Planned Home Birth Research Articles

Alternative birthing ways: the neonatologist's point of view

A recent Cochrane review [1] showed that “there is no strong evidence from randomised trials to favour either planned hospital birth or planned home birth for low-risk pregnant women”. However, in this review only one trial (involving 11 women) contributed data. This did not allow conclusions to be drawn about safety. More information emerges from another recent review [2] that assessed babies’ mortality differences between home birth and hospital birth in studies published between 1996 and 2011; they selected 11 studies, with no evidence of an increase of deaths in either group. However, these studies only included low-obstetrical-risk women from western countries. A wide metaanalysis [3] considered all studies in this field published in 1947–2010 (Table 1); 12 studies were retrieved and their conclusions were that, though perinatal mortality was similar between the two groups, “the overall neonatal death rate was almost twice as high in planned home vs planned hospital births, and almost tripled among nonanomalous neonates”. On these bases, the American college of obstetricians and gynecologists [4] affirmed that “reports suggesting that planned home births are safe involved only healthy pregnant women. Recent cohort studies reporting lower perinatal mortality rates with planned home birth describe the use of strict selection criteria for appropriate candidates (. . .). Failure to adhere to such criteria (because of postterm pregnancy, twins, or breech presentation) is clearly associated with a higher risk of perinatal death”. And added: “Another factor influencing the safety of planned home birth is the availability of safe and timely intrapartum transfer of the laboring patient”. The American Academy of Pediatrics agreed with this statement adding: “Geography also may adversely affect the safety of planned home birth, because travel times >20 minutes have been associated with increased risk of adverse neonatal outcomes, including mortality”. AAP requires for these babies the same guarantees given to hospital births, with regard to birth assessment and resuscitation, due

Planned Home Birth in the United States and Professionalism: A Critical Assessment

Planned home birth has been considered by some to be consistent with professional responsibility in patient care. This article critically assesses the ethical and scientific justification for this view and shows it to be unjustified. We critically assess recent statements by professional associations of obstetricians, one that sanctions and one that endorses planned home birth. We base our critical appraisal on the professional responsibility model of obstetric ethics, which is based on the ethical concept of medicine from the Scottish and English Enlightenments of the 18th century. Our critical assessment supports the following conclusions. Because of its significantly increased, preventable perinatal risks, planned home birth in the United States is not clinically or ethically benign. Attending planned home birth, no matter one's training or experience, is not acting in a professional capacity, because this role preventably results in clinically unnecessary and therefore clinically unacceptable perinatal risk. It is therefore not consistent with the ethical concept of medicine as a profession for any attendant to planned home birth to represent himself or herself as a "professional." Obstetric healthcare associations should neither sanction nor endorse planned home birth. Instead, these associations should recommend against planned home birth. Obstetric healthcare professionals should respond to expressions of interest in planned home birth by pregnant women by informing them that it incurs significantly increased, preventable perinatal risks, by recommending strongly against planned home birth, and by recommending strongly for planned hospital birth. Obstetric healthcare professionals should routinely provide excellent obstetric care to all women transferred to the hospital from a planned home birth.The professional responsibility model of obstetric ethics requires obstetricians to address and remedy legitimate dissatisfaction with some hospital settings and address patients' concerns about excessive interventions. Creating a sustained culture of comprehensive safety, which cannot be achieved in planned home birth, informed by compassionate and respectful treatment of pregnant women, should be a primary focus of professional obstetric responsibility.

Being Safe: Making the Decision to Have a Planned Home Birth in the United States

Although there is evidence that supports the safety of planned home birth for healthy women, less than 1 percent of women in the United States choose to have their baby at home. An ethnographic study of the experience of planned home birth provided rich descriptions of women's experiences planning, preparing for, and having a home birth.This article describes findings related to how women make the decision to have a planned home birth. For these women, being safe emerged as central in making the decision. For them, being safe included four factors: avoiding technological birth interventions, knowing the midwife and the midwife knowing them, feeling comfortable and protected at home, and knowing that backup hospital medical care was accessible if needed.

