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As Home Births Increase, Recent Studies Illuminate Controversies and Complexities

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Medical News & Perspectives

As Home Births Increase, Recent Studies Illuminate Controversies and Complexities Ricki Lewis, PhD


hree years ago, the New York Times published an article in its Fashion and Style section, “The Midwife as Status Symbol.” Trendy expectant mothers, it seemed, increasingly opted for midwives to deliver their babies at home or a birthing center rather than choose an obstetricianattended hospital birth. The recent medical literature, however, indicates that although home births may be considered fashionable, the decision of where to give birth is not to be taken lightly. Births are inherently unpredictable events, and an unexpected complication without a planned, quick route to a hospital can have tragic consequences. “People have been born at home for thousands of years. The majority of the time things are okay, but when they’re not, you’ve given up the opportunity to direct events toward a successful outcome,” said Hal Lawrence, MD, executive vice president for the American Congress of Obstetricians and Gynecologists (ACOG).

US Home Births on the Increase In 1940, 44% of births in the United States occurred outside of the hospital, with the majority occurring at home. Over the next 4 decades, birth patterns shifted, and by the 1980s the rate decreased to 1%. Recently, however, home birth rates have

health at Montefiore Medical Center. Rosser did not have a role in collecting or analyzing the CDC statistics. Those conversations are critical, experts say, particularly in view of ACOG’s official position, which acknowledges that hospitals and birthing centers are the safest settings for birth but doesn’t explicitly advise against home births. Instead, ACOG states that it “respects the right of a woman to make a medically informed decision about delivery.” The American Academy of Pediatrics issued a statement in 2013 in support of ACOG’s position, agreeing that health care facilities are safest for deliveries.

Home births are increasing in the US.

been steadily rising, increasing by 29% between 2004 and 2009, according to the Centers for Disease Control and Prevention’s (CDC’s) National Center for Health Statistics (NCHS) (http://www.cdc .gov/nchs/data/databriefs/db84.htm). “What’s very interesting about these latest CDC data are that they show that women choosing home birth are at lower risk of adverse outcomes. The fact that they have lower risk profiles means women are having conversations with their health care providers and higher-risk patients are selected out,” said Mary Rosser, MD, PhD, assistant professor in the department of obstetrics, gynecology, and women’s

Home Birth: Risky Business? Confusion and contention surround the safety of planned home births, and comparing studies from different nations and with varying methods of data collection and analyses can be an apples-and-oranges experience. At issue are the stringency criteria whereby patients are selected as suitable candidates for home birth and the level of training of attending midwives, according to James Byrne, MD, chair of obstetrics and gynecology at Santa Clara Medical Center and affiliated clinical professor at Stanford University School of Medicine. Three recent publications—in the American Journal of Obstetrics and Gynecology (AJOG), BMJ,

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and Journal of Midwifery and Women’s Health—illustrate the distinctions among key studies. The seeds of the AJOG report lay in a March 2013 meeting where Frank Chervenak, MD, chair of obstetrics and gynecology at Weill Cornell Medical College, learned about NCHS birth certificate data on nearly 12 million births from 2010 through 2012. “I realized that the dangers of home births were not being put forward,” he said. “The number of home births is increasing in the United States, and our professional societies are not being as clear as they should be.” With colleague Amos Grunebaum, MD, professor

planned home births didn’t meet ACOG recommendations for American Midwifery Certification Board standards. “When the report on the CDC data came out, it was controversial with midwives, but the findings are hard to refute. The report wasn’t taking a stand; it was just pointing out that without the same resources at home that are in a hospital, [fetal health] outcomes are worse,” said Byrne, who was not part of the study.

