Home Birth

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Home Birth

• Wendy Slater

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HOT because of Patricia Hewitt New NICE
Guideline Because of the condition of 2 GPRs
)
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Patricia Hewitt said.

• Women will have a choice of where to give birth
  and whether they want a midwife or a consultant
  present.
• More women would give birth at home if there was
  the choice
• Every birth will be supervised by a
  professionally qualified midwife
• No new money
• 1,000 midwives will qualify in the next few years

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Patricia Hewitt said..

• This will mean that care is designed around the
  needs of women and their partners
• We are signaling that maternity services will
  need to be a priority in the NHS in future years

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Patricia Hewitt said

• (When asked why the government was promoting home
  births despite its increased risks)
• I think the important thing here is to give women
  choice and give the women information so they can
  make informed choice

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Department of Health said..

• We are committed to offering all women the choice
  of how and where they give birth
• Flawed research from 1970s saying home births not
  safe had informed government policy for decades
• There was a well of evidence to suggest that
  home births were at least as safe a s hospital

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National Childbirth Trust say.

• Welcomed the move saying currently women were
  discouraged by doctors from having a home birth

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Prof Templeton RCOG said

• He welcomed choice but warned safety must come
  first
• If we are to provide mothers with more choice,
  then this can only happen when our places of
  birth are fully staffed

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RCOG said.

• We are obviously concerned that there will need
  to be enough midwives to make it happen.

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Was this a midwife and an obstetrician agreeing?
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History

• 100 yrs ago-ladies who helped deliver and laid
  out the dead
• 1945-since then majority of births at home
• 1960s and 70s inc in hospital births to 90
• 1970-Peel Report (based on Confidential Enquiry
  into Maternal Deaths)
• facilities should be provided for all women to
  give birth in hospital inc to 95

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History

• 1993 Changing Childbirth-women should have more
  choice in their place of birth
• 2004 NSF for Children, Young People Maternity
  Services-promoted midwife led care and home birth
  
• (Neither of the above were supported by strong
  evidence regarding safety of place of birth)

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History

• 2006- 90 births in consultant wards or combined
  GP/consultant wards
• (from Maternity Hospital Episode Statistics)

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Planned Home Birth vs Hospital -Evidence

• One RCT but n11 and no relevant outcome
• Planned Home birth reviewed in NICE Guideline
  Caesarian section- on the basis of Two systematic
  reviews, giving birth at home reduces the
  chance of caesarian section

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Planned Home Birth vs Hospital Birth-Evidence
NICE 2007

• 2 Reveiws-1st Cochrane excluded as had 1 RCT with
  n11, reported nil relevant too small
• 2nd-6 observational studies excluded due to poor
  methodology
• 1994 UK based study. Large (n8010) planned home
  vs planned hosp births. Some effort to match the
  women but 1000 unmatched home births included.
  The two groups had different demographic and
  obstetric risks.

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Evidence

• Canada 1998-1999(n862) HB less epidural,
  induction,CS and infection for no inc in 3rd or
  4ht deg tears or PPH
• Switzerland 1989-1992 (n489) HB less
  inductions,CS,analgaesic, augmentation,instrumenta
  tion, episiotomies, perineal tears

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Evidence

• Australia 1981-1987(n2928) HB-more likely to
  have a long (gt18hs) labour, more PPH and retained
  placenta but less instrumentation, CS, foetal
  distress

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What about the babies?

• UK cross sectional population based study 1983
  NRPMSCS
• IPPM1.86 per1000 births Home booked vs 1.23IPPM
  per 1000 hosp booked
• RR-1.51
• Canada-no diff in APGARs, O2 use or neonatal
  interhospital transfer

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What about the babies?

• Australia 1985-90 excluding extreme prematurity
  and congenital malformation- Intrapartum
  perinatal mortality rate was higher for babies
  born at home. 2.7 per 1000 live births cf 0.9 per
  1000 live births. Due to asphyxia in half. But
  included post term, breech and twins.

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What about the babies?

• Australia 1989-87 HB reduced number of infants
  with APGARs lt8

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What about the babies?

• NCC-WCH
• All births England and Wales 1994-2003 from
  Confidential Enquiry into Maternal and Child
  Health
• IPPM rate higher for booked home births (1.37 per
  1000 births) cf overall IPPM (0.68) RR 2.01
  (range 1.01-2.74)
• Worst IPPM was for women who transferred their
  care to hospital during pregnancy or labour
  6.59per 1000 (range 1.10-12.19)

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What about the babies?

• But if you book and complete Home birth your IPPM
  rate is low 0.5 per 1000 (range 0.41-0.62)

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NICE Summary 2007

• Lack of good quality evidence of womens and
  babies outcomes for birth at home
• Limited low quality evidence shows less
  intervention at home
• Transfer from Home to Hospital may be bad for
  babies
• Bastian (Australia) showed an excess of
  intrapartum perinatal mortality in home births cf
  hospital but it may have been partly due to high
  risk births at home

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NICE Summary 2007

• IPPM rates for completed home births was lower
  than the overall rate but it was not possible to
  control for any confounders.
• IPPH rates for booked home births were greater
  than for all births but this was driven up by a
  group who were transferred from home to hospital
  care some time after booking. It was not possible
  to distinguish antenatal transfer from transfer
  during labour

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NICE 2007

• The GDC was unable to reassure itself that
  planning birth in an non-obstetric setting is as
  safe as birth in an obstetric unit.

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Home Birth

• More SVD, intact perineum, less CS
• IPPM is the same as or higher than births booked
  for obstetric units
• If IPPM is higher it may be because of women
  transferred for complications
• If complications happen the outcome will be
  likely to be worse if they happen at home
• If the planned birth takes place at home the
  outcome is likely to be the same as if it took
  place in hospital

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Criteria for Midwifery Care During Birth

• Normal Pregnancy without complications
• Up to and including para5 with no prev
  complications
• Labouring at term 37-42 wks
• Singleton pregnancy with a cephalic presentation
• Does not want an epidural

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BUT

• Remember you cant tell if its cephalic or not!
• BMJ 2006

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Issues I can think of..

• May not be safe
• Shortage of midwives
• Will need lots more midwives
• These midwives surely see less births and
  de-skill
• NHS is a limited resource. Current system for
  maternity care has good outcomes why direct more
  money to it
• Should government headline making policy dictate
  health care provision or should it be the learned
  Professionals who decide?

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Issues you think of