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OBSTETRICS Perinatal risks of planned home births in the United States Amos Gru ¨nebaum, MD; Laurence B. McCullough, PhD; Robert L. Brent, MD, PhD, DSc (Hon); Birgit Arabin, MD; Malcolm I. Levene, MD, FRCP, FRCPH; Frank A. Chervenak, MD OBJECTIVE: We analyzed the perinatal risks of midwife-attended planned home births in the United States from 2010 through 2012 and compared them with recommendations from the American Col- lege of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) for planned home births. STUDY DESIGN: Data from the US Centers for Disease Control and Prevention’s National Center for Health Statistics birth certificate data files from 2010 through 2012 were utilized to analyze the frequency of certain perinatal risk factors that were associated with planned midwife-attended home births in the United States and compare them with deliveries performed in the hospital by certified nurse midwives. Home birth deliveries attended by others were excluded; only planned home births attended by midwives were included. Hospital deliveries attended by certified nurse midwives served as the reference. Peri- natal risk factors were those established by ACOG and AAP. RESULTS: Midwife-attended planned home births in the United States had the following risk factors: breech presentation, 0.74% (odds ratio [OR], 3.19; 95% confidence interval [CI], 2.87e3.56); prior cesarean delivery, 4.4% (OR, 2.08; 95% CI, 2.0e2.17); twins, 0.64% (OR, 2.06; 95% CI, 1.84e2.31); and gestational age 41 weeks or longer, 28.19% (OR, 1.71; 95% CI, 1.68e1.74). All 4 perinatal risk factors were significantly higher among midwife-attended planned home births when compared with certified nurse midwiveseattended hos- pital births, and 3 of 4 perinatal risk factors were significantly higher in planned home births attended by noneAmerican Midwifery Certifi- cation Board (AMCB)ecertified midwives (other midwives) when compared with home births attended by certified nurse midwives. Among midwife-attended planned home births, 65.7% of midwives did not meet the ACOG and AAP recommendations for certification by the American Midwifery Certification Board. CONCLUSION: At least 30% of midwife-attended planned home births are not low risk and not within clinical criteria set by ACOG and AAP, and 65.7% of planned home births in the United States are attended by non-AMCB certified midwives, even though both AAP and ACOG state that only AMCB-certified midwives should attend home births. Key words: home birth, midwives, perinatal risks Cite this article as: Gru ¨ nebaum A, McCullough LB, Brent RL, et al. Perinatal risks of planned home births in the United States. Am J Obstet Gynecol 2014;212:xx-xx. T here has been an increase in home births in the United States over the last 10 years. 1 Recent studies have shown that when compared with hospital births, planned home births by midwives are associated with an increase in adverse neonatal outcomes, such as neonatal deaths, 2-4 Apgar score of 0, neonatal sei- zures, or serious neurological dysfunction. 5 The American College of Obstetri- cians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have concluded that planned hospital births are safer than planned home births, and both professional or- ganizations have also identied clinical criteria for selecting low-risk patients for planned home births. 6,7 ACOG and AAP have also stated that midwives attending planned home births should be certied by the American Midwifery Certication Board (AMCB). 6,7 The purpose of this study was to evaluate the frequency of certain peri- natal risk factors that were associated with planned midwife-attended home births in the United States from 2010 through 2012 and to compare them with clinical criteria for planned home births established by the ACOG and AAP. MATERIALS AND METHODS We utilized data from the National Center for Health Statistics of the US Centers for Disease Control and Pre- vention (CDC) birth certicate data for 2010e2012, the most recent data avail- able to analyze the 4 ACOG/AAP clinical criteria for planned home births. The CDC les contain detailed information on each of the approximately 4 million births in the United States each year. Data on patient characteristics in- cluding birth setting, method of delivery, birth attendant, gestational age, infant birthweight, maternal age, history of From the Department of Obstetrics and Gynecology, Weill Medical College of Cornell University, New York, NY (Drs Grünebaum, Brent, and Chervenak); Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX (Dr McCullough); Departments of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, and Alfred I. DuPont Hospital for Children, Wilmington, DE (Dr Brent); Center for Mother and Child, Philipps University, Marburg, and Clara Angela Foundation, Berlin, Germany (Dr Arabin); and Division of Pediatrics and Child Health, University of Leeds, Leeds, England, UK (Dr Levene). Received Aug. 29, 2014; revised Sept. 9, 2014; accepted Oct. 13, 2014. The authors report no conict of interest. Corresponding author: Amos Grünebaum, MD. [email protected] 0002-9378/$36.00 ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.10.021 MONTH 2014 American Journal of Obstetrics & Gynecology 1.e1 Research ajog.org
Transcript