Persisting Rise in Referrals During Labor in Primary Midwife‐led Care in The Netherlands

There are concerns about the Dutch maternity care system, characterized by a strict role division between primary and secondary care. The objective of this study was to describe trends in referrals and in perinatal outcomes among labors that started in primary midwife-led care. We performed a descriptive study of all 789,795 labors that started in primary midwife-led care during 2000 to 2008 in The Netherlands. Referrals to obstetrician-led care or pediatrician were classified as urgent or nonurgent. Perinatal safety was described by perinatal mortality (intrapartum or neonatal 0-7 days), admission to neonatal intensive care unit 0-7 days, and Apgar score < 7 at 5 minutes. The proportion of referrals during labor or after birth declined from 52.6 to 42.6 percent for nulliparous women and from 83.2 to 76.7 percent for multiparous women. Especially nonurgent referrals during the first stage increased, for nulliparous women from 28.7 to 40.7 percent and for multiparous women from 10.5 to 16.5 percent. Referrals were less frequent in planned home births. Perinatal mortality was 0.9 per thousand births for nulliparous women, and 0.6 per thousand for multiparous women. A low Apgar score was registered in 8.6 per thousand births for nulliparous women, and 4.1 per thousand for multiparous women. There was a considerable rise in nonurgent referrals to obstetrician-led care in primary midwife-led care during labor. Perinatal safety did not improve significantly over time. The persisting rise in referrals challenges the sustainability of the current strict role division between primary and secondary maternity care in The Netherlands.

Change in primary midwife-led care in the Netherlands in 2000–2008: A descriptive study of caesarean sections and other interventions among 789,795 low risk births

Objectiveto study whether an increase in intrapartum referrals in primary midwife-led care births in the Netherlands is accompanied by an increase in caesarean sections. Designnationwide descriptive study. Settingthe Netherlands Perinatal Registry. Participants789,795 births of nine year cohorts of women with low risk pregnancies in primary midwife-led care at the onset of labour between 2000 and 2008. Measurementsprimary outcome is the caesarean section rate. Vaginal instrumental delivery, augmentation with oxytocin, and pharmacological pain relief are secondary outcomes. Trends in outcomes are described. We used logistic regression to explore whether changes in the planned place of birth and other maternal characteristics influenced the caesarean section rate. Findingsthe caesarean section rate did not increase and was 5.5 per cent (range 4.9–6.3 per cent) for nulliparous women, and 1.0 per cent (range 0.8–1.1 per cent) for multiparous women. After controlling for the decline in planned home births and other maternal characteristics no increase in the caesarean section rate was found. The vaginal instrumental birth rate showed no increase, and was 18.1 per cent (range 17.9–18.5 per cent) for nulliparous women and 1.5 per cent (range 1.4–1.7 per cent) for multiparous women. Augmentation of labour and/or pharmacological pain relief increased from 24.0 to 38.8 per cent for nulliparous women, and from 5.4 to 10.0 per cent for multiparous women. Conclusionthe rise in intrapartum referrals was not accompanied by an increase in caesarean section rate over the period 2000–2008. Despite a considerable rise in the use of pain relief and augmentation, the rate of spontaneous vaginal birth remained high for low risk women who started labour in primary midwife-led care. Implications for practicethe current strict role division between primary care midwives and the obstetrician-led team increasingly results in a change in care provider during labour. In a more integrated care system, more women can receive continuous support of labour from their own primary care midwife, as long as only supportive interventions are needed.

