¿Es seguro el parto planificado en casa para las gestantes de bajo riesgo? / Is planned home birth safe for low-risk pregnant women?

Objetivo: Identificar la evidencia sobre la seguridad del parto en casa en comparación con el parto en hospital en gestantes de bajo riesgo en los países desarrollados.Material y métodos: Para este artículo de revisión se realizó una búsqueda bibliográfica en las bases de datos Pubmed, Cochrane Library Plus, Embase, Web of Science y Google Scholar. La calidad metodológica de los artículos encontrados se valoró mediante dos instrumentos: el ResQu Index y la escala NOS.Resultados: Se identificaron y evaluaron 48 estudios; solo 23 pasaron a formar parte de la revisión. Se compararon los resultados maternos y neonatales según la localización del parto en los países desarrollados. La muestra total fue de 1881156 partos en casa y de 6835189 partos hospitalarios. Tras aplicar la escala de calidad metodológica ResQu Index, se valoró que 22 estudios eran de calidad alta y 1 de calidad moderada. Con la aplicación de la escala NOS, 9 estudios obtuvieron una puntuación de 8/9, 6 estudios de 7/9, 7 estudios de 6/9 y un único estudio de 4/9. Fueron en total 15 estudios de cohortes retrospectivos y 7 prospectivos. El artículo de calidad moderada fue incluido en la revisión para tener una muestra mayor.Conclusiones: Las mujeres que planificaron su parto en casa, con respecto a las que decidieron tener un parto en el hospital, tenían una mayor probabilidad de presentar un parto normal, menor tasa de episiotomía, parto instrumental y cesárea, hemorragia posparto, desgarros perineales complicados y menor demanda de epidural. Además, no se observó una mayor morbimortalidad neonatal: no hubo diferencias en la tasa de mortalidad perinatal ni en el test de Apgar, aunque hubo menor probabilidad de ingreso en la Unidad de Cuidados Intensivos Neonatal. (AU)

Objective: To identify the evidence on the safety of home versus hospital delivery in low-risk pregnant women in developed countries.Material and methods: Review. A bibliographic search was carried out in the Pubmed, Cochrane Library Plus, Embase, Web of Science and Google Scholar databases. The methodological quality of the articles found was assessed using two instruments: ResQu Index and NOS scale.Results: Forty-eight studies were identified and evaluated; only 23 were included in the review. There were 15 retrospective and 7 prospective cohort studies. They compared maternal and neonatal outcomes by delivery location in developed countries. The total sample was 1,881,156 home births and 6,835,189 hospital births. After applying the ResQu Index methodological quality scale, 22 studies were of high quality and 1 was of moderate quality. With the application of the NOS scale, 9 studies scored 8/9, 6 studies 7/9, 7 studies 6/9 and a single study 4/9.Conclusions: Women who planned home birth had increased likelihood of normal delivery, lower rate of episiotomy, instrumental delivery and cesarean section, postpartum hemorrhage, complicated perineal tears, and reduced demand for epidural over hospital birth. In addition, no increased neonatal morbidity and mortality was observed: there was no difference in the perinatal mortality rate or in the Apgar test, although there was a lower probability of admission to the Neonatal Intensive Care Unit. (AU)

Birth Outcomes for Planned Home and Licensed Freestanding Birth Center Births in Washington State.

