Tuesday, November 29, 2011

Birthplace in England: A Tale of Medical Reporting

A large prospective study comparing planned place of birth (home, hospital, freestanding midwife units, and in-hospital midwife units) for low-risk mothers in England, the BirthPlace study, was just published in the British Medical Journal. What has followed is a barrage of news headlines about the study--with drastically different conclusions.

If you click on the Daily Mail report, you'll be warned that "First-time mothers who opt for home birth face triple the risk of death or brain damage in child." TopNews Arab Emirates reports that "Motherhood is bliss but a minute mistake in planning the birth may lead to severe complications," while its US affiliate asserts that "According to a recent study, first time mothers should always opt for hospital birth." Even more dramatic is NewTonight's comment that home birth is "an extremely dangerous practice." (Definitely some one-upmanship going on here!)

If you're thinking that home birth is akin to traipsing over a minefield, you only have to turn to another set of news headlines that herald the opposite conclusion. "Study finds home birth is safe" proclaims the Peterborough Herald. "Women who have low-risk pregnancies should be able to choose where they give birth -- hospital, home or midwifery units -- researchers in Britain say," according to UPI. The Huffington Post declares that "over half of all pregnant women could give birth at home."

I've seen one report claiming that Professor Peter Brocklehurst, one of the study's authors, has "expressed disappointment that there is a significant increase in the number of first -time mothers who are planning to deliver their baby at home." (Granted, this was not a very reputable-looking site.) In contrast, the Huffington Post quoted Brocklehurst thus: "Birth isn't an abnormal process, it's a physiological process. And if your pregnancy and labor is not complicated, then you don't need a high level of specific expertise."

If news reports are this conflicting, imagine what's going on in the blogosphere. "SEE I TOLD YOU HOME BIRTH KILLS BABIES!" is coming from one corner of the net, while "SEE I TOLD YOU HOME BIRTH IS SAFE!" is coming from another. This controversy will keep certain bloggers entertained for months.

At this point, a reasonable response would be "what the $#@! is going on? Can't anyone agree on anything?"

Another reasonable response would be "So what about midwifery units? All the hullabaloo has focused on home and hospital birth and left out the other two studied locations!" 

This is how I'm feeling right about now:

I'm not going to tell you what to think. But here's where I'd suggest starting:

1. Read the original study.
2. Read the official National Health Service discussion of the study's significance and ramifications.
3. If your statistical skills are a bit rusty, you can polish them up over at Science and Sensibility's statistical discussion of the study.
4. Another statistical examination of the study: Are homebirths really risky? at Statistical Epidemiology

Original Study
Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011;343:d7400

Project details, including qualitative case studies and economic analysis

News reports emphasizing risk
News reports emphasizing safety


  1. What I love is that if you go to the front page of the "Pregnancy Section" on HuffPo (http://www.huffingtonpost.com/news/parents-pregnancy/), it actually has articles on both of those viewpoints! There's "Why Some Doctors Are Supporting Home Births," and right next to it, "Home Birth Risk for New Mothers," both reporting on the Birthplace study. Pick and choose - this website is happy to help you reinforce your view, whatever it is!

    The pro-homebirth articles tend to cite ~5/1000 adverse outcomes in the hospital vs. 9.5/1000 for first-time mothers. The anti-homebirth articles instead cite 3.5/1000 adverse outcomes vs. 9.5/1000. I did a little digging: the 5/1000 is the correct figure for first-time mothers in the hospital, and 9.5/1000 is correct for first-time mothers at home. 4.3/1000 is the number for all women in the hospital, so I'm guessing that the 3.5/1000 number (used in the "Home Birth Risk" story linked on HuffPo, for example) is multiparas in the hospital.

    I'm so glad that the actual study and reports are available online.

  2. You hit the nail on the head! And Bronwen, "Pick and choose - this website is happy to help you reinforce your view, whatever it is!"--Lol!

  3. Re: midwifery led units - in the UK NHS all births are under midwifery led care, unless there are complications where a doctor is called in. Prenatal care is done by your local midwifery clinic, if you are having a homebirth the same midwives that you met at prenatals will attend your birth (unless it is a holiday when they cover eachother's areas) and if you have a hospital birth then you are cared for by hospital midwives. After the birth you are cared for at home by your community midwife. (Yes, that is a home visit by your community midwife.) Therefore any research using UK homebirth/hospital birth statistics will not include stand-alone midwifery units.

  4. What strikes me most is the utter inapplicability of this study to the US. As Sarahvine said, the system is completely different. And outcomes seem totally different, too. What is the primary cesarean section rate in the US? I don't know it and can't find it quickly. But I doubt it's 11% which is the highest number quoted in the NHS article for first-time moms. I bet it's higher. I KNOW the epidural rate here for first time moms is higher than 30%. It sounds to me like hospital birth in the NHS may be a lot safer than hospital birth in the US, but that doesn't tell us anything about the comparison between home and hospital birth in the US.

  5. Some of what you're pointing out here is just a matter of how headlines are written for online. There is a very deliberate practice of intentionally highlighting "shocking" statistics or something likely to produce an emotional response because it encourages people to click and comment (but sadly, it often doesn't mean they actually read the article!)

    Consider that a little bit of 'reader beware' - online-only sites like HuffPo love them a good study that allows them to produce a piece of weakly reported content that will then insight raging internet debates. Pageviews and comments and likes rule the world of internet content. Not journalism and reporting.... that is sadly now considered 'old school'

  6. Thank you including links to the original sites.

    How can I translate these findings into an US-context?

  7. The same thing happens with "obesity" research - the obesity scare is almost entirely fabricated research by allergan and johnson & johnson to promote insurance and government coverage of weight loss surgery. I have a hard time trusting any source anymore. Instinct is where its at.

  8. Hi there, am new to your blog. I'm in the UK and a friend of mine who is having her fifth baby has been told her risks of having dangerously heavy bleeding with the 5th birth are higher so they want her to birth in hospital, rather than at home. She has had all home births before and would like to again - do you know anything about 5th births or where we could find any data?

    Thanks so much
    (I am a blog newbie, just started my own

  9. Hi,

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  10. I think we ALL know that news stations/papers/sites love a good headline. They also love to bash anything that is "out there" if it is not fashionable. Honestly no matter what study they look at, even a "perfect" homebirth study, they are still going to make the same headlines. "dead baby" headlines are going to generate more clicks and paper sales than "beautiful home birth and happy mom" headlines. Makes me sad.


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