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Outcomes Associated with Planned Home and Planned Hospital Births in Low-Risk Women Attended by Midwives in Ontario, Canada, 2003-2006: A Retrospective Cohort Study



Midwives in Ontario, Canada, provide care in the home and hospital and are required to submit data for all births to the Ontario Ministry of Health database. The purpose of this study was to compare maternal and perinatal/neonatal mortality and morbidity and intrapartum intervention rates for women attended by Ontario midwives who planned a home birth compared with similar low-risk women who planned a hospital birth between 2003 and 2006. The database provided outcomes for all women planning a home birth at the onset of labor (n = 6,692) and for a cohort, stratified by parity, of similar low-risk women planning a hospital birth. The rate of perinatal and neonatal mortality was very low (1/1,000) for both groups, and no difference was shown between groups in perinatal and neonatal mortality or serious morbidity (2.4% vs 2.8%; relative risk [RR], 95% confidence intervals [CI]: 0.84 [0.68-1.03]). No maternal deaths were reported. All measures of serious maternal morbidity were lower in the planned home birth group as were rates for all interventions including cesarean section (5.2% vs 8.1%; RR [95% CI]: 0.64 [0.56, 0.73]). Nulliparas were less likely to deliver at home, and had higher rates of ambulance transport from home to hospital than multiparas planning home birth and had rates of intervention and outcomes similar to, or lower than, nulliparas planning hospital births. Midwives who were integrated into the health care system with good access to emergency services, consultation, and transfer of care provided care resulting in favorable outcomes for women planning both home or hospital births.
180 BIRTH 36:3 September 2009
Outcomes Associated with Planned Home and
Planned Hospital Births in Low-Risk Women
Attended by Midwives in Ontario, Canada,
2003–2006: A Retrospective Cohort Study
Eileen K. Hutton, PhD, Angela H. Reitsma, BSc, BHSc(Midwifery), and
Karyn Kaufman, DrPH
ABSTRACT: Background: Midwives in Ontario, Canada, provide care in the home and
hospital and are required to submit data for all births to the Ontario Ministry of Health
database. The purpose of this study was to compare maternal and perinatal/neonatal mortality
and morbidity and intrapartum intervention rates for women attended by Ontario midwives
who planned a home birth compared with similar low-risk women who planned a hospital birth
between 2003 and 2006. Methods: The database provided outcomes for all women planning a
home birth at the onset of labor (n=6,692) and for a cohort, stratified by parity, of similar
low-risk women planning a hospital birth. Results: The rate of perinatal and neonatal mortality
was very low (1/1,000) for both groups, and no difference was shown between groups in
perinatal and neonatal mortality or serious morbidity (2.4% vs 2.8%; relative risk [RR], 95%
confidence intervals [CI]: 0.84 [0.68–1.03]). No maternal deaths were reported. All measures
of serious maternal morbidity were lower in the planned home birth group as were rates for
all interventions including cesarean section (5.2% vs 8.1%; RR [95% CI]: 0.64 [0.56, 0.73]).
Nulliparas were less likely to deliver at home, and had higher rates of ambulance transport
from home to hospital than multiparas planning home birth and had rates of intervention and
outcomes similar to, or lower than, nulliparas planning hospital births. Conclusions: Midwives
who were integrated into the health care system with good access to emergency services,
consultation, and transfer of care provided care resulting in favorable outcomes for women
planning both home or hospital births. (BIRTH 36:3 September 2009)
Key words: birth outcomes, cesarean section rates, home birth, midwifery care
Midwives in Ontario, Canada, provide care to low-risk
women in a model of continuity or case-based care
of midwives throughout pregnancy, birth, and the post-
partum period. Women who meet selective criteria have
the choice of a hospital birth or a planned home birth.
Midwives are expected to attend both home and hospital
births to the extent that maintenance of registration with
the regulatory college depends on a record of providing
care in both settings.
Midwives are well integrated into the Ontario
health care system; they have admission and discharge
Eileen K. Hutton is an Assistant Dean, Faculty of Health Sciences,
Director Midwifery Education Program and Associate Professor in
the Department of Obstetrics and Gynecology, McMaster University,
Hamilton; Angela H. Reitsma is a Registered Midwife, Practicing
Member at The Hamilton Midwives, Hamilton; and Karyn Kaufman is
a Professor Emeritus Faculty of Health Sciences, McMaster University,
Hamilton, Ontario, Canada.
Address correspondence to Dr. Eileen K. Hutton, McMaster University
Midwifery Program, 1200 Main Street West, MDCL 2210, Hamilton,
Ontario, Canada L8N 3Z5.
Accepted March 23, 2009
©2009, Copyright the Authors
Journal compilation ©2009, Wiley Periodicals, Inc.
BIRTH 36:3 September 2009 181
privileges at their local hospital(s), and access to other
health care providers for consultation or transfer of care
as required. Two midwives are in attendance at births
either in the home or in the hospital. The regulatory
body, the College of Midwives of Ontario, sets out eligi-
bility criteria for a home birth: women with twin, breech,
or medically complicated pregnancies; with more than
one previous cesarean section; or with gestation less
than 37 weeks or more than 43 weeks at labor onset
are ineligible. The college also prescribes the prenatal,
intrapartum, and postpartum conditions for which con-
sultation and transfer of care to a physician are manda-
tory (1,2). Random practice audits are undertaken by the
College of Midwives to ensure that standards and regu-
lations are followed.
We sought to compare the outcomes of home and
hospital births to inform the midwifery profession
and the wider obstetric community, because birth at
home remains controversial (3–9), and practitioners are
subjected to criticism for attending home births (10).
Although a single study cannot provide a definitive con-
clusion about the relative safety of birth setting, we
thought it was important to assess the relatively recent
experience within Ontario.
Evaluating the outcomes of home births poses sev-
eral challenges. Because adverse outcomes are infre-
quent, large samples are needed to detect important
differences; however, the number of births occurring at
home is not large in most Western countries. Studies of
home birth have been limited by sample size (4,11–24);
absence of a comparison group (15,18,20–22,25–30);
comparison with care provided by other practition-
ers (17,23,24,29,31,32); use of self-reporting survey
methods (25,27,30); or inclusion of both planned and
unplanned home births (31,33).
Midwifery care in Ontario is part of publicly funded
health care in the province. All midwives are required
to submit a “client tracking form,” which includes pre-
natal, intrapartum, and postpartum information for each
woman in care. A database of midwifery care has
Table 1. Details of Allocation of 419 Records Inconsistent with Home Birth Criteria
Number of
Record Allocation Record Details Cases
Retained in primary analysis (n=74) Breech delivering at home or transferred in labor 13
Preterm 35 wk 20
Antenatal transfer of care with possible return to midwifery care 41
Removed from any analysis (n=90) Breech with antenatal transfer of care and elective cesarean section 36
Very preterm 28 wk 25
Antenatal transfer of care for conditions judged to be permanent 29
Retained for sensitivity analysis (n=255) Breech with hospital delivery; no known transport in labor 30
Preterm <35 wk; >28 wk 41
Antenatal transfer of care unclear re possible return to midwifery 20
Oxytocin induction 164
been systematically compiled at the Ontario Ministry of
Health. Since 2003, the submission of data has been tied
to reimbursement, which together with ongoing audit and
adjustment for inconsistent information virtually ensures
a complete database.
