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Clinical Policy Bulletin:
Home Births
Number: 0329


Policy

Aetna considers planned deliveries at home and associated services not medically appropriate.

Note: However, coverage of home births will be considered when mandated by law under plans subject to state mandates.

See also CPB 0127 - Home Uterine Activity Monitoring.



Background

According to the policy statement on home delivery of the American College of Obstetricians and Gynecologists (ACOG), labor and delivery, while a physiological process, clearly presents hazards to both the mother and fetus before and after birth.  These hazards require standards of safety which are provided in the hospital setting and cannot be matched in the home situation. 

Guidelines for Perinatal Care published by the American Academy of Pediatrics and ACOG state that the hospital, including a birthing center within the hospital complex, or a freestanding birthing center, provides the safest setting for labor, delivery, and the postpartum period.  The use of other settings is not encouraged.  Further, any facility providing obstetrical care should have the services listed as essential components for a level I hospital.  This includes the availability of blood and fresh-frozen plasma for transfusion; anesthesia, radiology, ultrasound, electronic fetal heart rate monitoring and laboratory services available on a 24-hour basis; resuscitation and stabilization of all inborn neonates; nursery; and other services that are not available in the home setting.

Malloy (2010) stated that home births attended by certified nurse midwives (CNMs) make up an extremely small proportion of births in the United States (less than 1.0 %) and are not supported by ACOG.  The author examined the safety of CNM attended home deliveries compared with certified nurse midwife in-hospital deliveries in the United States as measured by the risk of adverse infant outcomes among women with term, singleton, vaginal deliveries.  United States linked birth and infant death files for the years 2000 to 2004 were used for the analysis.  Adverse neonatal outcomes including death were determined by place of birth and attendant type for in-hospital CNM, in-hospital "other" midwife, home certified nurse midwife, home "other" midwife, and free-standing birth center CNM deliveries.  For the 5-year period, there were 1,237,129 in-hospital CNM attended births; 17,389 in-hospital "other" midwife attended births; 13,529 home CNM attended births; 42,375 home "other" midwife attended births; and 25,319 birthing center CNM attended births.  The neonatal mortality rate per 1,000 live births for each of these categories was, respectively, 0.5 (deaths = 614), 0.4 (deaths = 7), 1.0 (deaths = 14), 1.8 (deaths = 75), and 0.6 (deaths = 16).  The adjusted odds ratio (OR) (95 % confidence interval [CI]) for neonatal mortality for home CNM attended deliveries versus in-hospital CNM attended deliveries was 2.02 (1.18 to 3.45).  The author concluded that deliveries at home attended by CNMs and "other midwives" were associated with higher risks for mortality than deliveries in-hospital by CNMs.

Kennare et al (2010) examined differences in outcomes between planned home births, occurring at home or in hospital, and planned hospital births.  The experimental design was a opulation-based study using South Australian perinatal data on all births and perinatal deaths during the period 1991 to 2006.  Analysis included logistic regression adjusted for predictor variables and standardized perinatal mortality ratios.  Main outcome measures included perinatal death, intra-partum death, death attributed to intra-partum asphyxia, Apgar score less than 7 at 5 mins, use of specialized neonatal care, operative delivery, perineal injury and post-partum hemorrhage.  Planned home births accounted for 0.38 % of 300,011 births in South Australia.  They had a perinatal mortality rate similar to that for planned hospital births (7.9 versus 8.2 per 1,000 births), but a 7-fold higher risk of intra-partum death (95 % CI: 1.53 to 35.87) and a 27-fold higher risk of death from intra-partum asphyxia (95 % CI: 8.02 to 88.83).  Review of perinatal deaths in the planned home births group identified inappropriate inclusion of women with risk factors for home birth and inadequate fetal surveillance during labor.  Low Apgar scores were more frequent among planned home births, and use of specialized neonatal care as well as rates of post-partum hemorrhage and severe perineal tears were lower among planned home births, but these differences were not statistically significant.  Planned home births had lower cesarean section and instrumental delivery rates, and a 7 times lower episiotomy rate than planned hospital births.  The authors concluded that perinatal safety of home births may be improved substantially by better adherence to risk assessment, timely transfer to hospital when needed, and closer fetal surveillance.

