Planned Home Birth Research Articles

How women with high risk pregnancies use lay information when considering place of birth: A qualitative study

Where to give birth is a key decision in pregnancy. Women use information from family, friends and other sources besides healthcare professionals when contemplating this decision. This study explored women's use of lay information during high risk pregnancies in order to examine differences and similarities in the use of information in relation to planned place of birth. Half the participants were planning hospital births and half were planning to give birth at home. A qualitative study using semi-structured interviews set in a hospital maternity department in South East England. Twenty-six participants with high risk pregnancies, at least 32 weeks pregnant. Results were analysed using thematic analysis. Three themes emerged: approaches to research - how much information women chose to seek out and from which sources; selection of sources - how women decided which sources they considered reliable; and unhelpful research - information they considered unhelpful. Women planning homebirths undertook more research than women planning to give birth in hospital and were more likely to seek out alternative sources of information. Women from both groups referred to deliberately seeking out sources of information which reflected their own values and so did not challenge their decisions. There are similarities and differences in the use of lay information between women who plan to give birth in hospital and those who plan homebirths. Professionals working with women with high risk pregnancies should consider these factors when interacting with these women.

The Birthplace in England national prospective cohort study: further analyses to enhance policy and service delivery decision-making for planned place of birth

BackgroundEvidence from the Birthplace in England Research Programme supported a policy of offering ‘low risk’ women a choice of birth setting, but a number of unanswered questions remained.AimsThis project aimed to provide further evidence to support the development and delivery of maternity services and inform women’s choice of birth setting: specifically, to explore maternal and organisational factors associated with intervention, transfer and other outcomes in each birth setting in ‘low risk’ and ‘higher risk’ women.DesignFive component studies using secondary analysis of the Birthplace prospective cohort study (studies 2–5) and ecological analysis of unit/NHS trust-level data (studies 1 and 5).SettingObstetric units (OUs), alongside midwifery units (AMUs), freestanding midwifery units (FMUs) and planned home births in England.ParticipantsStudies 1–4 focused on ‘low risk’ women with ‘term’ pregnancies planning vaginal birth in 43 AMUs (n = 16,573), in 53 FMUs (n = 11,210), at home in 147 NHS trusts (n = 16,632) and in a stratified, random sample of 36 OUs (n = 19,379) in 2008–10. Study 5 focused on women with pre-existing medical and obstetric risk factors (‘higher risk’ women).Main outcome measuresInterventions (instrumental delivery, intrapartum caesarean section), a measure of low intervention (‘normal birth’), a measure of spontaneous vaginal birth without complications (‘straightforward birth’), transfer during labour and a composite measure of adverse perinatal outcome (‘intrapartum-related mortality and morbidity’ or neonatal admission within 48 hours for > 48 hours). In studies 1 and 3, rates of intervention/maternal outcome and transfer were adjusted for maternal characteristics.AnalysisWe used (a) funnel plots to explore variation in rates of intervention/maternal outcome and transfer between units/trusts, (b) simple, weighted linear regression to evaluate associations between unit/trust characteristics and rates of intervention/maternal outcome and transfer, (c) multivariable Poisson regression to evaluate associations between planned place of birth, maternal characteristics and study outcomes, and (d) logistic regression to investigate associations between time of day/day of the week and study outcomes.ResultsStudy 1 – unit-/trust-level variations in rates of interventions, transfer and maternal outcomes were not explained by differences in maternal characteristics. The magnitude of identified associations between unit/trust characteristics and intervention, transfer and outcome rates was generally small, but some aspects of configuration were associated with rates of transfer and intervention. Study 2 – ‘low risk’ women planning non-OU birth had a reduced risk of intervention irrespective of ethnicity or area deprivation score. In nulliparous women planning non-OU birth the risk of intervention increased with increasing age, but women of all ages planning non-OU birth experienced a reduced risk of intervention. Study 3 – parity, maternal age, gestational age and ‘complicating conditions’ identified at the start of care in labour were independently associated with variation in the risk of transfer in ‘low risk’ women planning non-OU birth. Transfers did not vary by time of day/day of the week in any meaningful way. The duration of transfer from planned FMU and home births was around 50–60 minutes; transfers for ‘potentially urgent’ reasons were quicker than transfers for ‘non-urgent’ reasons. Study 4 – the occurrence of some interventions varied by time of the day/day of the week in ‘low risk’ women planning OU birth. Study 5 – ‘higher risk’ women planning birth in a non-OU setting had fewer risk factors than ‘higher risk’ women planning OU birth and these risk factors were different. Compared with ‘low risk’ women planning home birth, ‘higher risk’ women planning home birth had a significantly increased risk of our composite adverse perinatal outcome measure. However, in ‘higher risk’ women, the risk of this outcome was lower in planned home births than in planned OU births, even after adjustment for clinical risk factors.ConclusionsExpansion in the capacity of non-OU intrapartum care could reduce intervention rates in ‘low risk’ women, and the benefits of midwifery-led intrapartum care apply to all ‘low risk’ women irrespective of age, ethnicity or area deprivation score. Intervention rates differ considerably between units, however, for reasons that are not understood. The impact of major changes in the configuration of maternity care on outcomes should be monitored and evaluated. The impact of non-clinical factors, including labour ward practices, staffing and skill mix and women’s preferences and expectations, on intervention requires further investigation. All women planning non-OU birth should be informed of their chances of transfer and, in particular, older nulliparous women and those more than 1 week past their due date should be advised of their increased chances of transfer. No change in the guidance on planning place of birth for ‘higher risk’ women is recommended, but research is required to evaluate the safety of planned AMU birth for women with selected relatively common risk factors.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Costs of Planned Home vs. Hospital Birth in British Columbia Attended by Registered Midwives and Physicians.

