First time mothers may put themselves and baby at risk by choosing home-birth: Report

By Dr. Ananya Mandal, MDNov 28 2011

A new report suggests that first time mothers who opt for a home birth are almost three times more likely to have a baby who dies or suffers brain damage. It also found that traditional maternity units in hospital are the safest place for women to have their first child.

The Birthplace in England study, published in the British Medical Journal, compared data for 65,000 women deemed at low risk of complications who planned to give birth either in a hospital maternity department, at home or in a midwife-led birthing unit. It found that first-time mothers were 2.8 times more likely to suffer serious problems at home than in hospital obstetric units. These included the death of the child and injuries to its upper arms or shoulders. 

Almost half of women who chose to give birth at home had to be transferred to a hospital because of complications during labor the report said. Additionally these emergencies require intense medical attention, and are linked to trauma at birth or the baby becoming distressed or deprived of oxygen, potentially causing brain damage. The study also found that 36 per cent of women using birthing units – maternity units sometimes outside hospital grounds which are run by midwives – had to be transferred to hospital when problems arose.

Dr Tony Falconer, president of the Royal College of Obstetricians and Gynecologists, said, “This study has shown that first-time mothers wishing to deliver at home have an increased risk for their babies, thus raising questions about the right birth location for this group of women. In addition, having to transfer 36 per cent of mothers from a free-standing midwifery unit to obstetric units raises many issues.”

Professor Peter Brocklehurst, who led the study at Oxford University but has since moved to University College London, believes women should have a choice over where they have their babies. He said, “There is an increase in risk for first-time mums planning home births, but poor outcomes for the baby are still uncommon.”

The slightly worse outcomes at home for first-timers are unexplained. “I don't know why. We don't know which aspects of the care or the site contributed to this,” said Brocklehurst. It could be to do with the sort of women who chose home birth, who tended to be white, slightly older, better educated and live in more affluent areas, the midwife's experience, problems in transferring to hospital in an emergency or something else entirely. More work would be needed to establish what was happening.

Serious problems are rare for babies whose birth was planned in a maternity unit – occurring just 3.5 times for every 1,000 deliveries. But the research shows the rate rises to 9.5 per 1,000 babies if the birth is planned at home. Women who chose to give birth in a consultant-led hospital maternity unit had a higher chance of an intervention – such as a caesarean, delivery using ventouse or forceps, or being given an epidural.

In England last year, 2.5 per cent of mothers had a home birth – a slight fall on the previous year – with nine out of ten births occurring in hospital.

Only 58 per cent of these women who went to the hospital set up, had a natural birth without any intervention, compared with 88 per cent of women giving birth at home and three-quarters of women in a midwife-led unit.

Cathy Warwick, chief executive and general secretary of the Royal College of Midwives, said, “For women who do not have complications, planning to give birth at home or in a midwife-led unit is as safe as planning to give birth in a consultant-led unit. Where a woman is considering birth at home she needs to be aware that there is a chance that wherever she gives birth the baby may have a poor outcome, and at home this chance is increased.”

Mary Newburn, head of research and information at NCT, the UK’s largest charity for parents, said, “For first-time mothers planning a home birth there was a small increase in poor outcomes, but a greater chance of giving birth without interventions. Parents should have this explained to them, so they can then make up their minds where they would like to plan to have their baby.” “For low-risk women in first and subsequent pregnancies, care in a midwifery unit is safe for them and their babies, and leads to more straightforward births without medical interventions such as an emergency caesarean,” she said. The researchers found there was no increased risk for second or subsequent babies whose mothers chose home birth – the finding only applied to first-time mothers.

Maureen Treadwell, of the Birth Trauma Association, said, “These findings are useful but are based on a study of only 5,000 women in each type of midwifery unit and do not tell us how many babies died or were brain damaged in each group.” She feared that the government will use the findings as 'an excuse' to restrict women's choices to midwife-led units or home if they were classed as low risk, in order to save money. The study showed that a home birth cost £310 less than one in an obstetric unit in hospital, while a birth in a midwife-led unit was £130 cheaper.

Public Health Minister Anne Milton said, “Every woman should receive the highest quality maternity care. This study will help NHS organizations around the country design excellent maternity services, based on what women want and need. This report gives valuable evidence on which to base decisions about the design of services, including the opportunities for women to choose midwife-led care in both free-standing and alongside midwife-led units. It will also help midwives advice women so that they can make the most informed choice about their birth setting.”