"Having your baby at home means it's more likely to die, right? "
I mean that is one of my favorite Jim Gaffigan comedy segments, you have to see if this if you haven’t already:
Today I was reading a document from the Association of Ontario Midwives as part of a “re-entry” package of reading I need to do to change my midwifery status from inactive to active; go figure, I’m missing enough home births to make this easy so I have to jump through some extra hoops.
Anyways, I read the document “Guideline for discussing choice of birthplace with clients: Methodology and review of evidence“ which looked at the CANADIAN evidence on place of delivery, comparing outcomes at home and birth centre (there’s only two in Canada and no research yet), and hospital birth. I realized this review would make a great blog post because it’s a compilation of the 5 best Canadian studies/reviews on outcomes at home versus hospital.
Let's jump in!
I’m actually going to post the review conclusion first before I dig into the data, in case your eyes start to glaze over and you are tempted to leave this blog before hearing me out.
“In jurisdictions where midwifery services are well-integrated into the healthcare system, evidence shows that planning to give birth at home or in a birth centre is as safe as planning to give birth in a hospital for midwifery clients at low risk of complications.”
“It is also associated with a decreased need for obstetric and neonatal interventions.”
“WHAT DID YOU SAY?”
I think I just said that evidence shows that if you are LOW-RISK and have a Registered Midwife, giving birth at home or in a birth centre in Canada is safe, if not SAFER, than a planned hospital birth.
This review was done in 2016 and included 6 eligible studies: four observational cohort studies and 2 survey studies which focused on birthplace decision-making and satisfaction with the birth experience.
Although the gold-standard for evidence is a randomized, placebo-controlled double blind study, these types of studies are often unethical in maternity care when the outcomes studied are death or serious harm; it’s unethical to randomly assign a woman to an outcome where there is potentially more harm than the other group (even if after the study they discover there is no increased harm).
Articles were published between 1990 and 2015 and include women who were considered to be at low risk of complications, as defined by study authors.
"What does it mean to be low-risk?"
Typically low-risk in Canada means:
- No pre-existing health conditions
- No pregnancy-acquired health conditions, such as diabetes or high blood pressure
- One baby
- Spontaneous labour
- Head down at beginning of labour
- No more than one previous CS
"Why is the 'planned' place of birth more important than where baby was actually born?"
Outcomes can be different based on the preparation to deliver at home and then includes the component of transferring in to hospital when someone is screened out of a home birth while in labour.
Comparison of death rates:
Because rates of serious sickness or death in mom and baby are rare in Canada, those risks are the same regardless of where you are delivering; there was not a statistically significant difference in outcomes.
- Intrapartum stillbirth and neonatal mortality: 1.1/1000 for planned home birth, 0.9/1000 for planned hospital birth
- Maternal mortality: no deaths in all 4 studies
The researchers did state that these results may not be precise because the events are SO rare, that you need a HUGE group of women delivering to see differences.
It is good that there aren’t large amounts of women and babies dying in Canada.
Let’s celebrate that.
(Aside: maternal and infant death rates are continuing to rise in the US despite having the most expensive healthcare system. But that’s a discussion for another day.)
"Wait you said home birth was safer but babies aren’t dying more in hospital so..."
Let’s now look at rates of interventions. I have put these in table format, as I find that presentation of data most useful for my own learning and will assume you ALL learn just like I do 😉
|Intervention||Planned Home Birth||Planned Hospital Birth|
Pharmaceutical Pain Relief
Use of oxytocin in labour for augmentation
Meconium Aspiration Syndrome (baby inhales poop)
"So what makes homebirth safer?"
Researchers think there are a few factors at play here:
- Availability of interventions: if the bag of chips isn’t in my cupboard, I really have to believe it’s necessary to get in my car and drive to buy it at the corner store.
- Variation of practice: in hospital midwives are bound by policies and procedures they may not be bound to in-home.
- Difference in client differences in different birth places: perhaps families who chose home birth already have goals and ideals that align with a low-intervention birth.
- Other factors that are hard to measure
Other home birth myths:
- Home birth is messy: yes birth is bloody and wet, but us midwives work pretty hard at keeping your space clean, since there’s no staff housekeeper who will come post-delivery and clean the bed and mop the floor. We are REALLY good at getting blood out of carpet.
- Your house/apartment is too small: Ummm have you seen a hospital room? Imagine a bed, a huge charting computer/station, two or three chairs, a vitals machine, a sink, a baby warmer and a washroom crammed into a tiny space. No, your house is not too small, unless you legit live in a tiny home.
Home birth was the way babies were born for millenia, and this place of birth should still be honour and celebrated, especially since we now have enough evidence to support it’s safety for low-risk families.