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The U.K. Study: Is Home Birth a Reasonable Option?

December 6th, 2011 by avatar

 

As Kimmelin Hull’s recent blog post reported, we have another study to add to the short list (de Jonge 2009); Janssen 2009) of studies of:

  1. planned home birth,
  2. with a qualified home birth attendant,
  3. in women eligible for home birth at labor onset,
  4. that had a comparison group of similar women planning hospital birth, and
  5. where outcomes were obtainable for hospital transfers.

This study even had the bonus of being prospective, that is, the study was organized ahead of time, as opposed to retrospective, that is, data were collected after the fact from records or surveys. The study’s abstract concludes:

The results support a policy of offering healthy women with low risk pregnancies a choice of birth setting. Women planning birth in a midwifery unit* and multiparous [prior births] women** planning birth at home experience fewer interventions than those planning birth in an obstetric unit with no impact on perinatal outcomes. For nulliparous [no prior births] women, planned home births also have fewer interventions but have poorer perinatal outcomes (p. 1 of 13).

*The study also looked at freestanding and hospital-associated birth centers.

**Women with prior cesareans were excluded.

Let us dig deeper into this conclusion and consider the risk trade-offs between planned home versus planned hospital birth in low-risk first-time mothers.

Investigators created a composite perinatal outcome in order to increase the study’s power to detect a statistical difference in rare outcomes and to evaluate outcomes relevant to intrapartum quality of care. Some of the latter have no permanent or long-term consequences, so I will focus on the ones that do because these would matter most to women deciding where to plan to birth.

Their foremost concern would be, of course, the risk of perinatal death. Investigators report an intrapartum demise plus early neonatal (up to 7 days) death rate of 1.3 per 1000 in nulliparous women starting labor at home (6/4568) versus 0.5 per 1000 in similar women beginning labor in hospital (5/10,626), or a difference of 0.8 per 1000. Confidence intervals overlapped, which means that differences were not statistically significant, i.e. unlikely to be due to chance, but this could be because even populations this large are too small to detect a significant difference in an event that occurs so rarely. Let us assume, though, that the difference is real and that 8 more babies per 10,000 low-risk nulliparous women starting labor at home would die as a result of that decision. To be sure, no excess death rate, however small, is trivial, but to put this into perspective, the excess risk of losing the pregnancy as a result of having an amniocentesis is 60 per 10,000. No one is advising women against amniocentesis on grounds of its danger, so we may conclude that an excess risk considerably more than 8 per 10,000 is deemed tolerable by the obstetric community. Moreover, we have no details about the deaths, so we do not know whether some may have been unavoidable. For example, the study did not include congenital anomalies among its exclusion factors, which means it is possible that a couple who knew their baby would not survive might have chosen to give birth in the privacy and comfort of their home, or a woman might have refused transfer.

The second concern would be outcomes that could result in permanent deficit, which in this dataset were encephalopathy (neurologic symptoms) with no perceptible cause other than hypoxia during labor, and brachial plexus injury (injury to a nerve complex in the shoulder). Here, too, rates in nulliparous women planning home birth (5.5 per 1000) exceeded those with planned hospital birth (3.3 per 1000). Again, differences failed to achieve statistical significance, but, again, this may be because the population was too small to detect one. Assuming the difference is real, 2.2 more babies per 1000 of women beginning labor at home will experience encephalopathy or brachial plexus injury compared with women beginning labor in hospital; however, almost all babies will recover fully, making any difference in permanent injury rates miniscule.

Against perinatal risks must be set the excess maternal risks of planned hospital birth. No woman died, but investigators reported cesarean surgery and anal sphincter injury rates, both of which can result in future or permanent adverse effects.

Rates of anal sphincter injury in nulliparous women were nearly identical (43 per 1000 planned home birth vs. 45 per 1000 planned hospital birth), but differences are likely to be much greater in the United States and Canada, where median episiotomy (cut straight toward the anus) is usual, because, unlike mediolateral (cut angled to one side) episiotomy, the norm in the U.K., median episiotomy strongly predisposes to anal sphincter laceration. Women planning home birth were less likely to have episiotomies (160 per 1000) compared with women planning hospital birth (293 per 1000), which amounts to 133 fewer episiotomies per 1000 women beginning labor at home.

As for cesarean surgery, planning home birth cut the likelihood of cesarean nearly in half. The rate in nulliparous women starting labor at home was 85 per 1000 compared with 160 per 1000 in women planning hospital birth, which calculates to 75 fewer women per 1000 beginning labor at home ending up in the operating room. The consequences of cesarean surgery can be serious for both the current delivery and future pregnancies and deliveries, and the risks include increased likelihood of future maternal and perinatal death. Furthermore, the excess risk of cesarean can be much greater. A large, multicenter Canadian study in women who would have qualified for home birth according to the U.K. study’s criteria reported a cesarean rate of 299 per 1000 in nulliparous women.

