I haven’t read this study yet (it’s next on my list of things to read; but I have a sick child right now, and might come down with something myself, so I wanted to get this out ASAP, even if I hadn’t read it yet — especially since if I get sick and feel like my kids are acting, I won’t be in any mood to read it!); but here is a lay article summarizing it.
Here’s the abstract (although the link is to the complete study):
Background: Studies of planned home births attended by registered midwives have been limited by incomplete data, nonrepresentative sampling, inadequate statistical power and the inability to exclude unplanned home births. We compared the outcomes of planned home births attended by midwives with those of planned hospital births attended by midwives or physicians.
Methods: We included all planned home births attended by registered midwives from Jan. 1, 2000, to Dec. 31, 2004, in British Columbia, Canada (n = 2889), and all planned hospital births meeting the eligibility requirements for home birth that were attended by the same cohort of midwives (n = 4752). We also included a matched sample of physician-attended planned hospital births (n = 5331). The primary outcome measure was perinatal mortality; secondary outcomes were obstetric interventions and adverse maternal and neonatal outcomes.
Results: The rate of perinatal death per 1000 births was 0.35 (95% confidence interval [CI] 0.00–1.03) in the group of planned home births; the rate in the group of planned hospital births was 0.57 (95% CI 0.00–1.43) among women attended by a midwife and 0.64 (95% CI 0.00–1.56) among those attended by a physician. Wo men in the planned home-birth group were significantly less likely than those who planned a midwife-attended hospital birth to have obstetric interventions (e.g., electronic fetal monitoring, relative risk [RR] 0.32, 95% CI 0.29–0.36; assisted vaginal delivery, RR 0.41, 95% 0.33–0.52) or adverse maternal outcomes (e.g., third- or fourth-degree perineal tear, RR 0.41, 95% CI 0.28–0.59; postpartum hemorrhage, RR 0.62, 95% CI 0.49–0.77). The findings were similar in the comparison with physician-assisted hospital births. Newborns in the home-birth group were less likely than those in the midwife-attended hospital-birth group to require resuscitation at birth (RR 0.23, 95% CI 0.14–0.37) or oxygen therapy beyond 24 hours (RR 0.37, 95% CI 0.24–0.59). The findings were similar in the comparison with newborns in the physician-assisted hospital births; in addition, newborns in the home-birth group were less likely to have meconium aspiration (RR 0.45, 95% CI 0.21–0.93) and more likely to be admitted to hospital or readmitted if born in hospital (RR 1.39, 95% CI 1.09–1.85).
Interpretation: Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.
Now, the big question that so many people ask when faced with studies like this that show similar or better outcomes for mothers and babies who have home births is, “how is this possible?” The idea is that since hospitals have all the bells, whistles, gadgets, and even the machine that goes *ping*, that this means that births there have to be safer than births at home. Well, the answer, I believe, lies in the balance of risk and benefit. There are numerous studies that indicate that when interventions are used unnecessarily (whether that’s inductions without a medical reason, elective C-sections, etc.), then both mothers and babies have worse outcomes. Some of these worse outcomes are higher mortality, or higher morbidity, greater NICU admissions, and more infections (particularly maternal — healing from either a C-section or episiotomy incision). The situation at a home birth is that most of these interventions are simply not used at all — if there is an indication for an intervention, the mother is transferred to the hospital (for an epidural, Pitocin augmentation, a C-section, etc.), with very few interventions performed at home. Studies will keep any hospital transfers in the “planned home birth” group, but with the average rate of hospital transfer being 10%, that means that 90% or more of all planned home births are accomplished with few or no interventions. When interventions are necessary or beneficial, that’s one thing; but even a certain percentage of these will have adverse effects — so to reduce the “side effects” they should be limited to only those that are necessary. If 10% of women with epidurals have an adverse reaction, but 100% of all women get an epidural, then 10% of all women will have adverse reactions. If, however, only 30% of women get epidurals, and 10% of those have adverse side effects, then only 3% of all women will be negatively affected. The same thing applies to all other interventions, for both mothers and babies.
It appears that for low-risk women, avoiding the interventions (with their attendant risks), even if they have to stay out of a hospital to do it, then the risks and benefits balance, or even tip in favor of planned home birth. It may be that some babies born at home are negatively affected by a lack of immediate medical attention (for instance, a baby with an unknown heart condition that requires immediate surgery postpartum — obviously rare); but it also appears that other babies born at the hospital are negatively affected by too much “medical attention.” I have yet to see a study that shows worse maternal outcomes for planned home births; and most if not all good studies show similar or better fetal/neonatal outcomes for home birth.
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