Transcript Slide 1

HOME BIRTH
Ken Burke, Swindon/Bath GP Registrar DRC 8 Nov 2006
Brief history
• Hospital births became more popular at
the turn of the last century (middle class
women turned to doctors for maternity
care; more resources for poorer mothers).
• Doctors felt that the falling rates of
maternal mortality due to this shift.
• In 1980’s <1% UK births were at home
Current data from “Birth Choices” website:
Home Birth Rates For The Southwestern Region
Local Authority
All Birth (2004)
2004
2003
UK
710023
2.14%
2.06%
England
601395
2.25%
2.18%
Bristol
5218
2.9%
3.6%
Devon
10629
5.4%
5.8%
Gloucestershire
8818
2.6%
2.2%
Home birth rates (as %)
Somerset
Bath and North East Somerset
8652 (all
births
2004)
4.2%
(2004)
3.7%
(2003)
1601
6.2%
6.1%
Home birth rates (as %)
Wiltshire
7159
(all births 2004)
2.3%
(2004)
2.2%
(2003)
Salisbury
1209
5.0%
5.0%
Swindon
2347
1.3%
0.6%
Why do women choose home birth?
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Labour tends to progress well at home
Mother more relaxed, “in control”
Greater privacy
One-to-one care with a midwife who she
knows
• Less “interventions”
• Less failure to progress, foetal distress
• Less infection risk
Safety of home births
• BMJ editorial 1996: home birth was “safe
for normal, low risk women, with adequate
infrastructure and support”
• Large prospective study in North America
pub in BMJ in 2005 concluded that such
births were associated with “similar
intrapartum and neonatal mortality to that
of low risk hospital births”
Outcomes of planned home births with certified
professional midwives BMJ 2005;330:1316
• Of the population of 5418, 12.1% needed
transfer to hospital (main reasons were
failure to progress, pain relief, exhaustion
and malpresentation)
Intervention rates for home births
Intervention
% intended home
births
% >=37/40 USA
births in 2000
Induction of labour
9.6%
21%
Episiotomy
2.1%
33.0%
Forceps
1.0%
2.2%
Vacuum
0.6%
5.2%
Caesar
3.7%
19.0%
Outcomes
• Intrapartum and neonatal mortality 1.7 per
1000 (=14 deaths in total) - consistent
with rates for low risk births in American
hospitals
• Of 80 planned breeches at home, 2
intrapartum deaths
Perinatal death associated with planned home birth in
Australia: population based study (BMJ 1998)
• Included both high and low risk pregnancies
• Perinatal death rate of 7.1 per 1000
• 52% deaths associated with intrapartum
asphyxia
• Main contributors to the excess mortality were
underestimation of the risks associated with
post-term birth, twin pregnancy and breech
presentation, and a lack of response to foetal
distress
• Most midwives relatively inexperienced
• Transfer distances can be much greater
How many women want to have a home birth?
• 16% women would consider a home birth
(MORI poll)
• Interest is higher in areas where home
birth is seen as a realistic option and
where women know others who have
given birth at home
A woman’s right to a home birth
• The NSF for Children, Young People and
Maternity Services (2004) states that
women should be able “to choose the
most appropriate place to give birth from a
range of local options including home birth
and delivery in midwife-led units”.
• The NCT supports the Government’s aim.
However….
• Midwifery staffing constraints continue to
restrict access to home birth as an option
for women.
• A health authority cannot be forced by law
to provide a home birth service; however,
it is legally obliged to provide emergency
care at home.
Many women are not aware that home
birth is an option
• Joint statement between RCGP and RCM
(in 1995): “Women wishing to arrange a
home birth should be able to do so. GPs
who do not wish to provide care for home
births should refer women to a local
midwife or the local supervisor of midwives
(or to a GP who does provide full maternity
care).”
There is less need for pain relief
• TENS, birth pools and massage are
popular
• Woman can choose any position she
wants
• Entonox and pethidine are also used.
Transfer to hospital
• About 3 in 10 for primips; 1 in 12 for
multips
• Usually for slow progress or long labour
• Transfers rarely “blue light”
• 1 in 30 chance of transfer after birth
Cost
• Home births cost less – less use of
hospital facilities, less medical
interventions
Quote from BMJ editorial (1996)
• “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 settings is meticulous
selection of women at low risk of obstetric
complications. This results in equal or
better obstetric outcome compared with
hospital birth”
NICE guidance on antenatal care –
women needing additional care
• In conditions such as hypertension, cardiac or
renal disease, endocrine, psychiatric, or
haematological disorders, epilepsy, diabetes,
autoimmune diseases, cancer, HIV
• Age >40 or <18
• BMI >36 or <18
• Previous Caesar
• Severe pre-eclampsia
• Previous pre-eclampsia
Continued…
• >2 miscarriages
• Previous preterm birth or mid-trimester
loss
• Previous psychiatric illness
• Previous neonatal death or stillbirth
• Previous baby with congenital abnormality
• Previous SGA or large for gestational age
baby
• Family history of genetic disorder
Conclusion
• Home birth is a safe option for low risk
pregnancies
• However, diversion of resources to
hospital care and poor promotion of home
birth in most areas is likely to mean most
women will continue to ask for hospital
births in the near future