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.

As an antidote to some of the headlines served up this week I've just read this well written & objective article on the study if anyone's interested Birthplace Study: The Bigger Picture

In answer to the OP's original question: No, the report doesn't put me off at all. I'm a first timer planning a home birth & I'm more than happy to do so. I'm focussing on the extremely positive information to come out of this study; that wherever you choose to give birth in England it is very safe & outcomes are very good no matter where you are. Childbirth is not inherently risky; that's something I already knew but at 39+2 I'm happy to see it in black & white :) I think we're all very lucky to live somewhere we have a choice to give birth wherever we choose & I think that no one should be attacked for that choice; I personally have known a number of people go into hospital & come out with a really nasty virus, infections, even MRSA so for me personally hospital would really be a last resort. I feel much safer birthing at home but it's a personal choice.

Talk about scare mongering!!! Bloody hell!!!! I thought that the government were trying to increase the home birth rate?? Looks to me like they've taken a step backwards on this one! x

That's really interesting NICE. My HB was with an experienced IM whom I trusted implicitly having given me all my antenatal care. I'm not sure I would have been so confident with community midwives that I'd never met before and whose experience of a range of births is unknown to me.

WIOLLA MLUs got better results than CLus.

conclusion: being near surgical assistance does not appear to improve outcomes

Freestanding MLUs did not appear to have any consequent uplift in risk for first timers due to transfer time.

and 0.93 is not the 'actual' incidence, but the controlled variable. as being white and socio-economically advantaged has a strongly positive effect on outcomes for baby - though being older has the opposite effect - i don't know what the 'actual' figure would be...

there is basically stacks of info to read before i say it isn;t there though...

PinkFondant I had one HB with two NHS midwives. One arrived when I was at 9cm, read my birth plan and said "I can do that" and called for a second midwife. Then it all went to pot and I was - even with a trainee doula present - "encouraged" to do it all their way. Apparently I needed to lunge around, get on the bed, control my breathing, be coached to push - NO I DIDN'T, it was just what they were happy with and used to. I wanted to stay where I was (on all fours), do my hypnobreathing and given that I was experiencing the foetal explusion reflux, why the actual fuck were they yelling at me to hold my breath and push? They also broke my waters without consent or consultation - again, asking permission was not in their remit. Afterwards they were clearly freaked out at the idea of a natural third stage and were yanking on the cord to get the placenta out, desperate to cut it (they didn't know if it had stopped pulsating - never seen one?) and after I had delivered the placenta without the injection, they waited until DH and the doula had left the room and insisted I have the injection they had already prepared.
So in many ways it was a hospital birth in a home setting, the lack of consent and bullying, not taking my wishes into account really fucked me off.

Next two HB were at home with IMs. Who asked permission to take my blood pressure and stayed for breakfast afterwards. My last HB was the sort of birth that in hospital would have lead to all sorts of invention/CS, but DC4 was born (eventually) safely, gently at home.

NICE

Community MWs did not appear to do any worse on second births though, nor did MLU MWs who also only deal with low-risk women.

"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."

so the risk for your 2nd baby would be lower also, having given birth outside a CLU - this reports raises some serious questions about what's going on in CLUs that results in so much intervention.

i think it is a flaw in the methodology of this study that BBEs were not included -

giving birth on the way to hospital/MLU is a risk of that decision, so that should be included in the CLU/ MLU stats.

can anyone find if there was a similar disinclusion for a HB mother giving birth without a MW present?

EdlessAllenPoe

Labour itself is a very beautiful, but absolutely an unpredictable process. Being at the hospital near equipment gives you a chance to minimize the risk, it is just common sense especially for the first time.

How do you know how you/your body will react during labour? Who can tell you - no one, as this is only obvious during the labour itself. No matter how experienced is the midwife - she is not a doctor who has been specifically trained to deal with emergencies. Would you really be willing to be rushed in the midst of it to the hospital? I was in the car with contractions it was bad enough, to be taken to the hospital during the labour - no, thank you. And the baby? What if the baby needs urgent help and sometimes seconds matter, how much of this equipment do you have at home? How much help is available? What if second opinion is needed etc? I appreciate statistics, but as a mother I never regretted my choice of being in the hospital and having an obsteotritian to come to my help when 5 midwives did not know what to do.

All I say if you have no choice, have a home birth, if you have a choice go to the hospital, but make a research which hospital is the best in your area and it is best if your partner is there with you to control/ help. If there is a midwife unit in the same hospital and you can have a doctor should there be a need then I would have a birth there.IMHO.

