Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children

POLICY STATEMENT Planned Home Birth

COMMITTEE ON FETUS AND NEWBORN abstract KEY WORDS The American Academy of Pediatrics concurs with the recent statement birth, delivery, newborn infant, home birth, , obstetrician, of the American College of Obstetricians and Gynecologists affirming pediatrician ABBREVIATIONS that and birthing centers are the safest settings for birth in ACOG—American College of Obstetricians and Gynecologists the United States while respecting the right of women to make a med- AAP—American Academy of Pediatrics ically informed decision about delivery. This statement is intended to This document is copyrighted and is the property of the help pediatricians provide supportive, informed counsel to women American Academy of Pediatrics and its Board of Directors. All considering home birth while retaining their role as child advocates authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been and to summarize the standards of care for newborn infants born at resolved through a process approved by the Board of Directors. home, which are consistent with standards for infants born in a med- The American Academy of Pediatrics has neither solicited nor ical care facility. Regardless of the circumstances of his or her birth, accepted any commercial involvement in the development of the including location, every newborn infant deserves health care that content of this publication. adheres to the standards highlighted in this statement, more com- The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical pletely described in other publications from the American Academy care. Variations, taking into account individual circumstances, of Pediatrics, including Guidelines for Perinatal Care. The goal of pro- may be appropriate. viding high-quality care to all newborn infants can best be achieved All policy statements from the American Academy of Pediatrics through continuing efforts by all participating health care providers automatically expire 5 years after publication unless reaffirmed, and institutions to develop and sustain communications and under- revised, or retired at or before that time. standing on the basis of professional interaction and mutual respect throughout the health care system. Pediatrics 2013;131:1016–1020

INTRODUCTION Women and their families may desire a home birth for a variety of reasons, including hopes for a more family-friendly setting, increased control of the process, decreased obstetric intervention, and lower cost. Although the incidence of home birth remains below 1% of all www.pediatrics.org/cgi/doi/10.1542/peds.2013-0575 births in the United States, the rate of home birth has increased during doi:10.1542/peds.2013-0575 1 the past several years for white, non-Hispanic women. However, a PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). woman’s choice to plan a home birth is not well supported in the Copyright © 2013 by the American Academy of Pediatrics United States. Obstacles are pervasive and systemic and include wide variation in state laws and regulations, lack of appropriately trained and willing providers, and lack of supporting systems to ensure the availability of specialty consultation and timely transport to a hospi- tal. Geography also may adversely affect the safety of planned home birth, because travel times >20 minutes have been associated with increased risk of adverse neonatal outcomes, including mortality.2 Whether for these reasons or others, planned home birth in the United States appears to be associated with a two- to threefold in- crease in neonatal mortality or an absolute risk increase of ap- proximately 1 neonatal death per 1000 nonanomalous live births.3–5 Evidence also suggests that infants born at home in the United States

