"Home birth to ward increases risk" - anyone seen this today?

[bohemianbint]

here

I had a quick and straightforward HB with my first child and it was great. But now am pregnant with #2 am for some reason wondering if I got too lucky first time around?

Am sure it's just hormones and once I start the Hypno Birthing I'll feel loads better, please come and reassure me that I can do it again!

I reckon if you've done it once you can def do it again!!!! And don't forget...
"On average, around 15% of women who have chosen a home birth will be transferred - although the figure is significantly higher for first-time mothers and significantly lower for those who have already had children."
I had HB with my dd and had to go in after she was born, but would absolutely definitely do it at home again.

(into hospital) sorry

I had 2 succesful hb and one which went a bit awry!
Also when I had my fisrt HB it took me about an hour to convince the doctor that it really was what i wanted as it was really unusual back then (13 years ago!)

of course you can do it again, majority of transfers were for first time mothers.. it is normal to have a wobble about things. remember you can always transfer in if you find it harder to cope, but you cannot transfer back home !

Thanks! I'm not sure why I'm giving myself the fear. I'm going to get onto my HypnoBirthing teacher asap and get her to sort me out!

Out of all 3 of my children my HB was the easiest birth with no intervention and a happy baby throughout.

You can most definately do it.

IMHO I think this report is a tatic to relieve the strain that MW's are under at the moment,

I find the story a bit odd actually because they aren't comparing it with births that started in hospital (unless I am reading it right). So it seems obvious that births that have been transferred because of increased risk would have, well, increased risk.

err. "reading it wrong" sorry

I'm not a statistician, but this (the article) sounds like an odd way to set up a study.

As is often the case, I don't think the media report is very good. Always best to go to the actual research. Here's the abstract:

An estimation of intrapartum-related perinatal mortality rates for booked home births in England and Wales between 1994 and 2003.

Mori R, Dougherty M, Whittle M.
National Collaborating Centre for Women's and Children's Health, London, UK. [email protected]

OBJECTIVE: The objective of this study was to obtain the best estimate of intrapartum-related perinatal mortality (IPPM) rates for booked home births. DESIGN: A population-based cross-sectional study. SETTING: England and Wales. SUBJECTS: All births in England and Wales, including home births (intended or unintended) occurring between 1994 and 2003. METHODS: All IPPM data were derived from the Confidential Enquiry into Maternal and Child Health. Denominators were derived by using unintended home births and transfer rates from home to hospital, from previous studies, with sensitivity analyses. IPPM rates were calculated for the three following subgroups: (a) the completed home birth group, (b) the transferred group and (c) the unintended home birth group. OUTCOME: IPPM rate. RESULTS: The overall IPPM rate for England and Wales improved between 1994 and 2003. However, data to obtain a precise estimate of IPPM rate for booked home birth were not available. The average IPPM rate for all births in the study period was 0.79 per 1000 births (95% CI 0.77-0.81), and the estimated IPPM rate for booked home births was 1.28 or 0.74 per 1000 births, depending on the method of calculation (range 0.49-1.47). The IPPM rates for the completed home birth group appeared to be lower throughout the study period compared with the unintended home birth groups. Those women who had booked for a home birth, but later needed to transfer their care for a hospital birth, appeared to have the highest risk of IPPM in the study period. CONCLUSIONS: The results of this study need to be interpreted with caution due to inconsistencies occurring in the recorded data. However, the data do highlight two important features. First, they suggest that IPPM rates for home births do not appear to have improved over the study period examined, even though rates did so overall. Second, although the women who booked for home births and had their babies at home seemed to have a generally low IPPM rate, those who required their care to be transferred to hospital did not. Women who book for home births should be offered comprehensive evidence-based information about the potential benefits, risks and uncertainties associated with their choice of birthplace by the healthcare professional responsible for supporting their decision. It is of considerable concern that the data recorded nationally in England and Wales do not provide accurate information about when and why a transfer from home to hospital booking occurs and about their outcomes.

And here's the NCT's response to it:

Mori et al study on the safety of planned home births

There are fundamental weaknesses in the design of the Mori et al
study on the safety of home birth published in the BJOG today. There
are also some errors and inconsistencies in the calculations used
within the chosen design. The results carry a health warning from
the authors, who say "These data have substantial limitations and
should be treated with caution". We would say that they are
unreliable and may be seriously misleading.

To assess the safety of home birth accurately, prospective data is
needed. That is data collected for the purpose of the study, going
forwards in time, following women through their care and recording
outcomes for them and their baby.

This study is retrospective using data from several different
studies and from databases compiled for other purposes. There may be
problems of missing data, mis-coded cases and recall bias.

To compare the safety of planned home births with planned hospital
births it is vital to have similar samples of women, and to exclude
unplanned home births. Unplanned home births have much poorer
outcomes than planned home births as women who conceal their
pregnancies are often unattended in labour and have had no antenatal
care.

