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Is Homebirth a Safe and Responsible Option?

Is having my baby at home a safe and responsible option for caring parents? That's an important question every parent considering homebirth needs to address. In fact - a question for all prospective parents might be, "Is hospital a safe and responsible option?"



Here is a list of research articles that discuss the comparative safety pros and cons of homebirths and births in hospital.

Outcome of Planned Home and Hospital Births among Low-Risk Women in Iceland in 2005–2009: A Retrospective Cohort Study.
Background: At 2.2 percent in 2012, the home birth rate in Iceland is the highest in the Nordic countries and has been rising rapidly in the new millennium. The objective of this study was to compare the outcomes of planned home births and planned hospital births in comparable low-risk groups in Iceland.
Methods: The study is a retrospective cohort study comparing the total population of 307 planned home births in Iceland in 2005–2009 to a matched 1:3 sample of 921 planned hospital births. Regression analysis, adjusted for confounding variables, was performed for the primary outcome variables.
Results: The rate of oxytocin augmentation, epidural analgesia, and postpartum hemorrhage was significantly lower when labor started as a planned home birth. Differences in the rates of other primary outcome variables were not significant. The home birth group had lower rates of operative birth and obstetric anal sphincter injury. The rate of 5-minute Apgar score < 7 was the same in the home and hospital birth groups, but the home birth group had a higher rate of neonatal intensive care unit admission. Intervention and adverse outcome rates in both study groups, including transfer rates, were higher among primiparas than multiparas. Oxytocin augmentation, epidural analgesia, and postpartum hemorrhage rates were significantly interrelated.
Conclusions: This study adds to the growing body of evidence that suggests that planned home birth for low-risk women is as safe as planned hospital birth.

Perinatal and maternal outcomes in planned home and obstetric unit births in women at ‘higher risk’ of complications: secondary analysis of the Birthplace national prospective cohort study
Objective: To explore and compare perinatal and maternal outcomes in women at ‘higher risk’ of complications planning home versus obstetric unit (OU) birth.
Design: Prospective cohort study.
Setting: OUs and planned home births in England.
Population: 8180 ‘higher risk’ women in the Birthplace cohort.
Methods: We used Poisson regression to calculate relative risks adjusted for maternal characteristics. Sensitivity analyses explored possible effects of differences in risk between groups and alternative outcome measures.
Main outcome measures: Composite perinatal outcome measure encompassing ‘intrapartum related mortality and morbidity’ (intrapartum stillbirth, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus or clavicle) and neonatal admission within 48 hours for more than 48 hours. Two composite maternal outcome measures capturing intrapartum interventions/adverse maternal outcomes and straightforward birth.
Results: The risk of ‘intrapartum related mortality and morbidity’ or neonatal admission for more than 48 hours was lower in planned home births than planned OU births [adjusted relative risks (RR) 0.50, 95% CI 0.31–0.81]. Adjustment for clinical risk factors did not materially affect this finding. The direction of effect was reversed for the more restricted outcome measure ‘intrapartum related mortality and morbidity’ (RR adjusted for parity 1.92, 95% CI 0.97–3.80). Maternal interventions were lower in planned home births.
Conclusions: The babies of ‘higher risk’ women who plan birth in an OU appear more likely to be admitted to neonatal care than those whose mothers plan birth at home, but it is unclear if this reflects a real difference in morbidity. Rates of intrapartum related morbidity and mortality did not differ statistically significantly between settings at the 5% level but a larger study would be required to rule out a clinically important difference between the groups.

2013 Publicly funded homebirth in Australia: a review of maternal and neonatal outcomes over 6 years - The Medical Journal of Australia
Results: 
* Of the 1807 women who intended to give birth at home at the onset of labour, 1521 (84%) did so.
* 315 (17%) were transferred to hospital during labour or within one week of giving birth. Of these 315 women who transferred, 26 gave birth in a birth centre (1.4%), 163 (9.0%) in a labour ward and 97 (5.4%) in an operating theatre and 29 transferred within one week of giving birth at home.
* The c/section rate for these 1807 women was 5.4% (97 women).
* The rate of stillbirth and early neonatal death was 3.3 per 1000 births; when deaths because of expected fetal anomalies were excluded it was 1.7 per 1000 births.
* The rate of normal vaginal birth was 90%.
* 32% of the women were first time mothers.
* Nine-hundred and forty-five (52%) gave birth in water.
* 1631 women 90%) had a normal vaginal birth; 10 had breech births.
* 56% had an intact perineum, while 4% sustained a perineal graze and 34% had a first or second degree perineal tear.
* 3% had an episiotomy and 1% had a third degree tear.
* 2% had a PPH.
* Of 1807 babies born, 1794 (99%) had a birth weight greater than 2500g.
* Of 1807 babies born, 48 (3%) were admitted to the special care nursery.

