Potential Implications of Emerging Non-Traditional Childbirth Practices on Neonatal Health

In recent decades, women are increasingly incorporating non-traditional perinatal practices in their labor and birth plans. Maternal-Child health providers are becoming more aware of these practices, especially out-of-hospital births, water birth, vaginal seeding, and placental encapsulation. As an example, out-of-hospital births in the U.S. have increased since 2004 and most are planned home births rather than unplanned.¹ Home births increased by 19% between 2019 and 2020, peaking in May 2020 during the height of the COVID-19 pandemic in the U.S fueled in part by concerns for safety within a hospital environment.² For women in other parts of the world, including low-middle income countries, home births represent cultural norms and align with beliefs about privacy, protection, autonomy, and rituals.^3–5 As these non-traditional practices enter mainstream obstetric and pediatric clinical care, concern for potential adverse effects has emerged because many of these practices have been adopted without rigorous investigations or clinical trials. In fact, many are based on low level evidence like case reports and surveys, and their prevalence and potential benefits and/or complications are not entirely known.

As we describe the progress of adoption of new perinatal practices, we will limit our report to the potential implications of common non-traditional practices on neonatal health outcomes and highlight contemporary viewpoints of academic and regulatory organizations [the American Academy of Pediatrics (AAP), American College of Obstetrics and Gynecology (ACOG) and the Centers for Disease Control and Prevention (CDC)] to these evolving practices.

Out-of-hospital births

Hospitals are considered the safest environment for women to give birth in the U.S., and many high-resource and low-middle income countries.^6–8 However, there has been a gradual increase in out-of-hospital births (defined as births at home, usually with the attendance of a midwife, and at independent birth centers) over time, particularly in high-resource countries.^{1, 8, 9} Since 1990, home births have comprised about 1% of all births in the U.S.² Some women consider hospitals an unsatisfactory birth environment due to risks associated with procedural interventions and potential challenges to their psychological safety.^{5, 10–12} The recent COVID-19 pandemic limited the presence of maternal social support systems and increased the risk of in-hospital exposure to the virus, resulting in more women opting for home births or birthing centers.^13–15

Although non-Hispanic White women accounted for the majority (85%) of the overall increase in U.S. home births, an increase in out-of-hospital births was noted across all racial and ethnic groups. The number of home births by non-Hispanic Black women increased by 36% between 2019 and 2020, partly driven by inherent mistrust of the medical system and reported worse hospital outcomes for Black women and infants in popular media outlets and scientific literature.^{2, 10, 11, 16, 17} Black women die of pregnancy-related complications at 2 to 3 times the rate of non-Hispanic White women.¹⁸ Non-Hispanic Black infants continue to have the highest infant mortality rate, 2.3 times higher than that of non-Hispanic White infants.¹⁹

Many countries recognize home birth as an accepted cultural practice and have instituted government-sponsored systems to ensure safety, financial coverage and coordinated follow-up care for home births.^{8, 20–23} Regardless of the reason for choosing home birth, out-of-hospital births cost substantially less than hospital births. A national study in the U.S. found that home births and birthing center births cost an average of $4650 and $8309, respectively, compared with an average cost of $13,562 for uncomplicated vaginal hospital births.²⁴ Births at home or at a birthing center may present a more affordable option for mothers with inadequate insurance coverage or access to care but even mothers with sufficient financial resources may consider out-of-hospital birth as safer, more natural, and less stressful. Driving this change toward planned home births for low-risk pregnancies is the association with fewer maternal interventions. However, there are implications for the infant born at home, who may be at increased risk for perinatal death, neonatal seizures, or serious neurologic dysfunction.^{6, 20, 21, 25, 26} Although childbirth in any setting carries a risk of perinatal hypoxia, ischemia and/or asphyxia events, out-of-hospital birth has been associated with an increased risk of hypoxic ischemic encephalopathy (HIE) and a three-fold increase in neonatal seizures and neurologic dysfunction, including altered consciousness, hypotonia, hyporeflexia and insufficient respiratory drive and pattern.^{6, 27–29}