During the study period (2003–2006), approximately
130,000 births (34) per year were reported in Ontario,
with midwives attending about 8,600 (6.6%) births annu-
ally. Actual home births accounted for 1.6 percent of
the total provincial births and 25 percent of midwife-
attended births (35).
The purpose of this study was to compare maternal
and perinatal/neonatal mortality and morbidity and intra-
partum intervention rates for women attended by Ontario
midwives who planned a home birth, compared with
similar low-risk women who planned a hospital birth
between 2003 and 2006.
The Ministry of Health database of midwifery care was
used to undertake a retrospective cohort study of 13,384
midwife-attended births that occurred between April 1,
2003, and March 31, 2006, to compare the outcomes
for all women who planned a home birth (n=6,692)
at the outset of labor with a comparable low-risk group
of women who planned a hospital birth at the outset
of labor. All outcomes were analyzed according to the
planned place of birth irrespective of actual birth set-
ting. The groups were matched with respect to parity and
previous lower segment cesarean section. Midwives reg-
istered with and regulated by the College of Midwives in
Ontario attended all births included in the study. Ethics
approval for the project was received from McMaster
University Research Ethics Board.
Selection of Study Groups
Women discuss with their midwives their preference for
place of birth at several points during the pregnancy, and
182 BIRTH 36:3 September 2009
a Evidence from other data fields that care was organized for a hospital birth.
b Planned home birth seemed unlikely but could not be ruled out by information available; all records indicating oxytocin induction.
c Home birth occurred.
All midwife
births, 2003-
Indicated home,
other, or undecided
Indicated planned
hospital birth
Logic check
indicates possible
contraindication to
home birth
Excluded due to:
>1 previous cesarean section
Breech presentation
Multiple pregnancy
Preterm delivery
Medical induction
Any antenatal transfer of care
with home
from data set
Retain for
Return to
home birth
data setc
Eligible for
Primary analysis
Randomly selected
and matched on:
1 previous
cesarean section
Fig. 1. Selection of included records.
this information will be documented on the client medi-
cal record. The data form provides information about the
planned location of birth when labor begins, since inter-
vening situations and changes of preference can modify
the initial plan.
For this study, the planned home birth group included
all client records where “planned place of birth at the
outset of labor” was “home,” “other out-of-hospital loca-
tion” (Ontario offers no formal out-of-hospital alter-
native settings to home birth, such as birth centers),
or “undecided,” because in any of these situations the
occurrence of the birth outside the hospital was a pos-
sibility. To detect possible coding errors for the planned
place of birth, we carried out logic checks to identify
the records with contraindications to planned home birth
or records with interventions that were inconsistent with
home birth (oxytocin induction of labor) or in which an
antenatal transfer of care to a physician was documented.
Two experienced midwives independently used an algo-
rithm, developed a priori, to decide whether to include
the record in the main analysis, permanently exclude the
record, or reserve the record for the sensitivity analysis
The comparison group was derived from the remain-
ing records in the data set from the same time period,
all of which indicated that the hospital was the planned
place of birth at the outset of labor. To ensure a low-risk
cohort comparable to the planned home birth cohort, we
removed all the records in which a home birth would
have been contraindicated (had it been planned), or in
which a prelabor intervention had occurred that was
inconsistent with, or unlikely at, a home birth. Thus,
from the planned hospital group, we excluded the records
with more than one previous cesarean section, breech
presentation, multiple pregnancies, preterm delivery
prior to 37 weeks’ gestation, oxytocin induction of labor,
prostaglandin cervical ripening, or any antenatal transfer
of care to a physician.
To minimize the risk of bias, we stratified our cur-
rent low-risk hospital records on parity (0 or 1) and on
previous cesarean section (none or one), and from each
BIRTH 36:3 September 2009 183
strata selected a random sample of records matching the
groups on parity and previous cesarean section (36).
Our primary outcome was a composite measure of peri-
natal and neonatal mortality or serious morbidity, defined
as the presence of one or more of the following: death
(stillbirth or neonatal death 0–27 days, excluding lethal
anomalies and fetal demise before the onset of labor);
Apgar score of less than 4 at 5 minutes of age; neonatal
resuscitation requiring both positive pressure ventilations
and cardiac compressions; admission to a neonatal or
pediatric intensive care unit with a length of stay greater
than 4 days; or birthweight less than 2,500 g. We note
that although birthweight is not an outcome that can
be a result of birth place, failure to screen adequately
for extremes of weight can result in planning for an
inappropriate place of birth. Thus, low birthweight was
included as part of the composite. Perinatal or neonatal
mortality cases that listed a lethal anomaly were inde-
pendently reviewed by two authors blinded to group, and
Table 2. Baseline Characteristics of Women Planning
Home and Hospital Birth
Planned Planned
Home Hospital
(n=6,692) (n=6,692)
Characteristic No. (%) No. (%)
Age (yr)
<25 729 (10.9)844 (12.6)
25–34 4,428 (66.1)4,630 (69.2)
35 1,503 (22.5)1,199 (17.9)
Missing 32 (0.5)19 (0.3)
02,293 (34.3)2,298 (34.3)
1–4 4,172 (62.3)4,289 (64.1)
>4 221 (3.3)105 (1.6)
Missing 6 (0.1)
Geographical location
South rural 1,022 (15.3)901 (13.5)
South urban 5,305 (79.3)4,937 (73.8)
North rural 91 (1.4)192 (2.9)
North urban 271 (4.0)661 (9.9)
Missing 3 (0.0)1(0.0)
Repeat Ontario midwifery client
Yes 3 ,044 (45.5)2,331 (34.8)
No 3,642 (54.4)4,357 (65.1)
Missing 6 (0.1)4(0.1)
Previous cesarean section
06,479 (96.8)6,485 (96.9)
1 200 (3.0)207 (3.1)
Missing 7 (0.1)
Median gestation at booking 11.011.0
Median gestation at birth 40.040.0
a consensus decision was made with respect to exclusion
from the composite outcome.
Other outcomes included maternal mortality, signifi-
cant morbidity, rates of intrapartum interventions, and
breastfeeding. We included any maternal death from
a direct obstetrical cause (as determined by a provin-
cial coroner’s review of all maternal deaths) occurring
between the onset of labor and 6 weeks postpartum. Sig-
nificant maternal morbidity included blood loss greater
than 1,000 mL or bleeding requiring a consultation with
a physician; any infection after onset of labor requir-
ing a consultation with a physician; any third or fourth
degree laceration; and any postpartum transfer of care to
a physician. Any situation requiring a consultation or a
transfer of care was deemed to be a significant outcome
because the indications for consultation and/or transfer
of care are well defined by the College of Midwives of
Ontario. So, whereas practitioners might typically under-
estimate blood loss greater than 1,000 mL, any symp-
tomatic blood loss or transfusion would be captured in
our analysis by including the consultation or transfer of
care in the postpartum period.
