Thursday, April 16, 2009

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:
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:
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.

13 comments:

  1. I'm glad to see this study addresses perinatal mortality and morbidity. Those who oppose homebirth always hide behind "you should be looking at perinatal statistics to judge outcomes." In fact, I just heard that from the backup OB I fired last week . . .

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  2. This is an interesting thought about the study.
    http://www.givingbirthwithconfidence.org/?p=271
    What are your thoughts?

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  3. Unfortunately I think the article posted by maria is right - this study will do nothing to sway ACOG.

    I am a bit disappointed as well to see the "criteria" for safety put forward in the Dutch article, especially the transport to hospital rule, because it will make it virtually impossible to convince lawmakers of the safety of homebirth in rural states.

    Here in NE, that is one of the biggest arguments against us! Of course, having access to a midwife out in the boonies would generally be better than having the baby in the car on the side of the road trying to get to the hospital. Or worse, automatic scheduled inductions for everyone who lives more than 20 mins away from the hospital.

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  4. St├ęphanie St-Amant4/16/09, 4:29 PM

    About the interpretation of the Dutch study results, this may interest you:

    http://wiki.naissance.asso.fr/index.php/LetterBmjApril2008

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  5. I've asked my husband if he can get a copy. I will let you know if he can.

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  6. I've already had 3 readers email me the PDF, so thanks very much for your prompt assistance!

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  7. I checked the comments to see if you'd gotten the PDF yet, I'm glad you have! Happy reading!

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  8. This comment has been removed by the author.

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  9. "Home birth is a perfectly safe option, and has been proven time and time again to be just as safe as hospital birth, with a midwife in attendance...."

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  10. Rixa do you know if anyone has done anything like this with the US CDC NCHS birth data (from birth certificates)? The data are incredibly rich and, I believe include information about where the birth took place, who was in attendance, extent of prenatal care/complications, etc. It seems like it wouldn't be too difficult to replicate this for the US if it hasn't been done already.

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  11. Annie,

    Here is the link to the CDC on-line query where you can look up that information. The problem, though, is that there is no way to properly distinguish whether the births that ended up being outside the hospital were planned that way or if they just happened (precipitous labor, mom stuck in the snow, etc.). It is valuable information, but it has its limits.

    One thing I noticed in doing various searches (I was *hooked* on doing these things -- it was so interesting!), is that women who had planned home births with a non-nurse midwife (I assume that all births actually attended by a DEM were planned that way) had a greater incidence of babies with lethal congenital abnormalities, such as anencephaly and certain chromosomal abnomralities. If I remember the correct rate, it was over 3x as many such babies born at home vs. born at the hospital in the term period. This suggests to me that more women who choose home birth choose not to have ultrasounds or genetic tests that may indicate a problem with the baby, therefore don't have abortions or preterm inductions when they find out their babies have lethal conditions.

    Anyway, I have written at length on my blog (last year) about the CDC stats, looking at them from various different angles, and that's just one of many drawbacks with just looking at the bare data.

    -Kathy

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  12. Thanks. I've started looking at the CDC data for a research project I'm planning. I may contact you in the future.

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  13. Here is a link to the complete paper:
    http://tinyurl.com/298nc2z

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