Tuesday
Sep012009
Home births safer than hospital births for low risk pregnancies
Tuesday, September 1, 2009 
Image credit: yelahneb on flickrWhere is the safest place to give birth?
If you are at a low risk of complications, then a midwife assisted home birth is your best bet according to a new Canadian study by Dr. Patrician Janssen from the University of British Columbia.
Better outcome for the infant
According to the CBC, the study found that the rate of death per 1,000 births in the first month of life was:
- 0.35 for planned home births
- 0.57 for hospital births with a midwife
- 0.64 for hospital births with a physician
Newborns born at home were less likely to require resuscitation or oxygen therapy after birth and were less likely to have aspirite meconium. Babies born at home were more likely to be admitted to hospital after birth than those born in a hospital. However, this was for fairly easily treatable and common conditions like jaundice and a baby born in the hospital that has jaundice probably wouldn't have been sent home in the first place if it was jaundiced (therefore there would be no record of the baby being admitted to hospital).
To be fair, all of these are excellent outcomes and there are not significant statistical differences between them. But I still find the figures telling, due to the frequent criticism of or fear about the safety of home birth and assumption that hospital + doctor = safest.
(The scaremongers would have you believe that if the baby doesn't die during birth at a home birth, it would certainly die from suffocation co-sleeping with those crazy hippie parents.)
Fewer interventions and fewer problems
Women who planned to have a home birth were less likely than those who gave birth in a hospital to have obstetric interventions.
For example, the percentage of women that various types of interventions or undesirable outcomes by type of birth planned is as follows:
- Electronic fetal monitoring:
- planned home birth: 13.6%
- planned hospital birth with midwife: 41.9%
- planned hospital birth with physician: 78.8%
- Assisted vaginal delivery:
- planned home birth: 3%
- planned hospital birth with midwife: 7.2%
- planned hospital birth with physician: 13.8%
- C-section delivery:
- planned home birth: 7.2%
- planned hospital birth with midwife: 10.5%
- planned hospital birth with physician: 11%
- Third or fourth degree tear:
- planned home birth: 1.2%
- planned hospital birth with midwife: 2.9%
- planned hospital birth with physician: 3.4%
- Postpartum hemorrhage:
- planned home birth: 3.8%
- planned hospital birth with midwife: 6.0%
- planned hospital birth with physician: 6.7%
They were:
- 0.32 times less likely to receive electronic fetal monitoring.
- 0.41 times less likely to have an assisted vaginal delivery.
- 0.41 times less likely to suffer third- or fourth-degree perineal tears.
- 0.62 times less likely to have postpartum hemorrhage.
The study found that planning to have birth at home, even if the woman ended up in the hospital, resulted in her having fewer medical interventions. It isn't clear why, but the study's author hypothesized that one reason may be the determination of those women not to have interventions.
What was this study based on?
The initial reaction that a few people I spoke to had was to claim that these findings must be because midwives do not accept high risk pregnancies for home births. It is true that women must meet certain criteria to qualify as low-risk enough for a midwife assisted homebirth. However, this particular study included only low risk pregnancies that met the criteria for home birth. According to the Ottawa Citizen:
The new study involved 2,889 women attended by a midwife who began labour with the intention of giving birth at home. They were compared to 4,752 planned hospital births attended by the same group of midwives, and 5,331 physician-attended hospital births.
All the women met the same eligibility requirements for a home birth, meaning they were equally low-risk women.
Why is this the case?
Perhaps it is the confidence and attitude of home birthing moms that result in better outcomes. Perhaps it is the lack of pressure from the medical establishment to manage the birth process. Perhaps it is the model of care. Quite possibly it is a combination of all of those things.
This much is clear:
- If you are having a low risk pregnancy and are considering midwife assisted home birth, you shouldn't let anyone bully you into thinking it is unsafe.
- If you are planning a hospital birth, you should take what measures you can to avoid unnecessary interventions, such as hiring a doula, writing a birth plan, and taking other measures to avoid the medicalization of your birth.
