Postpartum infection rates - homebirth v hospital

[barkfox]

Hi -

I have a very specific question, following a conversation with a friend who is currently considering a homebirth.

She hasn't embarked on thorough research yet, and I've no doubt that she will be very meticulous when she does. However, she told me she'd already read somewhere that the postpartum infection rate for homebirths is around 4 percent, compared to 25 percent for hospital births.

I'd be v grateful if anyone can tell me if this is true or not! - and point me towards the source of the info if it is.

I wouldn't be at all suprised if the infection rate is higher for hospital births than homebirths. But that much higher?? For a quarter of women giving birth in hospital to get infections after birth seems extraordinarily high to me....

Thanks in advance.

Butterfly is spot on - a better comparison would be normal vaginal births at home and in hospital

the women who have homebirths us by definition do not have risk factors for postpartum infx inc PROM, preterm labour etc

am rummaging PubMed as we speak but tis hard to find good studies as most are either US (v few homebirths) or developing world

www.homebirth.org.uk/

This could be where your friend got her stats from. It could be that home birth has a lower risk of medical intervention such as episiotomy .

(It's under the heading 'Why Homebirth' - point 2 under second paragraph.)

Also have to bear in mind possible confounders - mothers at higher risk of infection (premature rupture of membranes, group B strep etc) are less likely to have homebirths.

Thanks mamalazarou -

It does indeed say exactly what my friend said!

But what's confusing is that it [point 2 in para 2 under 'Why Homebirth'] says "The rate of postpartum infection in women who give birth in hospital is about 25%, compared to about 4% in homebirth mothers (see the National Birthday Trust Fund study)".

So I clicked on the link to see the National Birthday Trust Fund study - dated 1994, so it's 15 years old - and unless I'm being a complete eejit, I can't see any reference at all to infection rates in the report summary.

I guess that raises a whole other set of questions... but thank you for locating the source quotation.

Mrs Badger/Butterfly effect, I see your points -

And any up-to-date good reliable comparative research about post partum infection rates in the UK would be v welcome if you do find any.

Butterfly, on homebirth and CS, I think the 1994 report on the homebirth.org website considers homebirths to be births that start off at home, with the intention to deliver there, even if they then transfer to hospital. They call them 'transferred home births.' Which is an interesting point, cos the mothers that do need a transfer tend to need emergency intervention, so are the group most likely to experience intervention. So their homebirthers do include women who have C/S's. Even though they obviously take place in hospital.

That's off the subject, really. Just me realising how much scutiny this info needs.

Or even 'scRutiny.'

I can't quite believe that the postpartum infection rate in hospital is 25%, whether that includes all birth methods or not. (Imagines Jane Seymour-like puerperal fever in every fourth bed...nah). For what it's worth I once read that, although UK hospitals do indeed have higher infection rates than other European hospitals, this didn't include maternity services. (and no, no idea where I read that either, so I suppose we are still waiting for someone with reliable stats....medical professional/researcher anyone???)

ok this study from the US suggests a slightly more believable 6%

NB remmeber 'postpartum infections' may include mastitis, UTIs, eye infections in the newborn resulting from STDs in the mother (eg trichomonas and chlamydia) and things like thrush as well as the 'biggies' of endometriosis and wound infections

That's interesting MrsB, thank you for finding that (US but more recent study) -

I see your point about postpartum infection including minor things. A good reminder, cos the first thing I think of in terms of hospital infections is MRSA, but that's just my alarmist brain.

I don't think the homebirth.org site includes infections in newborns, though. It says: ""The rate of postpartum infection in women who give birth in hospital is about 25%..."

I share bellissima's dubiousness about the 25 percent figure. I'm also starting to feel a bit cross and sad that my mate, starting to worry as her EDD gets nearer, has (very understandably) already been scared by this '25 percent/4 percent' figure. If it is bad info, it shouldn't be part of anyone's decision making process.

Hi - I'm the owner of www.homebirth.org.uk and I've just stumbled on this discussion. Quite a blast from the past as I think I summarised the results of that study a year or two after it was published, so late 1990s! The stats came from the National Birthday Trust Fund study on homebirth in the UK, which is the most comprehensive study of homebirth here - around 6,000 women planning homebirth were each matched for risk factors with a local woman planning a hospital birth (ie the midwives selected someone who was as similar as possible in terms of age, parity and obstetric history). It was a hugely detailed study, and was published as a hardback book, 293 pages long. Unfortunately the index is rubbish and comparisons and statistics are often not in the section where you would expect to find them. So, I've gone back to the book to try to find more details of the comparison of postpartum infection rates, and will report back when I track it down.

I would expect that the 25% rate would , as suggested above, include women with CS, whereas in this case the postpartum infection rate for homebirth is probably (if I remember right) for actual homebirths rather than planned homebirths (which would include transfers). So yes, a better comparison would be the straightforward vaginal births in hospital versus the actual homebirths. I would also expect, given the numbers, that this was not Jane Seymour-style puerperal fever, but would likely include postpartum would infections (eg cs scar infections and infected tears or episiotomies). The figure was for all postpartum infections, not uterine infections. You would expect the infection rate in hospital to be higher for several reasons though, even if we did have an ideal study comparing straightforward vaginal births in hospital and at home. For a start, the woman is not going to encounter any 'new' infectious organisms in her home, whereas in hospital there are more people and so a wider variety of bacteria. In addition, multiple vaginal examinations in labour are linked to a higher likelihood of uterine infection, and generally women labouring at home experience fewer VEs.

