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Research Summaries - Page Five

Scroll down to read the studies, or use the index to jump to each individually.

1. Simulated home delivery in hospital: a randomised controlled trial

MacVicar J, Dobbie G, Owen-Johnstone L, Jagger C, Hopkins M, Kennedy J (Department of Obstetrics & Gynaecology, Leicester Royal Infirmary, UK. )
Br J Obstet Gynaecol 1993 Apr;100(4):316-23

Two groups of women who delivered in hospital were compared in a randomised, controlled trial. The simulated home delivery group received midwife-led ante-natal care and delivery, and they laboured in a hospital room made to look like a home room. The control group received consultant-led care, and mothers laboured in delivery rooms containing resuscitation equipment, monitors, and a delivery bed.

The objective was presumably to see if some of the benefits of home birth could be reaped in hospital. The study found no significant differences between the two groups in maternal morbidity (ill mothers), or fetal morbidity of mortality (ill or sick babies). The only difference which the researchers found significant was that more mothers in the simulated home birth group were satisfied with the care they received.

Two points which strike me about this study:

Read abstract on Medline

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2. The Cost-Effectiveness of Home Birth

Anderson RE; Anderson DA (Dept. of Economics, Centre College, Danville, KY 40422, USA. )
J Nurse Midwifery, 44(1):30-5 1999 Jan-Feb

The authors compare costs of hospital, home and birth centre deliveries in the USA, noting that 40% of births there are covered by Medicaid. They state that 'informed birthing decisions cannot be made without information on costs, success rates, and any necessary trade-offs between the two...The average uncomplicated vaginal birth costs 68% less in a home than in a hospital, and births initiated in the home offer a lower combined rate of intrapartum and neonatal mortality and a lower incidence of cesarean delivery. '

Abstract on Medline

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3. Physician- and midwife-attended home births. Effects of breech, twin, and post-dates outcome data on mortality rates.

Mehl-Madrona L, Madrona MM (Native American Research and Training Center, University of Arizona College of Medicine, Tucson 85719, USA. )
J Nurse Midwifery 1997 Mar-Apr;42(2):91-8

Home births attended by apprentice-trained midwives (4,361 between 1970 and 1985) were compared to those attended by family doctors (4,107 between 1969 and 1981). The researchers matched 1,000 women from each group for age, sex, socioeconomic status, race, and medical risk. 'The perinatal mortality rate for the midwife-attended births was 14 per 1,000 (three fetal deaths before labor, six intrapartum fetal deaths, and five neonatal deaths). The perinatal mortality rate for births attended by family physicians was five per 1,000 (one fetal death before labor, two intrapartum fetal deaths, and two neonatal deaths)'.

However, when the outcomes for high-risk births were separated from low-risk, the picture changed. When breech, twin and post-dates deliveries were taken out, the mortality rate for midwives was not significantly different from that for doctors.

The authors conclude that 'Although the data are more than a decade old, they support the premise that outcomes for low-risk home births are comparably good whether attended by physicians or midwives. However, the findings do raise questions about the safety of attending high-risk births at home. '

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4. Home Delivery and Scientific Reasoning

Olsen O
Afdeling for Social Medicin, Kobenhavns Universitet.
Tidsskr Nor Laegeforen 1994 Dec 10;114(30):3655-7
[Article in Norwegian]

All the evidence relevant to Nordic women suggests that it is at least as safe for healthy women to give birth at home as in hospital, and perhaps safer. Clinical trials show that there are factors about home birth which make births easier. Despite this, many doctors still assume that hospital is the safest place for all women to give birth. The author considers how obstetricians can be encouraged to base their judgements on empirical evidence rather than 'pre-scientific dogmas'.

Abstract (in English) on Medline

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5. Perineal outcomes in a home birth setting

Aikins Murphy P, Feinland JB (Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, USA.)
Birth 1998 Dec;25(4):226-34

The researchers looked at data on damage to the perineum for 1068 women who delivered at home with a nurse-midwife in attendance. Most of the women - 69.6% - had an 'intact perineum', defined as no tears, minor abrasions (grazes) and small tears that were not stitched. Only 1.4% - 15 women - had an episiotomy, whilst 28.9% had first- or second-degree tears. Only 0.7% had third- or fourth-degree tears. Note that an episiotomy is equivalent to a second-degree tear, in that it involves a cut through underlying tissue as well as skin.

Women having their first babies were more likely to have an intact perineum if they delivered on hands and knees or kneeling, if the perineum was supported in delivery, or if they were 'low socioeconomic status'. They were more likely to tear if they had perineal massage during delivery.

