Pediatricians offer newborn care standards for home births
■ The policy comes as slightly more women choose to deliver at home, where babies face a higher death risk compared with infants born in hospitals.
Babies born through planned home deliveries should receive the same level of newborn care as those born in hospitals or freestanding birthing centers, according to American Academy of Pediatrics policy published in May.
The academy's statement, formulated by its Committee on Fetus and Newborn, is meant to supplement the American College of Obstetricians and Gynecologists' policy adopted in February 2011 and reaffirmed in 2013. The ob-gyns and pediatricians agree that hospitals and birthing centers are the safest settings for birth. Although the ACOG statement acknowledges that women have the right to make a medically informed choice about delivery, the AAP strikes a somewhat softer tone, saying its policy is “intended to help pediatricians provide supportive, informed counsel to women considering home birth.”
These statements from physician organizations come amid a rise in planned home births, with about 30,000 such deliveries happening annually. Less than 1% of U.S. births occur at home, but the proportion of such deliveries grew by 29% between 2004 and 2009, according to a January 2012 report released by the Centers for Disease Control and Prevention's National Center for Health Statistics. Planned home births are more popular among white women who have previously given birth and are 35 and older, the report said. The home-birth option is more prevalent in the Pacific Northwest, with 2.5% of Montana deliveries and nearly 2% of Oregon births happening at home.
Planned home births are two to three times likelier to result in neonatal death — about one more death in every 1,000 births — according to an American Journal of Obstetrics & Gynecology meta-analysis published in September 2010. The study found no difference in maternal death rates.
The AAP's statement echoes ACOG recommendations on limiting planned home births to low-risk, singleton pregnancies where the mother is healthy and the fetal presentation is cephalic. They also agree that planned home births should be accompanied by a pre-established arrangement for hospital transfer if needed, and attended by a physician or a midwife certified by the American Midwifery Certification Board. Ninety-eight percent of the board's certificants in 2012 were nurse midwives, yet the CDC says less than 20% of home births are attended by nurse midwives. About 5% of home births are attended by physicians, while the remainder are aided by lay midwives and others lacking the AMCB certification.
In case of emergency
The pediatricians' policy emphasizes the importance of having a professional who can revive a baby if a planned home birth does not go well.
“For any baby, whether born in the hospital, a birthing center or at home, there should be one person at the delivery whose primary responsibility is the care of the baby, and that person should have the training and the skills to resuscitate the baby should it be necessary,” said Kristi L. Watterberg, MD, lead author of the AAP statement. She also is chief of the Division of Neonatology at the University of New Mexico School of Medicine in Albuquerque.
Planned home births should follow standards for caring for well newborns, the pediatricians' policy says. That includes a detailed physical examination; a comprehensive risk assessment; screening for group B streptococcal disease, hypoglycemia and hyperbilirubinemia; and a hearing assessment within one month. The babies should receive vitamin K, a hepatitis B vaccination and an eye prophylaxis, a topical ointment to prevent neonatal conjunctivitis; be assessed for feeding difficulties; and get needed follow-up care within 48 hours.
“These standards are applicable to the care of babies regardless of who's providing that care,” Dr. Watterberg said.
The AAP adopted a “great document,” said George A. Macones, MD, chair of the ACOG Committee on Obstetric Practice and chair of the Dept. of Obstetrics and Gynecology at Washington University in St. Louis. A shortage of appropriate pediatric care for babies born at home appears to be “one of the driving concerns that led to this policy,” he added.
“It's more than just doing the right screenings,” Dr. Macones said. “It's also about having someone there that's focused on the baby at delivery. At least from what I know about home births, they are often attended by only one person. And that obviously is not ideal in terms of having someone dedicated to the baby. … Sometimes there are emergencies that happen with deliveries that will fully occupy the health care professional with mom, and then there's no one there to take care of baby. There's no way to tell when that will happen, when you will have major bleeding or some other complication after delivery.”
The American College of Nurse-Midwives did not respond to an interview request by this article's deadline.
The American Medical Association has policy stating that the safest setting for labor, delivery and the immediate postpartum period is in the hospital, a birth center at a hospital complex that meets ACOG and AAP standards, or a freestanding birthing center accredited by the Joint Commission, the American Assn. of Birth Centers or the Accreditation Assn. for Ambulatory Health Care. The AMA supports state legislation that acknowledges those locations as the safest birth settings and assures appropriate physician and regulatory oversight of midwifery practice.