Saturday, January 30, 2010

Study on Birth Outcomes by Location

A study in the American Journal of Obstetrics and Gynecology finds that when compared with hospital births, home births and birth center births showed longer labors and the infants had lower APGAR scores at 5 min. They also found that "out-of-hospital births are associated with otherwise less frequent maternal and newborn morbidity."

Maternal and newborn morbidity by birth facility among selected United States 2006 low-risk births

from the February 2010 issue of AJOG

We sought to evaluate perinatal morbidity by delivery location (hospital, freestanding birth center, and home).
Study Design
Selected 2006 US birth certificate data were accessed online from the Centers for Disease Control and Prevention. Low-risk maternal and newborn outcomes were tabulated and compared by birth facility.
A total of 745,690 deliveries were included, of which 733,143 (97.0%) occurred in hospital, 4661 (0.6%) at birth centers, and 7427 (0.9%) at home. Compared with hospital deliveries, home and birthing center deliveries were associated with more frequent prolonged and precipitous labors. Home births experienced more frequent 5-minute Apgar scores <7. In contrast, home and birthing center deliveries were associated with less frequent chorioamnionitis, fetal intolerance of labor, meconium staining, assisted ventilation, neonatal intensive care unit admission, and birthweight <2500 g.
Home births are associated with a number of less frequent adverse perinatal outcomes at the expense of more frequent abnormal labors and low 5-minute Apgar scores.

Notice how they call a long labor "abnormal." Its only long and abnormal because obstetricians rarely see a truly natural birth.    

So what does this study showing us? Are long labors and low 5 min APGAR scores an awful thing?

This means that home birth women were able to labor as long as was necessary to have their baby, instead of being told at the hospital that they were taking too long and therefore received medical interventions to speed things up. 

This means that at home births the baby's cords weren't immediately clamped, as is usual hospital policy, which means that the baby was getting oxygen from the placenta for a little bit longer and therefore was still a little bit blue. They also weren't being slapped or rubbed to be made to cry, they were simply left to be calm as long as they were noticeably alert. 

APGAR scores:

Five factors are used to evaluate the baby's condition at one min and again at 5 min after birth. Each factor is scored on a scale of 0 to 2. Baby is rated on:
  1. Activity and muscle tone
  2. Pulse (heart rate)
  3. Grimace response/reflex irritability
  4. Appearance (skin coloration)
  5. Respiration (breathing rate and effort) 

An extremely prolonged labor and very bad scores on the above 5 APGAR factors CAN indeed be worrying, but the study is showing that the results of these particular births, all low-risk women, resulted in fewer adverse outcomes. Therefore, there is no huge worry associated with out-of-hospital births for low-risk women.


  1. On the issue of Apgar scores and cord clamping, <7 Apgar scores may actually lead to long-term neurological damage. For reference, babies are given both one-minute and five-minute Apgar scores. If the baby is not breathing on its own by 5 minutes (blue means less oxygen, whether the baby may be getting it from a placenta or through its own lungs), that means its brain has been drowning for 5 minutes... not a good thing.

    Also, out of curiosity I looked it up and noticed delayed cord clamping can cause polycythemia (abnormal increase in red blood cell mass), which may lead to thrombosis, feeding difficulties, renal failure, lethargy, and seizures. Soo it's not necessarily a good thing to delay...

    Just making sure people are getting both sides of the story.

  2. I definitely appreciate you bringing the medical stuff in to the discussion! :) however...

    You may benefit from reading the original article that I posted in the entry Delayed Cord Clamping: which is written by an OBGYN.

    A bad APGAR score can of course be very bad, which is why they check those things. It can also sometimes be subjective (how much grimace or heart rate are you going to get from a calm baby? they might get a 1 instead of a 2 because they're not wailing and flailing!)

    The study and article here noted, however, that the home births, even with low APGAR scores at 5 min still required less frequent assisted ventilation of the baby and neonatal intensive care unit admission, showing that these were still healthy babies. Home Birth Midwives tend to not over-stimulate the baby right away in order to produce crying, etc the way that the hospital staff does.

    Here is another article on early breathing and cord clamping:

    I've heard a lot of stories about babies being born and thought to be dead because they weren't breathing right away... minutes and minutes go by... and then the baby is resuscitated and turns out fine! :)
    My dad actually told me one on the phone the other day about a woman who had her baby in a the bathroom of a gas station shop, carried the baby out in a blanket and put it in her trunk. when a employee came to ask her if she was ok (she didnt know what the woman had been doing in there for so long!) the woman told her she'd had a baby and it was dead. the employee managed to revive the baby and it was alive! 20 minutes later! crazy.

  3. fair enough, I don't know enough about this to make a fair judgment either way. I will say, though, that even if a baby stops breathing and gets resuscitated and is fine afterward, there is still a huge risk for neurological conditions like cerebral palsy...


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