Planned home birth poses no worse outcomes than hospital for low-risk women

Planned home birth poses no worse outcomes than hospital for low-risk women

Selected perinatal outcomes associated with planned home births in the United States

More women are planning home birth in the United States, although safety remains unclear. We examined outcomes that were associated with planned home compared with hospital births. We conducted a retrospective cohort study of term singleton live births in 2008 in the United States. Deliveries were categorized by location: hospitals or intended home births. Neonatal outcomes were compared with the use of the χ(2) test and multivariable logistic regression. There were 2,081,753 births that met the study criteria. Of these, 12,039 births (0.58%) were planned home births. More planned home births had 5-minute Apgar score <4 (0.37%) compared with hospital births (0.24%; adjusted odds ratio, 1.87; 95% confidence interval, 1.36-2.58) and neonatal seizure (0.06% vs 0.02%, respectively; adjusted odds ratio, 3.08; 95% confidence interval, 1.44-6.58). Women with planned home birth had fewer interventions, including operative vaginal delivery and labor induction/augmentation. Planned home births were associated with increased neonatal complications but fewer obstetric interventions. The trade-off between maternal preferences and neonatal outcomes should be weighed thoughtfully.

Severe adverse maternal outcomes among low risk women with planned home versus hospital births in the Netherlands: nationwide cohort study

Objectives To test the hypothesis that low risk women at the onset of labour with planned home birth have a higher rate of severe acute maternal morbidity than women with...

Accouchement à domicile ou à l’hôpital : comparaison des risques à travers une revue de la littérature internationale

ObjectiveTo assess the safety of planned home birth compared to hospital birth, in low-risk pregnancies. MethodAn international literature review was conducted. Mortality, adverse outcomes and medical interventions were compared. ResultsHome birth was not associated with higher mortality rates, but with lower maternal adverse outcomes. Perinatal adverse outcomes are not significantly different at home and in hospital. Medical interventions are more frequent in hospital births. ConclusionHome birth attended by a well-trained midwife is not associated with increased mortality and morbidity rates, but with less medical interventions.

Outcomes of Planned Home Births Attended by Certified Nurse‐Midwives in Southeastern Pennsylvania, 1983‐2008

In this study, we examined the perinatal outcomes of planned home births over a 25-year period (1983-2008) in a group of primarily Amish women (98%) attended by certified nurse-midwives (CNMs) in southeastern Pennsylvania. This was a retrospective, descriptive analysis of data (N = 1836 births) from several CNM practices. Data were abstracted for 25 items, including demographics, labor, and birth. Initially, 2 investigators abstracted 15 records to compare assessments and standardize definitions. Charts were then divided and abstracted individually by one investigator. Several relationships were examined in 2 by 2 tables using the chi-square procedure for the difference in proportions. Maternal and newborn transfers to the hospital were included in the analysis. Of the women who planned home birth for 1836 pregnancies, 1733 of the births occurred at home. Although more than one-third of the women were of high parity (gravida 5-13), rates of postpartum hemorrhage were low (n = 96, 5.5%). There were no maternal deaths. Nearly half of the maternal transfers to the hospital (n = 103, 5.6%) were for ruptured membranes without labor (n = 25, 1.4%) and/or failure to progress (n = 23, 1.3%). The neonatal hospital admission rate also was low (n = 13, 0.75%). Of the 7 (0.4%) early neonatal deaths, all were attributed to lethal congenital anomalies that are common to this population. This study is the first to describe the outcomes of planned home births in a primarily Amish population cared for by CNMs. It also adds to the literature on planned home births in the United States and supports the findings from previous studies that women who have home births attended by CNMs have safety profiles equal to or better than profiles of women who had hospital births in similar populations.