Recognizing the mother’s right to choose a non-traditional birth environment, ACOG acknowledges that women should be supported in their medically-informed decision regarding out-of-hospital birth.⁶ This statement was based on studies suggesting that for low-risk pregnancies (based on multiple characteristics including term gestation, absence of maternal disease and pregnancy complications, and low risk of neonatal disease or mortality), home births can be completed safely with the appropriate resources, including adequate personnel, available emergency equipment, timely access to consultation and a transfer facility and appropriate follow-up newborn and postpartum care.^{26, 30} Attendant health care providers should include a “CNM (certified nurse midwife), certified midwife or midwife whose education and licensure meet International Confederation of Midwives’ Global Standards for Midwifery Education, or physician practicing obstetrics within an integrated and regulated health system” as defined by ACOG.⁶ Two care providers should attend each birth, with at least one provider assigned to care for the neonate, as recommended by ACOG, the AAP and the American Heart Association (AHA). The provider assigned to care for the neonate should be NRP-trained and have the equipment required for neonatal resuscitation for timely recognition and response to reduce the risk of morbidity and mortality.³¹ Although we could not find published data on how often ACOG guidelines are currently followed for out-of-hospital births, ACOG guidelines with respect to NRP-training must be met by all maternal-child health providers and are locally regulated by credentialing and human resources departments. To increase safety, care providers usually establish reliable access to consultation for medical advice, and efficient and timely transport to a nearby hospital for effective management of perinatal complications.^{6, 31}

Current AAP guidelines recommend that newborn infants have a full assessment within the first 2 hours of life and that healthy, well-appearing infants receive a physical examination performed by the clinical healthcare team within 24 hours of birth. Follow-up evaluation after home birth should preferably be performed by a board-certified pediatrician or pediatric nurse practitioner with newborn care as recommended by the AAP, to include clinical evaluation for various neonatal conditions in the first 24–48 hours of life, including newborn screen for genetic and metabolic diseases, evaluation of glucose and bilirubin levels, and screens for critical congenital heart disease and hearing impairment.^{31, 32} Evaluation in a primary care physician’s office, hospital, or infant’s home can be arranged with effective planning.

As out-of-hospital births increase, maternal and neonatal providers should meet prenatally with families considering this option. For families to make an informed decision, providers should disclose the available data on the neurologic risks to the infant and review the guidelines provided by ACOG and the AAP on how to proceed with a safe and low-risk childbirth experience out of the hospital. These discussions should be included in the birth plans created between the provider team and the family and documented in the medical chart to ensure all parties are aware of the family’s desires and the advised course of action should birth complications arise.

Water birth

As women around the world, including the U.S., have sought less intervention and greater autonomy during childbirth, some have gravitated towards water immersion during labor and birth.³³ Although the prevalence in the United States is not well defined, the estimated number of U.S. hospitals offering this option is just under 10% of all maternal care facilities.³³ However, limited studies in other high-resource countries have shown rates of water immersion during labor to be as high as 25–50%, likely secondary to increased access in all birth environments in some European countries, including the United Kingdom and Sweden.^{34, 35} Water immersion is typically separated into immersion during the first stage and second stages of labor. Outcome data remain constrained by the lack of routine documentation regarding water immersion on birth records and inability to conduct randomized trials.^36–38 Despite these limitations, immersion during the first stage of labor has been associated with decreased labor duration, as well as spinal and epidural analgesia without apparent increased risk to the neonate. ^39–41

Immersion during the second stage of labor, including birth, introduces neonatal concerns of infection, aspiration, and cord avulsion. It has been reported that water birth has many potential risk factors for infection including inadequate sanitization of the birthing tub, heated water which can aid bacterial growth, and a contaminated water source. Multiple cases of infection with Legionella in newborns were identified after water births in Arizona and Texas, and these prompted development of public health guidelines surrounding water birth at the state level; however, universal guidelines for water immersion and birth are not available in many states. ^{42, 43}

