The World Health Organization (WHO) recommends that that all women should be offered midwife-led continuity models of care, which is not always common practice in our current system. The WHO also states that “83% of all maternal deaths, stillbirths and newborn deaths could be averted with the full package of midwifery care.” Still, more families are exploring birthing options that allow them to birth out of the hospital in recent years.
In a meta analysis from the American Journal of Obstetrics and Gynecology (AJOG), researchers looked at peer-reviewed medical literature detailing maternal and newborn safety of planned home birth versus planned hospital birth. Researchers looked at literature from developed western nations reporting outcomes for mothers and newborns based on their planned delivery location.
In this AJOG meta analysis, researchers found that a planned home birth was associated with fewer:
The table below indicates some of the findings reported.
|Number of studies||Planned home|
|Intervention (cesarean delivery)||10||731/14,616 (5.0)||3140/33,697 (9.3)|
|≧3-degree laceration||5||150/12,604 (1.2)||794/31,740 (2.5)|
|Postpartum bleeding/hemorrhage||7||933/18,720 (4.9)||1639/32,552 (5.0)|
|Infection||5||36/5,341 (0.7)||319/12,347 (2.6)|
|Newborn ventilation||3||497/13,525 (3.7)||502/10,701 (4.7)|
|Low birthweight ＜10% or ＜2500 g||4||209/15,411 (1.3)||468/21,290 (2.2)|
|Newborn ventilation||3||497/13,525 (3.7)||502/10,701 (4.7)|
The evidence also suggests that a newborns safety varies at different stages depending on whether they are born in a hospital or during a planned home birth. Researchers discovered that babies born in the hospital and during a planned home birth had similar perinatal (relating to the weeks immediately before and after a birth) mortality rates.
The neonatal mortality, in terms of absolute numbers, is shown in the table below. Of the nonanomalous or “fixed effects model” sample, 1.5 per 1000 planned home births are reported for neonatal mortality. It’s worth noting that the sample sizes for these comparisons are 15,633 and 31,999 for planned home births and planned hospital births, respectively.
|Number of studies||Planned home|
|6||229/331,666 (0.07)||140/175,443 (0.08)|
|Perinatal death (nonanomalous)||4||225/330,324 (0.07)||134/173,266 (0.08)|
|Neonatal mortality (all)||7||32/16,500 (0.20)||32/33,302 (0.09)|
|Neonatal mortality (nonanomalous)||6||23/15,633 (0.15)||14/31,999 (0.04)|
Harvard researchers explain that gathering data around the location of birth can be challenging without randomized studies, but in a systematic review and meta analysis using peer-reviewed protocol for research, McMaster University found “no clinically important or statistically different risk between home and hospital groups.”
The study, led by McMaster, is the first of its kind and used data from 21 studies published since 1990 comparing home and hospital birth outcomes in Sweden, New Zealand, England, Netherlands, Japan, Australia, Canada and the U.S. Outcomes from approximately 500,000 intended home births were compared to similar numbers of births intended to occur in hospital in these eight countries.
Eileen Hutton, professor emeritus of obstetrics and gynecology at McMaster stated: “Our research provides much needed information to policy makers, care providers and women and their families when planning for birth,” said Hutton.
In another study, Oregon researchers attempted to outline the safety of mothers and babies by closely examining whether a mother gave birth at home, the hospital, or was transferred from home to give birth at the hospital. The researchers looked at perinatal morbidity rates, maternal morbidity, and obstetrical procedures based on the different birth plans and found that “the absolute risk of death was low in both settings.”
Much of the research echoes the findings of this Oregon study in that there are risks to birth in all settings, but that the absolute risks of both planned home births and hospital births is low. The plan that families choose relies heavily on opportunities for safety, comfort and necessary interventions.
