Planned Home Birth Research Articles

Midwife-assisted planned home birth: an essential component of improving the safety of childbirth in Sub-Saharan Africa.

Hospital births, when compared to out-of-hospital births, have generally led to not only a significantly reduced maternal and perinatal mortality and morbidity but also an increase in certain interventions. A trend seems to be emerging, especially in the US where some women are requesting home births, which creates ethical challenges for obstetricians and the health care organizations and policy makers. In the developing world, a completely different reality exists. Home births constitute the majority of deliveries in the developing world. There are severe limitations in terms of facilities, health personnel and deeply entrenched cultural and socio-economic conditions militating against hospital births. As a consequence, maternal and perinatal mortality and morbidity remain the highest, especially in Sub-Saharan Africa (SSA). Midwife-assisted planned home birth therefore has a major role to play in increasing the safety of childbirth in SSA. The objective of this paper is to propose a model that can be used to improve the safety of childbirth in low resource countries and to outline why midwife assisted planned home birth with coordination of hospitals is the preferred alternative to unassisted or inadequately assisted planned home birth in SSA.

Trends in characteristics of women choosing contraindicated home births.

To characterize the American College of Obstetricians and Gynecologists (ACOG) contraindicated home births and the women who are receiving these births in hopes of identifying venues for intervention. The National Center for Health Statistics (NCHS) birth certificate records from 1990 to 2015 were used. "Planned home births" were defined as those births in which birthplace was coded as "residence" and birth attendant was coded as "certified nurse midwife (CNM)" or "other midwife". Contraindicated home births were defined as "planned home births" from 1990 to 2015 that had one or more of the ACOG risk factors for home births, which include vaginal birth after prior cesarean delivery (VBAC), breech presentation and multiple gestations. A review of trends in contraindicated home births from 1990 to 2015 suggests that they are increasing in number (481-1396) and as a percentage of total births (0.01%-0.04%, P<0.001). There has been an increase in the proportion of college-educated women (31%-51%, P<0.001). Most women receive prenatal care (>95%), which is most frequently initiated in the first trimester. The majority of home births were paid out-of-pocket (65%-69%). The increasing number of contraindicated home births in the United States requires public health action. Home births are likely a matter of choice rather than a lack of resources. It is unclear if women choose home births while knowing the risk or due to a lack of information. Prenatal education about contraindicated home births is possible, as almost all women receive prenatal care.

Resultados de partos domiciliares planejados assistidos por enfermeiras obstétricas

Objetivo: descrever os resultados maternos e neonatais de partos domiciliares planejados assistidos por enfermeiras obstétricas no Distrito Federal, Brasil. Método: estudo descritivo, exploratório, retrospectivo e de caráter quantitativo. A amostra foi composta por 99 prontuários de mulheres que planejaram ter o parto domiciliar com enfermeira obstétrica. Resultados: verificou-se média de idade de 31,6 anos; a maioria tinha ensino superior completo, união estável e exercia atividade remunerada; 63,6% eram primíparas ou tinham apenas cesárea anterior; todas adotaram posições verticalizadas; 87,5% dos recém-nascidos tiveram contato pele a pele e amamentação precoce; todos tiveram clampeamento tardio do cordão umbilical; e 98,7% apgar ≥7 no 5º minuto. Apenas 21,1% das mulheres e 1,2% dos recém-nascidos foram transferidos, todos com desfecho favorável. Conclusão: infere-se o parto domiciliar planejado como uma opção segura, e os resultados corroboram outros achados científicos que revelam uma assistência obstétrica de qualidade colaborando para a promoção do parto domiciliar no Brasil.

Narrativas sobre parto domiciliar planejado após parto hospitalar

Este estudo tem como objetivo conhecer as narrativas de mulheres que tiveram Parto Domiciliar Planejado, com história de parto hospitalar anterior. Trata-se de uma investigação qualitativa, com o uso de duas estratégias metodológicas: observação de grupo de apoio às gestantes e, entrevistas semi-estruturadas com quatro mulheres de um município do interior de São Paulo. As observações dos grupos permitiram a aproximação e contextualização do campo. A análise das entrevistas permitiu o delineamento das categorias temáticas: vulnerabilidade da mulher no hospital; as repercussões da separação precoce mãe e bebê; o parto em casa: informação e afirmação da autonomia e percepção corporal no parto.

