Homebirths in a modern setting – a cautionary tale

Abstract

In Western societies, homebirth instead of facility delivery pinpoints the essence of obstetrics: supporting and overseeing an uncomplicated delivery and providing timely intervention for a complicated birth. Could it be that easy, with no grey area in between? Homebirth could over-emphasize normality and a philosophy of natural childbirth, – approaches that could overlook complications, while facility delivery could over-emphasize pathology, – an approach that could lead to unnecessary interventions and overuse of technology. Nevertheless, contradictions and questioning is a prime rationale of development: normal versus complicated, nature versus nurture, intuitive knowledge versus empirical knowledge, women-centered care versus biomedical-centered care. The twentieth century natural birth movement developed by Grantly Dick-Read, Lamaze and Gaskin and the revival of the doula concept, already proposed by Soranus, do add much spirit to modern obstetrics. In Western countries, on the other hand, the homebirth movement relies on close co-existence with modern obstetric care, whether peaceful or not. Even the most pronounced critics of ‘medicalization’ of childbirth cannot disregard that modern obstetrics makes a difference. A gruesome reminder is the study of outcomes for deliveries from Faith Assembly (Indiana, USA) where mothers avoided antenatal and obstetric care, having a maternal mortality rate of 872 per 100,000 and perinatal mortality rate of 48 per 10,000 1. In the nineteenth century the Nordic countries successfully reached a high coverage of skilled attendance of homebirths conducted by midwives within surveillance and assistance of general practitioners. This health system approach achieved 1/3 of the maternal mortality rate of the US and the UK in the beginning of the twentieth century. However, with the emergence of modern medicine and more rapid responses the Nordic countries also achieved full coverage of facility deliveries. This transition was implemented without losing the leading role of midwifery for uncomplicated deliveries. Consensus obstetric care (team obstetric care) was instead enforced and is still evident with reference to the lower intervention rates in Scandinavian obstetrics compared to those in Anglo-Saxon countries. Presently, homebirths are in the margins of Western obstetric care; in most countries, less than 1% of births are at home. The two exceptions are the Netherlands, having about 30% as the country that never fully turned to hospital deliveries, and the UK with about 2–3% as a country that has encountered a renaissance of homebirths supported by the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives 2. The present knowledge from both quantitative and qualitative studies of homebirths in alternative settings can be summarized as follows: (a) booked homebirths are probably safe for certain women supported by adequate infrastructure; (b) less pharmacological pain alleviation is used; (c) homebirths are associated with less interventions; (d) women's birth experiences are positive; (e) homebirth allows for more continuity, self-determination, and control; (f) advantage of being at home and of experiencing joy and intimacy; and (g) heterogeneity of women choosing homebirths from eco-feminism, norm deviants, having bad earlier experience from hospital, fashion with respect to modern life style, and informed choice with similarities to those who have requested cesarean delivery. The evidence-based knowledge regarding home deliveries in alternative settings has its limitations with respect to safety and medical outcomes. The topic is one of several areas within obstetrics that are out of the realm of randomized controlled trials. There are several, mostly rather small, retrospective follow-up studies of home deliveries in alternative settings, and some were designed with a reference group of hospital births to address safety and medical outcomes. Inevitably, the studies have in-built biases regarding design, selection, and detection, biases that are not scientifically rigors. Lindgren et al. 3 writing in the July issue of Acta, strengthen the knowledge on this topic for a Nordic setting. A key issue applied for evaluation of homebirths is the concept of intention-to-treat, i.e. intention-to-homebirth. However, this pre-supposes a standardized protocol for treatment (birth assistance), criteria for transfer, and criteria to compare outcome with hospital deliveries. None of these are easily surmountable. Transfer rates reflect the degree of integration and articulation of homebirth within maternity care. The articulation is decisive for selection of women prone for home delivery and for transfer to hospital before, during, or after delivery. In the Netherlands, one-third of the women scheduled for home deliveries are transferred (primiparas 49% and multiparas 17%) 4. In the UK, rates are similar. However, a consistent pattern from studies of homebirths in alternative settings is that transfer rates are rather low at between 4% and 16%, in Sweden 12% 5. Hence, the most often cited reason for referral in settings with high transfer rates is the possibility of fetal asphyxia, while in settings with low transfer rates the most frequent reason for transfer are maternal complications. A low transfer rate from alternative birth settings should be a concern. Low transfer rates probably