1016 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 26, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS have an increased incidence of low Pediatricians must be prepared to hospitals and birthing centers. This Apgar scores and neonatal seizures.3,4 provide supportive, informed counsel situation places a larger burden on In contrast, a smaller study of all plan- to women considering home birth individual health care providers to ned home births attended by while retaining their role as child remember and carry out all compo- in British Columbia, Canada, from 2000 advocates in assessing whether the nents of assessment and care of the to 2004 revealed no increase in neo- situation is appropriate to support a newborn infant. To assist providers, natal mortality over planned planned home birth (Table 1). In ad- this policy statement addresses 2 births attended by either midwives dition to apprising the expectant specific areas: resuscitation and eval- or physicians.6 Registered midwives mother of the increase in neonatal uation of the newborn infant immedi- in British Columbia are mandated to mortality and other neonatal compli- ately after birth and essential elements offer women the choice to deliver in cations with planned home birth, the of care and follow-up for the healthy a hospital or at home if they meet the pediatrician should advise her that term newborn infant. eligibility criteria for home birth de- the American Academy of Pediatrics fined by the College of of (AAP) and ACOG support provision of ASSESSMENT, RESUSCITATION, British Columbia (Table 1). care only by midwives who are certi- AND CARE OF THE NEWBORN In a recent statement, the fied by the American Midwifery Certi- INFANT IMMEDIATELY AFTER BIRTH Committee on Obstetric Practice of the fication Board and should make her As recommended by the AAP and the American College of Obstetricians and aware that some women who plan to American Heart Association, there Gynecologists (ACOG) stated, “although deliver at home will need transfer to should be at least 1 person present the Committee on Obstetric Practice be- a hospital before delivery because of at every delivery whose primary re- lieves that hospitals and birthing cen- unanticipated complications. This per- sponsibility is the care of the newborn ters are the safest setting for birth, it centage varies widely among reports, infant.10 Situations in which both the respects the right of a woman to make from approximately 10% to 40%, with mother and the newborn infant si- a medically informed decision about a higher transfer rate for primiparous 8,9 multaneously require urgent attention delivery. Women inquiring about plan- women. The mother should be en- are infrequent but will nonetheless ned home birth should be informed of couraged to see successful transfer occur. Thus, each delivery should be its risks and benefits based on recent not as a failure of the home birth but attended by 2 individuals, at least 1 of evidence.”7 The statement reviewed ap- rather as a success of the system. whom has the appropriate training, propriate candidates for home delivery Care of the newborn infant born at skills, and equipment to perform a full and outlined the health care system home is a particularly important topic, resuscitation of the infant in accor- components “critical to reducing peri- because infants born at home are dance of the principles of the Neo- natal mortality rates and achieving fa- cared for outside the safeguards of the natal Resuscitation Program.10 To vorable home birth outcomes” (Table 1). systems-based protocols required of facilitate obtaining emergency assis- tance when needed, the operational integrity of the telephone or other TABLE 1 Recommendations When Considering Planned Home Birth communication system should be Candidate for home deliverya tested before the delivery (as should • Absence of preexisting maternal disease every other piece of medical equip- • fi Absence of signi cant disease occurring during the ment), and the weather should be • A singleton fetus estimated to be appropriate for • A monitored. In addition, a previous ar- • A gestation of 37 to <41 completed weeks of pregnancy rangement with a medical facility • Labor that is spontaneous or induced as an outpatient needs to be in place to ensure a safe • A mother who has not been referred from another hospital Systems needed to support planned home birth and timely transport in the event of an • The availability of a certified nurse-midwife, certified midwife, or physician emergency. practicing within an integrated and regulated health system • Attendance by at least 1 appropriately trained individual (see text) whose primary responsibility Care of the newborn infant immedi- is the care of the newborn infant ately after delivery should adhere to • Ready access to consultation standards of practice as described in • Assurance of safe and timely transport to a nearby hospital with a preexisting arrangement Guidelines for Perinatal Care11 and in- for such transfers Data are from refs 6, 7, 10, 11, and 13. clude provision of warmth, initiation a ACOG considers previous cesarean delivery to be an absolute contraindication to planned home birth.7 of appropriate resuscitation measures,

