Is Home Birth Really As Safe As Hospital Birth? “Woman-centred Care” vs “Baby-centred Care”

Imagine that you and your partner are having a baby in hospital. Tragically something goes wrong unexpectedly during birth and the baby is born blue. He urgently needs resuscitation if there is to be a chance of preventing permanent severe brain damage. How long would it be reasonable for doctors to wait before starting resuscitation? 15 minutes? 5 minutes? 1 minute?

What would be a reasonable excuse for delaying the commencement of resuscitation? They wanted to get a cup of coffee? The mother wanted to hold the baby first? The mother had catastrophic bleeding and this needed urgent attention?

If it were my baby, I would not want any delay in starting resuscitation. And there would be no justification for delaying resuscitation except some more serious, more urgent problem for another patient, such as the mother.

Yet when people choose homebirth, delay is precisely what they choose. It is simply not possible to start advanced resuscitation in the home within minutes. And their reason is not typically some relevant competing health concern that necessitates delivery at home.

Choosing home birth is choosing delay if some serious problem arises which requires immediate resuscitation.

If you could know for certain which babies were going to be born needing resuscitation, and which weren’t, you could deliver safely at home. But you can’t know for certain. Birth can be a dangerous, unpredictable time.

About 0.3% of babies are born with serious medical problems. So someone might argue that the chances of something going wrong at home or in hospital is sufficiently low for it not be necessary to further reduce an already small risk. However, given that around 700 000 women give birth in England and Wales every year, this translates to a large number with serious medical problems. Surely we should try to minimise avoidable severe life long disability?

If the numbers were very small, there may be reasons of cost-effectiveness not to try to reduce these to the very minimum. But even if the risk were 1/100,000, when it is your baby that is affected, it is a personal tragedy.

In a recent paper, Lach de Crespigny and I argued that a neglected outcome of choice of birth place was long term, significant avoidable disability. We argued that there are reasons to believe that the risk of this outcome is higher at home than in hospital, though accurate figures are not available. We called for more research to be done on what we call “future disability.”

Today, the National Institute for Clinical Excellence has issued a draft guideline for consultation entitled “Intrapartum care: care of healthy women and their babies during childbirth

Two key recommendations are:

  • Advise low-risk multiparous women to plan to give birth at home or in a midwifery-led unit (freestanding or alongside). Explain that this is because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit.
  • Advise low-risk nulliparous women to plan to give birth in a midwifery-led unit (freestanding or alongside). Explain that this is because the rate of interventions is lower and the outcome for the baby is no different compared with an obstetric unit, but if they plan birth at home there is a small increase in the risk of an adverse outcome for the baby.

The BBC reports, “Home births were just as safe as other settings for low-risk pregnant women who already had at least one child.”

This guidance is based on the largest prospective cohort study of the outcome of place of birth, The Birthplace Study. This followed nearly 65000 women. It found,

“There were 250 primary outcome events and an overall weighted incidence of 4.3 per 1000 births (95% CI 3.3 to 5.5). Overall, there were no significant differences in the adjusted odds of the primary outcome for any of the non-obstetric unit settings compared with obstetric units. For nulliparous women, the odds of the primary outcome were higher for planned home births (adjusted odds ratio 1.75, 95% CI 1.07 to 2.86) but not for either midwifery unit setting. For multiparous women, there were no significant differences in the incidence of the primary outcome by planned place of birth. “

This study found that home birth was riskier for first time mothers, but not for low risk women who had had at least one child already. But does that make home birth as safe as hospital birth for multiparous women?

This study did not examine the rates of severe long term disability arising from choice of birth place, which Lach and I argued is ethically the most relevant outcome. It tells us nothing about the outcome that matters most. What did this study measure as primary outcomes? It adopted a composite measure (that is it pooled a bunch of different outcomes): ” stillbirth after start of care in labour, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus, or fractured clavicle.”

Why did it do that? Although they studied nearly 65 000 women these adverse events are relatively rare – only 250 occurred in the study. To get statistical significance, they needed to combine these. But these outcomes are very different ethically. A fractured clavicle or humerus are fully correctable. They are completely different to permanent severe brain damage. Moreover, they don’t even grade the severity of these primary outcomes. Encephalopathy can be mild to severe. Some forms will not be associated with any long term severe disability. Taking these factors into account, this study is just underpowered to detect the outcome that matters most ethically – long term avoidable severe disability.

