Dear all,
Good idea to compare outcomes of planned home births across countries. A systematic review is in progress which will stratify for countries in which home birth is integrated in the maternity care system and countries where this is not the case:
Syst Rev. 2014 May 29;3:55. doi: 10.1186/2046-4053-3-55.
Protocol: systematic review and meta-analyses of birth outcomes for women who intend at the onset of labour to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital.
Hutton EK1, Reitsma A, Thorpe J, Brunton G, Kaufman K.
I agree with the comment that it is a problem to compare prospective and retrospective studies. The missing neonatal data in our study are, of course, a big disadvantage. However, as we have written in the discussion, these missing data are due to a large number of neonatal units not taking part in our national registration (which is quite unacceptable I think - people are working on getting data from all maternity care professionals into the national database). There is no reason to believe that these missing data are more prevalent among planned home versus planned hospital births as midwives who attend both work with the same neonatal units regardless which woman they are looking after.
Interesting how people assume Apgar scores will be 'overestimated' at home births and not hospital births. The same midwives attend both; at home they are assisted by a maternity care assistant, in hospital by a nurse - no doctor in sight who might provide the 'right' Apgar score at a hospital birth!
A prospective study, such as the beautiful Birthplace study in England would solve some of our methodological issues. So far, we did not manage to get funders interested in a Dutch home birth study. Quite embarrassing that the UK was prepared to put millions of pounds into a home birth study while less than 3% of women give birth at home and the Netherlands thinks it is not relevant while 30% of women used to give birth at home! Indeed, the rate is dropping - now settling since 3 years just under 20%.
A birth centre study has been funded (conducted by TNO and Erasmus Medical Center) which will generate data about home births as well. However, the number will not be large enough to compare hard outcomes between groups.
It is reassuring that all of our studies are generating discussions about becoming more positive towards home births, even among obstetricians in the US:
http://www.obgyn.net/pregnancy-and-birth/whats-ethical-response-home-birth
This is our ultimate aim: to broaden (and maintain) choices for women in childbirth by generating data about safe alternatives to overmedicalised hospital birth. Even while I write this, I think it should actually be the other way round: it always strikes me as odd that we are urged to show that home birth is safe. As hospital birth is an intervention in the physiological process of birth, should we not urge researchers to come up with evidence that hospital birth is safe (or not) for women at low risk of complications?
Hartelijke groeten/ Best wishes,
Ank de Jonge, PhD
http://www.emgo.nl/team/961/ankdejonge/personal-information/
Department of Midwifery Science
Tel. +31(0)20 4448196, +31(0)621115591
________________________________________
Van: A forum for discussion on midwifery and reproductive health research. [[log in to unmask]] namens Soo Downe [[log in to unmask]]
Verzonden: donderdag 16 april 2015 14:36
Aan: [log in to unmask]
Onderwerp: Re: [New post] Safety of home birth
there may be some interest in a cross-country review from the current EU COST IS1405 Action members (over 100 people from 27 European countries) who might be able to help on the ground?
all best
Soo
-----Original Message-----
From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Macfarlane, Alison
Sent: 16 April 2015 22:00
To: [log in to unmask]
Subject: Re: [New post] Safety of home birth
Some of these issues came up in reviews of home birth done in the past, but these happened quite a long time ago now.
It may be that, in addition to people on this list, some people in the Euro-Peristat group would be interested in helping. We found it difficult enough to even compile data about place of birth in Europe. www.europeristat.com
Alison Macfarlane
-----Original Message-----
From: Coxon, Kirstie [mailto:[log in to unmask]]
Sent: 16 April 2015 11:11
To: A forum for discussion on midwifery and reproductive health research.; Macfarlane, Alison
Subject: RE: [New post] Safety of home birth
This all sounds very positive -I was not fully awake earlier and didn't realise my initial post would go to the whole list, but it was a happy accident I think! I have been milling over the idea of doing some work on home birth along these lines for a while and it's good to hear that there is support for that as an idea - and potential collaborators.
The issue of transferability of findings between countries is a real conundrum. My earlier comment about Norway referred to the inclusion of findings from Blix et al's study in Norway in the NICE tables for implementation of place of birth advice. I have reservations based on whether it is reasonable to merge data from different types of epidemiological study (prospective and retrospective in this case), or to combine findings from countries with different maternity economies, and where the choice in question has different kinds of structural and policy support; my understanding from the Blix et al paper is that there is not widespread support for home birth in Norway and that women have to seek out midwives who are willing to do this and to engage them. I think that the study also excluded midwives who had done less than 30 home births, which makes the sample rather different from the English NHS, for all the reasons that colleagues have mentioned in this discussion - training, back-up and inter-professional relationships underpinning support for different birth settings and for transfer of care arrangements.
