Planned home births associated with tripling of neonatal mortality rate vs. planned hospital births

July 1, 2010, Elsevier

About 1 in 200 women in the US delivers her baby at home, with approximately 75% of these low-risk, single-baby births planned in advance as home deliveries. In a study published online today by the American Journal of Obstetrics & Gynecology (AJOG), researchers from Maine Medical Center, Portland, Maine, analyzed the results of multiple studies from around the world. They report that less medical intervention, characteristic of planned home births, is associated with a tripling of the neonatal mortality rate compared to planned hospital deliveries. Planned home births were characterized by a greater proportion of deaths attributed to respiratory distress and failed resuscitation.

"Our findings raise the question of a link between the increased neonatal mortality among planned home births and the decreased obstetric intervention in this group," according to lead investigator Joseph R. Wax, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maine Medical Center. "Women choosing home birth, particularly low-risk individuals who had given birth previously, are in large part successful in achieving their goal of delivering with less morbidity and medical intervention than experienced during hospital-based childbirth. Of significant concern, these apparent benefits are associated with a doubling of the neonatal mortality rate overall and a near tripling among infants born without congenital defects (nonanomalous). …These findings echo concerns raised in a recent large US cohort study in which home births experienced significantly more 5-minute Apgar scores < 7 as compared to low-risk term hospital births, suggesting an increased need for resuscitation among home births. therefore, the personnel, training, and equipment available for neonatal resuscitation represent other possible contributors to the excessive neonatal mortality rate among planned home births."

Investigators conducted a rigorous metaanalysis through which the peer-reviewed medical literature was searched for studies that contained information about home and hospital deliveries, including morbidity and mortality data for both mother and child. They extracted data for a total of 342,056 planned home and 207,551 planned hospital deliveries. The results are striking as women planning home births were of similar and often lower obstetric risk than those planning hospital births.

In contrast to rates, investigators observed that perinatal for planned home and hospital births were similar overall, as well as just among nonanomalous offspring.

Mothers in planned home births experienced significantly fewer medical interventions including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, and operative vaginal and cesarean deliveries. Likewise, women intending home deliveries had fewer infections, perineal and vaginal lacerations, hemorrhages, and retained placentas. Data also showed that planned home births are characterized by less frequent premature and low birthweight infants.

AJOG Editors-in- Chief Thomas J. Garite, MD, and Moon H. Kim, MD, commented that "The report by Wax et al supports the safety of planned home birth for the mother, but raises serious concerns about increased risks of home birth for the newborn infant. This topic deserves more attention from public health officials at state and national levels."

More information: The article is "Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis" by Joseph R. Wax, MD; F. Lee Lucas, PhD; Maryanne Lamont, MLS; Michael G. Pinette, MD; Angelina Cartin; and Jacquelyn Blackstone, DO. It will appear in the American Journal of Obstetrics & Gynecology, Volume 203, Issue 3 (September 2010). DOI: 10.1016/j.ajog.2010.05.028

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