The authors admit as much:

“The weaknesses of the study include the use of a composite primary outcome measure, because of the low event rates for individual perinatal outcomes. We cannot rule out the possibility that the use of a composite may have concealed important differences in outcomes between planned places of birth, such as less severe outcomes in a particular setting. However, examination of the distribution of outcomes by planned place of birth did not suggest that this was the case. In addition, although many of the outcomes included in the composite are likely to reflect problems which occur during labour and birth, their long term implications for the baby are uncertain. For example, although moderate and severe neonatal encephalopathy are associated with development of cerebral palsy and long term morbidity, mild encephalopathy has not been associated with detectable longer term impacts.”

These outcome measures are reasonable surrogates of future disability. But even if there is no difference in these surrogates, this does not tell us of the rates of future child disability. Such studies would have to be very large and conducted over a long period of time at great cost.

There are other reasons to believe that this study does not tell us much that is useful about future child disability. They took a random sample of hospitals providing obstetric care. But there are reasons to believe that hospitals will differ in their capacity to offer rapid resuscitation, just as delivery at home cannot offer this to the highest standard possible. A hospital with a neonatal intensive care facility, and highly trained staff readily available, will be able to offer more effective resuscitation than smaller regional centres. (It is for this reason that my friends who are doctors have their babies in hospitals with access to neonatal intensive care). Even if there were no difference between home and hospital with respect to future disability, this would tell us little about the comparison between best obstetric/paediatric care and best home birth care.

Two of the authors of the Birthplace Study in response to our article make the point (which is echoed by the BBC and NICE) that hospital based care can be associated with higher rates of intervention, such as Caesarean, which exposes the mother and future pregnancies to risk. For example, the BBC reports:

“The guidelines from NICE – the National Institute for Health and Care Excellence – say a home birth may be just as safe for low-risk pregnancies. Hospital labour wards with doctors should be for difficult cases, it says. Otherwise there is a danger of over-intervention, according to NICE.”

This is a valid concern. However, if true, it would hardly be a good a reason to have home birth. It would be a reason not over-intervene in hospital! To be sure, getting hospitals to change their practices (some shaped more by concerns about efficiency, or simply bad institutional habits, than optimal health) may not be easy and does indeed need sustained attention to correct. But our focus should be best obstetric care, not second best care. In addition, the harms experienced by women in hospital are of a different kind to those experienced by a baby from hypoxia. For example, treatable infection is very different to life long severe disability.

The NICE guideline talks proudly throughout of “Woman-centred care.” At very least, this should be “Woman and Baby-centred care”

The fact is, we just don’t know if best practice home birth is as safe with respect to future disability as best practice hospital birth. There is not enough research. There is evidence it is more dangerous for first time mothers (though again this is not in relation to the outcome of future disability) and there are good reasons based on understanding of the risks of child birth and the interventions available to believe there will be some elevated risk at least related to delay in resuscitation associated with transfer. In our article, we reviewed a variety of arguments and existing evidence that suggest risk associated with home birth of future disability will be higher. For example,  a meta-analysis which  included 12 studies and 500,000 planned homebirths in healthy low risk women showed neonatal mortality tripled. But good direct research has not been done and it would require extremely large studies over many years.

The elevation of future child risk associated with home birth, if it exists, is likely to be small. But small risks of tragic outcomes ought to be minimised. For this reason, the Royal College of Obstetricians recommends that home birth only be considered “provided transport arrangements are in place for hospital transfer in the event of an emergency ” (quoted by the BBC)

But what kind of “transport arrangement” would minimise risk? An ambulance on stand-by? Whatever transport is arranged, it will involve an inevitable delay compared with delivery in a tertiary centre. And minutes matter for the baby.

Some might argue this is excessively risk averse. But the risk of injury to the child from not wearing a seat belt on any single trip, or even over a year is extremely small. Nonetheless, we believe that it is right to minimise this risk by putting on a seat belt.