I would be really interested to know more about, and helping to identify, how home birth is conducted in different countries, and in looking at the variations between countries. I agree with Jane that understanding the broader social and political context is essential, and the 'Birth By Design' could be a guiding template for this..
-----Original Message-----
From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Macfarlane, Alison
Sent: 16 April 2015 10:29
To: [log in to unmask]
Subject: Re: [New post] Safety of home birth
I think it has long been recognised that that home birth differs between health care systems and findings aren't necessarily transportable. We don't even know that the findings of the Birthplace in England, not UK, study are transportable to other countries of the UK. Others on this list can comment on their transportability to Wales, Scotland and Northern Ireland. Indeed, as the Birthplace case studies have shown, the context of home birth varies within England. In many parts of England, fewer than on per cent of births occur at home and a significant proportion of these may well be unplanned, while in some areas the percentages are very much higher, suggesting that there is likely to be an organised home birth service and midwives experienced and confident with home home births. Also Birthplace covered NHS home births, which are the majority, so there are questions about the extent to which its findings apply to independent midwifery.
In countries where home births are 'outside the system', then surely conditions are very different from those in England and the Netherlands. I agree that it would be good to have a comparative study to document differences and commonalities.
Alison Macfarlane
-----Original Message-----
From: Mechthild Gross [mailto:[log in to unmask]]
Sent: 16 April 2015 09:28
To: [log in to unmask]
Subject: AW: [New post] Safety of home birth
Dear Jane,
maybe a pilot study on contextualization of out-of-hospital birth within the health care system could be the next step. Kind regards, Mechthild
Prof. Dr. Mechthild M. Gross, Hebamme
Head of Midwifery Research and Education Unit Department of Obstetrics, Gynaecology & Reproductive Medicine Hannover Medical School Carl-Neuberg-Str. 1 D - 30625 Hannover
Tel: ++49 511 532 6116, Fax: ++49 511 532 6191 [log in to unmask] www.mh-hannover.de/Hebammenwissenschaft.html
-----Ursprüngliche Nachricht-----
Von: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] Im Auftrag von Sandall, Jane
Gesendet: Donnerstag, 16. April 2015 10:22
An: [log in to unmask]
Betreff: Re: [New post] Safety of home birth
Lots to learn from Canada and new Zealand too. We found in our Birthplace case studies specific issues related to managing out of hospital birth. By this I mean FMU and home. These were around the escalation journey ie. decision making around transfer, managing transfer, and most importantly managing care in the tertiary setting. We looked at the role of emergency services but there is much variation and much more to learn. In addition to the clinical management, there was, and is much variation in how out of hospital services are organised and delivered in terms of cover for out of hours care, training and competencies.
A comparative study would be very helpful, but we need to be honest about the strengths and weaknesses of all countries, as no country is perfect. Most importantly these need to be contextualised within the health care system and financing which creates financial and structural barriers and incentives and sometimes perverse incentives as well about barriers to consultation and transfer.
You can see the full report to the case studies work on Birthplace, and a summary briefing for health services managers and policy makers.
http://www.nets.nihr.ac.uk/__data/assets/pdf_file/0008/84950/FR6-08-1604-140.pdf
http://www.nets.nihr.ac.uk/projects/hsdr/081604140
http://api.ning.com/files/EaBpbgf1JUYp0KEz7muw6dQstXl-68pWW4Tg0jhsqZuFW*-ogE-jubqfRUvjPgrEd4rH1wbR*-g35-vVeHp3mqTq6JGbtODu/birthplaceengland_130612.pdf
regards
Jane Sandall
-----Original Message-----
From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Jenny Hall
Sent: 16 April 2015 09:00
To: [log in to unmask]
Subject: Re: [New post] Safety of home birth
On Twitter he responded to this that FMUs were not the question so he didn't mention it Jenny
Sent from my iPhone
On 16 Apr 2015, at 08:55, Lucia Rocca <[log in to unmask]<mailto:[log in to unmask]>> wrote:
Hi,
I agree !
Let's do it!
I have links in Italy ans Spain....
