LAUSR

BACKGROUND Planned home births have leveled off in the United States in the last years after a significant rise starting in the mid-2000s. Planned home births in the U.S. are associated with increased patient-risk profiles. Multiple studies concluded that, compared to hospital births, absolute and relative risks of perinatal mortality and morbidity in U.S. planned home births are significantly increased. OBJECTIVE The purpose of this study was to explore the safety of birth in the United States by comparing the neonatal mortality outcomes of two locations, hospital birth and home birth, by four types of attendants: hospital midwife; certified nurse-midwife at home; direct-entry ("other") midwife at home; and attendant at home not identified, using the most recent U.S. Centers for Disease Control (CDC) natality data on neonatal mortality for planned home births in the United States. Outcomes are presented as absolute risks (neonatal mortality per 10,000 live births), and as relative risks of neonatal mortality (hospital certified nurse-midwife Odds ratio=1) overall, and for recognized risk factors. STUDY DESIGN We used the most current U.S. Centers for Disease Control Linked Birth and Infant Death Records for 2010-2017, to assess neonatal mortality (neonatal death days 0- 27 after birth) for single, term (37+ weeks), normal weight ( >2499 gms) infants for planned home births and hospital births by birth attendants: hospital certified nurse-midwives, home certified nurse-midwives, home other midwives (e.g., lay or direct-entry midwives), and other home birth attendant not identified. RESULTS The neonatal mortality for U.S. hospital midwife-attended births was 3.27 per 10,000 live births, 13.66 per 10,000 live births for all planned home births, and 27.98 per 10,000 live births for unintended/unplanned home births. Planned home births attended by direct-entry midwives and by certified nurse-midwives had a significantly elevated absolute and relative neonatal mortality risk compared to certified nurse-midwife-attended hospital births (Hospital certified nurse-midwife: 3.27/10,000 live births Odds ratio = 1; Home birth direct-entry midwives: Neonatal mortality 12.44, /10,000 live births, Odds ratio 3.81, 95%CI: 3.12-4.65, P<0.0001); Home birth certified nurse-midwife: neonatal mortality 9.48/10,000 live births, Odds ratio 2.90, 95% CI: 2.90; P<0.0001. These differences increased further when patients were stratified for recognized risk factors. CONCLUSION The safety of birth in the United States varies by location and attendant. Compared to U.S. hospital births attended by a certified nurse-midwife, planned U.S. home births for all types of attendants are a less safe setting of birth, especially when recognized risk factors are taken into account. The type of midwife attending U.S. planned home birth appears to have no differential effect on decreasing the absolute and relative risk of neonatal mortality of planned home birth, because the difference in outcomes of U.S. planned home births attended by direct-entry midwives or by certified nurse-midwives is not statistically significant.