How safe is home birth?
Having been born in my grandparents’ home (delivered by a community midwife who also delivered my aunt, uncle and cousin), I have always been interested in the home versus hospital delivery debate. Even as late as 1960, one in three births in the UK were at home, but by the early 1990s, following campaigns by women who saw birth in hospital as safer, and encouraged by the first House of Commons Health Committee Report on the Maternity Services (the ‘Short Report’), this had dropped to below 2%. However, the second House of Commons Health Committee Report on the Maternity Services published in 1991 (the ‘Winterton Report’), on which I had been an obstetric advisor, emphasised the importance of choice. Stimulated by a follow-up report by Lady Julia Cumberlege called ‘Changing Childbirth’, the rate of home births started rising again, albeit very slowly. In 2005, 17 279 of 645 835 total births in the UK were at home (2.7%). On 1 April 2007 in the (UK) Sunday Times, Ivan Lewis (Health Minister) was reported as planning that within the next 3 years, all women in the UK would be guaranteed the opportunity of giving birth at home. Given a rising birth rate and a falling number of midwives, some suspected that the date of the announcement was significant (Editor’s note: in many countries, there is a tradition of playing practical jokes on the first day of April), but subsequent announcements confirmed that the Minister was not joking (at least, intentionally). Even Sheila Kitzinger, a social anthropologist and powerful advocate of women’s choice commented ‘This plan is just spin. It cannot be done’ (UK Daily Telegraph 3 April 2007). As I mentioned in last month’s editor’s choice, arguments about the safety of home birth have been bedevilled by the lack of robust clinical trial evidence, and observational data can be misleading. The paper by Mori, Dougherty and Whittle on page 554 is a brave attempt to address this issue. They report perinatal mortality in England and Wales between 1994 and 2003. With the exception of 1 year, the perinatal mortality in home births was always higher (by 50 to 120%) than that in hospital. Unfortunately, women delivering at home unintentionally (due for example to an unanticipatedly rapid birth) are a high-risk group, and their inclusion in the summary figures makes it impossible to assess directly the mortality associated with intentional home birth. Mori et al. attempt to compensate for this by using figures for the proportion of deaths associated with planned and unplanned home births collected since 1994 by the Confidential Enquiry into Maternal and Child Health. Furthermore, they impute from previous smaller studies in various parts of England and Wales the proportion of home births planned to be at home but transferred to hospital because problems had developed in labour (this group also has a poor outcome). This enabled the authors to make an estimate, with confidence intervals, of the likely perinatal mortality associated with an intention to give birth at home. Although this should be a selected low-risk group, their perinatal mortality between 1994 and 1997 was no lower than that of hospital births and subsequently was consistently about 80–250% higher (significantly so in 1998–99 and 2002–03). It seems strange that the government of a major developed country should be encouraging a substantial return to home births without commissioning a major prospective study of its safety, and the practicality of providing the increased numbers of midwives that would be needed to implement it.
In this context, it is obviously important to know the views of women about their preferred place of birth. On page 560, Pitchforth et al. analysed in detail the views of 877 women who had recently given birth in Northern Scotland, where access to hospitals can be difficult, especially in winter. The main themes of their responses were extracted. These emphasised the dependence of the choices the women made (or would like to have made) on the local services available, including the possibility of rapid transfer to hospital in the case of an emergency. Family circumstances were also important; for example, women who already have small children dislike being separated from them. However, overall, the women sampled had ‘an overwhelming preference for (maternity) unit-based care as opposed to home birth’, and the majority also preferred physician-based care to midwifery-managed care. A cynic might suggest that the UK government has promised ‘home birth for all who want it’ with the expectation that only a few actually will.
The Dutch practice of continuing high rates of home birth (around 30%) with a relatively low perinatal mortality is often quoted as evidence for the safety of the practice. Unfortunately, the perinatal mortality rate in the Netherlands has been declining more slowly than in most European countries (Mackenbach, Ned Tijdschr Geneeskd 2006;150:409–12). The rate of perinatal deaths in that country is now the second highest in Europe (Sheldon, BMJ 2008;336:239), and Sheldon quotes two senior Dutch obstetricians as calling for the tradition of home births to be scrutinised (Visser and Steegers, Medisch Contact 2008;63:96–9). On page 570, Amelink-Verburg (a midwife working at the Netherlands Organisation for Applied Scientific Research) and her midwifery, obstetric and paediatric colleagues report a study of 280 097 women under the care of a midwife at the start of labour, of whom 79 270 were referred to an obstetrician non-urgently and 9985 were referred as an emergency. The short distances for travel and the good transport links within the Netherlands make such transfers less difficult than in many other countries. Half the referrals were due to perceived ‘fetal distress’ and another third to postpartum haemorrhage. Although intervention rates were substantially lower in home births, 1.7% had a blood loss exceeding 1 litre. In cases of urgent referral, 5.3% of babies had a 5-minute Apgar score of less than 7 and half of all neonatal deaths in the first 24 hours of life occurred in this group. More than 1 in 20 (5.6%) women having a home birth were transferred to hospital in the second stage of labour, which as the authors say, ‘may be more stressful for the mother’. Of course, the problem is that we do not know if the outcome would have been different if the women had had earlier access to specialist obstetric and neonatal care. Once again, only randomised trials will give us an answer to such questions.