Oscar Home Births and Birth Centers (CG038) Form

The Plan

Members who chose to have a home birth may be eligible for provider services. An expectant mother has options as to where she may plan to give birth including at home, at a birthing center, or at a hospital.

Risks Associated with Home Births

The American College of Obstetricians and Gynecologists (ACOG) states that a home birth has a twofold increased risk of perinatal death when compared to a hospital birth and a threefold increased risk of neonatal seizures or serious neurologic dysfunction for the newborn. An accredited birthing center is safer than a home birth. However, ACOG respects the right to make one’s own medically informed decision. A planned home birth is not appropriate for all pregnancies, and a screening should be done with an in-network provider to evaluate if a pregnancy is deemed medically appropriate for a home birth. Screening may include evaluating medical, obstetric, nutritional, environmental and psychosocial factors. Appropriate planning should also include arrangements for care at an in-network hospital should an emergent situation arise.

Birth Centers

Birth centers provide peripartum care for low-risk women with uncomplicated, singleton, term, vertex pregnancies who are expected to have an uncomplicated vaginal delivery and postpartum recovery. While birth centers do not provide an acute level of care, the center has arrangements in place for emergent transfer of members to a hospital for higher level of care when needed. The reported risk of needing an intrapartum transport to a hospital is 23-37% for nulliparous and 4-9% for multiparous women (ACOG, Reaffirmed 2023).

Definitions

• Certified Nurse-Midwife (CNM) is a registered nurse who has completed education in a midwife program. All CNMs must pass a national certification examination by the American Midwifery Certification Board.
• Certified Midwife (CM) is an individual who has completed education in a midwife program but is not a registered nurse. CMs must also pass a national certification examination by the American Midwifery Certification Board.
• Normal Pregnancy and childbirth is defined by the California Business and Profession Code section 2507(b)(1) as a singleton fetus with cephalic presentation and the absence of any preexisting maternal disease or condition likely to affect the pregnancy or significant disease arising from the pregnancy.
• High Risk Pregnancy describes a pregnancy in which the mother, fetus, or newborn is or will be at increased risk for morbidity or mortality before, after, or during delivery
• Perinatal Risk is risk specifically relating to the time around birth, including both before and after.
• Placenta Previa is a condition where the placenta covers the internal cervical os or the opening of the cervix.

Clinical Indications

Requirements Prior to Delivery

Women who are deemed at low risk for home births must meet ALL the following criteria to meet medical necessity:

1. Evaluated and classified as a normal pregnancy by a licensed CNM, DO, MD, or NP who is trained in obstetrics and gynecology or family practice with obstetrical expertise; and
2. Absence of preexisting conditions that may affect delivery, including:
   • Medical conditions, such as high blood pressure or diabetes (e.g., gestational, pre-gestational, or insulin dependent); or
   • A previous c-section or other uterine surgery (e.g., myomectomy); or
   • Pregnancy complications, such as premature labor, fetal intolerance of labor, preeclampsia, prolonged pre-labor rupture of membranes, intrauterine growth restriction, macrosomia, fetal anomaly, history of a previous postpartum hemorrhage, multiple gestation, or a baby in the breech or other malposition at 37 weeks and beyond; or
   • Contraindication to a vaginal birth (e.g., placenta previa or accreta, active genital herpes, previous hysterotomy in the upper uterine segment); or
   • Current history of substance abuse; or
   • High risk pregnancy, as defined in the exclusions below; and
3. Pre-existing arrangement for transfer to a nearby in-network hospital should an emergent situation arise.

Requirements at Time of Delivery

1. Have the state licensed and certified nurse-midwife, midwife, or physician practicing within an integrated and regulated health system in attendance; and
2. Have ready access to consultation at an in-network facility at which the treating nurse-midwife or provider of choice is affiliated or practicing. Examples of which include, but are not limited to, electronic, telephone or personal consultation, collaborative management, shared management, referral or transfer of care; and
3. Plan for transfer to a nearby in-network hospital should an emergent situation arise; and
4. Pregnancy is between 37 weeks and 0/7 days and 42 weeks and 0/7 days at time of delivery; and
5. Spontaneous labor or labor induced as an outpatient.

Freestanding Birth Centers (not within hospital systems)

For requests at accredited freestanding birthing centers, the above requirements prior to delivery and at the time of delivery will apply.

Experimental or Investigational / Not Medically Necessary

Duplicate Services

Duplicative services by health care providers are not medically necessary such as services of both a midwife and a physician concurrently in attendance at a home birth.

Home Births Further than 30-Minutes from an Emergency Facility

While access to emergency facilities is an important component of safety, it is hard to judge how close is required to be safest. Bastian et al. followed 7002 planned home births from 1985 to 1990 in Australia. For one of the authors’ measurements, asphyxia deaths, there had been warning signs during most of the labors. The authors noted that these often occurred early enough to have allowed timely transfer.1 From a more recent systematic review by Blix et al, the reported risk of needing intrapartum transport to a hospital varied from 9.9% to 31.9%.

