With increasing medical advances and the ability to rescue the mother and her baby, there has been a growth in the number of women who deliver in hospital facilities. This allows full care to be provided if required [1]. Maternal and perinatal mortality has fallen accordingly. This improvement in mother and baby outcomes has produced a conception of maternity safety in the developed world and a call for the return to home birth. This has concerned the obstetricians and particularly the paediatricians who feel that this produces unacceptable risk to the mother and her baby. However, evidence, mostly from Europe but some from the US, suggests that home birth can be relatively safe in the right circumstances. This needs a fully integrated comprehensive maternity care network that is supportive and responsive. The question is whether this should be supported to help improve the safety of home birth or resisted because home birth in many situations is inherently unsafe.
Introduction
Throughout history, most people have been born at home or in the community, and this remains true today. It is not that it was planned that way; it is just the way it was. It was not until the 1700s and 1800s did women begin to deliver in hospitals, but it was not for all . The wealthy delivered at home with their accoucheur . Hospital birth catered for the poor and destitute to give them the supportive surroundings that they did not have in the community . Maternity hospitals were not without their problems , and institutional birth was not seen as beneficial or safe by all.
From the mid-1800s, there were developments and greater understanding of sepsis , bacterial infection and aseptic techniques . In Edinburgh, the development of anaesthesia allowed for the opportunity for interventionist techniques to be developed. Caesarean section became established and was potentially lifesaving in cases of obstructed labour ( Table 1 ).
| 1888– 1940 |
| Aseptic techniques |
| Anaesthesia |
| Caesarean section |
| Suturing of the uterus |
| Influence of World War II |
| Safer anaesthesia |
| Antimicrobials (penicillin) |
| Blood Transfusion |
| Surgical skills and techniques |
| Institutional birth |
These changes were accompanied by a considerable reduction in maternal mortality: in Sweden, there was a steady decline from 900/100,000 births in 1750 to 6/100000 births in 1980. Two-thirds of this decrease occurred before 1900 and the remainder since . Similar reductions were found in the UK, although at slightly different times ( Figure 1 ) . Throughout this time, most women still gave birth at home.
In the late 1940s, the medical developments of blood transfusion , antibiotics and safe anaesthesia led to further reductions in maternal mortality ( Table 1 ). In the 1950s, the National Health Service encouraged mothers to give birth in hospital. At that time, housing conditions and general health were still relatively poor, and for many women, the hospital was the safest environment to give birth in. The move away from home births in the UK occurred largely between 1963 and 1974 ( Figure 2 ). In 1960, the percentage of women giving birth at home in the UK was 33%, but this fell to a 0.9% between 1985 and 1988, with a slight rise since. Maternal mortality continued to fall dramatically from 400/100000 in 1939 to 14/100000 in 1970 and to 10/100000 in 1980 ( Figure 1 ) .
In the Netherlands, there was a similar reduction in home births. In 1965, two-thirds of all births occurred at home. Over the next 25 years, this reduced so that two-thirds of births occurred in hospital and fewer than one-third at home . This is still a high rate of home birth, but the Dutch maternity care system depends on a high level of training for midwives .
Worldwide, institutional birth has been the cornerstone of actions aimed at reducing maternal mortality. However, there are various obstacles to this . These affect the efforts to reduce maternal mortality and are associated with three delays: (1) delay the decision to seek care, (2) delay arrival at a health facility and (3) delay the provision of adequate care ( Table 2 ).
| (1) Delay the decision to seek care |
| Lack of careful risk assessment and early referral |
| Unwillingness to escalate |
| Lack of fully trained midwives |
| No planned network structure or governance |
| (2) Delay arrival at a health facility |
| Poor communication between home carer and hospital |
| Lack of immediate transport arrangements |
| Excessive distance from facility |
| No planned network system for support and escalation |
| (3) Delay the provision of adequate care |
| Facility not receptive |
| No planned network response |
| Not treated as high risk on arrival |
| No obstetrician linked to care |
| No ownership of case as booked for home birth |
| Reasons for choosing home birth in the US | Total 169 | |
|---|---|---|
| 1 | safety | 38 |
| 2 | avoidance of unnecessary medical interventions common in hospital births | 38 |
| 3 | previous negative hospital experience | 37 |
| 4 | more personal control | 35 |
| 5 | comfortable, familiar environment | 30 |
| 6 | women’s trust in the birth process | 25 |
Is home birth safe? ( Table 4 )
The reduction in maternal mortality has made many people believe that pregnancy is now safe and forget that it is our ability to save in the hospital that has changed. However, this belief has led to a very vocal demand for a return to home birth, largely as a women’s right . Women who choose home birth are mostly married (91%) and caucasian (87%) with a college education (62%). The reasons they choose home birth are shown in Table 3 . The most common reason given was safety, the same reason people use to argue against it . These women equate medical intervention with reduced safety and trusted their bodies’ inherent ability to give birth without interference .