Die geplante Hausgeburt in industrialisierten Ländern: Bürokratische Traumvorstellung vs. professionelle Verantwortlichkeit

This article addresses in how far planned non-hospital births should be an alternative to planned hospital births. Advocates of planned non-hospital deliveries have emphasised patient safety, patient satisfaction, cost effectiveness, and respect for women's rights. We provide a critical evaluation of each of these claims and have doubts that the information available for the pregnant women and the public is in accord with professional responsibility. We understand that the increasing rates of interventions and operative deliveries in hospital births demand an answer, but we doubt that planned home birth is the appropriate professional solution. Complications during non-hospital births inevitably demand a transport of mother and child to a perinatal centre. The time delay by itself is an unnecessary risk for both and this cannot be abolished by bureaucratic quality criteria as introduced for non-hospital births in Germany. Evidence-based studies have shown that modern knowledge of the course of delivery including ultrasound as well as intensive care during the delivery all reduce the rate of operative deliveries. Unfortunately, this is not well-known and only rarely considered during any delivery. All these facts, however, are the best arguments to find a cooperative model within perinatal centres to combine the art of midwifery with modern science, reduction of pain and perinatal care of the pregnant women before, during and after birth. We therefore call on obstetricians, midwifes and health-care providers as well as health politicians to carefully analyse the studies from Western countries showing increasing risks if the model of intention-to-treat is considered and accoordingly not to support planned non-hospital births nor to include these models into prospective trials. Alternatively, we recommend the introduction of a home-like climate within hospitals and perinatal centres, to avoid unnecessary invasive measures and to really care for the pregnant mother before, during and after delivery within a cooperative model without the lack of patient safety for both mother and child in case of impending or acute emergencies.

US nulliparas' perceptions of roles and of the birth experience as predictors of their delivery preferences

Objectiveto develop a model for understanding predictors of nulliparas' delivery preferences: provider type, setting, mode of delivery and the use/avoidance of pain medication. Designa cross-sectional, descriptive, self-administered, web-based survey. The sample was composed of nulliparous women aged 18–40, living in the US and pregnant at 20 or fewer weeks' gestation (n=344). Data were analysed using structural equation modelling. Findingswomen who regard their active participation as effective and essential to the childbearing process are more likely to prefer the care of a midwife, the home as the birth setting, vaginal delivery and the avoidance of pain medication compared to women who see their role as a passive one. When women perceive their provider's role to be more central to the delivery process than their own, they are likely to prefer the care of a physician and the hospital setting. If the provider's role is seen as a collaborative one, women are likelier to prefer midwifery care and planned home birth. The more painful and fearful a woman expects the delivery experience to be, the more likely she is to prefer a caesarean delivery to vaginal birth. Key conclusionswomen's perceptions of (a) their role in pregnancy and delivery, (b) their providers' role in assisting them and (c) the nature of the delivery experience are effective predictors of their delivery preferences. Implications for practiceproviders can help ensure that the informational resources that influence women's perceptions about delivery are factual and evidence-based.

714: Adverse outcome in planned out-of-hospital births versus planned hospital births in Oregon

