Evidence-based commissioning o Harcourt Brace and Company ktd 1998

Planned home births are no less safe than planned hospital births for low-risk women

Olsen O. Meta.analysis of the safety of home births. Birth 1997; 24:4-13

Background

The debate about the risks of birth at home underlies planning of maternity services.

Objective

To compare the outcomes of planned home births (backed up by a modem hospital system) with those of planned hospital births for women with similarly low-risk pregnancies.

Selling

Six studies conducted in Switzerland, Western Australia, England, the Netherlands and the USA (in Tennessee and Wisconsin).

Method

Systematic review with meta-analysis. Studies had to separately identify planned

home births, have planned hospital birth controls of comparable risk, and adequately measure outcomes in order to be included in the meta-analysis.

Literature review

MEDLINE search on 'home childbirth' or 'home-care-services & delivery,' as well as MIDIRS midwifery database search on 'safety of home birth,' seminar papers and references from identified papers.

Outcomes

1. Perinatal mortality 2. Maternal mortality 3. APGAR scores of fetal distress 4. Maternal laceration 5. Relative rates of induction.

Episiotomy, operative vaginal birth and Caesarean section were also reported.

Results

Perinatal mortality was not significantly different in the home and hospital groups in any individual study or the pooled analysis. The planned hospital birth group had lower APGAR scores of fetal distress and significantly higher rates of second- or third-degree maternal lacerations. The hospital group was also more likely to experience hospital interventions (such as induction, episiotomy, etc.)

Authors' conclusions

The lack of comparability across studies (i.e. different measures, selection criteria, cut-off points, etc.) is cause for concern in any meta-analysis. However, the results of this study are comparable to others. Planned home births are no less safe than planned hospital births for women of low risk assisted by experienced home birth practitioners and backed up by a modem hospital system. Given a low-risk pregnancy, there may even be advantages to home births (such as lower risk of laceration). Because all studies on home births thus far are subject to selection bias (women planning home births may be in a lower-risk group than the control groups based on some unobserved characteristic, which is known to the mother), additional research is needed, such as a randomized, controlled trial.

.'OMMENTAR~

Home birth remains one of the most contentious issues in modern maternity systems. Despite a policy encouraging the woman's involvement in decisions about her care, ~ few women are given a genuine choice between home and hospital birth, and most are probably dissuaded from choosing a home birth. 2

The issue remains contentious because few, if any, studies have been large enough to detect an effect on the most dramatic outcome measure of a l l - death. Perinatal and maternal death rates are so tow that it would be difficult to conduct an RCT large enough to provide data on differences in mortality rates. Olsen has done the next best thing. He has conducted a meta-analysis on the best controtted-observational studies.

Olsen's conclusion that there is no support for claims that hospital births are safer than planned home births is in keeping with the conclusions from other studies) Moreover, the tower frequency of low Apgar scores and severe lacerations found in the home birth group indicate that there may be advantages to giving birth at home. However, the studies

synthesized are from five different countries, and undoubtedly include variations in practice and in the general social acceptance of home birth. As Olsen notes, further studies and subgroup analyses are needed to provide information on who might benefit from home birth, how practitioners should be prepared, and other considerations in considering home birth as an option for particular women. Some such studies are already under way, and a protocol for a systematic review has appeared in The Cochrane Library, proposing a method for reviewing studies comparing home with hospital birth. 4

Importantly, Olsen reminds us that it cannot be claimed that hospital birth is safe for all babies, nor can it be claimed that planned home birth is safe for all babies. However, it seems reasonable, in the light of this paper, to ensure that women feel able to make a genuine choice about place of birth. It may be worth setting up specialist teams of midwives to provide a home birth service. Midwives in Britain have a statutory obligation to provide care for women wishing to give birth at home, and can do so without the involvement of a doctor, s It is important that they have evidence to inform them in this practice.

References

1. Department of Health. Changing Childbirth Part I. Report of the Expert Maternity. London: HMSO, 1993 Court C. Britain's maternity services come under the microscope. BMJ 1994; 309:1106 Evidence-Based Health Policy and Management. Collaborative survey of perinatal loss in planned and unplanned home births 1997; 1(2): 41-42 Olsen O. Home vs hospital birth (Protocol). In: Neilson J P, Crowther C A, Hodnett E D, Hofmeyr G J (eds). Pregnancy and Childbirth Module of l'he Cochrane Database of Systematic Reviews (updated 2 December 1997). Available in lhe Cochrane Library (database on disk and CD-ROM). The Cochrane Collaboration, Issue 1, Oxford: Update Software (updated quarterly)

5. The United Kingdom Central Council for Nursing, Midwifery and Health Visiting. 1he Midwife's Code of Practice. London: HMSO, 1994

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Professor tesley Page Centre for Midwifery Practice

Thames Valley University Queen Charlotte's Hospital,

London, UK

40 EVIDENCE-BASED HEALTIt POLICY AND MANAGEMENT JUNE 1998