Research ajog.org

OBSTETRICS

Perinatal risks of planned home birthsin the United StatesAmos Grunebaum, MD; Laurence B. McCullough, PhD; Robert L. Brent, MD, PhD, DSc (Hon);Birgit Arabin, MD; Malcolm I. Levene, MD, FRCP, FRCPH; Frank A. Chervenak, MD

OBJECTIVE: We analyzed the perinatal risks of midwife-attended delivery, 4.4% (OR, 2.08; 95% CI, 2.0e2.17); twins, 0.64% (OR,

planned home births in the United States from 2010 through 2012and compared them with recommendations from the American Col-lege of Obstetricians and Gynecologists (ACOG) and the AmericanAcademy of Pediatrics (AAP) for planned home births.

STUDY DESIGN: Data from the US Centers for Disease Control andPrevention’s National Center for Health Statistics birth certificate datafiles from 2010 through 2012 were utilized to analyze the frequency ofcertain perinatal risk factors that were associated with plannedmidwife-attended home births in the United States and compare themwith deliveries performed in the hospital by certified nurse midwives.Home birth deliveries attended by others were excluded; only plannedhome births attended by midwives were included. Hospital deliveriesattended by certified nurse midwives served as the reference. Peri-natal risk factors were those established by ACOG and AAP.

RESULTS: Midwife-attended planned home births in the United Stateshad the following risk factors: breech presentation, 0.74% (odds ratio[OR], 3.19; 95% confidence interval [CI], 2.87e3.56); prior cesarean

From the Department of Obstetrics andGynecology,Weill Medical College ofYork, NY (Drs Grünebaum, Brent, and Chervenak); Center for Medical EthicsBaylor College of Medicine, Houston, TX (Dr McCullough); Departments of OGynecology, Thomas Jefferson University, Philadelphia, PA, and Alfred I. DuChildren, Wilmington, DE (Dr Brent); Center for Mother and Child, Philipps UnClara Angela Foundation, Berlin, Germany (Dr Arabin); and Division of PediatUniversity of Leeds, Leeds, England, UK (Dr Levene).

Received Aug. 29, 2014; revised Sept. 9, 2014; accepted Oct. 13, 2014.

The authors report no conflict of interest.

Corresponding author: Amos Grünebaum, MD. [email protected]

0002-9378/$36.00 � ª 2014 Elsevier Inc. All rights reserved. � http://dx.doi.org/10.1

2.06; 95% CI, 1.84e2.31); and gestational age 41 weeks or longer,28.19% (OR, 1.71; 95% CI, 1.68e1.74). All 4 perinatal risk factorswere significantly higher among midwife-attended planned homebirths when compared with certified nurse midwiveseattended hos-pital births, and 3 of 4 perinatal risk factors were significantly higher inplanned home births attended by noneAmerican Midwifery Certifi-cation Board (AMCB)ecertified midwives (other midwives) whencompared with home births attended by certified nurse midwives.Among midwife-attended planned home births, 65.7% of midwivesdid not meet the ACOG and AAP recommendations for certificationby the American Midwifery Certification Board.

CONCLUSION: At least 30% of midwife-attended planned home birthsare not low risk and not within clinical criteria set by ACOG and AAP,and 65.7% of planned home births in the United States are attended bynon-AMCB certified midwives, even though both AAP and ACOG statethat only AMCB-certified midwives should attend home births.