Home Birth in Low-Risk Pregnancies

Results from the Birthplace in England Collaborative Group (BMJ. 2011;343: d7400) are more optimistic. Their data derive from a prospective cohort of 64 538 “For women with known medical or women with obstetric risk factors such as diabetes, low-risk pregnancies from hypertension, cesarean section, or other 2008 to 2010 complications in a previous birth, whogavebirthat guidelines recommend that a hospital home, in freestanding midobstetric unit would be safer, and home wifery units, birth isn’t recommended.”-Jennifer “alongside” midwifery units (in a Hollowell, PhD hospital near an obstetrics unit), of clinical obstetrics and gynecology at and in obstetric units. About 20% of Weill Cornell, Chervenak convened a team the women who had hospital births had to mine the NCHS data to assess home risk factors for poor fetal outcomes, as birth safety (Grunebaum A et al. Am J did 7% of women choosing home birth. Obstet Gynecol. doi:10.1016/j.ajog.2014 The study assessed a composite pri.10.021 [published online October 14, mary outcome of perinatal mortality and 2014]). intrapartum-related neonatal morbidities, The investigators compared outcomes including stillbirth during labor, early neofrom planned home births attended by natal death, neonatal encephalopathy, and midwives with hospital births attended fractured humerus or clavicle. The inciby certified nurse midwives. “We found dence of adverse outcomes for all birth many-fold increases of stillbirths, infants settings was overall low (4.3 in 1000 with neurological dysfunction, and neona- births). While multiparous women had no tal death for women who had home births. significant differences in the adjusted These numbers undercounted the true odds across the 4 settings, nulliparous influence, because a bad outcome after women had nearly a 2-fold increased incitransport to the hospital was reported to dence of primary outcome events for be a hospital birth,” Chervenak said. “The planned home births compared with midrelative risk of an infant being born alive wifery and obstetric settings. In addition, but dying in the first 28 days is 4 times 3 6% t o 4 5% o f f i r st- t i m e m o t h e r s higher than a baby born in a hospital,” required transfer to the hospital, comadded Grunebaum. pared with 9% to 13% of multiparous However, about 30% of these planned women. home births were not low-risk (twins, “For women with known medical or breech presentation, vaginal birth after obstetric risk factors such as diabetes, cesarean, and postterm). What’s more, hypertension, cesarean section, or other two-thirds of the midwives who attended complications in a previous birth, guide554

lines recommend that a hospital obstetric unit would be safer, and home birth isn’t recommended. But home birth is now a recommended option for low-risk women having a second or subsequent baby in the UK,” explained Jennifer Hollowell, PhD, manager of the study and an epidemiologist for the National Perinatal Epidemiology Unit of the University of Oxford in the United Kingdom. National Health Service midwives in the United Kingdom, who have qualifications equivalent to those of a certified nurse midwife in the United States, attend nearly all home births. Furthermore, unlike the United States, criteria for transfer to a hospital in the United Kingdom are clear and the option is always available. Byrne regards the United Kingdom as a good model. “In an ideal format, home births are a great option,” he said. “That includes patients properly screened and who remain at low risk and are cared for by highly trained providers networked well with the local hospital so that any transfer of care can be smooth and seamless.” The third study (Cheyney M et al. J Midwifery Womens Health. 2014;59[1]: 17-27), the Midwives Alliance of North America (MANA) Statistics Project, collected data from midwives on 16 924 planned home births in the United States from 2004 to 2009. Eleven percent of the women required transfer to a hospital, most for failure to progress. Of 1054 women attempting vaginal birth after cesarean, 87% succeeded. Only 1.5% of mothers and 0.9% of neonates were transferred. However, women transferred to the hospital shortly before or after labor began but before giving birth were not included in calculating these rates. The researchers concluded “low-risk women in this cohort experienced high rates of physiologic birth and low rates of intervention without an increase in adverse outcomes.” However, because participation in the MANA data collection was voluntary, it’s difficult to determine how many less successful births went unreported. Collectively, these 3 studies suggest that carefully screening a patient’s risk for complications during birth as well as the attending midwife’s credentials can optimize the success of a planned home birth. “No matter how healthy a mother may be, and how normally a pregnancy may have