Another study stating things that have been known forever, well 44 years
I was born in hospital, my sister was born at home.
My mum says that was standard practice in the Sheffield at the time.

Seemed very sensible to me and DD1 was born in hospital and DD2 at home

wiolla i am looking at the stats. 'common sense' is often wrong.

" Being at the hospital near equipment gives you a chance to minimize the risk, it is just common sense especially for the first time."

these stats seem to show the 'common sense' conclusion that being close to surgical assistance improves outcomes is wrong, as freestanding MLUs don't have any uplift in risk.

why, then, the uplift in risk for first-time HBirthers...the authors don't know.

although having read the first part of the rather massive PDF files linked to on the methodology...

they used data from a 'stratified sample' of CLUs - that is to say they will have chosen a variety of types in order to represent the general picture of care in the UK. the data quality isn't quite as good as that for HB or MLU - particularly as 5 trusts did drop out to be resampled (though this may not be for my postulated reason above: the study went over two years and in that time some trusts changed/merged/closed their CLUs).

However any potential for inaccuracy between CLU data and HB data would still not answer the question: why are MLU outcomes for babies in this study better than for first time HB?

I didn't even consider a MLU as a potential birthplace, precisely because what was on offer there held no benefit over home, and some drawbacks. Due to the fact that our local MLU is an hours drive away also, i don't know anyone IRL who did give birth in a MLU.

could it be that the typical MLU - is attached to a better-than-average CLU and therefore transfer would offer less disadvantage? there doesn't seem to be a 'typical' MLU - the freestanding ones the study notes have quite a range of characteristics...

is that the disinclusion of babies born on the way to chosen birthplace (something associated with poor outcomes) has been done for MLU and CLU figures, but not for HB mothers whose MW didn't turn up (or only got a paramedic)?

anyone shed some light on this?

EdlessAllenPoe

well, as I said I do not trust statistics in this case and I do not want to be a part of the unexpected outcome of the home birth statistics and blame myself for life. Things may go wrong everywhere, what is meant to be is meant to be, but at least from my point of view I did what I could to minimize risks. Better be safe than sorry.

I wonder how many of those women had to be admitted to the hospital after the birth? How many had Srep B active during labour, considering the fact that this test is not routinely done in England and many people have no clue that they are carriers of potentially harmful infection for the newborn baby at the time of labour. etc etc.

The actual term low-risk women does not mean "no risk" and sorry but hospital seems to be safer for me, not only because of the equipment for me and baby but also paediatrician and other doctors who are available to help right there.

But I do think it is important to choose the right hospital for birth, it is important to know the capacity of the hospital, specialists who are available etc. IMHO

I wanted a HB for my first but she came early and we ended up with a C section. Second time round the attitude of my mid wife was very negative. I wanted to go for a natural delivery. I found a fab independent mid wife whose care was phenomenal. I had not one but two midwives with me throughout established labour. This I would not have had in hospital. Midwives are expperienced to realise when there is a problem. it can usually be detected very early on. When we realised baby was stuck they suggested we transferred and I was in agreement. baby was born with forceps an hour and half after transfer. I have No regrets about my decision to homebirth. Most of my labour was a thine, it was calm, the pool was fab and I managed very well without pain relief. I am convinced that with constant monitoring at hospital I would have not coped as well with pain. I do think I was well prepared for labour. I had read a lot and my midwife was also very helpful. My mum and sister have birth easily and I felt sure I could. Being mentally prepared is important. HB is not for everyone but for those who want it, they should not be given a hard time.

These were all NHS midwives - no IMs in the study as far as I know.
All women were low risk at the start of labour and the 'planned' place of birth was where they were planning at the start of labour (I think).

Like previous studies this study has found that home birth and birth centres reduce the intervention rates considerably.

It is great news that second time mums can choose between all the options without even considering safety as they were all found to be as safe as each other.

For first time mums birth is always riskier, and home birth did increase the risk from .53% to .93% chance of an 'adverse outcome'. But it seems that 1st time mums will still be offered home birth as an option as it is still considered safe.

I'd be interested to know whether transfer times played a part in these stats - standalone MW centres were found to be as safe as hospitals despite having exactly the same facilities as a home birth, and the same need to transfer by ambulance if problems developed. I wonder whether if you live 10 minutes from a hospital are you at less risk than if you live 35 mins away? Maybe standalone MW centres are a bit better at the logistics of transferring in?

