Home Births

Number: 0329

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

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Policy

Scope of Policy

This Clinical Policy Bulletin addresses home births.

1. Medical Necessity

   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. 

2. Related Policies

   • CPB 0127 - Home Uterine Activity Monitoring.

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Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
CPT codes not covered for indications listed in the CPB (not all-inclusive):
59400 - 59430	Vaginal delivery, antepartum and postpartum care [not covered for planned deliveries at home]
59510 - 59525	Cesarean delivery [not covered for planned deliveries at home]
59610 - 59622	Delivery after previous cesarean delivery [not covered for planned deliveries at home]
99199	Unlisted special service, procedure or report [not covered for planned deliveries at home]
99461	Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center [not covered for planned deliveries at home]
HCPCS codes not covered for indications listed in the CPB (not all-inclusive):
G0299	Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes
G0300	Direct skilled nursing services of a license practical nurse (LPN) in the home health or hospice setting, each 15 minutes
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-10 codes not covered for indications listed in the CPB (not all-inclusive):
O09.00 - O9a.53	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]
Z34.00 - Z34.93	Encounter for supervision of normal first pregnancy [not covered for planned deliveries at home]
Z37.0 - Z37.9	Outcome of delivery [not covered for planned deliveries at home]
Z38.1, Z38.4 Z38.7	Liveborn infants according to place of birth and type of birth (born outside of the hospital) [not covered for planned deliveries at home]
Z39.0 - Z39.2	Encounter for maternal postpartum care and examination

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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 population-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 minutes, 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 the 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, 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 backup 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 two review authors assessed trial quality and extracted data, and contacted study authors for additional information. Two trials met the inclusion criteria, but only one 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 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 identified 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 undermine patient safety and satisfaction, the raison d'être 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.

Tura et al. (2013) stated that although promising progress has been made towards achieving the Millennium Development Goal four through substantial reduction in under-five mortality, the decline in neonatal mortality remains stagnant, mainly in middle- and low-income countries. As an option, health facility delivery is assumed to reduce this problem significantly. However, the existing evidence shows contradicting conclusions about this fact, particularly in areas where enabling environments are constrained. Thus, this review was conducted with the aim of determining the pooled effect of health facility delivery on neonatal mortality. The reviewed studies were accessed through an electronic web-based search strategy from PUBMED, Cochrane Library, and Advanced Google Scholar by using combination key terms. The analysis was done using STATA-11. The I² test statistic was used to assess heterogeneity. Funnel plot, Begg's test, and Egger's test were used to check for publication bias. Pooled effect size was determined in the form of relative risk in the random-effects model using DerSimonian and Laird's estimator. A total of 2,216 studies conducted on the review topic were identified. During screening, 37 studies were found to be relevant for data abstraction. From these, only 19 studies fulfilled the preset criteria and were included in the analysis. In 10 of the 19 studies included in the analysis, facility delivery had a significant association with neonatal mortality, while in 9 studies the association was not significant. Based on the random effects model, the final pooled effect size in the form of relative risk was 0.71 (95% CI: 0.54 to 0.87) for health facility delivery as compared to home delivery. The authors concluded that health facility delivery is found to reduce the risk of neonatal mortality by 29% in low- and middle-income countries. Moreover, they stated that the expansion of health facilities, fulfilling the enabling environments, and promoting their utilization during childbirth are essential in areas where home delivery is a common practice.

In a retrospective analysis, Catling-Paull et al. (2013) reported maternal and neonatal outcomes for Australian women planning a publicly funded home birth from 2005 to 2010. Data for 2005 to 2010 (or from the commencement of a program to 2010) were requested from the 12 publicly funded home birth programs in place at the time. Main outcome measures included maternal outcomes (mortality; place and mode of birth; perineal trauma; type of management of the third stage of labor; postpartum hemorrhage; transfer to hospital) and neonatal outcomes (early mortality; Apgar score at 5 minutes; birth weight; breast-feeding initially and at 6 weeks; significant morbidity; transfer to hospital; admission to a special care nursery). Nine publicly funded home birth programs in Australia provided data, accounting for 97% of births in these programs during the period studied. Of the 1,807 women who intended to give birth at home at the onset of labor, 1,521 (84%) did so; 315 (17%) were transferred to the hospital during labor or within 1 week of giving birth. The rate of stillbirth and early neonatal death was 3.3 per 1,000 births; when deaths due to expected fetal anomalies were excluded, it was 1.7 per 1,000 births. The rate of normal vaginal birth was 90%. The authors concluded that the findings of this study provided the first national evaluation of a significant proportion of women choosing publicly funded home birth in Australia; however, the sample size did not have sufficient power to draw conclusions about safety. They stated that more research is needed to ascertain the safety of alternative places of birth within Australia.

