Page last updated at 08:08 GMT, Wednesday, 15 April 2009 09:08 UK
Home births 'as safe as hospital'
There have been few comprehensive studies into home births
The largest study of its kind has found that for low-risk women, giving birth at home is as safe as doing so in hospital with a midwife.
Research from the Netherlands - which has a high rate of home births - found no difference in death rates of either mothers or babies in 530,000 births.
Home births have long been debated amid concerns about their safety.
UK obstetricians welcomed the study - published in the journal BJOG - but said it may not apply universally.
The number of mothers giving birth at home in the UK has been rising since it dipped to a low in 1988. Of all births in England and Wales in 2006, 2.7% took place at home, the most recent figures from the Office for National Statistics showed.
The research was carried out in the Netherlands after figures showed the country had one of the highest rates in Europe of babies dying during or just after birth.
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It was suggested that home births could be a factor, as Dutch women are able and encouraged to choose this option. One third do so.
But a comparison of "low-risk" women who planned to give birth at home with those who planned to give birth in hospital with a midwife found no difference in death or serious illness among either baby or mother.
"We found that for low-risk mothers at the start of their labour it is just as safe to deliver at home with a midwife as it is in hospital with a midwife," said Professor Simone Buitendijk of the TNO Institute for Applied Scientific Research.
"These results should strengthen policies that encourage low-risk women at the onset of labour to choose their own place of birth."
Low-risk women in the study were those who had no known complications - such as a baby in breech or one with a congenital abnormality, or a previous caesarean section.
Nearly a third of women who planned and started their labours at home ended up being transferred as complications arose - including for instance an abnormal fetal heart rate, or if the mother required more effective pain relief in the form of an epidural.
The NHS is simply not set up to meet the potential demand for home births
Royal College of Midwives
But even when she needed to be transferred to the care of a doctor in a hospital, the risk to her or her baby was no higher than if she had started out her labour under the care of a midwife in hospital.
The researchers noted the importance of both highly-trained midwives who knew when to refer a home birth to hospital as well as rapid transportation.
While stressing the study was the most comprehensive yet into the safety of home births, they also acknowledged some caveats.
The group who chose to give birth in hospital rather than at home were more likely to be first-time mothers or of an ethnic minority background - the risk of complications is higher in both these groups.
The study did not compare the relative safety of home births against low-risk women who opted for doctor rather than midwife-led care. This is to be the subject of a future investigation.
But Professor Buitendijk said the study did have relevance for other countries like the UK with a highly developed health infrastructure and well-trained midwives.
Women need to be counselled on the unexpected emergencies which can arise during labour and can only be managed in a maternity hospital
In the UK, the government has pledged to give all women the option of a home birth by the end of this year. At present just 2.7% of births in England and Wales take place at home, but there are considerable regional variations.
Louise Silverton, deputy general secretary of the Royal College of Midwives, said, the study was "a major step forward in showing that home is as safe as hospital, for low risk women giving birth when support services are in place.
"However, to begin providing more home births there has to be a seismic shift in the way maternity services are organised. The NHS is simply not set up to meet the potential demand for home births, because we are still in a culture where the vast majority of births are in hospital.
"There also has to be a major increase in the number of midwives because they are the people who will be in the homes delivering the babies."
Mary Newburn, of the National Childbirth Trust, said: "This makes a significant contribution to the growing body of reassuring evidence that suggests offering women a choice of place of birth is entirely appropriate."
The Royal College of Obstetricians and Gynaecologists (RCOG) said it supported home births "in cases of low-risk pregnancies provided the appropriate infrastructures and resources are present to support such a system.
But it added: "Women need to be counselled on the unexpected emergencies - such as cord prolapse, fetal heart rate abnormalities, undiagnosed breech, prolonged labour and postpartum haemorrhage - which can arise during labour and can only be managed in a maternity hospital.
"Such emergencies would always require the transfer of women by ambulance to the hospital as extra medical support is only present in hospital settings and would not be available to them when they deliver at home."
The Department of Health said that giving more mothers-to-be the opportunity to choose to give birth at home was one of its priority targets for 2009/10.
A spokesman said: "All Strategic Health Authorities (SHAs) have set out plans for implementing Maternity Matters to provide high-quality, safe maternity care for women and their babies."
Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births
A de Jonge a , BY van der Goes b , ACJ Ravelli c , MP Amelink-Verburg a,d , BW Mol b , JG Nijhuis e , J Bennebroek Gravenhorst a , SE Buitendijk a
a TNO Quality of Life, Leiden, the Netherlands b Department of Obstetrics and Gynaecology, Amsterdam Medical Centre, Amsterdam, the Netherlands c Department of Medical Informatics, Amsterdam Medical Centre, Amsterdam, the Netherlands d Health Care Inspectorate, Rijswijk, the Netherlands e Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands
Correspondence to Dr A de Jonge, TNO Quality of Life, P.O. Box 2215, 2301 CE Leiden, the Netherlands. Email email@example.com
Copyright Journal compilation © 2009 RCOG
Midwifery • perinatal mortality • pregnancy outcome
Please cite this paper as: 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; DOI: 10.1111/j.1471-0528.2009.02175.x.
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.
Accepted 26 February 2009. Published Online 15 April 2009.
DIGITAL OBJECT IDENTIFIER (DOI)
10.1111/j.1471-0528.2009.02175.x About DOI
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