News & Commentary

Births Outside Hospital Are Riskier

Babies born to women who opt to give birth outside of hospitals are 2.4 times more likely to die during the birth process or in the first month after birth than babies born in the hospital, according to a study in the New England Journal of Medicine.

It’s not as bad as it sounds, however. Because only a tiny fraction of births in the United States occur outside of hospitals, the probability of something going wrong is still slight. Researchers looked at about 80,000 pregnancies in Oregon from Jan. 1, 2012 through Dec. 31, 2013.

“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,” concluded researchers at Oregon Health and Science University. The study states that 3.9 out of 1,000 planned out-of-hospital births resulted in a baby’s death, compared with 1.8 deaths out of 1,000 in planned hospital births.

During the study period, 75,923 births occurred in the hospital as planned while 3,203 occurred outside the hospital as planned (1,968 at home and 1,235 at a birth center). The “as planned” distinction is crucial, one reason being that 601 women planned on an out-of-hospital delivery, but wound up delivering in the hospital anyway.

The researchers said they used data from Oregon because at the national level “there is still no way to disaggregate hospital births that were intended to occur at a hospital and those that had not been intended to occur at a hospital,” the study states. In other words, when something goes wrong with an out-of-hospital birth the mothers are often rushed to a nearby emergency department.

Oregon introduced new questions on birth certificates in 2012 that pinpoint when that happens.

The study’s numbers don’t entirely explain its headline-grabbing impact when it was published December 30. The birth-in-hospital vs. birth-outside-of-hospital debate can be contentious, but both sides reportedly found the NEJM study to be fair.

“Very well done,” is how Mary Lawlor described the study to the New York Times. She’s the executive director of the National Association of Certified Professional Midwives.

There are “clearly pros and cons to the different birth settings, both with benefits and risks to moms and babies,” Joseph Wax, MD, of the American College of Obstetricians and Gynecologists, told the newspaper.

The study found that 24.7% of women who delivered in the hospital had cesarean deliveries compared with just 5.3% of women who had planned out-of-hospital births and who wound up having cesarean deliveries.

Women who planned out-of-hospital births were less likely to have induced labor but more likely to have maternal blood transfusions.

Cultural issues were also at play, and most of the women who planned out-of-hospital deliveries were white, had private health insurance or paid out of pocket, and were older than 35.

“Women who choose out-of-hospital birth have different values and goals for their delivery (e.g., control over surroundings and a nonmedicalized experience without unnecessary interventions) than do women who choose hospital birth (e.g., the availability of pain relief and access to emergency services).”

Researchers cite studies showing that out-of-hospital births in Europe can be as safe an option for women than hospital births thanks to uniform standards for training midwives. In the U.S., such training and credentialing is piecemeal.

Births at home and at birth centers accounted for 1.28% of all births in 2012, according to government data. That’s a small percentage, but it’s an increase from 0.79% in 2004.

More women might want to avoid hospitals because of the approach generally used for women who’ve had a cesarean section. As the study states, the fact that “U.S. hospitals generally decline to allow vaginal birth after a woman has undergone cesarean may be associated with the increase in home births.”

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