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Study of low risk women reveals good news on the home birth front

Women who give birth at home as part of a publicly funded home birth program have an overall low risk of problems such as…

The study revealed that low-risk women who gave birth at home had a much higher rate of vaginal birth than the national average. http://www.flickr.com/photos/63441482@N08/6274245629

Women who give birth at home as part of a publicly funded home birth program have an overall low risk of problems such as stillbirth, postpartum hemorrhaging and emergency cesarean section, a new study of women with low-risk pregnancies has found.

Home birth is not a popular choice in Australia compared to other countries, with only 0.9% of all women who gave birth in Australia in 2010 opting for home birth. In the Netherlands, however, around a third of women who had a baby in 2004 gave birth at home.

The researchers, whose study was published today in the Medical Journal of Australia, analysed data from 2005 to 2010 from nine publicly funded home birth programs in place in Australia at that time, a cohort that accounted for 97% of births in such programs at the time.

Most of the women in the study were aged between 26 and 35 years-old and had already given birth before.

“Of the 1807 women who intended to give birth at home at the onset of labour, 1521 (84%) did so. 315 (17%) were transferred to hospital during labour or within one week of giving birth. The rate of stillbirth and early neonatal death was 3.3 per 1000 births; when deaths because of expected fetal anomalies were excluded it was 1.7 per 1000 births. The rate of normal vaginal birth was 90%,” the study found.

Caroline Homer, Professor of Midwifery at University of Technology, Sydney and a co-author of the study, said those outcomes compared with a still birth rate of about 5.2 per 1000 births in low risk women who do not have home births, and a rate of normal vaginal birth of just 63%.

The average rate of third degree tears in the women in the study was 1.1%, compared with 2.3% in public hospital births, she said.

Post-partum haemorrhage

Many women are advised that receiving a post-birth injection of a drug called Syntocinon that mimics the effect of the hormone oxytocin will help the placenta come away cleanly and reduce the risk of post-partum haemorrhage, a technique called ‘active management’ of the third stage of labour.

“Many of the women in our home birth cohort didn’t use active management of third stage. In hospital births, a post-partum haemorrhage rate of 5% is not uncommon and ours was 1.8%,” said Professor Homer.

“When it comes to a low-risk birth, if all is going well, women are in their own environment, they are not stressed by external factors or a scary environment, things go well. Just letting nature take its course may well be a safe option for these women,” she said.

Over half (52%) of the women studied gave birth in water, an option that is not available at all labour wards. Six weeks after birth, 69% of the women were still breastfeeding, compared with Australian Bureau of Statistics data showing that 58% of all infants were exclusively breastfed eight weeks after birth.

However, the researchers stopped short of drawing any conclusions about safety because the sample size was not large enough.

The findings may reflect the fact a publicly funded home birth is only available for women who are not carrying twins, have no medical or surgical risk factors and are not over their due date or giving birth prematurely.

Reassuring

Hannah Dahlen, Professor of Midwifery at University of Western Sydney, said the findings we “very reassuring” and showed a very low perinatal mortality rate, comparable with birth centres.

“The findings should now reassure health services to provide publicly funded home birth as an option for low risk women. Currently, there is still a lot of reluctance and opposition from the medical establishment to home birth and it is time to look at the data and not the one or two cases (all involving high risk women) that hit the media,” she said.

“Home birth has doubled in the past four years in Australia, as it has in the USA, and while there is nervousness from doctors, there is increasing interest from women. In Australia the worrying rise in freebirth (birth at home with no health professional) is evidence we are not meeting women’s needs regarding a low intervention model such as homebirth,” she said.

Professor Dahlen said a 90% normal vaginal birth rate is “a testament to the benefits of a supportive, midwife-attended home birth.”

“In the Netherlands, if you have a birth in hospital, the women ask each other ‘What went wrong?’ In Australia, for some reason, we ask ‘What is wrong with you’?,” she said.

“It is time we looked at this issue and had an informed discussion based on scientific evidence instead of based on media sensation and medical bias.”

The Australian study follows a Dutch study featured in the BMJ last week that showed the risk of severe complications was lower for women who gave birth at home compared to those who had a baby in hospital.

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10 Comments sorted by

  1. Amy Tuteur

    logged in via Facebook

    Why are the authors boasting about a hideous death rate?