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progressed, a placental abruption may occur or a prolapsed umbilical cord drop through the cervix. Although such complications affect only 1% to 1.5% of pregnancies, if you don’t have the capacity to deal with them, it’s catastrophic for the fetus,” said Lawrence, who has delivered 7000 babies. Mairi Breen Rothman, CNM, MSN, who has a home birth practice in the Washington, DC, area and is a board member of the American College of Nurse-Midwives, agreed that rare complications are handled faster in a hospital. “But there are also risks in the hospital that don’t exist at home—a hospitalacquired, antibiotic-resistant infection or an adverse reaction to regional anesthesia,” she wrote in an email.

Increasingly Costly Birth Decisions The total costs for a home birth are generally much lower than for a hospital birth. In the United States, private insurers paid hospitals on average $18 329 for a vaginal birth in 2010, andtheassociatedaverageout-of-pocketcost

for patients was $2244, which quadrupled from 2004 to 2010 (http://transform As high-deductible insurance plans that can nearlydoubleout-of-pocketcostsbecomethe norm, the financial burden of hospital births is only expected to increase. Even with coverage through the Affordable Care Act, expectantmotherslikelywillfaceincreasingoutof-pocket expenses that are difficult to accurately predict (Wharam JF et al. JAMA. 2015;313[3]:245-246). In contrast, a home birth can cost as little as $1000, according to midwifery websites. While the potential financial benefits are considered a “perk” of home birth, at least according to the American Pregnancy Association’s website, the lower cost of a home birth may not apply to everyone. “Many private insurers will pay the majority of the hospital cost but only a small fraction of the cost of a home birth, sometimes nothing,” Rothman said. Medicaid covers hospital and birthing center births, but home births attended by certified professional midwives or certi-

fied nurse midwives are only covered in a handful of states. “I’ve met women who would have chosen home birth if their insurance covered it but ended up in a hospital environment because they can’t afford a home birth,” she said. Despite reports of promising outcomes for low-risk home births, some physicians firmly advise against home births and take issue with factoring costs into the equation when choosing where to deliver. Yet home birth remains a personal decision mired in a multitude of complex considerations, including finances, risk factors for adverse events during childbirth, the experience and qualifications of the attending midwife, the environment that the mother-to-be prefers, and the overall health of the pregnant woman and fetus.Theonethreadofconsensusamongexperts is that expectant mothers should be counseled and well-informed regarding their individual prenatal and perinatal risk factors when considering their choices. Correction: This article was corrected online February 19, 2015.

The JAMA Forum

Why Health Insurance Literacy Matters Larry Levitt, MPP

American Medical Association


uch ink has been spilled over the new health insurance marketplaces created under the Affordable Care Act (ACA), from the failed initial launch of last fall, to the surge in enrollment in the spring, to the debate over how many people will enroll during the open enrollment period that just began. Meanwhile, 6.7 million people are now buying insurance through the marketplaces operated by the federal government and 14 states (including the District of Columbia;, in addition to an increase of 9.1 million people covered through the Medicaid program following implementation of the ACA ( Millions of people have gone online to the marketplaces and picked a plan, sometimes choosing from among dozens of different options in their area with varying pre-

miums, deductibles, copays, provider networks, and drug formularies. The problem is, surveys show many people don’t understand what those words even mean. The Kaiser Family Foundation recently conducted a nationally representative survey of 1292 adults, asking them 10 questions to gauge their knowledge of how health insurance works ( The general public did reasonably well, with 68% answering more than half of the questions correctly (though only 4% got a perfect score of 10). For example, 79% knew that a health insurance premium has to be paid every month even if you don’t use any health care services, and 72% could identify the correct definition of a deductible. Questions involving arithmetic proved more challenging: Only 51% could correctly calculate the out-of-pocket cost for a hospi-

Larry Levitt, MPP

tal stay involving a deductible and copay, and only 16% could determine the cost of an outof-network lab test where the insurer caps

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