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.

the files are PDF and i don't have the first clue how to link to a specific section (i think it would just link the entire document). or indeed cut and paste.

which would be nice.

there is literally reams of information though - relevant to most debates on childbirth we have here on Mumsnet, and of a very good quality. I did go to bed cos i was getting eye strain.

as a general observation: this study seems to have functioned as several separate studies, one into homebirth, one into MLUs - a study serving as 'control' for 37 Obstetric Units (ie, typical maternity ward) as well as a broader questionnaire-based survey of 156 Obstetric Units. (ie they didn't collect data on individual births, but general data on the nature of care)

previous studies have tended to focus on straightforward Homebirth VS Obstetric Unit comparisons of varying kinds, and on stillbirth only, without recording other rare negative outcomes.

i'll try noting page number and do links tonight - it's been clear and DH has been out with his telescope so doesn't mind if i zone out completely.

AIMS say:

"Facts from the Birthplace study

Despite some of the outrageous press claims this study show the benefit of avoiding a hospital birth.

The study was unable to look at baby deaths as there were so few - only 32 babies died in over 65,000 births. There were only 250 adverse outcomes recorded these babies in total.

There was no significant differences in outcomes for subsequent babies planned to be born at home, in a birth centre or in hospital .

First babies whose births were planned in a birth centre did as well as those who were planned hospital births.

The only increased risk was for first babies planned to be born at home - and the risk remained small (9.3/1000 compared to 5.3/1000; or if using the comparison of women with no complication factor when they were first accessed in labour - 3.5/1000 to 9.5/1000 - which gives the 2.8 times risk...which was then rounded to 3 times the risk, which was quoted in some newspapers).

All groups of women had better outcomes if they did not plan to give birth in hospital. For example 88% of low risk women planning to birth at home had normal births compared to only 54% planning to birth in an obstetric unit. So, 30% had unnecessary interventions or problems when planning to birth in hospital.

This study show big improvements for low risk women by avoiding planning a hospital with only a very small additional risk for first babies."

final report 4 page 28 has the detail on the sort of thing included as a 'primary outcome' that is the recorded adverse outcomes for babies they are attempting to detect

hope link works.

yes crotchflakes this study is a resounding endorsement of midwife-led care outside of obstetric units from a wide range of angles.

the cost effectiveness studies indeed read very positively for both MLU and HB care, as do the maternal well-being studies - the infant well being studies endorse HB and MLU for second and subsequent birth, and MLU for first birth.

one thing i really got from this was how much more cost-effective it is to hire more midwives. Even with the overhead associated with running a MLU, even with the higher midwife per labouring woman ratio - they still came in cheaper per birth, and a very cost-effective option - due to the reduced rates of intervention. final report 5 page 16 - homebirth was cheaper still at about £300 per birth (adjusted) £500 (unadjusted) compared to obstetric units also.

the need for adjustment is due to the very different profile of the 'typical' homebirther.

one of the things i am trying to discover by further reading:

20% of women arriving at obstetric units had a complicating factor not known before then - that is to say, they were in fact at that point deemed to be 'higher risk' . there is no list of what these complicating factors consisted in - my theory at this point - was this complicating factor largely high blood pressure?

that is exactly the kind of thing that might not show in the relaxed circumstances of a midwife appointment, but would when in the stress of arrival at a hospital in labour.

Is the increased risk for first time homebirths related to primary or secondary outcomes on page 28? I've just read the list and realised that my home birth, which was safe and successful as far as I knew, would actually have counted as a negative secondary outcome, as DS was later admitted to a neo-natal unit with very high bilirubin. He had breastmilk jaundice though, so the place of birth was actually irrelevant.

Edless / Crotchflakes - i could kiss you, thank you for making sense of all this.

i am quite unscientically terrified of US-style hospital births taking over completely and feel really relieved that there is science on my side - and it's fucking cheaper too! up yours, medical establishment. midwife-led unit would have been my choice, had there been one near me to go to.

aha found it final report 5 bottom of page 30

the most prevalent complicating condition was prolonged rupture of membranes or meconium-stained licor. but only found in 7% of Hb, 4% of MLU ..?

that's odd. they say there is a discussion elsewhere though...
i thought meconium in waters was at the 3% level, and prolonged rupture of membranes ..only 1 in 12 waters go before labour, and 85% would go into labour before 24 hours up - are they classing women whose waters have gone before admission as a complicating factor?

it wasn't seen as a problem for my first HB. need to find the appendix with discussion of this.

ah it is in the 'prospective cohort report'...can't find it!

the bit i said about FMUs being a minority provision - basically there aren't that many of them. final report 3 page 20 65.8% of trusts only offer consultant led unit or homebirth. they may not even have a homebirth service as such.

although MLUs have increased in numbers from 2007-10 we'll have to see if that trend will continue, given that the case study interviews seemed to show decision makers think maternal choice is a 'fluffy' matter not relevant to outcomes.

in answer to one of my earlier questions:

are women from FMLUs transferring-in to better obstetric units...well..

homebirth tends to be really popular in areas where FMUs are also popular. table on final report page 24 -
basically a lot of homebirthers (though the data ranges are too vague to work out exactly how many as a %age this is true of, and whether that could explain the slight uplift in risk for first timers between HB and FMU) are transferring to the same CLUs as they would have from the FMU.

ie, if you live in cornwall, hospital can be 2 hours drive away, the FMU might be an hours drive, so ...homebirth in your area is popular, and so is the FMu, simply because the travel time makes them both appealing choices (and also because the rural demographic favours homebirth ie they are older, white, socially advantaged). in the event of transfer, whichever your first choice was, you end up in the same CLU.

i wish a level stats wasn't so long ago. actually, maye i don't...

I guess we can expect another not terribly balanced DM piece soon:

twitter.com/#!/JournalistJill/status/141199154130063362

mainly the stats were on 'primary outcome'.

although 'primary outcome' included stillbirth, in actual fact there were so few in all groups together that no statistically valid conclusions could be drawn about that single outcome. I am still looking for the breakdown to find out each type compares on each type of 'primary outcome'.

neo-natal admission for all reasons was most common amongst the obstetric unit group, but this could be for routine observation reasons (as the infant is already in hospital anyway).

final report 3 page 56

consultant presence on wards -

77% have 40 or more hours of consultant on-ward presence.
8% have 60 or more hours per were week on-ward presence (really big OUs).

there were of course on-call rotas as well.

the page before - 62% of obstetric patients deliver with care led by a midwife.
As consultants have day duties such as pre-natal appointments, that 40 or 60 hours will most likely be daytime.
so, if i have understood this correctly, if you are giving birth in the middle of the night in an Obstetric Unit, the chances are there isn't a consultant there, unless called.