Assessment

The number of home births in the United States has significantly increased since 2019. Home births made up approximately 1% of births in 2019 but have since increased to 1.4% in 2021, the highest level seen since 1990. There was a 22% increase between 2019 to 2020 and a 12% increase between 2020 to 2021[1].

Figure 1

The American College of Obstetricians and Gynecologists (ACOG) believes that a hospital or birth center setting is the safest location for childbirth. However, ACOG acknowledges that every birthing person has the right to make pregnancy and childbirth decisions for themselves. Similarly, the American College of Nurse-Midwives (ACNM) supports the birthing person’s right to choose the place of birth that best meets their needs and their newborn’s needs [2]. Home births are desired for various reasons, some of which include minimal interventions, intermittent fetal monitoring, and non-hospital birth settings [3]. Planned home births are associated with higher rates of unassisted vaginal births, as well as lower rates of obstetric interventions and NICU admissions. On the other hand, they are associated with an increase in perinatal deaths, neonatal seizures, and low 5-minute Apgar scores [4].

Despite the increasing numbers of home births, not all planned home births are successful. 23-37% of nulliparous planned home births will require transport to a hospital. Reasons vary from pain management to uncertain fetal status to lack of progress [3]. ACOG believes that existing arrangements with a hospital is a requirement for a planned home birth. The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) also recognizes the importance of having policies and procedures in place to ensure a smooth transition from one birth setting to another [5]. ACNM endorses the Home Birth Summit Best practice guidelines: transfer from planned home birth to hospital [6].

Established transfer processes and protocols are beneficial not only for the birthing person, but also for the community provider and hospital care team (EMS, nurses, midwives, and physicians). Often, pre-conceived biases and miscommunication lead to poor patient care and dissatisfaction for all parties involved. For the birthing person, transfer protocols allow for early discussion of expectations and preparation for hospital transfer. There is transparency around the process and time for questions and concerns to be addressed. For the community provider and hospital team, these processes promote clear communication, timely transfer to the hospital setting, and appropriate transfer of information. The concerns surrounding risk and liability are also mitigated by improved safety, satisfaction, and outcomes.

Given that hospitalists are often on the receiving end of out-of-hospital to hospital birth transfers, SOGH recognizes the importance of easy access to resources for its members. These include examples of transfer guidelines from various states and access to established transfer forms. We hope these resources will help you facilitate the care of these birthing persons.