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).

morestats - I was quoting from later in the same report - so on the one hand the report says that the Birthplace study was of good quality, but an individual sub-group says its studies are of poor quality. Which is it? As far as I can see, it's the lack of random controlled trials which makes them 'poor quality' but even some of the RCTs are poor quality.

The impression I get is that the studies are hamstrung in a lot of places by a lack of data being collected - but is that not a reflection of the poor quality given to previous research, that no-one has thought to include certain questions and their answers?

If we go back to Marjorie Tew's work in the 1970s/80s - she was a statistician, who fell into the work of analysing birth choices by accident. She asked her students to analyse the stats to show why the policy of promoting hospital births had come about. When her students said that the stats didn't show hospitals to be safer, her first thought was to disbelieve them. I was around in the 80s and followed the debate closely, and Tew was absolutely vilified by the then obstetric hierarchy, because they didn't like what she found.

But if we accept your arguments, morestats, that the Place of Birth study isn't robust enough - what would you put in its place? Or do we just carry on as we always have done because that's the system?

Lavolcan, the system we have is horribly flawed. So no, we clearly shouldn't carry on as before.

Women should be able to make an informed choice; homebirth, midwifery unit or consultant led but it is the quality of care in those places that matters most. Women should be able to expect the same quality in hospital as at home.

I would suggest collecting data on where all low risk women start labour and what their outcomes are including factors such as distance to the consultant unit for emergency transfers. We need enough data to have a reasonable chance of reaching statistical significance by individual outcome s such as death, brain damage or post partum haemorrhage. Moreover, low risk would need to be stratified because we know that the higher risk end of low risk women tend to opt for consultant unit and this distorts the outcomes as they have markedly more adverse outcomes.

I have seen Marjorie Tew's work and I imagine the reason hospitals had worse outcomes was because only the very low risk women could have home births at that time. All the prems, multiple pregnancies and breech would have gone to hospital and these are where most deaths occurred.

Aren't we all saying the same thing? That women need better quality information and their choices respected.

And going back to the OP, that kind of information - i.e. home birth is safer for high risk women is a complete misreading of the research findings.

We should all be saying the same on this otherwise women are going to misled into making decisions that lead to personal tragedies.

we know that the higher risk end of low risk women tend to opt for consultant unit.

Do we know? How many women are given a completely unbiased information: home birth pros/cons, CLU pros/cons? As for MLUs - for many there isn't one within reasonable distance - so no option there.

I imagine the reason hospitals had worse outcomes was because only the very low risk women could have home births at that time.

I believe not - I have Marjorie Tew's book on my shelves so will be able to check in the next couple of days. As far as I am aware she matched risk categories. She was at an advantage compared to today because more 'high risk' women could still deliver in cottage hospitals, so she had greater numbers to draw on. I believe they still had better outcomes - which of course was not a popular finding when the powers that be were busily shutting down such options.

However, 'we get all the high risk cases' has been a jolly convenient excuse for a good number of CLUs - when in fact the vast majority of them also get virtually all the low risk cases. Aren't those women entitled to have a decent standard of care - is it really acceptable that they end up with more severe tears, more EMCSs. Doesn't the mother's health matter?

For me the Place of Birth study was a revelation - it put flesh on the bones of anecdotal evidence - that those having home births/MLU births seemed to have better outcomes, so was this just luck? Probably not. What is needed now is to find out why this is? Research which should have been started back in the sixties/seventies IMO.

More stats - I think your assumption that among mothers classified as low risk, those with some risk factors are more likely to opt for a CLU is wrong. Mothers who opt for h/b tend to be older as a group for a start.

Minifingers - If you believe Birthplace is a good study then it did an analysis of which women chose which option and as I mentioned previously, the hospital group was consistently chosen by women with more risk factors. (The 'propensity' tables are right at the end of the study)

La Volcan - I totally agree most low risk women go to CLUs and they are entitled to a decent standard of care. But many want that care IN the CLU where they have access to epidurals and doctors in an emergency. I live in an area with a freestanding midwifery unit but most women here drive past it and go 16 miles or more to the consultant unit because that is their choice. CLUs needs to be radically improved because the majority of women given free choice want to deliver in a hospital. (An indesputable CQC fact!).

