Birthplace study: Homebirth more risky for first timers

[whostolemyname]

www.npeu.ox.ac.uk/birthplace/results

www.dailymail.co.uk/health/article-2065928/First-time-mothers-opt-home-birth-face-triple-risk-death-brain-damage-child.html

Just wondering what people think to the findings of this report. Would it put you off homebirth as a first timer? It suggests a 0.93% risk of serious adverse neonatal outcome.

I'd want to know what the equivalent risk in hospital was.
I'd want to know whether unplanned/unexpected/unattended homebirths were included in that statistic.

I've had two home births but my first birth was in a hospital. To me it seems common sense that a first birth would be more risky and more likely to have complications that cannot be solved during a home birth.

I just heard this on Today. It's 4 out of 1000 having serious complications for the baby in hospital, and 9 out of 1000 at home. That's a very big increase in my view. It was only planned home births that were considered low risk.

Well I'd wait until the full report is published and read it before making any judgments on the findings. I certainly wouldn't rely on the DM for a sensible interpretation because their health journalism is generally dreadful.

From the numbers presented in the key findings it is 9.3 adverse perinatal outcome events in 1000 compared with 5.3 in 1000 in hospital, so neither option is risk free.

I was due a home birth with my first, but ended up with a c-section due to transverse lie.

This has the key findings.

It seems it is much more likely that with a first birth planned at home that there will be transfer to an obstetric unit during or after birth - 45% for planned home births and in a second or subsequent birth planned at home only 12%.

It also doesn't say what the statistics are for adverse perinatal outcomes for a second or subsequent baby and mother where it is a home birth - just that it "appears to be safe".

OK, so I've just read the BMJ paper and the conclusion is: 'Our results support a policy of offering healthy nulliparous and multiparous women with low risk pregnancies a choice of birth setting'

There is a difference, but it is relatively small and there are a number of caveats. As I suspected the DM headline is totally misleading.

Looks like a good study.

There was no significant differences between the outcomes at the three different types of unit and home birth for births that were not the first.

what no-one seems to have noticed is that one of the most crucial things about a good outcome with a home birth is how skilled and knowledgeable the midwife/midwives are with homebirths. The birth of ones first baby is often more stressful and drawn out than subsequent ones, speaking from experience here, and a good deal of knowledge and experience on the midwifes part is necessary, and these days often lacking. I'm not arguing either way for home or hospital for first time deliveries or criticising anyone, thats the way things have become with midwife shortages, skilled professionals having left the profession, emphasis on hospital births etc.

I had both my babies at home because that is what I wanted and was lucky that everything was progessing normally with pregnancy etc, and there was midwife support. I had one midwife with me all the time during labour and a second arrived just in time for the delivery and sorting out afterwards, which was very reassuring. There were complications during the birth of my first. It was slow to progress, I was inexperienced and scared by the amount of pain, and the midwife was concerned that the baby's heartbeat was dipping at each contraction, I only had gas and air which did help. Being at home we just had to get on with it without panicking, suddenly everything moved up a gear and dilation speeded up dramatically and my son was delivered quite quickly. He had the cord round his neck and needed some rescusitation with oxygen and rubbing with towels etc, which the midwives were very efficient at and he was fine. His apgar score went from really low to normal quite quickly. If I had been in hospital I would have been having to sign up for c sections, strapped to monitors, and goodness knows what other interventions and I would have been really stressed and panicking and who knows what the outcome would have been. I have heard some horror stories about hospital deliveries that have gone horribly wrong because of the lack of care and experience in hospital.
I can only speak from my own experience and know that the hospital v home debate is far from black and white.
Oops Im rambling again... sorry for such a long post......

Have they distinguished between planned and unplanned homebirths?

I agree re more experienced MWs at HBs - I had a very experienced (independent) MW at mine and she really knew her stuff I felt compared to the NHS ones I met at appointments who were bogged down by paperwork etc.

Also what do they mean by adverse outcomes? Death/injury? To the baby only?

More info on the BBC news website -

www.bbc.co.uk/news/health-15861280

www.bmj.com/press-releases/2011/11/24/women-pregnancy-low-risk-complications-can-safely-be-offered-choice-where-

So a team led by Professor Peter Brocklehurst from the University of Oxford for the Birthplace in England Collaborative Group set out to compare perinatal outcomes and interventions in labour by planned place of birth across all NHS trusts in England.

Planned place of birth included home, freestanding midwifery units, midwife-led units on a hospital site with obstetric services, and obstetric units.

