Planned Home Birth Mortality Rates Distress

Elizabeth Millard

February 11, 2020

About 2% of deliveries in the United States are home births, but they account for a significantly higher proportion of neonatal mortality, even when planned in advance, results from a new study indicate.

"The safety of birth varies based on location and who is attending," said study investigator Amos Grünebaum, MD, professor of obstetrics and gynecology at the Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York.

"When you have a planned home birth with a direct-entry midwife, you are four times more likely to have a baby who dies," he told Medscape Medical News. "That's unacceptable."

The number of planned home births rose significantly in the mid-2000s, Grünebaum reported at the Society for Maternal–Fetal Medicine 2020 Annual Pregnancy Meeting in Grapevine, Texas.

There were 26,667 home births in the United States in 2007; this rose to 38,343 in 2017, where it seems to have plateaued, according to Centers for Disease Control and Prevention (CDC) records.

For their study, Grünebaum and his colleague, Frank Chervenak, MD, also at Zucker, assessed neonatal mortality using data from the CDC Linked Birth and Infant Death Records from 2007 to 2016.

During the study period, the rate of neonatal mortality was 3.27 per 10,000 live hospital births attended by a certified nurse midwife. By comparison, rates were significantly higher for home births.

Table. Neonatal Mortality for Home Births Compared With Hospital Births Attended by a Certified Nurse Midwife
Home Births Rate per 10,000 Live Births Odds Ratio P Value
With certified nurse midwife 9.48 2.90 <.0001
With direct-entry midwife 12.44 3.81 <.0001
Intended 13.66 4.19 <.0001
Unintended or unplanned 27.98 8.58 <.0001

These differences increased further when patients were stratified for recognized risk factors.

In a previous study of intended home births from 2016 to 2018 that Grünebaum and Chervenak were involved in, more than 60% of the pregnancies had risk factors that could lead to complications and possible maternal or neonatal mortality, including previous cesarean delivery, high maternal age, obesity, and first-time births.

In both these studies, "we see that the risk is always higher with a planned home birth" than with a hospital birth, said Grünebaum. And "in the current study, we highlight how that risk can be increased with the use of a direct-entry midwife."

Unlike certified nurse midwives, who receive a standard education, direct-entry midwives are not required to have any specific level of training, he explained. In some cases, the only form of training is an apprenticeship with an experienced midwife.

In the United States, people can call themselves a direct-entry midwife without having graduated from high school. However, these same people would not qualify "as midwives most places in the world because they wouldn't meet the minimum standards of training."

"In New York, I get my hair cut by someone who's certified and has the training for that, and I can only use a plumber who has an official license," he pointed out. "But with direct-entry midwives, anything goes.

The takeaway message is that if a woman wants a midwife, she should be able to employ one, but she should do extensive research into the midwife's training and experience, he explained.

"Women need to know that there is a much higher chance of a baby dying with a home delivery than a hospital delivery," he added. "Because of that, hospitals also need to step up their efforts to create a home-like experience for labor and delivery, so there can be the best of both worlds."

Call for Oversight

The surprising thing about this study is not the results, "it's that this seems to be the first time someone has looked at these data," said G. Thomas Ruiz, MD, an obstetrician–gynecologist at MemorialCare Orange Coast Medical Center in Fountain Valley, California.

"I can tell you, anecdotally, that we've seen unfortunate complications like this many times," he told Medscape Medical News.

The work by untrained midwives detracts from that being done by certified nurse midwives who either work in hospitals or attend home births, and who follow the stringent guidelines of the American College of Nurse-Midwives, he added.

Those guidelines dictate a set of best practices, such as selecting a location in the home for delivery that will allow for an ambulance gurney, if necessary, and understanding the timeframe for calling for medical assistance in the event of complications.

Many of these guidelines are used by the in-hospital midwives at MemorialCare, Ruiz reported.

The difficulty with home births is that when something goes wrong...and a repair has to be done, the wait time can be catastrophic.

No pregnancy should be considered low risk until the mother has successfully come back for a wellness check at her first postpartum visit, said Denise Castellanos, a certified nurse midwife at MemorialCare who has attended some home births.

"The difficulty with home births is that when something goes wrong, such as a mother who's bleeding unexpectedly, and a repair has to be done, the wait time can be catastrophic," she told Medscape Medical News. "There could be negative consequences for a lifetime."

Both Ruiz and Castellanos, as well as Grünebaum, emphasized that this study should not be interpreted as depicting midwives in a negative light — particularly certified nurse midwives — but rather, it should be a call for better training and oversight for home births.

"I'm a big fan of midwives," said Ruiz. "I'm very impressed by how much skill and training they bring when handling delivery. But with the way birthing centers are working to create a home-like atmosphere, I believe you can have the best of both worlds: a home experience with the resources of a hospital."

Society for Maternal–Fetal Medicine (SMFM) 2020 Annual Pregnancy Meeting: Abstract 54. Presented February 7, 2020.

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