For women having second or later babies, again they were less likely to tear if they were low socioeconomic status, and the more children they had had before, the less likely they were to have perineal damage. These women were more likely to tear if they had previously had an episiotomy (ie with another baby), were over forty years old, had gained more than forty pounds in weight, had a long second stage, or if they used oils and lubricants during delivery.

The authors conclude that 'The results of this study suggest that it is possible for midwives to achieve a high rate of intact perineums and a low rate of episiotomy in a select setting and with a select population.'

Comment from AH: This study is interesting, but problems with the data sample mean that we can only draw limited conclusions from it. The rate of episiotomies would be higher in more complicated births which would have been planned and delivered in hospital, and in those transferred from home to hospital. For example, forceps or ventouse deliveries in hospital would usually involve episiotomies.

However, even if we were just to consider low-risk planned hospital births, and exclude those which would have been transferred if they were at home, it is doubtful whether there are many hospitals where 69.9% of these women would have intact perineums after vaginal births. The study does suggest that some factors of hospital delivery make perineal damage more likely, and that episiotomies are often unnecessary interventions. The notes on socioeconomic status suggest that money can't buy you an intact tail end!

Abstract on Medline

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Blues and depression during early puerperium: home versus hospital deliveries.

Br J Obstet Gynaecol 1995 Sep;102(9):701-6
Pop VJ, Wijnen HA, van Montfort M, Essed GG, de Geus CA, van Son MM, Komproe IH
Department of Behavioural and Social Science, University of Tilburg, The Netherlands.

The aim of this study was to find out whether women who gave birth at home were less prone to the 'baby blues' and to postnatal depression than women who gave birth in hospital. The researchers looked at outcomes for 293 women registered for antenatal care at a clinic in the Netherlands. They considered not only the place of birth, but also the way in which women gave birth - for example, spontaneous vaginal birth, induced birth, assisted birth or caesarean section.

They found that neither place of birth, nor the way in which the woman gave birth, seemed to make a difference:

"In general, there was no difference in the incidence of blues and depression between women who gave birth at home and those who gave birth in hospital. Obstetric factors were not related to the occurrence of blues or depression in the early puerperium."

Read the abstract on Medline

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Home birth and hospital deliveries: a comparison of the perceived painfulness of parturition.

Res Nurs Health 1988 Jun;11(3):175-81
Morse JM, Park C
Faculty of Nursing, University of Alberta, Edmonton, Canada.

The researchers compared 282 couples who had planned home births with 191 who had planned hospital births. They asked both parents to rate the pain of childbirth, compared with other painful events. They found that:

"The hospital birth group rated childbirth pain significantly higher than the homebirth group"

They also compared how painful the fathers had thought the labour and birth was, with how painful the mothers thought it was. In the homebirth group, the fathers thought it was more painful than the mothers actually rated it. However, in the hospital group, the fathers thought it was less painful than the mothers found it to be.

Read the abstract on Medline

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Babies born before arrival at hospital.

Br J Obstet Gynaecol 1991 Jan;98(1):57-64
Bhoopalam PS, Watkinson M
Neonatal Unit, Marston Green Hospital, Birmingham.

This study did not look at planned home birth at all, but at the mortality rate of babies born before arrival at hospital in Birmingham, UK, and the reasons for deaths and illness (morbidity).

Statistics on the safety of home birth are sometimes confused when data on all 'out of hospital' births are combined. This includes unplanned births out of hospital, sometimes termed 'BBA' - born before arrival at hospital. The high mortality associated with these births makes the average outcomes for all out-of-hospital births look unsafe, which is why is is important to compare planned home birth with planned hospital birth.

The perinatal mortality rate was nearly six times higher for unplanned out-of-hospital births than for births in hospital. Most of the deaths were not caused simply by the baby being born out of hospital, however, but were related to prematurity and low birthweight. Why were these babies were born before their mothers got to hospital? It seems likely that fast labours of tiny premature babies were to blame, or perhaps some mothers did not realise that they were in labour because the baby was not due yet. The mothers were mainly either unmarried teenagers who were 'unbooked', which means that they had not received any antenatal care, and may have been concealing their pregnancies, or Asian mothers who had given birth before, and who lived a long way from the hospital.

CONCLUSIONS--The high perinatal mortality was related to immaturity and low birthweight, rather than to birth before arrival itself. Although groups of mothers at risk of delivery before arrival can be identified more information is needed to establish whether additional antenatal care would be beneficial for these women and their babies.

Read the abstract on Medline

If you have any suggestions for additions to this page, please contact angela@horns.freeserve.co.uk

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