Doula Services

ACOG and a Cochrane Review confirm that \

Maternal Age Considerations

conducted a retrospective analysis of 134,088 births that occurred from 1970 to 1990 in Utah. Maternal age <17 had a higher risk of adverse outcomes, these results held when controlling for prenatal care. The authors concluded that a younger maternal age was correlated with an increased risk of adverse outcomes.¹³ Maternal age above 40 years of age has been shown by numerous authors as linked to increased perinatal mortality. One such study is by Jacobsson et al. who conducted a national prospective cohort study following 1,566,313 deliveries over a 15 year period. They saw a positive correlation between maternal age and increased risks.¹⁴ Cleary-Goldman et al. similarly found that with maternal ages above 40, there were increased risks for placental abruption and perinatal mortality.¹⁵

Oligohydramnios and Polyhydramnios

Oligohydramnios and polyhydramnios are both indications of a high-risk pregnancy. Oligohydramnios has been studied to see if the amniotic fluid index can be used to predict adverse outcomes in pregnancies. Three recent studies over the past decade have found that oligohydramnios amniotic fluid volumes are insufficient to predict adverse outcomes.^16,17,18 Recommendations for pregnancies complicated by oligohydramnios includes fetal monitoring during labor. Due to the unpredictability of oligohydramnios on outcomes and the recommendation for fetal monitoring during labor, oligohydramnios is a contraindication for home birth.¹⁸ Polyhydramnios were found by Khan and Donnelly in a retrospective case control study to be linked with adverse neonatal outcomes. The authors followed 288 women and found increased risk for cesarean delivery, fetal distress, and NICU admissions.²⁰ In practice, pregnancies complicated by polyhydramnios are monitored for spontaneous membrane rupture, and for fetal abnormalities.²¹ As studied by Wiegand et al. who found an association between the severity of polyhydramnios and the risk for perinatal morbidity.²²

Placental Problems

Placental problems can be varied, but many have been linked to increased perinatal risk. One example is placenta previa. In a systematic review by Vanhanian et al., it was found that the rates of NICU admissions, neonatal death, and perinatal death were significantly increased in patients with placenta previa.²³

Intrauterine Growth Restriction/Fetal Growth Restriction

Infants with intrauterine growth restriction are defined as estimated fetal weight of <10th percentile (Mandy, 2020). This is caused by a genetic or environmental factor; some conditions associated are maternal hypertension, preeclampsia, and congenital infection). Infants with fetal growth restriction are at risk for preterm delivery, perinatal asphyxia, impaired thermoregulation, hypoglycemia, impaired immune function and other risks (Mandy, 2020).

Pre-pregnancy Weight Issues: <100lbs or BMI≥35

In a retrospective study, Ehrenberg et al. studied perinatal complication rates for low maternal weight. They found that when compared to a normal BMI, these mothers had increased risk for maternal delivery complications.²⁴ An increased BMI has also been associated with increased risk for maternal and fetal outcomes across a variety of measures including: increased length of labor, increased risk of cesarean delivery, increased risk of postpartum infection, and increased risk for asphyxia and death.²⁵

Presence of Any Medical or Surgical Condition That May Put the Mother and/or Fetus at Increased Risk

There are numerous medical or surgical conditions that can increase the perinatal risk. One such example is an expectant mother with chronic hypertension. In a systematic review and meta-analysis, Brahman et al. examined the adverse outcomes for pregnancies complicated by chronic hypertension and concluded that there were higher risks for many outcomes.²⁶

Presence of Severe Fetal Abnormalities or Abnormalities for Which Full Workup Has Not Been Performed to Determine the Extent

Home births in cases where the fetus has a known abnormality have not been extensively studied, but a recent case study discusses the ethical concerns of a home birth in this setting. The authors found that in the setting of fetal abnormalities, the pregnancy is not classified as a low risk pregnancy and delivery needs to be in a facility prepared for emergency intervention for the fetus.²⁷ In this line, if the extent of the fetal abnormality is unknown or if the abnormality is known to require intervention, a planned home birth is not suitable.

Presence of Fibroids with Characteristics Associated with Increased Risk for Pregnancy Complications

The presence of fibroids of large size, certain location, distortion of uterine cavity, or multiple fibroids has been linked in multiple studies, reviewed by Lee et al, to adverse perinatal outcomes such as placenta abruption, cesarean delivery, and postpartum hemorrhage. These outcomes have been reported to occur in as many as 10 to 30% of pregnancies.²⁸

Substance Abuse Disorder

Substance abuse disorder including alcoholism and drug addiction during pregnancy is associated with adverse pregnancy outcomes. One example is opioid abuse, as explored by Maeda et al., who found increased perinatal morbidity and mortality with opioid use.²⁹