2013 Cochrane Summary
"Most pregnancies among healthy women are normal, and most births could take place without unnecessary medical intervention. However, it is not possible to predict with certainty that absolutely no complications will occur in the course of a birth. Thus, in many countries it is believed that the safest option for all women is to give birth at hospital. In a few countries it is believed that as long as the woman is followed during pregnancy and assisted by a midwife during birth, transfer between home and hospital, if needed, is uncomplicated. In these countries home birth is an integrated part of maternity care. It seems increasingly clear that impatience and easy access to many medical procedures at hospital may lead to increased levels of intervention which in turn may lead to new interventions and finally to unnecessary complications. In a planned home birth assisted by an experienced midwife with collaborative medical back up in case transfer should be necessary these drawbacks are avoided while the benefit of access to medical intervention when needed is maintained. Increasingly better observational studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up, but may lead to more interventions and more complications. However, there is no strong evidence from randomised trials to favour either planned hospital birth or planned home birth for low-risk pregnant women."

2012 Cochrane Review

"It seems increasingly clear that impatience and easy access to many medical procedures at hospital may lead to increased levels of intervention which in turn may lead to new interventions and finally to unnecessary complications. In a planned home birth assisted by an experienced midwife with collaborative medical back up in case transfer should be necessary, these drawbacks are avoided while the benefit of access to medical intervention when needed is maintained. Increasingly better observational studies suggest that planned hospital birth is not any safer than planned home birth assisted by an experienced midwife with collaborative medical back up, but may lead to more interventions and more complications."

Media about the 2012 Cochrane Review: Birth is no reason to go to hospital

Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study

11 November 2011

"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 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."
  • For healthy women with low risk pregnancies, the incidence of adverse perinatal outcomes is low in all birth settings
  • For healthy multiparous women with a low risk pregnancy, there are no differences in adverse perinatal outcomes between planned births at home or in a midwifery unit compared with planned births in an obstetric unit
  • For healthy nulliparous women with a low risk pregnancy, the risk of an adverse perinatal outcome seems to be higher for planned births at home, and the intrapartum transfer rate is high in all settings other than an obstetric unit."

Homebirth: an annotated guide to the literature. May 2011
This annotated bibliography provides citations and critical appraisal of original studies on home birth.

Outcomes of planned homebirths with Registered Midwives versus planned hospital births with midwives or physicians
31 August 2009

This is the interpretation:

"Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician."

Here is the conclusion:

"Our study showed that planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and adverse maternal outcomes compared with planned hospital birth attended by a midwife or physician. Our population rate of less than 1 perinatal death per 1000 births may serve as a benchmark to other jurisdictions as they evaluate their home-birth programs.

Here is press coverage of the research:
Homebirth with Midwife as safe as hospital birth

HERE
is a discussion of the research from Science & Sensibility - a research blog about healthy pregnancy, birth and beyond. The author says the this study, plus the earlier study from The Netherlands in April 2009, usher in a new era in homebirth research.


Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births
15 April, 2009
This study concluded, "... planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system."

HERE is press coverage of this study.


Outcomes of Planned Homebirths with Certified Nurse Midwives - Large Prospective Study in North America
British Medical Journal, June 2005.
This study of 5418 women who planned to give birth at home in 2000 with a trained midwife showed that -
12% transfered to hospital either during pregnancy or labour (compared to a more than 40% transfer rate out of our birth centres in Australia)
5% had epidurals (compared to 26% of all births in Victoria in 2005)
1.6% had forceps or ventouse (compared to 13% of all births in Victoria in 2005)
3.7% had caesareans (that is about a tenth of the caesarean rate generally in America and Australia)
There were 1.7 baby deaths per 1000, compared with a national average of 4 baby deaths per 1000 in USA and Australia - one quarter of the average.
Conclusions: "Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States."
This is the largest prospective study of planned home births to date.
Quote:
"Despite a wealth of evidence supporting planned home birth as a safe option for women with low risk pregnancies, the setting remains controversial in most high resource settings," note Kenneth Johnson (Public Health Agency of
Canada) and Betty-Anne Daviss (International Federation of Gynecology and
Obstetrics, Ottawa). "Our study of certified professional midwives suggests that they achieve good outcomes among low-risk women without routine use of expensive hospital interventions," conclude Johnson and Daviss.


