspectives are often at odds, while other societies have devised systems maximizing advantages of each setting.[5]

The choice of birth setting is nothing if not contentious in the United States, and mothers-to-be commonly face scrutiny for their decisions.[6,7] Despite these pressures, out-of-hospital births have steadily increased over the past decade, up 72% from 0.87% of US births in 2004 to 1.5% in 2014.[8] This trend shows no sign of reversing; disengaging with the debate over whether out-of-hospital birth is safe and instead engaging examination of the factors that may make out-of-hospital birth safer is of critical import. Formally including home and birth center care in US maternity care systems will improve outcomes for the growing numbers of women seeking care outside of the hospital. In parallel, increasing the availability of physiologic birth in-hospital may decrease the number of women choosing out-of-hospital birth as a means of avoiding unnecessary intervention, with the added benefit of reducing iatrogenic maternal morbidity for the predominance of low- to moderate-risk women who choose hospital birth. While the vast majority of healthy women in the United States will deliver safely regardless of birth setting,[2] these advances would temper polarization around birth setting, improve interprofessional collaboration, and increase the safety of our entire maternity care system.


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