New study finds home births are SAFER for high risk women

[Jackieharris]

onlinelibrary.wiley.com/doi/10.1111/1471-0528.13283/abstract;jsessionid=82D9DA516329D2AF352315DA7E71420E.f04t03

Well this throws the cat amounts the pigeons!

I'm pro hb myself but still thought that I would probably choose hospital if I was high risk (depending on exact circs).

That's not what it says. It says there's no difference in morbidity ('sickness') or mortality ('death') between the two groups. There is a difference in how many babies are admitted for observation. Which makes sense, in a way, as those born in an obstetric unit are in closer proximity so probably easier to take in 'just in case' of for 'checking over'. Still over-medicalising but not exactly harmful. What do you think?

It clearly says 'lower' twice in the results.

Sure they say its a smallish sample size (anything with hbs will be) but the results are still in favour of home births for 'high risk' groups who have previously been advised not to.

I believe that Marjorie Tew's statistical analysis in the 1970s came to similar conclusions, but she was looking back to a time when more births happened at home anyway, so I am not sure whether you can extrapolate her findings to today's births.

I suppose it all comes down to what the risk is. E.g. slightly raised BMI: probably OK - other severe medical conditions: probably downright dangerous.

I also noted with some bemusement that they didn't know why some 'high risk' women chose home births. Why not ask them?

"I also noted with some bemusement that they didn't know why some 'high risk' women chose home births. Why not ask them?"

Presumably because they are working from controlled access/anonymised medical records. If not asked or nor contained in the version of the notes permitted to be passed to researchers, then it cannot be reflected in this tyoe of analysis.

I would urge anyone using this information to read the full article and discuss any aspect they are unsure of with their clinical team. My reading of it is that it does not find that home births are safer. It finds that:

1. Within this study there weren't enough higher risk people in the home birth group so that the specific differences in safety could be clearly seen.
2. In the higher risk group that was available there were more people with multiple risks and pre existing medical conditions in the obstetric unit group than the home birth group so the obstetric unit group were in general more complex.
3. Because of the small home birth high risk numbers they joined 2 outcomes (death or 'illness' of the baby and admission to a neonatal unit within 48 hours). It is this outcome that was better in those home birthing. This was solely due to the rates of admission to neonatal unit, baby death or illness was greater for homebirthing however the numbers were too small to be sure of these findings when looked at individually.
4. Intervention rates were lower with homebirthing which is great but expected.

So the secondary analysis of this data doesn't show it's safer to homebirthing if you're high risk. It indicates that there isn't enough data to be sure of the individual outcomes but that you will have less intervention during a homebirth and will probably have less chance of your baby being admitted to the neonatal unit however your baby may possibly be more at risk of death or illness.

Sure there will be other opinions but the paper itself suggests that no changes should be made to current guidance based on this data just that further studies are needed.

I am sure you are right, AuntieStella - it just seemed an odd thing to mention to me.

"Did not differ significantly" vs "it appears" plus what lam random says.

What Iamrandom said. OP I would strongly urge you change your thread title, misinformation on this matter could have dire consequences for some women.

The thread title does not reflect the study results very accurately, when really it is all rather more nuanced than that.

The main findings are:

"In ‘higher risk’ women, compared with planned OU birth, planned home birth was associated with a significantly reduced risk of ‘intrapartum related mortality and morbidity’ or neonatal admission within 48 hours for more than 48 hours. The difference reflected a higher neonatal admission rate in planned OU births. This finding was not materially altered by adjusting for maternal characteristics or risk factors, and remained of the same order when the definition of the neonatal admission component of the outcome measure was changed to admission for more than 4 days.

When the measure of adverse perinatal outcome was restricted to include only ‘intrapartum related mortality and morbidity’, a measure that encompassed intrapartum stillbirth, early neonatal death and specific intrapartum related morbidities, the direction of effect was reversed, with a higher proportion of adverse outcomes in planned home births, but this apparent difference in risk compared with planned OU birth was not statistically significant and confidence intervals were wide and compatible with a range of effects. Because of the small sample size it was not possible to adjust for maternal characteristics other than parity.

Compared with ‘low risk’ women planning home birth, ‘higher risk’ women who planned a home birth had a significantly higher risk of an adverse perinatal outcome.

Planned home birth was associated with lower intervention rates and an increased probability of having a straightforward vaginal birth compared with planned OU birth."

It is also impossible, given the comparatively small numbers, to work out which 'higher risk women' would have fewer complications and which would have more in a home birth, so further work is advised.

