The percentage of U.S. women choosing to give birth at home or in a birthing center rather than a hospital has grown by 56 percent in less than a decade, according to a new government report.
Although hardly the norm, out-of-hospital births accounted for 1.36 percent of U.S. births in 2012, according to the U.S. Centers for Disease Control and Prevention. A year earlier, 1.26 percent of births occurred away from a hospital, while just 0.87 percent of such deliveries took place in 2004.
By Sarah Wickline , Staff Writer, MedPage Today
A federal government report on home birthing trends suggested that out-of-hospital births were increasing, but the report omitted key information about attendants at home births and neonatal outcomes, according to one expert.
The overall rate of out-of-hospital births increased from 0.87% of all births in 2004 to 1.36% in 2012, Marian F. MacDorman, PhD, of the National Center for Health Statistics (NCHS), in Hyattsville, Md., and colleagues, wrote in a data brief issued Tuesday.
Among births in 2004, only 0.56% occurred at home. But by 2012, that rate rose to 0.89%, as 35,184 babies were born at home. The other 15,577 born out of the hospital were delivered in birthing centers across the U.S.
Amos Grunebaum, MD, chief of labor and delivery at New York-Presbyterian/Weill Cornell Medical Center in New York City, told MedPage Today that what's important about the report "is not what it says, but what it does not say."
"What this data brief does not say [is] that while there has been [an] increase in home birth, the birth attendants delivering those babies, the vast majority of them -- probably 75% to 80% -- are not certified by the nurse midwifery board," Grunebaum said.
Grunebaum said those deliveries are typically attended by people categorized as "others," anyone from taxi drivers or family members, and "other midwives," which "are ... direct-entry midwives who are much differently trained than certified midwives, and not licensed by the midwifery board."
"That is actually information that our patients should know," Grunebaum said. "It's not just about doing more home birth, but doing it in a safer way by people who are better trained."
MacDorman and colleagues used birth certificate data and, therefore, would have known who attended the out-of-hospital births (certified nurse midwife, "other," or other midwife), but all attendees were lumped together in the report, he noted. Neonatal outcome and mortality data would have also been accessible. But none of these data were published in the report.
On the other hand, Grunebaum said, "This data brief confirms that using birth certificates is a reliable way to look at home birth, which is important, because some of our studies have used birth certificate data and infant mortality data as a way to research this subject."
The report found that the highest percentage of out-of-hospital births were among non-Hispanic white women, with 2.05% of all births occurring outside a hospital in 2012 -- roughly one in 49.
After non-Hispanic white women, 0.81% of American Indian women, 0.54% of Asian/Pacific Islander women, 0.49% of non-Hispanic black women, and 0.46% of Hispanic women had out-of-hospital births.
The six states with the highest rates of out-of-hospital births were:
Louisiana, Mississippi, Alabama, and Georgia all had home-birth rates of less than 1%. A possible explanation for low rates of home birth in the Southeastern states may have to do with higher obesity rates contributing to more high-risk pregnancies, which require hospital monitoring.
Only 1.9% of out-of-hospital births were to teen mothers, a decline from 4.3% in 2004. But 19% of out-of-hospital births were to women ages 35 and older, down slightly from 20% in 2004.
Women may be choosing to have their babies at home because they want fewer medical interventions and a more comfortable environment for delivery, Grunebaum told MedPage Today. "There are some patients, some women, who prefer to have fewer interventions, and they want a surrounding that's a little bit more home-like."
He added, however, that there are increased risks for a baby being born at home. "The risks include an Apgar score of 0, neonatal seizures, for example, and also an increased risk of early and late neonatal mortality."
"More babies die after birth in those deliveries which are born at home as compared to hospital birth," Grunebaum said.
Grunebaum, who is a big supporter of hospital birthing centers staffed with certified nurse midwives, suggested that hospitals should start working with pregnant women to provide them with the birthing environment they really want.
"We need to listen to our patients, we need to figure out why patients want to deliver at home, and then address those issues individually," Grunebaum said. "It's all about informed consent and learning from our patients."
"We need to teach our patients that if they choose to have fewer interventions, they can have the same 'less intervention' in the hospital as long as they communicate well with their doctor, and at the same time they can deliver their baby much safer when they do this in the hospital as compared to home," Grunebaum added.
Hang on, I'm confused. This is the study we're talking about, right?: http://www.cdc.gov/nchs/data/databriefs/db144.htm Marian MacDorman is the lead author. She said her own data wasn't reliable?
Okay, I think I figured out what you were talking about. I googled MacDorman and quotes about birth certificate reliability, and found this Daily Beast article where MacDorman, criticizing the new Cornell study that showed higher death rates at home birth, says:
"Most of the alarmist studies come from data pulled from vital-statistics data, from birth certificates and infant death certificates that are linked together. These administrative records “aren’t designed for research,” says Marian MacDorman."
Yeah, that's weird. Why would she criticize one study for using CDC data, and then immediately publish her own study that also uses that same CDC data? If she really thought birth certificate data wasn't good enough for research, why would she use it for her own research?
It is easy to say that the birth certificate data is inaccurate when it doesn't show what you want it to.
However, when it agrees with your agenda you can say it is accurate and hope that people forget that just a couple weeks ago you said it wasn't.
I read through her report and I kept having to reread sentences. It seems to have been written with an agenda in mind. I think she understands quite well that most people aren't going to bother reading the article but they will quote the headlines as though that is the whole truth about the report.
I realized how carefully she constructed the wording when I saw the reference to "lower risk profile". If you aren't reading carefully, you will remember the phrase "low risk" and then tell others that OOH birth is only for low risk pregnancies and see this paper proves that midwives are only caring for low risk women. However, what it really referred to was that women choosing OOH birth had a lower risk profile than the general pregnant population. There were fewer preterm births taking place at home, not that midwives had decided to exclude women having a preterm birth. Her wording makes it appear that OOH midwives have developed some standards.
The other thing I noticed was the headlines say that the rate of home birth is increasing. However, the report was for all OOH births, including birth centers, dr's offices, clinics, and home birth. There was a smaller rise in home births than what the headline touts. More of a rise was seen in birth centers which are mostly operated by CNMs, who have a much better education, standards, and strict guidelines for risking out.
And even though she points out (when the stats are unfavorable to lay midwives) that the outcomes for "others" should not be included, here she uses those attending "others" (father, cab driver, neighbor, etc.) to increase the number of home births. If the birth was not attended by a midwife, she shouldn't be taking credit for the outcome. Frequently when a baby is born quickly enough that the family can't make it to the hospital, the baby is term and vigorous.
IMHO it seems that she chose parameters and wording that would allow her to counter the criticism of the MANA paper.
Have you noticed that this report has not really been talked about by home birth supporters?