Intrapartum interventions included rates of labor aug-
mentation, use of any pharmaceutical pain relief, epi-
siotomy and perineal trauma, assisted vaginal delivery,
and cesarean section. Rates of infant feeding with for-
mula supplementing breastfeeding or exclusive formula
feeding were compared at 1 and 6 weeks of age.
Data Analysis
All the analyses were conducted using SPSS 15.0 (37).
We used descriptive statistics to report baseline char-
acteristics. Comparative analyses used chi-square and
relative risk (RR) and 95 percent confidence inter-
vals (CI). We removed the possible misclassified home
birth records from the primary analysis and retained them
for a sensitivity analysis of the primary outcome. We also
conducted a subgroup analysis of nulliparas and multi-
paras using descriptive statistics.
Data Cleaning
We found 7,037 records indicating that at the outset
of labor, birth was intended to take place at home. Of
these, we identified 419 records in which an intervention
inconsistent with home birth was undertaken (induction
with oxytocin [n=164]) or a contraindication to home
birth existed (breech delivery [n=79], preterm labor
[n=86]), or an antenatal transfer of care had occurred
(n=90). These records were analyzed as described in
Fig. 1 and Table 1, resulting in 6,692 records for the
primary analysis, and 6,947 for the sensitivity analysis.
184 BIRTH 36:3 September 2009
Table 3. Comparison of Variables in Planned Home and Hospital Groups with Relative Risk Presented for Selected
Planned Home Planned Hospital
(n=6,692) (n=6,692)
Variable No. (%) No. (%) pRR [95% CI]
Actual place of birth
Home 5,259 (78.6)208 (3.1)
Hospital 1,371 (20.5)6,467 (96.6)
Other location 62 (0.9)17 (0.3)
Ambulance transport from home
during or immediately after birth
Yes 361 (5.4)44 (0.7)
No 6,307 (94.2)6,544 (97.8)
Missing 24 (0.4)104 (1.5)
Estimated intrapartum blood loss
<500 mL 6,048 (90.4)5,909 (88.3)
500–1000 mL 568 (8.5)678 (10.1)
>1000 mL 56 (0.8)82 (1.2)0.026 0.68 [0.49–0.96]
Missing 20 (0.3)23 (0.3)
Consultation or transfer of care for
79 (1.2)106 (1.6)0.046 0.75 [0.56–1.00]
Any laceration 3,612 (54.0)4,081 (61.0)
1st degree perineal 1,109 (16.6)1,186 (17.7)
2nd degree perineal 1,695 (25.3)1,939 (29.0)
3rd degree perineal 78 (1.2)123 (1.8)
4th degree perineal 21 (0.3)22 (0.3)
Labial 413 (6.2)381 (5.7)
Vaginal 474 (7.1)542 (8.1)
Any 2nd–4th degree perineal, labial
or vaginal tear, or episiotomy
2,589 (38.7)2,979 (44.5)0.000 0.87 [0.83–0.90]
Intrapartum transfer of care 837 (12.5)1,270 (19.0)0.000 0.66 [0.61–0.71]
Postpartum transfer of care 119 (1.8)104 (1.6)0.311 1.14 [0.88–1.49]
Intrapartum intervention
Labor induction
None 6,586 (98.4)6,524 (97.5)
ARM before labor 73 (1.1)136 (2.0)
Prostaglandin 27 (0.4)
Unknown/missing 15 (0.2)21 (0.3)
Labor augmentation
None 4,797 (71.7)4,203 (62.8)
Any augmentation 1,852 (27.7)2,426 (36.3)0.000 0.76 [0.72–0.80]
ARM 1,496 (22.4)1,889 (28.2)
Oxytocin 551 (8.2)878 (13.1)
Unknown/missing 43 (0.6)63 (0.9)
Pharmaceutical pain relief
None 5,570 (83.2)3,667 (54.8)
Any pharmaceutical pain relief 1,122 (16.8)3,025 (45.2)0.000 0.37 [0.35–0.39]
Nitrous oxide 221 (3.3)1,206 (18.0)
Narcotic analgesia 117 (1.7)423 (6.3)
Regional anesthesia
Epidural 655 (9.8)1405 (21.0)
Spinal 114 (1.7)199 (3.0)
General anesthesia 26 (0.4)48 (0.7)
Local anesthesia 191 (2.9)352 (5.3)
Episiotomy 286 (4.3)393 (5.9)0.000 0.73 [0.63–0.84]
Mode of delivery
Spontaneous vaginal 6,146 (91.8)5,852 (87.4)
Assisted vaginal 195 (2.9)293 (4.4)0.000 0.67 [0.56–0.80]
Forceps 81 (1.2)141 (2.1)
Vacuum 124 (1.9)168 (2.5)
Cesarean section 348 (5.2)544 (8.1)0.000 0.64 [0.56–0.73]
*Oxytocin induction is not undertaken at home and was an exclusion for the hospital birth cohort.
ARM =artificial rupture of membranes.
BIRTH 36:3 September 2009 185
Table 4. Comparison of Neonatal Variables in Planned Home and Hospital Groups with Relative Risk Presented for
Selected Outcomes
Planned Home Planned Hospital
(n=6,692) (n=6,692)
Variable No. (%) No. (%) pRR [95% CI]
Breech presentation 12 (0.2)
Multiple birth
Gestational age (wk)
<37 17 (0.3)
37–41, 6 days 6,555 (98.0)6,638 (99.2)
>41, 6 days 117 (1.7)54 (0.8)
Missing 3 (0.0)
Birthweight (g)
<2,500 38 (0.6)56 (0.8)
2,500–4,000 5,364 (80.2)5,410 (80.8)
>4,000 1,279 (19.1)1,220 (18.2)
Missing 11 (0.2)6(0.1)
Apgar scores
<4at1min 89(1.3)107 (1.6)
Missing 49 (0.7)36 (0.5)
<7at5min 47(0.7)58 (0.9)
Missing 40 (0.6)34 (0.5)
Infant resuscitation
PPV 432 (6.5)382 (5.7)
PPV and chest compressions 21 (0.3)23 (0.3)
Significant congenital anomalies
None 6,515 (97.4)6,513 (97.3)
Major 28 (0.4)24 (0.4)
Minor 140 (2.1)144 (2.2)
Life threatening 5 (0.1)4(0.1)
Unknown/missing 4 (0.1)7(0.1)
Infant feeding at 1 wk
Exclusively breastfed 6,122 (91.5)5,638 (84.2)
Breastfed with supplement, or exclusively formula fed 544 (8.1)1,016 (15.2)0.000 0.53 [0.48–0.59]
Unknown 26 (0.4)38 (0.6)
Infant feeding at 6 wk
Exclusively breastfed 5,853 (87.5)5,140 (76.8)
Breastfed with supplement, or exclusively formula fed 620 (9.3)1,260 (18.8)0.000 0.49 [0.44–0.53]
Unknown/missing 219 (3.3)292 (4.4)
Any mortality 9 (0.1)9(0.1)
Neonatal mortality6(0.1)4(0.1)
Infant death 28–42 days 1 (0.0)
*No congenital anomalies noted in either group.
