Hospitals and birth centers remain safest setting for giving birth, US obstetricians say

BMJ 2016; 354 doi: (Published 29 July 2016) Cite this as: BMJ 2016;354:i4217
  1. Michael McCarthy
  1. Seattle

Women considering a planned home birth should be fully informed of the benefits and risks when making their choice, such as a reduced risk of medical interventions but increased risk of perinatal death and neonatal seizures or neurologic dysfunction, the American College of Obstetricians and Gynecologists’ committee on obstetric practice has advised in a new opinion document.1

After reviewing the latest evidence the committee said that women should be informed that, although a planned home birth is associated with fewer maternal interventions than planned hospital birth, it is also associated with more than twice the risk of perinatal death (3.9 per 1000 births v 1.8 per 1000 hospital births; odds ratio 2.43) and a threefold increased risk of neonatal seizures or serious neurologic dysfunction (0.6 to 1.3 per 1000 births v 0.22 to 0.4 per 1000 hospital births; odds ratio 3.08 to 3.80).

“Although the American College of Obstetricians and Gynecologists 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 committee said. “Importantly, women should be informed that several factors are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes.”

Factors that should be considered in the decision to deliver at home include the health and parity of the mother; the availability of a qualified nurse-midwife, midwife, or physician practicing within an integrated health system; ready access to consultation; and access to safe and timely transport to nearby hospitals, the committee said. Fetal malpresentation, multiple gestation, and prior cesarean delivery are absolute contraindications to planned home birth, the committee added.

It noted that many women planning a home birth do so because of a desire to avoid medical intervention and the hospital atmosphere, and it acknowledged that recent studies had found planned home births to be associated with fewer interventions—such as labor induction, episiotomy, operative vaginal delivery, or cesarean delivery—than hospital births. Planned home births were also associated with fewer vaginal and perineal lacerations and less maternal infectious morbidity, the committee said.

However, it found that high quality evidence informing the debate over the safety of home birth remained limited. Most information has come from observational studies, and no adequate randomized clinical trials have been conducted to date. “In developed countries where home birth is more common than in the United States, attempts to conduct such studies have been unsuccessful, largely because pregnant women have been reluctant to participate in clinical trials that involve randomization to home or hospital birth,” the committee said.

The availability of safe and timely transfer to hospital of a woman in labor is an important factor in decision making because the risk of needing transport to a hospital is 23-37% among nulliparous women and 4-9% among multiparous women. One reason for the relatively low perinatal and newborn mortality rates reported among planned home births in some locations, such as the Netherlands, is that those places have highly integrated healthcare systems with established protocols for intrapartum transport, the committee said. This is not necessarily true in the US, where local health systems may be less integrated.

“The college believes that the availability of timely transfer and an existing arrangement with a hospital for such transfers is a requirement for consideration of a home birth,” the committee said.

It added, “When antepartum, intrapartum, or postpartum transfer of a woman from home to a hospital occurs, the receiving health care provider should maintain a nonjudgmental demeanor with regard to the woman and those individuals accompanying her to the hospital.”


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