Hausgeburt | Studien zur Sicherheit

Cochrane Database of Systematic Reviews (2023). https://doi.org/10.1002/14651858.CD000352.pub3

Planned hospital birth compared with planned home birth for pregnant women at low risk of complications

Ole Olsen O, Clausen JA.

BACKGROUND:

Observational studies of increasingly better quality and in different settings suggest that planned hospital birth in many places does not reduce mortality and morbidity but increases the frequency of interventions and complications. Euro‐Peristat (part of the European Union's Health Monitoring Programme) has raised concerns about iatrogenic effects of obstetric interventions, and the World Health Organization (WHO) has raised concern that the increasing medicalisation of childbirth tends to undermine women’s own capability to give birth and negatively impacts their childbirth experience. This is an update of a Cochrane Review first published in 1998, and previously updated in 2012.

OBJECTIVES:

To compare the effects of planned hospital birth with planned home birth attended by a midwife or others with midwifery skills and backed up by a modern hospital system in case a transfer to hospital should turn out to be necessary. The primary focus is on women with an uncomplicated pregnancy and low risk of medical intervention during birth.

SEARCH METHODS:

For this update, we searched Cochrane Pregnancy and Childbirth’s Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, WHO ICTRP, and conference proceedings), ClinicalTrials.gov (16 July 2021), and reference lists of retrieved studies.

SELECTION CRITERIA:

Randomised controlled trials (RCTs) comparing planned hospital birth with planned home birth in low‐risk women as described in the objectives. Cluster‐randomised trials, quasi‐randomised trials, and trials published only as an abstract were also eligible.

DATA COLLECTION AND ANALYSIS:

Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked the data for accuracy. We contacted study authors for additional information. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS:

We included one trial involving 11 participants. This was a small feasibility study to show that well‐informed women ‐ contrary to common beliefs ‐ were prepared to be randomised. This update did not identify any additional studies for inclusion, but excluded one study that had been awaiting assessment. The included study was at high risk of bias for three out of seven risk of bias domains. The trial did not report on five of the seven primary outcomes, and reported zero events for one primary outcome (caesarean section), and non‐zero events for the remaining primary outcome (baby not breastfed). Maternal mortality, perinatal mortality (non‐malformed), Apgar < 7 at 5 minutes, transfer to neonatal intensive care unit, and maternal satisfaction were not reported. The overall certainty of the evidence for the two reported primary outcomes was very low according to our GRADE assessment (downgraded two levels for high overall risk of bias (due to high risk of bias arising from lack of blinding, high risk of selective reporting and lack of ability to check for publication bias) and two levels for very serious imprecision (single study with few events)).

AUTHORS´ CONCLUSIONS:

This review shows that for selected, low‐risk pregnant women, the evidence from randomised trials to support that planned hospital birth reduces maternal or perinatal mortality, morbidity, or any other critical outcome is uncertain. As the quality of evidence in favour of home birth from observational studies seems to be steadily increasing, it might be just as important to prepare a regularly updated systematic review including observational studies as described in the Cochrane Handbook for Systematic Reviews of Interventions as to attempt to set up new RCTs. As women and healthcare practitioners may be aware of evidence from observational studies, and as the International Federation of Gynecology and Obstetrics and the International Confederation of Midwives collaboratively conclude that there is strong evidence that out‐of‐hospital birth supported by a registered midwife is safe, equipoise may no longer exist, and randomised trials may now thus be considered unethical or hardly feasible.

EClinicalMedicine, 21, 100319 (2020).

Maternal outcomes and birth interventions among women who begin labour intending to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses.

Reitsma A, Simioni J, Brunton G, Kaufman K, Hutton EK.

BACKGROUND:

We previously concluded that risk of stillbirth, neonatal mortality or morbidity is not different whether birth is intended at home or hospital. Here, we compare the occurrence of birth interventions and maternal outcomes among low-risk women who begin labour intending to birth at home compared to women intending to birth in hospital.

METHODS:

We used our registered protocol (PROSPERO, http://www.crd.york.ac.uk, No.CRD42013004046) and searched five databases from 1990–2018. Using R, we obtained pooled estimates of effect (accounting for study design, study setting and parity).