Coping with the stigma of home birth: Strategies of engagement and disengagement

BackgroundHome birth in most developed countries is stigmatised. Negative discourses frame women planning home births as risk mothers who put their desire for a particular birthing experience above the health and safety of their children. As a result, one of the primary challenges home-birthing women face during pregnancy is how to cope with this stigma.Participants and procedureThis study was conducted in the upper Midwest region of the United States with women who were planning home births with midwives. Eleven women participated in the study. Data included in-depth interviews, participant-observation field notes, and content from one participant’s blog. Data were analysed using inductive content analysis.ResultsParticipants coped with home birth stigma in three ways: (1) avoidance, (2) engaging in an education campaign, and (3) focusing on a family tradition of home birth. These responses represent both disengagement and engagement approaches to coping. Nine participants exhibited one dominant coping strategy: three relied on avoidance, three on an education campaign, and three on family tradition. Two participants used more than one approach. Both of these participants used avoidance and family tradition.ConclusionsHome birth stigma is a source of chronic stress for women who choose to give birth at home. Women cope with this stress in a number of ways. Interventions to increase women’s coping resources and processes may be helpful. Changing the environment through efforts to destigmatise home birth may reduce the overall stress experienced by home-birthing women and improve their wellbeing.

Home birth integration into the health care systems of eleven international jurisdictions.

The purpose of this study was to develop assessment criteria that could be used to examine the level of integration of home birth within larger health care systems in developed countries across 11 international jurisdictions. An expert panel developed criteria and a definition to assess home birth integration within health care systems. We selected jurisdictions based on the publications that were eligible for inclusion in our systematic review and meta-analysis on planned place of birth. We sent the authors of the included publications a questionnaire about home birth practitioners and practices in their respective health care system at the time of their studies. We searched published peer-reviewed, non-peer-reviewed, and gray literature, and the websites of professional bodies to document information about home birth integration in each jurisdiction based on our criteria. Where information was lacking, we contacted experts in the field from the relevant jurisdiction. Home birth is well integrated into the health care system in British Columbia (Canada), England, Iceland, the Netherlands, New Zealand, Ontario (Canada), and Washington State (USA). Home birth is less well integrated into the health care system in Australia, Japan, Norway, and Sweden. This paper is the first to propose criteria for the evaluation of home birth integration within larger maternity care systems. Application of these criteria across 11 international jurisdictions indicates differences in the recognition and training of home birth practitioners, in access to hospital facilities, and in the supplies and equipment available at home births, which give rise to variation in the level of integration across different settings. Standardized criteria for the evaluation of systems integration are essential for interpreting planned home birth outcomes that emerge from contextual differences.

Effect of Maternal and Pregnancy Risk Factors on Early Neonatal Death in Planned Home Births Delivering at Home

ObjectiveThe prevalence of home birth in the United States is increasing, although its safety is undetermined. The objective of this study was to investigate the effects of obstetrical risk factors on early neonatal death in planned home births delivering at home. MethodsThe authors conducted a retrospective 3-year cohort study consisting of planned home births that delivered at home in the United States between 2011 and 2013. The study excluded infants with congenital and chromosomal anomalies and infants born at ≤34 weeks' gestation. Multivariate logistic regression models were used to estimate the adjusted effects of individual obstetrical variables on early neonatal deaths within 7 days of delivery. ResultsDuring the study period, there were 71 704 planned and delivered home births. The overall early neonatal death rate was 1.5 deaths per 1000 planned home births. The risks of early neonatal death were significantly higher in nulliparous births (OR 2.71; 95% CI 1.71–4.31), women with a previous CS (OR 2.62, 95% CI 1.25–5.52), non-vertex presentations (OR 4.27; 95% CI 1.33–13.75), plural births (OR 9.79; 95% CI 4.25–22.57), preterm births (OR 4.68; 95% CI 2.30–9.51), and births at ≥41 weeks of gestation (OR 1.76; 95% CI 1.09–2.84). ConclusionEarly neonatal deaths occur more commonly in certain obstetrical contexts. Patient selection may reduce adverse neonatal outcomes among planned home births.

Contraindications in planned home birth in Iceland: A retrospective cohort study

ObjectivesIcelandic national guidelines on place of birth list contraindications for home birth. Few studies have examined the effect of contraindication on home birth, and none have done so in Iceland. The aim of this study was to examine whether contraindications affect the outcome of planned home birth or have a different effect at home than in hospital. MethodsThe study is a retrospective cohort study on the effect of contraindications for home birth on the outcome of planned home (n = 307) and hospital (n = 921) birth in 2005–2009. Outcomes were described for four different groups of women, by exposure to contraindications (unexposed vs. exposed) and planned place of birth (hospital vs. home). Linear and logistic regression analysis was used to evaluate the effect of the contraindications under study and to detect interactions between contraindications and planned place of birth. ResultsThe key findings of the study were that contraindications were related to higher rates of adverse maternal and neonatal outcomes, regardless of place of birth; women exposed to contraindications had higher rates of adverse outcomes in planned home birth; and healthy, unexposed women had higher rates of adverse outcomes in planned hospital birth. Contraindications significantly increased the risk of transfer in labour and postpartum haemorrhage in planned home births. ConclusionThe defined contraindications for home birth had a negative effect on maternal and neonatal outcomes in Iceland, regardless of place of birth. The study results do not contradict the current national guidelines on place of birth.