In a meta-analysis, Wax and colleagues (2010) reviewed the medical literature on the maternal and newborn safety of planned home versus planned hospital birth.  These investigators included English-language peer-reviewed publications from developed Western nations reporting maternal and newborn outcomes by planned delivery location.  Outcomes' summary OR with 95 % CI were calculated.  Planned home births were associated with fewer maternal interventions including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, and operative delivery.  These women were less likely to experience lacerations, hemorrhage, and infections.  Neonatal outcomes of planned home births revealed less frequent prematurity, low birth weight, and assisted newborn ventilation.  Although planned home and hospital births exhibited similar perinatal mortality rates, planned home births were associated with significantly elevated neonatal mortality rates.  The authors concluded that less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate.  Limitations of this study included those inherent in the included studies, self-selection of women for home birth, and insufficient data for some outcomes.

The ACOG Committee on Obstetric Practice's opinion on planned home birth (2011) noted that although the Committee believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery.  Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence.  Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a 2-fold to 3-fold increased risk of neonatal death when compared with planned hospital birth.  More importantly, women should be informed that the appropriate selection of candidates for home birth; the availability of a CNM, certified midwife, or physician practicing within an integrated and regulated health system; ready access to consultation; and assurance of safe and timely transport to nearby hospitals are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes.

Although ACOG does not support planned home births given the published medical data, it emphasizes that women who decide to deliver at home should be offered standard components of prenatal care, including group B Strep screening and treatment, genetic screening, as well as HIV screening.  It is also important for women thinking about a planned home birth to consider if they are healthy and considered low-risk and to work with a CNM, certified midwife, or physician who practices in an integrated and regulated health system; have ready access to consultation; and have a plan for safe and quick transportation to a nearby hospital in the event of an emergency.  Furthermore, the recommendations state that a prior cesarean delivery is an absolute contraindication to planning a home birth due to the risks, including uterine rupture.  Women who want to try for a vaginal birth after cesarean are advised to do so only in a hospital where emergency care is immediately available.  Attempting a home birth also is not advised for women who are post-term (greater than 42 weeks gestation), carrying twins, or have a breech presentation because all carry a greater risk of perinatal death.

The American Academy of Pediatrics (2013) states that hospitals and birthing centers are the safest places for U.S. women to deliver, and expectant mothers should be informed of the increase in neonatal mortality and complications that come with home births. However, the AAP says, clinicians must respect the right of women to make a medically informed decision about delivery. The AAP's statement concurs with the 2011 statement from the American College of Obstetricians and Gynecologists. The AAP notes that planned home birth in the United States appears to be associated with a two- to threefold increase in neonatal mortality. The AAP states that evidence also suggests that infants born at home in the United States have an increased incidence of low Apgar scores and neonatal seizures. Some women who plan to deliver at home will need transfer to a hospital before delivery because of unanticipated complications. This percentage varies widely among reports, from approximately 10% to 40%.

Olsen and Clausen (2012) stated that observational studies of increasingly better quality and in different settings suggested that planned home birth in many places can be as safe as planned hospital birth and with less intervention and fewer complications.  These investigators updated a Cochrane review first published in 1998.  They evaluated the effects of planned hospital birth compared with planned home birth in selected low-risk women, assisted by an experienced midwife with collaborative medical back up in case transfer should be necessary.  They searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 30, 2012) and contacted editors and authors involved with possible trials.  Randomized controlled trials comparing planned hospital birth with planned home birth in low-risk women as described in the objectives were selected for analysis.  The 2 review authors assessed trial quality and extracted data, and contacted study authors for additional information.  Two trials met the inclusion criteria but only 1 trial involving 11 women provided some outcome data and was included.  The evidence from this trial was of moderate quality and too small to allow conclusions to be drawn.  The authors concluded that there is no strong evidence from randomized trials to favor either planned hospital birth or planned home birth for low-risk pregnant women.  However, the trials showed that women living in areas where they are not well-informed about home birth may welcome ethically well-designed trials that would ensure an informed choice.  As the quality of evidence in favor of home birth from observational studies seems to be steadily increasing, it might be as important to prepare a regularly updated systematic review including observational studies as described in the Cochrane Handbook for Systematic Reviews of Interventions as to attempt to set up new randomized controlled trials.