In this study, Mori et al make a series of estimates about unplanned
home births and intra-partum related perinatal mortality (IPPM)
rates, applying estimates from previous studies to two unrelated
datasets. In particular, the estimates of unplanned home births are
unreliable. Two different methods have been used to calculate
unplanned home births: one of these estimates of around 66,000
(calculation A) is three times higher than another estimate of
20,000 (category B). A paper published in the BMJ by Murphy et al,
over 20 years ago showed calculation B to be more reliable, yet Mori
et al base their conclusions of calculation A. If estimates of IPPM
are based on calculation B then IPPM associated with home birth is
not different from rates for all births (home birth 0.74 per 1000
births; all births 0.79 per 1000 births).

Women who transfer to hospital

The Mori et al paper quotes an increased estimated IPPM rate for
women who plan a home birth but transfer to hospital. There are
three key problems with this:
? These are very rough and inaccurate estimates. The paper
does not make it clear that the calculation of 6 baby deaths per
1000 women transferred is a rough estimate, not a precise number.
The range using two different calculations was anything from 0.78 to
8.37 deaths per 1000 births. To put this in context, the rate for
all births was 0.79 per 1000 births.
? Over half of the women from the three research studies used
by Mori et al to calculate the estimate rate of baby deaths
transferred before the start of labour, so they had all their labour
care in hospital.
? A higher complication rate would be expected for women whose
pregnancy is not straightforward, but there is no means of comparing
the women planning a home birth (who, for example, might develop pre-
eclampsia, or have twins, or have a breech baby) with similar women
planning a hospital birth. Women booked for hospital care with these
kinds of risk factors will also have a higher complication rate than
other women (though no data is provided by Mori et al to allow
comparison).

Fortunately the Birthplace study is underway to address these issues
in a prospective study designed specifically to address these
issues. Everyone should avoid jumping to premature conclusions
before this study is completed. (www.npeu.ox.ac.uk/birthplace).

jan, I might well be missing something - but isn't the really important comparison between babies who died of condition x (or set of conditions x) after a transfer to hospital from home, and babies who died of x after a planned hospital birth? That would tell us what (it seems to me) we really want to know, which is whether home births are more dangerous for babies who develop unforseen complications during or after labour.

Also, the study doesn't seem to have allowed for the fact that the transfer-from-home-to-hospital set are self-selecting, in that these are (by definition) babies and/or mothers who are in trouble of one sort or another.

I would personally feel SAFER at home and feel they pick up potential problems earlier.

For both my Hospital births I was left alone until I begged for someone to come and see me. DD2 was straight forward but DD1'a birth, they could have lost us both due to their negligence.

At home M/w is with you from start to end so I feel the relationship of post natal deaths has no bearance on where the baby is born!!

That's the thing, during the same BBC interview a woman was saying that paradoxically HBs can in fact be safer as in hospital one intervention tends to lead to another...

I can't cope with info overload when I'm pregnant, my brain just shuts down!

Policywonk, yes I think you are partly right. But I think there may be an additional complication in the selected homebirth group too, in that if there is an indication that something is wrong prenatally they probably opted for hospital birth in the first place. Making the homebirth group less likely to encounter problems. Seems fraught with potential bias to me.

Well the nct woman summs it up towards the end of the article by saying you have to compare like with like which is not what they have done. Also it is not one large study but the results of several different studies put together which is always an inacurate way of looking at things.

The media are always taking these things out of context and misinforming people. I would be far more worried if it was one large study that compared women who were low risk at the outset of the pregnancy who chose to deliver in hospital, with women who were low risk at the outset who chose to deliver at home. If a large study like this still suggested the same outcomes (which I strongly suspect it wouldn't) I would give far more weight to it.

Well - one main problem is that they include in the homebirth arm all the women who switched to a hospital birth after developing complications in later pregnancy - in other words, women who never laboured at home at all and who, one would assume, were no longer considered as 'low risk'.

Then they compared this group - the ones who developed problems in pregancy who'd become 'high risk', plus all the women who'd developed problems in labour, with a group of women labouring in hospital about half of whom would be classified as 'low risk' (ie a group representative of the normal population).

Sabire - yes, that's the problem I have with this 'study'

It includes all women who booked homebirth a 12 WEEKS and ended up in hospital.

Put into practise, that means it includes:

Second Trimester miscarriages and terminations.
Premature births.
Problems in pregnancy including woman who develop high blood pressure, pre-eclampsia, gestational diabetes, obstetric cholestasis etc etc..
Planned sections for breech or placenta previa
Emergency sections without onset of labour IE placental abruption, cord prolapse
Induced births for post-dates

Then they spin this information to make it seem like huge amounts of women are transferring care IN LABOUR and their babies are suffering as a result.

If I've read it right - half of the women included in the homebirth arm were women who transferred into hospital BEFORE labour started.

That would include women like my friend, who'd booked a homebirth but had to go into hospital last night at 36 weeks, for PROM, and another girl I know who had an emergency c-section after low fluid was identified at her 40 week appointment......

'Transfers" did not refer exclusively to women who were rushed to hospital in labour, but included any woman who, having initially chosen a home birth at 12 weeks, ended up giving birth in hospital. '

WHY did Ir ead that?

Am 40+5, booked HB and looking at induction

why on earth did I open this?

Peachy - relaaaaaax.....

You've got PLENTY of time. You don't need to make any decisions at all for ..... oh days and days.

monday in fact, as can't get childcare without notice- if sweep doesnt work have to be induced as soona s they can fit me in