Dutch home birth study

A few days ago the results of a large study of midwife-attended births in home and hospital in Holland were published. This study examined a remarkably high number of births: 529,688 to be exact. 60.7% (over 321,500) of those were planned home births. Previously, the largest study of home birth outcomes was the CPM 2000 study, published in the British Medical Journal, which examined the outcomes of 5,418 planned home births in North America with Certified Professional Midwives.

The Dutch study concluded that "planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system."

In Holland, 30% of women give birth at home. Whether planning a hospital or home birth, pregnant women see a midwife unless there is a medical indication for obstetrical care (or unless they opt to pay out-of-pocket to see an OB).

This new study has been a prominent feature in the news recently, especially in the UK, where the government is attempting to expand access to home birth. Here's a sampling of some of the news articles:

• BBC News reported that: Home births 'as safe as hospital' and that Wales is pushing ahead on home births
• OnMedica News reported Home births 'as safe' as those in hospitals
• The Times: Births at home as safe as hospital, study suggests
• The Press Association noted that the NHS 'can't meet home births demand'
• The Independent: Annalisa Barbieri: I gave birth at home – and here's why
• The Telegraph: Boost home births call as research shows they are safe
  

And in Australia, several major papers have picked up on the study. This comes just a week or two after a national furor over several home birth deaths (which appear to have been unattended home births, but we have very little information on the details, other than what one physician reported to the media). More about this later. Anyway, here are a few media reports coming out of Australia:

• The Sydney Morning Herald: Midwife home birth as safe as hospital, says study
• The Herald Sun: 530,000 new mums prove home births safe
• The Age: Hospital, home births 'no difference'

Here in the U.S., we still face many challenges to making home births safe and accessible. As the study's authors noted, there are three key elements that they feel contributed to the overall safety of home births in Holland: access to well-trained midwives, a good transportation system for home birth transfers, and a referral system that allows midwives to collaborate and/or refer to specialists when indicated. In many states, women desiring home births lack access to least one or two of these key elements.

My university does not have full-text access to this journal. If any of my readers do, please send me a copy!

Article Citation:
de Jonge A, van der Goes B, Ravelli A, Amelink-Verburg M, Mol B, Nijhuis J, Bennebroek Gravenhorst J, Buitendijk S. Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births. BJOG 2009.

ABSTRACT

Objective: To compare perinatal mortality and severe perinatal morbidity between planned home and planned hospital births, among low-risk women who started their labour in primary care.

Design: A nationwide cohort study.

Setting: The entire Netherlands.

Population: A total of 529 688 low-risk women who were in primary midwife-led care at the onset of labour. Of these, 321 307 (60.7%) intended to give birth at home, 163 261 (30.8%) planned to give birth in hospital and for 45 120 (8.5%), the intended place of birth was unknown.

Methods: Analysis of national perinatal and neonatal registration data, over a period of 7 years. Logistic regression analysis was used to control for differences in baseline characteristics. Main outcome measures Intrapartum death, intrapartum and neonatal death within 24 hours after birth, intrapartum and neonatal death within 7 days and neonatal admission to an intensive care unit.

Results: No significant differences were found between planned home and planned hospital birth (adjusted relative risks and 95% confidence intervals: intrapartum death 0.97 (0.69 to 1.37), intrapartum death and neonatal death during the first 24 hours 1.02 (0.77 to 1.36), intrapartum death and neonatal death up to 7 days 1.00 (0.78 to 1.27), admission to neonatal intensive care unit 1.00 (0.86 to 1.16).

Conclusions: This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.