We are probably never going to agree on this but perhaps we should agree on one thing. That is that we need much better evidence before we can say with certainty which places of birth are safest EXCEPT in the cases of higher risk women and first time mothers giving birth at home where we know with a reasonable degree of certainty that the risks are higher.

I feel (but you probably don't) that there is also uncertainty around the safety of first time mothers in free standing MLUUs. RCOG has publicly stated its reservations and the Birthplace study has one table which shows a very clear doubling of risk.

Women should be perfectly entitled to make a choice that is statistically NOT the safest if that is what they choose. Equally, they are entitled to decent evidence on safety so they can make an informed choice.

At that point I am going to stop posting on this thread.

I really don't know how free the average woman's choice is. We have had 50 or more years of telling women that home births aren't safe, and at least 30 years of happily closing down small maternity units because they aren't safe either or the health authority wanted to flog the land off to make money.

I think it's reasonable to assume that the woman wanting a home birth has made a positive choice to have one. Some/many women going to the CLU will have made a positive choice - e.g. they want an epidural, but how many go to the CLU because they don't realise that they have a choice? I am not sure that anyone knows the answer to that.

One of the disappointments to me with the press reporting the Place of Birth study was the way they latched on to the slightly increased risk to the baby at a home birth for first time mothers, but totally ignored that the morbidity rates in CLUs were higher for low risk women - completely glossed over. Now if women knew that they were significantly more likely to have say an EMCS without an advantage to the baby, would they choose that?

I really don't know how free the average woman's choice is.
Exactly. The assumption is that you will trot off to hospital, and if you decide not to you find yourself at the receiving end of a lot of comments of the 'Aren't you mad brave!' and 'Oooh, are you sure?' variety.

When I booked in for my second baby the midwife said, 'So, Hospital X or Hospital Y?' That was her assumption. It wasn't until I said, 'Actually, I was thinking I'd like to deliver at home' that I discovered that she was very pro-home birth. I'd done my reading and gone armed with Marjorie Tew's stats (this was back in the 1990s), but she just said, 'Oh, great: one normal delivery behind you, low risk, no worries at all.'

The point I'm trying to make is that even midwives who are very keen on home birth and have the systems in place to support it don't immediately offer it as an option. Home birth is seen as a bit of a whacky, risky thing to do. Consequently, women don't really make a free choice: the information to enable them to weigh the risks is hard (impossible, judging by this thread) to come by, many don't know anyone who delivered at home, and no one says when they book in, 'So, home, Hospital X, midwife unit: have you considered those?'

...I've been told to home birth by a hospital consultant. But then again my first came so fast I almost didn't make the MLU (if it hadn't been 10pm I would have had her in the bloody taxi). I'm 'high risk' but at the low end of the scale.

I'm also constantly astonished and a bit appalled that the ASTONISHINGLY high excess of maternal morbidity in healthy women giving birth in CLU's is routinely ignored or glossed over - look at morestats posts on this thread for a flavour of the type of response to this information you generally get from the more medically minded.

I don't see anything in morestats posts to suggest he/she is pro-medicalisation of labour or opposed to home births. The OP posted a thread title and a post suggesting that a study had proven that high risk women are safer having home births. A few posters then pointed out that having read the paper, that isn't what it says at all and because this paper was a secondary analysis (hence the study was NOT designed to answer this particular question) the quality of the data is not very good.

I suspect if the subject matter was different morestats would still have read the paper and corrected an obvious misinterpretation of the findings because his/her username suggests a research/stats background.

Women should be able to make an informed choice regarding where to give birth. Making a choice based on a misinterpreted study is not informed and frankly dangerous.