Women should have choice over their place of delivery. But they should make that choice in full knowledge of the facts, arguments and gaps in evidence. There may be reasons to do with cost and distributive justice that preclude every woman and child being offered the best care possible. But where there is a choice, people should at very least know what is known, and what is not known, about the risks and benefits of each option.

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13 Responses to Is Home Birth Really As Safe As Hospital Birth? “Woman-centred Care” vs “Baby-centred Care”

  • Sarah says:

    It seems to me that the risks and benefits are not really well known at the moment, and that there appear to be significant difficulties in getting to know them (cost etc). So it is difficult to say what the doctor should say. Should she say the evidence we have is poor but doesn’t suggest a major difference and many prefer to be at home? Or should she say the evidence is poor, doesn’t suggest a major difference but a priori reasoning suggests that being closer to resuscitation is likely to be preferable? I think the latter, and it would have to be very strong data indeed that would have to prove that homebirth was actually *safer* before I would trust that over the fact that having operating theatres, NICU present is likely to produce a better outcome than waiting 20 minutes in the ambulance. So I am not sure “more research” is necessarily a panacea.

  • Julian Savulescu says:

    Thanks Sarah. I think my point was that patients have a right to have evidence put in context, with a reasonable range of interpreations. They also have a right to hear a range of reasonable arguments. One reasonable argument in this debate is that there is some reason to believe that hospital birth will be safer for the baby. Of course, it might be riskier – say there were high rates of semiskilled intervention that was dangerous to the baby. I agree a lot more research needs to be done but I think that it is telling that people who know the most about the risks (doctors themselves) tend not to choose homebirth for themselves. Of course, they may be institutionalised into thinking medical intervention is always good – or they might just appreciate the real risks better. As Lach and I said in our JME article, modern obstetrics has slashed the terrible perinatal and maternal mortality of a century ago. You can try to divide women into low risk and high risk, but there is always some risk in birth. I personally don’t believe in taking unnecessary risks. But everyone is different – the question here is what is a reasonable unnecessary risk. But essentially I agree – more research is not the answer. Because the risks are low, A LOT more research is necessary to definitively answer this question.

  • Natalie Brown says:

    The statistics are 5 in every 1000 have complications in hospital and 9 in every 1000 at home. That’s 1% more risk. Also regarding resuscitation, there are baby resus units set up at every home birth x

  • Jonathan Herring says:

    “Small risks of tragic outcomes ought to be minimised” we are told in this post. According to Banerjee (“Coital emergencies” (1996) 27 Postgrad Medical Journal 653–65) 0.6% of all sudden deaths occur during consensual sexual intercourse. That carries a non-negligable risk of cardiac failure. The message is clear you should only make love in a hospital. To adapt the wording of the post “Choosing home love making is choosing delay if some serious problem arises which requires immediate resuscitation” you might say. In fact pretty much any activity you would be safer doing with medical attention close by. Its only if one starts with a medicalised view of pregnancy and birth that the decision for a home birth is seen as a seen as “risk taking”.

    • Sarah says:

      But 100% of all childbirth deaths and injuries occur during childbirth…

      Child birth is medicalised not because it is a disease, but because it is a natural process which medicine has made a lot of progress in improving the outcome.

      Love-making is primarily (nowadays) for fun. So when we do it we accept that risk and would likely not want to damage the process by medicalising it since that is the whole point of the activity. But having a baby is primarily to get the baby from A to B, alive and undamaged to enjoy the rest of its life. Prioritising the mother’s enjoyment of the process is, I think, selfish.

      • Jonathan Herring says:

        Sarah, I think you have put your finger on the key issue. If you are right in saing ” having a baby is primarily to get the baby from A to B, alive and undamaged ” then your conclusions follow. However, it seems perfectly legitimately to see pregnancy and child birth as far far more than that and one that sees the experience in a relational context and does not reduce the pregnant woman to a baby production machine. In a similar way there is far more to parenting to producing a child 18 who is alive and undamaged.

