Nov 3, 2010

Home vs. Hospital Birth

           A constant small, but clinically important, number of American women choose to deliver at home. Contradictory professional and public policies reflect the polarization and politicization of the controversy surrounding this birth option. Women opting for home birth seek and often attain their goals of a nonmedicalized experience in comfortable, familiar surroundings wherein they maintain situational control. However, home deliveries in developed Western nations are often associated with excess perinatal and neonatal mortality, particularly among nonanomalous term infants.
          A home birth in developed countries is an attended or an unattended childbirth in a non-clinical setting, typically using natural childbirth methods, that takes place in a residence rather than in a hospital or a birth centre, and usually attended by a midwife or lay attendant with expertise in managing home births.
  • Women with access to high-quality medical care may choose home birth because they prefer the intimacy of a home and family-centered experience or desire to avoid a medically-centered experience typical of a hospital or clinical setting. Professionals attending women in home births are usually trained to provide limited medical care, including administering oxygen and managing events like shoulder dystocia, postpartum hemorrhage, repairing perineal tears, and resuscitating infants. Home birth was until the advent of modern medicine the de facto method of delivery.
  •  In developing countries, where women may not be able to afford medical care or it may not be accessible to them, a home birth may be the only option available, and the woman may or may not be assisted by an attendant of any kind.
  • The safety of home birth has been a subject of some controversy, especially among professional physicians groups. A number of studies have shown that the safety of an attended home birth for low-risk women is equal to the risks of giving birth in the hospital or a birthing center, though the quality and reliability of the available data has been called into question. The American Medical Association and the American College of Obstetricians and Gynecologists oppose home birth on the basis that a seemingly uncomplicated birth can still potentially become a medical emergency without warning, and they assert that home birth makes the birth experience a greater priority than safety.
      Wax JR and coauthors ( Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Maine Medical Center, Portland, ME, USA)  note that 1 in 200 women deliver infants at home, for a total of approximately 25,000 annual home deliveries in the United States, most of which seem to have been planned.
  •  The investigators further note that many studies comparing home deliveries with hospital deliveries have not accounted for whether the home delivery was planned; however, planned home deliveries that results in hospitalization often appear in the hospital delivery data, essentially leading to multiple systematic biases in those comparisons (ie, home births that go badly end up in the hospital and are treated as hospital births in comparison studies). By comparing planned home deliveries with planned hospital deliveries, Wax and colleagues sought to reduce some of the bias in reporting outcomes of all home vs hospital deliveries.
         The investigators conducted a systematic search for appropriate studies to include in the meta-analysis. They queried MEDLINE for the period 1950 through November 2009, searching for studies performed in developed Western countries, published in English, and peer-reviewed, that reported both maternal and newborn outcomes and included planned delivery location for each birth.
Maternal outcomes of interest were use 
  • of epidural anesthesia, 
  • electronic fetal heart rate monitoring, 
  • episiotomy, 
  • assisted vaginal delivery (forceps or vacuum), and 
  • cesarean delivery. 
 For infants, outcomes of interest were :
  • 5-minute Apgar score, prematurity (less than 37 weeks' gestation), 
  • low birthweight, 
  • macrosomia, post-due date delivery (42 weeks or more), 
  • need for assisted ventilation,
  • perinatal death (fetal death after 20 weeks), or
  • neonatal death (death of a live-born infant within 28 days of delivery).
   The meta-analysis included 12 studies published between 1984 and 2009;-maternal-infant numbers ranged from 11 to more than 470,000.
  1. Planned home births involved fewer interventions;
  2. they involved less epidural use (9.0% vs 22.9% in planned hospital deliveries), 
  3. lower rates of electronic fetal heart rate monitoring (13.8% vs 62.6%), and
  4. lower rates of cesarean delivery (5% vs 9.3%). 
  5. In general, rates of maternal complications (eg, lacerations) were also lower with planned home deliveries. 
  6. Neonatal outcomes were not favorable with planned home delivery, however. 
  7. Although birth of a premature infant (0.8% vs 4.7%) and birth of a low-birthweight infant (1.3% vs 2.2%) were less common among planned home deliveries than planned hospital deliveries and perinatal death rates were the same in both groups (0.07% vs 0.08%),
  8. neonatal death rates were higher among planned home deliveries (0.20% vs 0.09%),corresponding to an odds ratio of 1.98 (95% CI, 1.19-3.28). 
         Wax and colleagues state that the lower frequencies of premature and low birthweight infants among planned home births suggest that mothers who plan to deliver at home are at lower obstetric risk than those who plan to deliver in hospitals. That likelihood makes the finding of increased neonatal deaths even more compelling: Infants born to mothers with lower obstetric risk should generally be expected to have less problematic neonatal courses. We do not know whether the increased risk for neonatal death with home birth is the result of such factors as lower rates of intrapartum fetal monitoring or the fact that fewer skilled individuals are present at home deliveries. I would add to those possibilities the fact that all home births that require intensive care are by definition "outborn," meaning that they must be transported to a level 3 center to receive appropriate care. Among infants who require intensive care, outborn infants do worse than inborn infants.
      The increased risk for neonatal death among home-delivered infants probably has many contributing factors, and many unmeasured biases could play into these results. However, the fact that pregnancies with fewer complications were overrepresented among planned home births makes the disparity in neonatal outcomes very intriguing.
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