Academic Journal
Main Category: Pregnancy / Obstetrics
Also Included In: Pediatrics / Children's Health
Article Date: 27 Nov 2011 - 14:00 PST
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Women who are pregnant for the first time and decide to have a home birth should be aware that there is a significantly higher risk of complications, compared to first time mothers who have the baby in an an obstetric or midwifery unit, researchers from Oxford University reported in the BMJ (British Medical Journal). However, for second and subsequent births, women with low risk pregnancies do not have a statistically significantly higher risk, the authors added.
Professor Peter Brocklehurst and team explained that in general, women with low risk pregnancies should be able to freely select where they wish to give birth. They say their findings "support a policy of offering women with low risk pregnancies a choice of birth setting.". Mothers-to-be and their partners should have informed discussions with their medical team about where they plan to have the baby.
The authors explained, as background information to the article, that birth settings have been extensively debated over the last decade. However, there are very few quality studies which focus on the benefits and risks of home births, obstetric units, and midwifery units.
Brocklehurst and team set out to determine what the perinatal outcomes and interventions might be at four birthplace settings across all NHS trusts in England.
Lisa J. Patten gives birth, unassisted, at home
Planned places of birth included: The mother's homeFreestanding midwifery unitsMidwife-led units at a hospital which also had an obstetric unitObstetric unitsThey collected data on the following adverse outcomes: Upper arm or shoulder injuries during birthMeconium aspiration syndrome - feces in the lungs of the babyEarly neonatal deathEncephalopathy (brain injury)Stillbirth after start of care in labor
Clamping the umbilical cord of a newborn infant at a hospital
The study included 64,538 full term infants whose mothers had low-risk single pregnancies (no multiple births). The researchers took several factors into account, such as BMI (body mass index), ethnic group, and maternal age.
In all birth settings, the overall rate for adverse outcomes was 4.3 per 1,000 births. They found no important differences in the adverse outcome rate between non-obstetric and obstetric unit settings.
They report that for first time mothers - nulliparous women - the risk of a home birth adverse outcome was 9.3 per 1,000 births - more than double the 4.3 per 1,000 overall average. Nulliparous women who gave birth at home were also found to have a significantly higher risk of adverse outcomes compared to similar women who gave birth in a midwifery unit or obstetric unit.
For women who had already given birth before - multiparous women - there was no significant difference in risk between having the baby at home or elsewhere (uncomplicated pregnancies).
The intervention rate during labor was considerably lower in all non-obstetric unit settings, compared to obstetric unit ones.
45% of first time mothers were transferred from a non-obstetric unit setting to an obstetric one, compared to just 13% of those giving birth for the second, third, etc. time.
The researchers wrote:
"These results will enable women and their partners to have informed discussions with health professionals in relation to clinical outcomes and planned place of birth. For policy makers, the results are important to inform decisions about service provision and commissioning."
The authors say they are currently investigating the cost-effectiveness of different birth settings.
In an Abstract in the same journal, they concluded:
"Women planning birth in a midwifery unit and multiparous women planning birth at home experience fewer interventions than those planning birth in an obstetric unit with no impact on perinatal outcomes. For nulliparous women, planned home births also have fewer interventions but have poorer perinatal outcomes."
Compared to giving birth in an obstetric unit, one that occurs in a midwifery unit is £130 (US$200) cheaper, while a home birth is £310 (US$496) cheaper. The Daily Telegraph quoted Maureen Treadwell, from the Birth Trauma Association, as saying:
"These findings are useful but are based on a study of only 5,000 women in each type of midwifery unit and do not tell us how many babies died or were brain damaged in each group."
Treadwell hopes the UK government does not use this apparent cost-benefit to eventually limit women's choices to the cheapest option.
Written by Christian Nordqvist
Copyright: Medical News Today
Not to be reproduced without permission of Medical News Today
MLA
9 Dec. 2011.
Please note: If no author information is provided, the source is cited instead.
posted by Mary Gonzelaz on 27 Nov 2011 at 3:26 pm
I had a home birth eight years ago. The baby got stuck, I was rushed to hospital, which was a few miles away. fortunately, everything turned out OK. Had there been a traffic jam, it might have been another story. Never again.
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posted by Irma Johnson on 27 Nov 2011 at 3:28 pm
If a woman has a home birth and something goes wrong, who is responsible? The mother, the midwife who is with her, the doctor for allowing it to happen, the authorities for allowing it to happen?
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posted by Harry on 27 Nov 2011 at 3:51 pm
The study showed that of the current 90% of births in hospitals over half would be perfectly fine to go with a home delivery. Even the first time mother statistics that you say in the article have "more than double" the risk are still less than a 1% risk. Please stop the fear mongering and report what the article really says. One could just as easily flip this report and say that obstetric units needlessly perform cesarean deliveries almost 4 times as often as in home birth environments (table 4).
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posted by Susan Morganson on 27 Nov 2011 at 4:28 pm
The second paragraph clearly states "Professor Peter Brocklehurst and team explained that in general, women with low risk pregnancies should be able to freely select where they wish to give birth."
Try reading before shooting your mouth off!!