I planned a HB for my first but was transferred in to hospital. Having had a fantastic home birth with my second I still feel that first time mums should have the chance of birthing at home if they want to.

It would be great to see some more research into whether home births can be made even safer for first time mums - do all midwives attending home births have the same level of skills and experience?

• the average distance from FMU to CLU for a transfer was 17 miles - FMUs were typically in rural locations

MLUs - only 3 had medical staff (ie consultant, paed etc) - 13% had some level of GP involvement. AMUs did in some cases call-across staff eg Paeds...

the inclusion on all sets of data (sadly this will not C&P from the PDF) was-

to be an included planned HB, the woman must have a MW with her from established labour and have planned a HB (some 30% of HBs were unplanned, but these wouldn't have been included in either OU or HB stats)

to be a planned OU - that was their planned birthplace, and they must have received care in the OU prior to delivery

to be a Planned MLU birth - they must planned a MLU birth and have received care in the MLU prior to birth

so in answer to my own question: they have dis-included the planned homebirther that gives birth without a midiwife present

to my mind this is an error, as giving birth without a HCP present - either because they haven't made it to your house in time, or because you haven't made it to the CLU/MLU on time - is a possible consequence of that decision.

It would be great to see some more research into whether home births can be made even safer for first time mums - do all midwives attending home births have the same level of skills and experience?

i agree with the first bit and in answer to the second - no. it seems a minority of trusts use Maternity support workers as second midwife. not all trusts place HB midwives on ward-rotation (though in an area with a very high rate of HB, there may be less benefit from this - the MWs attending my first two births had attended other births the same night/day).

some of the lower-end negative outcomes such as 'mild encephalopathy' are hard to detect and defined by NICU admission, so there may be some mileage in the notion that HB midwives are being super-cautious about this and advising admission for slight feeding/breathing problems,in a way that their busier colleagues in MLUs/CLus are not- though i'm going to have to read a shedload more pdf before seeing if that could be a contributory part of the slight increase in risk.

compared to earlier studies, the transfer rate has increased from 40% to 45% for first timers so if anything midwives are leaning on the side of caution when it comes to transfer more than previously.

..average labour times very different too -

CLU - 9.01
MLU - 7.92
FMu - 7.49
HB - 6.61

and the transfer time is longest from FMU - 0.59 vs HB - 0.48 and 0.17

29 minutes home, 39 minutes FMU, 10 minutes from average AMU

in the event of transfer - FMUs labour longer before transfer at 6.68 hours then 6.5 hours AMU shortest of all HB - 5.71 hours before transfer.

length of average labour after transfer to OU is broadly similar - 6.6, 6.8 and 6.8 hours - basically, the average transfer to OU leaves plenty of time for decision making and observation upon arrival so long as the resource is there to provide it.

hum..'substantially more babies were admitted to neonatal care from the planned OU group, proportionate to other settings'
more women are also admitted to higher-dependency care also, though mainly for post-surgical care

having chugged through 53 pages of the 131 of case study (and there is some juicy stuff in there!)

,,my ponderings - 1) are FMUs transferring to better than average CLUs - FMUs are a minority provision and seem largely rural ? the HB data covers pretty much every trust.
2) 20% of the CLU group were found to have risk factors on arrival, compared with 7% of the non-CLU groups - this may because if you want a MLU/HB birth you get more pre-natal grillings on your PG. It may also be that CLu MWs are more likely to class things as a 'risk factor' that perhaps would go unnoted in the other settings. this 20% was disincluded from the stats, as was the higher-risk 7%.
3) is the sort of intrapartum care provided by a MLU better than allowing CMWs to practice solo - or in pairs - due to the ability to share skills and experience - in a way that compensates for the lesser continuity of care of having 1:1 midwife care at a HB?

I have not found a breakdown table of the actual incidence of each negative neonatal outcome. that would be useful to understand this better. there is no detail on whether that 9.3 adjusted figure is emerging from the transfers or not.

Edless it's really cool you are going through all this stuff but i am lost trying to read the jargon. i wish i understood it as it sounds as tho you know what you are talking about!

Edlas just link next time, I'm a biologist, but it's 1 am and that's just too much detail.

no no don't stop - just can you dumb it down a bit for the non-scientists?

Edlas I really appreciate your summaries of the highlights-the report is way too big for me to read right now so it's good to get your potted summaries, keep them coming!!