Cheng et al. (2013) noted that more women are planning home birth in the United States, although safety remains unclear. These investigators examined outcomes associated with planned home births compared with hospital births. They conducted a retrospective cohort study of term singleton live births in 2008 in the United States. Deliveries were categorized by location—hospitals or intended home births. Neonatal outcomes were compared using the χ² test and multivariable logistic regression. There were 2,081,753 births that met the study criteria; of these, 12,039 (0.58%) were planned home births. More planned home births had 5-minute Apgar scores less than 4 (0.37%) compared with hospital births (0.24%; adjusted OR, 1.87; 95% CI, 1.36–2.58) and neonatal seizures (0.06% versus 0.02%, respectively; adjusted OR, 3.08; 95% CI, 1.44–6.58). Women with planned home births had fewer interventions, including operative vaginal delivery and labor induction/augmentation. The authors concluded that planned home births were associated with increased neonatal complications but fewer obstetric interventions. They stated that the trade-off between maternal preferences and neonatal outcomes should be weighed thoughtfully.

A recent study reported a greater risk of infant death for home deliveries. Grunebaum and colleagues (2013) performed this study by analyzing Centers for Disease Control and Prevention (CDC) data and found that babies delivered at home were almost four times more likely to die than babies delivered in hospitals. The absolute risk of infant death at birth or within 28 days after delivery was 12.6 per 10,000 midwife-assisted home births, compared with 3.2 per 10,000 hospital births assisted by midwives, according to findings presented at the Society for Maternal-Fetal Medicine meeting. It is important to note that this study included only planned home births and undercounted the actual risk of death at home birth in three separate ways:

• Transfers to the hospital during attempted home birth ended up in the hospital group and were not counted in the home birth death rate.
• Intra-partum stillbirths were not included in these data, so home birth deaths were under-counted even further.
• The authors of this study examined all races, but white women account for more than 90 % of women choosing home birth, and the neonatal death rate for white women is much lower than that for all races.

Blix and colleagues (2014) stated that there is concern about the safety of home births, especially in women transferred to hospital during or after labor. The scope of transfer in planned home births has not been assessed in a systematic review. These investigators described the proportions and indications for transfer from home to hospital during or after labor in planned home births. The databases PubMed, Embase, CINAHL, Svemed+, and the Cochrane Library were searched using the MeSH term "home childbirth." Inclusion criteria were as follows: the study population was women who chose planned home birth at the onset of labor; the studies were from Western countries; the birth attendant was an authorized midwife or medical doctor; the studies were published in 1985 or later, with data not older than from 1980; and data on transfer from home to hospital were described. Of the 3,366 titles identified, 83 full-text articles were screened, and 15 met the inclusion criteria. Two of the authors independently extracted the data. Because of the heterogeneity and lack of robustness across the studies, there were considerable risks for bias if performing meta-analyses. A descriptive presentation of the findings was chosen. A total of 15 studies were eligible for inclusion, containing data from 215,257 women. The total proportion of transfer from home to hospital varied from 9.9% to 31.9% across the studies. The most common indication for transfer was labor dystocia, occurring in 5.1% to 9.8% of all women planning for home births. Transfer for indication of fetal distress varied from 1.0% to 3.6%, post-partum hemorrhage from 0% to 0.2%, and respiratory problems in the infant from 0.3% to 1.4%. The proportion of emergency transfers varied from 0% to 5.4%. The authors concluded that future studies should report indications for transfer from home to hospital and provide clear definitions of emergency transfers.