PEDIATRICS Volume 131, Number 5, May 2013 1017 Downloaded from www.aappublications.org/news by guest on September 26, 2021 and assignment of Apgar scores. has remained stable for 2 hours. transferred promptly to a medical Although skin-to-skin contact with An infant who is thought to be facility for continuing evaluation and mother is the most effective way to <37 weeks’ gestational age should treatment. provide warmth, portable warming be transferred to a medical facility  Eye prophylaxis: Every newborn infant pads should be available in case a for continuing observation for con- should receive prophylaxis against newborn infant requires resuscitation ditions associated with prematurity, gonococcal ophthalmia neonatorum. and cannot be placed on the mother’s including respiratory distress, poor  Vitamin K: Every newborn infant chest. A newborn infant who requires feeding, hypoglycemia, and hyper- should receive a single parenteral any resuscitation should be monitored bilirubinemia, as well as for a car dose of natural vitamin K oxide frequently during the immediate post- safety seat study. 1 (phytonadione [0.5–1 mg]) to pre- natal period, and infants who receive  Monitoring for group B strepto- – extensive resuscitation (eg, positive- vent vitamin K dependent hemor- coccal disease: As recommended rhagic disease of the newborn. pressure ventilation for more than by the Centers for Disease Control 30–60 seconds) should be transferred Oral administration of vitamin K and Prevention and the AAP, all has not been shown to be as effi- to a medical facility for close moni- pregnant women should be screened toring and evaluation. In addition, any cacious as parenteral administra- for group B streptococcal coloni- tion for the prevention of late infant who has respiratory distress, zation at 35 to 37 weeks of gesta- continued cyanosis, or other signs of hemorrhagic disease. This dose tion.14 Women who are colonized illness should be immediately trans- should be administered shortly af- should receive ≥4 hours of intrave- ferred to a medical facility. ter birth but may be delayed until nous penicillin, ampicillin, or cefazo- after the first breastfeeding. lin. If the mother has received this  Hepatitis B vaccination: Early hep- CARE OF THE NEWBORN intrapartum treatment and both atitis B immunization is recom- she and her newborn infant remain Subsequent newborn care should ad- mended for all medically stable asymptomatic, they can remain at here to the AAP standards as de- infants with a >2kg. scribed in Guidelines for Perinatal home if the infant can be observed  Assessment of feeding: Breastfeed- Care as well as to the AAP statement frequently by an experienced and ing, including observation of posi- regarding care of the well newborn knowledgeable health care provider. tion, latch, and milk transfer, infant.11–13 Although a detailed review If the mother shows signs of cho- should be evaluated by a trained of these standards would be far too rioamnionitis or if the infant does lengthy to include in this statement, not appear completely well, the in- caregiver. The mother should be a few practice points are worthy of fant should be transferred rapidly encouraged to record the time specific mention: to a medical facility for additional and duration of each feeding, as evaluation and treatment.14 well as urine and stool output, dur-  Transitional care (first 4–8 hours):  Glucose screening: Infants who ing the early days of breastfeeding. The infant should be kept warm  and undergo a detailed physical have abnormal fetal growth (esti- Screening for hyperbilirubinemia: examination that includes an as- mated to be small or large for ges- Infants whose mothers are Rh sessment of gestational age and tational age) or whose mothers negative should have cord blood intrauterine growth status (weight, have diabetes should be delivered sent for a Coombs direct antibody length, and head circumference), in a hospital or be- test; if the mother’s blood type is as well as a comprehensive risk cause of the increased risk of hy- O, the cord blood may be tested assessment for neonatal condi- poglycemia and other neonatal for the infant’s blood type and di- tions that require additional moni- complications. If, after delivery, an rect antibody test, but it is not toring or intervention. Temperature, infant is discovered to be small or required provided that there is ap- heart and respiratory rates, skin large for gestational age or has propriate surveillance, risk assess- color, peripheral circulation, respi- required resuscitation, he or she ment, and follow-up.16 All newborn ration, level of consciousness, tone, should be screened for hypoglyce- infants should be assessed for and activity should be monitored mia as outlined in the AAP state- risk of hyperbilirubinemia and un- and recorded at least once every ment.15 If hypoglycemia is identified dergo bilirubin screening between 30 minutes until the newborn’scon- and persists after feeding (glucose 24 and 48 hours. The bilirubin dition is considered normal and <45 mg/dL), the infant should be valueshouldbeplottedonthe