Unfortunately, not enough women have true choice about where and how to give birth. We need to improve that so that women can choose the safe option that is best for them.
Reader Comments (40)
When I got pregnant, I had NO intention of having a midwife-attended homebirth. I was upset at the thought of using a midwife, and when I got comfortable with her, I was upset at the thought of a homebirth! Now, I wouldn't have done it any other way; it was a beautiful experience. One of the things that stands out most in my memory is that a midwifery student attended my birth, and it was her first homebirth. As I held my baby, feeling stunned, gratified, and like I could face the world, the midwifery student looked at me with tears on her eyes, a huge smile on her lips, and said, "After seeing you, I know that I want to have a homebirth when I'm ready for a baby. That was AWESOME!"
I don't know how to help women choose other than by sharing my experiences with them. I met a couple at a child CPR class recently that was 36 weeks pregnant, and the woman was debating between a homebirth and a hospital birth. I shared my story, gave her my blog address, and let her know I'd be happy to talk more about homebirth. She never left a comment or emailed me or whatnot, but the next class, said they had decided on a homebirth. I hope I played a small role in that decision!
After 3 midwife attended hospital births I am about to (in Oct/Nov) have my first m/w attended homebirth. I am so excited! I wished after every baby that I had felt confident enough for a homebirth, and this time we are doing it! :)
I hate the language "these findings must be because midwives do not accept high risk pregnancies for home births". Midwives are not trained to do high risk pregnancies. Period. They make it sound like midwives hand select their clients to show better outcomes, but the reality is that they handle low risk pregnancies. As soon as the risk increases, their role changes. In an ideal world every low risk pregnancy would be attended by a midwife, freeing up OB's for situations in which there education and talent is required. Unfortunately it is near impossible to convince some people that the miracle of childbirth can occur outside the world of medicine...
Thanks for a nice take on the study.
I have had two midwife-attended hospital births (and if I have another it will be at home). I think that the high quality of post-partum care must be a factor in that lower death rate. A midwife comes to your home (even if you delivered in the hospital) and checks in on you and your baby on days 1, 3, and 5. You then follow up at their clinic every week for the first six weeks. The general health and well-being of the infant, the breastfeeding relationship, and the emotional and physical health of the mother are monitored closely by the same person who has attended you throughout your pregnancy. It truly is wonderful.
I understand your frustration at that comment. However, to be fair to the people who said it, I don't think that they intended to say that it is because midwives handpick their clients. I think they understand the situation and were simply making a comment that a high risk pregnancy is more likely to result in death than a low risk pregnancy. I just wanted to clarify that this study did control for that factor, so it isn't in any way skewing the data.
I am glad that some feel that way. I had a friendly discussion at playgroup today with a Mom that took that the way I responded. That is why that was fresh in my mind as a 'hot button'. :)
I was glad to see that did get mentioned, and was disappointed that CTV and CBC both left that out of their coverage of the study. Not sure if you have seen the study itself or not. Being a bit of an academic I had to chase it down and read it myself :) Here is the link incase you are interested.
http://www.cmaj.ca/cgi/rapidpdf/cmaj.081869
That's a great study! I didn't have a homebirth myself, but I'm a big fan since I myself was born at home. I was just wondering one thing, and I'm not sure if the info you have will answer it. Do the "planned homebirths" studied include births that were assessed to be low-risk, planned to be at home, and then required transfer to the hospital due to complications arising during labor? (My sense is that 5-10 percent of planned home births are transferred to the hospital at some point.) If those births were excluded, then the statistics may be skewed, since I'm sure the hospital births included births that were assessed to be low-risk but then some complications developed. Just wondering.
Oops, just reread what you wrote and saw that my question was answered. Sorry!
I thought I would throw in there that I have a friend who is a midwife in Manitoba, and in the 9 years that midwifery has been regulated in Manitoba there has been one emergency transfer to the hospital in the area south of Winnipeg. By emergency transfer I mean that the midwife felt the transfer was needed. Other transfers happen at the clients request - usually for access to pain measures not available at home...