FINDINGS:

16 studies provided data from ~500,000 intended home births for the meta-analyses. There were no reported maternal deaths. When controlling for parity in well-integrated settings we found women intending to give birth at home compared to hospital were less likely to experience: caesarean section OR 0.58(0.44,0.77); operative vaginal birth OR 0.42(0.23,0.76); epidural analgesia OR 0.30(0.24,0.38); episiotomy OR 0.45(0.28,0.73); 3rd or 4th degree tear OR 0.57(0.43,0.75); oxytocin augmentation OR 0.37(0.26,0.51) and maternal infection OR 0.23(0.15,0.35). Pooled results for postpartum haemorrhage showed women intending home births were either less likely or did not differ from those intending hospital birth [OR 0.66(0.54,0.80) and RR 1.30(0.79,2.13) from 2 studies that could not be pooled with the others]. Similar results were found when data were stratified by parity and by degree of integration into health systems.

INTERPRETATION:

Among low-risk women, those intending to birth at home experienced fewer birth interventions and untoward maternal outcomes. These findings along with earlier work reporting neonatal outcomes inform families, health care providers and policy makers around the safety of intended home births.

EClinicalMedicine, 21, 100319 (2020).

Maternal outcomes and birth interventions among women who begin labour intending to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses.

Reitsma A, Simioni J, Brunton G, Kaufman K, Hutton EK.

BACKGROUND:

We previously concluded that risk of stillbirth, neonatal mortality or morbidity is not different whether birth is intended at home or hospital. Here, we compare the occurrence of birth interventions and maternal outcomes among low-risk women who begin labour intending to birth at home compared to women intending to birth in hospital.

METHODS:

We used our registered protocol (PROSPERO, http://www.crd.york.ac.uk, No.CRD42013004046) and searched five databases from 1990–2018. Using R, we obtained pooled estimates of effect (accounting for study design, study setting and parity).

FINDINGS:

16 studies provided data from ~500,000 intended home births for the meta-analyses. There were no reported maternal deaths. When controlling for parity in well-integrated settings we found women intending to give birth at home compared to hospital were less likely to experience: caesarean section OR 0.58(0.44,0.77); operative vaginal birth OR 0.42(0.23,0.76); epidural analgesia OR 0.30(0.24,0.38); episiotomy OR 0.45(0.28,0.73); 3rd or 4th degree tear OR 0.57(0.43,0.75); oxytocin augmentation OR 0.37(0.26,0.51) and maternal infection OR 0.23(0.15,0.35). Pooled results for postpartum haemorrhage showed women intending home births were either less likely or did not differ from those intending hospital birth [OR 0.66(0.54,0.80) and RR 1.30(0.79,2.13) from 2 studies that could not be pooled with the others]. Similar results were found when data were stratified by parity and by degree of integration into health systems.

INTERPRETATION:

Among low-risk women, those intending to birth at home experienced fewer birth interventions and untoward maternal outcomes. These findings along with earlier work reporting neonatal outcomes inform families, health care providers and policy makers around the safety of intended home births.

Die Hebamme 2020; 33(04): 11-12. DOI: 10.1055/a-1205-6392.

Mütterliches Outcome und Interventionen während der Geburt bei Frauen mit geplanter Hausgeburt im Vergleich zu Frauen mit geplanter Klinikgeburt.

Loytved C.

ZIELE:

Ziel der Hebammenforscherinnen war es eine evidenzbasierte Aussage zur Sicherheit von Hausgeburten zu finden. Dazu verglichen sie die mütterlichen Ergebnisse von Frauen, die entweder das eigene Zuhause oder die Klinik als Geburtsort gewählt haben. Zuvor hatten die Forscherinnen aus Kanada alle Ergebnisse zu den Kindern analysiert [1].

METHODIK:

Für ihre Übersichtsarbeit (Review) suchten die Forscherinnen systematisch alle Studien, die das Outcome von Müttern verglichen haben, die entweder eine Hausgeburt oder eine Klinikgeburt planten. Damit die Ergebnisse vergleichbar sind, wurden nur Frauen ohne schwerwiegende Geburtsrisiken berücksichtigt. Vor der Literatursuche wurde die Vorgehensweise genau festgelegt und protokolliert. Die Literatursuche fand bis April 2018 in Embase, Medline, AMED, CINAHL und Cochrane Library statt. Studien mit Erscheinungsjahr vor 1990 wurden ausgeschlossen, da sie nicht die derzeitige Praxis widerspiegeln können. Die verbleibenden Treffer wurden von zwei Forscherinnen unabhängig voneinander danach beurteilt, ob sie Folgendes berücksichtigten: (1) Frauen ohne schwerwiegende Geburtsrisiken, aber mit geplanter Haus- oder Klinikgeburt, (2) die Ergebnisse sind nach geplantem Geburtsort ausgewertet. Dadurch zählt das Outcome einer begonnenen Hausgeburt mit subpartaler Verlegung zur Gruppe der Hausgeburten. Zwei Forscherinnen werteten zudem unabhängig voneinander die Studien nach dem Newcastle Ottawa Quality Assessment Scale for Cohort Studies (NOS) aus und teilten sie in ein Raster ein, das die Offenheit für Hausgeburten des Gesundheitssystems im jeweiligen Land bewertet.

ERGEBNISSE:

Alle Teilnehmerinnen hatten vergleichbare Eingangsvoraussetzungen. Es wurden nur Frauen eingeschlossen, die keine schwerwiegenden Geburtsrisiken aufwiesen. In den eingeschlossenen 16 Studien mit insgesamt knapp 500.000 Studienteilnehmerinnen war kein mütterlicher Todesfall verzeichnet. Die im Folgenden dargestellten Outcomes werden im Review differenziert nach Parität und Offenheit des jeweiligen Gesundheitssystems für Hausgeburten dargestellt. Alle ausgewerteten Vergleichsgruppen zeigen den gleichen Trend. Daher werden hier nur die Ergebnisse für Erstgebärende in einem Gesundheitssystem wie in Deutschland, das für Hausgeburten offen ist, präsentiert. Alle Ergebnisse erreichen das Signifikanzniveau. Die Oddsratio (OR) zeigt jeweils das Ergebnis für Frauen, die eine Hausgeburt planen, im Vergleich zu denen, die eine Klinikgeburt planen: Die Wahrscheinlichkeit für einen Kaiserschnitt (neun Studien) ist um etwa 30 % niedriger (OR 0,71 [95 % KI 0,62–0,81]), für eine Oxytocingabe zur Steigerung der Wehentätigkeit (fünf Studien) um etwa 35 % niedriger (OR 0,63 [95 % KI 0,47–0,86]), für eine vaginal-operative Entbindung (acht Studien) um etwa 25 % niedriger (OR 0,74 [95 % KI 0,64–0,85]), für eine PDA (vier Studien) um etwa 50 % niedriger (OR 0,51 [95 % KI 0,35–0,74]) und für eine Episiotomie (acht Studien) um etwa 25 % niedriger (OR 0,75 [95 % KI 0,64–0,87]). Dammrisse dritten oder viertes Grades (fünf Studien) traten in etwa gleich häufig auf (OR 1,39 [95 % KI 0,67–2,92]). Wird der erhöhte Blutverlust nach der Geburt (neun Studien) verglichen, so war die Rate in etwa gleich (OR 0,95 [95 % KI 0,87–1,05]).

SCHLUSSFOLGERUNG:

Die Forscherinnen sehen Unsicherheiten in ihren Ergebnissen, da in den ausgewerteten Studien keine Angaben zur Herkunft der Frauen, zu ihrem Bildungsstand und vor allem zu ihrer Überzeugung, keine Intervention benötigen zu müssen oder haben zu wollen, berücksichtigt wurden. Die Ergebnisse ihrer Analyse können daher nicht beweisen, dass Hausgeburten sicherer sind als Klinikgeburten. Eine Aussage hierüber könnte nur durch randomisiert kontrollierte Studien erfolgen. Aus verständlichen Gründen sind jedoch kaum Frauen für ein solches Zufallsprinzip zu gewinnen. Die Forscherinnen der Übersichtsarbeit sehen daher in ihren Ergebnissen vielmehr einen Beweis für die Wichtigkeit, den Geburtsort wählen zu können.

