PICO: Are midwife delivered newborns at higher risk for death when birth occurs at home versus

a hospital?
Group #9: Joy Austin, Tara Barnett, Allison Farley, Ashley Talbot, Katherine Tan, and Jessica Watson

Author,
Yr., LOE

Study
Purpose

Blix, et.
al., 2012

To
compare
outcomes
in home
versus
hospital
births

LOE 4

Cheng,
et. al.,
2013
LOE 4

Cheyney
, et. al.,
2014
LOE 2

De
Jonge,
et. al.,
2014

LOE 4

Grneba
um,, et.
al., 2015

LOE 4

Gruneba
um, et.
al., 2014

Sample

Intervention

Instruments
with Validity
and Reliability

Results/Findings

Article Conclusion

N = 17,941

Home versus
hospital births

Intervention
and
complication
rates; perinatal,
neonatal death
rates

Death rates and

interventions were
similar in home and
hospital births

No statistically significant
data to support increased
risk of perinatal or
neonatal mortality for
planned home births

Examine
outcomes
associated
with
planned
home
versus
hospital
births.

N=
2,081,753
(12,039
planned
home births)

Planned home
birth

Apgar scores,
interventions

Lower apgar scores

and higher seizure
rates with home
birth, but fewer
obstetric
interventions

Planned home births had

fewer obstetric
intervention and
increased neonatal
complications

To analyze
the safety
of planned
home
births

N = 16,924
women
N = 16, 983
babies

Outcomes with
home births

Maternal
demographics,
antenatal risk
profiles and
outcomes of
home births

Few interventions or
adverse events in
home births in low
risk women

Low rates of intervention

and adverse outcomes
with home births

To
compare
perinatal
outcomes
between
home
versus
hospital
births

N = 814, 979

Home versus
hospital birth

Intrapartum
and neonatal
death, apgar
scores

No significant
difference found in
deaths. Lower
apgar scores and 28
day admissions in
home births

No increased risk of
adverse perinatal
outcomes for home
versus hospital births
among low-risk women.

Compare
risk factors
in planned
home
births to
ACOG and
AAP
recommen
dations

N = 56,140

Home births

Perinatal risk
factors
established by
ACOG and
AAP

Risk factors were

significantly higher
in home births when
compared to
hospital births,

Compared to hospital
births, planned home
births are associated with
an increase in adverse
neonatal outcomes,

Compare
neonatal
mortality to

N=
13,936,071S

Birth setting
home versus
hospital

Mortality risk

Statistically
significant higher
rate of mortality in

Higher rates of infant

mortality when birth
occurs outside of the

LOE 4

birth
setting and
attendants

Hiraizum
i, &
Suzuki,,
2013
LOE 4

To
compare
risk of
adverse
events in
home
versus
hospital
births

N=508

Home versus
hospital birth

Miller &
Skinner,
2012

Compare
birth
outcomes
of home
versus
hospital
births

N= 109
home births
N= 116
hospital
births

Assess the
perinatal
risks of
out of
hospital
versus
hospital
births

LOE 1

Snowde
n, et. al.,
2015

LOE 4

Van der
Kooy, et.
al., 2011
LOE 2

van
Haarenten , et.
al.,
2015
LOE 4

Wax, et

home births

hospital with a midwife

than in the hospital

Length of labor,
apgar scores,
delivery mode,
hemorrhage

No differences found
in adverse perinatal
outcomes in home
versus hospital
births

No statistically significant
differences with midwifeled care for home versus
hospital births.

Home versus
hospital births

Birth outcomes
using evidence
based
guidelines

Statistically
significant difference
between hospital
group (more pain
and obstetric
interventions) than
home group

At home births used

fewer interventions with
more evidence-based
care than hospital births

N = 79,727

In hospital
versus out of
hospital birth
place

Perinatal and
maternal
morbidity and
mortality and
need for
obstetrical
procedures

Planned out-ofhospital births

associated with
increased perinatal
death; maternal
blood transfusion;
higher rate of
perinatal deaths;
depressed 5-minute
Apgar scores,
seizures

Based on this study, out

of hospital births have
more adverse effects on
the infant than in hospital
births.

To
compare
the
mortality
rate of
planned
home
births
versus
hospital
births

N = 679,952

Home versus
hospital births

Birth outcomes
using evidence
based
guidelines

No significant
increase in mortality
rate with home
births

Home births are not

associated with increased
risk of neonatal or
intrapartum death

Examine
the
associatio
n of
preferred
place of
birth and
care
model,
pregnancy
and labor

N = 576

Medical
intervention

Apgar scores,
medical
interventions,
induced labor

No statistically
significant difference
between place or
mode of birth

Home and hospital births

associated with fewer
medical interventions with
midwives.

Compare
newborn

N= 342,056
home births

Home versus
hospital birth

Obstetrical and
neonatal

Statistically
significant neonatal

Less medical
interventions were

al.,
2011
LOE 2

and
maternal
safety in
planned
home and
hospital
births

N= 207,552
hospital
births

interventions

death rate in
planned home birth
versus hospital

associated with increase

in infant mortality rates in
home births

Synthesis
All of the studies in this research table focused on outcomes of home births versus
hospital births. Our group wanted to compile the available data and determine if more deaths
and adverse outcomes were associated with midwife-delivered home births or hospital births.
The articles found were either controlled cohort studies (LOE 4) or randomized controlled trials
(LOE 2). Six of the studies found that there was an increased risk of death or adverse outcomes
for newborns when they were born at home versus in a hospital. Four of the studies found that
there was no significant risk of death or adverse outcomes for newborns when they were born at
home versus the hospital. Two of the studies did not attest to an increased risk of death or
adverse outcomes regarding home births, but rather stated that fewer interventions were used
at home rather than the hospital. None of the studies found that there were better outcomes for
babies born at home versus the hospital.
There were some inconsistencies with the results of the various studies. As previously
mentioned, half of the studies found an increased risk of death or adverse outcomes, and half of
the studies found no significant risk of death or adverse outcomes. There were some limitations
to the studies we found. One of the limitations to this study is the fact that most of them were
conducted using low risk pregnant women. Although these women are good candidates for
giving birth at home, this could skew the results in favor for home births. Another example that
could be a threat to validity is that the studies were done in numerous countries. If we would
have found studies that had all been conducted in one uniform place then the results might have
been more accurate and reliable. Another limitation to the studies found were the wide range of
sample sizes used. Some studies had thousands in their sample size while others only had
hundreds. This inconsistency could have an impact on the validity of the research.
Linking Evidence to Practice
Implications for practice should focus on education and planning with the pregnant
women about birth locations. Education and resources should be provided to pregnant women
about the options of various delivery locations, including the pros and cons and the expected
care that would be provided at each location (home and hospital). In addition, nurses should
help pregnant women create a plan of action if they choose to do a home birth, including what to
do in an emergency situation. These nursing implications only require for the nurse to be
knowledgeable about the subject and does not require any special training. It would be
beneficial for the nurse to provide references for the pregnant women and collaborate with the
midwife as well as include the midwife in the education and planning. The patients would

undoubtedly find these interventions useful, and it would help them make a more educated
decision on birth location.
References
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Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. (2014).
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