So there you have it. For multiparous women with no prior cesareans, planned home birth confers no excess risk. For nulliparous women, it isn’t a matter of risky versus safe but of which risks the woman prefers to run. As the other two high-quality studies conclude, home birth is a reasonable option with the provisos of low-risk status and a qualified attendant.

Posted by:  Henci Goer


Home Birth, New Research, Research , , , , , , , , ,

  1. avatar
    Hannah
    December 6th, 2011 at 09:28 | #1

    I think it is important to put this into context: the information was gathered in England. I am a huge defender of the NHS because I think it does what a lot of other health care systems fail to do, namely provide a relatively high level of care at a very competitive cost while keeping everyone on an equal footing. I love that doctors are paid a fixed sum, and they certainly don’t get paid more for “doing more” for the sake of it.
    I just don’t think the conclusions that were drawn at the end of this paper, as quoted in the abstract above, can be applied to other healthcare systems.

  2. avatar
    Erinn Streeter
    December 6th, 2011 at 09:56 | #2

    “No one is advising women against amniocentesis on grounds of its danger…”

    I don’t know if I agree with this statement. I see your point, and agree that amniocentesis is a good comparison: “…we may conclude that an excess risk considerably more than 8 per 10,000 is deemed tolerable by the obstetric community.” But to say that no care provider tells women about their risk doesn’t acknowledge those care providers who do, in fact, tell women about their risks.

    It might be more fair to say something like… When our current cultural perception of ‘a hospital birth means a safe birth’ is challenged with research evidence, it looks more like an ideal than an actuality.

  3. avatar
    elisabeth matthews
    December 6th, 2011 at 11:57 | #3

    “..for nulliparous women, it isn’t a matter of risky versus safe but of which risks the woman prefers to run.” This is the kind of mentality we need to drill into the heads of all humankind. It isn’t a matter of “is homebirth safe?” but a matter of “which risks” you prefer to work with.

    Although I am curious as to why the neonatal death rate is 1.3/1000 for labor starting at home vs .5/1000 for labor starting at hospital. I assume this means induced. What is the rate for a woman who begins labor in hospital without induction? This is a curious statistic that should be explored more..

  4. avatar
    elisabeth matthews
    December 6th, 2011 at 12:04 | #4

    @Erinn Streeter

    I think the point is clear. The article isn’t saying that care providers don’t explain the risks of amnio. The article is saying that no care provider would advise against amnio, BECAUSE of the risks, if they deemed the test necessary. I think the article assumes that providers ARE discussing risks and STILL advising for a far more risky procedure than homebirth is. Great point to discuss!!

  5. avatar
    Anna
    December 6th, 2011 at 12:20 | #5

    Are the newborns with the primary outcomes babies whose mothers planned home births and actually had their babies at home, or are they mothers who planned to have their babies at home and had them at either home, hospital or in transfer?

  6. avatar
    Hannah
    December 6th, 2011 at 15:03 | #6

    @ elisabeth matthews
    Why would you assume that the women who labour in the hospital would be induced? According to the guidelines, approx. 1 in 5 babies in the UK is induced. It would be standard to wait until at least 41+0 in a healthy pregnancy before inducing for post-dates.

  7. December 6th, 2011 at 16:05 | #7

    Anna :
    Are the newborns with the primary outcomes babies whose mothers planned home births and actually had their babies at home, or are they mothers who planned to have their babies at home and had them at either home, hospital or in transfer?

    I think that is one of the weakest parts of this study. It doesn’t differentiate between women who PLANNED to have their babies at home vs. women who actually DID. Both are included in the “homebirth” stats.

  8. December 6th, 2011 at 16:22 | #8

    Hannah :
    @ elisabeth matthews
    Why would you assume that the women who labour in the hospital would be induced? According to the guidelines, approx. 1 in 5 babies in the UK is induced. It would be standard to wait until at least 41+0 in a healthy pregnancy before inducing for post-dates.

    I would be interested in what the differences between said guidelines and reality are here. I know there are great differences between the US and the UK in some aspects of birth, and further differences between states within the US, differences between hospitals, differences between hospitals, et al. I know of one local hospital whose Pitocin rates are close to 90%. Even mothers who are laboring normally are routinely augmented with Pitocin. From that perspective, it’s a pretty fair assumption that most hospital births are induced or augmented.

    Having had five all-natural, non-induced, non-medicated hospital births, and knowing that this is far from the norm, I would actually be VERY interested in what the rates of induced vs non-induced outcomes.