Includes 2 infants with a major congenital anomaly in the planned hospital group (1 brain tumor, 1 liver cirrhosis).
PPV =positive pressure ventilation.
Once the records were classified, the planned home
birth group comprised 6,692 women. A sample of 6,692
women was then randomly selected and stratified for par-
ity and one previous cesarean section from the low-risk
planned hospital group for the analysis. The groups were
similar on baseline characteristics (Table 2). Most women
were between 25 and 34 years of age, multiparous, and
lived in the southern urban part of the province. More
women planning home births (45.5%) had received care
from a midwife in a previous pregnancy compared with
those in the hospital birth group (34.8%).
Of 6,692 women in each group, 5,259 (78.6%) of those
in the planned home birth group gave birth at home
and 6,467 (96.6%) of those in the planned hospital
birth group gave birth in hospital (Table 3). Overall,
98.6 percent of newborns were born between 37 and 41
completed weeks of pregnancy (Table 4). The planned
home birth group had more babies with a gestational age
greater than 42 weeks (1.7% vs 0.8%).
Table 5 displays the perinatal/neonatal composite out-
come (2.4% vs 2.8% RR [95% CI]: 0.84 [0.68, 1.03]).
No differences were reported in the rates of perinatal or
186 BIRTH 36:3 September 2009
Table 5. Primary Outcome Including Primary and Sensitivity Analyses
Planned Home Planned Hospital
(n=6,692) (n=6,690)
Outcome No. (%) No. (%) pRR [95% CI]
Primary outcome: Perinatal/neonatal
morbidity or mortality
Composite outcome in primary analysis159 (2.4)190 (2.8)0.092 0.84 [0.68–1.03]
Composite outcome in sensitivity analysis
(planned home birth, n=6,947)
180 (2.6)190 (2.8)0.371 0.91 [0.75–1.12]
Composite component outcomes
(primary analysis)
Perinatal/neonatal mortality 9 (0.1)6(0.1)0.600 1.50 [0.53–4.21]
Stillbirth (after onset of labor) 3 (0.0)4(0.1)
Neonatal death <28 days 6 (0.1)2(0.0)
Neonatal morbidity 155 (2.3)189 (2.8)0.063 0.82 [0.66–1.01]
Birthweight <2,500 g 38 (0.6)56 (0.8)
Apgar <4at5min 10(0.1)8(0.1)
PPV and cardiac compressions 21 (0.3)23 (0.3)
NICU >4 days 102 (1.5)115 (1.7)
Two infants with a major congenital anomaly excluded from planned hospital group.
PPV =positive pressure ventilation; NICU =neonatal intensive care unit.
neonatal mortality between the groups, or in the rates
of serious morbidity (2.3% vs 2.8% RR [95% CI]: 0.82
[0.66, 1.01]). The rate of perinatal and neonatal mortal-
ity was 1 death per 1,000 live births for both groups,
with 9 in the planned home birth group and 8 in the
planned hospital birth group (of which 2 had significant
congenital conditions and were removed from the com-
posite outcome). One additional death occurred between
28 and 42 days of age in the planned hospital group.
With respect to infant feeding, infants born to women
planning to birth at home were one half as likely to use
supplemental formula feeding or be exclusively formula
fed at 1 week (8.1% vs 15.2%, RR [95% CI]: 0.53 [0.48,
0.59]) and at 6 weeks of age (9.3% vs 18.8%, RR [95%
CI]: 0.49 [0.44, 0.53]).
No maternal deaths occurred in either group. Women
in the planned home birth group experienced fewer
intrapartum interventions for each specific intervention
studied (induction, augmentation, pharmaceutical pain
relief, episiotomy, assisted delivery), including an abso-
lute decrease of 2.9 percent in the rate of cesarean
section (5.2% vs 8.1%, RR [95% CI]: 0.64 [0.56, 0.73]).
Women in this group also had less perineal trauma and
reduced incidence of blood loss greater than 1,000 mL.
Intrapartum transfers of care from midwives to another
practitioner (typically an obstetrician) were significantly
fewer in the planned home birth group (12.5% vs 19.0%,
RR [95% CI]: 0.66 [0.61, 0.71]) (Table 3).
Sensitivity Analysis
As described earlier, after completing the logic checks,
we excluded from our primary analysis 255 records that
were identified as women who were planning a home
birth. Although we judged it unlikely that these records
were truly planned home births at the outset of labor, we
undertook a sensitivity analysis and added them to the
planned home birth group, and reanalyzed our primary
outcome. Inclusion of these additional records did not
change the findings (Table 5).
Subgroup Analysis
The results of the subgroup analysis are reported in
Table 6. In our sample, nulliparas were less likely to
deliver at home, and had higher rates of ambulance trans-
port from home to hospital compared with multiparas
planning a home birth. Compared with multiparas, nul-
liparas in both the planned home and hospital groups
were more likely to experience outcomes such as blood
loss greater than 1,000 mL; experience 2nd, 3rd, or 4th
degree tears; require consultation or transfer of care;
and have interventions such as augmentation, pain relief,
assisted vaginal delivery, and cesarean section. The rates
of intervention and outcomes among nulliparas plan-
ning home birth were similar to, or lower than, among
those planning hospital births. Neonatal morbidity and
mortality was similar among all subgroups. Multiparas
planning home birth were most likely to be exclusively
breastfeeding at 6 weeks, followed by nulliparas plan-
ning birth at home. Nulliparas planning hospital birth
had the lowest rate of breastfeeding.
As expected in a low-risk population, overall rates of
intervention, maternal morbidity, and perinatal/neonatal
morbidity and mortality were low for both groups. With
BIRTH 36:3 September 2009 187
Table 6. Subgroup Analysis of Selected Variables for Nulliparas and Multiparas by Planned Home and Hospital Groups
Planned Home Planned Hospital
Nulliparas (n=2,293) Nulliparas (n=2,298)
Multiparas (n=4,393) Multiparas (n=4,394)
Variable No.a(%) No.a(%)
Actual place of birth—home
Nulliparas 1,364 (59.5)76 (3.3)
Multiparas 3,891 (88.6)132 (3.0)
Ambulance transport from home during or
immediately after birth
Nulliparasb188 (8.2)14 (0.6)
Multiparasc173 (3.9)30 (0.7)
Estimated intrapartum blood loss >1,000 mL
Nulliparasd29 (1.3)31 (1.3)
Multiparase27 (0.6)51 (1.2)
Consultation or transfer of care for bleeding
Nulliparas 32 (1.4)39 (1.7)
Multiparas 47 (1.1)67 (1.5)
Laceration–any 2nd–4th degree perineal, labial,
or vaginal tear, or episiotomy
Nulliparas 1,406 (61.3)1,382 (60.1)
Multiparas 1,182 (26.9)1,597 (36.3)
Intrapartum transfer of care
Nulliparas 638 (27.8)798 (34.7)
Multiparas 197 (4.5)472 (10.7)
Postpartum transfer of care
Nulliparas 66 (2.9)49 (2.1)
Multiparas 53 (1.2)55 (1.3)
Any labor augmentation
Nulliparasf817 (35.8)1,038 (45.5)
Multiparasg1,032 (23.7)1,388 (31.9)
Any pharmaceutical pain relief
Nulliparas 782 (34.1)1,434 (62.4)
Multiparas 338 (7.7)1,591 (36.2)
Nulliparas 229 (10.0)277 (12.1)
Multiparas 57 (1.3)116 (2.6)
Assisted vaginal delivery
Nulliparas 166 (7.2)221 (9.6)
Multiparas 28 (0.6)72 (1.6)
Cesarean Section
Nulliparas 276 (12.0)365 (15.9)
Multiparas 71 (1.6)179 (4.1)
Infant feeding at 1 wk—exclusively breastfed
Nulliparash1,996 (87.4)1,825 (79.9)
Multiparasi4,122 (94.2)3,813 (87.2)
Infant feeding at 6 wk—exclusively breastfed
Nulliparasj1,962 (89.1)1,680 (76.7)
Multiparask3,887 (91.1)3,460 (82.2)
Composite perinatal neonatal morbidity/mortalityl
Nulliparas 80 (3.5)85 (3.7)
Multiparas 79 (1.8)105 (2.4)
Perinatal/neonatal mortalityl
Nulliparas 5 (0.2)4(0.2)
Multiparas 4 (0.1)2(0.1)
Neonatal morbidity
Nulliparas 78 (3.4)84 (3.7)
Multiparas 77 (1.8)105 (2.4)
aDenominator has been adjusted for missing data with missing data in home birth group and hospital birth group as follows: b8, 35; c16, 68; d6, 6;
e14, 15; f12, 15; g31, 48; h10, 15; i16, 23; j91, 107; k127, 185; l2 infants with a major congenital anomaly excluded from planned hospital group.
