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.

Great posts nap and mushroom. it saddens me that it's been reported by the DM in such a negative way, as I worry that it will put people off and prevent them from potentially having a wonderful homebirth. My gut feeling is that because only 3% (?) of all births are homebirths, there will be a massive bias caused by the women choosing to try for a homebirth ie there are too few homebirths in the study to draw any real conclusions. I had a wonderful homebirth with my DD (admittedly with an IM) and would choose it every time, even if this study had been available before I gave birth.

nice, the data I've seen suggested Dutch neo natal mortality is approx the same as the UK, are you sure it's one of the highest in Europe?

I had a great home birth, I'm not sure whether seeing these statistics might have put me off. Possibly, as I see doubling the very small risk as significant enough to be concerned about.

PinkFondantFancy - in terms of the number of homebirths used in the study, this is what they looked at. Homebirths were not 3% of the sample:

Participating units or trusts collected data for varying periods within the study period of 1 April 2008 to 30 April 2010. The target sample size was at least 57 000 women overall: 17 000 planned home births, 5000 planned alongside midwifery unit births, 5000 planned freestanding midwifery unit births, and 30 000 planned obstetric unit births (of which we estimated 20 000 would be low risk). Sample size calculations are provided in the study protocol.

Try again:

Participating units or trusts collected data for varying periods within the study period of 1 April 2008 to 30 April 2010. The target sample size was at least 57000 women overall: 17000 planned home births, 5000 planned alongside midwifery unit births, 5000 planned freestanding midwifery unit births, and 30000 planned obstetric unit births (of which we estimated 20000 would be low risk). Sample size calculations are provided in the study protocol

Talk about scare mongering!!! Wow.....

Oh ok, thanks NICE. I still think that more work is needed to understand the reason for differences between the outcomes in MW led units and homebirths. I suspect it's because the characteristics of the populations of women in each category are different but of course we won't know whether that's the case unless further research is done. My view of the report would be that seeing the risk double is frightening, but it's still a very small risk. However, it's good to see an up to date study with some stats-there was nothing up to date for me to look at when I was wrestling with whether or not to go for a HB.

TSC I don't think Don did say that, did she? She said that being well prepared helped her birth go smoothly. Nothing about whether being in hospital prevents women from being prepared.

I planned a home birth with my first and ended up transferring in. I knew this was likely and it was an informed choice when it came down to it. I'm happy with how things went in the end, and there were no complications - I transferred in because I was exhausted, which, along with wanting more pain relief, is the reason for 90% of transfers in first births IIRC. A very small number transfer because of complications, and even if complications do occur, often you don't get treated any slower because the anaesthetists and surgeons aren't waiting on hand at the hospital either, it can still take a while for them to become free to do the emergency c-section or whatever is needed.

I would support more midwife led units, though. There isn't the option of one here and I'd love it as an option. For that reason I'd go for a home birth but be willing to transfer in if necessary.

DP isn't keen (though babies are a long way off!) and was quoting this study at me this morning. It's irrelevant to me anyway as I've had DS. But I agree it always seems to be men who object I had a friend of XP's tell me when I was pregnant "If my girlfriend wanted a home birth I wouldn't let her." err okay then!

I wouldn't worry too much about people who take the Daily Mail to be a reliable source of scientific research. If there are any, they probably wouldn't be considering home birth anyway.

The point, for me, is that the baby's physical safety may be the primary concern during childbirth, but it isn't the only one. And if you take the mother's mental health and emotional well-being seriously, that interest may off-set the slightly increased risk to the baby. It did, and still would, for me.

The OP has quoted the risk of adverse neonatal outcome for home birth but actually in comparsion to a hospital birth there is only a 0.4% increased chance of adverse outcomes when having a home birth. That's 4 per 1000 births.

interesting. the methodology seems very different to that the National Birthday Trust which found no such association - the sample sizes here are much much larger which should give greater certainty.

babies booked in for hospital birth that were born before arrival were disincluded. hopefully babies for Home birth born without a MW turning up/ or with paramedic in attendance shouldn't be included either, therefore..but it doesn't note this.

National birthday trust methodology involved 'pairing' low risk women with similar ones that gave birth in hospital. sample sizes 5ooo and i think 4500 in each group.

this study has much larger sample sizes though a less controlled reporting method- 17000 HB vs 30000 CLU vs 5000 MLU vs 5000 AMU - 27% of the HB group were first timers so (ummm) 4590 and therefore - at 9.3 per 1000 42.687 actual adverse outcomes in that group. so not great considered the same clu (based on their findings) would be 5.3 or 24.3 actual adverse events. certainly statistically significant - but why not picked up in the earlier study?

1. has practice at home changed? (i'd never heard of ARM being done at home!)
2. is this due to change in the profile of first time home birthers (that slight age increase?)
   3)is this actually due to a data-reporting slant not considered in either/both studies (i'll admit i've been looking at the study precis to de-snag it, but it isn't detailed enough)

the skill set of the reporting midwife is different also - in a HB it would always be an experienced MW. might lower-end adverse outcomes be missed by lower skilled reporters? certainly my experience of HB was that the MWs had plenty of time to observe me & baby and finish paperwork - whereas in a busy CLU they could be going straight to another birth (reported experience of friends, so anecdotal).

some problems i note are that responses were not 100% and some obstetric locations were excluded for poor response rate. might one hazard that a CLU too busy to reply may also not have the best outcomes?

What I don't quite understand on the 'first time mums' thing is this.

We know that approx 45% will have transferred in. Most of those will have transferred in in a routine way for pain relief/exhaustion.

