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

Journal of Family Practice, August, 1990 by Louise S. Acheson, Stanley E. Harris, Stephen J. Zyzanski

Patients' Requests

At the initial obstetric visit, couples' requests were recorded[19,20]: 44% requested support for natural childbirth; 4% specifically asked for a hospital birth. In contrast, 31% specifically requested a home or clinic birth. The reasons cited included fear of iatrogenic problems (17%), financial reasons (18%), and belonging to a religious group that discouraged formal medical care or supported alternative methods of healing (16%). For multiparas, previous birth experiences were highly relevant. One third of the multiparas had previously given birth outside the hospital; 93% of these again planned clinic or home birth. Twenty-three percent of those requesting a home birth later decided on the clinic, most commonly because they lived too far away to be eligible for birth at home.

Medical Risk Factors

Clinical pelvimetry was customarily recorded at the initial examination. Forty-six percent of primiparas and 16% of multiparas were assessed as having small or "borderline" findings on clinical pelvimetry. Retrospective application of the Goodwin prenatal risk-scoring system classified 68% of primiparas and 76% of multiparas as low risk (score less than 4). Since most items in the Goodwin score pertain to prior obstetric history, it is most sensitive and specific for multiparas.[15] The mean Goodwin score differed significantly between those planning clinic or home birth and those planning hospital birth, however, for both primiparas (2.83 vs 3.31, t = 2.52, P [less than] .02) and multiparas (2.21 vs 2.72, t = 2.85, P [less than] .01). A similar relationship held when the groups were compared by actual birth location.

Planned and Actual Birth Location

Table 2 shows that 73.5% of all patients (581) planned birth outside the hospital: 71 at home and 510 in the clinic; 209 (26.5%) planned a hospital birth. Forty-four patients (5.6% of the total) actually gave birth at home, 387 (49%) in the clinic, 317 (40%) at a local hospital, and 42 (5.3%) at a tertiary care center.

Smokers, single women, those with anemia, obesity, or poor nutrition, and those with small or borderline findings on clinical pelvimetry were more likely to plan hospital births (data not shown). As noted above, those belonging to certain religious groups, those with no medical insurance, and those with prior OHB experience were more likely to plan a clinic or home birth. The percentage choosing OHB did not differ between primiparas (72%) and multiparas (74%). Only 54% of primiparas planning home or clinic births actually were delivered outside the hospital, however, compared with 84% of the multiparas. Twenty percent of primiparas and 11% of multiparas developed social or medical problems during pregnancy, such as hypertension, malpresentation, vaginal bleeding, anticipated lack of postpartum support at home, or illness at term, and were advised to give birth in the hospital. Eighteen percent of primiparas required intrapartum transfer to the local hospital. Seventy-nine percent of transfers occurred because of a need for augmentation of labor or operative delivery. Only 2.4% of multiparas required intrapartum transfer for a variety of reasons. Five percent of those planning clinic or home birth were referred to the tertiary care hospital because of premature labor, other severe problems, or occasional unavailability of local obstetric consultants. About the same proportion (6.4%) of those who had planned hospital birth required tertiary care.