        • Sarah says:

          Of course the pregnant woman is more than a baby machine, but likewise a child is more than an accessory or status symbol for the parents. A lot of the debate around homebirth and early child rearing is often rather competitive (e.g. breastfeeding, or those who have ‘orgasmic’ births), so the pressure is on the woman not to be a machine but rather to be a baby making goddess. Apart from anything else, it is a lot of pressure at a difficult, sleep deprived time.

          Can’t we settle on the fact that a mother is a human, producing another human, which, whilst joyful and special and normal is also painful and, on rare occasions, deadly. If we could stick to that understanding I think we might change how hospitals operate to make them more human-friendly. But likewise we could recognise that being a mother, even a very loving one, doesn’t protect your child from medical emergencies.

  • J Savulescu says:

    Thanks Jonathan. Well, I guess if your lovemaking with your wife (or partner) carried a 0.6% chance of killing your child at home, then we ought to consider whether you ought to make love in hospital, if that were significantly safer for your child. Indeed, sleeping with a baby if you drink alcohol, smoke cigarettes or take drugs ( carries a much less than 0.6% chance of killing your child, yet nonetheless the NHS recommends you should not do it. It is not about what you and your wife (or partner) consent to that ought to be the only consideration, but also what is the best interests of your child. Of course, these interests have to be weighed against each other – but lovemaking that has a 0.6% chance of killing your child is pretty hard to justify, using your analogy. So I stand by the claim that small risks of tragic outcomes (to innocent children) ought to be minimised. What you consent to (knowing the facts) affecting your own life is another matter. But many thanks for giving me the opportunity to clarify.

  • Jonathan Herring says:

    Thanks Julian. My example of sex was really designed to make this point. We would hope that a couple choosing a venue for sex would seek somewhere where they could be relaxed; express themselves freely; be open with each other etc. We would think it sad and indeed rather odd if the availability of medical assistance small risk of harm played a significant role in their decision (unless there were unusually at risk). That is because for acts of a particularly expressive and symbolic significance a small risk of harm and the potential need for medical help pales into significance. A couple who made their decision on location for love making based on the availability of medical help would have lost sight of what is important about the activity.

    The same is true of childbirth. Or at least there is nothing wrong in believing the same is true of childbirth.

    Your examples of smoking or drug taking are different because those activities are not activities with considerable personal symbolic and expressive significance.

    True, the baby cannot consent to this risk. But would we want parents who saw parenthood as all about risk avoidance and failed to recognise that the value in some activities lies precisely in putting aside concerns about small risks?

  • Julian Savulescu says:

    Jonathan writes, ” That is because for acts of a particularly expressive and symbolic significance a small risk of harm and the potential need for medical help pales into significance. A couple who made their decision on location for love making based on the availability of medical help would have lost sight of what is important about the activity.”

    Many people love sleeping together with their children when they were small. Not in any sexual way but in terms of in terms of the intimacy that was “particularly expressive and symbolic.” They also like it. I am sure it is even more important to mothers, especially breast feeding at night. It might even be psychologically beneficial for the child to sleep with a parent (though it seemed to me to not be conducive to learning to sleep by yourself). And it is completely natural – through most of human history it was the norm for children to sleep with the parents, not separated from them. Nonetheless, science has showed that it elevates the risk of smothering and killing the child if you sleep in the same bed with it. I was one of those people who loved engaging in this practice. I knew the risks when I did it. I probably would not do it much now, if I had small children. But the risks are small, so sleeping in the same bed as your child should not be illegal. Nonetheless, the NHS recommends against it.

    What I am arguing is that at the very least, people ought to confront the risks, the real risks, and decide whether they are worth taking. I have exposed my children to very significant risks by introducing them to off piste skiing, now they are older. They have avalanche transmitters and airbags to reduce the risks. And they have learnt to ski off piste with the best ski guide in St Anton. He is one of the few people I would trust with my life in that environment, and theirs. We have done everything to make it as safe as possible. Still risk remains – he was nearly killed in an avalanche in a low risk conditions (not with us). But I have made a judgement that the beauty and connection with nature that comes from great off piste skiing makes those risks worth taking, for me and my children. I worry about exposing them to those risks before they are 18. They love the skiing but I have exposed them to unnecessary risk. But I believe it is worth it. I will have to take responsibility if something happens to them.