Many American families still aren’t aware of their birthing options, such as home birth or birthing centers, but the data shows that women who have planned home births are actually safer from certain complications that can occur during birth. In fact, researchers discovered that when compared to those with planned hospital births, low-risk women had lower rates of:
The cohort study in the Netherlands aimed to learn whether low risk women at the onset of labour with planned home birth have a higher rate of severe acute maternal morbidity than women with planned hospital birth. It’s currently the largest study to date into the association between planned place of birth and severe adverse maternal outcomes.
Factors such as transportation, and the midwives training play significant roles in the outcomes of planned home births but when looking at the safety for mothers, the study showed that “There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system.”
A low-intervention approach is one of the main reasons why families choose to birth at home and seek the services of a midwife. Recent data shows that the rate of interventions during birth in hospitals has been steadily rising with varied results.
The scientific journal “Clinics in Perinatology” details intervention rates including cesarians which have seen rapid increases over recent years. The percentage of United States cesarean births increased from 20 percent in 1996 to 31 percent in 2006 for women of all ages, race/ethnic groups, and gestational ages and in all states. The journal explains that “Increases in primary cesareans in cases of ‘no indicated risk’ have been more rapid than in the overall population and seem the result of changes in obstetric practice rather than changes in the medical risk profile or increases in ‘maternal request.’”
The way families explore their birthing options is changing and so is the landscape of the healthcare industry, so it’s important for families to get a holistic view of their options based on the evidence. There are risks to birth in all settings, but there are also things expectant families can do to mitigate risk, such as learning as much as they can about their health and their available options.
|1||Maternal and newborn morbidity by birth facility among selected United States 2006 low-risk births.|
|2||Births: final data for 2006.|
|3||ACOG statement of policy: home births in the United States.|
|4||Home versus hospital deliveries: follow up study of matched pairs for procedure and outcome.|
|5||Five year prospective survey of risk of booking for a home birth in Essex.|
|6||Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands.|
|7||Outcomes of planned home births compared to hospital births in Sweden between 1992 and 2004: a population-based register study.|
|8||Meta-analysis of observational studies in epidemiology.|
|9||Data collection instrument and procedure for systematic reviews in the guide to community preventive services.|
|10||A matched cohort study of planned home and hospital births in Western Australia 1981-1987.|
|11||Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: a retrospective cohort study.|
|12||Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician.|
|13||Outcomes of a rural Sonoma county home birth practice: 1976-1982.|
|14||Should there be a trial of home versus hospital delivery in the United Kingdom?|
|15||Outcomes of planned home births in Washington State: 1989-1996.|
|16||Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births.|
|17||Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia.|
|18||Rates of and factors associated with delivery-related perinatal death among term infants in Scotland.|
|19||Planned homebirths in South Australia 1976-1987.|
|20||Perinatal death associated with planned home birth in Australia: population based study.|
|21||Evidence-based compared with reality-based medicine in obstetrics.|
|22||Planned home and hospital births in South Australia, 1991-2006: differences in outcomes.|
|23||Substandard factors in perinatal care in the Netherlands: a regional audit of perinatal deaths.|
|24||Perinatal audit on avoidable mortality in a Dutch rural region: a retrospective study.|
|25||Swedish women's interest in home birth and in-hospital birth center care.|
|26||Does a pregnant woman's intended place of birth influence her attitudes toward and occurrence of obstetric interventions?|
|27||Women's memories of home-birth 3-5 years on.|
|28||A psychosocial analysis of women planning birth outside hospital.|
|29||Planned and unplanned home births and hospital births in Calgary, Alberta, 1984-87.|
|30||Staying home to give birth: why women in the United States choose home birth.|
|31||Comparison of midwifery care to medical care in hospitals in the Quebec pilot study: clinical indicators.|
|32||Interspecialty differences in the obstetric care of low-risk women.|
|33||Do maternity care provider groups have different attitudes toward birth?|
|34||Outcomes of planned hospital birth attended by midwives compared with physicians in British Columbia.|
|35||Midwife-led versus other models of care for childbearing women.|
|36||Home versus hospital birth: process and outcome.|
|37||Economic implications of home births and birth centers: a structured review.|