Despite the presence of the diving reflex at this age, there are case reports of aspiration with water birth.^{36, 40, 44, 45} In addition, multiple reports have documented cases of cord avulsion or the rupture of the umbilical cord prior to planned ligation, leading to NICU admission secondary to hemorrhage, anemia, need for transfusion, and risk of hypoxic ischemic encephalopathy.^{34, 46, 47} Despite these concerns, some women still choose to labor in water for comfort and greater safety and control in their birth experience. ^{48, 49}

As the practice of water birth expands, ACOG and the AAP maintain that further investigation is warranted to identify potential risk-reducing practices, including timely birth and removal from the water to avoid aspiration, while still supporting maternal-infant bonding. ^{36, 50} However, based on findings of published observational studies, ACOG and the AAP recommend that mothers who wish to engage in water immersion limit the practice to the first stage of labor with use only in low-risk cephalic-positioned term pregnancies. Water immersion in the second stage of labor is not recommended.³⁶ Additionally, it is important to develop guidelines for birth centers and ensure appropriate training of midwives on infection reduction methods to help minimize water birth infection risk. Attending birth personnel also need to be adequately trained in methods to minimize the risk of cord avulsion, including ligation of the umbilical cord prior to movement of the mother infant dyad from the birthing tub, and gentle extraction of the infant from the water.

Vaginal seeding

The practice of vaginal seeding is placing maternal vaginal fluids on the skin or nasal and oral mucosa of the newborn to transfer vaginal flora to the newborn to stimulate the neonatal immune system and microbiome development. The practice has increased in recent years, following the increasing rates of cesarean births worldwide. ⁵¹ Although its prevalence is not well defined, vaginal seeding is being increasingly highlighted in the media, prompting more women to discuss it with their obstetric providers and influencing researchers to explore its effect via evidence-based investigations.⁵² Families are considering vaginal seeding because the naturally occurring bacterial transfer during labor and vaginal birth, and via skin-to-skin contact postpartum is less likely to occur with cesarean births, especially without prior rupture of membranes. The perceived short-term effects are stimulation of the infant’s immune system, protection against pathologic bacterial growth as the microbiome develops, and gut regulation, and long-term benefits may include reduction of the risk of immunologic and atopic conditions like asthma via early exposure to physiologic bacteria and initiation of the infant microbiome. ⁵² Multiple studies have retrospectively explored an association between mode of delivery and risk of immunologic conditions in early infancy, and this relationship continues to be investigated because many factors may contribute to the cause of immunologic conditions, and mode of delivery may not itself be a directly causative factor. ⁵¹

As many women are asymptomatic carriers of group B streptococci (GBS) or other vaginal pathogens known to be infectious in neonates, there is a potential risk of infection and early onset sepsis in the neonate following vaginal seeding. Considering the limited data available on infection risk associated with vaginal seeding, ACOG and the AAP do not recommend this practice outside of research protocols until further information is available.^{50, 51} There are multiple ongoing studies regarding vaginal seeding compared with physiologic transfer of bacteria and development of the infant microbiome. ⁵³ Families should be advised that breastfeeding and skin-to-skin contact can be used as an alternative method to provide natural gut flora to the neonate. Some women may be adamant about their wish to implement vaginal seeding on their own after delivery despite adequate counselling regarding the possible benefits and risks; we recommend documentation in both mother and infant’s medical record of engagement in vaginal seeding practice, to inform comprehensive risk assessment and appropriate work-up should a neonate present with clinical illness that may be a sequelae of vaginal flora exposure.

Placental encapsulation

Placentophagy is the postpartum consumption of the placenta. Over recent years, a cottage industry has grown around placentophagy, with companies offering placenta processing services internationally. Placenta encapsulation is the most popular form of consumption; however, the placenta can be consumed in many ways including raw, cooked, dehydrated, blended and as a tincture.^{54, 55} It is difficult to determine the prevalence of placentophagy, as it is mostly performed away from hospital providers, although awareness exists when mothers request to be given their placenta at birth. A national database study found that about 30% of women with planned home births engaged in placentophagy. ⁵⁴ Available data is mostly limited to surveys and self-reported data, microbiology studies, and tissue pathology evaluating hormones and nutrients.

