Dr. Marla Shapiro: Home births are a choice many women consider. But is it safe?

Home births are a choice many women consider. But is it safe? Now the largest study of its kind finds increased risk of stillbirth, neonatal seizures or serious neurological dysfunction in planned home births. Here are the details:

• the number of homebirths in the United States has grown over the last decade
• researchers  have found that babies born at home are roughly 10 times as likely to be stillborn
• almost four times as likely to have neonatal seizures or serious neurologic dysfunction compared to babies born in hospitals.
• largest study of its kind,
• includes data on more than 13 million U.S. births
• risk is associated with the location of a planned birth, rather than the credentials of the person delivering the baby
• study showed that the risk of stillbirth is even greater in first-born babies - 14 times the risk of hospital births
• magnitude of risk associated with home delivery is alarming
• practitioners have an ethical obligation to disclose the risks associated with planned home birth to expectant parents who express an interest in this delivery setting
• analyzing birth certificate files from the U.S. Centers for Disease Control and Prevention (CDC) National Center for Health Statistics to assess deliveries by physicians and midwives in and out of the hospital from 2007 to 2010
• researchers looked at 5-minute Apgar scores of zero, neonatal seizures and serious neurologic dysfunction
• Apgar score is a screening test to quickly assess the health of an infant one minute and five minutes after birth
• 5-minute Apgar score of zero is considered stillborn, although about 10 percent of these babies survive, usually with major health problems
• majority of pregnancies go smoothly but there can be unpredictable complications requiring immediate surgical intervention
• if  an emergency occurs at home that requires hospital transport, it's often difficult to beat the clock to prevent death or neurological issues
• study's findings are based on the birth setting, not whether the provider is a physician or midwife
• suspect that the findings understate the actual risks *the outcomes for patients whose care began out of the hospital but were then transferred to the hospital due to complications are reported as hospital deliveries
• if data were corrected, the risk of out-of-hospital delivery is likely to be much greater
• 1-warning parents about potential risks
• 2-critical for caregivers and hospitals to create a welcoming and comfortable birthing environment, often a primary motivation for planned homebirth

Appearance, Pulse, Grimace, Activity, and Respiration.

The Apgar test is usually given to a baby twice: once at 1 minute after birth, and again at 5 minutes after birth. Sometimes, if there are concerns about the baby's condition or the score at 5 minutes is low, the test may be scored for a third time at 10 minutes after birth.

Five factors are used to evaluate the baby's condition and each factor is scored on a scale of 0 to 2, with 2 being the best score:

• appearance (skin coloration)
• pulse (heart rate)
• grimace response (medically known as "reflex irritability")
• activity and muscle tone
• respiration (breathing rate and effort) Doctors, midwives, or nurses add these five factors together to calculate the Apgar score. Scores obtainable are between 10 and 0, with 10 being the highest possible score.

What Apgar Scores Mean

A baby who scores an 8 or above on the test is generally considered in good health. However, a lower score doesn't mean that your baby is unhealthy or abnormal. But it may mean that your baby simply needs some special immediate care, such as suctioning of the airways or oxygen to help him or her breathe, after which your baby may improve.

At 5 minutes after birth, the Apgar score is recalculated. If your baby's score was low at first and hasn't improved, or there are other concerns, the doctors and nurses will continue any necessary medical care and will closely monitor your baby. Some babies are born with conditions that require extra medical care; others just take a little longer than usual to adjust to life outside the womb. Most newborns with initial Apgar scores that are a little low will eventually do just fine.

It's important for new parents to keep their baby's Apgar score in perspective. The test was designed to help health care providers assess a newborn's overall physical condition so that they could quickly determine whether the baby needed immediate medical care. It was not designed to predict a baby's long-term health, behavior, intellectual status, personality, or outcome. Very few babies score a perfect 10, since their hands and feet usually remain blue until they have warmed up. And perfectly healthy babies sometimes have a lower-than-usual score, especially in the first few minutes after birth.

Keep in mind that a slightly low Apgar score (especially at 1 minute) is common for some newborns, especially those born after a high-risk pregnancy, cesarean section, or a complicated labor and delivery. Lower Apgar scores are also seen in premature babies, who usually have less muscle tone than full-term newborns and who, in many cases, will require extra monitoring and breathing assistance because of their immature lungs. More details here.