Perinatal Death Tripled in Home Compared With Hospital Births

Nancy A. Melville

March 15, 2019

Babies born outside of hospital were around three times more likely to die than those born in hospital, according to new research from Israel.

"This study matches the findings of larger studies conducted in the United States and confirmed our hypothesis that childbirth in nonhospital settings is far more dangerous than in hospitals," said coauthor Eyal Sheiner, MD, PhD, chair of the Obstetrics and Gynecology Department at Soroka University Medical Center, Be'er-Sheva, Israel, in a press statement from the university.

"There is no question that a hospital provides the most secure environment to give birth, both for mothers and their babies," said Sheiner, whose group presented their work last month at the Society for Maternal-Fetal Medicine's 39th Annual Pregnancy Meeting in Las Vegas, Nevada.

"Even with the advances in modern medicine, childbirth is still traumatic for both the mother and child and it is critical to be prepared for any scenario," he said.

Of Total Deliveries, 1.5% Occurred Outside of Hospital

For the study, lead author Gil Gutvirtz, MD, also of Soroka University Medical Center, and colleagues identified 243,682 singleton deliveries that occurred between 1991 and 2014; 3580 of them (1.5%) occurred outside of hospital.

The nature of the database prevented the researchers from distinguishing between out-of-hospital births that were planned or unplanned.

Women who gave birth outside of hospital were more likely to have had previous pregnancies (95.9% vs 76.1%; P < 0.001) and inadequate prenatal care (26.2% vs 8.7%; P < .001) compared with those who had their babies in hospital.

The rate of perinatal mortality that occurred in-hospital was 5 deaths per 1000 births, compared with 15 deaths per 1000 births outside hospital (P < .001).

After adjusting for factors including gestational age, diabetes, hypertensive disorders, smoking, and ethnicity, the risk of perinatal mortality was still significantly higher among births occurring outside of hospital (adjusted odds ratio [OR], 2.6; P < .001).

Other notable differences between the groups included the fact that preterm births were also more likely to occur in out-of-hospital deliveries (9.1% vs 6.8%; P < 0.001), as was the likelihood of low birth weight (weight < 2500 g; 11.6% vs 6.7%; P < .001).

Diabetes, Hypertension Lower in Out-of-Hospital Group

However, women who delivered out of hospital had a significantly lower likelihood of being diagnosed with diabetes (pregestational or gestational; 2.4% vs 5.0%; P < .001) or hypertensive disorder of pregnancy (chronic, gestational hypertension or pre-eclampsia; 1.2% vs 5.1%; P < .001) compared with the in-hospital birth group.

The inclusion of planned home births could partially explain these findings, as riskier populations would be expected to have a lower likelihood of planning childbirth at home, Sheiner told Medscape Medical News.

Such issues of selection bias are a common concern in studies comparing in-hospital and home births, Sheiner added.

"In some previous studies, births that occurred in the hospital only after complications arose during a planned home birth were included in the 'in-hospital' birth group," Sheiner said.

Nevertheless, the new findings add to substantial evidence of the benefits of delivering in hospital, where life-saving assistance is available, if needed.

"Women, unfortunately, sometimes tend to delay their arrival to the hospital until they are 'ready,'" Sheiner said. "They should be informed regarding the fact that the safest place to deliver is in the hospital."

ACOG Urges Clinicians to Inform Women of Risks, Benefits

According to the American College of Obstetricians and Gynecologists (ACOG), the number of home births in the United States is even lower than that reported in the current study, at just less than 1% of all births (0.9%; about 35,000 births per year), and approximately a quarter of those are unplanned or unattended.

As reported by Medscape Medical News, the latest ACOG recommendations advise: "Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence.

"Specifically, they should be informed that although planned home birth is associated with fewer maternal interventions than planned hospital birth, it also is associated with a more than twofold increased risk of perinatal death (1-2 in 1000) and a threefold increased risk of neonatal seizures or serious neurologic dysfunction (0.4-0.6 in 1000)."

Critical factors when considering home birth include proper candidate selection; availability of a certified nurse, midwife or physician; ready access to consultation; and access to safe and timely transport to nearby hospitals in case it is required, ACOG recommends.

Conditions considered strong contraindications to a planned home birth include fetal malpresentation, multiple gestation, or prior cesarean delivery.

Ultimately, however, the organization defends women's right to ultimately choose where to give 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 authors have reported no relevant financial relationships.

Society for Maternal-Fetal Medicine's 39th Annual Pregnancy Meeting. Presented February 2019. Abstract 854.

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