BackgroundHome birth is available to women in Canada who meet eligibility requirements for low risk status after assessment by regulated midwives. While UK researchers have reported lower costs associated with planned home birth, there have been no published studies of the costs of home versus hospital birth in Canada.MethodsCosts for all women planning home birth with a regulated midwife in British Columbia, Canada were compared with those of all women who met eligibility requirements for home birth and were planning to deliver in hospital with a registered midwife, and with a sample of women of similar low risk status planning birth in the hospital with a physician. We calculated costs of physician service billings, midwifery fees, hospital in-patient costs, pharmaceuticals, home birth supplies, and transport. We compared costs among study groups using the Kruskall Wallis test for independent groups.ResultsIn the first 28 days postpartum, we report a $2,338 average savings per birth among women planning home birth compared to hospital birth with a midwife and $2,541 compared to hospital birth planned with a physician. In longer term outcomes, similar reductions were observed, with cost savings per birth at $1,683 compared to the planned hospital birth with a midwife, and $1,100 compared to the physician group during the first eight weeks postpartum. During the first year of life, costs for infants of mothers planning home birth were reduced overall. Cost savings compared to planned hospital births with a midwife were $810 and with a physician $1,146. Costs were similarly reduced when findings were stratified by parity.ConclusionsPlanned home birth in British Columbia with a registered midwife compared to planned hospital birth is less expensive for our health care system up to 8 weeks postpartum and to one year of age for the infant.

