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.

Edless, I don't think I can be making my point clearly enough.

The HB can be going swimmingly. Mother, baby, MW all doing perfectly. Then there is a problem that requires immediate surgical intervention for the very best outcome. As it is a HB, there is no such surgical team nearby and even the fastest ambulance is a delay (assuming there is even a decent hospital within reach). A delay that could cost the mother and baby dearly for life.

You don't get to theatre instantly in a hospital though either. There has to be one free, plus a surgeon, anaesthetist and scrub nurses available. Then there is some prep involved. If you are blue lighted in from a HB they phone ahead and prep. I was told that if you live within 20-30mins of the hospital here you get into surgery as quickly as you do if you were in the hospital to start with.

Not to mention that the one-to-one monitoring means that problem are often picked up earlier.

Some people feel safer in hospital, some people feel safer at home. Ultimately the study shows that for 2nd and subsequent births there is no difference, and for first births there is very little difference.

Well, ImpYCelyn, I take your point but if you are on site there will be SOMEONE on site in hospital who knows more than a MW. There is more equipment, more staff, more people, more experience, more A&E staff who can help stabilise the situation immediately.

In an entire hospitals worth of doctors and consultants, there would be SOMEONE who could medically or surgically help a dying baby or labouring mother more than the single MW and perhaps the father, who are available at home.

Surgeons can perform life saving surgery in the most basic of amenities. No, they may not be scrubbed up, no they may not have the scrub nurses to hand. But YES they have more in depth medical knowledge than a MW.

i gave birth to all my babies at home, and it was most important for me 1st time round - i was vaguely tempted to go into hospital with the others but didn't see the point in the end.

i had to do plenty of explaining to overly concerned relatives about why being at home was the best and safest option for me. i discussed all the possible nightmare scenarios with my midwife on their behalf and was very happy with her explanations on how they would be dealt with at home. i also live round the corner from a good hospital which helps!

as much as i believe it is safer in any emergency situation (not just giving birth) to be in a hospital i was also convinced i would labour much better in my own home and give birth the way i wanted, which i did.

The situation that sleepyspaniel is describing is exactly what happened to me. It clearly isn't common, but the knowledge of the extended staff and the proximity of the theatre are the reason that I did not need serious medical attention and an extended stay in hospital post-birth.

(Love your name, Imp)

Surgeons will not perform a c section without being scrubbed in and without nurses - that would be their careers over.

A&E staff would not be anywhere near a delivery suite - the MWs are far, far better trained to be there than they are.

Hospitals are not full of drs with the relevant knowledge, they have however many are on shift, and if they are already busy then you will have to wait.

Many people I know were left by themselves with just their birth partner for hours on end. So there might theoretically be people in the hospital with that knowledge, but they are not necessarily in the room. By the time they realise something has gone wrong it is a very serious emergency, at a home birth the one-to-one means that they can spot these things sooner.

I'm not saying a home birth is better, but I do think it's naive to think that being in a hospital means you automatically get better care.

(Thank you Sarge ) Sorry to hear you had a nasty time of it, glad it all worked out!

it strikes me in order to get a sample group 0f 17k of home birthers you have to sample data from a much wider area than the 30k of clu attendees. so they would have had HB data only from some trusts, looking at the way the study was done.

previous studies have shown risk clustered on transfers-in. i think this study shows that too - second and subsequent - low transfer rate - same risk
first birth- high transfer rate - higher risk

to get 17000 home births you would need a great many more trusts to report than you would in order to get 30000 CLU births -therefore -

in a trust which has very busy staff - too busy to participate in a study - but the community MW service still participates - you would get HB data and not CLU data - this must have happened in many trusts in order to acquire a sample size of 17000. question: do these trusts have poorer outcomes than the trusts where both HB and CLU stats were reported?

hopefully someone may have access to stuff they can C&P on this...

I was left alone during labour, in a major London teaching hospital. Being 'in hospital' doesn't mean you will be safe. Being 'in hospital' doesn't mean there will actually be anyone there to spot that things are going wrong. I know damn well my experience is very far from unique - after the event the community midwives told me St Thomas's had a reputation for being 'lucky' because despite known short-staffing, they hadn't managed to kill anyone. (Unlike Queen's Romford, for instance.)

Fortunately for me and ds, the stuff that went wrong wasn't immediately life-threatening. Unpleasant and entirely avoidable, but sheer good luck it wasn't anything more urgent and dangerous for either of us.

this is so difficult... i read the guardian write up of the report and it looks sound scientifically. but the idea that home-birth on low-risk pregnancies is twice as likely to have a bad outcome makes me tense just reading it! it's hard to square with my immediate experience: i don't know anybody how had a bad home birth (first or otherwise, including me), but PLENTY of people who had a really shit birth experience in hospital.

the same report says that hospital births are far more likely to have escalating interventions and use of forceps etc. it makes it sound like: if everything at home goes well, it's a much better experience than in hospital. but in the small number of cases where something goes wrong, it has a worse outcome. that makes me very sad.

I thought it was interesting that the reporting where I am (in Canada) focused on the positive, with headlines like 'Home births safe for low-risk pregnancies', 'Women with low-risk pregnancies can give birth outside hospitals, 'Women with low-risk pregnancies can give birth outside hospitals' etc

It's just so depressing when papers like the Daily Mail cherry pick to find the most alarmist and anti-women slant they can find on anything.

