Homebirth transfer rates

We hear a lot about transfer rates, and I am not sure if a transfer rate is a good thing or a bad thing! It seems that high and low rates appeal to different audiences and mean different things to different people. I have always regarded a transfer rate as a sign of safety.  A 0% transfer rate might be a bit worrying; likewise, a 50%+ transfer rate might also be a bit worrying.  By transfer, we mean a situation where a woman had planned to give birth at home, but ends up birthing in hospital.  A transfer can happen at any stage of the pregnancy or labour.

So what is a woman really asking when she asks her midwife what her midwife’s transfer rate is?  I consider that the woman is really asking, “If I ask you to be my midwife and care for me through my pregnancy and birth, what’s my chance of being transferred to hospital?” and when women ask the same question of several midwives, they are most reassured by the midwife with the lowest transfer rate because they perceive that they have the lowest chance of transferring if they go with the midwife with the lowest transfer rate.

Is it a fair assumption to make, that the midwife’s transfer rate, representing her previous client’s outcomes, are a valid gauge for the current woman’s likelihood of transfer?

Often, I find that transfers can’t be predicted. If we could predict it, we’d recommend a planned hospital birth. Considering transfer rates from this perspective, a midwife’s transfer rate has no bearing on the current woman sitting with her. As well as this, some transfers occur because the woman has requested it – eg a request for transfer for an epidural, but not on the advice of the midwife as the labour is actually progressing very normally. The other situation that can arise is that the midwife foresees problems occurring and makes some recommendations to avert those problems, but the woman considers the recommendations and decides against them. In these cases, again, the midwife’s transfer rate has no bearing on each new client who interviews a midwife.

So what’s a “good” homebirth transfer rate?

Well, many might argue that the lowest transfer rate is the best transfer rate. You’re setting out for a homebirth, right?

I did some scouting around on the lovely internet and found that transfer rates range from 10% through to 50%. The Netherlands has a transfer rate of 52%! This surprised me. In the Netherlands, 86% women start in “primary” care (midwifery care), 28% are transferred in pregnancy and 17% are transferred in labour, leaving 41% women birthing with midwifery care. Of this 41%, 30% occurred at home and 11% occurred in hospital.

The St George hospital homebirth program reported a transfer rate of 37% for its first 100 births and this was in a low-risk clientele (at the start of pregnancy). Their outcomes were excellent, and the satisfaction of the women and midwives using / working in the service was very high.

Private midwives’ transfer rates vary – anywhere from 10% to 40% in some States of Australia as well as overseas. So there’s a wide fluctuation. What can we deduce from these transfer rates?

Well, with the exception of the Netherlands - which has large numbers – we can’t really deduce very much at all. You never can when you’re dealing with small numbers. Private midwives in Australia typically don’t attend more than 20-40 births a year, and some as few as 5 births a year. One transfer in 5 births is 20%, whereas if that same midwife had attended more births without complication, perhaps the transfer rate would have only been 10%.

There are a few things to consider with transfer rates:

  1.  The health needs of the woman at booking
  2.  Safety guidelines
  3. The decisions that the woman makes
  4. The recommendations that the midwife makes

Midwives with low transfer rates might only book the lowest of low-risk women: those who have previously had a vaginal birth without complications.  Midwives with high transfer rates might not be transferring willy-nilly, but might be taking on a higher risk group of women and adopting a wait and see approach – eg, “yes, you have a family history of high blood pressure and you had it with your last pregnancy, but let’s try some preventative measures and see what happens this time”, and continue with homebirth plans. If this woman’s blood pressure went up, she would transfer, contributing to the midwife’s “high” transfer rate. The low risk / low transfer rate midwife might not have accepted this woman for homebirth at all, hence the difference in transfer rates.

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