We sought to systematically review the medical literature on the maternal and newborn safety of planned home vs planned hospital birth.
We included English-language peer-reviewed publications from developed Western nations reporting maternal and newborn outcomes by planned delivery location. Outcomes’ summary odds ratios with 95% confidence intervals were calculated.
Planned home births were associated with fewer maternal interventions including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, and operative delivery. These women were less likely to experience lacerations, hemorrhage, and infections. Neonatal outcomes of planned home births revealed less frequent prematurity, low birthweight, and assisted newborn ventilation. Although planned home and hospital births exhibited similar perinatal mortality rates, planned home births were associated with significantly elevated neonatal mortality rates.
Less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate.
Approximately 1 in 200 US women deliver at home, accounting for approximately 25,000 deliveries annually. An estimated 75% of low-risk singleton home births appear to be planned home deliveries. The American College of Obstetricians and Gynecologists does not support home birth, citing safety concerns and lack of rigorous scientific study. Ideally, further investigation regarding the relative safety of planned home vs planned hospital delivery would occur via randomized trials, which are, however, impractical. Large cohort studies comparing outcomes of actual home with actual hospital births provide valuable data, particularly regarding rare but serious events. However, such investigations likely underestimate the risks associated with planned home birth, as up to 9% of parous and 37% of nulliparous women intending home birth require intrapartum transfer to hospital. Thus, adverse outcomes among the latter deliveries are attributed to hospital births. Therefore, cohort studies comparing planned home with planned hospital births provide the only sources of data by intended delivery location. Since individual reports of this design are limited by sample size, we employed metaanalysis according to proposed reporting methods to clarify the relative merits of planned home vs planned hospital birth.
For Editors’ Commentary, see Table of Contents
Materials and Methods
Computerized literature searches of MEDLINE and EMBASE were performed by a physician and medical librarian.
MEDLINE search results
The search strategy for the query for “all studies, regardless of methods, comparing intended/planned home births to intended/planned hospital births for maternal and newborn outcomes” was run in the MEDLINE database from 1950 through November week 1 2009 ( Figure 1 ). The following terms were used: explosion of the medical subject heading “Home Childbirth” (defined as childbirth taking place at home); explosion of the medical subject heading “Delivery, Obstetric” (defined as delivery of the fetus and placenta under the care of an obstetrician or a health worker; obstetric deliveries may involve physical, psychological, medical, or surgical interventions); explosion of the medical subject heading “Hospitalization” (defined as being in a hospital or being placed in a hospital; the confinement of a patient in a hospital); and explosion of the medical subject heading “Inpatients” (defined as persons admitted to health facilities that provide board and room, for the purpose of observation, care, diagnosis, or treatment). The terms “Hospitalization” or “Inpatients” or any mention of the word form “Hospital*” (designated with an asterisk as the wild card picking up any letters after the “l,” eg, “hospitals,” “hospitalized”) was then combined with the term “Delivery, Obstetric” to limit to a hospital birth. These results were then “anded” with the term “Home Childbirth” and by doing so indicated that the citation must include indexing for both terms; thus the discussion in the article would include both concepts. Limits to English language and human studies were then included. The final line of strategy was to take the retrieval and limit to any citations that would include the word forms for “outcome*” or “compar*” or “intend*” or “plan*” as a way to narrow the results to include the concepts of outcomes, comparisons, comparing, intended, or planned by using the asterisk as a wild card.
EMBASE search results
This strategy was done using EMBASE classic (1947 through present). Using the all subject words feature the term “Home Delivery” was searched. The term “Childbirth” was also searched and combined with any form of the word “Hospital?” with the ? indicating a wild card to pick up any forms of the word, such as “hospitals” and “hospitalization.”
The Cochrane Database of Systematic Reviews was also searched for relevant publications. Titles and abstracts of citations were reviewed for potential relevance and selected manuscripts were reviewed. References in these papers were manually reviewed and retrieved if potentially relevant.
Study selection criteria
Inclusion criteria were determined before the literature search was performed. Studies were included if performed in developed Western countries, published in English-language peer-reviewed literature, maternal and newborn outcomes were analyzed by planned delivery location, and data were presentable in a 2×2 table. Manuscripts were evaluated for quality using a published instrument. Outcome data were extracted by 2 physicians, with differences resolved by consensus. Outcomes for maternal intervention included epidural analgesia, electronic fetal heart rate monitoring, episiotomy, operative vaginal delivery (forceps or vacuum), and cesarean delivery. Maternal outcomes included mortality, morbidity measures of lacerations (≥3 degrees, vaginal, and perineal), infections (chorioamnionitis, endometritis, wound, and urinary), postpartum hemorrhage, retained placenta, and umbilical cord prolapse. Neonatal outcomes included 5-minute Apgar score <7, prematurity (<37 weeks’ gestation), low birthweight (<10% for gestational age or <2500 g), macrosomia (≥90% for gestational age or ≥4000 g), postdatism (≥42 weeks’ gestation), assisted ventilation requirement, perinatal death (stillbirth of at least 20 weeks or 500 g or death of liveborn within 28 days of birth), and neonatal death (death of a liveborn within 28 days of delivery). Perinatal and neonatal deaths were evaluated overall and for nonanomalous offspring. The study did not require institutional review board approval.
