Home birth Safety
This article has been supplied by Anitra Carr and is also available in the Birthplace Yourplace booklet.
I like the idea of a homebirth, but is it safe? This is a question that many of us ask when trying to decide on the best place to give birth to our precious babies. All we really want is what is best for our children, from conception through to birth and beyond. Historically, childbirth took place primarily at home. Now hospital birth is so entrenched in our society, many women do not realise that they have a choice of where to give birth. What is more unfortunate is that many women are unaware that scientific research shows that homebirth is as safe, if not safer, than hospital birth for healthy, low risk women.
Researchers who study the safety of homebirth use three different study methods: retrospective studies, prospective studies and clinical trials. Each of these study types provides evidence for the safety of homebirth.
Retrospective studies look backwards at the results, after birth has occurred. The outcomes; morbidity (illness) and mortality (death) rates are compared between women who choose homebirth and those who birth in hospital. This type of study is susceptible to bias as the researchers already know the outcome and this may subtly influence their selection of subjects for study.
A New Zealand retrospective study, investigated the perinatal and maternal mortality rates for planned homebirths over a 20 year period between 1973 and 1993. Information from almost 9800 planned homebirths were looked at and showed that the perinatal mortality rates was no different than the death rate in babies of low risk women who birthed in hospital. The study concluded that homebirth was a safe and increasingly popular option for New Zealand women.
In Australia, data was examined retrospectively of 7000 planned homebirths during 1985 to 1990. They found that homebirth for low risk women compared favourably with hospital birth. However, high risk homebirths involving post-term birth, twin pregnancies and breech presentation, contributed to excess mortality.
Prospective studies look ahead, i.e. what the researchers want to investigate is decided upon before the study is begun, e.g. before the women have given birth. This type of study is less vulnerable to bias compared to retrospective studies. Seven prospective studies have been carried out internationally over the last couple of decades to investigate the outcomes and safety of homebirth. Five of these were published in the British Medical Journal and the largest study involved 5418 women who planned to birth at home.
Three of the seven prospective studies investigated planned homebirth alone, while the others directly compared homebirth with hospital delivery. Overall, the studies found that there were no significant differences in outcomes or safety between the homebirth and hospital delivery groups. The durations of labour, occurrence of severe perineal tears, maternal blood loss, condition of the babies and perinatal mortality were similar between the two groups (Apgar scores were often better for babies born at home). Of the women planning to birth at home, an average of only 13 percent were transferred to hospital for various reasons, including failure to progress, pain relief or exhaustion.
The studies clearly showed that women who gave birth at home needed significantly less medication and had fewer medical interventions during labour. The average caesarean section rate for planned hospital deliveries was over three times that for planned homebirths (17% versus 5%). One study concluded that the lower rate of interventions with homebirths also meant a lower risk of subsequent complications for mother and baby.
All of the prospective studies concluded that homebirth is as safe and in some instances safer than hospital delivery for healthy low risk women. It is interesting to note that an uncomplicated vaginal birth in hospital (in the US) costs on average three times as much as a similar birth at home with a midwife. One of the studies found that 85% of the women who had had a previous hospital birth preferred the homebirth experience, even though 66% found the hospital experience not unpleasant.
The gold standard in scientific research is the randomised controlled trial. However, there are a number of practical and ethical issues with respect to carrying out a clinical trial to investigate the safety of homebirth versus hospital birth. In a randomised trial, women would be assigned to one of either group, they would not be able to choose for themselves. Nevertheless, a small clinical trial has been carried out in the UK as a feasibility study. The trial involved 11 low risk women, five allocated to homebirth and six to hospital birth. The researchers found no difference in outcomes between either group. The majority of mothers in the hospital group were disappointed about the allocation, suggesting that properly informed women prefer homebirth.
When researching homebirth safety it is important to see that homebirth statistics exclude high risk, unplanned, unattended homebirths as these have a poor safety profile.
In the Netherlands approximately 30% of women give birth at home. In New Zealand it is estimated that 7% of women, and up to 10% of women in some regions, give birth at home.
When low risk women are provided with sufficient unbiased information regarding the safety of planned homebirth, it is likely more would choose to birth at home. One study subject commented that “It is not for everyone, but freedom of choice is priceless.” Another mother stated that “Although my previous two hospital deliveries were very positive they did not compare to the delight of giving birth at home. It was just so right.”
Last updated 18 March 2009.