Key words: home birth, midwives, perinatal risks

Cite this article as: Grunebaum A, McCullough LB, Brent RL, et al. Perinatal risks of planned home births in the United States. Am J Obstet Gynecol 2014;212:xx-xx.

here has been an increase in home

T births in the United States over thelast 10 years.1 Recent studies have shownthat when compared with hospital births,planned home births by midwives areassociated with an increase in adverseneonatal outcomes, such as neonataldeaths,2-4 Apgar score of 0, neonatal sei-zures, or serious neurological dysfunction.5

The American College of Obstetri-cians and Gynecologists (ACOG) and

the American Academy of Pediatrics(AAP) have concluded that plannedhospital births are safer than plannedhome births, and both professional or-ganizations have also identified clinicalcriteria for selecting low-risk patients forplanned home births.6,7 ACOG and AAPhave also stated that midwives attendingplanned home births should be certifiedby the AmericanMidwifery CertificationBoard (AMCB).6,7

Cornell University, Newand Health Policy,bstetrics andPont Hospital foriversity, Marburg, andrics and Child Health,

016/j.ajog.2014.10.021

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The purpose of this study was toevaluate the frequency of certain peri-natal risk factors that were associatedwith planned midwife-attended homebirths in the United States from 2010through 2012 and to compare themwithclinical criteria for planned home birthsestablished by the ACOG and AAP.

MATERIALS AND METHODS

We utilized data from the NationalCenter for Health Statistics of the USCenters for Disease Control and Pre-vention (CDC) birth certificate data for2010e2012, the most recent data avail-able to analyze the 4 ACOG/AAP clinicalcriteria for planned home births. TheCDC files contain detailed informationon each of the approximately 4 millionbirths in the United States each year.

Data on patient characteristics in-cluding birth setting, method of delivery,birth attendant, gestational age, infantbirthweight, maternal age, history of

erican Journal of Obstetrics & Gynecology 1.e1

Research Obstetrics ajog.org

prior cesarean delivery, and parity arereported on birth certificates filed eachyear with each of the states in the UnitedStates and compiled by National Centerfor Health Statistics. These data arepublicly accessible on the Internet(http://205.207.175.93/vitalstats/ReportFolders/ReportFolders.aspx), wheredetailed tables can be created anddownloaded for further evaluation.

According to CDC data, “almost allthe home births attended by certifiednurse-midwives⁄certified midwives(98%) or “other” midwives (99%) wereplanned,”8,9 and therefore, we definedplanned home births as births attendedat home by midwives. We excluded fromplanned home births those performed athome by others (eg, family members,emergency medical service, or police,taxi drivers as well as unattended births).

Planned US midwife home deliveriesfor the years 2010e2012, themost recentyears available, were analyzed for ACOGand AAP perinatal risk factors thatshould be excluded from home births7:vaginal breech deliveries, prior cesareandelivery, twin gestations, and postdatepregnancies (gestational age 41 weeksor longer). Hospital births attendedby certified nurse midwives served asa reference. Home birtheplannedmidwife-attended deliveries werecompared with hospital-certified nursemidwives (CNM)eattended deliveries.

The CDC database separates mid-wives into CNM and other midwives.The AMCB certifies 2 kinds of midwives:CNMs and certified midwives (CMs),both of whom have graduated from amidwifery education program accredi-ted by the American Commission forMidwifery Education. The total numberof AMCB-certified midwives (CNMsplus CMs) includes only a small per-centage of CMs because CMs arepermitted to practice in only 5 states.Therefore, the CDC designation ofCNMs captures nearly all of AMCB-certified midwives.

In addition to CNMs, the CDC alsohas a designation of other midwives,which includes certified professionalmidwives, who are not eligible for cer-tification by the AMCB and who have norequirement of a Bachelor’s degree or

1.e2 American Journal of Obstetrics & Gynecology

graduate training. In addition, the CDCdesignation of other midwives mayinclude lay midwives and others withoutany graduate midwifery training. Weperformed a subanalysis and comparedthe frequency with which certain peri-natal risk factors were associated withhome births attended by CNMs withthose attended by other midwives (ie,midwives not eligible to get certified bythe AMCB).Data were abstracted from the US

birth certificate data. Because non-identifiable data from a publicly availabledata set were used, this study was notconsidered human subject research anddid not require review by the Institu-tional Review Board of Weill MedicalCollege of Cornell University.Statistical analyses were conducted

for comparisons between plannedmidwife- attended home births andCNM-attended deliveries in the hospi-tal. Odds ratios and 95% confidenceintervals were calculated for each of the3 provider groups (CNM-attendedhome birth, other midwife-attendedhome birth, and CNM-attended hos-pital birth) and 4 of the risk groups. Allstatistical analyses were conducted inOpenEpi.10