Perinatal Risks of Planned Home Births in the United States

Planned home births by midwives, compared with hospital births, are associated with increased risk of neonatal deaths, neonatal seizures, serious neurological dysfunction, and other adverse neonatal outcomes, according to recent studies. The American College of Obstetricians and Gynecologists (ACOG) recommends home births be cephalic singleton pregnancies between 37 and 41 weeks’ gestation, with no prior cesarean deliveries, and recommends these births be attended by certified midwives or physicians. This study investigated perinatal risks associated with planned home births by midwives and compared them with recommendations and clinical criteria from the ACOG and the American Academy of Pediatrics. Birth certificate data from 2010 to 2012 were collected from the National Center for Health Statistics of the US Centers for Disease Control and Prevention, which included information on each of the births in the United States each year. The proportion of births that were high risk, particularly breech, twins, prior cesarean delivery, or late term or postterm were compared between in-hospital and out-of-hospital midwifery-attended births. Three provider groups were compared: certified nurse-midwife (CNM)–attended home births, CNM-attended hospital births, and other midwife-attended home births, and odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. The search found 11,905,817 deliveries in the United States between 2010 and 2012, including 85,318 home births and 736,070 hospital deliveries attended by CNMs; 29,178 of the 85,318 home births were performed by someone other than a midwife and were excluded from the study, leaving 56,140 planned midwife-attended home births, 19,263 of which were attended by a CNM and 36,877 attended by other midwives. For the high-risk conditions examined, each is reported as the rate in out-of-hospital births, and ORs are comparing the risk of home births to in-hospital deliveries with midwives. Of the midwife-attended planned home births, approximately 1 in 156 were twin births (OR, 2.06; 95% CI, 1.84–2.31, as compared with in-hospital deliveries), 1 in 23 were vaginal births after cesarean deliveries (OR, 2.08; 95% CI, 2.0–2.17), 1 in 35 were with breech presentation (OR, 3.19; 95% CI, 2.87–3.56), and 3 in 10 were at a gestation of 41 weeks or longer (OR, 1.71; 95% CI, 1.68–1.74). Thus, each of these higher-risk conditions makes up a larger proportion of births in intended home deliveries as compared with in-hospital births attended by CNMs. In conclusion, the study found that at least 30% of planned home births attended by midwives include the prenatal risks identified by ACOG and the American Academy of Pediatrics as contradictions for planned home births. These risks are associated with adverse birth outcomes. Planned home births attended to by non–American Midwifery Certification Board–certified midwives account for 65.7% of planned home births in the United States.

Home birth constructed as a safe choice in Iceland: A content analysis on Icelandic media

BackgroundThe rate of home birth in Iceland increased from 0.1% in the 90's, to 2.2% in 2012. As the media contributes to the development and public perceptions, engagement and use of health care, it is of interest to explore the media representation of planned home birth in Iceland. ObjectivesThe aim of this study was to explore the way in which the constructions of planned home birth are represented in the Icelandic media; the frequency with which planned home birth was discussed and by whom it was discussed; whether the discourse was congruent with practice development in the country; and if so, how such congruency was effected. MethodsData from the main newspapers in Iceland published from the beginning of 1990 until the end of 2011 were explored using content analysis. ResultsIn total, 127 items were summarized and we identified five themes: approach to safety, having a choice, the medicalization of childbirth, the relationship between women and midwives, and the reaction of the pregnant woman's local community. Central in the analysis were the importance of being able to choose a safe place of birth and the need for woman-centred care. ConclusionOverall planned home birth was not discussed with much intensity or frequency, but in general the discussion was shaped by a positive attitude. There was a distinction in the public media discourse among midwives and physicians or obstetricians who do not argue against planned home birth but who nevertheless speak with caution. The pregnant women who chose home birth found their own home to be safe and similar views were identified among women and midwives.

Planned home birth: benefits, risks, and opportunities.