[...] Read more at PhD in Parenting. [...]
It's a great study, but a couple of things you've written here are misleading. While the perinatal deaths superficially look like a progression, there was no statistical significance to the differences, which is important to note. And the way you have interpreted the relative risk figures is incorrect.
Nevertheless, this is a very important addition to the literature on homebirth safety. Something that I found particularly striking was that the homebirth eligibility criteria didn't exclude women having HBAC unless they'd had more than one C section, and also allowed women having outpatient inductions with ARM or vaginal prostaglandins - and excluding these women didn't change the results at all.
lauredhel: It has been 10 years since my last quantitative methods class. Can you help my old brain by further clarifying what you are saying. I don't want to be misleading, but I'm not sure I understand the problem fully.
Sure. For the first bit,I'm assuming you're familiar with notions of statistical significance and confidence interval, so I won't go over that.
For the second bit, you say "0.32 times less likely to receive electronic fetal monitoring" (etc), which is kinda garbled - the risk isn't reduced by '0.32 times'. The figures are actually relative risk figures, which means that for every 100 woman who had EFM in hospital, 32 women had EFM at home. Wikipedia has fairly decent writeups of statistical terminology - http://en.wikipedia.org/wiki/Relative_risk" rel="nofollow">here is the article on relative risk.
I fixed the bit on the relative risk. That is what I get for relying on the media report in a hurry. I should have known better (*head - desk*).
With regards to the statistical significance, I'm still not sure exactly what you are saying. I recognize that there is not a statistically significant difference in the outcomes between the three groups. I felt I addressed that by saying "to be fair, all of these are excellent outcomes" but I will add "and there is not a significant difference between them" and clarify why I find them "telling". I assume that is what you were addressing and not that the sample wasn't large enough for it to be statistically significant. But if I am wrong, let me know.
Ah, ok - yes, that media report is a hot mess. I didn't realise you hadn't read the actual study, sorry! It's available in fulltext online. I http://viv.id.au/blog/20090902.6454/canadian-study-finds-mothers-babies-much-less-likely-to-be-injured-in-homebirth/" rel="nofollow">linked it from my post earlier today, the study should make it much clearer!
Yes - I went to the actual study when I was making the edits to the post that I mentioned in my previous comment. Didn't go to it last night, but should have.
I hemorrhaged with my first birth as a result of a retained placenta, which happened because of an infection. This also caused me to go into labour prematurely and birth in the hospital. Following that experience, I chose a hospital birth the 2nd time around. Both times I was attended by midwives, and I would have been totally eligible for homebirth the 2nd time. So I wonder if birth history colours things a little bit. That is, women who have had previous complications may be less likely to choose home birth and more prone to the complications naturally.
All the same, I am glad to see this study. I think that if you want to choose homebirth that it should be an option, and you shouldn't be dissuaded from it because of fearmongering. My belief is that the best birth happens under conditions that make the mother comfortable and relaxed, whatever those may be. So expanding options, especially when proven safe, is always a good thing.
Apparently there is a limit to how far comments can be threaded. The last comment was supposed to be a reply to @lauredhel's last comment.
An unbelievably well timed story for me.
I am 8 days past my EDD with my first child. We have been planning a homebirth with our midwife, but are getting a little frustrated now that our little peanut is waiting so long to come out that we may have our hand forced and end up getting induced. I just got back from the hospital where my m/w and the on call OB did a non-stress test. Everything is fine, baby is kicking like crazy, the biophysical profile they did 2 days ago was also perfect. And yet the OB still suggested that we could just induce today if I wanted (obviously I don't!). After I declined that, she tried very hard to convince me to schedule an induction for the day after tomorrow, when I will be 10 days over. I know that this is often the "theoretical" ceiling that they use for inducing labour, but it made me a little crazy. All the tests show that baby is still fine, and there are tons of women who go up to 2 weeks over with no complications. I ended up convincing her to schedule it for 1w+5 days, and I'll have another BPP and NST between now and then just to make sure everything is still good. (Of course praying that baby comes on his own before then!)