Grunebaum et al. (2014) examined neonatal mortality in relation to birth settings and birth attendants in the United States from 2006 through 2009. Data from the CDC-linked birth and infant death dataset in the United States from 2006 through 2009 were used to assess early and total neonatal mortality for singleton, vertex, and term births without congenital malformations delivered by midwives and physicians in the hospital and midwives and others out of the hospital. Deliveries by hospital midwives served as the reference. Midwife home births had a significantly higher total neonatal mortality risk than deliveries by hospital midwives (1.26 per 1,000 births; relative risk [RR], 3.87 versus 0.32 per 1,000; p < 0.001). Midwife home births of 41 weeks or longer (1.84 per 1,000; RR, 6.76 versus 0.27 per 1,000; p < 0.001) and midwife home births of women with a first birth (2.19 per 1,000; RR, 6.74 versus 0.33 per 1,000; p < 0.001) had significantly higher risks of total neonatal mortality than deliveries by hospital midwives. In midwife home births, neonatal mortality for first births was twice that of subsequent births (2.19 versus 0.96 per 1,000; p < 0.001). Similar results were observed for early neonatal mortality. The excess total neonatal mortality for midwife home births compared with midwife hospital births was 9.32 per 10,000 births, and the excess early neonatal mortality was 7.89 per 10,000 births. The authors concluded that the findings of this study showed a significantly increased total and early neonatal mortality for home births and even higher risks for women of 41 weeks or longer and women having a first birth. These significantly increased risks of neonatal mortality in home births must be disclosed by all obstetric practitioners to all pregnant women who express an interest in such births.

In a nationwide cohort study, de Jonge et al. (2015) compared rates of adverse perinatal outcomes between planned home births versus planned hospital births. Low-risk women in midwife-led care at the onset of labor were included in this analysis. Main outcome measures were intra-partum and neonatal death, Apgar scores, and admission to a neonatal intensive care unit (NICU) within 28 days of birth. Of the total of 814,979 women, 466,112 had a planned home birth and 276,958 had a planned hospital birth. For 71,909 women, their planned place of birth was unknown. The combined intra-partum and neonatal death rates up to 28 days after birth, including cases with discrepancies in the registration of the moment of death, were: for nulliparous women, 1.02% for planned home births versus 1.09% for planned hospital births, adjusted OR (aOR) 0.99, 95% CI: 0.79 to 1.24; and for parous women, 0.59% versus 0.58%, aOR 1.16, 95% CI: 0.87 to 1.55. The rates of NICU admissions and low Apgar scores did not significantly differ among nulliparous women (NICU admissions up to 28 days, 3.41% versus 3.61%, aOR 1.05, 95% CI: 0.92 to 1.18). Among parous women, the rates of Apgar scores below seven and NICU admissions were significantly lower among planned home births (NICU admissions up to 28 days, 1.36 versus 1.95%, aOR 0.79, 95% CI: 0.66 to 0.93). The authors concluded that there was no increased risk of adverse perinatal outcomes for planned home births among low-risk women. They stated that these findings may only apply to regions where home births are well integrated into the maternity care system.

Snowden et al. (2015) stated that 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. These researchers 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 intra-partum transfer to the hospital. They evaluated perinatal morbidity and mortality, maternal morbidity, and obstetrical procedures according to the planned birth setting (out of hospital versus hospital). Planned out-of-hospital birth was associated with a higher rate of perinatal death than was planned in-hospital birth (3.9 versus 1.8 deaths per 1,000 deliveries, p = 0.003; OR after adjustment for maternal characteristics and medical conditions, 2.43; 95% CI: 1.37 to 4.30; adjusted risk difference, 1.52 deaths per 1,000 births; 95% CI: 0.51 to 2.54). The odds for neonatal seizure were higher, and the odds for admission to a NICU were 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% versus 71.9% with planned in-hospital births; p < 0.001) and with decreased odds for obstetrical procedures. The authors concluded that 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.

The ACOG’s Committee Opinion on "Planned Home Birth" (2017) stated that in the United States, approximately 35,000 births (0.9%) per year occur in the home. Approximately 1/4 of these births were unplanned or unattended. Although the ACOG believes that hospitals and accredited birth centers are the safest settings for birth, each woman has the right to make a medically informed decision about delivery. Importantly, women should be informed that several factors are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes. These factors include the appropriate selection of candidates for home birth; the availability of a certified nurse-midwife, certified midwife, or midwife whose education and licensure meet International Confederation of Midwives’ Global Standards for Midwifery Education, or a physician practicing obstetrics within an integrated and regulated health system; ready access to consultation; and access to safe and timely transport to nearby hospitals. The Committee on Obstetric Practice considers fetal malpresentation, multiple gestation, or prior cesarean delivery to be an absolute contraindication to planned home birth.