While the number of women in developed countries who plan a home birth is low, the number has increased over the past decade in the US, and there is evidence that more women would choose this option if it were readily available. Rates of planned home birth range from 0.1% in Sweden to 20% in the Netherlands, where home birth has always been an integrated part of the maternity system. Benefits of planned home birth include lower rates of maternal morbidity, such as postpartum hemorrhage, and perineal lacerations, and lower rates of interventions such as episiotomy, instrumental vaginal birth, and cesarean birth. Women who have a planned home birth have high rates of satisfaction related to home being a more comfortable environment and feeling more in control of the experience. While maternal outcomes related to planned birth at home have been consistently positive within the literature, reported neonatal outcomes during planned home birth are more variable. While the majority of investigations of planned home birth compared with hospital birth have found no difference in intrapartum fetal deaths, neonatal deaths, low Apgar scores, or admission to the neonatal intensive care unit, there have been reports in the US, as well as a meta-analysis, that indicated more adverse neonatal outcomes associated with home birth. There are multiple challenges associated with research designs focused on planned home birth, in part because conducting randomized controlled trials is not feasible. This report will review current research studies published between 2004 and 2014 related to maternal and neonatal outcomes of planned home birth, and discuss strengths, limitations, and opportunities regarding planned home birth.

BJOG Editor's Choice

BJOG Editor's Choice

How baloch women make decisions about the risks associated with different childbirth settings in southeast iran.

In Zahedan City in Southeast Iran, some women prefer to give birth at home despite the availability of the equipped hospitals and expert advice that hospital births are safer. This study explains how Baloch women make decisions regarding the risks associated with childbirth at home versus a hospital. This study identifies and defines the factors that influence the choice of the place of delivery by Baloch women. The article draws on data from a grounded theory. In particular, on in-depth interviews with 25 Baloch women, 21 of whom had planned home births and 4 planned hospital births in their most recent childbirth. Six categories emerged from the data as follows: 1) deliberation and risk assessment; 2) obstacles to hospital births; 3) preference for hospital births; 4) obstacles to homebirth; 5) preference for homebirth; and 6) risk management. The core category was deliberation and risk assessment. Our interviews showed that Baloch woman weighed the negative and positive aspects of each option when deciding on a childbirth setting. In this process, their assessment of risk included physical wellbeing and sociao-cultural values. Furthermore, their assessment of risk can, in some circumstances, result in delays or avoidance of having hospital childbirth. Managers and service providers need to know an ordinary woman's perception of risk to address the gap between current and desired childbirth services and encourage women to use current hospital services.

Os sentidos do parto domiciliar planejado para mulheres do município de São Paulo, São Paulo

No Brasil, o parto domiciliar tem sido associado à falta de recursos econômicos e a dificuldades de acesso aos serviços de saúde, uma vez que 98% dos partos ocorrem em hospitais. Entretanto, nos grandes centros urbanos, onde há maior oferta de leitos obstétricos, mulheres de estratos sociais médios têm escolhido o parto domiciliar planejado. Para compreender os sentidos dessa escolha, realizamos uma pesquisa qualitativa na qual entrevistamos 20 mulheres que tiveram parto domiciliar planejado: 19 mulheres entrevistadas tinham ensino superior completo; 1 delas tinha ensino superior incompleto; e 10 delas tinham históricos de parto hospitalar. A análise das entrevistas possibilitou caracterizar os sentidos da escolha pelo parto domicilicar em quatro categorias: a casa como uma alternativa ao modelo de atenção obstétrica vigente; hospital, um lugar a ser evitado; "Louca não, informada!": repercussões da escolha à margem do sistema de saúde; parto em casa como facilitador do protagonismo das mulheres.

Puts the magic back into life: Fathers' experience of planned home birth.

In Ireland, planned home birth is seen as an alternative but safe choice of maternity care. Women's experience of home birth is reported as positive but little is known about fathers' thoughts and feelings about planned home birth. The aim of the study was to explore fathers' experience of planned home birth. Hermeneutic phenomenology was selected to explore the experiences of eight fathers whose partners had a recent planned home birth. Data were analysed using Interpretative Phenomenological Analysis (IPA). Themes identified were 'negotiating the decision', 'ownership of the birth' and 'changed way of being'. Fathers overcame their initial reservations about home birth before the decision to plan a home birth was agreed. They were actively involved with their partner in labour which gave themselves a sense of ownership of the experience and a valued post-birth intimacy. Their belief in natural birth was reaffirmed and the experience gave them a new perspective on life. When men have a positive experience of childbirth they benefit personally and emotionally. This experience can strengthen their relationship with their partner and the family. Midwives are ideally placed to involve fathers actively in birth either in a home or hospital setting.