| Home birth benefits, risks and myths |
|---|
| Benefits |
| Reduced medical interventions |
| Better than previous hospital experience |
| More personal control |
| Comfortable, familiar environment |
| Risks |
| Increased risk of neonatal morbidity in primigravida |
| Need for hospital transfer in up to 45% of cases in primigravida |
| Less choice of analgesia |
| Less-skilled midwifery support |
| Women’s over trusting of the birth process |
| Myths |
| Home birth is not safer although interventions may be less |
| Epidurals are not less necessary, and they are just not available without transfer |
| The caesarean section rate is not reduced |
| Women are not happier after home birth |
Health practitioners who support home birth do so for three main reasons: a woman’s right to choose; it may be more cost effective; and if home birth is not supported, some women might choose to have a free birth, which is even more dangerous. Those who opposed home birth argue that complications can occur during childbirth, and timely transfer may not be possible .
In Europe, there is a long tradition of midwifery-led care, based in the community, in countries such as the Netherlands, the UK and Sweden. These services are integrated into the local maternity services. Various studies have tried to answer the safety question, but many have built-in biases and small numbers, making the power of the studies inadequate to assess considerable morbidity or mortality.
In the Netherlands, planned home births were found to be at least as safe as that of planned hospital births . However, when intrapartum and early neonatal mortality rates are compared, the raw data suggested that it was lower in home birth, but after case-mix adjustment, the relative risk showed a non-significant increase in perinatal mortality (OR 1.05, 95% CI 0.91–1.21). The study concluded that in certain at-risk subgroups, home birth has added risk (up to 20% increase) . A small study of cord gas analysis in 85 home births and 85 hospital births showed that the median values for pH in the umbilical artery (7.19) and base excess (−9.9 mmol/l) in home deliveries differed significantly from those of matched controls (7.25 and -7.7, respectively) delivered in the hospital. It appears that delivery in the hospital with continuous foetal monitoring favours the birth of less acidotic children . These studies suggest that although for the majority home birth is safe, it may be because things do not usually go wrong, but if they do, the risks are higher. Similarly, the rate of severe acute maternal morbidity in low risk women was low at 2.0 per 1000 births, and there was no evidence that planned home birth led to an increased risk . However, it is to be remembered that this was in a maternity care system with well-trained midwives and a good referral and transportation system where most homes are within 5 km of a hospital .
One of the main arguments of those advocating home birth is the psychological benefits. However, a study that assessed whether women who give birth at home are less prone to mood disturbances during the early puerperium than those who give birth in hospital found no difference in the incidence of blues and depression between women who gave birth at home and those who gave birth in hospital .
In the UK, a large prospective cohort study (Birthplace) provides some of the best data about the relative risk of place of birth, and its results are widely quoted (and misquoted). It compared perinatal and maternal outcomes and interventions in labour by planned place of birth at the start of care in labour for women with low-risk pregnancies. It involved women who gave birth at home, in freestanding midwifery units (FMUs), in alongside midwifery units (AMUs – midwife-led units on a hospital site with an obstetric unit) and a stratified random sample of obstetric units. Overall, 64,538 eligible women participated in the study. There were 250 primary outcome events giving an incidence of 4.3 per 1000 births (95% CI 3.3–5.5), again emphasising the relatively low incidence of complications. Overall, no significant differences were observed in the adjusted odds of the primary outcome for any of the non-obstetric unit settings compared with obstetric units. However, in nulliparous women, the odds of primary outcome were higher for planned home births (adjusted OR 1.75, 95% CI 1.07–2.86) but not for either midwifery unit setting. For multiparous women, no significant differences were observed in the incidence of the primary outcome by planned place of birth but the incidence of primary outcome was lower. Transfers from non-obstetric unit settings were high for nulliparous women (36%–45%) and lower for multiparous women (9%–13%).
Therefore, home birth is associated with fewer interventions, but for nulliparous women, there is a poorer perinatal outcome . Secondary analysis of the data showed a reduction in instrumental delivery and an increase in ‘straightforward vaginal birth’ in community-based care but no difference in intrapartum caesarean section rates .
