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.

Secondtimelucky that doesn't quite seem to add up, if you look at first time mums giving birth at home. You would expect to see the same patterns for nulliparous women AND multiparous women, across the board. The fact that HB first time mothers really stick out and don't fit in with a similar pattern of all the other figures, says to me, that its not about one to one care, its about something else....

nooka, I had a look at those parts of the report you linked to. WOW. Section 3 is just FULL of really interesting examples. They took case studies for 4 different types of Trust: Seaview, Shire, Inner City and Hillside. Select comments below. Apologies about the length but this is utterly fascinating:

Not paying attention to patient experience has been found to be a safety hazard in its own right

One woman with severe Symphysis Pubis Dysfunction was booked for an elective caesarean section because the Trust could not guarantee her the necessary opportunity to labour and birth in water to aid her mobility.

In City some staff viewed the clientele as challenging in terms of level of risk and the choices that women made (seeking interventions as well as wishing to avoid them), but argued that medical complexity was the real challenge faced by the Trust.

At Shire Trust, in contrast, obstetricians saw the characteristics of the population itself ? being rural ? as contributing to the high out-of-hospital and normal birth rates. One obstetrician, for example, described the local women as being resilient and having more knowledge and experience of natural processes than women elsewhere.

In Seaview, a small number of community midwives operated an informal caseload midwifery approach, but this was concentrated in more affluent areas, which indicated inequity of access to local services

At City Trust, whether women received full information about choice of birth setting, or were able to enter a caseloading practice with one-to-one care, depended to some extent on "luck" ? being in a relevant area ? but also on their knowledge of how to play the system. Although this Trust had caseload practices that were specifically set up to provide care in the more deprived neighbourhoods the Trust served, midwives felt that some women were quicker to gain access to this popular form of care

However, teenage mothers were particularly susceptible to a lack of information to make decisions about place of birth and other options within the maternity system. This was not offered evenly across the board, and it seemed that for some, "luck" determined whether they received the necessary support:
"I... I wasn't given any, I wasn't made aware of my options and choices until my aunt said to me, "you don't... you can refuse any medical intervention." I wouldn't have known that if she hadn't have told me."

They [the midwives] say it's difficult [working with women who don't speak English] because you're talking to them but you don't know if they understand. You're not necessarily getting informed consent. Working with women who don't speak English takes a lot of time

Groups in community settings such as children's centres enabled women to learn of possibilities for choice. Women heard about each other's experiences and realised that some were being privileged and others excluded. For example, one woman living in a low-income area heard about the option of a home birth at an antenatal group meeting quite late in her pregnancy. Only then did she realise that her midwife had presumed she would be giving birth in hospital and had not suggested other options

Making informed decisions was more viable for women accustomed to using the internet and other channels to keep up to date with research and guidelines relevant to their care. Seaview staff often found themselves dealing with women who had done their homework and were able to challenge their recommendations

I really could post a hell of a lot more. Very very interesting and I really would encourage people to read section 3 (Its not that hard going either as its examples and quotes). It reveals a hell of a lot, that stats don't....

Statistics do not make any difference to my decision. I'm a first timer, due in 5 weeks and from the onset of my pregnancy being confirmed I chose hospital over home birth. My mum had both myself and my brother at home (unplanned) without complications, but there are a lot of factors to consider when making the decision and every decision is unique to that person.

As I have mentioned before in other threads, I feel better in myself knowing I am going into hospital. I live in a village and my nearest main hospital is York - 40 minutes drive away. There is a midwife led unit 20 minutes away in the opposite direction to York. I chose York because they offered everything - pain relief, assisted delivery, c-sections and a neonatal unit - that the midwife led unit cannot. I do not know how I am going to cope, if there are going to be complications etc, etc so knowing I had everything in the same building was reassuring. If I chose the midwife led unit, I would be transported another 40 minutes to a different hospital (an hour from home) in a different county if complications became apparent. I didn't want that. Some complications can take only minutes to prove fatal or to be serious to mother and baby and at least at York, it is a corridor away to be given the right treatment instead of an ambulance journey (which I may have had to wait for at the midwife led unit).