versus planned hospital births in Oregon Jonathan Snowden, Janice Snynder, Stella Dantas, Lani Doser, Yvonne Cheng, Aaron Caughey Oregon Health and Science University, Department of Obstetrics & Gynecology, Portland, OR, Northwest Permanente PC, Physicians and Surgeons, Department of Obstetrics & Gynecology, Portland, OR, University of California, San Francisco, Department of Obstetrics & Gynecology, San Francisco, CA OBJECTIVE: While recent research has been able to delineate planned home birth from accidental home birth in the US, there remain challenges to delineating planned hospital births from births occurring in the hospital after transfer. We compared perinatal outcomes between planned home births and planned hospital births in Oregon. STUDY DESIGN: This study was a retrospective cohort study of all births occurring in Oregon between 2008 and 2010, using vital statistics data. In 2008 the Oregon birth certificate began collecting data on hospital transfers, allowing identification of intended hospital births. We calculated the prevalence of several adverse outcomes (including neonatal death and low Apgar scores) in planned home births and planned hospital births, using multiple hospital comparison groups. Hospital comparison groups A and B excluded hospital transfers to get at intended hospital birth; Comparison group A was further limited to births meeting eligibility criteria for home birth in Oregon (e.g, gestational age 35 or greater, no preeclampsia, etc). The conventional hospital comparison group (group C, frequently employed due to data limitations) was all hospital births regardless of transfer status. RESULTS: When comparing planned home birth to the appropriate hospital comparison group (A), the rate of neonatal death was lower in hospital births (0.08% versus 0.26%, P 0.002), as was the rate of 5-minute Apgar score 7. NICU admission was more common in planned hospital births in comparison group A (3.3% versus 0.7%; P 0.001). For all outcomes studied, rates were higher in hospital comparison groups B and C, reflecting the higher risk profile of hospital transfers and other high-risk births excluded from comparison group A. CONCLUSION: It is now acknowledged that studying the relative safety of birth locale requires analysis of planned home birth; similarly, it is important to compare these outcomes to intended hospital births, where prevalence of adverse outcomes is much lower than in hospital births overall. 715 Development and validation of a risk factor scoring system for first-trimester prediction of pre-eclampsia Katherine Goetzinger, Methodius Tuuli, Alison Cahill, George Macones, Anthony Odibo Washington University in St. Louis, Obstetrics and Gynecology, St. Louis, MO OBJECTIVE: 1) To develop a risk-based scoring system for first-trimester prediction of pre-eclampsia (PEC) by combining maternal characteristics and first-trimester biomarkers of placental dysfunction and 2) to validate this scoring system in our patient population. STUDY DESIGN: This is a secondary analysis of a prospective cohort of 1200 patients presenting for aneuploidy screening between 11-14 weeks’ gestation. Maternal history was collected through questionnaire and medical record review. Maternal serum pregnancy-associated plasma protein A (PAPP-A) levels were measured by immunoassay and bilateral uterine artery (UA) Doppler studies performed. The primary outcome was PEC, defined as blood pressure 140/90 in the presence of proteinuria after 20 weeks’ gestation. Using the first half of the study population, a prediction model for PEC was created, and a weighted score was assigned to each risk factor based on the adjusted odds ratios from the model. Receiver-operating characteristic (ROC) curves and test performance characteristics were used to determine the optimal score for the prediction of PEC. The model was then validated in the second half of the study population by comparing test performance characteristics and area under the ROC curves (AUC). RESULTS: Significant risk factors and their weighted scores derived from the prediction model were chronic hypertension (4), history of PEC (3), pre-gestational diabetes (2), body mass index 30 kg/m (2), presence of bilateral UA notching (1), and PAPP-A multiples of the median 10th percentile (1). The AUC for the risk scoring system was 0.76 (95% CI 0.69-0.83), and the optimal threshold for predicting PEC was a total score of 6. This AUC did not differ significantly from the AUC observed in our validation cohort [AUC 0.78 (95% CI 0.690.86), p 0.75]. Test characteristics are shown in the Table. CONCLUSION: We present a reproducible risk-based scoring system for first-trimester prediction of PEC that may be useful in future intervention studies. Rates of labor induction among women without indications for IOL of varying body mass index in California, 2007

Planned home birth

International Journal of Gynecology & ObstetricsVolume 120, Issue 2 p. 204-205 FIGO committee reports Planned home birth FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health, FIGO Committee for the Ethical Aspects of Human Reproduction and Women's HealthSearch for more papers by this author FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health, FIGO Committee for the Ethical Aspects of Human Reproduction and Women's HealthSearch for more papers by this author First published: 27 November 2012 https://doi.org/10.1016/j.ijgo.2012.10.001Citations: 3Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume120, Issue2February 2013Pages 204-205 RelatedInformation