In France, in 2005–2006, the out-of-hospital birth rate was 4.3 per 1000 births, but the rates were more than double in women living 30 km or more from their nearest maternity unit . The risk of neonatal mortality and morbidity is the highest in those living <5 km from a maternity unit, probably related to urban deprivation, and it increased again at ≥45 km compared with those living 5–45 km from a maternity unit. They concluded that neonatal deaths associated with out-of-hospital birth were rare but more frequent at longer distances of transfer . The Birthplace study demonstrated that the median transfer time from decision to transfer to first hospital assessment was 49 min. If the transfer distance was within 20 km, the time was 47 min, increasing to 55 min 20–40 km away and 61 min if more remote. In women who gave birth within 60 min after transfer, adverse neonatal outcomes occurred in 1%–2%. Therefore, transfers from home commonly take up to 60 min from decision to transfer and first assessment in the hospital, even for transfers for potentially urgent reasons . In a German study of 360 transfer cases, the most frequent reasons for transfer were premature rupture of membranes and failure to progress in labour. There was an increase in operative deliveries (caesarean section and instrumental vaginal delivery), and the babies were more likely to have low Apgar scores and be admitted to the neonatal unit, particularly in primigravida. Therefore, intrapartum-transferred women, in particular when nulliparous, represent a special high-risk group who may require operative intervention . These studies of distance and time taken to transfer need to be considered along with the studies on the effect of the decision to delivery interval for emergency delivery .
In Sweden, between 1992 and 2004, the neonatal mortality rate was found to be 2.2 per 1000 in the home birth group compared with 0.7 in the hospital group, but this did not reach significance (RR 3.6; 0.2–14.7) . In New Zealand, which has an independent midwife-led model of care, a study of 244,047 pregnancies showed that medical-led births were associated with lower odds of an Apgar score of <7 at 5 min (OR 0.52; 0.43–0.64), intrauterine hypoxia (OR 0.79; 0.62–1.02), birth-related asphyxia (OR 0.45; 0.32–0.62) and neonatal encephalopathy (OR 0.61; 0.38–0.97) than midwife-led care. There was a trend towards fewer infant deaths, but this did not reach significance for perinatal-related mortality (OR 0.80; 0.54–1.19), stillbirth (0.86; 0.55–1.34) and neonatal mortality (0.62; 0.25–1.53). The main difference in New Zealand is that midwives practice autonomously without close links to obstetric services, and these results may reflect this .
Over the last decade, the number of planned home births in the United States (US) has increased. Neonatal mortality rates in hospital births attended by certified midwives were significantly lower (3.2/10000) than those in home births attended both by certified (10.0/10000) (RR 0.33 95% CI 0.21–0.53) and uncertified midwives (13.7/10000) (RR 1.41 95% CI 0.83–2.38). This study confirms that in the US, neonatal mortality rates for home births are significantly higher than those for hospital births . Similarly, a New York study showed that neonates with hypoxic ischaemic encephalopathy (HIE) had a 44.0-fold (95%; CI 1.7–256.4) increased odds of having been delivered out of hospital, whether unplanned or planned . These results probably reflect the disconnect of home birth from hospital-based obstetrics in the US. The evidence of lower cord gas results , HIE rates and higher mortality opens the debate on the role of the future child in the decision-making process. The choice of place of birth may only be justified if it does not expose the future child to an unreasonable increased risk of avoidable disability. Couples should be informed of these risks, and doctors should attempt to dissuade couples when they elect a place of birth that puts the health and well-being of the future child at risk .
The UK studies suggest that home birth can be carried out in relative safety, but it requires teamwork, extensive expertise, neonatal and anaesthesia support, and ready access to equipment such as ultrasonography. Most women undergoing home birth have full access to all that modern maternity care can provide, including an obstetrician for advice and support. None of these are generally available in US home births .
Is home birth safe? ( Table 4 )
The reduction in maternal mortality has made many people believe that pregnancy is now safe and forget that it is our ability to save in the hospital that has changed. However, this belief has led to a very vocal demand for a return to home birth, largely as a women’s right . Women who choose home birth are mostly married (91%) and caucasian (87%) with a college education (62%). The reasons they choose home birth are shown in Table 3 . The most common reason given was safety, the same reason people use to argue against it . These women equate medical intervention with reduced safety and trusted their bodies’ inherent ability to give birth without interference .
| Home birth benefits, risks and myths |
|---|
| Benefits |
| Reduced medical interventions |
| Better than previous hospital experience |
| More personal control |
| Comfortable, familiar environment |
| Risks |
| Increased risk of neonatal morbidity in primigravida |
| Need for hospital transfer in up to 45% of cases in primigravida |
| Less choice of analgesia |
| Less-skilled midwifery support |
| Women’s over trusting of the birth process |
| Myths |
| Home birth is not safer although interventions may be less |
| Epidurals are not less necessary, and they are just not available without transfer |
| The caesarean section rate is not reduced |
| Women are not happier after home birth |
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