OBJECTIVE: To describe rates of maternal and perinatal birth outcomes for community births and to compare outcomes by planned place of birth (home vs state-licensed, freestanding birth center) in a Washington State birth cohort, where midwifery practice and integration mirrors international settings. METHODS: We conducted a retrospective cohort study including all births attended by members of a statewide midwifery professional association that were within professional association guidelines and met eligibility criteria for planned birth center birth (term gestation, singleton, vertex fetus with no known fluid abnormalities at term, no prior cesarean birth, no hypertensive disorders, no prepregnancy diabetes), from January 1, 2015 through June 30, 2020. Outcome rates were calculated for all planned community births in the cohort. Estimated relative risks were calculated comparing delivery and perinatal outcomes for planned births at home to state-licensed birth centers, adjusted for parity and other confounders. RESULTS: The study population included 10,609 births: 40.9% planned home and 59.1% planned birth center births. Intrapartum transfers to hospital were more frequent among nulliparous individuals (30.5%; 95% CI 29.2-31.9) than multiparous individuals (4.2%; 95% CI 3.6-4.6). The cesarean delivery rate was 11.4% (95% CI 10.2-12.3) in nulliparous individuals and 0.87% (95% CI 0.7-1.1) in multiparous individuals. The perinatal mortality rate after the onset of labor (intrapartum and neonatal deaths through 7 days) was 0.57 (95% CI 0.19-1.04) per 1,000 births. Rates for other adverse outcomes were also low. Compared with planned birth center births, planned home births had similar risks in crude and adjusted analyses. CONCLUSION: Rates of adverse outcomes for this cohort in a U.S. state with well-established and integrated community midwifery were low overall. Birth outcomes were similar for births planned at home or at a state-licensed, freestanding birth center.

Home delivery practice and its predictors in South Ethiopia.

BACKGROUND: Institutional delivery is one of the key interventions to reduce maternal death. It ensures safe birth, reduces both actual and potential complications, and decreases maternal and newborn death. However, a significant proportion of deliveries in developing countries like Ethiopia are home deliveries and are not attended by skilled birth attendants. We investigated the prevalence and determinants of home delivery in three districts in Sidama administration, Southern Ethiopia. METHODS: Between 15-29 October 2018, a cross sectional survey of 507 women who gave birth within the past 12 months was conducted using multi-stage sampling. Sociodemographic and childbirth related data were collected using structured, interviewer administered tools. Univariate and backward stepwise multivariate logistic regression models were run to assess independent predictors of home delivery. RESULTS: The response rate was 97.6% (495). In the past year, 22.8% (113), 95% confidence interval (CI) (19%, 27%) gave birth at home. Rural residence, adjusted odds ratio (aOR) = 13.68 (95%CI:4.29-43.68); no maternal education, aOR = 20.73(95%CI:6.56-65.54) or completed only elementary school, aOR = 7.62(95% CI: 2.58-22.51); unknown expected date of delivery, aOR = 1.81(95% CI: 1.03-3.18); being employed women (those working for wage and self-employed), aOR = 2.79 (95%CI:1.41-5.52) and not planning place of delivery, aOR = 26.27, (95%CI: 2.59-266.89) were independently associated with place of delivery. CONCLUSION: The prevalence of institutional delivery in the study area has improved from the 2016 Ethiopian Demography Health Survey report of 26%. Uneducated, rural and employed women were more likely to deliver at home. Strategies should be designed to expand access to and utilization of institutional delivery services among the risky groups.

Parto domiciliario: un fenómeno creciente con potenciales riesgos / Home births: A growing phenomenon with potential risks

El parto extrahospitalario es un tema controvertido que genera dudas a obstetras y pediatras sobre su seguridad. El nacimiento hospitalario fue la pieza clave en la reducción de la mortalidad materna y neonatal. Esta reducción en la mortalidad ha derivado en considerar el embarazo y el parto como fenómenos seguros, lo que, unido a una mayor conciencia social de la necesidad de humanización de estos procesos, ha conducido a un aumento en la demanda del parto domiciliario. Estudios en países como Australia, Holanda y Reino Unido muestran que el parto en casa puede aportar ventajas para la madre y el recién nacido, pero es necesario que se dote de los suficientes medios materiales, que sea atendido por profesionales formados y acreditados, y que se encuentre perfectamente coordinado con las unidades de obstetricia y neonatología hospitalarias, para poder garantizar su seguridad. En nuestro medio, no hay suficientes datos de seguridad ni evidencia científica que avalen el parto domiciliario en la actualidad