Not all midwife led units are set up in the same way as my nearest. Some are based only across the corridor from consultant led units and when making a decision to have a home, midwife led unit or hospital delivery depends on the circumstances of the mother and the location and services.

Statistics are an overall picture. But those figures can be different for each NHS authority depending on the location of hospitals in relation to mothers' homes. I dare say that home births can become riskier for those living far away from medical expertise in the sense that it is NOT the fact that giving birth in the home is riskier, it is more to do with how quickly assistance can be given depending on your location to the hospital - therefore making it look like home births in some areas are more problematic than others.

I suppose had I lived in a city, 10 minutes from my nearest main hospital, a home birth wouldn't be as scary as it is for me at the moment.

As it turns out, I have to have a hospital birth anyhow due to a couple of issues with my pregnancy. One of which was detected at my insistence and had it not, may have proved catastrophic.

Mum2be79 Good luck for your birth - I had both of mine in York and think they're great.

"if you look at first time mums giving birth at home. You would expect to see the same patterns for nulliparous women AND multiparous women, across the board. The fact that HB first time mothers really stick out and don't fit in with a similar pattern of all the other figures, says to me, that its not about one to one care, its about something else...."

Doesn't it have to do with multiparous homebirthers already having had at least one successful vaginal birth (otherwise they would have been risked out), so they're by default in a lower risk group than nulliparous women?

It's worth mentioning as well that in hospitals, consultants, theatre staff etc arent hanging round scrubbed up just waiting for a problem to occur. A problem that is detected at the hospital can be sat on and monitored for a lot longer than a problem at home. For example, if the baby has a low heartrate during contractions, the woman would be advised to transfer in, it might take 40 minutes but when she gets there staff are aware of the issues and ready to act if necessary. Or the woman is already in hospital, the heartrate starts to drop, the CTG goes on, that is monitored for a bit, we have a chat with the reg, he decides we can carry on for a bit, before you know it 40 minutes have passed. By that time both women are in the same place and ready for the same treatment.

36 obstetric units participated - and 96% of all trusts in the UK gave their hb data. clearly the HB data covers a much greater area.

Anyone who thinks it takes as long to get to theatre from hospital as it does from home is kidding themselves, of course it doesn't!

Yes exactly WidowWadman - that's what I was trying to say earlier :)

It can do, sparkly. If the theatre is in use they aren't going to turf the last person out and leave them in the corridor with their guts hanging out. Or rush one person's treatment because there is another waiting. It still takes time for the surgeons to get scrubbed up and the anaesthetist to potentially finish something at the other end of the hospital. It can take up to an hour. That preparation can happen while the woman is in a labour room in the hospital, or while she is being rushed in by ambulance. Her being closer doesn't make that go any quicker.

Of course on the occasion that the theatre is free and all the staff required are free, prepared and nearby, it would be quicker to be in hospital, but I think that situation is rare.

MrsJRT - what you describe is true for borderline cases, where it is ok to monitor for a bit, but in any catastrophic event, such as e.g. placenta abruption, uterine rupture etc they wouldn't bumble along for 40 minutes.

Yes, those events are rare - however in those rare cases it does make a difference whether you're a 40 minutes ambulance ride (plus 8 minutes for the ambulance to get there, plus loading time) away from hospital or on the labour ward.

so: if you want the best comparison, you only include HB data from trusts which also provided CLU data

imagine: my local CLU has a good reputation for low-risk women. they are happy therefore to participate in a study - about low-risk women. they have time.

the city teaching hospital down the road has a terrible reputation for low-risk women. (an excellent rep for high-risk though) they are very busy. they don't participate in the study.

data from HB in both areas is still collected.

i will have a look at breakdown to see if i can stats-out the data in a bit...