Differences in optimality index between planned place of birth in a birth centre and alternative planned places of birth, a nationwide prospective cohort study in The Netherlands: results of the Dutch Birth Centre Study

ObjectivesTo compare the Optimality Index of planned birth in a birth centre with planned birth in a hospital and planned home birth for low-risk term pregnant women who start labour...

When general practitioners meet new evidence: an exploratory ethnographic study

Objective: To explore how general practitioners (GPs) think and act when presented with new evidence in relation to planned home birth and a proposal to change information practices.Design: Exploratory ethnographic study of GPs. The GPs were encountered one or more times during a two-year period, 2011–2013, while the author tried to set up formal focus group interviews. Dialogues about the evidence, personal experiences, values and other issues unavoidably occurred. Field notes were written concomitantly.Setting: Danish GPs, primarily in Copenhagen.Subjects: Fifty Danish GPs.Results: The GPs reacted very differently, both spontaneously and later. Spontaneous reactions were often emotional involving private and professional experiences whereas later reactions were more influenced by rational deliberations. Approximately half the GPs (n = 18) who were asked whether they would personally hand out the local information leaflet about home birth were prepared to do so. The time lag between presentation of the evidence and the GPs’ decision to hand out the leaflets was up to one and a half year.Conclusions: A significant number of GPs were prepared to change their information practices. However, for many GPs, the new evidence challenged previous perceptions, and ample time and resources for dialogue, deliberations and adaptation to local circumstances were required to accommodate change.Implications: Changing information practices on a larger scale will require a systematic approach involving key stakeholders.Key PointsCurrent awareness•Patients and pregnant women should receive evidence-based information about possible choices of care – also in relation to place of birth.Most important results•Doctors often find the new evidence supporting planned home birth counterintuitive and spontaneously react emotionally rather than rationally to the evidence.•The new evidence challenging previous views elicits fast, emotional reactions, later deliberate reflections, perhaps cognitive dissonance and, finally, for some, change in clinical practice.Significance for the readers•The findings may be applicable to other fields where an evidence-based choice between an interventionist and a conservative approach is relevant.

Planned home compared with planned hospital births: mode of delivery and Perinatal mortality rates, an observational study

BackgroundTo compare the mode of delivery between planned home versus planned hospital births and to determine if differences in intervention rates could be interpreted as over- or undertreatment.MethodsIntervention and perinatal mortality rates were obtained for 679,952 low-risk women from the Dutch Perinatal Registry (2000–2007). Intervention was defined as operative vaginal delivery and/or caesarean section. Perinatal mortality was defined as the intrapartum and early neonatal mortality rate up to 7 days postpartum.Besides adjustment for maternal and care factors, we included for additional casemix adjustment: presence of congenital abnormality, small for gestational age, preterm birth, or low Apgar score. The techniques used were nested multiple stepwise logistic regression, and stratified analysis for separate risk groups. An intention-to-treat like analysis was performed.ResultsThe intervention rate was lower in planned home compared to planned hospital births (10.9% 95% CI 10.8–11.0 vs. 13.8% 95% CI 13.6–13.9). Intended place of birth had significant impact on the likelihood to intervene after adjustment (planned homebirth (OR 0.77 95% CI. 0.75–0.78)).The mortality rate was lower in planned home births (0.15% vs. 0.18%). After adjustment, the interaction term home- intervention was significant (OR1.51 95% CI 1.25–1.84). In risk groups, a higher perinatal mortality rate was observed in planned home births.ConclusionsThe potential presence of over- or under treatment as expressed by adjusted perinatal mortality differs per risk group. In planned home births especially multiparous women showed universally lower intervention rates. However, the benefit of substantially fewer interventions in the planned home group seems to be counterbalanced by substantially increased mortality if intervention occurs.

The European Court of Human Rights on planned home birth: resolution of a paradoxical ruling.

On November 15, 2016, the European Court of Human Rights issued its judgment in the case of Krejzova v. the Czech Republic, which concerned the policy of the Czech State not to provide skilled attendance by midwives at planned home births. The issue was whether this policy violated Article 8 of the European Convention on Human Rights: “Everyone has the right to respect for his private and family life, his home and his correspondence.”(1) The Czech health policy before the Court did not prohibit unattended planned home birth but it created technical requirements for attendance at planned home birth that had the effect of prohibiting attendance by midwives. This article is protected by copyright. All rights reserved.

