Other geographic factors also determine who chooses out-of-hospital birth. Regional differences in laws that apply to home births, as well as the availability of a trained provider to attend a home birth, can affect a woman’s willingness to pursue such an option. Currently, the Pacific Northwest (Alaska, Oregon and Montana) have the highest percentages of home births.
The type of provider may also be important for a successful home birth. A recent study from New Zealand showed that medical-led births were associated with lower odds of low Apgar scores (OR, 0.52; 95% CI, 0.43–0.64; P<.001), lower rates of hypoxia/neonatal encephalopathy (OR, 0.62; 95% CI, 0.51-0.75; P<.001) and birth-related asphyxia (OR, 0.45; 95% CI, 0.32-0.62; P<.001) (Wernham, 2016). There were either no or small differences for gestational age, neonatal mortality or stillbirth. The study was limited by the fact that New Zealand uses more midwives who act autonomously than is the case in the US, so it may not be appropriate to generalize the results. Further, how midwives in the study were trained was not clarified; “midwives” are not a uniform group (CNMs vs. lay midwives).
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The large number of VBACs at home is concerning. The high rate may be because many women who desire a trial of labor after cesarean can only do it as a planned home birth — it is not offered in many US hospitals. A recent study compared 4544 planned, midwife-assisted home births after cesarean delivery with hospital births (Grunebaum, 2016). The incidence of an Apgar score of 0 was 0.093 per 1000 among hospital births and 0.660 per 1000 among home births (risk ratio [RR], 7.09; 95% CI, 2.27-22.13; P<.001). The incidence of seizure or serious neurologic dysfunction was 0.192 per 1000 for hospital births and 1.98 per 1000 for home births (RR, 10.15; 95% CI, 5.25–19.63; P<.0001). These results may indicate that fetal monitoring and access to cesarean delivery could reduce morbidity associated with VBAC.
Finally, a recent opinion piece from JAMA discussed the potential of hospital-affiliated birthing centers as a solution to the problem (Woo, 2016). The authors suggest that safety can be improved by having an integrated team in the birth center and in the associated hospital, regular drills to ensure rapid transport capability and staffing with an experienced pediatric clinician. Hospital-associated birth centers may provide a model for low-risk pregnancies that would allow coordinated care, lower costs and improved patient satisfaction. Presently, only 0.4% of births take place in 300 existing freestanding facilities within the US. Increasing the number of hospital-based birth centers may offer a safe birth experience that provides interventions only when necessary. There is room to grow.
My personal take as an OB/GYN is that I support this model of care. When patients come to me, they are “buying” the services that I offer. However, I am constrained by my profession, insurance, ACOG and hospital rules. The problem comes when a woman asks me to support something else, something that I am not “selling.” I am not allowed to attend a home birth.
Patients are asked to take chances all the time. There is a risk for women who choose VBAC, higher than the risk for perinatal loss during home birth. But we offer that option routinely. The truth is that despite all our safety precautions, bad things can still happen. Delivering in a hospital does not guarantee safety, and when bad things happen, women must deal with the consequences.
We need to learn how to communicate better with our patients, and I believe that is what ACOG is saying. Patient autonomy and right to decline or accept treatment is well established, and that includes decisions made during pregnancy (ACOG , 2016). But women need to be told the risks, benefits and alternatives when making their decisions. We need to remind our patients where we have been and how much medical care has improved the safety of giving birth, while at the same time acknowledging that our cesarean delivery rate may be too high and our interventions too frequent. In fact, the reason that we can even have this discussion is because of all the advances modern obstetric care has provided. We take it for granted that birth is safe, but there is nothing “natural” about how that safety came about. We need transparency. We need to defend the practice of OB/GYN — and we need to do all this while continuing to advocate for and support women and their choices.
References
Planned Home Birth. ACOG Committee opinion, number 669, August 2016.
Refusal of medically recommended treatment during pregnancy. ACOG Committee Opinion, number 664, June 2016.
Grunebaum A, Chervenak FA. Apgar Score of 0 and Seizure/Serious Neurologic Dysfunction in Home Births of Patients With Prior Cesarean Delivery [2]. Obstet Gynecol. 2016; 127(Suppl 1):1S. doi: 10.1097/01.AOG.0000483619.33365.2e. PMID: 27176156.
MacDorman MF, Declercq E. Trends and characteristics of United States out-of-hospital births 2004-2014: new information on risk status and access to care. Birth. 2016. doi: 10.1111/birt.12228. PMID: 26991514.
Wernham E, Gurney J, Stanley J, Ellison-Loschmann L, Sarfati D. A Comparison of Midwife-Led and Medical-Led Models of Care and Their Relationship to Adverse Fetal and Neonatal Outcomes: A Retrospective Cohort Study in New Zealand. PLoS Med. 2016;13(9):e1002134. doi: 10.1371/journal.pmed.1002134. PMID: 27676611
Woo VG, Milstein A, Platchek T. Hospital-affiliated outpatient birth centers. A possible model for helping to achieve the triple aim in obstetrics. JAMA. October 11, 2016.
World historical and predicted infant mortality rates per 1,000 births (1950–2050) UN, 2008.
How much does it cost to have a baby? Hospital study finds huge price range. Kaiser Health News. From http://khn.org/news/how-much-does-it-cost-to-have-a-baby-hospital-study-finds-huge-price-range/ obtained on October 7, 2016.
Cost of home vs. hospital birth – is natural home birthing with a midwife right for you? Money Crashers. From http://www.moneycrashers.com/home-birth-vs-hospital-birth-cost/ obtained on October 7, 2016.