BertieBotts is right. Particularly at the CLU I had DD in - there's one operating theatre, so if it's in use, you've got to wait and it doesn't matter how long it takes, you wait. If they've just delivered a CS baby in there, that's 40 minutes of stitching up before cleaning out and getting changed and scrubbed up again for a new patient, so you're looking at about an hour.

With the consultant on call, anaesthetist and other senior staff in there dealing with the current situation, then it wouldn't matter if you were on your way in from home or sitting in a labour room waiting for theatre to become free - you would be attended to by a midwife until the operating theatre and surgical staff became free.

In my case, I'd been pushing for two hours and needed forceps as DD would not move, but the consultant was called away to deal with an emergency in theatre before he could do anything for me. Even being in hospital didn't guarantee that I would be seen quickly - it was another 30 minutes or so before he came back.

Widow, with something like uterine rupture there are often signs earlier on that indicate things aren't going well. It's not like everything is going swimmingly and woah all of a sudden the uterus is ruptured, nuances in the maternal and feral observations would be picked up and acted on more quickly because midwives are aware of what it can turn into. I don't want to get into a home vs hospital as I know things can go wrong in both places but in childbirth I'd say there is usually some warning of things going wrong that would be sat on longer in hospital because you do become more complacent knowing you have the technology on hand to get you out of even the stickiest spits.

Spits? Spots even.

The baby's death would obviously be profoundly distressing in any situation. But we're talking about relative risk here, and for me - and for some, though not all, other women - the near-certainty of disabling mental illness following hospital birth outweighs any small increase in likelihood of 'adverse birth outcome.' Or, to put it differently, there are various kinds of 'adverse birth outcome', one of which is PTSD/PND in the mother, which is not part of this study. Maternal well-being needs to be part of this conversation, not only because women matter (an idea which is clearly controversial to some of you), but because traumatised, depressed women will usually struggle to mother their babies, earn their living and generally contribute the world around them. Some women find being in hospital reassuring - fine, there are hospitals - others find it deeply distressing and damaging in the long term. Naturally, these two groups of women are balancing different risks in different ways. That's why we have choices, and why we need information to make good choices. This information wouldn't change my choice.

MrsJRT that's what my midwife told me which convinced me and my relatives that I was as safe at home as I would have been in hospital.

I wanted the best birth possible, guaranteed water birth and for me that was being in my own, familiar environment with my own water pool and 1:1 then 2:1 midwife care.

mrsjrt this is what i am trying to tease out. transfers for first timers are by and large not emergencies - 90% is for pain relief. therefore the risk-uplift shown by this study..is not explained. the study authors don't think they know the reason.

this is why the methodology is in question: the level of difference, if it was a simple fact - should have been picked up by the NBT study and other earlier studies that found no such uplift in risk for first-time mothers- their sample was large enough. have they over-controlled for the varying factors? is their basis for comparison valid? i would say this is a very good study, but there's no such thing as a perfect one.

also, reading the study....if it was purely transfer time - why wouldn't there be a similar adverse outcome uplift reported from FMU births? the transfer rate for first timers is 35% from those...

If i gave birth in the FMU for our trust....the transfer time would actually be much longer than from my own home (not to mention it takes an hour to get there in the first place!)

I had my first at home. I really hate being in hospitals. if i had wound up in one anyway - would that have had more of a negative impact on the birth than upon a similar-risk person without the same level of dislike? hard to control for that kind of thing.

I had a look at the link for data tables...not found yet.

BertieBotts -
Of course on the occasion that the theatre is free and all the staff required are free, prepared and nearby, it would be quicker to be in hospital, but I think that situation is rare.

Sorry but I work in a hospital!! The situation you describe is the norm - in an emergency a room will be found.

Really Sparkly? There are a fixed numbers of operating theatres and I can't believe they languish empty most of the time.