Grunebaum and colleagues (2017) noted that planned home births in the United States are associated with fewer interventions but with increased adverse neonatal outcomes such as perinatal and neonatal deaths, neonatal seizures or serious neurologic dysfunction, and low 5-minute Apgar scores. The ACOG’s Committee on Obstetric Practice stated that, to reduce perinatal death and to improve outcomes at planned home births, strict criteria are necessary to guide the selection of appropriate candidates for planned home birth. The committee listed three absolute contraindications for a planned home birth: fetal malpresentation, multiple gestations, and a history of cesarean delivery. These investigators examined if there are risk factors that should be considered contraindications to planned home births in addition to the three that are listed by the ACOG. They conducted a population-based, retrospective cohort study of all term (greater than or equal to 37 weeks gestation), normal weight (greater than or equal to 2,500 grams), singleton, non-anomalous births from 2009 to 2013 using the Centers for Disease Control and Prevention's period-linked birth-infant death files that allowed for identification of intended and unintended home births. These researchers examined neonatal deaths (days 0 to 27 after birth) across three groups (hospital-attended births by certified nurse-midwives, hospital-attended births by physicians, and planned home births) for five risk factors: two of the three absolute contraindications to home birth listed by the ACOG (breech presentation and previous cesarean delivery) and three additional risk factors (parity [nulliparous and multiparous], maternal age [women less than 35 and greater than or equal to 35 years old], and gestational age at delivery [37 to 40 and greater than or equal to 41 weeks]). The overall risk of neonatal death was significantly higher in planned home births (12.1 neonatal deaths per 10,000 deliveries; p < 0.001) compared with hospital births by certified nurse-midwives (3.08 neonatal deaths per 10,000 deliveries) or physicians (5.09 neonatal deaths per 10,000 deliveries). Neonatal mortality rates were increased significantly at planned home births, with the following individual risk factors: breech presentation (neonatal mortality rate, 127.52 per 10,000 births), nulliparous pregnant women (neonatal mortality rate, 22.5 per 10,000), previous cesarean delivery (18.91 per 10,000 births), and a gestational age greater than or equal to 41 weeks (neonatal mortality rate, 17.17 per 10,000 births). Planned home births with greater than or equal to one of the five risk factors had significantly higher neonatal death risks compared with deliveries with none of the risks. Neonatal death risk was further increased when a woman's age of greater than or equal to 35 years was combined with either a first-time birth or a gestational age of greater than or equal to 41 weeks. The authors showed two risk factors with significantly increased neonatal mortality rates at planned home births in addition to the three factors that are listed by the ACOG. These additional risk factors had neonatal mortality rates that were approaching or exceeding those for planned home birth after cesarean delivery: first-time births and a gestational age of greater than or equal to 41 weeks. Thus, two additional risk factors (first-time births and a gestational age of greater than or equal to 41 weeks) should be added to the three absolute contraindications of planned home births that are listed by the ACOG (previous cesarean delivery, malpresentation, multiple gestations) for a total of five contraindications for planned home births.

Bachilova and associates (2018) stated that the prevalence of home birth in the United States is increasing, although its safety is undetermined. These researchers examined the effects of obstetrical risk factors on early neonatal death in planned home births delivering at home. They 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 less than or equal to 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. During the study period, there were 71,704 planned and delivered home births. The overall early neonatal death rate was 1.5 deaths per 1,000 planned home births. The risks of early neonatal death were significantly higher in nulliparous births (OR 2.71; 95% CI: 1.71 to 4.31), women with a previous cesarean delivery (OR 2.62; 95% CI: 1.25 to 5.52), non-vertex presentations (OR 4.27; 95% CI: 1.33 to 13.75), plural births (OR 9.79; 95% CI: 4.25 to 22.57), preterm births (OR 4.68; 95% CI: 2.30 to 9.51), and births at greater than or equal to 41 weeks of gestation (OR 1.76; 95% CI: 1.09 to 2.84). The authors concluded that early neonatal deaths occurred more commonly in certain obstetrical contexts; patient selection may reduce adverse neonatal outcomes among planned home births.

