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.

Headlines like this increase fear of terrible things happening if you step outside the NHS expected norm for pg. It is about assessing the risks for yourself - statements like double the risk are often bandied about in relation to pg and birth but double may be 2 in a million instead of 1 in a million. It is all relative and open to (mis)interpretation.

I had my first baby at home, against all advice not to. We had a wonderful time. I did have an accomplished independant midwife and had fully prepared myself for birth though, which I think make a massive difference to the birth experience.

There were more adverse outcomes in hospitals than midwife-led centres - 5.3 per 1000 in hospital compared to 4.5 in birth centres. Yet I bet no-one is going to go around saying, ooh, you don't want to have your baby in hospital, it's terribly dangerous you know... (it seems these were low-risk pregancies, so it's not a simple explanation of hospitals dealing with the more complicated cases).

I was just writing a post about the Daily Fail reporting on this when computer crashed

Anyway!

Their headline and subheadline on this says:
First-time mothers who opt for home birth face triple the risk of death or brain damage in child
Half of women who chose home births had to be transferred to hospitals due to complications

Shagmundfreud has just pointed out the stuff with the 45% figure being misleading.

Their quote from President of RCOG is extremely negative and makes it appear as if the RCOG are anti-homebirth:
Dr Tony Falconer, president of the Royal College of Obstetricians and Gynaecologists, said: ?This study has shown that first-time mothers wishing to deliver at home have an increased risk for their babies, thus raising questions about the right birth location for this group of women.

?In addition, having to transfer 36 per cent of mothers from a free-standing midwifery unit to obstetric units raises many issues.?

THIS is the full statement from RCOG HERE

First point the RCOG concluded about the study:
It found that for women with no complications in pregnancy, childbirth is generally very safe. The outcome for mothers was good in all birth locations. In 250 births however, the baby had a poor outcome (4.3 events per 1000 births) across the four birth locations.

To point out, thats 250 babies in ALL locations out of 64,500 births.

And the actual quote from Dr Tony Falconer?:
?The RCOG has always supported appropriately selected home birth but this study has shown that first-time mothers wishing to deliver at home have an increased risk of poor outcomes for their babies thus raising questions about the right birth location for this group of women. In addition, the high transfer rates from FMU and AMUs for first-time mothers pose serious logistical problems. The potential of having to transfer 36% of mothers from FMU to obstetric units raises many issues. In contrast, the close proximity of AMUs provides easier transfer thereby reducing stress and anxiety.

?The case is different for mothers with no complications in their subsequent pregnancies delivering at home or in a midwifery unit. There is therefore a need to expand these facilities with appropriate midwifery staffing to improve women?s choices.

?Following from our High Quality Women?s Health Care report, we recommend that services should be provided in managed clinical networks which link primary, community, secondary and tertiary services. This study supports the concept of configuring maternity services differently and the expansion of midwifery units should occur.

?Within an obstetric unit, care is provided in a multidisciplinary, multi-professional manner, involving midwives and specialist doctors. Midwifery and obstetric units both work to standard clinical guidelines and medical help is provided only when indicated. This study identified the need for further work on the adverse outcomes of home birth for first-time mothers and to examine why intervention rates are higher in obstetric units. The RCOG agrees that better information systems in maternity, through the implementation of the national maternity data set would be beneficial for delivering higher quality care.

?In order for our maternity services to work better, there is the need to concentrate obstetric care for the expanding numbers of complex pregnancies and also for the women bring transferred from other birth locations. These units should provide continuous senior medical staff presence on the labour ward, achieved by expanding the numbers of consultants in O&G.?

Certainly not as anti-homebirth or anti-midwife unit as the Daily Fail would have you believe...

Is that 9.3 per 1000 homebirths or per 1000 of all births?
If it is per 1000 homebirths then 9.3 is around 175 of all births IYSWIM.

Guardian article on same story

www.guardian.co.uk/lifeandstyle/2011/nov/25/low-risk-pregnancies-birth-choices

Noting this paragraph:
The slightly worse outcomes at home for first-timers are unexplained. "I don't know why. We don't know which aspects of the care or the site contributed to this," said Brocklehurst. It could be to do with the sort of women who chose home birth, who tended to be white, slightly older, better educated and live in more affluent areas, the midwife's experience, problems in transferring to hospital in an emergency or something else entirely. More work would be needed to establish what was happening.

gallicgirl:

For women having a first baby, a planned home birth increases the risk for the baby
For nulliparous women, there were 9.3 adverse perinatal outcome events per 1000 planned home births compared with 5.3 per 1000 births for births planned in obstetric units, and this finding was statistically significant.

Cheers. So it's still a slightly worse outcome per 1000 but absolute numbers are less.

Weird, isn't it? I was going to suggest it's a question of preparation but homebirthers are likely to be more prepared.