Obviously this is somewhat off topic, but it just seems like the OBs are so intervention happy that they would gladly induce when there is no medical reason to. Baby does not seem overly big, all tests are passed with flying colours. I actually got told by the OB "I'm on call tomorrow so it would work well if we induce you then". Seriously? You seem nice, but I just met you 10 minutes ago! Why on earth would I schedule my baby's birth around YOU?
Sorry for the rant... just needed a forum and this seemed a good one. Love your blog by the way, I've devoured every posting, especially while I've been home for the past few weeks waiting impatiently!
Anna
hooray for homebirths!
here in BC we enjoy a wonderful midwifery community and wish the same for all communities. truly powerful experience for us even though, because of an immediate flag for the midwife, we had to stop at home and go to the hospital. our midwife was with us the whole way and witnessed hospital staff giving our midwife all the room and respect she needed to do her best at assisting my wife through the birth and the unpredictable complications that confronted us.
this is a very powerful document that gives the respect midwifery deserves.
dz.
Would you say the conclusions/results of this study also apply to American women? I'm trying to think if there's any reason why the study would not apply..... I'm not coming up with anything....... Maybe I'll try for a homebirth for my third child (if I am blessed with the financial situation that we could try for a 3rd child!)
I think maybe you would need to look at whether the training that the midwives recieve is comparable to that in BC where the study was done. There MWs undergo 4 years of university training and extensive practical placement experience. Also, the MW delivering in the hospital would be practicing independently (for the most part, unless a consult was needed) from MDs, and they have their own admitting privileges, etc. I know that training in the US depends what state you are in, and whether you are talking nurse-midwives or lay midwives...
What Lindsay said....
I wouldn't do a home birth, but I respect women who choose to do so. My neighbour just last week gave birth to her third daughter, at her home.
However, and I'm only basing this on my experience, when I gave birth to my second son earlier this year, there was a complication during the delivery. His heart rate dropped drastically (120 to 60) and thankfully there was an obstetrician on hand who knew exactly what to do and managed to reach in and release the cord which was around his neck. It was probably the most frightening moment of my life.
I was thankful to be in a hospital, because if the doctors hadn't managed to solve the problem, the next step would have been an emergency c-section, which thankfully was not needed, but if it had, we may have only had a matter of minutes to get him out.
I realize this is a one-off incident and that most deliveries run smoothly. It's a personal experience that has definitely influenced any decision making should I have any more children.
I had a beautiful home VBAC for my second child. I didn't start off wanting a home birth, but all of the extra precautions they place on a VBAC led me to changing providers to my wonderful midwives and choosing home over hospital. I am so grateful I had the opportunity to birth at home, I wish I had done it for my first.
Scary indeed! I also chose a hospital birth for a number of reasons, but one of them was the distance from our home to the hospital. I even chose to go to a hotel for part of my early labour so that I would be close to the hospital, but not in the hospital where interventions were more likely. As I said in the post, both home births and hospital births can be very safe, but I think that women that choose hospital births would be best advised to consider doing things like hiring a doula, having a birth plan, and ensuring their hospital is supportive of natural birth.
[...] studies that back up the safety of home birth. I was so happy to see news of a study showing that home births are safer than hospital births for low risk pregnancies. Yes! Shout it from the rooftops! Do more studies! Spread the [...]
I think having a doula or midwife present at a hospital birth would be my ideal scenario.
Yay home birth! I read more and more studies that say this very thing, healthy low risk births are safe at home. We need to give more women the option to choose home.
[...] studies that back up the safety of home birth. I was so happy to see news of a study showing that home births are safer than hospital births for low risk pregnancies. Yes! Shout it from the rooftops! Do more studies! Spread the [...]
