Home birth after prior cesarean: What are the risks?

Home births, compared to delivery in the hospital, pose significantly elevated and preventable neonatal risks, according to research findings by Amos Grünebaum, MD, and Frank A Chervenak, MD, of Weill Medical College of Cornell University, New York, New York. These risks include an Apgar score of 0 and seizure or serious neurologic dysfunction.

In the first prize, award-winning paper presented by Dr Grünebaum at the American College of Obstetricians and Gynecologists 2016 annual meeting, the researchers conclude that the lack of fetal monitoring and not being able to perform a timely cesarean delivery outside of a hospital setting combine to result in the increased risk.

“Our study confirms other studies,” comments Dr Grünebaum, Professor and Director of Obstetrics and Chief of Labor & Delivery at Weill Cornell Medicine, “which show that planned home birth in the United States, in this case in women with prior cesarean deliveries, is not safe for neonates when one considers its absolute and relative risks in the context of patient safety.”

Given the increase of vaginal births after cesarean (VBAC) seen among planned home births, the investigators undertook an evaluation of the risks of an Apgar score of 0 and seizure/serious neurologic dysfunction for neonates of patients who deliver at home with a VBAC. They conducted a retrospective cohort analysis of the Centers for Disease Control and Prevention birth certificate data (2007–2013) for infants at term (>37 weeks) whose birthweight was more than 2499 g and mothers who had had a prior cesarean delivery.

Related: Home birth: The obstetrician's ethical response

Planned home births overseen by midwives were compared with hospital births in this study, the population of which included 2,404,505 hospital births and 4544 planned home births of women with a prior cesarean delivery who had been assisted by a midwife. For hospital births, the incidence of Apgar 0 was 0.093 per 1000, as compared with 0.660 per 1000 for home births (risk ratio [RR], 7.09; P<.001). In further assessing the incidence of seizure or serious neurologic dysfunction in these patient groups, the researchers found that it was 0.192 per 1000 for hospital births, versus 1.98 per 1000 for home births (RR, 10.15; P<.0001).

Finally, considering the higher risk implications, they note that these results are important for health care professionals to share with all patients with a prior cesarean delivery who have expressed interest in having a home birth for their next child. They comment that professionals managing women with a prior cesarean delivery should strongly recommend against a planned home birth.

As Dr Grünebaum further articulates: “As professionals, we are ethically obliged to reduce preventable, increased relative and absolute risks of birth. Women who express an interest in planned home birth should be informed that it results in increased risks of perinatal and neonatal mortality and morbidity that can be prevented by planned hospital birth.”

“Providing our patients with this information,” he emphasizes, “strengthens a woman’s autonomy to make an informed decision about the place and circumstances of birth.”