KOMMENTAR:

Dieser Review ist insofern vorbildlich, als dass er vor Beginn der Recherche ein Protokoll über das Vorgehen hinterlegt. So wird Manipulationsvorwürfen zuvorgekommen. Auch wird bedacht mit der Tatsache umgegangen, dass nicht jedes Gesundheitssystem gleiche Arbeitsbedingungen für Hausgeburtshebammen ermöglicht. Dass eine erfolgte Episiotomie in der Hausgeburtsgruppe auf das Konto der Hausgeburten geht, obwohl sie in der Klinik geschnitten wurde, erscheint auf den ersten Blick ungerecht, aber noch ungerechter wäre es, alle verlegten Problemfälle dem Konto der Klinikgeburten zuzurechnen. Diese Analysemethode nach „intention-to-treat“ stellt auf jeden Fall die Hausgeburtsgruppe nicht besser dar, als sie ist, und vermeidet dadurch mögliche Vorwürfe bereits im Vorfeld. Die herausgearbeitete Evidenz stützt die Forschung, jeder Frau das Recht auf die Wahl des Geburtsortes zu gewähren. Um möglichst vielen Schwangeren eine Entscheidungshilfe zu bieten, benötigen wir mehr Studien, die Schwangere mit besonderen Voraussetzungen wie etwa Zustand nach Sectio berücksichtigen.

EClinicalMedicine, 14, 59–70 (2019).

Perinatal or neonatal mortality among women who intend at the onset of labour to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses.

Hutton EK, Reitsma A, Simioni J, Brunton G, Kaufman K.

BACKGROUND:

More women are choosing to birth at home in well-resourced countries. Concerns persist that out-of-hospital birth contributes to higher perinatal and neonatal mortality. This systematic review and meta-analyses determines if risk of fetal or neonatal loss differs among low-risk women who begin labour intending to give birth at home compared to low-risk women intending to give birth in hospital.

METHODS:

In April 2018 we searched five databases from 1990 onward and used R to obtain pooled estimates of effect. We stratified by study design, study settings and parity. The primary outcome is any perinatal or neonatal death after the onset of labour. The study protocol is peer-reviewed, published and registered (PROSPERO No.CRD42013004046).

FINDINGS:

We identified 14 studies eligible for meta-analysis including ~ 500,000 intended home births. Among nulliparous women intending a home birth in settings where midwives attending home birth are well-integrated in health services, the odds ratio (OR) of perinatal or neonatal mortality compared to those intending hospital birth was 1.07 (95% Confidence Interval [CI], 0.70 to 1.65); and in less integrated settings 3.17 (95% CI, 0.73 to 13.76). Among multiparous women intending a home birth in well-integrated settings, the estimated OR compared to those intending a hospital birth was 1.08 (95% CI, 0.84 to 1.38); and in less integrated settings was 1.58 (95% CI, 0.50 to 5.03).

INTERPRETATION:

The risk of perinatal or neonatal mortality was not different when birth was intended at home or in hospital.

J Obstet Gynaecol Can 2019;41(2):223-227

No. 372-Statement on Planned Homebirth.

Campbell K, Carson G, Azzam H, Hutton E.

KEY MESSAGES
1. Registered Midwives and some physicians provide homebirth care in Canada.
2. The SOGC reaffirms and emphasizes the importance of choice for women and their families in the birthing process.
The SOGC promotes well-integrated community and hospital birthing care to ensure safe maternal and newborn care.
3. In Canada, planning a homebirth with a registered midwife or an appropriately trained physician in the integrated system described is a reasonable choice for persons with low degree of risk where the birth is anticipated to be uncomplicated and neither mother nor neonate will require resources beyond the
local capacity.
4. All pregnant women should receive information about the risks and benefits of their chosen place for giving birth and should understand any identified limitation at their planned birth setting. Risk assessments should be ongoing throughout pregnancy and birth and care providers must ensure the individual is advised of any change in their risk status to support their ability to make an informed choice for most
suitable birth site.
5. Communication amongst and between the hospital and community obstetric teams using set standards supporting emergency transport are critical components of a seamless integrated system and should remain a priority in supporting best practice outcomes for planned homebirths.
6. The SOGC endorses evidence-based practice and encourages ongoing research into optimizing birthing
outcomes in all birth settings. Prospective data collection should capture all births and include planned and actual place of birth.

Australian College of Midwives, 2019

Position Statement for Planned Birth at Home.