Rossi and Prefumo (2018) stated that new interest in home birth has recently arisen among women with low-risk pregnancies. Maternal and neonatal morbidity of women planning delivery at home has yet to be comprehensively quantified. These researchers quantified pregnancy outcomes following planned home (PHB) versus planned hospital birth (PHos). They performed a systematic review of maternal and neonatal morbidity following PHB versus PHos. These investigators 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. They 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. These researchers pooled estimates of the association between outcomes and planning place of birth using meta-analyses. The study protocol was registered with PROSPERO, protocol number CRD42017058016. They included 8 studies of the 4,294 records identified, consisting of 14,637 (32.6%) in the PHB group and 30,177 (67.4%) in the PHos group. Spontaneous delivery was significantly higher in the PHB than PHos group (OR: 2.075; 95% CI: 1.654 to 2.063). Women in the PHB group were less likely to undergo cesarean section compared with women in the PHos group (OR: 0.607; 95% CI: 0.553 to 0.667). The PHB group was less likely to receive medical interventions than the PHos group. The risk of fetal dystocia was lower in the PHB than PHos group (OR: 0.287; 95% CI: 0.133 to 0.618). The risk of post-partum hemorrhage was lower in the PHB than PHos group (OR: 0.692; 95% CI: 0.634 to 0.755). The two groups were similar with regard to neonatal morbidity and mortality. The authors concluded that births assisted at hospitals were more likely to receive medical interventions, fetal monitoring, and prompt delivery in case of obstetrical complications. They stated that further studies are needed to clarify whether home births are as safe as hospital births.

Scarf and colleagues (2018) compared maternal and perinatal outcomes from different places of birth via a systematic review of high-quality research and meta-analysis of appropriate data. Reviewers searched CINAHL, Embase, Maternity and Infant Care, Medline, and PsycINFO databases to identify studies comparing selected outcomes by place of birth among women with low-risk pregnancies in high-income countries. They critically appraised identified studies using an instrument specific to birthplace research and then combined outcome data via meta-analysis, using RevMan software. A total of 28 articles met inclusion criteria, yielding comparative data on perinatal mortality, mode of birth, maternal morbidity, and/or NICU admissions. Meta-analysis indicated that women planning hospital births had statistically significantly lower odds of normal vaginal birth than in other planned settings. Women experienced severe perineal trauma or hemorrhage at a lower rate in planned home births than in obstetric units. There were no statistically significant differences in infant mortality by planned place of birth, although most studies had limited statistical power to detect differences for rare outcomes. Differences in location, context, quality, and design of identified studies render results subject to variation. The authors concluded that high-quality evidence about low-risk pregnancies indicated that place of birth had no statistically significant impact on infant mortality. The lower odds of maternal morbidity and obstetric intervention supported the expansion of birth center and home birth options for women with low-risk pregnancies.

Nygaard and Kesmodel (2018) stated that evidence-informed guidelines, high-quality studies, and standardized data collection methods are needed in the area of home births, both in terms of safety and also regarding reasons behind the trends and women's needs, motivations, and attitudes toward birthplace. "Both women and health care providers deserve that."

Bessa and Bonatto (2019) attempted to promote informed choice for women and compared home and hospital births in relation to the Apgar score. Mother's profile and Apgar scores of naturally born infants (without forceps assistance) in Brazil between 2011 and 2015, in both settings – hospital or home – were collected from live birth records provided by the Informatics Department of the Unified Health System (DATASUS, in the Portuguese acronym). For the analysis, these researchers included only data from low-risk deliveries, including gestational time between 37 and 41 weeks, singleton pregnancy, at least 4 visits of prenatal care, infants weighing between 2,500 g and 4,000 g, mother age between 20 to 40 years old, and absence of congenital anomalies. Home birth infants presented significantly higher risk of 0 to 5 Apgar scores, both in 1 minute (6.4% versus 3%, OR = 2.2, CI: 2 to 2.4) and in 5 minutes (4.8% versus 0.4%, OR = 11.5, CI: 10.5 to 12.7). Another finding was related to recovery estimates when from an initially bad 1-minute Apgar (less than 6) to a subsequently better 5-minute Apgar (greater than 6). In this scenario, home infants had poorer recovery; Apgar scores were persistently less than 6 throughout the 5th minute in most cases (71% versus 10.7%, OR 20.4, CI: 17 to 24.6). The authors concluded that these findings showed worse Apgar scores for babies born at home compared with those born in the hospital setting. This is a pioneer and preliminary study that brings attention to differences in Apgar scores related to home versus hospital place of birth in Brazil.

