Editor’s Choice


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.

Gynaecological cancer and genetic inheritance

The established importance of the BRCA1, BRCA2, CDH1, PTEN, STK11 and TP53 genes in increasing the risk of breast cancer has encouraged many to look for similar oncogenes in gynaecological malignancy. On page 633, Singh et al. from the Departments of Genetics and Obstetrics and Gynaecology in Lucknow, India, report on the association of IL-1RN genotypes 1/2 and 2/2 with a significantly elevated risk of cervical cancer (OR = 3.3; P= 4.9 × 10−6 and OR = 2.9, P= 0.02). Cervical cancer is the most common cancer of women in India. They investigated the hypothesis that genes controlling the expression of interleukins, involved in the inflammatory processes modulating the development of the disease, would be altered in women with cervical cancer compared with controls. This targeted approach contrasts with other techniques in which genome-wide screening is undertaken using microarrays. This latter technique throws up multiple associations, but with no prior hypotheses about why the identified genes should be involved, the process of untangling the aetiological processes remains daunting. On page 548, Catherine Holland of the University of Manchester explains the background to current translational research in this area. She gives as an exemplar of the value of the genetic approach, improvements in the treatment of advanced gastrointestinal stromal tumours. The detection of mutations of the receptor tyrosine kinases KIT and PDGFRA in affected individuals suggested the use of a tyrosine kinase inhibitor, imatinib, which led to dramatic improvements in survival. She proposes that not only will such discoveries encourage the development of new therapies but can also assist in targeting resources to the women most at risk.

More gynaecological magic

While Catherine Holland suggests that the ultimate objective of genetic research is to develop prevention or treatments for cancer to render surgery obsolete, the development of new physical techniques in surgery continues apace. Natural Orifice Transluminal Endoscopic Surgery or ‘NOTES’ is developing fast, with a transgastric approach initially developed by Anthony Kalloo and his team at the Johns Hopkins School of Medicine. This route was natural to them because Kalloo is a Professor of gastrointestinal medicine, but securing closure of the gastric incision without leakage is difficult. The vaginal route presents fewer such problems, and already there are competing claims as to who carried out the first transvaginal cholecystectomy (e.g. Marescaux et al., Arch Surg 2007;142:823–6 and Zoron et al., Surg Innov 2007;14:279–83). Researchers at my own University, Imperial College London, are investigating the use of the i-Snake—a long-tube housing special motors, sensors and imaging tools. But the Holy Grail is to perform physical extirpation without any form of surgical incision. On page 653, Zowall et al. report a collaboration between McGill University in Canada and Imperial College London to destroy uterine fibroids using a small bean-shaped volume of focused ultrasound energy that is directed into the target for approximately 15 seconds and heats the tissue between 60 and 90°C to induce thermal coagulation. The key to its safe use is the monitoring of the temperature rise induced, and its spatial location, using contemporaneous magnetic resonance imaging (MRI). The advantages of this technique over existing thermo-ablative methods are that it provides continuous MRI of fibroids and adjacent structures such as bowel, bladder and sacral nerves, with continuous temperature monitoring to optimise tissue coagulation and prevent injury to adjacent normal tissue. In this paper, they concentrate on assessing its cost-effectiveness and estimate that even with the use of MRI, an expensive imaging modality, its use will result in cost savings overall. A note of caution about this claim is voiced by Manyonda and Gorti on page 551. For those not familiar with the technique, their description of it is a model of clarity. They point out that the technique has in principle been around for over 50 years and that probably the availability (or not) of MRI is a major limiting factor in its use. They argue for prospective randomised trials before it can be considered suitable for introduction into routine practice—and end with a plea for a more user-friendly acronym than ‘MRgFUS’.

Continuing controversies, and yet more innovations for BJOG

We like papers that encourage discussion, and the debates about centralisation of services for the management of ovarian cancer, and the use of ST segment analysis (STAN) for the detection of fetal acidosis in labour, continue in our correspondence section. Watch out for more on STAN in the coming months. In the meantime, the paper in our February issue on single blastocyst transfer by Khalaf et al., explaining the need and the technique to reduce the multiple pregnancy rate with IVF, stirred up such interest that we commissioned our first video podcast, to discuss the controversies it highlighted. In the video podcast, I interview two of the authors, Yacoub Khalaf and Tarek El-Toukhy, plus Tony Rutherford, Chair of the Practice and Policies of the British Fertility Society, and Professor Bill Ledger of Sheffield University and a member of the Human Fertilisation and Embryology Authority of the UK. I strongly recommend that you listen to their fascinating discussion and update yourself on some of the clinical and political issues surrounding this important topic.

To watch the video free online, visit: http://www.blackwellpublishing.com/podcast/bjog.asp