Women have a fundamental right to determine where and how to give birth. This right is supported in the Convention on the Elimination of All Forms of Discrimination Against All Women (CEDAW) to which Australia is a signatory (CEDAW, 1999). Article 12 of the CEDAW requires countries to provide free and accessible health services for women in relation to pregnancy and postnatal care. It is the responsibility of health services to support women choosing birth at home. Further, the right to information, informed consent and refusal to consent, respect for choices and preferences, liberty, autonomy, self-determination, and freedom from coercion are all supported by the Respectful Maternity Care: Universal Rights of Childbearing Women (White Ribbon Alliance, 2011).

Midwifery 2018, 62, 240-55.

Maternal and perinatal outcomes by planned place of birth among women with low-risk pregnancies in high-income countries: A systematic review and meta-analysis.

Scarf VL, Rossiter C, Vedam S, Dahlen HG, Ellwood D, Forster D et al.

BACKGROUND:

The comparative safety of different birth settings is widely debated. Comparing research across high-income countries is complex, given differences in maternity service provision, data discrepancies, and varying research techniques and quality. Studies of births planned at home or in birth centres have reported both better and poorer outcomes than planned hospital births. Previous systematic reviews have focused on outcomes from either birth centres or home births, with inconsistent attention to quality appraisal. Few have attempted to synthesise findings.

OBJECTIVE:

To compare maternal and perinatal outcomes from different places of birth via a systematic review of high-quality research, and meta-analysis of appropriate data (Prospero registration CRD42016042291).

DESIGN:

Reviewers searched CINAHL, Embase, Maternity and Infant Care, Medline and PsycINFO databases to identify studies comparing selected outcomes by place of birth among women with low-risk pregnancies in high-income countries. They critically appraised identified studies using an instrument specific to birth place research and then combined outcome data via meta-analysis, using RevMan software.

FINDINGS:

Twenty-eight articles met inclusion criteria, yielding comparative data on perinatal mortality, mode of birth, maternal morbidity and/or NICU admissions. Meta-analysis indicated that women planning hospital births had statistically significantly lower odds of normal vaginal birth than in other planned settings. Women experienced severe perineal trauma or haemorrhage at a lower rate in planned home births than in obstetric units. There were no statistically significant differences in infant mortality by planned place of birth, although most studies had limited statistical power to detect differences for rare outcomes. Differences in location, context, quality and design of identified studies render results subject to variation.

CONCLUSIONS and implications for practice:

High-quality evidence about low-risk pregnancies indicates that place of birth had no statistically significant impact on infant mortality. The lower odds of maternal morbidity and obstetric intervention support the expansion of birth centre and home birth options for women with low-risk pregnancies.

Eur J Obstet Gynecol Reprod Biol 2018;222:102-108. doi: 10.1016/j.ejogrb.2018.01.016.

Planned home versus planned hospital births in women at low-risk pregnancy: A systematic review with meta-analysis.

Rossi AC, Prefumo F.

New interest in home birth have recently arisen in women at low risk pregnancy. Maternal and neonatal morbidity of women planning delivery at home has yet to be comprehensively quantified. We aimed to quantify pregnancy outcomes following planned home (PHB) versus planned hospital birth (PHos). We did a systematic review of maternal and neonatal morbidity following planned home (PHB) versus planned hospital birth (PHos). We included prospective, retrospective, cohort and case-control studies of low risk pregnancy outcomes according to planning place of birth, identified from January 2000 to June 2017. We excluded studies in which high-risk pregnancy and composite morbidity were included. Outcomes of interest were: maternal and neonatal morbidity/mortality, medical interventions, and delivery mode. We pooled estimates of the association between outcomes and planning place of birth using meta-analyses. The study protocol is registered with PROSPERO, protocol number CRD42017058016. We included 8 studies of the 4294 records identified, consisting in 14,637 (32.6%) in PHB and 30,177 (67.4%) in PHos group. Spontaneous delivery was significantly higher in PHB than PHos group (OR: 2.075; 95%CI:1.654-2.063) group. Women in PHB group were less likely to undergo cesarean section compared with women in PHos (OR:0.607; 95%CI:0.553-0.667) group. PHB group was less likely to receive medical interventions than PHos group. The risk of fetal dystocia was lower in PHB than PHos group (OR:0.287; 95%CI:0.133-0.618). The risk of post-partum hemorrhage was lower in PHB than PHos group (OR:0.692; 95% CI.0.634-0.755). The two groups were similar with regard to neonatal morbidity and mortality. Births assisted at hospital are more likely to receive medical interventions, fetal monitoring and prompt delivery in case of obstetrical complications. Further studies are needed in order to clarify whether home births are as safe as hospital births.

