A good midwife makes giving birth at home as safe as in hospital

Researchers in the Netherlands say giving birth at home with a midwife is as safe as doing so in hospital.

The researchers say a home birth assisted by a trained midwife is just as safe for low-risk mothers and their babies as a delivery led by a midwife in hospital.

The team from the TNO Institute for Applied Scientific Research carried out a study of 529,688 low-risk women who were in the care of a midwife at the start of labour - of these women 321,307 (60.7%) planned to give birth at home and 163,261 (30.8%) planned to give birth in hospital and for 45,120 (8.5%), the intended place of birth was unknown.

The nationwide study set out to compare home and planned hospital births, among low-risk women who started their labour in primary care and the team found over a seven year period that there was no difference in death or serious illness among either mothers or their babies if they gave birth at home rather than in hospital.

Concerns about the safety of home births has always been an issue and obstetricians have welcomed the study but say it may not apply universally.

The research was carried out after figures showed the country had one of the highest rates in Europe of babies dying during or just after birth and home births were suspected of being a factor.

In Holland home birthing is an option which is encouraged and a third of mothers choose to have their baby this way and the research revealed that among "low-risk" women who planned to give birth at home there was no difference in death or serious illness rates among either babies or mothers.

Professor Simone Buitendijk who led the research says they found that for low-risk mothers at the start of their labour it is just as safe to deliver at home with a midwife as it is in hospital with a midwife.

Professor Buitendijk says the results should strengthen policies that encourage low-risk women at the onset of labour to choose their own place of birth.

In the study low-risk were deemed to be those who had no known complications such as a baby in breech or one with a congenital abnormality, or a previous Caesarean section.

Of women in the study, almost a third who planned and started their labours at home ended up being transferred as complications arose, such as an abnormal fetal heart rate, or if the mother needed more effective pain relief in the form of an epidural.

In many countries the health system is not set up to meet an increase in a potential demand for home births and the researchers emphasise the importance of both highly-trained midwives who know when to refer a home birth to hospital as well as the availability of rapid transportation to get a mother into hospital if necessary.

The researchers say while the study was the most comprehensive yet into the safety of home births, they also acknowledged that the group who chose to give birth in hospital rather than at home were more likely to be first-time mothers or of an ethnic minority background and the risk of complications is higher in both these groups.

The study also did not compare the relative safety of home births against low-risk women who opted for doctor rather than midwife-led care and say this will be the subject of a future investigation.

Professor Buitendijk says the study has relevance for other countries with a highly developed health infrastructure and well-trained midwives.

The researchers say the study shows that planning a home birth does not increase the risks among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.

The UK government has pledged to give all women the option of a home birth by the end of this year - currently 2.7% of births in England and Wales take place at home - but critics say changes will be needed in the way maternity services are organised and a major increase in the number of midwives, before that can be realised.

The Royal College of Obstetricians and Gynaecologists (RCOG) said it supported home births in cases of low-risk pregnancies provided the appropriate infrastructures and resources are present to support such a system but women need to be counselled on the unexpected emergencies which can arise during labour, such as cord prolapse, fetal heart rate abnormalities, undiagnosed breech, prolonged labour and postpartum haemorrhage - which can arise during labour and can only be managed in a maternity hospital.

The RCOG says such emergencies would always require the transfer of women by ambulance to the hospital as extra medical support is only present in hospital settings and would not be available to them when they deliver at home.

The study has been welcomed by midwives and home-birth advocates in Australia and is expected to put further pressure on the Federal Government to review and update maternity services.

The Australian College of Midwives reportedly says there is ample evidence that mothers have higher satisfaction rates when giving birth at home, but concerns about the impact on the baby had seen home birth remain under question.

However the Royal Australian and New Zealand College of Obstetricians and Gynaecologists warned caution is called for in comparing the Dutch experience to Australia as they say pregnant women are cared for very differently in the two countries.

The study is published in the journal BJOG: An International Journal of Obstetrics & Gynaecology.

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