Grunebaum and associates (2019) stated that two prominent proposed defenses have been offered of planned home birth. The first defense focuses on the very low absolute risk of planned home birth, which is considered to be safe because it is so low, irrespective of its significantly elevated relative risk. The second defense invokes an analogy between trial of labor after cesarean delivery and planned home birth. Because trial of labor after cesarean delivery and planned home birth have similar, very low absolute risks, and because the former is an acceptable clinical practice, defenders of planned home birth argue that the latter should be considered acceptable. These investigators presented a critical appraisal of these two proposed defenses of planned home birth. Question 1: Are proposed defenses of planned home birth focused on its low absolute risks consistent with the commitment to patient safety? This commitment to patient safety requires the identification of variation in the processes of patient care and reduction of variation when reduction improves outcomes. Relative, as well as absolute, risks therefore must be identified. Compared with hospital midwives, planned home births have a significantly higher relative total neonatal mortality risk of 3.87 (1.26 versus 0.32 per 1,000 births; p < 0.001) and a significantly higher relative risk of 5-minute Apgar score of zero of 18.11 (1.63 versus 0.0/1,000 births; p < 0.001). Planned hospital birth prevents these risks. It follows that planned home birth as a variant in birth setting is not consistent with the commitment to patient safety. Question 2: Is the analogy to trial of labor after cesarean delivery consistent with the philosophic rules of analogic reasoning? The long-established philosophic rules for analogic reasoning require that the two cases that are compared are similar in all relevant respects and that all relevant analogies have been considered. The two cases are dissimilar because the perinatal risks of planned home births are approximately three times higher than trial of labor after cesarean delivery. At least eight clinical analogies to other situations of very low absolute, but unacceptable, risks are ignored. The clinical implication of the results of this critical appraisal is that obstetricians should respond to expressions of interest in planned home birth based on these proposed defenses with a respectful explanation of the inadequacies, the failure to commit to patient safety, and a recommendation for planned hospital birth.

Stone et al. (2023) stated that midwifery care at home birth and in free-standing birth centers requires context-specific skills, including the ability to offer low-intervention care for women who choose physiological birth in these settings. When midwives offer birth assistance at home birth and free-standing birth centers, they must adapt their skill set. To date, there are no comprehensive insights on the skills and knowledge that midwives need to work in those settings. These investigators examined available evidence that describes the skills and knowledge of certified midwives at home births and free-standing birth centers. They carried out a systematic review that included searches on five databases, author runs, citation tracking, journal searches, and reference checking. Meta-ethnographic techniques of reciprocal translation were used to interpret the dataset, and a line of argument synthesis was developed. The search identified 13 studies – 12 from 7 countries, and 1 that included 5 Nordic countries. Three overarching themes and seven sub-themes were developed: “Building trustworthy connections,” “Midwife as instrument,” and “Creating an environment conducive to birth.” The authors concluded that the findings of this review highlighted that midwives integrated their sensorial experiences with their clinical knowledge of anatomy and physiology to care for women at home birth and in free-standing birth centers. The interactive relationship between midwives and women is at the core of creating an environment that supports physiological birth while integrating the lived experience of laboring women. Moreover, these researchers stated that further investigations are needed to ascertain how these skills are learned and cultivated so that they can be integrated into student midwifery programs.

The authors stated that a drawback of this review was the lack of studies that specifically had the objective of describing the skills and knowledge of midwives at home birth and in free-standing birth centers. Although this could be overcome via the meta-ethnographical process, more studies are needed that aim to describe practical midwifery in those settings, especially skills for emergencies. Another drawback, which is a limitation for all syntheses of this kind, was that many different interpretations were likely possible.

