Home birth with midwife safe as hospital

Giving birth at home with a registered midwife can be as safe as a hospital birth for the infant and the mom, according to a Canadian study released Monday.

Midwives provide round-the-clock care for women during pregnancy, childbirth and postpartum in hospitals, birthing centres and at the homes of women.

The rate of deaths was about two per 1,000 for planned home births involving midwives as well as deliveries in hospitals involving either midwives or doctors, the researchers found.

"Women planning birth at home experienced reduced risk for all obstetric interventions measured, and similar or reduced risk for adverse maternal outcomes," such as electronic fetal monitoring and postpartum hemorrhage, Dr. Patricia Janssen from the University of British Columbia and her co-authors wrote in the Canadian Medical Association Journal.

The Society of Obstetricians and Gynecologists of Canada does not take a specific stand on the safety of home births, and has called for more research on it. The society said it should be up to each woman to decide where to give birth.

The American, Australian and New Zealand Colleges of Obstetricians and Gynecologists oppose home births while the United Kingdom's Royal College of Obstetrics and Gynecology and the Royal College of Midwives are supportive, as are midwife organizations in Canada, Australia and New Zealand.

In the study, researchers looked at 2,889 home births attended by regulated midwives in British Columbia and 4,752 planned hospital births attended by the same group of midwives, compared with 5,331 births in hospital attended by a physician.

The rate of deaths per 1,000 births in the first month of life was 0.35 for the planned home births, 0.57 for the hospital births with a midwife, and 0.64 with a physician, the researchers found.

Women in the planned home-birth group were much less likely than those who gave birth in hospital to have obstetric interventions including:

• 0.32 times less likely to receive electronic fetal monitoring.
• 0.41 times less likely to have an assisted vaginal delivery.
• 0.41 times less likely to suffer third- or fourth-degree perineal tears.
• 0.62 times less likely to have postpartum hemorrhage.

Women who planned to give birth at home needed less medical intervention, even among those who ended up in the hospital. Janssen doesn't know why, but it may be because women who choose home birth are determined not to have those procedures.

"So our study is not to say that home birth causes you to have fewer interventions," said Janssen. "It's really to say for women choosing this option, do they put themselves at increased risk for bad outcomes? And the answer to that is no."

Newborns who were born at home were also 0.23 times less likely to require resuscitation or oxygen therapy after 24 hours compared with those who were born in hospital with a midwife.

Infants born at home were also 0.45 times less likely to have aspirate meconium (inhaling a mixture of their feces and amniotic fluid).

Babies born to mothers who planned a home birth were 1.39 times more likely to be admitted to hospital after the birth, but Janssen believes the hospitalizations were related to jaundice, an easily treatable and relatively common condition.

Women self-selecting home births

It's not well understood what factors may help decrease the risks while giving birth at home, but researchers cautioned that those who choose to do so are self-selecting and may be healthier, which would be an important way to manage the risk.

The study also excluded women with medical conditions either before or during pregnancy. The results also don't cover deliveries by midwives who lacked extensive academic and clinical training.  

"Given the current lack of evidence from randomized controlled trials, the study by Janssen and colleagues makes an important contribution to our knowledge about the safety of home birth," midwife Helen McLachlan from La Trobe University in Bundoora, Australia, and Della Forster of Royal Women's Hospital in Parville, Australia, wrote in a journal commentary.

Despite ethical hurdles for conducting randomized controlled trials on home births, the pair called for such research to provide better evidence.

"The available evidence suggests that planned home birth is safe for women who are at low risk of complications and are cared for by appropriately qualified and licensed midwives with access to timely transfer to hospital if required," they wrote.

Option to consider

McLachlan and Forster also noted that while policymakers often support choice in childbirth, home-birthing options may be limited, particularly in rural and remote areas.

Acceptance of home births is generally low. For example, six per cent of all births in B.C. involve a midwife.

"Obviously a research study such as this provides more information for women to carefully consider their options," said Kris Robinson, who chairs the Canadian Midwife Regulators Consortium. "You know, one of them might be more attractive to women if they see results of this research that are so favourable."

In Canada, midwives are registered in British Columbia, Alberta, Manitoba, Ontario and Quebec and the Northwest Territories, according to the Society of Obstetricians and Gynecologists of Canada.

B.C.'s regulations for home births are stricter than in most provinces, said Dr. André Lalonde, executive vice-president of the society.

The study may not offer a fair comparison between between home and hospital births, Lalonde said.

"What I would like to see is that we have a hospital setting where every woman that comes into a hospital setting has a full-time nurse with her from the beginning to the end of delivery," Lalonde said. "Then we can compare."

In 2007, Statistics Canada reported that the majority of Canadian mothers who gave birth during a three-month period in 2006 were happy with their labour and the birth of their child.

Among those who had a midwife delivery, 71 per cent rated it as "very positive" compared with 53 per cent of women who had their babies delivered by obstetricians/gynecologists, family doctors or nurses and nurse practitioners.

The B.C. researchers are planning to compare the costs involved for home births, and to track the health of each of the babies up to one year of age.