Serious adverse outcomes included stillbirth after start of care in labour, early neonatal death, brain injury (encephalopathy), faeces in the lungs (meconium aspiration syndrome), and injuries to the upper arm or shoulder during birth.

A total of 64,538 single, full term infants born to women with low risk pregnancies were involved in the study. Factors, such as maternal age, ethnic group, body mass index and deprivation score were taken into account.

Overall, the rate of adverse outcomes was low in all birth settings (4.3 per 1,000 births) and there were no significant differences in the odds of an adverse outcome for any of the non-obstetric unit settings compared with obstetric units.

For women giving birth for the first time (nulliparous women), the risk of an adverse outcome was higher (9.3 per 1,000 births) for planned home births compared with obstetric units, but not for either midwifery unit settings. In contrast, for women who had given birth before (multiparous women), there were no significant differences in the rate of adverse outcomes between birth settings.

The results also show that interventions during labour, such as epidural, forceps delivery or caesarean section, were substantially lower in all non-obstetric unit settings. Transfers from non-obstetric unit settings were also much higher (up to 45%) for nulliparous women than for multiparous women (up to 13%).

That any clearer Iggly?

Isn't the transfer rate for first time home birthers something like 60%? How does that work in the statistics?

Thanks NICE

About 45% of women planning to have their first baby at home were transferred during labour, although this was mainly because of delays in giving birth and the need for an epidural pain-relief injection, rather than because the baby was in distress.

So when the report says "for planned home births" does that include those who transferred in from home but actually gave birth in hospital, or just those who birthed at home?

I transferred in from my first planned homebirth because it was going on for days and my heart-rate was rising and I was being sick and getting dehydrated. The resultant 'care' left me with PTSD and PND requiring in-patient treatment. My second child was born at home, where I had a big pph and was blue-lighted in to hospital, unconscious. I would choose a home-birth again every time, almost regardless of risk to the baby or my own physical health, because my experience and anecdotal evidence about NHS hospital obstetric care is that it couldn't be more destructive to women's mental health and ability to care for their babies if it were planned with that intention. The baby is not the only outcome of childbirth; it is also a process of making mothers. And mothers matter too.

I would like a home birth, but, looking at my family history I think that this one has to be in a hospital. If it goes well and we decide to have another baby, I'll definitely opt for a home birth as I have read that just going to the hospital inhibits the mother and makes labour even longer.

'PLANNED' methods include all outcomes from that plan. So if the outcome of a planned homebirth ends up with complication that need hospital attention they are included in the stats.

Equally, if a PLANNED hospital birth ends up with a woman giving birth in her bathroom, thats included in the stats for a planned hospital birth.

It is the planning aspect that is key, not the actual place of birth if that makes sense CrotchFlakes

(its similar to the planned VB versus planned CS debate - EMCS are included in planned VB stats as its about the plan not the outcome that you can not predict).

How does that fit with the National Birthday study saying just planninga HB reduces the likelihood of having a CS by 50%?

And when does the PLANNING become fixed - when home/hospital is checked at booking in, or later in pregnancy?

So if you planned at HB at 12 weeks, later on found there was an issue that changed your place of birth to hospital: where does that go in the statistics?

I 'think' would be the last agreed plan immediately before delivery commences. But don't quote me on that.

And where do IM stats fit in - are they taken into account? I know they are only a small %, but a positive small %

Haha no idea. The report is about the place of birth, not who is attending it. I doubt that would appear on any stats, especially on a study of this scale. (Its for 65000 live births).

The BBC News report says "All the women followed had healthy pregnancies and began labour with no known risk factors."

This report also says that planned HBs mean an EMCS is less likely - "The emergency Caesarean rate for the low-risk women in the study was 11% in doctor-led units compared with only 2.8% at home, and 4.4% in a midwife led unit on a hospital site."

This report is all about risk to the baby. Specifically, the risk to the baby (including stillbirth and serious trauma) of a first time mother having a home birth. "The rates of complications, including stillbirth or other problems affecting the baby, was 5.3 per 1,000 births in hospital compared with 9.3 per 1,000 home births."

The relative risk almost doubles for first time mothers homebirthing compared to those having a hospital birth. However, the absolute risk is still very low.

Am I right in thinking that home birth shows up as better for the baby and only .5% worse for the mum than a midwife centre birth. Hospitals still come out worse

I do wish that the Daily Fail had pointed out that the majority of transfers for first time mums are for labours which aren't progressing. IE - absolutely NOT emergency situations.