Doula Services

A doula is a trained, non‑clinical maternal support professional who provides continuous emotional, physical, and informational support during pregnancy, childbirth, and the postpartum period. Evidence demonstrates that doulas complement—not replace—clinical providers by improving communication, offering psychosocial support, and enhancing the birthing person’s experience within the healthcare system.

Bohren et al. (2017) examined the impact of continuous, one-on-one intrapartum support on maternal and neonatal outcomes compared to usual care, noting that such support has historically been provided by women during labor but has become less common in hospitals. The primary objective was to assess the effects of continuous support, while secondary objectives explored how various factors, such as birth environment policies, the provider's relationship to the woman, timing of support, model of support, and country income level, might influence these effects. The researchers analyzed 26 trials involving 15,858 women across different countries, finding that continuous support was associated with higher rates of spontaneous vaginal births, shorter labor durations, and lower rates of cesarean and instrumental births, as well as reduced negative feelings about childbirth. However, the quality of evidence was low due to biases in the studies. The authors concluded that continuous labor support may improve outcomes for mothers and infants without evidence of harm, and they suggested that future research should focus on long-term outcomes and include more woman-centered measures, particularly in low-income settings.

ACOG (2019) states that evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor. Benefits identified in randomized trials include shortened labor, decreased need for analgesia, fewer operative deliveries, and fewer reports of dissatisfaction with the labor experience. A Cochrane evidence review summarizes that women who received continuous support were less likely to have a cesarean birth (RR, 0.75; 95% CI, 0.64–0.88) or a newborn with a low 5-minute Apgar score (RR, 0.62; 95% CI, 0.46–0.85). Additionally, continuous support from a nonmedical person has a modest positive effect on shortening labor duration (mean difference −0.69 hours; 95% CI, −1.04 to −0.34) and improving the rate of spontaneous vaginal birth (RR, 1.08; 95% CI, 1.04–1.12). Teaching labor-support techniques to a friend or family member may also be effective, as demonstrated in a randomized trial of 600 nulliparous, low-income, low-risk women, which resulted in significantly shorter labor and higher Apgar scores at 1 and 5 minutes. Furthermore, continuous labor support may be cost-effective due to the associated lower cesarean rates, with one analysis suggesting that funding such personnel could lead to substantial annual cost savings. Given these benefits and the absence of demonstrable risks, patients, obstetrician–gynecologists and other obstetric care providers, and health care organizations may want to develop programs and policies to integrate trained support personnel into the intrapartum care environment to provide continuous one-to-one emotional support to women undergoing labor.

Alvarado et al. (2024) stated that the field of maternal health has advanced significantly over the past decades; however, the U.S. continues to have poor outcomes in comparison with other industrialized nations. With emerging evidence on the promise of doula care, states are including doula care under their Medicaid programs. These investigators carried out a scoping review across four academic databases and gray literature published between January 1, 2012, and March 10, 2022, to describe the landscape of literature on U.S. doula programs and their outcomes in order to inform state policymakers considering laws or programs related to doula care. Of 740 records identified, 100 met inclusion criteria. Outcomes fell into four areas: birthing women's outcomes, infant outcomes, systems of care and implementation, and cross-cutting issues. Data on outcomes related to doula care in the literature were predominantly clinical, even though doulas are not clinical providers. Although some studies have found associations between doula care and improved clinical outcomes for birthing women and infants, the evidence was limited due to small sample sizes, study methodology, or conflicting conclusions. Doula outcomes are under-explored in the literature, with mainly qualitative data describing low levels of diversity and equity within the doula workforce and ineffective payment models. When cost-effectiveness estimates have been calculated, they largely rely on savings realized from averted cesarean births, preterm births, and neonatal intensive care unit (NICU) admissions. The authors concluded that as state Medicaid programs expand to include doula care, policymakers should be aware of the limitations in the evidence as they plan for successful implementation, such as the narrow focus on certain clinical outcomes to quantify cost savings and conflicting conclusions on the impact of doula care. An important consideration is the impact of the reimbursement rate on the adoption of doula care, which is why it is important to engage doulas in compensation determinations, as well as the development of improved metrics to untangle the components that contribute to maternal health outcomes in the U.S. Moreover, these investigators stated that this review's limitations include the single-reviewer approach and the broad scope rather than a smaller, more targeted review. However, this review provided an analysis of the larger landscape of published literature on doula care as a starting point for further exploration and analysis.