CMAJ 2016;188(5):E80-E90. doi: 10.1503/cmaj.150564.

Outcomes associated with planned place of birth among women with low-risk pregnancies.

Hutton EK, Cappelletti A, Reitsma AH, Simioni J, Horne J, McGregor C, Rashid JA.

BACKGROUND:
Previous studies have shown that planned home birth is associated with a decreased likelihood of intrapartum intervention with no difference in neonatal outcomes compared with planned hospital birth. The purpose of our study was to evaluate different birth settings by comparing neonatal mortality, morbidity and rates of birth interventions between planned home and planned hospital births in Ontario, Canada.

METHODS:
We used a provincial database of all midwifery-booked pregnancies between 2006 and 2009 to compare women who planned home birth at the onset of labour to a matched cohort of women with low-risk pregnancies who had planned hospital births attended by midwives. We conducted subgroup analyses by parity. Our primary outcome was stillbirth, neonatal death (< 28 d) or serious morbidity (Apgar score < 4 at 5 min or resuscitation with positive pressure ventilation and cardiac compressions).

RESULTS:
We compared 11 493 planned home births and 11 493 planned hospital births. The risk of our primary outcome did not differ significantly by planned place of birth (relative risk [RR] 1.03, 95% confidence interval [CI] 0.68-1.55). These findings held true for both nulliparous (RR 1.04, 95% CI 0.62-1.73) and multiparous women (RR 1.00, 95% CI 0.49-2.05). All intrapartum interventions were lower among planned home births.

INTERPRETATION:
Compared with planned hospital birth, planned home birth attended by midwives in a jurisdiction where home birth is well-integrated into the health care system was not associated with a difference in serious adverse neonatal outcomes but was associated with fewer intrapartum interventions.

CMAJ 2016;188(5):E80-E90. doi: 10.1503/cmaj.150564.

Outcomes associated with planned place of birth among women with low-risk pregnancies.

Hutton EK, Cappelletti A, Reitsma AH, Simioni J, Horne J, McGregor C, Rashid JA.

BACKGROUND:
Previous studies have shown that planned home birth is associated with a decreased likelihood of intrapartum intervention with no difference in neonatal outcomes compared with planned hospital birth. The purpose of our study was to evaluate different birth settings by comparing neonatal mortality, morbidity and rates of birth interventions between planned home and planned hospital births in Ontario, Canada.

METHODS:
We used a provincial database of all midwifery-booked pregnancies between 2006 and 2009 to compare women who planned home birth at the onset of labour to a matched cohort of women with low-risk pregnancies who had planned hospital births attended by midwives. We conducted subgroup analyses by parity. Our primary outcome was stillbirth, neonatal death (< 28 d) or serious morbidity (Apgar score < 4 at 5 min or resuscitation with positive pressure ventilation and cardiac compressions).

RESULTS:
We compared 11 493 planned home births and 11 493 planned hospital births. The risk of our primary outcome did not differ significantly by planned place of birth (relative risk [RR] 1.03, 95% confidence interval [CI] 0.68-1.55). These findings held true for both nulliparous (RR 1.04, 95% CI 0.62-1.73) and multiparous women (RR 1.00, 95% CI 0.49-2.05). All intrapartum interventions were lower among planned home births.

INTERPRETATION:
Compared with planned hospital birth, planned home birth attended by midwives in a jurisdiction where home birth is well-integrated into the health care system was not associated with a difference in serious adverse neonatal outcomes but was associated with fewer intrapartum interventions.

Birth 2015;42(1):16-26. doi: 10.1111/birt.12150.

Outcome of planned home and hospital births among low-risk women in Iceland in 2005-2009: a retrospective cohort study.

Halfdansdottir B, Smarason AK, Olafsdottir OA, Hildingsson I, Herdis Sveinsdottir H.

BACKGROUND:

At 2.2 percent in 2012, the home birth rate in Iceland is the highest in the Nordic countries and has been rising rapidly in the new millennium. The objective of this study was to compare the outcomes of planned home births and planned hospital births in comparable low-risk groups in Iceland.

METHODS:

The study is a retrospective cohort study comparing the total population of 307 planned home births in Iceland in 2005-2009 to a matched 1:3 sample of 921 planned hospital births. Regression analysis, adjusted for confounding variables, was performed for the primary outcome variables.