1018 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 26, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS

hour-specific nomogram to deter- that first evaluation. The initial that adheres to the standards high- mine the risk of severe hyperbilir- follow-up visit should include in- lighted in this statement and more ubinemia and the need for repeat fant weight and physical examina- completely described in other AAP determinations.13 tion, especially for jaundice and publications.11–16 The goal of provid-  Universal newborn screening: Every hydration. If the mother is breast- ing high-quality care to all newborn newborn infant should undergo feeding, the visit should include infants can best be achieved through universal newborn screening in evaluation of any maternal history continuing efforts by all participat- accordance with individual state of breast problems (eg, pain or ing providers and institutions to de- mandates, with the first blood engorgement), infant elimination velop and sustain communications specimen ideally collected between patterns, and a formal observed and understanding on the basis of 24 and 48 hours of age. (A list evaluation of breastfeeding, includ- professional interaction and mutual of conditions for which screening ing position, latch, and milk trans- respect throughout the health care is performed in each state is fer. The results of maternal and system. neonatal laboratory tests should maintained online by the National LEAD AUTHOR be reviewed; clinically indicated Newborn Screening and Genetic Kristi L. Watterberg, MD Resource Center, available at http:// tests, such as serum bilirubin, genes-r-us.uthscsa.edu/resources/ should be performed; and screen- COMMITTEE ON FETUS AND consumer/statemap.htm.) ing tests should be completed in NEWBORN, 2012–2013 accordance with state regulations. Lu-Ann Papile, MD, Chairperson  Hearing screening: The newborn Screening for congenital heart dis- Jill E. Baley, MD infant’s initial caregiver should en- William Benitz, MD ease should be performed by us- sure that the hearing of any infant James Cummings, MD ing oxygen saturation testing as born outside the hospital setting Waldemar A. Carlo, MD recommended by the AAP.17 Eric Eichenwald, MD is screened by 1 month of age, in Praveen Kumar, MD accordance with AAP recommen- Richard A. Polin, MD CONCLUSIONS dations. Rosemarie C. Tan, MD, PhD  The AAP concurs with the recent po- Provision of follow-up care: Com- PAST COMMITTEE MEMBER sition statement of the ACOG, affirming prehensive documentation and Kristi L. Watterberg, MD communication with the follow-up that hospitals and birthing centers are provider are essential. Written the safest settings for birth in the LIAISONS records should describe prenatal United States, while respecting the Capt. Wanda Denise Barfield, MD, MPH – Centers care, delivery, and immediate post- right of women to make a medically for Disease Control and Prevention natal course, clearly documenting informed decision about delivery.7 In George Macones, MD – American College of addition, the AAP in concert with the Obstetricians and Gynecologists which screenings and medications Ann L. Jefferies, MD – Canadian Pediatric So- have been provided by the birth ACOG does not support the provision ciety attendant, and which remain to of care by lay midwives or other Erin L. Keels, APRN, MS, NNP-BC – National As- be performed. All newborn infants midwives who are not certified by the sociation of Neonatal Nurses Tonse N. K. Raju, MD, DCH – National Institutes of should be evaluated by a health American Midwifery Certification 7 Health care professional who is knowl- Board. Kasper S. Wang, MD – Section on Surgery edgeable and experienced in pedi- Regardless of the circumstances of his atrics within 24 hours of birth and or her birth, including location, every STAFF subsequently within 48 hours of newborn infant deserves health care Jim Couto, MA

REFERENCES

1. MacDorman MF, Mathews TJ, Declercq E. perinatal outcomes in women at term in the 4. Chang JJ, Macones GA. Birth outcomes of Home births in the United States, 1990– 2009. Netherlands. BJOG. 2011;118(4):457–465 planned home births in Missouri: a population- NCHS Data Brief. 2012;Jan(84):1–8 3. Malloy MH. Infant outcomes of certified nurse based study. Am J Perinatol. 2011;28(7):529–536 2. Ravelli AC, Jager KJ, de Groot MH, et al. Travel midwife attended home births: United States 5. Wax JR, Lucas FL, Lamont M, Pinette MG, time from home to hospital and adverse 2000 to 2004. JPerinatol. 2010;30(9):622–627 Cartin A, Blackstone J. Maternal and newborn