    During the 5 years of the study, there were 1807 women who intended, at the start of labor, to give birth at home. 83% had a homebirth, 52% in water. The transfer rate was 17%. The C-section rate was 5.4% and the neonatal death rate was 2.2/1000. That’s more than 5X the rate of 0.4/1000 found in a 2009 report on birth in South Australia.In addition, 2 babies suffered hypoxic ischemic encephalopathy (brain damage due to lack of oxygen…

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    1. Hugh McColl

      Geographer

      In reply to Amy Tuteur

      Amy Tuteur, there is only one 'author' and I can't see any boasting. However, you raise a couple of very pertinent points about the death rate found in this study. It would be excellent if the author (and/or interviewees) could find up-to-date national statistics for death rates or at least confirm the 2009 South Australian numbers given and perhaps provide some context in which these figures can be interpreted/compared.

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    2. Sunanda Creagh

      Editor at The Conversation

      In reply to Hugh McColl

      Hi Hugh, hopefully this par answers your question:

      "Caroline Homer, Professor of Midwifery at University of Technology, Sydney and a co-author of the study, said those outcomes compared with a still birth rate of about 5.2 per 1000 births in low risk women who do not have home births, and a rate of normal vaginal birth of just 63%."

      Also, it seems some of those deaths in the homebirth study were expected because of fetal anomalies but the women decided to go ahead with the labour anyway. From…

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    3. Julie Leslie

      GIS Coordinator

      In reply to Sunanda Creagh

      So what is the adjusted death rate for births when anomalous babies are excluded in hospitals then? How does it compare to 1.7/1,000 home births?

      Apples to apples.

      Also the mind boggles that women, who knew that there were anomalies with the baby would still go through a home birth. I can understand that in some cases it would not matter whether the birth was in a hospital or a home, but given the smidgen of a chance that an emergency hospital response would a better outcome for the baby and mother, why persist with the home birth?

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    4. Amy Tuteur

      logged in via Facebook

      In reply to Sunanda Creagh

      The neonatal death rate for low risk birth in the hospital (as opposed to all risk birth) is 0.4/1000. Neonatal deaths do not include stillbirths, so I have no idea why Homer mentions stillbirth.

      Horner is NOT entitled to remove congenital anomalies from the homebirth group because she didn't remove them from the hospital group.

      Therefore, the neonatal death rate (4 babies died out of 1807 for a neonatal death rate of 2.2/1000) is a terrible death rate, as it is 5X higher than low risk hospital birth. There is simply no question about that fact.

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  2. Michael Brown

    Professional, academic, company director

    A few years ago the high rate of issues with home births with midwives in Victoria caused insurers to withdraw cover. They could only continue because the government arranged for them to be associated with public hospitals and get cover through the health department. There has been a complete lack of adequate research on this matter so the authors are to be congratulated for making a start.

    A good question to ask is: how many female doctors, who would be expected to assess the risks better than anyone, elect to have their babies at home? I suspect the answer is none.

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  3. Sue Ieraci

    Public hospital clinician

    This paper presents its findings with significant spin. Home-birth is an ideological approach that only considers maternal experience - there are no benefits, and only greater risks - for babies. The assertion of Prof Homer that ''When it comes to a low-risk birth, if all is going well, women are in their own environment, they are not stressed by external factors or a scary environment, things go well. Just letting nature take its course may well be a safe option for these women,” is just not supportable…

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  4. foibles58

    logged in via Twitter

    I would suggest rather that we have medicalised childbirth to the extreme obstetrician involvement and medical interventions have become routine in normal childbirth, without evidence of effectiveness. Factors associated with increased obstetric intervention seem to include private practice, medicolegal pressures, and not involving women fully in decision making

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    1. Sue Ieraci

      Public hospital clinician

      In reply to foibles58

      "foibles" - if you claim ''obstetrician involvement and medical interventions have become routine in normal childbirth, without evidence of effectiveness'', then you are in disagreement with not only the world obstetric literature but also the WHO.

      Worldwide, the greatest causes of maternal and foetal death include obstructed labour and haemorrhage. Neither of these can be circumvented by doing nothing.

      We are the victims of our own success - like in vaccination, the lack of deaths from infectious diseases makes us suspect the very things that prevent them. Thank goodness that modern obstetrics AND midwifery have presided over a dramatic improvement of birth outcomes, for both young women and newborns.

      Midwifery is no longer a fringe movement of radical women. In Australia, it is firmly science-based, and uses evidence and interventions to improve outcomes, in collaboration with obstetrics.

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  5. Leo Braun

    Conscientious Objector

    "If a health care approach were to be taken, rather than an ideological one, both authors and commentators would be discussing how the avoidable harms could be reduced"! So, if you just found out you're pregnant, one of the first - and most important - test you and your partner should have is a blood-type test. This basic test determines specific blood group: A, B, AB or O, plus the Rhesus Factor, if any inherited. Since your partner's Rh factor may play a role in your baby's jeopardy, so it's important…

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