So, because this is based around planned place of birth, this means that the 'homebirth' population actually includes quite a few women who effectively ended up with a birth in a consultant led unit. I would like to know whether the increased adverse outcomes are either (i) clustered amongst the women who actually stayed at home or had an emergency transfer; or (ii) spread amongst the whole of the group.

If it's the former, the transfers may be masking a higher risk. If it's the latter, is it correlation rather than causation? Some other factor about those who choose a home birth?

I think another thing to consider is that it's harder to tell if a first time mum is high risk. You can take certain factors into account, but birth history is an important one, and first time mums don't have any - so it's not that their births are riskier per se but that it's harder to calculate the risk. As I understand it, anyway.

What is AMU, Edless?

It's Alongside Midwife Unit - the on site ones as opposed to stand alone where transfer needs an ambulance.

Ah okay, thanks :)

As far as I am concerned, the question of comparing home or hospital births is very simple.

if there is sudden and severe difficulty during labour, would I rather be a) stuck at home with midwifes or b) in a hospital with a variety of anaesthetists, consultants, surgeons and a crash team to hand?

for the record, the answer is b).

That's all I need to know, stats or no stats.

Blanche you say "I would choose a home-birth again every time, almost regardless of risk to the baby or my own physical health"

I totally disagree - and how can you say regardless of risk to baby or your own physical health???!.Unbelieveable!!

I had my dd in hospital 7 months ago and the midwives were really lovely and the whole experience did not traumatise me in the least!!! I was induced due to waters breaking and no contractions starting (also was overdue). I also would not have had the pain relief options if I had givem birth at home (I had an epidural and it was the best thing ever - took away virtually all the pain and didn't make it any more difficult to push). Like you I also had a post partum haemorrage but I didn't go unconscious or need a blood transfusion as they fixed me to a drip which gave me a drug to help the bleeding stop. This would not have been possible in a home birth.

I don't disagree with home births especially if a woman has already had an uncomplicated first labour and she is aware of the risks - but although I admit there are problems with some hospitals I still think it is safer to give birth in one.

sleepyspaniel - and you are entitled to that view and absolutely entitled to make that choice. I would defend to the last every woman's right to a CLU birth if she wants one. But the stats in this study say that you are no more likely to have a serious adverse outcome (assuming it's not a first birth) in either setting, so perhaps there are also other factors at play except just proximity...like the possibility that the close one to one attention of a midwife more than compensates for journey time because you don't get left on your own for hours whilst issues become severe.

I thought the statistics on this study said that it was safer for second babies to be born outside of hospital? So do what you feel most comfortable with. I'm more scared of hospitals myself but if the hospital is well staffed with caring midwives the experience is likely to be positive. Some hospitals are better than others.

I can only say what my experience was- I fought for a home birth with my first as I was a convinced it was right for me. Luckily I had a young midwife who was inspired by my example. She attended me on the day along with a more experienced midwife. Birth was long 24 hours but because they saw I was coping there was no question of me going into hospital. Later my midwife said that watching me had totally changed her ideas about childbirth- about what it was like to let a woman get on with it and labour in her own time, rather than watching the clock. I was so proud that my son came in his own time, he was never distressed and was so pink and healthy when born.

Secondtimelucky - I am making the point that no matter how good the care we receive be it one-to-one MW or consultant or whatever -

ultimately NO-ONE can predict if they will suddenly experience a severe problem during labour

Yes I know it's rare...

but I still don't want to be that 1 in 1,000 or even 1 in 10,000 who experiences a severe and unexpected problem during labour that even the best MW with the best training and experience in the world can do nothing about, because it requires immediate surgical intervention for myself and the baby to survive or to survive without major birth injuries.

I just don't want to be too far from an operating theatre, crash team, consultant paeds, resusitation unit. etc etc. About 20 metres and 20 seconds away is good. 20 miles and 20 mins drive is not good.

HB cannot and do not have the capacity to deal with the rare and unexpected problem. Unfortunately, nobody can predict accurately who or when the rare and unexpected problems will strike. It could be me. It might not be me, but it definitely IS the woman I read about in the paper last month, or even the MNetter I know of whose baby sadly suffered severe birth injuries in HB gone wrong. I'm sure they didn't expect to be the one with the problem either.

sleepy i suspect that the 9.3 per 1000 of adverse outcomes will be happening in a hospital, or most of them (this is what previous studies have shown, though they haven't shown an increase in total adverse outcomes, and it isn't noted so far as i saw in this study) ...which raises the question of why transfers are getting a worse deal than women who started their labour in the CLU...

sleepyspaniel you are much more likely to get cascades of intervention in hospitals. Interfering in essentially a natural process is a bad idea.The babies who have died from a hospital infection may have been safer at home. Everything in life involves risk. Choose what risks you are prepared to accept. Hospital births go wrong. Home births go wrong.BUT remember, birth is pretty safe in Britain and choosing home birth is a valid choice.

I haven't read the rest of this thread, but my experience makes me glad I was in a big hospital.

I live around a 45 minute drive from the nearest hospital, if there's no traffic. So I assume that'd be upward of 30 minutes even with blue lights flashing.

During labour with DS I suffered a punctured lung with pushing. This was diagnosed by a doctor as the midwives didn't know what had happened. In fact, the midwife sister suggested I should be given some antihistamines and told to carry on.

If I hadn't been in hospital where there was a second opinion available and if I had been encouraged to keep pushing my lung could have collapsed which, obviously, would have been a pretty negative outcome.

(DS was born with forceps and was perfect - I recovered fairly quickly but have been 'strongly advised' to have a csection should I have any more).

I'm not suggesting that other people should go into hospital, but it was definitely the right thing for me and DS.