RESULTS

Between 2010 and 2012, there were atotal of 11,905,817 deliveries in theUnited States, of which 736,070 wereattended by CNMs in the hospital. Therewere 85,318 home births (0.71% of allbirths in the United States) and afterexclusion of 29,178 home birth de-liveries performed by others, weincluded 56,140 deliveries that wereattended by midwives at home and areconsidered planned midwife-attendedhome births. CNMs attended 19,263(34.3%) of these home births, whereasother midwives attended 36,877 (65.7%)of planned home births.Table 1 shows the comparisons of

perinatal risk factors between deliveriesattended in the hospital by CNMs andplanned midwife-attended home birthsby CNMs and other midwives. Of themidwife-attended planned home births,approximately 3 in 10 were at a gestationof 41 weeks or longer, 1 in 156 were

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births with twins, approximately 1 in23 were vaginal births after cesareandeliveries, and 1 in 135 home births werebirths with breech presentation.

Planned home births attended byCNMs and other midwives had asignificantly higher frequency of certainperinatal risks when compared withCNM-attended hospital births. Plannedhome births attended by noneAMCB-certified other midwives had a signifi-cantly higher frequency of perinatal risksfor breech presentation, prior cesareandeliveries, and twins, when comparedwith planned home births attended byCNMs.

COMMENT

The AAP and ACOG previously pub-lished policy statements on plannedhome birth with recommendationswhen to consider planned home birth,and they listed the use of strict selectioncriteria for planned home births(Tables 2 and 3).6,7 According to theACOG, selection criteria for home birthsinclude singletons, cephalic pregnanciesbetween 37 and 41 weeks, no prior ce-sarean deliveries, and certified midwivesor physicians as birth attendants.

This study shows that 1 in 156 ofmidwife-attended planned home births(0.64%) were twin pregnancies, eventhough the ACOG considers twins acontraindication for home birthsbecause there is no adequate fetalmonitoring, no experienced team, andno ultrasound available in homebirths.6,7 Studies on the safety of homebirths from Canada, England, and TheNetherlands excluded twins as candi-dates for home birth because ofincreased risks.11-14 Even within hospi-tals, delivery of the second twin, espe-cially when not engaged or nonvertex,requires an experienced obstetrician toprevent perinatal morbidity or evenmortality.15 We note that our data indi-cate that in some hospitals there wereapparently CNM deliveries of twin andbreech-presentation pregnancies.

The data in this study show that 1 in135 of planned home births attended bymidwives (0.74%) were vaginal breechdeliveries. Breech vaginal birth is asso-ciated with significantly increased risks.

TABLE

1Perinatalrisk

factors:CNM-attendedhospitalbirths

vsmidwife-attended

homebirths

Riskfactor

Hospitalb

irths

Hom

ebirths

CNM-attended

(n[

736,070),

%(n)

CNM-

attend

ed(n

[19,263),

%(n)

Other

MW-

attend

ed(n

[36,877),

%(n)

AllMW-

attend

ed(n

[56,140),

%(n)

MW-attended

homebirths

vsCNM-attended

hospitalbirths,

OR(95%

CI)

CNM-attended

homebirths

vsCNM-attended

hospitalbirths,

OR(95%

CI)

Other

MW-

attend

edhome

births

vsCNM-

attend

edhospital

births,O

R(95%

CI)

Other

MW-

attend

edhome

births

vsCNM-

attend

edhome

births,O

R(95%

CI)

Vaginalbreech

0.23

(1716)

0.61

(118)

0.81

(298)

0.74

(416)

3.19

(2.87e

3.56)

2.64

(2.19e

3.18)

3.49

(3.08e

3.94)

1.32

(1.07e

1.64)

Priorcesarean

delivery

2.11

(15,455)

3.99

(767)

4.6(1696)

4.4(2463)

2.08

(2.0e2.17)

1.93

(1.8e2.08)

2.25

(2.14e

2.37)

1.15

(1.06e

1.26)

Twins

0.31

(2276)

0.52

(101)

0.69

(256)

0.64

(357)

2.06

(1.84e

2.31)

1.7(1.39e

2.08)

2.25

(1.98e

2.57)

1.33

(1.05e

1.67)

Postdates�4

1wks

18.59(136,729)

27.7(5320)

28.45(10,435)

28.19(15,755)

1.71

(1.68e

1.74)

1.67

(1.62e

1.73)

1.73

(1.69e

1.77)

1.03

(0.99e

1.06)

Postdates�4

2wks

6.91

(50,848)

9.08

(1744)

9.73

(3567)

9.5(5311)

1.41

(1.37e

1.45)

1.34

(1.28e

1.41)

1.44

(1.39e

1.5)

1.08

(1.01e

1.14)

CI,confidenceinterval;CNM,certified

nursemidwife;MW,midwife;OR,odds

ratio.

