Outcomes of a Rural Sonoma County Home Birth Practice: 1976–1982

Abstract

Of 741 women who appeared for orientation by an obstetrician flay midwife, 521 were delivered by them. Of 258 primiparae, 191 had planned home births while 24 were transported to the hospital during labor, and 42 had planned hospital births. Of the multiparae, 233 delivered at home; 2 were transported to the hospital after birth and 3 during labor. Hospital births were planned by 25 multiparae. The cesarean rate was 6.1 per cent. There were 4 premature births (all in hospital and all with normal outcomes), 6 minor malformations, and 3 postpartum infections. The 3 perinatal deaths included a prepartum death at 34 weeks, a stillborn double jootling breech with a prolapsed cord, and an infant who was resuscitated at home but died after two weeks of intensive care. (BIRTH 11: 3, Fall 1984) Several authors have recently tried to establish that for selected, well-educated women, outcomes of home births are associated with lower perinatal mortality and cesarean rates, fewer complications, and optimum family-infant This paper reports data from the first 741 women seen by an obstetrician and lay midwife in a home birth practice in rural Sonoma County, California. Description of PracticeServing a primarily well-educated, Caucasian, middle-class population, this obstetrician and lay midwife provide birth attendance and complete prenatal and postpartum care, along with comprehensive childbirth education classes. Women come for prenatal visits once a month through the seventh month, every two weeks during the eighth month and once a week during the ninth month. The initial prenatal visit includes an orientation session with the client in which the obstetrician explains that he will support the parents in whatever kind of birth they chooseNan Ullrike Koehler, M.S., is a lay midwife and Donald A. Solomon, M.D., is an obstetrician. Marilyn Murphy is a freelance writer studying midwifery. Address inquiries to N. l% K. at 13140 Frati Lane, Sebastopol, CA 954 72. natural or medicated, home or hospital. Generally accepted guidelines are used to screen women. However, individual situations are taken into consideration when making a final decision to accept a woman for a home birth. For example, a woman over 35 years of age who is in otherwise perfect health is not disqualified from attempting a home birth.Prenatal supervision may be assisted by apprentices or labor coaches. Each woman checks her weight, urinary glucose and protein, and records them on her chart at each visit. Routine laboratory screening includes complete blood count, urinalysis, culture, and sensitivity if indicated, syphilis serology, blood type and Rh factor, antibody screen, rubella titer and Pap smear. Other screening tests are used when indicated. For example, amniocentesis for older women, glucose tolerance tests for women at risk of diabetes, or coagulation testing for women with fetal demise, are offered as indicated.Time is allotted at each prenatal visit for discussion of diet, rest, exercise, health habits, and emotional concerns. Emphasis is placed o...

Home Versus Hospital Birth—Process and Outcome

“…Likewise, among earlier reports, NMRs for actual and planned home births are consistently 0.4 to 2.8/ 1000 greater than those of corresponding actual and planned hospital births (14,17,18,24,34). Excess neonatal mortality persisted among nonanomalous and term offspring at rates of 0.7 to 2.8/1000 (14,18,24,34).…”

“…Excess neonatal mortality persisted among nonanomalous and term offspring at rates of 0.7 to 2.8/1000 (14,18,24,34). In contrast, one of the 2 cited recent Canadian studies also examined neonatal mortality rates, finding no differ- Home Versus Hospital Birth Y CME Review Article ences among planned home (0.9/1000) and planned hospital (0.6/1000) deliveries (21).…”

“…Alternatively, home birth exclusion criteria in some practice settings, such as prior cesarean delivery (17,22), may not preclude planned home birth in others (9,24). Therefore the extent to which past medical and obstetrical histories are used to determine home birth eligibility represents a potential confounder when considering maternal and newborn outcomes by planned or actual birth location.…”

“…Among actual and planned home births versus hospital deliveries, intrapartum interventions such as labor induction (1.5%-9.6% vs. 2.0%-27%) (9,13,(16)(17)(18)(19), electronic fetal heart rate monitoring (9.6%-14.7% vs. 71.9%-84.3%) (13,17,20), and regional anesthesia (7.7%-8.4% vs. 19%-27%) (13,16,(20)(21)(22) are typically less frequent. Likewise, intended home birth is generally associated with fewer episiotomies (2.1%-8.3% vs. 5.9%-60.3%) (9,13,14,16,17,(19)(20)(21)23,24), operative vaginal deliveries (1.6%-4.1% vs. 4.6%-26.6%) (9,13,(16)(17)(18)20,21), and cesarean deliveries (1.5%-7.2% vs. 8.1%-19%) (9,13,14,(16)(17)(18)(19)(20)(21)(22)(23). Moreover, these relationships tend to persist when outcomes are further stratified by parity (14,20,25).…”

“…Thus, complications necessitating prenatal or intrapartum transfer, or resulting from these deliveries following transfer to hospital are attributed to hospital, rather than home birth, thereby underestimating risks associated with home birth. An "intent to treat" analysis is desirable to avoid these biases, and is best approximated by cohort studies of planned home versus planned hospital birth (Table 1) (9,(17)(18)(19)(20)(21)23,24,34).…”