I've had hospital births - just as well. I had a 3a tear after my first birth, and a 2nd degree tear after my second. No way would I have felt calm and relaxed if I'd have been at home giving birth with that to look forward to at the end!

I suggest the OP reads 'bad science' by Ben Goldacre as an exercise in interpreting research findings accurately!

I don't believe this report. Sounds like there is an agenda here.

High-risk pregnancy and having a home birth? Not wise.

I had two hospital births and boy am I glad I did - both times a team of people there at the end as my babies' heart-rates started failing and the baby needed to get out asap. If I had been at home, I believe that neither me nor my children would be alive today.

I really don't think there is agenda here. The Place of Birth study is pretty robust. They have just extractèd the high risk data and published it. It is a great example of a study that would be hard to bias. If anything, I think the obstetricians involved would have surprised that the outcomes for higher risk home births wEre so good.

However this is secondary analysis of the place of birth data. Secondary analysis isn't robust data especially when outcomes are combined in an attempt to provide enough numbers for a significant outcome. The authors do recognise the limitations which is why there is a recomendation not to change practice just that further research is needed. I think that this is a great example of the importance of 'lay summaries' to be included with research as with cochrane reviews as many people suck as the OP will skim read or misinterpret the meaning of the findings reported. I almost lost the will to read the whole paper but this has to be done to fully understand the outcomes and meaning to practice.

"Still over-medicalising but not exactly harmful. What do you think?"

Unless you count separating infants from their mothers as harmful.

"Sure there will be other opinions but the paper itself suggests that no changes should be made to current guidance based on this data just that further studies are needed."

What evidence supports current recommendations for the care of all high risk women in obstetric settings? Especially given the very high rates of possibly avoidable and harmful interventions that women are currently exposed to in hospital?

"High-risk pregnancy and having a home birth? Not wise."

It was a wise choice for me.

"I've had hospital births - just as well. I had a 3a tear after my first birth, and a 2nd degree tear after my second. No way would I have felt calm and relaxed if I'd have been at home giving birth with that to look forward to at the end!"

You may not have had such bad tears had you been at home. The Birthplace study notes that overall rates of third and fourth degree tears for healthy women birthing in obstetric units was 3.2%. For similar women having their babies at home the figure was 1.9%.

"I suggest the OP reads 'bad science' by Ben Goldacre as an exercise in interpreting research findings accurately!"

I suggest you (and most others on this thread) read Marjorie Tew's 'Safer Childbirth' to gain some insight into the faulty and partial (and actually non-existent) 'evidence' on which arrangements for place of birth for 90% of UK mothers are currently made.

Sunshine- I have!

It's the naysayers on this thread who have an 'agenda'.

It's difficult to see how they can do further research given the relatively small numbers of 'high risk' women who don't have a CLU birth. Unless they start to have a good look at what exactly constitutes 'high risk'? From memory, I think Marjorie Tew talks about how they kept tightening the criteria for 'low risk'.

High risk as in things like placenta praevia, which is what I had? My understanding was it would be extremely dangerous to attempt a non medical birth? Is that the sort of thing?

Surely depends on the type, level and nature of the risk?

Oh also i don't think it's right to tell people that their feelings are wrong. If someone says they feel more comfortable in a hospital I don't think it's reasonable to tell them they are wrong. People can't help how they feel, and many have good reasons for feeling the way they do.

Am massive supporter of HB (Have in fact had 2 myself) but not entirely sure how I could have accessed the CS it took to save DD (and me) if I'd insisted on my booked home birth. DD would certainly have died without the CS (it was close thing even in the hospital) but I might have made it with suitable antibiotics. I don't dare think how badly wrong a detaching placenta could go at home.

No agenda here re place of birth. I don't believe that hospital is the right place for every woman to give birth just as I don't believe that home is the correct place for every woman.

I do however have an agenda about ensuring that people are able to interpret research. Unfortunately not all research is not interpreted and the true meaning we can attach to it is lost. This means that people may base a decision on incorrect assumptions of how safe or risky something is.

That is my worry here. I would not want a mum with high risk complications to base her decision to home birth on the incorrect interpretation of this paper being that home birth is safer for her and the baby. As pointed out above in my previous post this isn't true based on this paper. It may still be the right choice for her based on other data, beliefs or feelings but not based on this data.

Imbalanced views and passing on poor interpretations of fairly complex information do our fellow mums no service in helping inform choice. In fact it is doing exactly the same as the many criticisms levelled at health professionals on here, namely stifling informed choice and misinforming people in order to lead them to give birth in a setting/way that some people believe is best no matter what the suruation.