Planned Out-of-Hospital Birth and Birth Outcomes

Abstract

Background The frequency of planned out-of-hospital birth in the United States has increased in recent years. The value of studies assessing the perinatal risks of planned out-of-hospital birth versus hospital birth has been limited by cases in which transfer to a hospital is required and a birth that was initially planned as an out-of-hospital birth is misclassified as a hospital birth. Methods We performed a population-based, retrospective cohort study of all births that occurred in Oregon during 2012 and 2013 using data from newly revised Oregon birth certificates that allowed for the disaggregation of hospital births into the categories of planned in-hospital births and planned out-of-hospital births that took place in the hospital after a woman’s intrapartum transfer to the hospital. We assessed perinatal morbidity and mortality, maternal morbidity, and obstetrical procedures according to the planned birth setting (out of hospital vs. hospital). Results Planned out-of-hospital birth was associated with a higher rate of perinatal death than was planned in-hospital birth (3.9 vs. 1.8 deaths per 1000 deliveries, P = 0.003; odds ratio after adjustment for maternal characteristics and medical conditions, 2.43; 95% confidence interval [CI], 1.37 to 4.30; adjusted risk difference, 1.52 deaths per 1000 births; 95% CI, 0.51 to 2.54). The odds for neonatal seizure were higher and the odds for admission to a neonatal intensive care unit lower with planned out-of-hospital births than with planned in-hospital birth. Planned out-of-hospital birth was also strongly associated with unassisted vaginal delivery (93.8%, vs. 71.9% with planned in-hospital births; P<0.001) and with decreased odds for obstetrical procedures. Conclusions Perinatal mortality was higher with planned out-of-hospital birth than with planned in-hospital birth, but the absolute risk of death was low in both settings. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.)

Vaginal birth after cesarean: neonatal outcomes and United States birth setting

“…Because it is not possible to disaggregate women who intended out-of-hospital birth but ultimately delivered in-hospital from women who planned and birthed in-hospital, 10 we conducted sensitivity analyses to estimate effects of this misclassification bias. 20, 21 We utilized random resampling to estimate how odds of neonatal death and Apgar < 4 might be affected if transfers were identifiable.…”

“…Because Oregon birth certificates enable disaggregation by intended birth setting, Oregon vital statistics were used to estimate that 0.44% of observed hospital births were likely out-of-hospital-to-hospital transfers. 10 This rate informed calculation of the number of transfers from the out to in-hospital setting; records equaling this number were randomly chosen under different scenarios and placed in the out-of-hospital birth category to assess outcome odds ratio sensitivity reclassification.…”

“…This may create barriers to obtaining prior records when women transfer care to a CPM mid-pregnancy, leaving onset and total quantity of prenatal visits uncertain. Understanding such birth setting practice pattern differences and maternal care preferences is critical to increasing integration of maternity care services across birth settings in the US, 10 a change that we see as essential for improving maternal and neonatal outcomes. 25 Evidence from Canada and Europe have demonstrated that integration of maternal care across birth settings is associated with lower rates of adverse outcomes in all settings and smaller or no morbidity differentials between settings.…”

“…Increasing numbers of US women seek out-of-hospital birth, 4, 5 including those seeking VBAC. 6, 7 While it is well-established that in-hospital VBAC carries a small but significantly increased risk for neonatal mortality 8, 9 and evidence suggests a small but significant relative increase in intrapartum fetal and neonatal mortality associated with out-of-hospital birth, 10, 11 less is known about neonatal outcomes for out-of-hospital VBAC.…”

Reliability and Validity of a Smartphone-Paired Pulse Oximeter for Screening of Critical Congenital Heart Defects in Newborns

“…Besides the Netherlands, rates of planned out-of-hospital birth (i.e., births intended to occur at home or at a freestanding birth center) have increased in high- and middle-income countries [24,25,26]. In addition, there is an increasing tendency toward early discharge after uncomplicated deliveries in hospital [13].…”