Safety of home births questioned

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New research has placed home births “under scrutiny,” ... women who plan home births recover more quickly but there is a greater risk of the child dying.

The news is based on a high quality review of data from over half a million births from several Western countries, exploring how planned birth locations affect a number of birth outcomes for both mothers and babies. The findings are complex, and cannot simply be summed up as showing that hospital births are safer than home births ... although it appears to show a greater risk of newborn deaths with home births, the absolute risk in either location is still very low (0.2% for planned home births and 0.09% for planned hospital births).

... some of the higher mortality rate may be attributable to fewer ... interventional deliveries with home deliveries. This theory cannot be proven or disproved by this research ... although home births appeared favourable for certain maternal outcomes, the study was unable to shed any light on the risk of maternal death for either location ... when the analysis only looked at homebirths that had been attended by a certified midwife, there was no difference in risk of neonatal mortality compared to hospital births.

... Though home births were associated with lower rates of ... vaginal tear, instrumental delivery, haemorrhage, infection ... it must be remembered that mothers with any identified pregnancy complications would be more likely to be planned to deliver in hospital rather than at home.

The study did not consider the mother’s experience of home birth or hospital birth and crucially, the important outcome of maternal mortality could not be assessed ...

This was a systematic review of reportedly all Western publications ... that had reported outcomes for babies and mothers in relation to location of birth, e.g. whether at hospital or at home.

... when combining results of multiple studies, the differences in their methods, the populations included and assessments of outcomes, must be taken into account ...

... They looked at a number of interventions and outcome for both mothers and newborns:

Mothers

* Interventions: epidural analgesia, electronic foetal heart rate monitoring, episiotomy, ... operative vaginal delivery ... and caesarean delivery. * Outcomes: mortality, lacerations (>3 degree tear to the vagina or perineum), chorioamnionitis, ... endometritis, ... wound infection, urinary infection, postpartum haemorrhage, retained placenta, and umbilical cord prolapse.

Newborns

* Outcomes: Five-minute Apgar score <7, ... prematurity, ... post-[term], ... low birthweight, ... large baby, ... assisted ventilation requirement, perinatal death, ... and neonatal death ...

Twelve studies ... were included, which covered a total of 342,056 planned home births and 207,551 planned hospital deliveries. Studies came from US, Canada, UK, Australia and several European countries.

Planned home births were associated with fewer maternal interventions, including epidural analgesia, electronic foetal heart rate monitoring, operative delivery and episiotomy ... mothers who had home deliveries had fewer infections, vaginal and perineal tears, haemorrhages, and retained placentas (no difference in the rate of umbilical cord prolapsed).

Of outcomes in the newborn, babies born at home were less likely to be premature, less likely to be of low birthweight, and less likely to require assisted ventilation. However, there was greater likelihood of the baby being born post-dates if delivered at home.

Planned home and hospital births were found to have similar perinatal ... mortality rates, though planned home births were associated with significantly greater neonatal mortality rates ... These were two-to-three times as frequent (32 deaths in 33,302 hospital births [0.09%] and 32 deaths in 16,500 home births [0.20%]).

This observation was consistent across studies. The anticipated population-based attributable risk of neonatal death overall was 0.3% (i.e. 0.3% of neonatal deaths could be accounted for by birth occurring in the home rather than the hospital). The researchers noted an increased proportion of deaths attributed to respiratory distress or failed resuscitation in the home birth groups.

Applying sensitivity analyses that excluded poorer quality studies had little effect on the findings. However, when the researchers excluded studies of home births attended by people other than certified midwives, there was no significant difference between the newborn mortality rates associated with the two locations of birth.

... researchers conclude that less medical intervention during planned home birth is associated with an almost-tripled neonatal mortality rate.

... the associations seen should not be considered as a direct cause-and-effect relationship, i.e. it is an oversimplification to assume that planned birth location is directly or solely responsible for the birth outcomes seen.

... the principal limitation is that of attributing home or hospital birth as the actual cause of the outcome. For example, it is possible that home birth is associated with fewer instances of prematurity, low birthweight and assisted ventilation, not because home birth reduces the risk of this, but because mothers of babies who are identified as having some problem during antenatal care ... would be more likely to be recommended a hospital delivery.

Likewise, mothers who have an obstetric or medical history putting them at higher risk ... are more likely to be recommended a hospital birth. Consistent with this, the researchers noted that women planning home births tended to be at lower risk of complications and were less likely to be overweight or obese, giving birth to their first baby or to have history of previous pregnancy complications.

* Although home birth was associated with greater neonatal death ... [it] is still very rare, and the absolute size of the risk is low (0.2% among planned home births and 0.09% among planned hospital births). The researchers calculated that only 0.3% of neonatal deaths could be attributable to birth occurring in the home rather than the hospital. * It is also important to note that there was no increased risk of neonatal death with home birth compared to hospital birth once the analyses excluded those studies of home births attended by people other than certified midwives. That is to say, when the home birth was assisted by a certified midwife, there was no increase in mortality compared to a hospital birth. ... * Maternal mortality rates were an important outcome that was not able to be assessed ... the four studies that had considered this outcome (covering 10,977 planned home and 28,501 planned hospital births), experienced no maternal deaths. Therefore, more research is needed on this outcome. Additionally low Apgar scores could not be assessed.

... future study needs to be directed at identifying the factors that contribute to the apparently excessive neonatal mortality among planned home births, and also considering the effect upon maternal mortality.