Babies can be born anywhere: home, hospital, and sometimes in a cab ride between the two. Regardless of the site chosen, patients must be carefully selected to ensure safety for both the mother and the child.
Each year, about 25,000 deliveries occur at home, two-thirds of which are planned. While the vast majority of births in the US occur in a hospital-based setting, an increasing number of women are using alternatives such as free-standing birthing centers or planned home birth. Whereas delivery at free-standing birthing centers has gained acceptance in the medical community, home births have incited strong opinions regarding maternal and neonatal safety.
This retrospective population-based cohort study sought to compare maternal and neonatal morbidity by delivery location among women with low obstetric risk using 2006 birth data files from the online CDC National Center for Health Statistics. Demographics and perinatal outcomes were selected from the 2003 revision of the US Standard Certificate of Birth used by 19 states (which covers 49 percent of all US births).
Low obstetrical risk criteria specifcally excluded women with multiple gestations (twins, triplets, etc.), preterm deliveries, diabetes, chronic hypertension or hypertension in pregnancy, prior cesarean delivery, and smokers.
Maternal morbidity was defined as clinically diagnosed chorioamnionitis, fetal intolerance, prolonged labor, precipitous labor, and meconium staining of amniotic fluid. Neonatal morbidity included assisted ventilation, birth injury, bony fracture, neurologic injury, hemorrhage, neonatal intensive unit (NICU) admission, 5-minute APGAR (an assassment of initial newborn vitality) of less than 7, and birthweight less than 2500g (5.5lbs).
Demographic characteristics and morbidity measures by delivery location were compared using a statistical significance of p<0.003. Of the over four million births reported in the US in 2006, 745,690 met inclusion criteria. Although the greatest number (733,143 or 97 percent) of births took place in the hospital setting, more births (7427 or 0.9 percent) occurred in the home than in free-standing birthing centers (4661 or 0.6 percent). APGAR scores were lowest for newborns delivered at home; whereas birthing center and home births had fewer cases of chorioamnionitis, fetal intolerance, meconium staining, assisted ventilation, NICU admission, and low birthweight. Women who chose home birth were more likely to be older, multiparous, white, and have lower education.
The Affordable Care Act expands Medicaid services to more low-income Americans. This includes coverage for free-standing birth center services. Although, there is mention of providing home health care services through maternal, infant, and child home visiting programs, there is no specific provision addressing home birthing services. At first glance, this may not seem terribly inequitable. Consider, however, the lack of accessibility to hospital or birth centers in rural communities. According to the CDCs National Vital Statistics Report, home births were 74 percent higher in rural communities. Most of these births were attended by midwives.
After years of strongly opposing home births, the American College of Obstetricians and Gynecologists released a Committee Opinion on January 20, 2011 stating that while hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery. This statement is vital in advocating not only for physicians and other delivery attendants, but for patients with limited access to hospitals and birthing centers.
Two questions arise: (1) Under healthcare reform, will patients delivering at home receive Medicaid coverage? (2) Will providers, especially midwives, be fully reimbursed for home deliveries? In order to provide equitable coverage, home births should be fully covered and reimbursed. As of January 2011, the ACA requires that midwives are reimbursed at the same rate as physicians for their services. Unlike midwives, physicians are required to have malpractice insurance. While midwifery practice has accommodated home birth, this would present challenges for physicians who largely subscribe to practice in the clinical setting and who risk not finding malpractice insurance. Is more reform on the horizon?
Renee Volny, DO, MBA