188 BIRTH 36:3 September 2009
an overall rate of maternal mortality in Canada approx-
imately 7 per 100,000 live births, it is clear that catas-
trophic events in the low-risk population are very rare,
and that this study cannot address this issue (38). Peri-
natal mortality rates in our study were 1 death per 1,000
live births in both groups. Statistics Canada reports a
perinatal mortality rate of 6.7 per 1,000 in Ontario in
2003, and 6.3 in all of Canada (39). This rate, however,
includes outcomes for pregnancies of all risk categories,
and is not directly comparable with the low-risk term
population that is reported in our study. Our findings
were comparable to, or lower than, those reported in
2002 of home birth in British Columbia, Canada, where
the perinatal mortality rate reported for home birth group
was 3.5 per 1,000 and for a similar group of physician
attended hospital births 1.3 per 1,000 (14).
We found no increase in risk of adverse perinatal and
neonatal outcomes in morbidity or mortality between
groups, but we found significantly lower rates of intra-
partum intervention and of serious maternal morbidity in
the planned home birth group compared with the planned
hospital group. With respect to the cases included in the
sensitivity analysis, it is possible that desire for home
birth at the outset of labor (despite a contraindication)
is construed at times to be a “plan” for a home birth.
We judged that for some of the 419 cases, where the
data file indicated that home birth was planned at the
outset of labor in the presence of a clear contraindi-
cation, some midwives might have erroneously entered
responses to indicate that a home birth had at some point
in the pregnancy been planned or desired. We believe
that our careful categorization of the two study groups,
our approach to these cases, and the sensitivity analysis
minimize the overestimation or underestimation of the
outcome rates for the planned home birth cohort.
Although the planned hospital birth group experienced
somewhat higher rates of labor augmentation, epidural
use, assisted vaginal birth, and an increase in cesarean
section, the women’s outcomes are reassuring. In con-
sidering explanations for the very favorable outcomes of
the planned home birth group, we believe it is unlikely
that variations in midwifery practice are responsible. The
same midwives cared for both groups of women. When
midwives provide care in the home, they may use differ-
ent skills to enhance normal labor and birth, but it seems
unlikely that such differences would extend systematically
across the number of midwives who provided care to the
study women. We cannot discount the possibility of biased
reporting of outcomes for the planned home birth group,
but audits of midwifery data forms compared with hospi-
tal records have not shown systematic underreporting of
problems for women transported from home to hospital.
In addition, one or more midwives are present for each
birth, and typically a student is in attendance, so several
individuals contribute to completing a client record.
It is far more likely that differences are due to the
women themselves, since they self-select the planned
place of birth. We noted no major confounders between
the two groups; however, more subtle but important dif-
ferences likely exist between the women planning home
and those planning hospital births. In Ontario, midwives
are already caring for a self-selected subgroup of the
population who has selected midwifery care over the
more typical obstetrical model. Women who plan a home
birth are often more motivated to avoid interventions
such as epidural analgesia, which reduces the potential
for other interventions compared with other women (16).
A finding that supports the hypothesis of differences
between the groups is the decreased rate of supple-
mented or formula fed infants at 6 weeks of age in
the planned home birth group. It is also possible that
multiparas in our sample who planned a home birth
did so because they had an uncomplicated first birth,
whereas those who experienced problems with previous
births were more likely to choose a hospital setting. We
were unable to verify this hypothesis, since we did not
have access to actual medical records with detailed client
It is also plausible that the setting itself influences the
outcomes. Being in one’s own home environment may
go beyond mere comfort and enhance the very process of
labor and birth. We found the 40 percent decrease in the
rate of cesarean section, an absolute difference of nearly
3 percent, surprising and speculated about the possible
influence of the hospital setting. Several hospitals in the
province require that midwives transfer care to a physi-
cian according to institutional criteria, the result being
more transfers than if criteria of the College of Midwives
were followed. This factor is borne out with our finding
of an increased rate of intrapartum transfer of care in the
planned hospital group, and leads to a greater number of
women having care in labor managed by hospital staff.
Distress at losing a known midwife as the attendant, a
more interventionist style of care, or both may contribute
to an increase in assisted or operative births.
Whatever their relative balance, we conclude that multi-
ple factors contribute to the decreased rate of interven-
tions and of maternal morbidity we found in the group
who planned home birth. Appropriate self-selection by
the women themselves and good screening by mid-
wives likely contribute to the observed results. A well-
integrated midwifery care system is known to have a
positive impact on outcomes (40), and it is likely that
the Ontario context of self-regulation, good integration
into the health care system with access to emergency
services, and consultation and transfer of care when nec-
essary also contribute to favorable outcomes.
BIRTH 36:3 September 2009 189
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... 26,27 This aligns with many international studies in countries with robust availability and integration of midwifery services in the maternity care system that report fewer maternal interventions and similar perinatal outcomes in low-risk home births. 23,[28][29][30][31] Criteria for a low-risk home birth may include the absence of significant maternal or pregnancyassociated disease, the absence of fetal anomalies, a term, cephalic-presenting singleton fetus, no prior history of cesarean birth, and labor that is spontaneous. 30,31 Home births with higher-risk pregnancies, however, are associated with a higher incidence of both maternal and neonatal morbidity. ...
