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Home Birth Study

 

BMJ  2005;330:1416 (18 June), doi:10.1136/bmj.330.7505.1416

 

Outcomes of planned home births with certified professional

midwives: large prospective study in North America


Kenneth C Johnson, senior epidemiologist1, Betty-Anne Daviss,

project manager2

1 Surveillance and Risk Assessment Division, Centre for Chronic

Disease Prevention and Control, Public Health Agency of Canada, PL

6702A, Ottawa, ON, Canada K1A OK9, 2 Safe Motherhood/Newborn

Initiative, International Federation of Gynecology and Obstetrics,

Ottawa, Canada

 

Objective To evaluate the safety of home births in North America

involving direct entry midwives, in jurisdictions where the practice

is not well integrated into the healthcare system.

 

Design Prospective cohort study.

 

Setting All home births involving certified professional midwives

across the United States (98% of cohort) and Canada, 2000.

 

Participants All 5418 women expecting to deliver in 2000 supported

by midwives with a common certification and who planned to deliver

at home when labour began.

 

Main outcome measures Intrapartum and neonatal mortality, perinatal

transfer to hospital care, medical intervention during labour,

breast feeding, and maternal satisfaction.

 

Results 655 (12.1%) women who intended to deliver at home when

labour began were transferred to hospital. Medical intervention

rates included epidural (4.7%), episiotomy (2.1%), forceps (1.0%),

vacuum extraction (0.6%), and caesarean section (3.7%); these rates

were substantially lower than for low risk US women having hospital

births. The intrapartum and neonatal mortality among women

considered at low risk at start of labour, excluding deaths

concerning life threatening congenital anomalies, was 1.7 deaths per

1000 planned home births, similar to risks in other studies of low

risk home and hospital births in North America. No mothers died. No

discrepancies were found for perinatal outcomes independently

validated.

 

Conclusions Planned home birth for low risk women in North America

using certified professional midwives was associated with lower

rates of medical intervention but similar intrapartum and neonatal

mortality to that of low risk hospital births in the United States.

 

 

 

   Despite a wealth of evidence supporting planned home birth as a safe

option for women with low risk pregnancies,1-4 the setting remains

controversial in most high resource countries. Views are

particularly polarised in the United States, with interventions and

costs of hospital births escalating and midwives involved with home

births being denied the ability to be lead professionals in

hospital, with admitting and discharge privileges.5 Although several

Canadian medical societies6 7 and the American Public Health

Association8 have adopted policies promoting or acknowledging the

viability of home births, the American College of Obstetricians and

Gynecologists continues to oppose it.9 Studies on home birth have

been criticised if they have been too small to accurately assess

perinatal mortality, unable to distinguish planned from unplanned

home births accurately, or retrospective with the potential of bias

from selective reporting. To tackle these issues we carried out a

large prospective study of planned home births. The North American

Registry of Midwives provided a rare opportunity to study the

practice of a defined population of direct entry midwives involved

with home birth across the continent. We compared perinatal outcomes

with those of studies of low risk hospital births in the United

States.

 

     The competency based process of the North American Registry of

Midwives provides a certified professional midwife credential,

primarily for direct entry midwives who attend home births,

including those educated through apprenticeship. Our target

population was all women who engaged the services of a certified

professional midwife in Canada or the United States as their primary

caregiver for a birth with an expected date of delivery in 2000. In

autumn 1999, the North American Registry of Midwives made

participation in the study mandatory for recertification and

provided an electronic database of the 534 certified professional

midwives whose credentials were current. We contacted 502 of the

midwives (94.0%); 32 (6.0%) could not be located through email,

telephone, post, or local associations, 82 (15.4%) had stopped

independent practice, and 11 (2.1%) had retired. We sent a binder

with forms and instructions for the study to the 409 practising

midwives who agreed to participate.

 

Data collection

For each new client, the midwife listed identifying information on

the registration log form at the start of care; obtained informed

consent, including permission for the client to be contacted for

verification of information after care was complete; and filled out

a detailed data form on the course of care. Every three months the

midwife was required to send a copy of the updated registration log,

consent forms for new clients, and completed data forms for women at

least six weeks post partum. To confirm that forms had been received

for each registered client, we linked the entered data to the

registration database. We reviewed the clinical details and

circumstances of stillbirths and intrapartum and neonatal deaths and

telephoned the midwives for confirmation and clarification. To

verify this information we obtained reports from coroners,

autopsies, or hospitals on all but four deaths. For these four, we

obtained peer reviews.