This is lazy of me as I haven't read the detail of the report but does it include hospital aquired infections (mother or baby) as an adverse outcome? This was other factor in my decision to have a HB, and one of my antenatal group was very lucky to survive a nasty hospital acquired infection that she picked up...

Quote from a colleague who attended the RSM Birthplace Report Event where the study was discussed: "The study is extremely positive and shows that not only is birth generally very safe for both mums and babies in all settings, but that being in hospital greatly increases risks for all low risk mothers compared to being at home or in a midwife led unit (either alongside or freestanding), for
example, increasing the risk of caesarean section by three times.

What the press are misreporting, is that home birth, for first time mums
may increase the risks to baby. The risks being mortality and morbidity
combined. There were so few deaths in the study (38 out of nearly 65,000
births) that they had to bundle together a host of adverse outcomes in
order to come up with any statistically significant results! First time
mums planning to be at home increase the risk of one of a number of adverse
outcomes for babies from about 0.5% to just under 1%. The important bit of
that sentence being "planning" to be at home. We do not know how many of
those adverse outcomes occurred in those who transferred to hospital or
what processes in hospital may have contributed to those outcomes.

The study leader, Peter Brockelhurst, emphasised how cautious we need to be
with these results."

.......I am a Mum who was denied a home birth at the last minute due to midwives being "too tired to attend" despite having booked an home birth and given the impression that a midwife WOULD attend my home only hours before the birth. I therefore gave birth in the back of my car as we attempted to get to hospital at the last minute. There is a petition calling for home birth to be an absolute right for women. You can see it here:

www.thepetitionsite.com/1/uphold-the-absolute-right-for-women-to-give-birth-at-home/

I would never risk having a baby anywhere but hospital fully equipped to deal with all potential risks. Home birth, midwife centres etc are out of the question. No one knows how the labour will progress, and the worst is to be rushed to the hospital in the midst of it worrying for yourself and for your baby.

Just on the specific point about if the emergency theatre on a CLU is busy with another case, if a serious emergency arises with another labouring mother e.g. a bradycardia on CTG that cannot wait any time at all, main theatre would usually be phoned and the woman/miwife/avilable medical staff would all be taken to a theatre within the main theatre block within the hospital. As a junior doctor I saw this happen amazingly quickly - yes there may only be on anaesthetist on call for obstetrics but they can summon or "crash call" the one covering the intensive care unit who who be statiscally unliekly to be dealing with a dire emergency at that time, plus many CLUs have registrars on call for both gynaecology and obsetrics, so if the obsetetic one is in meain theatres on Labour Ward they can put out an emergency call for the one covering gynaecology and they would expect to be called in an emergency such as this, In the day time it is different as many more people available but as you can see even at night they can access more than one theatre if needed, for most "dire" emergencies.

I do love MN! Such intelligent, measured comments. Love the point about the DM as a reliable source... when I was a Charity CEO during the Foot & Mouth Epidemic I had a lot of contact with the media and never saw an error free article in a newspaper I had been interviewed by!
This is surely about personal atrtitude to risk. I just wanted to minimise the risk to my baby full stop. The quality of my own experience wasn't a factor in my equation. I did have DH - a farmer used to lambing - and my Mum, a nurse to bat for me though as I was well and truly 'out of it'! An informed, level headed birthing partner is a good idea...most DHs probably feel out of their depth here.

The conclusions the study had in the section I was talking about above was interesting, and kind of ties in with what all4u says.

Women's concerns about their safety and that of their baby (or babies) were expressed but not always listened to by staff. Being heard and receiving timely support was aided by continuity of carer and/or presence of a birth partner or relative.

another conclusion that grabbed me with regard to homebirths and the 'safety' issue was this one:
For example, community midwives who may assist at a low volume of births and only attend 'low risk' births may benefit from periodic rotation into settings in which they can gain experience of births, including higher risk births.

I hadn't really thought about the implications of midwives only dealing with low risk patients constantly.