PEDIATRICS Volume 131, Number 5, May 2013 1019 Downloaded from www.aappublications.org/news by guest on September 26, 2021 outcomes in planned home birth vs plan- maternity units: matched comparison Perinatal Care. 7th ed. Elk Grove Village, IL: ned hospital births: a meta-analysis [pub- study. BMJ. 2009;Jun 11(338):b2060 American Academy of Pediatrics; 2012:321– lished correction appears in Am J Obstet 10. Kattwinkel J, Perlman JM, Aziz K, et al; 382 Gynecol. 2011;204(4):e7–e13]. Am J Obstet American Heart Association. Neonatal resusci- 14. Baker CJ, Byington CL, Polin RA; Commit- Gynecol. 2010;203(3):243.e1–243.e8 tation: 2010 American Heart Association guide- tee on Infectious Diseases; Committee on 6. Janssen PA, Saxell L, Page LA, Klein MC, lines for cardiopulmonary resuscitation and Fetus and Newborn. Policy statement— Liston RM, Lee SK. Outcomes of planned emergency cardiovascular care. Pediatrics. recommendations for the prevention of home birth with registered midwife versus 2010;126(5). Available at: www.pediatrics. perinatal group B streptococcal (GBS) dis- planned hospital birth with midwife or org/cgi/content/full/126/5/e1400 ease. Pediatrics. 2011;128(3):611–616 physician [published correction appears in 11. American Academy of Pediatrics; American 15. Adamkin DH; Committee on Fetus and CMAJ. 2009;181(9):617]. CMAJ. 2009;181(6– College of Obstetricians and Gynecologists. Newborn. Postnatal glucose homeostasis in 7):377–383 Care of the newborn. In: Riley LE, Stark AR, late-preterm and term infants. Pediatrics. 7. ACOG Committee on Obstetric Practice. Kilpatrick SJ, Papile L-A, eds. Guidelines for 2011;127(3):575–579 ACOG Committee opinion no. 476: planned Perinatal Care. 7th ed. Elk Grove Village, IL: 16. American Academy of Pediatrics Sub- home birth [published correction appears American Academy of Pediatrics; 2012:265– committee on Hyperbilirubinemia. Man- in Obstet Gynecol. 2011;117(5):1232]. Obstet 320 agement of hyperbilirubinemia in the Gynecol. 2011;117(2 pt 1):425–428 12. American Academy of Pediatrics Committee newborn infant 35 or more weeks of ges- 8. Lindgren HE, Rådestad IJ, Hildingsson IM. on Fetus and Newborn. Hospital stay for tation [published correction appears in Transfer in planned home births in Sweden— healthy term newborns. Pediatrics. 2010; Pediatrics. 2004;114(4):1138]. Pediatrics. effects on the experience of birth: a nation- 125(2):405–409 2004;114(1):297–316 wide population-based study. Sex Reprod 13. American Academy of Pediatrics; American 17. Kemper AR, Mahle WT, Martin GR, et al. Healthc. 2011;2(3):101–105 College of Obstetricians and Gynecologists. Strategies for implementing screening for 9. Symon A, Winter C, Inkster M, Donnan PT. Neonatal complications and management critical congenital heart disease. Pediat- Outcomes for births booked under an in- of high-risk infants. In: Riley LE, Stark AR, rics. 2011;128(5). Available at: www.pediat- dependent midwife and births in NHS Kilpatrick SJ, Papile L-A, eds. Guidelines for rics.org/cgi/content/full/128/5/e1259

1020 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 26, 2021 Planned Home Birth COMMITTEE ON FETUS AND NEWBORN Pediatrics originally published online April 29, 2013;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2013/04/24/peds.2 013-0575 Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 26, 2021 Planned Home Birth COMMITTEE ON FETUS AND NEWBORN Pediatrics originally published online April 29, 2013;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2013/04/24/peds.2013-0575

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2013 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Downloaded from www.aappublications.org/news by guest on September 26, 2021