ACOG Revises Committee Opinion on Planned Home Birth

Diana Swift

July 27, 2016

A revised Committee Opinion from the American College of Obstetricians and Gynecologists (ACOG) aims to inform pregnant women planning to give birth at home of the attendant risks. Taking into account emerging information, the statement, published in the August issue of Obstetrics & Gynecology, updates ACOG's 2011 opinion on planned home birth.

"Although [ACOG] believes that hospitals and accredited birth centers are the safest settings for birth, each woman has the right to make a medically informed decision about delivery," the opinion reads.

Although the absolute risk of planned home birth remains and delivery in the home setting is associated with fewer intrapartum interventions, it is also associated with more than double the risk for perinatal death and three times the risk for neonatal seizures or neurologic dysfunction, according to an ACOG news release.

Recent studies highlight the risks in terms of adverse events per 1000 births. The rate for neonatal seizures has been reported as 0.58 for planned home birth vs 0.22 for hospital birth, for an odds ratio (OR) of 3.08 (95% confidence interval [CI], 1.44 - 6.58). For perinatal and neonatal death, the rate was 3.9 vs 1.8, translating to an OR of 2.43 (95% CI, 1.37 - 4.30). In addition, the serious neurologic dysfunction rate was 0.86 for home birth and 0.22 for hospital birth (OR, 3.80; 95% CI, 2.80 - 5.16).

As for the measure of Apgar score of less than 7 at 5 minutes, the at-home setting rate was 24.2 vs 11.7 for in-hospital birth, for an OR of 2.42 (95% CI, 2.13 - 2.74).

Among ACOG's updated recommendations:

  • Healthcare providers should stress to women that planned home birth has a more than twofold increased risk for perinatal death (from one to two in 1000 births) and a threefold increased risk for neonatal seizures or serious neurologic dysfunction (0.4 - 0.6 in 1000 births).

  • ACOG recommends that only carefully selected low-risk mothers should have home delivery. Selection criteria should include no maternal disease, a singleton fetus, cephalic presentation of baby, gestational age of more than 36 to 37 and less than 41 to 42 completed weeks of pregnancy, and spontaneous or outpatient-induced labor.

  • Fetal malpresentation, multiple gestation, or prior cesarean delivery are absolute contraindications to planned out-of-hospital birth.

  • Home births should be attended by certified nurse-midwives, certified midwives, midwives meeting International Confederation of Midwives' Global Standards for Midwifery Education, or physicians practicing obstetrics within an integrated and regulated health system.

  • Home birth care providers should have ready access to institutional consultation and access to safe and timely transport of laboring mothers to nearby hospitals for emergency care.

"Obstetrician-gynecologists recognize that women are seeking home births for a variety of reasons," said Joseph R. Wax, MD, an obstetrician-gynecologist in Portland, Maine, and a primary author of the ACOG opinion, in an ACOG news release. "Our goal is to help them understand and balance the benefits with the risks by providing information to help them come to a medically informed decision."

According to the 2016 opinion statement, each year about 35,000 US births (0.9%) occur at home, with about 25% of these unplanned or unattended. With no provision for professional care during childbirth, home births are associated with higher rates of perinatal and neonatal mortality.

On the plus side, planned out-of-hospital births are associated with less labor induction/augmentation, regional analgesia, fetal heart rate monitoring, episiotomy, and operative vaginal or cesarean delivery. Per 1000 births, for example, a 2015 study found 247 cesarean deliveries for in-hospital delivery vs 53 for at-home delivery, according to the ACOG committee opinion. Labor inductions were 304 vs 48, and augmentations were 263 vs 75.

Home births also entail fewer maternal lacerations and less maternal infection. However, the authors write, "These observations may reflect fewer obstetric risk factors among women planning home births compared with those planning hospital births."

Dr Wax and coauthors note that a larger proportion of those planning home births are mothers who have already given birth, and parous women are significantly less likely to experience obstetric intervention, maternal morbidity, and neonatal morbidity and mortality, regardless of where they deliver their babies.

The authors caution that reports of low perinatal and neonatal mortality rates for planned home birth from other countries with highly integrated health systems and established back-up and transport facilities may not be generalizable to the United States.

Obstet Gynecol. 2016;128:420-421. Abstract

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