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.