Home birth is a controversial issue that raises safety concerns for paediatricians and obstetricians. Hospital birth was the cornerstone to reduce maternal and neonatal mortality. This reduction in mortality has resulted in considering pregnancy and childbirth as a safe procedure, which, together with a greater social awareness of the need for the humanisation of these processes, have led to an increase in the demand for home birth. Studies from countries such as Australia, the Netherlands, and United Kingdom show that home birth can provide advantages to the mother and the newborn. It needs to be provided with sufficient material means, and should be attended by trained and accredited professionals, and needs to be perfectly coordinated with the hospital obstetrics and neonatology units, in order to guarantee its safety. Therefore, in our environment, there are no safety data or sufficient scientific evidence to support home births at present

Place of delivery and perinatal mortality in Kenya.

BACKGROUND: Increasing access to skilled birth attendants is a key goal in reducing perinatal mortality. In Kenya, where 40% of births occur at home, efforts toward this goal have focused on providing free maternity services in government facilities and discouraging home births. PURPOSE: To identify trends in facility deliveries and determine the association between delivery location and PM in Kenya. METHODS: We utilized data on 36,375 deliveries from the Kenya site of the Global Network for Women's and Children's Health Research, which maintains a prospective, population-based observational study of pregnancy and neonatal outcomes. We identified temporal trends in facility utilization and perinatal mortality. We then assessed associations between delivery location and PM using generalized linear mixed equations. RESULTS: The percentage of facility births increased from 38.4% in 2009 to 47.6% in 2013, with no change in perinatal mortality. Infants delivered in a facility had a higher risk of perinatal mortality than infants delivered at home (aOR = 1.41, p = 0.005). In stratified analyses, hospital deliveries had a higher adjusted odds of perinatal mortality than home and health center deliveries, with no difference between health center and home deliveries. CONCLUSION: The increase in facility deliveries between 2009 and 2013 was not associated with a decline in perinatal mortality. Infants born in facilities had a 41% greater risk of perinatal mortality than infants born at home. Further research is needed to assess possible explanations for this finding, including delays in referring and caring for complicated pregnancies, higher risk infants delivering at facilities, and poor quality of care in facilities.

Unplanned out-of-hospital birth and risk factors of adverse perinatal outcome: findings from a prospective cohort.

BACKGROUND: In France, while most babies are delivered at hospital, emergency medical services (EMS) weekly manage calls for unplanned out-of-hospital births. The objective of our study was to describe neonatal morbidity and mortality, defined as death or neonatal intensive care unit hospitalization at Day 7, in a prospective multicentric cohort of unplanned out-of-hospital births. METHODS: We prospectively analyzed out-of-hospital births from 25 prehospital EMS units in France. The primary outcome was neonatal morbidity and mortality, and the secondary outcome was risk factors associated with neonatal morbidity and mortality. A univariate logistic regression was first made, followed by a multivariate logistic regression with backward selection. RESULTS: From October 2011 to August 2018, a total of 1670 unplanned out-of-hospital births were included. Of these, 1652 (99.2%) were singleton and 1537 (93.5%) had prenatal care. Maternal mean age of the study population was 30 ± 5.5 (range 15 to 48). The majority of women were multiparous, but 13% were nulliparous. Overall, 45.3% of these unplanned out-of-hospital births were medically-driven, either by phone during medical regulation (12.5%) or on scene by the prehospital emergency medical service units (32.9%). The prevalence of neonatal morbidity and mortality was 6.3% (n = 106) after an unplanned out-of-hospital birth (death before Day 7: n = 20; 1.2%). The multivariate logistic regression found that multiparity (adjusted Odds Ratio = 70.7 [4.7-1062]), prematurity (adjusted Odds Ratio = 6.7 [2.1-21.4]), maternal pathology (adjusted Odds Ratio = 2.8 [1.0-7.5]) and hypothermia (adjusted Odds Ratio = 2.8 [1.1-7.6]) were independent predictive factors of neonatal morbidity and mortality. CONCLUSIONS: Our study assessed for the first time risk factors for adverse perinatal outcome in a large and multicenter cohort of unplanned out-of-hospital births. We have to improve temperature management in the out-of-hospital field and future trials are required to investigate strategies to optimize newborns management in the prehospital area.