EdlessAllanPoe you can get right into the data here www.sdo.nihr.ac.uk/projdetails.php?ref=08-1604-140 - you need to scroll down to the bottom of the page and then there are in fact six reports on different aspects of birth in different settings - no 4 is the one that is being given the press coverage (number 5 is about cost, 6 is about experience of transfer)

This is what they said about response rates:
'There was a high level of participation from all unit types: 97% of trusts providing home birth services, 95% of FMUs and 84% of AMUs. Five of the original sample of 37 OUs had to be replaced by resampling; 36 OUs participated.
74% of participating units/trusts achieved a response rate of 85% or more.'

Generally speaking for this sort of research that is an very good participation and response rate.

OU = obstetric units
FMU = Freestanding Midwifery Units
AMU = Alongside Midwifery Units

I haven't see the report but wonder if episiotomy rates are mentioned?

Blanche - 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.

How selfish and irresponsible you sound.

Sleepyspaniel - sorry, I had gone to bed! I hope you don't think I'm being rude, but I'm going to copy and paste your post since the thread has moved on a bit to make it clear what I'm responding to

"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."

What you have said makes total logical sense. It should logically be the case that, all other things being equal, if a sudden and severe problem happens in labour, being near immediate surgical intervention gave the best outcome for mother and baby.

And there will, of course, be people whose personal experience is,very sadly, that their baby suffered problems resulting from home birth. I don't want to talk about particular people, because I think that could be upsetting, but remember that this is focusing on those who are low risk. On the reverse, I have seen another MNer tell a story of her child suffering problems because she was left alone during labour in a major hospital and she believed that being in hospital had caused her child's problems.

The point I was making is that the stats don't seem to bear out the (again, totally logical) expectation that, if you are the 1 in a 1,000 (or whatever) for whom something goes seriously wrong, you are better of in a CLU. The stats in this study are showing that, for multiparous women, home births and consultant led units are experiencing the same numbers of deaths/other similarly serious outcomes. To put it really bluntly, being near all those facilities for the whole labour does not appear to be saving baby's lives

So what's happening? I don't know. Maybe the 'sudden' events aren't so sudden if you have a midwife paying attention to you? Maybe the cautious nature of home birth midwives mean that transfer is recommended on minor issues (such as concerns about minor issues with heart rate) so that by the time the sudden major problem manifests itself, those women are at the hospital. Maybe if CLU's were properly staffed and women had the levels of attention they can expect in homebirth, we would see a spike in the safety of a birth in a CLU. Maybe it's all those things plus others, maybe it's none of them. We need more research.

canttakeanymore it saddens me that you think it's selfish and irresponsible, as Blanche makes a valid point. Fact is, the chances of something happening to your baby are very small in either settling, but the chances of the mother having a difficult/frightening time and intervention are much higher in a hospital birth. The better the mother feels after labour, physically and mentally, the better, surely?

The interesting thing about the argument that it's safer to be in hospital if something goes wrong, is that the figures in this study suggest that it's actually slightly safer to be in a midwife run unit (without all those specialist surgeons etc).

As much as the safety of the baby concerns me, I also think that the environment a woman gives birth in isn't irrelevant. She needs to feel safe and as comfortable as possible. Some woman like to know that the highest level of emergency care is available to feel safe. Others women feel safer, more relaxed in a less clinical environment with specialists in childbirth as a natural process rather than a medical emergency. They don't want more interventions than are necessary during childbirth and want to feel comfortable afterward in order to nurse.

I just hope I'll have these choices when the time comes. (TTC at present) I'm worried that I wouldn't be considered low risk. I know losing more weight, and getting fitter would improve the outcomes, but there isn't much I can do about other things.

I haven't read while thread but as someone who's first son was severely brain damaged following a homebirth, I wish this study had come out 3 years ago instead of everyone telling me it was safe. I have to live with that decision for the rest of my life and knowing this now just makes it even worse.

secondtimelucky- even though they are called 'consultant led units' there arent actually consultants there 24/7. If you are giving birth at the weekend/overnight and have serious complications they will have to calle the consultant in (from his bed) which could take 1/2 hour+.

chocabloc- you can get an iv drip and drugs at home, they practically bring a whole hospital to your house, forceps, neo natal resusitation equipment and oxygen, the lot. They just dont do epidurals, inductions or c sections.

Of course more importantly my son also has to live with the consequences for the rest of his life. How can I explain to him when he grows up that his disability is all down to my f-cling stupid decision.

badkitty- I'm sorry to hear that. But are you sure that the hb caused the complication? My DD ended up in NICU after a hb but I dont regret the decision. It could have happened in either place of birth and hospital birth does not guarantee good outcomes.

But do you think parents who choose to give birth in hospital, who suffer serious complications and whose child ends up damaged in some way are to blame for their decision to give birth there? Even if it's likely the same cascade of interventions or whatever caused it would have been less likely at home? I don't think so and I don't think for a second you are to blame for your son's disability either, though of course you will feel guilt, it's human nature. When there's nobody to blame we blame ourselves. But sometimes awful and terrible things just happen. We can only make the best decision with the information we have at the time. I'm sorry to hear about your son.

Spiritedwolf: its important to take into account where these midwife-led centres are too: the one I plan to give birth in is nextdoor to the consultant-led unit. In this circumstance obviously the consultant-led unit has poorer outcomes: its a 20 second transfer time and you can only go in the midwife-led bit if you are low risk, happy to do without an epidural etc. So the low-intervention area is reserved for the safest of births and there is a relaxed environment and so on.

But if anything goes wrong the limiting time is purely how long it takes to get a surgeon scrubbed up, and there is a CPR team on site.

"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."

Just wondering, what would a dead or severely disabled baby do to your mental health?

(I'm not arguing against homebirth in low risk women who've made an informed choice, but the line of argument above doesn't make sense to me)