Hospital births for healthy women? What does the research say?

The recent Birthplace Study was the first of its kind to compare outcomes for low-risk, healthy women who gave birth in midwife-led units (both alongside and freestanding), obstetric units and at home. My previous blog post described the findings for first-time Mums birthing at home, but what did the findings say about hospital birth?

The study is extremely positive and shows that birth is generally very safe for mothers and babies who are low risk and healthy. In fact, the chance of something going very wrong for the baby was so low that the researchers had to combine mortality and morbidity to get any meaningful data. There were so few deaths in the study (38 out of nearly 65,000 births) that they had to combine a host of adverse outcomes in order to come up with any statistically significant results. Therefore the "primary outcome" included baby deaths and serious morbidity (injury / illness) to the baby. Overall, a low risk woman had a 4.3/1,000 risk of having a "primary outcome" (that is, death or serious injury to the baby). For women birthing in hospital, the figure was 4.4/1,000 and was actually lower for babies born at home and in midwifery-led units. Imagine that: the risk to the baby overall was highest in hospital!

Breaking this down further, if we look at first-time Mums separately to second and subsequent time Mums, the figures look different. First time Mums had a 5.3/1,000 chance of a "primary outcome" overall. This rose to 9.3/1,000 for women who planned to birth at home, and fell to 4.5 for women birthing in a midwifery-led unit. It was 5.3/1,000 for first-time mums who birthed in hospital. Again, we see that hospital birth confers some increased risk for first time Mums.

Now looking at women birthing for the second (or subsequent) time, we find that the overall risk of a "primary outcome" was very low: 3.1/1,000. This was higher in an obstetric (hospital) unit at 3.3/1,000, lower in a midwifery-led unit (2.7/1,000) and lowest for women birthing at home (2.3/1,000). So once again, the study is showing that hospital is not the safest place to birth a baby if you are a low-risk, healthy women.

If you are having your first baby and are low-risk, the safest place to birth is in a midwifery unit, and if you have birthed before and are low-risk, the safest place to birth is at home.

Of course, midwifery units have limited capabilities to provide higher levels of care, and as labour and birth are unpredictable, there needs to be robust transfer arrangements in place. Some 10-45% of women transfer in birth. This figure is lowest for women who have birthed before, and highest in first-time Mums. As well as robust transfer arrangements, women - particularly first-time Mums - need to be aware of the chance of transfer and to be comfortable with this possibility. This is best accommodated if the woman can transfer in with her own midwife.

What were the intervention rates like?

Not surprisingly, intervention rates were highest in women who planned a hospital birth. 93% women who planned a homebirth had a normal birth, versus only 74% women in the hospital. 11% had a caesarean in the obstetric (hospital) unit, versus a mere 2.8% in women who planned a home birth. 24% women had their labours sped up with a syntocinon drip in the planned hospital birth group, versus only 5% in the women who planned a homebirth. 31% women had an epidural in the planned hospital birth group, versus 8% at home. And of course, episiotomy rates were lowest at home.

It is clear that being in hospital greatly increases risks for all low risk mothers compared to being at home or in a midwife led unit (either alongside or freestanding).

It is clear that low-risk women have much to gain by planning a birth with midwives in a birth centre or some other form of midwifery-led care. Planned homebirth does increase the risks to the babies of first-time Mums, with an increase in adverse outcomes for babies from about 0.5% to just under 1%. But what is it about planning a homebirth that increases the risk to the baby? The study used intention to treat analysis, so we are not able to know how many of those adverse outcomes occurred in those who transferred to hospital after a planned homebirth, versus those that happened in the births that actually occurred at home. We do know that the outcomes of homebirth transfers are generally worse than those who had been planned to occur in hospital, and first-time Mums are more likely to transfer. We also know that birth is generally riskier for a first-time Mum than a woman who has birthed before.

Regardless, the study is extremely positive in supporting the role of primary midwifery care and the excellent outcomes that low-risk women can achieve when they choose a midwife as their care provider. Imagine the benefits as well for high-risk women who receive midwifery care with appropriate and timely obstetric care.

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