Midwife-assisted planned home birth: an essential component of improving the safety of childbirth in Sub-Saharan Africa.

Hospital births, when compared to out-of-hospital births, have generally led to not only a significantly reduced maternal and perinatal mortality and morbidity but also an increase in certain interventions. A trend seems to be emerging, especially in the US where some women are requesting home births, which creates ethical challenges for obstetricians and the health care organizations and policy makers. In the developing world, a completely different reality exists. Home births constitute the majority of deliveries in the developing world. There are severe limitations in terms of facilities, health personnel and deeply entrenched cultural and socio-economic conditions militating against hospital births. As a consequence, maternal and perinatal mortality and morbidity remain the highest, especially in Sub-Saharan Africa (SSA). Midwife-assisted planned home birth therefore has a major role to play in increasing the safety of childbirth in SSA. The objective of this paper is to propose a model that can be used to improve the safety of childbirth in low resource countries and to outline why midwife assisted planned home birth with coordination of hospitals is the preferred alternative to unassisted or inadequately assisted planned home birth in SSA.

Planned home versus planned hospital births in women at low-risk pregnancy: A systematic review with meta-analysis.

New interest in home birth have recently arisen in women at low risk pregnancy. Maternal and neonatal morbidity of women planning delivery at home has yet to be comprehensively quantified. We aimed to quantify pregnancy outcomes following planned home (PHB) versus planned hospital birth (PHos). We did a systematic review of maternal and neonatal morbidity following planned home (PHB) versus planned hospital birth (PHos). We included prospective, retrospective, cohort and case-control studies of low risk pregnancy outcomes according to planning place of birth, identified from January 2000 to June 2017. We excluded studies in which high-risk pregnancy and composite morbidity were included. Outcomes of interest were: maternal and neonatal morbidity/mortality, medical interventions, and delivery mode. We pooled estimates of the association between outcomes and planning place of birth using meta-analyses. The study protocol is registered with PROSPERO, protocol number CRD42017058016. We included 8 studies of the 4294 records identified, consisting in 14,637 (32.6%) in PHB and 30,177 (67.4%) in PHos group. Spontaneous delivery was significantly higher in PHB than PHos group (OR: 2.075; 95%CI:1.654-2.063) group. Women in PHB group were less likely to undergo cesarean section compared with women in PHos (OR:0.607; 95%CI:0.553-0.667) group. PHB group was less likely to receive medical interventions than PHos group. The risk of fetal dystocia was lower in PHB than PHos group (OR:0.287; 95%CI:0.133-0.618). The risk of post-partum hemorrhage was lower in PHB than PHos group (OR:0.692; 95% CI.0.634-0.755). The two groups were similar with regard to neonatal morbidity and mortality. Births assisted at hospital are more likely to receive medical interventions, fetal monitoring and prompt delivery in case of obstetrical complications. Further studies are needed in order to clarify whether home births are as safe as hospital births.

Effect of Maternal and Pregnancy Risk Factors on Early Neonatal Death in Planned Home Births Delivering at Home.

OBJECTIVE: The prevalence of home birth in the United States is increasing, although its safety is undetermined. The objective of this study was to investigate the effects of obstetrical risk factors on early neonatal death in planned home births delivering at home. METHODS: The authors conducted a retrospective 3-year cohort study consisting of planned home births that delivered at home in the United States between 2011 and 2013. The study excluded infants with congenital and chromosomal anomalies and infants born at ≤34 weeks' gestation. Multivariate logistic regression models were used to estimate the adjusted effects of individual obstetrical variables on early neonatal deaths within 7 days of delivery. RESULTS: During the study period, there were 71 704 planned and delivered home births. The overall early neonatal death rate was 1.5 deaths per 1000 planned home births. The risks of early neonatal death were significantly higher in nulliparous births (OR 2.71; 95% CI 1.71-4.31), women with a previous CS (OR 2.62, 95% CI 1.25-5.52), non-vertex presentations (OR 4.27; 95% CI 1.33-13.75), plural births (OR 9.79; 95% CI 4.25-22.57), preterm births (OR 4.68; 95% CI 2.30-9.51), and births at ≥41 weeks of gestation (OR 1.76; 95% CI 1.09-2.84). CONCLUSION: Early neonatal deaths occur more commonly in certain obstetrical contexts. Patient selection may reduce adverse neonatal outcomes among planned home births.