    Everyone has a different attitude to risk. But to be really autonomous, you have to know what the risks are and stare them in the face. If you really believe having a birth at home is worth exposing your child to an uncertain but probably elevated risk, that risk is small enough for you to be able to expose your child to it. But when people are told that homebirth is “safe” they being denied the opportunity to stare the facts in the face and make a fully autonomous decision.

  • Jonathan Herring says:

    Julian, no one is saying that home births is “safe”. The question is the whether the elevation of risk (if any) is significant. To me your analogy with skiing makes my point.

    You do not state the precise risk for skiing off piste, its enough for you that it is “significant”. If I pushed you to state a precise risk and then told you in fact it was 0.1% higher, that would not affect your assessment. Skiers take the risk of death or injury because it is reasonable, not a precise percentage. To suggest that skiiers lack autonomy because they do not get the percentage figure exactly correct is absurd. Similarly for a woman choosing home births to say she lacks autonomy because you believe her assessment of the risk is too very slightly too small is bizarre. It puts an impossible burden on pregnant women to be engaging in complex statistical calculations in their birthing decisions to be able to competent.

    There may be some skiers who believe that skiing is all about getting from A to B without injury and obsess about precisely which route is safest to the finest statistical detail. Many skiers would think they have slightly missed the point of skiing. When selecting between a series of routes approved as reasonably safe the one that most puts the wind in your hair is more important than the precise percentage risk.

    So too there may be some who think pregnancy is about getting the baby from A to B without injury (see Sarah above) and they will want to know every statistic. For many other women, quite reasonably in selecting between reasonably safe options, the precise percentages matter less than the powerfully symbolic, expressive and relational values of birth. As skiing shows it is perfectly legitimate to know there is a small risk but be willing to take it, without being required or expected to know the precise statistical value of that risk.

  • Julian Savulescu says:

    No one is saying home birth is “safe” – really? I just went to the National Childbirth Trust website and it describes it as “very safe” for low risk women. The Guardian, May 13, 2014 ran its article with the title “More women should give birth at home, advice suggests”. You might think that is just a newspaper, distorting things again. But NHS Choices begins its page on homebirth this way, ” “More women should give birth at home, advice suggests,” reports The Guardian after draft guidelines produced by the National Institute for Health and Care Excellence (NICE) recommended that women with a low risk of complications in childbirth should be encouraged to either give birth at home or at a midwife-led unit.”

    I wouldn’t recommend to anyone that they should take their children off-piste skiing. I would advise them that there are life-threatening risks, they should take all possible precautions, they should learn how to do it as safely as possible and that they should very carefully about it before doing it. Off piste skiing has got even more dangerous as skiers and snowboarders, watching ski movies or clips, barrel into dangerous terrain, creating avalanches, killing others because they have no idea what they are doing or where they are. The real problem is that people don’t understand risk and don’t take it seriously, and most of all don’t deal with it responsibly.

    The most serious off piste or extreme skiers live with risk. They consider it all the time. And they seek to minimize it to allow them do they activities they love. It is possible to live with risk, and think about it, and still enjoy the best things in life. You have missed the point when you don’t fully appreciate the uncertainty and risk of living and doing. The fact is that every birth, now matter whether NICE calls it “low risk”, has some risk. You should think about it and decide what you are going to do about it. Saying it is “very safe” is misleading and irresponsible. I would describe both home birth and off piste skiing as “risky”. Because these words can be used to describe the very same risk of dying, it is far better to give people precise statistics, if they are available. When they aren’t available, the reasonable thing to do is to describe what could happen, and roughly how likely it is to happen. It is not that helpful just to tell people you think it is very safe, or risky.

  • Julian Savulescu says:

    One further thing. I have seen people die off-piste skiing. And I have seen the results of a birth go wrong, completely unexpectedly. When you see these things, you develop a respect for risk. Perhaps people would be less inclined to describe these things as safe if they saw the vivid results of a dead or severely brain damaged person. You might call this a bias but I call it healthy respect. And it needn’t paralyse you. But it does tend to reduce recklessness.