Perspectives on risk: Assessment of risk profiles and outcomes among women planning community birth in the United States.
There is little agreement on who is a good candidate for community (home or birth center) birth in the United States.



Data on n=47 394 midwife-attended, planned community births come from the Midwives Alliance of North America Statistics Project. Logistic regression quantified the independent contribution of 10 risk factors to maternal and neonatal outcomes. Risk factors included: primiparity, advanced maternal age, obesity, gestational diabetes, preeclampsia, postterm pregnancy, twins, breech presentation, history of cesarean and vaginal birth, and history of cesarean without history of vaginal birth. Models controlled additionally for Medicaid, race/ethnicity, and education.



The independent contributions of maternal age and obesity were quite modest, with adjusted odds ratios (AOR) less than 2.0 for all outcomes: hospital transfer, cesarean, perineal trauma, postpartum hemorrhage, low/very-low Apgar, maternal or neonatal hospitalization, NICU admission, and fetal/neonatal death. Breech was strongly associated with morbidity and fetal/neonatal mortality (AOR 8.2, 95% CI, 3.7-18.4). Women with a history of both cesarean and vaginal birth fared better than primiparas across all outcomes; however, women with a history of cesarean but no prior vaginal births had poor outcomes, most notably fetal/neonatal demise (AOR 10.4, 95% CI, 4.8-22.6). Cesarean births were most common in the breech (44.7%), preeclampsia (30.6%), history of cesarean without vaginal birth (22.1%), and primipara (11.0%) groups.



The outcomes of labor after cesarean in women with previous vaginal deliveries indicates that guidelines uniformly prohibiting labor after cesarean should be reconsidered for this subgroup. Breech presentation has the highest rate of adverse outcomes supporting management of vaginal breech labor in a hospital setting.
Epidemiology Program, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA.
Marit L
0000-0003-2139-0549
ML
Bovbjerg
Department of Anthropology, Oregon State University, Corvallis, OR, USA.
Melissa
M
Cheyney
College of Agricultural and Environmental Sciences, University of California, Davis, CA, USA.
Jennifer
J
Brown
College of Nursing, University of New Mexico, Albuquerque, NM, USA.
Kim J
KJ
Cox
School of Medicine, University of New Mexico, Albuquerque, NM, USA.
Lawrence
L
Leeman
D000328:Adult; D001034:Apgar Score; D016550:Birthing Centers; D001946:Breech Presentation / Q000453:epidemiology; D002585:Cesarean Section / Q000706:statistics & numerical data*; D016640:Diabetes, Gestational / Q000453:epidemiology; D005260:Female; D005313:Fetal Death; D006700:Home Childbirth; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D007363:Intensive Care Units, Neonatal / Q000706:statistics & numerical data*; D016015:Logistic Models; D008423:Maternal Age; D008880:Midwifery; D009765:Obesity / Q000453:epidemiology; D010298:Parity; D010360:Patient Transfer / Q000706:statistics & numerical data*; D066087:Perinatal Death; D010502:Perineum / Q000293:injuries*; D006473:Postpartum Hemorrhage / Q000453:epidemiology*; D011225:Pre-Eclampsia / Q000453:epidemiology; D011247:Pregnancy; D011273:Pregnancy, Prolonged / Q000453:epidemiology; D059285:Pregnancy, Twin / Q000706:statistics & numerical data; D018570:Risk Assessment; D012307:Risk Factors; D014481:United States / Q000453:epidemiology
birth center; home birth; home childbirth; midwifery; obstetric labor complications; vaginal birth after cesarean