Planned out-of-hospital birth associated with higher mortality

1. Planned out-of-hospital birth was associated with a significantly higher fetal, perinatal, and neonatal mortality compared with planned in-hospital birth.

2. A significantly higher rate of depressed 5-minute Apgar score, neonatal seizures, and blood transfusions were observed in planned out-of-hospital births compared with in-hospital births.

Evidence Rating Level: 2 (Good)

Study Rundown: The proportion of out-of-hospital births at home or at a freestanding birth centre have increased to approximately 60% in recent years. These births have been associated with lower rates of obstetrical interventions and higher rates of infant complications and death. However, studying planned out-of-hospital births has been limited by cases where transfer

to a hospital was required and a birth that was initially planned as an out-of-hospital birth has been misclassified as a hospital birth. This study assessed the perinatal risk of a planned out-of-hospital birth versus hospital birth by using data from the newly revised Oregon birth certificates which allowed the disaggregation of hospital births into the categories of planned in-hospital birth and planned out-of-hospital births.

The rate of fetal, perinatal, and neonatal death was higher among out-of-hospital births than among in-hospital births. Planned in-hospital births had a significantly higher rate of obstetrical procedures compared to the out-of-hospital group. Planned out-of-hospital birth was also associated with increased odds of perinatal and neonatal death but was not associated with a significant increase in infant death. Planned in-hospital births were associated with higher odds of NICU admission compared with planned out-of-hospital admission. Planned out-of-hospital birth was associated with a significantly greater rate of depressed 5-minute Apgar score, neonatal seizures, and blood transfusions. Serious adverse events for the mother were rare in both groups.

Click to read the study, published today in NEJM

Relevant Reading: Early and total neonatal mortality in relation to birth setting in the United States, 2006-2009

In-Depth [cross-sectional]: A total of 79,727 cephalic, singleton, term, nonanomalous deliveries in Oregon were included in the analysis of this study. Out-of-hospital births had a higher rate of fetal death compared to in-hospital births (2.4 vs. 1.2 deaths per 1000 deliveries, p=0.05). Rate of perinatal and neonatal death was significantly higher in the planned out-of-hospital group compared to the in-hospital group (perinatal: 3.9 vs. 1.8 deaths per 1000 deliveries, p=0.003; neonatal, 1.6 vs. 0.6 deaths per 1000 deliveries, p=0.02). Planned out-of-hospital births were associated with a significantly lower proportion of obstetrical procedures compared with planned in-hospital births (1.5% vs. 30.4% for induction of labor and 26.4% vs. 1.1% for augmentation of labor, p<0.001).

Planned out-of-hospital birth was associated with increased odds of perinatal and neonatal death (perinatal: adjusted OR=2.43; 95% [CI], 1.37 to 4.30; neonatal: adjusted odds ratio, 2.87; 95% [CI], 1.10 to 7.47). The odds of NICU admission were lower in the planned out-of-hospital births (adjusted OR=0.71; 95% [CI], 0.55 to 0.92). Planned out-of-hospital births were associated with a greater rate of lower 5-minute Apgar score (0.6 vs 0.4; p=0.04), neonatal seizures (0.13 vs. 0.04; p=0.02), and blood transfusions (0.6 vs. 0.4; p=0.05). 

Image: PD

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