Low risk home births are safe

How risky are home births? Dr. Brian Goldman says the risk is manageable if the rules are followed.

Of the close to 400,000 births in Canada each year, fewer than two per cent take place at home.  That might change as a growing number of midwives set up shop.  A new study just published in the Canadian Medical Association Journal (I'll post a link as soon as it becomes available) looks at the safety of home births - and puts a very positive spin on a traditional practice.

For women with low-risk pregnancies, a home birth is no more risky than one that takes place in hospital.  That's the main conclusion of an Ontario study that compared eleven thousand five hundred planned home births with an equal number of planned hospital births.  Researchers from McMaster University compared the outcomes.  Compared to the babies born in hospital, those born at home were not more likely to be stillborn or to die shortly after birth. Those born at home were not any more likely to have serious illness in the newborn period, and were not more likely to need cardiopulmonary resuscitation or CPR, or to have to be put in a ventilator.  

The key to safety is that the birth is judged to be low-risk. A low-risk pregnancy is one in which there are no anticipated complications that require that a midwife transfer care to an obstetrician or family doctor. That excludes women with medical conditions such as type 1 diabetes, chronic high blood pressure, anemia not responsive to treatment, gestational diabetes, eclampsia, too much or too little amniotic fluid, vaginal bleeding prior to birth, abruption or torn placenta, breech birth, more than one prior Caesarean section. The list is long, and includes other conditions.  The researchers made sure the home births met the criteria for low risk, and were planned home births rather than ones that took place as the result of an unplanned emergency. To make sure the comparisons between home and hospital births were fair, the researchers excluded the hospital births of women with high-risk pregnancies.

The reaction among physicians is decidedly mixed. Dr. Michael Klein, one of Canada's foremost experts on low risk births, co-authored a 2009 study that concluded planned home births under regulated midwives are safe.  Around the same time, the BC Medical Association stated that births should take place in hospitals or birthing units linked to hospitals for safety's sake.  A 2013 paper in the American Journal of Obstetrics and Gynecology showed a higher rate of stilllbirths and newborn seizures in babies born at home. But the study did not distinguish between planned and unplanned home births.

I could not find a position statement by Canada's obstetricians. However, a 2011 position statement by the American College of Obstetricians and Gynecologists (re-affimed in 2015) states that although it believes hospitals and birthing centers are the safest for birth, it respects the right of a woman to make a medically informed decision based on the availability of a certified midwife, nurse-midwife or MD as well as assurance of safe and timely transport to hospital if necessary.  

The authors of the study in CMAJ say compared to hospital births, home births had some significant advantages.  Those women who gave birth at home had fewer obstetrical interventions. They were less likely to have their membranes ruptured artificially.  They were less likely to be given medications like oxytocin to speed up labour.  They were less likely to have forceps assisting the birth.  They were less likely to need a Caesarean section.  They were also less likely to have an episiotomy, and less likely to tear themselves requiring stitches.  They were also less likely to have severe bleeding following the birth.  The babies were more likely to be breastfeeding three and 10 days following birth. The 2009 paper co-authored by Dr. Michael Klein reached similar conclusions.

The study is important because Canada is on the cusp of a major shift in who attends the birth.  Right now, obstetricians attend most of them - virtually none of which take place at home.  With an average age of close to 60, the imminent retirement of many OBGYNs means a gap is opening up.  Just 11 per cent of Canada's family doctors attend births.  In Ontario, midwives attend just 10 per cent of births - 20 per cent of which take place at home.  But the trend is up, and as the number of midwives increases, so will the number of home births.  

As has been stated eloquently by others, increasing the number orf home births means changing the belief held by many that the hospital is always safer.  Changing the culture won't be easy. Making sure only low- risk pregnancies lead to home births is a good place to start.  


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