Committee Opinion No 697 Summary: Planned Home Birth.

In the United States, approximately 35,000 births (0.9%) per year occur in the home. Approximately one fourth of these births are unplanned or unattended. 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. Importantly, women should be informed that several factors are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes. These factors include the appropriate selection of candidates for home birth; the availability of a certified nurse-midwife, certified midwife or midwife whose education and licensure meet International Confederation of Midwives' Global Standards for Midwifery Education, or physician practicing obstetrics within an integrated and regulated health system; ready access to consultation; and access to safe and timely transport to nearby hospitals. The Committee on Obstetric Practice considers fetal malpresentation, multiple gestation, or prior cesarean delivery to be an absolute contraindication to planned home birth.

Committee Opinion No. 697: Planned Home Birth.

In the United States, approximately 35,000 births (0.9%) per year occur in the home. Approximately one fourth of these births are unplanned or unattended. 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. Importantly, women should be informed that several factors are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes. These factors include the appropriate selection of candidates for home birth; the availability of a certified nurse-midwife, certified midwife or midwife whose education and licensure meet International Confederation of Midwives' Global Standards for Midwifery Education, or physician practicing obstetrics within an integrated and regulated health system; ready access to consultation; and access to safe and timely transport to nearby hospitals. The Committee on Obstetric Practice considers fetal malpresentation, multiple gestation, or prior cesarean delivery to be an absolute contraindication to planned home birth.

Planned Home Birth In Victoria From 2000 to 2013 Among ‘Higher Risk’ Women

Planned Home Birth In Victoria From 2000 to 2013 Among ‘Higher Risk’ Women

Serious adverse neonatal outcomes such as 5-minute Apgar score of zero and seizures or severe neurologic dysfunction are increased in planned home births after cesarean delivery.

The United States is with 37,451 home births in 2014 the country with the largest absolute number of home births among all developed countries. The purpose of this study was to examine the occurrence and risks of a 5-minute Apgar score of zero and neonatal seizures or serious neurologic dysfunction in women with a history of prior cesarean delivery for planned home vaginal birth after cesarean (VBAC), compared to hospital VBAC and hospital birth cesarean deliveries for term normal weight infants in the United States from 2007–2014. We report in this study outcomes of women who had one or more prior cesarean deliveries and included women who had a successful vaginal birth after a trial of labor after cesarean (TOLAC) at home and in the hospital, and a repeat cesarean delivery in the hospital. We excluded preterm births (<37 weeks) and infants weighing under 2500 g. Hospital VBACS were the reference. Women with a planned home birth VBAC had an approximately 10-fold and higher increase in adverse neonatal outcomes when compared to hospital VBACS and hospital repeat cesarean deliveries, a significantly higher incidence and risk of a 5-minute Apgar score of 0 of 1 in 890 (11.24/10,000, relative risk 9.04, 95% confidence interval 4–20.39, p<.0001) and an incidence of neonatal seizures or severe neurologic dysfunction of 1 in 814 (Incidence: 12.27/10,000, relative risk 11.19, 95% confidence interval 5.13–24.29, p<.0001). Because of the significantly increased neonatal risks, obstetric providers should therefore not offer or perform planned home TOLACs and for those desiring a VBAC should strongly recommend a planned TOLAC in the appropriate hospital setting. We emphasize that this stance should be accompanied by effective efforts to make TOLAC available in the appropriate hospital setting.

Transfers to Hospital in Planned Home Birth in 4 Nordic Countries: A Prospective Cohort Study

(Acta Obstet Gynecol Scand. 2016;95:420–428) Research has shown that of women planning to give birth at home in western countries up to one-third are transferred to a hospital during labor or after the birth. The objective of this study was to describe how often women and neonates were transferred from home to a hospital during labor or after birth; the indications for transfer; how long before or after birth the transfer occurred; the mode and duration of transfer; and the proportion of transfers classified as potentially urgent.

Utah obstetricians' opinions of planned home birth and conflicting NICE/ACOG guidelines: A qualitative study.