The other issue from Jim's commentary is that he completely ignores the existence of FMUs........In his conclusions Jim recommends all nulliparas to give birth in Hospital without even considering the other option of out of hospital birth, which is FMU!
I will reply to his conclusions!
Best wishes
Lucia
Lucia Rocca-Ihenacho
Consultant Midwife for Public Health
St George's NHS Trust
4th Floor Lanesborough Wing
St Georges Hospital
Blackshaw Rd
SW17 0QT
London
UK
PhD Student
Centre for Maternal and Child Health Research School of Health Sciences City University London
1 Myddelton Street
London EC1R 1UW
07989 230313
Skype contact: luciainsky
On 16 April 2015 at 08:19, Coxon, Kirstie <[log in to unmask]<mailto:[log in to unmask]>> wrote:
Thanks Jane
I like the conclusion - by the same argument, we can't assume home birth in Norway is equivalent to home birth in UK ..
I think the time is coming right for a funded comparative study of how home birth is managed in different countries?
I think we have a lot to learn from the Dutch model (and possibly quite a bit to share too).
Kirstie
Sent from my iPhone
On 15 Apr 2015, at 19:15, Sandall, Jane <[log in to unmask]<mailto:[log in to unmask]>> wrote:
Professor Jane Sandall
King's College London
Mobile 07713743150
PA Fiona 02071883639
[log in to unmask]<mailto:[log in to unmask]>
Sent from my iPhone
Begin forwarded message:
From: "Ripe-tomato.org<http://Ripe-tomato.org>" <[log in to unmask]<mailto:[log in to unmask]>>
Date: 15 April 2015 18:20:00 BST
To: [log in to unmask]<mailto:[log in to unmask]>
Subject: [New post] Safety of home birth
Reply-To: "Ripe-tomato.org<http://Ripe-tomato.org>" <[log in to unmask]<mailto:[log in to unmask]>>
jimgthornton posted: "Important, and reassuring, new evidence from the Netherlands Evaluating the relative safety of home and hospital birth is tricky; most home births are low-risk and many hospital ones high risk, so comparing outcomes for babies born in either place is hop"
Respond to this post by replying above this line
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Safety of home birth<http://ripe-tomato.org/2015/04/15/safety-of-home-birth/>
by jimgthornton<http://ripe-tomato.org/author/jimgthornton/>
Important, and reassuring, new evidence from the Netherlands
Evaluating the relative safety of home and hospital birth is tricky; most home births are low-risk and many hospital ones high risk, so comparing outcomes for babies born in either place is hopelessly biased. And it's difficult to adjust for risk status after the event, so until recently most researchers have ended up concluding that home birth might be safe, or might be a bit more dangerous, but they can't be sure. This has left the field clear for partisans to shout at each other across the barricades.
To answer the question properly we need to identify, before labour starts, low-risk women who plan to deliver at home and low-risk women who plan to deliver in hospital, and compare outcomes by the planned, not the actual, place of birth. Unfortunately such data are rarely recorded.
Until 2011, when the UK Birthplace Study (click here<https://www.npeu.ox.ac.uk/birthplace>), registered 17,000 women planning to deliver at home, and 20,000 planning to deliver in hospital, recorded their risk status before they went into labour and compared outcomes by planned place of birth. For the low-risk women who had already had a baby, home birth was as safe as hospital. But for low-risk women giving birth for the first time, "there were 9.3 adverse perinatal outcome events per 1000 planned home births compared with 5.3 per 1000 births for births planned in obstetric units, and this finding was statistically significant". Hence current UK advice that hospital is slightly safer for first births.
However, some Birthplace "adverse perinatal outcomes", like encephalopathy and meconium aspiration, while undoubtedly serious, are things from which most babies eventually recover, and their diagnosis could also be influenced by knowledge of the intended place of birth. Perinatal death is a harder outcome, but rare. Among low-risk women giving birth for the first time in Birthplace there were only six deaths out of 4,500 deliveries in the planned home birth group and five out of 10,000 in the planned hospital group. These raw numbers favour hospital, but they are hardly conclusive. We need larger numbers, and this month the Dutch have provided them.