  9. avatar
    Walker Karraa, MFA, MA, CD
    December 6th, 2011 at 19:05 | #9

    I would love to hear from a wider response audience. It seems that only a few have been dominating the discussion. I find I am reading less and less, and sharing the site with fewer colleagues as the respondents are the same, and the tone dogmatic as to be redundant. Maybe I am looking for a deeper understanding and discussion about the issues beyond basic epidemiology and an iterative cycle of choir preaching. Now don’t get all hostile on me, I am just gently suggesting that to keep ourselves relevant, we need a breath of fresh air every once in a while. This is starting to sound like women out-experting each other. You all deserve better discourse, but we need to engage in it to create it.

    Okay…fire away women…I can take it!

  10. December 6th, 2011 at 22:31 | #10

    Karen Joy :

    Anna :

    I think that is one of the weakest parts of this study. It doesn’t differentiate between women who PLANNED to have their babies at home vs. women who actually DID. Both are included in the “homebirth” stats.

    According to the study, “unplanned home births were excluded.” This can be seen here, http://www.ncbi.nlm.nih.gov/pubmed?term=bmjJour+AND+2011pdat+AND+planned+place+of+birth&TransSchema=title&cmd=detailssearch

    This link was provided at the top of the post.

  11. December 7th, 2011 at 00:22 | #11

    First off, the risk of losing baby is always discussed with parents deciding about amniocentesis. Second, the data also looked at freestanding birth center (which you left out) and in-hospital midwifery units (which you also left out). The data clearly showed an increased risk of stillbirth/neonatal death both in home and freestanding birth center planned birth. I am an birth center owner and support OOH birth, but am ashamed to see you and other OOH birth advocates simply wipe the excess baby deaths under the carpet because they don’t fit your agenda. Shame on you, many midwives and parents rely on you for unbiased information.

  12. avatar
    Walker Karraa, MFA, MA, CD
    December 7th, 2011 at 09:20 | #12

    @Samantha McCormick, CNM
    Now that is what I am talking about! Thank you.

  13. avatar
    Walker Karraa, MFA, MA, CD
    December 7th, 2011 at 09:22 | #13

    Forest, meet the rest of the trees…
    Thank you Samantha for offering a different view, of the big picture.

  14. December 7th, 2011 at 10:33 | #14

    Karen Joy :

    Anna :
    Are the newborns with the primary outcomes babies whose mothers planned home births and actually had their babies at home, or are they mothers who planned to have their babies at home and had them at either home, hospital or in transfer?

    I think that is one of the weakest parts of this study. It doesn’t differentiate between women who PLANNED to have their babies at home vs. women who actually DID. Both are included in the “homebirth” stats.

    The fact that the study started with women still eligible for home birth at the start of labor and followed them through if they transferred during labor or the postpartum is a strength of the study, not a weakness. It is the only way to determine accurately the risks of labor at home.

  15. December 7th, 2011 at 11:02 | #15

    Samantha McCormick, CNM :
    First off, the risk of losing baby is always discussed with parents deciding about amniocentesis. Second, the data also looked at freestanding birth center (which you left out) and in-hospital midwifery units (which you also left out). The data clearly showed an increased risk of stillbirth/neonatal death both in home and freestanding birth center planned birth. I am an birth center owner and support OOH birth, but am ashamed to see you and other OOH birth advocates simply wipe the excess baby deaths under the carpet because they don’t fit your agenda. Shame on you, many midwives and parents rely on you for unbiased information.

    I didn’t omit freestanding birth centers; I just didn’t go into detail because I wanted to stay focused on a single topic. I’ve pasted in the abstract conclusion I quoted in the blog post. I cut the home birth section so that you can see more clearly what investigators concluded about birth center birth with midwives either in freestanding or hospital-associated units.

    “The results support a policy of offering healthy women with low risk pregnancies a choice of birth setting. Women planning birth in a midwifery unit* . . . experience fewer interventions than those planning birth in an obstetric unit with no impact on perinatal outcomes. (p. 1 of 13).
    *The study also looked at freestanding and hospital-associated birth centers.”

    As you can see, no excess in perinatal mortality/morbidity was found, and there was no distinction between women with prior vaginal births and first-time mothers.

    As for the risks of amniocentesis, as another commenter pointed out, I wasn’t saying that the risks were never discussed; I was saying that no one tells women they shouldn’t (or can’t) have one because it is too dangerous for the baby. Women are presumed capable of making an informed decision on this point. I want the same respect for the decision-making capability of women considering home birth.

  16. December 7th, 2011 at 11:32 | #16

    Hannah :
    I think it is important to put this into context: the information was gathered in England. . . .
    I just don’t think the conclusions that were drawn at the end of this paper, as quoted in the abstract above, can be applied to other healthcare systems.