Grünebaum

.PerinatalrisksofplannedUShomebirths.A

mJObstetGynecol2014.

ajog.org Obstetrics Research

MONTH 2014 Am

Since the publication of the Term BreechTrial, clinical practices changed aroundthe world, increasing cesarean deliveriesfor breech births.16 The ACOG recom-mends that planned vaginal breechbirths should be done only underhospital-specific protocol guidelines.17

Azria et al18 recommended that a trialfor vaginal births in breech presentationsshould be attempted only with contin-uous electronic fetal heart rate moni-toring and the presence of ultrasoundduring labor and delivery. Neither elec-tronic fetal heart rate monitoring norultrasound is available in home births.

Janssen et al11 from Canada andthe Home Birth in England Study12

excluded breech presentations from theirhome birth eligibility requirements.Therefore, it is not surprising that theMidwives Alliance ofNorthAmerica studyof planned home births reported anintrapartum death rate of 13.51 per 1000and a 9.16 per 1000 neonatal mortalityrate in breech presentations.19 Whencompared with the neonatal death ratesfrom hospital deliveries,2-4 these adverseneonatal outcomes are significantlyincreased.

The ACOG and AAP criteria for homebirths specifically exclude pregnancies 41weeks or longer from their home birtheligibility.6,7 In this study, 28.19% ofhome births were 41 weeks or longer.Postterm pregnancies are associated withmultiple, well-known complications,such as labor dystocia, increased peri-natal mortality rate, low umbilical arterypH levels at delivery, low 5minute Apgarscores, postmaturity syndrome, fetaldistress, cephalo-pelvic disproportion,postpartum hemorrhage, and anincreased risk of neonatal death withinthe first year of life.20,21

A trial of labor after prior cesareandelivery (TOLAC) is associated with agreater perinatal risk than is electiverepeat cesarean delivery without labor.TOLACs have an overall small butsignificantly increased risk of uterinerupture with often catastrophic conse-quences to mother and/or fetus.22,23

This study showed that nearly 1 in 23midwife-attended home births (n ¼2463, 4.4%) had a home vaginal birthafter prior cesarean delivery (VBAC) in

erican Journal of Obstetrics & Gynecology 1.e3

TABLE 2Planned home birth: recommendations when considering planned home birthCandidates for home delivery� Absence of preexisting maternal disease� Absence of significant disease occurring during the pregnancy� A singleton fetus estimated to be appropriate for gestational age� A cephalic presentation� A gestation of 37 to less than 41 completed weeks of pregnancy� Labor that is spontaneous or induced as an outpatient� A mother who has not been referred from another hospital

Systems needed to support planned home birth� The availability of a certified nurse midwife, certified midwife, or physician practicing within an integrated and regulated health system� Attendance by at least 1 appropriately trained individual (see text) whose primary responsibility is the care of the newborn infant� Ready access to consultation� Assurance of safe and timely transport to a nearby hospital with a preexisting arrangement for such transfers

Adapted from American Academy of Pediatrics.6

Grünebaum. Perinatal risks of planned US home births. Am J Obstet Gynecol 2014.

Research Obstetrics ajog.org

spite of the fact that ACOG considersprior cesarean section an absolutecontraindication to planned homebirth.7 TOLACs at home births are evenmore worrisome, considering the in-crease in VBACs in home births.24 Therecent Midwives Alliance of NorthAmerica study showed a very high 2.85per 1000 intrapartum fetal death ratewith VBACs.19

The ACOG and AAP recommend thatonly midwives certified by the AMCBshould attend home births.6,7 Never-theless, this study shows that approxi-mately 2 of 3 planned home births wereperformed by non-AMCB-certifiedmidwives. Professional organizationslike the ACOG and AAP should respondto these findings by continuing to

TABLE 3ACOG Statement on planned home b� Recent cohort studies reporting lower perin

appropriate candidates. These criteria includethe pregnancy, a singleton fetus, a cephalicpregnancy, labor that is spontaneous or induc

� Trial of labor after cesarean should be undertCollege of Obstetricians and Gynecologists’ Cdication to planned home birth.