An Exploration of the Unmet Demand forHome Birth in Ireland

PURPOSE: The home birth rate in Ireland is less than 0.5%. There is no formal record of the demand for home birth; however, it is suggested that it exceeds availability by as much as tenfold. This study sought the experiences of women who had tried but were unsuccessful in securing a midwife-attended, planned home birth in Ireland in the years 2009–2013.STUDY DESIGN: An online questionnaire was made available over an 8-week period in the summer of 2013.RESULTS: Sixty-two women responded. Three main reasons were identified for refusal of home birth: “unsuitability for home birth,” “unavailability of a midwife,” and “distance from the midwife.” The Dublin regions’ high level of unmet demand is consistent with its high population density. December and other holiday periods were reported as particularly difficult times to access a midwife. Eighty percent of women eventually gave birth in a hospital setting, whereas 15% gave birth outside a hospital setting without a midwife in attendance. Five percent of women accessed a planned home birth elsewhere.DISCUSSION: Online survey is a methodology that is unable to quantify unmet demand for home birth. This exploratory study has however confirmed the inequity of the home birth service, even for those fully eligible. The choice made by some multiparous women to birth at home unattended, even in the knowledge of risk criteria, is a concern and remains unaddressed by the Irish Health Service Executive.CONCLUSION: Health Service Executive dependence on self-employed community midwives (SECMs) to deliver their “national” home birth service means that demand for home birth is greater than can be supplied. This research highlights the need for the inclusion of requests for home birth in their audit of services. Capacity building of community midwifery in Ireland is recommended, with recruitment and support of SECMs identified as a priority.

Are planned home births safe?

Capitulo', Kathleen Leask PhD, RN, FAAN, FACCE; Olafsdottir, Olof Asta PhD, RN, RM; Huang, Zhaoxia BSN, RN Author Information

727: Temporal trends of risks among planned home births in the US 2006-2012

727: Temporal trends of risks among planned home births in the US 2006-2012

Transfer from planned home birth to hospital: improving interprofessional collaboration.

Women's heightened interest in choice of birthplace and increased rates of planned home birth in the United States have been well documented, yet there remains significant public and professional debate about the ethics of planned home birth in jurisdictions where care is not clearly integrated across birth settings. Simultaneously, the quality of interprofessional interactions is recognized as a predictor of health outcomes during obstetric events. When care is transferred across birth settings, confusion and conflict among providers with respect to roles and responsibilities can adversely affect both outcomes and the experience of care for women and newborns. This article reviews findings of recent North American studies that examine provider attitudes toward planned home birth, differing concepts of safety of birthplace as reported by women and providers, and sources of conflict among maternity care providers during transfer from home to hospital. Emerging evidence and clinical exemplars can inform the development of systems for seamless transfer of women and newborns from planned home births to hospital and improve experience and perceptions of safety among families and providers. Three successful models in the United States that have enhanced multidisciplinary cooperation and coordination of care across birth settings are described. Finally, best practice guidelines for roles, communication, and mutual accommodation among all participating providers when transfer occurs are introduced. Research, health professional education, and policy recommendations for incorporation of key components into existing health care systems in the United States are included.

The Canadian birth place study: examining maternity care provider attitudes and interprofessional conflict around planned home birth.

