International data demonstrate home birth safety

Perinatal mortality and morbidity up to 28 days after birth among 743 070 low-risk planned home and hospital births: a cohort study based on three merged national perinatal databases

OBJECTIVE

To compare rates of adverse perinatal outcomes between planned home births versus planned hospital births.

DESIGN

A nationwide cohort study.

SETTING

The Netherlands.

POPULATION

Low-risk women in midwife-led care at the onset of labour.

METHODS

Analysis of national registration data.

MAIN OUTCOME MEASURES

Intrapartum and neonatal death, Apgar scores, and admission to a neonatal intensive care unit (NICU) within 28 days of birth.

RESULTS

Of the total of 814 979 women, 466 112 had a planned home birth and 276 958 had a planned hospital birth. For 71 909 women, their planned place of birth was unknown. The combined intrapartum and neonatal death rates up to 28 days after birth, including cases with discrepancies in the registration of the moment of death, were: for nulliparous women, 1.02‰ for planned home births versus 1.09‰ for planned hospital births, adjusted odds ratio (aOR) 0.99, 95% confidence interval (95% CI) 0.79-1.24; and for parous women, 0.59‰ versus 0.58‰, aOR 1.16, 95% CI 0.87-1.55. The rates of NICU admissions and low Apgar scores did not significantly differ among nulliparous women (NICU admissions up to 28 days, 3.41‰ versus 3.61‰, aOR 1.05, 95% CI 0.92-1.18). Among parous women the rates of Apgar scores below seven and NICU admissions were significantly lower among planned home births (NICU admissions up to 28 days, 1.36 versus 1.95‰, aOR 0.79, 95% CI 0.66-0.93).

CONCLUSIONS

We found no increased risk of adverse perinatal outcomes for planned home births among low-risk women. Our results may only apply to regions where home births are well integrated into the maternity care system.

Planned hospital birth versus planned home birth

BACKGROUND

Observational studies of increasingly better quality and in different settings suggest that planned home birth in many places can be as safe as planned hospital birth and with less intervention and fewer complications. This is an update of a Cochrane review first published in 1998.

OBJECTIVES

To assess the effects of planned hospital birth compared with planned home birth in selected low-risk women, assisted by an experienced midwife with collaborative medical back up in case transfer should be necessary.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 March 2012) and contacted editors and authors involved with possible trials.

SELECTION CRITERIA

Randomised controlled trials comparing planned hospital birth with planned home birth in low-risk women as described in the objectives.

DATA COLLECTION AND ANALYSIS

The two review authors as independently as possible assessed trial quality and extracted data. We contacted study authors for additional information.

MAIN RESULTS

Two trials met the inclusion criteria but only one trial involving 11 women provided some outcome data and was included. The evidence from this trial was of moderate quality and too small to allow conclusions to be drawn.

AUTHORS' CONCLUSIONS

There is no strong evidence from randomised trials to favour either planned hospital birth or planned home birth for low-risk pregnant women. However, the trials show that women living in areas where they are not well informed about home birth may welcome ethically well-designed trials that would ensure an informed choice. As the quality of evidence in favour of home birth from observational studies seems to be steadily increasing, it might be as important to prepare a regularly updated systematic review including observational studies as described in the Cochrane Handbook for Systematic Reviews of Interventions as to attempt to set up new randomised controlled trials.

Home Birth: A Story of “Infinite Love and Enormous Rejection”

This article calls for a new way of looking at the home birth debate by challenging the underlying assumptions and beliefs that lead to the polarized discourse. The debate around home birth is about more than place of birth or perinatal mortality. It raises deeper and more complex issues that need to be explored. This article moves the debate about home birth from one about death to one about human nature, from one about statistics, to one about why the statistics will not end the debate. It explores less familiar discourses such as confirmation bias, group polarization, fear, risk, scientific paradigms, and power using insights from disciplines such as philosophy and psychology for guidance as to why “infinite love and enormous rejection” have come to fill the discourse about home birth. If we do not try and understand why the home birth debate is so polarized and develop new strategies to overcome the great divide, we will never make progress with important decisions as how home birth should safely be made available to women.