Home birth

Safe in selected women, and with adequate infrastructure and support

Birth is an event of great importance in family life. Although pregnancy and delivery are, under healthy conditions, normal social and physiological processes, childbirth has become hospital centred in most industrialised countries. The assumption is that hospital based deliveries are safer for mother and child. Yet the Cumberlege report sees home birth as a real option,1 and the wishes of women to have home births must be viewed in that light. A randomised controlled trial would help to resolve the controversy over the relative safety of home and hospital birth,2 but conditions for a “fair” trial are difficult to achieve. Such a study would require large numbers because of the low frequency of adverse events, and the necessary environment of experienced home deliveries has virtually disappeared. In the absence of a randomised trial, observational studies are welcome, and this week's BMJ carries four papers reporting on the safety, professional support, and patient satisfaction of home births.3 4 5 6

The first of these, from the Northern region's perinatal mortality survey, reports 134 perinatal losses in 3466 births outside the hospital,3 about four times the number of losses in hospital births. At first sight this seems to endorse the view that hospital is the safest place to deliver. But 97% (131) of these perinatal deaths at home were recorded in women who were actually booked for a hospital delivery or had no prearranged plan for delivery. The perinatal outcome in planned home births was better than for all women giving birth in the region—a result in line with Swiss and Dutch findings also reported in this week's BMJ.4 5 This supports the safety of home birth provided it is offered to women at low risk of obstetric complications. Most perinatal deaths occur in women with health or obstetric problems that existed before or developed during pregnancy, and these women can be identified and referred before the onset of labour.

Assessing a woman's risk and providing appropriate care is bread and butter to general practitioners. The key to the consistently good results of home births in Dutch primary care settings5 7 is meticulous selection of women at low risk of obstetric complications. This results in equal or better obstetric outcome compared with hospital birth, and fewer interventions, for a large number of women in the community.7 Risk assessment is based on a protocol for referral8 (the Kloostermanlist, named after its designer), which is used routinely in the community7 and serves as the national reference of good practice.

Promotion of home birth is not restricted to Europe: there have also been initiatives in the United States and Australia.9 10 In our view such initiatives should be integrated in comprehensive primary care, as the roles of general practitioner and midwife are not limited to the place of birth—they cover the whole of pregnancy, delivery, and neonatal care.7 However, some primary care practitioners may need to be persuaded to provide the option to their patients: the survey from Britain's Northern region found that general practitioners, and to a lesser extent midwives, often had reservations about the safety of home birth and tended to discourage it.

General practitioners and midwives have responsibility for creating the right circumstances for safe and satisfying home births. This means, firstly, selecting women who are not at high risk of complications; secondly, establishing an infrastructure for safe obstetric interventions—such as providing elevated beds and ensuring adequate hygiene; thirdly, providing support during labour and in the days after delivery, for which maternity home care assistants are important; and, finally, allowing access to hospital facilities—this is vital, as serious complications during labour can never be excluded. Transfer during labour can be safe,6 7 but safety must not be assumed, and the availability of obstetric care must be established beforehand. Coordinated planning between primary care practitioners and obstetricians is crucial, and much will depend on local conditions: hospital facilities are usually available within 15 minutes in densely populated Holland, but transfer will take much longer in remote areas of North America and Australia. Such variation underlines the importance of comprehensive care for pregnant women. This should focus on patients' individual needs, based on a proper assessment of risk and local circumstances, rather than simply accommodating patients' demands.