Homebirth under scrutiny

Interested in home birth, hospital birth or private midwifery care? Questions or comments? Email Melissa Maimann or call 0400 418 448. Link and another link from the SMH

Women who plan home births recover more rapidly from childbirth, but there is a higher risk of their child dying, an international study suggests.

US analysis of more than 500,000 births in North America and Europe found death rates for babies in planned home births were double that of those in planned hospital births.

But the risk was still low, at 0.2%.

UK doctors said the evidence needed to be taken into account, but a midwives' body questioned its relevance. The research … examined studies on the relative safety of planned home and hospital births from around the world. Researchers looked at data from nearly 350,000 planned home births and more than 200,000 planned hospital deliveries. … it looked at where the woman had planned to give birth, rather than the actual birthplace.

The researchers argued that the safety of home births may have previously been overplayed by the fact that when there are complications and a woman is rushed to hospital, any adverse outcome is recorded as a hospital birth.

They described their findings of a three-fold increase in mortality rates among those planning home birth as "striking", because it is often those with the lowest risk of complications who do not need to deliver in hospital.

When deaths occurred among the home birth group, they were overwhelmingly attributed to respiratory problems during birth and failed attempts at rescusitation.

Overall these problems have been decreasing in recent decades, which is thought to be down to greater medical intervention, including more liberal use of ultrasound, electronic fetal heart monitoring, the induction of labour and Caesarean delivery.

The numbers of homebirths are still very low, even in the UK, making meaningful and concrete conclusions about the results difficult

… the lack of medical intervention may explain why the mothers who planned a home birth tended to end up with fewer tears or lacerations, fewer cases of postpartum haemorrhage and fewer infections.

… "Women choosing home birth, particularly low-risk individuals who had given birth previously, are in large part successful in achieving their goal of delivering with less morbidity and medical intervention than experienced during hospital-based childbirth," …

"Of significant concern, these apparent benefits are associated with a doubling of the neonatal mortality rate overall and a near tripling among infants born without congenital defects."

In the UK, the Royal College of Obstetricians and Gynaecologists said the fact that planned home births resulted in fewer interventions for the mother was something which specialists were already aware of.

"The finding that the consequences for the baby are more severe needs to be carefully considered by women, policy makers and care providers," said its president, Professor Sir Sabaratnam Arulkumaran.

"Certainly, the move towards offering women a choice in their place of birth in the UK needs to be weighed against such evidence."

But, he added, with a robust selection system which ensured high-risk pregnancies were excluded from homebirths and by making sure all midwives providing the services had good resuscitation skills, risks to the baby could be reduced.

"With the above systems in place and provided women receive one-to-one midwifery care, planned home births for low-risk women are a viable option," said Prof Arulkumaran.

"However, birth can be unpredictable and these women should also have quick access to obstetric care if and when an emergency occurs."

Mervi Jokinen of the Royal College of Midwives, said the study was interesing, but questioned the validity of its findings for the UK.

"Comparison of the results is difficult because the study's authors are working with data collected differently in many countries.

"Here we have services delivered by midwives who are skilled and experienced at home births and resuscitating newborns. "This is perhaps in contrast to many of the other countries this research covers."

… "NCT's own detailed review of home birth concluded that, although the quality of comparative evidence on safety of home birth is poor, there is no evidence that for women with a low risk of complications the likelihood of a baby dying during or shortly after labour is any higher if they plan for a home birth compared with planning a hospital birth."

It’s always important to compare like with like when doing research. Although this study was large, an even larger study from the Netherlands would be a more appropriate study from which to draw conclusions about homebirth. This is a better study because it compared homebirths within the same country and used the same criteria for homebirth. The study referred to in this article does not detail whether all the midwives adhered to the same criteria for homebirth suitability, or the training and ongoing education of the midwives. Were all the midwives university-educated? There are several types of midwives in the US and each type of midwife has a different level of training. Countries such as the UK, The Netherlands and Australia have standard requirements for registration as a midwife; this is not the case in other countries.

There was a comment that the study contained small numbers for homebirth. Whenever small numbers are measured in a small sample size, the rate of an adverse outcome occurring (such as baby deaths) will always be unreliable. Hence, the Netherlands study would be a more reliable study from which to draw conclusions. We can’t draw any significant conclusions from the increase in death rates, however the conclusions: educational updates on neonatal resuscitation, proximity to hospital and readiness to transfer when indicated and good selection processes for homebirth, are essential for safety in any country. On reading the full study, it would also appear that about 25% of the births occurred without a midwife's presence.

The SMH article pointed to additional risks for first time mums, stating that firsttime Mums faced a 1 in 3 chance of transfer, whereas the rate of transfer was 1 in 10 for second time Mums. I don't believe that this is a reason for first-time Mums to avoid planning a homebirth. A successful homebirth sets a woman up for being low risk for her subsequent births, and because rates of intervention are lower for homebirth - particularly caesarean - this is an important deciding factor for choosing homebirth. Also, women who plan homebirths usually feel extremely satisfied with their pregnancy and birth experience. However, given the higher transfer rate for first time Mums, it is important that midwives present an accurate picture when promoting homebirth so that women understand that there is a 1 in 3 chance of moving to hospital. Even in this situation, women should expect that their chosen midwife will remain by their side.

Melissa Maimann, Essential Birth Consulting 0400 418 448