Tuesday, July 19, 2011

Studies Confirm Homebirth Safer for Normal Births

Photograph by Sandi Heinrich
Over the recent decades many studies have confirmed the safety of home birth. However the results are strict in their findings - home birth is only recommended when accompanied by a certified midwife, or certified nurse midwife, and the risk of complication is low.

Here I present the results of large, comprehensive study comparing home births with registered midwives, versus hospital births with a physician, in British Columbia. The study group included nearly 13,000 births.

Planned home births attended by a registered midwife were associated with 45% less perinatal death compared to planned hospital birth with a physician. There were also significantly reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital births attended by a physician:

Augmentation of labour = 53% less
Narcotic analgesia, intramuscular or intravenous = 88% less
Epidural analgesia = 72% less
Assisted vaginal delivery = 78% less
Cesarean delivery = 35% less
Episiotomy = 81% less
Third- or fourth-degree perineal tear = 66% less
Postpartum hemorrhage = 43% less
Infection = 74% less
Pyrexia = 77% less

Perinatal death = 45% less
Apgar score < 7 at 1 min = 26% less
Apgar score < 7 at 5 min = 1% less
Meconium aspiration = 55% less
Asphyxia at birth = 30% less
Birth trauma = 67% less
Resuscitation at birth = 44% less
Birth weight < 2500 g = 5% less
Seizures = 34% less
Oxygen therapy > 24 h = 62% less
Assisted ventilation > 24 h = 32% less
Admission to hospital after home birth or readmission if hospital birth = 39% more

What I found odd about this study was that the results were heavily adjusted to bring down the risks associated with physcian attended births, but the characteristics and confounding factors for each of the groups were identical! Here were the actual results of home births attended by midwives before they were adjusted:

Perinatal mortality = 2 fold less
Electronic fetal monitoring = 6 fold less
External tocometer = 6 fold less
Fetal scalp electrode = 5 fold less
Augmentation of labour = 2 fold less
Amniotomy = 2 fold less
Oxytocin = 3 fold less
Nitrous oxide = 8 fold less
Epidural = 4 fold less
Narcotic = 8 fold less
Spontaneous vaginal = 19% more
Assisted vaginal = 5 fold less
Cesarean = 52% less
Cesarean among nulliparous women = 67% less
Cesarean among multiparous women = 13% less

Either way, home birth with a certified midwife is shown to be as safe, if not safer than hospital birth with a physican. The added bonus is significantly less unnecessary medical intervention.

The full text study is available here:
Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742137/

There are also many other large studies confirming these findings:

Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births
http://www.internationalmidwives.org/Portals/5/Home%20Birth%20-%20Netherlands%20-%202009%20BJOG.pdf
"This study shows that 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."

Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia
http://www.cmaj.ca/content/166/3/315.full
"There was no increased maternal or neonatal risk associated with planned home birth under the care of a regulated midwife. The rates of some adverse outcomes were too low for us to draw statistical comparisons, and ongoing evaluation of home birth is warranted."

Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. Zurich Study Team
http://www.ajog.org/medline/record/ivp_09598138_313_1313
"During delivery the home birth group needed significantly less medication and fewer interventions."
"Healthy low risk women who wish to deliver at home have no increased risk either to themselves or to their babies."

Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands
http://www.bmj.com/content/313/7068/1309.abstract
"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."
"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."

Home or hospital birth: A prospective study of midwifery care in the Netherlands
http://nvl002.nivel.nl/postprint/PPpp1096.pdf
"Our study has shown that for women at low risk of obstetric complications, the outcome of planned home births is at least as good as the outcome of planned hospital births for first time mothers, while for other mothers the outcome of planned home births is significantly better."
"To maintain confidence in home birth and reduce the fear of unplanned transfer to hospital, leading to an increased choice for hospital birth, it is essential that certain conditions are met. One of these is a well functioning selection system to ensure that only those women who are really at low risk are offered the opportunity and are encouraged to give birth at home."

Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome
http://www.bmj.com/content/313/7068/1313.full
"Healthy low risk women who wish to deliver at home have no increased risk either to themselves or to their babies. There are no obvious disadvantages of home delivery for mother or child when the mother opts for home delivery."
"Interventions (induction, caesarean section, medication, forceps, or vacuum extraction) may be considerably less frequent in women who originally opt for home delivery:"
Hypertention = 60% less
Preterm birth = 40% less
Breech presentation = 33% less
Induction = 18%
Cesarean = 45%
Analgesics = 16%
Medication during expulsion period = 34%
Forceps or vacuum = 41%
Episiotomy with perineal lesion = 9%
Perineal lesion = 3 fold
Perineal and vaginal lesion = 25%
Intact perineum = 6 fold more
Though these results favour midwives, again these results are heavily adjusted to bring down the risks associated with hospital births with a physician. Below are the real, unadjusted results that compare specifically matched pairs of birthing mothers (if these were matching pairs why did they need adjusting?) There is a huge discrepancy, for instance a 500% increased occurrence of induction in physician led hospital births, has been brought down to just 18%. I don't see how a reduction of 482% can be justified in a group of specifically matched pairs of birthing mothers:
Induction of labour = 5 fold less
Caesarean section = 2 fold less
Analgesics = 3 fold less
Medication during expulsion period = 5 fold less
Forceps or vacuum extraction = 2 fold less
Episiotomy without perineal lesion = 3 fold less
Perineal and vaginal lesion = 4 fold less
Intact perineum = 4 fold more

Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: a retrospective cohort study
http://www.internationalmidwives.org/Portals/5/Home%20Birth%20Statsitics%20-%20Canada%20-%20BIRTH%20September%202009.pdf
"Midwives who were integrated into the health care system with good access to emergency services, consultation, and transfer of care provided care resulting in favorable outcomes for women planning both home or hospital births."
"All measures of serious maternal morbidity were lower in the planned home birth group as were rates for all interventions including cesarean section."

Outcomes of planned home births with certified professional midwives: Large prospective study in North America
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC558373/?tool=pubmed
"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":
Electronic Fetal Monitoring = 9 fold less
Induction = 2 fold less
Episiotomy = 16 fold less
Forceps = 2.2 fold less
Vacuum = 9 fold less
Cesarean = 5 fold less

Outcomes of 11,788 planned home births attended by certified nurse-midwives. A retrospective descriptive study
http://www.ncbi.nlm.nih.gov/pubmed/8568573
"This study supports previous research indicating that planned home birth with qualified care providers can be a safe alternative for healthy lower risk women."
"Most nurse-midwives in this study used standard risk-assessment criteria, only delivered low-risk women at home, and were prepared with emergency equipment necessary for immediate neonatal resuscitation or maternal emergencies."

It should be reiterated that the homebirths included in these studies involve certified midwives or certified nurse midwives, and the births have to meet a low-risk criteria to be deemed suitable for home birth. Below is typical of what is required.

Eligibility requirements for home birth
As referenced in the above studies:
  • Absence of significant pre-existing disease, including heart disease, hypertensive chronic renal disease or type 1 diabetes
  • Absence of significant disease arising during pregnancy, including pregnancy-induced hypertension with proteinuria (> 0.3 g/L by urine dipstick), antepartum hemorrhage after 20 weeks' gestation, gestational diabetes requiring insulin, active genital herpes, placenta previa or placental abruption
  • Singleton fetus
  • Cephalic presentation (not breech or transverse)
  • Gestational age greater than 36 and less than 41 completed weeks of pregnancy
  • Mother has had not had a cesarean section
  • Labour is spontaneous, not induced 
  • Mother has not been transferred to the delivery hospital from a referring hospital
Other important factors included:
  • Well trained midwives 
  • A good transportation and referral system
  • Midwives are prepared with emergency equipment necessary for immediate neonatal resuscitation or maternal emergencies

So what's your opinion on home birth, have you had one, would you consider having one, are you planning one? Do you agree a midwife is always needed?

2 comments :

  1. Hi Natural Mama! You actually helped me debate about homebirth safety on ten centimeters. Glad to have found you!!

    ReplyDelete
  2. Hey hon! Hehe we did well, glad to have found you too ;o)

    ReplyDelete