One thing that helped my husband come on board for the homebirth decision was that regulations require a hospital to be able to stage a crash c-section in 20 minutes. That's how long it takes to prep the OR, scrub in, get the anesthesiologist there, etc. So we reasoned that if we were within 20 minutes of the hospital by ambulance (we are actually about 5 min away), then in the very unlikely even that I needed an emergency c-section, the MWs would call ahead and the OR would be ready when we arrived, leaving us no further ahead or behind than if we'd been in the hospital in the first place. I thought it was so interested that even though they talk about 'crash sections' and 'emegency situations', it still take 20 minutes?! I'm wondering if certain bigger hospitals could get things together a little faster, though.
The answer is no. Since no hospital has staff waiting doing nothing in the event of an emergency they need time to be pulled from their posts and the appropriate steps put in motion; Meds need to be retrieved from locked cabinets or internal pharmacies; the OR needs to be prepped for the relevant procedure... In smaller hospitals the wait CAN be longer if the limited OR's are already in use - or staff has to paged from off-site... 20 minutes is a very short time to get things pulled together.
This kind of study is essential at empowering women to make choices that are in line with their values and preferences. I think that is what it comes down to, being able to choose. And not have to deal with nay sayers who try and guilt pregnant women in to giving up on some personal quest that is self indulgent to the risk of their child. The more I read about homebirth, the more sense it makes.
Many women would not feel comfortable with home birth, and that is their choice. I am a woman who feels comfortable with home birth, and is still angry at the unhelpful, irrational lines of reasoning that were given to me about how dangerous home birth is.
So glad there's a well controlled, Canadian study showing these results. My first child was born in a mid-wife assisted hospital birth but I am seriously considering a home birth for my next child - I laboured much better at home - my labour slowed significantly once we got to the hospital.
I'm sure Ina May Gaskin would not be suprised by these results! She's been saying this for years! They've also known this in Europe for years - homebirths are the norm there.
Thank you for posting this. The article came out while we were readying our family for a much-needed long weekend away and I haven't had time to write about it. I am SO glad that the statistical safety of homebirth (compared to being in a germ-infested hospital) is the safest choice for most moms and babies is finally getting some of the recognition and understanding that it needs and deserves.
Thank you for writing this!
The study reported statistics on infant mortality; just wondering if anyone has come across stats related to infant morbidity (e.g. incidence of cerebral palsy (CP) or other neurological issues) after home birth vs. hospital birth. Given that there were lower rated of infants requiring resuscitation or oxygen therapy after birth at home, I'd suspect that incidence of neurological issues would also be lower, but I'm wondering if there is any evidence to support this. I've done some searching but haven't been able to find anything - any help would be really appreciated!
Rebecca, the British Columbia study did look at birth trauma to the baby as well. The risk of birth injury (brain haemorrhage, skull and clavicle fractures, and nerve injuries) was far greater in hospital, and the difference was statistically significant. I've written a bit of it up http://hoydenabouttown.com/20090902.6454/canadian-study-finds-mothers-babies-much-less-likely-to-be-injured-in-homebirth/" rel="nofollow">here. I put that http://farm5.static.flickr.com/4050/4279180356_4e511a55ed_o.jpg" rel="nofollow">data table up here for you, also. (If you can't access it, I'm sorry, I can't transcribe it right now - perhaps someone else can?)
There was a study published in the British Medical Journal that shows basically the same results for American women. It compared births in North America (USA included for sure, and I think Canada was as well) showing homebirths with a trained attendant had equal if not better outcomes than hospital births.
Not knowing your story or the details, is there any reason to think a midwife wouldn't have caught that or wouldn't have been able to remedy it?
[...] [...]
I am insanely jealous of the mothers who get to choose.
I'm a type II diabetic. I am apparently not allowed choice when it comes to having a baby. I have a hospital birth with every intervention shoved down my throat until I cave during a contraction and have a C-section.
I'm 14 weeks tomorrow and they're already trying to force me to schedule a section and if not a section, my induction. It's going to be a long 6 months.