Attitudes in the Netherlands are completely different to here: my first pregnancy was there and the doctor nearly fell over because I went straight to her. She said "what's wrong? Are you ill? Do you want an abortion?"
When I explained that going to the GP would be routine in the UK, she was intrigued. And then sent me off to a midwife practice, like everyone else.
I ended up moving to the UK in month 6 or so, and was told by everyone that it was insane to have a first birth at home. I was quoted this stat and that stat. All totally at odds with the Dutch stats. My experience was that there was a kind of masonic attitude in the UK, owned by the NHS, doctors, whoever: a sort of reluctance to let go and let people be what the Dutch call 'boss of your own belly'.
Then I met someone, a chiropractor, who was an advocate of home birth, very wary of the 'cascade of interventions' that hospitals tend to bring on, and who recommended a practice (Thames Valley Midwives) and I was away - only, massive downside, I had to pay through the nose for it. The baby was presenting breach in the final days and she dealt with it, the whole process of birthing in a pool, at home, was calm, professional, perfect - I ended up moving back to NL and had my next two babies just as easily, also at home. Unless there was a genuine physical reason not to try it, I have to say - in the face of all critics - I'd recommend it every time.

I might add, as a PS, that I've only ever found hostile attitudes to this in the UK (have got into several rows, especially, oddly, with men, about how irresponsible it is to try and have a baby at home), where there are many experts and, perhaps, less trust in what our bodies are really able to do for themselves. I imagine this has got a lot worse with Health and Safety. I thought things wre getting better, but this DM article is depressing. In the UK we could look to reforming birthing practice and taking it out of the hospital completely - in the Netherlands, you even get a subsidised 'cradle-nurse' coming to help out at home for a few weeks after the birth.

Long post - phew. Hope the birth is quicker.

A problem is that people read or hear the word 'risk' and think it means 'risky' as in dangerous. Risk is just a way of callibrating and presenting information. There are risks associated with everything, including

Driving to hospital
Driving in bad weather
Being pregnant in the first place

And so on.

I wish people had a better understanding of risk and specifically conditional probability, and also the need to assess risk with regard to the individual since all women and babies and labours and births are different.

I had my first at home and it was fantastic. Obviously, I was very lucky in that there were no complications and it progressed normally but I would recommend it totally.
I think if I had been in hospital I would have ended up with interventions because I would have been more frightened. It would have been a huge change in the middle of labour and I think I'd have thought more about what was going to happen IYSWIM?

The attitudes towards homebirth in the UK are astonishing, I'm currently pg with dc2 and have moved counties, I'm already battling to be "allowed" a homebirth.

I wonder what the statistics are for safety in second births at home if you've already had a birth at home and if they're any different?

tsunami - your experience of maternity care in Holland sounds wonderful. We clearly have a lot to learn and improve on in the UK with our maternity services.

It's refreshing to at least see some fairly extensive research into maternity services/birth locations and it certainly isn't as straight forward as the figures may suggest (as demonstrated by all the questions raised on here!). Personally hope it will trigger more investigation and focus on how best to combine obstetric and midwife knowledge to provide the best maternity care for mother and baby.

What will be interesting is to see how the medical profession reacts, whether consultants will start quoting the stats if they want to prevent a women from having a home birth? Strikes me there is still more research to be done to use the stats in a meaningful way.

I'd also love to see the stats split out by region/healthcare trust.

MushroomMagee My understanding from this study is that for 'low risk women' second (and subsequent) births are as safe (if not safer) as births in an CLU or MLU.

To answer the OP's question anyway - no, this wouldn't have put me off planning a homebirth for DD.

I'd be more happy about the Dutch model, if they didn't have one of the highest rates of neo-natal mortality in Europe. I'm not against HB, but the Dutch model does seem to have its own flaws which should be pointed out if you are going to talk about how great it is compared to the NHS. The NHS has different flaws.

There is definitely a good case for expanding HB take up from this though, but caution should be exercised for 1st time mums.

On balance, if you were going on the evidence in the study, as a low risk woman, it does suggest you should perhaps try and go for a hospital midwife led unit attached to an obstetric unit for your first birth, and then a HB for your subsequent ones.

Here in Bude, Cornwall we have super, very experienced Midwives. The nearest hospital is a minimum of 40 mins away, homebirth is very popular and most of us have had an Ikea shower curtain packed away just in case we decide on the day to have it at home.

The midwives are experienced enough to make it all seem very casual, but clearly make a professional call between those that should be in hospital and those that would be all right at home if it goes that way on the night.

I'm guessing it's very different if you're only 20 mins from the maternity unit.

3 out of 6 of us that I can think of had our first at home rising to 5 for the second.

I have heard this news described in several different ways today.

I understand it as there is slightly increased risk of a negative outcome in first home births.

There is no increase in subsequent births.

Midwife led units do very well.

Hospita births for 2nd etc births seem to be more risky than unit or home births.

Does this mean that people will stop calling me selfish for having homebirths for 4&5?

As if...