Mode of childbirth and neonatal outcome after external cephalic version: A prospective cohort study.

OBJECTIVE: to assess the mode of childbirth and adverse neonatal outcomes in women with a breech presentation with or without an external cephalic version attempt, and to compare the mode of childbirth among women with successful ECV to women with a spontaneous cephalic presentation. DESIGN: prospective matched cohort study. SETTING: 25 clusters (hospitals and its referring midwifery practices) in the Netherlands. Data of the Netherlands perinatal registry for the matched cohort. PARTICIPANTS: singleton pregnancies from January 2011 to August 2012 with a fetus in breech presentation and a childbirth from 36 weeks gestation onwards. Spontaneous cephalic presentations (selected from national registry 2009 and 2010) were matched in a 2:1 ratio to cephalic presentations after a successful version attempt. Matching criteria were maternal age, parity, gestational age at childbirth and fetal gender. Main outcomes were mode of childbirth and neonatal outcomes. MEASUREMENTS AND FINDINGS: of 1613 women eligible for external cephalic version, 1169 (72.5%) received an ECV attempt. The overall caesarean childbirth rate was significantly lower compared to women who did not receive a version attempt (57% versus 87%; RR 0.66 (0.62-0.70)). Women with a cephalic presentation after ECV compared to women with a spontaneous cephalic presentation had a decreased risk for instrumental vaginal childbirth (RR 0.52 (95% CI 0.29-0.94)) and an increased risk of overall caesarean childbirth (RR 1.7 (95%CI 1.2-2.5)). KEY CONCLUSIONS: women who had a successful ECV are at increased risk for a caesarean childbirth but overall, ECV is an important tool to reduce the caesarean rate. IMPLICATION FOR PRACTICE: ECV is an important tool to reduce the caesarean section rates.

Planned Out-of-Hospital Birth and Birth Outcomes.

BACKGROUND: The frequency of planned out-of-hospital birth in the United States has increased in recent years. The value of studies assessing the perinatal risks of planned out-of-hospital birth versus hospital birth has been limited by cases in which transfer to a hospital is required and a birth that was initially planned as an out-of-hospital birth is misclassified as a hospital birth. METHODS: We performed a population-based, retrospective cohort study of all births that occurred in Oregon during 2012 and 2013 using data from newly revised Oregon birth certificates that allowed for the disaggregation of hospital births into the categories of planned in-hospital births and planned out-of-hospital births that took place in the hospital after a woman's intrapartum transfer to the hospital. We assessed perinatal morbidity and mortality, maternal morbidity, and obstetrical procedures according to the planned birth setting (out of hospital vs. hospital). RESULTS: Planned out-of-hospital birth was associated with a higher rate of perinatal death than was planned in-hospital birth (3.9 vs. 1.8 deaths per 1000 deliveries, P=0.003; odds ratio after adjustment for maternal characteristics and medical conditions, 2.43; 95% confidence interval [CI], 1.37 to 4.30; adjusted risk difference, 1.52 deaths per 1000 births; 95% CI, 0.51 to 2.54). The odds for neonatal seizure were higher and the odds for admission to a neonatal intensive care unit lower with planned out-of-hospital births than with planned in-hospital birth. Planned out-of-hospital birth was also strongly associated with unassisted vaginal delivery (93.8%, vs. 71.9% with planned in-hospital births; P<0.001) and with decreased odds for obstetrical procedures. CONCLUSIONS: 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. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.).