BackgroundAvailable birth settings have diversified in Canada since the integration of regulated midwifery. Midwives are required to offer eligible women choice of birth place; and 25-30% of midwifery clients plan home births. Canadian provincial health ministries have instituted reimbursement schema and regulatory guidelines to ensure access to midwives in all settings. Evidence from well-designed Canadian cohort studies demonstrate the safety and efficacy of midwife-attended home birth. However, national rates of planned home birth remain low, and many maternity providers do not support choice of birth place.MethodsIn this national, mixed-methods study, our team administered a cross-sectional survey, and developed a 17 item Provider Attitudes to Planned Home Birth Scale (PAPHB-m) to assess attitudes towards home birth among maternity providers. We entered care provider type into a linear regression model, with the PAPHB-m score as the outcome variable. Using Students’ t tests and ANOVA for categorical variables and correlational analysis (Pearson’s r) for continuous variables, we conducted provider-specific bivariate analyses of all socio-demographic, education, and practice variables (n=90) that were in both the midwife and physician surveys.ResultsMedian favourability scores on the PAPHB–m scale were very low among obstetricians (33.0), moderately low for family physicians (38.0) and very high for midwives (80.0), and 84% of the variance in attitudes could be accounted for by care provider type. Amount of exposure to planned home birth during midwifery or medical education and practice was significantly associated with favourability scores. Concerns about perinatal loss and lawsuits, discomfort with inter-professional consultations, and preference for the familiarity of the hospital correlated with less favourable attitudes to home birth. Among all providers, favourability scores were linked to beliefs about the evidence on safety of home birth, and confidence in their own ability to manage obstetric emergencies at a home birth.ConclusionsIncreasing the knowledge base among all maternity providers about planned home birth may increase favourability. Key learning competencies include criteria for birth site selection, management of obstetric emergencies at planned home births, critical appraisal of literature on safety of home birth, and inter-professional communication and collaboration when women are transferred from home to hospital.

Perinatal risks of planned home births in the United States

We analyzed the perinatal risks of midwife-attended planned home births in the United States from 2010 through 2012 and compared them with recommendations from the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) for planned home births. Data from the US Centers for Disease Control and Prevention's National Center for Health Statistics birth certificate data files from 2010 through 2012 were utilized to analyze the frequency of certain perinatal risk factors that were associated with planned midwife-attended home births in the United States and compare them with deliveries performed in the hospital by certified nurse midwives. Home birth deliveries attended by others were excluded; only planned home births attended by midwives were included. Hospital deliveries attended by certified nurse midwives served as the reference. Perinatal risk factors were those established by ACOG and AAP. Midwife-attended planned home births in the United States had the following risk factors: breech presentation, 0.74% (odds ratio [OR], 3.19; 95% confidence interval [CI], 2.87-3.56); prior cesarean delivery, 4.4% (OR, 2.08; 95% CI, 2.0-2.17); twins, 0.64% (OR, 2.06; 95% CI, 1.84-2.31); and gestational age 41 weeks or longer, 28.19% (OR, 1.71; 95% CI, 1.68-1.74). All 4 perinatal risk factors were significantly higher among midwife-attended planned home births when compared with certified nurse midwives-attended hospital births, and 3 of 4 perinatal risk factors were significantly higher in planned home births attended by non-American Midwifery Certification Board (AMCB)-certified midwives (other midwives) when compared with home births attended by certified nurse midwives. Among midwife-attended planned home births, 65.7% of midwives did not meet the ACOG and AAP recommendations for certification by the American Midwifery Certification Board. At least 30% of midwife-attended planned home births are not low risk and not within clinical criteria set by ACOG and AAP, and 65.7% of planned home births in the United States are attended by non-AMCB certified midwives, even though both AAP and ACOG state that only AMCB-certified midwives should attend home births.

Are there risks associated with planned home birthing?

Evidence-Based Answer In low-risk multiparous women, home births have equivalent risk and fewer interventions compared with hospital births (SOR: B, prospective and retrospective cohort study). However, planned home births are associated with higher neonatal mortality when not risk stratified (SOR: B, single retrospective cohort study).

Supporting and Sharing-Home Birth: Fathers' Perspective.

