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Home births more risky than hospital deliveries

Babies born at home are more likely to lack pulse after five minutes

HOME BIRTH, STATE BY STATE This map shows home births are more common in the northwestern U.S. than in southeastern states.
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The risks attached to giving birth in the home, even with a midwife present, are greater than in the hospital, an analysis of U.S. birth records suggests. Babies born at home are 10 times more likely to lack a pulse and be unresponsive when they are five minutes old.

Despite the increase, the overall risk of such a dire condition was low regardless of birth location, researchers report in the October American Journal of Obstetrics and Gynecology. Of every 1,000 babies born at home with a midwife attending, 1.6 lacked a pulse and weren’t breathing five minutes after birth, the researchers found. For hospital births with a doctor, the rate was 0.16 per 1,000 infants.

“It’s a very low occurrence rate,” says Michael Malloy, a neonatologist at the University of Texas Medical Branch in Galveston, who wasn’t part of the study. “I’m not a great advocate of home delivery. It scares me. But I can see the other side, if a woman wishes to have the experience of doing this at home.”

The risk seen in this study far exceeds those from previous studies. Those had indicated that, compared with hospital delivery, giving birth at home doubled or tripled the risk of neonatal death. The American College of Obstetricians and Gynecologists’ guidelines cite that level of risk in home birth and caution that women delivering at home should have ready access to transport to a hospital.

Location matters, says study coauthor Amos Grunebaum, an obstetric gynecologist at New York Presbyterian Hospital and Weill Cornell Medical Center. If complications arise during  home delivery, it can be dangerous for mother or baby. Women lose time racing to a hospital, he says. “It’s often difficult to play ‘beat the clock’ to save the baby.”

The analysis relied on 13 million birth certificates from 2007 to 2010. The vast majority of births occurred in hospitals. Of more than 60,000 home-births attended by a midwife, 98 infants lacked pulse, breath, activity and response to stimulation, and were blue or pale five minutes after birth. Babies born at home were also four times as likely to have seizures as babies born in the hospital, the data showed.

But birth certificate data can be subjective and unreliable, says Christina Johnson, director of professional practice and health policy for the American College of Nurse-Midwives in Silver Spring, Md. What’s more, these data failed to reveal how many of the pulseless babies were resuscitated. Since the study doesn’t provide the babies’ fate, she says, “it’s a little bit alarmist.”

Grunebaum counters that such infants “are essentially dead.” Reviving them requires extraordinary measures involving a medical staff and an oxygen tube, he says.

Peter Brocklehurst, an obstetrician at University College London, finds the new data difficult to interpret. Those who chose home birth were self-selected and therefore don’t represent a typical sample of the population. Compared with women giving birth at a hospital, women at home were more likely to be white, age 30 or over, carrying a large baby and delivering late – 41 weeks or more into gestation. Some of those characteristics affect birth risks negatively, he says. Brocklehurst also wonders to what extent the midwives providing home birth care worked within acceptable practice guidelines.

Johnson notes that 97 percent of certified nurse-midwives, who typically hold masters degrees, work in hospitals. Many home-birth midwives have lesser credentials and training, and qualifications vary from state to state. In this study, in-hospital births facilitated by midwives had fewer problems than the physician-assisted births.

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