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The study was a voluntary survey that examined data from almost 17,000 home births. The voluntary nature troubles Dr. Grunebaum, who pointed out that midwives with poor outcomes probably would not have submitted data.
There was an 11% hospital transfer rate in the cohort from the midwives study. There were 43 fetal deaths in the intrapartum, early, and late neonatal periods; 8 of these were from lethal congenital defects. The remaining deaths translated to a total neonatal mortality rate of 1.3/1,000.
Twenty-two died during labor, but before birth. For 13, the causes were known: placental abruption (2), intrauterine infection (2), cord accidents (3), complications of maternal gestational diabetes (2), meconium aspiration (1), shoulder dystocia (1), complications of preeclampsia (1), and liver rupture and hypoxia (1).
Seven babies died during the first 6 days of life. The causes were secondary to cord accidents (2, one with shoulder dystocia), and hypoxia or ischemia of unknown origin (5).
Six infants died in the late neonatal period. Two deaths were secondary to cord accidents, and four were from unknown causes.
Of 222 breech births, three infants died (13/1,000). Of 3,773 births to primiparous women, 11 infants died (2.9/1,000). Of 1,052 attempted vaginal births, 3 infants died (2.85/1,000)
"These numbers are horrible," Dr. Grunebaum said. "There is no longer room for the argument from home birth supporters that while the risk may be increased, it’s still very low in terms of absolute risk."
"This view has even been expressed by our own specialists," he added, referring to an American Academy of Pediatrics position paper on planned home birth (Pediatrics 2013;131:1016-20). While maintaining that birth is safest in a hospital or birthing center, the paper acknowledges that the two- or threefold overall increase in mortality associated with home birth is low – generally translating to about 1 in 1,000 newborns.
"That minimizes the extra risk involved in home birth," Dr. Grunebaum said. "We should have no acceptance for any increase in death or injury in exchange for parental convenience or for fewer interventions. We need to disclose these increased risks to mothers, and perform direct counseling against home birth."
His study fans a long-simmering debate about the best places to birth. Proponents of both philosophies want the same primary outcome: healthy mothers and infants. The debate? How to best get there.
Midwife-assisted home birth has grown exponentially over the past decade. According to CDC data, there were about 16,000 in 2007; by 2012, it was about 23,500. The rise is mostly seen in a very specific demographic – well-educated, financially secure white women with at least one other child who was, most frequently, born in a hospital.
Dr. Grunebaum attributed the rise to some women’s desire to avoid what they perceive as intrusive labor and birth management. With this thought, at least, others do agree.
Eugene DeClercq, Ph.D., a professor of obstetrics and gynecology and of public health at Boston University, has worked on three national surveys that poll new mothers about their experiences with pregnancy, labor and delivery, and postpartum life.
Childbirth Connection (childbirthconnection.org) conducted the Listening to Mothers surveys in 2002, 2006, and 2012. The survey reports are intended to serve as policy resources for improving the childbearing experience for women and their families.
"One of the real questions we need to look at is, what’s going on in hospitals that makes women consider giving birth outside the hospital," Dr. DeClercq said in an interview. "What has come through in our interviews is that many women are quite fine with the ways things go in a hospital. They are for any intervention that they think will make a safer birth. But many women are not. They report feeling pressured to have interventions, and worried that one will lead to another and another, in a cascade that can eventually end up in a cesarean section."
This is a legitimate concern in the United States, he said – a country in which the cesarean rate hovers around 30%, and ranges from 7% to 70% across hospitals. "If you lived ... where there was a 70% rate of cesarean – 70%! – might you be thinking about some way to avoid that?"
In the Listening to Mothers II survey, women were asked a series of questions about their experiences with labor and delivery. The results of the survey revealed that 47% of first-time mothers were induced. "Of those having an induction, 78% had an epidural, and of those mothers who had both an attempted induction and an epidural, the unplanned cesarean rate was 31%," the report noted. "Those who experienced either labor induction or an epidural, but not both, had cesarean rates of 19% to 20%. For those first-time mothers who experienced neither attempted induction nor an epidural, the unplanned cesarean rate was 5%."