... 23,[28][29][30][31] Criteria for a low-risk home birth may include the absence of significant maternal or pregnancyassociated disease, the absence of fetal anomalies, a term, cephalic-presenting singleton fetus, no prior history of cesarean birth, and labor that is spontaneous. 30,31 Home births with higher-risk pregnancies, however, are associated with a higher incidence of both maternal and neonatal morbidity. 26 Although planned CPM-accompanied home births are overall low-risk, CPM education is not uniform and students can earn certification through either an accredited institution or an apprenticeship with a demonstrated portfolio of experiences. ...
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Given concerns of coronavirus disease 2019 (COVID‐19) acquisition in health care settings and hospital policies reducing visitors for laboring patients, many pregnant women are increasingly considering planned home births. Several state legislatures are considering increasing access to home births by granting licensure and Medicaid coverage of certified professional midwife (CPM) services. In this commentary, issues surrounding the expansion of CPM services including safety, standardization of care, patient satisfaction, racial and income equity, and an overburdened health care system are discussed. Lawmakers must account for these factors when considering proposals to expand CPM practice and payment during a pandemic.
... De Jonge et al concluded that planned home births also showed variability in delayed cord clamping times, skin-to-skin contact times, and breastfeeding compared to deliveries in hospitals (24). In a study conducted in Canada, it was observed that mothers who gave birth at home breastfed their babies at a rate of 95.5%, while mothers who gave birth in a hospital nursed their babies at a rate of 84.5% (25). In our study, regarding the skinto-skin contact times of mothers with their newborn babies, it was found that 32.6%, 42.8%, and 21.4% of them were contacted for 10, 30, and 60 minutes, respectively. ...
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Background: Although there are very few studies in the literature, out-of-hospital deliveries are increasing in Turkey. Our aim was to examine trends in out-of-hospital deliveries, the risk profile of these deliveries, differences in women’s access to these deliveries, and delivery outcomes. Methods: This cross-sectional study included 215 women and was conducted retrospectively in a rural setting in Turkey between 2020 and 2021. Data were collected using a questionnaire developed by the authors. The questionnaire included demographic information, obstetric background, and reasons for giving birth at home, as well as data on who encouraged the decision to give birth at home and who helped with home births. Results: In the study, the delivery time of mothers was found to be 5.99 hours, which is shorter than the average delivery time in the literature. It was observed that 87% of the mothers did not undergo episiotomy, and none of them experienced the need for induction at birth. It was determined that 49.8% of the mothers gave birth in the position they wanted and chose to give birth in bed. It was observed that 99.1% of the mothers did not experience complications at birth. Conclusion: Overall, midwife-managed births met the mothers’ expectations of privacy, a safe environment, social support, and uninterrupted birth. More importantly, there were no complications in midwife-led deliveries, and midwifery care was given in line with evidence-based practices.
... Some studies show higher among planned home deliveries than among hospital deliveries [20][21][22]. In contrast, there are also reports showing no significant difference between them [23][24][25][26]. The number of women who deliver in hospitals grew with advanced medical care and a higher ability to rescue newborns and mothers [27]. ...
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Background and Objectives: COVID-19 is a pandemic disease, and its unpredictable outcome makes it particularly dangerous, especially for pregnant women. One of the decisions they have to make is where they will give birth. This study aimed to determine the factors influencing the choice of place of delivery and the impact of the COVID 19 pandemic on these factors. Materials and Methods: The study was conducted on 517 respondents from Poland. The research methods comprised the authors' own survey questionnaire distributed via the Internet from 8 to 23 June 2021. The survey was fully anonymous, voluntary, and addressed to women who gave birth during the pandemic or will give birth shortly. Results: A total of 440 (85.1%) respondents were afraid of SARS-CoV-2 infection. The most frequently indicated factors were fear of complications in the newborn, fear of intrauterine fetal death, and congenital disabilities in a newborn. A total of 74 (14.3%) women considered home delivery. The main factors that discouraged the choice of home birth were the lack of professional medical care 73.1% (N = 378), the lack of anesthesia 23.6% (N = 122), and the presence of indications for caesarean section 23.4% (N = 121). The possibility of mother-child isolation caused the greatest fear about hospital delivery. During the COVID-19 pandemic, pregnant women concerned about SARS-CoV-2 infection were more likely to consider home delivery than those without such fears. The most important factors affecting the choice of the place of delivery included the possibility of a partner's presence, excellent sanitary conditions and optimal distance from the hospital, and the availability of epidural analgesia for delivery. Conclusions: Our study identifies the determinants of place of delivery during the COVID-19 pandemic. The data we obtained can result in the healthcare system considering patients' needs in case of similar crisis in the future.
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Background Over one‐third of nulliparae planning births either at home or in freestanding midwife‐led birthing centers (community births) in high‐income countries are transferred during labor. Perinatal data are reported each year in Germany for women planning community birth. So far, data sets have not been linked to describe time‐related factors associated with nulliparous transfer to hospital. Objectives To describe the prevalence of referral for nulliparae and assess maternal and labor characteristics associated with intrapartum transfer. Methods Perinatal data from 2010 to 2015 were linked (n = 26,115). Women were reviewed with respect to international eligibility criteria for community birth; 1997 women were excluded (7.6%). Descriptive statistics were reported; unadjusted and adjusted odds ratios with 95% confidence intervals (CI) tested the predictive effect of demographic and labor factors on rates of intrapartum transfer. Results One in three nulliparous women (30.6%) were transferred to hospital. Compared with community births, transferred women were significantly more likely to experience longer time intervals during labor: from rupture of membranes (ROM) until birth lasting 5 to 18 h (OR 6.05, CI 5.53–6.61) and 19 to 24 h (OR 10.83, CI 9.45–12.41) compared to one to 4 h; and from onset of labor until birth 11 to 24 h (OR 6.72, CI 6.24–7.23) and 25 to 29 h (OR 26.62, CI 22.77–31.11) compared to one to 10 h. When entering all factors into the model, we found the strongest predictors of transfer to be fetal distress, longer time intervals between ROM until birth and onset of labor until birth. Conclusions Nulliparous transfer rates were similar to rates in other high‐income countries; 94% of referrals were non‐urgent. Time was found to be an independent risk factor for the transfer of nulliparae planning community birth.
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Background: Infant obesity is a risk factor for diseases in childhood and even in adulthood. Maternal feeding behaviors are strongly associated with infant obesity, hence factors relevant to mother's perception, socioeconomic status, and social support that influence the feeding behaviors need to be explored. Therefore, this study aimed to examine associated factors of feeding behaviors among mothers with obese infants. Methods: This cross-sectional study was conducted at the pediatric wards of a tertiary hospital in Wenzhou, Zhejiang Province, China. Participants (n=134) were mothers of infant with obesity aged 6-12 months. Data were collected by structured questionnaires. Maternal feeding characteristics and the relationship between mothers' age, monthly personal income, parental self-efficacy, social support, benefits of maternal feeding behaviors, barriers to maternal feeding behaviors and feeding behaviors were examined. The Data was analyzed by descriptive statistics and multiple regression analysis. Results: Most of the infants (84.3%) was in the 98th-100th percentile. Nearly half of the mothers were 30-39 years old and unemployed (46.3%). One-third (61.40%) were multiparous mothers and 73.1% cared for their infants for more than 6 hours per day. Monthly personal income, parenting self-efficacy and social support together explained 28% of variance on feeding behaviors (P<0.05). Parenting self-efficacy (β=0.309, P<0.05) and social support (β=0.224, P<0.05) had significantly positive influence on feeding behaviors. Maternal personal income (β=-0.196, P<0.05) had a significantly negative influence on feeding behaviors among mothers having infants with obesity. Conclusions: Nursing interventions should be focused on enhancing parenting self-efficacy and promoting social support for the feeding behaviors of mothers.