Chervenak et al (2013) addressed the recrudescence of and new support for midwife-supervised planned home birth in the United States and the other developed countries in the context of professional responsibility.  Advocates of planned home birth have emphasized patient safety, patient satisfaction, cost effectiveness, and respect for women's rights.  These investigators provided a critical evaluation of each of these claims and identify professionally appropriate responses of obstetricians and other concerned physicians to planned home birth.  They started with patient safety and showed that planned home birth has unnecessary, preventable, irremediable increased risk of harm for pregnant, fetal, and neonatal patients.  They documented that the persistently high rates of emergency transport undermines patient safety and satisfaction, the raison d'etre of planned home birth, and that a comprehensive analysis undermines claims about the cost-effectiveness of planned home birth.  These researchers then argued that obstetricians and other concerned physicians should understand, identify, and correct the root causes of the recrudescence of planned home birth; respond to expressions of interest in planned home birth by women with evidence-based recommendations against it; refuse to participate in planned home birth; but still provide excellent and compassionate emergency obstetric care to women transported from planned home birth.  They explained why obstetricians should not participate in or refer to randomized clinical trials of planned home versus planned hospital birth.  The authors called on obstetricians, other concerned physicians, midwives and other obstetric providers, and their professional associations not to support planned home birth when there are safe and compassionate hospital-based alternatives and to advocate for a safe home-birth-like experience in the hospital.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes not covered for indications listed in the CPB (not all-inclusive):
59400 - 59430
59510 - 59525
59610 - 59622
99199
99432
HCPCS codes not covered for indications listed in the CPB (not all-inclusive):
G0154 Direct skilled nursing services of a licensed nurse (LPN or RN) in the home health or hospice setting, each 15 minutes [not covered for planned deliveries at home]
S8415 Supplies for home delivery of infant
S9123 - S9124, T1000 - T1003, T1030 - T1031 Nursing care in the home [not covered for planned deliveries at home]
ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):
640.00 - 677 Complications mainly related to pregnancy, normal delivery and other indications for care in pregnancy, labor, and delivery, complications occurring mainly in the course of labor and delivery, and complications of the puerperium [not covered for planned deliveries at home]
V22.0 - V24.2 Supervision of pregnancy and postpartum care and examination [not covered for planned deliveries at home]
V27.0 - V27.9 Outcome of delivery [not covered for planned deliveries at home]
V30 - V39 with 4th digit 2 Liveborn infants according to type of birth, born outside hospital and not hospitalized [not covered for planned deliveries at home]


The above policy is based on the following references:
  1. Bastian H, Keirse MJ, Lancaster PAL. Perinatal death associated with planned home birth in Australia: Population based study. BMJ. 1998;317(7155):384-388.
  2. Olsen O, Jewell MD. Home versus hospital birth. Cochrane Database Syst Rev. 1998;(3):CD000352.
  3. American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG). Guidelines for Perinatal Care. 6th ed. Elk Grove Village, IL: AAP; 2007.
  4. American College of Obstetricians and Gynecologists (ACOG). Statement on Home Delivery. Washington, DC: ACOG; September 1999.
  5. American College of Obstetricians and Gynecologists (ACOG). Home births double risk of newborn death. ACOG Press Release. Washington, DC: ACOG; July 31, 2002.
  6. Pang JW, Heffelfinger JD, Huang GJ, et al. Outcomes of planned home births in Washington State: 1989-1996. Obstet Gynecol. 2002;100(2):253-259.
  7. McKenna P, Matthews T. Safety of home delivery compared with hospital delivery in the Eastern Region Health Authority in Ireland in the years 1999-2002. Ir Med J. 2003;96(7):198-200.
  8. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Home births. College Statement. Statement No. C-Obs 2. East Melbourne, VIC: RANZCOG; November 2006.
  9. American College of Obstetricians and Gynecologists (ACOG). Home births in the United States. ACOG Statement of Policy. Washington, DC: ACOG; approved May 4, 2007.
  10. Wax JR, Pinette MG, Cartin A, Blackstone J. Maternal and newborn morbidity by birth facility among selected United States 2006 low-risk births. Am J Obstet Gynecol. 2010;202(2):152.e1-e5.
  11. Malloy MH. Infant outcomes of certified nurse midwife attended home births: United States 2000 to 2004. J Perinatol. 2010;30(9):622-627.
  12. Kennare RM, Keirse MJ, Tucker GR, Chan AC. Planned home and hospital births in South Australia, 1991-2006: Differences in outcomes. Med J Aust. 2010;192(2):76-80.
  13. Wax JR, Lucas FL, Lamont M, et al. Maternal and newborn outcomes in planned home birth vs planned hospital births: A metaanalysis. Am J Obstet Gynecol. 2010;203(3):243.e1-e8.
  14. ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 476: Planned home birth. Obstet Gynecol. 2011;117(2 Pt 1):425-428.
  15. Olsen O, Clausen JA. Planned hospital birth versus planned home birth. Cochrane Database Syst Rev. 2012;9:CD000352.
  16. Chervenak FA, McCullough LB, Brent RL, et al. Planned home birth: The professional responsibility response. Am J Obstet Gynecol. 2013;208(1):31-38.
  17. American Academy of Pediatrics, Committee on Fetus and Newborn. Planned home birth. Policy Statement. Pediatrics. 2013;131(5):1016-1020.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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