 

Validation and satisfaction

We contacted a stratified, random 10% sample, of over 500 mothers,

including at least one client for every midwife in the study. The

mothers were asked about the date and place of birth, any required

hospital care, any problems with care, the health status of

themselves and their baby, and 11 questions on level of satisfaction

with their midwifery care.

 

 Data analysis

Our analysis focused on personal details of the clients, reasons for

leaving care prenatally, the rates and reasons for transfer to

hospital during labour and post partum, medical interventions,

health and admission to hospital of the newborn or mother from birth

up to six weeks post partum, intrapartum and neonatal mortality, and

breast feeding. We compared medical intervention rates for the

planned home births with data from birth certificates for all 3 360

868 singleton, vertex births at 37 weeks or more gestation in the

United States in 2000, as reported by the National Center for Health

Statistics,10 which acted as a proxy for a comparable low risk

group. We also compared medical intervention rates with the

listening to mothers survey,5 a national survey weighted to be

representative of the US birthing population aged 18-44. Intrapartum

and neonatal death rates were compared with those in other North

American studies of at least 500 births that were either planned out

of hospital or comparable studies of low risk hospital births.

 

    A total of 409 certified professional midwives from across the

United States and two Canadian provinces registered 7623 women whose

expected date of delivery was in 2000. Eighteen of the 409 midwives

(4.4%) and their clients were excluded from the study because they

failed to actively participate and had decided not to recertify or

left practice. Sixty mothers (0.8%) declined participation. The

figure provides an overview of why women left care before labour and

their intended place of birth at the start of labour.

 

Characteristics of the mothers

We focused on the 5418 women who intended to deliver at home at the

start of labour. Table 1 compares them with all women who gave birth

to singleton, vertex babies of at least 37 weeks or more gestation

in the United States in 2000 according to 13 personal and

behavioural variables associated with perinatal risk. Women who

started birth at home were on average older, of a lower

socioeconomic status and higher educational achievement, and less

likely to be African-American or Hispanic than women having full

gestation, vertex, singleton hospital births in the United States in

2000.

 

 Transfers to hospital

Of the 5418 women, 655 (12.1%) were transferred to hospital

intrapartum or post partum. Table 2 describes the transfers

according to timing, urgency, and reasons for transfer. Five out of

every six women transferred (83.4%) were transferred before

delivery, half (51.2%) for failure to progress, pain relief, or

exhaustion. After delivery, 1.3% of mothers and 0.7% of newborns

were transferred to hospital, most commonly for maternal haemorrhage

(0.6% of total births), retained placenta (0.5%), or respiratory

problems in the newborn (0.6%). The midwife considered the transfer

urgent in 3.4% of intended home births. Transfers were four times as

common among primiparous women (25.1%) as among multiparous women

(6.3%), but urgent transfers were only twice as common among

primparous women (5.1%) as among multiparous women (2.6%).

 

 Medical interventions

Individual rates of medical intervention for home births were

consistently less than half those in hospital, whether compared with

a relatively low risk group (singleton, vertex, 37 weeks or more

gestation) that will have a small percentage of higher risk births

or the general population having hospital births (table 3). Compared

with the relatively low risk hospital group, intended home births

were associated with lower rates of electronic fetal monitoring

(9.6% versus 84.3%), episiotomy (2.1% versus 33.0%), caesarean

section (3.7% versus 19.0%), and vacuum extraction (0.6% versus

5.5%). The caesarean rate for intended home births was 8.3% among

primiparous women and 1.6% among multiparous women.

