Studies mentioning transfers

Here are details from some studies which looked, at least in part, at transfers from home births.

Transfer from home to hospital: what is its effect on the experience of childbirth?

Wiegers TA; van der Zee J; Keirse MJ
Netherlands Institute of Primary Health Care (NIVEL).
Birth, 25(1):19-24 1998 Mar

Many low-risk women in the Netherlands give birth at home, attended by a midwife. This study asked 2301 women planning home births for their opinions on their experience of childbirth, satisfaction with birth, midwife care, and the first days after the birth.

Amongst women having their first babies, 39.3% transferred to hospital; amongst women having subsequent children, 10.3% transferred. Tthese rates are similar to those in the National Birthday Trust study and others.

The women who transferred "were as positive about the birth, early puerperium, and attendance of the midwife as the women who wanted to give birth in hospital...."

The authors concluded: "Our research showed, contrary to expectations, that an unplanned transfer from a planned home birth to hospital has little influence on the experience of childbirth."

Read this abstract on Medline

Note from Angela: This conclusion is surprising as many women say that they are disappointed after transferring. I wonder if the mothers' satisfaction, despite transferring, is a result of the midwifery system in the Netherlands? For more details, see Beatrijs Smulder's article about midwifery and home birth in the Netherlands.

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Place of delivery in The Netherlands: actual location of confinement.

Kleiverda G, Steen AM, Andersen I, Treffers PE, Everaerd W
Eur J Obstet Gynecol Reprod Biol 1991 Apr 16;39(2):139-46
Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, The Netherlands.

Preferred and actual locations of confinement were compared in a group of 170 nulliparous women. Voluntary changes in preferred location for birth were rare and concerned only changes from hospital to home confinement.

Obligatory changes due to referral to consultant obstetricians occurred frequently: 58.8% of the total sample. Fewer referrals were found for women with an initial preference for a home confinement (53%) than for those who preferred a hospital confinement (64%). Most referrals occurred in the group of older women initially in doubt about their preferred location for giving birth: 72%.

The explained variance for the group of referrals in which psychosocial influences were presupposed was not better, with the exception of referrals due to insufficient progress during labour: 76.4% of the variance could be explained at the 34th gestational week. When birth weight and amenorrhoea were included, these percentages increased to 79.0 and 84.8%, respectively.

This last paragraph suggests that it could be fairly easy to predict which mothers are likely to transfer to hospital because of slow progress in labour. It is a shame that the abstract doesn't mention which psychosocial factors it was that enabled them to make the prediction!

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Four years' experience with home birth by licensed midwives in Arizona.

Am J Public Health 1983 Jun;73(6):641-5
Sullivan DA, Beeman R

Arizona state in the USA began licensing lay midwives in 1978. During four years of this program, 3% of home birth clients were transferred to hospital for complications and another 15% received postnatal outpatient care, primarily for second degree perineal tears or cuts.

Five per cent of the babies required medical care after delivery; half of these were hospitalized. Complications declined over the period due to increased experience, close supervision, and continuing education.

Read this abstract on Medline

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Studies discussed elsewhere on this site:

Further discussions of the studies below can be found via the index of research papers; on this page, only the findings relevant to transfers are discussed. These may not be covered in earlier mentions of the studies.

National Birthday Trust Report on Home Births 1994

The NBTF study of nearly all planned home births in the UK in 1994 found that 16% of all mothers who had booked home births transferred to hospital - 4% before labour started and 12% in labour.

The study recorded reasons for transfer:

When transfer occurred Reason Number % of total transfers
Transfers occurring before labour commenced: Premature rupture of membranes 222 24.8%
  Intra-uterine growth retardation 19 2.1%
  Intra-uterine death 2 0.2%
Transfer before or during labour: High blood pressure 69 7.7%
Transfer during or after labour: No progress 333 37.2%
  Foetal distress 131 14.6%
  Cord prolapse 1 0.2%
  Haemorrhage 65 7.3%

Slow Labours

These findings from the study also show how many mothers who transfer have slow progress, particularly first-time mums:

What happened after transfer?

Most of the women who transferred to hospital received some form of treatment, apart from extra pain relief. Because some women had more than one treatment, the percentages below add up to more than 100%.

Induction of labour 206 23.1%
Drip to accelerate labour 292 32.7%
Assisted delivery: forceps or ventouse 121 13.6%
Caesarean Section 100 11.2%
Blood transfusion 22 2.5%
Removal of placenta 104 11.7%
Repair of tear 260 29.1%
No treatment given 165 18.5%

How did the mothers feel about transferring?

Women who transferred to hospital were interviewed soon after the birth about their experiences. 59% found the transfer upsetting, while 41% did not. 89% of mothers agreed with the reasons for transfer, but 4% thought that the transfer was not necessary and was due largely to the midwife or doctor's anxiety.

89% of the mothers who transferred said they would still book a home birth for their next baby. Of the 11% who said they would book a hospital birth next time, we are told that half transferred because of prolonged labour. Since many of the transferred women had intervention at hospital, they might well have felt would make a home birth unwise for them in future, in case similar help was needed again. For example, 11.2% of the transferred mothers had caesarean sections, and while it is possible to have a home birth after a previous caesarean, many mothers would not want to try.

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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.

Parturition occurred where it had been planned in 77% of women; referral occurred later on in pregnancy in 11% and during labour in 12%. Nullipara had to be referred significantly more often than multipara.

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Outcome of planned home births in an inner city practice.

Ford C, Iliffe S, Franklin O
BMJ 1991 Dec 14;303(6816):1517-9

Department of Primary Health Care, Whittington Hospital, London.

Of 277 women planning home birth, six had miscarriages, 26 (9.4%) were transferred to specialist care during pregnancy, another 26 (9.4%) were transferred during labour, and four were transferred after birth. 215 women (77.6%) had normal births at home without needing specialist help.

Transfer to specialist care during pregnancy was not significantly different for first-time mothers or other mothers, but first-time mothers were significantly more likely to require transfer during labour. Postnatal complications requiring specialist attention were uncommon among mothers delivered at home (four cases) and rare among their babies (three cases). First-time mothers are more likely to require transfer to hospital during labour because of delay in labour.

Read the abstract on Medline

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Home Births in South-West Australia

Howe KA
Med J Aust 1988 Sep 19;149(6):296-7, 300, 302

This study covered 165 women planning a home birth with a registered midwife. 31% of the women were first-time mothers. 16% of the study group transferred to hospital, 5% of the group had an assisted delivery, and 1% had caesareans.

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Prospective regional study of planned home births

Davies J, Hey E, Reid W, Young G.
BMJ 1996;313:1302-1306 (23 November 1996)

This study followed 256 women who expressed an interest in home birth. Of those who went on to book a home birth, 14% transferred to hospital during labour, but 'on no occasion was obstetric intervention required in the first hour after transfer. Women transferred appreciated having spent part of their labour at home...Intrapartum transfers were uneventful, and half the mothers commented spontaneously that they valued having spent even part of their labour at home. '

Read this article in the British Medical Journal

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Outcomes of 1001 midwife-attended home births in Toronto, 1983-1988

By H Tyson
Birth 1991 Mar;18(1):14-9

This study followed the progress of 361 first-time mothers and 640 multiparas (women who have given birth before) who planned home births.

92% of mothers having second or later babies gave birth at home, and 8% (51 women) transferred to hospital during labour or the first four days afterwards. 68% of first-time mothers stayed at home, and 32% (116 women) transferred.

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Last updated 4 March 2000

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