Home Delivery: Is It Really Safe?
By Richard Ehrenkranz, MD
Anumber of recent reports from europe have revisited an issue that from time to time resurfaces in the United Statesnamely, the rationale and safety of home deliveries. Individual families may opt for home delivery because they view labor and delivery as normal social and physiologic processes and reject their medicalization. In most of the western world, it is accepted (assumed?) that hospital-based deliveries are safer for mother and child. However, there are very few solid data to support this. In fact, despite this prevailing view, a blue-ribbon commission in the United Kingdom described home birth of selected low-risk pregnancies as a "real option."1
Many evaluations of home delivery have focused on perinatal mortality as an index of safety, but because of the low frequency of adverse events and the infrequency of home deliveries in the United States, United Kingdom, and much of Europe, a large, randomized, controlled study would be necessary to prove this, and it is unlikely that such a study would be possible anywhere in the developed world.2 In the absence of a randomized trial, evaluations must be made based upon observational studies. Recent papers from Europe address the safety of and patient satisfaction with home births.2-6
The first, from the northern region of the United Kingdom, documented the fetal mortality associated with planned and unplanned births outside of the hospital during 1981-1994.3 There were four times the number of perinatal losses (38.7/1000) as for all registered births (9.7/1000). This would seem to indicate that the hospital is the safer place for delivery; but, in fact, 97% of the perinatal deaths occurred in pregnancies that had either planned to have a hospital delivery or had no prearrangement for delivery. In a prospective cohort study with matched pairs from Switzerland, no difference in neonatal mortality was noted in a hospital- vs. home-delivered group.4 The home deliveries occurred in a self-selected, low-risk group of healthy mothers. The authors note that the number of participants was too small to detect differences on either maternal or perinatal mortality and that their findings should be interpreted with caution.
Another study from Holland, where home deliveries often attended by midwives occur in about one-third of pregnancies, showed that the outcome of planned home births is at least as good as that of planned hospital births in women at low risk.5 In Holland, there is a system for meticulous selection of mothers at low risk for obstetrical complications using a set of national reference standards.
A final paper by Arya and colleagues takes a somewhat different tack by seeing what happened to pregnancies in mothers who were retrospectively identified as being low risk.6 This study, covering five years, revealed that only 4% (1314) of the 32,424 deliveries fulfilled criteria for being potentially suitable for home delivery.5 Of these, an operative delivery was required by 67 women, and a pediatrician was requested to attend 122 births. This suggests that about 15% of deliveries considered suitable for home delivery might require that a woman be transferred to a hospital in labor and/or that an infant be resuscitated and stabilized at birth. Since screening procedures cannot predict which individual women or infants in a low-risk group will experience intrapartum difficulties, and since parents place such a high premium on having children whose potential for neurodevelopmental outcome is not compromised, this report further convinces this neonatologist that home delivery should not be an option for low-risk pregnant women, especially in areas where high-level obstetrical and pediatric services are available.
As clearly pointed out in an accompanying editorial in the British Medical Journal,2 if home delivery is to be considered, it is essential that: 1) women selecting this are not at high risk of complications; 2) an infrastructure for safe obstetric intervention is established; 3) support during labor and delivery are provided; and 4) immediate access to hospital facilities is assured, because serious complications during labor can never be excluded or predicted.
References
1. Department of Health Expert Maternity Group. Changing Childbirth. 1. The Cumberlege Report. London: HMSO, 1993.
2. Editorial: Home Birth. Safe in selected women and with adequate infrastructure and support. BMJ 1996;313:1276-1277.
3. Barron SL, et al. Collaborative survey of perinatal loss in planned and unplanned home deliveries. BMJ 1996;313:1306-1309.
4. Ackerman-Liebrich U, et al. Home vs. hospital deliveries: Follow-up study of matched & pairs for procedures and outcomes. BMJ 1996;313:1313-1318.
5. Weigers TA, et al. Outcomes of planned home and planned hospital births in low risk pregnancies. BMJ 1996;313:1309-1313.
6. Arya R, et al. Outcome in low risk pregnancies. Arch Dis Child 1996;75:F97-F102.
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