Studies were assessed for homogeneity using the Breslow-Day test. When present, a fixed effects model was used; when absent, a random effects model was employed. Summary odds ratios (ORS) with 95% confidence intervals (CIS) were calculated for maternal and newborn outcomes, comparing planned home to planned hospital deliveries. Sensitivity analyses were conducted for studies employing matched planned home and hospital births, those primarily based upon pre-1990 data, lesser quality reports, and those not clearly specifying home birth attendants or in which home births were conducted by other than certified or certified nurse midwives. We used software (SAS, version 9.2; SAS Institute Inc, Cary, NC) for most data analysis. Random effects results were analyzed using an online metaanalysis calculator from the University of Pittsburgh ( www.pitt.edu/∼super1/lecture/lec1171/meta5.doc ).
The results of the literature search are noted in Figure 2 . Characteristics of the 12 included studies are described in Table 1 . A total of 342,056 planned home and 207,551 planned hospital deliveries were available for analysis. No maternal deaths were reported in 4 studies totaling 10,977 planned home and 28,501 planned hospital births, precluding metaanalysis. However, we calculated the upper 95% confidence limits for these rates, expressed per 100,000 births, as 27.3 and 10.5, respectively. Table 2 presents the metaanalysis of maternal outcomes by intended delivery location. Planned home births experienced significantly fewer medical interventions including epidural analgesia, electronic fetal heart rate monitoring, episiotomy, and operative vaginal and cesarean deliveries. Likewise, women intending home deliveries had fewer infections, ≥3-degree lacerations, perineal and vaginal lacerations, hemorrhages, and retained placentas. There was no significant difference in the rate of umbilical cord prolapse.
|Setting||Study design||Time period studied||Publication year||Data source||Inclusions||Data analysis by parity||Planned deliveries, n||Intrapartum transfer to hospital rate|
|California, United States||Retrospective cohort||1976-1982||1984||ND||Single obstetrician and lay midwife practice, nulliparous and parous||Stratification||454||67||25/258 (9.7)||5/263 (1.9)||30/521 (5.8)|
|United Kingdom||Prospective cohort||1978-1983||1985||Submitted data collection forms||Low risk, parous, no past obstetric complications, 26 practices||Parous only||202||185||ND||3.5%||3.5%|
|Western Australia||Matched cohort||1981-1987||1994||Birth records, transfer forms, computer system||All Western Australian women booking for home birth and matched cohort of not planned home birth, nulliparous and parous||Matching||976||2928||ND||ND||14.0%|
|Switzerland||Prospective cohort with matched pairs||1989-1992||1996||Special data collection forms||Women receiving care from 1 team of physicians and midwives, no formal policy for planned home delivery, nulliparous and parous||Matching||489||385||25%||ND||15.9%|
|Netherlands||Prospective cohort||1990-1993||1996||Questionnaire, birth records||Low-risk pregnancies receiving midwifery care in 54 practices, nulliparous and parous||Stratification||1140||696||36.7%||8.7%||20.3%|
|Sweden||Population-based cohort||1992-2004||2008||Swedish Medical Birth Register||All Swedish women planning home birth and control group of 37-42 wk low-risk singletons in ratio of 1:10, nulliparous and parous||No||897||11,341||ND||ND||ND|
|British Columbia, Canada||Prospective cohort||1998-1999||2002||British Columbia Reproductive Care Program antenatal, birth, and newborn records||Low-risk women ≥36 wk planning home birth with midwife enrolled in Home Birth Demonstration Project and low-risk women 37-41 wk planning hospital birth, physician or midwife, nulliparous and parous||No||862||1314||ND||ND||16.5%|
|United Kingdom||Randomized trial||1994||1996||ND||Low-risk parous women in 1 practice||Parous only||5||6||0||0||0|
|Washington State, United States||Population-based cohort||1989-1996||2002||Birth certificates||Low-risk singletons ≥34 wk and ≥37 wk, nulliparous and parous||Adjustment||6133||10,593||ND||ND||ND|
|Netherlands||Population-based cohort||2000-2006||2009||National perinatal registration data||Low-risk singletons 37-42 wk, nulliparous and parous||Stratification||321,307||163,261||ND||ND||ND|
|Ontario, Canada||Population-based cohort with matched controls||2003-2006||2009||Ministry of Health midwifery database||Low-risk singletons 37-43 wk, nulliparous and parous||Matching||6692||6692||ND||ND||5.4%|
|British Columbia, Canada||Population-based cohort with matched controls||2000-2004||2009||Provincial perinatal database||Low-risk singletons 36-41 wk, nulliparous and parous||Not performed||2899||10,083||ND||ND||ND|