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Background Analyses of factors that determine quality of perinatal care consistently rely on clinical markers, while failing to assess experiential outcomes. Understanding how model of care and birth setting influence experiences of respect, autonomy, and decision making, is essential for comprehensive assessment of quality. Methods We examined responses (n = 1771) to an online cross-sectional national survey capturing experiences of perinatal care in the United States. We used validated patient-oriented measures and scales to assess four domains of experience: (1) decision-making, (2) respect, (3) mistreatment, and (4) time spent during visits. We categorized the provider type and birth setting into three groups: midwife at community birth, midwife at hospital-birth, and physician at hospital-birth. For each group, we used multivariate logistic regression, adjusted for demographic and clinical characteristics, to estimate the odds of experiential outcomes in all the four domains. Results Compared to those cared for by physicians in hospitals, individuals cared for by midwives in community settings had more than five times the odds of experiencing higher autonomy (aOR: 5.22, 95% CI: 3.65–7.45), higher respect (aOR: 5.39, 95% CI: 3.72–7.82) and lower odds of mistreatment (aOR: 0.16, 95% CI: 0.10–0.26). We found significant differences across birth settings: participants cared for by midwives in the community settings had significantly better experiential outcomes than those in the hospital settings: high- autonomy (aOR: 2.97, 95% CI: 2.66–4.27), respect (aOR: 4.15, 95% CI: 2.81–6.14), mistreatment (aOR: 0.20, 95% CI: 0.11–0.34), time spent (aOR: 8.06, 95% CI: 4.26–15.28). Conclusion Participants reported better experiential outcomes when cared for by midwives than by physicians. And for those receiving midwifery care, the quality of experiential outcomes was significantly higher in community settings than in hospital settings. Care settings matter and structures of hospital-based care may impair implementation of the person-centered midwifery care model.
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Objective: This study aimed to bibliometrically analyse the main features of the 100 top-cited articles on the midwifery index on the Web of Science. Methods: Academic articles on midwifery' research published from 1985 to 2020 were included. VOSviewer 1.6.15, SPSS 22.0 software and a homemade applet were used to identify, analyse and visualise the citation ranking, publication year, journal, country and organisation of origin, authorship, journal impact factor and keywords along with the total link strength of countries, organisations and keywords. Results: Among the 100 top-cited articles, the highest number of citations of the retrieved articles was 484. The median number of citations per year was 5.16 (interquartile range: 3.74-8.38). Almost two-thirds of the included articles (n = 61) centred on nursing and obstetrics/gynaecology. The top-cited articles were published in 38 different journals, the highest number of which was published by Midwifery (15%). Australia was the most productive country (24%). According to the total link strength, the sequence ran from the United States (28) to England (28) to Australia (19). The University of Technology Sydney and La Trobe University in Australia topped the list with four papers each. Hunter B was the most productive author (n = 4), and the average citations were positively related to the number of authors (r = 0.336, p < 0.05). Conclusion: This study identified the most influential articles on midwifery and documented the core journals and the most productive countries, organisations and authors along with future research hotspots for this field; the findings may be beneficial to researchers in their publication and scientific cooperation endeavours.
Purpose This guideline aims to summarize the current state of knowledge about vaginal birth at term. The guideline focuses on definitions of the physiological stages of labor as well as differentiating between various pathological developments and conditions. It also assesses the need for intervention and the options to avoid interventions. This first part presents recommendations and statements about patient information and counselling, general patient care, monitoring of patients, pain management and quality control measures for vaginal birth. Methods The German recommendations largely reproduce the recommendations of the National Institute for Health and Care Excellence (NICE) CG 190 guideline “Intrapartum care for healthy women and babies”. Other international guidelines were also consulted in specific cases when compiling this guideline. In addition, a systematic search and analysis of the literature was carried out using PICO questions, if this was considered necessary, and other systematic reviews and individual studies were taken into account. For easier comprehension, the assessment tools of the Scottish Intercollegiate Guidelines Network (SIGN) were used to evaluate the quality of the additionally consulted studies. Otherwise, the GRADE system was used for the NICE guideline and the evidence reports of the IQWiG were used to evaluate the quality of the evidence. Recommendations Recommendations and statements were formulated based on identified evidence and/or a structured consensus.
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Objective To reproduce the absence of postpartum hemorrhage (PPH) experienced by all mammals except humans, in humans, by implementation of the 1,2,3 minute expedient squatting protocol The protocol prevents postpartum hemorrhage ≥ 500 mL after vaginal birth. It only requires a digital watch to precisely time 2 minutes. Design, Setting, Sample and Methods Mean Blood Loss and PPH rate are reported for 2,149 consecutive planned, attended vaginal births using the 1,2,3 minute squatting third stage protocol. Main Outcome measures: Blood loss; PPH ≥ 1000 mL Results Expedient delivery of the placenta in squatting within 3 to 5 minutes postpartum resulted in an average blood loss of 100 mL in the first 2 hours after birth and no cases of PPH≥500 mL in the first 24 hours after birth. The lowest previously published PPH≥1000 mL rate at vaginal birth is 4%. The PPH≥1000 mL using Active Management is 5%. Conclusion Less bleeding occurs when women expediently push out the placenta within 3 minutes of the birth of the newborn, in squatting, taking advantage of the still open cervix, gravity, and the increased effectiveness of their diaphragm and abdominal muscles.
Objectives For healthy women entering labor after an uneventful pregnancy, advantages of birth in midwife-led models of care have been demonstrated. We aimed to study the level of awareness regarding care in alongside midwifery units (AMU), factors involved in the decision for birth in obstetrician-led units (OLU), and wishes for care and concerns about birth in women registering for birth in OLU who would have been eligible for care in AMU. Methods Healthy women with a term singleton cephalic fetus after an uneventful pregnancy course booking for birth in OLU were prospectively recruited. Data were collected by questionnaire. Results In total, 324 questionnaires were analyzed. One quarter (23.1%) of participants never had heard of care in AMU. Two thirds (64.2%) of women had made their choice regarding model of care before entering late pregnancy; only 16.4% indicated that health professionals had the biggest impact on their decision. One-to-one care and the availability of a pediatrician were most commonly quoted wishes (30.8 and 34.0%, respectively), and the occurrence of an adverse maternal or perinatal event the greatest concern (69.5%). Conclusions Although the majority of respondents had some knowledge about care in AMU, expressed wishes for birth matching core features of AMU and concerns matching those of OLU, a decision for birth in OLU was taken. This finding may be a result of lack of knowledge about details of care in AMU; additionally, wishes and concerns may be put aside in favor of other criteria.