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posted by Georgio Carrazo on 27 Nov 2011 at 4:30 pm
We had our first two babies at home. All was fine. The third one was also done at home, my wife hemorrhaged. Everything would have been easier and safer at a specialized unit in a hospital.
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posted by barbara Smythe on 27 Nov 2011 at 4:35 pm
I am pregnant. I would like to know if my risk is 9.3 or 4.3 per 1,000. Please do not use the word "spin", which is a push for censorship. Let people like me, pregnant mothers, make that decision. I can assure you - Harry - I could well do without your advocacy!!!! Thank God you are not in charge of issuing information to the public!!
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posted by Suki Boydston on 27 Nov 2011 at 5:11 pm
If a woman has a hospital birth and something goes wrong, who is responsible? The mother, the doctor who is with her, the midwife for allowing it to happen, the authorities for allowing it to happen?
As a labor and delivery nurse, I many times saw doctors do interventions intended to "speed things up," oblivious to the other effects, and then getting the parents' intense gratitude for "saving the baby" from the damage with an emergency caesarian.
I chose to be home for my children's births, with a good midwife and a pre-toured available hospital. No regrets.
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posted by whitney on 27 Nov 2011 at 6:12 pm
I heartily agree with Suki. I'm an MD, and though my field of specialty is not obstetrics, I did go through my student rotations and caught a bunch of low-risk babies delivered in a hospital. When it came time to have my own, I had planned home births with a trained midwife (not available in all states - I'm in the US).
There are risks unique to each setting and each woman has to decide which set she is more comfortable taking on. I read the research articles and carefully investigated the local practices of hospital and homebirth practitioners (which may or may not allow you to generalize the research results to your location, for me they did).
Hospital-based birthing care is a highly variable and less evidence based field than most other fields of medicine, because it carries so much medicolegal baggage. It's a frustrating topic.
For me, I saw what Suki saw too many times and even though I was coming into the birthing process well informed, I didn't want that for me. Too many cascades of interventions and teams making decisions based on EFM strips (which are not evidence based) and the vagaries of change of shift.
Each woman deserves to be where she feels safe and most comfortable, without judgement.
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posted by Linda on 27 Nov 2011 at 7:40 pm
4.3 vs 9.3 per thousand - that's a difference of one bad outcome per 200 babies. Lets look at REAL NUMBERS - how about 400+ per thousand C-sections (most wouldn't have been necessary without medical interference), premature babies due to inducing for convenience (the doctors mostly), hospital acquired infections-I wonder what that fatality rate is, distressed infants with low apgar scores due to too much medical interference, interference with normal childbirth through restricting movement and monitors. Interference with early bonding and breastfeeding. BTW, having a baby at home without help, as shown in that picture, is pure idiocy- that's probably why they showed a higher problem rate. I had 2 healthy home-births, but my son had shoulder dystocia. Without a highly qualified midwife who quickly recognized and managed it, he would have been in serious trouble. Staying out of the hospital is NOT equal to not having a qualified and experienced support person with you.
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posted by Georgina on 28 Nov 2011 at 4:38 pm
I have been reading this with some thought as a mother who had all three babies at home, based on research from the 1990s showing it was safer.
The one thing that seems to be missing from this data is what influence continuity of caregiver has. As we hired an indepedent midwife who knew us and our foetus, we felt that improved our care significantly. She was also a very experienced and confident homebirth midwife. I also had a postpartum haemorrage bleed after the first birth, a 800ml loss, that was handled calmly and confidently, and I have never felt traumatised by it, although another poster on this board seems to have been.
After I had my children, I went on to work as a doula for six years, attending around 40 births. I was often struck by the lack of homebirth experience of some midwifes who were sent to attend women. They were much more used to working in an obsteric unit. Some midwives were fantastic, others much less confident and some clearly unhappy at attending a homebirth. Thinking about the Hannah Trial for breech birth which has been largely discredited now with criticism aimed at the skill and ability of the birth attendants, I see prarallels with this research. I'd like to see research that focuses on woman attended by homebirth midwives, not just hospital midwives attending homebirths. Is there a different in skill, confidence and style - absolutely!
I attended more than one birth where midwives came and left again because the woman "wasn't in established labour", but then the woman would progress very fast and the midwife wouldn't get back in time and you'd end up with the baby being born without the midwife. That was always frustrating for the women and the midwives, but due to labour ward pressures, the midwives weren't allowed to stay.
Equally, I also attended births where a transfer was decided on, because the mum ran out of steam after a prolonged labour or the baby wasn't coming, I never saw an emergency transfer. But I was always struck by the delay when we got into hospital. It was never a smooth transfer of care, it always seemed to take a long time and a lot of fluffing around. My hunch is that this is a major cause of the significant gap between homebirthers and hosptial birthers, that the transfer of care isn't snappy enough and I think this warrents more research.
Ultimately, I think we also need to consider the benefits of homebirth - the significant decreases in surgical and assisted delieveries, increases in breastfeeding rates, decreased neonatal intensive care admissions. For example: http://onlinelibrary.wiley.com/doi/10.1111/j.1523-536X.2010.00458.x/abstract
Ultimately it is a woman's choice as to where she gives birth. However, in the current climate of lip service and shroud waving, I fear this research will be used as another stick to bully women into doing what the system wants them to do.
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