reflect alternative birth preparations and self-determination to have a home delivery. Furthermore, the joint decision-making process in case of the need for transfer during delivery, might be challenging. Although the concept of intention-to-treat is rather vague for comparing outcome for alternative birth settings, the choice of a group for comparison makes it even more difficult to obtain a proper evaluation of outcomes. A ‘healthy mother effect’ is indicative of homebirths. In a Swedish cohort of pregnant women, 2% expressed interest in a home delivery and 98% were not interested/did not know, and the two groups differed remarkably, as 41% and 3%, respectively, did not want any pain alleviation and 88% and 41%, respectively, had a positive expectation for the birth 6. Furthermore, women actually having a homebirth had an earlier hospital birth with a much lesser incidence of dystocic labor, epidural use, vacuum extraction or cesarean delivery than a reference group 7. Thus the ‘healthy mother effect’ should be taken into account as well. The next difficulty with retrospective evaluation is the selection of a proper reference group so that outcomes can be compared. As with Lindgren et al. 3, the selection of the reference group (term, singleton, spontaneous start of delivery) from the Swedish Medical Birth Registry figures for 1992–2005 gave a cesarean delivery rate of 7% in the reference group and 2.5% (22/897) in the case group and an odds ratio of 0.4 (CI 0.3–0.5). The result may vary by source of reference group. For example, Umeå University Hospital had a mean cesarean delivery rate of 16% between 1990 and 2002. However, by selecting from the computerized records, the cesarean delivery rate according to the Robson criteria was only 2.7% (singleton, term, vertex, spontaneous labor or rupture of the membranes, not earlier a cesarean delivery); thus a rate similar to that for the intention-to-homebirth group was seen 3. Furthermore, as homebirths are skewed toward multiparity, a prerequisite for analysis should be stratification by parity. The third difficulty is the possibility of detection-bias when comparing homebirth with hospital births. Diagnosis of dystocic labor, post-partum hemorrhage, neonatal asphyxia, vaginal and perineal tears, and sphincter rupture all depend on common definitions and training. A meta-analysis of homebirths concluded, ‘It is possible, however, that home birth practioners underreported low Apgar score and perineal trauma’ 8. Diagnosis of sphincter injuries is a delicate issue; second opinion assessment duplicates the rate 9. In a population perspective safety issues should be paramount in an assessment of home deliveries. Although an alternative homebirth with skilled attendance can be considered as a reasonable option for the individual case, it can be questioned if it is safe with respect to other safety margins applied in maternity or health care on the whole. Although the studies are small and each can be criticized, they report intrapartum/early neonatal deaths by 1:200–1:1,000 and a persistent tendency toward an excess death risk, with an OR 1.6–2.5, in relation to hospital births 3, 10-12. A recent study from the UK reports a relative risk of 1.62 (CI 1.31–1.99) for homebirths in a setting with a high degree of referral, where one child died intrapartum per 783 booked homebirths. Out of those with emergency referrals, 1:165 died 13. The English experience could be interpreted according to the setting in the Netherlands where perinatal mortality rate has declined slower than in other European countries and is now second highest in Europe 14. Although the transfer rate during delivery is even higher in the Netherlands, the death rate among the transferred was 8.3 per 1,000, a percentage similar to what was found in England 4. One reason might be substandard care: intrapartum/early neonatal deaths for booked home deliveries were higher (30%) than for hospital births (22%), especially after transfers (44%) 15. The other explanation might be that even a full integration of homebirth practice into a modern health system is not enough to accomplish a safe birth according to modern standards. Although Lindgren et al. 3 add valuable information from the Swedish setting of home deliveries, their findings call for further research and improvement of management. The English guidelines of governance for homebirths are most appropriate also for alternative homebirths settings: ‘contemporary and accurate record keeping is vital, computer programmes aid auditing practices, both personal and organisational (home birth, transfer and intervene rates as minimum).’ Robust clinical governance systems for monitoring quality of homebirths should include both quality and quantitative audit data (women's experience stories, transfer rates, ambulance response times, emergency scenarios). The concept of substandard care (detection, therapy, logistics, communication) should also be applied to near-miss cases and perinatal deaths in homebirths in alternative settings. With all respect for the skilled midwives attending home deliveries, a common effort should opt for articulation as much as possible to the hospital in the catchment area. Preparations and information should be integrated in maternity care for women wanting home delivery. Women should also be aware that in a Scandinavian/Nordic context homebirth cannot provide the same safety as a hospital birth.