[Ank-de-Jong]<https://ripetomato2uk.files.wordpress.com/2015/04/ank-de-jong.jpg>
Professor Ank de Jong (above) from the Department of Midwifery Science at the Free University in Amsterdam, and her obstetric colleagues, combined three Dutch registries to do a Birthplace type analysis; namely one based on planned place of birth among women judged at low risk before the onset of labour. The 750,000 women planning home birth dwarf all previous similar studies, so her conclusions matter. The paper is in this month's BJOG (click here<http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.13084/abstract>) or for those with access problems Jonge_et_al-2015<https://ripetomato2uk.files.wordpress.com/2015/04/jonge_et_al-2015-bjog-_an_international_journal_of_obstetrics__gynaecology.pdf>.
There was no difference in perinatal death between planned home and planned hospital births among low-risk women. The lack of difference applied to both first and later births. For first births the rates were 1.02/1000 for planned home births v. 1.09/1000 for planned hospital births, (adjusted odds ratio 0.99, 95% confidence interval 0.79-1.24).
In summary, and in contrast to the UK Birthplace results, home appears to be safe for first births in Holland. This is important news.
The BJOG editor obviously realised the topic was controversial and commissioned not one, but two commentaries.
[frank chervenak]<https://ripetomato2uk.files.wordpress.com/2015/04/frank-chervenak.jpg>
The first (click here<http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.13130/full>) (or Chervenak_et_al-2015<https://ripetomato2uk.files.wordpress.com/2015/04/chervenak_et_al-2015-bjog-_an_international_journal_of_obstetrics__gynaecology.pdf>) was led by Frank Chervenak (above) a respected New York obstetrician. (Full disclosure Dr Chervenak is a well-known opponent of home birth. I've known him for years, and coincidentally I debated this topic with him at an obstetric conference a few weeks ago. I wasn't aware of de Jonge at that time!)
Read it for yourself, but in my, perhaps biased, opinion he made five weak points in his commentary, and one good one.
1. He cited a quite different, much smaller, and much criticised, single centre Dutch study (click here<http://www.bmj.com/content/341/bmj.c5639>) to suggest that the data on intended place of delivery was inaccurate.
2. He grumbled about the high rate of missing data on neonatal deaths after one week of age, while ignoring the fact that this was probably random. The fact that some neonatal units did not report any data at all to the national registry is a pity but hardly likely to introduce bias. The authors' sensitivity analyses did not alter the conclusions.
3. He suggested that home birth recording of Apgar scores may be inaccurate. This may be correct, but it has no bearing on risk of death. You can misrecord an Apgar, but dead is dead!
4. NICU admissions were higher among babies of nulliparous women planning to deliver at home, as compared with multiparous women planning to deliver at home, but this is also irrelevant to the question at hand.
5. Finally he found a Dutch language article in which one of the authors, professor Jan Nijhuis from Maastricht, had apparently recommended that all nulliparous women should deliver in hospital. I don't have access, and can't read Dutch, but surely the fact that Nijhuis was not a reflex supporter of home birth, but happy to stand behind de Jong's paper strengthens her conclusions!
However, Chervenak made one good point.
1. Even if home birth is safe for low risk women in the Netherlands, a small country with well-trained midwives, and well-regulated systems in place, it may not be safe in the US where home births are often supervised by untrained self-styled experts.
He is surely right about that! Although whether this means US obstetricians should campaign for better midwifery support for home birth, or for everyone to deliver in hospital, is another matter!
[Marian Knight]<https://ripetomato2uk.files.wordpress.com/2015/04/marian-knight.jpg>
The other comment piece (click here<http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.13168/full>) was by Marion Knight (above), one of the Birthplace researchers. She agreed that the Dutch data were reassuring, but worried about the same missing deaths which had concerned Chervenak; although they were probably random and probably wouldn't have altered the conclusions, there were rather a lot of them. Since Birthplace had more complete data, she suggested it may more accurately reflect the relative safety for low-risk women giving birth for the first time in the UK.
I agree with Dr Knight. For low-risk women in their first pregnancy I will continue to advise that in the UK hospital is probably safer. But if they wish to go ahead and deliver at home, these new Dutch data suggest there's no need to make a fuss.
Of course none of this applies to women with significant risk factors (click here<http://ripe-tomato.org/2015/04/11/jims-tweet/>); they would be much safer in hospital.
Jim Thornton
jimgthornton<http://ripe-tomato.org/author/jimgthornton/> | April 15, 2015 at 6:19 pm | Categories: Health general<http://ripe-tomato.org/?cat=165504>, Pregnancy and maternity<http://ripe-tomato.org/?cat=24650227> | URL: http://wp.me/p1LNkD-2sR
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