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Objective: To assess procedures and outcomes in deliveries planned at home versus those planned in hospital among women choosing the place of delivery. Design: Follow up study of matched pairs. Setting: Antenatal clinics and reference hospitals in Zurich between 1989 and 1992. Subjects: 489 women opting for home delivery and 385 opting for hospital delivery; the women comprised all those attending members of the study team for antenatal care and those attending the reference hospital for antenatal care who could be matched with the women planning home confinement. Main outcome measures: Need for medication and incidence of interventions during delivery (caesarean section, forceps, vacuum extraction, episiotomy), duration of labour, occurrence of severe perineal lesions, maternal blood loss, and perinatal morbidity and death. Results: All women were followed up from their first antenatal visit till three months after delivery. Referrals during pregnancy (n = 37) and labour (70), changes of mind (15 home to hospital, eight hospital to home), and 17 miscarriages resulted in 369 births occurring at home and 486 in hospital. During delivery the home birth group needed significantly less medication and fewer interventions whereas no differences were found in durations of labour, occurrence of severe perineal lesions, and maternal blood loss. Perinatal death was recorded in one planned hospital delivery and one planned home delivery (overall perinatal mortality 2.3/1000). There was no difference between home and hospital delivered babies in birth weight, gestational age, or clinical condition. Apgar scores were slightly higher and umbilical cord pH lower in home births, but these differences may have been due to differences in clamping and the time of transportation. Conclusion: Healthy low risk women who wish to deliver at home have no increased risk either to themselves or to their babies. Key messages Interventions (induction, caesarean section, medication, forceps, or vacuum extraction) may be considerably less frequent in women who originally opt for home deliveryThere are no obvious disadvantages of home delivery for mother or child when the mother opts for home deliveryMore studies are needed to look into the small risks of death, serious bleeding, and complications of interventions, which could not be evaluated in this study owing to limited power
We conducted a survey of 1,064 out-of-hospital Kentucky births during 1981 to 1983 in order to classify each by planning status (planned or unplanned to occur out of hospital) and attendant. Among the 809 births for which we obtained information, 575 (71.1%) were planned. We examined birth outcome by low birth weight (LBW) and neonatal mortality (NM). Compared with planned births, unplanned births were associated with increased risk of LBW (odds ratio=6.6; 95% confidence limits [CL], 3.9 to 11.2, adjusted for maternal age). Furthermore, after adjusting for maternal age and parity, LBW births occurred at less than expected frequency among planned births (observed to expected [O:E] ratio=0.48; 95% CL, 0.29 to 0.73), but at greater than expected frequency among unplanned births (O:E ratio=2.9; 95% CL, 2.2 to 3.8). A similar, but nonsignificant, trend was seen for NM and NM was much greater in the unplanned group (72.7 per 1,000 live births) than in the planned group (3.5 per 1,000). (JAMA 1985;253:1578-1582)
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A meta-analysis of observational studies have suggested that planned home birth may be safe and with less interventions than planned hospital birth. The objective of this review was to assess the effects of planned home birth compared to hospital birth on the rates of interventions, complications and morbidity as determined in randomised trials. We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register. Date of last search: September 1999. Controlled trials comparing planned hospital birth to planned home birth in selected women, assisted by an experienced home birth practitioner, and backed up by a modern hospital system in case transfer should be necessary. Trial quality was assessed and data were extracted by one reviewer and checked by the other reviewer. Study authors were contacted for additional information. One study involving 11 women was included. The trial was of reasonable quality, but was too small to be able to draw conclusions. There is no strong evidence to favour either planned hospital birth or planned home birth for low risk pregnant women.
OBJECTIVE: To determine whether there was a difference between planned home births and planned hospital births in Washington State with regard to certain adverse infant outcomes (neonatal death, low Apgar score, need for ventilator support) and maternal outcomes (prolonged labor, postpartum bleeding). METHODS: We examined birth registry information from Washington State during 1989–1996 on uncomplicated singleton pregnancies of at least 34 weeks' gestation that either were delivered at home by a health professional (n = 5854) or were transferred to medical facilities after attempted delivery at home (n = 279). These intended home births were compared with births of singletons planned to be born in hospitals (n = 10,593) during the same years. RESULTS: Infants of planned home deliveries were at increased risk of neonatal death (adjusted relative risk [RR] 1.99, 95% confidence interval [CI] 1.06, 3.73), and Apgar score no higher than 3 at 5 minutes (RR 2.31, 95% CI 1.29, 4.16). These same relationships remained when the analysis was restricted to pregnancies of at least 37 weeks' gestation. Among nulliparous women only, these deliveries also were associated with an increased risk of prolonged labor (RR 1.73, 95% CI 1.28, 2.34) and postpartum bleeding (RR 2.76, 95% CI 1.74, 4.36). CONCLUSION: This study suggests that planned home births in Washington State during 1989–1996 had greater infant and maternal risks than did hospital births.
Objective - To collect data from a cohort of women requesting a home birth and examine the experience and outcome of pregnancy, the indications for hospital transfer, and the attitudes of mothers, midwives, and general practitioners. Design - Follow up study with anonymised postal questionnaires. Setting - Northern Regional Health Authority area. Subjects - The 256 women resident in the Northern region who expected to deliver in 1993 and whose request for a home birth became known to one of the local supervisors of midwives. Limited cross validating information was also collected retrospectively on all other women delivering a baby outside hospital in 1993. Main outcome measures - Rate of and reason for transferred care; maternal, midwifery, and general practitioner views; perinatal outcome. Results - Five women miscarried, leaving 251 in the study, Of these, 142 (57%) delivered at home. There were 17 (7%) caesarean sections but no perinatal deaths. General practitioners had reservations about half of the booking requests. Two thirds of the women thought they had not been offered any option about place of birth, 74 (29%) were referred to hospital for delivery before the onset of labour, and 35 (14%) were referred to hospital during labour. Intrapartum transfers were uneventful, and half the mothers commented spontaneously that they valued having spent even part of their labour at home. Conclusions - Home birth is valued for its family setting. General practitioners' support is sought and influential but uncommon, possibly because of a lack of understanding of the responsibilities of the midwife and general practitioner.
A retrospective descriptive study of 1001 midwife-attended home births in Toronto, Ontario, was carried out between January 1983 and July 1988. Interviews with 26 midwives and reviews of client records provided data on maternal age, socio-economic status, gestation, ruptured membranes, length of labor, episiotomies and perineal lacerations, transfer to hospital of mother or baby or both, infant resuscitation, and breastfeeding. Of 1001 planned home births, 361 involved primiparous women, of whom 245 (68%) remained at home and 116 (32%) required transfer of mother or baby to hospital during labor or the first four postpartum days. Of the 640 multiparous births, 591 (92%) women remained at home and 49 (8%) required transfer to hospital. Among women transferred, 91 had spontaneous vaginal births, 34 had forceps deliveries, and 35 had cesarean sections. Variables significantly associated with maternal transfer for both primiparas and multiparas were length of latent and active phases of the first stage of labor, length of the second stage of labor, and duration of ruptured membranes. Five neonates were transferred and two died, one each after birth at home and in hospital. There were no maternal deaths. The proportion of mothers breastfeeding without supplement at 28 days postpartum was 98.6 percent.