Outcomes of planned home births with certified professional midwives: large prospective study in North America

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Highlights from this study below.

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.

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.

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.

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.

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