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Home birth: as safe as in hospital?
Sir,
As a neonatologist, I have read the paper of de Jonge
et al.1 on planned home births with great interest. Unfortunately,
I do not support their conclusion that planned
home birth is not associated with increased perinatal morbidity
and mortality. This is because the authors have
excluded children with congenital abnormalities and pregnancies
with prolonged rupture of membranes, many of
whom gave birth at home. By thus excluding a group at
particular risk, the authors have missed the opportunity to
study the practise of home birth in real life. Why did the
authors not either study all home births (without exclusions)
or in contrast focus on outcome of pregnancies with
unexpected adverse events such as perinatal asphyxia to
compare care at home and in-hospital?
Secondly, I understand from table 3 that risks of death
or NICU admission are increased in women who are
primiparous, at a gestational age of 41 weeks or more, aged
35 years or more, or of a non-Dutch ethnic background.
From Dutch registries we know that 46% of women are
primiparous, 20% of women give birth at a maternal age
of 35 years or more and 18% of women are non-Dutch, so
1684 ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology
Correspondence
in all these women planned home birth carries an elevated
risk.2 Are these women counselled that their risk is elevated
when they plan to give birth at home?
Finally, if the conclusions of the authors are correct, one
has to explain why Dutch obstetricians and paediatricians do
not perform better in dealing with unexpected adverse events
during labour in hospital than a midwife at home, despite
their additional expertise. Some reports suggest the possibility
of substandard care in hospitals during night shifts.3
Perinatal audits have recently been started in the
to investigate all aspects of substandard perinatal care,
because the
neonates which is worse than the European average.
One of the authors of the paper has said in the Dutch
media that the issue of safety of home births has been
settled ‘once and for all’. Even with optimal risk selection
by midwives, unexpected medical emergencies will continue
to occur. In my opinion, well-trained teams of medical
specialists in hospital should be able to perform better in
dealing with unexpected medical emergencies such as
perinatal asphyxia than caregivers at home. If they are not,
then perhaps our most important challenge is to find out
why and do something about it.j
References
1 de Jonge A, van der Goes BY, Ravelli ACJ, Amelink-Verburg MP, Mol
BW, Nijhuis JG, et al. Perinatal mortality and morbidity in a nationwide
cohort of 529 688 low-risk planned home and hospital births.
BJOG 2009;116:1177–84.
2 Hukkelhoven CWPM, Mohangoo AD, Nijhuis JG, Ravelli ACJ, Rijninksvan
Driel GC, Tamminga P, et al. Characteristics of pregnant women
and pregnancy in European perspective. Ned tijdschrift Obstet Gynaecol
2009;122:71–4.
3 Gould JB, Qin C, Chavez G. Time of birth and the risk of neonatal
death. Obstet Gynecol 2005;106:352–8.
F Groenendaal
Perinatal Center,
the
Accepted 23 April 2009.
DOI: 10.1111/j.1471-0528.2009.02276.x
Home birth: as safe as in hospital?
Authors’ Reply
Sir,
We thank Dr Groenendaal for his interest in our study into
the comparison of planned home births versus planned
hospital births.1,2
Groenendaal queries our decision to exclude children
with congenital abnormalities and women with prolonged
rupture of membranes. We excluded women who had contra-
indications for a home birth in the
as start of labour before 37 or after 42 weeks, previous
caesarean section or known non-cephalic presentation, even
if women with these risk factors may have ended up actually
giving birth at home. The reason for doing so is that
we wanted to study two truly comparable groups of women
who had the choice of a home birth. We excluded congenital
abnormalities, because if these had been detected or suspected
during pregnancy, women might have been advised
to give birth in hospital. To avoid a systematic bias to the
disadvantage of the hospital group, we felt they should be
excluded in our study.
Ruptured membranes for more than 24 hours without
contractions is an indication for referral to obstetrician-led
care, as are all the other factors listed above. In the Dutch
system, these women are not offered the choice to give
birth at home and they were therefore excluded. However,
women who were in labour after 24 hours and who were
still in primary midwife-led care were included in the
study.
Groenendaal may have misinterpreted the results in
table 3. Indeed, babies of women who were primiparous,
who gave birth at 41 weeks or more, who were 35 years
or older or of non-Dutch ethnic background had an
increased risk of death or admission to a NICU. However,
their elevated risk was not different in the planned home
birth compared with the planned hospital birth group.
This was demonstrated by the fact that interactions
between these factors and place of birth had no statistically
significant effect on outcomes. For example, primiparous
women had higher risks than multiparous women,
regardless whether they planned a home or hospital birth.
The crude relative risks showed better outcomes in
planned home births, although only the difference in
NICU admission was statistically significant. After controlling
for known confounding factors, the adjusted relative
risks became 1.0, indicating that there were no significant
differences between the groups.
We agree with Groenendaal that it would be useful to
study adverse events, such as perinatal asphyxia, and compare
care given at home versus in hospital. These studies
may shed light on care factors that can be improved in both
locations. However, these studies do not answer the question
whether planning a birth at home increases the risk of
adverse perinatal outcomes compared with planning a birth
in hospital. Large cohort studies, such as the one we conducted,
are the only way to answer this particular question.
Indeed, obstetricians and paediatricians have more
expertise than midwives when it comes to dealing with
medical emergencies. That is why midwives refer women or
babies to the medical specialist if emergencies occur.
However, during a planned hospital birth too, primary care
ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology 1685
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