The United Kingdom's National Institute for Health and Care Excellence (NICE) recently published recommendations that support planned home birth for low-risk women. The American College of Obstetricians and Gynecologists (ACOG) remains wary of planned home birth, asserting that hospitals and birthing centers are the safest birth settings. Our objective was to examine opinions of obstetricians in Salt Lake City, Utah about home birth in the context of rising home birth rates and conflicting guidelines. Participants were recruited through online searches of Salt Lake City obstetricians and through snowball sampling. We conducted individual interviews exploring experiences with and attitudes toward planned home birth and the ACOG/NICE guidelines. Fifteen obstetricians who varied according to years of experience, location of medical training, sex, and subspecialty (resident, OB/GYN, maternal-fetal medicine specialist) were interviewed. Participants did not recommend home birth but supported a woman's right to choose her birth setting. Obstetrician opinions about planned home birth were shaped by misconceptions of home birth benefits, confusion surrounding the scope of care at home and among home birth providers, and negative transfer experiences. Participants were unfamiliar with the literature on planned home birth and/or viewed the evidence as unreliable. Support for ACOG guidelines was high, particularly in the context of the United States health care setting. Physician objectivity may be limited by biases against home birth, which stem from limited familiarity with published evidence, negative experiences with home-to-hospital transfers, and distrust of home birth providers in a health care system not designed to support home birth.

Planned home births: the need for additional contraindications

Planned home births in the United States are associated with fewer interventions but with increased adverse neonatal outcomes such as perinatal and neonatal deaths, neonatal seizures or serious neurologic dysfunction, and low 5-minute Apgar scores. The American College of Obstetricians and Gynecologists' Committee on Obstetric Practice states that, to reduce perinatal death and to improve outcomes at planned home births, strict criteria are necessary to guide the selection of appropriate candidates for planned home birth. The committee lists 3 absolute contraindications for a planned home birth: fetal malpresentation, multiple gestations, and a history of cesarean delivery. The aim of this study was to evaluate whether there are risk factors that should be considered contraindications to planned home births in addition to the 3 that are listed by the American College of Obstetricians and Gynecologists. We conducted a population-based, retrospective cohort study of all term (≥37 weeks gestation), normal weight (≥2500 grams), singleton, nonanomalous births from 2009-2013 using the Centers for Disease Control and Prevention's period-linked birth-infant death files that allowed for identification of intended and unintended home births. We examined neonatal deaths (days 0-27 after birth) across 3 groups (hospital-attended births by certified nurse midwives, hospital-attended births by physicians, and planned home births) for 5 risk factors: 2 of the 3 absolute contraindications to home birth listed by the American College of Obstetricians and Gynecologists (breech presentation and previous cesarean delivery) and 3 additional risk factors (parity [nulliparous and multiparous], maternal age [women <35 and ≥35 years old], and gestational age at delivery [37-40 and ≥41 weeks]). The overall risk of neonatal death was significantly higher in planned home births (12.1 neonatal death/10,000 deliveries; P<.001) compared with hospital births by certified nurse midwives (3.08 neonatal death/10,000 deliveries) or physicians (5.09 neonatal death/10,000 deliveries). Neonatal mortality rates were increased significantly at planned home births, with the following individual risk factors: breech presentation (neonatal mortality rate, 127.52/10.000 births), nulliparous pregnant women (neonatal mortality rate, 22.5/10,000), previous cesarean delivery (18.91/10,000 births), and a gestational age ≥41 weeks (neonatal mortality rate, 17.17/10,000 births). Planned home births with ≥1 of the 5 risk factors had significantly higher neonatal death risks compared with deliveries with none of the risks. Neonatal death risk was further increased when a woman's age of ≥35 years was combined with either a first-time birth or a gestational age of ≥41 weeks. In this study, we show 2 risk factors with significantly increased neonatal mortality rates at planned home births in addition to the 3 factors that are listed by the American College of Obstetricians and Gynecologists. These additional risks factors have neonatal mortality rates that are approaching or exceeding those for planned home birth after cesarean delivery: first-time births and a gestational age of ≥ 41 weeks. Therefore, 2 additional risk factors (first-time births and a gestational age of ≥41 weeks) should be added to the 3 absolute contraindications of planned home births that are listed by the American College of Obstetricians and Gynecologists (previous cesarean delivery, malpresentation, multiple gestations) for a total of 5 contraindications for planned home births.

In This Issue—Making Home Birth Even Safer for Mothers and Babies

ABSTRACTThere is research that supports the safety of planned home birth for healthy women, and more women in the United States are choosing to give birth at home. Strategic initiatives developed at the Home Birth Summit in 2011 address issues related to planned home birth including integration into the health system. This editorial discusses the ongoing work on these initiatives including the development and endorsement of best practice guidelines for safe transfer from home to hospital. The American College of Obstetricians and Gynecologists revised policy statement on home birth calls for the integration of home birth into the health system. This is an important step in making home birth even safer for mothers and babies.