To: ACNM Members

The following is ACNM's preliminary statement in response to the recent study, Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting to be published in the October American Journal of Obstetrics & Gynecology (AJOG). ACNM is now exploring a more in-depth analysis to respond to the AJOG article.

Women and their families deserve reliable information about how to have the safest possible birth, including whether to have their baby at home, at a birth center, or in a hospital. Although the latest study is headline-grabbing, it is seriously flawed and does little to help families and clinicians make informed decisions about the risks and benefits of various settings for giving birth.

The study looked at two newborn outcomes, Apgar of 0 at 5 minutes, and neonatal seizures or serious neurologic dysfunction as reported on birth certificate data and analyzed by site of birth and birth attendant. The study authors concluded that babies who are born in out-of-hospital settings are more likely to have a seizure or low Apgar score, and that pregnant women should be counseled against a planned out-of-hospital birth.

This study has major problems with both how it was conducted and how the authors interpreted their results, resulting in invalid assertions about the safety of home and birth center births. It claims that women who choose out-of-hospital births are more likely to have a stillbirth, based on an analysis of one Apgar score recorded on certificates of live birth. However, it is not possible to draw conclusions about stillbirths from these data because stillbirths are not recorded on the certificates of live birth, which were the source documents for this study. Further, the authors’ assertions are not consistent with the Centers for Disease Control and Prevention’s Vital Statistics data on stillbirths.

It is well-accepted by researchers—and even acknowledged by the study authors—that the information entered into the birth certificate is often unreliable. A wealth of studies and a recent joint statement by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologist strongly caution against reading too much into Apgar scores.

Finally, the total number of 0 Apgar scores and neonatal seizures was a small fraction of 1 %. These are extremely rare events that do not justify the authors’ conclusion that out-of-hospital settings are not medically reasonable choices for women and their families.

The most comprehensive and accurate studies on birth outcomes are those that follow a woman throughout her pregnancy and track her outcomes and experiences. One example is the National Birth Center Study II which was published in the January/February 2013 issue of Journal of Midwifery & Women’s Health. This is a large, long-term prospective cohort study of more than 15,500 women who received care in 79 midwife-led birth centers in 33 states from 2007 through 2010. The National Birth Center Study II found that women who gave birth in birth centers were less likely to have cesarean births, only 6 percent, while the U.S. cesarean rate is nearly 33 percent. Fetal and newborn deaths were extremely low in this study (0.47/1000 births and 0.40/1000 births, respectively) and were comparable to the number of fetal and newborn deaths experienced by women with similar risks who gave birth in a hospital setting. The National Birth Center Study II demonstrated the safety of the midwife-led birth center model of collaborative care.

"When women talk to their health care providers about birth options, they should ask about the likelihood of various outcomes for themselves and their newborns,” said ACNM CEO Lorrie Kline Kaplan, CAE. “For example, what is the likelihood of a cesarean section? What is the likelihood that my baby will need assistance at birth, and what is the plan for handling emergencies? Just stating ‘the risk is doubled’ does not help women make informed decisions. An event that occurs in a few instances out of 10,000 is a still very rare event, even when doubled."

Health care providers need to be prepared for informed conversations about these issues. A 2012 ACNM survey of 1200 women found that half of women surveyed want more discussion with their health care providers about place of birth, but most women are not receiving helpful information about these choices.