Home birth also safer for ‘higher risk’ women

medium_15473825157Hot on the heels of data from New Zealand, two more studies have evidenced the safety of home birth; this time from the UK (Li et al 2015) and Iceland (Halfdansdottir et al 2015).

The Icelandic study is a retrospective cohort study which compares the outcomes of the 307 women who planned home births in 2005-2009 with 921 matched women who planned hospital birth in the same period, and the results are reassuringly similar to those generated in the studies carried out in other countries, further evidencing that home birth is safe for women and babies and more likely to result in straightforward vaginal birth:

“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.”  (Halfdansdottir et al 2015). 

Across the North Atlantic, the latest analysis of the Birthplace data adds a new dimension to our knowledge as, in contrast to most of the existing studies which understandably tend to include only those women who are deemed to be at low risk of complications, it considers the outcomes of those women who are deemed to be at higher risk. In the Birthplace study, this was around 7% of the women who planned home birth, 4% of those who planned birth in an alongside midwifery unit (AMU), and 3% of the women who planned to give birth in a freestanding midwifery unit (FMU).

medium_14319580749Risk can be a bit of a slippery concept, of course.  As Li et al (2015) point out, although we know that there are a few situations in which ‘at risk’ women may genuinely be better off in hospital (which still does not mean they have to go there, of course, and individual situations will vary), many of the conditions and situations that women are told are risky are in fact not well-researched, and the idea that they are risky is sometimes based more on opinion than research evidence.  This is one reason why the analysis presented in this particular research paper is so needed.

So what were the results?  Well, it is important to know that women who were deemed to be at higher risk and who planned a home birth in the Birthplace study did have a significantly higher risk of an adverse perinatal outcome than women who were at low risk and who planned a home birth, but it would appear from these results that the ‘higher risk’ women who planned home births had better outcomes compared with those who planned hospital birth:

“In ‘higher risk’ women, compared with planned OU birth, planned home birth was associated with a significantly reduced risk of ‘intrapartum related mortality and morbidity’ or neonatal admission within 48 hours for more than 48 hours. The difference reflected a higher neonatal admission rate in planned OU births.”  (Li et al 2015)

They also had a greater chance of having a straightforward vaginal birth without interventions:

“Compared with planned OU birth, planned home birth was associated with a significantly lower risk of intrapartum interventions and adverse maternal outcomes requiring obstetric care in both nulliparous and parous ‘higher risk’ women and a significantly higher probability of straightforward vaginal birth in both nulliparous and parous ‘higher risk’ women” (6).  (Li et al 2015)

medium_517148389It is uncertain, however, whether the increase in neonatal admissions reflects an actual difference in morbidity or is due to some other reason, for example perhaps health care providers are more likely to recommend transferring babies to a neonatal unit ‘just in case’.  Women and midwives have long been concerned that intervention is more likely in hospital and that this often occurs when it is not really warranted, and this may be reflective of that.

We need to explore this question further.

 

References

Halfdansdottir B, Smarason AK, Olafsdottir OA (2015). Outcome of Planned Home and Hospital Births among Low-Risk Women in Iceland in 2005–2009: A Retrospective Cohort Study.  Birth DOI: 10.1111/birt.12150
Article first published online: 23 JAN 2015

Li Y, Townend J, Rowe R et al (2015). 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. BJOG; DOI: 10.1111/1471-0528.13283

 

The Research

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.

photo credits: benjaflynn, Jason R. Berg and tiarescott via photopin cc, cc, cc.

7 comments for “Home birth also safer for ‘higher risk’ women

  1. February 3, 2015 at 12:00 pm

    Thank you so much for your work!

  2. Sherri Holley
    August 3, 2015 at 8:59 pm

    I have taken many higher risk women throughout my 36 yrs of Midwifery. My clients have proved this point so many times. I also attend breech babies, twins and over 607 VBAC all out of the hospital .

  3. October 1, 2015 at 9:00 pm

    It is what we supporters of woman led care have felt and believed – so fantastic to have some good research to back us. So how can we ensure that this becomes mainstream reading and affects practice? thoughts welcome.

  4. Sami
    March 17, 2016 at 8:57 am

    Again Sara, thank you for highlighting these studies that may prove crucial to truly woman-centred care and informed decision making.

  5. Chinamonkey
    March 20, 2016 at 9:11 pm

    Thank you for this, I wrote my dissertation on the birthplace study and mlu’s for low risk but also touching on high risk women. Articles like this are fantastic. I’m currently 22/40 with my second child and classed as high risk due to BMI ( of which evidence is sketchy!) And currently “discussing” this with my consultant. I’m opting for home this time seen as I had a normal onset and delivery last time . . thanks again!

  6. Kelly
    March 31, 2016 at 11:15 am

    I would love to see more research on ‘higher risk’ home birth. I made the decision to have my second child at home despite being classed as ‘high risk’ due to 5 miscarriages after my first pregnancy (a live birth) and being on blood thinners until 34 weeks. The consultants at the recurrent miscarriage clinic were supportive of that decisions, aware that the risks in the pregnancy were during the antenatal period, not the labour. Unfortunately the consultants and midwives at my local hospital were not as supportive. However I went on to have a lovely normal home birth that is the happiest memory among a sea of hospital appointments and loss. I attribute much of my mental stability during the pregnancy to the control over the process that I was able to assert for myself. I’m in my final year as a student midwife now and hope I can advocate for women in similar situations to myself.

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