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Planned home births: the need for additional contraindications.
Am J Obstet Gynecol. 2017 04; 216(4):401.e1-401.e8.AJ

Abstract

BACKGROUND

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.

OBJECTIVE

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.

STUDY DESIGN

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]).

RESULTS

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.

CONCLUSIONS

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.

Authors+Show Affiliations

Department of Obstetrics and Gynecology, Weill Medical College of Cornell University, New York, NY. Electronic address: amg2002@med.cornell.edu.Department of Obstetrics and Gynecology, Weill Medical College of Cornell University, New York, NY.Department of Obstetrics and Gynecology, Weill Medical College of Cornell University, New York, NY.Center for Mother and Child, Philipps University, Marburg, Germany and Clara Angela Foundation, Berlin, Germany.Department of Obstetrics and Gynecology, Weill Medical College of Cornell University, New York, NY.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

28153656

Citation

Grünebaum, Amos, et al. "Planned Home Births: the Need for Additional Contraindications." American Journal of Obstetrics and Gynecology, vol. 216, no. 4, 2017, pp. 401.e1-401.e8.
Grünebaum A, McCullough LB, Sapra KJ, et al. Planned home births: the need for additional contraindications. Am J Obstet Gynecol. 2017;216(4):401.e1-401.e8.
Grünebaum, A., McCullough, L. B., Sapra, K. J., Arabin, B., & Chervenak, F. A. (2017). Planned home births: the need for additional contraindications. American Journal of Obstetrics and Gynecology, 216(4), e1-e8. https://doi.org/10.1016/j.ajog.2017.01.012
Grünebaum A, et al. Planned Home Births: the Need for Additional Contraindications. Am J Obstet Gynecol. 2017;216(4):401.e1-401.e8. PubMed PMID: 28153656.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Planned home births: the need for additional contraindications. AU - Grünebaum,Amos, AU - McCullough,Laurence B, AU - Sapra,Katherine J, AU - Arabin,Birgit, AU - Chervenak,Frank A, Y1 - 2017/01/30/ PY - 2016/11/11/received PY - 2016/12/19/revised PY - 2017/01/13/accepted PY - 2017/2/6/pubmed PY - 2017/6/1/medline PY - 2017/2/4/entrez KW - breech KW - home birth KW - maternal age KW - midwife KW - neonatal death KW - parity KW - previous cesarean delivery SP - 401.e1 EP - 401.e8 JF - American journal of obstetrics and gynecology JO - Am J Obstet Gynecol VL - 216 IS - 4 N2 - BACKGROUND: 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. OBJECTIVE: 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. STUDY DESIGN: 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]). RESULTS: 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. CONCLUSIONS: 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. SN - 1097-6868 UR - https://www.unboundmedicine.com/medline/citation/28153656/Planned_home_births:_the_need_for_additional_contraindications_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0002-9378(17)30119-9 DB - PRIME DP - Unbound Medicine ER -