RESULTS:

The rate of oxytocin augmentation, epidural analgesia, and postpartum hemorrhage was significantly lower when labor started as a planned home birth. Differences in the rates of other primary outcome variables were not significant. The home birth group had lower rates of operative birth and obstetric anal sphincter injury. The rate of 5-minute Apgar score < 7 was the same in the home and hospital birth groups, but the home birth group had a higher rate of neonatal intensive care unit admission. Intervention and adverse outcome rates in both study groups, including transfer rates, were higher among primiparas than multiparas. Oxytocin augmentation, epidural analgesia, and postpartum hemorrhage rates were significantly interrelated.

CONCLUSIONS:

This study adds to the growing body of evidence that suggests that planned home birth for low-risk women is as safe as planned hospital birth.

BJOG 2015;122(5):720-8. doi: 10.1111/1471-0528.13084.

Perinatal mortality and morbidity up to 28 days after birth among 743 070 low-risk planned home and hospital births: a cohort study based on three merged national perinatal databases.

de Jonge A, Geerts CC, van der Goes BY, Mol BW, Buitendijk SE, Nijhuis JG.

OBJECTIVE:
To compare rates of adverse perinatal outcomes between planned home births versus planned hospital births.

DESIGN:
A nationwide cohort study.

SETTING:
The Netherlands.

POPULATION:
Low-risk women in midwife-led care at the onset of labour.

METHODS:
Analysis of national registration data.

MAIN OUTCOME MEASURES:
Intrapartum and neonatal death, Apgar scores, and admission to a neonatal intensive care unit (NICU) within 28 days of birth.

RESULTS:
Of the total of 814 979 women, 466 112 had a planned home birth and 276 958 had a planned hospital birth. For 71 909 women, their planned place of birth was unknown. The combined intrapartum and neonatal death rates up to 28 days after birth, including cases with discrepancies in the registration of the moment of death, were: for nulliparous women, 1.02‰ for planned home births versus 1.09‰ for planned hospital births, adjusted odds ratio (aOR) 0.99, 95% confidence interval (95% CI) 0.79-1.24; and for parous women, 0.59‰ versus 0.58‰, aOR 1.16, 95% CI 0.87-1.55. The rates of NICU admissions and low Apgar scores did not significantly differ among nulliparous women (NICU admissions up to 28 days, 3.41‰ versus 3.61‰, aOR 1.05, 95% CI 0.92-1.18). Among parous women the rates of Apgar scores below seven and NICU admissions were significantly lower among planned home births (NICU admissions up to 28 days, 1.36 versus 1.95‰, aOR 0.79, 95% CI 0.66-0.93).

CONCLUSIONS:
We found no increased risk of adverse perinatal outcomes for planned home births among low-risk women. Our results may only apply to regions where home births are well integrated into the maternity care system.

Midwifery 2014;30(7):869-76. doi: 10.1016/j.midw.2014.01.008.

Deciding on home or hospital birth: results of the Ontario Choice of Birthplace Survey.

Murray-Davis B, McDonald H, Reitsma A, Coubrough M, Hutton E.

OBJECTIVE:

Decision-making autonomy regarding where to give birth is associated with maternal satisfaction with childbirth but how women decide their location of birth is poorly understood. The aim of this study was to understand how pregnant women in Ontario, Canada decide to give birth at home or hospital and why they choose one birthplace over another.

DESIGN:

A mixed methods survey completed by midwifery clients in Ontario pertaining to sources of information about choice of birthplace and decision-making priorities.

FINDINGS:

Decisions about choice of birthplace are made before becoming pregnant or during the first trimester. Books and research are important sources of information for women when deciding where to give birth. Women who planned home birth wanted to avoid interventions and felt most comfortable at home. Those who planned hospital birth wanted access to pain medication and found the idea of home birth stressful. Questions about the safety of home birth are a critical barrier to those who are undecided about where to give birth.

KEY CONCLUSIONS:

Beliefs and values about birth and the desire for pain relief options play significant roles in women׳s decisions, but are balanced with views of safety and risk. Regardless of where they have their baby, midwifery clients believe that birth is a natural process.

IMPLICATIONS FOR PRACTICE:

The findings provide health care providers and women with a deeper understanding of the factors for consideration when deciding where to give birth.