 

 Outcomes

No maternal deaths occurred. After we excluded four stillborns who

died before labour but whose mothers still chose home birth, and

three babies with fatal birth defects, five deaths were intrapartum

and six occurred during the neonatal period (see box). This was a

rate of 2.0 deaths per 1000 intended home births. The intrapartum

and neonatal mortality was 1.7 deaths per 1000 low risk intended

home births after planned breeches and twins (not considered low

risk) were excluded. The results for intrapartum and neonatal

mortality are consistent with most North American studies of

intended births out of hospital11-24 and low risk hospital births

(table 4).14 21 22 24-30

 

 Breech and multiple births at home are controversial among home

birth practitioners. Among the 80 planned breeches at home there

were two deaths and none among the 13 sets of twins. In the 694

births (12.8%) in which the baby was born under water, there was one

intrapartum death (birth at 41 weeks, five days) and one fatal birth

defect death.

 

Apgar scores were reported for 94.5% of babies; 1.3% had Apgar

scores below 7 at five minutes. Immediate neonatal complications

were reported for 226 newborns (4.2% of intended home births). Half

the immediate neonatal complications concerned respiratory problems,

and 130 babies (2.4%) were placed in the neonatal intensive care

unit.

 

Health in first six weeks post partum

Health problems in the six weeks post partum were reported for 7% of

newborns. Among the 5200 (96%) mothers who returned for the six week

postnatal visit, 98.3% of babies and 98.4% of mothers reported good

health, with no residual health problems. At six weeks post partum,

95.8% of these women were still breast feeding their babies, 89.7%

exclusively.

 

Outcome validation and client satisfaction

Among the stratified, random 10% sample of women contacted directly

by study staff to validate birth outcomes, no new transfers to

hospital during or after the birth were reported and no new

stillbirths or neonatal deaths were uncovered. Mothers' satisfaction

with care was high for all 11 measures, with over 97% reporting that

they were extremely or very satisfied. For a subsequent birth, 89.6%

said they would choose the same midwife, 9.1% another certified

professional midwife, and 1.7% another type of caregiver.

 

Women who intended at the start of labour to have a home birth with

a certified professional midwife had a low rate of intrapartum and

neonatal mortality, similar to that in most studies of low risk

hospital births in North America. A high degree of safety and

maternal satisfaction were reported, and over 87% of mothers and

neonates did not require transfer to hospital.

 

A randomised controlled trial would be the best way to tackle

selection bias of mothers who plan a home birth, but a randomised

controlled trial in North America is unfeasible given that even in

Britain, where home birth has been an incorporated part of the

healthcare system for some time, and where cooperation is more

feasible, a pilot study failed.31 Prospective cohort studies remain

the most comprehensive instruments available.

 

Our results for intrapartum and neonatal mortality are consistent

with most other North American studies of intended births out of

hospital and studies of low risk hospital birth (table 4). A meta-

analysis2 and the latest research in Britain,3 4 32 Switzerland,33

and the Netherlands34 have reinforced support of home birth.

Researchers reported high overall perinatal mortality in a study of

home birth in Australia,35 qualifying that low risk home births in

Australia had good outcomes but that high risk births gave rise to a

high rate of avoidable death at home.36 Two prospective studies in

North America found positive outcomes for home birth,23 24 but the

studies were not of sufficient size to provide relatively stable

perinatal death rates. None of this evidence, including ours, is

consistent with a study in Washington State based on birth

certificates.21 That study reported an increased risk with home

birth but lacked an explicit indication of planned place of birth,

creating the potential inclusion of high risk unplanned, unattended

home births.28 37

 

Our study has several strengths. Internationally it is one of the

few, and the largest, prospective studies of home birth, allowing

for relatively stable estimates of risk from intrapartum and

neonatal mortality. We accurately identified births planned at home

at the start of labour and included independent verification of

birth outcomes for a sample of 534 planned home births. We obtained

data from almost 400 midwives from across the continent.

 

Regardless of methodology, residual confounding of comparisons

between home and hospital births will always be a possibility. Women

choosing home birth (or who would be willing to be randomised to

birth site in a randomised trial) may differ for unmeasured

variables from women choosing hospital birth. For example, women

choosing home birth may have an advantageous enhanced belief in

their ability to give birth safely with little medical intervention.

On the other hand, women who choose hospital birth may have a

psychological advantage in North America associated with not having

to deal with the social pressure and fears of spouses, relatives, or

friends from their choice of birth place.