    The other two home birth studies, carried out in the Netherlands and Canada, respectively, support that the U.K. study conclusions can be applied to any system that integrates out-of-hospital and in-hospital care, by which I mean that out-of-hospital practitioners can consult, collaborate, and transfer care seamlessly when needed, and in which out-of-hospital birth attendants are regulated to ensure they have the necessary skills and experience to conduct out-of-hospital birth safely. This being the case, it behooves the U.S. maternity care system to incorporate these elements throughout the country in the name of the health and safety of mothers and babies because, like it or not, out-of-hospital birth is here to stay. I’m happy to say that this is among the conclusions of the recent Home Birth Consensus Summit http://homebirthsummit.org/summit-outcomes.html.

  17. avatar
    Hannah
    December 8th, 2011 at 01:26 | #17

    Henci Goer :
    The other two home birth studies, carried out in the Netherlands and Canada, respectively, support that the U.K. study conclusions can be applied to any system that integrates out-of-hospital and in-hospital care…

    Yes, this is true to an extent. However, I think the system in the UK falls short on one point: if a woman decides to birth at home, midwives (if they are available) are sent out to her at home. She will not necessarily know them well or even have met them before. I believe this is different in the Netherlands (not sure about Canada) and I think it makes a huge difference to a woman’s labour, even if it is not something that can be measured or expressed with statistics.
    Anyway, my main concern was that the study would be applied directly to the system in the US. It would be great to see some of the summit outcomes become reality across the USA!

  18. avatar
    Snorkel
    December 8th, 2011 at 05:41 | #18

    “the study did not include congenital anomalies among its exclusion factors, which means it is possible that a couple who knew their baby would not survive might have chosen to give birth in the privacy and comfort of their home, or a woman might have refused transfer.”

    Oh that is really clutching at straws.

  19. January 13th, 2012 at 23:09 | #19

    @Snorkel

    Um… no, it is NOT “clutching at straws” … it is factual to identify flaws in any study and consider them for what they are. Henci simply states that there IS the possibility of perinatal deaths due to congenital anomalies, which were NOT excluded in any setting.

    Furthermore, we actually can not conclude (from the home birth transfer data) that poor perinatal outcomes after a home birth transport are a direct result of PLANNING a birth at home or beginning labor there. Risking women OUT of labor & birth and home is the entire point! We move to a higher level of care to safeguard the mother and baby. That doesn’t remove the risk as it then exists for that mother and her baby.

    A midwife, for example, might identify fetal stress/distress during the course of labor and transport the mother appropriately, risking her out from further laboring/birth at home. That stress/distress event is not necessarily the CAUSAL factor in the actual outcome however. As we all know… some depressed babies will still do well, needing only close monitoring but require few other interventions and result in a healthy birth and baby; while others, despite closer monitoring and necessary interventions will continue to spiral precariously downward, requiring cesarean delivery to potentially safeguard their health (although C-sec does not guarantee a live, healthy baby is ANY circumstance)…

    My point is… just because a home birth TRANSPORT OUTCOME ends in a perinatal morbidity or mortality does not MEAN that the DECISION to plan a home birth and begin labor at home is CAUSAL in the OUTCOME. If that were the case, then we could suggest we transport healthy, low risk, planned hospital birthing women to a birth center or home to birth and still use the same rationale “the decision and plan to birth in hospital” as CAUSAL in those hypothetical outcomes.

    I believe that it is a serious FLAW in the study to base the OUTCOME of transports on the PLAN and ONSET of labor LOCATION as CAUSAL. You really can’t prove that.

  20. January 13th, 2012 at 23:14 | #20

    Hello Henci, could you clarify the grammar in one of the sentences of this article? It is: “Confidence intervals overlapped, which means that differences were not statistically significant, i.e. unlikely to be due to chance.”

    Does that mean differences WERE or WERE NOT “unlikely to be due to chance”? I was confused and this seemed important. Thanks!

  21. January 22nd, 2012 at 23:01 | #21

    Ananda Lowe :
    Hello Henci, could you clarify the grammar in one of the sentences of this article? It is: “Confidence intervals overlapped, which means that differences were not statistically significant, i.e. unlikely to be due to chance.”
    Does that mean differences WERE or WERE NOT “unlikely to be due to chance”? I was confused and this seemed important. Thanks!

    Sorry about the double negative. “Statistically significant” means that a probability calculation shows that the difference between groups was unlikely to be due to chance. The difference in mortality rates was *not* statistically significant, which means it may have been due to chance. The thing with calculations of statistical significance, though, is that they never rule in or rule out chance absolutely. They just quantify how likely or unlikely it is that chance caused the difference.

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