Anyway, I'll go back to the NBTF study and see what I can find for you. It would be nice to have something up-to-date, but as MrsBadger says, the research we want isn't necessarily there.

Cheers,
Angela

Angela, I was the OP on this thread, under another name - you are very diligent to respond!

I am still very interested in post-birth infection rates in hospital - if they are anywhere near 25 percent, then it would be deeply shocking. I think the overall rate of post operative infection in hospitals in the UK is around 7 percent, so it would be nothing short of a scandal.

I would assume that HB rates of infection are lower than hospital births, for all the reasons you list above. If that forms part of someone's decision about a HB, then great - but the comparison between 25 percent and 4 percent is so extreme (and had quite an impact on my friend), I really want to know if it's accurate.

HB is definitely not for me, btw, BUT I think every woman has the right to make an informed choice about birth based on facts. Otherwise choice isn't choice, really.

In my friend's case, FWIW, I think a HB might have given her a better outcome, although it's all guesswork really. She was never that strong in her desire for a HB, and was told by a MW that because she was a strep B (is that right?) carrier, she had to give birth in hospital anyway. She had a miserable time, was left alone for very long periods of time, was given a syntocin drip with out of date drugs, and a mistake in the dosage - it all ended in a EMCS and long stay in hospital for her. She subsequently made a complaint, and several areas of practice were changed as a result. Which is good, but she still had an awful birth.

I too am planning a home birth, and yes there is lots and lots of evidence that infection risk is much lower for home births than hospital.

Also true when comparing only low risk (tick all the boxes to be "allowed" a NHS homebirth) birth in a hospital and comparing the same group of low risk mums who home birth.

For low risk mums to be a home birth is the safest place all round.

(having read up alot from numerous sources, off the top of my head, i dont recall the difference being as extreme as 25% VS 4% though, but most definitely a significant difference

Has for "having" to give birth is a hospital..... NO ONE (unless sectioned under mental health) has to give birth in a hospital. The NHS / Drs / Midwives will advise on where to give birth, but regardless of advice decision is ultimately the mothers. I dont think NHS midwives will attend a birth of a baby before 37 weeks though

Hi Fruitybread. I haven't had a chance to trawl through the NBTF book yet to track down that ref, but I can assure you it will be based on fact - it was a generally well-designed study, thoroughly checked out by ethics committees, conducted by a well-respected charity (the National Birthday Trust) and overseen by three authors - a consultant obstetrician, a midwife and a statistician, I believe. And I was even more uptight about being strictly accurate about quoting research then than I am now ;-) But, as you say, the figures do look strange compared to more modern studies - for instance, this eMedicine article is referencing rates well under 10%: emedicine.medscape.com/article/796892-clinical#a0218

What I suspect is that the categories of 'infection' included were wider than the usual for postpartum infections. But, as you say, informed choice must be based on accurate information, and that also means as up-to-date as possible (although tbh 15 years or so is fairly recent for obstetric research) so I will put this on my 'to do' list for updating. My personal mission is to give info about homebirth, warts and all; we're not doing anyone any favours by being over-optimistic about one birth choice compared to another. I think people sometimes are over-optimistic about their preferred choice, but I do fight that consciously, because you know, I really don't want to persuade people to have homebirths; I just want to put the information together in one place, that I had trouble finding when I wanted it. I guess now, 13 years and 6 babies later, I'm probably a bit more detached about birth choices than I was back then. Nobody is totally unbiased, but I think we can be aware of our personal preferences and continually question them and ask if they are justified.
Anyway, thanks for raising this; I am really sorry to hear that the OP's friend was scared by that material on infection rates. Just goes to show how context is important; I might hear 'infection' and think episiotomy wound, while someone else might be thinking Jane Seymour death throes.

Re your friend with GBS - yes, it's quite common for women to be told they 'have' to have intrapartum antibiotics. There's a good case for it, but the Royal College of Obstetricians and Gynaecologists point out in their evidence-based guidelines, routine antibiotics in labour for GBS carries a different set of risks. I just don't understand what's wrong with offering women the information and respecting their decisions :-( Anyway, if you're interested - www.homebirth.org.uk/gbs.htm

Cheers,
Angela

my friend had a hideous infection after her first (very straight forward) first birth. she was in hopsital for the first 3 weeks of her childs life whilst her perfectly healthy baby was at home with daddy.
anything that could be done to help lower infection rates should be done!

Really appreciate your post Angela. I totally hear what you say about birth preferences/info. Thank you in advance for trawling the study to find the PP infection rates.

As a PS, ironically, once my friend was in hospital, and in labour, there was some long drawn out business as to whether she was supposed to be having IV antibiotics or not. She hadn't read up about it all, just assumed there was a protocol and everyone would know what it was, so she found it very alarming. :(

Greyskull, the first person I talked to about homebirth was a lecturer in microbiology who had previously worked in a hospital lab and spent a lot of her time examining infectious organisms. She also got a dreadful infection after her first birth, in hospital. She chose to have her next baby at home on the basis of the infection risk. I remember being shocked - "Are you allowed to do that?" and the utter revelation of her explaining that nobody could "allow" her to do anything, and as a mentally competent adult woman she could make her own decisions. I just didn't know it was possible.