 

Our results may be generalisable to a larger community of direct

entry midwives. The North American Registry of Midwives was created

in 1987 to develop the certified professional midwife credential—a

route for formal certification for midwives involved in home birth

who were not nurse midwives and who came from diverse educational

backgrounds. Thus the women who chose to become certified

professional midwives were a subset of the larger community of

direct entry midwives in North America whose diverse educational

backgrounds and midwifery practice were similar to certified

professional midwives. From 1993 to 1999, using an earlier iteration

of the data form, we collected largely retrospective data on a

voluntary basis mainly from direct entry midwives involved with home

births approached through the Midwives Alliance of North America

Statistics and Research Committee and the Canadian Midwives

Statistics' Collaboration. This earlier unpublished data of over 11

000 planned home births showed similar demographics, rates of

intervention, transfers to hospital, and adverse outcomes.

 

As with the prospective US national birth centre study19 and the

prospective US home birth study,23 the main study limitation was the

inability to develop a workable design from which to collect a

national prospective low risk group of hospital births to compare

morbidity and mortality directly. Forms for vital statistics do not

reliably collect the information on medical risk factors required to

create a retrospective hospital birth group of precisely comparable

low risk,38-40 and hospital discharge summary records for all births

are not nationally accessible for sampling and have some

limitations, being primarily administrative records.

 

One exception, and an important adjunct to our study, was

Schlenzka's study in California.22 In this PhD thesis, Schlenzka was

able to establish a large defined retrospective cohort of planned

home and hospital births with similar low risk profiles, because

birth and death certificates in California include intended place of

birth and these had been linked to hospital discharge abstracts for

1989-90 for a caesarean section study. When the author compared 3385

planned home births with 806 402 low risk hospital births, he

consistently found a non-significantly lower perinatal mortality in

the home birth group. The results were consistent regardless of

liberal or more restrictive criteria to define low risk, and whether

or not the analysis involved simple standardisation of rates or

extensive adjustment for all potential risk variables collected.22

 

An economic analysis found that an uncomplicated vaginal birth in

hospital in the United States cost on average three times as much as

a similar birth at home with a midwife41 in an environment where

management of birth has become an economic, medical, and industrial

enterprise.42 Our study of certified professional midwives suggests

that they achieve good outcomes among low risk women without routine

use of expensive hospital interventions. Our results are consistent

with the weight of previous research on safety of home birth with

midwives internationally. This evidence supports the American Public

Health Association's recommendation8 to increase access to out of

hospital maternity care services with direct entry midwives in the

United States. We recommend that these findings be taken into

account when insurers and governing bodies make decisions about home

birth and hospital privileges with respect to certified professional

midwives.

 

 

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We thank the North American Registry of Midwives Board for helping

facilitate the study; Tim Putt for help with layout of the data

forms; Jennesse Oakhurst, Shannon Salisbury, and a team of five

others for data entry; Adam Slade for computer programming support;

Amelia Johnson, Phaedra Muirhead, Shannon Salisbury, Tanya Stotsky,

Carrie Whelan, and Kim Yates for office support; Kelly Klick and

Sheena Jardin for the satisfaction survey; members of our advisory

council (Eugene Declerq (Boston University School of Public Health),

Susan Hodges (Citizens for Midwifery and consumer panel of the

Cochrane Collaboration's Pregnancy and Childbirth Group), Jonathan

Kotch (University of North Carolina Department of Maternal and Child

Health),, Patricia Aikins Murphy (University of Utah College of

Nursing), and Lawrence Oppenheimer (University of Ottawa Division of

Maternal Fetal Medicine); and the midwives and mothers who agreed to

participate in the study.

Contributors: KCJ and B-AD designed the study, collected and

analysed the data, and prepared the manuscript. KCJ is guarantor for

the paper.

 

Funding: The Benjamin Spencer Fund provided core funding for this

project. The Foundation for the Advancement of Midwifery provided

additional funding. Their roles were purely to offset the costs of

doing the research. This work was not done under the auspices of the

Public Health Agency of Canada or the International Federation of

Gynecology and Obstetrics and the views expressed do not necessarily

represent those of these agencies.

 

Competing interests: None declared.

 

Ethical approval: Ethical approval was obtained from an ethics

committee created for the North American Registry of Midwives to

review epidemiological research involving certified professional

midwives.

 

 

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