Planned home birth: the professional responsibility response

This article addresses the recrudescence of and new support for midwife-supervised planned home birth in the United States and the other developed countries in the context of professional responsibility. Advocates of planned home birth have emphasized patient safety, patient satisfaction, cost effectiveness, and respect for women's rights. We provide a critical evaluation of each of these claims and identify professionally appropriate responses of obstetricians and other concerned physicians to planned home birth. We start with patient safety and show that planned home birth has unnecessary, preventable, irremediable increased risk of harm for pregnant, fetal, and neonatal patients. We document that the persistently high rates of emergency transport undermines patient safety and satisfaction, the raison d'etre of planned home birth, and that a comprehensive analysis undermines claims about the cost-effectiveness of planned home birth. We then argue that obstetricians and other concerned physicians should understand, identify, and correct the root causes of the recrudescence of planned home birth; respond to expressions of interest in planned home birth by women with evidence-based recommendations against it; refuse to participate in planned home birth; but still provide excellent and compassionate emergency obstetric care to women transported from planned home birth. We explain why obstetricians should not participate in or refer to randomized clinical trials of planned home vs planned hospital birth. We call on obstetricians, other concerned physicians, midwives and other obstetric providers, and their professional associations not to support planned home birth when there are safe and compassionate hospital-based alternatives and to advocate for a safe home-birth-like experience in the hospital.

Outcomes of planned home births and planned hospital births in low-risk women in Norway between 1990 and 2007: A retrospective cohort study

BackgroundThe safety of planned home births remains controversial in Western countries. The aim of the present study was to compare outcomes in women who planned, and were selected to, home birth at the onset of labor with women who planned for a hospital birth. MethodsData from 1631 planned home births between 1990 and 2007 were compared with a random sample of 16,310 low-risk women with planned hospital births. The primary outcomes were intrapartum intervention rates and complications. Secondary outcomes were perinatal and neonatal death rates. ResultsPrimiparas who planned home births had reduced risks for assisted vaginal delivery (OR 0.32; 95% CI 0.20–0.48), epidural analgesia (OR 0.21; CI 0.14–0.33) and dystocia (OR 0.40; CI 0.27–0.59). Multiparas who planned home births had reduced risks for operative vaginal delivery (OR 0.26; CI 0.12–0.56), epidural analgesia (OR 0.08; CI 0.04–0.16), episiotomy (OR 0.48; CI 0.31–0.75), anal sphincter tears (OR 0.29; CI 0.12–0.70), dystocia (OR 0.10; CI 0.06–0.17) and postpartum hemorrhage (OR 0.27; CI 0.17–0.41). We found no differences in cesarean section rate. Perinatal mortality rate was 0.6/1000 (CI 0–3.4) and neonatal mortality rate 0.6/1000 (CI 0–3.4) in the home birth cohort. In the hospital birth cohort, the rates were 0.6/1000 (CI 0.3–1.1) and 0.9/1000 (CI 0.5–1.5) respectively. ConclusionsPlanning for home births was associated with reduced risk of interventions and complications. The study is too small to make statistical comparisons of perinatal and neonatal mortality.

The Canadian Birth Place Study: Describing maternity practice and providers' exposure to home birth

Objectives(1) to describe educational, practice, and personal experiences related to home birth practice among Canadian obstetricians, family physicians, and registered midwives; (2) to identify barriers to provision of planned home birth services, and (3) to examine inter-professional differences in attitudes towards planned home birth. Designthe first phase of a mixed-methods study, a quantitative survey, comprised of 38 items eliciting demographic, education and practice data, and 48 items about attitudes towards planned home birth, was distributed electronically to all registered midwives (N=759) and obstetricians who provide maternity care (N=800), and a random sample of family physicians (n=3,000). SettingCanada. This national investigation was funded by the Canadian Institutes for Health Research. ParticipantsCanadian registered midwives (n=451), obstetricians (n=245), and family physicians (n=139). Findingsalmost all registered midwives had extensive educational and practice experiences with planned home birth, and most obstetricians and family physicians had minimal exposure. Attitudes among midwives and physicians towards home birth safety and advisability were significantly different. Physicians believed that home births are less safe than hospital births, while midwives did not agree. Both groups believed that their views were evidence-based. Midwives were the most comfortable with including planned home birth as an option when discussing choice of birth place with pregnant women. Both midwives and physicians expressed discomfort with inter-professional consultation related to planned home births. In addition, both family physicians and obstetricians reported discomfort with discussing home birth with their patients. A significant proportion of family physicians and obstetricians would have liked to attend a home birth as part of their education. Conclusionsthe amount and type of education and exposure to planned home birth practice among maternity care providers were associated with attitudes towards home birth, comfort with discussing birth place options with women, and beliefs about safety. Barriers to home birth practice across professions were both logistical and philosophical. Implications for practiceformal mechanisms for midwifery and medical education programs to increase exposure to the theory and practice of planned home birth may facilitate evidence based informed choice of birth place, and increase comfort with integration of care across birth settings. An increased focus among learners and clinicians on reliable methods for assessing the quality of the evidence about birth place and maternal-newborn outcomes may be beneficial.

