Patient selection and outcomes for out-of-hospital births in one family practice

Abstract

This paper reports a study of the pregnancies followed to delivery in one family medicine group practice that offered a choice of childbirth settings. Those choosing out-of-hospital birth (OHB) were a self-selected group of highly motivated couples interested in natural childbirth or desiring to minimize the cost of pregnancy care. Of 790 singleton pregnancies followed to term, 71 (9.0%) planned home births, 510 (64.6%) planned clinic births, and 209 (26.5%) planned hospital births. Of those planning clinic or home birth, 73% gave birth outside the hospital as planned (44 at home and 379 in the clinic), 81 (14%) changed plans prenatally and gave birth in a local hospital, 46 (8%) were transferred to the local hospital intrapartum, and 29 (5%) were referred to tertiary care. Primiparas who initially chose OHB were more likely than multiparas to give birth in a hospital (46% vs 16%). Controlling retrospectively for obstetric risk and parity, there were few differences in outcome between local hospital and out-of-hospital births. The observed rates of serious complications for OHB were low, but overall, 27% of those initially considered candidates for birth outside the hospital required a change to a higher level of care. For primiparas initially planning clinic or home birth, discriminant analysis revealed five variables that together might have improved the prediction of the eventual decision for hospital delivery in 46%. Clinical pelvimetry was the most powerful variable, in keeping with the finding that most intrapartum transfers were for arrests of labor. The results also suggest that financial factors and other features of the physician-patient relationship influenced clinical decision making.