Missed opportunities for institutional delivery and associated factors among urban resident pregnant women in South Tigray Zone, Ethiopia: a community-based follow-up study.

BACKGROUND: Every pregnant woman is considered to be at risk and some risks may not always be foreseeable or detectable. Therefore, the presence of a skilled birth attendant at every delivery is considered to be the most critical intervention in reducing maternal mortality and morbidity. In Ethiopia, the proportion of births attended by skilled personnel in urban settings can be as low as 10%. Therefore, the main purpose of this research was to identify factors affecting unplanned home delivery in urban settings, where there is relatively good access in principle to modern healthcare institutions. DESIGN: A community-based follow-up study was conducted from 17 January 2014 to 30 August 2014, among second- and third-trimester pregnant women who had planned for institutional delivery in South Tigray Zone. A systematic sampling technique was used to get a total of 522 study participants. A pre-tested and structured questionnaire was used to collect relevant data. Bivariate and multivariate data analyses were performed using SPSS version 16.0. RESULTS: The study revealed that among 465 pregnant women who planned for institutional delivery, 134 (28.8%) opted out and delivered at their home (missed opportunity). Single women (AOR 2.34, 95% CI 1.17-4.68), illiterate mothers (AOR 6.14, 95% CI 2.20-17.2), absence of antenatal clinic visit for indexed pregnancy (AOR 3.11, 95% CI 1.72-5.61), absence of obstetric complications during the index pregnancy (AOR 2.96, 95% CI 1.47-5.97), poor autonomy (AOR 2.11, 95% CI 1.27-3.49), and absence of birth preparedness and complication readiness (AOR 3.83, 95% CI 2.19-6.70) were significant predictors of unplanned home delivery. CONCLUSIONS: A significant proportion of pregnant women missed the opportunity of modern delivery assistance. Educational status, antenatal care status, lack of obstetric complications, poor autonomy, and lack of birth preparedness and complication readiness were among the important predictors of unplanned home delivery.

Intrapartum and neonatal mortality in primary midwife-led and secondary obstetrician-led care in the Amsterdam region of the Netherlands: A retrospective cohort study.

OBJECTIVE: To compare intrapartum- and neonatal mortality and intervention rates in term women starting labour in primary midwife-led versus secondary obstetrician-led care. DESIGN: Retrospective cohort study. SETTING: Amsterdam region of the Netherlands. PARTICIPANTS: Women with singleton pregnancies who gave birth beyond 37+0 weeks gestation in the years 2005 up to 2008 and lived in the catchment area of the neonatal intensive care units of both academic hospitals in Amsterdam. Women with a primary caesarean section or a pregnancy complicated by antepartum death or major congenital anomalies were excluded. For women in the midwife-led care group, a home or hospital birth could be planned. MEASUREMENTS: Analysis of linked data from the national perinatal register, and hospital- and midwifery record data. We assessed (unadjusted) relative risks with confidence intervals. Main outcome measures were incidences of intrapartum and neonatal (<28 days) mortality. Secondary outcomes included incidences of caesarean section and vaginal instrumental delivery. FINDINGS: 53,123 women started labour in primary care and 30,166 women in secondary care. Intrapartum and neonatal mortality rates were 37/53,123 (0.70‰) in the primary care group and 24/30,166 (0.80‰) in the secondary care group (relative risk 0.88; 95% CI 0.52-1.46). Women in the primary care group were less likely to deliver by secondary caesarean section (5% versus 16%; RR 0.31; 95% CI 0.30-0.32) or by instrumental delivery (10% versus 13%; RR 0.76; 95% CI 0.73-0.79). KEY CONCLUSIONS: We found a low absolute risk of intrapartum and neonatal mortality, with a comparable risk for women who started labour in primary versus secondary care. The intervention rate was significantly lower in women who started labour in primary care. IMPLICATIONS FOR PRACTICE: These findings suggest that it is possible to identify a group of women at low risk of complications that can start labour in primary care and have low rates of medical interventions whereas perinatal mortality is low.