Resultado de partos domiciliares atendidos por enfermeiras de 2005 a 2009 em Florianópolis, SC

A cross-sectional study was performed to analyze obstetric and neonatal results of planned home births assisted by obstetric nurses in the city of Florianópolis, Southern Brazil. Data collected from the medical records of 100 parturient women cared for between 2005 and 2009 indicated 11 hospital transfers, nine of which underwent a Cesarean section. The majority of women who had a home birth showed normal fetal heart beat (94.0%) and progress on the partogram (61.0%), vertical water delivery was the position most frequently chosen (71.9%), newborns had an Apgar score ≥ 7 at five minutes (98.9%), episiotomy was performed in 1.0%, and 49.4% did not need perineal suturing. Outcomes indicated that planned home birth is safe.

No fixed place of birth: Unplanned BBAs in Victoria, Australia

Objectivesthe primary objective—to present data on the incidence of unplanned births before arrival (BBAs) in Victoria between 1991 and 2008. The secondary objective—to provide an extensive literature review highlighting the issues surrounding an unplanned BBA. Settingthe incidence of BBAs in Victoria published in the relevant government reports. Designdata were extracted from published government reports pertaining to perinatal statistics in Victoria—The Australian Institute of Health and Wellbeing and the Perinatal Data Collection Unit of Victoria. Data on place of birth for each year from both sources was identified and tabulated. Comparisons between the data sources were undertaken to provide a picture of the scope of out of hospital birth. Findingsthe incidence and absolute numbers of unplanned birth before arrival (BBA) to hospital in Victoria, are low compared to the total births. However, this number is comparable to unplanned BBAs in other developed countries with similar health systems. The incidence of unplanned BBAs has slowly but steadily doubled since 1991–2008. The two data sources almost mirror each other except for 1999 when there was an unexplained difference in the reported incidence in unplanned BBAs. Maternal and neonatal outcomes are disproportionally much poorer after unplanned BBAs than either planned home births or in hospital births. Various maternal factors can increase the risk of an unplanned BBA. Key conclusionsmultiple approaches should be adopted to manage unplanned BBAs. Antenatal screening should be undertaken to identify the women most at risk. Strategies can be developed that will reduce poor neonatal and maternal outcomes, including education for women and their partners on immediate management of the newborn; ensuring paramedics have current knowledge on care during childbirth; and maternity and ambulance services should develop management plans for care of women having unplanned BBAs.

In The Literature: Home Birth: Safe Enough, But Not for the First Baby

The "Birthplace in England" study compared low-risk pregnancies by planned place of birth at the onset of labor: home, midwifery unit, or obstetric unit. The study showed that childbirth interventions were less frequent in all nonobstetric settings than in obstetric units, confirming what has been noted elsewhere. For parous women, there was no difference in perinatal outcomes by place of birth. For nulliparous women, perinatal outcomes were similar in midwifery and obstetric units, but the frequency of poor outcomes with planned home births was higher. The major strengths of the study are its prospective design and large sample size. The results support providing choices to women, but suggest that women should not be encouraged to give birth at home for their first baby. (BIRTH 39:2 June 2012).