These researchers stated that three steps are needed to ensure that doula care maximizes its impact and sustainability: First, policymakers should prioritize input from the doula community, including fair compensation when considering Medicaid reimbursement. Second, doula program implementers should strengthen research partnerships to develop comprehensive evaluation measures to assess the impacts of doula care on different dimensions of maternal health. Third, researchers should examine the differences in outcomes between hospital and community-based doulas and the impact of factors such as racial/cultural concordance, positionality, lived experience, as well as connection to local resources.

Lemon et al. (2025) conducted a retrospective study aimed to evaluate the association between doula care and a broad range of maternal and neonatal outcomes in various subpopulations. Their cohort study of deliveries were recorded from January 2021 to December 2022 at a single institution where the study participants received prenatal care. Their study focused on the impact of doula care received both prenatally and during delivery, evaluating various maternal outcomes (such as cesarean delivery rates, gestational hypertension, and postpartum visits) and neonatal outcomes (including NICU admissions and breastfeeding rates). The cohort comprised 17,831 deliveries, with 486 receiving doula care. Their findings indicated that patients who utilized doula services were more likely to identify as Black, be publicly insured, and reside in disadvantaged neighborhoods. For every 100 patients receiving doula care, there were 15 to 34 additional vaginal births after cesarean, and 5 to 6 more postpartum office visits compared to those without doula support. Additionally, infants born to these patients were 20% more likely to be exclusively breastfed, and doula care was linked to 3 to 4 fewer preterm births per 100 deliveries. The authors state that these results were consistent across racial and insurance status groups, even when doula care was defined as having at least three prenatal encounters. The authors concluded that doula care was associated with increased rates of vaginal births after cesarean, higher postpartum visit attendance, improved breastfeeding rates, and reduced preterm deliveries, demonstrating its effectiveness across diverse populations.

Dias et al. (2025) conducted a systematic review and meta-analysis to estimate the association between doula support and cesarean delivery compared with standard of care. Eighteen studies were included in the final analysis (n=367,662), including eight randomized controlled trials (RCTs) and ten observational studies. Random-effects models were used to calculate pooled relative risks (RRs) and weighted mean difference. Heterogeneity was assessed with the Cochran Q test and I2 statistic. The authors found that intrapartum doula support was associated with a lower rate of cesarean delivery compared with standard care in RCTs (n=7, 17.5% doula support vs 23.6% standard care, pooled RR 0.71, 95% CI, 0.53-0.95). However, there were substantial study heterogeneity ( I2 =60.1%) and borderline evidence of small-study effects, which could suggest publication bias (Harbord test P =.046). Patients receiving intrapartum doula support in RCTs had significantly lower rates of operative vaginal delivery (n=5, 7.9% doula support vs 13.2% standard care, pooled RR 0.64, 95% CI, 0.44-0.94, I2 =46.0%) but no difference in low 5-minute Apgar score (n=3, 1.6% doula support vs 4.1% standard care, pooled RR 0.47, 95% CI, 0.16-1.34; I2 =0%) or regional anesthesia (n=7, 57.3% doula support vs 69.5% standard care, pooled RR 0.64, 95% CI, 0.36-1.12, I2 =98.75%). Findings were similar in a sensitivity analysis limited to high-quality studies. Doula support was associated with lower cesarean delivery rates among all subgroup analyses except RCTs in the United States (four studies, 16.1% doula support vs 22.2% standard care, pooled RR 0.71, 95% CI, 0.47-1.06). The authors concluded that intrapartum doula support is associated with reduced cesarean delivery, though variability across studies warrants cautious interpretation.

The limited research on the use of doulas for home births highlights several challenges, as they account for a small percentage of total births in many countries, making it difficult to conduct adequately powered randomized trials. Additionally, women who choose home births often already have continuous support from midwives and companions, complicating efforts to isolate the specific effects of adding a doula. As a result, the evidence for doula support during home births is largely absent from peer-reviewed literature, necessitating that any recommendations for doula use in this setting be drawn from hospital-based studies, while acknowledging the significant differences in birth environments, available interventions, baseline risk profiles, and support structures between home and hospital settings.

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References