Mortality and perinatal infectious complications following home birth in Washington State: 2003-2014

Planned home birth is defined as a pregnancy in which the mother intends to deliver at home. Washington State has one of the highest proportions of home births in the United States (2.3%), more than double the national average. Despite the rapid rise in popularity of the home birth movement over the last decade, controversy remains over the safety of this practice and how women should best be counseled regarding their decision on where to give birth. We conducted a population based cohort study of births in Washington State from 2003-2013, with the planned place of care at the onset of labor as the exposure of interest (planned delivery in hospital versus planned home delivery) as defined by the Washington state birth filing form. The primary endpoint was all cause mortality during the first 28 days of life. The secondary outcome was a composite variable indicating hospitalization for a neonatal infection in the first 28 days after birth, obtained from linked hospital records data. After exclusions, 12,590 planned home births and 44,739 planned hospital births were included in analyses. The risk of neonatal death among infants born to women who planned to give birth at home was double that of infants whose mothers had planned a hospital delivery (RR 2.1, 95% CI 1.2, 3.6). Compared to planned hospital births, home births were associated with fewer infant hospitalizations for infection within 28 days of delivery (RR 0.6, 95% CI 0.4, 0.8), as well as with a lower risk of induced labor (RR 0.05, 95% CI 0.05, 0.06), maternal laceration (RR 0.4, 95% CI 0.3, 0.5), and neonatal ICU admission (RR 0.4, 95% CI 0.3, 0.4). Prolonged labor was also more common in the planned home birth group (RR 1.7, 95% CI 1.5, 1.9). The most common specific neonatal infectious etiologies requiring hospitalization were urinary and respiratory tract infections. While neonatal mortality was a rare event in our study, it is concerning that the relative risk of death remains elevated among a highly selected population of women choosing to give birth at home. Further studies are needed to explore the underlying mechanisms of increased neonatal mortality associated with planned home birth and to replicate our findings regarding the disparity in infectious diseases between planned home and hospital births.