From Medscape Medical News
Jim Kling
February 2, 2011 — New guidelines from the American College of Obstetricians and Gynecologists' Committee on Obstetric Practice outline recommendations for women who are planning at-home births.
The committee explained that although the absolute risk is low, planned at-home births are associated with a 2- to 3-fold risk for neonatal death compared with hospital births. The committee stated that “it respects the right of a woman to make a medically informed decision about delivery.” Recommendations to inform women interested in planned at-home birth of the risks and how to curb these risks were published in the February 2011 issue of Obstetrics & Gynecology.
To reduce the risks, women who choose at-home birth should be informed about appropriate candidates for home birth; have at hand a certified midwife, certified nurse-midwife, or physician; have consultation access; and ensure timely transport to a nearby hospital if needed.
About 25,000 births occur at home each year (0.6%), but only observational studies have been done to address the relative risks of planned home births. These studies suffer from small sample sizes, lack of controls, reliance on questionable birth certificate data, and other methodological issues. A meta-analysis of observational studies concluded that there is a 2- to 3-fold increased risk for death for planned home births.
The analysis also found that planned home births were associated with fewer maternal interventions, such as epidural analgesia, electronic fetal heart rate monitoring, episiotomy, operative vaginal delivery, and caesarean delivery. There were also fewer third- and fourth-degree lacerations and maternal infections and similar rates of postpartum hemorrhage, perineal laceration, vaginal laceration, and umbilical cord prolapse.
Several criteria should be used to identify good candidates for home delivery, according to the committee. These include the absence of maternal disease previous to or during the pregnancy, singleton fetus, cephalic presentation, minimum gestational age of at least 36 but fewer than 41 completed weeks of pregnancy, spontaneous labor or labor induced as an outpatient, and women who have not been transferred from a referring hospital. Women who have had previous cesarean deliveries should absolutely not undergo planned home birth.
Previous studies have also shown a decrease in neonatal mortality in regions with readily available transport to hospitals. In the United States, studies show that the lowest mortality rates in the presence of a highly trained midwife who is well-connected to the healthcare system.
The meta-analysis has drawn some criticism, primarily because of the deficiencies of the observational studies. The committee's opinion is based on "what I think is a flawed study. It's a concern," said Eugene Declercq, PhD, professor of maternal and child health at the Boston University School of Public Health in Massachusetts, explained in an email correspondence with Medscape Medical News.
The percentage of planned home births will likely continue to grow, and it is incumbent on the medical profession to adapt and integrate the practice, though many physicians remain resistant to working with midwives, said Dr. Declercq. "I'd prefer to have people finding ways to work together, rather than this ceaseless interprofessional battle. The reality is that there are more and more women seeking planned home birth, and we need to make it safer for everybody."
Obstet Gynecol. 2011;117:425-428. Abstract
Jim Kling
February 2, 2011 — New guidelines from the American College of Obstetricians and Gynecologists' Committee on Obstetric Practice outline recommendations for women who are planning at-home births.
The committee explained that although the absolute risk is low, planned at-home births are associated with a 2- to 3-fold risk for neonatal death compared with hospital births. The committee stated that “it respects the right of a woman to make a medically informed decision about delivery.” Recommendations to inform women interested in planned at-home birth of the risks and how to curb these risks were published in the February 2011 issue of Obstetrics & Gynecology.
To reduce the risks, women who choose at-home birth should be informed about appropriate candidates for home birth; have at hand a certified midwife, certified nurse-midwife, or physician; have consultation access; and ensure timely transport to a nearby hospital if needed.
About 25,000 births occur at home each year (0.6%), but only observational studies have been done to address the relative risks of planned home births. These studies suffer from small sample sizes, lack of controls, reliance on questionable birth certificate data, and other methodological issues. A meta-analysis of observational studies concluded that there is a 2- to 3-fold increased risk for death for planned home births.
The analysis also found that planned home births were associated with fewer maternal interventions, such as epidural analgesia, electronic fetal heart rate monitoring, episiotomy, operative vaginal delivery, and caesarean delivery. There were also fewer third- and fourth-degree lacerations and maternal infections and similar rates of postpartum hemorrhage, perineal laceration, vaginal laceration, and umbilical cord prolapse.
Several criteria should be used to identify good candidates for home delivery, according to the committee. These include the absence of maternal disease previous to or during the pregnancy, singleton fetus, cephalic presentation, minimum gestational age of at least 36 but fewer than 41 completed weeks of pregnancy, spontaneous labor or labor induced as an outpatient, and women who have not been transferred from a referring hospital. Women who have had previous cesarean deliveries should absolutely not undergo planned home birth.
Previous studies have also shown a decrease in neonatal mortality in regions with readily available transport to hospitals. In the United States, studies show that the lowest mortality rates in the presence of a highly trained midwife who is well-connected to the healthcare system.
The meta-analysis has drawn some criticism, primarily because of the deficiencies of the observational studies. The committee's opinion is based on "what I think is a flawed study. It's a concern," said Eugene Declercq, PhD, professor of maternal and child health at the Boston University School of Public Health in Massachusetts, explained in an email correspondence with Medscape Medical News.
The percentage of planned home births will likely continue to grow, and it is incumbent on the medical profession to adapt and integrate the practice, though many physicians remain resistant to working with midwives, said Dr. Declercq. "I'd prefer to have people finding ways to work together, rather than this ceaseless interprofessional battle. The reality is that there are more and more women seeking planned home birth, and we need to make it safer for everybody."
Obstet Gynecol. 2011;117:425-428. Abstract
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