The planned home birth has provoked discussion around the world. Home birth has been described as a positive experience, but results regarding the safety of home birth are controversial. To date, the phenomenon has mainly been examined from the mother's point of view, and there is only one previous study reporting fathers' perspective. The purpose of the present phenomenological qualitative interview study was to investigate fathers' experiences of planned home birth. Eleven fathers were interviewed, and the data were analyzed using Colaizzi's phenomenological method. The fathers followed the woman's wish in choosing the birthplace and set aside their own views. Furthermore, hospital birth was not an option for the fathers due to their own prior negative experiences of hospital births such as disturbing the natural progress of birth. The fathers' experience of home birth included sharing the responsibility, supporting the woman, and participating in the home birth process. The experience was challenging; fathers had to take the role of a midwife, and no support or information on organizing home birth was offered by public health services. The fathers felt that the home birth connected them as family, and the experience was empowering. Our study results suggest that the health care professionals need more education and information on home birth and that the families (including fathers) interested in home birth need greater support from health care professionals. There is a need for proper national home birth guidelines, while family-and client-centered care has to be improved in birthing hospitals.

Severe Adverse Maternal Outcomes Among Low-risk Women With Planned Home Versus Hospital Births in the Netherlands

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 planned hospital birth, and to compare the rate of postpartum haemorrhage and manual removal of placenta. Design Cohort study using a linked dataset. Setting Information on all cases of severe acute maternal morbidity in the Netherlands collected by the national study into ethnic determinants of maternal morbidity in the netherlands (LEMMoN study), 1 August 2004 to 1 August 2006, merged with data from the Netherlands perinatal register of all births occurring during the same period. Participants 146 752 low risk women in primary care at the onset of labour. Main outcome measures Severe acute maternal morbidity (admission to an intensive care unit, eclampsia, blood transfusion of four or more packed cells, and other serious events), postpartum haemorrhage, and manual removal of placenta. Results Overall, 92 333 (62.9%) women had a planned home birth and 54 419 (37.1%) a planned hospital birth. The rate of severe acute maternal morbidity among planned primary care births was 2.0 per 1000 births. For nulliparous women the rate for planned home versus planned hospital birth was 2.3 versus 3.1 per 1000 births (adjusted odds ratio 0.77, 95% confidence interval 0.56 to 1.06), relative risk reduction 25.7% (95% confidence interval −0.1% to 53.5%), the rate of postpartum haemorrhage was 43.1 versus 43.3 (0.92, 0.85 to 1.00 and 0.5%, −6.8% to 7.9%), and the rate of manual removal of placenta was 29.0 versus 29.8 (0.91, 0.83 to 1.00 and 2.8%, −6.1% to 11.8%). For parous women the rate of severe acute maternal morbidity for planned home versus planned hospital birth was 1.0 versus 2.3 per 1000 births (0.43, 0.29 to 0.63 and 58.3%, 33.2% to 87.5%), the rate of postpartum haemorrhage was 19.6 versus 37.6 (0.50, 0.46 to 0.55 and 47.9%, 41.2% to 54.7%), and the rate of manual removal of placenta was 8.5 versus 19.6 (0.41, 0.36 to 0.47 and 56.9%, 47.9% to 66.3%). Conclusions Low risk women in primary care at the onset of labour with planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital birth. For parous women these differences were statistically significant. Absolute risks were small in both groups. There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system.

Information for the option of planned home birth: women's right to choose

This article is part of an investigation which used the institutional ethnography of Dorothy Smith, aiming to describe women's process of choice in planned home birth. It used interviews held with 17 women who gave birth at home between 2008 and 2010 in Rio de Janeiro. We selected one category: information - a step for the option for planned home birth. The category was constructed based on six subcategories: knowing persons who had a home birth; knowing persons with negative experiences; the Internet as a source of information; books as a source of information, information from health professionals; and, the exchanging of information between women. The information acts as a network of knowledge, reports and experiences in their symbolic dimensions, favoring the raising of consciousness and the social organization of support. These knowledges and practices are a foundation for a social understanding and the women's discourse in the option for planned home birth.