An editorial from the British Medical Journal, 1996: Homebirth is safe for selected women, with adequate infrastructure and support. This editorial overviews 4 studies that indicate that although it is commonly assumed that hospital based deliveries are safer for mother and child, homebirth is a safe and real option.


Here at Ronnie Falcao's Gentle Birth Midwife Archives, is a list of articles and research papers on the risks and benefits of homebirth and hospital birth. You'll be up to date and very well informed by the time you've waded through this lot.

Outcome of Planned Home and Planned Hospital Births in Low Risk Pregnancies: - prospective study in midwifery practices in the Netherlands. British Medical Journal, November 1996
This is a study of 1836 women, considered to be 'low risk', attended by 97 midwives who planned to give birth at home or in hospital in The Netherlands
Results:
There was no relation between the planned place of birth and perinatal outcome in primiparous women when controlling for a favourable or less favourable background. In multiparous women, perinatal outcome was significantly better for planned home births than for planned hospital births, with or without control for background variables.
Conclusions:
The outcome of planned home births is at least as good as that of planned hospital births in women at low risk receiving midwifery care in the Netherlands.


Choosing Between Home and Hospital Delivery: Home Birth in Britain Can Be Safe
British Medical Journal, March 2000.
Quote: "There has been no intrapartum death and only one neonatal (0-27 day) death in the past 15 years among the estimated 3400 mothers (0.6%) who were booked for home birth when labour started. That home birth has become statistically “safer” than hospital birth is not, of course, unexpected, as high risk mothers seldom press for home delivery. There is no evidence that hospital is the safest place to give birth."


Here is a comprehensive list of medical research on homebirth collated by James J. Hughes Ph.D who writes,
"Home birth can be a safe option for 90% of mothers, with appropriate prenatal care and attendant personnel. It makes both financial sense and medical sense for state laws to permit home birth attended by midwives, for insurers to reimburse for home delivery, and for hospitals and obstetricians to provide medical back-up. Obstetricians need to take their blinders off and learn to cooperate with folks who want to deliver in their own homes."


Perineal Outcomes in a Homebirth Setting
The results of this study suggest that it is possible for midwives to achieve a high rate of intact perineums and a low rate of episiotomy, and that the kneeling or hands & knees birth position, and a hands-off approach with no perineal massage when the baby is crowning, is your best chance for an intact perineum. Further suggestions here


A study of planned homebirths with independent midwives in Victoria

This 1995-1998 study revealed that:
- 96.4% of women went into labour spontaneously
- 91.6% experienced a spontaneous vaginal birth
- the transfer rate from home to hospital was 20%
- 64.2% had no perineal trauma
and concluded that that "planned home birth with a qualified midwife remains a demonstrably safe option for women who choose this model."


MIPP Calling Card to Julia Guillard

Statistics compiled by Independent Midwives in Victoria in 2009.

These statistics are from the Perinatal Data Collection Unit, concerning births in 2007, the latest year we have statistics available so far.

"Babies born at home had similar Apgar scores to babies born in hospital. Less than 3% of babies born at home required admission to special, or intensive care nurseries, compared to 15% of babies born in hospitals."


More Irrefutable Evidence of the Safety of Homebirth

These are statistics provided by the Victorian Dept of Health concerning 170 primiparae mothers who planned homebirths between 2003 and 2007.

Of these 170 first time mums:
- none were induced. All started labour naturally. (Compared to a 30% induction rate in hospitals)

- 11 had c/sections (6.5%) compared to a nearly 50% c/section rate for first time mothers in many Australian hospitals

- 159 had a vaginal birth. Of these, one woman had a 3-4th degree perineal tear in hospital. (0.6%)

- 138 gave birth safely at home. Of these 138, none were induced and none had 3-4th degree perineal lacerations.

- of 30 women who had previously had caesareans who then planned homebirths between 2003-2007, all 30 gave birth safely at home, a success rate of 100%. It is less than 20% in hospitals.

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