MrsDevere They'll probably tell you that not only are you selfish but that it costs more to have a homebirth because you are not using the facilities already there, and have two MWs to yourself, but on one of the pages of the full report, it confirms that HBs are significantly cheaper and actually the more you have, the less your care costs the NHS.

i had a planned home birth- first child. Read all the stats and lots of books. Made an informed decision and had to see consultant who then tried to scare with with what she had to say. I stood my ground and she said she had to tell all that to me (regulations) and as i was a very fit, healthy young woman , with an uncomplicated pregnancy etc she saw no reason why i shouldn't go ahead. I needed an extra scan to check placenta wasn't lying low. Had a safe natural labour/ delivery, no pain killers, just my bath and hubby to rub my back as the baby was lying against my spine. Wonderful, just felt so right to be safe at home. This was 20 years ago! Funnily enough if i had one now at my age i'd go for a planned c-section. I think it is so important to do what feels right for you after taking into account the particular risks of your pregnancy . oh i should add we lived about 5-10 minutes by ambulance from local maternity unit and that did add reassurance when making my decision.

oh should have said, mother and baby were absolutely fine!

I fancied home birth with my first but found out the hospital had a birth pool and fancied using that. Despite induction and 20 minutes of monitoring I was allowed to use the pool and had a very positive experience. I moved house before my next child was born and argued with the hospital to be allowed to take in a birth pool as I could not imagine being without it in labour. Obs refused this request and head of midwifery recommended home birth. Had magical home birth. Its good to see this study which gives an idea of the relative risks involved. Distance from hospital should be taken into account when deciding on what place of birth mothers are comfortable with. It is an emotive subject but I would not discourage a first time mother from trying for a homebirth on the basis of this report, it's her decision.

Full Report HERE for all the nerds like me.

Couple of interesting points I noticed:

Compared with the obstetric unit group, women planning to give birth at home were more likely to be older, white, have a fluent understanding of English, and live in a more socioeconomically advantaged area. The characteristics of women in the freestanding midwifery unit and alongside midwifery unit groups tended to fall between the obstetric unit and home birth groups, with women in the alongside midwifery unit group generally more similar to the obstetric unit group. The biggest difference between the groups was for parity: 27% of the planned home birth women were nulliparous compared with 46% of the freestanding midwifery unit women, 50% of the alongside midwifery unit women, and 54% of the obstetric unit women.

There were marked differences between planned places of birth in the proportion of women with complicating conditions identified by the attending midwife at the start of care in labour. Almost 20% of women in the obstetric unit group had at least one complicating condition noted at the start of care in labour, compared with ≤7% in each of the other settings. This finding was unexpected and suggested that the risk profile of the ?low risk women? varied between the different groups. Before the analysis of the outcomes, the co-investigators and independent advisory group agreed to modify the analysis plan to include additional analyses of outcomes restricted to women without complicating conditions at the start of care in labour.
The figures being quoted on this thread seem to be the raw figures before adjusting for the above. There is a table in the document which shows the difference.

There were 250 primary outcome events and an overall weighted incidence of 4.3 per 1000 births (95% confidence interval 3.3 to 5.5). Intrapartum stillbirths and early neonatal deaths accounted for 13% of events, neonatal encephalopathy for 46%, meconium aspiration syndrome for 30%, brachial plexus injury for 8%, and fractured humerus or clavicle for 4%.

Most individual perinatal outcomes were rare, and adjusted odds ratios could not be estimated because of the small numbers of events. Babies were significantly more likely to be breast fed at least once for planned births at home and at freestanding midwifery units compared with planned obstetric unit births.

The proportion of women with a ?normal birth? (birth without induction of labour, epidural or spinal analgesia, general anaesthesia, forceps or ventouse delivery, caesarean section, or episiotomy) varied from 58% for planned obstetric unit births to 76% in alongside midwifery units, 83% in freestanding midwifery units, and 88% for planned home births; the adjusted odds of having a ?normal birth? were significantly higher in all three non-obstetric unit settings. For other maternal outcomes (third or fourth degree perineal trauma, maternal blood transfusion, and maternal admission to higher level care), there was no consistent relation with planned place of birth, although these adverse outcomes were generally lowest for planned births in freestanding midwifery units

The weaknesses of the study include the use of a composite primary outcome measure, because of the low event rates for individual perinatal outcomes. We cannot rule out the possibility that the use of a composite may have concealed important differences in outcomes between planned places of birth, such as less severe outcomes in a particular setting. However, examination of the distribution of outcomes by planned place of birth did not suggest that this was the case. In addition, although many of the outcomes included in the composite are likely to reflect problems which occur during labour and birth, their long term implications for the baby are uncertain. For example, although moderate and severe neonatal encephalopathy are associated with development of cerebral palsy and long term morbidity, mild encephalopathy has not been associated with detectable longer term impacts.

I attempted a home birth with my first baby last July. I had to transfer because the midwife broke my waters at 7cm thinking it would speed everything up, but instead I stopped dilating. What she didn't tell me was that from the moment she broke the waters, I would have 24 hours to deliver naturally before I would be bussed in for a c-section. If she had told me this I would never have let her break them. So, my attempted homebirth will count as one of the failed 'emergency' cases, even though it was caused by an intervention that I would never have allowed if I had been more experienced or if I'd had the full information.