Placentophagy is a relatively common tradition in China dating back over 2000 years because of its anecdotal anti-ageing properties. It has emerged as an appealing practice to some women in the U.S. and other countries because of published, pre-clinical and clinical self-reported survey studies citing positive effects on maternal nutrient and hormone levels, lactation, mood, and fatigue. ^54–56 Studies have shown that the human placenta still contains some nutrients and elements (e.g., iron, copper, zinc) after processing; however, levels are below the recommended daily intake and therefore may not have significant benefit to those ingesting placenta capsules daily. ^{57, 58} One study found improvement in the mood of women who ingested their placenta; however, the study introduced selection bias because the sample of women had already chosen postpartum placentophagy. Moreover, the improvement in mood was not shown to be related to a change in maternal hormone levels of estradiol, progesterone and allopregnanolone after placenta consumption, despite the persistence of the hormones in the placenta after the preparation process.^{59, 60}

It is unknown whether those engaged in placentophagy are aware of the risk of infection. Microorganisms can persist in placenta tissue despite processing, although this risk is mitigated if the placenta is treated with antibiotics, steamed, and dehydrated.⁶¹ There is a compelling case report published by the CDC in 2017 regarding an infant with recurrent late-onset GBS infection secondary to maternal placentophagy in encapsulated form, in which GBS isolates were consistent between the placenta capsules and the infant’s sepsis evaluation.⁶² Another risk associated with placentophagy is the exposure to toxic metals and products that can collect in placenta tissue; even though processing decreases toxic metals, nutrients, and hormone concentrations, these are not fully removed.⁶³ Although conceivable that accumulation of heavy metals can occur over time with chronic ingestion of placenta products, it is probably unlikely.

Given the lack of standardization and regulation of placenta processing in the U.S., the CDC and the AAP do not recommend placentophagy.^{50, 62} The AAP maintains that placentophagy should be seen as a risk factor in evaluation of exposed neonates for sepsis.⁵⁰ Obstetric providers should document requests for the placental tissue in the medical charts of the mother and infant. This can improve neonatal provider assessment of risk and comprehensive management if the infant presents with a clinical illness.

Umbilical Nonseverance

Umbilical nonseverance, or “lotus birth,” is an uncommon perinatal practice of maintaining umbilical cord attachment to the placenta until the cord and placenta unit dries and spontaneously separates from the umbilicus. Natural separation usually occurs within a few days. The prevalence of umbilical nonseverance in the U.S. is unknown. There is no published scientific literature on its benefit to the mother or infant, and it is deemed a spiritual or ritualistic practice. As such, there is no formal guidance on the risks and benefits of practicing umbilical nonseverance.⁵⁰ It is presumed that a significant risk of neonatal sepsis exists due to the physiology of placental tissue necrotization after removal from the circulatory support of the mother as well as necrotic tissue-thrombus formation with potential for embolization to the heart and brain. More data and scientific evidence are needed on the practice of umbilical nonseverance before formal recommendations can be made regarding the risk and benefits to neonates, although encountering an ill neonate with this relevant history should prompt sepsis evaluation and neuroimaging.

Conclusion

ACOG, the AAP, and CDC have clear recommendations on safe perinatal practices to reduce poor neonatal outcomes. All organizations maintain that women should have autonomy regarding their labor, childbirth, and postpartum care, along with sufficient information about the associated risks to their neonates. Care teams should thoroughly counsel women on the risks of nontraditional perinatal practices based on the limited available evidence, and a shared decision-making model can be used for planning labor, birth, and postnatal practices. Additionally, obstetrics and pediatrics providers should encourage open, non-judgmental communication with families about their perinatal practices to promote accurate history-taking. Obstetric and neonatal providers should be knowledgeable of the associated risks and improve disclosure and documentation of patient engagement in these nontraditional perinatal practices to inform women better about clinical management of exposed infants.