� Ready access to consultation and assurance oachieving favorable home birth outcomes.

� Availability of a certified nurse midwife, certifiand safety reasons, the American College of Ocertified by the American Midwifery Certifica

Adapted from ACOG Committee.7

Grünebaum. Perinatal risks of planned US home births. Am

1.e4 American Journal of Obstetrics & Gynecology

support collaborative practices in thehospital between physicians and AMCB-certified midwives and strive for a hos-pital birth that resembles more closely ahome birth environment.25

Selection of patients for home birthsby countries withmidwife organizations,such as the Royal Dutch Organisation ofMidwives, follows collaborative guide-lines with strict protocols for selectingpatients for home births.26 The Amer-ican College of Nurse Midwives has notestablished midwife-generated guide-lines of patient selection for home birthsin the United States saying that “.guidelines would impact [midwives’]autonomy” and “guidelines might notsupport midwives if they choose toattend the home birth of a womanwith a

irth (ACOG 2011)atal mortality rates with planned home birth desthe absence of any preexisting maternal disease, thepresentation, gestational age greater than 36 weeked as an outpatient, and that the patient has not beeaken only in facilities with staff immediately availabommittee on Obstetric Practice considers a prior c

f safe and timely transport to nearby hospitals are cr

ed midwife, or physician practicing within an integrabstetricians and Gynecologists does not support thetion Board.

J Obstet Gynecol 2014.

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breech presentation or a twin gestationor a woman who desires a trial of laborafter a previous cesarean.”27

It is possible that some pregnantwomen with risk factors may insist onhome births despite the increased risksof adverse outcomes. In circumstances inwhich home births are contraindicatedbecause of risk factors, physicians andmidwives have the professional re-sponsibility to strongly recommend forhospital birth, to recommend againsthome births, and to refuse the woman’srequest to attend their home birth. Thisis because patients’ requests by them-selves do not determine professionalresponsibility.28

Kennare et al29 and Bastian et al30

showed that the increase in neonatal

cribe the use of strict selection criteria forabsence of significant disease arising durings and less than 41 completed weeks ofn transferred from another referring hospital.le to provide emergency care. The Americanesarean delivery to be an absolute contrain-

itical to reducing perinatal mortality rates and

ted and regulated health system. For qualityprovision of care by lay midwives who are not

ajog.org Obstetrics Research

mortality in planned home births wasassociated with a poor selection of can-didates for home births. Our findings ofincreased perinatal risks among USmidwife-attended planned home birthsmay partially explain reports thatshow preventable increased adverseoutcomes such as increased neonatalmortality rates, low Apgar scores,neonatal seizures, and serious neuro-logical dysfunction among US midwife-attended planned home births.2-5

The strength of this study is that theCDC data are nationally comprehensive.No comparable database exists. A limi-tation of the results is that the actualnumber of patients with increased peri-natal risks in home births is possiblyhigher than reported here because pa-tients transferred prior to delivery from aplanned home birth to the hospital arecounted in the CDC birthing data ashospital births and not home births.

Other limitations in this study includeconcerns that have been expressed aboutthe quality of certain data collected inbirth certificates, especially those thataddress maternal health behaviors orcertain medical and obstetric conditions(eg, anemia, gestational diabetes,pregnancy-induced hypertension, con-current illnesses, congenital anomalies,and comorbidities).31-34 These data ele-ments were not used in our study. Ourstudy used data elements found to be agood source of reliable information inbirth certificates and that were validatedsuch as place of births, gestational weeks,presentation, history of prior cesareandelivery, and multiple births.34,35

ConclusionThis study demonstrates that manymidwife-attended planned home birthsin the United States do not have lowperinatal risks but include readily iden-tifiable prenatal risks such as breechpresentation, twins, patients with priorcesarean deliveries, and postdate preg-nancies. These risks as well as otherperinatal risks are known to be associ-ated with increased adverse birth out-comes and are therefore listed by theACOG and AAP as contraindications forplanned home births. In addition, abouttwo-thirds of planned midwife-attended

home births in the United Statesare attended by noneAMCB-certifiedmidwives. Our study also shows thatplanned home births attended by mid-wives not certified by the AMCB have ahigher frequency of perinatal risks thanplanned home births attended byAMCB-certified nurse midwives. -

REFERENCES

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